Patterns of partnership and condom use in two communities of female sex workers in Tanzania.

Two rapid ethnographic studies have found that commercial sex workers (CSWs) and other high-risk women in Tanzania have different categories of partners, ranging from single-time contacts to long and enduring relationships. Since the advent of HIV/AIDS prevention programs in Tanzania in the late 1980s, CSWs and their clients have been aware of the multiple benefits of condom use for the prevention of pregnancy and STDs including HIV. These women often use condoms for the single-time contact. However, since the HIV/AIDS epidemic, casual partners have decreased in number. These days, most of their sexual contacts occur within long-term partnerships, and within these relationships, condom use is rare. Although the message that condoms should be used during high-risk behavior has been largely accepted, the definition of a high-risk relationship needs to be extended from casual partnerships to include multiple long-term partnerships. In addition, men and women's empowerment through education, business, and equal rights needs to be addressed at all levels of society.

Mothers' perceptions and knowledge on childhood malaria in the holendemic Kibaha district, Tanzania: implications for malaria control and the IMCI strategy.

Prior to an intervention on improving the quality of malaria case management, we assessed mothers' abilities to recognize nonsevere and severe/complicated malaria in children when a child has fever with other physiological and behavioural symptoms associated with malaria. Malaria was mentioned as the commonest febrile illness (94. 1%), convulsions the least (11.4%). Fever and enteric symptoms featured as the most important symptoms of childhood malaria at frequencies of 93.5% and 73.8%, respectively. The need for laboratory diagnosis was very high (98.3%), the reason being to get accurate diagnosis and treatment (89.4%). Poor outcome of treatment was ascribed to incorrect diagnosis and prescription, noncompliance at home and ineffective drugs (62.1%). Most mothers (86.6%) would take antipyretic measures first when a child has fever, and subsequently the majority (92.9%) would seek care at a modern health facility. About 50% of the mothers would give traditional treatments for childhood convulsions and wait till fits cease before the next action. A high proportion of the mothers (75%) held the belief that an injection in a child with high fever would precipitate convulsions or death. The implications of these findings for chemotherapeutic malaria control in holoendemic areas within the context of the Integrated Management of Childhood Illnesses (IMCI) strategy are discussed.

The incidence of HIV infection among women using family planning methods in Dar es Salaam, Tanzania.

OBJECTIVES: To determine the risk factors for HIV seroconversion and assess the association between contraceptive use and HIV infection among women attending three large family planning clinics in Dar es Salaam, Tanzania. DESIGN: Prospective cohort study. METHODS: Between 1992 and 1995, 2471 HIV-negative women were followed prospectively. Information about sociodemographic characteristics, sexual behavior, contraceptive use and other risk factors was collected at recruitment and updated at follow-up visits. At the end of the study, specimens were collected for HIV testing and laboratory diagnosis of sexually transmitted diseases. RESULTS: The overall HIV incidence was 3.4 per 100 person-years [95% confidence interval (Cl), 2.6-4.1]. The risk of HIV seroconversion decreased with increasing age (P=0.04, test for trend). Women reporting three or more sex partners during the follow-up period had the highest risk of HIV [age-adjusted relative risk (RR), 4.89; 95% Cl, 2.61-9.17]. Having an uncircumcised husband was associated with a significantly increased risk of HIV (age-adjusted RR, 3.60; 95% Cl, 1.12-11.59). The risk of HIV was also significantly increased among women with gonorrhoea (age-adjusted RR, 3.51; 95% Cl, 1.60-7.71) and candidiasis at baseline (age-adjusted RR, 1.98; 95% Cl, 1.17-3.33) and among women reporting alcohol consumption during the follow-up period. After controlling for other risk factors, the risk of HIV infection amongst users of oral contraceptive, intrauterine device and injectable contraceptive was not significantly increased. Similarly, there was no significant trend associated with increasing duration of use of any of these contraceptive methods. CONCLUSION: These findings confirm that a large number of new HIV infections continue to occur in this population. Reassuringly, no significant association was observed between HIV and use of specific contraceptive methods. Interventions to reduce further spread of HIV are still urgently needed.

Local terminology for febrile illnesses in Bagamoyo District, Tanzania and its impact on the design of a community-based malaria control programme.

This paper reviews results of several ethnographic studies that have examined the issue of local terminology for malaria in Africa, then presents findings from an on-going study in Bagamoyo District, Tanzania. The study used a mixture of qualitative and quantitative interview methods to examine local perceptions of malaria and malaria treatment practices. Although the local term homa ya malaria or malaria fever appeared on the surface to correspond closely with the biomedical term malaria, significant and often subtle differences were found between the two terms. Of perhaps greatest importance, common consequences of malaria in endemic areas such as cerebral malaria in young children, severe anaemia and malaria in pregnancy were not connected with homa ya malaria by many people. A set of guidelines are described that were used to determine how best to promote acceptance and use of insecticide-impregnated mosquito nets, given these results. It is demonstrated that the position of the term used to denote malaria in the local taxonomy of febrile illnesses has important implications for the design of health education interventions.

