Male partner approval on the use of modern contraceptive methods: factors determining usage among couples in Kibaha district, Tanzania.

BACKGROUND: Men in developing countries play an important role in the adoption of family planning (FP), either as actual users or supporters of their partners. Notwithstanding the universal knowledge on the contraceptive methods, their approval and use have been low among men in Tanzania. This study determined the magnitude and factors that influence men to use or approve the use of modern contraceptive methods with their spouses. METHODS: A cross sectional, community-based study was conducted in Kibaha, Pwani region in 2014. A total of 365 randomly selected married and cohabiting men; aged 18 to 60 years who had at least a child below the age of 5 years were interviewed using a structured questionnaire. Descriptive statistics were performed and associations between status of men using modern FP with their partners and potential factors were tested using Chi-square and Fisher's exact tests as appropriate. Logistic regression model was fitted to determine significant factors associated with male use of the methods with their partners. RESULTS: About 60 % of men (59.7%) reported to use modern FP methods. In the bivariate analysis, education level (odds ratio (OR) = 2.6, CI = 1.4-4.8; p = 0.002); men knowledge on any contraceptive method (OR = 24.1, CI = 7.3-79.9; p < 0.001); awareness of a nearby FP clinic (OR = 6.2, CI = 3.1-12.3; p < 0.001); number of children (OR = 2, CI = 1.1-3.6; p < 0.025) and presence of a provider during clinic visit (OR = 12.0, CI = 2.26-63.7; p < 0.004) were significantly associated with the use of FP. However, in the multivariable analysis, only knowledge on FP methods (adjusted odds ratios (AOR) =26.4; CI = 7.9-88.4, p < 0.001) and number of children a man had (AOR = 1.9; CI = 1.0-3.6, p = 0.039) remained significantly associated with the use of modern FP methods. CONCLUSION: This study has shown that for men to use family planning methods with their partners, knowledge of FP methods and number of children are critical factors. Visiting a FP center alone or with a spouse, and availability of FP provider (during visit) also influence this practice. These findings emphasize a need to increase knowledge on contraception and family planning services access among men.

Primacy of effective communication and its influence on adherence to artemether-lumefantrine treatment for children under five years of age: a qualitative study.

BACKGROUND: Prompt access to artemesinin-combination therapy (ACT) is not adequate unless the drug is taken according to treatment guidelines. Adherence to the treatment schedule is important to preserve efficacy of the drug. Although some community based studies have reported fairly high levels of adherence, data on factors influencing adherence to artemether-lumefantrine (AL) treatment schedule remain inadequate. This study was carried-out to explore the provider's instructions to caretakers, caretakers' understanding of the instructions and how that understanding was likely to influence their practice with regard to adhering to AL treatment schedule. METHODS: A qualitative study was conducted in five villages in Kilosa district, Tanzania. In-depth interviews were held with providers that included prescribers and dispensers; and caretakers whose children had just received AL treatment. Information was collected on providers' instructions to caretakers regarding dose timing and how to administer AL; and caretakers' understanding of providers' instructions. RESULTS: Mismatch was found on providers' instructions as regards to dose timing. Some providers' (dogmatists) instructions were based on strict hourly schedule (conventional) which was likely to lead to administering some doses in awkward hours and completing treatment several hours before the scheduled time. Other providers (pragmatists) based their instruction on the existing circumstances (contextual) which was likely to lead to delays in administering the initial dose with serious treatment outcomes. Findings suggest that, the national treatment guidelines do not provide explicit information on how to address the various scenarios found in the field. A communication gap was also noted in which some important instructions on how to administer the doses were sometimes not provided or were given with false reasons. CONCLUSIONS: There is need for a review of the national malaria treatment guidelines to address local context. In the review, emphasis should be put on on-the-job training to address practical problems faced by providers in the course of their work. Further research is needed to determine the implication of completing AL treatment prior to scheduled time.

How rational are indications for emergency caesarean section in a tertiary hospital in Tanzania?

The rate of caesarean section (CS) at Muhimbili National Hospital (MNH) in Tanzania has been on progressive increase for past three decades. Concerns have been raised if this increase is justified by rational decisions but no study so far has investigated this problem. The aim of the study was to find out whether decisions made for CS comply with a set of locally made standards, with an assumption that if the standards are met, then the increase in CS rate seen at MNH is genuine. The five most common indications for CS were identified from the obstetric electronic data base. Most common indications included obstructed labour, cephalopelvic disproportion (CPD), failure to progress, repeat CS and foetal distress. Criteria for the best practice for each indication were developed based on the National guidelines and local expert consensus. Information extracted from the case notes, antenatal cards and partographs were compared to the standard audit criteria and the decision judged as standard or substandard. Three hundred forty five women had a decision made for emergency CS. Repeat CS was the most frequent indication (30.2%), followed by obstructed labour (14.4%) and foetal distress (13.6%). Audit of 324 women's files showed that 30% of women had substandard decisions for CS mostly in the foetal distress group (59.1%) and least in the repeat CS group (9.1%). Among the-324 mothers with decision for emergency CS, 279 (86.1%) delivered by CS as decided and 45 (13.9%) delivered vaginally before CS could be performed. Women who delivered vaginally after decision for CS and the nulliparous women had significantly more substandard decisions compared to those delivered by CS and parous women respectively. In conclusion, a substantial proportion of decisions for emergency CS made in the hospital is substandard and may contain women in whom surgical intervention could be avoided. This calls for a need to improve quality of assessment and decision before performing CS.

