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1.
CMAJ ; 191(43): E1179-E1188, 2019 Oct 28.
Article in English | MEDLINE | ID: mdl-31659058

ABSTRACT

BACKGROUND: Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India. METHODS: We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity. RESULTS: In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%. INTERPRETATION: Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.


Subject(s)
Child Health Services/standards , Health Services Accessibility/standards , Maternal Health Services/standards , Adult , Child Health Services/statistics & numerical data , Ethiopia , Female , Health Services Accessibility/statistics & numerical data , Humans , India , Infant, Newborn , Insurance Coverage/statistics & numerical data , Maternal Health Services/statistics & numerical data , Nigeria , Pregnancy , Rural Population/statistics & numerical data , Socioeconomic Factors
2.
Malar J ; 15(1): 439, 2016 08 27.
Article in English | MEDLINE | ID: mdl-27567531

ABSTRACT

BACKGROUND: Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania. METHODS: A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs. RESULTS: Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs. CONCLUSION: RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.


Subject(s)
Community Health Workers , Diagnostic Tests, Routine/methods , Disease Management , Malaria/diagnosis , Patient Acceptance of Health Care , Rural Population , Caregivers , Cross-Sectional Studies , Female , Humans , Interviews as Topic , Male , Tanzania
3.
BMC Pediatr ; 14: 187, 2014 Jul 22.
Article in English | MEDLINE | ID: mdl-25052850

ABSTRACT

BACKGROUND: In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation. METHODS: All 132 wards in the 6-district study area were randomised to intervention or comparison groups. Starting in 2010, in intervention areas trained volunteers made home visits during pregnancy and after childbirth to promote recommended newborn care practices including hygiene, breastfeeding and identification and extra care for low birth weight babies. In 2011, in a representative sample of 5,240 households, we asked women who had given birth in the previous year both about counselling visits and their childbirth and newborn care practices. RESULTS: Four of 14 newborn care practices were more commonly reported in intervention than comparison areas: delaying the baby's first bath by at least six hours (81% versus 68%, OR 2.0 (95% CI 1.2-3.4)), exclusive breastfeeding in the three days after birth (83% versus 71%, OR 1.9 (95% CI 1.3-2.9)), putting nothing on the cord (87% versus 70%, OR 2.8 (95% CI 1.7-4.6)), and, for home births, tying the cord with a clean thread (69% versus 39%, OR 3.4 (95% CI 1.5-7.5)). For other behaviours there was little evidence of differences in reported practices between intervention and comparison areas including childbirth in a health facility or with a skilled attendant, thermal care practices, breastfeeding within an hour of birth and, for home births, the birth attendant having clean hands, cutting the cord with a clean blade and birth preparedness activities. CONCLUSIONS: A home-based counselling strategy using volunteers and designed for scale-up can improve newborn care behaviours in rural communities of southern Tanzania. Further research is needed to evaluate if, and at what cost, these gains will lead to improved newborn survival. TRIAL REGISTRATION: Trial Registration Number NCT01022788 (http://www.clinicaltrials.gov, 2009).


Subject(s)
Community Health Workers , Directive Counseling/organization & administration , Health Knowledge, Attitudes, Practice , House Calls , Infant Care/methods , Rural Health Services/organization & administration , Volunteers , Adolescent , Adult , Breast Feeding/methods , Breast Feeding/statistics & numerical data , Developing Countries , Directive Counseling/methods , Female , Humans , Infant Care/organization & administration , Infant Care/statistics & numerical data , Infant, Newborn , Middle Aged , Outcome Assessment, Health Care , Perinatal Care/methods , Perinatal Care/organization & administration , Perinatal Care/statistics & numerical data , Pregnancy , Surveys and Questionnaires , Tanzania , Young Adult
4.
BMC Health Serv Res ; 13: 61, 2013 Feb 14.
Article in English | MEDLINE | ID: mdl-23410228

