Evaluation of the Implementation of Health Interventions and their Impact on Child Survival in Tanzania

It is widely accepted that achieving the highest and most equitable levels of health of populations through the most rational use of resources is the ultimate goal of national and international policymakers, public health officials and health professionals at large. However, doing this depends upon understanding the burden of disease, its distribution and causes in a given population and the effectiveness of different preventive, curative and palliative interventions that can reduce these burdens. Demand for comparable cause-specific mortality data of high quality has grown due to increased pressure to meet ambitious short-term goals and targets set by the international donor community. Robust data are urgently needed to assist policy makers and health planners in setting intervention priorities, the allocation of resources, and the analysis of the equity and effectiveness of health interventions and systems. The counting of births, deaths by age and sex, and documentation of causes of death is the norm for all routine vital registration systems implemented throughout the developed world. But in most developing countries, routine empirical data on population burden of disease are usually missing, or at best, grossly incomplete due to the lack of systems and resources to support their collection and documentation. Mortality surveillance systems or surveys using verbal autopsy have the potential to provide invaluable data for informing the health system on the burden of disease, and for monitoring and evaluating of the impact of different health and health system interventions as they are being implemented. The sentinel surveillance platform that includes the Ifakara, Rufiji and AMMP Demographic Surveillance System sites in Tanzania offers a great opportunity to examine this potential. The goal of this thesis was to explore a variety of innovative approaches to evaluating the implementation of health interventions and their impact on child survival in Tanzania. Ths was pursued by analyzing the burden of disease for the period from 2000-2002 in the rural areas of Kilombero and Ulanga district in which a population of approximately 65,000 people is under continuous surveillance. I also examined health systems access for pregnant women and children younger than five in a rural area in Rufiji district by combining demographic surveillance systems with geographic information systems in a population of approximately 70,000 people in 12,000 households. Using a sentinel surveillance platform in a non-randomised "plausibility" design across the four districts of Kilombero, Ulanga, Morogoro Rural and Rufiji, the thesis also examines the child survival effectiveness, cost and impact of the integrated management of childhood illness (IMCI). The main findings were: - 42% of mortality in children younger than five years of age occurred due to conditions that are well known and for which Districts have the technology to prevent or treat. - Spatial access to health care by children and pregnant women in Rufiji District was similar with an average travel time to a health facility of less than 1 hour. - Facility based IMCI improved quality of care and was associated with a 13% reduction in mortality in children younger than five in intervention districts. - The costs of child health care in districts implementing IMCI was similar to or lower than those in comparison districts. - Introduction of IMCI led to improvements in child health that did not occur at the expense of equity. - Changes in the programmatic delivery strategy of vitamin A supplementation improved coverage in Tanzania and has been sustained for more than three years. - Delivery of high dose of vitamin A supplementation in mothers and children less than six months of age was well tolerated, but did not confer any important absolute effect on morbidity. Experience gained from the studies documented in this work can contribute to the body of knowledge on the estimation of causes of death, inform future evaluations, and help to shape child health policy in Tanzania and other similar settings. The need for robust, representative routine demographic and health statistics is critical for the monitoring and evaluation of health interventions and systems. The model recently proposed by the Health Metrics Network provides this opportunity for more countries. Investing in the strengthening of health systems, including health information sub-systems such as sentinel surveillance, is necessary if strategies like IMCI are to be prioritized and implemented effectively. IMCI implementation was successful in Tanzania because of the strong health system support that existed. Although results from the DHS 2004 and from sentinel surveillance indicate dramatic improvements, overall, infant and under five mortality rates are still unacceptably high. Achieving the Millennium Development Goal of reducing the 1990 level of child mortality by two-thirds by 2015 will require infensified efforts and new interventions to prevent deaths from major killers of children in Tanzania which include malaria, pneumonia, diarrhoea, under nutrition and perinatal causes. Wider and more equitable coverage is required, especially for the districts that are still lagging behind in the implementation. This thesis shows that important progress can be made with a practical mix of population based evidence used in a health systems approach

The Influence of Weather on Mortality in Rural Tanzania: A Time-Series Analysis 1999�-2010

