Public Reform and the Privatisation of Poverty: Some Institutional Determinants of Health Seeking Behaviour in Southern Tanzania

This paper explores the changing institutional context of health servicedelivery in rural Tanzania through an anthropological analysis of thekinds of healing strategies pursued by men and women when they are ill.In some rural districts popular dissatisfaction with state medicalprovision is not manifested in a rejection of the allopathic medicinewith which it is associated, but in increased reliance on an emerginginformal sector of private medical provision. Although this sectorprovides a valued and accessible service to certain categories ofclients it delivers poor quality treatment, serving to reinforce thecyclical relationship between poverty and ill health. Despite the bestintentions of major public sector reforms neither government nor otheragencies are able to meet rural demand for health services. Reliance onthe parallel market for medical provision is likely to continue, atleast in the short term, with negative consequences for health.     

Clinical presentation of T.b. rhodesiense sleeping sickness in second stage patients from Tanzania and Uganda

Background

A wide spectrum of disease severity has been described for Human African Trypanosomiasis (HAT) due to Trypanosoma brucei rhodesiense (T.b. rhodesiense), ranging from chronic disease patterns in southern countries of East Africa to an increase in virulence towards the north. However, only limited data on the clinical presentation of T.b. rhodesiense HAT is available. From 2006-2009 we conducted the first clinical trial program (Impamel III) in T.b. rhodesiense endemic areas of Tanzania and Uganda in accordance with international standards (ICH-GCP). The primary and secondary outcome measures were safety and efficacy of an abridged melarsoprol schedule for treatment of second stage disease. Based on diagnostic findings and clinical examinations at baseline we describe the clinical presentation of T.b. rhodesiense HAT in second stage patients from two distinct geographical settings in East Africa.

Methodology/Principal Findings:

138 second stage patients from Tanzania and Uganda were enrolled. Blood samples were collected for diagnosis and molecular identification of the infective trypanosomes, and T.b. rhodesiense infection was confirmed in all trial subjects. Significant differences in diagnostic parameters and clinical signs and symptoms were observed: the median white blood cell (WBC) count in the cerebrospinal fluid (CSF) was significantly higher in Tanzania (134cells/mm³) than in Uganda (20cells/mm³; p<0.0001). Unspecific signs of infection were more commonly seen in Uganda, whereas neurological signs and symptoms specific for HAT dominated the clinical presentation of the disease in Tanzania. Co-infections with malaria and HIV did not influence the clinical presentation nor treatment outcomes in the Tanzanian study population.

Conclusions/Significance

We describe a different clinical presentation of second stage T.b. rhodesiense HAT in two distinct geographical settings in East Africa. In the ongoing absence of sensitive diagnostic tools and safe drugs to diagnose and treat second stage T.b. rhodesiense HAT an early identification of the disease is essential. A detailed understanding of the clinical presentation of T.b. rhodesiense HAT among health personnel and affected communities is vital, and awareness of regional characteristics, as well as implications of co-infections, can support decision making and differential diagnosis.     

Leopard abundance,distribution and food habits in the Mt. Rungwe–Kitulo landscape,Southern Tanzania

Between 2003 and 2010, 2178.5 km of transect was walked and 76 leopard scats counted in the Mt. Rungwe–Kitulo landscape. The number of scats per 10 km ranged between 0 and 0.83 in Mt Rungwe and between 0 and 1.41 in Kitulo. Leopards chiefly selected bamboo forest between 2500 and 2950 m asl. Some 126 interviews revealed that leopards were encountered more in the 1980s than latterly. Leopards used to attack livestock, but in the 1960s and 1970s, were heavily poisoned. We analysed 59 scats for undigested materials and compared them to a hair reference atlas. Some 135 different prey items were found, with an average of 2.3 items per scat. Some 14 samples were identified to species level and four to genus level. The average prey body weight was 5.9 kg. The diet was dominated by small mammals and rodent species up to 5.0 kg (59.57%) of biomass, followed by carnivores (29.14%), primate species (8.91%) and small rodents <1 kg (2.24%). The highest relative biomass consumed was prey classes of 1.1–5.0 kg (61.06%), followed by prey 5.1–50 kg (35.22%) and small rodents <1 kg (2.24%). The total absence of ungulate prey and conservation implications are discussed.     

Reasons for Missing Antiretroviral Therapy: Results from a Multi-Country Study in Tanzania,Uganda, and Zambia

Objectives

To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence.

