Papers by Elizabeth Msoka
“Let him die. He caused it”: A qualitative study on cancer stigma in Tanzania
PLOS global public health, Jun 12, 2024
Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation a... more Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with PLOS GLOBAL PUBLIC HEALTH
BMJ global health, 2024
Introduction Musculoskeletal disorders, experienced as joint pain, are a significant global healt... more Introduction Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition. Methods Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists. Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software. Results Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi, cold disease; ugonjwa wa uzee, old age disease; rimatizim, disease of the joints; and gauti, gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals. Conclusions Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care.
Springer Nature, 2024
Background Antimicrobial resistance (AMR) is a global threat to human and livestock health. Altho... more Background Antimicrobial resistance (AMR) is a global threat to human and livestock health. Although AMR is driven by use of antimicrobials, it is often attributed to "misuse" and "overuse", particularly for antibiotics. To curb resistance, there has been a global call to embrace new forms of moral personhood that practice "proper" use, including prescription, dispensing and consumption of antimicrobials, especially antibiotics. This paper seeks to reflect on complex questions about how morality has become embedded /embodied in the AMR discourse as presented in the data collected on antimicrobial prescription, dispensing and use in human and livestock health in Tanzania, primarily focusing on antibiotics. Methods This reflection is anchored on Jarrett Zigon's morality framework that is comprised of three dimensions of discourse; the institutional, public, and embodied dispositions. The data we use within this framework are derived from a qualitative study targeting human and animal health care service providers and community members in northern Tanzania. Data were collected through 28 in-depth interviews and ten focus group discussions and analysed through content analysis after translation and transcription. In addition, a review of the Tanzania's National Action Plans on antimicrobial resistance was conducted. Results Application of the framework demonstrates points of convergence and divergence in the institutional morality discourse articulated by the Tanzania National Action Plans, the public discourse and the embodied dispositions/ lived experiences of human and animal health care service providers and community members. We demonstrate that AMR is not just associated with "inappropriate" behaviour on the part of drug prescribers, dispensers, and users but also with shortcomings in health systems and service delivery.
World Journal Surgery, 2024
Introduction: Cancer-related stigma is a key driver of advanced breast cancer stage in Sub-Sahara... more Introduction: Cancer-related stigma is a key driver of advanced breast cancer stage in Sub-Saharan Africa (SSA). We developed and tested the impact of a breast cancer survivor-led Stigma reduction intervention (SRI) on stigma and treatment adherence of newly diagnosed patients with breast cancer in Tanzania. Methods: Breast cancer survivors were trained on breast cancer knowledge and motivational interviewing. A total of 4 trained survivors delivered a SRI (standardized flipchart breast education talk, personal testimony, and motivational interviewing) to 30 newly diagnosed patients with breast cancer before treatment. Pre-and post-intervention knowledge surveys and stigma scale surveys were analyzed via Fisher's exact test and Wilcoxon rank-sum tests. A discussion was held with a group of survivors after the intervention period to elicit feedback on their intervention experience. Results: Among the 30 patients, breast cancer knowledge (median overall percent correct) increased from 28% (IQR: 18%-45%) to 85% (IQR: 79%-88%) (p < 0.001) and stigma (median score) decreased from 75 (IQR: 57-81) to 53 (IQR: 44-66) (p < 0.01) following the intervention. All participants were willing to pursue hospital-based treatment after undergoing the intervention. Eighty-seven percent (n = 26) initiated treatment at 8-week follow-up after the intervention. All survivors endorsed feeling empowered and valued in their role in this intervention. Conclusions: Breast cancer survivors are a powerful group to combat the lack of knowledge and stigma in community and healthcare settings. Expanding the scope and scale of this intervention holds promise for improving treatment-seeking behavior and ultimately breast cancer outcomes in SSA.
