Frequency and impact of suboptimal immune recovery on first-line antiretroviral therapy within the International Epidemiologic Databases to Evaluate AIDS in East Africa

OBJECTIVE

To describe patterns of suboptimal immune recovery (SO-IR) and associated HIV-related-illnesses during the first 5 years following first-line antiretroviral therapy (ART) initiation across seven ART sites in East Africa.

DESIGN

Retrospective analysis of data from seven ART clinical sites (three Uganda, two Kenya and two Tanzania).

METHODS

SO-IR was described by proportions of ART-treated adults with CD4 cell counts less than 200, less than 350 and less than 500 cells/μl. Kaplan-Meier survival analysis techniques were used to assess predictors of SO-IR, and incident rates of HIV-related illnesses at CD4 cell counts less than 200, 200-350, 351-499, and >500 cells/μl, respectively.

RESULTS

Overall 80 843 adults initiated non-nucleoside reverse transcriptase inhibitor-based first-line ART; 65% were women and median CD4 cell count was 126 [interquartile range (IQR), 52-202] cells/μl. Cumulative probability of SO-IR <200 cells/μl, <350 cells/μl and <500 cells/μl, after 5 years, was 11, 38 and 63%, respectively. Incidence of HIV-related illnesses was higher among those with CD4 cell counts less than 200 and 200-350 cells/μl, than those who achieved CD4 counts above these thresholds. The most common events, at CD4 < 200 cells/μl, were pulmonary tuberculosis [incident rate 15.98 (15.47-16.51)/100 person-years at risk (PYAR), oral candidiasis [incident rate 12.5 (12.03-12.94)] and herpes zoster [incident rate 6.30 (5.99-6.64)] events/100 PYAR. With attainment of a CD4 cell count level 200-350 cells/μl, there was a substantial reduction in events/100 PYAR - by 91% to 1.45 (1.29-1.63) for TB, by 94% to 0.75 (0.64-0.89) for oral candidiasis, by 84% to 0.99 (0.86-1.14) for Herpes Zoster, and by 78% to 1.22 (1.07-1.39) for chronic diarrhea. The incidence of all events decreased further with CD4 counts above these thresholds.

CONCLUSION

Around 40% of adults initiated on ART have suboptimal immune recovery with CD4 counts <350 cells/μl after five years. Such patients will require closer monitoring for both HIV-related and non-HIV-related clinical events.

Increased isolation of nontuberculous mycobacteria among TB suspects in Northeastern, Tanzania: public health and diagnostic implications for control programmes

BACKGROUND

Non-tuberculous mycobacteria (NTM) are increasingly reported worldwide associated with human disease. Defining the significance of NTM in settings with endemic tuberculosis (TB) requires the discrimination of NTM from TB in suspect patients. Correct and timely identification of NTM will impact both therapy and epidemiology of TB and TB-like diseases. The present study aimed at determining the frequency and diversity of NTM among TB suspects in northeastern Tanzania.

METHODS

A cross-sectional study was conducted between November 2012 through January 2013. Seven hundred and forty-four sputum samples were collected from 372 TB suspects. Detection was done by using phenotypic, GenoType(®) Mycobacterium CM/AS kits, 16S rRNA and hsp65 gene sequencing for identification of isolates not identified by Hain kits. Binary regression model was used to analyse the predictors of NTM detection.

RESULTS

The prevalence of NTM was 9.7% of the mycobacterial isolates. Out of 36 patients with confirmed NTM infection, 12 were HIV infected with HIV being a significant predictor of NTM detection (P < 0.001). Co-infection with Mycobacterium tuberculosis (M. tb) was found in five patients. Twenty-eight NTM isolates were identified using GenoType(®) Mycobacterium CM/AS and eight isolates could not be identified. Identified species included M. gordonae and M. interjectum 6 (16.7%), M. intracelullare 4 (11.1%), M. avium spp. and M. fortuitum 2 (5.5%), M. kansasii, M. lentiflavum, M. simiae, M. celatum, M. marinum 1 (2.8%) each. Of isolates not identified to subspecies level, we identified M. kumamotonense (2), M. intracellulare/kansasii, M. intermedium/triplex, M. acapulcensis/flavescens, M. stomatepiae, M. colombiense and M. terrae complex (1) each using 16S rRNA sequencing. Additionally, hsp65 gene sequencing identified M. kumamotonense, M. scrofulaceum/M. avium, M. avium, M. flavescens/novocastrense, M. kumamotonense/hiberniae, M. lentiflavum, M. colombiense/M. avium and M. kumamotonense/terrae/hiberniae (1) each. Results of the 16S rRNA and hsp65 gene sequencing were concordant in three and discordant in five isolates not identified by GenoType(®) Mycobacterium CM/AS.

