Prevalence of late antenatal care booking among pregnant women attending public health facilities of Kigamboni Municipality in Dar es Salaam region, Tanzania

Background

Good care during pregnancy is important for the health of mothers and development of the unborn baby. The study determined the prevalence and factors associated with late ANC booking among pregnant women at health facilities in Kigamboni Municipality in Dar es Salaam, Tanzania.

Methods

This was an analytical cross-sectional study among pregnant women attending ANC services during second and third trimester in the selected health facilities. The study recruited 204 through convenient sampling. Multi-stage cluster sampling was used to select health facilities. A Standardised questionnaire was used to collect information through face-to-face interviews. Data was analysed using SPSS version 25.0. Proportions were used to estimate the magnitude of late ANC booking while bivariate and multivariate analyses were performed to determine factors associated with the magnitude of late ANC booking.

Results

Late ANC bookings were high 174 (85.3%) among pregnant women who attended clinic week 13 and later compared to those who attended earlier than 13 weeks 30 (14.7%). Factors associated with likelihood for late ANC booking during the initial visit included tertiary education [AOR= 10.174, 95%CI: 1.002-103.301] and primigravida [AOR=0.101, 95%CI: 0.170-0.605].

Conclusion

Majority of the pregnant women started ANC later than the recommended time. Health education provision at all community levels on the advantages and disadvantages of early and late ANC booking respectively should be strengthened.

Comparison on treatment outcomes of patients enrolled on anti-retroviral therapy at different levels of the health-care system in a high HIV/AIDS setting

HIV/AIDS prevalence in Botswana is amongst the highest in the world and remains a significant public health problem. however, the introduction of anti-retroviral therapy (ART) lead to a significant reduction in morbidity and mortality. Decentralization of anti-retroviral therapy has improved access to treatment for people living with HIV. Treatment outcomes for patient initiated on treatment at different levels of care is unknown and this study seeks to compare treatment outcomes of patients enrolled on ART at different levels of the health care. This is a retrospective cross-sectional study that included review of data from January 2017 to December 2018. The study was conducted in 2 health districts in the country. Nine hundred and sixty (960) patient's record were included in analysis. More than half (63%) of patients were enrolled at primary care level while 37% were at tertiary level. Sixty one percent (n = 587) were female while 39% (n = 373) were males. There were no statistically significant differences in viral load suppression after 12 months of treatment between patients enrolled at tertiary level and primary care level, x2 = 0.75, p value = 0.56. Time to initiation was longer at tertiary (median = 126) compared to primary are level (median = 18), p < 0.001. We reccommend further decentralization of ART services to lower levels of the health care system to initiate PLWHIV early on treatment and improve their health outcomes and reduce transmission through treatment by prevention.

Sexual Practices among Cobblestone Construction Workers in Addis Ababa, Ethiopia: Challenge to the Prevention of HIV Infection2020

BACKGROUND: HIV infection remains a public health challenge. This study assessed sexual practices among casual workers at the Cobblestone construction, Addis Ababa, Ethiopia. METHODS: This was a quantitative cross-sectional study carried out among the labourers at the Cobblestone construction sites between October &ndash; December 2018. Multi-stage sampling was used to estimate the sample size. Demographic and sexual practice information were collected using a structured questionnaire. Bivariate and multivariate analyses were used to determine associations between variables; P &lt; 0.05 was considered statistically significant. RESULTS: We recruited 627 labourers. Majority (82.2%) were aged between 18 and 38 years; average age at onset of sexual debut was 17.9 &plusmn;2.67 and 19.14 &plusmn;2.18 years among males and females respectively. Majority (68.5%) were married; exposure to pornography was 40.2% and 32% among male and female respectively. Lifetime multiple sexual practices were prevalent (59.9% and 50.0%) among males and females respectively; extramarital sex was prevalent (66.9%) among males but protected sex was relatively low (46.2%). Being employed significantly associated with likelihood of first exposure to alcohol (P =0.029), level of education, exposure to pornography and knowledge of symptoms of STIs significantly associated with multiple sexual practices. CONCLUSION: Prevalence of risky sexual practices among the labourers were high which risks them to HIV infections. Innovative approaches to behavioural change are needed to reduce risks of HIV infection.

Uptake of HIV Re-Testing among Postpartum Women Who Initially Tested Negative during Antenatal Visit in Ubungo District, Dar es salaam

BACKGROUND: It is recommended that HIV re-testing should be done at third trimester, labour and at six months postpartum. Reports indicate low rates of HIV re-testing among women after delivery. The study assessed the uptake of HIV re-testing among women during postpartum after initially testing negative at ANC clinic in Ubungo district, Dar es salaam. METHOD: A cross-sectional analytical study was conducted among women who delivered during the study period. Data was collected through a standardised questionnaire and secondary data was collected from the Health Information System and ANC cards. SPSS version 28 was used to analyse data. Bivariate and multivariate logistic regression models were used to calculate the adjusted odds ratio and to quantify the association. RESULTS: 426 women participated in the study. The overall HIV re-testing rate was 76.1%, 23.9% did not re-test and 2.1% were infected with HIV after the second test. Married women have higher re-testing rates (52.8%) than single, separated and divorcees. Women aged 25-34 years have significant higher (84.6%) proportion of re-testing for HIV than those &lt; 25 and those &gt; 34 years of age (p&lt;0.001). Other significant predictors for HIV re-testing were women who made at least five or more visits to ANC and those who knew the HIV status of their partners. CONCLUSION: HIV re-testing has not reached the Tanzania national target of 95%. Efforts to sensitise communities on the importance of early ANC booking at ANC and re-testing for HIV during labour, delivery and postpartum should be enhanced.

Gaps, Challenges, and Opportunities for Global Health Leadership Training

Background

Global Health Leadership (GHL) programs are essential for training emerging health care professionals to be effective leaders. Synthesizing knowledge acquired through experience implementing GHL programs can inform future recommendations for GHL.

Objective

To describe the lessons learned, highlighting gaps, challenges and opportunities, during implementation of two GHL capacity building programs, namely the Afya Bora Consortium Fellowship in Global Health Leadership and the Sustaining Technical and Analytic Resources (STAR) fellowship and internship program for global health professionals.

Methods

A mixed methods case-comparison study was conducted, using qualitative data (expert opinion) collected from the Program Directors in order to understand the experiences of the two GHL programs. A structured response guide was used to assess the overall experience in GHL program implementation, operational challenges and reported gaps. Afya Bora and STAR have been implemented for 8 and 2.5 years respectively. Thus, the analysis reflects a snapshot of the two programs at different stages.

