Community determinants of health care seeking for tuberculosis : the role of socio-cultural determinants and gender in Tanzania

The WHO End TB strategy targets to end the global tuberculosis epidemic by 2035 with a reduction of 90% new cases, a 95% reduction in deaths, and to ensure that no family is burdened by catastrophic costs as a result of tuberculosis. In order to reach this ambitious goal, not only strengthening of tuberculosis control programs, discovery, development and evaluation of novel and sensitive tuberculosis diagnostics tools will be required, but also actions with regard to social determinants of tuberculosis and health care seeking, particularly in low-income settings with high tuberculosis burden. Furthermore, novel and more sensitive TB diagnostics tools will only have an impact at the population-level if the millions of undiagnosed TB cases reach health care centres timely for diagnosis and treatment. The low tuberculosis case detection observed in Tanzania and elsewhere is not only due to limitations in tuberculosis diagnostics, but also in the socio-cultural and economic factors which are relevant for tuberculosis healthcare seeking, timely diagnosis and treatment. This doctoral thesis therefore aimed to assess the pathways and costs of care from the onset of tuberculosis symptoms, to explain patient and diagnostic delays and loss to diagnostic follow-up during health care seeking, and finally to explore the role of traditional healers in tuberculosis management and control in Tanzania, using quantitative and qualitative methods. It firstly makes use of data obtained from the on-going tuberculosis cohort study in Dar es Salaam Tanzania, interviewing 100 confirmed and 100 presumptive tuberculosis patients on pathways to care and on direct and indirect costs, with data recording on tablets using the OpenDataKit (ODK) application. Secondly, data were collected during an intervention study on intensified case findings at pharmacies in Tanzania, administering a semi-structured explanatory model interview based on the EMIC framework for cultural epidemiology to 136 presumptive and confirmed TB patients. It further used data from in-depth interviews and structured interviews with 90 traditional healers in urban, peri-urban and rural districts of Tanzania. Pathways to care in confirmed tuberculosis patients were complex compared to the presumptive patients. In confirmed patients, pathways involved several visits to health care facilities before diagnosis, while that of the presumptive patients were more direct with only one or few visits to healthcare facilities before diagnosis. Confirmed and presumptive TB patients spent a median of 31% of their monthly household income on health expenditure for all five visits to healthcare facilities. Indirect costs were considerably higher than direct costs both in confirmed and presumptive TB patients. A patient delay of ≥3 weeks was observed in almost two thirds of our participants from the intervention study. In addition, loss to diagnostic follow-up was observed in 44.1%. Prior consultations with traditional healers were associated with patient delay but not with loss to diagnostic follow-up. Gender differences were observed in patient delay and LDFU, whereby the odds of patient delay were higher in females than in males, and also loss to diagnostic follow-up was higher in females than in males. Knowledge on cough and tuberculosis related symptoms was limited among traditional healers and varied in urban, peri-urban and the rural settings. Costs spent for traditional healers for treatment of cough and tuberculosis symptoms were lower than costs incurred by patients from the formal healthcare providers. Traditional healers in all three study sites referred patients for further treatment. Collaboration among the traditional healers, the government (NTLP) and other stakeholders was limited. There was a significant association between collaboration with the government and referring patients to hospitals for further treatment. The results from this PhD project contribute to our understanding on the pathways and costs of care in confirmed and presumptive tuberculosis patients. This study is among a few to report costs associated with tuberculosis taking into account gender differences and poverty status. Furthermore, it contributes to open questions regarding patient delay and loss to diagnostic follow-up during healthcare seeking. Our study is also among the few to address the gap on the role of traditional healers in tuberculosis management particularly from sub-Sahara Africa. Given the importance of tuberculosis in terms of global disease burden, and the WHO’s ambitious goal to end tuberculosis by 2035, planning and specific interventions which integrate social and biomedical solutions are needed

Diagnostic Delay and Associated Factors among Patients with Pulmonary Tuberculosis in Dar es Salaam, Tanzania.