Predictors of AIDS knowledge, condom use and high-risk sexual behaviour among women in Dar-es-Salaam, Tanzania.

Reducing the number of sex partners and using condoms are the major means for individuals to protect themselves from STDs and AIDS in sub-Saharan Africa. To identify predictors of having only one sex partner in the last year and to assess knowledge and use of condoms among women of reproductive age in Dar-es-Salaam, Tanzania, we interviewed 2285 women at 3 representative family planning clinics between February 1991 and June 1992. After interview, blood and genital specimens were collected for laboratory diagnosis of HIV and other sexually transmitted diseases (STDs). Although knowledge of sexual transmission of AIDS was very high, less than a half of the respondents (42.8%) mentioned use of condoms as an AIDS preventive measure. Younger and more educated women were more likely to mention use of condoms for AIDS prevention, however only 4.6% of women interviewed were regular users of condoms, while 19.8% were occasional users. The majority of women who had never used a condom (57.5%) reported not using condoms because 'men did not like them'. Condom use was positively associated with increasing level of education and increasing number of sexual partners. 14.8% of women reported having more than one sex partner in the last year; this behaviour was more likely among cohabiting women (increased by 210%); HIV-positives (increased by 120%); and among women with STDs (increased by 50%).(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The authors interviewed 2285 women at three representative family planning clinics in Dar-es-Salaam, Tanzania, between February 1991 and June 1992 to identify predictors of having only one sex partner in the preceding year and to assess levels of knowledge and use of condoms among women of reproductive age in the study area. Blood and genital specimens were collected for the laboratory diagnosis of HIV and other sexually transmitted diseases (STD). 37.5% of the women had abnormal vaginal discharge on examination and 26.1% had microbiological evidence of STD. 11.5% of the women were HIV-seropositive. 98.3% of the women mentioned sexual contact as a mode of HIV transmission, but only 42.8% cited condom use as a way to prevent HIV/AIDS infection. Younger and more educated women were more likely to mention condom use for the prevention of AIDS. Only 4.6%, however, reported using condoms on a regular basis, and 19.8% on an occasional basis. 57.5% of women who had never used a condom reported not using them because men did not like them. Condom use was positively associated with increasing level of education and increasing number of sex partners. 14.8% of women reported having more than one sex partner in the preceding year. Having sex with multiple partners increased by 210% among cohabiting women, 120% among HIV-seropositive women, and 50% among women with STDs. These findings indicate that AIDS prevention activities have been only partially successful in reaching at-risk women in this population. Even among these high-risk women, only a minority used condoms. Men's negative attitudes about condoms was identified as the major reason for low condom use. Interventions designed to increase condom use should therefore aim to change male attitudes.

Seasonal variation in the perceived risk of malaria: implications for the promotion of insecticide-impregnated bed nets.

Bed nets (mosquito nets), impregnated every 6 months with pyrethroid insecticides, are a simple, low-cost malaria control method well suited to conditions in sub-Saharan Africa. As large seasonal variations in levels of net usage may seriously limit the potential impact of the nets on malaria transmission, a study was conducted on local definitions of seasons, perceptions of seasonal variation in mosquito populations and incidence of febrile illnesses in Bagamoyo District, Tanzania, to aid in the design of a communication strategy for promoting sustained use of the nets. Both the diagnosis and treatment of febrile illnesses are affected by what season people think it is, by what illnesses they think are common in each season, and also by their perceptions of how abundant mosquitoes are. During dry seasons when mosquitoes are scarce and malaria is thought to be unlikely, it will be difficult to attain high rates of net usage. It will be necessary to develop locally-appropriate messages and communication materials that explain how it is possible that malaria can be a threat even when mosquitoes are few. Cultural consensus analysis was found to be a particularly valuable tool for understanding the reasons behind large variations in local perceptions of seasonality.

Risk factors for HIV infection among women in Dar-es-Salaam, Tanzania.

To identify risk factors for HIV infection among women not known to be members of high-risk groups in Dar-es-Salaam, Tanzania, and assess associations between contraceptive use and HIV infection, we conducted a cross-sectional case-control study at three representative family planning clinics. Between February 1991 and June 1992, we enrolled 2,285 women; women were interviewed using a structured questionnaire, and specimens were collected for laboratory diagnosis of HIV and other sexually transmitted diseases (STDs). The overall HIV prevalence was 11.5% (95% CI: 10.2-12.8). Other prevalent STDs included gonorrhea (4.2%), trichomoniasis (14.3%), candidiasis (11.5%), and syphilis (2.5%). HIV seroprevalence was significantly lower among younger women and women in nonpolygamous marriages. HIV risk increased with both women's education and male partner's education. Number of sex partners in the last 5 years was positively associated with HIV risk; however, among HIV-seropositive women, the median number of sexual partners was only two. For married women with only a single partner, their risk increased significantly if their husbands had other partners. The risk of HIV infection was higher among subjects with STDs, although only significantly so for gonorrhea (OR 1.95, 95% CI: 1.10-3.45). After controlling for known and potential risk factors, the risk of HIV infection was significantly increased among women who had ever used an intrauterine device (IUD) (OR 2.50, 95% CI: 1.35-4.64). Use of other contraceptives, including oral contraceptives, was not significantly associated with HIV infection. Our findings confirm that HIV and STDs are a major public health problem among women in Dar-es-Salaam.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS epidemic in Kagera region, Tanzania--the experiences of local people.