Adherence to artemether/lumefantrine treatment in children under real-life situations in rural Tanzania.

A follow-up study was conducted to determine the magnitude of and factors related to adherence to artemether/lumefantrine (ALu) treatment in rural settings in Tanzania. Children in five villages of Kilosa District treated at health facilities were followed-up at their homes on Day 7 after the first dose of ALu. For those found to be positive using a rapid diagnostic test for malaria and treated with ALu, their caretakers were interviewed on drug administration habits. In addition, capillary blood samples were collected on Day 7 to determine lumefantrine concentrations. The majority of children (392/444; 88.3%) were reported to have received all doses, in time. Non-adherence was due to untimeliness rather than missing doses and was highest for the last two doses. No significant difference was found between blood lumefantrine concentrations among adherent (median 286 nmol/l) and non-adherent [median 261 nmol/l; range 25 nmol/l (limit of quantification) to 9318 nmol/l]. Children from less poor households were more likely to adhere to therapy than the poor [odds ratio (OR)=2.45, 95% CI 1.35-4.45; adjusted OR=2.23, 95% CI 1.20-4.13]. The high reported rate of adherence to ALu in rural areas is encouraging and needs to be preserved to reduce the risk of emergence of resistant strains. The age-based dosage schedule and lack of adherence to ALu treatment guidelines by health facility staff may explain both the huge variability in observed lumefantrine concentrations and the lack of difference in concentrations between the two groups.

Who gets prompt access to artemisinin-based combination therapy? A prospective community-based study in children from rural Kilosa, Tanzania.

BACKGROUND: Effective and timely case management remains one of the fundamental pillars for control of malaria. Tanzania introduced artemisinin-combination therapy [ACT] for uncomplicated malaria; however, the policy change is challenged by limited availability of ACTs due to high cost. This study aimed to determine factors influencing prompt access to ACTs among febrile children in rural Kilosa, Tanzania. METHODS AND FINDINGS: In a community-based study, 1,235 randomly selected children under five were followed up weekly for six months, in 2008. Using a structured questionnaire, children's caretakers were asked about the child's febrile history in the last seven days, and treatment actions including timing, medicines used and source of care. Caretakers' knowledge about malaria and socioeconomic and demographic data were also obtained. About half of followed-up children had at least one episode of fever. Less than half (44.8%) of febrile children were taken to government facilities. Almost one-third (37.6%; 95% CI 33.1-42.1) of febrile children had prompt access to ACT. Care-seeking from a government facility was the overriding factor, increasing the likelihood of prompt access to an ACT 18 times (OR 17.7; 95% CI 10.55-29.54; adjusted OR 16.9; 95% CI 10.06-28.28). Caretakers from the better-off household (3rd-5th quintiles) were more likely to seek care from government facilities (OR 3.66; 95% CI 2.56-5.24; adjusted OR 1.80; 95% CI 1.18-2.76). The majority of antimalarials accessed by the poor were ineffective [86.0%; 295/343], however, they paid more for them (median Tsh 500) compared to the better-offs (median Tsh 0). CONCLUSIONS: Prompt access to ACT among febrile children was unacceptably low, due mainly to limited availability of subsidised ACT at the location where most caretakers sought care. There is urgent need to accelerate implementation of strategies that will ensure availability of ACT at an affordable price in remote rural areas, where the burden of malaria is highest.

Understanding caretakers' dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate.

BACKGROUND: Malaria kills. A single rectal dose of artesunate before referral can reduce mortality and prevent permanent disability. However, the success of this intervention depends on caretakers' adherence to referral advice for follow-up care. This paper explores the dilemma facing caretakers when they are in the process of deciding whether or not to transit their child to a health facility after pre-referral treatment with rectal artesunate. METHODS: Four focus group discussions were held in each of three purposively selected villages in Mtwara rural district of Tanzania. Data were analysed manually using latent qualitative content analysis. RESULTS: The theme "Caretakers dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate" depicts the challenge they face. Caretakers' understanding of the rationale for going to hospital after treatment--when and why they should adhere--influenced adherence. Caretakers, whose children did not improve, usually adhered to referral advice. If a child had noticeably improved with pre-referral treatment however, caretakers weighed whether they should proceed to the facility, balancing the child's improved condition against other competing priorities, difficulties in reaching the health facilities, and the perceived quality of care at the health facility. Some misinterpretation were found regarding the urgency and rationale for adherence among some caretakers of children who improved which were attributed to be possibly due to their prior understanding. CONCLUSION: Some caretakers did not adhere when their children improved and some who adhered did so without understanding why they should proceed to the facility. Successful implementation of the rectal artesunate strategy depends upon effective communication regarding referral to clinic.

