Understanding Household Poverty among Landless Returnees in Burundi ()
1. Introduction
Burundi has experienced multiple episodes of violent conflict, which have forced thousands of its population into exile (Watt, 2008). The most violent events, which caused a significant displacement of people, occurred in 1972 and 1993, resulting in the forced exile of approximately 300,000 and 687,000 individuals respectively.
At the end of 2002, the political agreement on the cessation of hostilities encouraged the repatriation of Burundians. Between 2002 and 2011, over 500,000 Burundian refugees returned from Tanzania, the DRC, and Rwanda (Fransen & Kuschminder, 2012). Following this significant influx of returnees, the government and its partners implemented initiatives to reintegrate them into Burundian society. The initiatives had two objectives: 1) to reintegrate landless returnees; 2) to encourage cohabitation between returnees and vulnerable members of the host communities in less populated areas of the country (Fransen & Kuschminder, 2012). Studies conducted after significant return movements have demonstrated that reintegration efforts have had a short-term impact by providing refugees with access to the same living conditions as non-displaced individuals, thus indicating the success of reintegrating Burundian returnees into their living environments (Ministries, 2012). However, some studies challenge this view by questioning the effectiveness and sustainability of the reintegration process for Burundian returnees. For instance, it was found that returnee households typically have limited access to agricultural land, which is the primary productive asset for rural households in Burundi. Land scarcity is closely linked to poverty in the Burundian context (Ministries, 2012; Fransen, 2017). According to existing literature, the poverty is defined as a state of deprivation across multiple dimensions that affect human well-being, including consumption, food security, health, education, rights, voice, security, dignity, and decent work (OECD, 2001). Fifteen years after the major movements of returnees, studies have shown that many have not been able to recover their farmland, which is a significant source of income for rural households (Fransen, Ruiz, & Vargas‐Silva, 2015; Mbazumutima, 2021). One of the key research problems addressed in this study is the lack of information available on the living conditions of returnees belonging to the most vulnerable categories, such as landless returnees. This study came at the right time, as it was carried out on families who had spent between 10 and 15 years in Burundi after their repatriation, this period is viewed as sufficient to ensure a sustainable reintegration of returnees (Rogge, 1994). This study contributes to the existing literature on the causes and consequences of violent conflicts, particularly in relation to poverty and social inequality. Indeed, previous research has identified these factors as potential drivers of conflict within a country (Bintarsari, N. K., & Utami, A. T. (2023), Tollefsen, A. F. (2020)). The purpose of this article is to analyse the poverty of landless returnee households in relation to their conditions as ex-refugees. This analysis will inform measures that can be taken to improve the living conditions of this population. This article aims to analyse the socio-economic conditions of households repatriated from the 1972 and 1993 crises. It also examines the long-term poverty-determining factors for landless repatriated households more than ten years after their return to Burundi. The objective is to analyse the extent to which their integration has been sustainable. As stated in the scientific literature, the ultimate objective of reintegration is to ensure that all returnees have equal access to political, civil, economic, social, and cultural rights (Jallow, Heinbecker, & Malik, 2004). This study is therefore to analyse the extent to which returnees who did not recover their former lands enjoy their economic and socio-cultural rights.
2. Access to Land and Poverty in Repatriated Burundian Households
Land is the primary source of income for most Burundians, with about 90% of the population dependent on agriculture for their livelihoods (Nzabakenga, Feng, & Yaqin, 2013). As one of Africa’s most densely populated countries, Burundi faces significant challenges in agricultural land access and use (Kohlhagen, 2011; Keringingo & Kayakayacı, 2023). The country’s agricultural sector is characterized by subsistence farming, low productivity, and chronic food deficits (Jenicek & Grofová, 2016). Factors contributing to these issues include limited access to land, environmental degradation, climatic shocks, and rapid population growth (Jenicek & Grofová, 2016). Land conflicts have become a major concern, particularly with the return of refugees and internally displaced persons (Wittig, 2017). Returnee households face economic challenges, including lower livestock ownership and limited access to agricultural land (Fransen, 2017; Fransen, Ruiz, & Vargas‐Silva, 2015). The socio-economic sustainability of refugee return is questionable, with second-generation returnees facing additional difficulties (Fransen, 2017). While local conflict resolution mechanisms and dialogue have been employed (Leeuwen & Haartsen, 2005; Mbazumutima, 2021), the politicization of land issues continues to threaten Burundi’s fragile peace process (Wittig, 2017). Research on poverty among returnee households in Burundi reveals significant challenges. Returnees face lower food security, nutrition, and overall welfare compared to non-displaced neighbors, with effects persisting for 8 - 10 years after return (Verwimp & Muñoz-Mora, 2013). They are less likely to own agricultural land and experience worse living conditions, particularly second-generation returnees (Fransen, 2017). Communities with higher concentrations of returnees show increased food insecurity and lower living standards for all households (Fransen, 2017). The duration of displacement and time since return are key factors affecting welfare outcomes (Verwimp & Muñoz-Mora, 2013). Exposure to conflict violence is associated with persistent poverty, trapping poor households in chronic deprivation (Mercier & Ngenzebuke, 2015; Mercier, Ngenzebuke, & Verwimp, 2020).
