Despite expanding international commitment to community health worker (CHW) deployment, little is... more Despite expanding international commitment to community health worker (CHW) deployment, little is known about how such workers actually use their time. This paper investigates this issue for paid CHWs named "Community Health Agents," which in Swahili is "Wawezeshaji wa Afya ya Jamii" ("WAJA"), trained for 9 months in primary health care service delivery and deployed to villages as subjects of a randomized trial of their impact on childhood survival in three rural districts of Tanzania. To capture information about time allocation, 30 WAJA were observed during conventional working hours by research assistants for 5 days each over a period of 4 weeks. Results were presented in term of percentage time allocation for direct client treatment, documentation activities, health education, health promotion non-work-related activities and personal activities. During routine 8-h workdays, 59.5 % of WAJA time was spent on the provision of health services and other ...
Background: Tanzania, like other African countries, faces significant health workforce shortages.... more Background: Tanzania, like other African countries, faces significant health workforce shortages. With advisory and partnership from Columbia University, the Ifakara Health Institute and the Tanzanian Training Centre for International Health (TTCIH) developed and implemented the Connect Project as a randomized cluster experimental trial of the childhood survival impact of recruiting, training, and deploying of a new cadre of paid community health workers (CHW), named " Wawazesha wa afya ya Jamii " (WAJA). This paper presents an estimation of the cost of training and deploying WAJA in three rural districts of Tanzania. Methods: Costing data were collected by tracking project activity expenditure records and conducting in-depth interviews of TTCIH staff who have led the training and deployment of WAJA, as well as their counterparts at Public Clinical Training Centres who have responsibility for scaling up the WAJA training program. The trial is registered with the International Standard Randomized Controlled Trial Register number (ISRCTN96819844).
ABSTRACT En Afrique, plus qu'ailleurs, l'offre de soins reste insuffisante. La co... more ABSTRACT En Afrique, plus qu'ailleurs, l'offre de soins reste insuffisante. La construction de nouvelles infrastructures sanitaires suffit-elle à faire progresser la santé de la population ? La question se pose lorsque de nouvelles installations sanitaires sont construites sans être suivies d'une amélioration rapide des indicateurs de santé. Comment alors expliquer la lenteur des changements ? Provient-elle de l'inadéquation entre l'offre et les besoins ? De « freins culturels » empêchant de nouveaux comportements de se diffuser ? Cet article examine les facteurs en cause dans le cas de l'implantation d'un hôpital moderne en 2003 au coeur d'une région rurale du Sénégal, jusqu'alors mal équipée. L'observation démographique suivie de la population pendant plusieurs décennies montre que la mortalité maternelle n'a pas baissé de façon sensible juste après l'ouverture de l'hôpital.Pour mieux comprendre les raisons de cet échec, plusieurs enquêtes ont été menées sur les comportements de recours aux soins et l'utilisation que les habitants faisaient de cet équipement, notamment en cas d'accouchement.Les villageois ont, dans l'ensemble, peu recours à l'hôpital quatre ans après son ouverture. La plupart des femmes ne s'y rendent pas en visite prénatale et ne vont pas y accoucher. Les responsables de l'hôpital attribuent cet échec aux villageois, et notamment à leurs traditions. Ces enquêtes montrent que le problème vient plutôt d'une inadéquation entre l'offre de soins de l'hôpital et les besoins. Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. It is difficult to account for the slowness of change here. Does it stem from a mismatch between supply and demand? Or from "cultural brakes" hindering the spread of modern ideas? This article investigates possible factors in the case of a modern hospital built in Bandafassi, a rural area of Senegal where facilities had previously been scarce. Data collected over several decades through demographic surveillance of the local population showed that there was no noticeable decline in maternal mortality immediately following the hospital's opening. To identify the reasons for this failure, we conducted several surveys of local people's health-seeking behaviour and the way they utilized this facility, notably for childbirth. Four years on, villagers were still making very little use of the hospital. Few women went there either for antenatal visits or to give birth. The hospital management ascribed this failure to the villagers themselves and, more particularly, to their traditions. These surveys, however, indicate that the heart of the problem lies in a mismatch between the services offered by the hospital and local people's actual needs. En África, más que en otros países, la oferta sanitaria es todavía insuficiente ¿ La construcción de nuevas estructuras sanitarias basta para mejorar la salud de la población? Esta pregunta se plantea cuando se observa que la construcción de nuevas instalaciones sanitarias no es seguida de una mejora rápida de los indicadores de salud ¿ Cómo explicar en este caso la lentitud de los cambios? ¿ Se trata de una inadecuación entre la oferta sanitaria y las necesidades de la población? ¿ Hay « frenos culturales » que impiden la difusión de nuevos comportamientos? Este artículo examina los factores responsables en el caso de la implantación en 2003 de un hospital moderno en el centro mismo de una región rural de Senegal, hasta entonces mal equipada. La observación demográfica de la población durante varias décadas muestra que la mortalidad materna no ha disminuido de manera significativa inmediatamente después de la apertura del hospital. Para comprender mejor las razones de este fracaso, varias encuestas han sido realizadas sobre los comportamientos de recurso a la asistencia médica y la utilización que los habitantes hacían del hospital, particularmente en lo que concierne el parto. Cuatro años después de la apertura, los habitantes continúan haciendo poco uso del hospital. La mayor parte de las mujeres no acuden a él en visita prenatal ni van para dar a luz. Los responsables del hospital atribuyen este fracaso a los aldeanos y en particular a sus tradiciones. Sin embargo, las encuestas realizadas muestran que el problema proviene más bien de una inadecuación entre la oferta sanitaria y las necesidades de la población.
