'What kind of life is this?' Diabetes related notions of wellbeing among adults in eastern Uganda and implications for mitigating future chronic disease risk.

BACKGROUND: Effective prevention and care for type 2 diabetes requires that people link healthy behaviours to chronic disease-related wellbeing. This study explored how people perceive current and future wellbeing, so as to inform lifestyle education. METHODS: Eight focus group discussions and 12 in-depth interviews were conducted in Iganga and Mayuge districts in rural Eastern Uganda among people aged 35-60 years in three risk categories (1) People with diabetes, (2) people at higher risk of diabetes (with hypertension or overweight) and (3) community members without diabetes. RESULTS: People define wellbeing in three notions: 1) Physical health, 2) Socio-economic status and 3) Aspirational fulfilment. Most people hold the narrower view of wellbeing that focuses on absence of pain. Most overweight participants did not feel their condition as affecting their wellbeing. However, for several people with hypertension, the pains they describe indicate probable serious heart disease. Some people with diabetes expressed deep worry and loss of hope, saying that 'thoughts are more bothersome than the illness'. Wellbeing among people with diabetes was described in two perspectives: Those who view diabetes as a 'static' condition think that they cannot attain wellbeing while those who view it as a 'dynamic' condition think that with consistent treatment and healthy lifestyles, they can be well. While many participants perceive future wellbeing as important, people without diabetes are less concerned about it than those with diabetes. Inadequate knowledge about diabetes, drug stock-outs in health facilities, unaffordable healthier food, and contradictory information were cited as barriers to future wellbeing in people with diabetes. CONCLUSIONS: To make type 2 diabetes prevention relevant to healthy people, health education messages should link current lifestyles to future wellbeing. Diabetes patients need counselling support, akin to that in HIV care, to address deep worry and loss of hope.

IMPLEMENTING TOOLS TO PROMOTE ADHERENCE TO ANTIRETROVIRAL THERAPY AT FACILITIES IN KENYA.

BACKGROUND: Lack of effective systems and tools to identify and track defaulters are some of the factors that pose challenges in adherence monitoring for patients on anti-retroviral treatment (ART). An intervention was performed to introduce a facility-based appointment keeping system, and a revised clinic form to monitor patients' adherence to ART. OBJECTIVE: To assess facility staff perceptions of, motivation for and self-reported practice in the implementation, and on the use of adherence-based indicators to inform decisions for performance improvement. DESIGN: Qualitative explorative study aiming to evaluate a quasi-experimental intervention. SETTINGS: Six conveniently sampled health facilities in Kenya located in Central, Eastern and Rift Valley provinces. SUBJECTS: Thirty-six clinic staff members were interviewed, six at each facility, including facility managers, clinicians, nursing and pharmacy staff, counsellors, health records information officers and social workers. Analysis was performed in line with the Pettigrew and Whipp framework. RESULTS: Providers perceived that the intervention had empowered them to assess their clinic's daily workload and to identify those patients who missed their appointments. Factors enhancing the positive uptake of the intervention included the availability of tools to monitor appointment keeping, training on adherence principles and supervisory support. Early detection of treatment defaulters helped the providers design targeted patient support to enhance appointment keeping. CONCLUSION: The effect of the intervention led to implementation of changes within the clinic to enhance patients' appointment keeping and improve adherence to treatment. We expect the reported and observed changes to be sustainable as data generation and calculation of indicators to inform decision-making were performed by the providers themselves.

STI management in Tanzanian private drugstores: practices and roles of drug sellers.

OBJECTIVES: To describe the role and possible contribution of private drugstores in sexually transmitted infection (STI) management in rural Tanzania. METHODS: A cross-sectional study that included drug sellers in private drugstores in eight districts of Tanzania. Data collected through interviews with drug sellers and the simulated client method presenting a male and female STI case. "QATI" scores (Questions, Advice, Treatment and drug Information) were developed to describe overall STI management. RESULTS: Although 74% of drug sellers stated that there were no STI-related drugs in the store, medications were dispensed in 78% of male and 63% of female simulated client visits. The clients were dispensed drugs recommended in the Tanzanian guidelines for syndromic management of urethral or vaginal discharge in 80% of male and 90% of female cases. Drug sellers dispensed antibiotics during 76% of male and 35% of female simulated client visits. Dosage regimens were often incorrect and complete syndromic management rarely provided. Most drug sellers agreed that it is within their professional role to give information on STI treatment (89%) and prevention (95%). Drug-use information was almost always provided. Advice was however seldom given and questions occasionally asked. Overall STI management was better for men than for women. CONCLUSIONS: The drug sellers, although aware of the prescription-only status of antibiotics, saw themselves as having a role in STI management and were ready to provide drugs. In this resource-limited setting, drug sellers could provide effective and safe STI management especially to male patients if given appropriate tools to improve practice. The consequences of this for official policy need to be discussed.