CONCLUSION

NTM infections may play a vital role in causing lung disease and impact management of TB in endemic settings. GenoType(®) Mycobacterium CM/AS represents a useful tool to identify clinical NTM infections. However, 16S rRNA gene sequencing should be thought for confirmatory diagnosis of the clinical isolates. Due to the complexity and inconsistence of NTM identification, we recommend diagnosis of NTM infections be centralized by strengthening and setting up quality national and regional infrastructure.

Explaining retention of healthcare workers in Tanzania: moving on, coming to 'look, see and go', or stay?

BACKGROUND

In the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope?

METHODS

This is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes.

RESULTS

Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by 'Look, See and Go'; 'Movers On' were those who left due to family commitments or because they were pushed to go. The remaining staff were 'Stayers'. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post.

CONCLUSIONS

The Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers' profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices.

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania

BACKGROUND

Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation.

METHODS

A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs.

RESULTS

Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles.

CONCLUSIONS

Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits.

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis

BACKGROUND

Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths.

METHODOLOGY

Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95% CI for categorical and numerical data respectively.

RESULTS

There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95% CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60% from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2% of the forms and gestation age of the pregnancy resulting into the death in 23.8%. Sixty one deaths (76.3%) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7%) respectively.

CONCLUSION

Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.

Head and neck cancers: a clinico-pathological profile and management challenges in a resource-limited setting

BACKGROUND

Head and neck cancer (HNC) is one of the most common cancers worldwide and its incidence is reported to be increasing in resource-limited countries. There is a paucity of published data regarding head and neck cancers in Tanzania, and Bugando Medical Centre in particular. This study describes the clinicopathological profile of HNC in our local setting and highlights the challenges in the management of this disease.

METHODS

This was a retrospective study of histopathologically confirmed cases of head and neck cancers treated at Bugando Medical Center between January 2009 and December 2013.

RESULTS

A total of 346 patients (M:F = 2.1:1) were studied representing 9.5 % of all malignancies. The median age of patients was 42 years. Cigarette smoking (76.6 %) and heavy alcohol consumption (69.9 %) were the most frequently identified risk factors for head and neck cancer. The majority of patients (95.9 %) presented late with advanced stages. Twenty-five (7.2 %) patients were HIV positive with a median CD4+ count of 244 cells/μl. The oral cavity (37.3 %) was the most frequent anatomical site affected. The most common histopathological type was carcinomas (59.6 %) of which 75.7 % were squamous cell carcinoma. A total of 196 (56.6 %) patients underwent surgical procedures for HNC. Radiotherapy and chemotherapy was reported in 9.5 and 16.8 % of patients, respectively. Only 2 (0.6 %) patients received chemo-radiation therapy. The mortality rate was 24.4 %. The overall 5-year survival rate (5-YSR) was 20.6 %. The predictors of overall 5-YSR were age of patient at diagnosis, stage of disease, extent of lymph node involvement, HIV seropositivity and CD4+ count <200 cells/μl (P < 0.001). Local recurrence was reported in 22 (23.4 %) patients and this was significantly associated with positive resection margins, stage of the tumor and presence of metastasis at diagnosis and non-adherence to adjuvant therapy (P < 0.001).

CONCLUSION

Head and neck cancers are not uncommon at Bugando Medical Centre and show a trend towards a relative young age at diagnosis and the majority of patients present late with advanced stage cancer. Therefore, public enlightenment, early diagnosis, and effective cost-effective treatment and follow-up are urgently needed to improve outcomes of these patients in our environment.

Maternal, newborn and child health needs, opportunities and preferred futures in Arusha and Ngorongoro: hearing women's voices

BACKGROUND

With the approaching sunset on the Millennium Development Goals (MDGs), Tanzania continues with its final national push towards achievement of MDG #4 and MDG #5. The Mama Kwanza Socio-economic Health Initiative (MKSHI) was introduced in the hope of contributing to improving maternal, newborn, and child health in Arusha and Ngorongoro. The MKSHI project is a holistic, inter-sectoral approach to maternal, newborn, and child health which aligns with the Government of Tanzania's Vision 2025. At the project onset, a baseline assessment was conducted to launch ongoing benchmarking, monitoring, and evaluation of the project's impacts and implications. The aim of this baseline assessment was twofold. First it was to determine the state of maternal, newborn, and child health in the two project sites. Second it was to ensure that a baseline of key indicators was established as well as identification of unique indicators relevant to the populations of interest.

RESULTS

The baseline study was a mixed methods approach to identify maternal, newborn, and child risk factors and indicators in the two target sites. This paper focuses on the qualitative methods and findings. The qualitative component included a series of five community dialogue meetings and thirty-seven individual/dyad interviews with women, providers, and stakeholders. Initially, community meetings were held as open dialogues on maternal, newborn, and child health issues, opportunities, and preferred futures. Individual/dyad interviews were held with women, providers, and stakeholders who held unique information or experiences. Both community dialogue and interview data was analysed for themes and guiding or critical comments. Three over-arching findings emerged: What took you so long to come? How do we know what you know? and How will it change for our daughters?