ABSTRACT

BACKGROUND: The poor maintenance of equipment and inadequate supplies of drugs and other items contribute to the low quality of maternity services often found in rural settings in low- and middle-income countries, and raise the risk of adverse patient outcomes through delaying care provision. We aim to describe staff experiences of providing maternal and neonatal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies. METHODS: Focus group discussions and in-depth interviews were conducted with different staff cadres from all facility levels in order to explore experiences and views of providing maternity care in the context of poorly maintained equipment, and insufficient drugs and other supplies. A facility survey quantified the availability of relevant items. RESULTS: The facility survey, which found many missing or broken items and frequent stock outs, corroborated staff reports of providing care in the context of missing or broken care items. Staff reported increased workloads, reduced morale, difficulties in providing optimal maternity care, and carrying out procedures with potential health risks to themselves as a result. CONCLUSIONS: Inadequately stocked and equipped facilities compromise the health system's ability to reduce maternal and neonatal mortality and morbidity by affecting staff personally and professionally, which hinders the provision of timely and appropriate interventions. Improving stock control and maintaining equipment could benefit mothers and babies, not only through removing restrictions to the availability of care, but also through improving staff working conditions.


Subject(s)
Attitude of Health Personnel , Equipment and Supplies/supply & distribution , Health Personnel/psychology , Maintenance , Maternal Health Services/organization & administration , Pharmaceutical Preparations/supply & distribution , Rural Health Services , Adult , Female , Focus Groups , Humans , Male , Middle Aged , Qualitative Research , Tanzania , Young Adult
5.
Bull World Health Organ ; 90(9): 672-684E, 2012 Sep 01.
Article in English | MEDLINE | ID: mdl-22984312

ABSTRACT

OBJECTIVE: To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas. METHODS: Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies. FINDINGS: A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement. CONCLUSION: There is a broad taxonomy of strategies for delivering ITNs at scale.


Subject(s)
Insecticide-Treated Bednets/economics , Insecticides/economics , Malaria/prevention & control , Public Health/economics , Social Marketing , Animals , Global Health , Humans , Malaria/economics , Plasmodium malariae , Plasmodium vivax , Public Health/methods
6.
BMC Pregnancy Childbirth ; 12: 16, 2012 Mar 21.
Article in English | MEDLINE | ID: mdl-22436344

ABSTRACT

BACKGROUND: Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant women's first antenatal care visit and identifies factors influencing early and late attendance. METHODS: The study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis. RESULTS: The majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single. CONCLUSIONS: Factors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women.


Subject(s)
Gestational Age , Health Knowledge, Attitudes, Practice/ethnology , Patient Acceptance of Health Care/psychology , Prenatal Care/psychology , Abortion, Spontaneous/psychology , Adolescent , Adult , Female , Humans , Middle Aged , Parity , Pregnancy , Regression Analysis , Socioeconomic Factors , Stillbirth/psychology , Surveys and Questionnaires , Tanzania , Young Adult
7.
Hum Resour Health ; 10: 3, 2012 Feb 22.
Article in English | MEDLINE | ID: mdl-22357353

ABSTRACT

BACKGROUND: Recent years have seen an unprecedented increase in funds for procurement of health commodities in developing countries. A major challenge now is the efficient delivery of commodities and services to improve population health. With this in mind, we documented staffing levels and productivity in peripheral health facilities in southern Tanzania. METHOD: A health facility survey was conducted to collect data on staff employed, their main tasks, availability on the day of the survey, reasons for absenteeism, and experience of supervisory visits from District Health Teams. In-depth interview with health workers was done to explore their perception of work load. A time and motion study of nurses in the Reproductive and Child Health (RCH) clinics documented their time use by task. RESULTS: We found that only 14% (122/854) of the recommended number of nurses and 20% (90/441) of the clinical staff had been employed at the facilities. Furthermore, 44% of clinical staff was not available on the day of the survey. Various reasons were given for this. Amongst the clinical staff, 38% were absent because of attendance to seminar sessions, 8% because of long-training, 25% were on official travel and 20% were on leave. RCH clinic nurses were present for 7 hours a day, but only worked productively for 57% of time present at facility. Almost two-third of facilities had received less than 3 visits from district health teams during the 6 months preceding the survey. CONCLUSION: This study documented inadequate staffing of health facilities, a high degree of absenteeism, low productivity of the staff who were present and inadequate supervision in peripheral Tanzanian health facilities. The implications of these findings are discussed in the context of decentralized health care in Tanzania.