Care-seeking in the development of severe community acquired pneumonia in Ugandan children.

BACKGROUND: Improved case management of paediatric pneumonia is recognised as a key strategy for pneumonia control. Since symptoms of pneumonia and malaria often overlap, there are concerns that children with pneumonia are treated with antimalarial drugs. There is a need to describe how children with severe pneumonia have been managed prior to their arrival at hospital, including possible risks of developing more severe disease. METHODS: A case-series study of 140 children, aged 2-59 months, with severe radiologically verified pneumonia at Mulago Hospital, Kampala was undertaken. Caretakers were interviewed about initial symptoms, treatment given and care sought. Using WHO definitions, children were clinically classified as having severe or very severe pneumonia. RESULTS: The children had been ill for a median of 7 days before arrival at hospital, 90/140 (64%) had received treatment at home, and 72/140 (51%) had seen another health-care provider prior to presentation at hospital. Altogether, 32/140 (23%) children had reportedly received antibiotics only prior to admission, 18/140 (13%) had received anti-malarials only and 35/140 (25%) had received both. Being classified as very severe pneumonia was more common among children who had received anti-malarials only (OR 5.5, 1.8-16.4). CONCLUSIONS: Although the majority of caretakers were able to recognise the key symptoms of pneumonia, they did not respond with any immediate care-giving action. Since progression from first recognition of pneumonia symptoms to severe disease is rapid, management guidelines regarding timing of care-seeking need to be clearly defined. The reason why children who sought health facility care failed to improve should be investigated. Meanwhile, there is a need to increase caretakers' and health workers' awareness of the urgency to act promptly when key pneumonia symptoms are observed.

Clinical diagnosis of malaria and the risk of chloroquine self-medication in rural health centres in Burkina Faso.

OBJECTIVE: To assess the quality of healthcare workers' performance with regard to malaria diagnosis and treatment and to assess patients' self-medication with chloroquine (CQ) before and after presentation at a health centre. METHODS: In the rainy season 2004, in five rural dispensaries in Burkina Faso, we observed 1101 general outpatient consultations and re-examined all these patients. CQ whole blood concentrations of confirmed malaria cases were measured before and after treatment. RESULTS: The clinical diagnosis based on fever and/or a history of fever had a sensitivity of 75% and a specificity of 41% when compared to confirmed malaria (defined as an axillary temperature of >/=37.5 degrees C and/or a history of fever and parasites of any density in the blood smear). Few febrile children under 5 years of age were assessed for other diseases than malaria such as pneumonia. No antimalarial was prescribed for 1.3% of patients with the clinical diagnosis malaria and for 24% of confirmed cases, while 2% received an antimalarial drug prescription without the corresponding clinical diagnosis. CQ was overdosed in 22% of the prescriptions. Before and 2 weeks after consultation, 25% and 46% respectively of the patients with confirmed malaria had potentially toxic CQ concentrations. CONCLUSION: As long as artemisinin-based combination therapy remains unavailable or unaffordable for most people in rural areas of Burkina Faso, self-medication with and prescription of CQ are likely to continue despite increasing resistance. Apart from considering more pragmatic first-line regimens for malaria treatment such as the combination of sulfadoxine-pyrimethamine with amodiaquine, more and better training on careful clinical management of febrile children including an appropriate consideration of other illnesses than malaria should be made available in the frame of the IMCI initiative in sub-Saharan Africa.

Antibiotic use and health-seeking behaviour in an underprivileged area of Perú.

OBJECTIVE: To describe the health-seeking behaviour and use of antibiotics in the urban community of Yurimaguas in the Amazonian area of Peru. METHOD: Cross-sectional survey of caregivers of 798 children aged 6-72 months by interview using a semi-structured questionnaire. Reported symptoms were classified as illnesses where antibiotics would or would not be recommended based on principles of the integrated management of childhood illnesses algorithm. RESULTS: Forty-one per cent of consultations were with health care professionals; 71% of antibiotics were obtained through the formal public health sector and prescribed mainly by medical doctors. All prescribed antibiotics were on the Peruvian essential drugs list. When prescribing, doctors and nurses hardly discriminated between illnesses where antibiotic treatment was or was not indicated; there was no significant difference in antibiotic prescribing rates between the two (doctors, P = 0.24; nurses, P = 0.32). Not all caregivers sought help for children with severe symptoms. CONCLUSION: Although most of the antibiotics were prescribed by doctors and nurses, they were commonly prescribed for illnesses where they were not indicated. The use of antibiotics needs to be rationalized, and barriers to health care must be overcome.