Findings

The results reflect knowledge gained through extensive experience in implementing the two GHL programs. Afya Bora has trained 188 multi-disciplinary fellows, and 100% of the African fellows are engaged in leadership positions in government departments and non-governmental organizations (NGOs) in their countries. STAR has placed 147 participants (89 fellows and 58 interns) in more than 25 countries globally. Both programs were successful in strengthening south-south and north-south collaborations for a common goal of improving global health. Implementation of both fellowships identified room for improvement in operational procedures and financing of the programs, and highlighted knowledge and skills gaps, as well as challenges in sustainability of the training programs.

Conclusions

Afya Bora and STAR have had significant impact and have contributed to changing the leadership landscape in global health. Future GHL programs should address sustainability in terms of financing, delivery modalities and domestic integration of knowledge.

Health care workers experiences in emergency obstetric care following implementation of an in-service training program: case of 2 Referral Hospitals in Botswana

Background: Maternal mortality rate remains a challenge in many developing countries. Objectives: This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality. Methods: Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Par- ticipants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach. Results: Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised. Conclusion: Strengthening health education at health facility levels, stakeholders’ involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality. Keywords: Maternal mortality; health care workers; EMOC, in-service training.

AFYA BORA CONSORTIUM FELLOWSHIP: a journey of success in Global Health Leadership Training

Nil.

Health care workers experiences in emergency obstetric care following implementation of an in-service training program: case of 2 Referral Hospitals in Botswana

Background

Maternal mortality rate remains a challenge in many developing countries.

Objectives

This study explored experiences of Health Care Workers on Emergency Obstetrics Care (EMOC) in-service training and its effect on maternal mortality.

Methods

Descriptive qualitative study design was conducted using in-depth interviews and focus group discussions. Participants were EMOC trained midwives and doctors purposively selected from the 2 referral hospitals in the country. Data were transcribed verbatim, coded, and analysed using Grounded Theory approach.

Results

Four themes emerged including training, EMOC implementation, maternal death factors and EMOC prioritisation. The duration of training was viewed inadequate but responsiveness to and confidence in managing obstetric emergencies improved post EMOC training. Staff shortage, HCWs non-adherence and negative attitude to EMOC guidelines; delays in instituting interventions, inadequate community involvement, minimal or no health talk to women and their partners and communities on sexual reproductive matters and non-prioritisation of EMOC by authorities were concerns raised.

Conclusion

Strengthening health education at health facility levels, stakeholders' involvement; and prioritising EMOC in-service training are necessary in reducing the national maternal mortality.

O36: DEVELOPING A TRAUMA REGISTRY IN A MIDDLE INCOME COUNTRY – BOTSWANA

Background

Botswana has a large burden of disease from injury, but no trauma registry. This study sought to design and pilot test a trauma registry at two hospitals.

Methods

A cross sectional study was piloted at a tertiary hospital and a secondary level hospital in Botswana. The study consisted of two stages: stage 1 mainly involved stakeholder consultations on existing data collection tools. Stage 2 consisted of two phases: Phase I involved retrospective collection of existing data from existing data collection tools and Phase II collected data prospectively using the proposed trauma registry prototype.

Results

The pre-hospital road traffic accident data is collected using hard copy forms and some of this data is transferred to a stand-alone electronic registry. The hospital phase of road traffic accident data all goes into hard copy files then stored in institutional registry departments. The post-hospital data is also partially stored as hard copies and some data is stored in a stand-alone electronic registry. The demographics, pre-hospital, triage, diagnosis, management and disposition had a high percent variable completion rate with no significant difference between phases I and II. However, the primary survey variables in Phase I had a low percent variable completion rate which was significantly different from the high completion rates in phase II at both hospitals. A similar picture was observed for the secondary survey at both hospitals.

Conclusion

Electronic trauma registries are feasible and data completion rate is high when using the electronic data registry as opposed to data collected using the existing paper-based data collection tools.

Keywords

Trauma registry, Injury registry, Road Traffic Accident Trauma Registry, Road Traffic Crushes Registry, Road Accident Registry.

SYSTEMATIC REVIEWS

Transition of adolescents with intellectual disability from schools for learners with special educational needs: Parents views for the preparedness

BACKGROUND

Studies on preparedness of parents of adolescents living with intellectual disabilities transitioning from school to adulthood are scarce in sub-Saharan Africa. This study explored views of parents on their preparedness to handle adolescents transitioning from special schools to adulthood.

METHODS

Descriptive qualitative method was used to collect views of parents of adolescents with intellectual disability on their preparedness to handle transition of their children from school into community life. Content analysis was used to analyse the data.

FINDINGS

Twelve female and two male participants expressed concerns on lack of transition plans, adolescent's future, culture and beliefs and inadequate community support. Views of parents of younger children and those of parents of older children were similar.

CONCLUSION

Parents were unprepared for transition of their children from school to community life. Multidisciplinary approach including family involvement and community support is necessary to enhance the transition of adolescents with intellectual disability.

Antimicrobial utilization research and activities in Botswana, the past, present and the future

A number of activities are ongoing to reduce AMR in Botswana by improving antimicrobial utilization across all sectors. However, there is a need to share experiences. With the objective of sharing these, the second one day symposium was held in the University of Botswana in October 2018 involving both private and public hospitals. In Lenmed Bokamoso hospital, ESKAPE organisms were associated with 50-90% of clinical infections; however, there was no correlation between healthcare associated infections (HAIs) and admission swab positivity with ESKAPE or ESBL isolates. Hang times, the time between a prescription and IV administration, were also discussed. At Nyangabwe Hospital, the prevalence of HAIs was 13.54%, 48.9% were laboratory confirmed of which 8.5% were blood stream infections (BSIs). The prevalence of different bacteria causing neonatal BSIs was also investigated. At Princess Marina Hospital, positive cultures were seen in 22.4% of blood cultures with contaminants comprising the majority. Several activities are ongoing in Botswana across sectors as a result of the findings and will be periodically reported to further improve antibiotic utilization.

Integrated management of HIV/NCDs: knowledge, attitudes, and practices of health care workers in Gaborone, Botswana

Background

The epidemiologic transition and double disease burden from chronic infections and Non-communicable diseases (NCDs) worldwide requires re-engineering of healthcare delivery systems. Healthcare workers (HCWs) need to adapt to new integrated disease management approaches and change from current disease-specific management.

Objectives

The study aimed to determine HCWs knowledge, capacity and skills for management of NCDs among HIV patients and their attitudes towards integrated HIV/NCDs disease management approaches for future clinical practice.

Methods

Descriptive cross-sectional survey among HCWs attending to HIV patients at selected government facilities.