3. Methods
3.1. Study Setting
The study took place in Nyanza Lac, a commune located on the border with Tanzania in the province of Makamba. This area has a significant number of returnees who were forced into exile in Tanzania during the crises of 1972 and 1993. The focus of the study is on this area because previous research has highlighted the challenges that returnees face in the process of reclaiming their former land. Therefore, this study analyses the vulnerability of landless returnee households in a commune like this one to understand the socio-economic conditions they face fifteen years after returning to Burundi.
3.2. Study Design and Period
In November 2023, a study was done to understand poverty faced by landless repatriated families, focusing on their living situations. We chose a phenomenological study because it helps to show the real experiences and views of people. This method lets us explore how these households see and deal with their situations, giving us detailed qualitative data to help guide policy and action. The research included interviews with important people, such as heads of repatriated families, local officials, and members of civil society organizations (CSOs) that work with returnees. Heads of households shared details about their living situations after returning home, the problems they encounter, and the ways they cope. This direct information is key to understanding their specific experiences. We also talked to local officials and CSO members to get their perspectives, which provided an alternate view on the issues faced by returnees. This helped to confirm the information collected and ensured a fuller analysis. Furthermore, focus group discussions were held with men, women, boys, and girls to gather different views based on gender and age. This varied approach enhanced the study’s findings and revealed the complexities of poverty among landless repatriated families.
3.3. Study Population and Sampling
The study population consisted of households repatriated up to 2010 who resided in the commune of Nyanza Lac and did not possess agricultural land. Additionally, the study included leaders of returnee associations and local authorities in the administrative entities where these households reside. A “purposive” non-probability sampling method was used to identify the administrative authorities and the representatives of the returnee associations who would participate in this study. This research method involves the researcher using personal judgement to select respondents who are best informed to answer the research questions (Rea & Parker, 2014). The study employed the non-probability snowball sampling method to identify landless returnee households. This method involves non-random selection of respondents, in which the researcher identifies some respondents and asks them to identify others (Rea & Parker, 2014). To achieve this, initial contact was made with two associations of returnees who are active in the commune of Nyanza Lac. The representatives of these associations were then asked to identify five members who had been repatriated since 2010 but had not been able to recover their former farmland. The focus group consisted of men and women over the age of 18 living in landless returnee households from hills that had not been selected for individual interviews.
3.4. Data Collection, Analysis and Ethical Clearance
The article presents data collected from ten individual interviews and four focus group discussions. Six of the individual interviews were conducted with heads of repatriate households, while the remaining four were conducted with representatives of repatriate associations and local authorities. To triangulate the information gathered from the individual interviews, four focus groups were organized by age and gender. Two focus group discussions were conducted, one for men aged 18 - 35 and another for men over 35. Similarly, two focus groups were conducted for women, each consisting of eight women in the same age groups as the male participants. The discussions were structured using an interview guide, and the raw data from both individual and focus group discussions were recorded on a smartphone. The transcriptions were created using Microsoft Word 2016. The transcripts were subjected to content analysis and coding to identify the themes present in the text. This was achieved using the qualitative data analysis steps of deconstruction, interpretation, and reconstruction (Stemler, 2000; Sargeant, 2012).
