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Biomedical subjects

Don de Savigny

Publications and source records attributed to Don de Savigny.

17 recordsLinked to original sources
PubMed2006

Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage.

BACKGROUND: Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania METHODS: We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked. RESULTS: Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations. CONCLUSION: Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.

Child, Preschool↗
PubMed2006

Socio-cultural determinants of treatment delay for childhood malaria in southern Ghana.

We studied socio-cultural determinants of timely appropriate treatment seeking for children under 5 years suspected of having a perceived malaria-related illness. Caretakers of children with suspected malaria were interviewed about illness-related experiences, meanings and behaviour in two endemic villages in southern Ghana. Only 11% of children suspected of having a perceived malaria-related illness received timely appropriate treatment consistent with the Abuja target of treating malaria within 24 h of illness onset; 33% of children received appropriate treatment within 48 h. Reported perceived causes of phlegm predicted timely, appropriate treatment within 24 h of illness onset (P = 0.04) in a multivariate logistic regression model; playing on the ground (P < 0.01) predicted such treatment within 48 h. Two categories of distress, paleness or shortage of blood (P = 0.05) and sweating profusely (P = 0.03), also predicted timely, appropriate treatment within 24 h in a multivariate logistic regression model. Knowing that mosquitoes transmit malaria was not associated with timely, appropriate help seeking for the children, even though such knowledge may promote personal protective measures, especially use of bednets. Patterns of distress and PC were related to timely, appropriate help seeking, but not as expected. Effects on health seeking of illness-related experience and meaning are complex, and explaining their role may strengthen interventions for childhood malaria.

Adolescent↗
PubMed2006

Using knowledge brokering to promote evidence-based policy-making: The need for support structures.

Knowledge brokering is a promising strategy to close the "know-do gap" and foster greater use of research findings and evidence in policy-making. It focuses on organizing the interactive process between the producers and users of knowledge so that they can co-produce feasible and research-informed policy options. We describe a recent successful experience with this novel approach in the Netherlands and discuss the requirements for effective institutionalization of knowledge brokering. We also discuss the potential of this approach to assist health policy development in low-income countries based on the experience of developing the Regional East-African Health (REACH)-Policy Initiative. We believe that intermediary organizations, such as regional networks, dedicated institutional mechanisms and funding agencies, can play key roles in supporting knowledge brokering. We recommend the need to support and learn from the brokerage approach to strengthen the relationship between the research and policy communities and hence move towards a stronger culture of evidence-based policy and policy-relevant research.

Africa, Eastern↗
PubMed2005

Community concepts of malaria-related illness with and without convulsions in southern Ghana.

BACKGROUND: Malaria, both with or without convulsions, is a serious hardship for people living in endemic areas, especially in sub-Saharan Africa. Community references to malaria, however, may encompass other conditions, which was collectively designated malaria-related illness (MRI). Inasmuch as the presence or absence of convulsions reportedly affects timely help-seeking for malaria, a local comparison of these conditions is needed to inform malaria control. METHODS: Vignette-based EMIC interviews (insider-perspective interviews) for MRI with convulsions (convulsion positive, MRI-CP) and without convulsions (convulsion negative, MRI-CN) were developed to study relevant features of MRI-related experience, meaning and behaviour in two rural communities in Ghana. These semi-structured interviews elicited both qualitative narrative and categorical codes for quantitative analysis. Interviews with 201 respondents were conducted. RESULTS: The conditions depicted in the vignettes were well recognized by respondents and named with various local terms. Both presentations were considered serious, but MRI-CP was more frequently regarded potentially fatal than MRI-CN. More than 90.0% of respondents in both groups acknowledged the need to seek outside help. However, significantly more respondents advised appropriate help-seeking within 24 (p = 0.01) and 48 (p = 0.01) hours for MRI-CP. Over 50.0% of respondents responding to questions about MRI-CP identified MRI-CN as a cause of convulsions. CONCLUSION: Local comparison of MRI-CP and MRI-CN based on vignettes found a similar profile of reported categories of perceived causes, patterns of distress, help-seeking and preventive measures for both presentations. This differs from previous findings in sub-Saharan Africa, which assert communities regard the two conditions to be unrelated. The perceived relationships should be acknowledged in formulating strategies to control malaria through timely help-seeking and treatment to reduce childhood mortality.

Adult↗
PubMed2005

Does the Integrated Management of Childhood Illness cost more than routine care? Results from the United Republic of Tanzania.

