Oscar Mukasa

Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania.

BACKGROUND Insecticide-treated nets have proven efficacy as a malaria-control tool in Africa. However, the transition from efficacy to effectiveness cannot be taken for granted. We assessed coverage and the effect on child survival of a large-scale social marketing programme for insecticide-treated nets in two rural districts of southern Tanzania with high perennial malaria transmission. METHODS Socially marketed insecticide-treated nets were introduced step-wise over a 2-year period from May, 1997, in a population of 480000 people. Cross-sectional coverage surveys were done at baseline and after 1, 2, and 3 years. A demographic surveillance system (DSS) was set up in an area of 60000 people to record population, births, and deaths. Within the DSS area, the effect of insecticide-treated nets on child survival was assessed by a case-control approach. Cases were deaths in children aged between 1 month and 4 years. Four controls for each case were chosen from the DSS database. Use of insecticide-treated nets and potential confounding factors were assessed by questionnaire. Individual effectiveness estimates from the case-control study were combined with coverage to estimate community effectiveness. FINDINGS Insecticide-treated net coverage of infants in the DSS area rose from less than 10% at baseline to more than 50% 3 years later. Insecticide-treated nets were associated with a 27% increase in survival in children aged 1 month to 4 years (95% CI 3-45). Coverage in such children was higher in areas with longer access to the programme. The modest average coverage achieved by 1999 in the two districts (18% in children younger than 5 years) suggests that insecticide-treated nets prevented 1 in 20 child deaths at that time. INTERPRETATION Social marketing of insecticide-treated nets has great potential for effective malaria control in rural African settings.

Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania

BACKGROUND The Integrated Management of Childhood Illness (IMCI) strategy is designed to address major causes of child mortality at the levels of community, health facility, and health system. We assessed the effectiveness of facility-based IMCI in rural Tanzania. METHODS We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI, from 1997 to 2002, in a non-randomised study. We assessed quality of case-management for childrens illness, drug and vaccine availability, and supervision involving case-management, through a health-facility survey in 2000. Household surveys were used to assess child-health indicators in 1999 and 2002. Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000. Further information on contextual factors was gathered through interviews and record review. The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national, district, facility, and household levels. FINDINGS During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI -7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3.8 fewer deaths per 1000 child-years. Contextual factors, such as use of mosquito nets, all favoured the comparison districts. Costs of childrens health care with IMCI were similar to or lower than those for case-management without IMCI. INTERPRETATION Our findings indicate that facility-based IMCI is good value for money, and support widespread implementation in the context of health-sector reform, basket funding, good facility access, and high utilisation of health facilities.

Impact on malaria morbidity of a programme supplying insecticide treated nets in children aged under 2 years in Tanzania: community cross sectional study

Abstract Objective: To assess the impact of a social marketing programme for distributing nets treated with insecticide on malarial parasitaemia and anaemia in very young children in an area of high malaria transmission. Design: Community cross sectional study. Annual, cross sectional data were collected at the beginning of the social marketing campaign (1997) and the subsequent two years. Net ownership and other risk and confounding factors were assessed with a questionnaire. Blood samples were taken from the children to assess prevalence of parasitaemia and haemoglobin levels. Setting: 18 villages in the Kilombero and Ulanga districts of southwestern Tanzania. Participants: A random sample of children aged under 2 years. Main outcome measures: The presence of any parasitaemia in the peripheral blood sample and the presence of anaemia (classified as a haemoglobin level of ≤80 g/l). Results: Ownership of nets increased rapidly (treated or not treated nets: from 58% to 83%; treated nets: from 10% to 61%). The mean haemoglobin level rose from 80 g/l to 89 g/l in the study children in the successive surveys. Overall, the prevalence of anaemia in the study population decreased from 49% to 26% in the two years studied. Treated nets had a protective efficacy of 62% (95% confidence interval 38% to 77%) on the prevalence of parasitaemia and of 63% (27% to 82%) on anaemia. Conclusions: These results show that nets treated with insecticide have a substantial impact on morbidity when distributed in a public health setting.