8.
Bull World Health Organ ; 88(11): 807-14, 2010 Nov 01.
Article in English | MEDLINE | ID: mdl-21076561

ABSTRACT

OBJECTIVE: To develop a decision-support tool to help policy-makers in sub-Saharan Africa assess whether intermittent preventive treatment in infants (IPTi) would be effective for local malaria control. METHODS: An algorithm for predicting the effect of IPTi was developed using two approaches. First, study data on the age patterns of clinical cases of Plasmodium falciparum malaria, hospital admissions for infection with malaria parasites and malaria-associated death for different levels of malaria transmission intensity and seasonality were used to estimate the percentage of cases of these outcomes that would occur in children aged <10 years targeted by IPTi. Second, a previously developed stochastic mathematical model of IPTi was used to predict the number of cases likely to be averted by implementing IPTi under different epidemiological conditions. The decision-support tool uses the data from these two approaches that are most relevant to the context specified by the user. FINDINGS: Findings from the two approaches indicated that the percentage of cases targeted by IPTi increases with the severity of the malaria outcome and with transmission intensity. The decision-support tool, available on the Internet, provides estimates of the percentage of malaria-associated deaths, hospitalizations and clinical cases that will be targeted by IPTi in a specified context and of the number of these outcomes that could be averted. CONCLUSION: The effectiveness of IPTi varies with malaria transmission intensity and seasonality. Deciding where to implement IPTi must take into account the local epidemiology of malaria. The Internet-based decision-support tool described here predicts the likely effectiveness of IPTi under a wide range of epidemiological conditions.


Subject(s)
Antimalarials/therapeutic use , Decision Support Techniques , Health Policy , Malaria/prevention & control , Plasmodium malariae/isolation & purification , Africa South of the Sahara/epidemiology , Age Distribution , Algorithms , Antimalarials/administration & dosage , Child , Child, Preschool , Confidence Intervals , Epidemiologic Methods , Female , Hospitalization , Humans , Infant , Infant, Newborn , Malaria/epidemiology , Malaria/mortality , Male , Models, Theoretical , Stochastic Processes , Time Factors
9.
BMC Pregnancy Childbirth ; 9: 10, 2009 Mar 04.
Article in English | MEDLINE | ID: mdl-19261181

ABSTRACT

BACKGROUND: Although antenatal care coverage in Tanzania is high, worrying gaps exist in terms of its quality and ability to prevent, diagnose or treat complications. Moreover, much less is known about the utilisation of postnatal care, by which we mean the care of mother and baby that begins one hour after the delivery until six weeks after childbirth. We describe the perspectives and experiences of women and health care providers on the use of antenatal and postnatal services. METHODS: From March 2007 to January 2008, we conducted in-depth interviews with health care providers and village based informants in 8 villages of Lindi Rural and Tandahimba districts in southern Tanzania. Eight focus group discussions were also conducted with women who had babies younger than one year and pregnant women. The discussion guide included information about timing of antenatal and postnatal services, perceptions of the rationale and importance of antenatal and postnatal care, barriers to utilisation and suggestions for improvement. RESULTS: Women were generally positive about both antenatal and postnatal care. Among common reasons mentioned for late initiation of antenatal care was to avoid having to make several visits to the clinic. Other concerns included fear of encountering wild animals on the way to the clinic as well as lack of money. Fear of caesarean section was reported as a factor hindering intrapartum care-seeking from hospitals. Despite the perceived benefits of postnatal care for children, there was a total lack of postnatal care for the mothers. Shortages of staff, equipment and supplies were common complaints in the community. CONCLUSION: Efforts to improve antenatal and postnatal care should focus on addressing geographical and economic access while striving to make services more culturally sensitive. Antenatal and postnatal care can offer important opportunities for linking the health system and the community by encouraging women to deliver with a skilled attendant. Addressing staff shortages through expanding training opportunities and incentives to health care providers and developing postnatal care guidelines are key steps to improve maternal and newborn health.


