Yohana Mashalla

Cement dust exposure and ventilatory function impairment: An exposure-response study

We investigated cumulative total cement dust exposure and ventilatory function impairment at a Portland cement factory in Tanzania. All 126 production workers were exposed. The control group comprised all 88 maintenance workers and 32 randomly chosen office workers. Exposed workers had significantly lower forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEF), FEV1/FVC, FVC%, FEV1% and PEF%, than controls adjusted for age, duration of employment, height, and pack-years. Cumulative total dust exposure was significantly associated with reduced FVC, forced expiratory volume in 1 second, and peak expiratory flow rate adjusted for age, height and pack-years. Cumulative total dust exposure more than 300 mg/m3 year versus lower than 100 mg/m3 years was significantly associated with increased risk of developing airflow limitation (odds ratio = 9.9). The current occupational exposure limit for total cement dust (10 mg/m3) appears to be too high to prevent respiratory health effects among cement workers.

Nutritional variation and cardiovascular risk factors in Tanzania--rural-urban difference.

OBJECTIVE To assess the relationship between dietary factors and cardiovascular (CVD) risk factors in middle-aged men and women, in urban, rural and pastoral settings in Tanzania. DESIGN Cross-sectional epidemiological study designed according to the protocol of the World Health Organisation (WHO) Cardiovascular Diseases and Alimentary Comparison (CARDIAC) study. SETTING Three centres in Tanzania, namely Dar es Salaam (urban), Handeni (rural) and Monduli (pastoral population). SUBJECTS The subjects, aged 47-57 years, were recruited randomly from administrative lists available from each centre. OUTCOME MEASURES Blood pressure (BP) was measured using a centrally calibrated automatic BP machine (Khi machine). Dietary history of the participants was obtained using a standard questionnaire designed on the basis of a seven-day recall system. Height, weight, serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDLC), haemoglobin A1c, sodium, potassium and magnesium were measured. RESULTS The prevalence of hypertension (BP > or = 140/90 mmHg or antihypertensive drug use), obesity (body mass index (BMI) > or = 30 kg/m2) and hypercholesterolaemia (TC > 5.2 mmol/l) were lowest in the rural area. Consumption of green vegetables, milk, coconut milk, meat, and fish varied significantly between the three areas. Important determinants for BP among men were BMI (p < 0.001), and salt intake (p < 0.05). Among women, TC (p < 0.05), age (p < 0.05), BMI (p < 0.001) and coconut milk consumption (p < 0.001) were important BP determinants. Salt intake was positively associated with systolic BP (SBP) and diastolic BP (DBP) in men but not among women (both SBP and DBP p < 0.05 respectively). Dietary determinants of serum TC were meat, fish and green vegetable consumption. CONCLUSION Differences in dietary habits contributed significantly to the urban-rural-pastoral variations in CVD risk pattern in Tanzania.

The relation of oxidative DNA damage to hypertension and other cardiovascular risk factors in Tanzania.

Objectives To clarify the mechanism of involvement of oxidative stress in hypertensives, we investigated the relationship between the marker of oxidative DNA damage, urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG), and cardiovascular risk factors, such as hypertension and serum glycosylated hemoglobin (HbA1c), among Tanzanians aged 46–58 years who were not on antihypertensive medication. Design and methods Sixty subjects (males/females, 28/32) were selected randomly from the subjects who completed a 24h urine collection in our epidemiological study at Dar es Salaam, Tanzania in 1998. The subjects were divided into two groups, hypertensive subjects (systolic blood pressure (SBP) ⩾ 140 mmHg and/or diastolic blood pressure (DBP) ⩾90 mmHg) and normotensive subjects (SBP <140 mmHg and DBP <90 mmHg) or hyperglycemic subjects (HbA1c ⩾ 6.0%) and normoglycemic subjects (HbA1c< 6.0%). Biological markers from urine and blood were analyzed centrally in the WHO Collaborating Center. Results The mean levels of HbA1c and 8-OHdG were significantly higher in the hypertensive subjects than in the normotensive subjects (P < 0.05). Urinary 8-OHdG was significantly higher in hyperglycemic subjects than in normoglycemic subjects. HbA1c was positively correlated with the 24-h urinary 8-OHdG excretions (r = 0.698, P < 0.0001). Conclusions These findings suggest oxidative DNA damage is increased in hypertensive subjects, and there is a positive correlation between the level of blood glucose estimated as HbA1c and oxidative DNA damage. Hyperglycemia related to insulin resistance in hypertension in Tanzania is associated with increased urinary 8-OHdG.