Weather and climate changes are associated with a number of immediate and long-term impacts on human health that occur directly or indirectly, through mediating variables. Few studies to date have established the empirical relationship between monthly weather and mortality in sub-Saharan Africa. The objectives of this study were to assess the association between monthly weather (temperature and rainfall) on all-cause mortality by age in Rufiji, Tanzania, and to determine the differential susceptibility by age groups. We used mortality data from Rufiji Health and Demographic Surveillance System (RHDSS) for\ud the period 1999 to 2010. Time-series Poisson regression models were used to estimate the association between monthly weather and mortality adjusted for long-term trends. We used a distributed lag model to estimate the delayed association of monthly weather on mortality. We stratified the analyses per age group to assess susceptibility. In general, rainfall was found to have a stronger association in the age group 0_4 years (RR_1.001, 95% CI_0.961_1.041) in both short and long lag times, with an overall increase of 1.4% in mortality risk for a 10 mm rise in rainfall. On the other hand, monthly average temperature had a stronger association with death in all ages while mortality increased with falling monthly temperature. The association per age group was estimated as: age group 0_4 (RR_0.934, 95% CI_0.894_0.974), age group 5_59 (RR_0.956, 95% CI_ 0.928_0.985) and age group over 60 (RR_0.946, 95% CI_0.912_0.979). The age group 5_59 experienced more delayed lag associations. This suggests that children and older adults are most sensitive to weather related mortality. These results suggest that an early alert system based on monthly weather information may be useful for disease control management, to reduce and prevent fatal effects related to weather and monthly weather.\u

Causes and Risk Factors for Maternal Mortality in Rural Tanzania - Case of Rufiji Health and Demographic Surveillance Site (HDSS)

Complications of childbirth and pregnancy are leading causes of death among women of reproductive age. Developing countries account for 99% of maternal deaths. The aim of this study was to explore levels, causes and risk factors associated with maternal mortality in rural Tanzania. Longitudinal data (2002-2006) from Rufiji HDSS was used where a total of 26 427 women aged 15-49 years were included in the study; 64 died and there were 15 548 live births. Cox proportional hazards regression was used to assess the risk factors associated with maternal deaths. MMR was 412 per 100 000 live births. The main causes of death were haemorrhage (28%), eclampsia (19%) and puerperal sepsis (8%). An increased risk of 154% for maternal death was found for women aged 30-39 versus 15-19 years (HR=2.54, 95% CI=1.001-6.445). Married women had a protective effect of 62% over unmarried ones (HR=0.38, 95% CI=0.176-0.839). (Afr J Reprod Health 2013; 17[3]: 119-130).\u

The Effect of Distance to Formal Health Facility on Childhood Mortality in Rural Tanzania, 2005-2007.

Major improvements are required in the coverage and quality of essential childhood interventions to achieve Millennium Development Goal Four (MDG 4). Long distance to health facilities is one of the known barriers to access. We investigated the effect of networked and Euclidean distances from home to formal health facilities on childhood mortality in rural Tanzania between 2005 and 2007. A secondary analysis of data from a cohort of 28,823 children younger than age 5 between 2005 and 2007 from Ifakara Health and Demographic Surveillance System was carried out. Both Euclidean and networked distances from the household to the nearest health facility were calculated using geographical information system methods. Cox proportional hazard regression models were used to investigate the effect of distance from home to the nearest health facility on child mortality. Children who lived in homes with networked distance>5 km experienced approximately 17% increased mortality risk (HR=1.17; 95% CI 1.02-1.38) compared to those who lived <5 km networked distance to the nearest health facility. Death of a mother (HR=5.87; 95% CI 4.11-8.40), death of preceding sibling (HR=1.9; 95% CI 1.37-2.65), and twin birth (HR=2.9; 95% CI 2.27-3.74) were the strongest independent predictors of child mortality. Physical access to health facilities is a determinant of child mortality in rural Tanzania. Innovations to improve access to health facilities coupled with birth spacing and care at birth are needed to reduce child deaths in rural Tanzania

Risk Factors for Injury Mortality in Rural Tanzania: A Secondary Data Analysis.