:Africa continues to suffer from an acute lack of healthcare provision. Is the construction of ne... more :Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. What are the reasons for the slowness of change here? Does
Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are t... more Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women com...
:Africa continues to suffer from an acute lack of healthcare provision. Is the construction of ne... more :Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. What are the reasons for the slowness of change here? Does
To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of t... more To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3-147.4) in 2000 to 66.2 (95% CI: 59.0-74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1-130.7) in 2000 to 76.2 (95% CI: 66.7-86.9) in 2011. Combining both sites, in 2000-2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08-1.92) higher than for children of mothers who had received education beyond primary school and in 2010-2011, the HR was 1.18 (95% CI: 0.90-1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99-1.47) in 2000-2001 to 1.48 (95% CI: 1.15-1.89) in 2010-2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09-1.55) to 1.15 (95% CI: 0.95-1.39) in the same period. While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.
Despite four decades of global experience with community-based primary health care, the strategic... more Despite four decades of global experience with community-based primary health care, the strategic details of community health worker (CHW) recruitment, training, compensation, and deployment remain the subject of continuing discussion and debate. Responsibilities and levels of clinical expertise also vary greatly, as well as contrasting roles of public- versus private-sector organisations as organisers of CHW effort. This paper describes a programme of implementation research in Tanzania, known as the Connect Project, which aims to guide national policies with evidence on the impact and process of deploying of paid, professional CHWs. Connect is a randomised-controlled trial of community exposure to CHW integrated primary health-care services. A qualitative appraisal of reactions to CHW implementation of community stakeholders, frontline workers, supervisors, and local managers is reviewed. Results highlight the imperative to plan and implement CHW programmes as a component of a bro...
Tropical medicine & international health : TM & IH, Jan 25, 2016
In the Tanzanian health system, women are expected to first visit their nearest front line health... more In the Tanzanian health system, women are expected to first visit their nearest front line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behavior. Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered "bypassers". Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited; among 521 women with no previous complications; and among 407 women not primigravida and without previous complications. More than 75.4% of women bypassed. In the fully adjusted model of all 597 women, those who had experienced complications were more likely to byp...
... pointed out that care during childbirth has, in principle, been free of charge throughout Sen... more ... pointed out that care during childbirth has, in principle, been free of charge throughout Senegal since 2004 (Witter et al ... De Bernis Luc, Dumont Alexandre, Bouillin Dominique, Gueye Abdoulaye, Dompnier Jean-Pierre, Bouvier-Colle Marie-Hélène, 2000, Maternal morbidity and ...
High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnata... more High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnatal care (PNC) services for addressing this problem remain severely underutilized. This study assesses factors associated with utilization of PNC among mothers in rural Tanzania. This study analyzed household survey data collected in 2011 to understand health service utilization patterns among women of reproductive age and children less than 5 years of age in the Rufiji, Kilombero, and Ulanga districts of Tanzania. A total of 889 mothers were eligible for the current analysis. Multinomial logistic regression was used to determine factors associated with the likelihood of mothers seeking the WHO recommended PNC visits. The percent of newborns and their mothers with full PNC was low (10.4 %). Factors explaining PNC completion were district of residence, ethnic group, pregnancy wantedness, ANC attendance, place of delivery, and any incidence of newborn. Mothers of unwanted pregnancies were le...
