Angel Dillip

In Tanzania, the roles of men and women are classified based on the local cultural context. While men are usually the breadwinners, women are traditionally responsible for most domestic chores. Particularly for malaria prevention, studies in Africa have revealed women as being responsible for daily up-keep of the net. Using social role theory, this study explored the role of men and women in net care and repair and gender-related motivation and barriers to net care and repair in Tanzania. The study was conducted in the two villages of Ruangwa district in Lindi Region. The study applied qualitative approaches and carried out in-depth interviews and focus group discussions with men, women, women with children under the age of five, and village key informants. Mosquito nets were valued by all participants as a protection measure against mosquitoes. Study findings indicate that net care and repair falls under a woman’s daily household responsibilities. While men were said to assist in stitching damaged nets, washing dirty bed nets was regarded inappropriate for men and not traditionally accepted. Motivation for net care and repair was reported to come from both men and women; for a woman keeping the net clean defined a caring and responsible woman, while men indirectly promoted net washing when complaining about nets being dirty. Women reported that men could do everything that women do regarding net care and repair, but that it does not fit into societal norms. With increased globalization in Tanzania, more women are becoming part of the workforce, which may limit their full commitment to net care and repair activities, leading to increased net damage, malaria incidences and higher costs for malaria treatment. The National Malaria Control Programme should consider incorporating research-informed gender-transformative messages into their behaviour change communication on mosquito nets and work closely with trusted Community Health Workers to inform communities about the importance of sharing responsibilities in net care and repair. It is acknowledged that changing people’s behaviour and practices is a long process, which will require a deep cultural and political shift.

Bed nets reduce malaria-related illness and deaths, by forming a protective barrier around people sleeping under them. When impregnated with long-lasting insecticide formulations they also repel or kill mosquitoes attempting to feed upon sleeping humans, and can even suppress entire populations of malaria vectors that feed predominantly upon humans. Nevertheless, an epidemiological study in 2012 demonstrated higher malaria prevalence among bed net users than non-users in urban Dar es Salaam, Tanzania. Focus group discussions were conducted with women from four selected wards of Dar es Salaam city, focusing on four major themes relating to bed net use behaviours: (1) reasons for bed net use, (2) reasons for not using bed nets, (3) stimuli or reminders for people to use a bed net (4) perceived reasons for catching malaria while using a bed net. An analytical method by framework grouping of relevant themes was used address key issues of relevance to the study objectives. Codes were reviewed and grouped into categories and themes. All groups said the main reason for bed net use was protection against malaria. Houses with well-screened windows, with doors that shut properly, and that use insecticidal sprays against mosquitoes, were said not to use bed nets, while frequent attacks from malaria was the main stimulus for people to use bed nets. Various reasons were mentioned as potential reasons that compromise bed net efficacy, the most common of which were: (1) bed net sharing by two or more people, especially if one occupant tends to come to bed late at night, and does not tuck in the net 71%; (2) one person shares the bed but does not use the net, moving it away from the side on which s/he sleeps 68%; (3) ineffective usage habits, called ulalavi, in which a sprawling sleeper either touches the net while sleeping up against it or leaves a limb hanging outside of it 68%. Less common reasons mentioned included: (1) Small bed nets which become un-tucked at night (31%); (2) Bed nets with holes large enough to allow mosquitoes to pass (28%); and (3) Going to bed late after already being bitten outdoors (24%). Behaviours associated with bed net use like; bed sharing, bed net non compliant-bedfellow, sleeping pattern like ulalavi and some physical bed net attributes compromise its effectiveness and supposedly increase of malaria infection to bed net users. While some well-screened houses looked to instigate low malaria prevalence to non-bed net users.

