Effectiveness of a community intervention on malaria in rural Tanzania - a randomised controlled trial.

BACKGROUND: Malaria infections are a major public health problem in Africa and prompt treatment is one way of controlling the disease and saving lives. METHODS: This cluster-randomised controlled community intervention conducted in 2003-2005 aimed at improving early malaria case management in under five children. Health workers were trained to train community-based women groups in recognizing malaria symptoms, providing first-line treatment for uncomplicated malaria and referring severe cases. Evaluation was through a pre- (2004) and a post-intervention survey (2005). Anaemia prevalence was the primary outcome. RESULTS: 1715 children aged 6-59 months were included in the pre-intervention survey and 2169 in the post-intervention survey. The prevalence of anaemia decreased significantly from 37% [95% CI 34.7-39.3] to 0.5% [95% CI 0.2-0.7] after the intervention (p<0.001); slightly more in the intervention (from 43.9% to 0.8%) than in the control (30.8% to 0.17%) group (p=0.038). Fever and reported fever decreased significantly and the mean body weight of the children increased significantly over the study period in both control and intervention groups. CONCLUSION: The decrease in anaemia was significantly associated with the intervention, whereas the fever and body weight trends might be explained by other malaria control activities or seasonal/climate effects in the area. The community intervention was shown to be feasible in the study context.

Effects of daily chlorpromazine administration on behavioural and physiological parameters in the rat.

Chlorpromazine is a classical neuroleptic drug which produces both therapeutic effects as well as unwanted side effects in human such as sedation, autonomic, endocrine and neurological effects. It is thought that blockade of dopamine D-2 receptors caused by chlorpromazine induces these untoward side effects. Pre-clinical studies on catalepsy has been proposed as an animal model for neuroleptic induced extrapyramidal side effects. The drug also blocks certain stereotypic behaviours in animals induced by dopamine agonists such as apomorphine and amphetamine. These stereotypic behaviours are circling, chewing, rearing, grooming and hyperactivity. Daily administration of chlorpromazine (1, 3 and 10 mg/kg, i.p) to rats for 21 days induced catalepsy, tolerance to catalepsy and locomotor sensitization following PCP (10 mg/kg, i.p) challenge. These results suggest that daily chlorpromazine treatment induced DA/NMDA-receptor sensitization to total locomotor activity following PCP challenge. Furthermore, there were no changes in other behavioural parameters assessed. Surprisingly daily chlorpromazine administration in rats also produced no changes in other physiological parameters assessed (body weight, food and water intake).

Assessing the performance, practices and roles of drug sellers/dispensers and mothers'/guardians' behaviour for common childhood conditions in Kibaha district, Tanzania.

In most third world countries, self-medication is common and pharmacies, drug stores and drug shops are important providers of health advice and inexpensive medicines. We used exit interviews to assess drug sellers'/dispensers' roles and consumers' behaviour in Kibaha district, Coast region, Tanzania. Exit interviews with mothers/guardians reported the following childhood conditions treated with or without prescriptions at drug shops: respiratory infections (34%), fever (21%), a combination of diarrhoea, acute respiratory infection (ARI) and fever (14%), diarrhoea alone (13%) and other conditions (17%). The majority of drug sellers/dispensers prescribed or dispensed branded drugs (85%) for most mothers/guardians who visited these drug shops. In addition, antibiotics in total were prescribed for 31% of the mothers/guardians. Of the antibiotics dispensed, 38% were not prescribed by clinicians. In total, oral rehydration salts (ORSs) (3%), antimalarials (sulphadoxine/pyrimethamine) (24%) and antipyretics (11%), were prescribed in 20% but were bought by only 9%; multivitamins (6%), cough mixtures (4%) and other drugs (2%) (antihelminthics, benzylbenzoate emulsions, ear and eye drops) were also purchased from these facilities. Of the diarrhoea case histories presented by simulated clients at the drug shops, only 35% of the bloody diarrhoea scenarios were accurately diagnosed for getting antibiotics as compared with 44% for watery diarrhoea for which the use of antibiotics were wrongly advised (P<0.01). Furthermore, drug sellers/dispensers in these drug shops recommended use of ORS less frequently (3%) for a combination of diarrhoea, ARI and fever, and 2% for ARI alone than for watery (29%) and bloody diarrhoea (32%), respectively, for children under five years of age (P<0.001). Antimicrobial agents were advised for ARI (38%), watery diarrhoea (44%) and bloody diarrhoea (35%), respectively, with no significant difference among the three common childhood conditions. Antipyretics were advised in almost all childhood conditions but were least in watery (2%) and bloody diarrhoea (4%). This study demonstrates that antibiotics are overused in both the urban and rural settings of Kibaha district and that this is due to both clinicians'and drug sellers'prescribing practices in public and private facilities. The use of branded drugs was more common than that of generic drugs in private pharmacies, drug stores and ordinary shops. It is hereby proposed that any intervention should focus on training both facilities in the district on selectively prescribing and rational use of antibiotics for ARI and diarrhoea, and also to prescribe and dispense generic drugs so that it costs patients less when they buy drugs in shops. There is a need to increase awareness in recommending the use of ORS for clients to manage watery and bloody diarrhoea, and ARI in children under five years of age.

Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa.

Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

Self-medication with chloroquine in a rural district of Tanzania: a therapeutic challenge for any future malaria treatment policy change in the country.

BACKGROUND: Malaria continues to be a leading cause of morbidity and mortality in children aged 5 years or younger in Tanzania. Children who develop mild disease can rapidly progress to severe malaria (cerebral malaria with convulsions) and even death, because of mismanagement, delays and inappropriate drug therapy in the remote areas where primary health care facilities are inaccessible or unavailable. The threat is particularly severe in those who are unable to take oral medications. OBJECTIVE: To identify treatment strategies adopted by mothers or guardians of children under five for malaria. METHOD: A cross-sectional descriptive study using a questionnaire and blood sampling was carried in Kibaha district primary health care facilities. Over 500 mothers/guardians of sick children aged up to 5 years who visited the public facilities seeking care were interviewed in order to assess what management they offered to their sick children in their homes prior to coming to the public health facilities. RESULTS: Seventy-four per cent of the mothers/guardians stated that they had given some medication to their children prior to visiting the public health facilities: mostly analgesics (asprin, paracetamol) and chloroquine. Eighty-five per cent of the sick children given chloroquine had whole blood chloroquine levels above 500 nmol/L and 33% of the sick children with whole blood chloroquine levels above 1,000 nmol/L had malaria parasites in their blood. Of the sick children given chloroquine at the health facilities, 63% had no malaria parasites in their blood. CONCLUSION: There is a need to educate both rural communities, and health care providers about rational prescribing, dispensing and use of antimalarials.

Assessing prescribing practice in church-owned primary healthcare (PHC) institutions in Tanzania: a pilot study.

A retrospective survey of prescribing patterns in 10 church-owned primary healthcare (PHC) institutions in Dar es Salaam region, Tanzania, was carried out by trained research assistants in order to assess the prescribing practices of healthcare providers in these institutions. From a total of 15,000 prescriptions, 600 were recorded randomly from patient registers retrospectively. This work was carried out between April to September 1996. Each prescription was recorded using World Health Organization Action Programme on Essential Drugs (WHO/DAP) forms and analysed manually. The average number of drugs per prescription was 2.9; the percentage encounters for injections and antibiotics was 38 and 71, respectively. Ninety-four per cent of all drugs were prescribed according to the essential drug list of Tanzania.

Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district--implications for malaria control.