Objectives To examine levels, trends and correlates of childbearing in childhood (CiC) in the Ruf... more Objectives To examine levels, trends and correlates of childbearing in childhood (CiC) in the Rufiji district of Tanzania from 2002 to 2010. Methods Using longitudinal data collected in, and by, the Rufiji health and demographic surveillance system in Tanzania from 2002 to 2010, all women who initiated childbearing in this period (n = 5491) were selected for analysis. CiC was defined as childbearing initiation before age 18. Data analysis involved one-way tabulations of each variable-most of which were socio-demographic-to obtain frequency distributions, cross-tabulations of CiC and each of the independent variables with a Chi square test for associations, and multivariate analysis using multilevel logistic regression to examine covariates of CiC. Results CiC was 44 % and remained constant over the 2002-2010 period (P = 0.623). The relative odds of CiC was significantly reduced by 83 percent among women with secondary or higher educational attainment relative to CiC among uneducated women (OR = 0.17, CI 0.12-0.23). Moreover, the odds of CiC significantly declines monotonically as relative household wealth increases by quintile (OR = 0.70, CI 0.57-0.86). CiC also declines significantly with employment and marital status of the respondent. Conclusions CiC represents a challenging social and health problem. Forty-four percent of first time mothers in Rufiji district of Tanzania are of childhood age, and this has not changed over the past 9 years since 2002. Prioritizing girls' formal education-especially up to secondary level or higher-as well as devising some economic empowerment modalities, may be worthwhile measures towards curbing CiC in the study area.
Breastfeeding is widely known for its imperative contribution in improving maternal and newborn h... more Breastfeeding is widely known for its imperative contribution in improving maternal and newborn health outcomes. However, evidence regarding timing of initiation of breastfeeding is limited in Tanzania. This study examines the extent of and factors associated with early initiation of breastfeeding in three rural districts of Tanzania. Data were collected in 2011 in a cross-sectional survey of random households in Rufiji, Kilombero and Ulanga districts of Tanzania. From the survey, 889 women who had given birth within 2 years preceding the survey were analyzed. Both descriptive and inferential statistical analyses were conducted. Associations between the outcome variable and each of the independent variables were tested using chi-square. Logistic regression was used for multivariate analysis. Early initiation of breastfeeding (i.e. breastfeeding initiation within 1 h of birth) stood at 51 %. The odds of early initiation of breastfeeding was significantly 78 % lower following childbirth by caesarean section than vaginal birth (adjusted odds ratio (OR) = 0.22; 95 % confidence interval (CI) 0.14, 0.36). However, this was almost twice as high for women who gave birth in health facilities as for those who gave birth at home (OR = 1.75; 95 % CI 1.25, 2.45). Furthermore, maternal knowledge of newborn danger signs was negatively associated with early initiation of breastfeeding (moderate vs. high: OR = 1.73; 95 % CI 1.23, 2.42; low vs. high: OR = 2.06; 95 % CI 1.43, 2.96). The study found also that early initiation of breastfeeding was less likely in Rufiji compared to Kilombero (OR = 0.52; 95 % CI 0.31, 0.89), as well as among ever married than currently married women (OR = 0.46; 95 % CI 0.25, 0.87). To enhance early initiation of breastfeeding, using health facilities for childbirth must be emphasized and facilitated among women in rural Tanzania. Further, interventions to promote and enforce early initiation of breastfeeding should be devised especially for caesarean births. Women residing in rural locations and women who are not currently married should be specifically targeted with interventions aimed at enhancing early initiation of breastfeeding to ensure healthy outcomes for newborns.
This paper identifies factors influencing differences in the prevalence of diarrhea, fever and ac... more This paper identifies factors influencing differences in the prevalence of diarrhea, fever and acute respiratory infection (ARI), and health seeking behavior among caregivers of children under age five in rural Tanzania. Using cross-sectional survey data collected in Kilombero, Ulanga, and Rufiji districts, the analysis included 1,643 caregivers who lived with 2,077 children under five years old. Logistic multivariate and multinomial regressions were used to analyze factors related to disease prevalence and to health seeking behavior. One quarter of the children had experienced fever in the past two weeks, 12.0 % had diarrhea and 6.7 % experienced ARI. Children two years of age and older were less likely to experience morbidity than children under one year [ORfever = 0.77, 95 % CI 0.61-0.96; ORdiarrhea = 0.26, 95 % CI 0.18-0.37; ORARI = 0.60 95 % CI 0.41-0.89]. Children aged two and older were more likely than children under one to receive no care or to receive care at home, rather ...
