"We have become doctors for ourselves": motives for malaria self-care among adults in southeastern Tanzania

Community knowledge, attitude, practices and beliefs associated with persistence of malaria transmission in North-western and Southern regions of Tanzania

BACKGROUND

Despite significant decline in the past two decades, malaria is still a major public health concern in Tanzania; with over 93% of the population still at risk. Community knowledge, attitudes and practices (KAP), and beliefs are key in enhancing uptake and utilization of malaria control interventions, but there is a lack of information on their contribution to effective control of the disease. This study was undertaken to determine KAP and beliefs of community members and service providers on malaria, and how they might be associated with increased risk and persistence of the disease burden in North-western and Southern regions of Tanzania.

METHODS

This was an exploratory study that used qualitative methods including 16 in-depth interviews (IDI) and 32 focus group discussions (FGDs) to collect data from health service providers and community members, respectively. The study was conducted from September to October 2017 and covered 16 villages within eight districts from four regions of mainland Tanzania (Geita, Kigoma, Mtwara and Ruvuma) with persistently high malaria transmission for more than two decades.

RESULTS

Most of the participants had good knowledge of malaria and how it is transmitted but some FGD participants did not know the actual cause of malaria, and thought that it is caused by bathing and drinking un-boiled water, or consuming contaminated food that has malaria parasites without warming it. Reported barriers to malaria prevention and control (by FGD and IDI participants) included shortage of qualified health workers, inefficient health financing, low care-seeking behaviour, consulting traditional healers, use of local herbs to treat malaria, poverty, increased breeding sites by socio-economic activities and misconceptions related to the use of bed nets and indoor residual spraying (IRS). Among the misconceptions, some participants believed that bed nets provided for free by the government came with bedbugs while others reported that free bed nets caused impotence among men.

CONCLUSION

Despite good knowledge of malaria, several risk factors, such as socio-economic and behavioural issues, and misconceptions related to the use of bed nets and IRS were reported. Other key factors included unavailability or limited access to health services, poor health financing and economic activities that potentially contributed to persistence of malaria burden in these regions. Relevant policies and targeted malaria interventions, focusing on understanding socio-cultural factors, should be implemented to reduce and finally eliminate the disease in the study regions and others with persistent transmission.

Individual and Contextual Factors Associated With Malaria Among Children 6-59 Months in Burkina Faso

Objective: This study aims to understand the individual and contextual factors associated with malaria among children aged 6-59 months in Burkina Faso. Methods: This cross-sectional study used secondary data extracted from the Burkina Faso Malaria Indicator Survey 2017-2018. Descriptive analysis was used to analyse socio-demographic characteristics. We performed a multilevel logistic regression model to highlight individual and contextual factors of children's exposure to malaria. Results: Our analysis included 5,822 children aged 6-59 months. Of these, 15% had a positive rapid diagnostic test. Factors associated with malaria among children 6-59 months were age, maternal education, household wealth, rural residence, and region. The variability in malaria exposure was 16% attributable to the strata level and 23% to the primary sampling unit level. Some factors, such as the family's socio-economic status, access to hospital care, and place of living, were positively associated withs malaria cases in children. Conclusion: The study identified some individual and contextual determinants of malaria among children aged 6-59 months in Burkina Faso. Taking them into account for the design and implementation of policies will undeniably help in the fight against malaria in Burkina Faso.

Renal and hepatic dysfunction parameters correlate positively with gender among patients with recurrent malaria cases in Birnin Kebbi, Northwest Nigeria

Background

Simultaneous increase in transaminases and bilirubin is an indicator of hepatic dysfunction in malaria. Malaria-induced hyperbilirubinemia has been associated with acute kidney injury and pathogenesis of cerebral malaria which are significantly associated with mortality in malaria infection. This retrospective study was designed to assess the lipid profile, and hematological, renal and hepatic function data of malaria patients in Sir Yahaya Memorial hospital Birnin Kebbi from 2016 to 2020 who are 18 years and above.

Methods

The data of all patients between 2016 and 2020 who are 18 years and above were collected. Complete data of 370 subjects who met the inclusion criteria which consist of 250 malaria subjects and 120 control subjects were analyzed.

Results

The results showed that females constitute 65.2% of malaria patients with complete records while the remaining 34.8% were males. Age distribution of the patients showed that the infection was more prevalent among 26–45 years and least among 65 years and above. Anemia and thrombocytopenia were prevalent among the female malaria patients compared to the male patients. Liver and kidney function parameters analyzed correlate positively with the gender. The infected male showed higher dysfunction in liver parameters while infected female patients showed significant dysfunction in kidney function parameters and lipid profile.

Conclusions

In conclusion, to prevent the potential widespread of acute renal and hepatic failure with the attendant morbidity and mortality among malaria patients, it is recommended that liver and kidney function tests be mandated for patients with recurring malaria and those with a history of treatment failure in the endemic area to ensure early diagnosis of malarial induced kidney and liver injury among malaria patients.

Zero malaria: a mirage or reality for populations of sub-Saharan Africa in health transition

The global burden of malaria continues to be a significant public health concern. Despite advances made in therapeutics for malaria, there continues to be high morbidity and mortality associated with this infectious disease. Sub-Saharan Africa continues to be the most affected by the disease, but unfortunately the region is burdened with indigent health systems. With the recent increase in lifestyle diseases, the region is currently in a health transition, complicating the situation by posing a double challenge to the already ailing health sector. In answer to the continuous challenge of malaria, the African Union has started a "zero malaria starts with me” campaign that seeks to personalize malaria prevention and bring it down to the grass-root level. This review discusses the contribution of sub-Saharan Africa, whose population is in a health transition, to malaria elimination. In addition, the review explores the challenges that health systems in these countries face, that may hinder the attainment of a zero-malaria goal.

