Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India

BACKGROUND

Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India.

METHODS

We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity.

RESULTS

In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%.

INTERPRETATION

Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania

Background

Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania.

Methods

A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs.

Results

Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs.

Conclusion

RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.

Effect of home-based counselling on newborn care practices in southern Tanzania one year after implementation: a cluster-randomised controlled trial

BACKGROUND

In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation.

METHODS

All 132 wards in the 6-district study area were randomised to intervention or comparison groups. Starting in 2010, in intervention areas trained volunteers made home visits during pregnancy and after childbirth to promote recommended newborn care practices including hygiene, breastfeeding and identification and extra care for low birth weight babies. In 2011, in a representative sample of 5,240 households, we asked women who had given birth in the previous year both about counselling visits and their childbirth and newborn care practices.

RESULTS

Four of 14 newborn care practices were more commonly reported in intervention than comparison areas: delaying the baby's first bath by at least six hours (81% versus 68%, OR 2.0 (95% CI 1.2-3.4)), exclusive breastfeeding in the three days after birth (83% versus 71%, OR 1.9 (95% CI 1.3-2.9)), putting nothing on the cord (87% versus 70%, OR 2.8 (95% CI 1.7-4.6)), and, for home births, tying the cord with a clean thread (69% versus 39%, OR 3.4 (95% CI 1.5-7.5)). For other behaviours there was little evidence of differences in reported practices between intervention and comparison areas including childbirth in a health facility or with a skilled attendant, thermal care practices, breastfeeding within an hour of birth and, for home births, the birth attendant having clean hands, cutting the cord with a clean blade and birth preparedness activities.

CONCLUSIONS

A home-based counselling strategy using volunteers and designed for scale-up can improve newborn care behaviours in rural communities of southern Tanzania. Further research is needed to evaluate if, and at what cost, these gains will lead to improved newborn survival.

TRIAL REGISTRATION

Trial Registration Number NCT01022788 (http://www.clinicaltrials.gov, 2009).

Staff experiences of providing maternity services in rural southern Tanzania - a focus on equipment, drug and supply issues

BACKGROUND

The poor maintenance of equipment and inadequate supplies of drugs and other items contribute to the low quality of maternity services often found in rural settings in low- and middle-income countries, and raise the risk of adverse patient outcomes through delaying care provision. We aim to describe staff experiences of providing maternal and neonatal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies.

METHODS

Focus group discussions and in-depth interviews were conducted with different staff cadres from all facility levels in order to explore experiences and views of providing maternity care in the context of poorly maintained equipment, and insufficient drugs and other supplies. A facility survey quantified the availability of relevant items.

RESULTS

The facility survey, which found many missing or broken items and frequent stock outs, corroborated staff reports of providing care in the context of missing or broken care items. Staff reported increased workloads, reduced morale, difficulties in providing optimal maternity care, and carrying out procedures with potential health risks to themselves as a result.

CONCLUSIONS

Inadequately stocked and equipped facilities compromise the health system's ability to reduce maternal and neonatal mortality and morbidity by affecting staff personally and professionally, which hinders the provision of timely and appropriate interventions. Improving stock control and maintaining equipment could benefit mothers and babies, not only through removing restrictions to the availability of care, but also through improving staff working conditions.

Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review

OBJECTIVE

To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas.

METHODS

Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies.

FINDINGS

A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement.

CONCLUSION

There is a broad taxonomy of strategies for delivering ITNs at scale.

Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania

Background

Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant women's first antenatal care visit and identifies factors influencing early and late attendance.

Methods

The study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis.

Results

The majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single.

Conclusions

Factors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women.

Human resources for health care delivery in Tanzania: a multifaceted problem

BACKGROUND

Recent years have seen an unprecedented increase in funds for procurement of health commodities in developing countries. A major challenge now is the efficient delivery of commodities and services to improve population health. With this in mind, we documented staffing levels and productivity in peripheral health facilities in southern Tanzania.

METHOD

A health facility survey was conducted to collect data on staff employed, their main tasks, availability on the day of the survey, reasons for absenteeism, and experience of supervisory visits from District Health Teams. In-depth interview with health workers was done to explore their perception of work load. A time and motion study of nurses in the Reproductive and Child Health (RCH) clinics documented their time use by task.

RESULTS

We found that only 14% (122/854) of the recommended number of nurses and 20% (90/441) of the clinical staff had been employed at the facilities. Furthermore, 44% of clinical staff was not available on the day of the survey. Various reasons were given for this. Amongst the clinical staff, 38% were absent because of attendance to seminar sessions, 8% because of long-training, 25% were on official travel and 20% were on leave. RCH clinic nurses were present for 7 hours a day, but only worked productively for 57% of time present at facility. Almost two-third of facilities had received less than 3 visits from district health teams during the 6 months preceding the survey.

CONCLUSION

This study documented inadequate staffing of health facilities, a high degree of absenteeism, low productivity of the staff who were present and inadequate supervision in peripheral Tanzanian health facilities. The implications of these findings are discussed in the context of decentralized health care in Tanzania.

Neonatal deaths in rural southern Tanzania: care-seeking and causes of death

Introduction. We report cause of death and care-seeking prior to death in neonates based on interviews with relatives using a Verbal Autopsy questionnaire. Materials and Methods. We identified neonatal deaths between 2004 and 2007 through a large household survey in 2007 in five rural districts of southern Tanzania. Results. Of the 300 reported deaths that were sampled, the Verbal Autopsy (VA) interview suggested that 11 were 28 days or older at death and 65 were stillbirths. Data was missing for 5 of the reported deaths. Of the remaining 219 confirmed neonatal deaths, the most common causes were prematurity (33%), birth asphyxia (22%) and infections (10%). Amongst the deaths, 41% (90/219) were on the first day and a further 20% (43/219) on day 2 and 3. The quantitative results matched the qualitative findings. The majority of births were at home and attended by unskilled assistants. Conclusion. Caregivers of neonates born in health facility were more likely to seek care for problems than caregivers of neonates born at home. Efforts to increase awareness of the importance of early care-seeking for a premature or sick neonate are likely to be important for improving neonatal health.

