Local Understanding and Practices Related to IMCI Interventions in Eastern Tanzania

This PhD thesis presents findings of the health seeking component of the Tanzania Essential Health Intervention Project (TEHIP). It was carried out from 1998 to 2001 in two districts of southern Tanzania where Integrated Management of Childhood Illness (IMCI) was introduced in 1997. The rationale is that best IMCI services are of little benefit, if they do not reach community and household levels. Caregivers need to understand and comply with IMCI core principles, i.e. learn to recognize the correct danger signs and seek prompt and effective treatment. The goal of our study was to contribute to increasing “community effectiveness” (Tanner et al. 1993) of health care in the study districts. Our specific objectives were to generate local knowledge to better adjust the IMCI interventions to local health seeking behavior and to improve the ways in which caretakers identify and manage common childhood illness. We define health seeking to encompass three dimensions: 1) health concepts including signs and symptoms recognized by the community; 2) aetiology comprising interpretations and explanations of illness; and 3) help seeking referring to home management and all forms of seeking help from experts, whether these are neighbors, traditional healers or health care staff. We first investigated the local illness terminology and the relative importance of symptom recognition and labeling in care-seeking. We found that local illness terms overlap with biomedical classifications such as “malaria”, but this overlap does not constitute direct correspondence. Caregivers rarely see a link between malaria and convulsions and create new links between convulsions and polio, tetanus and epilepsy. We identified intra-cultural diversity in symptom recognition and severity ranking of the same illness. Caregivers search for illness labels which are not only a name but contain information about treatment. In this search they face difficulties due to two reasons: 1) different illnesses produce similar symptoms, and 2) different persons provide changing and even contradictory advice and information. We introduce the term “fuzzy concept” and suggest that fuzziness can be explained by the diverse manifestations of malaria, by intra-cultural variability and/or by culture change confronting individual persons with multiple meanings. In a second step we analyze local aetiologies which we consider equally important for appropriate care-seeking as prompt recognition of danger signs and symptoms. Community aetiologies of IMCI related illness encompass a wide spectrum ranging from natural to supernatural causes. Some caregivers act on these notions, others are not interested in causes, and the majority remains ambivalent and pragmatic. A closer analysis of malaria-related aetiology shows that caregivers clearly attribute malaria to mosquito bites but have fragmented knowledge about the aetiology of homa (fever) and degedege (convulsions). We suggest that aetiological uncertainty leads to difficulties in therapy choice and thus to pragmatic ambivalence. In a third step we assess care-seeking in actual illness episodes. Caregivers make extensive use of formal health care facilities, not only for homa and malaria but for most other IMCI related illnesses. Exceptions are the folk illnesses degedege and kimeo (elongated uvula). The basic distinction found in many parts of Africa also applies to our study sites: 1) mild and “normal” malaria is first treated at home and if not cured brought to a formal health care facility; 2) severe forms of the disease presenting convulsions are rarely considered as malaria but as a distinct illness entity requiring traditional treatment at home or from a traditional healer. Our most important finding is that many children who suffer and sometimes even die from convulsions have had not only a history of homa but have even been diagnosed and treated for malaria in a health facility before they developed convulsions. In the fourth and final step we examine the impact of malaria care-seeking patterns on childhood mortality. Our findings show that nearly 80 percent of malaria-attributable deaths used modern biomedical care as a first resort, both in the form of antimalarial pharmaceuticals from shops or formal health care services. If care was sought more than once in these fatal cases, modern care was included in the first or second resort in 90 percent with convulsions and 99 percent without convulsions. There clearly is an urgent need for a thorough analysis of what is happening in these cases. Health providers often formulate the problem of recurrent illness in terms of a delay in treatment or a lack of adherence to treatment regimes. We argue that victim blaming does not bring us any further. Our case studies demonstrate that many mothers make an enormous effort in time, energy and money searching for the best care for their child. They should be supported rather than blamed by the health system

Spatial microhabitat selection by Biomphalaria pfeifferi in a small perennial river in Tanzania

A study was carried out in the Mlali river in south-central Tanzania with two aims. First, to determine microhabitat availability in two sites (A and B) with respect to water depth, water velocity and dominant substratum type. Second, to assess microhabitat use by Biomphalaria pfeifferi, the intermediate host snail of intestinal schistosomiasis and to investigate whether these snails show preferences for certain microhabitats. The two sites differed significantly with respect to width, water depth, water velocity and substratum composition. It is suggested that the absence of B. pfeifferi from site B is mainly associated with the high water velocities at that site, where 62% of the measurements exceeded30 cm s-1. In site A, the microhabitat use by 327 B. pfeifferi snails was assessed by means of direct observation. No significant relationships were found between snail size and the habitat variables investigated, indicating that snail size appeared to be of no importance in spatial microhabitat selection. B. pfeifferi snails showed statistically significant preferences for shallow water (depth: 2-7 cm) and the preferred water velocities ranged between 12 and 21 cm s-1 with an estimated optimum at13.3 cm s-1. No statistically significant preferences for substratum type were foun

Care-seeking patterns for fatal malaria in Tanzania.