Contextualising health seeking behaviours for febrile illness: Lived experiences of farmers in northern Tanzania

Understanding how people seek treatment for febrile illness can provide important insights into when care is sought and under what circumstances. This is includes examining how people engage with health facilities and the barriers to care they experience. However, a focus on individual actions runs the risk of overemphasising the agency of individuals to make apt health decisions while underestimating the ways which health behaviours are circumscribed by their place-specific social, historic and political contexts. Drawing on the experiences of approximately 100 farmers in a small livestock keeping community in northern Tanzania, this study uses biosocial theory of health to better understand how febrile illness is managed among individuals. The paper draws attention to the ways in which health decisions are mediated by individual, intrinsic and extrinsic health system factors. Some extrinsic factors (such as hospital user fees) are legacies of neoliberal healthcare reform policies which continue to have consequences for how people manage febrile illness in Tanzania. The findings highlight the need for considerations of health behaviours to look beyond the individual and to appreciate the role of the wider health landscape in influencing individual choice and agency when seeking treatment for illness.

Determinants of treatment-seeking behavior during self-reported febrile illness episodes using the socio-ecological model in Kilombero District, Tanzania

Background

Febrile diseases in Sub-Saharan Africa cause acute and chronic illness. Co-infections are common and these diseases have a complex etiology that includes zoonoses. For the implementation of appropriate treatment and control strategies, determinants of lay treatment-seeking behavior by the affected communities need to be understood. The objective of this study was to explore, using the socio-ecological model, the determinants of treatment-seeking actions among self-identified febrile illness cases in the Kilombero District of Tanzania.

Methods

Thirty-nine in-depth interviews were conducted with 28 men and 11 women in three villages in Kilombero district. These villages were purposively selected due to malaria endemicity in the area, animal husbandry practices, and proximity to livestock-wildlife interaction, all risk factors for contracting febrile zoonotic infections. Thematic analysis was conducted on the interviews to identify the key determinants of treatment-seeking actions.

Results

Study participants attributed febrile illnesses to malaria, typhoid and urinary tract infections. Treatment-seeking behavior was an iterative process, influenced by individual, socio-cultural, ecological and policy factors. Age, expendable income, previous history with a febrile illness, perceptions on disease severity, seasonal livelihood activities and access to timely healthcare were some of the determinants. Self-treatment with pharmaceutical drugs and herbs was usually the initial course of action. Formal healthcare was sought only when self-treatment failed and traditional healers were consulted after the perceived failure of conventional treatment. Delays in seeking appropriate health care and the consultation of medically unqualified individuals was very common.

Conclusion

The results imply that treatment-seeking behavior is shaped by multiple factors across all levels of the socio-ecological model. Public policy efforts need to focus on facilitating prompt health care seeking through community education on the complicated etiology of febrile illnesses. Improved access to timely treatment and better differential diagnostics by health professionals are essential to ensure correct and appropriate treatment and to reduce reliance of patients on unqualified persons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11027-w.

Significant symptoms and nonsymptom-related factors for malaria diagnosis in endemic regions of Indonesia

OBJECTIVES

This study aims to identify significant symptoms and nonsymptom-related factors for malaria diagnosis in endemic regions of Indonesia.

METHODS

Medical records are collected from patients suffering from malaria and other febrile diseases from public hospitals in endemic regions of Indonesia. Interviews with eight Indonesian medical doctors are conducted. Feature selection and machine learning techniques are used to develop malaria classifiers for identifying significant symptoms and nonsymptom-related factors.

RESULTS

Seven significant symptoms (duration of fever, headache, nausea and vomiting, heartburn, severe symptom, dizziness, and joint pain) and patients' history of malaria as a nonsymptom-related factor contribute most to malaria diagnosis. As a symptom, fever duration is more significant than temperature or fever for distinguishing malaria from other febrile diseases. Shivering, fever, and sweating (known to indicate malaria presence in Indonesia) are shown to be less significant than other symptoms in endemic regions.

CONCLUSIONS

Three most suitable malaria classifiers have been developed to identify the significant features that can be used to predict malaria as distinct from other febrile diseases. With extensive experiments on the classifiers, the significant features identified can help medical doctors in the clinical diagnosis of malaria and raise public awareness of significant malaria symptoms at early stages.

Retrospective Analysis of Malaria Cases in a Potentially High Endemic Area of Morogoro Rural District, Eastern Tanzania

Background

Malaria is increasingly characterized by appreciable fine-scale variability in ecology and topography, and it is likely that we are missing some salient foci with unprecedented malaria transmission intensity in different parts of Tanzania. Therefore, efforts aimed at identifying area-specific malaria situation and intervening are needed to preserve the realized health gains and achieve elimination. Mkuyuni and Kiroka, adjacent wards within Morogoro Rural District, are purported to form one of such foci.

Patients and Methods

A retrospective study was conducted to determine six-year (2014-2019) malaria prevalence rates based on outpatients and laboratory registers obtained from two health facilities, one per ward, carrying out diagnosis of malaria either through microscopy or malaria rapid diagnostic test (mRDT). These data were checked for completeness before carrying out statistical analysis.

