An Evaluation of Integrated Interventions to Improve Access to Malaria Treatment in Tanzania (ACCESS PROGRAMME)\ud

Malaria causes an estimated one million deaths annually although it is a curable disease if treated promptly and correctly. Most cases occur in young children in sub-Saharan Africa, supporting a vicious circle of disease and poverty. Hence, ensuring access to malaria treatment is a major public health and development priority. The purpose of this research was to evaluate the ACCESS programme, which aimed at understanding and improving access to malaria treatment in rural Tanzania. This evaluation focuses on the first phase of implementation of the programme, which covered the years between 2004 and 2008. The ACCESS strategy is based on a set of integrated interventions at three levels: 1) community level; 2) public heath facilities; and 3) commercial drug sector. The interventions are accompanied by a comprehensive set of monitoring and evaluation activities. Between 2004 and 2007 the ACCESS programme’s main intervention at community level was a social marketing campaign for improved recognition of the disease and more effective care seeking. Various communication channels were used and material developed to disseminate information on malaria transmission, symptoms and prevention as well as to stress the importance of prompt and effective treatment. Road shows were the main activity and included role plays, public lectures and quizzes. In addition, promotional materials (e.g. stickers, leaflets, t-shirts) were distributed, and billboards and posters displayed in public places. In health facilities the ACCESS programme intervened to improve quality of care. The main activity was refresher training for health facility staff based on Integrated Management of Childhood Illness (IMCI) algorithms conducted in 2004 and 2005. In addition the study period saw the change of the first line treatment for malaria. In 2006 the Government of Tanzania switched from Sulphadoxine Pyrimethamine (SP) to the highly efficacious Artemether Lumefantrine (ALu), due to the high levels of resistance to SP. In parallel the Accredited Drug Dispensing Outlets (ADDOs) programme was rolled out in the study area from 2006 onwards to improve access to treatment and quality of care in commercial drug shops. The private retail sector plays a very important role in the delivery of antimalarial treatment in most African countries as retailers tend to be more accessible and flexible, especially with regards to opening hours and charges. However, unqualified staff invariably sell drugs they are not allowed to stock, which often includes antimalarials. The aim of the ADDO programme is to improve access to quality care in drug shops with a mix of dispenser training, incentives, accreditation and regulation. ALu was made available to the programme at a highly subsidised price towards the end of 2007. Findings from the monitoring and evaluation activities showed that access to malaria treatment improved following the interventions in health facilities and drugs shops. Drug shops became more available to the community (from 24 shops for every 100,000 people in 2004 to 39 in 2008) and more accessible (from 71% of households within 5km of a shop in 2004 to 87% in 2008) following the ADDO roll-out. In addition, the 2006 change of treatment policy from SP to ALu led to an increase in the availability of antimalarial drugs in health facilities (from 40% to 80% of months in stock of the drug). Treatment was generally more expensive in drug shops compared to health facilities and prices increased by 50-80% in shops between 2004 and 2008. Nevertheless, antimalarial sales in private retail grew (from 49% to 59% of market shares). This is likely to be a result of increased availability and accessibility of shops but better quality of care may also have played a role. Unfortunately the ADDO programme was not able to promote widespread availability of ALu in its outlets (only one third of outlets were found to stock the drug in 2008). This resulted in a low uptake of the new drug (19% of all malaria treatments sold or dispensed) despite the fact that it was available in almost all the health facilities in the area. Results from treatment seeking surveys conducted in the community showed an improvement in malaria treatment between 2004 and 2008. This was ascribed to: 1) improved access to treatment; and 2) a better understanding of the importance of prompt treatment thanks to social marketing campaigns. The proportion of fever cases treated with an antimalarial increased (from 86% to 96% between 2004 and 2008) as well as the proportion of cases treated promptly (80% to 93-97% doses started within 24 hrs). However, the proportion of cases taking a recommended treatment was only 53% in 2008 since many cases were treated in the private retail sector where the first line treatment ALu was not widely available. Improved treatment appears to have had an impact on malaria morbidity and mortality. Community surveys showed a 28% decrease in the incidence of fever (from 2.5 to 1.8 average cases per person per year between 2005 and 2008). Under-five mortality decreased by 17% after the ACCESS interventions (from 28.4 cases per 1000 person years in the period 1997-2004 to 18.9 cases in 2008). However, due to the absence of a control it is difficult to know how much the ACCESS interventions contributed to this decrease compared to other malaria control strategies implemented in the area. In conclusion this thesis has shown that an integrated approach tackling both users and providers can lead to tangible improvements in access to malaria. This can in turn have a substantial impact on morbidity and mortality. Interventions targeting providers in sub-Saharan Africa should recognise the important role of the private sector. Social marketing has proven to be a successful strategy to sensitise users on the importance of prompt treatment