Subject(s)
Postnatal Care/statistics & numerical data , Prenatal Care/statistics & numerical data , Adolescent , Adult , Attitude , Community Health Workers/psychology , Female , Humans , Infant, Newborn , Middle Aged , Postnatal Care/psychology , Pregnancy , Quality of Health Care , Rural Population , Tanzania , Young Adult
10.
Trop Med Int Health ; 13(3): 410-7, 2008 Mar.
Article in English | MEDLINE | ID: mdl-18298608

ABSTRACT

OBJECTIVE: To describe the epidemiology of malaria in Guinea-Bissau, in view of the fact that more funds are available now for malaria control in the country. METHODS: From May 2003 to May 2004, surveillance for malaria was conducted among children less than 5 years of age at three health centres covering the study area of the Bandim Health Project (BHP) and at the outpatient clinic of the national hospital in Bissau. Cross-sectional surveys were conducted in the community in different malaria seasons. RESULTS: Malaria was overdiagnosed in both health centres and hospital. Sixty-four per cent of the children who presented at a health centre were clinically diagnosed with malaria, but only 13% of outpatient children who tested for malaria had malaria parasitaemia. Only 44% (963/2193) of children admitted to hospital with a diagnosis of malaria had parasitaemia. The proportion of positive cases increased with age. Among hospitalized children with malaria parasitaemia, those less than 2 years old were more likely to have moderate anaemia (RR = 1.27; 95% CI: 1.02-1.56) (P = 0.03) or severe anaemia (RR = 1.67; 95% CI: 1.25-2.24) (P = 0.0005) than older children. The prevalence of malaria parasitaemia in the community was low (3%, 53/1926). CONCLUSION: In Bissau, the prevalence of malaria parasitaemia in the community is now low and malaria is over-diagnosed in health facilities. Laboratory support will be essential to avoid unnecessary use of the artemisinin combination therapy which is now being introduced as first-line treatment in Bissau with support from the Global Fund.


Subject(s)
Malaria, Falciparum/epidemiology , Parasitemia/epidemiology , Anemia, Iron-Deficiency/epidemiology , Child, Preschool , Cross-Sectional Studies , Female , Guinea-Bissau/epidemiology , Humans , Infant , Male
11.
Malar J ; 7: 213, 2008 Oct 21.
Article in English | MEDLINE | ID: mdl-18939971

ABSTRACT

BACKGROUND: Intermittent preventive treatment of malaria in infants (IPTi) reduces the incidence of clinical malaria. However, before making decisions about implementation, it is essential to ensure that IPTi is acceptable, that it does not adversely affect attitudes to immunization or existing health seeking behaviour. This paper reports on the reception of IPTi during the first implementation study of IPTi in southern Tanzania. METHODS: Data were collected through in-depth interviews, focus group discussions and participant observation carried out by a central team of social scientists and a network of key informants/interviewers who resided permanently in the study sites. RESULTS: IPTi was generally acceptable. This was related to routinization of immunization and resonance with traditional practices. Promoting "health" was considered more important than preventing specific diseases. Many women thought that immunization was obligatory and that health staff might be unwilling to assist in the future if they were non-adherent. Weighing and socialising were important reasons for clinic attendance. Non-adherence was due largely to practical, social and structural factors, many of which could be overcome. Reasons for non-adherence were sometimes interlinked. Health staff and "road to child health" cards were the main source of information on the intervention, rather than the specially designed posters. Women did not generally discuss child health matters outside the clinic, and information about the intervention percolated slowly through the community. Although there were some rumours about sulphadoxine pyrimethamine (SP), it was generally acceptable as a drug for IPTi, although mothers did not like the way tablets were administered. There is no evidence that IPTi had a negative effect on attitudes or adherence to the expanded programme on immunisation (EPI) or treatment seeking or existing malaria prevention. CONCLUSION: In order to improve adherence to both EPI and IPTi local priorities should be taken into account. For example, local women are often more interested in weighing than in immunization, and they view vaccination and IPTi as vaguely "healthy" rather preventing specific diseases. There should be more emphasis on these factors and more critical consideration by policy makers of how much local knowledge and understanding is minimally necessary in order to make interventions successful.


