Antiretroviral therapy clinic attendance among children aged 0-14 years in Kahama district, Tanzania: a cross-sectional study

Background: Efforts made to scale up care and treatment for HIV in Tanzania have started to pay off. The number of people living with HIV (PLHIV) who are on antiretroviral therapy (ART) has massively increased owing to an increase in investment made. However, this is not reflected in all populations, especially children living with HIV. This study, therefore, aims to determine the magnitude and factors associated with ART uptake among children living with HIV in Kahama district, Tanzania.Methods: This cross-sectional study was conducted among pairs of children aged 0-14 years and their caregivers. A total of 423 randomly selected caregivers of HIV-positive children were interviewed using a structured questionnaire. The outcome variable was ART uptake while independent variables constituted of socio-demographic, health facility, and systemic factors.Results: A total of 132 (31%) of all caregivers reported to have missed at least one clinic visit for their children during a period of three months before the survey. Of them, one in four missed at least two clinics. Caregivers cited factors such as lack of transport fare and distance to the health facility as barriers to attend the planned clinics. After adjusting for the important confounders and other covariates, factors associated with ART uptake were being divorced/widowed (AOR= 0.57, 95% CI; 0.33-0.97) and having primary education or more (AOR 0.30, 95% CI 0.11-0, 82).Conclusion: One in every three HIV-positive children miss their scheduled routine ART clinics in Kahama, Shinyanga. Tailored interventions should target caregivers of such children who are divorced or widowed and those with low or no education while addressing distance and transportation challenges in this and other areas with similar contexts. 

Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania

<p>Abstract</p> <p>Background</p> <p>Effective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved.</p> <p>Methods</p> <p>A cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed.</p> <p>Results</p> <p>Overall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed.</p> <p>Conclusions</p> <p>Maternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.</p

Nutrition Training Improves Health Workers' Nutrition Knowledge and Competence to Manage Child Undernutrition: A Systematic Review.

Medical and nursing education lack adequate practical nutrition training to fit the clinical reality that health workers face in their practices. Such a deficit creates health workers with poor nutrition knowledge and child undernutrition management practices. In-service nutrition training can help to fill this gap. However, no systematic review has examined its collective effectiveness. We thus conducted this study to examine the effectiveness of in-service nutrition training on health workers' nutrition knowledge, counseling skills, and child undernutrition management practices. We conducted a literature search on nutrition interventions from PubMed/MEDLINE, CINAHL, EMBASE, ISI Web of Knowledge, and World Health Organization regional databases. The outcome variables were nutrition knowledge, nutrition-counseling skills, and undernutrition management practices of health workers. Due to heterogeneity, we conducted only descriptive analyses. Out of 3910 retrieved articles, 25 were selected as eligible for the final analysis. A total of 18 studies evaluated health workers' nutrition knowledge and showed improvement after training. A total of 12 studies with nutrition counseling as the outcome variable also showed improvement among the trained health workers. Sixteen studies evaluated health workers' child undernutrition management practices. In all such studies, child undernutrition management practices and competence of health workers improved after the nutrition training intervention. In-service nutrition training improves quality of health workers by rendering them more knowledge and competence to manage nutrition-related conditions, especially child undernutrition. In-service nutrition training interventions can help to fill the gap created by the lack of adequate nutrition training in the existing medical and nursing education system. In this way, steps can be taken toward improving the overall nutritional status of the child population

The quality of antenatal care in rural Tanzania: what is behind the number of visits?

Background: Antenatal care (ANC) provides an important opportunity for pregnant women with a wide range of interventions and is considered as an important basic component of reproductive health care.Methods: In 2008, severe maternal morbidity audit was established at Saint Francis Designated District Hospital (SFDDH), in Kilombero district in Tanzania, to ascertain substandard care and implement interventions. In addition, a cross-sectional descriptive study was carried out in 11 health facilities within the district to assess the quality of ANC and underlying factors in a broader view.Results: Of 363 severe maternal morbidities audited, only 263 (72%) ANC cards were identified. Additionally, 121 cards (with 299 ANC visits) from 11 facilities were also reviewed. Hemoglobin and urine albumin were assessed in 22% - 37% and blood pressure in 69% - 87% of all visits. Fifty two (20%) severe maternal morbidities were attributed to substandard ANC, of these 39 had severe anemia and eclampsia combined. Substandard ANC was mainly attributed to shortage of staff, equipment and consumables. There was no significant relationship between assessment of essential parameters at first ANC visit and total number of visits made (Spearman correlation coefficient, r = 0.09; p = 0.13). Several interventions were implemented and others were proposed to those in control of the health system.Conclusions: This article reflects a worrisome state of substandard ANC in rural Tanzania resulting from inadequate human workforce and material resources for maternal health, and its adverse impacts on maternal wellbeing. These results suggest urgent response from those in control of the health system to invest more resources to avert the situation in order to enhance maternal health in this country. © 2012 Nyamtema et al.;

Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania

Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions. Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit. Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented

Sources of Community Health Worker Motivation: A Qualitative Study in Morogoro Region, Tanzania.