Methods

Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from 18 purposefully selected sites in Tanzania, Uganda, and Zambia. We interviewed 250 systematically selected patients per facility (≥18 years) on reasons for missing ART and symptoms they had experienced (using the HIV Symptom Index). We abstracted clinical data from the patients’ medical, pharmacy, and laboratory records. Incomplete adherence was defined as having missed ART for at least 48 consecutive hours during the past 3 months.

Results

Twenty-nine percent of participants reported at least one reason for having ever missed ART (1278/4425). The most frequent reason was simply forgetting (681/1278 or 53%), followed by ART-related hunger or not having enough food (30%), and symptoms (12%). The median number of symptoms reported by participants was 4 (IQR: 2–7). Every additional symptom increased the odds of incomplete adherence by 12% (OR: 1.1, 95% CI: 1.1–1.2). Female participants and participants initiated on a regimen containing stavudine were more likely to report greater numbers of symptoms.

Conclusions

Symptoms were a common reason for missing ART, together with simply forgetting and food insecurity. A combination of ART regimens with fewer side effects, use of mobile phone text message reminders, and integration of food supplementation and livelihood programmes into HIV programmes, have the potential to decrease missed ART and hence to improve adherence and the outcomes of ART programmes.     

高血压的分类、症状及并发症与公众认知

高血压(hypertension,high blood pressure)是动脉血压持续偏高的慢性疾病,是人类社会最为常见的慢性医学问题.80％以上的高血压患者了解他们自身的血压状况,其中70％以上的患者服用治疗高血压药物.然而,这些认识到自身高血压状况的人中,只有48％的患者的高血压得到了充分的控制.本文系统地阐述了高血压的类型、诊断标准及治疗或控制策略,以期提高公众对高血压的认知,有利于患者对高血压的控制和管理.     

Solar-Dried Traditional African Vegetables in Rural Tanzania: Awareness,Perceptions, and Factors Affecting Purchase Decisions

Economic Botany - This paper analyzes rural households’ awareness, perceptions, and factors influencing decisions to purchase solar-dried traditional African vegetables (TAVs). Solar-dried...     

Evaluation of facial cleanliness and environmental improvement activities: Lessons learned from Malawi,Tanzania, and Uganda

The World Health Organization promotes the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements) strategy for trachoma control and prevention. The F&E components of the strategy focus on promotion of healthy hygiene and sanitation behaviors. In order to monitor F&E activities implemented across villages and schools in Malawi, Tanzania, and Uganda, an F&E Monitoring and Evaluation (FEME) framework was developed to track quarterly program outputs and to provide the basis for a pre and post evaluation of the activities. Results showed an increase in knowledge at the school and household levels, and in some cases, an increase in presence of hand/face washing stations. However, this did not always result in a change in trachoma prevention behaviors such as facial cleanliness or keeping compounds free of human feces. The results highlight that the F&E programs were effective in increasing awareness of trachoma prevention but not able to translate that knowledge into changes in behavior during the time between pre and post-surveys. This study also indicates the potential to improve the data collection and survey design and notes that the period of intervention was not long enough to measure significant changes.     

The biology of the Bush rat, Aethomys hindei Thomas in Southern Uganda

Studies were made on the Bush rat, Aethomys hindei in Lunyo forest (0° 5', 32° E) on the Northern shores of Lake Victoria. Rats were trapped daily (Monday-Saturday) for 47 weeks during November 1970 to November 1972 from 20–49 live traps set in a 40 by 100 m grid. In the laboratory they were examined for the condition of the external genitalia and for signs of pregnancy. Some pregnant rats were kept in the laboratory and their progeny measured at weekly intervals. The rate of growth (weight gain in g per day) was determined for both laboratory and field rats. Growth curves of laboratory rats were used to calculate the ages of young (<100 g) field rats, even though the results showed that at between 50 to 100 g field rats grew faster than laboratory rats and between 100 to 150 g, laboratory rats grew faster than field rats.
The weight distribution of rats in the field showed a clear weight difference between males and females; with some males weighing as much as 171 g while the maximum weight recorded for females was only 146 g. The weights obtained extend the weight range of these rats beyond that previously published.
Breeding (pregnancies) in the field occurred mostly in the wetter months of November- December and April whereas young animals occurred more in the drier months of December and January. Births obtained by calculation from laboratory growth curves occurred more in November.
Seasonality in the intensity of breeding was indicated although monthly breeding throughout the year was observed. The months of highest population densities were December, January and April.     