Results

Overall, 35,386 (46.19%) out of 76,604 patients were positive for malaria. The average proportion of malaria cases was significantly higher in Mkuyuni (51.23%; n=19,438) than Kiroka (41.21%; n = 15,938) (P <0.001). Females were more affected than males (P <0.001);, and irrespective of the sex, most malaria cases were recorded in children <5 years of age (P <0.001) except at Mkuyuni. Malaria was recorded virtually all year round; however, the highest proportion of cases was recorded in April and July (P <0.001).

Conclusion

This study revealed high malaria endemicity in Mkuyuni and Kiroka, with prevalence rate as high as 60.98%, which is far higher than the overall national average prevalence of 9%. More studies are needed in these and other putatively high endemic foci in Tanzania in order to inform the future course of action in disease surveillance and control.

Does improving appropriate use of malaria medicines change population beliefs in testing and treatment? Evidence from a randomized controlled trial

A major puzzle in malaria treatment remains the dual problem of underuse and overuse of malaria medications, which deplete scarce public resources used for subsidies and lead to drug resistance. One explanation is that health behaviour, especially in the context of incomplete information, could be driven by beliefs, pivotal to the success of health interventions. The objective of this study is to investigate how population beliefs change in response to an experimental intervention which was shown to improve access to rapid diagnostic testing (RDT) through community health workers (CHWs) and to increase appropriate use of anti-malaria medications. By collecting data on individuals' beliefs on malaria testing and treatment 12 and 18 months after the experimental intervention started, we find that the intervention increases the belief that a negative test result is correct, and the belief that the first-line anti-malaria drugs (artemisinin-based combination therapies or ACTs) are effective. Using mediation analysis, we also explore some possible mechanisms through which the changes happen. We find that the experience and knowledge about RDT and experience with CHWs explain 62.4% of the relationship between the intervention and the belief that a negative test result is correct. Similarly, the targeted use of ACTs and taking the correct dose-in addition to experience with RDT-explain 96.8% of the relationship between the intervention and the belief that the ACT taken is effective. As beliefs are important determinants of economic behaviour and might guide individuals' future decisions, understanding how they change after a health intervention has important implications for long-term changes in population behaviour.

Understanding risk communication for prevention and control of vector-borne diseases: A mixed-method study in Curaçao

Background

Risk communication (RC) is an essential tool for the prevention and control of diseases as it impacts risk perception, increases awareness and might change behaviour. It is the interactive exchange of information about risks among experts and people. Effective RC can minimize the impact that diseases such as dengue, chikungunya and Zika have on populations. This study aimed to understand RC regarding vector-borne diseases in its social context and from the viewpoint of the audience to strengthen RC strategies in Curaçao.

Methods

In 2015, a cross-sectional mixed-method study applying focus group discussions (n = 7), in-depth interviews (n = 20) and a structured survey questionnaire (n = 339) was done in Curaçao. The study was designed based on the Health Belief Model and the Theory of Planned Behaviour. In addition, the Social Amplification of Risk Framework and the theory of cultural schemas were applied to understand RC in the social context.

Results

Television, radio and newspapers were the most important channels of information regarding dengue and chikungunya. Moreover, individuals also reported receiving information via social media, the internet and family/friends. Interestingly, the use of internet to obtain information diminished with age, while females were more likely to use internet compared to men. These key findings were statistically significant. An important outcome was that the risk perception towards chikungunya at the beginning of the outbreak was attenuated. This might be due to the (perceived) lack of RC before the epidemic. This same risk perception was amplified later during the outbreak by the increased exposure to information. Lastly, we show how cultural schemas influence people’s perception regarding preventive measures and treatment of chikungunya and dengue.

Conclusions

Data obtained emphasise the importance of understanding the user of media platforms and sharing information in a timely fashion through a transparent process with the content that convinces people of the seriousness of the matter.

Vector-borne diseases (VBDs) such as dengue, chikungunya and Zika are an increasing public health concern worldwide. The mentioned VBDs are transmitted to humans through the bite of an infected mosquito from the Aedes species. Preventing or reducing VBDs continues to depend mainly on vector control and interrupting human-vector contact. Risk communication (RC) is the interactive exchange of information about hazards among experts and individuals. As it influences individuals’ behaviour, a better understanding of how it works is vital to improving RC strategies in the context of VBD prevention and control strategies. Our study highlighted the complexity of this matter as we found that there are multiple factors, including the volume of information, trust, experience with a similar disease and cultural schemas that determine how people cope with risk and information. We recommend broadening the use and scope of media platforms to share information and to customise the messages taking the cultural schemas of the community into account.

Assessing the role of the private sector in surveillance for malaria elimination in Haiti and the Dominican Republic: a qualitative study

BACKGROUND

Haiti and the Dominican Republic (DR) are targeting malaria elimination by 2022. The private health sector has been relatively unengaged in these efforts, even though most primary health care in Haiti is provided by non-state actors, and many people use traditional medicine. Data on private health sector participation in malaria elimination efforts are lacking, as are data on care-seeking behaviour of patients in the private health sector. This study sought to describe the role of private health sector providers, care-seeking behaviour of individuals at high risk of malaria, and possible means of engaging the private health sector in Hispaniola's malaria elimination efforts.