Tanzania is among the 30 countries with the highest tuberculosis (TB) burdens. Because TB has a long infectious period, early diagnosis is not only important for reducing transmission, but also for improving treatment outcomes. We assessed diagnostic delay and associated factors among infectious TB patients. We interviewed new smear-positive adult pulmonary TB patients enrolled in an ongoing TB cohort study in Dar es Salaam, Tanzania, between November 2013 and June 2015. TB patients were interviewed to collect information on socio-demographics, socio-economic status, health-seeking behaviour, and residential geocodes. We categorized diagnostic delay into ≤ 3 or > 3 weeks. We used logistic regression models to identify risk factors for diagnostic delay, presented as crude (OR) and adjusted Odds Ratios (aOR). We also assessed association between geographical distance (incremental increase of 500 meters between household and the nearest pharmacy) with binary outcomes. We analysed 513 patients with a median age of 34 years (interquartile range 27-41); 353 (69%) were men. Overall, 444 (87%) reported seeking care from health care providers prior to TB diagnosis, of whom 211 (48%) sought care > 2 times. Only six (1%) visited traditional healers before TB diagnosis. Diagnostic delay was positively associated with absence of chest pain (aOR = 7.97, 95% confidence intervals [CI]: 3.15-20.19; P < 0.001), and presence of hemoptysis (aOR = 25.37, 95% CI: 11.15-57.74; P < 0.001) and negatively associated with use of medication prior to TB diagnosis (aOR = 0.31, 95% CI: 0.14-0.71; P = 0.01). Age, sex, HIV status, education level, household income, and visiting health care facilities (HCFs) were not associated with diagnostic delay. Patients living far from pharmacies were less likely to visit a HCF (incremental increase of distance versus visit to any facility: OR = 0.51, 95% CI: 0.28-0.96; P = 0.037). TB diagnostic delay was common in Dar es Salaam, and was more likely among patients without prior use of medication and presenting with hemoptysis. Geographical distance to HCFs may have an impact on health-seeking behaviour. Increasing community awareness of TB signs and symptoms could further reduce diagnostic delays and interrupt TB transmission

Prevalence and clinical relevance of helminth co-infections among tuberculosis patients in urban Tanzania

Helminth infections can negatively affect the immunologic host control, which may increase the risk of progression from latent Mycobacterium tuberculosis infection to tuberculosis (TB) disease and alter the clinical presentation of TB. We assessed the prevalence and determined the clinical relevance of helminth co-infection among TB patients and household contact controls in urban Tanzania.; Between November 2013 and October 2015, we enrolled adult (≥18 years) sputum smear-positive TB patients and household contact controls without TB during an ongoing TB cohort study in Dar es Salaam, Tanzania. We used Baermann, FLOTAC, Kato-Katz, point-of-care circulating cathodic antigen, and urine filtration to diagnose helminth infections. Multivariable logistic regression models with and without random effects for households were used to assess for associations between helminth infection and TB.; A total of 597 TB patients and 375 household contact controls were included. The median age was 33 years and 60.2% (585/972) were men. The prevalence of any helminth infection among TB patients was 31.8% (190/597) and 25.9% (97/375) among controls. Strongyloides stercoralis was the predominant helminth species (16.6%, 161), followed by hookworm (9.0%, 87) and Schistosoma mansoni (5.7%, 55). An infection with any helminth was not associated with TB (adjusted odds ratio (aOR) 1.26, 95% confidence interval (CI): 0.88-1.80, p = 0.22), but S. mansoni infection was (aOR 2.15, 95% CI: 1.03-4.45, p = 0.040). Moreover, S. mansoni infection was associated with lower sputum bacterial load (aOR 2.63, 95% CI: 1.38-5.26, p = 0.004) and tended to have fewer lung cavitations (aOR 0.41, 95% CI: 0.12-1.16, p = 0.088).; S. mansoni infection was an independent risk factor for active TB and altered the clinical presentation in TB patients. These findings suggest a role for schistosomiasis in modulating the pathogenesis of human TB. Treatment of helminths should be considered in clinical management of TB and TB control programs

Home-Based and Facility-Based Directly Observed Therapy of Tuberculosis Treatment under Programmatic Conditions in Urban Tanzania.