The extensive use of indoor residual spraying (IRS) and insecticide-treated nets (ITNs) in Africa has contributed to a significant reduction in malaria transmission. Even so, residual malaria transmission persists in many regions, partly driven by mosquitoes that bite people outdoors. In areas where Anopheles gambiae s.s. is a dominant vector, most interventions target the reduction of indoor transmission. The increased use of ITNs/LLINs and IRS has led to the decline of this species. As a result, less dominant vectors such as Anopheles funestus and Anopheles arabiensis, both also originally indoor vectors but are increasingly biting outdoors, contribute more to residual malaria transmission. The study reports the investigated community perceptions on malaria and their implications of this for ongoing outdoor malaria transmission and malaria control efforts. This was a qualitative study conducted in two rural villages and two peri-urban areas located in Kilombero Valley in south-eastern Tanzania. 40 semi-structured in-depth interviews and 8 focus group discussions were conducted with men and women who had children under the age of five. The Interviews and discussions focused on (1) community knowledge of malaria transmission, and (2) the role of such knowledge on outdoor malaria transmission as a contributing factor to residual malaria transmission. The use of bed nets for malaria prevention has been stressed in a number of campaigns and malaria prevention programmes. Most people interviewed believe that there is outdoor malaria transmission since they use interventions while indoors, but they are unaware of changing mosquito host-seeking behaviour. Participants pointed out that they were frequently bitten by mosquitoes during the evening when outdoors, compared to when they were indoors. Most participants stay outdoors in the early evening to undertake domestic tasks that cannot be conducted indoors. House structure, poor ventilation and warm weather conditions were reported to be the main reasons for staying outdoors during the evening. Participants reported wearing long sleeved clothes, fanning and slapping themselves, using repellents, and burning cow dung and neem tree leaves to chase away mosquitoes. Community understanding of multiple prevention strategies is crucial given changes in mosquito host seeking behaviour and the increased incidence of outdoor biting. The current low use of outdoor control measures is attributed largely to limited awareness of outdoor transmission. Improved community understanding of outdoor malaria transmission is critical: efforts to reduce or eliminate malaria transmission will not be successful if the control of outdoor transmission is not emphasized.

In Tanzania, progress toward achieving the 2015 Millennium Development Goals for maternal and newborn health was slow. An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. This study explored barriers, successes, and promising approaches to increasing timely access to care by linking the three levels of health care provision. The study was conducted in the Kibaha district, where we applied qualitative approaches with in-depth interviews and focus group discussions. In-depth interview participants included retail drug shop dispensers (36), community health workers (45), and health facility staff members (15). We conducted one focus group discussion with district officials and four with mothers of newborns and children under 5 years old. Relationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality. Reported challenges included stock-outs of medicines at the health facility, participating ADDO dispensers who left to work in other regions, documentation of referrals, and lack of treatment available at health facilities on the weekend. The primary issue that threatens the sustainability of the intervention is that local council health management team members, who are responsible for facilitating the linkage, had not made any supervision visits and were therefore unaware of how the program was running. The study highlights the benefits of approaches that link different levels of care providers to improve access to maternal and child health care. To strengthen this collaboration further, health campaign platforms should include retail drug dispensers as a type of community health care provider. To increase linkage sustainability, the council health management team needs to develop feasible supervision plans.

In the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope? This is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes. Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by ‘Look, See and Go’; ‘Movers On’ were those who left due to family commitments or because they were pushed to go. The remaining staff were ‘Stayers’. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post. The Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers’ profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices.

People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania’s accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials. We purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs. Four hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription. ADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants.