CONCLUSIONS

Participant voices are vital in ensuring the achievement of local and global efforts and preferred futures for maternal, newborn, and child health services. This study contributes to the inclusion of women in all aspects of the planning, implementation, and delivery of maternal, newborn, and child health services in the target areas and beyond.

Would you test for 5000 Shillings? HIV risk and willingness to accept HIV testing in Tanzania

OBJECTIVES

Despite substantial public health efforts to increase HIV testing, testing rates have plateaued in many countries and rates of repeat testing for those with ongoing risk are low. To inform policies aimed at increasing uptake of HIV testing, we identified characteristics associated with individuals' willingness-to-accept (WTA) an HIV test in a general population sample and among two high-risk populations in Moshi, Tanzania.

METHODS

In total, 721 individuals, including randomly selected community members (N = 402), female barworkers (N = 135), and male Kilimanjaro mountain porters (N = 184), were asked in a double-bounded contingent valuation format if they would test for HIV in exchange for 2000, 5000 or 10,000 Shillings (approximately $1.30, $3.20, and $6.40, respectively). The study was conducted between September 2012 and February 2013.

RESULTS

More than one quarter of participants (196; 27 %) stated they would be willing to test for Tanzania Shilling (TSH) 2000, whereas one in seven (98; 13.6 %) required more than TSH 10,000. The average WTA estimate was TSH 4564 (95 % Confidence Interval: TSH 4201 to 4927). Significant variation in WTA estimates by gender, HIV risk factors and other characteristics plausibly reflects variation in individuals' valuations of benefits of and barriers to testing. WTA estimates were higher among males than females. Among males, WTA was nearly one-third lower for those who reported symptoms of HIV than those who did not. Among females, WTA estimates varied with respondents' education, own and partners' HIV testing history, and lifetime reports of transactional sex. For both genders, the most significant association was observed with respondents' perception of the accuracy of the HIV test; those believing HIV tests to be completely accurate were willing to test for approximately one third less than their counterparts. The mean WTA estimates identified in this study suggest that within the study population, incentivized universal HIV testing could potentially identify undiagnosed HIV infections at an incentive cost of $150 per prevalent infection and $1400 per incident infection, with corresponding costs per quality adjusted life year (QALY) gained of $70 for prevalent and $620 for incident HIV infections.

CONCLUSIONS

The results support the value of information about the accuracy of HIV testing, and suggest that relatively modest amounts of money may be sufficient to incentivize at-risk populations to test.

Why has canine rabies remained endemic in the Kilosa district of Tanzania? Lessons learnt and the way forward

BACKGROUND

Domestic dogs are the main targets for rabies control as they are the principal reservoir for transmission of the rabies virus to humans and other domestic animals. The purpose of this study was to identify the factors that contribute to the rabies virus infecting the human population in a rural community of Eastern Tanzania.

METHODS

Using a cross-sectional study design, field visits were conducted to gather information on villagers' knowledge on and practices associated with canine rabies control and dog vaccination campaigns.

RESULTS

A total of 248 individuals were interviewed in the Kilosa district, Tanzania. Almost two-thirds (61.3 %) had a primary school education. The majority (91.1 %) of the respondents were aware that rabies is acquired through dog bites and 66.9 % knew about the clinical signs of rabies in an animal. Very few (17.7 %), however, were aware of the clinical signs of rabies in humans. Only 20.4 % of the respondents knew how rabies is controlled in dogs and 71 % were not aware of dog vaccination campaigns. The average number of dogs kept per household was 4 ± 3.3; 70.0 % of the respondents had one to five dogs, 28.3 % had six to dog dogs, and 1.6 % had 16-20 dogs. The dogs were primarily used to guard livestock and property, and to hunt. About 59.7 % of the respondents indicated that rabies was a public health problem. Low vaccination coverage was observed in the study area, with previous mass vaccination campaigns covering only 24.4 % of the dog population. Dogs appeared to have limited value in the studied community. Furthermore, there were no proper waste disposal facilities and oftentimes wild canids and felids visited the villages to scavenge on kitchen leftovers.

CONCLUSION

Although communities in the Kilosa district had knowledge on rabies in dogs, they were not aware of the public health implication of the disease, which thus led a poor response during mass dog vaccination campaigns. Establishment of a well-coordinated rabies control program, strategic public health awareness campaigns, and active and passive surveillance systems for humans and domestic and wild animals should be considered as strategies to control and eradicate rabies.

Surgical management of vascular anomalies in children at a tertiary care hospital in a resource-limited setting: a Tanzanian experience with 134 patients

BACKGROUND

Vascular anomalies pose major diagnostic and therapeutic challenges among pediatricians and pediatric surgeons practicing in resource limited countries. There is paucity of published data regarding this subject in Tanzania and Bugando Medical Centre in particular. This study describes our experiences on the challenges and outcome of surgical management of childhood vascular anomalies in our environment.

