Knowledge, perceptions and practices of farming communities on linkages between malaria and agriculture in Mvomero District, Tanzania

This study was carried out to determine knowledge, perceptions and practices of farming communities on linkages between agriculture and malaria in Mvomero District in Tanzania. A total of 661 adult males and females were interviewed using a structured questionnaire. Most respondents (85.6%) were engaged in crop production. Significantly, a larger proportion (55.2%) of the respondents had primary school education (P < 0.001). Majority (88.2%) respondents described malaria as the most important public health problem. However, only 48.2% of the respondents had high knowledge of malaria. The level of knowledge on malaria was associated with level of education of the respondent. Those who had attended at least primary school education were more knowledgeable that those without formal education. A significantly larger proportion (67%) of the respondents experienced most malaria episodes during the rainy season (P < 0.001). Respondents with low knowledge on malaria experienced 2.3 times more malaria cases in their households than those with higher knowledge. Respondents with low knowledge preferred to seek care from health facilities (OR: 7.28) than those with high knowledge (OR: 0.15). Rice farming was significantly associated with malaria transmission compared to either maize or sugarcane farming (P < 0.001). Cattle, sheep and goats were the domestic animals most frequently incriminated to create aquatic habitats for mosquito breeding. Householders with formal education (OR: 4.6, CI: 1.33-15.89, P-value = 0.016) and higher knowledge (OR: 1.7, CI: 1.15-2.55, P-value = 0.008) reported to incur large losses when having a malaria case than those without education/low knowledge. Majority (60.2%) of the respondent owned at least an insecticide treated mosquito net (ITN). Respondents with higher knowledge of malaria were likely to own at least an ITN than those with low knowledge (P < 0.001). In conclusion, the knowledge on malaria and its linkage with agriculture among farming communities in Mvomero District is low. Malaria is a complex health problem and its control approach needs understanding of the environmental factors associated with agricultural practices. It therefore is important that education and communication messages on malaria targeting farming communities take into consideration local agricultural practices.     

Social engagement and health and social care use and medication use among older people

Social engagement has been associated with improved health outcomes in older people, although the precise mechanisms by which this is mediated are not clear. The aim of this study was to examine the relationship between social engagement and health and social care use and medication use in older people. Data were derived from the 1985, 1989 and 1993 waves of the Nottingham Longitudinal Study of Activity and Ageing, a nationally representative sample of people aged 65 and over. Logistic regression models were used to determine whether social engagement predicted cross-sectional and longitudinal health and social care use and medication use. People with higher social engagement were significantly less likely to have seen their family doctor, the district nurse or home help services, and to be taking two or more medications cross-sectionally. This relationship was independent of demographic factors, physical and mental health and physical activity for contact with the district nurse or home help services. Higher social engagement was associated with reduced contact with home help services after 4 years, independent of demographic factors, physical and mental health, and with reduced medication use after 4 years in unadjusted models. Higher social engagement was associated with increased contact with home help services after 8 years, when controlling for demographic factors, physical and mental health and physical activity. Higher social engagement may help to reduce cross-sectional health and social care service and medication use but further research is required to understand the benefits of social engagement and medium- and long-term service/medication use.     

Social engagement and health and social care use and medication use among older people

Social engagement has been associated with improved health outcomes in older people, although the precise mechanisms by which this is mediated are not clear. The aim of this study was to examine the relationship between social engagement and health and social care use and medication use in older people. Data were derived from the 1985, 1989 and 1993 waves of the Nottingham Longitudinal Study of Activity and Ageing, a nationally representative sample of people aged 65 and over. Logistic regression models were used to determine whether social engagement predicted cross-sectional and longitudinal health and social care use and medication use. People with higher social engagement were significantly less likely to have seen their family doctor, the district nurse or home help services, and to be taking two or more medications cross-sectionally. This relationship was independent of demographic factors, physical and mental health and physical activity for contact with the district nurse or home help services. Higher social engagement was associated with reduced contact with home help services after 4 years, independent of demographic factors, physical and mental health, and with reduced medication use after 4 years in unadjusted models. Higher social engagement was associated with increased contact with home help services after 8 years, when controlling for demographic factors, physical and mental health and physical activity. Higher social engagement may help to reduce cross-sectional health and social care service and medication use but further research is required to understand the benefits of social engagement and medium- and long-term service/medication use.     