METHODS

In-depth interviews with 26 key informants (e.g. government officials), 62 private providers, and 63 patients of private providers, as well as 12 focus group discussions (FGDs) with community members, were conducted within seven study sites in Haiti and the DR. FGDs focused on local definitions of the private health sector and identified private providers for interview recruitment, while interviews focused on private health sector participation in malaria elimination activities and treatment-seeking behaviour of febrile individuals.

RESULTS

Interviews revealed that self-medication is the most common first step in the trajectory of care for fevers in both Haiti and the DR. Traditional medicine is more commonly used in Haiti than in the DR, with many patients seeking care from traditional healers before, during, and/or after care in the formal health sector. Private providers were interested in participating in malaria elimination efforts but emphasized the need for ongoing support and training. Key informants agreed that the private health sector needs to be engaged, especially traditional healers in Haiti. The Haitian migrant population was reported to be one of the most at-risk groups by participants from both countries.

CONCLUSION

Malaria elimination efforts across Hispaniola could be enhanced by engaging traditional healers in Haiti and other private providers with ongoing support and trainings; directing educational messaging to encourage proper treatment-seeking behaviour; and refining cross-border strategies for surveillance of the high-risk migrant population. Increasing distribution of rapid diagnostic tests (RDTs) and bi-therapy to select private health sector facilities, accompanied by adopting regulatory policies, could help increase numbers of reported and correctly treated malaria cases.

'He usually has what we call normal fevers': Cultural perspectives on healthy child growth in rural Southeastern Tanzania: An ethnographic enquiry

Introduction

While parents’ construction of and actions around child growth are embedded in their cultural framework, the discourse on child growth monitoring (CGM) has been using indicators grounded in the biomedical model. We believe that for CGM to be effective, it should also incorporate other relevant socio-cultural constructs. To contribute to the further development of CGM to ensure that it reflects the local context, we report on the cultural conceptualization of healthy child growth in rural Tanzania. Specifically, we examine how caregivers describe and recognize healthy growth in young children, and the meanings they attach to these cultural markers of healthy growth.

Methods

Caregivers of under-five children, including mothers, fathers, elderly women, and community health workers, were recruited from a rural community in Kilosa District, Southeastern Tanzania. Using an ethnographic approach and the cultural schemas theory, data for the study were collected through 19 focus group discussions, 30 in-depth interviews, and five key informant interviews. Both inductive and deductive approaches were used in the data analysis.

Results

Participants reported using multiple markers for ascertaining healthy growth. These include ‘being bonge’ (chubby), ‘being free of illness’, ‘eating well’, ‘growing in height’, as well as ‘having good kilos’ (weight). Despite the integration of some biomedical concepts into the local conceptualization of growth, the meanings attached to these concepts are largely rooted in the participants’ cultural framework. For instance, a child’s weight is ascribed to the parents’ adherence to postpartum sex taboos and to the nature of a child’s bones. The study noted conceptual differences between the meanings attached to height from a biomedical and a local perspective. Whereas from a biomedical perspective the height increment is considered an outcome of growth, the participants did not see height as linked to nutrition, and did not believe that they have control over their child’s height.

Conclusions

To provide context-sensitive advice to mothers during CGM appointments, health workers should use a tool that takes into account the mothers’ constructs derived from their cultural framework of healthy growth. The use of this approach should facilitate communication between health professionals and caregivers during CGM activities, increase the uptake and utilization of CGM services, and, eventually, contribute to reduced levels of childhood malnutrition in the community.

Malaria care-seeking behaviour among HIV-infected patients receiving antiretroviral treatment in South-Eastern Nigeria: A cross-sectional study

This study assesses malaria prevention and treatment behaviour among people living with HIV/AIDS (PLWHA) in Owerri, South Eastern Nigeria. Although Nigeria bears one of the world’s largest burdens of both malaria and HIV, there is almost no research studying how co-infected patients manage their care. We systematically sampled 398 PLWHA receiving care at Imo State Specialist Hospital and the Federal Medical Centre in Owerri to complete a structured, pre-tested questionnaire on malaria care-seeking behaviour. Descriptive statistics were reported and chi-square tests and multivariate logistic regressions were also used. The majority of HIV-infected patients (78.9%) reported having had an episode of suspected malaria quarterly or more often. There was a large variation in care-seeking patterns: on suspicion of malaria, 29.1% of participants engaged in self-medication; 39.2% went to drug shops, and only 22.6% visited HIV/AIDS care centres. Almost 40% waited more than 24 hours before initiating treatment. Most (60.3%), reported taking recommended artemisinin-based combination treatments (ACT) but a significant minority took only paracetamol (25.6%) or herbal remedies (3.5%). Most (80%) finished their chosen course of treatment; and completion of treatment was significantly associated with the frequency of suspected malaria occurrence (p = 0.03). Most (62.8%) did not take anti-malaria medication while taking antiretroviral treatment (ART) and almost all (87.6%) reported taking an ACT regimen that could potentially interact with Nigeria’s first-line ART regimen. Our findings suggest the need to pay more attention to malaria prevention and control as a crucial element in HIV/AIDS management in this part of Nigeria and other areas where malaria and HIV/AIDS are co-endemic. Also, more research on ART-ACT interactions, better outreach to community-level drug shops and other private sector stakeholders, and clearer guidelines for clinicians and patients on preventing and managing co-infection may be needed. This will require improved collaboration between programmes for both diseases.