Antimalarial resistance and DHFR/DHPS genotypes of Plasmodium falciparum three years after introduction of sulfadoxine-pyrimethamine and amodiaquine in rural Tanzania.

We assessed the efficacy of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) and DHFR/DHPS genotypes of Plasmodium falciparum in rural Tanzania, 3 years after their introduction as first- and second-line treatments for uncomplicated malaria, respectively. Under five children with uncomplicated malaria were given standard treatments of either SP (n=66) or AQ (n=30) and treatment outcomes after 14 and 28 days were determined. Total treatment failure of 18 and 42.5% was observed for SP on days 14 and 28, respectively. For AQ, total treatment failure of 27 and 53% was found on day 14 and 28, respectively. On day 14, significantly lower SP total treatment failures were observed in 2004 compared with results from a study conducted in 1999 in the same location. No relationship was detected between clinical outcome and DHFR/DHPS genotypes, but the point mutation prevalence in parasites was higher than in 1999. Pre-treatment blood levels of SP were detected in a quarter of the study children: less than expected. We report unacceptably high levels of total treatment failures, both for first- and second-line treatments for uncomplicated malaria in Tanzania 3 years after their introduction, supporting the decision to replace them with artemisinin-based combination therapy.

Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda.

BACKGROUND: Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services. METHODS: Collaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors. RESULTS: The intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25-28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6-9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2-60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0-28%). CONCLUSIONS: The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points. TRIAL REGISTRATION: Pan African Clinical Trials Registry: PACTR201311000681314.

Decision-makers and the usefulness of research evidence in policy implementation--a case study from Lao PDR.

The involvement of researchers in the policy process and policy-makers in research is little studied, particularly in developing countries. In 1993, the Lao National Drug Policy (NDP) was endorsed in a consultative process involving many stakeholders. Lao People's Democratic Republic is a poor country in South East Asia. Five pilot provinces were selected for implementation of the policy, which had a health system research (HSR) component. This case study explores decision-makers' knowledge and attitudes regarding the usefulness of HSR in the NDP implementation process. Ninety decision-makers from different health institutions including hospitals, medical schools and main drug suppliers were surveyed using a self-administrated structured questionnaire, filled in during a NDP conference in 2001. Results from six HSR projects related to the NDP implementation had been presented during the conference, but also 6 months previously and through written reports. There were 75 respondents (83% of attendees, 90% of whom were men), 39% with medical, 50% with pharmacy and 11% with other background. Ninety-eight percent of the participants found operational research useful, and 87% supported it to be an element of the NDP. Two-thirds knew the objectives of the NDP. There was no significant difference in knowledge and attitudes between pilot and non-pilot provinces and between professions. Ninety-two percent were aware of the Essential Drug List, and 88% found it adequate to drug need. Ninety-seven percent agreed with generic drug prescribing. Seventy percent reported to have heard about Good Pharmacy Practice (GPP), but only a few could explain it. Although most participants agreed that HSR should be one main component of the NDP and found HSR results useful, few had heard about them before the conference, and research was not well understood. The paper discusses various factors influencing decision-makers' perceptions of usefulness of research in this case during the NDP implementation process. It is concluded that the acceptance of research and major NDP concepts probably is a result of close interaction between researchers and policy-makers and that the interface between research and policy-making needs further studies.

Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial.

Private pharmacies are the first line of health care in many communities, commonly selling antibiotics in small doses and prescription-only drugs such as steroids without medical supervision. The aim was to study the effectiveness of a multi-faceted intervention on the dispensing practices of drug sellers in Hanoi and Bangkok. The study was a randomized, controlled trial with 68 Hanoi and 78 Bangkok pharmacies, randomly selected and assigned for intervention and control. Behaviour was assessed by five simulated client visits per pharmacy per dispensing practice, at baseline and a month or more after each intervention. Three three-month interventions were implemented sequentially with four months in between: enforcement of regulations with local inspectors visiting to emphasize the importance of prescription-only medicine legislation; education, performed face-to-face in Hanoi and by a large group in Bangkok; and peer review, voluntary in Bangkok and compulsory in Hanoi. The intervention resulted in significant improvements in Hanoi, reducing the dispensing of illegal steroids (29% vs. 62%) and low dose antibiotics (69% vs. 90%), sustained by means of the peer review (17% vs. 57% steroids and 71% vs. 95% antibiotics), and in fewer dispensers asking no questions and giving no advice (11% vs. 30% steroids and 51% vs. 81% antibiotics). The only significant improvement in Bangkok was the reduction in illegally dispensing steroids (25% vs. 44%) after the regulatory intervention. In Bangkok, fewer of those in the group who volunteered for the peer review asked no questions and gave no advice for low-dose antibiotics requests after the peer review (58% vs. 81%). A multi-component intervention can have a profound effect in changing dispensers' behaviour, but the effect is dependant on the context and the method of implementation. Possible reasons for differences are discussed.