Public and private sector treatment of malaria in Lao PDR

This study aimed to examine the care-seeking choices for treatment of a febrile illness compatible with malaria in the public and private sectors in Lao PDR. We conducted interviews with 745 heads of household in 14 villages in the Sekong province, using a structured-questionnaire. We asked each about who the care-providers were for febrile illness episodes affecting their household members during the past year. If patients used more than one care-provider for a single episode over a period of time, we identified patterns of the care-sequences for the initial and subsequent care choices. Then, we analyzed the relationship between the initial care choices and secondary care choices for care-providers by Chi-square test, categorizing care-providers into public (hospital, health centre, and village health volunteer) and private care-providers (private pharmacy, informal retailer, faith healing and herbs). As a result, we found that 624 patients sought care at least once, 255 (40.9%) twice, and 66 (10.6%) three times or more during a single episode. Of 138 patients who started with a public care-provider and then sought a secondary care, 71 (51.4%) switched to a private care-provider. In contrast, of 117 patients who started with a private care-provider and then sought a secondary care, 82 (70.1%) switched to a public care-provider (p < 0.001). In conclusion, although most patients who failed being treated by a private care-provider switched to a public one, some exclusively relied on care within the private sector. An intervention is necessary to make the private sector an integral component of malaria treatment in Lao PDR.     

Malaria preventive measures, health care seeking behaviour and malaria burden in different epidemiological settings in Sudan

Objectives  To provide information about preventive measures and treatment seeking behaviour as well as an estimate of the malaria burden in different epidemiological settings for effective monitoring and evaluation of the ongoing efforts.
Methods  Cross-sectional survey carried out in four areas representing different levels of transmission to explore the use of preventive measures, care-seeking behaviour and accessibility in addition to point prevalence was followed by a follow-up phase in which the health workers registered and reported all fever cases including malaria. The relation between the reported malaria incidence, the product of symptomatic/asymptomatic ratio and the prevalence of confirmed malaria cases was used to develop the equation that could predict the true malaria incidence.
Results  Thousand households and 3628 individuals were surveyed. The presence of any net varied between 6.6% and 40%; the percentage of people who reportedly slept under mosquito nets in the previous night varied between 35 and 80. Prompt use of medications ranged between 14 and 48% with a delay of more than 24 h noticed in different areas. The mean number of individuals per household who reported use of anti-malarial drugs in the last 2 weeks ranged between 0.6 (SD = 0.92) and 1.2 (SD = 1.1), with variable cost per treatment and affordability. The prevalence of asymptomatic parasitaemia, fever and confirmed malaria at time of the survey differed by area. The incidence of malaria during the follow-up period was estimated to be 8.5, 178.6, 23.7 and 10.3 episodes per 1000 population in Malakal, Elrank, Elhosh and El Matama, respectively. Based on this, a prediction equation was developed.
Conclusion  We found suboptimal health care seeking behaviour, coverage and use of preventive measures with a high malaria burden. We developed a model for future estimation of malaria episodes.     

深圳市生殖道感染相关求医保健行为和医疗服务状况的定性研究

目的了解深圳市不同特征人口生殖道感染相关的保健、求医行为和服务状况，为制定干预方案提供依据。方法定性研究方法为个人深入访谈、专题小组讨论、现场观察和假扮病人。结果当地已婚育龄妇女和性服务者(CSW)深信阴道冲洗具有防病作用，并广泛使用；流动人口和CSW会首选私人诊所就医，他们不掌握区分有牌诊所和无牌诊所的技巧；性伴通知实施障碍较多；私人诊所存在医源性感染隐患。结论生殖道感染综合干预要充分考虑私人诊所与医源性感染问题，考虑脆弱人群的求医行为和过度阴道冲洗问题，同时关注性伴通知实施中的阻力和障碍。     

Prevalence of malaria parasitemia among clients seeking treatment for fever or malaria at drug stores in rural Tanzania 2004