Predictors of residual antimalarial drugs in the blood in community surveys in Tanzania

Background

Understanding pattern of antimalarials use at large scale helps ensuring appropriate use of treatments and preventing the spread of resistant parasites. We estimated the proportion of individuals in community surveys with residual antimalarials in their blood and identified the factors associated with the presence of the most commonly detected drugs, lumefantrine and/or desbutyl-lumefantrine (LF/DLF) or sulfadoxine-pyrimethamine (SP).

Methods

A cross-sectional survey was conducted in 2015 in three regions of Tanzania with different levels of malaria endemicity. Interviews were conducted and blood samples collected through household surveys for further antimalarial measurements using liquid chromatography coupled to tandem mass spectrometry. In addition, diagnosis and treatment availability was investigated through outlet surveys. Multilevel mixed effects logistic regression models were used to estimate odds ratios for having LF/DLF or SP in the blood.

Results

Amongst 6391 participants, 12.4% (792/6391) had LF/DLF and 8.0% (510/6391) SP in the blood. Factors associated with higher odds of detecting LF/DLF in the blood included fever in the previous two weeks (OR = 2.6, p<0.001), living in districts of higher malaria prevalence (OR = 1.5, p<0.001) and living in a ward in which all visited drug stores had artemisinin-based combination therapies in stocks (OR = 2.7, p = 0.020). Participants in older age groups were less likely to have LF/DLF in the blood (OR = 0.9, p<0.001). Factors associated with higher odds of having SP in the blood included being pregnant (OR = 4.6, p<0.001), living in Mwanza (OR = 3.9, p<0.001 compared to Mbeya), fever in the previous two weeks (OR = 1.7, p<0.001) and belonging to older age groups (OR = 1.2, p<0.001).

Conclusion

The most significant predictors identified were expected. History of fever in the past two weeks and young age were significant predictors of LF/DLF in the blood, which is encouraging. Antimalarial drug pressure was high and hence the use of recommended first-line drugs in combination with malaria Rapid Diagnostics Tests should be promoted to ensure appropriate treatment.

Utility of passive malaria surveillance in hospitals as a surrogate to community infection transmission dynamics in western Kenya

Background

Malaria continued to be the major public health concern in sub-Sahara Africa, thus for better planning of control activities, periodic surveillance of both clinical and asymptomatic cases remains important. However, the usability of routinely collected malaria data in Kenyan hospitals as a predictor of the asymptomatic malaria infection in the community amidst rapid infection resurgence or reduction in different areas of disease endemicities remains widely unstudied. This study was therefore aimed to evaluate the utility of passive surveillance of malaria in health facilities as a proxy of infection transmission of the surrounding community in different transmission intensities.

Methods

Prospective multiple cross-sectional surveys were done in three villages in western Kenya. Monthly asymptomatic malaria positivity among school children, number of outpatient (OPD) confirmed malaria cases and abundancy of indoor resting malaria vectors were surveyed from June 2015 to August 2016. Community surveys on antimalarial drug use among adults and children were also done. Detection of malaria parasitaemia was done using thick and thin Giemsa stained blood slide microscopy for both clinical and school participants. A questionnaire was used to collect information on self-use of antimalarial drugs from randomly selected households.

Results

The overall OPD blood slide positivity from all study sites was 26.6% (95%CI 26.2–27.0) and highest being among the 5–14 years (41.2% (95% CI 40.1–42.3). Asymptomatic malaria positivity among the school children were 6.4% (95%CI 5.3–7.5) and 38.3% (95%CI 36.1–40.5) in low and high transmission settings respectively. A strong correlation between overall monthly OPD positivity and the school age children positivity was evident at Marani (low transmission) (rho = 0.78, p = 0.001) and at Iguhu (Moderate transmission) (rho = 0.61, p = 0.02). The high transmission setting (Kombewa) showed no significant correlation (rho = − 0.039, p = 0.89).

Conclusion

Hospital malaria data from low and moderate malaria transmission predicted the infection transmission dynamics of the surrounding community. In endemic sites, hospital based passive surveillance didn’t predict the asymptomatic infection dynamics in the respective community.

Electronic supplementary material

The online version of this article (10.1186/s13690-018-0288-y) contains supplementary material, which is available to authorized users.

Cross-Study of Malaria Prevalence in History, Bed Net Utilization, and Knowledge about the Disease among Tanzanian College Students

University campuses are potential reservoirs of infectious diseases, but they are not in the research focus. It is obvious that the use of malaria preventive tools is extremely necessary in campus conditions in endemic countries. This study is the first malaria survey, conducted in a student campus in Tanzania. This cross-sectional study uncovered a surprisingly high prevalence of malaria history among students: 89,4% of 246 random respondents assume that they had malaria in history, among whom 145 (58,9%) suffered from the disease during the last year. And although students are relatively confident about the vector, parasite, and prevention measures of the disease, only 44,7% of the students use bed nets and 4,5% use a body spray or ointment daily. The others seldom use spray or ointment or do not care about the problem at all. This situation was found to be associated with two factors, financial and educational. Current results show that students are relatively educated on malaria, but they do not follow the malaria prevention guidance. It has become clear that at least proper informational propaganda of bed net use is required in Tanzanian university campuses.

Health-related impact on quality of life and coping strategies for chikungunya: A qualitative study in Curaçao

INTRODUCTION

Chikungunya is an emerging public health problem in tropical and subtropical regions, due to ongoing transmission and its incapacitating acute disease phase, and chronic sequelae. The disease is responsible for a major impact on Health Related Quality of Life (HRQoL), which may last several years. To our knowledge, this study is the first qualitative examination of HRQoL and coping strategies of chikungunya-infected individuals.

