Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage

Effect of Deworming on Health Outcomes among Children Aged 12-59 Months in Tanzania: A Multilevel Mixed Effects Analysis

Introduction

Mass deworming of preschool children is a strategy suggested to prevent soil-transmitted helminth infections in most developing countries. Nonetheless, there is a scarcity of data showing the contribution of mass deworming to a child's nutritional status. The purpose of this study was to assess the effect of deworming on nutritional health outcomes (stunting, underweight, and anemia) in children aged 12 to 59 months.

Methods

A secondary analysis of data extracted from the Tanzania Demographic and Health Survey (TDHS) 2015-16 data was carried out. A total of 7,962 children were included in this study. A multilevel logistic regression was used at a 5% level of significance to determine the individual- and community-level determinants of deworming on health outcomes among children.

Results

The prevalence of underweight (62.6%), stunting (61.0%), and anemia (61.8%) was higher in children who were not dewormed than those who were dewormed. Female children were more likely to suffer from poor health outcomes (OR = 1.01 and 95% CI = 0.95-1.07) than male children. Children aged 24-35 months and 36-47 months were significantly less likely to suffer from poor health outcomes (OR = 0.89; 95% CI = 0.82-0.97 and OR = 0.88; 96% CI = 0.81-0.96, respectively; p < 0.01). Children from households with unimproved toilets (OR = 1.38 and 95% CI = 1.25-1.52), unimproved water sources (OR = 1.08 and 95% CI = 1.01-1.16), and living in rural areas (OR = 1.02 and 95% CI = 0.91-1.14) had higher odds for poor health outcomes.

Conclusion

Deworming may be an effective technique for preventing poor health outcomes in children and the risks associated with them, such as poor growth and development.

Co-implementing vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study

Background

Bi-annual high dose vitamin A supplements administered to children aged 6–59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. This study explored the feasibility and acceptability of integrating VAS with SMC in one local government area in Sokoto State.

Methods

A concurrent QUAN-QUAL mixed methods study was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one LGA of Sokoto state. Existing SMC implementation tools and job aids were revised and SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were subsequently assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The qualitative component involved key informant interviews and focus group discussions with policymakers, programme officials and technical partners to explore feasibility and acceptability. Thematic analysis was carried out on the qualitative data.

Results

At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2 to 59% (p < 0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p = 0.412) at endline. There was no significant change (p = 0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at baseline (54%) compared to endline (68%). The qualitative findings are presented as two overarching themes relating to feasibility and acceptability of the integrated VAS-SMC strategy, and within each, a series of sub-themes describe study participants’ views of important considerations in implementing the strategy.

Conclusion

This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaigns can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Methodologies to measure the coverage of vitamin A supplementation: a systematic review

Countries are increasingly transitioning from event-based vitamin A supplementation (VAS) distribution to delivery through routine health system contacts, shifting also to administrative, electronic-based monitoring tools, a process that brings certain limitations affecting the quality of administrative VAS coverage. At present, there is no standardised methodology for measuring the coverage of VAS delivered through routine health services. To address this gap, we conducted a systematic review of the literature to identify and recommend methods to measure VAS coverage, with the aim of providing guidance to countries on the collection of consistent data for planning, monitoring and evaluating VAS programmes integrated into routine health systems. We searched the PubMed®, Embase®, Scopus, Google Scholar and World Health Organization (WHO) Global Index Medicus databases for studies published from 1 January 2000 to 1 January 2021, reporting original data on VAS coverage and methodologies used for measurement. We screened 2371 original titles and abstracts, assessed twenty-seven full-text articles and ultimately included eighteen studies. All but two studies used a coverage cluster survey (CCS) design to measure VAS coverage, adapting the WHO Vaccination Coverage Cluster Surveys methodology, by modifying sample size and sampling parameters. Annual two-dose VAS coverage was reported from only four studies. Until electronic-based systems to collect and analyse VAS data are equipped to measure routine two-dose VAS coverage using administrative data, CCSs that comply with the 2018 WHO Vaccination Coverage Cluster Surveys Reference Manual represent the gold-standard method for effective VAS programme monitoring.

Factors associated with the decline in under five diarrhea mortality in Tanzania from 1980-2015

Background

Tanzania has made great progress in reducing diarrhea mortality in under- five children. We examined factors associated with the decline and projected the impact of scaling up interventions or reducing risk factors on diarrhea deaths.

Methods

We reviewed economic, health, and diarrhea-related policies, reports and programs implemented during 1980 to 2015. We used the Lives Saved Tool to determine the percentage reduction in diarrhea-specific mortality attributable to changes in coverage of the interventions and risk factors, including direct diarrhea-related interventions, nutrition, and water, sanitation and hygiene (WASH). We projected the number of diarrhea deaths that could be prevented in 2030, assuming near universal coverage of different intervention packages.

Results

Diarrhea-specific mortality among under-five children in Tanzania declined by 89% from 35.3 deaths per 1000 live births in 1980 to 3.9 deaths per 1000 live births in 2015. Factors associated with diarrhea-specific under-five mortality reduction included oral rehydration solution (ORS) use, changes in stunting prevalence, vitamin A supplementation, rotavirus vaccine, change in wasting prevalence and change in age-appropriate breastfeeding practices. Universal coverage of direct diarrhea, nutrition and WASH interventions has the potential reduce the diarrhea-specific mortality rate by 90%.

