Health care for chronic diseases in rural Tanzania:Including non-communicable diseases in primary care towards health for all

Klatser, P.R. [Promotor]Geubbels, E. [Copromotor]Dieleman, M.A. [Copromotor

Tackling the triple threats of childhood malnutrition.

The term 'double burden of malnutrition' is usually interpreted in terms of the physical status of children: stunted and wasted children on the one hand and overweight/obese children on the other. There is a third category of malnutrition that can occur at either end of the anthropometric spectrum or, indeed, in children whose physical size may be close to ideal. This third type is most commonly articulated with the phrase 'hidden hunger' and is often illustrated by micronutrient deficiencies; thus, we refer to it here as 'undernutrition'. As understanding of such issues advances, we realise that there is a myriad of factors that may be influencing a child's road to nutritional health. In this BMC Medicine article collection we consider these influences and the impact they have, such as: the state of the child's environment; the effect this has on their risk of, and responses to, infection and on their gut; the consequences of poor nutrition on cognition and brain development; the key drivers of the obesity epidemic across the globe; and how undernourishment can affect a child's body composition. This collection showcases recent advances in the field, but likewise highlights ongoing challenges in the battle to achieve adequate nutrition for children across the globe

Use of delivered energy in a food process chain : a case study of the Kenyan fluid milk chain

Food is a basic need, but so is a sustainable society. There is an urgent need to increase our knowledge on the environmental consequences of food production, processing and handling in order to make improvements that promote sustainability (Berlin, 2002). However, in order to make real improvements in the environmental performance of a food supply chain, specific empirical data on systems energy requirements need to be assessed in a specific manner prior to decision making (Owens, 1997). The theory of ecology of scale may hold an important key to more sustainable food processing as it suggests that the major influence on ecological performance of food supply chains results from the scale associated with the involved companies (Schlich, 2008). The present study sought to gather empirical data on the delivered energy requirements of the Kenyan fresh milk chain while applying the Life Cycle Assessment (LCA) technique. The study aimed at investigating whether the operation efficiency as influenced by the size of the surveyed dairy enterprises is more important than corresponding transport distances by regarding all energy efforts in this process chain. Energy balances were used as a component of LCA to establish the energy consumption, and from this database the primary energy and environmental impacts were then calculated as carbon dioxide (CO2) emissions related to the main processes involved in this milk chain. The total energy uses were then allocated to a functional unit of 1 kg of milk ready for retailing to obtain the specific energy use. Comparisons were then drawn between the specific energy turnovers and corresponding business sizes presented as milk throughput per year. The environmental “hot spots” (life cycle steps that are more burdensome to the environment) were also identified. This method has also been extensively applied by Schlich et al., (2006) to investigate a number of food supply chains, such as lamb, wine, beef and pork. Strong logarithmic digression relation between firm size and specific energy turnover were observed; thus supporting the theory of ecology of scale similar to the findings of this study. Additionally, this study also identified the farming stage as an important environmental hot spot, consuming the most energy compared to all other stages investigated in this product chain. Diesel emerged as the most important fuel useful for any energy saving interventions aimed at reducing the CO2 emissions of this product chain; although electricity and wood were also quite popular. The application of energy balances as part of the LCA methodology is useful in studying the environmental performance of food supply chains in developing economies to establish hot spots and optimum business sizes for more energy-efficient food supply chains.Lebensmitteln zählen zu den Grundbedürfnissen des Menschen neben Kleidung und Behausung, ebenso wie eine nachhaltige Gesellschaft. Um Nachhaltigkeit fördern zu können, ist es notwendig das eigene Wissen um die Auswirkung von Lebensmittelproduktion, -verarbeitung und –handel auf die Umwelt zu erweitern (Berlin 2002). Zur Verbesserung der ökologischen Auswirkungen der Prozessketten der Lebensmittelbereitstellung, müssen vor der Entscheidungsfindung spezifische empirische Daten anhand des entsprechenden Fallbeispiels bezüglich des Endenergiebedarfs der Systeme bewertet werden (Owens 1997). Die Theorie der Ecology of Scale könnte ein wichtiger Schlüssel für die Entscheidung nachhaltiger Prozessketten der Lebensmittelbereitstellung darstellen. Sie verdeutlicht, dass von der Großenordnung der beteiligten Betriebe einen bedeutlichter Einfluss auf die ökologischen Auswirkungen von Prozessketten der Lebensmittelbereitstellung ausgeht (Schlich, 2008). Im Rahmen der vorliegenden Arbeit werden empirische Daten zum Endenergiebedarf der Kenianischen Bereitstellung von Frischmilch gesammelt, unter Anwendung der Technik der Ökobilanzierung. Das Ziel der Studie liegt darin zu untersuchen, ob die Effizienz der Arbeitsabläufe beeinflusst durch die Größe der beteiligten Betriebe, wichtiger ist als die Transportentfernung, bei Berücksichtigung des kompletten Energieaufwands dieser Prozesskette. Energiebilanzierung als ein Teil der Ökobilanzierung wird angewendet, um Endenergieverbrauch und Kohlendioxidemission (CO2), verursacht durch die wichtigsten Prozessketten der Milchbereitstellung, zu ermitteln. Die absoluten Endenergieumsätze werden auf die funktionelle Einheit 1 kg verkaufsfertige Milch bezogen, um spezifische Endenergieumsätze zu erhalten. Die spezifischen Endenergieumsätze werden mit den zugehörigen Betriebsgrößen, die als Milchdurchsatz pro Jahr angegeben werden verglichen. Des Weiteren werden ökologische „hot spots“ identifiziert. Diese Methode wird von Schlich et al. (2006) bereits zur Untersuchung der Bereitstellung weiterer Lebensmittel wie Lammfleisch, Wein, Rindfleisch und Schweinefleisch angewendet. In diesen Untersuchungen wird eine starke logarithmische Abnahme des spezifischen Energieumsatzes mit steigender Betriebsgröße beobachtet, was die Theorie der Ecology of Scale unterstützt, ebenso wie die Ergebnisse der vorliegenden Arbeit. Zusätzlich wird in dieser Studie die Stufe der Landwirtschaft als wichtiger ökologischer „hot spot“ identifiziert, der den größten Endenergieverbrauch im Vergleich zu allen anderen Bereichen dieser Prozessketten der Lebensmittelbereitstellung aufweist. Diesel stellt sich als wichtigster Treibstoff dieser Prozesskette heraus, der für Endenergiesparmaßnahmen mit dem Ziel der Reduktion von CO2-Emissionen genutzt werden kann, Elektrizität und Holz sind jedoch ebenfalls sehr gängige Triebstoffe. Die Anwendung von Endenergiebilanzierungen als Teil der Ökobilanz ist geeignet zur Untersuchung ökologischer Auswirkungen in Form von „hot spot“ und zur Ermittlung von optimalen Betriebgrößen für eine effiziente Endenergienutzung innerhalb von Prozessketten der Lebensmittelbereitstellung in einer sich entwickelnden Wirtschaft