Knowledge on local understanding, perceptions and practices of care providers regarding management of childhood malaria are needed for better malaria control in urban, peri-urban and rural communities. Mothers of under five children attending five purposively selected public health facilities in the Kibaha district, Tanzania, were invited to participate in 10 focus group discussions (FGDs). The health workers of these facilities were included in six other FGDs to elicit their professional views. Analysis was done using interpretative and qualitative approaches. Both health workers and all mothers were clear about the signs and symptoms of homa ya malaria, a description consistent with the biomedical definition of mild malaria. Although most of the mothers related this to mosquito bites, some did not. Mothers also described a severe childhood illness called degedege, consistent with convulsions. Most of the mothers failed to associate this condition with malaria, believing it is caused by evil spirits. Urinating on or fuming the child suffering from degedege with elephant dung were perceived to be effective remedies while injections were considered fatal for such condition. Traditional healers were seen as the primary source of treatment outside homes for this condition and grandmothers and mother in-laws are the key decision makers in the management. Our findings revealed major gaps in managing severe malaria in the study communities. Interventions addressing these gaps and targeting mothers/guardians, mother in-laws, grandmothers and traditional healers are needed.

Comparative in vitro and in vivo study of a sugar-coated chloroquine preparation marketed in Tanzania versus an ordinary brand.

OBJECTIVE: To investigate the absorption and the quality of a sugar-coated chloroquine (CQ) marketed in Tanzania. METHOD: Twenty healthy volunteers were randomised to take either the test brand (group A) or a control chloroquine phosphate (group B). Each subject received 300 mg chloroquine base. Whole blood dried on filter papers were collected at time 0 and at 15 and 30 min and at 1, 2, 3, 4, 6, 8, 24, 36, 48, 72 and 168 h after drug intake. Urine samples were collected at time 0, 0-4 h, 4-8 h, 8-24 h, 24-48 h and 48-72 h after drug administration. In an in vitro study, six tablets from each of the two CQ preparations were checked for the amount of active drug contained in each tablet and their dissolution rates. RESULTS: The blood concentration Area Under the Curve (AUC) of group B was about 10% larger than that of group A. The total amounts of CQ plus deethylchloroquine excreted with the urine during the 72-h study period were 5% for group A and 6% for group B. None of the pharmacokinetic parameters were significantly different between the two groups. All the tablets contained the labelled amount of chloroquine; however, one tablet from the test drug failed to fulfil the required dissolution rate. CONCLUSION: We found no major difference between the AUCs of the two CQ preparations, but the sugar-coated brand has shown to have variable dissolution rate.

Prescribing habits in church-owned primary health care facilities in Dar Es Salaam and other Tanzanian coast regions.

OBJECTIVE: To assess prescribing practice of Primary Health Care (PHC) workers in church owned health care facilities using WHO drug use indicators. DESIGN: A cross-sectional study in which twenty primary health care facilities were randomly selected. Prescribing indicators were obtained by analysing outpatient records retrospectively for the past 14 months between January 1997 and February 1998. This period was chosen because of compete records of outpatient attendances. Patient care and facility indicators were recorded prospectively during the study period. SETTING: The study was conducted in the Coast and Dar es Salaam regions of Tanzania. Six districts were randomly selected from both regions. The selected districts included Ilala, Temeke and Kinondoni in Dar es Salaam, Kibiti, Bagamoyo and Kisarawe in Coast region. SUBJECTS/MATERIALS: Twenty primary health care facilities were randomly selected from the chosen districts. Patient registers were collected and patients' characteristics including age, sex, diagnosis, and drugs prescribed for the period January 1997 to February 1998 were recorded on data collection forms. Patient care indicators were measured by recording consultation time, dispensing time, per cent of drugs actually dispensed and adequately labelled whereas patients' knowledge of correct drug dosage was obtained using exit interviews. Verification of facility indicators was done by direct observation. RESULTS: The average number of drugs per prescription was 2.3 (range 1.8-2.8). Generic prescribing prevailed with a mean of 75.5% of all drugs. Antibiotic and injection encounters per prescription was 35.4 and 19%, respectively. Most drugs were prescribed according to the essential drug list of Tanzania (NEDLIT). Patient's average consultation time was 3.6 minutes whereas average dispensing time was 39.9 seconds. On average, 87% of all drugs dispensed were adequately labelled and patients' knowledge of correct dose was adequate. All facilities possessed drugs for treating important illnesses, all had reference educational materials. CONCLUSION: The study shows that there is an overuse of injections 19% +/- 1.7 (range 0.73%) compared to the recommended figure of 15%. The use of antibiotics appears appropriate when compared with the morbidity patterns in the study areas. A focus group discussion with prescribers in these facilities to address the question of overuse of injections is needed in order to plan an appropriate intervention.