METHODS

Between January 2009 and December 2013, a prospective study on the surgical management of vascular anomalies was undertaken at Bugando Medical Centre.

RESULTS

A total of 134 patients (M; F = 1:2.5) were studied. The median age at presentation was 6 years. Of the 134 patients, 101 (75.4%) were diagnosed as having vascular tumors and 33 (24.6%) had vascular malformations. The head and the neck were the most frequent anatomical site recorded as having a tumor (56.7% of patients). Out of 134 patients, 129 (96.3%) underwent surgical treatment. Failure to respond to non-operative treatment (86.8%), huge disfiguring/obstructing mass (4.7%), infection (3.1%), ulceration (3.1%) and hemorrhage (2.3%) were indications for surgical intervention. Tumor excision and primary wound closure was the most common type of surgical procedure performed in 80.6% of patients. Surgical site infection was the most frequent complications accounting for 33.8% of cases. Mortality rate was 1.5%. Tumor excision and primary wound closure gave better outcome compared with other surgical options (p < 0.001). Outcome of injection sclerotherapy in 3 (3.7%) children, serial ligation of feeder vessels employed in 2 (1.6%), and conservative treatment in 5 (3.7%), were poor and required conversion to surgical excision. Despite low mortality rate recorded in this study, but ugly scar, 14 (20.6%) and limb deformity, 6 (8.8%) were problems. The overall result of surgical treatment at the end of follow up period was excellent in 108 (87.1%) patients.

CONCLUSION

Surgical excision and primary wound closure gave good outcome which could be employed in complicated and vascular anomalies which failed to respond to other treatment in regions with limited resources.

The influence of perceived behaviour control, attitude and empowerment on reported condom use and intention to use condoms among adolescents in rural Tanzania

BACKGROUND

Despite the declining trends of Human immunodeficiency virus (HIV) infection in Sub-Saharan Africa (SSA), unsafe sexual behaviours among adolescents still represent a public health challenge. It is important to understand factors acting at different levels to influence sexual behaviour among adolescents. This study examined the influence of perceived behaviour control, subjective norms, attitudes and empowerment on intention to use condoms and reported use of condoms among adolescents in rural Tanzania.

METHODS

We used a questionnaire to collect data from 403 adolescents aged 14 through 19 years from nine randomly selected secondary schools in the Newala district located in the Southern part of Tanzania. The self-administered questionnaire collected information on sexual practices and factors such as attitudes, subjective norms, perceived behaviour control and empowerment. Binary logistic regression was performed to identify factors associated with intention to use and reported use of condoms.

RESULTS

Sexually active adolescents constituted 40.6 % of the sample, among them 49.7 % did not use a condom at last sexual intercourse and 49.8 % had multiple sex partners. Many (85 %) of sexually active respondents had their sexual debut between the ages of 14 to 17 years. Girls became sexually active earlier than boys. Perceived behaviour control predicted intentions to use condoms (AOR = 3.059, 95 % CI 1.324-7.065), thus demonstrating its importance in the decision to use a condom. Empowerment (odds ratio = 3.694, 95 % CI 1.295-10.535) and a positive attitude (AOR = 3.484, 95 % CI 1.132-10.72) predicted reported condom use, thus turning the decision to actions. Subjective norms had only indirect effects on intention and reported use of condoms.

CONCLUSION

The findings suggest that unsafe sex practices are prevalent among school adolescents in rural areas of Tanzania. Perceived behaviour control and positive attitudes predict intensions to use condoms whereas empowerment predicts reported condom use. The findings may imply that safe sex promotion interventions that simultaneously address socio-cognitive and ecological determinants of sexual behaviours may improve adolescents' safe sex behaviours.

Determinants of demand for condoms to prevent HIV infections among barmaids and guesthouse workers in two districts, Tanzania

BACKGROUND

Condoms are scientifically recommended as potential products for preventing infections attributable to human immuno-deficiency viruses (HIV). However, evidence on factors leading to their inadequate use in developing countries is still scanty. This paper reports an exploratory study of factors constraining condoms use in Tanzania from the perspectives of barmaids, guest-house workers and retailers.

METHODS

Data were collected in two districts-Mpwapwa in Dodoma Region and Mbeya Rural in Mbeya Region-between October and December 2011, using structured interviews with 238 individuals including barmaids, guesthouse workers and 145 retailers. Data analysis was performed using STATA 11 software.