OBJECTIVE: To determine the prevalence of malaria parasitemia and other common illnesses among drug store clients in one rural community, with a view to the potential role of specialist drug stores in expanding coverage of effective malaria treatment to households in highly endemic areas. METHOD: Follow-back study of 2466 client visits selected from all 10 drug stores operating in the town of Ikwiriri between May 30 and August 31 2004. Of these, 521 (21.2%) were made by or on behalf of persons ill with fever or malaria. Two hundred and ninety three were eligible as residents of the surrounding nine villages and all agreed to participate in the study. Each patient was evaluated by a clinical officer and provided a blood sample for malaria on the day of the shop visit, either at the shop or at home. RESULTS: Only 50 (17.1%) visits by or on behalf of febrile patients resulted in the purchase of an antimalarial drug, while an antipyretic medication was obtained at 226 visits (77.1%). Clinicians diagnosed malaria in 63.8% of patients. Malaria parasites were identified in blood film samples from 24.2% (95% CI: 19.6, 29.5). This is double the parasite prevalence rate of 10.7% (95% CI: 8.6, 13.1) obtained from a household survey of 1004 healthy individuals selected from these villages at the same time. It is not significantly lower than the prevalence observed among 880 clients presenting with fever at health facilities in the district: 29.7% (95% CI: 23.0, 37.3). The prevalence of malaria parasitemia among children younger than 5 years whose families sought fever treatment from drug stores (42.1%; 95% CI: 31.4, 53.5) was equal to that of children presenting with fever at health facilities (42.5%; 95% CI: 25.0, 62.2). CONCLUSIONS: Currently, drug store clients do not obtain malaria-specific treatment in the majority of cases where it might be warranted. Parasitological findings indicate that drug store clients, especially children, are as likely to be infected with malaria as patients seeking care for similar illnesses at health facilities. Drug stores may be attractive partners for policy makers eager to engage the private retail sector in expanding coverage of malaria treatment.     

'To help them is to educate them': power and pedagogy in the prevention and treatment of malaria in Tanzania

OBJECTIVES: Acknowledging that mothers are often the primary caregivers at the household level, malaria control efforts have emphasized educating women in its early recognition. This fails to consider the context in which knowledge will be transformed into action, as women lack decision-making responsibility and financial resources. We examine the knowledge and power dynamics of provider-patient interactions and the implications for malaria treatment of educating mothers during consultations. METHODS: We conducted in-depth interviews in Tanga, Tanzania, with 79 household participants over 2 years to explore knowledge and perceptions of febrile illness, its treatment and prevention. We also interviewed 55 clinicians at government and private healthcare facilities about their patients' knowledge and treatment-seeking behaviour. We analysed our data using a grounded theory approach. RESULTS: Informants had good knowledge of malaria aetiology, symptoms and treatment. Healthcare workers reported that mothers were able to give them sufficient information about their child for accurate diagnosis. However, health staff continued to see mothers who present 'late' as uneducated, intellectually incapable and lazy. Whilst evidence shows that decisions about treatment do not rest with mothers, but with male family members, it is women who continue to be blamed and targeted by health education. CONCLUSIONS: Aggressive didactic teaching methods used by health staff may be disempowering those already equipped with knowledge, yet unable to control treatment decisions within the household. This may lead to further delays in presentation at a healthcare facility. We propose a rethinking of health education that is context-sensitive, acknowledges class and gendered power relations, and targets men as well as women.     

男性性病患者延迟就诊和性伴侣通知现况及影响因素的研究

目的　了解男性性病患者延迟就诊和性伴侣通知的现状及影响因素。方法　在 4家性病门诊对男性初诊患者进行横断面研究。结果　在 4 0 6例中 ,80 %的人感受到由性病引起的羞辱 ,2 8%的病人在发现症状 >1周才就医 ,4 0 %的病人在自感症状期内仍发生性行为。羞辱感和延迟就诊之间不存在明显的联系。 77%的已婚患者不愿意告诉妻子自己感染了性病。有羞辱感的病人更不愿意告诉妻子自己的病情 (OR =0 4 4 ;95 %CI:0 2 1～0 85 )。结论　需要开展包括健康咨询在内的预防措施 ,以减少病人的羞辱感 ,提高及时就诊率和鼓励性伴侣通知。     

Diagnostic accuracy and case management of clinical malaria in the primary health services of a rural area in south-eastern Tanzania

Malaria control continues to rely on the diagnosis and prompt treatment of both suspected and confirmed cases through the health care structures. In south-eastern Tanzania malaria is one of the leading causes of morbidity and mortality. The absence of microscopic examination in most of the health facilities implies that health workers must rely on clinical suspicion to identify the need of treatment for malaria. Of 1558 randomly selected paediatric consultations at peripheral health facilities throughout Kilombero District, 41.1% were diagnosed by the attending health worker as clinical malaria cases and 42.5% prescribed an antimalarial. According to our malaria case definition of fever or history of fever with asexual falciparum parasitaemia of any density, 25.5% of all children attending the health services had malaria. This yielded a sensitivity of 70.4% (IC95% = 65.9-74.8%) and a specificity of 68.9% (IC95% = 66.2-71.5%). Accordingly, 30.4% of confirmed cases left with no antimalarial treatment. Among malaria-diagnosed patients, 10% were underdosed and 10.5% were overdosed. In this area, as in many African rural areas, the low diagnostic accuracy may imply that the burden of malaria cases may be overestimated. Greater emphasis on the functioning and quality of basic health services in rural endemic areas is required if improved case management of malaria is to help roll back this scourge.     