Antenatal care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley, south-eastern Tanzania

BACKGROUND

The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers' performance have not yet been fully understood. This paper uses ethnographic methods to document health workers' antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers' performance. Potential implications for improving antenatal care provision in Tanzania are discussed.

METHODS

Combining different qualitative techniques, we studied health workers' antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers' practices and contextual factors influencing antenatal care provision.

RESULTS

The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers' practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or "street-level bureaucracy".

CONCLUSIONS

Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to the identification of informal practices resulting from individual coping strategies and "street-level bureaucracy" in order to tackle problems before they become part of the organizational culture.

Measuring newborn foot length to identify small babies in need of extra care: a cross sectional hospital based study with community follow-up in Tanzania

Background

Neonatal mortality because of low birth weight or prematurity remains high in many developing country settings. This research aimed to estimate the sensitivity and specificity, and the positive and negative predictive values of newborn foot length to identify babies who are low birth weight or premature and in need of extra care in a rural African setting.

Methods

A cross-sectional study of newborn babies in hospital, with community follow-up on the fifth day of life, was carried out between 13 July and 16 October 2009 in southern Tanzania. Foot length, birth weight and gestational age were estimated on the first day and foot length remeasured on the fifth day of life.

Results

In hospital 529 babies were recruited and measured within 24 hours of birth, 183 of whom were also followed-up at home on the fifth day. Day one foot length <7 cm at birth was 75% sensitive (95%CI 36-100) and 99% specific (95%CI 97-99) to identify very small babies (birth weight <1500 grams); foot length <8 cm had sensitivity and specificity of 87% (95%CI 79-94) and 60% (95%CI 55-64) to identify those with low birth weight (<2500 grams), and 93% (95%CI 82-99) and 58% (95%CI 53-62) to identify those born premature (<37 weeks). Mean foot length on the first day was 7.8 cm (standard deviation 0.47); the mean difference between first and fifth day foot lengths was 0.1 cm (standard deviation 0.3): foot length measured on or before the fifth day of life identified more than three-quarters of babies who were born low birth weight.

Conclusion

Measurement of newborn foot length for home births in resource poor settings has the potential to be used by birth attendants, community volunteers or parents as a screening tool to identify low birth weight or premature newborns in order that they can receive targeted interventions for improved survival

Intermittent preventive treatment for malaria in infants: a decision-support tool for sub-Saharan Africa

OBJECTIVE

To develop a decision-support tool to help policy-makers in sub-Saharan Africa assess whether intermittent preventive treatment in infants (IPTi) would be effective for local malaria control.

METHODS

An algorithm for predicting the effect of IPTi was developed using two approaches. First, study data on the age patterns of clinical cases of Plasmodium falciparum malaria, hospital admissions for infection with malaria parasites and malaria-associated death for different levels of malaria transmission intensity and seasonality were used to estimate the percentage of cases of these outcomes that would occur in children aged <10 years targeted by IPTi. Second, a previously developed stochastic mathematical model of IPTi was used to predict the number of cases likely to be averted by implementing IPTi under different epidemiological conditions. The decision-support tool uses the data from these two approaches that are most relevant to the context specified by the user.

FINDINGS

Findings from the two approaches indicated that the percentage of cases targeted by IPTi increases with the severity of the malaria outcome and with transmission intensity. The decision-support tool, available on the Internet, provides estimates of the percentage of malaria-associated deaths, hospitalizations and clinical cases that will be targeted by IPTi in a specified context and of the number of these outcomes that could be averted.

CONCLUSION

The effectiveness of IPTi varies with malaria transmission intensity and seasonality. Deciding where to implement IPTi must take into account the local epidemiology of malaria. The Internet-based decision-support tool described here predicts the likely effectiveness of IPTi under a wide range of epidemiological conditions.

Age-patterns of malaria vary with severity, transmission intensity and seasonality in sub-Saharan Africa: a systematic review and pooled analysis

Background

There is evidence that the age-pattern of Plasmodium falciparum malaria varies with transmission intensity. A better understanding of how this varies with the severity of outcome and across a range of transmission settings could enable locally appropriate targeting of interventions to those most at risk. We have, therefore, undertaken a pooled analysis of existing data from multiple sites to enable a comprehensive overview of the age-patterns of malaria outcomes under different epidemiological conditions in sub-Saharan Africa.

Methodology/Principal Findings

A systematic review using PubMed and CAB Abstracts (1980–2005), contacts with experts and searching bibliographies identified epidemiological studies with data on the age distribution of children with P. falciparum clinical malaria, hospital admissions with malaria and malaria-diagnosed mortality. Studies were allocated to a 3×2 matrix of intensity and seasonality of malaria transmission. Maximum likelihood methods were used to fit five continuous probability distributions to the percentage of each outcome by age for each of the six transmission scenarios. The best-fitting distributions are presented graphically, together with the estimated median age for each outcome. Clinical malaria incidence was relatively evenly distributed across the first 10 years of life for all transmission scenarios. Hospital admissions with malaria were more concentrated in younger children, with this effect being even more pronounced for malaria-diagnosed deaths. For all outcomes, the burden of malaria shifted towards younger ages with increasing transmission intensity, although marked seasonality moderated this effect.

Conclusions

The most severe consequences of P. falciparum malaria were concentrated in the youngest age groups across all settings. Despite recently observed declines in malaria transmission in several countries, which will shift the burden of malaria cases towards older children, it is still appropriate to target strategies for preventing malaria mortality and severe morbidity at very young children who will continue to bear the brunt of malaria deaths in Sub-Saharan Africa.

Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys

OBJECTIVES

To evaluate the impact of the Tanzania National Voucher Scheme on the coverage and equitable distribution of insecticide treated nets, used to prevent malaria, to pregnant women and their infants.

DESIGN

Plausibility study using three nationally representative cross sectional household and health facility surveys, timed to take place early, mid-way, and at the end of the roll out of the national programme.

SETTING

The Tanzania National Voucher Scheme was implemented in antenatal services, and phased in on a district by district basis from October 2004 covering all of mainland Tanzania in May 2006.