\ud \ud Injuries rank high among the leading causes of death and disability annually, injuring over 50 million and killing over 5 million people globally. Approximately 90% of these deaths occur in developing countries. To estimate and identify the risk factors for injury mortality in the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania. Secondary data from the RHDSS covering the period 2002 and 2007 was examined. Verbal autopsy data was used to determine the causes of death based on the 10th revision of the International Classification of Diseases (ICD-10). Trend and Poisson regression tests were used to investigate the associations between risk factors and injury mortality. The overall crude injury death rate was 33.4/100 000 population. Injuries accounted for 4% of total deaths. Men were three times more likely to die from injuries compared with women (adjusted IRR (incidence risk ratios)=3.04, p=0.001, 95% CI (2.22 to 4.17)). The elderly (defined as 65+) were 2.8 times more likely to die from injuries compared with children under 15 years of age (adjusted IRR=2.83, p=0.048, 95% CI (1.01 to 7.93)). The highest frequency of deaths resulted from road traffic crashes. Injury is becoming an important cause of mortality in the Rufiji district. Injury mortality varied by age and gender in this area. Most injuries are preventable, policy makers need to institute measures to address the issue

Relationship Between Child Survival and Malaria Transmission: An Analysis of the Malaria Transmission Intensity and Mortality Burden Across Africa (MTIMBA) Project Data in Rufiji Demographic Surveillance System, Tanzania.

The precise nature of the relationship between malaria mortality and levels of transmission is unclear. Due to methodological limitations, earlier efforts to assess the linkage have lead to inconclusive results. The malaria transmission intensity and mortality burden across Africa (MTIMBA) project initiated by the INDEPTH Network collected longitudinally entomological data within a number of sites in sub-Saharan Africa to study this relationship. This work linked the MTIMBA entomology database with the routinely collected vital events within the Rufiji Demographic Surveillance System to analyse the transmission-mortality relation in the region. Bayesian Bernoulli spatio-temporal Cox proportional hazards models with village clustering, adjusted for age and insecticide-treated nets (ITNs), were fitted to assess the relation between mortality and malaria transmission measured by entomology inoculation rate (EIR). EIR was predicted at household locations using transmission models and it was incorporated in the model as a covariate with measure of uncertainty. Effects of covariates estimated by the model are reported as hazard ratios (HR) with 95% Bayesian confidence interval (BCI) and spatial and temporal parameters are presented. Separate analysis was carried out for neonates, infants and children 1-4 years of age. No significant relation between all-cause mortality and intensity of malaria transmission was indicated at any age in childhood. However, a strong age effect was shown. Comparing effects of ITN and EIR on mortality at different age categories, a decrease in protective efficacy of ITN was observed (i.e. neonates: HR = 0.65; 95% BCI: 0.39-1.05; infants: HR = 0.72; 95% BCI:0.48-1.07; children 1-4 years: HR = 0.88; 95% BCI: 0.62-1.23) and reduction on the effect of malaria transmission exposure was detected (i.e. neonates: HR = 1.15; 95% BCI:0.95-1.36; infants: HR = 1.13; 95% BCI:0.98-1.25; children 1-4 years: HR = 1.04; 95% BCI:0.89-1.18). A very strong spatial correlation was also observed. These results imply that assessing the malaria transmission-mortality relation involves more than the knowledge on the performance of interventions and control measures. This relation depends on the levels of malaria endemicity and transmission intensity, which varies significantly between different settings. Thus, sub-regions analyses are necessary to validate and assess reproducibility of findings

Antiretroviral Treatment Knowledge and Stigma--Implications for Programs and HIV Treatment Interventions in Rural Tanzanian Populations.

To analyse antiretroviral treatment (ART) knowledge and HIV- and ART-related stigma among the adult population in a rural Tanzanian community. Population-based cross-sectional survey of 694 adults (15-49 years of age). Latent class analysis (LCA) categorized respondents' levels of ART knowledge and of ART-related stigma. Multinomial logistic regression assessed the association between the levels of ART knowledge and HIV- and ART-related stigma, while controlling for the effects of age, gender, education, marital status and occupation. More than one-third of men and women in the study reported that they had never heard of ART. Among those who had heard of ART, 24% were east informed about ART, 8% moderately informed, and 68% highly informed. Regarding ART-related stigma, 28% were least stigmatizing, 41% moderately stigmatizing, and 31% highly stigmatizing toward persons taking ART. Respondents that had at least primary education were more likely to have high levels of knowledge about ART (OR 3.09, 95% CI 1.61-5.94). Participants highly informed about ART held less HIV- and ART-related stigma towards ART patients (OR 0.26, 95% CI 0.09-0.74). The lack of ART knowledge is broad, and there is a strong association between ART knowledge and individual education level. These are relevant findings for both HIV prevention and HIV treatment program interventions that address ART-related stigma across the entire spectrum of the community