Results

One hundred out of 105 responses were analysed. Only 6% could fully define NCDs. Awareness levels of NCDs were high: Diabetes and hypertension 98%; cancer 96%; cardiovascular diseases 86%. However, 11.8% and 58% classified HIV and malaria respectively as NCDs. Most respondents (88%) believe that integrating HIV/NCDs care would be good use of resources while 62% disagreed with current separate facility management of HIV patients with NCDs. Over 60% routinely screened HIV patients for NCDs risk factors: Smoking (87.2%), alcohol (90.8%), diet (84.9%) and physical activity (73.5%).

Conclusion

There were gaps in detailed knowledge on NCDs, but positive attitude towards routine primary care integrated HIV/NCDs management, showing likely support for implementation of such policy.

Perceptions and attitudes towards acceptability of HIV self-testing among female sex workers in Selibe Phikwe, Botswana

Background: Sub-Saharan Africa accounts for 71% of the global burden of HIV infection. For the general population of Botswana, the estimated HIV prevalence is 18.5%; for female sex workers it is 61.9%. This study explored and documented female sex workers' perceptions and attitudes towards the acceptability of HIV self-testing in Selibe Phikwe, north-eastern Botswana. Methods: Purposive convenience sampling and snowballing approaches were used to recruit 17 participants into the study which was carried out in collaboration with a community-based organisation, the Silence Kills Support Group. Two focus group discussions and five in-depth interviews were conducted. Information was collected on female sex workers' awareness of HIV self-testing, their willingness to use it, their preferred distribution model, and their preferred test kit. Themes and subthemes that emerged were interpreted based on the Integrated Behavioural Model. Results: HIV self-testing (HIVST) was not known to most participants. Participants expressed negative attitude towards HIVST due to a lack of knowledge and confidence to carry out self-testing independently. Participants preferred facility-based services and a blood test over HIVST. Inadequate post-test counselling and lack of assisted HIVST were among their major concerns. Raising community awareness of HIVST through education was suggested. Conclusion: Improving the uptake of HIVST will require community sensitization, the availability of counselling services, close follow-ups, and the introduction of assisted HIVST approaches.

Sexual and Reproductive Health among High School Adolescents in West Shoa zone, Oromia Region in Ethiopia

Adolescent's sexual and reproductive health is a challenge in many low and middle-income countries. We assessed the knowledge and attitude towards sexual and reproductive health among adolescents in West Shoa zone, Oromia region, Ethiopia. The study was cross-sectional using simple multi-stage random sampling and a structured questionnaire was used to collect data among adolescents aged 15 - 19 years. Frequency distribution of dependent and independent variables were computed and Odds ratios were calculated to determine association between variables. Most participants were from poor and illiterate families. Slightly over half of them had heard about sexual and reproductive health and the knowledge of emergency contraceptive was limited. About 80% of the girls who had become pregnant ended the pregnancy with an abortion and discussion between parents and adolescents on sexuality issues were poor. Effort to empower adolescents and communities with correct sexual and reproductive health is required; academic curricula should be reviewed and health facilities should be engaged to provide sexuality education.

Maternal mortality trends at the Princess Marina and Nyangabwe referral hospitals in Botswana

Despite the fact that about 94% of pregnant women attend ANC, 95% deliver at health facilities and 99% deliveries are assisted by skilled birth attendants in Botswana, the national Maternal Mortality Rate is still high.

Assessment of prescribing practices at the primary healthcare facilities in Botswana with an emphasis on antibiotics: Findings and implications

BACKGROUND AND AIMS

Inappropriate drug prescribing has increased especially in developing countries where systems for monitoring medicine use are not well developed. This increases the rate of antimicrobial resistance. The study aim was to assess the prescribing patterns among urban primary health facilities in Botswana to provide future guidance including developing future quality indicators.

METHODS

Retrospective data from patients' records between January and December 2013 in 19 clinics were collected in a cross-sectional study. The WHO/International Network for Rational Use of Drugs indicators were used to assess prescribing patterns in the study clinics.

RESULTS

Average number of drugs per prescription was 2.8; 78.6% of the prescribed antibiotics were by International Non-proprietary Name and 96.1% complied with the Botswana Essential Drugs List. Overall rate of antibiotic prescribing was high (42.7%) with 14.7%, 5.9% and 1.3% of prescriptions having two, three and four antibiotics, respectively. Systemic antibiotics (JO1C) accounted for 45.4% of prescribed antibiotics of which amoxicillin accounted for 28.4% and metronidazole 14.4% of all antibiotic prescriptions. There was low use of co-amoxiclav (0.3% of all antibiotic prescriptions). Third generation cephalosporins and macrolides accounted for 9.8% and 6.2% of antibiotic prescriptions respectively, with no prescribing of fluoroquinolones. The majority of indications (87%) for antibiotic prescriptions were according to ICD classification.

CONCLUSIONS

While most indications for antibiotic prescriptions were based on signs and symptoms according to ICD, antibiotic prescribing rates were high with some conditions not requiring antibiotics because they are viral infections. There is a need to further improve prescribing practices through induction and training of in-service prescribers. An effective management tool for monitoring antibiotic prescribing practices at Primary Health Care facilities should be designed and implemented, including developing robust quality indicators.

Undiagnosed and diagnosed diabetes mellitus among hospitalised acute heart failure patients in Botswana

Objective:

The objective of this study was to determine the burden of diagnosed and undiagnosed type 2 diabetes mellitus among patients hospitalised with acute heart failure in Botswana.

Methods:

The study enrolled 193 consecutive patients admitted with acute heart failure to the medical wards at Princess Marina Hospital in Gaborone. Patients were classified as previously known diabetics, undiagnosed diabetics (glycated haemoglobin ≥ 6.5%) or as non-diabetics (glycated haemoglobin < 6.5%). Data on other comorbid conditions such as hypertension, atrial fibrillation, ischaemic heart disease, stroke, and renal failure were also collected.

Results:

The mean (SD) age of the participants was 54.2 (17.1) years and 53.9% were men. The percentage of known and undiagnosed diabetes mellitus was 15.5% and 12.4%, respectively. Diabetic patients were significantly more likely to have hypertension (77.8% vs 46.0%, p < 0.001), ischaemic heart disease (20.4% vs 5.0%, p < 0.001), chronic kidney disease (51.3% vs 23.0%, p  < 0.001), and stroke (20.4% vs 5.8%, p  < 0.01). In addition, diabetics were older than non-diabetics (61.0 years vs 51.6 years, p  < 0.001).

Conclusion:

About 27.9% of patients admitted with acute heart failure in Botswana had diabetes, and almost half of them presented with undiagnosed diabetes. These findings indicate that all hospitalised patients should be screened for diabetes.

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis

Background

Botswana has a well-developed antiretroviral therapy (ART) program that serves as a regional model. With wide ART availability, the burden of advanced human immunodeficiency virus (HIV) and associated opportunistic infections would be expected to decline. We performed a nationwide surveillance study to determine the national incidence of cryptococcal meningitis (CM), and describe characteristics of cases during 2000-2014 and temporal trends at 2 national referral hospitals.