INTRODUCTION Decentralization of Directly Observed Treatment (DOT) for tuberculosis (TB) to the community (home-based DOT) has improved the coverage of TB treatment and reduced the burden to the health care facilities (facility-based DOT). We aimed to compare TB treatment outcomes in home-based and facility-based DOT under programmatic conditions in an urban setting with a high TB burden. METHODOLOGY A retrospective analysis of a cohort of adult TB patients (≥15 years) routinely notified between 2010 and 2013 in two representative TB sub-districts in the Temeke district, Dar es Salaam, Tanzania. We assessed differences in treatment outcomes by calculating Risk Ratios (RRs). We used logistic regression to assess the association between DOT and treatment outcomes. RESULTS Data of 4,835 adult TB patients were analyzed, with a median age of 35 years, 2,943 (60.9%) were men and TB/HIV co-infection prevalence of 39.9%. A total of 3,593 (74.3%) patients were treated under home-based DOT. Patients on home-based DOT were more likely to die compared to patients on facility-based DOT (RR 2.04, 95% Confidence Interval [95% CI]: 1.52-2.73), and more likely to complete TB treatment (RR 1.14, 95% CI: 1.06-1.23), but less likely to have a successful treatment outcome (RR 0.94, 95% CI: 0.92-0.97). Home-based DOT was preferred by women (adjusted Odds Ratio [aOR] 1.55, 95% CI: 1.34-1.80, p<0.001), older people (aOR 1.01 for each year increase, 95% CI: 1.00-1.02, p = 0.001) and patients with extra-pulmonary TB (aOR 1.45, 95% CI: 1.16-1.81, p = 0.001), but less frequently by patients on a retreatment regimen (aOR 0.12, 95% CI: 0.08-0.19, p<0.001). CONCLUSIONS/SIGNIFICANCE TB patients under home-based DOT had more frequently risk factors of death such as older age, HIV infection and sputum smear-negative TB, and had higher mortality compared to patients under facility-based DOT. Further operational research is needed to monitor the implementation of DOT under programmatic conditions

Pathways and associated costs of care in patients with confirmed and presumptive tuberculosis in Tanzania : a cross-sectional study

To assess pathways and associated costs of seeking care from the onset of symptoms to diagnosis in patients with confirmed and presumptive tuberculosis (TB).; Cross-sectional study.; District hospital in Dar es Salaam, Tanzania.; Bacteriologically confirmed TB and presumptive TB patients.; We calculated distance in metres and visualised pathways to healthcare up to five visits for the current episode of sickness. Costs were described by medians and IQRs, with comparisons by gender and poverty status.; Of 100 confirmed and 100 presumptive TB patients, 44% of confirmed patients sought care first at pharmacies after the onset of symptoms, and 42% of presumptive patients did so at hospitals. The median visits made by confirmed patients was 2 (range 1-5) and 2 (range 1-3) by presumptive patients. Patients spent a median of 31% of their monthly household income on health expenditures for all visits. The median total direct costs were higher in confirmed compared with presumptive patients (USD 27.4 [IQR 18.7-48.4] vs USD 19.8 [IQR 13.8-34.0], p=0.02), as were the indirect costs (USD 66.9 [IQR 35.5-150.0] vs USD 46.8 [IQR 20.1-115.3], p&lt;0.001). The indirect costs were higher in men compared with women (USD 64.6 [IQR 31.8-159.1] vs USD 55.6 [IQR 25.1-141.1], p&lt;0.001). The median total distance from patients' household to healthcare facilities for patients with confirmed and presumptive TB was 2338 m (IQR 1373-4122) and 2009 m (IQR 986-2976) respectively.; Patients with confirmed TB have complex pathways and higher costs of care compared with patients with presumptive TB, but the costs of the latter are also substantial. Improving access to healthcare and ensuring integration of different healthcare providers including private, public health practitioners and patients themselves could help in reducing the complex pathways during healthcare seeking and optimal healthcare utilisation