METHODS

Qualitative research methods consisted of 20 in-depth interviews and seven Focus Group Discussions (FGDs), n = 50. Analysis was based on the principles of the grounded theory.

RESULTS

Different impacts on HRQoL were reported. The physical and emotional domains of the HRQoL were mainly affected by chikungunya, while social and individual financial consequences were limited. Individual financial impact was limited through the universal health care program of Curaçao. Long-term lingering musculoskeletal and other manifestations caused significant pain and limited mobility. Hence, participants experienced dependency, impairment of normal daily life activities, moodiness, hopelessness, a change of identity, and insecurity about their future. The unpredictable nature and consequences of chikungunya gave rise to various coping strategies. Problem-focused coping styles led to higher uptake of medical care and were linked to more negative impact of HRQoL, whereas emotional coping strategies focusing on acceptance of the situation were linked to less uptake of medical care and more positive impact on HRQoL.

CONCLUSIONS

This study provides an in-depth understanding of acute and long-term HRQoL impact of chikungunya. The results can better inform health promotion policies and interventions. Messages to the public should focus on promoting healthy and efficient coping strategies, in order to prevent additional stress in affected individuals.

Illness experiences of diabetes in the context of malaria in settings experiencing double burden of disease in southeastern Tanzania

BACKGROUND

Tanzania is doubly burdened with both non-communicable and infectious diseases, but information on how Tanzanians experience the co-existence of these conditions is limited. Using Kleinman's eight prompting questions the study synthesizes explanatory models from patients to describe common illness experiences of diabetes in a rural setting where malaria is the predominant health threat.

METHODS

We conducted 17 focus group discussions with adult members of the general community, diabetes patients, neighbours and relatives of diabetes patients to gain insight into shared experiences. To gain in-depth understanding of the individual illness experiences, we conducted 41 in-depth interviews with malaria or diabetes patients and family members of diabetes patients. The analysis followed grounded theory principles and the illness experiences were derived from the emerging themes.

RESULTS

The illness experiences showed that malaria and diabetes are both perceived to be severe and fatal conditions, but over the years people have learned to live with malaria and the condition is relatively manageable compared with diabetes. In contrast, diabetes was perceived as a relatively new disease, with serious life-long consequences. Uncertainty, fear of those consequences, and the increased risk for severe malaria and other illnesses impacted diabetes patients and their families' illness experiences. Unpredictable ailments and loss of consciousness, memory, libido, and functional incapability were common problems reported by diabetes patients. These problems had an effect on their psychological and emotional health and limited their social life. Direct and indirect costs of illness pushed individuals and their families further into poverty and were more pronounced for diabetes patients.

CONCLUSION

The illness experiences revealed both malaria and diabetes as distressing conditions, however, diabetes showed a higher level of stress because of its chronicity. Strategies for supporting social, emotional, and psychological well-being that build on the patient accounts are likely to improve illness experiences and quality of life for the chronically ill patient.

Individual and contextual factors associated with appropriate healthcare seeking behavior among febrile children in Tanzania

INTRODUCTION

Fever in malaria endemic areas, has been shown to strongly predict malaria infection and is a key symptom influencing malaria treatment. WHO recommended confirmation testing for Plasmodium spp. before initiation of antimalarials due to increased evidence of the decrease of morbidity and mortality from malaria, decreased malaria associated fever, and increased evidence of high prevalence of non-malaria fever. To immediately diagnose and promptly offer appropriate management, caretakers of children with fever should seek care where these services can be offered; in health facilities.

OBJECTIVES

This study was conducted to describe healthcare seeking behaviors among caretakers of febrile under five years, in Tanzania. And to determine children's, household and community-level factors associated with parents' healthcare seeking behavior in health facilities.

METHODS

Secondary data analysis was done using the Tanzania HIV and Malaria Indicator Surveys (THMIS) 2011-2012. Three-level mixed effects logistic regression was used to assess children's, household and community-level factors associated with appropriate healthcare seeking behavior among care takers of febrile children as well as differentiating between household and community variabilities.

RESULTS

Of the 8573 children under the age of five years surveyed, 1,675(19.5%) had a history of fever two weeks preceding the survey. Of these, 951 (56.8%) sought appropriate healthcare. Febrile children aged less than a year have 2.7 times higher odds of being taken to the health facilities compared to children with two or more years of age. (OR: 2.7; 95%CI: 1.50-4.88). Febrile children from households headed by female caretakers have almost three times higher odds of being taken to the health facilities (OR: 2.85; 95%CI; 1.41-5.74) compared to households headed by men. Febrile children with caretakers exposed to mass media (radio, television and newspaper) have more than two times higher odds of being taken to health facilities compared to those not exposed to mass media. Febrile children from regions with malaria prevalence above national level have 41% less odds of being taken to health facilities (OR: 0.49; 95%CI: 0.29-0.84) compared to those febrile children coming from areas with malaria prevalence below the national level. Furthermore, febrile children coming from areas with higher community education levels have 57% (OR: 1.57; 95%CI: 1.14-2.15) higher odds of being taken to health facilities compared to their counterparts coming from areas with low levels of community education.