Methods

Cerebrospinal fluid data from all 37 laboratories performing meningitis diagnostics in Botswana were collected from the period 2000-2014 to identify cases of CM. Basic demographic and laboratory data were recorded. Complete national data from 2013-2014 were used to calculate national incidence using UNAIDS population estimates. Temporal trends in cases were derived from national referral centers in the period 2004-2014.

Results

A total of 5296 episodes of CM were observed in 4702 individuals; 60.6% were male, and median age was 36 years. Overall 2013-2014 incidence was 17.8 (95% confidence interval [CI], 16.6-19.2) cases per 100000 person-years. In the HIV-infected population, incidence was 96.8 (95% CI, 90.0-104.0) cases per 100000 person-years; male predominance was seen across CD4 strata. At national referral hospitals, cases decreased during 2007-2009 but stabilized during 2010-2014.

Conclusions

Despite excellent ART coverage in Botswana, there is still a substantial burden of advanced HIV, with 2013-2014 incidence of CM comparable to pre-ART era rates in South Africa. Our findings suggest that a key population of individuals, often men, is developing advanced disease and associated opportunistic infections due to a failure to effectively engage in care, highlighting the need for differentiated care models.

The Afya Bora Fellowship: An Innovative Program Focused on Creating an Interprofessional Network of Leaders in Global Health

PROBLEM

Most current health professions education programs are focused on the development of clinical skills. As a result, they may not address the complex and interconnected nature of global health. Trainees require relevant clinical, programmatic, and leadership skills to meet the challenges of practicing in an increasingly globalized environment.

APPROACH

To develop health care leaders within sub-Saharan Africa, the Afya Bora Consortium developed a one-year fellowship for medical doctors and nurses. Fellows from nine institutions in the United States and sub-Saharan Africa participate in 12 learning modules focused on leadership development and program management. Classroom-based training is augmented with an experiential apprenticeship component.

OUTCOMES

Since 2011, 100 fellows have graduated from the program. During their apprenticeships, fellows developed projects beneficial to their development and to host organizations. The program has developed fellows' skills in leadership, lent expertise to local organizations, and built knowledge in local contexts. Most fellows have returned to their countries of origin, thus building local capacity. U.S.-based fellows examine global health challenges from regional perspectives and learn from sub-Saharan African experts and peers.

NEXT STEPS

The Consortium provides ongoing support to alumni through career development awards and alumni network engagement with current and past fellow cohorts. The Consortium expanded from its initial network of five countries to six and continues to seek opportunities for geographical and institutional expansion.

Training tomorrow's leaders in global health: impact of the Afya Bora Consortium Fellowship on the careers of its alumni

BACKGROUND

Effective leadership is a cornerstone of successful healthcare delivery in resource limited settings throughout the world. However, few programs in Africa prepare healthcare professionals with the leadership skills vital to the success of the healthcare systems in which they work. One such program, the Afya Bora Consortium Fellowship in Global Health Leadership, has been training health professionals since 2011. The purpose of this study was to assess what career changes, if any, the Afya Bora Fellowship's alumni have experienced since completing the fellowship, and to describe those changes.

METHODS

The Afya Bora Fellowship is a multidisciplinary, one-year training program that teaches health professionals leadership skills through didactic and experiential learning in four African countries. Between January 2011 and June 2013 the consortium trained 42 nurses and doctors. In November 2013, an electronic survey was sent to all alumni to assess their performance in the workplace post-fellowship.

RESULTS

Thirty-one (74 %) of 42 alumni completed surveys. Twenty-one (68 %) reported changes to their position at work; of those, sixteen (76 %) believed the change was due to participation in the fellowship. All alumni reported improved performance at work, and cited the application of a wide range of fellowship skills, including leadership, research, communication, and mentoring. Twenty-six (84 %) alumni spearheaded improvements in their workplaces and almost all (97 %) remained in contact with colleagues from the fellowship. Among the respondents there were five publications, nine manuscripts in preparation, and three international conference presentations.

CONCLUSIONS

Afya Bora alumni overwhelmingly reported that the one year fellowship positively influenced both their work and career trajectory. Training health professionals in leadership skills through didactic modules with the opportunity to apply learned skills at attachment sites in the Afya Bora Fellowship has an impact on performance in the workplace and the potential to improve long-term institutional capacity.

Presentation and mortality of patients hospitalised with acute heart failure in Botswana

INTRODUCTION

Heart failure is a common cause of hospitalisation and therefore contributes to in-hospital outcomes such as mortality. In this study we describe patient characteristics and outcomes of acute heart failure (AHF) in Botswana.

METHODS

Socio-demographic, clinical and laboratory data were collected from 193 consecutive patients admitted with AHF at Princess Marina Hospital in Gaborone between February 2014 and February 2015. The length of hospital stay and 30-, 90- and 180-day in-hospital mortality rates were assessed.

RESULTS

The mean age was 54 ± 17.1 years, and 53.9% of the patients were male. All patients were symptomatic (77.5% in NYHA functional class III or IV) and the majority (64.8%) presented with significant left ventricular dysfunction. The most common concomitant medical conditions were hypertension (54.9%), human immuno-deficiency virus (HIV) (33.9%), anaemia (23.3%) and prior diabetes mellitus (15.5%). Moderate to severe renal dysfunction was detected in 60 (31.1%) patients. Peripartum cardiomyopathy was one of the important causes of heart failure in female patients. The most commonly used treatment included furosemide (86%), beta-blockers (72.1%), angiotensin converting enzyme inhibitors (67.4%), spironolactone (59.9%), digoxin (22.1%), angiotensin receptor blockers (5.8%), nitrates (4.7%) and hydralazine (1.7%). The median length of stay was nine days, and the in-hospital mortality rate was 10.9%. Thirty-, 90- and 180-day case fatality rates were 14.7, 25.8 and 30.8%, respectively. Mortality at 180 days was significantly associated with increasing age, lower haemoglobin level, lower glomerular filtration rate, hyponatraemia, higher N-terminal pro-brain natriuretic peptide levels, and prolonged hospital stay.

CONCLUSIONS

AHF is a major public health problem in Botswana, with high in-hospital and post-discharge mortality rates and prolonged hospital stays. Late and symptomatic presentation is common, and the most common aetiologies are preventable and/or treatable co-morbidities, including hypertension, diabetes mellitus, renal failure and HIV.

Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda

INTRODUCTION

Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings.

METHODS

The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows' projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analyzed manually using pre-determined themes to assess the effect of the program on fellows' daily leadership opportunities.

RESULTS

Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows' foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes, bottlenecks in implementation of national HIV early infant diagnosis and prevention of mother-to-child HIV-transmission programs, and use of routine laboratory data about antibiotic resistance to guide updates of essential drug lists.