Global networks, alliances and consortia in global health education-the case for south-to-south partnerships.

As President’s Emergency Plan for AIDS Relief (PEPFAR) delegates its operations on the African continent to local providers, close attention should be given to appropriate capacity building and strengthening of health care systems by nurturing partnerships between institutions on the subcontinent. Health infrastructures originally crafted for treating HIV will also need to be expanded to cope with the coming wave of chronic diseases. Given the alarming discrepancy between the small health workforce and the burden of disease, such workforce capacity will likely only be achievable through sharing partnerships—or “networks, alliances and consortia” as suggested in a recent article in The Lancet (2010). Medical schools, as the training ground of the emerging workforce, will be at the forefront of this change. How global donors allocate funding to emerging medical and nursing schools will be crucial to the ultimate success of a sustainable health workforce development. A 2011 publication identified 168 medical schools in Africa. With scores of new medical schools likely to open in Africa over the next decade (by some estimates, more than 100 schools), the need for sharing of ideas, faculty, and resources will become more pressing. Compatible with current global financial exigencies, donor nations should consider making available smaller grants to complement the current strategy of awarding multimillion dollar funding to a few schools. This is where the Medical Education Partnership Initiative (MEPI) should have a decisive role to play. MEPI was established by PEPFAR in partnership with the National Institutes of Health Fogarty International Center to strengthen health care systems in Africa by training an additional 140,000 new health care workers through

Respiratory inflammation among workers exposed to airborne dust with endotoxins in a coffee curing factory.

133 million in grants to established African schools of medicine and nursing over a 5-year period (2010–2014). The strategy by which MEPI decided to disburse this funding has been perplexing. MEPI funds were largely awarded to just 11 medical schools –mostly well-established schools rather than to new schools. (The University of Botswana was an exception, a new school that did garner MEPI support.) These were competitive awards and a number of variables went into the complex decision-making process. Nonetheless, we believe that a broader distribution of funds to more African medical schools would have been more equitable and ultimately also have achieved a wider range of sustainable goals in terms of health-care strengthening and capacity building. Smaller awards to more medical schools could serve a vital role in developing novel medical school curricula, context-appropriate competencies, and training programs. Such an MEPI funding strategy might also have been better aligned with the proposals of the recent landmark report in The Lancet (2010) by a panel of distinguished global health

Training tomorrow’s global health leaders: applying a transtheoretical model to identify behavior change stages within an intervention for health leadership development

Objective: To study dust exposure and inflammatory reactions in the respiratory tract among coffee curing workers in Tanzania. Methods: A cross-sectional study was conducted in a Tanzanian coffee curing factory. Coffee workers (n = 15) were compared with unexposed controls (n = 18); all workers were nonsmokers. Exhaled nitric oxide was examined using an electrochemistry-based NIOX MINO device. Personal air samples were analyzed for total dust and endotoxins, using gravimetric analysis and the chromogenic Limulus amebocyte lysate endpoint assay, respectively. Results: Total dust levels ranged from 0.2 to 27.9 mg/m3, and endotoxin levels ranged from 42 to 75,083 endotoxin units/m3. Concentrations of exhaled nitric oxide, analyzed by linear regression and adjusted for age (&bgr; = 0.57; 95% confidence interval, 0.08 to 1.06; P = 0.02), was higher among coffee workers than among the control group. Conclusion: The results indicate a relationship between the coffee dust and signs of respiratory inflammation.

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis

Training health professionals in leadership and management skills is a key component of health systems strengthening in low-resource settings. The importance of evaluating the effectiveness of these programs has received increased attention over the past several years, although such evaluations continue to pose significant challenges. This article presents evaluation data from the pilot year of the Afya Bora Fellowship, an African-based training program to increase the leadership capacity of health professionals. Firstly, we describe the goals of the Afya Bora Fellowship. Then, we present an adaptation of the transtheoretical model for behavior change called the Health Leadership Development Model, as an analytical lens to identify and describe evidence of individual leadership behavior change among training participants during and shortly after the pilot year of the program. The Health Leadership Development Model includes the following: pre-contemplation (status quo), contemplation (testing and internalizing leadership), preparation – (moving toward leadership), action (leadership in action), and maintenance (effecting organizational change). We used data from surveys, in-depth interviews, journal entries and course evaluations as data points to populate the Health Leadership Development Model. In the short term, fellows demonstrated increased leadership development during and shortly after the intervention and reflected the contemplation, preparation and action stages of the Health Leadership Development Model. However, expanded interventions and/or additional time may be needed to support behavior change toward the maintenance stages. We conclude that the Health Leadership Development Model is useful for informing health leadership training design and evaluation to contribute to sustainable health organizational change.