JAMA Network Open, 2024
IMPORTANCE Effective communication between patients and health care teams is essential in the hea... more IMPORTANCE Effective communication between patients and health care teams is essential in the health care setting for delivering optimal cancer care and increasing cancer awareness. While the significance of communication in health care is widely acknowledged, the topic is largely understudied within African settings. OBJECTIVE To assess how the medical language of cancer and oncology translates into African languages and what these translations mean within their cultural context. DESIGN, SETTING, AND PARTICIPANTS In this multinational survey study in Africa, health professionals, community health workers, researchers, and scientists involved in cancer care and research and traditional healers were invited to participate in an online survey on a voluntary basis through online platforms. The survey provided 16 cancer and oncologic terms used in cancer Author affiliations and article information are listed at the end of this article.
SSM - Qualitative Research in Health, 2024
The increased prevalence of non-communicable diseases (NCDs) in recent years has led many Low-and... more The increased prevalence of non-communicable diseases (NCDs) in recent years has led many Low-and Middle-Income Countries (LMICs), including Tanzania, to develop policies to manage their burden. Musculoskeletal (MSK) conditions, such as arthritis, account for 20% of all years lived with disability in LMICs, but the NCD strategies rarely address them. There is substantial research on the disruption MSK conditions cause to people's lives within High-Income Countries, but very little is known about the lived experiences in LMICs. We investigated the experience of MSK conditions in 48 in-depth qualitative interviews with participants from the Hai District in Tanzania, East Africa, all of whom had a MSK disorder (confirmed through clinical examination as part of a broader study). We found that loss of mobility and pain associated with MSK disorders severely limits people's everyday lives and livelihoods. Help from others, mainly those within a household, is necessary for most tasks and those with limited or no support experience particular problems. We found barriers to accessing care and treatment in the form of high direct and indirect (through travel) care costs within formal health services in Tanzania. We argue for increased attention to the growing problem of MSK disorders in LMICs and that this agenda should be driven by a patient-centred approach which designs services accessible to the target population and designed to recognise their embodied expertise.
Social Science & Medicine, 2024
Capability wellbeing can potentially provide a holistic outcome for health economic evaluation an... more Capability wellbeing can potentially provide a holistic outcome for health economic evaluation and the capability approach seems promising for African countries. As yet there is no work that has explored the evaluative space needed for health and care decision making at the whole population level and procedures that merely translate existing measures developed in the global north to contexts in the global south risk embedding structural inequalities. This work seeks to elicit the concepts within the capability wellbeing evaluative space for general adult populations in Tanzania and Malawi. Semi-structured interviews with 68 participants across Tanzania and Malawi were conducted between October 2021 and July 2022. Analysis used thematic coding frames and the writing of analytic accounts. Interview schedules were common across the two country settings, however data collection and analysis were conducted independently by two separate teams and only brought together once it was clear that the data from the two countries was sufficiently aligned for a single analysis. Eight common attributes of capability wellbeing were found across the two countries: financial security; basic needs; achievement and personal development; attachment, love and friendship; participation in community activities; faith and spirituality; health; making decisions without unwanted interference. These attributes can be used to generate outcome measures for use in economic evaluations comparing alternative health interventions. By centring the voices of Tanzanians and Malawians in the construction of attributes that describe a good life, the research can facilitate greater equity within economic evaluations across different global settings.
Social Science & Medicine, 2024
Capability wellbeing can potentially provide a holistic outcome for health economic evaluation an... more Capability wellbeing can potentially provide a holistic outcome for health economic evaluation and the capability approach seems promising for African countries. As yet there is no work that has explored the evaluative space needed for health and care decision making at the whole population level and procedures that merely translate existing measures developed in the global north to contexts in the global south risk embedding structural inequalities. This work seeks to elicit the concepts within the capability wellbeing evaluative space for general adult populations in Tanzania and Malawi. Semi-structured interviews with 68 participants across Tanzania and Malawi were conducted between October 2021 and July 2022. Analysis used thematic coding frames and the writing of analytic accounts. Interview schedules were common across the two country settings, however data collection and analysis were conducted independently by two separate teams and only brought together once it was clear that the data from the two countries was sufficiently aligned for a single analysis. Eight common attributes of capability wellbeing were found across the two countries: financial security; basic needs; achievement and personal development; attachment, love and friendship; participation in community activities; faith and spirituality; health; making decisions without unwanted interference. These attributes can be used to generate outcome measures for use in economic evaluations comparing alternative health interventions. By centring the voices of Tanzanians and Malawians in the construction of attributes that describe a good life, the research can facilitate greater equity within economic evaluations across different global settings.