Subject(s)
Antimalarials/administration & dosage , Malaria Vaccines/administration & dosage , Malaria/prevention & control , Patient Acceptance of Health Care/statistics & numerical data , Female , Humans , Infant , Interviews as Topic , Malaria/epidemiology , Tanzania/epidemiology
12.
Trans R Soc Trop Med Hyg ; 102(7): 669-78, 2008 Jul.
Article in English | MEDLINE | ID: mdl-18513769

ABSTRACT

In order to understand home-based neonatal care practices in rural Tanzania, with the aim of providing a basis for the development of strategies for improving neonatal survival, we conducted a qualitative study in southern Tanzania. In-depth interviews, focus group discussions and case studies were used through a network of female community-based informants in eight villages of Lindi Rural and Tandahimba districts. Data collection took place between March 2005 and April 2007. The results show that although women and families do make efforts to prepare for childbirth, most home births are assisted by unskilled attendants, which contributes to a lack of immediate appropriate care for both mother and baby. The umbilical cord is thought to make the baby vulnerable to witchcraft and great care is taken to shield both mother and baby from bad spirits until the cord stump falls off. Some neonates are denied colostrum, which is perceived as dirty. Behaviour-change communication efforts are needed to improve early newborn care practices.


Subject(s)
Breast Feeding/psychology , Home Care Services/standards , Home Childbirth/standards , Infant Care/psychology , Mothers/psychology , Patient Acceptance of Health Care/psychology , Perinatal Care/standards , Breast Feeding/ethnology , Culture , Female , Health Knowledge, Attitudes, Practice , Home Childbirth/psychology , Humans , Infant Care/standards , Infant Mortality/trends , Infant, Newborn , Medicine, Traditional , Patient Acceptance of Health Care/ethnology , Pregnancy , Qualitative Research , Rural Health/standards , Socioeconomic Factors , Tanzania
13.
BMC Public Health ; 8: 205, 2008 Jun 10.
Article in English | MEDLINE | ID: mdl-18544162

ABSTRACT

BACKGROUND: The Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E). METHODS: A comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme. RESULTS: The evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time. CONCLUSION: The M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.


Subject(s)
Bedding and Linens/economics , Insecticides/economics , Malaria/prevention & control , National Health Programs , Program Evaluation/methods , Public Assistance , Animals , Female , Humans , Interdisciplinary Communication , Maternal-Child Health Centers/statistics & numerical data , Mosquito Control/methods , Pregnancy , Process Assessment, Health Care/methods , Tanzania
14.
Emerg Themes Epidemiol ; 4: 5, 2007 Jun 01.
Article in English | MEDLINE | ID: mdl-17543099

