Behavioural objectives for medical auxiliary training in Tanzania: 9 years'' experience with an education model

The behavioural objectives model of curriculum design was introduced to the Medical Auxiliary Training Sector in Tanzania during the 1970s while problems of expansion, novelty and economic stress were abundant. Experience in a relatively privileged school, Rural Medical Training Centre, Sengerema, shows that the model did not result in more practical teaching time, due mainly to various constraints. The students did, however, appreciate the 'sharing of objectives' at the onset of a teaching block as a great help for their (theoretical) learning. Due to unfamiliarity of teachers with new subject matter related to primary health care, the model has failed thus far to result in a relevant practical course in public health promotion. A more problem-oriented approach to curriculum development is recommended.     

Imbalances in the health labour force: an assessment using data from three national health facility surveys

Accurate knowledge of the characteristics of the health labour force that can affect health care production is of critical importance to health planners and policymakers. This study uses health facility survey data to examine characteristics of the primary health care labour force in Nicaragua, Tanzania and Bangladesh. The characteristics examined are those that are likely to affect service provision, including urban/rural distribution, demographic characteristics, and experience and in-service training, for three types of providers (physicians, nurses and auxiliary nurses). The profiles suggest a pattern of urban/rural imbalances in Nicaragua and Tanzania. The Bangladesh facility survey did not include hospitals, thereby making concrete conclusions on the supply and distribution of providers difficult to make. Multivariate logistic regressions are used to assess the relationship between the urban/rural placement of providers by health need, population demand and facility characteristics. Health need, as measured by child mortality rates, does not have a significant association with the placement of providers in either country, unlike population size and annual growth rates. The mean number of years providers have worked at a facility is significantly associated with a decreased likelihood of rural placement for the three types of providers in Nicaragua. The mean age and percentage of female providers at each facility has a negative association with the placement of rural providers in Tanzania. The use of health facility data to profile the health care labour force is also discussed.     

"I thought it was only ordinary fever!" cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania

Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria.     

Difference in Blood Pressure Readings with Mercury and Automated Devices: Impact on Hypertension Prevalence Estimates in Dar es Salaam, Tanzania

Objectives

(1) To compare blood pressure (BP) readings with an automated arm cuff oscillometric device (AutoBP) to readings with a mercury sphygmomanometer (HgBP) and (2) to evaluate the impact on the prevalence of hypertension (HBP) in a population-based survey.

Methods

(1) In a convenience sample (“Comparison Study”), we measured?BP with both AutoBP (Visomat® OZ2) and?HgBP and we modeled BP difference (ΔBP = HgBP?AutoBP) with multiple regression analysis. (2) Using ΔBP, we calculated HgBP in a survey previously conducted in Dar es Salaam (“Population Survey”) in which BP was measured with the automatic device Visomat® OZ2 and we compared the prevalence of HBP (≥140/90 mmHg or treatment).

Results

In the Comparison Study (404 subjects aged 25–64), systolic/diastolic BP was higher by 4.4/4.7 mmHg (SE: 0.4/0.3) with HgBP than AutoBP. The prevalence of HBP was 42% with HgBP and 36% with AutoBP (relative difference of 14%). ΔBP was associated with age, BP and arm circumference. In the Population Survey (9.254 subjects aged 25–64), the prevalence of HBP was 17% with calculated HgBP and 14% with AutoBP (relative difference of 20%).

Conclusion

A small systematic bias in BP readings between two different devices had large impact on hypertension prevalence estimates. This suggests that automated devices used in epidemiological studies should be validated with particular care.     

Schistosoma mansoni in pregnancy and associations with anaemia in northwest Tanzania

Schistosomiasis among pregnant women has been inadequately investigated. In order to determine the importance of Schistosoma mansoni in this subgroup, we conducted a cross-sectional survey of 972 women in Tanzania and investigated the prevalence of Schistosoma mansoni, hookworm and malaria and their associations with anaemia. Overall, 63.5% of women were infected with S. mansoni, with prevalence highest among younger women and decreasing with increasing age. The prevalence of hookworm was 56.3%, and 16.4% of women had malaria parasitaemia. Overall, 66.4% of women were anaemic. Increased risk of anaemia was associated with heavy infection with S. mansoni but not hookworm or Plasmodium falciparum parasitaemia.     