RESULTS

Awareness about condoms was high among all study groups. Male condoms were more popular and available than female ones. A considerable proportion of the barmaids and guesthouses were disappointed with condoms being promoted and distributed to young children and disliked condom use during sexual intercourse. Accessibility of condoms was reported as being lowered by condom prices, shortage of information concerning their availability; short supply of condoms; some people shying away to be watched by children or adult people while purchasing condoms; retailers' using bad languages to condom customers; occasionally condom shops/kiosks found closed when they are urgently needed; and prevailing social perception of condoms to have low/no protective efficacy. Regression analysis of data from barmaids and guesthouse-workers indicated variations in the degree of condom acceptability and methods used to promote condoms among respondents with different demographic characteristics.

CONCLUSION

A combination of psychosocial and economic factors was found contributing to lower the demand for and actual use of condoms in study communities. Concerted measures for promoting condom use need to address the demand challenges and making operational research an integral element of monitoring and evaluation of the launched interventions, hence widening the evidence for informed policy decisions.

Determinants of postnatal care use at health facilities in rural Tanzania: multilevel analysis of a household survey

BACKGROUND

Postnatal care (PNC) for the mother and infant is a neglected area, even for women who give birth in a health facility. Currently, there is very little evidence on the determinants of use of postnatal care from health facilities in Tanzania.

METHODS

This study examined the role of individual and community-level variables on the use of postnatal health services, defined as a check up from a heath facility within 42 days of delivery, using multilevel logistic regression analysis. We analyzed data of 1931 women, who had delivered in the preceding 2-14 months, from a two-stage household survey in 4 rural districts of Morogoro region, Tanzania. Individual level explanatory variables included i) Socio-demographic factors: age, birth order, education, and wealth, ii) Factors related to pregnancy: frequency of antenatal visits, history of complications, mode of delivery, place of delivery care, and counseling received. Community level variables included community levels of family planning, health service utilization, trust, poverty and education, and distance to health facility.

RESULTS

Less than one in four women in Morogoro reported having visited a health facility for postnatal care. Individual-level attributes positively associated with postnatal care use were women's education of primary level or higher [Odds Ratio (OR) 1.37, 95 % Confidence Interval (CI) 1.04-1.81], having had a caesarean section or forceps delivery (2.95, 1.8-4.81), and being counseled by a community health worker to go for postnatal care at a health facility (2.3, 1.36-3.89). Other positive associations included those recommended HIV testing for baby (1.94, 1.19-3.15), and whose partners tested for HIV (1.41, 1.07-1.86). High community levels of postpartum family planning usage (2.48, 1.15-5.37) and high level of trust in health system (1.77, 1.12-2.79) were two significant community-level predictors. Lower postnatal care use was associated with having delivered at a hospital (0.5, 0.33-0.76), health center (0.57, 0.38-0.85), or dispensary (0.48, 0.33-0.69), and having had severe swelling of face and legs during pregnancy (0.65, 0.43-0.97).

CONCLUSIONS

In the context of low postnatal care use in a rural setting, programs should direct efforts towards reaching women who do not avail themselves of postnatal care as identified in our study.

Fournier's gangrene at a tertiary health facility in northwestern Tanzania: a single centre experiences with 84 patients

BACKGROUND

Fournier's gangrene (FG) is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia and perineum, leading to soft-tissue necrosis. Despite antibiotics and aggressive debridement, the mortality rate of FG remains high. This study describes our experiences in the management of FG and identifies prognostic factors.

METHODS

This was a descriptive retrospective study of patients with FG treated at Bugando Medical Centre between November 2006 and April 2014.

RESULTS

A total of 84 patients (M:F = 41:1) were studied. The median age was 34 years (range 15-76 years). The most common predisposing factor was diabetes mellitus (16.7%). Nine (11.3%) patients were HIV positive. Bacterial culture results were obtained in only 46 (54.8%) patients. Of these, 38(82.6%) had polymicrobial bacterial growth while 8 (17.4%) had monomicrobial bacterial growth. Escherichia coli (28.3%) were the most frequent bacterial organism isolated. All the microorganisms isolated showed high resistance to commonly used antibiotics except for Meropenem and imipenem, which were 100% sensitive each respectively. All patients were treated with a common approach of resuscitation, broad-spectrum antibiotics, and wide surgical excision. The median length of hospital stay (LOS) was 28 days and mortality rate was 28.6%. Systemic inflammatory response syndrome and diabetes mellitus were significantly associated with prolonged LOS (p < 0.001), whereas advancing age (>60 years), late presentation (>48 h), systemic inflammatory response syndrome on admission, diabetes mellitus, extension of infection to the abdominal wall, FG severity score >9 and HIV infection with CD4 count <200 μl/cells) were independent predictors of mortality (p < 0.001).

CONCLUSION

Fournier's gangrene remains a very severe disease with high mortality rates. Early recognition of infection associated with invasive and aggressive treatment is essential for attempting to reduce mortality rates associated with this disease in our setting.

"Once the government employs you, it forgets you": Health workers' and managers' perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania

BACKGROUND

In many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems' function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention.