Conclusions

Scaling up of a few key childhood interventions such as ORS and nutrition, and reducing the prevalence of stunting would address the remaining diarrhea-specific under-five mortality by 2030.

Contextual factors in maternal and newborn health evaluation: a protocol applied in Nigeria, India and Ethiopia

Background

Understanding the context of a health programme is important in interpreting evaluation findings and in considering the external validity for other settings. Public health researchers can be imprecise and inconsistent in their usage of the word “context” and its application to their work. This paper presents an approach to defining context, to capturing relevant contextual information and to using such information to help interpret findings from the perspective of a research group evaluating the effect of diverse innovations on coverage of evidence-based, life-saving interventions for maternal and newborn health in Ethiopia, Nigeria, and India.

Methods

We define “context” as the background environment or setting of any program, and “contextual factors” as those elements of context that could affect implementation of a programme. Through a structured, consultative process, contextual factors were identified while trying to strike a balance between comprehensiveness and feasibility. Thematic areas included demographics and socio-economics, epidemiological profile, health systems and service uptake, infrastructure, education, environment, politics, policy and governance. We outline an approach for capturing and using contextual factors while maximizing use of existing data. Methods include desk reviews, secondary data extraction and key informant interviews. Outputs include databases of contextual factors and summaries of existing maternal and newborn health policies and their implementation. Use of contextual data will be qualitative in nature and may assist in interpreting findings in both quantitative and qualitative aspects of programme evaluation.

Discussion

Applying this approach was more resource intensive than expected, in part because routinely available information was not consistently available across settings and more primary data collection was required than anticipated. Data was used only minimally, partly due to a lack of evaluation results that needed further explanation, but also because contextual data was not available for the precise units of analysis or time periods of interest. We would advise others to consider integrating contextual factors within other data collection activities, and to conduct regular reviews of maternal and newborn health policies. This approach and the learnings from its application could help inform the development of guidelines for the collection and use of contextual factors in public health evaluation.

Electronic supplementary material

The online version of this article (10.1186/s12982-018-0071-0) contains supplementary material, which is available to authorized users.

Differentials in vitamin A supplementation among preschool-aged children in Ethiopia: evidence from the 2011 Ethiopian Demographic and Health Survey

BACKGROUND

Vitamin A supplementation is one of the best proven, safest and most cost-effective interventions in public health. However, childhood vitamin A supplementation has not reached adequate levels of coverage in developing countries. This study aimed to identify factors associated with childhood vitamin A supplementation in Ethiopia.

STUDY DESIGN

Cross-sectional study with stratified, two-stage cluster design.

METHODS

Analysis of data from the 2011 Ethiopian Demographic and Health Survey (EDHS) was used to identify factors associated with childhood vitamin A supplementation. Data for 9276 children aged 6-59 months were included in the analysis. Binary and multivariable logistic regression models were used.

RESULTS

Over half [54.5%, 95% confidence interval (CI) 53.48-55.51%] of children aged 6-59 months had received vitamin A supplementation in the last six months. Regional differences were found, ranging from 28.1% in Somali to 83.2% in Tigray (P < 0.001). Children in the poorest wealth index category [adjusted odds ratio (AOR) 0.60, 95% CI 0.47-0.77], children with mothers who did not attend any antenatal care (ANC) appointments (AOR 0.56, 95% CI 0.48-0.67), infants aged 6-11 months (AOR 0.52, 95% CI 0.42-0.65), children with mothers who did not have a postnatal medical check-up (AOR 0.69, 95% CI 0.56-0.86) and children with mothers who had not worked in the last year (AOR 0.86, 95% CI 0.76-0.97) were less likely to have received vitamin A supplementation in the last six months.

CONCLUSION

Coverage of childhood vitamin A supplementation was not optimum in Ethiopia and regional differences were found. Lack of a maternal postnatal medical check-up, lack of ANC attendance, poorest wealth index, mother who had not worked in the last year and infant in youngest age group were associated with lower odds of receiving vitamin A supplementation over the last six months. Provision and promotion of ANC and postnatal care, and strengthening routine immunization activity, especially among infants in the youngest age group, are recommended to increase coverage of childhood vitamin A supplementation.

Need for and access to health care and medicines: are there gender inequities?

OBJECTIVE

Differences between women and men in political and economic empowerment, education, and health risks are well-documented. Similar gender inequities in access to care and medicines have been hypothesized but evidence is lacking.

METHODS

We analyzed 2002 World Health Survey data for 257,922 adult respondents and 80,932 children less than 5 years old from 53 mostly low and middle-income countries. We constructed indicators of need for, access to, and perceptions of care, and we described the number of countries with equal and statistically different proportions of women and men for each indicator. Using multivariate logistic regression models, we estimated effects of gender on our study outcomes, overall and by household poverty.