PLOS GLOBAL PUBLIC HEALTH, 2024
Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation a... more Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with PLOS GLOBAL PUBLIC HEALTH
BMJ Global Health, 2024
Introduction Musculoskeletal disorders, experienced as joint pain, are a significant global healt... more Introduction Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition. Methods Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists. Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software. Results Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi, cold disease; ugonjwa wa uzee, old age disease; rimatizim, disease of the joints; and gauti, gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals. Conclusions Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care. copyright.
Alicia Davis, 2022
Background: The current Coronavirus disease pandemic reveals political and structural inequities ... more 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-today health challenges.
Elizabeth F. Msoka, 2021
Objectives Early diagnosis and timely treatment are key elements of a successful healthcare syste... more Objectives Early 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. Setting Secondary 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. Participants Using 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. Results A 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. Conclusion Our 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.
Knowledge and misconceptions about epilepsy among people with epilepsy and their caregivers attending mental health clinics: A qualitative study in Taenia solium endemic pig‐keeping communities in Tanzania
Epilepsia Open
Culturally-informed adaptation and psychometric properties of the Cataldo Cancer Stigma Scale in Northern Tanzania
Journal of Psychosocial Oncology
International Journal of Wellbeing
This paper presents a mixed methods approach to understanding wellbeing in the Kilimanjaro region... more This paper presents a mixed methods approach to understanding wellbeing in the Kilimanjaro region of northern Tanzania—a country consistently ranked by the World Happiness Report as one of the least happy in the world. A primary objective is to demonstrate how qualitative data offering bottom-up perspectives on wellbeing offer a necessary complement to quantitative self-report measures, allowing for more nuanced cultural understandings of lived experience and wellbeing that recognize diversity both globally and locally. The research contextualized responses to standardized life evaluations (including the Cantril ladder question used by the World Happiness Report) through observations and interviews along with culturally sensitive measures of emotional experience. Findings show Kilimanjaro to have more positive life evaluations than Tanzania as a whole, and significant within-region demographic variation driven particularly by lower levels of wellbeing for nonprofessional women compa...
JCO Global Oncology
PURPOSE In Tanzania, women are diagnosed at an advanced stages of breast cancer. The aim of this ... more PURPOSE In Tanzania, women are diagnosed at an advanced stages of breast cancer. The aim of this study is to identify reasons for this finding from the patient perspective. METHODS Semi-structured in-depth interviews were conducted in inpatient and outpatient settings in the Kilimanjaro Cancer Care Center. Thematic coding via grounded theory technique was done by two independent reviewers. RESULTS Ten 10 patients (five rural and five urban) participated in the study. The average ages was 48. Seven (70.0%) were Christian. Eight (80.0%) patients had primary education, six (60.0%) were married, and eight (80.0%) were not employed. Two women (20.0%) had stage 2, four women (40.0%) had stage 3, and 4 (40.0%) had stage 4. The most common reasons reported by patients for advanced stage breast cancer at time of diagnosis are initially seeking care from traditional healers (n = 6, 60.0%), lack of breast cancer sign and symptoms knowledge (n = 8, 80.0%), misconceptions about breast cancer tre...
JCO Global Oncology
PURPOSE Early hospital presentation and completion of treatment is crucial for better treatment o... more PURPOSE Early hospital presentation and completion of treatment is crucial for better treatment outcomes in children with cancer. There are thousands of children who die of cancer each year without ever being diagnosed in Tanzania. To address this gap and inform childhood cancer awareness campaigns, it is important to understand the inherent cultural values and beliefs that influence health care seeking behavior among the Tanzanian community. METHODS This was a descriptive qualitative study conducted in Mwanza, Kilimanjaro and Dar- es Salaam regions. Community members aged ≥ 18 years from three rural and three urban communities were purposively selected to participate in seven focus group discussions (each with 8-12 respondents) between March and June 2021. Data were transcribed, coded and analyzed by thematic content-analysis with the support of NVIVO software. RESULTS A total of 72 participants were interviewed. Many had heard of breast or cervical cancer however, awareness of ped...