Tanzania introduced the accredited drug dispensing outlet (ADDO) program more than a decade ago. Previous evaluations have generally shown that ADDOs meet defined standards of practice better than non-accredited outlets. However, ADDOs still face challenges with overuse of antibiotics for acute respiratory infections (ARI) and simple diarrhea, which contributes to the emergence of drug resistance. This study aimed to explore the attitudes of ADDO owners and dispensers toward antibiotic dispensing and to learn how accreditation has influenced their dispensing behavior. The study used a qualitative approach. We conducted in-depth interviews with ADDO owners and dispensers in Ruvuma and Tanga regions where the government implemented the ADDO program under centralized and decentralized approaches, respectively; a secondary aim was to compare differences between the two regions. Findings indicate that the ADDO program has brought about positive changes in knowledge of dispensing practices. Respondents were able to correctly explain treatment guidelines for ARI and diarrhea. Almost all dispensers and owners indicated that unnecessary use of antibiotics contributed to antimicrobial resistance. Despite this knowledge, translating it to appropriate dispensing practice is still low. Dispensers’ behavior is driven by customer demand, habit (“mazoea”), following inappropriate health facility prescriptions, and the need to make a profit. Although the majority of dispensers reported that they had intervened in situations where customers asked for antibiotics unnecessarily, they tended to give in to clients’ requests. Small variations were noted between the two study regions; for example, some dispensers in Ruvuma reported sending clients with incorrect prescriptions back to the health facility, a practice that may reflect regional differences in ADDO implementation and in Integrated Management of Childhood Illness training. Dispensers in rural settings reported more challenges in managing ARI and diarrhea than their urban counterparts did. To reduce inappropriate antibiotic use, integrated interventions must include communities, health facilities, and ADDOs. Periodic refresher training with an emphasis on communication skills is crucial in helping dispensers deal with customers who demand antibiotics. Responsible authorities should ensure that ADDOs always have the necessary tools and resources available.

To improve access to treatment in the private retail sector a new class of outlets known as accredited drug dispensing outlets (ADDO) was created in Tanzania. Tanzania changed its first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (ALu) in 2007. Subsidized ALu was made available in both health facilities and ADDOs. The effect of these interventions on access to malaria treatment was studied in rural Tanzania.

The ACCESS programme aims at understanding and improving access to prompt and effective malaria treatment. Between 2004 and 2008 the programme implemented a social marketing campaign for improved treatment-seeking. To improve access to treatment in the private retail sector a new class of outlets known as accredited drug dispensing outlets (ADDO) was created in Tanzania in 2006. Tanzania changed its first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (ALu) in 2007 and subsidized ALu was made available in both health facilities and ADDOs. The effect of these interventions on understanding and treatment of malaria was studied in rural Tanzania. The data also enabled an investigation of the determinants of access to treatment.

Background: Convulsions is one of the key signs of severe malaria among children under five years of age, potentially leading to serious complications or death. Several studies of care-seeking behaviour have revealed that local illness concepts linked to convulsions (referred to as degedege in Tanzanian Kiswahili) called for traditional treatment practices while modern treatment was preferred for common fevers. However, recent studies found that even children with convulsions were first brought to health facilities. This study integrated ethnographic and public health approaches in order to investigate this seemingly contradictory evidence. Carefully drawn random samples were used to maximize the representativity of the results. Methods: The study used a cultural epidemiology approach and applied a locally adapted version of the Explanatory Model Interview Catalogue (EMIC), which ensures a comprehensive investigation of disease perception and treatment patterns. The tool was applied in three studies; i) the 2004 random sample cross-sectional community fever survey (N = 80), ii) the 2004–2006 longitudinal degedege study (N = 129), and iii) the 2005 cohort study on fever during the main farming season (N = 29). Results: 71.1% of all convulsion cases were brought to a health facility in time, i.e. within 24 hours after onset of first symptoms. This compares very favourably with a figure of 45.6% for mild fever cases in children. The patterns of distress associated with less timely health facility use and receipt of anti-malarials among children with degedege were generalized symptoms, rather than the typical symptoms of convulsions. Traditional and moral causes were associated with less timely health facility use and receipt of anti-malarials. However, the high rate of appropriate action indicates that these ideas were not so influential any more as in the past. Reasons given by caretakers who administered anti-malarials to children without attending a health facility were either that facilities were out of stock, that they lacked money to pay for treatment, or that facilities did not provide diagnosis. Conclusion: The findings from this sample from a highly malaria-endemic area give support to the more recent studies showing that children with convulsions are more likely to use health facilities than traditional practices. This study has identified health system and livelihood factors, rather than local understandings of symptoms and causes relating to degedege as limiting health-seeking behaviours. Improvements on the supply side and the demand side are necessary to ensure people's timely and appropriate treatment: Quality of care at health facilities needs to be improved by making diagnosis and provider compliance with treatment guidelines more accurate and therapies including drugs more available and affordable to communities. Treatment seeking needs to be facilitated by strengthening livelihoods including economic capabilities.