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Comparing approaches for deriving diabetes care cascades to inform policy:a cross-sectional analysis using national data from 88 countries

Low Level of physical activity and their determinants among adults aged 18-69 years in Tanzania: Results from the 2023 National STEPS survey

Background: Non-communicable diseases are the leading cause of mortality globally, accounting for approximately 74% of all deaths. Physical inactivity is a major modifiable behavioural risk factor, with an estimated 27.5% of adults worldwide not achieving sufficient levels to obtain health benefits, including the prevention of non-communicable diseases. Current nationally representative evidence on the prevalence of insufficient physical activity and its associated determinants remains limited. Objective: To estimate the prevalence of insufficient physical activity, defined as <600 MET-minutes per week, and to identify its socio-demographic and behavioural determinants among Tanzanian adults aged 18–69 years. Methods: A national population-based household survey employed a three-stage cluster sampling design using the 2022 Tanzania Population and Housing Census as the sampling frame, with 4,320 participants, conducted from September 2022 to September 2023. Data on major NCD risk factors were collected using WHO STEPS methodology. Physical activity was measured using an adapted Global Physical Activity Questionnaire and expressed in metabolic equivalent task units (MET) units. Chi-square tests and modified Classical logistics regression were used to assess factors associated with leisure-time physical inactivity. Results: Overall, 2.5% (95% CI: 1.6–3.8) of participants had insufficient physical activity. Older age (46–69 years) (aOR = 2.61, 95% CI: 1.38–4.92), urban residence (aOR = 1.71, 95% CI: 1.09–2.68), being married or cohabiting (aOR = 2.29, 95% CI: 1.03–5.09), having a college education (aOR = 2.44, 95% CI: 1.05–5.70) and being in the “other” occupation category (aOR = 1.63, 95% CI: 1.02–2.61) were independently associated with insufficient physical activity. Conclusion: Insufficient physical activity is relatively low but disproportionately affects older adults, urban residents, married individuals, those with higher education and certain occupations, highlighting emerging lifestyle transitions and the need for targeted prevention strategies to sustain adequate activity levels.

Hypertension Burden and its determinants among adults aged 18 to 69 years in Tanzania: Results from the 2023 National STEPS survey

Background: Hypertension is a major public health concern and a leading risk factor for non-communicable diseases (NCDs) globally. In Tanzania, up to date national level data on the prevalence and determinants of raised blood pressure (BP) are limited. This study analyzed data from the 2023 Tanzania STEPS survey to assess the prevalence and associated factors of raised BP among adults aged 18–69 years. Methods: A cross-sectional, household survey was conducted from September to November 2023 across all 31 regions of Tanzania. A three-stage stratified sampling approach was used to select 4,320 individuals from 288 enumeration areas. Data were collected through structured interviews, physical measurements, and biochemical sample collection. Raised BP was defined as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or current use of antihypertensive medication. Multivariable analysis using Modified Poisson regression was performed to identify factors associated with raised BP. Results: The overall prevalence of raised BP was 23.1% (95% CI: 19.9–26.4). Prevalence increased significantly with age, from 12.6% (95% CI: 7.7–17.4) among individuals aged 18–30 years to 46.4% (95% CI: 40.7–52.1) among those aged 46–69 years (p < 0.001). Overweight/obese individuals had a higher prevalence of raised BP (36.4%, 95% CI: 31.0–42.2) compared to those with normal weight (19.2%, 95% CI: 16.0–22.7; p < 0.001). Geographic zones such as the Southern Highlands (aPR 1.07, 95% CI: 1.02–1.13, p = 0.003) and Unguja (aPR 1.09, 95% CI: 1.04–1.14, p = 0.001) were associated with higher prevalence. Conclusion: Hypertension is prevalent among Tanzanian adults, with older age, obesity, and geographic location identified as significant risk factors. Targeted interventions focusing on lifestyle modifications, improved healthcare access, and region-specific strategies are essential to reduce the burden of hypertension in Tanzania.