Factors influencing adherence to referral advice following pre-referral treatment with artesunate suppositories in children in rural Tanzania.

OBJECTIVE: WHO recommends artemisinin suppository formulations as pre-referral treatment for children who are unable to take oral medication and cannot rapidly reach a facility for parenteral treatment. We investigated factors influencing caretakers' adherence to referral advice following pre-referral treatment of their children with rectal artesunate suppositories. METHODS: The study was nested within an intervention study that involved pre-referral treatment of all children who came to a community dispenser for treatment because they were unable to take oral medications because of repeated vomiting, lethargy, convulsions or altered consciousness. All patients who did not comply with referral advice were stratified by actions taken post-referral: taking their children to a drug shop, a traditional healer, or not seeking further treatment, and added to a random selection of patients who complied with referral advice. Caretakers of the children were interviewed about their socio-economic status (SES), knowledge about malaria, referral advice given and actions they took following pre-referral treatment. Interview data for 587 caretakers were matched with symptoms of the children, the time of treatment, arrival at a health facility or other actions taken post-pre-referral treatment. RESULTS: The majority (93.5%) of caretakers reported being given referral advice by the community drug dispenser. The odds of adherence with this advice were three times greater for children with altered consciousness and/or convulsions than for children with other symptoms [odds ratio (OR) 3.47, 95% confidence interval (CI) 2.32-5.17, P < 0.001]. When questioned, caretakers who remembered when (OR 2.19, 95% CI 1.48-3.23, P < 0.001) and why (OR 1.77, 95% CI 1.07-2.95, P = 0.026) they were advised to proceed to health facility - were more likely to follow referral advice. Cost did not influence adherence except within a catchment area of facilities that charged for services. In these areas, costs deterred adherence by four to five times for those who had previously paid for laboratory services (OR = 0.25, 95% CI: 0.09-0.67, P = 0.006) or consultation (OR 0.20, 95% CI: 0.06-0.61, P = 0.005) compared with those who had not. CONCLUSION: When given referral advice, caretakers of patients with life-threatening symptoms adhere to referral advice more readily than other caretakers. Health service charges deter adherence.

Volunteerism among out-of-school adolescent reproductive health peer educators: is it a sustainable strategy in resource constrained countries?

Out-of-school peer educators [PE] are resourceful in transmitting reproductive health information but their retention remains a contentious issue. This study aimed to assess motivation and sustainability of out-of-school PEs in disseminating reproductive health information among adolescents. A structured questionnaire was used to interview 406 PEs in Mbeya region, Tanzania. Focus Group Discussions [FGDs] were also conducted with the PEs and other relevant stakeholders. Most PEs had hopes for future employment and allowances through continuous training. The fact that majority of PEs had primary level education [89%] and were either peasants or self employed [92%] posed a serious question as to whether voluntary work is for the less educated, peasants and self-employed. Sustenance of PEs needs to be a continuous activity aimed at increasing the number of trained adolescents from their own social and economic groups. Otherwise, provision of transport and compensation for time spent should be considered.

Referral pattern of patients received at the national referral hospital: challenges in low income countries.

OBJECTIVE: To examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in order to inform the process of strengthening the referral system. METHODS: The study design was a prospective study conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH. RESULTS: Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). CONCLUSION: Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased so as to limit inappropriate use of national referral hospitals.

Application of ICT in strengthening health information systems in developing countries in the wake of globalisation.

Information Communication Technology (ICT) revolution brought opportunities and challenges to developing countries in their efforts to strengthen the Health Management Information Systems (HMIS). In the wake of globalisation, developing countries have no choice but to take advantage of the opportunities and face the challenges. The last decades saw developing countries taking action to strengthen and modernise their HMIS using the existing ICT. Due to poor economic and communication infrastructure, the process has been limited to national and provincial/region levels leaving behind majority of health workers living in remote/rural areas. Even those with access do not get maximum benefit from ICT advancements due to inadequacies in data quality and lack of data utilisation. Therefore, developing countries need to make deliberate efforts to address constraints threatening to increase technology gap between urban minority and rural majority by setting up favourable policies and appropriate strategies. Concurrently, strategies to improve data quality and utilisation should be instituted to ensure that HMIS has positive impact on people's health. Potential strength from private sector and opportunities for sharing experiences among developing countries should be utilised. Short of this, advancement in ICT will continue to marginalise health workers in developing countries especially those living in remote areas.