Factors influencing implementation of integrated management of childhood illness in Lindi Region, Southern Tanzania

Background: Save the Children Tanzania has been supporting several projects in Lindi Region including implementation of health facility based Integrated Management of Childhood Illness (IMCI) services in Kilwa, Ruangwa and Lindi rural districts. The objective of this study was to assess the IMCI services in a sample of health facilities and explore factors affecting the service provision and sustainability in Lindi, Tanzania.Methods: A cross-sectional study was conducted involving 27 health facilities. Quantitative and qualitative approaches were used to collect the required data. Focus group discussions and in-depth interviews were also used to evaluate the IMCI services in these facilities.Results: All health facilities visited were found to have adequate supply of IMCI equipment. However, there was inadequate availability and distribution of clinical officers in the districts. None of the 41 clinical officers observed, assessed sick children for all items in the IMCI checklist. Furthermore, health centres and dispensaries were found to have a serious shortage of essential medicines. Oral antibiotics for bacterial infections were available across health facilities. Amoxicillin was found in 4(44%) health centres and 7 (46.7%) dispensaries; Ampicillin was only available at 4(44.4%) health centres and 1 (6.7%) dispensary. Considerable challenges in access to health services were identified and they included long distances to health facilities, inadequate and unaffordable transport systems and continuous limited quality of care due to shortages of trained staff and drug stock outs. In addition, caregivers were found to have limited awareness of danger signs and symptoms of childhood illnesses.Conclusions: The implementation of IMCI services in the three districts of Lindi region experiences multiple challenges despite the availability of adequate infrastructure for program implementation. This calls for strengthened supportive supervision, constant provision of medical supplies and training of IMCI health workers to improve services delivery to sick children. In addition community level promotion of prompt modern health care seeking behaviour is essential to enhance childhood illness care and treatment

Prevalence of Bacterial Febrile Illnesses in Children in Kilosa District, Tanzania.

Bacterial etiologies of non-malaria febrile illnesses have significantly become important due to high mortality and morbidity, particularly in children. Despite their importance, there are few reports on the epidemiology of these diseases in Tanzania, and the true burden of such illnesses remains unknown. This study aimed to identify the prevalence of leptospirosis, brucellosis, typhoid fever and urinary tract infections and their rate of co-infections with malaria. A cross-sectional study was conducted at Kilosa district hospital in Tanzania for 6 months. Febrile children aged from 2-13 years were recruited from the outpatient department. Patients were screened by serological tests such as IgM and IgG ELISA, and microscopic agglutination test. A total of 370 patients were enrolled; of these 85 (23.0%) had malaria parasites, 43 (11.6%) had presumptive acute leptospirosis and 26/200 (13%) had confirmed leptospirosis. Presumptive acute brucellosis due to B. abortus was identified among 26 (7.0%) of patients while B. melitensis was detected in 57 (15.4%) of the enrolled patients. Presumptive typhoid fever due to S. Typhi was identified in thirty eight (10.3%) of the participants and 69 (18.6%) had urinary tract infections. Patients presented with similar symptoms; therefore, the identification of these diseases could not be done based on clinical ground alone. Co-infections between malaria and bacterial febrile illnesses were observed in 146 patients (39.5%). Although antibacterials and/or anti-malarials were prescribed in most patients, some patients did not receive the appropriate treatment. The study has underscored the importance of febrile bacterial diseases including zoonoses such as leptospirosis and brucellosis infebrile children, and thus such illnesses should be considered by clinicians in the differential diagnoses of febrile diseases. However, access to diagnostic tests for discrimination of febrile illnesses is needed. This would allow febrile patients to receive the correct diagnoses and facilitation of accurate and prompt treatment

Enhancing HIV status disclosure and partners’ testing through counselling in Tanzania