CONCLUSION

In-service leadership training was feasible, with ensured protected time for fellows to generate evidence-based solutions to challenges within their work environment. With structured mentorship, collaborative activities at academic institutions and local health care programs equipped health care providers with leadership skills.

Beneficial effects of omega-3 polyunsaturated Fatty acids in gestational diabetes: consequences in macrosomia and adulthood obesity

Omega-3 polyunsaturated fatty acids (PUFAs) are increasingly being used to prevent cardiovascular diseases, including diabetes and obesity. In this paper, we report data on the observed effects of omega-3 PUFA on major metabolic disorders and immune system disruption during gestational diabetes and their consequences on macrosomia. While controversies still exist about omega-3 PUFA effects on antioxidant status regarding the level of omega-3 PUFA in diet supplementation, their lipid-lowering effects are unanimously recognized by researchers. Animal studies have shown that omega-3 PUFA contributes to the maintenance of the immune defense system by promoting the differentiation of T helper (Th) cell to a Th2 phenotype in diabetic pregnancy and by shifting the Th1/Th2 ratio from a deleterious proinflammatory Th1 phenotype to a protective anti-inflammatory Th2 phenotype in macrosomia and in adulthood obesity that results from macrosomia at birth. Based on the available evidence, international nutritional and food agencies recommend administration of omega-3 PUFA as triglyceride-lowering agents, for the prevention of cardiovascular disease risk and during human pregnancy and lactation. Furthermore, studies targeting humans are still required to explore application of the fatty acids as supplement in the management of gestational diabetes and inflammatory and immune diseases.

Training tomorrow’s global health leaders: applying a transtheoretical model to identify behavior change stages within an intervention for health leadership development

Training health professionals in leadership and management skills is a key component of health systems strengthening in low-resource settings. The importance of evaluating the effectiveness of these programs has received increased attention over the past several years, although such evaluations continue to pose significant challenges. This article presents evaluation data from the pilot year of the Afya Bora Fellowship, an African-based training program to increase the leadership capacity of health professionals. Firstly, we describe the goals of the Afya Bora Fellowship. Then, we present an adaptation of the transtheoretical model for behavior change called the Health Leadership Development Model, as an analytical lens to identify and describe evidence of individual leadership behavior change among training participants during and shortly after the pilot year of the program. The Health Leadership Development Model includes the following: pre-contemplation (status quo), contemplation (testing and internalizing leadership), preparation – (moving toward leadership), action (leadership in action), and maintenance (effecting organizational change). We used data from surveys, in-depth interviews, journal entries and course evaluations as data points to populate the Health Leadership Development Model. In the short term, fellows demonstrated increased leadership development during and shortly after the intervention and reflected the contemplation, preparation and action stages of the Health Leadership Development Model. However, expanded interventions and/or additional time may be needed to support behavior change toward the maintenance stages. We conclude that the Health Leadership Development Model is useful for informing health leadership training design and evaluation to contribute to sustainable health organizational change.

Asthma prevalence, knowledge, and perceptions among secondary school pupils in rural and urban coastal districts in Tanzania

Background

Asthma is a common chronic disease of childhood that is associated with significant morbidity and mortality. We aimed to estimate the prevalence of asthma among secondary school pupils in urban and rural areas of coast districts of Tanzania. The study also aimed to describe pupils’ perception towards asthma, and to assess their knowledge on symptoms, triggers, and treatment of asthma.

Methods

A total of 610 pupils from Ilala district and 619 pupils from Bagamoyo district formed the urban and rural groups, respectively. Using a modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, a history of “diagnosed” asthma or the presence of a wheeze in the previous 12 months was obtained from all the studied pupils, along with documentation of their perceptions regarding asthma. Pupils without asthma or wheeze in the prior 12 months were subsequently selected and underwent a free running exercise testing. A ≥ 20% decrease in the post-exercise Peak Expiratory Flow Rate (PEFR) values was the criterion for diagnosing exercise-induced asthma.

Results

The mean age of participants was 16.8 (±1.8) years. The prevalence of wheeze in the past 12 months was 12.1% in Bagamoyo district and 23.1% in Ilala district (p < 0.001). Self-reported asthma was found in 17.6% and 6.4% of pupils in Ilala and Bagamoyo districts, respectively (p < 0.001). The prevalence of exercise-induced asthma was 2.4% in Bagamoyo, and 26.3% in Ilala (P < 0.002). In both districts, most information on asthma came from parents, and there was variation in symptoms and triggers of asthma reported by the pupils. Non-asthmatic pupils feared sleeping, playing, and eating with their asthmatic peers.

Conclusion

The prevalence rates of self-reported asthma, wheezing in the past 12 months, and exercise-induced asthma were significantly higher among urban than rural pupils. Although bronchial asthma is a common disease, pupils’ perceptions about asthma were associated with fear of contact with their asthmatic peers in both rural and urban schools.

Reduced lung function among sisal processors

OBJECTIVES

The objective of this study was to examine lung function and chronic respiratory symptoms among sisal workers in Tanzania and compare the results with a control group.

METHODS

A cross-sectional study on chronic respiratory symptoms and lung function was conducted in 2006 among male Tanzanian sisal processing workers from six sisal estates. Participants included 86 workers in decortication departments, 68 workers in brushing departments and 30 low exposed security guards. The response rate was 97%. Chronic respiratory symptoms and background information were obtained by structured interview. Forced ventilatory capacity (FVC) and forced expiratory volume in 1 s (FEV(1)) were estimated before and after a work shift, and FEV(1)/FVC ratio calculated.

RESULTS

Workers were aged 19-85, with the oldest in the brushing and security departments. Chronic cough and chest tightness were experienced by 38% and 68% of workers in brushing departments, 20% and 6% of workers in decortication and 7% and 0% of security workers, respectively. A reduced FEV(1)/FVC ratio related to years of work was found among workers in brushing departments when adjusting for age, smoking, previous respiratory illnesses and body mass index, using regression analyses. Work in decortication departments was not related to reduced lung function parameters. The prevalence of FEV(1)/FVC<70 was above 50 for all three groups. Lung function parameters were similar before and after work shifts, except that peak expiratory flow increased among workers in brushing departments after work shifts.

CONCLUSIONS

The results indicate a relationship between work in sisal brushing departments and the development of obstructive lung disorders.

