David Whiting

Hypertension prevalence and care in an urban and rural area of Tanzania

Objective To describe the prevalence, detection, treatment and control of hypertension in an urban and rural area of Tanzania. Design Two linked cross-sectional population-based surveys Setting A middle-income urban district of Dar es Salaam (Ilala) and a village in the relatively prosperous rural area of Kilimanjaro (Shari) Participants Seven hundred and seventy adults (> 15 years) in Ilala and 928 adults in Shari were studied Results Hypertension prevalence (blood pressure >140 and/or 90 mmHg, or known hypertensives receiving antihypertensive treatment) was 30% (95% confidence interval, 25.1–34.9%) in men and 28.6% (24.3–32.9%) in women in Ilala, and 32.2% (27.7–6.7%) in men and 31.5% (27.8–35.2%) in women in Shari. Age-standardized hypertension (to the New World Population) prevalence was 37.3% (32.2–42.5%) among men and 39.1% (34.2–44.0%) in women in Illala, and 26.3% (22.4–30.4%) in men and 27.4% (24.4–30.4%) in women in Shari. In both areas, just under 20% of hypertensive subjects were aware of their diagnosis, approximately 10% reported receiving treatment and less than 1% were controlled (blood pressure < 140/90 mmHg). Hypertensive subjects were older, had greater body mass indices and waist: hip ratios, and had more risk factors for hypertension and its complications (smoking, heavy alcohol consumption, physical inactivity, obesity and diabetes) than nonhypertensives. Conclusions There is a high prevalence of hypertension in rural and urban areas of Tanzania, with low levels of detection, treatment and control. This demonstrates the need for cost-effective strategies for primary prevention, detection and treatment of hypertension and the growing public health challenge of non-communicable diseases in Sub-Saharan Africa.

Stroke mortality in urban and rural Tanzania

Summary Background Most data for stroke mortality in sub-Saharan Africa are hospital based. We aimed to establish the contribution of cerebrovascular disease to all-cause mortality and cerebrovascular disease mortality rates in adults aged 15 years or more in one urban and two rural areas of Tanzania. Methods Regular censuses of the three surveillance populations consisting of 307 820 people (125 932 aged below 15 years and 181 888 aged 15 or more) were undertaken with prospective monitoring of all deaths arising in these populations between June 1, 1992 and May 31, 1995. Verbal autopsies were completed with relatives or carers of the deceased to assess, when possible, the cause of death. Findings During the 3-year observation period 11 975 deaths were recorded in the three surveillance areas, of which 7629 (64%) were in adults aged 15 years or more (4088 [54%] of these in men and 3541 [46%] in women). In the adults, 421 (5·5%) of the deaths were attributed to cerebrovascular disease, 225 (53%) of these in men and 196 (47%) in women. The yearly age-adjusted rates per 100 000 in the 15–64 year age group for the three project areas (urban, fairly prosperous rural, and poor rural, respectively) were 65 (95% Cl 39–90), 44 (31–56), and 35 (22–48) for men, and 88 (48–128), 33 (22–43), and 27 (16–38) for women, as compared with the England and Wales (1993) rates of 10·8 (10·0–11·6) for men and 8·6 (7·9–9·3) for women. Interpretation We postulate that the high rates in Tanzania were due to untreated hypertension. Our study assessed mortality over a single time period and therefore it is not posible to comment on trends with time. However, ageing of the population is likely to lead to a very large increase in mortality from stroke in the future.

Rural and urban differences in diabetes prevalence in Tanzania: the role of obesity, physical inactivity and urban living

A population-based survey in 1996 and 1997 of 770 adults (aged > or = 15 years) from an urban district of Dares Salaam and 928 from a village in rural Kilimanjaro district (Tanzania) revealed that the prevalence of diabetes, impaired fasting glucose (IFG), overweight, obesity, and physical inactivity was higher in the urban area for men and women. The difference between urban and rural prevalence of diabetes was 3.8 [1x1-6.5]% for men and 2x9 [0x8-4.9]% for women. For IFG, the difference was 2x8 [0x3-5x3]% for men and 3x9 [1x4-6x4]% for women; for overweight and obesity, the difference was 21.5 [15.8-27.1]% and 6.2 [3x5-8.9]% for men and 17x4 [11.5-23.3]% and 12.7 [8x5-16x8]% for women, respectively. The difference in prevalence of physical inactivity was 12x5 [7.0-18.3]% for men and 37.6 [31x9-43.3]% for women. For men with diabetes, the odds for being overweight, obese and having a large waist:hip ratio were 14.1, 5.3 and 12.5, respectively; for women the corresponding values were 9x0, 10x5 and 2x4 (the last not significant) with an attributable fraction for overweight between 64% and 69%. We conclude that diabetes prevalence is higher in the urban Tanzanian community and that this can be explained by differences in the prevalence of overweight. The avoidance of obesity in the adult population is likely to prevent increases in diabetes incidence in this population.