Background: In Tanzania HIV Testing and Counselling (HTC) is being implemented through voluntary counselling and testing (VCT), provider initiated counselling and testing (PITC) and work place counselling and testing (HTC). Within these programmes, HIV status disclosure is emphasized. However, among persons who test HIV positive, many do not disclose their status to their partners and social networks.  However, data are lacking on the effectiveness of the different HTC strategies on HIV positive status disclosure.Objective: To investigate which of the three HIV Testing and Counselling (HTC) strategies: Voluntary Counselling and Testing (VCT), Provider Initiated Counselling and Testing (PITC) and work place Counselling and testing is associated with improved HIV-positive status disclosure in Eastern Tanzania.Methods: Structured interviews were conducted with 455 newly diagnosed HIV-positive clients at 6 HTC sites during enrolment and at three months follow-up to collect data on disclosure status.Results: We found that PITC strategy attended a relatively higher proportion of clients 182/455(40.1%) as compared to VCT 169/455 (37.1%) and work place HTC strategies 104/455(22.9%) respectively. Among clients, about one third 130/455(28.6%) were found to be HIV-positive. HIV status disclosure rates were variable and were in order of preference of disclosing to family members 86/130(66.2 %), followed by relatives 74/130(56.9%) and sexual partners 71/130(54.6%). A high proportion of participants 77/130(59.2%) experienced violence acts from sexual partners in form of stigma and discrimination, abuse, divorce and termination from employment. In the multivariate logistic regression, disclosure to sexual partners was associated with violence acts of about two times higher (Disclosure to Partners OR=1.89) when compared to the group that did not disclose to their partners.Conclusion: PITC strategy was found to result into higher rates of HIV positive status disclosure when compared to VCT and work place HTC strategies. Stigma, discrimination and violence acts are still prevalent in Tanzania and discourages HIV positive status disclosure. Based on these findings, there is an urgent need of promoting public education on HIV transmission, prevention and treatment and enhancing strategies to reduce risky sexual behaviour and increase condom use

Differences in Life-Saving Obstetric Hemorrhage Treatments for Women with Abortion Versus Nonabortion Etiologies in Tanzania.

Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving interventions among women with abortions versus other maternal hemorrhage etiologies. Interventions included: non-pneumatic anti-shock garment (NASG) (N = 393), blood transfusion (N = 249), and referral to a higher-capacity facility (N = 131). After controlling for severity of disease and other confounders, women with abortion-related hemorrhage and shock had 78 percent decreased odds of receiving NASG (p < 0.001) and 77 percent decreased odds of receiving a blood transfusion (p < 0.001) compared to women with hemorrhage and shock from other etiologies. Our findings suggest that, in Tanzania, women with abortion-related hemorrhage received lower quality of care than women with other hemorrhage etiologies

Prevalence and Correlates of Cardio-Metabolic Risk Factors Among Regular Street Food Consumers in Dar es Salaam, Tanzania

Background: Regular street food consumers (RSFCs) in Africa are at an increased risk of unhealthy eating practices, which have been associated with intermediate risk factors of cardio-metabolic diseases. However, knowledge of the magnitude and correlates of these risk factors is limited in Tanzania. This study aimed to fill this gap using data collected from RSFCs in Dar es Salaam, the largest city in Tanzania. Methodology: A cross-sectional study was carried out among 560 RSFCs in three districts of Dar es Salaam between July and September 2018. Information on socio-economic factors and demographics, behavioral risks, anthropometric and biochemical indicators was collected. Adjusted odds ratios (OR) and prevalence ratio (PR) with corresponding 95% confidence intervals (CI) were estimated using multivariable binary logistic and modified Poisson regression models, respectively. Results: On average, participants consumed 11 street food meals/week. The prevalence (95% CI) of cardio-metabolic risk factors was 63.9% (60.6– 69.9%) for overweight/obesity, 42.5% (38.3– 46.9%) for raised blood pressure, 13.5% (10.9– 16.8%) for raised triglycerides and 6.6% (4.9– 9.3%) for raised glucose levels. The correlates of overweight/obesity were female vs male sex (APR=1.3; 95% CI 1.2– 1.5), age of 41– 64 vs 25– 40 years (APR=1.4; 95% CI 1.2– 1.6), high vs low income (APR=1.2; 95% CI 1.04– 1.3), being married/cohabiting vs other (APR=1.2; 95% CI 1.01– 1.4) and family history of diabetes vs no family history (APR=1.2; 95% CI 1.01– 1.3). Age 41– 64 vs 25– 40 years, was the only significant factor associated with raised blood pressure APR (95% CI) 2.2 (1.7– 2.9) and raised glucose AOR (95% CI) 3.9 (1.5– 10.5). Conclusion: Our study revealed that RSFCs are at risk of cardio-metabolic health problems, especially women, middle-aged people and those with higher incomes. Transdisciplinary studies to understand the drivers of street food consumption are needed in order to inform interventions to mitigate the risk of developing cardio-metabolic diseases. These interventions should target both street food vendors and their consumers. Keywords: street food consumers, cardio-metabolic risks, cardio-metabolic correlates, Tanzani

Household factors associated with access to insecticide-treated nets and house modification in Bagamoyo and Ulanga districts, Tanzania.