上海市金山区居民和中小学生疟疾防治知识知晓情况分析

目的了解上海市金山区居民和小学生疟疾防治知识知晓情况,评估当地消除疟疾期间健康教育成效。方 法2010年和2014年,在金山区分别采取分层抽样和整群抽样等方法,抽取3个行政村、1所中学、1所小学,对其中15 岁以上的居民和学校学生进行问卷调查,了解该区消除疟疾前后居民及学生的疟疾防治知识知晓率情况。结果2010 年基线调查时,人群疟疾防治知识总知晓率为74.22%,居民和中小学生分别为75.68%、61.86%、72.20%;男、女知晓率差 异无统计学意义（ χ2 = 1.755,P ＞ 0.05）,居民知晓率高于中小学生（ χ2 = 59.838,P ＜0.01）;2010-2014年开展了一系列 有关疟疾防治知识的健康教育。2014年终期考核调查时,人群疟疾总知晓率为96.03%,居民和中小学生分别为92.28%、 98.59%、99.49%,中小学生知晓率明显高于居民（χ2 = 275.794,P < 0.01）。结论金山区通过健康教育课和社区宣传,提 高了辖区居民疟疾防治知识知晓率,达到了消除疟疾评估要求。     

The effects of social support and education interventions on health care costs

Objective . To determine whether experimentally developed social support and education about appropriate use of the health care system decrease health care costs without negatively affecting health status. Method . Three hundred sixty-three health maintenance organization members with osteoarthritis were randomly assigned to 1 of 3 intervention groups or to a control group. Health status and health care use were assessed upon entering the study, and after 1 year and 2 years. Results . A savings of $1, 1561 participant/year was obtained when health care costs of the experimental groups were compared with those of the control group. Production or implementation costs were least for the social support intervention. The nearly equal effects of the 3 interventions on health care costs make implementation costs the primary focus when deciding which intervention to use. Conclusion . We believe that the social support treatment is the most cost-effective intervention.     

Social and cultural factors affecting rates of regular retreatment of mosquito nets with insecticide in Bagamoyo District, Tanzania

Insecticide-treated mosquito nets have an impact on mortality and morbidity in young children under controlled conditions. When integrated into larger control programs, there is the danger that rates of regular retreatment of the nets with insecticide will drop, greatly limiting their effectiveness as a public health intervention. In Bagamoyo District, Tanzania, rates of retreatment dropped significantly when payment for the insecticide was introduced. A series of neighbourhood (hamlet) meetings were held in all study villages to discuss people's concerns about the insecticide and ways to increase rates of retreatment. Although changes were made in the procedure for retreatment, rates of retreatment remained lower than expected and showed marked variation within as well as between villages. We then conducted unstructured key informant interviews as well as informal discussions in a village with strong variation between different sectors of the village in rates of retreatment. While logistical problems were most frequently cited as reasons not to bring nets for retreatment, political and social divisions within the community provided a better explanation. This is borne out by the low response to rearrangements in logistics which made retreating the nets significantly easier for households, and the higher response when changes were made in the channels of communication as well as the logistic features. It is clearly more difficult for villagers to appreciate the benefits of the insecticide than those of the nets. Great emphasis needs to be placed on the insecticide and its beneficial effects from the outset for any large-scale programme to be sustainable.     

The effects of social support and education on health care costs after three years

Objective . To determine whether experimentally developed social support, education about appropriate use of the health care system, and their combination are effective in reducing health care costs for people with osteoarthritis at a 3-year followup assessment. Method . Three hundred sixty-three health maintenance organization members with osteoarthritis were randomly assigned to 1 of 3 intervention groups or to a control group. Two hundred fifty-six participants completed the 3-year assessment. Health status and health care use were assessed upon entering the study, and after 1, 2, and 3 years. Results . Health care costs in the combined experimental groups were lower than those in the control group by $1,279/participant/year in year 3. There were no significant changes in health status between participants' entry into the study and the year 3 assessment. The 3 interventions had nearly equal effects on health status and health care costs. Implementation costs were least for the social support intervention, but the group that combined education and social support had less attrition and greater persistence. Conclusion . Interventions that target appropriate use of the health care system can be highly costeffective without adversely affecting health status.     