Use of traditional medicine in Lao PDR.

OBJECTIVES: Exploring the attitudes and knowledge of household members and health staff in Lao PDR regarding the use of traditional medicine. BACKGROUND: Along with modern medicine, traditional medicine utilisation is officially supported in Laos, being part of the cultural heritage and considered useful for this low-income country in relation to the problems with access to modern pharmaceuticals. METHODS: The study population comprised 600 households from one lowland (Pakse) and one mountainous (Paksong) district. In a stratified two-stage sampling procedure, household surveys were conducted and focus group discussions (FGD) were performed among health staff and villagers in the same districts. RESULTS: Seventy-seven per cent of the households stated the ever use of traditional medicine including herbal medicines, sauna, massage and acupuncture. The main reason given was perceived efficacy. Traditional medicine was used for both chronic and acute diseases. The FGD revealed the perceived need to have training courses for traditional medicine providers and to have a medicinal garden in the villages. Utilisation was similar in lowland and mountainous districts as well as in urban and rural areas. CONCLUSIONS: The study indicates that traditional medicine is widely used and perceived as effective by a fairly large proportion of Lao people. The findings may form a basis for health sector reforms that are congruent with perceived local needs, e.g. in establishing a strategic plan for the development of the traditional medicine sector in Lao PDR.

Relation of naproxen kinetics to effect on platelet prostaglandin release in men and dysmenorrheic women.

The purpose of our investigation was to determine kinetics of naproxen [(+)-6-methoxy-alpha-methyl-2-naphthaleneacetic acid] relative to its inhibition of PGF 2 alpha release during thrombin-induced platelet aggregation in man after a single oral dose of 250 or 500 mg. Naproxen and its metabolite 6-hydroxy-alpha-methyl-2-naphthaleneacetic acid were measured by high-performance, reversed-phase liquid chromatography with fluorimetric detection. PGF 2 alpha was measured by radioimmunoassay in platelet-rich plasma (PRP). Our subjects were four healthy adult men and five dysmenorrheic women. Peak concentrations of naproxen varied between 26 and 69 microgram/ml and half-lifes varied between 9.5 and 21.9 hr, mean = 16.4 hr +/- 4.4 (SD). Naproxen plasma protein binding exceeded 99.9%. The concentration of the metabolite was less than 1% of naproxen and followed the same plasma concentration profile as the parent compound. The based concentration of PGF 2 alpha varied between 0.13 and 6.3 ng/ml, mean = 1.5 +/- 1.9 ng/ml. With no exception, there was a marked decrease in the PGF 2 alpha concentration in thrombin-stimulated PRP during therapy, and concentration was inversely correlated to the total plasma naproxen concentration.

Drug use and the role of patients and prescribers.

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing; the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.

Influencing prescribing for urinary tract infection and asthma in primary care in Sweden: a randomized controlled trial of an interactive educational intervention.

Our aim was to evaluate effects on prescribing for urinary tract infection (UTI) and asthma, of an education with messages based on national guidelines, aimed at improving prescribing in primary care in Sweden. The study is part of the European Drug Education Project. A randomized controlled trial, with groups of general practitioners (GPs) allocated to education on UTI (18 groups, 104 GPs) or asthma (18 groups, 100 GPs), the two parallel intervention arms being controls for each other. Feedback was provided on the GP's judgments of simulated cases and prescribing. Prescribing indicators were developed and measured before and after the intervention. Analysis was performed by multi-level technique. Prescribing of first choice UTI drugs increased in the intervention arm from 52% to 70% and remained constant in the control arm (P < 0.001). The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms. The educational model can be used to improve prescribing. Further studies are needed to define when the model is effective.

Effects of "group detailing" on the prescribing of lipid-lowering drugs: a randomized controlled trial in Swedish primary care.