METHODS

In-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director's office). An interview guide was used with questions pertaining to informants' perspective on provision of maternal health care service, working environment, living conditions, handling of staff's financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers' role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach.

RESULTS

Overall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers' role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers' claims timely and that there is no transparency and fairness in dealing with health workers' financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers' concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers' knowledge and skills necessary for providing quality maternal health care.

CONCLUSION

Health workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers' financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.

Population status of chimpanzees in the Masito-Ugalla Ecosystem, Tanzania

More than 75 percent of Tanzania's chimpanzees live at low densities on land outside national parks. Chimpanzees are one of the key conservation targets in the region and long-term monitoring of these populations is essential for assessing the overall status of ecosystem health and the success of implemented conservation strategies. We aimed to assess change in chimpanzee density within the Masito-Ugalla Ecosystem (MUE) by comparing results of re-walking the same line transects in 2007 and 2014. We further used published remote sensing data derived from Landsat satellites to assess forest cover change within a 5 km buffer of these transects over that same period. We detected no statistically significant decline in chimpanzee density across the surveyed areas of MUE between 2007 and 2014, although the overall mean density of chimpanzees declined from 0.09 individuals/km(2) in 2007 to 0.05 individuals/km(2) in 2014. Whether this change is biologically meaningful cannot be determined due to small sample sizes and large, entirely overlapping error margins. It is therefore possible that the MUE chimpanzee population has been stable over this period and indeed in some areas (Issa Valley, Mkanga, Kamkulu) even showed an increase in chimpanzee density. Variation in chimpanzee habitat preference for ranging or nesting could explain variation in density at some of the survey sites between 2007 and 2014. We also found a relationship between increasing habitat loss and lower mean chimpanzee density. Future surveys will need to ensure a larger sample size, broader geographic effort, and random survey design, to more precisely determine trends in MUE chimpanzee density and population size over time.

Birth preparedness and complication readiness among recently delivered women in chamwino district, central Tanzania: a cross sectional study

BACKGROUND

Unacceptably high maternal mortality rates remain a challenge in developing countries such as Tanzania. Birth Preparedness and Complication Readiness is among the key interventions that can reduce maternal mortality. Despite this, its status in Tanzania is not well documented. We assessed the practice and determinants of Birth preparedness and complication readiness among recently delivered women in Chamwino district, Central Tanzania.

METHODS

A community based cross-sectional study was conducted to women who delivered two years prior to survey in January 2014 at Chamwino district, Tanzania. Woman was considered as prepared for birth and its complication if she reported at least three of these; know expected date of delivery, saved money, identified a skilled birth attendant/health facility, mode of transport and Identified two compatible blood donors. Descriptive, bivariate and multivariable logistic regression analyses were performed at P value < 0.05 level of significance.

RESULTS

We interviewed 428 women whose median age (IQR) was 26.5 (22-33) years. About 249 (58.2 %) of the respondents were considered as prepared for birth and its complications. After controlling for confounding and clustering effect, significant determinants of birth preparedness and complication readiness were found to be maternal education (AOR = 2.26, 95 % CI; 1.39, 3.67), spouse employment (AOR = 2.18, 95 % CI; 1.46, 3.25), booking at ANC (AOR = 2.03, 95 % CI; 1.11, 3.72), Four or more antenatal visits, (AOR = 1.94, 95 % CI; 1.17, 3.21) and knowledge of key danger signs (AOR = 4.16, 95 % CI; 2.32, 7.45). Prepared for birth was found to be associated with institutional delivery (AOR = 2.45, 95 % CI; 1.12, 5.34).

CONCLUSION

The proportion of women who prepared for birth and its complications were found to be low. District reproductive and child health coordinator should emphasis on early and frequent antenatal care visits, since they were among predictors of birth preparedness and complication readiness.

Prescriber and patient-oriented behavioural interventions to improve use of malaria rapid diagnostic tests in Tanzania: facility-based cluster randomised trial

BACKGROUND

The increasing investment in malaria rapid diagnostic tests (RDTs) to differentiate malarial and non-malarial fevers, and an awareness of the need to improve case management of non-malarial fever, indicates an urgent need for high quality evidence on how best to improve prescribers' practices.

METHODS

A three-arm stratified cluster-randomised trial was conducted in 36 primary healthcare facilities from September 2010 to March 2012 within two rural districts in northeast Tanzania where malaria transmission has been declining. Interventions were guided by formative mixed-methods research and were introduced in phases. Prescribing staff from all facilities received standard Ministry of Health RDT training. Prescribers from facilities in the health worker (HW) and health worker-patient (HWP) arms further participated in small interactive peer-group training sessions with the HWP additionally receiving clinic posters and patient leaflets. Performance feedback and motivational mobile-phone text messaging (SMS) were added to the HW and HWP arms in later phases. The primary outcome was the proportion of patients with a non-severe, non-malarial illness incorrectly prescribed a (recommended) antimalarial. Secondary outcomes investigated RDT uptake, adherence to results, and antibiotic prescribing.