Physical symptoms as a predictor of health care use and mortality among older adults

PURPOSE: To describe the patterns of physical symptoms in older adults and to examine the validity of symptoms in predicting hospitalization and mortality. SUBJECTS AND METHODS: Adults aged 60 years and older (N=3498) who completed screening for self-reported symptoms at routine primary care visits. Self-reported symptoms were collected using an abbreviated PRIME-MD screening instrument. Clinical characteristics, hospitalization, and mortality in the year following screening were measured using data taken from a comprehensive electronic medical record. RESULTS: The mean patient age was 69 years, 69% were women, and 56% were African-American. A majority (51%) of respondents characterized their health as fair or poor. The most commonly reported symptoms were musculoskeletal pain (65%), fatigue (55%), back pain (45%), shortness of breath (41%), and difficulty sleeping (38%). A summary score of physical symptoms (range 0-12) was a significant independent predictor of future hospitalization and death even when controlling for clinical characteristics, chronic medical conditions, self-rated health, and affective symptoms. Disease-specific symptoms were more common among patients diagnosed with the specific condition but there was also a substantial background prevalence of these symptoms. CONCLUSION: Physical symptoms are highly prevalent in older primary care patients and predict hospitalization and mortality at one year. Future work is needed to determine how to target symptoms as a potential mechanism to reduce health care use and mortality.     

Costs of tuberculosis for households and health care providers in Dar es Salaam, Tanzania

OBJECTIVE: To assess the costs of tuberculosis at household level in Dar es Salaam and to compare them with the provider costs of the national tuberculosis control programme. DESIGN: Tuberculosis patients were found by active case searching within a routine census in three areas of Dar es Salaam, and by examining records for residents already receiving treatment. Costs at household level were evaluated through a cross-sectional household survey. RESULTS: One hundred and ninety-one tuberculosis cases were included in the survey. With treatment periods of 8 to 12 months, extrapolated average costs of a period of illness to patients and their families were as follows: US 2 dollars for examination and laboratory costs, between US 17 dollars and US 50 dollars for consultation and drugs, less than US 1 dollar for hospitalization and between US 13 dollars and US 20 dollars for transport. The analysis revealed high costs due to inability to work, ranging from US 154 dollars to US 1384 dollars. These data were compared with the operation costs of the tuberculosis programme and proved to comprise 68% to 94% of total costs. CONCLUSIONS: For patients and their families, tuberculosis implies three main types of cost: drugs, transportation and, most importantly, financial loss due to inability to work. They represent around two thirds of total cost and are a high economic burden for households, in particular those with a low-income. While assessing tuberculosis control strategies such as direct case finding at home, it is therefore important to also include costs incurred at household level.     

Factors influencing decision-making by social care and health sector professionals in cases of elder financial abuse

This study aimed to identify the factors that have the greatest influence on UK social care and health sector professionals’ certainty that an older person is being financially abused, their likelihood of intervention, and the type of action most likely to be taken. A factorial survey approach, applying a fractional factorial design, was used. Health and social care professionals (n = 152) viewed a single sample of 50 elder financial abuse case vignettes; the vignettes contained seven pieces of information (factors). Following multiple regression analysis, incremental F tests were used to compare the impact of each factor on judgements. Factors that had a significant influence on judgements of certainty that financial abuse was occurring included the older person’s mental capacity and the nature of the financial problem suspected. Mental capacity accounted for more than twice the variance in likelihood of action than the type of financial problem. Participants from social care were more likely to act and chose more actions compared to health sector participants. The results are discussed in relation to a bystander intervention model. The impact of the older person’s mental capacity on decision-making suggests the need for training to ensure action is also taken in cases where older people have full mental capacity and are being abused. Training also needs to highlight the more subtle types of financial abuse, the types that appear not to lead to certainty or action.     

Unheard voices: complaint patterns of older persons in the health care system

To examine the patterns and prevalence of complaints about health services among older clients of Health Maintenance Organizations (HMOs), explore demographic correlates, and compare results with the patterns in the younger population. Primary data were collected from the responses of subjects who participated in two national phone surveys, conducted in Israel over a period of 2 years. The final sample included 372 participants aged 65 and older, and 796 younger persons, who believed they had reasons to complain about their HMO. Of the 372 participants with cause to complain, only 23% had actually complained. Subjects who were 75-years-old and above, with below-average income, had 2.5 times higher probability for not complaining than people under 65. No statistically significant differences were found between the older participants and younger participants regarding the reasons for complaints or the procedures for making them. Recommendations are made for the recognition of older persons as a unique group within the health care system and for developing organizational mechanisms for capturing their unheard voices by HMOs.