Concepción del tiempo, de la vida y de la muerte en la Mendoza colonial

El presente trabajo pertenece a una investigación más extensa sobre el tema “La Religiosidad en Mendoza durante los siglos XVII y XVIII", que hemos venido realizando desde hace algunos años. Ante la necesidad de llenar un vacío importante en el estudio de esta temática de la Historia Regional, creemos interesante y útil investigar sobre aspectos de la religiosidad colonial en nuestra ciudad, siempre desde la óptica de una Historia de las Mentalidades, puntualmente las que se refieren a la concepción del tiempo, de la vida y de la muerte en aquella época. Entendemos que esta perspectiva de análisis metodológico, nos permite iluminar aquellos factores que actúan como motor en el comportamiento humano frente al entorno y sus distintos sucesos, atendiendo especialmente a lo colectivo, a lo cotidiano y automático, a lo que parece inconsciente y que escapa a los sujetos individuales.This work belongs to a wider research that we have been doing for some years, about the Topic, “Religiosity in Mendoza during the XVII and XVIII centuries". Since we have realized the need of completing the study on this subject of regional History, we think it will be interesting and useful to investigate about the different aspects of the colonial religiosity in our town, always talking into account the History of the mentalities, especially the ones which are referred to the conception of time, life and death in those early times. We believe that this perspective of methodological analysis, enlightens the factors that factors that act as the main parts in human behavior within the environment and its different events paying attention especially to the group action, the daily activities and the automatic. That is to say those things which seem to be unconscious and that are not important to individuals.Fil: Acevedo, Alba. Universidad Nacional de Cuyo. Facultad de Filosofía y LetrasFil: Pérez Stocco, Sandra. Universidad Nacional de Cuyo. Facultad de Filosofía y Letra

Morir como Dios manda : religiosidad popular y devociones en los testamentos de la Mendoza colonial

Después del descubrimiento de América, y a medida que se iba desarrollando la vida de la sociedad colonial, se instaló en estas tierras una de las bases fundamentales de la vida jurídica, tal fue la de la Escribanía o Notaría. Hoy, los archivos de esta institución nos dan la posibilidad de acercarnos a uno de los tantos documentos que componen los expedientes notariales: el testamento, definido como aquel instrumento jurídico a través del cual se canalizan los problemas que ocasiona la muerte. Documento profano, pero esencialmente religioso en su concepción, el testamento nos proporciona el mejor testimonio de la preparación para la buena muerte, en paz con Dios y con los hombres. En aquel lejano tiempo, la muerte era un hecho cotidiano, constante, un acto que se podía presentar en cualquier momento y que convivía con el hombre de un modo diferente al de la sociedad contemporánea. En general ante ella, se tenía la actitud cristiana de resignación al tiempo, lugar y forma en que Dios dispusiera el final de la vida. En esta ocasión, el criterio adoptado en la selección de los testamentos, que han sido incluidos en este artículo, intenta reflejar las disposiciones testamentarias de un universo social variado teniendo en cuenta blancos, indígenas, varones, mujeres, personas en situación socioeconómica acomodada y también otras con una situación más humilde.Die as God intended. Popular Religiosity and Devotion in the Testaments of Colonial Mendoza. After the discovery of America, and as life was developing, colonial society settled in this land one of the cornerstones of legal life, such was the Clerk or Notary. 52 Alba Acevedo – Sandra Pérez Stocco Today, the files of this institution give us the possibility to approach one of several documents that comprises the records of attorney: the testament, defined as the legal instrument through which the problems that caused death are channeled. A Document profane, but essentially religious in its conception, the will gives us the best assurance of good preparation for death, at peace with God and men. In such distant time, death was a daily fact, constant, an act that could be submitted at any time and that lived with the man in a different way of contemporary society. In general before death, the Christian had an attitude of resignation to time, place and manner in which God has ordained the end of life. This time, the approach taken in the selection of wills, which have been included in this article tries to reflect the testamentary provisions of a varied social universe, taking into account whites, Indians, men, women, socio-economically well-off people and also others in a humble situation.Fil: Acevedo, Alba. Universidad Nacional de CuyoFil: Pérez Stocco de Buere, Sandra. Universidad Nacional de Cuy

Procedimiento para la donación de Sangre de Cordón Umbilical. Revisión bibliográfica