Availability of guidelines and policy documents for enhancing performance of practitioners at the Primary Health Care (PHC) facilities in Gaborone, Tlokweng and Mogoditshane, Republic of Botswana

Background Botswana has a well-developed antiretroviral therapy (ART) program that serves as a regional model. With wide ART availability, the burden of advanced human immunodeficiency virus (HIV) and associated opportunistic infections would be expected to decline. We performed a nationwide surveillance study to determine the national incidence of cryptococcal meningitis (CM), and describe characteristics of cases during 2000-2014 and temporal trends at 2 national referral hospitals. Methods Cerebrospinal fluid data from all 37 laboratories performing meningitis diagnostics in Botswana were collected from the period 2000-2014 to identify cases of CM. Basic demographic and laboratory data were recorded. Complete national data from 2013-2014 were used to calculate national incidence using UNAIDS population estimates. Temporal trends in cases were derived from national referral centers in the period 2004-2014. Results A total of 5296 episodes of CM were observed in 4702 individuals; 60.6% were male, and median age was 36 years. Overall 2013-2014 incidence was 17.8 (95% confidence interval [CI], 16.6-19.2) cases per 100000 person-years. In the HIV-infected population, incidence was 96.8 (95% CI, 90.0-104.0) cases per 100000 person-years; male predominance was seen across CD4 strata. At national referral hospitals, cases decreased during 2007-2009 but stabilized during 2010-2014. Conclusions Despite excellent ART coverage in Botswana, there is still a substantial burden of advanced HIV, with 2013-2014 incidence of CM comparable to pre-ART era rates in South Africa. Our findings suggest that a key population of individuals, often men, is developing advanced disease and associated opportunistic infections due to a failure to effectively engage in care, highlighting the need for differentiated care models.

Factors Influencing Women's Preferences for Places to Give Birth in Addis Ababa, Ethiopia.

This study aimed to determine the profile and availability of policies and guidelines as reference documents at Primary Health Care (PHC) facilities in Gaborone and its surrounding in Botswana using the World Health Organisation/Drug Action programme (WHO/DAP) Questionnaire. The Questionnaire is a standard recommended by WHO and therefore was not piloted. All 20 PHC facilities were included in the study, however, data from 18 clinics was collected and analysed. The Matron from each PHC facility was asked to name and produce as evidence, guidelines and policy documents available as reference in his/her PHC facility. Data was entered in an Excel spread sheet and percentages, averages and frequencies were used to describe the profile and availability of the documents at each facility. Fifty two different documents were available at the facilities, 50% of them were on treatment and management of diseases. The remaining 50% were distributed between general information/policy, Ante-Natal Clinic, obstetrics and gynaecological care, and family planning. Except for guidelines for treating sexually transmitted diseases (86%), availability of the other guidelines and policy documents was low (56%) or less. Policy and guideline reference information for disease immunisation and prevention were available at 4 and 13% PHC, respectively. This low availability of such important instruments may be compromising patient care in the studied PHC facilities and should be addressed. While the Ministry of Health has produced many policy documents and guidelines as reference documents for PHC providers, none of the clinics had all the documents, raising questions on what is available at the facilities as reference and guide in the prescription practices. It is recommended that ministries of health and PHC workers should ensure that necessary reference documents are available at the facilities and staff should be trained and retrained on the use of such documents. Key words: Rational drug use, general policy documents, medical guidelines, benefits of the guidelines, health facilities.

Assessment of prescribing practices at the primary health care facilities in Botswana with an emphasis on antibiotics; findings and implications

The main aim of this study was to examine factors determining womens preference for places to give birth in Addis Ababa, Ethiopia. A quantitative and cross-sectional community based study design was employed. Data was collected using structured questionnaire administered to 901 women aged 15–49 years through a stratified two-stage cluster sampling technique. Multinomial logistic regression model was employed to identify predictors of delivery care. More than three-fourth of slum women gave birth at public healthcare facilities compared to slightly more than half of the nonslum residents. Education, wealth quintile, the age of respondent, number of children, pregnancy intention, and cohabitation showed net effect on womens preference for places to give birth. Despite the high number of ANC attendances, still many pregnant women especially among slum residents chose to deliver at home. Most respondents delivered in public healthcare institutions despite the general doubts about the quality of services in these institutions. Future studies should examine motivating factors for continued deliveries at home and whether there is real significant difference between the quality of maternal care service offered at public and private health facilities.