Factors affecting home delivery in rural Tanzania

BACKGROUND\ud \ud Studies of factors affecting place of delivery have rarely considered the influence of gender roles and relations within the household. This study combines an understanding of gender issues relating to health and help-seeking behaviour with epidemiological knowledge concerning place of delivery.\ud \ud METHODS\ud \ud In-depth interviews, focus group discussions and participant observation were used to explore determinants of home delivery in southern Tanzania. Quantitative data were collected in a cross-sectional survey of 21,600 randomly chosen households.\ud \ud RESULTS\ud \ud Issues of risk and vulnerability, such as lack of money, lack of transport, sudden onset of labour, short labour, staff attitudes, lack of privacy, tradition and cultures and the pattern of decision-making power within the household were perceived as key determinants of the place of delivery. More than 9000 women were interviewed about their most recent delivery in the quantitative survey. There were substantial variations between ethnic groups with respect to place of delivery (P<0.0001). Women who lived in male-headed households were less likely to deliver in a health facility than women in female-headed households (RR 0.86, 95% CI 0.80-0.91). Mothers with primary and higher education were more likely to deliver at a health facility (RR 1.30, 95% CI 1.23-1.38). Younger mothers and the least poor women were also more likely to deliver in a health facility compared with the older and the poorest women, respectively.\ud \ud CONCLUSIONS\ud \ud To address neonatal mortality, special attention should be paid to neonatal health in both maternal and child health programmes. The findings emphasize the need for a systematic approach to overcome health-system constraints, community based programmes and scale-up effective low-cost interventions which are already available

Access to Artemisinin-Based Anti-Malarial Treatment and its Related Factors in Rural Tanzania.

Artemisinin-based combination treatment (ACT) has been widely adopted as one of the main malaria control strategies. However, its promise to save thousands of lives in sub-Saharan Africa depends on how effective the use of ACT is within the routine health system. The INESS platform evaluated effective coverage of ACT in several African countries. Timely access within 24 hours to an authorized ACT outlet is one of the determinants of effective coverage and was assessed for artemether-lumefantrine (Alu), in two district health systems in rural Tanzania. From October 2009 to June 2011we conducted continuous rolling household surveys in the Kilombero-Ulanga and the Rufiji Health and Demographic Surveillance Sites (HDSS). Surveys were linked to the routine HDSS update rounds. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data on individual treatment seeking, access to treatment, timing, source of treatment and household costs per episode were collected. Data are presented on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. In Kilombero-Ulanga, 41.8% (CI: 36.6-45.1) and in Rufiji 36.8% (33.7-40.1) of fever cases had access to an authorized ACT provider within 24 hours of fever onset. In neither of the HDSS site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. Timely access to authorized ACT providers is below 50% despite interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. To improve prompt diagnosis and treatment, access remains a major bottle neck and new more innovative interventions are needed to raise effective coverage of malaria treatment in Tanzania

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

BACKGROUND\ud \ud 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\ud \ud METHODS\ud \ud 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.\ud \ud RESULTS\ud \ud 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.\ud \ud CONCLUSION\ud \ud 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

The uneasy heirs of acquaintance

My contribution to the first round of a tetralog with Bill Brewer, Anil Gupta, and John McDowell. Each of us has written a response to the writings of the other three philosophers on the topic "Empirical Reason". My initial contribution focuses on what we know a priori about perception. In the second round, we will each respond to the each writer's first-round contributions

Application of realistic effective interactions to the structure of the Zr isotopes

We calculate the low-lying spectra of the zirconium isotopes Z=40 with neutron numbers from N=52 to N=60 using the 1p1/20g9/2 proton and 2s1d0g7/20h11/2 neutron sub-shells to define the model space. Effective proton-proton, neutron--neutron and proton-neutron interactions have been derived using 88Sr as closed core and employing perturbative many-body techniques. The starting point is the nucleon-nucleon potential derived from modern meson exchange models. The comprehensive shell-model calculation performed in this work provides a qualitative reproduction of essential properties such as the sub-shell closures in 96Zr and 98Zr.Comment: To appear in Phys Rev C, june 2000, 8 figs, Revtex latex styl

Standing in a Garden of Forking Paths

According to the Path Principle, it is permissible to expand your set of beliefs iff (and because) the evidence you possess provides adequate support for such beliefs. If there is no path from here to there, you cannot add a belief to your belief set. If some thinker with the same type of evidential support has a path that they can take, so do you. The paths exist because of the evidence you possess and the support it provides. Evidential support grounds propositional justification. The principle is mistaken. There are permissible steps you may take that others may not even if you have the very same evidence. There are permissible steps that you cannot take that others can even if your beliefs receive the same type of evidential support. Because we have to assume almost nothing about the nature of evidential support to establish these results, we should reject evidentialism

A versatile fluorescence lifetime imaging system for scanning large areas with high time and spatial resolution