Comparison of drug utilisation in public and private primary health care clinics in Tanzania.

A study was carried out in 20 public and 20 private out patient clinics (dispensaries) in Dar es Salaam. At least 30 prescriptions were collected from each clinic. A total of 1200 were collected for analysis. Prescribing indicators from the WHO/DAP "how to investigate drugs in health facilities" were used. The average number of drugs per prescription in public clinics was 2.2 compared to 2.5 in private ones (p > 0.05). The percentage generics was 51.7 in public clinics against 47.7 in private (p > 0.05). On the other hand the percentage of antibiotics was 12.3 in public against 19.7 in private (p < 0.05) whereas injections percentage was 9.6 in public against 12.7 in private clinics (p < 0.05). The results suggest a need for intervention to curb the irrational use of antibiotics and injections in private clinics.

Knowledge and management of malaria in Dar es Salaam, Tanzania.

A study of knowledge and management of malaria was undertaken prospectively in 20 dispensaries, 20 drug stores, 120 patients attending dispensaries and 120 customers at drug stores in Dar es Salaam, Tanzania. This was a descriptive study where two different questionnaires were developed and administered to the target groups in oral interview. All the respondents were aged 14 years and above. The results of the interview showed that the knowledge of rural medical aides (RMA's) on signs and symptoms of malaria and which drugs cure malaria was satisfactory. However, only 65% of the RMA's could remember the correct dose of chloroquine for an adult. Although the knowledge of drug sellers on signs and symptoms of malaria was adequate, 45% of them did not know the correct dose of chloroquine. In view of the fact that only 30% of patients and 20% of shoppers knew the correct dose of chloroquine for adults, it appears that their management of malaria is inadequate. To improve the management of malaria at dispensary and drug store level, there is a need to introduce treatment charts and/or guidelines and the Ministry of Health should promote health education to the public.

PIP: In early 1992 in Tanzania, trained research assistants interviewed 20 rural medical aides (RMAs), 20 drug sellers, 120 patients at 20 dispensaries, and 120 customers of drug stores, all in Dar es Salaam, to examine knowledge and practices of health workers, drug sellers, and patients concerning malaria. The RMAs had adequate knowledge of the signs and symptoms of malaria (e.g., 90% for fever, 85% for headache, and 80% for painful joints). The drug sellers also had adequate knowledge of signs and symptoms (e.g., 80% for fever, 45% for headache, and 50% for painful joints). Even though chloroquine-resistant strains of Plasmodium falciparum malaria exist in Tanzania, all RMAs and most drug sellers (85%) believed that chloroquine could cure malaria. Further, it is the only antimalarial that the Ministry of Health provides its dispensaries. Just 65% of RMAs knew the correct dosage of chloroquine for people 14 years old and older. An even lower percentage of drug sellers knew the correct dosage (50%). Just 33.7% of patients and 22.5% of customers knew the correct dosage of chloroquine. An inadequate supply of chloroquine was available at 15% of dispensaries and 30% of drug stores. RMAs sometimes gave patients too few chloroquine tablets for a full course of therapy. Other drugs mentioned by RMAs to treat malaria were quinine, amodiaquine, cotrimoxazole, halofantrine, pyrimethamine/sulphalene, and pyrimethamine/sulphadoxine. Those mentioned by drug sellers included aspirin plus chloroquine, cotrimoxazole, pyrimethamine/sulphadoxine, and traditional medicines. These findings suggest that irrational drug therapy of malaria promotes resistant strains and prolongs the duration of illness. Introduction of treatment charts and health education promotion to the public are needed to improve malaria management at dispensaries and drug stores.