RESULTS

Standard RDT training reduced pre-trial levels of antimalarial prescribing, which was sustained throughout the trial. Both interventions significantly lowered incorrect prescribing of recommended antimalarials from 8% (749/8,942) in the standard training arm to 2% (250/10,118) in the HW arm (adjusted RD (aRD) 4%; 95% confidence interval (CI) 1% to 6%; P = 0.008) and 2% (184/10,163) in the HWP arm (aRD 4%; 95% CI 1% to 6%; P = 0.005). Small group training and SMS were incrementally effective. There was also a significant reduction in the prescribing of antimalarials to RDT-negatives but no effect on RDT-positives receiving an ACT. Antibiotic prescribing was significantly lower in the HWP arm but had increased in all arms compared with pre-trial levels.

CONCLUSIONS

Small group training with SMS was associated with an incremental and sustained improvement in prescriber adherence to RDT results and reducing over-prescribing of antimalarials to close to zero. These interventions may become increasingly important to cope with the wider range of diagnostic and treatment options for patients with acute febrile illness in Africa.

A study on use of animals as traditional medicine by Sukuma Tribe of Busega District in North-western Tanzania

BACKGROUND

Faunal resources have played an extensive range of roles in human life from the initial days of recorded history. In addition to their importance, animals have been acknowledged in religion, art, music and literature and several other different cultural manifestations of mankind. Human beings are acquainted with use of animals for foodstuff, cloth, medicine, etc. since ancient times. Huge work has been carried out on ethnobotany and traditional medicine. Animal and their products are also holding medicinal properties that can be exploited for the benefit of human beings like plants. In Tanzania, many tribal communities are spread all over the country and these people are still totally depended on local customary medicinal system for their health care. In the world Tanzania is gifted with wide range of floral and faunal biodiversity. The use of traditional medicine from animals by Sukuma ethnic group of Busega district is the aim of the present study.

METHOD

In order to collect the information on ethnozoological use about animal and their products predominant among this tribe in Busega district, a study was carried out from August 2012, to July 2013. Data were collected through semi-structured questionnaire and open interview with 180 (118 male and 62 females) selected people. The people from whom the data were collected comprise old age community members, traditional health practicener, fishermen and cultural officers. The name of animal and other ethnozoological information were documented. Pictures and discussion were also recorded with the help of camera and voice recorder.

RESULT

A total of 42 various animal species were used in nearly 30 different medicinal purposes including STD, stoppage of bleeding, reproductive disorders, asthma, weakness, tuberculosis, cough, paralysis and wound and for other religious beliefs. It has been noticed that animal used by Sukuma tribe, comprise of seventeen mammals, seven birds, four reptiles, eight arthropods and two mollusks. Some of the protected species were also used as important medicinal resources. We also found that cough, tuberculosis, asthma and other respiratory diseases are the utmost cited disease, as such, a number of traditional medicines are available for the treatment.

CONCLUSIONS

The present work indicates that 42 animal species were being used to treat nearly 30 different ailments and results show that ethnozoological practices are an important alternative medicinal practice by the Sukuma tribe living in Bungesa district. The present study also indicates the very rich ethnozoological knowledge of these people in relation to traditional medicine. So there is a critical need to properly document to keep a record of the ethnozoological information. We hope that the information generated in this study will be useful for further research in the field of ethnozoology, ethnopharmacology and conservation approach.

I-RREACH: an engagement and assessment tool for improving implementation readiness of researchers, organizations and communities in complex interventions

BACKGROUND

Non-communicable chronic diseases are the leading causes of mortality globally, and nearly 80% of these deaths occur in low- and middle-income countries (LMICs). In high-income countries (HICs), inequitable distribution of resources affects poorer and otherwise disadvantaged groups including Aboriginal peoples. Cardiovascular mortality in high-income countries has recently begun to fall; however, these improvements are not realized among citizens in LMICs or those subgroups in high-income countries who are disadvantaged in the social determinants of health including Aboriginal people. It is critical to develop multi-faceted, affordable and realistic health interventions in collaboration with groups who experience health inequalities. Based on community-based participatory research (CBPR), we aimed to develop implementation tools to guide complex interventions to ensure that health gains can be realized in low-resource environments.

METHODS

We developed the I-RREACH (Intervention and Research Readiness Engagement and Assessment of Community Health Care) tool to guide implementation of interventions in low-resource environments. We employed CBPR and a consensus methodology to (1) develop the theoretical basis of the tool and (2) to identify key implementation factor domains; then, we (3) collected participant evaluation data to validate the tool during implementation.