Researchers have intensively demonstrated the socioeconomic inequalities in fertility everywhere ... more Researchers have intensively demonstrated the socioeconomic inequalities in fertility everywhere in the World. There are however limited researches on the causal effects of distance to facilities on fertility. This paper uses unique longitudinal data collected in three rural districts of Tanzania to test whether enhanced proximity to health services can reduce inequalities in fertility between rich and poor. Data on births, deaths, migrations, SES and geographic data on households and facilities have been recorded every 120 days since 1999 (n≈200,000). We will use multivariate analysis to measure the causal effects of distance to health facilities on fertility and to test interactions between distance to health facilities and maternal education and households' SES. Initial results indicate that, from 2000 to 2010, TFR remains high around 5.3 births per woman with significant differences between poor (6.4) and rich (3.4) and between educated (2.9) and not educated (5.9). The dist...
Distance to health facilities is often cited as a major barrier limiting access to care in sub-Sa... more Distance to health facilities is often cited as a major barrier limiting access to care in sub-Saharan and other developing countries. There are however limited data on the causal effects of distance to facilities on child survival. This paper uses unique longitudinal data collected in a rural district of Tanzania to test whether enhanced proximity to health services arising from investment in dispensaries contributed to the rapid decline in under-five mortality recently observed in Tanzania. Data on births, deaths, migrations, SES and geographic data on households and facilities have been recorded every 120 days since 1999 (n≈85,000). We use multivariate analysis to measure the causal effects of distance to health facilities on child survival and to test interactions between distance to health facilities and maternal education and households’ SES. Initial results indicate that, from 2000 to 2010, child mortality declined close to 40% (from 115 to 70 per 1000). The distance to the c...
In low and middle-income countries (LMICs), siblings&... more In low and middle-income countries (LMICs), siblings' survival histories (SSH) are often used to estimate maternal mortality, but SSH data on causes of death at reproductive ages have seldom been validated. We compared the accuracy of two SSH instruments: the standard questionnaire used during the demographic and health surveys (DHS) and the siblings' survival calendar (SSC), a new questionnaire designed to improve survey reports of deaths among women of reproductive ages. We recruited 1,189 respondents in a SSH survey in Niakhar, Senegal. Mortality records from a health and demographic surveillance system (HDSS) constituted the reference dataset. Respondents were randomly assigned to an interview with the DHS or SSC questionnaires. 164 respondents had a sister who died at reproductive ages over the past 15 years before the survey according to the HDSS. The DHS questionnaire led to selective omissions of deaths: DHS respondents were significantly more likely to report their sister's death if she had died of pregnancy-related causes than if she had died of other causes (96.4% vs 70.9%, p<0.007). Among reported deaths, both questionnaires had high sensitivity (>90%) in recording pregnancy-related deaths. But the DHS questionnaire had significantly lower specificity than the SSC (79.5% vs. 95.0%, p=0.015). The DHS questionnaire overestimated the proportion of deaths due to pregnancy-related causes, whereas the SSC yielded unbiased estimates of this parameter. Statistical models informed by SSH data collected using the DHS questionnaire might exaggerate maternal mortality in Senegal and similar settings. The SSC could permit better tracking progress towards the reduction of maternal mortality. This article is protected by copyright. All rights reserved.
In Tanzania, despite the fact that majority of population lives within 5 kilometers of a primary ... more In Tanzania, despite the fact that majority of population lives within 5 kilometers of a primary health facility, utilization of these facilities is limited owing to poor quality of services. This study tests the hypothesis that women bypass nearest primary health facility in order to receive better antenatal care (ANC) elsewhere and assesses covariates of this behavior. We combine original data on mothers with recent pregnancies from cross-sectional household survey (n=912) with health facility information collected in 2011 in Rufiji, Kilombero and Ulanga Districts. Bypassers are defined as mothers who opt to seek ANC at facilities other than the facility nearest to her home village. Multivariate logistic regression is used to examine maternal and contextual factors associated with odds of bypassing proximate facilities. Results show more than half of women are categorized as 'bypassers'. Bypassers were 5 to 6 times more likely to visit a health center (OR 4.95, p<0.00) ...
Despite expanding international commitment to community health worker (CHW) deployment, little is... more Despite expanding international commitment to community health worker (CHW) deployment, little is known about how such workers actually use their time. This paper investigates this issue for paid CHWs named "Community Health Agents," which in Swahili is "Wawezeshaji wa Afya ya Jamii" ("WAJA"), trained for 9 months in primary health care service delivery and deployed to villages as subjects of a randomized trial of their impact on childhood survival in three rural districts of Tanzania. To capture information about time allocation, 30 WAJA were observed during conventional working hours by research assistants for 5 days each over a period of 4 weeks. Results were presented in term of percentage time allocation for direct client treatment, documentation activities, health education, health promotion non-work-related activities and personal activities. During routine 8-h workdays, 59.5 % of WAJA time was spent on the provision of health services and other ...