La sangre de cordón umbilical es considerada, hoy en día, una alternativa eficaz para la realización de trasplantes hematopoyéticos debido a su alto contenido en células madre. Desde su descubrimiento, el uso de esta fuente celular se ha hecho más frecuente gracias a la creación de bancos públicos que almacenan las unidades donadas. Entre otras ventajas, como una escasa alorreactividad y una disponibilidad inmediata para su trasplante, la obtención de sangre de cordón se realiza mediante un proceso sencillo e inocuo para la mujer y su hijo. Teniendo como principal objetivo conocer el proceso para la donación de sangre de cordón umbilical, se realizó una búsqueda bibliográfica en diferentes bases de datos mediante tesauros y palabras naturales, unidas entre sí por los operadores booleanos “AND” y “OR”. Además, se consultó el Boletín Oficial del Estado, un Plan Nacional, varios sitios web y revistas de enfermería, considerando válidos un total de 13 artículos. El proceso de donación conlleva una sucesión de pasos, desde la entrega de información, hasta la recogida de la sangre de cordón umbilical, en los que la enfermera, especialmente la matrona, cumple una labor primordial, teniendo especial importancia la técnica de recolección, ya que de ella dependerá la calidad y cantidad de la muestra donada y su posible utilidad en un futuro trasplante. Asimismo, es fundamental la promoción de la donación, ya que, por un lado, cada día son más los trasplantes de sangre de cordón umbilical que se realizan, y por otro, las evidencias de la utilidad de dicha sangre para uso autólgo son muy escasasGrado en Enfermerí

Diseño, implementación y evaluación de un demostrador de captura y procesamiento de audio multicanal en espacios inteligentes

Este proyecto describe el diseño, desarrollo, implementación y evaluación de un demostrador en tiempo real de captura y procesamiento de audio multicanal para localización de hablantes mediante agrupaciones de micrófonos dentro de espacios inteligentes. Para conseguir este objetivo se han combinado los resultados de trabajos previos de otros Proyectos Fin de Grado y Fin de Máster en los que se desarrollaron librerías de adquisición y reproducción de audio multicanal, algorítmica de detección de actividad de voz en entornos con agrupaciones de micrófonos, módulos de visualización de entornos virtuales y algorítmica de localización de locutores, integrando su funcionalidad y adaptándola a las exigencias del funcionamiento en tiempo real. Asimismo, se ha completado el hardware disponible en la sala ispace, que consta de dos agrupaciones de micrófonos, implementando las conexiones oportunas para añadir dos nuevos arrays al sistema, estudiando la geometría de estos. Asimismo, se ha diseñado e implementado un quinto array que consta de una nueva topología con el fin de estudiar sus ventajas. Palabras clave: Localización acústica, detección de actividad de voz, demostrador en tiempo real, procesamiento basado en agrupaciones de micrófonos, espacio inteligente.This project describes the design, development, implementation and evaluation of a real time demonstrator of multi-channel audio capture and processing for localization of speakers using microphone arrays in smart spaces. To achieve this goal it has been combined the results of previous Thesis which developed multichannel acquisition and reproduction libraries, activity voice detection algorithms in environments with microphone clusters, virtual environment visualization modules and speaker location algorithms, integrating their functionalities and adapting them to real time operating requirements. Likewise, the hardware available in the room ispace, which consists of two groups of microphones, has been completed, implementing the appropriate connections to add two new arrays to the system, studying the geometry of these. In addition, a fifth array consisting of a new topology has been designed and implemented in order to study its advantages. Keywords: Acoustic localization, voice activity detection, real time demonstration, microphone array processing, smart space.Grado en Ingeniería Electrónica de Comunicacione

Una nueva identidad para los farmacéuticos : la Sociedad Farmacéutica Mexicana en el cambio de siglo (1890-1919)

La Sociedad Farmacéutica Mexicana fue fundada en 1871. En su interior los farmacéuticos se organizaron y apoyaron las tareas necesarias para el desarrollo de su profesión : elaborar una farmacopea, velar por los intereses y el mejoramiento de la profesión, y reunir las leyes relativas al ejercicio de la farmacia. La Sociedad desempeñó un importante papel en el proceso de institucionalización de la farmacia y en la conquista de nuevos espacios, particularmente en lo referente al traslado de la carrera de farmacia de la Escuela Nacional de Medicina a la Facultad de Ciencias Químicas en 1919. En este establecimiento los farmacéuticos asumieron una nueva identidad como químicos

Mystery Shopping in Community Drug shops: Research as Development in Rural Tanzania