The use of personal digital assistants for data entry at the point of collection in a large household survey in southern Tanzania

BackgroundSurvey data are traditionally collected using pen-and-paper, with double data entry, comparison of entries and reconciliation of discrepancies before data cleaning can commence. We used Personal Digital Assistants (PDAs) for data entry at the point of collection, to save time and enhance the quality of data in a survey of over 21,000 scattered rural households in southern Tanzania.MethodsPendragon Forms 4.0 software was used to develop a modular questionnaire designed to record information on household residents, birth histories, child health and health-seeking behaviour. The questionnaire was loaded onto Palm m130 PDAs with 8 Mb RAM. One hundred and twenty interviewers, the vast majority with no more than four years of secondary education and very few with any prior computer experience, were trained to interview using the PDAs. The 13 survey teams, each with a supervisor, laptop and a four-wheel drive vehicle, were supported by two back-up vehicles during the two months of field activities. PDAs and laptop computers were charged using solar and in-car chargers.Logical checks were performed and skip patterns taken care of at the time of data entry. Data records could not be edited after leaving each household, to ensure the integrity of the data from each interview. Data were downloaded to the laptop computers and daily summary reports produced to evaluate the completeness of data collection. Data were backed up at three levels: (i) at the end of every module, data were backed up onto storage cards in the PDA; (ii) at the end of every day, data were downloaded to laptop computers; and (iii) a compact disc (CD) was made of each teams data each day.A small group of interviewees from the community, as well as supervisors and interviewers, were asked about their attitudes to the use of PDAs.ResultsFollowing two weeks of training and piloting, data were collected from 21,600 households (83,346 individuals) over a seven-week period in July-August 2004. No PDA-related problems or data loss were encountered.Fieldwork ended on 26 August 2004, the full dataset was available on a CD within 24 hours and the results of initial analyses were presented to district authorities on 28 August. Data completeness was over 99%.The PDAs were well accepted by both interviewees and interviewers.ConclusionThe use of PDAs eliminated the usual time-consuming and error-prone process of data entry and validation. PDAs are a promising tool for field research in Africa.

Introducing insecticide‐treated nets in the Kilombero Valley, Tanzania: the relevance of local knowledge and practice for an Information, Education and Communication (IEC) campaign

Since 1997 the WHO has been recommending an integrative strategy to combat malaria including new medicines, vaccines, improvements of health care systems and insecticide‐treated nets (ITNs). After successful controlled trials with ITNs in the past decade, large‐scale interventions and research now focus on operational issues of distribution and financing. In developing a social marketing approach in the Kilombero Valley in south‐east Tanzania in 1996, a combination of qualitative and quantitative methods was employed to investigate local knowledge and practice relating to malaria. The findings show that the biomedical concept of malaria overlaps with several local illness concepts, one of which is called maleria and refers to mild malaria. Most respondents linked maleria to mosquitoes (76%) and already used mosquito nets (52%). But local understandings of severe malaria differed from the biomedical concept and were not linked to mosquitoes or malaria. A social marketing strategy to promote ITNs was developed on the basis of these findings, which reinforced public health messages and linked them with nets and insecticide. Although we did not directly evaluate the impact of promotional activities, the sharp rise in ownership and use of ITNs by the population (from 10 to > 50%) suggests that they contributed significantly to the success of the programme. Local knowledge and practice is highly relevant for social marketing strategies of ITNs.

Socially marketed insecticide-treated nets improve malaria and anaemia in pregnancy in southern Tanzania.

OBJECTIVES To study the uptake of socially marketed insecticide‐treated nets (ITNs) and their impact on malaria and anaemia in pregnancy; and to report on a discount voucher system which aimed to increase coverage in pregnancy.

Risk factors for child mortality in rural Tanzania.

