Towards Eliminating Malaria in High Endemic Countries: The Roles of Community Health Workers and Related Cadres and their Challenges in Integrated Community Case Management for Malaria: A Systematic Review.

Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM). This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review. A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges. Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts

Nutrition Training Improves Health Workers' Nutrition Knowledge and Competence to Manage Child Undernutrition: A Systematic Review.

Medical and nursing education lack adequate practical nutrition training to fit the clinical reality that health workers face in their practices. Such a deficit creates health workers with poor nutrition knowledge and child undernutrition management practices. In-service nutrition training can help to fill this gap. However, no systematic review has examined its collective effectiveness. We thus conducted this study to examine the effectiveness of in-service nutrition training on health workers' nutrition knowledge, counseling skills, and child undernutrition management practices. We conducted a literature search on nutrition interventions from PubMed/MEDLINE, CINAHL, EMBASE, ISI Web of Knowledge, and World Health Organization regional databases. The outcome variables were nutrition knowledge, nutrition-counseling skills, and undernutrition management practices of health workers. Due to heterogeneity, we conducted only descriptive analyses. Out of 3910 retrieved articles, 25 were selected as eligible for the final analysis. A total of 18 studies evaluated health workers' nutrition knowledge and showed improvement after training. A total of 12 studies with nutrition counseling as the outcome variable also showed improvement among the trained health workers. Sixteen studies evaluated health workers' child undernutrition management practices. In all such studies, child undernutrition management practices and competence of health workers improved after the nutrition training intervention. In-service nutrition training improves quality of health workers by rendering them more knowledge and competence to manage nutrition-related conditions, especially child undernutrition. In-service nutrition training interventions can help to fill the gap created by the lack of adequate nutrition training in the existing medical and nursing education system. In this way, steps can be taken toward improving the overall nutritional status of the child population

タンザニアのダルエスサラームにおける注射薬物使用者の薬物使用およびエイズ感染予防に対するメサドン補助療法の役割

学位の種別: 課程博士審査委員会委員 : （主査）東京大学教授 水口 雅, 東京大学教授 渋谷 健司, 東京大学教授 川上 憲人, 東京大学教授 森屋 恭爾, 東京大学教授 小林 廉毅University of Tokyo(東京大学

Strong nutrition governance is a key to addressing nutrition transition in low and middle-income countries: review of countries’ nutrition policies

METHODS: We reviewed nutrition policies, nutrition governance, and the trends of nutrition status from LAMICs. We retrieved data on the policies from the global database on the implementation of nutrition actions (GINA). We also retrieved data on the trends of nutrition status and nutrition governance from the nutrition landscape information system (NLiS), and on LAMICs from the World Bank database. We then analyzed the data both descriptively and by using a mixed effects model with random-intercept by country. RESULTS: Of the 139 LAMICs reviewed, only 39.6% had policies to address both undernutrition and overweight/obesity. A higher proportion of low-income countries (LICs) had policies to address undernutrition compared to that of middle-income countries (MICs) (86.1% vs. 63.1%, p = 0.002), and a low proportion of both had policy to address overweight. Having a nutrition policy that addresses undernutrition was not associated with better nutrition status outcomes. Strong nutrition governance in LAMICS was associated with low magnitudes of stunting (beta = -4.958, p = 0.015); wasting (beta = -5.418, p = 0.003); and underweight (beta = -6.452, p = 0.001). CONCLUSION: Despite high magnitudes of undernutrition and overweight/obesity in LAMICs, only about one third of them had nutrition policies to address such nutrition transition. Having strong nutrition governance may help to bring down the magnitudes of undernutrition in LAMICs. Nutrition transition necessitates low and middle-income countries (LAMICs) to scale up their efforts in addressing the burdens of undernutrition and overweight/obesity. Magnitudes of undernutrition and overweight are high in LAMICs, but no study has reviewed the existence of nutrition policies to address it. No evidence is also available on the effect of nutrition policies and governance on the undernutrition and overweight/obesity patterns in such countries. We conducted a policy review to examine the presence and associations of nutrition policies and governance with the children’s nutrition statuses in LAMICs

Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough

BackgroundThe prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania.MethodsFrom September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children\u27s anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods.ResultsART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children\u27s households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.In the multivariate analysis, child\u27s HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p \u3c 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p \u3c 0.001).ConclusionHIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea

Expanded Total Facility Approach Stigma-reduction Training for Health Workers: In-Service Training Guide