Depressive Symptoms,HIV Medication Adherence,and HIV Clinical Outcomes in Tanzania: A Prospective,Observational Study

Depressive symptoms have been shown to independently affect both antiretroviral therapy (ART) adherence and HIV clinical outcomes in high-income countries. We examined the prospective relationship between depressive symptoms and adherence, virologic failure, and suppressed immune function in people living with HIV/AIDS in Tanzania. Data from 403 study participants who were on stable ART and engaged in HIV clinical care were analyzed. We assessed crude and adjusted associations of depressive symptoms and ART adherence, both at baseline and at 12 months, using logistic regression. We used logistic generalized estimating equations to assess the association and 95% confidence intervals (CI) between depressive symptoms and both virologic failure and suppressed immune function. Ten percent of participants reported moderate or severe depressive symptoms at baseline and 31% of participants experienced virologic failure (>150 copies/ml) over two years. Depressive symptoms were associated with greater odds of reported medication nonadherence at both baseline (Odds Ratio [OR] per 1-unit increase  = 1.18, 95% CI [1.12, 1.24]) and 12 months (OR  = 1.08, 95% CI [1.03, 1.14]). By contrast, increases in depressive symptom score were inversely related to both virologic failure (OR = 0.93, 95% CI [0.87, 1.00]) and immune system suppression (OR = 0.88, 95% CI [0.79, 0.99]), though the association between depressive symptoms and clinical outcomes was less precise than for the association with nonadherence. Findings indicate a positive association between depressive symptoms and nonadherence, and also an inverse relationship between depressive symptoms and clinical outcomes, possibly due to informative loss to follow-up.     

The Aetiologies and Impact of Fever in Pregnant Inpatients in Vientiane,Laos

Introduction

Laos has the highest maternal mortality ratio in mainland Southeast Asia and a high incidence of infectious diseases. Globally, malaria has been the pathogen most intensively investigated in relation to impact on pregnancy, but there has been relatively little research on the aetiology and impact of other diseases. We therefore aimed to determine the causes and impact of fever in pregnant women admitted to two central hospitals in Vientiane City, Lao PDR (Laos).

Materials and Methods

This hospital-based prospective study was conducted in Mahosot Hospital and the Mother and Child Hospital, Vientiane, between 2006 and 2010, with the aim to recruit 250 consenting pregnant women admitted with tympanic temperature ≥37.5°C. Primary outcome was the cause of fever and secondary outcomes were pregnancy outcomes. Specific investigations (culture, antigen, molecular and serological tests) were performed to investigate causes of fever. After discharge, all pregnant women were asked to return for review and convalescence serum on day 10–14 and were monitored until delivery.

Principle findings

250 pregnant women were recruited to this study between February 2006 and November 2010. Fifty percent were pregnant for the first time. Their median (range) gestational age on admission was 24 (4–43) weeks. The median (range) tympanic admission temperature was 38.5°C (37.5–40.5°C). Fifteen percent of patients stated that they had taken antibiotics before admission. Headache, myalgia, back pain and arthralgia were described by >60% of patients and 149 (60%) were given a laboratory diagnosis. Of those with confirmed diagnoses, 132 (53%) had a single disease and 17 (7%) had apparent mixed diseases. Among those who had a single disease, dengue fever was the most common diagnosis, followed by pyelonephritis, scrub typhus, murine typhus and typhoid. Patients were also diagnosed with tuberculosis, appendicitis, Staphylococcus aureus septicemia, leptospirosis, Japanese encephalitis virus infection and Plasmodium falciparum malaria. Severe consequences, including maternal death, miscarriage, stillbirth, low birth weight and preterm birth, were found among 28 (78%) mothers with dengue fever, rickettsioses and typhoid.

Conclusion

Fevers other than malaria, such as dengue, pyelonephritis, rickettsioses and typhoid are common causes of fever during pregnancy in the Asian tropics. Further investigations of their impact in the community on maternal death, fetal loss, vertical transmission, low birth weight and preterm birth are needed.     