PARTICIPANTS

6115, 6260, and 6198 households (in 2005, 2006, and 2007, respectively) in a representative sample of 21 districts (out of a total of 113).

INTERVENTIONS

A voucher worth $2.45 ( pound1.47, euro1.74) to be used as part payment for the purchase of a net from a local shop was given to every pregnant woman attending antenatal services.

MAIN OUTCOME MEASURES

Insecticide treated net coverage was measured as household ownership of at least one net and use of a net the night before the survey. Socioeconomic distribution of nets was examined using an asset based index.

RESULTS

Steady increases in net coverage indicators were observed over the three year study period. Between 2005 and 2007, household ownership of at least one net (untreated or insecticide treated) increased from 44% (2686/6115) to 65% (4006/6198; P<0.001), and ownership of at least one insecticide treated net doubled from 18% (1062/5961) to 36% (2229/6198) in the same period (P<0.001). Among infants under 1 year of age, use of any net increased from 33% (388/1180) to 56% (707/1272; P<0.001) and use of an insecticide treated net increased from 16% (188/1180) to 34% (436/1272; P<0.001). After adjusting for potential confounders, household ownership was positively associated with time since programme launch, although this association did not reach statistical significance (P=0.09). Each extra year of programme operation was associated with a 9 percentage point increase in household insecticide treated net ownership (95% confidence interval -1.6 to 20). In 2005, only 7% (78/1115) of nets in households with a child under 1 year of age had been purchased with a voucher; this value increased to 50% (608/1211) in 2007 (P<0.001). In 2007, infants under 1 year in the least poor quintile were more than three times more likely to have used an insecticide treated net than infants in the poorest quintile (54% v 16%; P<0.001).

CONCLUSIONS

The Tanzania National Voucher Scheme was associated with impressive increases in the coverage of insecticide treated nets over a two year period. Gaps in coverage remain, however, especially in the poorest groups. A voucher system that facilitates routine delivery of insecticide treated nets is a feasible option to "keep up" coverage.

The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania

BACKGROUND

Although antenatal care coverage in Tanzania is high, worrying gaps exist in terms of its quality and ability to prevent, diagnose or treat complications. Moreover, much less is known about the utilisation of postnatal care, by which we mean the care of mother and baby that begins one hour after the delivery until six weeks after childbirth. We describe the perspectives and experiences of women and health care providers on the use of antenatal and postnatal services.

METHODS

From March 2007 to January 2008, we conducted in-depth interviews with health care providers and village based informants in 8 villages of Lindi Rural and Tandahimba districts in southern Tanzania. Eight focus group discussions were also conducted with women who had babies younger than one year and pregnant women. The discussion guide included information about timing of antenatal and postnatal services, perceptions of the rationale and importance of antenatal and postnatal care, barriers to utilisation and suggestions for improvement.

RESULTS

Women were generally positive about both antenatal and postnatal care. Among common reasons mentioned for late initiation of antenatal care was to avoid having to make several visits to the clinic. Other concerns included fear of encountering wild animals on the way to the clinic as well as lack of money. Fear of caesarean section was reported as a factor hindering intrapartum care-seeking from hospitals. Despite the perceived benefits of postnatal care for children, there was a total lack of postnatal care for the mothers. Shortages of staff, equipment and supplies were common complaints in the community.

CONCLUSION

Efforts to improve antenatal and postnatal care should focus on addressing geographical and economic access while striving to make services more culturally sensitive. Antenatal and postnatal care can offer important opportunities for linking the health system and the community by encouraging women to deliver with a skilled attendant. Addressing staff shortages through expanding training opportunities and incentives to health care providers and developing postnatal care guidelines are key steps to improve maternal and newborn health.

The acceptability of intermittent preventive treatment of malaria in infants (IPTi) delivered through the expanded programme of immunization in southern Tanzania

Background

Intermittent preventive treatment of malaria in infants (IPTi) reduces the incidence of clinical malaria. However, before making decisions about implementation, it is essential to ensure that IPTi is acceptable, that it does not adversely affect attitudes to immunization or existing health seeking behaviour. This paper reports on the reception of IPTi during the first implementation study of IPTi in southern Tanzania.

Methods

Data were collected through in-depth interviews, focus group discussions and participant observation carried out by a central team of social scientists and a network of key informants/interviewers who resided permanently in the study sites.

Results

IPTi was generally acceptable. This was related to routinization of immunization and resonance with traditional practices. Promoting "health" was considered more important than preventing specific diseases. Many women thought that immunization was obligatory and that health staff might be unwilling to assist in the future if they were non-adherent. Weighing and socialising were important reasons for clinic attendance. Non-adherence was due largely to practical, social and structural factors, many of which could be overcome. Reasons for non-adherence were sometimes interlinked. Health staff and "road to child health" cards were the main source of information on the intervention, rather than the specially designed posters. Women did not generally discuss child health matters outside the clinic, and information about the intervention percolated slowly through the community. Although there were some rumours about sulphadoxine pyrimethamine (SP), it was generally acceptable as a drug for IPTi, although mothers did not like the way tablets were administered. There is no evidence that IPTi had a negative effect on attitudes or adherence to the expanded programme on immunisation (EPI) or treatment seeking or existing malaria prevention.

Conclusion

In order to improve adherence to both EPI and IPTi local priorities should be taken into account. For example, local women are often more interested in weighing than in immunization, and they view vaccination and IPTi as vaguely "healthy" rather preventing specific diseases. There should be more emphasis on these factors and more critical consideration by policy makers of how much local knowledge and understanding is minimally necessary in order to make interventions successful.

Vouchers for scaling up insecticide-treated nets in Tanzania: methods for monitoring and evaluation of a national health system intervention

BACKGROUND

The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E).

METHODS

A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme.

RESULTS

The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time.

CONCLUSION

The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.

Understanding home-based neonatal care practice in rural southern Tanzania

In order to understand home-based neonatal care practices in rural Tanzania, with the aim of providing a basis for the development of strategies for improving neonatal survival, we conducted a qualitative study in southern Tanzania. In-depth interviews, focus group discussions and case studies were used through a network of female community-based informants in eight villages of Lindi Rural and Tandahimba districts. Data collection took place between March 2005 and April 2007. The results show that although women and families do make efforts to prepare for childbirth, most home births are assisted by unskilled attendants, which contributes to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Some neonates are denied colostrum, which is perceived as dirty. Behaviour-change communication efforts are needed to improve early newborn care practices.