Throughout Africa, the private sector plays an important role in malaria treatment complementing formal health\ud services. However this sector is faced by a number of challenges including poor dispensing practices by unqualified staff. The Accredited Drug Dispensing Outlet (ADDO) program was introduced in Tanzania in 2002 to improve\ud the quality of retail services and especially of dispensing practices. The study adapted the often contested mystery\ud shopping methodology and trained local community members to assess practices of ADDO dispensers. The study then compared the assessed dispensers’ practices before and after ADDO interventions. Mystery shoppers were identified in the villages with the assistance of Health Demographic Surveillance System field staff. A total of 865 visits were made to general shops and drug shops between 2004 and 2009. Three case scenarios were developed to assess the quality of treatment; a) child aged 2 - 4 months, with fever/hot body for one day and problems with drinking/breastfeeding, b) child aged 2 - 4 years, with recurring fever/hot body for 3 days problems with drinking, eating, diarrhoea and tiredness/ not playing as usual and c) adult, with recurring fever/hot body for 2 days, headache, dizziness and loss of appetite. Study findings indicate improvements in dispensers’ knowledge and practices in management of fever, especially after the roll out of ADDO program in the study area. A 30 percent increase was noted after ADDO interventions on four assessed indicators developed based on the national malaria control guideline on malaria case management. On the other hand advice on the use of Insecticide Treated Nets as a measure to prevent malaria was not consistent over years even after ADDO interventions.\ud Children aged two to four years and adults were more likely to be provided with anti-malarials than children\ud between two to four months. Despite challenges posed against the methodology, findings reveals how useful\ud the mystery shopping technique can be for community assessments of ADDO interventions in retail outlets.\ud Study findings signify the importance of ADDO interventions in improving malaria case management in drug retail\ud outlets. If ADDOs are closely monitored and strengthened to provide appropriate malaria treatment and the program\ud is rolled throughout the country, a reduction in malaria morbidity and mortality is possible in the country. Innovative community based participatory research approaches and more systematic mystery shopping techniques would allow for comparative community-based assessments of ADDO interventions across regions.\u

Child mortality patterns in rural Tanzania: an observational study on the impact of malaria control interventions

Background Between 1997 and 2009, a number of key malaria control interventions were implemented in the Kilombero and Ulanga Districts in south central Tanzania to increase insecticide-treated nets (ITN) coverage and improve access to effective malaria treatment. In this study we estimated the contribution of these interventions to observed decreases in child mortality. Methods The local Health and Demographic Surveillance Site (HDSS) provided monthly estimates of child mortality rates (age 1 to 5 years) expressed as cases per 1000 person-years (c/1000py) between 1997 and 2009. We conducted a time series analysis of child mortality rates and explored the contribution of rainfall and household food security. We used Poisson regression with linear and segmented effects to explore the impact of malaria control interventions on mortality. Results Child mortality rates decreased by 42.5% from 14.6 c/1000py in 1997 to 8.4 c/1000py in 2009. Analyses revealed the complexity of child mortality patterns and a strong association with rainfall and food security. All malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security. Conclusions Reaching the fourth Millenium Development Goal will require the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions. Distinguishing between the effects of these multiple factors is difficult and represents a major challenge in assessing the effect of routine interventions. However, this study suggests that credible estimates can be obtained when high-quality data on the most important factors are available over a sufficiently long time perio

Assessing the impact of malaria interventions on morbidity through a community-based surveillance system

Background The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment in rural Tanzania with a set of integrated interventions targeting both users and providers. The aim of this article is to evaluate the programme's impact on the community and health facility burden of malaria and to investigate the value of community-based reporting for routine malaria control programme monitoring. Methods This work was implemented within the Ifakara Demographic Surveillance System (DSS) between 2004 and 2008. At community level the DSS staff routinely collected data on reported history of fever and severe malaria (convulsions) based on a 2-week recall. In parallel, we collected in-patient and out-patient fever and malaria diagnoses data from the 15 health facilities in the area. Treatment-seeking surveys conducted in the study area and nationally representative data were used to validate our measure of community fever. Results Between 2005 and 2008, community-reported fever incidence rates in children under the age of 5 years declined by 34%, from 4.9 to 3.2 average cases per child per year, whereas convulsions, a marker of severe malaria morbidity in children, decreased by 46%, from 4263 to 2320 cases for every 100 000 children per year. The decrease in the community rates was paralleled by a decrease in the health facility fever rates, although the number of fever cases seen in health facilities did not change because of population growth. Our data showed very good internal and external consistency with independent local and national surveys. Conclusions There is an evidence of a substantial decline in the community burden of malaria morbidity between 2005 and 2008 in the Kilombero and Ulanga DSS areas in Tanzania, most likely as a result of malaria control efforts. The good internal and external consistency of the data shows that history of fever in the previous 2 weeks in children under the age of 5 years can be used as a morbidity monitoring too