Impact of the COVID-19 pandemic on type 2 diabetes care and factors associated with care disruption in Kenya and Tanzania

Background: The COVID-19 pandemic affected healthcare delivery globally, impacting care access and delivery of essential services. Objectives: We investigated the pandemic’s impact on care for patients with type 2 diabetes and factors associated with care disruption in Kenya and Tanzania. Methods: A cross-sectional study was conducted among adults diagnosed with diabetes pre-COVID-19. Data were collected in February–April 2022 reflecting experiences at two time-points, three months before and the three months most affected by the COVID-19 pandemic. A questionnaire captured data on blood glucose testing, changes in medication prescription and access, and healthcare provider access. Results: We recruited 1000 participants (500/country). Diabetes care was disrupted in both countries, with 34.8% and 32.8% of the participants reporting change in place and frequency of testing in Kenya, respectively. In Tanzania, 12.4% and 17.8% reported changes in location and frequency of glucose testing, respectively. The number of health facility visits declined, 14.4% (p &lt; 0.001) in Kenya and 5.6% (p = 0.001) in Tanzania. In Kenya, there was a higher likelihood of severe care disruption among insured patients (adjusted odds ratio [aOR] 1.56, 95% confidence interval [CI][1.05–2.34]; p = 0.029) and a lower likelihood among patients residing in rural areas (aOR, 0.35[95%CI, 0.22–0.58]; p &lt; 0.001). Tanzania had a lower likelihood of severe disruption among insured patients (aOR, 0.51[95%CI, 0.33–0.79]; p = 0.003) but higher likelihood among patients with low economic status (aOR, 1.81[95%CI, 1.14–2.88]; p = 0.011). Conclusions: COVID-19 disrupted diabetes care more in Kenya than Tanzania. Health systems and emergency preparedness should be strengthened to ensure continuity of service provision for patients with diabetes

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

Distinct clinical characteristics and helminth co-infections in adult tuberculosis patients from urban compared to rural Tanzania

Differences in rural and urban settings could account for distinct characteristics in the epidemiology of tuberculosis (TB). We comparatively studied epidemiological features of TB and helminth co-infections in adult patients from rural and urban settings of Tanzania.; Adult patients (≥ 18 years) with microbiologically confirmed pulmonary TB were consecutively enrolled into two cohorts in Dar es Salaam, with ~ 4.4 million inhabitants (urban), and Ifakara in the sparsely populated Kilombero District with ~ 400 000 inhabitants (rural). Clinical data were obtained at recruitment. Stool and urine samples were subjected to diagnose helminthiases using Kato-Katz, Baermann, urine filtration, and circulating cathodic antigen tests. Differences between groups were assessed by χ; 2; , Fisher's exact, and Wilcoxon rank sum tests. Logistic regression models were used to determine associations.; Between August 2015 and February 2017, 668 patients were enrolled, 460 (68.9%) at the urban and 208 (31.1%) at the rural site. Median patient age was 35 years (interquartile range [IQR]: 27-41.5 years), and 454 (68%) were males. Patients from the rural setting were older (median age 37 years vs. 34 years, P = 0.003), had a lower median body mass index (17.5 kg/m; 2; vs. 18.5 kg/m; 2; , P &lt;  0.001), a higher proportion of recurrent TB cases (9% vs. 1%, P &lt;  0.001), and in HIV/TB co-infected patients a lower median CD4 cell counts (147 cells/μl vs. 249 cells/μl, P = 0.02) compared to those from urban Tanzania. There was no significant difference in frequencies of HIV infection, diabetes mellitus, and haemoglobin concentration levels between the two settings. The overall prevalence of helminth co-infections was 22.9% (95% confidence interval [CI]: 20.4-27.0%). The significantly higher prevalence of helminth infections at the urban site (25.7% vs. 17.3%, P = 0.018) was predominantly driven by Strongyloides stercoralis (17.0% vs. 4.8%, P &lt;  0.001) and Schistosoma mansoni infection (4.1% vs. 16.4%, P &lt;  0.001). Recurrent TB was associated with living in a rural setting (adjusted odds ratio [aOR]: 3.97, 95% CI: 1.16-13.67) and increasing age (aOR: 1.06, 95% CI: 1.02-1.10).; Clinical characteristics and helminth co-infections pattern differ in TB patients in urban and rural Tanzania. The differences underline the need for setting-specific, tailored public health interventions to improve clinical management of TB and comorbidities