Changing pattern of malaria in Bissau, Guinea Bissau

OBJECTIVE

To describe the epidemiology of malaria in Guinea-Bissau, in view of the fact that more funds are available now for malaria control in the country.

METHODS

From May 2003 to May 2004, surveillance for malaria was conducted among children less than 5 years of age at three health centres covering the study area of the Bandim Health Project (BHP) and at the outpatient clinic of the national hospital in Bissau. Cross-sectional surveys were conducted in the community in different malaria seasons.

RESULTS

Malaria was overdiagnosed in both health centres and hospital. Sixty-four per cent of the children who presented at a health centre were clinically diagnosed with malaria, but only 13% of outpatient children who tested for malaria had malaria parasitaemia. Only 44% (963/2193) of children admitted to hospital with a diagnosis of malaria had parasitaemia. The proportion of positive cases increased with age. Among hospitalized children with malaria parasitaemia, those less than 2 years old were more likely to have moderate anaemia (RR = 1.27; 95% CI: 1.02-1.56) (P = 0.03) or severe anaemia (RR = 1.67; 95% CI: 1.25-2.24) (P = 0.0005) than older children. The prevalence of malaria parasitaemia in the community was low (3%, 53/1926).

CONCLUSION

In Bissau, the prevalence of malaria parasitaemia in the community is now low and malaria is over-diagnosed in health facilities. Laboratory support will be essential to avoid unnecessary use of the artemisinin combination therapy which is now being introduced as first-line treatment in Bissau with support from the Global Fund.

Efficacy of pyrethroid-treated nets against malaria vectors and nuisance-biting mosquitoes in Tanzania in areas with long-term insecticide-treated net use

OBJECTIVE

To measure pyrethroid susceptibility in populations of malaria vectors and nuisance-biting mosquitoes in Tanzania and to test the biological efficacy of current insecticide formulations used for net treatment.

METHODS

Anopheles gambiae Giles s.l., An. funestus Giles s.l. and Culex quinquefasciatus Say were collected during three national surveys and two insecticide-treated net (ITN) studies in Tanzania. Knockdown effect and mortality were measured in standard WHO susceptibility tests and ball-frame bio-efficacy tests. Test results from 1999 to 2004 were compared to determine trends in resistance development.

RESULTS

Anopheles gambiae s.l. and An. funestus s.l. were highly susceptible to permethrin (range 87-100%) and deltamethrin (consistently 100%) in WHO tests in 1999 and 2004, while Culex quinquefasciatus susceptibility to these pyrethroids was much lower (range 7-100% and 0-84% respectively). Efficacy of pyrethroid-treated nets was similarly high against An. gambiae s.l. and An. funestus s.l. (range 82-100%) while efficacy against Cx. quinquefasciatus was considerably lower (range 2-100%). There was no indication of development of resistance in populations of An. gambiae s.l. or An. funestus s.l. where ITNs have been extensively used; however, susceptibility of nuisance-biting Cx. quinquefasciatus mosquitoes declined in some areas between 1999 and 2004.

CONCLUSION

The sustained pyrethroid susceptibility of malaria vectors in Tanzania is encouraging for successful malaria control with ITNs. Continued monitoring is essential to ensure early resistance detection, particularly in areas with heavy agricultural or public health use of insecticides where resistance is likely to develop. Widespread low susceptibility of nuisance-biting Culex mosquitoes to ITNs raises concern for user acceptance of nets.

The use of personal digital assistants for data entry at the point of collection in a large household survey in southern Tanzania

BACKGROUND

Survey data are traditionally collected using pen-and-paper, with double data entry, comparison of entries and reconciliation of discrepancies before data cleaning can commence. We used Personal Digital Assistants (PDAs) for data entry at the point of collection, to save time and enhance the quality of data in a survey of over 21,000 scattered rural households in southern Tanzania.

METHODS

Pendragon Forms 4.0 software was used to develop a modular questionnaire designed to record information on household residents, birth histories, child health and health-seeking behaviour. The questionnaire was loaded onto Palm m130 PDAs with 8 Mb RAM. One hundred and twenty interviewers, the vast majority with no more than four years of secondary education and very few with any prior computer experience, were trained to interview using the PDAs. The 13 survey teams, each with a supervisor, laptop and a four-wheel drive vehicle, were supported by two back-up vehicles during the two months of field activities. PDAs and laptop computers were charged using solar and in-car chargers. Logical checks were performed and skip patterns taken care of at the time of data entry. Data records could not be edited after leaving each household, to ensure the integrity of the data from each interview. Data were downloaded to the laptop computers and daily summary reports produced to evaluate the completeness of data collection. Data were backed up at three levels: (i) at the end of every module, data were backed up onto storage cards in the PDA; (ii) at the end of every day, data were downloaded to laptop computers; and (iii) a compact disc (CD) was made of each team's data each day.A small group of interviewees from the community, as well as supervisors and interviewers, were asked about their attitudes to the use of PDAs.

RESULTS

Following two weeks of training and piloting, data were collected from 21,600 households (83,346 individuals) over a seven-week period in July-August 2004. No PDA-related problems or data loss were encountered. Fieldwork ended on 26 August 2004, the full dataset was available on a CD within 24 hours and the results of initial analyses were presented to district authorities on 28 August. Data completeness was over 99%. The PDAs were well accepted by both interviewees and interviewers.

CONCLUSION

The use of PDAs eliminated the usual time-consuming and error-prone process of data entry and validation. PDAs are a promising tool for field research in Africa.

Revaccination with Bacillus Calmette-Guerin (BCG) vaccine does not reduce morbidity from malaria in African children

BACKGROUND

Studies in West Africa and elsewhere have suggested that Bacillus Calmette-Guérin (BCG) vaccine given at birth is beneficial for child survival. It is possible that this effect is mediated partly through an effect on malaria, a hypothesis supported by animal studies. We investigated whether revaccination with BCG at 19 months of age reduced morbidity from malaria.