ABSTRACT

BACKGROUND: Survey data are traditionally collected using pen-and-paper, with double data entry, comparison of entries and reconciliation of discrepancies before data cleaning can commence. We used Personal Digital Assistants (PDAs) for data entry at the point of collection, to save time and enhance the quality of data in a survey of over 21,000 scattered rural households in southern Tanzania. METHODS: Pendragon Forms 4.0 software was used to develop a modular questionnaire designed to record information on household residents, birth histories, child health and health-seeking behaviour. The questionnaire was loaded onto Palm m130 PDAs with 8 Mb RAM. One hundred and twenty interviewers, the vast majority with no more than four years of secondary education and very few with any prior computer experience, were trained to interview using the PDAs. The 13 survey teams, each with a supervisor, laptop and a four-wheel drive vehicle, were supported by two back-up vehicles during the two months of field activities. PDAs and laptop computers were charged using solar and in-car chargers. Logical checks were performed and skip patterns taken care of at the time of data entry. Data records could not be edited after leaving each household, to ensure the integrity of the data from each interview. Data were downloaded to the laptop computers and daily summary reports produced to evaluate the completeness of data collection. Data were backed up at three levels: (i) at the end of every module, data were backed up onto storage cards in the PDA; (ii) at the end of every day, data were downloaded to laptop computers; and (iii) a compact disc (CD) was made of each team's data each day.A small group of interviewees from the community, as well as supervisors and interviewers, were asked about their attitudes to the use of PDAs. RESULTS: Following two weeks of training and piloting, data were collected from 21,600 households (83,346 individuals) over a seven-week period in July-August 2004. No PDA-related problems or data loss were encountered. Fieldwork ended on 26 August 2004, the full dataset was available on a CD within 24 hours and the results of initial analyses were presented to district authorities on 28 August. Data completeness was over 99%. The PDAs were well accepted by both interviewees and interviewers. CONCLUSION: The use of PDAs eliminated the usual time-consuming and error-prone process of data entry and validation. PDAs are a promising tool for field research in Africa.

15.
BMC Health Serv Res ; 6: 142, 2006 Nov 01.
Article in English | MEDLINE | ID: mdl-17078872

ABSTRACT

BACKGROUND: Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania METHODS: We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked. RESULTS: Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations. CONCLUSION: Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.


Subject(s)
Dietary Supplements/supply & distribution , Immunization Programs/organization & administration , Primary Health Care/methods , Vitamin A Deficiency/prevention & control , Vitamin A/therapeutic use , Child, Preschool , Dietary Supplements/statistics & numerical data , Health Care Surveys , Health Knowledge, Attitudes, Practice , Humans , Immunization Programs/economics , Immunization Programs/statistics & numerical data , Infant , Nutritional Status , Primary Health Care/economics , Socioeconomic Factors , Surveys and Questionnaires , Tanzania , Universal Health Insurance , Vitamin A/economics , Vitamin A Deficiency/economics
16.
Lancet ; 362(9379): 233-41, 2003 Jul 19.
Article in English | MEDLINE | ID: mdl-12885488

ABSTRACT

Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidized health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.


Subject(s)
Child Health Services/supply & distribution , Delivery of Health Care/standards , Infant Mortality , Child , Global Health , Health Services Accessibility/standards , Humans , Infant
17.
Soc Sci Med ; 60(2): 369-81, 2005 Jan.
Article in English | MEDLINE | ID: mdl-15522492

ABSTRACT

There is a growing appreciation of the role of the private sector in expanding the use of key health interventions. At the policy level, this has raised questions about how public sector resources can best be used to encourage the private sector in order to achieve public health impact. Social marketing has increasingly been used to distribute public health products in developing countries. The Kilombero and Ulanga Insecticide-Treated Net Project (KINET) project used a social marketing approach in two districts of Tanzania to stimulate the development of the market for insecticide-treated mosquito nets (ITNs) for malaria control. Using evidence from household surveys, focus group discussions and a costing study in the intervention area and a control area, this paper examines two issues: (1) How does social marketing affect the market for ITNs, where this is described in terms of price and coverage levels; and (2) What does the added cost of social marketing "buy" in terms of coverage and equity, compared with an unassisted commercial sector model? It appears that supply improved in both areas, although there was a greater increase in supply in the intervention area. However, the main impact of social marketing on the market for nets was to shift demand in the intervention district, leading to a higher coverage market outcome. While social marketing was more costly per net distributed than the unassisted commercial sector, higher overall levels of coverage were achieved in the social marketing area together with higher coverage of the lowest socioeconomic group, of pregnant women and children under 5 years, and of those living on the periphery of their villages. These findings are interpreted in the context of Tanzania's national plan for scaling up ITNs.