克拉玛依区社区慢性病患者健康管理实践及效果研究

目的:随着人们物质生活水平的不断提高,与生活方式密切相关的慢性非传染性疾病(noninfectious chronic disease,NCD,以下简称慢性病)已成为危害人们健康的头号"公敌"。本课题立足克拉玛依市居民,通过健康管理干预方式,摸索一种更适合本地区特点的社区慢性病健康管理的方式方法,让本地区社区慢性病患者能够系统地、有效地掌握慢性病的相关知识和防控技能,建立有利于健康的生活方式,有效减少慢性病的远期并发症。方法:设立实验组和对照组。对照组采用传统的慢性病管理模式,以医院门诊、社区卫生服务中心的医务人员做一般的健康教育指导为主。实验组120人,首先建立人员的健康管理档案,进行人员的健康评估,针对每个患者的健康危险因素,制定健康管理干预措施以及健康指标的管理目标,并进行动态跟踪。6个月后统计资料,实验组与对照组进行对照分析。结果:本此实验历时6个月,通过对实验组和对照组的健康知识、生活方式、饮食结构等的健康教育干预和比较发现,健康管理干预后,试验组对慢性非传染性疾病的相关知识知晓明显优于对照组,其血压、血糖、血脂的知晓率、不良生活方式改善情况均明显好于对照组。实验组的多数患者还掌握了血压测量、指尖血糖检测、食用盐、食用油的控制,以及合理营养搭配、科学运动等。研究显示,健康管理班可让患者有效掌握健康相关知识与技能,并在实际中应用。特别是对自身疾病的认识、治疗、生活方式、饮结构改善方面,明显好于对照组。但是,对于吸烟与饮酒,两组患者在健康管理前后进行比较,没有显著性差异(p>0.05),提示短期健康管理对某些不良生活习惯影响不明显,可能需要更长时间的管理才有可能见效。结论:本研究以建立"健康管理培训班"的健康管理方式,对社区慢病患者进行系统的、有组织、有计划的健康知识与技能培训,达到了患者提升自我健康意识、管理自己健康生活方式的效果。对于克拉玛依区的社区慢病患者健康管理方式的探索,积累了一定的经验。     

Perceptions of HIV and Safe Male Circumcision in High HIV Prevalence Fishing Communities on Lake Victoria,Uganda

Background

In 2010, the Uganda Ministry of Health introduced its Safe Male Circumcision (SMC) strategy for HIV prevention with the goal of providing 4.2 million voluntary medical male circumcisions by 2015. Fishing communities, where HIV prevalence is approximately 3–5 times higher than the national average, have been identified as a key population needing targeted HIV prevention services by the National HIV Prevention Strategy. This study aimed to understand perceptions of HIV and identify potential barriers and facilitators to SMC in fishing communities along Lake Victoria.

Methods

We conducted 8 focus group discussions, stratified by sex and age, with 67 purposefully sampled participants in 4 communities in Kalangala District, Uganda.

Results

There was universal knowledge of the availability of SMC services, but males reported high uptake in the community while females indicated that it is low. Improved hygiene, disease prevention, and improved sexual performance and desirability were reported facilitators. Barriers included a perceived increase in SMC recipients’ physiological libido, post-surgical abstinence, lost income during convalescence, and lengthier recovery due to occupational hazards. Both males and females reported concerns about spousal fidelity during post-SMC abstinence. Reported misconceptions and community-held cultural beliefs include fear that foreskins are sold after their removal, the belief that a SMC recipient’s first sexual partner after the procedure should not be his spouse, and the belief that vaginal fluids aid circumcision wound healing.

Conclusions

Previous outreach efforts have effectively reached these remote communities, where availability and health benefits of SMC are widely understood. However, community-specific intervention strategies are needed to address the barriers identified in this study. We recommend the development of targeted counseling, outreach, and communication strategies to address barriers, misconceptions, and community-held beliefs. Interventions should also incorporate female partners into the SMC decision-making process and develop compensation strategies to address lost income during SMC recovery.     

Dengue and Chikungunya Fever among Viral Diseases in Outpatient Febrile Children in Kilosa District Hospital,Tanzania

Introduction

Viral etiologies of fever, including dengue, Chikungunya, influenza, rota and adeno viruses, cause major disease burden in tropical and subtropical countries. The lack of diagnostic facilities in developing countries leads to failure to estimate the true burden of such illnesses, and generally the diseases are underreported. These diseases may have similar symptoms with other causes of acute febrile illnesses including malaria and hence clinical diagnosis without laboratory tests can be difficult. This study aimed to identify viral etiologies as a cause of fever in children and their co-infections with malaria.

Methods

A cross sectional study was conducted for 6 months at Kilosa district hospital, Tanzania. The participants were febrile children aged 2–13 years presented at the outpatient department. Diagnostic tests such as IgM and IgG ELISA, and PCR were used.