We conducted a community‐based nested case–control study of post‐neonatal deaths in children under 5 years, with frequency‐matched controls chosen from a full sampling frame provided by a demographic surveillance system. Using a questionnaire, we studied treatment‐seeking behaviour in fatal illness. In cases and controls we investigated demographic and socio‐economic factors, health‐seeking behaviour, the household environment including accessibility of health care, and individual child care factors. Half of the deaths (215/427) occurred at home, and one‐third (146/427) at a health facility. Three‐quarters (330/427) of the children who died had received treatment from a health facility in their fatal illness. Four independent risk factors for death were identified which were each associated with more than 5% of child mortality: not being carried on the back while the mother cooked [odds ratio (OR) 1.6: 1.3, 2.0], poor maternal education (OR 1.4: 95% CI 1.0, 1.9 for those with no education compared with those with complete primary education), lack of exclusive breastfeeding in the first 3 months of life (OR 1.4: 1.1, 1.8), and low socio‐economic status (OR 1.3: 1.0, 1.6). The majority of children who died had sought treatment at a health facility during the fatal illness, which would lend support to interventions to improve case‐management. The association between mothers carrying their children and child survival was unexpected and deserves further investigation.

Anaemia in pregnancy and infant mortality in Tanzania

Tanzania is an area of moderate to high risk for severe anaemia during pregnancy. There is extensive literature examining the consequences of severe anaemia for pregnant women, but the impact this problem has on their infants in malaria‐endemic regions is poorly understood. Between 1999 and 2001 we used a demographic surveillance system in the Kilombero Valley, Tanzania to link morbidity and socio‐economic status data for 301 pregnant women to the survival of 365 days of their singleton babies, looking for evidence of an association between infant mortality and maternal haemoglobin (Hb). The hazards ratio for infant mortality amongst women who had been severely anaemic in pregnancy (Hb < 8 g/dl) was 3.1 [95% confidence interval (CI) 1.1–9.1, P = 0.04] compared with women with Hb above this level after controlling for other factors. Prevention of anaemia in pregnancy may lead to an improvement in infant survival.

Anaemia during pregnancy in southern Tanzania.

Abstract Anaemia in pregnancy is associated with maternal morbidity and mortality and is a risk factor for low birth-weight. Of 507 pregnant women recruited in a community, cross-sectional study in southern Tanzania, 11% were severely anaemic (<8g haemoglobin/dl). High malarial parasitaemia [odds ratio (OR)=2.3] and iron deficiency (OR=2.4) were independent determinants of anaemia. Never having been married (OR=2.9) was the most important socio-economic predictor of severe anaemia. A subject recruited in the late dry season was six times more likely to be severely anaemic than a subject recruited in the early dry season. Compared with the women who were not identified as severely anaemic, the women with severe anaemia were more likely to present at mother-and-child-health (MCH) clinics early in the pregnancy, to seek medical attention beyond the MCH clinics, and to report concerns about their own health. Pregnancy-related food taboos in the study area principally restrict the consumption of fish and meat. Effective anti-malaria and iron-supplementation interventions are available but are not currently in place; improvements in the mechanisms for the delivery of such interventions are urgently required. Additionally, opportunities for contacting the target groups beyond the clinic environment need to be developed.

Spatial Effects of the Social Marketing of Insecticide-Treated Nets on Malaria Morbidity.

Randomized controlled trials have shown that insecticide‐treated nets (ITNs) have an impact on both malaria morbidity and mortality. Uniformly high coverage of ITNs characterized these trials and this resulted in some protection of nearby non‐users of ITNs. We have now assessed the coverage, distribution pattern and resultant spatial effects in one village in Tanzania where ITNs were distributed in a social marketing programme. The prevalence of parasitaemia, mild anaemia (Hb <11 g/dl) and moderate/severe anaemia (Hb <8 g/dl) in children under five was assessed cross‐sectionally. Data on ownership of ITNs were collected and inhabitants’ houses were mapped. One year after the start of the social marketing programme, 52% of the children were using a net which had been treated at least once. The ITNs were rather homogeneously distributed throughout the village at an average density of about 118 ITNs per thousand population. There was no evidence of a pattern in the distribution of parasitaemia and anaemia cases, but children living in areas of moderately high ITN coverage were about half as likely to have moderate/severe anaemia (OR 0.5, 95% CI: 0.2, 0.9) and had lower prevalence of splenomegaly, irrespective of their net use. No protective effects of coverage were found for prevalence of mild anaemia nor for parasitaemia. The use of untreated nets had neither coverage nor short distance effects. More efforts should be made to ensure high coverage in ITNs programmes to achieve maximum benefit.