Type 2 Diabetes care cascade among adults aged 18 to 69 in Tanzania: Results from the 2023 National STEPS survey

Background: The diabetes care cascade outlines the steps required to achieve effective glycaemic control at the population level: screening, diagnosis, engagement in care, treatment initiation, and glycaemic control. In low- and middle-income countries, such as Tanzania, significant attrition occurs at various stages of the cascade, particularly between prevalence and diagnosis, and between treatment initiation and glycaemic control. Determinants of these gaps include patient, provider, and health-system factors, as well as geographic and sociodemographic inequities. Objective: To analyze the diabetes care cascade in Tanzania, identify points of attrition, and provide evidence for targeted interventions to improve detection, retention, and glycaemic control. Methods: A population-based cross-sectional study was conducted among Tanzanians aged 18–69 years. Data on diabetes prevalence, diagnosis, treatment, and glycaemic control were collected and analyzed. The cascade was disaggregated by age, sex, and urban/rural residence. Confidence intervals (CI) were calculated to assess the precision of estimates. Results: The overall prevalence of diabetes in the population aged 18–69 years was 2.9% (95% CI: 1.9–3.9), of these 0.9% (95% CI: 0.4–1.4) were currently on diabetes medication. Among identified diabetes cases, 72.4% were not previously diagnosed, 17.2% were previously diagnosed and on medication, and 10.3% were previously diagnosed but not on medication. Diabetes prevalence increased with age, with the highest rates observed in the 46–69 age group (6.5%, 95% CI: 3.8–9.1). Conclusion and Recommendations: The diabetes care cascade in Tanzania reveals significant gaps in screening, diagnosis, and treatment, with the majority of cases undiagnosed and untreated. Targeted interventions, such as community-based screening, task-sharing to primary care providers, improved medicine supply chains, and integration with other health platforms, are essential to address these gaps and reduce diabetes-related morbidity and mortality.

Clustering of NCD Risk Factors Among Adults aged 18 to 69 in Tanzania: Results from the 2023 STEPS Survey

Background: Non-communicable diseases (NCDs) are a leading cause of morbidity and mortality globally, with a rapidly increasing burden in low- and middle-income countries such as Tanzania. The clustering of multiple NCD risk factors within individuals substantially increases the risk of cardiovascular disease, diabetes, and premature mortality, yet national evidence on risk factor clustering remains limited. Methods: This study analysed data from the nationally representative Tanzania WHO STEP-wise Survey conducted between September and November 2023. A total of 3,369 adults aged 18–69 years were included using a three-stage stratified sampling design. Five NCD risk factors were assessed: current daily smoking, inadequate fruit and vegetable intake, insufficient physical activity, overweight or obesity, and hypertension. Clustering was defined as the presence of three or more concurrent risk factors. Weighted analyses and modified Poisson regression models were used to identify associated factors. Results: Overall, 15.5% (95% CI: 13.2–18.1) of adults had three or more NCD risk factors. The prevalence increased sharply with age, from 5.6% among adults aged 18–30 years to 24.6% among those aged 46–69 years. Urban residents had a significantly higher prevalence than rural residents (18.9% vs. 12.6%). Significant geographic variation was observed, with the highest prevalence in the Southern zone (33.0%) and elevated risk in Unguja and Southern Highlands. In adjusted analyses, older age, urban residence, and geographic zone were independently associated with risk factor clustering. Conclusion: Clustering of NCD risk factors is common among Tanzanian adults, particularly among older and urban populations, underscoring the need for integrated and targeted NCD prevention strategies.

Investigating the evolutionary dynamics of second-line Mycobacterium tuberculosis drug resistance in Tanzania using hypercubic modelling and the Baum–Welch algorithm

Mycobacterium tuberculosis (MTB) continues to pose a significant threat to public health, particularly with the emergence of drug-resistant strains. Research shows that first-line anti-tuberculosis drugs are increasingly failing, and second-line drugs are also showing resistance. This study investigates the evolutionary dynamics of second-line drugs used against MTB, specifically Bedaquiline, Delamanid, Linezolid, Clofazimine, and Levofloxacin. Data were collected from the Tanzania National Institute of Medical Research (NIMR) at the Central Tuberculosis Reference Laborator Muhimbili Centre (CTRL). The data were analysed using a 5-hypercubic model, with parameters estimated using the Baum–Welch algorithm. The findings show that the most probable drug-resistant acquisition, independent of other drugs analysed, is Bedaquiline with a probability of 0.8660 and Levofloxacin with a probability of 0.134. The evolutionary pattern begins with Bedaquiline, followed by Levofloxacin, then Clofazimine, and finally either Linezolid or Delamanid, each with an equal probability of occurring. This highlights the evolutionary patterns of drug resistance, providing insights that can inform health experts and policymakers in developing evidence-based, effective interventions to combat this growing public health challenge. • Resistance of Mycobacterium tuberculosis to second-line drugs is growing. • The study examines resistance paths among Bedaquiline, Delamanid, Linezolid, Clofazimine, and Levofloxacin. • A 5-hypercubic model was used to analyse evolutionary drug resistance patterns. • The Baum-Welch algorithm estimated model parameters for public health insights. • Most likely paths: { } → B D Q → L F X → C F Z → L Z D → D L M or { } → B D Q → L F X → C F Z → D L M → L Z D

Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries.