Working conditions and exposure to dust and bioaerosols in sisal processing factories in Tanzania

Information was collected on working conditions and personal exposures to dust, bacteria, and fungi in sisal fiber processing factories in Tanzania to identify health hazards and possible needs for preventive measures. Walkthrough surveys were performed in the brushing and decorticating departments of six sisal factories. The number of departments showing adequate scores for ergonomics and work organization, physical working environment, and occupational health items were determined. Personal thoracic dust samples were collected during sisal processing and analyzed for concentration of dust (n = 24) and for fungi and bacteria (n = 32). In both departments, most items considered to be a prerequisite for a good working environment were either missing or inadequate. Ergonomic and physical hazards were observed. Repetitive strenuous tasks, awkward work postures, and high noise levels were found. Visible dust and inadequate ventilation were seen in the brushing departments, and wet floors were observed in the decortication departments. Personal protective equipment was hardly used. The arithmetic mean exposure of sisal processors was 1.2 mg thoracic dust/m(3), 43 x 10(6) bacteria/ m(3), and 2.35 x 10(6) fungal spores/m(3). The highest exposure levels were measured in the decortication departments when machines were cleaned of waste. Significant differences were found for mean thoracic dust exposure and bacteria counts between the brushing and decortication departments and the security guards. Within individual departments, there were no significant differences in exposures between the different work tasks. A linear mixed effect model of thoracic dust including department as fixed effect explained 65% of the between-worker variability for thoracic dust exposure. The study shows that workers in sisal processing in Tanzania are exposed to bioaerosols, and suitable control measures should be implemented. More exposure studies are needed in this type of industry.

High prevalence of immunoglobulin E (IgE) sensitization among sisal (Agave sisalana) processing workers in Tanzania

PURPOSE

Allergic sensitization among workers exposed to sisal is scarcely documented. We examined whether sisal processing is associated with IgE sensitization and its relationship to the prevalence of respiratory symptoms among Tanzanian processors.

METHODS

138 sisal exposed workers and 78 non-exposed controls were skin prick tested (SPT) using dry sisal extract and fresh sisal sap. Sera from a subset of 43 participants were analyzed for total and sisal specific IgE. SPT wheal size, prevalence of positive SPTs and adjusted relative risk (RR) for sisal sensitization were determined and compared between exposed and controls. Prevalences for respiratory symptoms were compared between sensitized and non-sensitized sisal workers.

RESULTS

Significantly higher prevalence of positive SPTs to sisal was found among 74 % of sisal workers compared to 17 % among controls. Compared to controls, the RR of sensitization to sisal was 4 times higher (95 % CI; 2.4-6.7) among exposed workers. All exposed workers had elevated IgE levels (>100 kU/l) and 27 % of tested sera had elevated sisal specific IgE. A high prevalence of respiratory symptoms was found in both sensitized and non-sensitized sisal workers.

CONCLUSION

Sisal processing is associated with increased risk of IgE sensitization, but its clinical implication is not obvious.

Acute respiratory symptoms among sisal workers in Tanzania

BACKGROUND

Few studies have focused on respiratory health effects among sisal workers.

AIM

To report on the prevalence of acute respiratory symptoms among sisal processors.

METHODS

We interviewed 163 dust-exposed brushing and decortication workers and 31 low-exposed security workers from six sisal estates in Tanzania using a modified symptom score questionnaire to determine the prevalence of acute respiratory symptoms during work. Groups were compared using chi-square tests, Fisher's exact tests, t-tests and logistic regression, adjusting for confounding factors.

RESULTS

After the first working day of the week, 73% of the brushing workers reported dry cough, 66% sneezing, 65% productive cough, 63% running nose and 34% stuffy nose. Brushing workers had a significantly higher prevalence of these symptoms than decortication workers. Brushing and decortication workers had significantly more dry cough and sneezing than the control group of security workers, when adjusting for age, smoking, past respiratory diseases and residence.

CONCLUSION

Processors of sisal fibre have a high prevalence of acute respiratory symptoms. More detailed studies on work and health in sisal estates are needed, including exposure studies.

High prevalence of respiratory symptoms among workers in the development section of a manually operated coal mine in a developing country: a cross sectional study

BACKGROUND

Few studies of miners have been carried out in African countries; most are from South Africa, where the working conditions are assumed to be better than in the rest of Africa. Several studies have focused on respiratory disorders among miners, but development workers responsible for creating underground road ways have not been studied explicitly. This is the first study assessing the associations between exposure to dust and quartz and respiratory symptoms among coal mine workers in a manually operated coal mine in Tanzania, focusing on development workers, as they have the highest exposure to coal dust.

METHODS

A cross-sectional study was carried out among 250 production workers from a coal mine. Interviews were performed using modified standardized questionnaires to elicit information on occupational history, demographics, smoking habits and acute and chronic respiratory symptoms. The relationships between current dust exposure as well as cumulative respirable dust and quartz and symptoms were studied by group comparisons as well as logistic regression.

RESULTS

Workers from the development group had the highest dust exposure, with arithmetic mean of 10.3 mg/m3 for current respirable dust and 1.268 mg/m3 for quartz. Analogous exposure results for mine workers were 0.66 mg/m3 and 0.03 mg/m3, respectively; and for other development workers were 0.88 mg/m3 and 0.10 mg/m3, respectively. The workers from the development section had significantly higher prevalence of the acute symptoms of dry cough (45.7%), breathlessness (34.8%) and blocked nose (23.9%). In addition, development workers had significantly more chronic symptoms of breathlessness (17.0%) than the mine workers (6.4%) and the other production workers (2.4%). The highest decile of cumulative exposure to respirable dust was significantly associated with cough (OR = 2.91, 95% CI 1.06, 7.97) as were cumulative exposure to quartz and cough (OR = 2.87, CI 1.05, 7.88), compared with the reference consisting of the group of workers with the lowest quartile of the respective cumulative exposure.

CONCLUSION

The development workers in a coal mine had more acute and chronic respiratory symptoms than the mine and the other production workers. In addition, there was an association between high cumulative coal dust and respiratory symptoms.

Respiratory symptoms and chronic obstructive pulmonary disease among cement factory workers

OBJECTIVES

This study assessed chronic respiratory symptoms and chronic obstructive pulmonary disease (COPD) among workers exposed to cement dust at a Tanzanian cement factory.

METHODS

A total of 120 exposed workers and 107 controls participated in this cross-sectional investigation. Information on demographics, occupational history, chronic respiratory symptoms, smoking habits, and use of respiratory protection equipment was collected by questionnaire. Ventilatory function testing and measurement of personal total dust exposure were also carried out. COPD was diagnosed for workers with chronic bronchitis who also had spirometric airflow obstruction. Chronic respiratory symptoms and COPD were correlated with cumulative total dust exposure and adjusted for age, pack-years, and education.