METHOD

In the capital of Guinea-Bissau, between January and November 2003, children who had previously received BCG vaccination and who did not have a strong reaction to tuberculin were individually randomised to either receive revaccination with BCG at the age of 19 months or to be a control. Episodes of malaria were recorded during the 2003 malaria transmission season through passive case detection at health centres in the study area and at the national hospital. Cross-sectional surveys were carried out at the beginning and at the end of the rainy season.

RESULTS

Incidence rates of first episodes of malaria associated with any level of parasitaemia were 0.16 episodes per child-year among 713 revaccinated children and 0.12 among 720 control children [incidence rate ratio (IRR) = 1.37; 95% confidence intervals (CI): 0.84-2.25]. Results were similar when the diagnosis of malaria was based on the presence of parasitaemia >5000 parasites/microl (IRR = 1.30; 95% CI: 0.61-2.77). The incidence of all-cause hospitalisation was higher among BCG-revaccinated children than among controls (IRR = 2.13; 95% CI: 1.10-4.13). There were no significant differences in the prevalence of parasitaemia between the two groups of children at cross-sectional surveys.

CONCLUSION

We found no evidence that BCG revaccination reduces morbidity from malaria.

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

BACKGROUND

Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania

METHODS

We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked.

RESULTS

Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations.

CONCLUSION

Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.

Impact of Integrated Management of Childhood Illness on inequalities in child health in rural Tanzania

We examined the impact of the Integrated Management of Childhood Illness (IMCI) strategy on the equality of health outcomes and access across socioeconomic gradients in rural Tanzania, by comparing changes in inequities between 1999 and 2002 in two districts with IMCI (Morogoro Rural and Rufiji) and two without (Kilombero and Ulanga). Equity differentials for six child health indicators (underweight, stunting, measles immunization, access to treated and untreated nets, treatment of fever with antimalarial) improved significantly in IMCI districts compared with comparison districts (p<0.05), while four indicators (wasting, DPT coverage, caretakers' knowledge of danger signs and appropriate careseeking) improved significantly in comparison districts compared with IMCI districts (p<0.05). The largest improvements were observed for stunting among children between 24-59 months of age. The concentration index improved from -0.102 in 1999 to -0.032 in 2002 for IMCI, while it remained almost unchanged -0.122 to -0.133 in comparison districts. IMCI was associated with improved equity for measles vaccine coverage, whereas the opposite was observed for DPT antigens. This study has shown how equity assessments can be incorporated in impact evaluation at relatively little additional cost, and how this may point to specific interventions that need to be reinforced. The introduction of IMCI led to improvements in child health that did not occur at the expense of equity.

Context matters: interpreting impact findings in child survival evaluations

Appropriate consideration of contextual factors is essential for ensuring internal and external validity of randomized and non-randomized evaluations. Contextual factors may confound the association between delivery of the intervention and its potential health impact. They may also modify the effect of the intervention or programme, thus affecting the generalizability of results. This is particularly true for large-scale health programmes, for which impact may vary substantially from one context to another. Understanding the nature and role of contextual factors may improve the validity of study results, as well as help predict programme impact across sites. This paper describes the experience acquired in measuring and accounting for contextual factors in the Multi-Country Evaluation of the IMCI (Integrated Management of Childhood Illness) strategy in five countries: Bangladesh, Brazil, Peru, Uganda and Tanzania. Two main types of contextual factors were identified. Implementation-related factors include the characteristics of the health systems where IMCI was implemented, such as utilization rates, basic skills of health workers, and availability of drugs, supervision and referral. Impact-related factors include baseline levels and patterns of child mortality and nutritional status, which affect the scope for programme impact. We describe the strategies used in the IMCI evaluation in order to obtain data on relevant contextual factors and to incorporate them in the analyses. Two case studies - from Tanzania and Peru - show how appropriate consideration of contextual factors may help explain apparently conflicting evaluation results.

Out-of-pocket payments for under-five health care in rural southern Tanzania

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.

Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania

OBJECTIVES

To assess the effect of Integrated Management of Childhood Illness (IMCI) relative to routine care on the quality and efficiency of providing care for sick children in first-level health facilities in Tanzania, and to disseminate the results for use in health sector decision-making.

DESIGN

Non-randomized controlled trial to compare child health care quality and economic costs in two intervention (>90% of health care workers trained in IMCI) and two comparison districts in rural Tanzania.

PARTICIPANTS

For quality measures, all sick children presenting for care at random samples of first-level health facilities; for costs, all national, district, facility and household costs associated with child health care, taking a societal perspective.

RESULTS

IMCI training is associated with significantly better child health care in facilities at no additional cost to districts. The cost per child visit managed correctly was lower in IMCI than in routine care settings: $4.02 versus $25.70, respectively, in 1999 US dollars and after standardization for variations in population size.

CONCLUSION

IMCI improved the quality and efficiency of child health care relative to routine child health care in the study districts. Previous study results indicated that the introduction of IMCI in these Tanzanian districts was associated with mortality levels that were 13% lower than in comparison districts. We can therefore conclude that IMCI is also more cost-effective than routine care for improving child health outcomes. The dissemination strategy for these results led to adoption of IMCI for nationwide implementation within 12 months of study completion.

Does the Integrated Management of Childhood Illness cost more than routine care? Results from the United Republic of Tanzania

OBJECTIVE

The Integrated Management of Childhood Illness (IMCI) strategy is designed to address the five leading causes of childhood mortality, which together account for 70% of the 10 million deaths occurring among children worldwide annually. Although IMCI is associated with improved quality of care, which is a key determinant of better health outcomes, it has not yet been widely adopted, partly because it is assumed to be more expensive than routine care. Here we report the cost of IMCI compared with routine care in four districts in the United Republic of Tanzania.

METHODS

Total district costs of child care were estimated from the societal perspective as the sum of child health-care costs incurred in a district at the household level, primary health-facility level and hospital level. We also included administrative and support costs incurred by national and district administrations. The incremental cost of IMCI is the difference in costs of child health-care between districts with and without IMCI, after standardization for population size.