This study is part of a collaborative study of HIV infection and AIDS which was launched in 1987 in the Kagera region, Tanzania. This region is characterized as one of the areas most affected by the AIDS epidemic. In order to describe and analyse the epidemiology of HIV infection in the area and also to contribute to the intervention process, a long-term population-based project was initiated. The study was launched in January 1989 as an in-depth behavioural study to describe the experiences of the local people of the AIDS epidemic in the region. The specific objectives were to determine the people's attitudes, perceptions, responses and norms relevant to AIDS-related problems. The data were collected through tape recorded interviews, focus group discussions and direct observations of risk behaviour. The interviews were conducted in 10 villages, in urban and rural Bukoba as well as in Muleba districts. In each village five households were selected and visited once a week for about 6 months. The focus group discussions were held mainly with young males, females, married women and married men, elders and religious leaders, government and party leaders, and other key informants. Perceptions, attitudes and patterns of behaviour among the local people are described in the context of the HIV transmission in the area. The descriptions give answers to questions like: How do people perceive and interpret AIDS? How do they react to AIDS? How do they judge causes and risks? What are the attitudes to people with AIDS and those suspected to have AIDS? What are the implications of these values in affected communities?

Longitudinal study on the health status of children in a rural Tanzanian community: comparison of community-based clinical examinations, the diseases seen at village health posts and the perception of health problems by the population.

Standardised household interviews among adults and children, open-ended questionnaires, and clinical examinations administered during cross-sectional health status surveys, as well as the registers of village health posts (VHP), were used to assess the pattern of health problems of a rural community in southeastern Tanzania, and their results compared. All four approaches gave very similar results for the two major health problems (fever/malaria and abdominal pain or discomfort) which were mentioned by both children and adults. The parasitological data from the cross-sectional surveys also revealed hyperendemic P. falciparum malaria and a high prevalence and incidence for infections with hookworm (N. americanus), Strongyloides, and G. lamblia. However besides consistently revealing the two major health problems, each approach showed a distinct pattern for the additional health problems: household interviews and open-ended questionnaires resulted in a higher ranking of problems that had not yet been solved by the health care facilities available in the community at the time of the interview. This view was further biased by the fact that the interviews were done by people representing the health professionals. The statistics from the registers of VHP clearly reflected the types of treatment provided by this service. Malnutrition and various eye problems only became evident during the clinical examination of the population. However, the clinical examination did not identify the importance of the abdominal problems in the community. The cross-sectional survey (questionnaires, clinical examination) chiefly showed the health problems affecting the population around the time of the surveys (end of the dry season). Interestingly, the registers of the VHP did not show marked seasonal variations in the morbidity statistics for this community. Both questionnaire approaches and the registers of VHP showed a change in both the morbidity and the disease perception pattern that may reflect the effects of interventions launched at community level (activities of village health workers, mass-treatment against hookworm and G. lamblia). The study indicated that the individual ranking of the major health problems matched with data from health status surveys. It also pointed to the possibility that disease perception patterns could become a tool for community diagnosis and for the monitoring of health care programs.

Community participation within a primary health care programme.

Based on experiences made in rural communities of Tanzania, aspects of community participation in schistosomiasis control within a primary health care (PHC) programme are discussed. Community participation is seen as prerequisite for PHC. Building up community participation can not be disease- or even symptom-orientated, it must be community problem-orientated. The assessment of village priorities as they are recognized by the community governs any control strategy based on PHC. As schistosomiasis is often not first ranking among community problems, schistosomiasis control must become part of a multisectorial approach to improve community health. This process can initiate and ensure community participation and may lead to cost-effective control measures within PHC.

Failure to participate in a malaria chemosuppression programme: North Mara, Tanzania.

A malaria prophylaxis programme for 100 000 children in one rural district of Tanzania was carried out under the very favourable conditions of 1) a government genuinely committed to rural public health, 2) a well organized system of village government for distribution of the drug to children, and 3) free chloroquine supplied without interruption by WHO to the project area. The project failed to suppress malaria for a combination of the following reasons. Small delays in distribution because of poor communication, vehicle breakdowns, bad roads, key people being away or too busy resulted in the drug not being available for ingestion at regular intervals. A few children from families with marginal social status were excluded by local leaders. Some people were not convinced that regular chloroquine taking might prevent children's malaria and therefore saved it to treat fever in all family members. Various survey techniques were used to discover why children might refuse to swallow tablets, and as many as 28% of children complained of vomiting, as many as 56% complained of itching, and other unfavourable qualities of chloroquine were indicated.