RESULTS

The exposed workers had more chronic cough [odds ratio (OR) 4.5, 95% confidence interval (95% CI) 1.9-10.4], chronic sputum production (OR 10.8, 95% CI 4.4-26.4.), dyspnea (OR 5.3, 95% CI 1.9-15.2), work-related shortness of breath (OR 4.8, 95% CI 1.6-14.2), and chronic bronchitis (OR 5.5, 95% CI 2.0-15.3) than the controls. Chronic cough, chronic sputum production, dyspnea, work-related shortness of breath, and chronic bronchitis were significantly related to cumulative dust exposure of 20.0-99.9 and > or = 100.0 versus <20.0 mg/m3-years. The prevalence of COPD was higher for the exposed group (18.8%) than for the controls (4.8%). The odds ratio for COPD was significantly increased for cumulative dust exposure, > or = 100.0 versus <20.0 mg/m3-years (OR 11.2, 95% CI 2.2-56.0).

CONCLUSIONS

Cement workers seem to be at high risk of developing chronic respiratory symptoms and COPD, probably caused by cumulative total dust exposure independent of smoking habits.

Cement dust exposure and ventilatory function impairment: an exposure-response study

We investigated cumulative total cement dust exposure and ventilatory function impairment at a Portland cement factory in Tanzania. All 126 production workers were exposed. The control group comprised all 88 maintenance workers and 32 randomly chosen office workers. Exposed workers had significantly lower forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEF), FEV1/FVC, FVC%, FEV1% and PEF%, than controls adjusted for age, duration of employment, height, and pack-years. Cumulative total dust exposure was significantly associated with reduced FVC, forced expiratory volume in 1 second, and peak expiratory flow rate adjusted for age, height and pack-years. Cumulative total dust exposure more than 300 mg/m year versus lower than 100 mg/m years was significantly associated with increased risk of developing airflow limitation (odds ratio = 9.9). The current occupational exposure limit for total cement dust (10 mg/m) appears to be too high to prevent respiratory health effects among cement workers.

Nutritional variation and cardiovascular risk factors in Tanzania--rural-urban difference

OBJECTIVE

To assess the relationship between dietary factors and cardiovascular (CVD) risk factors in middle-aged men and women, in urban, rural and pastoral settings in Tanzania.

DESIGN

Cross-sectional epidemiological study designed according to the protocol of the World Health Organisation (WHO) Cardiovascular Diseases and Alimentary Comparison (CARDIAC) study.

SETTING

Three centres in Tanzania, namely Dar es Salaam (urban), Handeni (rural) and Monduli (pastoral population).

SUBJECTS

The subjects, aged 47-57 years, were recruited randomly from administrative lists available from each centre.

OUTCOME MEASURES

Blood pressure (BP) was measured using a centrally calibrated automatic BP machine (Khi machine). Dietary history of the participants was obtained using a standard questionnaire designed on the basis of a seven-day recall system. Height, weight, serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDLC), haemoglobin A1c, sodium, potassium and magnesium were measured.

RESULTS

The prevalence of hypertension (BP > or = 140/90 mmHg or antihypertensive drug use), obesity (body mass index (BMI) > or = 30 kg/m2) and hypercholesterolaemia (TC > 5.2 mmol/l) were lowest in the rural area. Consumption of green vegetables, milk, coconut milk, meat, and fish varied significantly between the three areas. Important determinants for BP among men were BMI (p < 0.001), and salt intake (p < 0.05). Among women, TC (p < 0.05), age (p < 0.05), BMI (p < 0.001) and coconut milk consumption (p < 0.001) were important BP determinants. Salt intake was positively associated with systolic BP (SBP) and diastolic BP (DBP) in men but not among women (both SBP and DBP p < 0.05 respectively). Dietary determinants of serum TC were meat, fish and green vegetable consumption.

CONCLUSION

Differences in dietary habits contributed significantly to the urban-rural-pastoral variations in CVD risk pattern in Tanzania.

Determinants of hyperleptinaemia in an African population

OBJECTIVE

To examine the determinants for elevated plasma leptin concentration in normal weight (NW), obese (OB), and morbidly obese (MO) individuals in Tanzania.

DESIGN

Cross-sectional epidemiological study, the CARDIAC study.

SETTING

Three areas in Tanzania; Dar es Salaam, urban (U), Handeni, rural (R) and Monduli, pastoralists (P), in August 1998.

SUBJECTS

Five hundred and forty five participants from a random sample of 600 people aged 46-58 years.

MAIN OUTCOME MEASURES

Plasma leptin concentrations, height, weight, body mass index (BMI), lipid profiles, haemoglobin A1c (HBA1c), and blood pressure (BP).

RESULTS

Plasma leptin concentrations were higher in women than in men (women; 16.0 ng/mL, men; 3.1 ng/mL; p<0.0001). Women showed a higher mean body mass index (BMI), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) than men. In both genders, plasma leptin concentration, total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), systolic BP (SBP) and diastolic BP (DBP) were significantly higher in OB than in NW participants. MO women had significantly higher leptin concentration, SBP and DBP compared with the other two groups. In NW men, log leptin concentrations showed a direct correlation with weight, BMI, HBA1c, TC, LDL-C, TG, SBP and DBP (all p<0.0001 except TG; p<0.001), while among NW women and OB men, weight and BMI correlated positively with log leptin (all p<0.05). OB women observed a positive correlation between log leptin and weight, BMI and LDL-C. Regression analysis indicated that among NW subjects, gender, BMI and TC explained 53.9% of the variation in log leptin. In OB subjects, gender, BMI and LDL-C explained 51.7% of the variability in leptin levels. No relationship was found between log leptin and CVD risk factors among MO subjects.

CONCLUSION

The most important determinants for hyperleptinaemia in NW participants were gender, BMI, TC, while in addition to these LDL-C, was an important determinant of leptin concentration in OB individuals. In MO women, the high leptin concentrations did not reflect the amount of adipose stores.

Prevalence of obesity and dyslipidemia in middle-aged men and women in Tanzania, Africa: relationship with resting energy expenditure and dietary factors

The prevalence of obesity and dyslipidemia and the mean frequency of intake of selected dietary factors were studied in 545 participants aged 46-58 y and living in three areas in Tanzania. The prevalence of obesity (body mass index of > or = 30 kg/m2) was 22.5% among women and 5.4% among men, p < 0.001. Higher rates of obesity were observed in both men and women in an urban (U) area of Dar. The prevalence of dyslipidemia [(TC-HDL-C)/HDL-C > 5] among men was higher in a pastoralists (P) population of the Maasai in Monduli (22.6%) than in Dar (9.6%) and rural (R) Handeni (7.3%, p < 0.05). The mean resting energy expenditure (REE) was higher in subjects from the rural and pastoralists populations than in urban dwellers (0.024 kcal/min/kg, p < 0.001). The three areas showed different dietary patterns with subjects from the urban area consuming coconut milk (4 d/wk, p < 0.001) and meat (2.5 d/wk, p < 0.05), more often than the rural population of Handeni which had the highest consumption of green vegetables (4.2 d/wk, p < 0.001). Participants from Monduli had the highest consumption of milk per day (1,219 mL/d, p < 0.001). A simple correlation analysis showed that body mass index (BMI) correlated positively with the frequency of intake of coconut milk, fish and meat, and negatively with REE and milk consumption. Total cholesterol (TC) was negatively correlated with the frequency of intake of green vegetables, fish and the REE, and correlated positively with meat consumption and BMI in both genders. Independent of other factors, important contributors to obesity and dyslipidemia in this population were dietary factors such as meat (p < 0.001) and fish (p < 0.05), and a lower REE (p < 0.05). These findings suggest that unhealthy diet and lower energy expenditure are important contributors to obesity and dyslipidemia in Tanzania.

