Background Women in Tanzania report a high unmet need for both information about and access to family planning. Prior studies have demonstrated the complex and variable relationship between religious faith and beliefs about family planning in sub-Saharan Africa. We hypothesized that a major reason for the poor uptake of family planning in Tanzania is that women and their partners are uncertain about whether pregnancy prevention is compatible with their religious beliefs. Methods Twenty-four focus group discussions with 206 participants were conducted in Mwanza, Tanzania between 2016 and 2017: six groups were conducted among Christian men, six among Christian women, six among Muslim men, and six among Muslim women. Among Christians, 98% were Protestants. Focus groups were also divided by gender and religion to facilitate discussion about gender-specific and religion-specific factors influencing family planning utilization. Qualitative data were analyzed using a thematic, phenomenological approach. Results We identify two important themes regarding the intersections of religion and family planning practices. First, we report that dynamics of family planning are experienced differently based on gender, and that male authority conflicts with female embodied knowledge, leading to negotiation or covert contraceptive use. Second, religious acceptability of family planning methods is of central importance, though participants differed in their interpretations of their religion’s stance on this question. Most who found family planning incompatible with their faith affirmed their responsibility to give birth to as many children as God would give them. Others found family planning to be acceptable given their moral responsibility to care for and protect their children by limiting the family size. Conclusions Both religious tradition and gender dynamics strongly influence the uptake of family planning, with a wide range of interpretations of religious traditions affecting the perceived acceptability of family planning. Regardless of gender or religious affiliation, participants were unified by a desire to live according to religious tradition. Future efforts to improve uptake of family planning are likely to have maximal impact if they are tailored to inform, involve, and empower male heads of households, and to address questions of religious acceptability.

SummaryBackgroundMale circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village.MethodsIn this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity (<60 km) and the time that a free male circumcision outreach campaign from the Tanzanian Ministry of Health became available in their village. All villages received the standard male circumcision outreach activities provided by the Ministry of Health. Within the village pairs, villages were randomly assigned by coin toss to receive either additional education for Christian church leaders on scientific, religious, and cultural aspects of male circumcision (intervention group), or standard outreach only (control group). Church leaders or their congregations were not masked to random assignment. The educational intervention consisted of a 1-day seminar co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health, and meetings with the study team every 2 weeks thereafter, for the duration of the circumcision campaign. The primary outcome was the proportion of male individuals in a village who were circumcised during the campaign, using an intention-to-treat analysis that included all men in the village. This trial is registered with ClinicalTrials.gov, number NCT 02167776.FindingsBetween June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3·2 [95% CI, 1·4–7·3]; p=0·006).InterpretationEducation of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings.FundingBill & Melinda Gates Foundation, National Institutes of Health, and the Mulago Foundation.

Background Use of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need for FP is high. This study aimed: (1) to use focus group data to construct a theoretical framework to understand the multidimensional factors impacting the decision to use FP in rural Tanzania; (2) to design and pilot-test an educational seminar, informed by this framework, to promote uptake of FP; and (3) to assess acceptability and further refine the educational seminar based on focus group data collected 3 months after the education was provided. Methods We performed a thematic analysis of 10 focus group discussions about social and religious aspects of FP from predominantly Protestant church attenders prior to any intervention, and afterwards from six groups of church leaders who had attended the educational seminar. Results Key interpersonal influences included lack of support from husband/partner, family members, neighbours and church communities. Major intrapersonal factors impeding FP use were lack of medical knowledge and information, misconceptions, and perceived incompatibility of FP and Christian faith. Postseminar, leaders reported renewed intrapersonal perspectives on FP and reported teaching these perspectives to community members. Conclusions Addressing intrapersonal barriers to FP use for leaders led them to subsequently address both intrapersonal and interpersonal barriers in their church communities. This occurred primarily by increasing knowledge and support for FP in men, family members, neighbours and church communities.

ObjectivesMale circumcision (MC) reduces HIV infection by approximately 60% among heterosexual men and is recommended by the WHO for HIV prevention in sub-Saharan Africa. In northwest Tanzania, over 60% of Muslims but less than 25% of Christian men are circumcised. We hypothesised that the decision to circumcise may be heavily influenced by religious identity and that specific religious beliefs may offer both obstacles and opportunities to increasing MC uptake, and conducted focus group discussions to explore reasons for low rates of MC among Christian church attenders in the region.DesignQualitative study using focus group discussions and interpretative phenomenological analysis.SettingDiscussions took place at churches in both rural and urban areas of the Mwanza region of northwest Tanzania.ParticipantsWe included 67 adult Christian churchgoers of both genders in a total of 10 single-gender focus groups.ResultsChristians frequently reported perceiving MC as a Muslim practice, as a practice for the sexually promiscuous, or as unnecessary since they are taught to focus on ‘circumcision of the heart’. Only one person had ever heard MC discussed at church, but nearly all Christian parishioners were eager for their churches to address MC and felt that MC could be consistent with their faith.ConclusionsChristian religious beliefs among Tanzanian churchgoers provide both obstacles and opportunities for increasing uptake of MC. Since half of adults in sub-Saharan Africa identify themselves as Christians, addressing these issues is critical for MC efforts in this region.

Background Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities. Methods We conducted 31 in-depth interviews with Christian (n=17) and Muslim (n=14) religious leaders in rural Tanzania. Interviews focused on religious leaders’ perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders’ perspectives on, and experiences with, hypertension. Results Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders. Conclusions Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.

Unmet need for family planning (FP) remains prevalent worldwide. In Tanzania, 21.7% of women desire to delay pregnancy, but do not use modern contraception despite its free availability at local clinics. Our prior data suggest that this is related to complex gender and religious dynamics in rural communities. To understand how education about FP could be improved, we developed a discrete choice experiment (DCE) to rank preferences of six attributes of FP education. Results were stratified by gender. Sixty-eight women and 76 men completed interview-assisted DCEs. Participants significantly preferred education by a clinician (men = 0.62, p < .001; women = 0.38, p < .001) and education in mixed-gender groups (men = 0.55, p < .001; women = 0.26, p < .001). Women also significantly preferred education by a religious leader (0.26, p = .012), in a clinic versus church, mosque, or community centre (0.31, p = .002), and by a female educator (0.12, p = .019). Men significantly preferred a male educator (0.17, p = .015), whom they had never met (0.25, p < .001), and educating married and unmarried people separately (0.22, p = .002). Qualitative data indicate women who had not previously used contraception preferred education led by a religious leader in a church or mosque. FP education tailored to these preferences may reach a broader audience, dispel misconceptions about FP and ultimately decrease unmet need.

Muslim religious and lay leaders in rural Tanzania interpreted Islamic teachings as accepting of family planning (FP) for birth spacing and uniformly supported spacing through breastfeeding and the calendar method. nThe need for more FP education in Muslim communities was widely agreed upon, and leaders were open to helping to provide this education. n Leaders' insights yielded recommendations for educating Muslim religious leaders in their communities. These included educating men and women both together and separately depending on context and partnerships between medical and religious leaders to co-teach educational sessions.n Muslim religious leaders can be empowered to teach their own communities by receiving education about contraceptive methods, including how the methods work, their efficacy, and potential side effects.

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