FINDINGS

The annual cost per child of caring for children less than five years old in districts with IMCI was USD 11.19, 44% lower than the cost in the districts without IMCI (USD 16.09). Much of the difference was due to higher rates of hospitalization of children less than 5 years old in the districts without IMCI. Not all of this difference can be attributed to IMCI but even when differences in hospitalization rates are excluded, the cost per child was still 6% lower in IMCI districts.

CONCLUSION

IMCI was not associated with higher costs than routine child health-care in the four study districts in the United Republic of Tanzania. Given the evidence of improved quality of care in the IMCI districts, the results suggest that cost should not be a barrier to the adoption and scaling up of IMCI.

The economics of social marketing: the case of mosquito nets in Tanzania

There is a growing appreciation of the role of the private sector in expanding the use of key health interventions. At the policy level, this has raised questions about how public sector resources can best be used to encourage the private sector in order to achieve public health impact. Social marketing has increasingly been used to distribute public health products in developing countries. The Kilombero and Ulanga Insecticide-Treated Net Project (KINET) project used a social marketing approach in two districts of Tanzania to stimulate the development of the market for insecticide-treated mosquito nets (ITNs) for malaria control. Using evidence from household surveys, focus group discussions and a costing study in the intervention area and a control area, this paper examines two issues: (1) How does social marketing affect the market for ITNs, where this is described in terms of price and coverage levels; and (2) What does the added cost of social marketing "buy" in terms of coverage and equity, compared with an unassisted commercial sector model? It appears that supply improved in both areas, although there was a greater increase in supply in the intervention area. However, the main impact of social marketing on the market for nets was to shift demand in the intervention district, leading to a higher coverage market outcome. While social marketing was more costly per net distributed than the unassisted commercial sector, higher overall levels of coverage were achieved in the social marketing area together with higher coverage of the lowest socioeconomic group, of pregnant women and children under 5 years, and of those living on the periphery of their villages. These findings are interpreted in the context of Tanzania's national plan for scaling up ITNs.

Measuring the quality of child health care at first-level facilities

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.

Improving antimicrobial use among health workers in first-level facilities: results from the multi-country evaluation of the Integrated Management of Childhood Illness strategy

OBJECTIVE

The objective of this study was to assess the effect of Integrated Management of Childhood Illness (IMCI) case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities. Antimicrobial drugs are an essential child-survival intervention. Ensuring that children younger than five who need these drugs receive them promptly and correctly can save their lives. Prescribing these drugs only when necessary and ensuring that those who receive them complete the full course can slow the development of antimicrobial resistance.

METHODS

Data collected through observation-based surveys in randomly selected first-level health facilities in Brazil, Uganda and the United Republic of Tanzania were statistically analysed. The surveys were carried out as part of the multi-country evaluation of IMCI effectiveness, cost and impact (MCE).

FINDINGS

Results from three MCE sites show that children receiving care from health workers trained in IMCI are significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI. They are also more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they leave the health facility.

CONCLUSIONS

IMCI case management training is an effective intervention to improve the rational use of antimicrobial drugs for sick children visiting first-level health facilities in low-income and middle-income countries.

Anaemia in pregnancy and infant mortality in Tanzania

Tanzania is an area of moderate to high risk for severe anaemia during pregnancy. There is extensive literature examining the consequences of severe anaemia for pregnant women, but the impact this problem has on their infants in malaria-endemic regions is poorly understood. Between 1999 and 2001 we used a demographic surveillance system in the Kilombero Valley, Tanzania to link morbidity and socio-economic status data for 301 pregnant women to the survival of 365 days of their singleton babies, looking for evidence of an association between infant mortality and maternal haemoglobin (Hb). The hazards ratio for infant mortality amongst women who had been severely anaemic in pregnancy (Hb < 8 g/dl) was 3.1 [95% confidence interval (CI) 1.1-9.1, P = 0.04] compared with women with Hb above this level after controlling for other factors. Prevention of anaemia in pregnancy may lead to an improvement in infant survival.

The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania

Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.

Inequities among the very poor: health care for children in rural southern Tanzania

BACKGROUND

Few studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania.

METHODS

In a baseline household survey in Tanzania early in the implementation phase of integrated management of childhood illness (IMCI), we included cluster samples of 2006 children younger than 5 years in four rural districts. Questions focused on the extent to which carers' knowledge of illness, care-seeking outside the home, and care in health facilities were consistent with IMCI guidelines and messages. We used principal components analysis to develop a relative index of household socioeconomic status, with weighted scores of information on income sources, education of the household head, and household assets.

FINDINGS

1026 (52%) of 1968 children reported having been ill in the 2 weeks before the survey. Carers of 415 (41%) of 1014 of these children had sought care first from an appropriate provider. 71 (26%) carers from families in the wealthiest quintile knew > or =2 danger signs compared with 48 (20%) of those from the poorest (p=0.03 for linear trend across quintiles) and wealthier families were more likely to bring their sick children to a health facility (p=0.02). Their children were more likely than poorer children to have received antimalarials, and antibiotics for pneumonia (p=0.0001 and 0.0048, respectively).

INTERPRETATION

Care-seeking behaviour is worse in poorer than in relatively rich families, even within a rural society that might easily be assumed to be uniformly poor.

Cost-effectiveness of social marketing of insecticide-treated nets for malaria control in the United Republic of Tanzania

OBJECTIVE

To assess the costs and consequences of a social marketing approach to malaria control in children by means of insecticide-treated nets in two rural districts of the United Republic of Tanzania, compared with no net use.

METHODS

Project cost data were collected prospectively from accounting records. Community effectiveness was estimated on the basis of a nested case-control study and a cross-sectional cluster sample survey.

FINDINGS

The social marketing approach to the distribution of insecticide-treated nets was estimated to cost 1560 US dollars per death averted and 57 US dollars per disability-adjusted life year averted. These figures fell to 1018 US dollars and 37 US dollars, respectively, when the costs and consequences of untreated nets were taken into account.

CONCLUSION

The social marketing of insecticide-treated nets is an attractive intervention for preventing childhood deaths from malaria.