FINDINGS

Women reported significantly more need for care for three of six chronic conditions surveyed, and they were more likely to have at least one of the conditions (OR 1.41 [95% CI 1.38, 1.44]). Among those with reported need for care, there were no consistent differences in access to care between women and men overall (e.g., treatment for all reported chronic conditions, OR 1.00 [0.96, 1.04]) or by household poverty. Of concern, access to care for chronic conditions was distressingly low among both men and women in many countries, as was access to preventive services among boys and girls less than 5 years old.

CONCLUSIONS

These cross-country results do not suggest a systematic disadvantage of women in access to curative care and medicines for treating selected chronic conditions or acute symptoms, or to preventive services among boys and girls.

Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper

Much has been written about the measurement of socio-economic position (SEP) in high-income countries (HIC). Less has been written for an epidemiology, health systems and public health audience about the measurement of SEP in low- and middle-income countries (LMIC). The social stratification processes in many LMIC-and therefore the appropriate measurement tools-differ considerably from those in HIC. Many measures of SEP have been utilized in epidemiological studies; the aspects of SEP captured by these measures and the pathways through which they may affect health are likely to be slightly different but overlapping. No single measure of SEP will be ideal for all studies and contexts; the strengths and limitations of a given indicator are likely to vary according to the specific research question. Understanding the general properties of different indicators, however, is essential for all those involved in the design or interpretation of epidemiological studies. In this article, we describe the measures of SEP used in LMIC. We concentrate on measures of individual or household-level SEP rather than area-based or ecological measures such as gross domestic product. We describe each indicator in terms of its theoretical basis, interpretation, measurement, strengths and limitations. We also provide brief comparisons between LMIC and HIC for each measure.

Integrated HIV testing, malaria, and diarrhea prevention campaign in Kenya: modeled health impact and cost-effectiveness

BACKGROUND

Efficiently delivered interventions to reduce HIV, malaria, and diarrhea are essential to accelerating global health efforts. A 2008 community integrated prevention campaign in Western Province, Kenya, reached 47,000 individuals over 7 days, providing HIV testing and counseling, water filters, insecticide-treated bed nets, condoms, and for HIV-infected individuals cotrimoxazole prophylaxis and referral for ongoing care. We modeled the potential cost-effectiveness of a scaled-up integrated prevention campaign.

METHODS

We estimated averted deaths and disability-adjusted life years (DALYs) based on published data on baseline mortality and morbidity and on the protective effect of interventions, including antiretroviral therapy. We incorporate a previously estimated scaled-up campaign cost. We used published costs of medical care to estimate savings from averted illness (for all three diseases) and the added costs of initiating treatment earlier in the course of HIV disease.

RESULTS

Per 1000 participants, projected reductions in cases of diarrhea, malaria, and HIV infection avert an estimated 16.3 deaths, 359 DALYs and $85,113 in medical care costs. Earlier care for HIV-infected persons adds an estimated 82 DALYs averted (to a total of 442), at a cost of $37,097 (reducing total averted costs to $48,015). Accounting for the estimated campaign cost of $32,000, the campaign saves an estimated $16,015 per 1000 participants. In multivariate sensitivity analyses, 83% of simulations result in net savings, and 93% in a cost per DALY averted of less than $20.

DISCUSSION

A mass, rapidly implemented campaign for HIV testing, safe water, and malaria control appears economically attractive.

Child survival gains in Tanzania: analysis of data from demographic and health surveys

BACKGROUND

A recent national survey in Tanzania reported that mortality in children younger than 5 years dropped by 24% over the 5 years between 2000 and 2004. We aimed to investigate yearly changes to identify what might have contributed to this reduction and to investigate the prospects for meeting the Millennium Development Goal for child survival (MDG 4).

METHODS

We analysed data from the four demographic and health surveys done in Tanzania since 1990 to generate estimates of mortality in children younger than 5 years for every 1-year period before each survey back to 1990. We estimated trends in mortality between 1990 and 2004 by fitting Lowess regression, and forecasted trends in mortality in 2005 to 2015. We aimed to investigate contextual factors, whether part of Tanzania's health system or not, that could have affected child mortality.

FINDINGS

Disaggregated estimates of mortality showed a sharp acceleration in the reduction in mortality in children younger than 5 years in Tanzania between 2000 and 2004. In 1990, the point estimate of mortality was 141.5 (95% CI 141.5-141.5) deaths per 1000 livebirths. This was reduced by 40%, to reach a point estimate of 83.2 (95% CI 70.1-96.3) deaths per 1000 livebirths in 2004. The change in absolute risk was 58.4 (95% CI 32.7-83.8; p<0.0001). Between 1999 and 2004 we noted important improvements in Tanzania's health system, including doubled public expenditure on health; decentralisation and sector-wide basket funding; and increased coverage of key child-survival interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation, immunisation, and exclusive breastfeeding. Other determinants of child survival that are not related to the health system did not change between 1999 and 2004, except for a slow increase in the HIV/AIDS burden.

INTERPRETATION

Tanzania could attain MDG 4 if this trend of improved child survival were to be sustained. Investment in health systems and scaling up interventions can produce rapid gains in child survival.