TEG and ROTEM: Technology and clinical applications

Initially described in 1948 by Hertert thromboelastography (TEG) provides a real‐time assessment of viscoelastic clot strength in whole blood. Rotational thromboelastometry (ROTEM) evolved from TEG technology and both devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated. Activation of clot formation can be initiated with both intrinsic (kaolin, ellagic acid) and extrinsic (tissue factor) activators. In addition, the independent contributions of platelets and fibrinogen to final clot strength can be assessed using added platelet inhibitors (abciximab and cytochalasin D). Increasingly, ROTEM and TEG analysis is being incorporated in vertical algorithms to diagnose and treat bleeding in high‐risk populations such as those undergoing cardiac surgery or suffering from blunt trauma. Some evidence suggests these algorithms might reduce transfusions, but further study is needed to assess patient outcomes. Am. J. Hematol. 89:228–232, 2014.

Outlook for survivors of childhood in sub-Saharan Africa: adult mortality in Tanzania. Adult Morbidity and Mortality Project.

Abstract Objective: To measure age and sex specific mortality in adults (15-59 years) in one urban and two rural areas of Tanzania. Design: Reporting of all deaths occurring between 1 June 1992 and 31 May 1995. Setting: Eight branches in Dar es Salaam (Tanzanias largest city), 59 villages in Morogoro rural district (a poor rural area), and 47 villages in Hai district (a more prosperous rural area). Subjects: 40304 adults in Dar es Salaam, 69964 in Hai, 50465 in Morogoro rural. Main outcome measures: Mortality and probability of death between 15 and 59 years of age (45Q15). Results: During the three year observation period a total of 4929 deaths were recorded in adults aged 15-59 years in all areas. Crude mortalities ranged from 6.1/1000/year for women in Hai to 15.9/1000/year for men in Morogoro rural. Age specific mortalities were up to 43 times higher than rates in England and Wales. Rates were higher in men at all ages in the two rural areas except in the age group 25 to 29 years in Hai and 20 to 34 years in Morogoro rural. In Dar es Salaam rates in men were higher only in the 40 to 59 year age group. The probability of death before age 60 of a 15 year old man (45Q15) was 47% in Dar es Salaam, 37% in Hai, and 58% in Morogoro; for women these figures were 45%, 26%, and 48%, respectively. (The average 45Q15s for men and women in established market economies are 15% and 7%, respectively.) Conclusion: Survivors of childhood in Tanzania continue to show high rates of mortality throughout adult life. As the health of adults is essential for the wellbeing of young and old there is an urgent need to develop policies that deal with the causes of adult mortality. Key messages Key messages Adult mortality is currently being measured in one urban and two rural areas of Tanzania Survivors of childhood continue to experience high mortality throughout adult life Mortality was generally higher in men but was higher in women aged 15 to 39 years in Dar es Salaam and in women aged 25 to 29 in the two rural areas While childhood mortality in sub-Saharan Africa remains a major problem, mortality in young adults may now be equally serious in many areas in the region and deserving of increased attention by the policy makers

Tobacco smoking in Tanzania, East Africa: Population based Smoking Prevalence Using Expired Alveolar Carbon Monoxide as a Validation Tool.

Objectives: To describe the prevalence of tobacco smoking in an urban East African population while using a simple validation procedure to examine the degree of under reporting in men and women. Design: A cross sectional population based study in adults (15 years and over) with sampling from a well maintained census register. Setting: Ilala Ilala, a middle income district of Dar es Salaam, Tanzania. Subjects: An age and sex stratified random sample of 973 men and women. Main outcome measures: Self reported smoking status with correction by exhaled alveolar carbon monoxide (EACO). Results: From the 605 participants (response rate 67.9%) age standardised (new world population) smoking prevalence, based on questionnaire and EACO, was 27.0% (95% confidence interval (CI) 20.8% to 33.2%) in males and 5.0% (95% CI 2.8% to 7.2%) in females. The age specific prevalence of smoking was highest in the age group 35–54 years (34.3%) for men and in the over 54 years group (16%) for women. Of those classified as smokers, 7.3% of men and 27.3% of women were reclassified as current smokers based on EACO (≥ 9 parts per million), after they had reported themselves to be an ex- or non-smoker in the questionnaire. Conclusions: The data suggest: (1) high rates of smoking among men in an urban area of East Africa; and (2) the importance of validating self reports of smoking status, particularly among women.