This article presents a study conducted as part of a doctoral thesis at the University of Burundi. The research protocol for this study received approval from the Doctoral School of the University of Burundi, which issued a research permit for all tasks related to data collection, analysis, and interpretation. The study protocol was validated by the Research Chair on Forced Displacement of the University of Dar Es Salaam, which funded the data collection for this study. Before conducting interviews and focus group discussions, participants were provided with a clear explanation of the research objectives and given the opportunity to either agree or refuse to participate. Verbal consent was obtained from those who chose to participate, with the understanding that their information would remain anonymous.
4. Results and Discussions
This section presents and discusses the results of the analysis of the qualitative data collected during the study. Before discussing the results of the study in detail, it is important to present the socio-demographic data of the landless households that participated in the study.
4.1. Sociodemographic Features of Return Landless Household
The interviews showed that most heads of repatriated households without agricultural land are men and women over the age of 70 with low levels of education. The second category consists of heads of households who were born in exile and returned with their parents upon repatriation. They have since established their own households without having access to land, as their parents are landless. Usually, these households comprise of over six children residing on a plot of land that is seldom larger than five acres. Girls are typically confined to the family compound until they get married. In most households, girls are generally kept within the family compound until they are married. Boys tend to leave at an early age in search of better living conditions elsewhere. Table 1 illustrates the socio-demographic characteristics of landless returnees’ household.
Table 1. Characteristics of repatriated households participating in the study.
Criteria |
Categorisation |
Number of households |
Period at which the head of the
household went into exile |
1972 |
34 |
1993 |
4 |
Gender of the household head |
Male |
23 |
Female |
15 |
Head of household’s age |
Over 70 |
27 |
Under 70 |
11 |
Number of children per household |
More than 6 children |
29 |
Less than 6 children |
9 |
This table shows that men and women who fled or whose parents fled after the 1972 crisis make up the majority of returnee households that had not managed to obtain agricultural land by 2023. These results confirm Mbazumutima’s finding that the land restitution process was slower and more complicated for returnees from the 1972 crisis (Mbazumutima, 2021). Those who returned following the 1993 crisis did not face serious difficulties in accessing their former land when they returned home.
4.2. Sources of Income of the Surveyed Households
In Burundi, the majority of rural households rely on subsistence farming and animal husbandry as their main source of income (Mineagrie, 2018). However, research has already shown that certain categories of landless people cannot derive income directly from farming (Niragira, Brusselaers, Buysse, Van Orshoven, & Ndimubandi, 2018). Landless returnees are also included in this non-farm population. This study analyses how landless returnees access income to meet their daily living expenses. Table 2 presents an analysis of the main sources of income for the 38 households participating in the study.
Table 2. Main source of income for landless returnee households.
Main source of income |
Number of households |
Non-agricultural daily work |
5 |
Daily agricultural work for others households |
18 |
Remittances from household members who are migrants |
9 |
Small business |
3 |
Craftwork |
2 |
The study revealed that a considerable number of landless returnee households earn their livelihoods by working as day labourers on other people’s farms. This source of income is crucial as it is accessible and exploitable by female returnees. Landless returnees are appealing to wealthier farmers because they provide cheap labour. One interviewee noted that wealthier farmers prefer to hire cheap labour over individuals who have not fled the country and who will not accept payment below a certain threshold: “My three daughters and I have developed the habit of working on other people’s farms to earn food or money for our daily expenses. We sometimes face exploitation, as we are paid less than what we deserve. This is because the employers are aware that if we do not work for them, my family will not be able to survive” Female Respondent; Mvugo hill, 01/11/2023.
The second most significant source of income for landless returnee households is remittances from family members who have migrated for economic opportunities. These migrants are mostly young men who, after experiencing economic hardship, prefer to return to Tanzania to work as itinerant traders and support their families financially. One man interviewed said, “if my son had not returned to Tanzania, my children and I would be starving. In fact, he sends us money at the end of each month to help us buy food. I regret my decision to return to Burundi, relying on the words of politicians who guaranteed that our land would be returned to us”. Female Respondent; Mvugo hill, 04/11/2023.