Background: Tanzania, like other African countries, faces significant health workforce shortages.... more Background: Tanzania, like other African countries, faces significant health workforce shortages. With advisory and partnership from Columbia University, the Ifakara Health Institute and the Tanzanian Training Centre for International Health (TTCIH) developed and implemented the Connect Project as a randomized cluster experimental trial of the childhood survival impact of recruiting, training, and deploying of a new cadre of paid community health workers (CHW), named " Wawazesha wa afya ya Jamii " (WAJA). This paper presents an estimation of the cost of training and deploying WAJA in three rural districts of Tanzania. Methods: Costing data were collected by tracking project activity expenditure records and conducting in-depth interviews of TTCIH staff who have led the training and deployment of WAJA, as well as their counterparts at Public Clinical Training Centres who have responsibility for scaling up the WAJA training program. The trial is registered with the International Standard Randomized Controlled Trial Register number (ISRCTN96819844).
ABSTRACT En Afrique, plus qu&#39;ailleurs, l&#39;offre de soins reste insuffisante. La co... more ABSTRACT En Afrique, plus qu&#39;ailleurs, l&#39;offre de soins reste insuffisante. La construction de nouvelles infrastructures sanitaires suffit-elle à faire progresser la santé de la population ? La question se pose lorsque de nouvelles installations sanitaires sont construites sans être suivies d&#39;une amélioration rapide des indicateurs de santé. Comment alors expliquer la lenteur des changements ? Provient-elle de l&#39;inadéquation entre l&#39;offre et les besoins ? De « freins culturels » empêchant de nouveaux comportements de se diffuser ? Cet article examine les facteurs en cause dans le cas de l&#39;implantation d&#39;un hôpital moderne en 2003 au coeur d&#39;une région rurale du Sénégal, jusqu&#39;alors mal équipée. L&#39;observation démographique suivie de la population pendant plusieurs décennies montre que la mortalité maternelle n&#39;a pas baissé de façon sensible juste après l&#39;ouverture de l&#39;hôpital.Pour mieux comprendre les raisons de cet échec, plusieurs enquêtes ont été menées sur les comportements de recours aux soins et l&#39;utilisation que les habitants faisaient de cet équipement, notamment en cas d&#39;accouchement.Les villageois ont, dans l&#39;ensemble, peu recours à l&#39;hôpital quatre ans après son ouverture. La plupart des femmes ne s&#39;y rendent pas en visite prénatale et ne vont pas y accoucher. Les responsables de l&#39;hôpital attribuent cet échec aux villageois, et notamment à leurs traditions. Ces enquêtes montrent que le problème vient plutôt d&#39;une inadéquation entre l&#39;offre de soins de l&#39;hôpital et les besoins. Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. It is difficult to account for the slowness of change here. Does it stem from a mismatch between supply and demand? Or from &quot;cultural brakes&quot; hindering the spread of modern ideas? This article investigates possible factors in the case of a modern hospital built in Bandafassi, a rural area of Senegal where facilities had previously been scarce. Data collected over several decades through demographic surveillance of the local population showed that there was no noticeable decline in maternal mortality immediately following the hospital&#39;s opening. To identify the reasons for this failure, we conducted several surveys of local people&#39;s health-seeking behaviour and the way they utilized this facility, notably for childbirth. Four years on, villagers were still making very little use of the hospital. Few women went there either for antenatal visits or to give birth. The hospital management ascribed this failure to the villagers themselves and, more particularly, to their traditions. These surveys, however, indicate that the heart of the problem lies in a mismatch between the services offered by the hospital and local people&#39;s actual needs. En África, más que en otros países, la oferta sanitaria es todavía insuficiente ¿ La construcción de nuevas estructuras sanitarias basta para mejorar la salud de la población? Esta pregunta se plantea cuando se observa que la construcción de nuevas instalaciones sanitarias no es seguida de una mejora rápida de los indicadores de salud ¿ Cómo explicar en este caso la lentitud de los cambios? ¿ Se trata de una inadecuación entre la oferta sanitaria y las necesidades de la población? ¿ Hay « frenos culturales » que impiden la difusión de nuevos comportamientos? Este artículo examina los factores responsables en el caso de la implantación en 2003 de un hospital moderno en el centro mismo de una región rural de Senegal, hasta entonces mal equipada. La observación demográfica de la población durante varias décadas muestra que la mortalidad materna no ha disminuido de manera significativa inmediatamente después de la apertura del hospital. Para comprender mejor las razones de este fracaso, varias encuestas han sido realizadas sobre los comportamientos de recurso a la asistencia médica y la utilización que los habitantes hacían del hospital, particularmente en lo que concierne el parto. Cuatro años después de la apertura, los habitantes continúan haciendo poco uso del hospital. La mayor parte de las mujeres no acuden a él en visita prenatal ni van para dar a luz. Los responsables del hospital atribuyen este fracaso a los aldeanos y en particular a sus tradiciones. Sin embargo, las encuestas realizadas muestran que el problema proviene más bien de una inadecuación entre la oferta sanitaria y las necesidades de la población.