BACKGROUND: Insecticide-treated nets (ITNs) and house modifications are proven vector control tools, yet in most regions, full coverage has not been achieved. This study investigates household factors associated with access to ITNs and house modification in Tanzania. METHODS: Baseline cross-sectional survey data from previous studies on spatial repellants and indoor residual spray evaluation was analysed from 6757 households in Bagamoyo (60 km north of Dar es Salaam) and 1241 households in Ulanga (a remote rural area in southeast Tanzania), respectively. Regression models were used to estimate the associations between the outcomes: population access to ITNs, access to ITN per sleeping spaces, window screens and closed eaves, and the covariates household size, age, gender, pregnancy, education, house size, house modification (window screens and closed eaves) and wealth. RESULTS: Population access to ITNs (households with one ITN per two people that stayed in the house the previous night of the survey) was 69% (n = 4663) and access to ITNs per sleeping spaces (households with enough ITNs to cover all sleeping spaces used the previous night of the survey) was 45% (n = 3010) in Bagamoyo, 3 years after the last mass campaign. These findings are both lower than the least 80% coverage target of the Tanzania National Malaria Strategic Plan (Tanzania NMSP). In Ulanga, population access to ITNs was 92% (n = 1143) and ITNs per sleeping spaces was 88% (n = 1093), 1 year after the last Universal Coverage Campaign (UCC). Increased household size was significantly associated with lower access to ITNs even shortly after UCC. House modification was common in both areas but influenced by wealth. In Bagamoyo, screened windows were more common than closed eaves (65% vs 13%), whereas in Ulanga more houses had closed eaves than window screens (55% vs 12%). CONCLUSION: Population access to ITNs was substantially lower than the targets of the Tanzania NMSP after 3 years and lower among larger households after 1 year following ITN campaign. House modification was common in both areas, associated with wealth. Improved access to ITNs and window screens through subsidies and Behaviour Change Communication (BCC) strategies, especially among large and poor households and those headed by people with a low level of education, could maximize the uptake of a combination of these two interventions

Nutrients’ distribution and their impact on Pangani River Basin’s ecosystem – Tanzania

Research Articles published by Taylor & Francis GroupSurface and groundwater from Pangani River Basin (PRB) were sampled in dry and wet seasons, analysed for dissolved organic and inorganic nutrients (N, P, Si and Urea). There was spatial and seasonal nutrients’ variability, with enrichment of dissolved inorganic fractions accumulated from natural and anthropogenic sources. Silicates increased in dry season, whereas nitrate, ammonium, phosphate and urea increased in wet season; except for phosphate, other nutrients increased from upstream to the river mouth. High rate of chemical weathering possibly due to tropical climate and volcanic rocks has caused PRB to have higher concentration of silicates than average freshwater African Rivers. Contribution of PRB to the coast of Indian Ocean was 2.6, 39.0, 45.2, 67.4 and 5444.8 (mol/km2/yr) for nitrite, phosphate, ammonium, nitrate and silicates, respectively, which were lower than most of the tropical rivers in the world. Levels of nitrate and phosphate for most of the stations were higher than recommended levels for aquatic ecosystem health. Furthermore, observed hypoxia condition in some stations threatens aquatic life. This study recommends the efficient use of fertilizers to reduce nutrients’ uptake into the lakes and rivers so as to meet the recommended level for aquatic and human health

Do health systems delay the treatment of poor children? A qualitative study of child deaths in rural Tanzania.

Child mortality remains one of the major public-health problems in Tanzania. Delays in receiving and accessing adequate care contribute to these high rates. The literature on public health often focuses on the role of mothers in delaying treatment, suggesting that they contact the health system too late and that they prefer to treat their children at home, a perspective often echoed by health workers. Using the three-delay methodology, this study focus on the third phase of the model, exploring the delays experienced in receiving adequate care when mothers with a sick child contact a health-care facility. The overall objective is to analyse specific structural factors embedded in everyday practices at health facilities in a district in Tanzania which cause delays in the treatment of poor children and to discuss possible changes to institutions and social technologies. The study is based on qualitative fieldwork, including in-depth interviews with sixteen mothers who have lost a child, case studies in which patients were followed through the health system, and observations of more than a hundred consultations at all three levels of the health-care system. Data analysis took the form of thematic analysis. Focusing on the third phase of the three-delay model, four main obstacles have been identified: confusions over payment, inadequate referral systems, the inefficient organization of health services and the culture of communication. These impediments strike the poorest segment of the mothers particularly hard. It is argued that these delaying factors function as 'technologies of social exclusion', as they are embedded in the everyday practices of the health facilities in systematic ways. The interviews, case studies and observations show that it is especially families with low social and cultural capital that experience delays after having contacted the health-care system. Reductions of the various types of uncertainty concerning payment, improved referral practices and improved communication between health staff and patients would reduce some of the delays within health facilities, which might feedback positively into the other two phases of delay

The chicken or the egg? Exploring bi-directional associations between Newcastle disease vaccination and village chicken flock size in rural Tanzania