Determinants of Appropriate Child Health and Nutrition Practices among Women in Rural Gambia

Health education and awareness involves providing knowledge about causes of illness and choices to promote a change in individual behaviour and, thus, improves survival of individuals. Studies have, however, shown that improved knowledge and awareness is not always translated into appropriate actions. This study aimed at exploring the factors determining mothers’ choices of appropriate child health and nutrition practices in the Gambia. Eight focus-group discussions (FGDs) were held with 63 women whose children had been seen at the Keneba MRC Clinic within the 12 months preceding the study. The FGDs were analyzed using a thematic framework. Gender inequality, presence or absence of support networks, alternative explanatory models of malnutrition, and poverty were identified as the main factors that would determine the ability of a mother to practise what she knows about child health and nutrition. The findings highlight the need to consider the broader social, cultural and economic factors, including the value of involving men in childcare, when designing nutritional interventions

"I Don't Have Options but to Persevere." Experiences and practices of care for HIV and diabetes in rural Tanzania: a qualitative study of patients and family caregivers.

The high prevalence of chronic diseases in Tanzania is putting a strain on the already stretched health care services, patients and their families. This study sought to find out how health care for diabetes and HIV is perceived, practiced and experienced by patients and family caregivers, to inform strategies to improve continuity of care. Thirty two in-depth interviews were conducted among 19 patients (10 HIV, 9 diabetes) and 13 family caregivers (6 HIV, 7 diabetes). Diabetes patients and caregivers were accessed through one referral facility. HIV patients and caregivers were accessed through HIV clinics at the district hospital, one health centre and one dispensary respectively. The innovative care for chronic conditions framework informed the study design. Data was analysed with the help of Nvivo 10. Three major themes emerged; preparedness and practices in care, health care at health facilities and community support in care for HIV and diabetes. In preparedness and practices, HIV patients and caregivers knew more about aspects of HIV than did diabetes patients and caregivers on diabetes aspects. Continued education on care for the conditions was better structured for HIV than diabetes. On care at facilities, HIV and diabetes patients reported that they appreciated familiarity with providers, warm reception, gentle correction of mistakes and privacy during care. HIV services were free of charge at all levels. Costs involved in seeking services resulted in some diabetes patients to not keep appointments. There was limited community support for care of diabetes patients. Community support for HIV care was through community health workers, patient groups, and village leaders. Diabetes and HIV have socio-cultural and economic implications for patients and their families. The HIV programme is successfully using decentralization of health services, task shifting and CHWs to address these implications. For diabetes and NCDs, decentralization and task shifting are also important and, strengthening of community involvement is warranted for continuity of care and patient centeredness in care. While considering differences between HIV and diabetes, we have shown that Tanzania's rich experiences in community involvement in health can be leveraged for care and treatment of diabetes and other NCDs

Maternal perception of malnutrition among infants using verbal and pictorial methods in Kenya.