Tanzania journal of health research, 2015
Irrational antibiotic use is an important factor for development and spread of resistance to curr... more Irrational antibiotic use is an important factor for development and spread of resistance to currently used antibiotics. This study was carried out to assess antibiotic prescribing practices among cases diagnosed as malaria at three hospitals in Moshi Municipality in northern Tanzania. This was a cross sectional, retrospective study that included patients files from Kilimanjaro Christian Medical Centre (KCMC), Mawenzi Regional Hospital and St Joseph Hospital. Patient files whose primary provisional diagnosis was malaria were analysed using a convenient sampling method. Variables of interest were the types of medications prescribed, whether or not a laboratory test was requested and treatment was initiated before laboratory reports. A total of 250 patients 19 files were included in the analysis (KCMC=62.8%; Mawenzi=23.2%; St. Joseph=14.0%). In 232 (92.8%) prescriptions made in the three hospitals, laboratory tests were requested to confirm diagnoses. Among laboratory tests requested,...
Rheumatology
Background/Aims Musculoskeletal disorders (MSKD) are an important global health problem, but we k... more Background/Aims Musculoskeletal disorders (MSKD) are an important global health problem, but we know little about how it is understood and explained in Tanzanian communities. This understanding is crucial for developing culturally competent interventions and services for MSKD which avoid unintended impacts. This study aims to examine how joint pain is understood, explained, and responded to in rural and peri-urban communities in northern Tanzania. Methods We conducted rapid ethnographic assessment (REA) in two communities in Kilimanjaro region (one peri-urban, one rural) to document the language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts the pain has and how people respond to it. The REA included 60 short interviews with community leaders, traditional healers, community members, and pharmacists. The research team also wrote detailed field notes and, with written consent, took photographs which were used to develop ‘thick...
How Public Health Crises Expose Systemic, Day-to-Day Health Inequalities in Low- and-Middle Income Countries - An Example From East Africa
SSRN Electronic Journal, 2021
Background: The Coronavirus disease pandemic reveals political and structural inequities of the w... more Background: The Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and with the largest burdens of poor health. This is in parallel to a more persistent but 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. Findings: 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. Interpretation: 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. Funding Statement: This research was funded by the Antimicrobial Resistance Cross-Council Initiative through a grant from the Medical Research Council, a Council of UK Research and Innovation and the National Institute for Health Research (MRC/AMR/ MR/S004815/1). Hilton’s time was also funded by a core grant for the Medical Research Council/Chief Scientist Office (MRC/CSO) Social and Public Health Sciences Unit (MC_UU_12017/14; SPHSU14; MC_UU_12017/15; SPHSU15). This publication was supported by the University of Edinburgh and the University of Glasgow Jointly Funded PhD studentships (Loosli). Declaration of Interests: There are no conflicts of interests between the authors and/or institutions. Ethics Approval Statement: The study received approval from the Kilimanjaro Christian Medical University College Ethics Review committee with certificate n. 2408 and the Catholic University Health and Allied Sciences committee with certificate n. CREC/318/2018; National Institute for Medical Research (NIMR), Tanzania, with Reference Number NIMR/HQ/R.8a/Vol. IX/3017; Tanzanian Commission for Science and Technology (Davis, permit n. 2020-335-NA-2019-205; Lembo, permit n. 2020-333-NA-2019-205; Laurie, permit n. 2020-332-NA-2019-205; Mutua, permit n. 2020-334-NA-2019-205; Nthambi, permit n. 2020-336-NA-2019-205; Matthews, permit n. 2019-482-NA-2019-205; and Hilton, permit n.2019-476-NA-2019-205); and College of Medical Veterinary and Life Sciences ethics committee at the University of Glasgow (project application number 200180046). Permission for research in communities was obtained from relevant local and district authorities. All participants were explained study objectives and written and/or verbal informed consent was obtained. Verbal consent was utilised instead of written consent with participants who were unable to write. Informed consent forms and participant information sheets were approved by all ethics panels.
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Papers by Elizabeth Msoka