Paediatric referrals in rural Tanzania: the Kilombero District Study - a case series

BACKGROUND: Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital METHODS: A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred. RESULTS: From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward. CONCLUSIONS: The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.

Socially marketed insecticide-treated nets improve malaria and anaemia in pregnancy in southern Tanzania

OBJECTIVES

To study the uptake of socially marketed insecticide-treated nets (ITNs) and their impact on malaria and anaemia in pregnancy; and to report on a discount voucher system which aimed to increase coverage in pregnancy.

METHODS

A 12-month cross-sectional study of women in the second or third trimester of pregnancy. ITN use and other factors were assessed by questionnaire and a blood sample taken for malaria parasitaemia and anaemia. 'Non-users' of ITNs included both women not using any net and women using untreated nets.

RESULTS

Fifty three per cent of pregnant women used ITNs. Women aged 15-19, primigravidae, unmarried women, and those with no access to cash had the lowest ITN use. Fewer ITN users were positive for malaria than ITN non-users (25 vs. 33%: P=0.06), and the protective efficacy (PE) for parasitaemia was 23% (CI 2-41). Multiparous ITN users had a twofold decrease in parasite density compared with multiparous non-ITN users (625 parasites/microl vs. 1173 parasited/microl: P=0.01). Fewer ITN users were anaemic (Hb < 11 g/dl) than ITN non-users (72 vs. 82%: P=0.01). ITNs had a PE of 12% (CI 2-21) against mild anaemia and a PE of 38% (CI 4-60) against severe anaemia (Hb < 8 g/dl). There was a trend in the prevalence of severe, mild and no anaemia, and of high density, low density and no malaria infection by ITN status. Recently treated nets were most effective at preventing malaria and anaemia (prevalence of mild anaemia was 68% compared with 82% for those without nets (P=0.002); prevalence of malaria was 22% compared with 33% for those without nets (P=0.02). Knowledge and reported use of the discount voucher system were low. Further qualitative research is ongoing.

CONCLUSIONS

A modest impact of ITNs on pregnancy malaria and anaemia was shown in our high malaria transmission setting. The development of ITN programmes for malaria control should include pregnant women as a specific target group.

Introducing insecticide-treated nets in the Kilombero Valley, Tanzania: the relevance of local knowledge and practice for an information, education and communication (IEC) campaign

Since 1997 the WHO has been recommending an integrative strategy to combat malaria including new medicines, vaccines, improvements of health care systems and insecticide-treated nets (ITNs). After successful controlled trials with ITNs in the past decade, large-scale interventions and research now focus on operational issues of distribution and financing. In developing a social marketing approach in the Kilombero Valley in south-east Tanzania in 1996, a combination of qualitative and quantitative methods was employed to investigate local knowledge and practice relating to malaria. The findings show that the biomedical concept of malaria overlaps with several local illness concepts, one of which is called malaria and refers to mild malaria. Most respondents linked malaria to mosquitoes (76%) and already used mosquito nets (52%). But local understandings of severe malaria differed from the biomedical concept and were not linked to mosquitoes or malaria. A social marketing strategy to promote ITNs was developed on the basis of these findings, which reinforced public health messages and linked them with nets and insecticide. Although we did not directly evaluate the impact of promotional activities, the sharp rise in ownership and use of ITNs by the population (from 10 to > 50%) suggests that they contributed significantly to the success of the programme. Local knowledge and practice is highly relevant for social marketing strategies of ITNs.

Impact on malaria morbidity of a programme supplying insecticide treated nets in children aged under 2 years in Tanzania: community cross sectional study

OBJECTIVE

To assess the impact of a social marketing programme for distributing nets treated with insecticide on malarial parasitaemia and anaemia in very young children in an area of high malaria transmission.

DESIGN

Community cross sectional study. Annual, cross sectional data were collected at the beginning of the social marketing campaign (1997) and the subsequent two years. Net ownership and other risk and confounding factors were assessed with a questionnaire. Blood samples were taken from the children to assess prevalence of parasitaemia and haemoglobin levels.

SETTING

18 villages in the Kilombero and Ulanga districts of southwestern Tanzania.

PARTICIPANTS

A random sample of children aged under 2 years.

MAIN OUTCOME MEASURES

The presence of any parasitaemia in the peripheral blood sample and the presence of anaemia (classified as a haemoglobin level of <80 g/l).

RESULTS

Ownership of nets increased rapidly (treated or not treated nets: from 58% to 83%; treated nets: from 10% to 61%). The mean haemoglobin level rose from 80 g/l to 89 g/l in the study children in the successive surveys. Overall, the prevalence of anaemia in the study population decreased from 49% to 26% in the two years studied. Treated nets had a protective efficacy of 62% (95% confidence interval 38% to 77%) on the prevalence of parasitaemia and of 63% (27% to 82%) on anaemia.

CONCLUSIONS

These results show that nets treated with insecticide have a substantial impact on morbidity when distributed in a public health setting.

African children with malaria in an area of intense Plasmodium falciparum transmission: features on admission to the hospital and risk factors for death

Malaria remains the most important parasitic cause of mortality in humans. Its presentation is thought to vary according to the intensity of Plasmodium falciparum transmission. However, detailed descriptions of presenting features and risk factors for death are only available from moderate transmission settings. Such descriptions help to improve case management and identify priority research areas. Standardized systematic procedures were used to collect clinical and laboratory data on 6,624 children admitted to hospital over a 1-year period in an intensely malarious part of Tanzania. Frequencies of signs and symptoms were calculated and their association with a fatal outcome was assessed using multivariate logistic regression. There were 72 deaths among 2,432 malaria cases (case fatality rate [CFR] = 3.0%); 44% of the cases and 54% of the deaths were in individuals less than 1 year of age. There was no association between level of parasitemia and CFR. Increased risk of dying was independently found in all children with hypoglycemia (odds ratio [OR] = 6.7, 95% confidence interval [CI] = 3.9-11.7), in children 1-7 months of age with tachypnea (OR = 8.8, 95% CI = 2.6-30.5) and dehydration (OR = 5.0, 95% CI = 1.9-14.2), and in children 8 months to 4 years of age with chest indrawing (OR = 4.7, 95% CI = 2.0-11.2) and inability to localize a painful stimulus (OR = 6.9, 95% CI = 2.9-16.5). Children in the bottom quartile of weight-for-age were more likely to die (OR = 2.1, 95% CI = 1.3-3.5). Eight percent of the malaria cases had severe anemia (packed cell volume < 15%) but 24% received a blood transfusion. The epidemiology of malaria disease may be more complex than previously thought. Improved case management in a wide variety of health facilities may result from adequate identification and treatment of dehydration and hypoglycemia. Transfusion-requiring anemia is a major problem and sustainable, effective preventive measures are urgently needed.