CONCLUSION AND RECOMMENDATION

To effectively and appropriately manage and control febrile illnesses, the low proportion of febrile children taken to health facilities by their caretakers should be addressed through frequent advocacy of the importance of appropriate healthcare seeking behavior, using mass media particularly in areas with high malaria prevalence. Multifaceted approach needs to be used in malaria control and eradication as multiple factors are associated with appropriate healthcare seeking behavior.

Knowledge, attitudes and practices on malaria in relation to its transmission among primary school children in Bagamoyo district, Tanzania

Background

Communities' knowledge, attitudes and practices on malaria disease often remain unobserved during malaria control efforts. In Tanzania, many studies focus on increasing community knowledge and awareness on malaria prevention but the potential participation and contribution of schoolchildren towards knowledge, attitudes and practices on malaria has received little attention. We investigated the knowledge and understanding of primary school children on malaria transmission, recognition of symptoms, treatment seeking behaviour, preventive measures and practices in order to potentially include this group in Tanzania's malaria control efforts.

Materials and methods

125 children were recruited from three purposively selected primary schools in Bagamoyo district, Tanzania. A semi-structured interview guide, including both closed and open-ended questions, was used to collect information from the participants to obtain their knowledge and understanding on malaria transmission, treatment and prevention.

Results

More than half of the school children (79/125; 63.2% ) had knowledge on malaria as a disease and its transmission; 101/125 (80.8%) of the respondents reported that going to the hospital was their immediate care-seeking behaviour once they felt malaria symptoms, while 14/125 (11.2%) opted for self-medication. With regard to malaria prevention and control, 115/125 (92.0%) of the respondents reported using bednets as their main malaria prevention strategy, while 6/125 (4.8%) preferred the use of medicine, mostly artemether lumefantrine, as prophylaxis. Narratives obtained were able to explain clearly the rationale behind different options children took to treat and to protect themselves against malaria.

Conclusions

Findings indicated that primary school children in Bagamoyo district are aware of malaria, its symptoms and preventive measures, although some had misconceptions and could not associate the disease with its transmission. We conclude that inclusion of school children on malaria control educational programmes could yield substantial benefits towards malaria elimination.

Community Knowledge and Perceived Effectiveness of Interventions to Reduce Malaria: Implications for Sustained Use of Malaria Interventions in Rufiji District, Southeastern Tanzania

Insecticides treated-nets (ITNs) and artemether-lumefantrine (ALu), crucial for malaria elimination, depend on perceived effectiveness in reducing malarial fevers. We examined community knowledge and perceived effectiveness of ITNs and ALu for reducing malaria in Rufiji district. Heads of households were interviewed on causes of fever in underfives, fever history, and antimalarial use during the last 2 weeks, perceived effectiveness of, and willingness to continue using ALu and ITNs. A total of 1,885 respondents were interviewed, a majority (88.2%) females. Illnesses with fever (malaria-76.1% and respiratory conditions-58.9%) were major health problems. There was a very high recognition of fever as malaria symptom (95.1%). There were mixed perceptions on effectiveness of ALu and ITNs: ALu (52.8%) and on ITNs as highly effective (48.1%). Both ALu and ITNs were judged partially effective. Reorientation of social marketing to increase demand for ALu and ITNs for malaria control consolidation is crucial.

Accrediting retail drug shops to strengthen Tanzania's public health system: an ADDO case study

INTRODUCTION

Retail drug sellers are a major source of health care and medicines in many countries. In Tanzania, drug shops are widely used, particularly in rural and underserved areas. Previously, the shops were allowed to sell only over-the-counter medicines, but sellers who were untrained and unqualified often illegally sold prescription drugs of questionable quality.

CASE DESCRIPTION

In 2003, we worked with Tanzania's Ministry of Health and Social Welfare to develop a public-private partnership based on a holistic approach that builds the capacity of owners, dispensers, and institutions that regulate, own, or work in retail drug shops. For shop owners and dispensers, this was achieved by combining training, business incentives, supervision, and regulatory enforcement with efforts to increase client demand for and expectations of quality products and services. The accredited drug dispensing outlet (ADDO) program's goal is to improve access to affordable, quality medicines and pharmaceutical services in retail drug outlets in rural or peri-urban areas with few or no registered pharmacies. The case study characterizes how the ADDO program achieved that goal based on the World Health Organization's health system strengthening building blocks: 1) service delivery, 2) health workforce, 3) health information systems, 4) access to essential medicines, 5) financing, and 6) leadership and governance.

DISCUSSION AND EVALUATION

The ADDO program has proven to be scalable, sustainable, and transferable: Tanzania has rolled out the program nationwide; the ADDO program has been institutionalized as part of the country's health system; shops are profitable and meeting consumer demands; and the ADDO model has been adapted and implemented in Uganda and Liberia. The critical element that was essential to the ADDO program's success is stakeholder engagement-the successful buy-in and sustained commitment came directly from the effort, time, and resources spent to fully connect with vital stakeholders at all levels.

CONCLUSIONS

Beyond improving the quality of medicines and dispensing services, availability of essential medicines, and the regulatory system, the impact of a nationwide accredited drug seller approach on the pharmaceutical sector promises to provide a model framework for private-sector pharmaceutical delivery in the developing world that is sustainable without ongoing donor support.