RESULTS

The I-RREACH tool was successfully developed using a community-based consensus method and is rooted in participatory principles, equalizing the importance of the knowledge and perspectives of researchers and community stakeholders while encouraging respectful dialogue. The I-RREACH tool consists of three phases: fact finding, stakeholder dialogue and community member/patient dialogue. The evaluation for our first implementation of I-RREACH by participants was overwhelmingly positive, with 95% or more of participants indicating comfort with and support for the process and the dialogue it creates.

CONCLUSIONS

The I-RREACH tool was designed to (1) pinpoint key domains required for dialogue between the community and the research team to facilitate implementation of complex health interventions and research projects and (2) to identify existing strengths and areas requiring further development for effective implementation. I-RREACH has been found to be easily adaptable to diverse geographical and cultural settings and can be further adapted to other complex interventions. Further research should include the potential use of the I-RREACH tool in the development of blue prints for scale-up of successful interventions, particularly in low-resource environments.

Rapid assessment of infrastructure of primary health care facilities - a relevant instrument for health care systems management

BACKGROUND

Health care infrastructure constitutes a major component of the structural quality of a health system. Infrastructural deficiencies of health services are reported in literature and research. A number of instruments exist for the assessment of infrastructure. However, no easy-to-use instruments to assess health facility infrastructure in developing countries are available. Present tools are not applicable for a rapid assessment by health facility staff. Therefore, health information systems lack data on facility infrastructure.

METHODS

A rapid assessment tool for the infrastructure of primary health care facilities was developed by the authors and pilot-tested in Tanzania. The tool measures the quality of all infrastructural components comprehensively and with high standardization. Ratings use a 2-1-0 scheme which is frequently used in Tanzanian health care services. Infrastructural indicators and indices are obtained from the assessment and serve for reporting and tracing of interventions. The tool was pilot-tested in Tanga Region (Tanzania).

RESULTS

The pilot test covered seven primary care facilities in the range between dispensary and district hospital. The assessment encompassed the facilities as entities as well as 42 facility buildings and 80 pieces of technical medical equipment. A full assessment of facility infrastructure was undertaken by health care professionals while the rapid assessment was performed by facility staff. Serious infrastructural deficiencies were revealed. The rapid assessment tool proved a reliable instrument of routine data collection by health facility staff.

CONCLUSIONS

The authors recommend integrating the rapid assessment tool in the health information systems of developing countries. Health authorities in a decentralized health system are thus enabled to detect infrastructural deficiencies and trace the effects of interventions. The tool can lay the data foundation for district facility infrastructure management.

Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study

We report the infant feeding experiences in the first month of life for 2,053 infants participating in "Malnutrition and Enteric Infections: Consequences for Child Health and Development" (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.

Distribution and determinants of young child feeding practices in the East African region: demographic health survey data analysis from 2008-2011

We utilized the most recent Demographic Health Survey data to explore the distribution of feeding practices and examine relationships between complementary feeding and socio-demographic and health behaviour indicators in Kenya, Uganda and Tanzania. We based our analysis on complementary dietary diversity scores calculated for children 6-23 months old. Geographically, Kenya displayed clear division of children's diet diversity scores across its regions, unlike Uganda and Tanzania. Less than 40% of the children's meal frequencies in Uganda and Tanzania had met the minimum daily recommended levels. Only 30-40% of children in Kenya, Tanzania and Uganda had consumed diets with adequate diversity. Children's age, breastfeeding status, mother's education level and working status, household wealth index, prenatal care visits, receiving vitamin A supplements, using modern contraceptives and meal frequencies were significantly associated with adequate complementary food diversity in at least one of the three countries included in the current analyses. These analyses contribute to a better understanding and targeting of infant and young child feeding within the East African region.

Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania

BACKGROUND

Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs.

METHODS

Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision.

RESULTS

CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled.

CONCLUSIONS

Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

"Bend a fish when the fish is not yet dry": adolescent boys' perceptions of sexual risk in Tanzania

Despite decades of effort, the spread of HIV/AIDS continues among many African young people. A key contributor is unsafe sexual behavior that is desired, persuaded, or coerced. We explored the masculinity norms shaping pubescent boys' perceptions of and engagement in (unsafe) sexual behaviors in Tanzania. Through a comparative case study in rural and urban Tanzania, qualitative and participatory methods were used with 160 adolescent boys in and out of school to better understand the social and contextual factors promoting unsafe sexual behaviors. Adolescent boys in both the rural and urban sites reported struggling with intense sexual desires, strong peer pressures to have sex, and social norms dissuading condom use. A growing "normalization" of AIDS suggests messages promoting the dangers of HIV infection may be less effective. Findings reinforce the need for interventions with very young adolescents. Research is needed to identify more effective approaches for promoting safer sexual practices among boys in sub-Saharan Africa. Harm reduction approaches and gender transformative approaches might prove more effective than current HIV prevention efforts focused on youth.