Other sources of income are non-agricultural day labour, such as masonry work on construction sites, or any non-agricultural work paid on a daily basis. Trades/crafts and petty trading are uncommon sources of income, as very few of the respondents had received vocational training in either Tanzania or Burundi to practice a trade, while the obstacle to running a petty business remains the lack of start-up capital. To sum up, the returnee households surveyed were found to have limited diversified income-earning opportunities. For example, many of the returnees we interviewed are unable to participate in community-based savings and credit structures due to the required financial contribution. This was explained by a woman in a discussion group we held in Nyanza Lac: “My friends are always urging me to join their savings and credit groups so that I can benefit from small loans on the sole condition that I pay a start-up capital of ten thousand francs. I can assure you that I have been chasing this sum for two years. The money I earn every day is not even enough to feed my children. I don’t have anything to sell to earn this money”. Female Respondent; Muyange Hill, 04/11/2023.
To analyse the extent to which the skills acquired in exile influence returnees’ current sources of income, it was found that the vast majority of those interviewed lived in Tanzania as farmers. They were able to produce and sell food to earn the money they needed. Therefore, they did not attach any importance to other income diversification activities, such as vocational training or apprenticeships. The absence of arable land makes them extremely vulnerable to poverty, as they have no other viable sources of income.
4.3. Analysis of the Main Expenses of the Surveyed Household
An analysis of the spending priorities of returnees shows that a clear majority of returnees give priority to spending their income on legal procedures for the recovery of their land. This takes precedence over investing in human capital development, such as the health and education of household members, as demonstrated in Table 3.
Table 3. Prioritized expenditure in households of landless returnees.
Expenses type |
Number of households prioritising
this expenditure |
Land reclamation lawsuit |
24 |
Purchasing food |
7 |
Health care |
2 |
School fees and school material |
2 |
Transport fees for migrant |
3 |
The table shows that a significant proportion of householders are willing to sacrifice other expenses to finance legal proceedings aimed at recovering their agricultural land. This is a concerning situation as all households surveyed for this study had ongoing or pending land-related lawsuits in court. As a result, some individuals are willing to sacrifice basic necessities such as food, health and education for their children in order to reclaim their land. As one man explained, “Without land to farm, I feel that my family’s future is uncertain. I had to withdraw my children from school so that the money I earn could be used to regain my fields.’ Regrettably, my children no longer attend school and I have been unable to reclaim the land due to a court case that has been ongoing since 2010.” Male Respondent; Kabonga hill, 08/11/2023.
This situation hinders the ability of returning households to invest in their family’s human capital, which significantly compromises their ability to generate income both presently and, in the future (Diagne, 2007). Additionally, it is important to note that there are families who have lost all hope of living a decent life in Burundi. According to an interview with a man who repatriated in 2009, the returnees prefer to finance the emigration of its members to countries in the sub-region, hoping to receive remittances. One man interviewed stated “I’ve been back for 15 years now and I’ve realized that I made the wrong choice in returning to this country because all the promises were false. I have no hope that my children will ever have a plot of land.’ That is why I am encouraging them to seek a better future in Tanzania. If they succeed, they will send funds for their mothers and me”. Male Respondent; Kabondo hill, 05/11/2023.
Young boys are often sent on these adventures, while girls are left behind due to socio-cultural restrictions that prevent them from travelling unaccompanied by their parents and languishing in poverty alongside their mothers. Regrettably, due to their households limited economic capacity, these boys lack the necessary travel and residence documents required by the host countries’ laws. This situation exposes them to precarious security conditions and the risk of living in clandestine conditions.
4.4. Analysis of the Factors Determining Poverty in Landless Returnee Households
To conduct this analysis, the study utilised the guidelines of the Development Assistance Committee (DAC) of the Organisation for Economic Cooperation and Development (OECD). The guidelines identify the economic, human, political, socio-cultural, and defensive capacities of the individual as the primary dimensions that determine poverty (OECD, 2001). This study analyses the economic, human, and sociocultural dimensions. The results for each dimension are presented in the following sections.
4.4.1. Analysis of the Economic Capacity of Landless Returnee Households
This section examines the capacity of landless returnee households to generate income, consume, and accumulate assets for the purposes of food security, material well-being, and social status. The analysis reveals that landless returnee households have limited economic capacity, which restricts their access to productive resources such as land, agricultural implements and inputs, livestock, and decent employment. Many repatriated households dream of reliving the same conditions they experienced in exile, where life was easier than it is today. Table 4 presents a qualitative assessment of the economic capacities of the studied households.
Table 4. Analysis of economic capacities of landless returnees household.