OBJECTIVE: The Integrated Management of Childhood Illness (IMCI) strategy is designed to address the five leading causes of childhood mortality, which together account for 70% of the 10 million deaths occurring among children worldwide annually. Although IMCI is associated with improved quality of care, which is a key determinant of better health outcomes, it has not yet been widely adopted, partly because it is assumed to be more expensive than routine care. Here we report the cost of IMCI compared with routine care in four districts in the United Republic of Tanzania. METHODS: Total district costs of child care were estimated from the societal perspective as the sum of child health-care costs incurred in a district at the household level, primary health-facility level and hospital level. We also included administrative and support costs incurred by national and district administrations. The incremental cost of IMCI is the difference in costs of child health-care between districts with and without IMCI, after standardization for population size. FINDINGS: The annual cost per child of caring for children less than five years old in districts with IMCI was USD 11.19, 44% lower than the cost in the districts without IMCI (USD 16.09). Much of the difference was due to higher rates of hospitalization of children less than 5 years old in the districts without IMCI. Not all of this difference can be attributed to IMCI but even when differences in hospitalization rates are excluded, the cost per child was still 6% lower in IMCI districts. CONCLUSION: IMCI was not associated with higher costs than routine child health-care in the four study districts in the United Republic of Tanzania. Given the evidence of improved quality of care in the IMCI districts, the results suggest that cost should not be a barrier to the adoption and scaling up of IMCI.

Child Health Services↗
PubMed2005

Impact of Integrated Management of Childhood Illness on inequalities in child health in rural Tanzania.

We examined the impact of the Integrated Management of Childhood Illness (IMCI) strategy on the equality of health outcomes and access across socioeconomic gradients in rural Tanzania, by comparing changes in inequities between 1999 and 2002 in two districts with IMCI (Morogoro Rural and Rufiji) and two without (Kilombero and Ulanga). Equity differentials for six child health indicators (underweight, stunting, measles immunization, access to treated and untreated nets, treatment of fever with antimalarial) improved significantly in IMCI districts compared with comparison districts (p<0.05), while four indicators (wasting, DPT coverage, caretakers' knowledge of danger signs and appropriate careseeking) improved significantly in comparison districts compared with IMCI districts (p<0.05). The largest improvements were observed for stunting among children between 24-59 months of age. The concentration index improved from -0.102 in 1999 to -0.032 in 2002 for IMCI, while it remained almost unchanged -0.122 to -0.133 in comparison districts. IMCI was associated with improved equity for measles vaccine coverage, whereas the opposite was observed for DPT antigens. This study has shown how equity assessments can be incorporated in impact evaluation at relatively little additional cost, and how this may point to specific interventions that need to be reinforced. The introduction of IMCI led to improvements in child health that did not occur at the expense of equity.

Child Health Services↗
PubMed2004

Care-seeking patterns for fatal malaria in Tanzania.

BACKGROUND: Once malaria occurs, deaths can be prevented by prompt treatment with relatively affordable and efficacious drugs. Yet this goal is elusive in Africa. The paradox of a continuing but easily preventable cause of high mortality raises important questions for policy makers concerning care-seeking and access to health systems. Although patterns of care-seeking during uncomplicated malaria episodes are well known, studies in cases of fatal malaria are rare. Care-seeking behaviours may differ between these groups. METHODS: This study documents care-seeking events in 320 children less than five years of age with fatal malaria seen between 1999 and 2001 during over 240,000 person-years of follow-up in a stable perennial malaria transmission setting in southern Tanzania. Accounts of care-seeking recorded in verbal autopsy histories were analysed to determine providers attended and the sequence of choices made as the patients' condition deteriorated. RESULTS: As first resort to care, 78.7% of malaria-attributable deaths used modern biomedical care in the form of antimalarial pharmaceuticals from shops or government or non-governmental heath facilities, 9.4% used initial traditional care at home or from traditional practitioners and 11.9% sought no care of any kind. There were no differences in patterns of choice by sex of the child, sex of the head of the household, socioeconomic status of the household or presence or absence of convulsions. In malaria deaths of all ages who sought care more than once, modern care was included in the first or second resort to care in 90.0% and 99.4% with and without convulsions respectively. CONCLUSIONS: In this study of fatal malaria in southern Tanzania, biomedical care is the preferred choice of an overwhelming majority of suspected malaria cases, even those complicated by convulsions. Traditional care is no longer a significant delaying factor. To reduce mortality further will require greater emphasis on recognizing danger signs at home, prompter care-seeking, improved quality of care at health facilities and better adherence to treatment.

Adolescent↗
PubMed2004

The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania.

Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.

Case Management↗
PubMed2004

Mosquito nets and the poor: can social marketing redress inequities in access?

