Community directed approach beyond ivermectin in Tanzania: a promising mechanism for the delivery of complex health interventions.

The Community Directed Intervention (CDI) is currently used for Ivermectin distribution for the treatment of onchocerciasis in Africa. This study was carried out to determine the extent to which the CDI process can be used for the delivery of other health interventions with different degrees of complexity. The study was conducted in five districts of Kilosa, Muheza, Lushoto, Korogwe and Ulanga in Tanzania and involved communities, health facility and district healthcare providers. Implementation of CDI across these health interventions involved addressing six major processes, namely, stakeholder processes, health system dynamics, engaging communities, empowering communities, engaging CDI implementers and broader system effects. Community and health systems changes were triggered, such that the inherent value of community involvement and empowerment could be internalized by communities and health workers, leading to a more receptive health system. The CDI process was accepted at the community levels as many were willing and ready to adopt the approach. Health workers at community levels were readily available and supportive of the process. Additionally, noted were the verified willingness and ability of community implementers to deliver multiple interventions; confirmed efficiency of CDI leading to cost savings at health systems level; increasing interest of the health system in CDI; interest of health workers in the process of integrated planning. However, there were factors that may have a negative influence on the CDI process. Drug and supply policy for CDI process was lacking at the national and district levels and the presence of parallel community-based programmes that provide financial incentives for community members to run them discouraged Community-directed distributors who in most cases are volunteers. In conclusion, the results have clearly and evidently demonstrated the potential of CDI approach for effectively and efficiently control of other diseases such as malaria, tuberculosis and childhood illnesses. The study has provided unique information on the feasibility and effectiveness of integrated delivery of interventions at the community level.

Community knowledge, attitudes and practices related to tick-borne relapsing fever in dodoma rural district, central Tanzania.

Tick-borne Relapsing Fever (TBRF) is a vector-borne disease of humans which causes serious illness, primarily for children under five years old and pregnant women. Understanding people's knowledge, attitude and practices on the disease is important in designing appropriate interventions. This study was conducted to explore community knowledge, attitudes and practices regarding TBRF transmission and control to provide baseline data for the planned scaling up of intervention in Dodoma rural District in central Tanzania. A total of 198 heads of households were interviewed using a semi-structured questionnaire. Of these, 94.5% were aware of TBRF. Fever of unknown origin (69.5%), body pain (8.5%), headache (8.5%), chills (4.5%) and vomiting (3.5%) were the most commonly mentioned symptoms. The domestic tick-infestation and tick-bites was known to 82.8%. High domestic tick infestation reported to occur during dry season (85.4%). The majority believed that the disease spreads through tick-bites (85.9%). Regular plastering of house floors and walls was the most common method used by the community to control domestic tick infestation (96.5 %). Majority (84.3%) of the respondents preferred public healthcare facilities for treatment. Only a small proportion (15.7%) preferred using traditional medicines. Poor knowledge of the study subjects about the disease and its control underscores the need for health educational campaigns if any control and/or elimination programme is to succeed.

Manifestations and reduction strategies of stigma and discrimination on people living with HIV/AIDS in Tanzania.

HIV/AIDS-related stigma, and its associated discrimination, is known to negatively affect all aspects of HIV prevention, care and treatment. Studies have revealed the extent to which individuals are stigmatized and discriminated against the health care system. However, there has been limited information on stigma manifestations and reduction interventions. The main objective of the study was to determine the magnitude and factors influencing HIV/AIDS-related stigma and discrimination with a specific focus on the manifestations and reduction interventions. In-depth interviews, exit interviews and focus group discussions were deployed in the study. Results have shown that HIV/AIDS is increasingly conceptualized as a continuum between prevention and care, effects of stigma and discrimination are from both health facilities and communities. While religious leaders isolate people living with HIV/AIDS (PLWHAs) and consider them as most promiscuous, health workers also have strong negative attitudes and feelings and as a result PLWHAs refrain from counselling and testing services. A stigmatizing social environment was found to pose barriers to all strategies and/or interventions that are aimed at reducing this situation. Because of stigma and discrimination, people living with HIV/AIDS receive inadequate treatment, as such they decline to divulge their status to partners or change their behaviour avoiding depressing reactions. Basing on that therefore, adequate outreach services at both community and health facility levels be established and line up in the fight against stigma and discrimination facing people living with HIV/AIDS.

Community directed interventions for malaria, tuberculosis and vitamin A in onchocerciasis endemic districts of Tanzania.

In recognising the success attained through community-directed treatment with Ivermectin, there has been a growing interest to use a similar approach for delivery of interventions against other communicable diseases. This study was conducted in 2007 to evaluate the impact of community directed intervention (CDI) on delivering five health interventions namely Vitamin A supplementation (VAS), community-directed treatment with Ivermectin (CDTi), distribution of insecticide-treated nets (ITN), directly observed treatment of tuberculosis (DOTS), and home-based management of malaria (HMM). The study was carried out in onchocerciasis endemic districts of Kilosa, Muheza, Lushoto, Korogwe and Ulanga districts in Tanzania. A total of 250 households were involved in the study for the period of two years. During the first year, one new intervention was added in each study district. A second new intervention was then added in the same manner during the second study year. In the control district all interventions, with the exception of Ivermectin distribution, continued to be delivered in the traditional manner throughout the study period. Results showed that Ivermectin treatment coverage in the CDI districts (88%) was significantly (P<0.005) higher than in the control district (77%). The coverage of VAS was 84 +/- 7%, showing very little difference between control and intervention districts (P>0.05). The DOTS treatment completion rate was observed only in Korogwe where 4 out 7 patients had completed their treatment. The proportions of pregnant women and <5 years children sleeping under ITN in the CDI districts (range: 83-100%) were significantly higher (P< 0.05) than those in the control district (40-43%). There was also a higher proportion of malaria cases referred in the intervention districts (42%) than in the control district (21%) (P<0.005). Likewise, the proportion of <5 years children who were presumptively diagnosed with malaria and received appropriated treatment within 24 hours in the intervention districts (17-29%) was higher than those in the control district (4%) (P<0.005). The costs incurred per integrated programme in the intervention districts were much lower than those in the control district. In conclusion, our results showed higher coverage of interventions in the CDI districts without necessarily increasing the cost.

Community Knowledge; Attitudes and Practices Related to Tick-Borne Relapsing Fever in Dodoma Rural District; Central Tanzania

Tick-borne Relapsing Fever (TBRF) is a vector-borne disease of humans which causes serious illness; primarily for children under five years old and pregnant women. Understanding people's knowledge; attitude and practices on the disease is important in designing appropriate interventions. This study was conducted to explore community knowledge; attitudes and practices regarding TBRF transmission and control to provide baseline data for the planned scaling up of intervention in Dodoma rural District in central Tanzania. A total of 198 heads of households were interviewed using a semi-structured questionnaire. Of these; 94.5were aware of TBRF. Fever of unknown origin (69.5); body pain (8.5); headache (8.5); chills (4.5) and vomiting (3.5) were the most commonly mentioned symptoms. The domestic tick-infestation and tickbites was known to 82.8. High domestic tick infestation reported to occur during dry season (85.4). The majority believed that the disease spreads through tick-bites (85.9). Regular plastering of house floors and walls was the most common method used by the community to control domestic tick infestation (96.5). Majority (84.3) of the respondents preferred public healthcare facilities for treatment. Only a small proportion (15.7) preferred using traditional medicines. Poor knowledge of the study subjects about the disease and its control underscores the need for health educational campaigns if any control and/or elimination programme is to succeed