Subject(s)
Bedding and Linens/economics , Bedding and Linens/supply & distribution , Insecticides , Malaria/prevention & control , Mosquito Control/economics , Mosquito Control/methods , Social Marketing , Animals , Developing Countries , Focus Groups , Humans , Insecticides/economics , Malaria/economics , Models, Econometric , Socioeconomic Factors , Tanzania
19.
ISRN Pediatr ; 2012: 953401, 2012.
Article in English | MEDLINE | ID: mdl-22518328

ABSTRACT

Introduction. We report cause of death and care-seeking prior to death in neonates based on interviews with relatives using a Verbal Autopsy questionnaire. Materials and Methods. We identified neonatal deaths between 2004 and 2007 through a large household survey in 2007 in five rural districts of southern Tanzania. Results. Of the 300 reported deaths that were sampled, the Verbal Autopsy (VA) interview suggested that 11 were 28 days or older at death and 65 were stillbirths. Data was missing for 5 of the reported deaths. Of the remaining 219 confirmed neonatal deaths, the most common causes were prematurity (33%), birth asphyxia (22%) and infections (10%). Amongst the deaths, 41% (90/219) were on the first day and a further 20% (43/219) on day 2 and 3. The quantitative results matched the qualitative findings. The majority of births were at home and attended by unskilled assistants. Conclusion. Caregivers of neonates born in health facility were more likely to seek care for problems than caregivers of neonates born at home. Efforts to increase awareness of the importance of early care-seeking for a premature or sick neonate are likely to be important for improving neonatal health.

20.
PLoS One ; 5(2): e8988, 2010 Feb 01.
Article in English | MEDLINE | ID: mdl-20126547

ABSTRACT

BACKGROUND: There is evidence that the age-pattern of Plasmodium falciparum malaria varies with transmission intensity. A better understanding of how this varies with the severity of outcome and across a range of transmission settings could enable locally appropriate targeting of interventions to those most at risk. We have, therefore, undertaken a pooled analysis of existing data from multiple sites to enable a comprehensive overview of the age-patterns of malaria outcomes under different epidemiological conditions in sub-Saharan Africa. METHODOLOGY/PRINCIPAL FINDINGS: A systematic review using PubMed and CAB Abstracts (1980-2005), contacts with experts and searching bibliographies identified epidemiological studies with data on the age distribution of children with P. falciparum clinical malaria, hospital admissions with malaria and malaria-diagnosed mortality. Studies were allocated to a 3x2 matrix of intensity and seasonality of malaria transmission. Maximum likelihood methods were used to fit five continuous probability distributions to the percentage of each outcome by age for each of the six transmission scenarios. The best-fitting distributions are presented graphically, together with the estimated median age for each outcome. Clinical malaria incidence was relatively evenly distributed across the first 10 years of life for all transmission scenarios. Hospital admissions with malaria were more concentrated in younger children, with this effect being even more pronounced for malaria-diagnosed deaths. For all outcomes, the burden of malaria shifted towards younger ages with increasing transmission intensity, although marked seasonality moderated this effect. CONCLUSIONS: The most severe consequences of P. falciparum malaria were concentrated in the youngest age groups across all settings. Despite recently observed declines in malaria transmission in several countries, which will shift the burden of malaria cases towards older children, it is still appropriate to target strategies for preventing malaria mortality and severe morbidity at very young children who will continue to bear the brunt of malaria deaths in sub-Saharan Africa.


Subject(s)
Malaria, Falciparum/epidemiology , Malaria, Falciparum/transmission , Africa South of the Sahara/epidemiology , Age Factors , Child , Child, Preschool , Humans , Infant , Patient Admission/statistics & numerical data , Seasons
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