An analysis of the geographical distribution of severe malaria in children in Kilifi District, Kenya

BACKGROUND

Although malaria is known to be a major cause of child mortality and morbidity throughout sub-Saharan Africa there are few detailed studies of malaria mortality rates and incidence of severe malarial disease in defined communities. We have studied the geographical pattern of admissions to hospital with severe malaria and the stability of this pattern over time in Kilifi District on the Kenyan Coast.

METHODS

Over a 2-year period all children under 5 years of age with severe malaria admitted to the district hospital and living in a rural study population of about 50,000 people were identified. Annual censuses were carried out in the study area, and all households were mapped using a hand-held satellite navigation system. The resulting databases were linked using a geographical information system (GIS).

RESULTS

Using methods originally developed for the study of the geographical distribution of childhood leukaemia we assessed the spatial pattern of hospital admission rates for severe malaria. As expected, admission rates were significantly higher in children with easier access to the hospital. For example, those living more than 25 km from the hospital had admission rates which were about one-fifth of those for children living within 5 km of the hospital. Those living more than 2.5 km from the nearest road had admission rates that were about half of those for children living within 0.5 km of a road. We also investigated short-term local fluctuations in severe malaria and found evidence of space-time clustering of severe malaria.

CONCLUSIONS

Hospital admission rates for severe malaria are higher in households with better access to hospital than in those further away. The finding of space-time clusters of severe malaria suggests that it would be of value to conduct case-control studies of environmental, genetic and human behavioural factors involved in the aetiology of the disease.

Coma scales for children with severe falciparum malaria

The Blantyre coma scale (BCS) is used to assess children with severe falciparum malaria, particularly as a criterion for cerebral malaria, but it has not been formally validated. We compared the BCS to the Adelaide coma scale (ACS), for Kenyan children with severe malaria. We examined the inter-observer agreement between 3 observers in the assessment of coma scales on 17 children by measuring the proportion of agreement (PA), disagreement rate (DR) and fixed sample size kappa (kappa n). We assessed the sensitivity and specificity of the scales in detecting events (seizures and hypoglycaemia) in 240 children during admission and the usefulness of the scales in predicting outcome. There was considerable disagreement between observers in the assessment of both scales (BCS: PA = 0.55, DR = 0.09 and kappa n = 0.27; ACS: PA = 0.36, DR = 0.31, and kappa n = 0.31), particularly with the verbal component of the BCS (kappa n = 0.02). Compared to the ACS, the BCS was more specific (0.85 for BCS and 0.80 for ACS), but less sensitive (0.25-0.69 vs. 0.38-0.88 respectively) in detecting events and was a worse predictor of neurological sequelae. The BCS provided a better overall assessment of a child's incapacity from falciparum malaria, but the ACS was more useful in assessing neurological disturbances.

Attributable fraction estimates and case definitions for malaria in endemic areas

Asymptomatic carriage of malaria parasites occurs frequently in endemic areas and the detection of parasites in a blood film from a febrile individual does not necessarily indicate clinical malaria. In areas of low and moderate endemicity the parasite prevalence in fever cases can be compared with that in community controls to estimate the fraction of cases which are attributable to malaria. In areas of very high transmission such estimates of the attributable fraction may be imprecise because very few individuals are without parasites. Furthermore, non-malarial fevers appear to suppress low levels of parasitaemia resulting in biased estimates of the attributable fraction. Alternative estimation techniques were therefore explored using data collected during 1989-1991 from a highly endemic area of Tanzania, where over 80 per cent of young children are parasitaemic. Logistic regression methods which model fever risk as a continuous function of parasite density give more precise estimates than simple analyses of parasite prevalence and overcome problems of bias caused by the effects of non-malarial fevers. Such models can be used to estimate the probability that any individual episode is malaria-attributable and can be extended to allow for covariates. A case definition for symptomatic malaria that is used widely in endemic areas requires fever together with a parasite density above a specific cutoff. The choice of a cutoff value can be assisted by using the probabilities derived from the logistic model to estimate the sensitivity and specificity of the case definition.

Comparison of mortality between villages with and without Primary Health Care workers in Upper River Division, The Gambia

Health services utilization was analysed in a rural area of the The Gambia. In general, health workers were consulted frequently. However, verbal autopsies showed that children who died had rarely consulted health workers, particularly if they came from villages where such workers were not posted. Traditional healers were consulted frequently, independently of the presence of a village health worker. The relationship between cause specific mortality and the utilization of health services is discussed. Childhood mortality was similar in villages with or without a primary health care worker at the time of the study.

A trial of the synthetic malaria vaccine SPf66 in Tanzania: rationale and design

The development of a safe, affordable and effective malaria vaccine to form part of control schemes in malaria endemic countries is a priority for researchers and public health officials. SPf66 is the first malaria vaccine to have shown partial protection against natural challenge in a phase III trial carried out in a hypoendemic area of Colombia. This paper describes the rationale and design of the first field trial of SPf66 outside South America, and the first to be conducted in an area of high perennial transmission.

Patterns of delayed marriage: how special are the Irish?

"This paper deals with delayed marriage and singlehood among the Irish as a focus for the study of the persistence of ethnic characteristics. Patterns of delayed marriage in Ireland in the nineteenth and twentieth centuries are reviewed, and evidence is also presented that Irish persons in other countries (especially in the United States) continue to show significantly higher rates of singlehood and postponed marriage than persons of other nationality groups. Discussion includes how delayed marriage became common in Ireland during the past 150 years and what may be involved in the apparent persistence of this pattern today in Ireland and among the Irish in other countries."