OBJECTIVE: To compare mothers' perceptions of their own infants' nutritional status with anthropometric indicators of undernutrition. DESIGN: A qualitative study and cross-sectional quantitative survey. The qualitative study involved developing tools to assess mother's perception. Two methods of verbal description and a pictorial scale were developed. The quantitative survey involved measuring maternal perception and comparing it with the anthropometric measures of weight-for-age Z-score (WAZ) and mid-upper arm circumference-for-age Z-score (MUACZ). SETTING: A rural community setting in Kenya. SUBJECTS: Seventy-four infants aged between 4 and 6 months, and their mothers, living in rural Kenya were enrolled. RESULTS: Using verbal description, the positive and negative likelihood ratios were 3.57 (95 % CI 1.44, 9.98) and 0.69 (95 % CI 0.50, 0.96) respectively for MUACZ<-2; and 4.60 (95 % CI 1.60, 13.3) and 0.67 (95 % CI 0.49, 0.92) respectively for WAZ<-2. Using the pictorial scale, the positive and negative likelihood ratios were 8.30 (95 % CI 1.91, 36.3) and 0.69 (95 % CI 0.52, 0.93) respectively for MUACZ<-2; and 4.31 (95 % CI 1.22, 15.0) and 0.78 (95 % CI 0.61, 1.00) respectively for WAZ<-2. CONCLUSIONS: In a rural community, mothers better identify undernutrition in their infants using a pictorial scale than verbal description. However, neither can replace formal anthropometric assessment. Objective anthropometric tools should be validated for identification of severe acute malnutrition among infants aged less than 6 months

A qualitative study of the determinants of HIV guidelines implementation in two south-eastern districts of Tanzania.

Current HIV policies in Tanzania have adopted the three long-term impact results of zero new infections, zero HIV deaths and zero stigma and discrimination. Strategies to reach these results include scaling-up HIV Testing and Counselling (HTC); Preventing Mother-To-Child Transmission (PMTCT); and strengthening Care and Treatment Clinic (CTC) services. Previous studies showed that HIV policy and guideline recommendations were not always implemented in rural South Tanzania. This study aims to identify the determinants of HIV guideline implementation. A qualitative study of 23 semi-structured interviews with facility in-charges; healthcare workers; district, regional and national HIV coordinators was conducted. Five health facilities were purposively selected by level, ownership and proximity to district headquarters. Interviews were analysed according to Fleuren's five determinants of innovation uptake related to: strategies used in guideline development and dissemination; guideline characteristics; the guideline implementing organization; guideline users; and the socio-cultural and regulatory context. None of the facilities had the HTC national guideline document. Non-involvement of providers in revisions and weak planning for guideline dissemination impeded their implementation. Lengthy guidelines and those written in English were under-used, and activities perceived to be complicated, like WHO-staging, were avoided. Availability of staff and lack of supplies like test kits and medication impeded implementation. Collaboration between facilities enhanced implementation, as did peer-support among providers. Provider characteristics including education level, knowledge of, and commitment to the guideline influenced implementation. According to providers, determinants of clients' service use included gender norms, stigma, trust and perceived benefits. The regulatory context prohibited private hospitals from buying HIV supplies. Being tools for bringing policies to practice, national guidelines are crucial in the efforts towards the three zeros. Strategies to improve providers' adherence to guidelines should include development of clearer guideline dissemination plans, strengthening of the health system, and possibly addressing of provider-perceived patient-level barriers to utilizing HIV services

Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research.

BACKGROUND: Globally, some 4.7 million infants aged under 6 months are moderately wasted and 3.8 million are severely wasted. Traditionally, they have been over-looked by clinicians, nutritionists, and policy makers. OBJECTIVE: To present evidence and arguments for why treating acute malnutrition in infants under 6 months of age is important and outline some of the key debates and research questions needed to advance their care. METHODS: Narrative review. RESULTS AND CONCLUSIONS: Treating malnourished infants under 6 months of age is important to avoid malnutrition-associated mortality in the short-term and adverse health and development outcomes in the long-term. Physiological and pathological differences demand a different approach from that in older children; key among these is a focus on exclusive breastfeeding wherever possible. New World Health Organization guidelines for the management of severe acute malnutrition (SAM) include this age group for the first time and are also applicable to management of moderate acute malnutrition (MAM). Community-based breastfeeding support is the core, but not the sole, treatment. The mother-infant dyad is at the heart of approaches, but wider family and community relationships are also important. An urgent priority is to develop better case definitions; criteria based on mid-upper-arm circumference (MUAC) are promising but need further research. To effectively move forward, clinical trials of assessment and treatment are needed to bolster the currently sparse evidence base. In the meantime, nutrition surveys and screening at health facilities should routinely include infants under 6 months of age in order to better define the burden and outcomes of acute malnutrition in this age group