Criteria |
Categorisation |
Number of households |
Coverage of monthly expenditure
by income |
Yes |
38 |
No |
0 |
Material well-being of the household |
Acceptable |
0 |
Poor |
38 |
Ownership of a plot of land larger
than 5 acres |
Yes |
2 |
No |
36 |
Work for all active members of the household |
Yes |
0 |
No |
38 |
Ownership of livestock |
Yes |
3 |
No |
35 |
Ease of obtaining agricultural inputs |
Yes |
2 |
No |
36 |
Table 4 illustrates that landless returnee households are poor household, with incomes insufficient to cover their expenses. Furthermore, these households are impacted by the lack of employment opportunities for some of their working-age members. The economic hardship is more acutely felt by the younger generation than the elderly. During group discussions with young men and women, it was revealed that they are dissatisfied with their current living conditions, which were promised to be better than their previous exile. One participant expressed frustration towards their parents for encouraging them to leave in 2009. The interviewees were promised that life in Burundi would be economically easier and more fulfilling, but upon returning, they found themselves working in other people’s farms.
Additionally, the households who have returned do not have the resources to purchase agricultural inputs, such as improved seeds and mineral fertilizers, which impedes their ability to produce food for their own consumption on their small plots of land. This has left them feeling like their future has been wasted.
4.4.2. Analysis of the Human Capacity of Landless Returnee Households
This analysis looks at households’ ability to provide health care, education, food, and other necessities to ensure that they have human resources to engage in productive employment that will enhance their economic capacity. It was found that returnee households without land have very low levels of investment in human capacity development. Table 5 shows a qualitative assessment of the investment capacity of returnee households.
Table 5. Analysis of human capacities of landless returnee household.
Criteria |
Categorisation |
Number of households |
Number of meals per day |
Two or more meals |
5 |
Less than two meals |
33 |
Household with children who have dropped out of school due to lack of school fees or school material |
Yes |
27 |
No |
11 |
Household with health insurance |
Yes |
6 |
No |
32 |
Decent housing (with bricks and
metal sheets) |
Yes |
24 |
No |
14 |
The data indicate that most landless returnee households consume less than two meals per day. Many choose to skip meals during the day to ensure they have food for the evening. Investigating the diversity of household diets revealed a lack of variety, highlighting poor nutritional quality of the diets consumed in households. Due to limited employment opportunities for women, female-headed households are the most affected by food insecurity. Women are primarily employed in daily agricultural work and petty trade, while men have access to a wider range of non-agricultural jobs. In terms of education, a significant number of repatriated households have children who dropped out of school due to lack of resources. A greater number of students dropped out of school before completing secondary education. In addition, even those who complete secondary education often have difficulty financing their children’s higher education. As a result, the children of returnees tend to have lower levels of education compared to those from host community households or other returnees who have access to land. Those who do not complete their studies, especially men, face difficult economic conditions. Consequently, unable to return to refugee camps after official repatriation, they resort to becoming illegal economic migrants in Tanzania.
Due to their unstable financial situation, the returnee households surveyed faced significant barriers to accessing health care as found previously (Maniraguha, 2011). Many individuals reported that they were not able to afford health insurance for their families. However, pregnant women and children under the age of 5 have easier access to healthcare as they receive free treatment in accordance with the Burundian government’s policy of providing free healthcare to this category of the population. Access to healthcare remains a significant challenge for households that do not qualify for free healthcare, as mentioned in the interview extract with a Woman “healthcare is a major concern for our household. I have been ill for about a year, but I have not been able to afford medical check-ups to determine the cause of my illness”. Female Respondent; Mvugo Hill, 03/11/2023.
At the end of this chapter on human capacity, it is worth noting that returnees often have access to decent housing, thanks to organisations that build houses for them.
4.4.3. Analysis of the Socio-Cultural Capacity of Landless Returnee Households
The purpose of this analysis was to evaluate the level of socio-cultural integration of returnees in a host community more than 10 years after repatriation. The findings indicate that the social status of landless repatriated households remains problematic in terms of acceptability within the communities. The population recognises that the returnees are Burundians who should live in the commune. However, the returnees often face discrimination due to their former refugee status. They are commonly referred to as “Abasabini”, which translates to “people from 1972”. This label identifies them as poor, landless Burundians with no economic assets, who are there to sue members of the host community for land. Using the term “Abasabini” to refer to landless returnees from the 1972 crisis is seen as marginalising and degrading. Abasabini are seen as poor people with no future. One interviewee stated, “Living with the people who occupy our land can be challenging. They refer to us as ‘Abasabini’ to distinguish us from others. If someone hears that you are among the ‘Abasabini’, they may assume that you have nothing and are causing problems in the community by demanding agricultural land”. Focus Group Discussion with men, 01/11/2023.