Obesity and lipid profiles in middle aged men and women in Tanzania

OBJECTIVE

To examine the relationship between obesity and lipid profiles and to compare the effects of total obesity and central adiposity on lipids in three locations in Tanzania.

DESIGN

Cross-sectional epidemiological study.

SETTING

Three areas in Tanzania: Dar es Salaam (urban), Handeni (rural) and Monduli (pastoralists), in August 1998.

SUBJECTS

Five hundred and forty five men and women from a random sample of 600 people aged 46-58 years.

MAIN OUTCOME MEASURES

Mean BMI, waist circumference, WHR, TC, HDL-C, LDL-C, TG and LDL/HDL ratio. Prevalence rates of overweight,obesity, central obesity and dyslipidaemia.

RESULTS

As compared to men, women had higher BMI (24.7 versus 22.5 kg/m2, p<0.0001), waist circumference (92.4 versus 89.1 cm, p<0.05), TC (4.9 versus 4.2 mmol/L, p<0.0001) and LDL-C (3.3 versus 2.6 mmol/L, p<0.0001). The urban population demonstrated higher levels of lipid factors than the rural population (TC, men 4.8 mmol/L; women 5.3 mmol/L, p<0.0001; TG, men 3.6 mmol/L; women 3.7 mmol/L, p<0.0001, LDL-C, men 2.8 mmol/L, p<0.0001). BMI and waist circumference correlated positively with serum TC, TG, and LDL-C in both genders. Stepwise regression analysis showed that BMI predicted triglyceride concentration in men (p<0.05) and women (p<0.0001). Waist circumference predicted levels of TC in women only (p<0.0001) and of LDL-C in both genders (men p<0.05, women p<0.0001). The prevalence of overweight, obesity and central obesity were significantly higher in urban than in rural areas in both men and women. Compared to lean subjects, obese men and women had significantly higher mean serum TC, TG, LDL-C and a higher prevalence of dyslipidaemia. The mean levels of TC, TG and LDL cholesterol increased across successive increases in BMI and waist circumference quintiles in both genders.

CONCLUSION

Subjects from the urban area had greater lipid abnormalities related to obesity than those from the rural area and that, central adiposity had a greater effect on total cholesterol and LDL cholesterol among women than was BMI.

Cardiovascular risk factors in Tanzania: a revisit

In this assessment of cardiovascular risk factors, we examined the prevalence of selected risk factors according to the World Health Organisation (WHO) CARDIAC Study protocol and compared them with a similar study conducted more than a decade ago. The survey was carried out in Dar es Salaam (D, urban), Handeni (H, rural) and Monduli (Mo, semi-nomadic area). Subjects aged 47-57 were recruited randomly for blood pressure and anthropometrical measurements, 24 h urine collection and blood sampling. A structured questionnaire was used to obtain dietary information. The 1998 survey studied 446 subjects, while the 1987 survey included 496 men and women. The measured weight, body mass index (BMI) and prevalence of obesity (BMI > or = 30 kg/m(2)) increased significantly among women in the 1998 survey in rural Handeni and urban Dar. The overall prevalence of obesity was higher for women in the most recent survey (22.8%, P < 0.0001). Diastolic blood pressure (DBP) was higher in the most recent survey for women in Handeni. The overall prevalence of hypertension (blood pressure > 160/95 mmHg, or antihypertensive drug use), rose to 41.1% in 1998, (P < 0.001) for men and to 38.7% (P < 0.05) for women. The mean total serum cholesterol and prevalence of hypercholesterolaemia increased significantly in the most recent survey in the three studied areas. The overall prevalence of hypercholestrolaemia (serum cholesterol > 5.2 mmol/l) was higher in the 1998 survey for both men (21.8%, P < 0.0001) and women (54.0%, P < 0.0001). The mean HDL cholesterol increased significantly in the most recent survey, with a significant reduction in the mean atherogenic index, though these were still at higher levels (men 5.8, P < 0.0001; women 5.1, P < 0.0001 vs. 1987). A strong positive correlation was observed between blood pressure (SBP and DBP) and body mass index, total serum cholesterol and sodium to potassium ratio. These data suggest that for the past decade there has been an increase in the mean levels and prevalence of selected cardiovascular risk factors in Tanzania.

The relation of oxidative DNA damage to hypertension and other cardiovascular risk factors in Tanzania

OBJECTIVES

To clarify the mechanism of involvement of oxidative stress in hypertensives, we investigated the relationship between the marker of oxidative DNA damage, urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG), and cardiovascular risk factors, such as hypertension and serum glycosylated hemoglobin (HbA1c), among Tanzanians aged 46-58 years who were not on antihypertensive medication.

DESIGN AND METHODS

Sixty subjects (males/females, 28/ 32) were selected randomly from the subjects who completed a 24h urine collection in our epidemiological study at Dar es Salaam, Tanzania in 1998. The subjects were divided into two groups, hypertensive subjects (systolic blood pressure (SBP) > or = 140 mmHg and/or diastolic blood pressure (DBP) > or =90 mmHg) and normotensive subjects (SBP < 140 mmHg and DBP < 90 mmHg) or hyperglycemic subjects (HbA1c > or = 6.0%) and normoglycemic subjects (HbA1c < 6.0%). Biological markers from urine and blood were analyzed centrally in the WHO Collaborating Center.

RESULTS

The mean levels of HbA1c and 8-OHdG were significantly higher in the hypertensive subjects than in the normotensive subjects (P < 0.05). Urinary 8-OHdG was significantly higher in hyperglycemic subjects than in normoglycemic subjects. HbA1c was positively correlated with the 24-h urinary 8-OHdG excretions (r= 0.698, P < 0.0001).

CONCLUSIONS

These findings suggest oxidative DNA damage is increased in hypertensive subjects, and there is a positive correlation between the level of blood glucose estimated as HbA1c and oxidative DNA damage. Hyperglycemia related to insulin resistance in hypertension in Tanzania is associated with increased urinary 8-OHdG.