Care-seeking at patent and proprietary medicine vendors in Nigeria

Background

To achieve health development goals, policymakers are increasingly focused on improving primary care in low- and middle-income countries, and private sector drug retailers offer one channel through which basic services may be delivered. In Nigeria, patent and proprietary medicine vendors (PPMVs) serve as a main source of medications, but little is known about their clientele or how care is sought at PPMVs for common illnesses. We explore differences in care-seeking at PPMV shops based on the most commonly reported symptoms.

Methods

In Kogi and Kwara states, Nigeria, 250 PPMV shop workers and 2,359 customers purchasing drugs were surveyed, and each worker-customer interaction was observed. Multivariate regression analysis was used to assess the association of commonly reported symptoms with care-seeking behavior prior to attending the shop and while interacting with the provider at the shop.

Results

Most customers sought care for headache (30.5 %), fever (22.9 %), cough/cold (18.1 %), or diarrhea (8.4 %). Customers with fever were more likely to report being diagnosed by a formally trained person, to have discussed the illness with and be examined by the shop worker, and have more difficulty paying. In contrast, customers with headache symptoms were less likely to experience these outcomes and spent less money purchasing drugs. Those reporting cough or cold symptoms were less likely to have been diagnosed by a formally trained person, waited longer before visiting the PPMV shop, and were more likely to discuss the illness with the shop worker, but were less likely to be examined or to recommend the purchased drug themselves. If a sick child was brought to the shop, a discussion of the illness and an exam were more likely and more money was spent on drugs.

Conclusions

Because care-seeking behaviors vary by symptoms and the sick person’s age, PPMVs should be trained to treat common illnesses for which customers are unlikely to seek a formal medical consultation. Interventions aimed at improving primary care need to target the places where most people access care, and equip PPMV workers with knowledge and tools to provide basic services.

Malaria elimination in Haiti by the year 2020: an achievable goal?

Haiti and the Dominican Republic, which share the island of Hispaniola, are the last locations in the Caribbean where malaria still persists. Malaria is an important public health concern in Haiti with 17,094 reported cases in 2014. Further, on January 12, 2010, a record earthquake devastated densely populated areas in Haiti including many healthcare and laboratory facilities. Weakened infrastructure provided fertile reservoirs for uncontrolled transmission of infectious pathogens. This situation results in unique challenges for malaria epidemiology and elimination efforts. To help Haiti achieve its malaria elimination goals by year 2020, the Laboratoire National de Santé Publique and Henry Ford Health System, in close collaboration with the Direction d’Épidémiologie, de Laboratoire et de Recherches and the Programme National de Contrôle de la Malaria, hosted a scientific meeting on “Elimination Strategies for Malaria in Haiti” on January 29-30, 2015 at the National Laboratory in Port-au-Prince, Haiti. The meeting brought together laboratory personnel, researchers, clinicians, academics, public health professionals, and other stakeholders to discuss main stakes and perspectives on malaria elimination. Several themes and recommendations emerged during discussions at this meeting. First, more information and research on malaria transmission in Haiti are needed including information from active surveillance of cases and vectors. Second, many healthcare personnel need additional training and critical resources on how to properly identify malaria cases so as to improve accurate and timely case reporting. Third, it is necessary to continue studies genotyping strains of Plasmodium falciparum in different sites with active transmission to evaluate for drug resistance and impacts on health. Fourth, elimination strategies outlined in this report will continue to incorporate use of primaquine in addition to chloroquine and active surveillance of cases. Elimination of malaria in Haiti will require collaborative multidisciplinary approaches, sound strategic planning, and strong ownership of strategies by the Haiti Ministère de la Santé Publique et de la Population.

"In a situation of rescuing life": meanings given to diabetes symptoms and care-seeking practices among adults in Southeastern Tanzania: a qualitative inquiry

Background

Diabetes mellitus is an emerging public health problem in Tanzania. For the community and the health system to respond adequately to this problem, it is important that we understand the meanings given to its symptoms, and the care-seeking practices of individuals.

Methods

To explore collective views on the meanings given to diabetes symptoms, we conducted nine focus group discussions with adult diabetes patients and members of the general community. To gain a better understanding of how the meanings in the community inform the care-seeking practices of individuals, 19 in-depth interviews were conducted with diabetes patients. The data were analyzed using principles of grounded theory and applying cultural schema theory as a deductive framework.

Results

In the communities and among the patients, knowledge and awareness of diabetes are limited. Both people with diabetes and community members referred to their prevailing cultural meaning systems and schemas for infectious diseases to interpret and assign meaning to the emerging symptoms. Diabetes patients reported that they had initially used anti-malarial medicines because they believed their symptoms—like headache, fever, and tiredness—were suggestive of malaria. Schemas for body image informed the meaning given to diabetes symptoms similar to those of HIV, like severe weight loss. Confusion among members of the community about the diabetes symptoms instigated tension, causing patients to be mistrusted and stigmatized. The process of meaning-giving and the diagnosis of the diabetes symptoms was challenging for both patients and health care professionals. Diabetes patients reported being initially misdiagnosed and treated for other conditions by medical professionals. The inability to assign meaning to the symptoms and determine their etiologies informed the decision made by some patients to consult traditional healers, and to associate their symptoms with witchcraft causes.

Conclusion

The meanings given to diabetes symptoms and the care-seeking practices described in the study are shaped by the prevailing cultural schemas for infectious diseases and their treatments. Efforts to educate people about the symptoms of diabetes and to encourage them to seek out appropriate care should build on the prevailing cultural meaning system and schemas for diseases, health and illness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1504-0) contains supplementary material, which is available to authorized users.