Returnees often struggle to establish social ties, such as marriage, with members of host communities due to their reputation for having land disputes. Testimonies confirm that when a boy from a landless repatriated family plans to marry a girl from a non-repatriated family, the girl’s family is often opposed on the grounds that the repatriates are poor and frequently have land disputes with others. During the focus group discussions, male participants said that it is difficult for boys from repatriated families to be accepted by non-repatriated families when they are seeking marriage proposals. He stated that non-repatriate families view them as financially unstable and unable to provide a happy life for their daughters.
It is important to note that the economic instability of repatriate households often leads to the filing of numerous lawsuits against them by financially stable non-repatriates. This tactic of filing endless lawsuits drains returnees’ resources and ultimately leads them to give up their claim to their land. The strategy of exhaustion is commonly used to initiate proceedings to expropriate the land of repatriates, which they acquired through the National Commission for Land and Other Property (CNTB). The CNTB’s mission was to return land and other property unjustly taken by those who had not fled. The study revealed that a considerable number of returnees had regained their land with the help of CNTB. However, they were forced to abandon their land to the socio-economically powerful due to prolonged legal battles that exhausted their resources, rendering them landless once again. During the group discussions, one of the participants stated that many returnees have lost the land they received through the CNTB.’ Mock trials were conducted until the returnees’ resources were exhausted, resulting in the expropriation of their land.
5. Summary of the Findings
A comparative analysis of the data collected from the various categories of interviewees revealed that those who returned from the 1972 crisis were the most severely affected by the scarcity of farmland. Those who returned from the 1993 crisis were resettled on their original land. Those who returned from the 1972 crisis and are currently without land are experiencing severe poverty. As a result, they are unable to meet their basic food requirements and live in conditions of extreme economic insecurity. Such individuals are unable to afford the fees associated with secondary education or healthcare for their dependents. These challenging circumstances are further exacerbated by the persistent land disputes. This results in a depletion of household resources to the extent that expenditures related to the development of the household’s human capital, such as health and education, are no longer feasible. Furthermore, landless returnees are subjected to a form of social discrimination associated with their status as landless former refugees.
In order to adapt to these challenging circumstances, returnee households have been known to resort to more extreme coping strategies, such as offering inexpensive agricultural labour to households with farms, including those occupying their disputed properties. This can result in a form of exploitation of the returnees’ vulnerability and hardship. Another common strategy is to remove children, particularly girls, from school so that they can contribute to the household’s labour force and generate financial income.
6. Conclusion
To achieve lasting peace in post-conflict countries, refugees must not only be able to return to their countries of origin but also be effectively integrated into their host communities. This process is known as “sustainable repatriation (Black & Gent, 2006). The process of sustainable reintegration can take 10 to 15 years (Rogge, 1994). The study conducted in Burundi aimed to analyse the economic conditions of landless returnee households more than 10 years after their return. The findings revealed that these households live in extreme poverty, which prevents them from living in dignity and security in their own country. Their only economic asset is physical force, which is rarely enough to cover the costs associated with the frequent land disputes they face. Investing in endless court cases prevents returnees from investing in the development of their households’ human capital, such as health, education, and nutrition. This study suggests that the government of Burundi and its development partners implement a targeted economic empowerment strategy for landless returnees from the 1972 crisis. This will enable them to live a dignified life and invest in human capital, ultimately breaking the cycle of intergenerational poverty. The aim of this strategy is to develop non-farm activities in areas with a large-scale return, providing employment opportunities for landless families and enabling them to earn an income to develop their human capital. The study also recommends improving the legal framework to be more sensitive to the vulnerability of landless returnees by allowing free or subsidised access to the entire national education system, from primary to university for returnee children. The study suggests that further research should be conducted to analyse the factors that contribute to the increase in income of landless returnee households, allowing them to finance their basic needs.
Acknowledgements
The study was funded by the International Development Research Centre through the Research Chair on Forced Displacement at the University of Dar Es Salaam. We would like to acknowledge their support. We are grateful to all study participants for their willingness to participate.