INTRODUCTION: The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS: Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION: This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data.

BACKGROUND: There has been increasing awareness about the importance of type 1 diabetes (T1D) globally. Diabetic ketoacidosis (DKA) is a life-threatening complication of T1D in low-income settings. Little is known about health system capacity to manage DKA in low- and lower-middle income countries (LLMICs). As such, we describe health system capacity to diagnose and manage DKA across nine LLMICs using data from Service Provision Assessments. METHODS: In this cross-sectional study, we used data from Service Provision Assessment (SPA) surveys, which are part of the Demographic and Health Survey (DHS) Program. We defined an item set to diagnose and manage DKA in higher-level (tertiary or secondary) facilities, and a set to assess and refer patients presenting to lower-level (primary) facilities. We quantified each item's availability by service level in Bangladesh (Survey 1: May 22 2014-Jul 20 2014; Survey 2: Jul 2017-Oct 2017), the Democratic Republic of the Congo (DRC) (Oct 16 2017-Nov 24 2017 in Kinshasha; Aug 08 2018-Apr 20 2018 in rest of country), Haiti (Survey 1: Mar 05 2013-Jul 2013; Survey 2: Dec 16 2017-May 09 2018), Ethiopia (Feb 06 2014-Mar 09 2014), Malawi (Phase 1: Jun 11 2013-Aug 20 2013; Phase 2: Nov 13 2013-Feb 7 2014), Nepal (Phase 1: Apr 20 2015-Apr 25 2015; Phase 2: Jun 04 2015-Nov 05 2015), Senegal (Survey 1: Jan 2014-Oct 2014; Survey 2: Feb 09 2015-Nov 10 2015; Survey 3: Feb 2016-Nov 2016; Survey 4: Mar 13 2017-Dec 15 2017; Survey 5: Apr 15 2018-Dec 31 2018; Survey 6: Apr 15 2019-Feb 28 2020), Tanzania (Oct 20 2014-Feb 21 2015), and Afghanistan (Nov 1 2018-Jan 20 2019). Variation in secondary facilities' capacity and trends over time were also explored. FINDINGS: We examined data from 2028 higher-level and 7534 lower-level facilities. Of these, 1874 higher-level and 6636 lower-level facilities' data were eligible for analysis. Availability of all item sets were low at higher-level facilities, where less than 50% had the minimal set of supplies, less than 20% had the full minimal set, and less than 15% had the ideal set needed to diagnose and manage DKA. Across countries in lower-level facilities, less than 14% had the minimal set of supplies and less than 9% the full set of supplies for diagnosis and transfer of DKA patients. No country had more than 20% of facilities with the minimal set of items needed to assess or manage DKA. Where data were available for more than one survey (Bangladesh, Senegal, and Haiti), changes in availability of the minimal set and ideal set of items did not exceed 15%. Tertiary facilities performed best in Haiti, Ethiopia, Malawi, Nepal, Senegal, Tanzania, and Afghanistan. Secondary facilities that were rural, public, and had fewer staff had lower capacity. INTERPRETATION: Health system capacity to manage DKA was low across these nine LLMICs. Although efforts are underway to strengthen health systems, a specific focus on DKA management is still needed. FUNDING: Leona M. and Harry B. Helmsley Charitable Trust, and Juvenile Diabetes Research Foundation Ltd.

Availability of equipment and medications for non-communicable diseases and injuries at public first-referral level hospitals: a cross-sectional analysis of service provision assessments in eight low-income countries.

CONTEXT AND OBJECTIVES: Non-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions. DESIGN: Secondary analysis of existing cross-sectional survey data. SETTING: We used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country. OUTCOME MEASURES: We defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities. RESULTS: Overall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40% to 95%) and stage 1-2 hypertension (28%-83%). Availability was low for type 1 diabetes (1%-70%), type 2 diabetes (3%-57%), asthma (0%-7%) and acute presentations of diabetes (0%-26%) and asthma (0%-4%). Few hospitals had equipment or medications for heart failure (0%-32%), rheumatic heart disease (0%-23%), hypertensive emergencies (0%-64%) or acute minor surgical conditions (0%-5%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability. CONCLUSIONS: Our findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.