BACKGROUND\ud \ud Once malaria occurs, deaths can be prevented by prompt treatment with relatively affordable and efficacious drugs. Yet this goal is elusive in Africa. The paradox of a continuing but easily preventable cause of high mortality raises important questions for policy makers concerning care-seeking and access to health systems. Although patterns of care-seeking during uncomplicated malaria episodes are well known, studies in cases of fatal malaria are rare. Care-seeking behaviours may differ between these groups.\ud \ud METHODS\ud \ud This study documents care-seeking events in 320 children less than five years of age with fatal malaria seen between 1999 and 2001 during over 240,000 person-years of follow-up in a stable perennial malaria transmission setting in southern Tanzania. Accounts of care-seeking recorded in verbal autopsy histories were analysed to determine providers attended and the sequence of choices made as the patients' condition deteriorated.\ud \ud RESULTS\ud \ud As first resort to care, 78.7% of malaria-attributable deaths used modern biomedical care in the form of antimalarial pharmaceuticals from shops or government or non-governmental heath facilities, 9.4% used initial traditional care at home or from traditional practitioners and 11.9% sought no care of any kind. There were no differences in patterns of choice by sex of the child, sex of the head of the household, socioeconomic status of the household or presence or absence of convulsions. In malaria deaths of all ages who sought care more than once, modern care was included in the first or second resort to care in 90.0% and 99.4% with and without convulsions respectively.\ud \ud CONCLUSIONS\ud \ud In this study of fatal malaria in southern Tanzania, biomedical care is the preferred choice of an overwhelming majority of suspected malaria cases, even those complicated by convulsions. Traditional care is no longer a significant delaying factor. To reduce mortality further will require greater emphasis on recognizing danger signs at home, prompter care-seeking, improved quality of care at health facilities and better adherence to treatment

Community-Based Questionnaires and Health Statistics as Tools for the Cost-Efficient Identification of communities at Risk of Urinary Schistosomiasis

Self-administered questionnaries, distributed by existing administrative channels to village party chairman, head-teachers and schoolchildren, showed good diegnostic perfomance for the qualitative assessment of unirary schistosomiasis endemicity. At a cost 34 times below that of the WHO- recommended persitological screening strategy, the schoolchildren's questionnaire allowed the screening of 75 out of 77 school of a rural Tanzanian district in six weeks, and the exclusion of school not at high risk for urinary schistosomiasis with over 90% confidence. The headteacher and party questinnalres made it possible to assess the perceived important of a spectrum of discease and symptoms, among which was schistosomiasis. The priroty rank of schistosomiasis control was stronglycorreled with the prevalence rate of the disease in the community. The queationnaires also looked for the prioritization of health among other community issues and thus contributed important for planning at district level. Standardized monthly dieases reports, sent by all primary health services, were also analysed. They allowed a zonal schistosomiasis endemicity classificatio

Health status and quality of life among older adults in rural Tanzania

BACKGROUND\ud \ud Increasingly, human populations throughout the world are living longer and this trend is developing in sub-Saharan Africa. In developing African countries such as Tanzania, this demographic phenomenon is taking place against a background of poverty and poor health conditions. There has been limited research on how this process of ageing impacts upon the health of older people within such low-income settings.\ud \ud OBJECTIVE\ud \ud The objective of this study is to describe the impacts of ageing on the health status, quality of life and well-being of older people in a rural population of Tanzania.\ud \ud DESIGN\ud \ud A short version of the WHO Survey on Adult Health and Global Ageing questionnaire was used to collect information on the health status, quality of life and well-being of older adults living in Ifakara Health and Demographic Surveillance System, Tanzania, during early 2007. Questionnaires were administered through this framework to 8,206 people aged 50 and over.\ud \ud RESULTS\ud \ud Among people aged 50 and over, having good quality of life and health status was significantly associated with being male, married and not being among the oldest old. Functional ability assessment was associated with age, with people reporting more difficulty in performing routine activities as age increased, particularly among women. Reports of good quality of life and well-being decreased with increasing age. Women were significantly more likely to report poor quality of life (odds ratio 1.31; p<0.001, 95% CI 1.15-1.50).\ud \ud CONCLUSIONS\ud \ud Older people within this rural Tanzanian setting reported that the ageing process had significant impacts on their health status, quality of life and physical ability. Poor quality of life and well-being, and poor health status in older people were significantly associated with marital status, sex, age and level of education. The process of ageing in this setting is challenging and raises public health concerns

Evaluation of chemical and physical-morphological factors as potential determinants of Biomphalaria pfeifferi(Krauss, 1848) distribution

This study was carried out in five sites along a small perennial river system in south-central Tanzania, which had been identified as the focus for transmission of intestinal schistosomiasis in the area. Malacological surveys preceding the study showed a focal distribution of Biomphalaria pfeifferi, intermediate host snail of Schistosoma mansoni, the snails being present in three sites but absent from the other two sites. The objective of this study was to evaluate to what extent chemical and/or physical-morphological factors determine the distribution of B. pfeifferi between these five sites. It was found that none of the chemical constituents in the waters examined were outside the tolerance range of B. pfeifferi snails. Moreover, the composition of water from B. pfeifferi-free sites was not different from that in those sites where snails occurred. Furthermore, none of the physical-morphological constituents seemed likely to be a determinant for the absence of B. pfeifferi. In view of these findings, and those of previous studies, it is concluded that the focal distribution of B. pfeifferi cannot be associated with a single environmental factor and is rather the result of more complex interactions of habitat factors