The objective was to study the effect of "academic group detailing" on the prescribing of lipid-lowering drugs in Swedish primary care. A randomized controlled trial was conducted, randomization being by group. Groups of doctors at 134 community health centres were randomly allocated to an intervention and a control group. The 67 intervention health centres were offered four sessions, conducted by a pharmacist, with group information on guidelines for the management of hyperlipidaemia. The number of prescriptions of lipid-lowering drugs per month increased in the intervention health centres and the increase was statistically different from the corresponding change in the control health centres among women in the age group 30-65 years (p = 0.03). The prescription of first-line lipid-lowering drugs increased by 20% in the intervention health centres (p = 0.03). "Academic group detailing" by pharmacists to primary care doctors can be an effective method for influencing prescribing practices.

Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri lanka.

The intervention level of epidemiology is useful for studying effects in health systems research. Due to practical and ethical reasons, it is often difficult to apply experimental methods such as classical randomized clinical trials in the field. However with alternative approaches such as 'randomization by group' some of these problems can be overcome. Drug information has since long been considered as an instrument to influence physicians, however evaluation of its effects is a new field of research. In the present study the impact of drug information on prescribing behaviour was evaluated in an outpatient setting in Sri Lanka. The study included 15 state health institutions (45 prescribers) with a common drug formulary. Groups of prescribers were randomized into two interventions; newsletters and newsletters reinforced by a group seminar, and one control group. The target topic was 'rational prescribing of antibiotics'. Some 18,766 randomly selected outpatient drug prescriptions were studied. Antibiotics (and sulphonamides) were prescribed to 33.2% of the patients. An overall trend towards a decrease in proportion of patients prescribed antibiotics in the two intervention groups was seen, although the difference was not significant (p greater than 0.05) compared to the control group. This is similar to the effect of written information on prescribing in other studies. A mean difference of -7.4% in written, -7.3% in written + seminar and -0.4% in the control group was shown. The general antibiotic prescribing pattern did not change in any of the three groups. Penicillin was the most commonly prescribed antibiotic and tetracycline was only rarely prescribed to children. This experiment indicates the feasibility of drug information intervention studies in developing countries.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomization by group in studying the effect of drug information in primary care.

Drug information is a technology which is rarely evaluated. Practical and ethical considerations limit the use of a classical experimental method (a randomized controlled trial) in studying the effect of drug information in primary care. An alternative approach, randomization by group, is preferable for several reasons: it avoids contamination of the control group; the effect of information can be evaluated in the natural working environment; and the impact of information is increased via diffusion. This article describes the selection of a control group, the Hawthorne effect and 'blindness' in information experiments. Sample size tables and power calculations are presented when randomization by group is used. The study power is influenced by the number of health centres and the variance between them. The number of doctors per health centre plays a less important role, and the number of patients is relatively unimportant. There is also a need to use qualitative methods to prepare information and to understand factors influencing change of behaviour among prescribers.

Patterns of resistance and DHFR/DHPS genotypes of Plasmodium falciparum in rural Tanzania prior to the adoption of sulfadoxine-pyrimethamine as first-line treatment.

A study was carried out to assess the patterns of resistance and occurrence of DHFR/DHPS genotypes of Plasmodium falciparum prior to the adoption of sulfadoxine-pyrimethamine (SP) as first-line treatment for uncomplicated malaria in Tanzania. Children under five years (n = 117) with clinical, uncomplicated malaria were randomly allocated to standard treatments of either chloroquine (CQ) (25 mg/kg) or SP (25 mg sulfadoxine and 1.25 mg pyrimethamine/kg). Patients were monitored for 28 days. Clinical recovery was achieved in 98% (n = 58) and 90% (n = 59) of the patients in the SP and CQ groups, respectively. Parasitologically, 14% of the patients in the SP group and 51% in the CQ group exhibited RII/RIII resistance. When relating pre-treatment blood drug levels to treatment outcome and the degree of parasite resistance to the number of mutations, no relationships could be detected. There was an overall significant increase in haemoglobin levels from day 0 to day 28 in both patient groups. Sulfadoxine-pyrimethamine produced an acceptable clinical response but the high degree of parasitological resistance (RII/RIII) observed two years prior to the introduction of the drug as first-line treatment is of concern, especially considering the long half-lives of sulfadoxine and pyrimethamine.

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.

Medicines and culture--a double perspective on drug utilization in a developing country.

A double perspective, one medical-pharmacological and one social-anthropological, is used to understand the logic of drug utilization among practitioners and outpatients at a health unit in Sri Lanka. Both negative and positive aspects of local prescribing practices are highlighted. Western pharmaceuticals are integrated into therapeutic choices for outpatients in Sri Lanka by means of the Ayurvedic theory of balance and practitioners' and patients' behaviour in consultations results in their expectations being met, even if they do not use the same set of health ideas and interpretations of health intervention. The healing power ascribed to Western pharmaceuticals is described and their possible risks discussed from both a biomedical and an anthropological point of view.