"Published in SPIE Proceedings Vol. 9286"We present a flexible fluorescence lifetime imaging device which can be employed to scan large sample areas with a spatial resolution adjustable from many micrometers down to sub-micrometers and a temporal resolution of 20 picoseconds. Several different applications of the system will be presented including protein microarrays analysis, the scanning of historical samples, evaluation of solar cell surfaces and nanocrystalline organic crystals embedded in electrospun polymeric nanofibers. Energy transfer processes within semiconductor quantum dot superstructures as well as between dye probes and graphene layers were also investigated.This work was financially supported by the European Regional Development Fund (ERDF) through Programa Operacional Factores de Competitividade (COMPETE: FCOMP-01-0124-FEDER-014628) and the Portuguese Fundacao para a Ciencia e Tecnologia (FCT) through the projects "Functional structuring, inter-particle interaction and energy transfer in ensembles of nanocrystal dots" (PTDC/FIS/113199/2009), Ultra-fast spectroscopy on the dynamics and relaxation of Dirac electrons in graphene" (PTDC/FIS/101434/ 2008) and "Low dimensional nanostructures for nonlinear optical applications" PTDC/CTmNAN/114269/2009

Staff experiences of Providing Maternity Services in Rural Southern Tanzania -- A Focus on Equipment, Drug and Supply Issues.

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 maternal outcomes through delaying care provision. We aim to describe staff experiences of providing maternal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies. 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. 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 that carried potential health risks to themselves as a result. 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

Microbiome profiling by Illumina sequencing of combinatorial sequence-tagged PCR products

We developed a low-cost, high-throughput microbiome profiling method that uses combinatorial sequence tags attached to PCR primers that amplify the rRNA V6 region. Amplified PCR products are sequenced using an Illumina paired-end protocol to generate millions of overlapping reads. Combinatorial sequence tagging can be used to examine hundreds of samples with far fewer primers than is required when sequence tags are incorporated at only a single end. The number of reads generated permitted saturating or near-saturating analysis of samples of the vaginal microbiome. The large number of reads al- lowed an in-depth analysis of errors, and we found that PCR-induced errors composed the vast majority of non-organism derived species variants, an ob- servation that has significant implications for sequence clustering of similar high-throughput data. We show that the short reads are sufficient to assign organisms to the genus or species level in most cases. We suggest that this method will be useful for the deep sequencing of any short nucleotide region that is taxonomically informative; these include the V3, V5 regions of the bac- terial 16S rRNA genes and the eukaryotic V9 region that is gaining popularity for sampling protist diversity.Comment: 28 pages, 13 figure

Randomized, Controlled Trial of the Long Term Safety, Immunogenicity and Efficacy of RTS,S/AS02(D) Malaria Vaccine in Infants Living in a Malaria-Endemic Region.

The RTS,S/AS malaria candidate vaccine is being developed with the intent to be delivered, if approved, through the Expanded Programme on Immunization (EPI) of the World Health Organization. Safety, immunogenicity and efficacy of the RTS,S/AS02(D) vaccine candidate when integrated into a standard EPI schedule for infants have been reported over a nine-month surveillance period. This paper describes results following 20 months of follow up. This Phase IIb, single-centre, randomized controlled trial enrolled 340 infants in Tanzania to receive three doses of RTS,S/AS02(D) or hepatitis B vaccine at 8, 12, and 16 weeks of age. All infants also received DTPw/Hib (diphtheria and tetanus toxoids, whole-cell pertussis vaccine, conjugated Haemophilus influenzae type b vaccine) at the same timepoints. The study was double-blinded to month 9 and single-blinded from months 9 to 20. From month 0 to 20, at least one SAE was reported in 57/170 infants who received RTS,S/AS02(D) (33.5%; 95% confidence interval [CI]: 26.5, 41.2) and 62/170 infants who received hepatitis B vaccine (36.5%; 95% CI: 29.2, 44.2). The SAE profile was similar in both vaccine groups; none were considered to be related to vaccination. At month 20, 18 months after completion of vaccination, 71.8% of recipients of RTS,S/AS02(D) and 3.8% of recipients of hepatitis B vaccine had seropositive titres for anti-CS antibodies; seroprotective levels of anti-HBs antibodies remained in 100% of recipients of RTS,S/AS02(D) and 97.7% recipients of hepatitis B vaccine. Anti-HBs antibody GMTs were higher in the RTS,S/AS02(D) group at all post-vaccination time points compared to control. According to protocol population, vaccine efficacy against multiple episodes of malaria disease was 50.7% (95% CI: -6.5 to 77.1, p = 0.072) and 26.7% (95% CI: -33.1 to 59.6, p = 0.307) over 12 and 18 months post vaccination, respectively. In the Intention to Treat population, over the 20-month follow up, vaccine efficacy against multiple episodes of malaria disease was 14.4% (95% CI: -41.9 to 48.4, p = 0.545). The acceptable safety profile and good tolerability of RTS,S/AS02(D) in combination with EPI vaccines previously reported from month 0 to 9 was confirmed over a 20 month surveillance period in this infant population. Antibodies against both CS and HBsAg in the RTS,S/AS02(D) group remained significantly higher compared to control for the study duration. Over 18 months follow up, RTS,S/AS02(D) prevented approximately a quarter of malaria cases in the study population. CLINICAL TRIALS: Gov identifier: NCT00289185