:Africa continues to suffer from an acute lack of healthcare provision. Is the construction of ne... more :Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. What are the reasons for the slowness of change here? Does
Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are t... more Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women com...
:Africa continues to suffer from an acute lack of healthcare provision. Is the construction of ne... more :Africa continues to suffer from an acute lack of healthcare provision. Is the construction of new healthcare facilities sufficient to improve the health of the population? This is certainly a question raised when the opening of a new hospital fails to bring about any rapid improvement in health indicators. What are the reasons for the slowness of change here? Does
To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of t... more To explore trends in socioeconomic disparities and under-five mortality rates in rural parts of the United Republic of Tanzania between 2000 and 2011. We used longitudinal data on births, deaths, migrations, maternal educational attainment and household characteristics from the Ifakara and Rufiji health and demographic surveillance systems. We estimated hazard ratios (HR) for associations between mortality and maternal educational attainment or relative household wealth, using Cox hazard regression models. The under-five mortality rate declined in Ifakara from 132.7 deaths per 1000 live births (95% confidence interval, CI: 119.3-147.4) in 2000 to 66.2 (95% CI: 59.0-74.3) in 2011 and in Rufiji from 118.4 deaths per 1000 live births (95% CI: 107.1-130.7) in 2000 to 76.2 (95% CI: 66.7-86.9) in 2011. Combining both sites, in 2000-2001, the risk of dying for children of uneducated mothers was 1.44 (95% CI: 1.08-1.92) higher than for children of mothers who had received education beyond primary school and in 2010-2011, the HR was 1.18 (95% CI: 0.90-1.55). In contrast, mortality disparities between richest and poorest quintiles worsened in Rufiji, from 1.20 (95% CI: 0.99-1.47) in 2000-2001 to 1.48 (95% CI: 1.15-1.89) in 2010-2011, while in Ifakara, disparities narrowed from 1.30 (95% CI: 1.09-1.55) to 1.15 (95% CI: 0.95-1.39) in the same period. While childhood survival has improved, mortality disparities still persist, suggesting a need for policies and programmes that both reduce child mortality and address socioeconomic disparities.
Despite four decades of global experience with community-based primary health care, the strategic... more Despite four decades of global experience with community-based primary health care, the strategic details of community health worker (CHW) recruitment, training, compensation, and deployment remain the subject of continuing discussion and debate. Responsibilities and levels of clinical expertise also vary greatly, as well as contrasting roles of public- versus private-sector organisations as organisers of CHW effort. This paper describes a programme of implementation research in Tanzania, known as the Connect Project, which aims to guide national policies with evidence on the impact and process of deploying of paid, professional CHWs. Connect is a randomised-controlled trial of community exposure to CHW integrated primary health-care services. A qualitative appraisal of reactions to CHW implementation of community stakeholders, frontline workers, supervisors, and local managers is reviewed. Results highlight the imperative to plan and implement CHW programmes as a component of a bro...
Tropical medicine & international health : TM & IH, Jan 25, 2016
In the Tanzanian health system, women are expected to first visit their nearest front line health... more In the Tanzanian health system, women are expected to first visit their nearest front line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behavior. Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered "bypassers". Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited; among 521 women with no previous complications; and among 407 women not primigravida and without previous complications. More than 75.4% of women bypassed. In the fully adjusted model of all 597 women, those who had experienced complications were more likely to byp...
... pointed out that care during childbirth has, in principle, been free of charge throughout Sen... more ... pointed out that care during childbirth has, in principle, been free of charge throughout Senegal since 2004 (Witter et al ... De Bernis Luc, Dumont Alexandre, Bouillin Dominique, Gueye Abdoulaye, Dompnier Jean-Pierre, Bouvier-Colle Marie-Hélène, 2000, Maternal morbidity and ...