Results

A total of 364 patients were enrolled, of these 83(22.8%) had malaria parasites, 76 (20.9%) had presumptive acute dengue infection and among those, 29(38.2%) were confirmed cases. Dengue was more likely to occur in children ≥ 5 years than in <5 years (OR 2.28, 95% CI: 1.35–3.86). Presumptive acute Chikungunya infection was identified in 17(4.7%) of patients. We observed no presenting symptoms that distinguished patients with Chikungunya infection from those with dengue infection or malaria. Co-infections between malaria and Chikungunya, malaria and dengue fever as well as Chikungunya and dengue were detected. Most patients with Chikungunya and dengue infections were treated with antibacterials. Furthermore, our results revealed that 5(5.2%) of patients had influenza virus while 5(12.8%) had rotavirus and 2(5.1%) had adenovirus.

Conclusion

Our results suggest that even though viral diseases are a major public health concern, they are not given due recognition as a cause of fever in febrile patients. Emphasis on laboratory diagnostic tests for proper diagnosis and management of febrile patients is recommended.     

Environmental Management for Malaria Control: Knowledge and Practices in Mvomero,Tanzania

Environmental conditions play an important role in the transmission of malaria; therefore, regulating these conditions can help to reduce disease burden. Environmental management practices for disease control can be implemented at the community level to complement other malaria control methods. This study assesses current knowledge and practices related to mosquito ecology and environmental management for malaria control in a rural, agricultural region of Tanzania. Household surveys were conducted with 408 randomly selected respondents from 10 villages and qualitative data were collected through focus group discussions and in-depth interviews. Results show that respondents are well aware of the links between mosquitoes, the environment, and malaria. Most respondents stated that cleaning the environment around the home, clearing vegetation around the home, or draining stagnant water can reduce mosquito populations, and 63% of respondents reported performing at least one of these techniques to protect themselves from malaria. It is clear that many respondents believe that these environmental management practices are effective malaria control methods, but the actual efficacy of these techniques for controlling populations of vectors or reducing malaria prevalence in the varying ecological habitats in Mvomero is unknown. Further research should be conducted to determine the effects of different environmental management practices on both mosquito populations and malaria transmission in this region, and increased participation in effective techniques should be promoted.     

The breeding pattern of the Soft-furred rat, Praomys morio in an evergreen forest in Southern Uganda

Observations were made on the breeding of Praomys morio in a lake shore forest in Uganda, during a mark-release-recapture programme whose other aim was to study the role of rodents in the epidemiology of arboviruses. Because of the few numbers of animals captured other means of increasing reproduction data were employed. These included calculating the months of birth of very young animals from their weights.
It was found that pregnancies and births were more numerous in January, April, July, August and November. Recruitment of young animals occurred in three peaks, viz; February, June and September, corresponding to low rainfall months. It was concluded that P. morio shows some form of seasonality in its breeding that may be related to rainfall.     

Aetiology of Pulmonary Symptoms in HIV-Infected Smear Negative Recurrent PTB Suspects in Kampala,Uganda: A Cross-Sectional Study

Introduction

Previously treated TB patients with pulmonary symptoms are often considered recurrent TB suspects in the resource-limited settings, where investigations are limited to microscopy and chest x-ray. Category II anti-TB drugs may be inappropriate and may expose patients to pill burden, drug toxicities and drug-drug interactions.

Objective

To determine the causes of pulmonary symptoms in HIV-infected smear negative recurrent pulmonary tuberculosis suspects at Mulago Hospital, Kampala.

Methods

Between March 2008 and December 2011, induced sputum samples of 178 consented HIV-infected smear negative recurrent TB suspects in Kampala were subjected to MGIT and LJ cultures for mycobacteria at TB Reference Laboratory, Kampala. Processed sputum samples were also tested by PCR to detect 18S rRNA gene of P.jirovecii and cultured for other bacteria.

Results

Bacteria, M. tuberculosis and Pneumocystis jirovecii were detected in 27%, 18% and 6.7% of patients respectively and 53.4% of the specimens had no microorganisms. S. pneumoniae, M. catarrhalis and H. influenzae were 100% susceptible to chloramphenicol and erythromycin but co-trimoxazole resistant.

Conclusion

At least 81.5% of participants had no microbiologically-confirmed TB. However our findings call for thorough investigation of HIV-infected smear negative recurrent TB suspects to guide cost effective treatment.