There is a renewed interest in community health workers (CHWs) in Tanzania, but also a concern that low motivation of CHWs may decrease the benefits of investments in CHW programs. This study aimed to explore sources of CHW motivation to inform programs in Tanzania and similar contexts. We conducted semi-structured interviews with 20 CHWs in Morogoro Region, Tanzania. Interviews were digitally recorded, transcribed, and coded prior to translation and thematic analysis. The authors then conducted a literature review on CHW motivation and a framework that aligned with our findings was modified to guide the presentation of results. Sources of CHW motivation were identified at the individual, family, community, and organizational levels. At the individual level, CHWs are predisposed to volunteer work and apply knowledge gained to their own problems and those of their families and communities. Families and communities supplement other sources of motivation by providing moral, financial, and material support, including service fees, supplies, money for transportation, and help with farm work and CHW tasks. Resistance to CHW work exhibited by families and community members is limited. The organizational level (the government and its development partners) provides motivation in the form of stipends, potential employment, materials, training, and supervision, but inadequate remuneration and supplies discourage CHWs. Supervision can also be dis-incentivizing if perceived as a sign of poor performance. Tanzanian CHWs who work despite not receiving a salary have an intrinsic desire to volunteer, and their motivation often derives from support received from their families when other sources of motivation are insufficient. Policy-makers and program managers should consider the burden that a lack of remuneration imposes on the families of CHWs. In addition, CHWs' intrinsic desire to volunteer does not preclude a desire for external rewards. Rather, adequate and formal financial incentives and in-kind alternatives would allow already-motivated CHWs to increase their commitment to their work

Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough

BackgroundThe prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania.MethodsFrom September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children\u27s anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods.ResultsART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children\u27s households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.In the multivariate analysis, child\u27s HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p \u3c 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p \u3c 0.001).ConclusionHIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea

Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change

The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52%-65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71%-75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single magic bullet intervention exists for reduction of maternal mortality and that all interventional programs should be integrated in order to bring significant changes. State leaders and key actors in the health sectors in these countries and the international community are proposed to translate the lessons learnt into actions and intensify efforts in order to achieve the goals set for maternal health

QUALITY STANDARDS IN PROVISION OF FACILITY BASED HIV CARE AND TREATMENT: A CASE STUDY FROM DAR ES SALAAM REGION, TANZANIA

Objective: A cross- sectional descriptive study was conducted to assess the quality standards of health facilities providing antiretroviral treatment (ART) in Dar es Salaam from May to July 2005. Methods: All ten health facilities (both public and private) already designated by Ministry of Health (MOH) to provide ART, six of them since October 2004 and four since May 2005, were included in the study purposively . The other two not designated were randomly picked and added. A checklist with the MOH required standards was used to assess the availability of infrastructure (equipment and staff) for provision of ART, and noted the number of patient eligible, started on ART and their follow ups. Results: The study findings indicated that there were inadequate trained personnel, inadequate laboratory equipments, inadequate antiretroviral drugs and isoniazed was under utilized. There were inadequate confidential places for counseling and information system was weak. Not all the eligible patients were able to start ART and comprehensive HIV care and treatment was not provided in all the designated facilities. Conclusion: Quality standards for providing ART in eligible health facilities in Dar es Salaam varied from facility to facility with better quality standards in facilities that were designated earlier than those designated later indicating a potential for improvement in future. However fast Improvement in staff training, infrastructure, equipment and drugs supplies, health management information system is needed if we are to treat estimated more than 400,00 HIV/AIDS patients by the year 2010.

Body Mass Index and self perceptions of weight status among outpatients attending hospital health facilities in Dar es Salaam

Background: Overweight/obesity is on the rise in developing countries, especially in urban areas. Although overweight/obesity is one of the leading preventable causes of death less is known about the prevalence of obesity and the perceptions about weight among patients attending healthcare facilities. Previous studies have shown that correct perception of body weight is an important factor in weight control. This study determined prevalence of overweight/obesity and assessed perception scores about body weight among patients attending healthcare facilities in Dar es Salaam, Tanzania.Methods: In this study, a cross- sectional study was conducted in three district government hospitals in Dar es Salaam. A structured questionnaire was used to collect data on socio demographic characteristics and perception about body weight, Height and weight were measured following standard procedures. Chi-square tests and logistic regressions were used to determine the prevalence and demographic factors which influence perceptions about body weight. A total of 410 outpatients aged 18-59 years were randomly recruited into the study.Results: The prevalence of overweight and obesity among patients was 25.8% and 23.9%, respectively. This was higher among women compared to men (33% versus 14%). (P=0.02). Despite this higher prevalence, Majority of patients tended to underestimate their weight, (50.6%) considered their overweight as normal weight, (66.2%) perceived their obese status as normal. In total, only 41.2% of patients accurately classified their weight. Logistic regression analysis showed that Education level, (AOR=O.18. 95% CI 0.09-0.34), occupation (AOR=1.96 95% CI 0.86-4.50), and nutritional status (AOR=9.19, 95% CI 4.34-19.48), were significant predictors of correct perception of one’s body weight.Conclusions: The prevalence of overweight and obesity is high in this population. However, more than half of overweight and obese outpatients had incorrect perception of their body weights. We recommend health facilities increase awareness of weight status and promote a healthy body weight. Increasing patient’s awareness of their overweight problems is the first step in preventing diet related NCDs.Keywords: Outpatients, body mass index, self-perceptions, Non communicable disease