Newcastle disease (ND) is a viral disease of poultry with global importance, responsible for the loss of a potential source of household nutrition and economic livelihood in many low-income food-deficit countries. Periodic outbreaks of this endemic disease result in high mortality amongst free-ranging chicken flocks and may serve as a disincentive for rural households to invest time or resources in poultry-keeping. Sustainable ND control can be achieved through vaccination using a thermotolerant vaccine administered via eyedrop by trained "community vaccinators". This article evaluates the uptake and outcomes of fee-for-service ND vaccination programs in eight rural villages in the semi-arid central zone of Tanzania. It represents part of an interdisciplinary program seeking to address chronic undernutrition in children through improvements to existing poultry and crop systems. Newcastle disease vaccination uptake was found to vary substantially across communities and seasons, with a significantly higher level of vaccination amongst households participating in a longitudinal study of children's growth compared with non-participating households (p = 0.009). Two multivariable model analyses were used to explore associations between vaccination and chicken numbers, allowing for clustered data and socioeconomic and cultural variation amongst the population. Results demonstrated that both (a) households that undertook ND vaccination had a significantly larger chicken flock size in the period between that vaccination campaign and the next compared with those that did not vaccinate (p = 0.018); and (b) households with larger chicken flocks at the time of vaccination were significantly more likely to participate in vaccination programs (p < 0.001). Additionally, households vaccinating in all three vaccination campaigns held over 12 months were identified to have significantly larger chicken flocks at the end of this period (p < 0.001). Opportunities to understand causality and complexity through quantitative analyses are limited, and there is a role for qualitative approaches to explore decisions made by poultry-keeping households and the motivations, challenges and priorities of community vaccinators. Evidence of a bi-directional relationship, however, whereby vaccination leads to greater chicken numbers, and larger flocks are more likely to be vaccinated, offers useful insights into the efficacy of fee-for-service animal health programs. This article concludes that attention should be focused on ways of supporting the participation of vulnerable households in ND vaccination campaigns, and encouraging regular vaccination throughout the year, as a pathway to strengthen food security, promote resilience and contribute to improved human nutrition

"In starvation, a bone can also be meat": a mixed methods evaluation of factors associated with discarding of long-lasting insecticidal nets in Bagamoyo, Tanzania.

BACKGROUND: Between 2000 and 2019, more than 1.8 billion long-lasting insecticidal nets (LLINs) were distributed in Africa. While the insecticidal durability of LLINs is around 3 years, nets are commonly discarded 2 years post distribution. This study investigated the factors associated with the decision of users to discard LLINs. METHODS: A mixed-method sequential explanatory approach using a structured questionnaire followed by focus group discussions (FGDs) to collect information on experiences, views, reasons, how and when LLINs are discarded. Out of 6,526 households that responded to the questionnaire of LLINs durability trial, 160 households were randomly selected from the households in four villages in Bagamoyo Tanzania for FGDs but only 155 households participated in the FGDs. Five of the household representatives couldn't participate due to unexpected circumstances. A total of sixteen FGDs each comprising of 8-10 adults were conducted; older women (40-60 years), older men (40-60 years), younger women (18-39 years), younger men (18-39 years). During the FGDs, participants visually inspected seven samples of LLINs that were "too-torn" based on Proportionate Hole Index recommended by the World Health Organization (WHO) guidelines on LLIN testing, the nets were brought to the discussion and participants had to determine if such LLINs were to be kept or discarded. The study assessed responses from the same participants that attended FGD and also responded to the structured questionnaire, 117 participants fulfilled the criteria, thus data from only 117 participants are analysed in this study. RESULTS: In FGDs, integrity of LLIN influenced the decision to discard or keep a net. Those of older age, women, and householders with lower income were more likely to classify a WHO "too-torn" net as "good". The common methods used to discard LLINs were burning and burying. The findings were seen in the quantitative analysis. For every additional hole, the odds of discarding a WHO "too-torn" LLIN increased [OR = 1.05 (95%CI (1.04-1.07)), p < 0.001]. Younger age group [OR = 4.97 (95%CI (3.25-7.32)), p < 0.001], male-headed households [OR = 6.85 (95%CI (4.44 -10.59)), p < 0.001], and wealthy households [OR = 3.88 (95%CI (2.33-6.46)), p < 0.001] were more likely to discard LLINs. CONCLUSION: Integrity of LLIN was the main determinant for discarding or keeping LLINs and the decision to discard the net is associated with socioeconomic status of the household, and the age and gender of respondents. WHO "too torn" nets are encouraged to be used instead of none until replacement, and disposal of nets should be based on recommendation