Why the Rise of Commercial Gambling in African Countries is a Public Health Concern

No abstract available

Care cascades for hypertension and diabetes: Cross-sectional evaluation of rural districts in Tanzania

Noncommunicable diseases (NCDs), especially hypertension and diabetes, are rapidly rising in sub-Saharan Africa, necessitating health systems transformations. In Tanzania, current policies aim to improve control of hypertension and diabetes, but information is still needed to assess the gaps in treatment.; We conducted a cross-sectional household survey of 784 adults in two districts in Tanzania from December 2020 to January 2021, capturing the cascade-of-care for hypertension and diabetes. The ages of the respondents ranged from 18 to 89 years. Of those screened positive for these conditions, we measured the proportion in each step of the cascades: awareness, care engagement, treatment, and control. We conducted multivariable logistic regression analyses for all four steps along the hypertension care cascade with the independent variables of social health protection schemes, and prior diagnosis of comorbid diabetes, and demographic information. In our sample, of the 771 who had their blood pressure measured, 41% (95% confidence interval (CI): 38% to 44%) were screened positive for hypertension, and of the 707 who had their blood sugar measured, 6% (95% CI: 4% to 8%) were screened positive for diabetes. Of those with hypertension, 43% (95% CI: 38% to 49%) had a prior diagnosis, 25% (95% CI: 21% to 31%) were engaged in care, 21% (95% CI: 3% to 25%) were on treatment, and 11% (95% CI: 8% to 15%) were controlled. Of the 42 respondents with diabetes, 80% (95% CI: 69% to 93%) had a prior diagnosis. The diabetes care cascade had much less drop-off, so 66% of those with diabetes (95% CI: 52% to 82%) were engaged in care and on treatment, and 48% (95% CI: 32% to 63%) had their diabetes controlled at the point of testing. Healthcare fee exemptions were independently associated with higher odds of being previously diagnosed (OR 5.81; 95% CI [1.98 to 17.10] p < 0.005), engaged in care (OR 4.71; 95% CI [1.59 to 13.90] p 0.005), and retained in treatment (OR 2.93; 95% CI [1.03 to 8.35] p < 0.05). Prior diagnosis of comorbid diabetes was highly associated with higher odds of being engaged in care for hypertension (OR 3.26; 95% CI [1.39 to 7.63] p < 0.005). The two primary limitations of this study were reliance on screening at a single time point only of people available at the village at the time of the sample and dependence on self-report for to inform the three cascade steps of prior diagnosis, healthcare visits for engagement in care, and treatment use.; The high burden of hypertension and low levels of control in our study underscores the importance of improving the awareness and treatment of hypertension. The differences in the care cascades for hypertension and diabetes demonstrates that chronic NCD treatment is possible in this setting, but efforts will be needed across the entire care cascade to improve hypertension control