High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnata... more High neonatal mortality persists in Tanzania. Rates of decline are slow, in part because postnatal care (PNC) services for addressing this problem remain severely underutilized. This study assesses factors associated with utilization of PNC among mothers in rural Tanzania. This study analyzed household survey data collected in 2011 to understand health service utilization patterns among women of reproductive age and children less than 5 years of age in the Rufiji, Kilombero, and Ulanga districts of Tanzania. A total of 889 mothers were eligible for the current analysis. Multinomial logistic regression was used to determine factors associated with the likelihood of mothers seeking the WHO recommended PNC visits. The percent of newborns and their mothers with full PNC was low (10.4 %). Factors explaining PNC completion were district of residence, ethnic group, pregnancy wantedness, ANC attendance, place of delivery, and any incidence of newborn. Mothers of unwanted pregnancies were le...
Objectives To examine levels, trends and correlates of childbearing in childhood (CiC) in the Ruf... more Objectives To examine levels, trends and correlates of childbearing in childhood (CiC) in the Rufiji district of Tanzania from 2002 to 2010. Methods Using longitudinal data collected in, and by, the Rufiji health and demographic surveillance system in Tanzania from 2002 to 2010, all women who initiated childbearing in this period (n = 5491) were selected for analysis. CiC was defined as childbearing initiation before age 18. Data analysis involved one-way tabulations of each variable-most of which were socio-demographic-to obtain frequency distributions, cross-tabulations of CiC and each of the independent variables with a Chi square test for associations, and multivariate analysis using multilevel logistic regression to examine covariates of CiC. Results CiC was 44 % and remained constant over the 2002-2010 period (P = 0.623). The relative odds of CiC was significantly reduced by 83 percent among women with secondary or higher educational attainment relative to CiC among uneducated women (OR = 0.17, CI 0.12-0.23). Moreover, the odds of CiC significantly declines monotonically as relative household wealth increases by quintile (OR = 0.70, CI 0.57-0.86). CiC also declines significantly with employment and marital status of the respondent. Conclusions CiC represents a challenging social and health problem. Forty-four percent of first time mothers in Rufiji district of Tanzania are of childhood age, and this has not changed over the past 9 years since 2002. Prioritizing girls&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; formal education-especially up to secondary level or higher-as well as devising some economic empowerment modalities, may be worthwhile measures towards curbing CiC in the study area.
Breastfeeding is widely known for its imperative contribution in improving maternal and newborn h... more Breastfeeding is widely known for its imperative contribution in improving maternal and newborn health outcomes. However, evidence regarding timing of initiation of breastfeeding is limited in Tanzania. This study examines the extent of and factors associated with early initiation of breastfeeding in three rural districts of Tanzania. Data were collected in 2011 in a cross-sectional survey of random households in Rufiji, Kilombero and Ulanga districts of Tanzania. From the survey, 889 women who had given birth within 2 years preceding the survey were analyzed. Both descriptive and inferential statistical analyses were conducted. Associations between the outcome variable and each of the independent variables were tested using chi-square. Logistic regression was used for multivariate analysis. Early initiation of breastfeeding (i.e. breastfeeding initiation within 1 h of birth) stood at 51 %. The odds of early initiation of breastfeeding was significantly 78 % lower following childbirth by caesarean section than vaginal birth (adjusted odds ratio (OR) = 0.22; 95 % confidence interval (CI) 0.14, 0.36). However, this was almost twice as high for women who gave birth in health facilities as for those who gave birth at home (OR = 1.75; 95 % CI 1.25, 2.45). Furthermore, maternal knowledge of newborn danger signs was negatively associated with early initiation of breastfeeding (moderate vs. high: OR = 1.73; 95 % CI 1.23, 2.42; low vs. high: OR = 2.06; 95 % CI 1.43, 2.96). The study found also that early initiation of breastfeeding was less likely in Rufiji compared to Kilombero (OR = 0.52; 95 % CI 0.31, 0.89), as well as among ever married than currently married women (OR = 0.46; 95 % CI 0.25, 0.87). To enhance early initiation of breastfeeding, using health facilities for childbirth must be emphasized and facilitated among women in rural Tanzania. Further, interventions to promote and enforce early initiation of breastfeeding should be devised especially for caesarean births. Women residing in rural locations and women who are not currently married should be specifically targeted with interventions aimed at enhancing early initiation of breastfeeding to ensure healthy outcomes for newborns.
This paper identifies factors influencing differences in the prevalence of diarrhea, fever and ac... more This paper identifies factors influencing differences in the prevalence of diarrhea, fever and acute respiratory infection (ARI), and health seeking behavior among caregivers of children under age five in rural Tanzania. Using cross-sectional survey data collected in Kilombero, Ulanga, and Rufiji districts, the analysis included 1,643 caregivers who lived with 2,077 children under five years old. Logistic multivariate and multinomial regressions were used to analyze factors related to disease prevalence and to health seeking behavior. One quarter of the children had experienced fever in the past two weeks, 12.0 % had diarrhea and 6.7 % experienced ARI. Children two years of age and older were less likely to experience morbidity than children under one year [ORfever = 0.77, 95 % CI 0.61-0.96; ORdiarrhea = 0.26, 95 % CI 0.18-0.37; ORARI = 0.60 95 % CI 0.41-0.89]. Children aged two and older were more likely than children under one to receive no care or to receive care at home, rather ...
