Knowledge, attitudes and practices towards malaria diagnostics among healthcare providers and healthcare-seekers in Kondoa district, Tanzania: a multi-methodological situation analysis.

BACKGROUND Despite the large-scale rollout of malaria rapid diagnostic tests (RDTs) in Tanzania, many healthcare providers (HCPs) continue using blood film microscopy (BFM) and clinical examination to diagnose malaria, which can increase the risk of mal-diagnosis and over-prescribing of anti-malarials. Patients disregarding negative test results and self-treating exacerbate the problem. This study explored the knowledge, attitudes and practices of HCPs and healthcare-seekers regarding RDTs in comparison to BFM testing. METHODS A situational analysis was, therefore, conducted in Kondoa District, Dodoma Region, Tanzania. A multi-methodological approach was adopted including (i) a health facility inventory and screening of logbooks from May 2013 to April 2014 with 77,126 patient entries from 33 health facilities; (ii) a survey of 40 HCPs offering malaria services; and iii) a survey of 309 randomly selected household members from the facilities' catchment area. Surveys took place in April and May 2014. RESULTS Health facility records revealed that out of 77,126 patient entries, 22% (n = 17,235) obtained a malaria diagnosis. Of those, 45% were made with BFM, 33% with RDT and 22% with clinical diagnosis. A higher rate of positive diagnoses was observed with BFM compared with RDT (71% vs 14%). In the HCP survey, 48% preferred using BFM for malaria testing, while 52% preferred RDT. Faced with a negative RDT result for a patient presenting with symptoms typical for malaria, 25% of HCPs stated they would confirm the result with a microscopy test, 70% would advise or perform a clinical diagnosis and 18% would prescribe anti-malarials. Interviews with household members revealed a preference for microscopy testing (58%) over RDT (23%), if presented with malaria symptoms. For participants familiar with both tests, a second opinion was desired in 45% after a negative microscopy result and in 90% after an RDT. CONCLUSIONS Non-adherence to negative diagnostics by HCPs and patients continues to be a concern. Frequent training and supportive supervision for HCPs diagnosing and treating malaria and non-malaria febrile illnesses is essential to offer quality services that can instil confidence in HCPs and patients alike. The introduction of new diagnostic devices should be paired with context-specific behaviour change interventions targeting healthcare-seekers and healthcare providers

Quality of care for non-communicable diseases in the Republic of Moldova : a survey across primary health care facilities and pharmacies

The Republic of Moldova is faced with a high prevalence of non-communicable diseases (NCDs) related to lifestyle and health behavioural factors. Within the frame of the decentralisation reform, the primary health care system has been tasked to play an important role in the provision of preventative and curative NCD health services. There is however limited evidence available on the actual coverage and quality of care provided. Our paper aims to provide an updated overview of the coverage and quality of service provision in rural and urban regions of Moldova.; We designed a facility-based survey to measure aspects of coverage and quality of care of NCD services across 20 districts of the Republic of Moldova. This study presents descriptive data on the structural, procedural and clinical aspects of primary healthcare delivery at health centre and family doctor office level. Adjacent private pharmacies were also assessed for the availability of essential NCD medicine.; Organised under the WHO Health Systems Framework, our findings highlight that service provision and information were generally the strongest among the six health systems building blocks, with more weaknesses found in the area of the health workforce, medical products, financing, and leadership/governance. Urban facilities generally fared better across all indicators.; The gaps in service provision identified by this study require broad health system improvements to ensure NCD related policies and strategies are embedded in primary health care service provision. This likely calls for stronger coordination and collaboration between the public and private sectors and the different levels of government working towards ensuring universal health coverage in Moldova

The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms.

Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320

HIV-serostatus disclosure in the context of free antiretroviral therapy and socio-economic dependency : experiences among women living with HIV in Tanzania

The worldwide implementation of free antiretroviral therapy (ART) raised great hopes among policy makers and health organisations about the positive changes it would bring about in attitudes and behaviours towards HIV and AIDS, as well as for infected people's lives. A change in illness perception was anticipated, leading to the hypothesis of a possible change in disclosure rates, patterns and the choice of significant others to inform. In the era of free treatment availability in the United Republic of Tanzania, we examined reasons for disclosure and non-disclosure among HIV-seropositive women enrolled on ART and their choice of significant others to inform. In so doing, we contribute to the necessary yet neglected debate about the social impact of ART on the lives of infected women. The study, for which an ethnographic cross-sectional pilot approach was chosen, was conducted at the Care and Treatment Center (CTC) at Bombo Regional Hospital (BRH) in Tanga city, Tanzania. Data presented here derive from participant observation, questionnaires and semi-structured interviews conducted with 59 HIV-seropositive women on ART. Interestingly, and despite treatment availability, the choice of significant others to inform, as well as reasons for disclosure and non-disclosure, mirror findings from previous studies conducted before the introduction of free ART. The main reason for non-disclosure was fear of discrimination. The hope for social, economic or health support was the main motivation for disclosure, followed by the need for a 'clinic companion' in order to receive ART, as requested by hospital staff. Nevertheless, healthcare staff were not unanimous in thinking that disclosure is always beneficial, thus the recommended extent of disclosure varied. ART and concomitant factors were raised as an entirely new and significant reason for disclosure by interviewees. Finally, findings confirm that despite ART, disclosure remains a highly stressful event for women

Strengthening accountability for improved maternal and newborn health : a mapping of studies in Sub-Saharan Africa

To describe the types of maternal and newborn health program accountability mechanisms implemented and evaluated in recent years in Sub-Saharan Africa, how these have been implemented, their effectiveness, and future prospects to improve governance and MNH outcomes.; A structured review selected 38 peer-reviewed papers between 2006 and 2016 in Sub-Saharan Africa to include in the analysis.; Performance accountability in MNH through maternal and perinatal death surveillance was the most common accountability mechanism used. Political and democratic accountability through advocacy, human rights, and global tracking of progress on indicators achieved greatest results when multiple stakeholders were involved. Financial accountability can be effective but depend on external support. Overall, this review shows that accountability is more effective when clear expectations are backed by social and political advocacy and multistakeholder engagement, and supported by incentives for positive action.; There are few accountability mechanisms in MNH in Sub-Saharan Africa between decision-makers and those affected by those decisions with both the power and the will to enforce answerability. Increasing accountability depends not only on how mechanisms are enforced but also, on how providers and managers understand accountability