Treated mosquito nets are a practical malaria control tool. However, implementation of efficient delivery mechanisms remains a challenge. We investigated whether social marketing of treated mosquito nets results in decreased equity in rural Tanzania, through household surveys before the start of a social marketing programme and 3 years later. About 12,000 household heads were asked about ownership of nets and other assets including a tin roof, radio, or bicycle. A socio-economic status score was developed for each household. Net ownership was calculated for households in each quintile of this score, from poorest to least poor. In 1997, about 20% of the poorest households and over 60% of the least poor households owned a mosquito net. Three years later, more than half of the poorest households owned a net, as did over 90% of the least poor: the ratio of net ownership among the poorest to least poor increased from 0.3 in 1997 to 0.6 in 2000. Social marketing in the presence of an active private sector for nets was associated with increased equity.

Animals↗
PubMed2004

Monitoring future impact on malaria burden in sub-saharan Africa.

Ambitious new goals for control of malaria have been set and significant additional resources for malaria control are being mobilized. Yet for many of the countries most severely burdened by malaria, both baseline data and reliable monitoring of key impact indicators is lacking. For such countries, it will be difficult to know when targets are met or whether to make mid-course corrections if progress is inadequate. The new investments in malaria control have triggered resurgence in demand for health information, both for performance-based resource allocation and for health impact. We argue here that some of these resources will need to be diverted to support more integrated information systems able to monitor change and guide approaches, not just for malaria, but also for other important health and poverty related interventions. This paper urges a re-thinking of the nature of management information systems and sources in resource poor settings. A pathway is suggested that helps situate monitoring and evaluation more strategically in a framework of other information management steps for longitudinal, iterative, evidence-based decision making. Health Information Systems of the future will need much greater coherence in the use of information from disparate sources and much greater influence on action.

Africa South of the Sahara↗
PubMed2003

Inequities among the very poor: health care for children in rural southern Tanzania.

BACKGROUND: Few studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania. METHODS: In a baseline household survey in Tanzania early in the implementation phase of integrated management of childhood illness (IMCI), we included cluster samples of 2006 children younger than 5 years in four rural districts. Questions focused on the extent to which carers' knowledge of illness, care-seeking outside the home, and care in health facilities were consistent with IMCI guidelines and messages. We used principal components analysis to develop a relative index of household socioeconomic status, with weighted scores of information on income sources, education of the household head, and household assets. FINDINGS: 1026 (52%) of 1968 children reported having been ill in the 2 weeks before the survey. Carers of 415 (41%) of 1014 of these children had sought care first from an appropriate provider. 71 (26%) carers from families in the wealthiest quintile knew > or =2 danger signs compared with 48 (20%) of those from the poorest (p=0.03 for linear trend across quintiles) and wealthier families were more likely to bring their sick children to a health facility (p=0.02). Their children were more likely than poorer children to have received antimalarials, and antibiotics for pneumonia (p=0.0001 and 0.0048, respectively). INTERPRETATION: Care-seeking behaviour is worse in poorer than in relatively rich families, even within a rural society that might easily be assumed to be uniformly poor.

Child Health Services↗
PubMedDate not supplied

Decentralizing EPI services and prospects for increasing coverage: the case of Tanzania.

Primary health Care (PHC) strategies were adopted widely in 1978 after the Alma Ata declaration to improve accessibility to health services and the health of the people. Of the strategies of PHC was the decentralization of health services to lower levels in order to enhance participation and responsiveness of the health system to local problems. While PHC was being promoted vertical programmes such as the expanded programme on immunization (EPI) were also being promoted and achieved substantial benefits. However, almost 25 years later many countries have not been able to achieve these health goals. This study addressed the question: Can we make the process of health care decentralization more likely to support health system and EPI goals? This study analysed the experience of EPI decentralization at national, regional and district levels. Several stakeholders were identified who were supportive and others who were non-supportive of the process. Community support to EPI measured by using willingness to pay (WTP) for kerosene (to keep vaccines cool) was low. It was significantly (p < 0.05) associated with whether providers in the nearest health facility properly attended the target population and whether the providers in the facility were available when needed. There was a substantial stakeholder support and opposition to the process of decentralization at the district level. Community support was not high possibly due to the perceived non-availability of the service providers and their lack of awareness of the population they serve. It was proposed that reforms should give priority to the involvement of communities and peripheral health facility providers in the process.

Delivery of Health Care↗
PubMedDate not supplied

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 children's 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 children's 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.

Case Management↗
PubMedDate not supplied

How can we achieve and maintain high-quality performance of health workers in low-resource settings?

In low and middle income countries, health workers are essential for the delivery of health interventions. However, inadequate health-worker performance is a very widespread problem. We present an overview of issues and evidence about the determinants of performance and strategies for improving it. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions. Few interventions have been evaluated with rigorous cost-effectiveness trials, and such studies are urgently needed to guide policy. We propose an international collaborative research agenda to generate knowledge about the true determinants of performance and about the effectiveness of strategies to improve performance. Furthermore, we recommend that ministries of health and international organisations should actively help translate research findings into action to improve health-worker performance, and thereby improve health.

Behavior↗