Researchers have intensively demonstrated the socioeconomic inequalities in fertility everywhere ... more Researchers have intensively demonstrated the socioeconomic inequalities in fertility everywhere in the World. There are however limited researches on the causal effects of distance to facilities on fertility. This paper uses unique longitudinal data collected in three rural districts of Tanzania to test whether enhanced proximity to health services can reduce inequalities in fertility between rich and poor. Data on births, deaths, migrations, SES and geographic data on households and facilities have been recorded every 120 days since 1999 (n≈200,000). We will use multivariate analysis to measure the causal effects of distance to health facilities on fertility and to test interactions between distance to health facilities and maternal education and households' SES. Initial results indicate that, from 2000 to 2010, TFR remains high around 5.3 births per woman with significant differences between poor (6.4) and rich (3.4) and between educated (2.9) and not educated (5.9). The dist...
Distance to health facilities is often cited as a major barrier limiting access to care in sub-Sa... more Distance to health facilities is often cited as a major barrier limiting access to care in sub-Saharan and other developing countries. There are however limited data on the causal effects of distance to facilities on child survival. This paper uses unique longitudinal data collected in a rural district of Tanzania to test whether enhanced proximity to health services arising from investment in dispensaries contributed to the rapid decline in under-five mortality recently observed in Tanzania. Data on births, deaths, migrations, SES and geographic data on households and facilities have been recorded every 120 days since 1999 (n≈85,000). We use multivariate analysis to measure the causal effects of distance to health facilities on child survival and to test interactions between distance to health facilities and maternal education and households’ SES. Initial results indicate that, from 2000 to 2010, child mortality declined close to 40% (from 115 to 70 per 1000). The distance to the c...
In low and middle-income countries (LMICs), siblings&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;... more In low and middle-income countries (LMICs), siblings&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; survival histories (SSH) are often used to estimate maternal mortality, but SSH data on causes of death at reproductive ages have seldom been validated. We compared the accuracy of two SSH instruments: the standard questionnaire used during the demographic and health surveys (DHS) and the siblings&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; survival calendar (SSC), a new questionnaire designed to improve survey reports of deaths among women of reproductive ages. We recruited 1,189 respondents in a SSH survey in Niakhar, Senegal. Mortality records from a health and demographic surveillance system (HDSS) constituted the reference dataset. Respondents were randomly assigned to an interview with the DHS or SSC questionnaires. 164 respondents had a sister who died at reproductive ages over the past 15 years before the survey according to the HDSS. The DHS questionnaire led to selective omissions of deaths: DHS respondents were significantly more likely to report their sister&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s death if she had died of pregnancy-related causes than if she had died of other causes (96.4% vs 70.9%, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.007). Among reported deaths, both questionnaires had high sensitivity (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;90%) in recording pregnancy-related deaths. But the DHS questionnaire had significantly lower specificity than the SSC (79.5% vs. 95.0%, p=0.015). The DHS questionnaire overestimated the proportion of deaths due to pregnancy-related causes, whereas the SSC yielded unbiased estimates of this parameter. Statistical models informed by SSH data collected using the DHS questionnaire might exaggerate maternal mortality in Senegal and similar settings. The SSC could permit better tracking progress towards the reduction of maternal mortality. This article is protected by copyright. All rights reserved.
In Tanzania, despite the fact that majority of population lives within 5 kilometers of a primary ... more In Tanzania, despite the fact that majority of population lives within 5 kilometers of a primary health facility, utilization of these facilities is limited owing to poor quality of services. This study tests the hypothesis that women bypass nearest primary health facility in order to receive better antenatal care (ANC) elsewhere and assesses covariates of this behavior. We combine original data on mothers with recent pregnancies from cross-sectional household survey (n=912) with health facility information collected in 2011 in Rufiji, Kilombero and Ulanga Districts. Bypassers are defined as mothers who opt to seek ANC at facilities other than the facility nearest to her home village. Multivariate logistic regression is used to examine maternal and contextual factors associated with odds of bypassing proximate facilities. Results show more than half of women are categorized as 'bypassers'. Bypassers were 5 to 6 times more likely to visit a health center (OR 4.95, p<0.00) ...
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