Mosquito nets and the poor: can social marketing redress inequities in access?

Treated mosquito nets are a practical malaria control tool. However, implementation of efficient delivery mechanisms remains a challenge. We investigated whether social marketing of treated mosquito nets results in decreased equity in rural Tanzania, through household surveys before the start of a social marketing programme and 3 years later. About 12,000 household heads were asked about ownership of nets and other assets including a tin roof, radio, or bicycle. A socio-economic status score was developed for each household. Net ownership was calculated for households in each quintile of this score, from poorest to least poor. In 1997, about 20% of the poorest households and over 60% of the least poor households owned a mosquito net. Three years later, more than half of the poorest households owned a net, as did over 90% of the least poor: the ratio of net ownership among the poorest to least poor increased from 0.3 in 1997 to 0.6 in 2000. Social marketing in the presence of an active private sector for nets was associated with increased equity.     

A 22 year follow-up study on lymphatic filariasis in Tanzania: analysis of immunological responsiveness in relation to long-term infection pattern

Seventy-one individuals who had been examined for Wuchereria bancrofti microfilaraemia in 1975, some of whom had been offered mass treatment with diethylcarbamazine (DEC) in subsequent years, were re-identified in 1996 and examined for microfilaraemia, circulating filarial antigenemia and cellular and humoral immunoresponsiveness to crude antigen homogenates prepared from Brugia pahangi parasite material. 85.9% of the study individuals had the same infection status in 1975 and 1996, suggesting strong predisposition to infection over extended periods of time. IL-4, IL-5 and IFNγ responses were associated with being infection negative in 1996 whereas IL-10 responses were associated with being infection positive. Similarly, specific IgG3 and IgE were strongly associated with being infection negative in 1996 whereas specific IgG4, and thus high IgG4/IgE ratios, were strongly associated with being infection positive. Intermediary levels of mainly IL-5, IFNγ and PBMC stimulation indices were observed for study individuals who changed from being infection positive in 1975 to infection negative in 1996, or vice versa, suggesting a transition in cellular immunoresponsiveness associated with changing infection status. The findings suggest that some people are more disposed to infection with bancroftian filariasis than others and that this is largely unaffected by treatment with DEC. The findings also suggest that specific cellular and antibody responses are more related to current than past infection status, and that IL-4, IL-5, IFNγ, specific IgG3 and IgE are associated with parasite clearance, whereas IL-10 and specific IgG4 are associated with parasite protection.     

An Eye for Inequality: How Trachoma Relates to Poverty in Tanzania and Vietnam

Purpose: An important challenge for trachoma control strategies is to break the circle of poverty, poor hygiene and poor health by bringing its benefits to the poor. This article aims to assess to what extent trachoma is a disease of the poor, and trachoma services reach the poor in Tanzania and Vietnam. Methods: Individual level data on trachoma prevalence (active trachoma and trichiasis) and utilization of trachoma-related services were collected in both countries in 2004. Prevalence data were also available for Vietnam in 2001. We used household level data to construct an asset index as our living standards measure. Next, we related trachoma prevalence and service use to living standards, and used concentration indices to summarize and test the degree of inequality. Results: Trachoma prevalence was higher among the poorest groups in Tanzania. No such relation could be established in Vietnam where prevalence declined over the period 2001–2004 and particularly so among the least poor. Antibiotics were used more by the poorest in Tanzania and by the less poor in Vietnam. In both countries, there was no unequivocal pattern for the relation between living standards and the use of trachoma services. Conclusions: Trachoma is found to be a disease of the poorest in Tanzania, but not in Vietnam. In the latter country there are indications that district characteristics have an important impact on trachoma prevalence. The higher use of antibiotics among the better-off in Vietnam may have contributed to their larger decline in active trachoma prevalence between 2001 and 2004 compared to the poorer segments.