Validation of the Kiswahili version of the SF-36 Health Survey in a representative sample of an urban population in Tanzania

The objective of this study was to assess the validity of a Kiswahili translation of the SF-36 Health Survey (SF-36) among an urban population in Tanzania, using the method of known-groups validation. People were randomly selected from a demographic surveillance system in Dar es Salaam. The representative sample consisted of 3,802 adults (15 years and older). Health status differences were hypothesized among groups, who differed in sex, age, socio-economic status and self-reported morbidity. Mean SF-36 scale scores were calculated and compared using t-test and ANOVA. Women had significantly lower mean SF-36 scale scores (indicating worse health status) than men on all scales and scores were lower for older people than younger on all domains, as hypothesized. On five of the eight SF-36 scales, means were higher for people of higher socio-economic status compared to those of lower socio-economic status. People who reported an illness within the previous 2 weeks scored significantly lower on all scales compared to those who were healthy, as did people who said they had a disability or a chronic condition.

A Kiswahili version of the SF-36 Health Survey for use in Tanzania: translation and tests of scaling assumptions.

The objective of the study was to translate and adapt the SF-36 Health Survey for use in Tanzania and to test the psychometric properties of the Kiswahili SF-36. A cross-sectional study was conducted as part of a household survey of a representative sample of the adult population of Dar es Salaam, Tanzania. The IQOLA method of forward and backward translation was used to translate the SF-36 into Kiswahili. The translated questionnaire was administered by trained interviewers to 3,802 adults (50% women, mean (SD) age 31 (13) years, 50% married and 60% with primary education). Data quality and psychometric assumptions underlying the scoring of the eight SF-36 scales were evaluated for the entire sample and separately for the least educated subgroup (n=402), using multitrait scaling analysis. Forward and backward translation procedures resulted in a Kiswahili SF-36 that was considered conceptually equivalent to the US English SF-36. Data quality was excellent: only 1.2% of respondents were excluded because they answered less than half of the items for one or more scales; ninety percent of respondents answered mutually exclusive items consistently. Median item–scale correlations across the eight scales ranged from 0.47 to 0.81 for the entire sample. Median scaling success rates were 100% (range 87.5–100.0). The median internal consistency reliability of the eight scales for the entire sample was 0.81 (range 0.70–0.92). Floor effects were low and ceiling effects were high on five of the eight scales. Results for n=402 people without formal education did not differ substantially from those of the entire sample. The results of data quality and psychometric tests support the scoring of the eight scales using standard scoring algorithms. The Kiswahili translation of the SF-36 may be useful in estimating the health of people in Dar es Salaam. Evidence for the validity of the SF-36 for use in Tanzania needs to be accumulated.

Community-based monitoring of safe motherhood in the United Republic of Tanzania.

OBJECTIVE To examine the progress made towards the Safe Motherhood Initiative goals in three areas of the United Republic of Tanzania during the 1990s. METHODS Maternal mortality in the United Republic of Tanzania was monitored by sentinel demographic surveillance of more than 77,000 women of reproductive age, and by prospective monitoring of mortality in the following locations; an urban site; a wealthier rural district; and a poor rural district. The observation period for the rural districts was 1992-99 and 1993-99 for the urban site. FINDINGS During the period of observation, the proportion of deaths of women of reproductive age (15-49 years) due to maternal causes (PMDF) compared with all causes was between 0.063 and 0.095. Maternal mortality ratios (MMRatios) were 591-1099 and maternal mortality rates (MMRates; maternal deaths per 100,000 women aged 15-49 years) were 43.1-123.0. MMRatios in surveillance areas were substantially higher than estimates from official, facility-based statistics. In all areas, the MMRates in 1999 were substantially lower than at the start of surveillance (1992 for rural districts, 1993 for the urban area), although trends during the period were statistically significant at the 90% level only in the urban site. At the community level, an additional year of education for household heads was associated with a 62% lower maternal death rate, after controlling for community-level variables such as the proportion of home births and occupational class. CONCLUSION Educational level was a major predictor of declining MMRates. Even though rates may be decreasing, they remained high in the study areas. The use of sentinel registration areas may be a cost-effective and accurate way for developing countries to monitor mortality indicators and causes, including for maternal mortality.

Cost and results of information systems for health and poverty indicators in the United Republic of Tanzania

OBJECTIVE To examine the costs of complementary information generation activities in a resource-constrained setting and compare the costs and outputs of information subsystems that generate the statistics on poverty, health and survival required for monitoring, evaluation and reporting on health programmes in the United Republic of Tanzania. METHODS Nine systems used by four government agencies or ministries were assessed. Costs were calculated from budgets and expenditure data made available by information system managers. System coverage, quality assurance and information production were reviewed using questionnaires and interviews. Information production was characterized in terms of 38 key sociodemographic indicators required for national programme monitoring. FINDINGS In 2002-03 approximately US