The training guide is a handbook for health workers and members of partner organisations who have been trained as HIV stigma-reduction facilitators. It was developed as part of the Expanded Toral Facility Approach (TFA) project, being implemented in health facilities in Ghana, Tanzania and Zambia with the aim of reducing HIV-related stigma and discrimination in health facilities. Health worker facilitators use the handbook, having been trained as trainers, when they roll out training to the majority of staff in their health facilities. This training guide has built on approaches to HIV stigma and discrimination developed over the last 20 years and has been shown to significantly impact HIV stigma and discrimination. All the stigma reduction exercises are participatory and depending on skillful use of interactive methodologies

HIV virologic response, patterns of drug resistance mutations and correlates among adolescents and young adults: A cross-sectional study in Tanzania.

BackgroundThe emergence of HIV drug resistance mutations (DRMs) is of significant threat to achieving viral suppression (VS) in the quest to achieve global elimination targets. We hereby report virologic outcomes and patterns of acquired DRMs and its associated factors among adolescents and young adults (AYA) from a broader HIV drug resistance surveillance conducted in Tanzania.MethodsData of AYA was extracted from a cross-sectional study conducted in 36 selected facilities using a two-stage cluster sampling design. Dried blood spot (DBS) samples were collected and samples with a viral load (VL) ≥1000 copies/mL underwent genotyping for the HIV-1 pol gene. Stanford HIV database algorithm predicted acquired DRMs, Fisher's exact test and multivariable logistic regression assessed factors associated with DRMs and VS, respectively.FindingsWe analyzed data of 578 AYA on antiretroviral therapy (ART) for 9-15 and ≥ 36 months; among them, 91.5% and 88.2% had VS (VLConclusionsVS amongst AYA is lower than the third UNAIDs target. Additionally, a high prevalence of ADR and high levels of circulating clinically relevant DRMs may compromise the long-term VS in AYA. Furthermore, the first VL result of ≥1000copies/ml after ART initiation is a significant risk factor for developing DRMs. Thus, strict VL monitoring for early identification of treatment failure and genotypic testing during any ART switch is recommended to improve treatment outcomes for AYA

High burden of anemia among pregnant women in Tanzania: a call to address its determinants

Abstract Background Anemia in pregnancy is behind a significant burden of maternal mortality and poor birth outcomes globally. Efforts to address it need evidence on trends and its pertinent factors as they vary from one area to another. Methods We pooled data of 23,203 women of reproductive age whose hemoglobin levels were measured from two Tanzania Demographic and Health Surveys (TDHS). Of them, 2,194 women were pregnant. Analyses employed descriptive analyses to determine the burden of anemia, its characteristics, and severity; GIS mapping to determine the regional changes of anemia between 2005 and 2015; and logistic regression to determine the remaining determinants of anemia among pregnant women using Stata 15. Results The burden of anemia among pregnant women in Tanzania has remained unprecedently high, and varies between regions. There was no significant decline of anemia in general between the two periods after adjusting for individual, households, reproductive, and child characteristics [AOR = 0.964, 95% CI = 0.774–1.202, p = 0.747). Anemia is currently prevalent in 57% of pregnant women in Tanzania. The prevalence is more likely to be higher among women aged 15–19 years than those aged between 20–34 years. It is more likely to be prevalent among those within large families, with no formal education, food insecurity, lack of health insurance, had no antimalaria during pregnancy, and had low frequency of ANC attendance. On the other hand, delivery in a health facility may be potentially protective against anemia. Conclusions Anemia in pregnancy remained persistently high and prevalent among 57% of pregnant women in Tanzania. Efforts to address anemia are crucial and need to be focused in regions with increasing burden of anemia among pregnant women. It is imperative to address important risk factors such as food insecurity, strengthening universal health coverage, empowering women of reproductive age with education and especially nutritional knowledge and advocating for early antenatal booking, attendance, and facility delivery. </jats:sec

High Burden of Anemia Among Pregnant Women in Tanzania: A Call to Address Its Determinants

Abstract Background: Anemia in pregnancy is behind a significant burden of maternal mortality and poor birth outcomes globally. Efforts to address it need evidence on trends and its pertinent factors as they vary from one area to another. Methods: We analyzed data of 23,203 women of reproductive age whose hemoglobin levels were measured from two Tanzania Demographic and Health Surveys (TDHS). Of them, 2,194 women were pregnant. Analyses employed descriptive analyses to determine the burden of anemia, its characteristics, and severity; GIS mapping to determine the regional changes of anemia between 2005 and 2015; and logistic regression to determine the remaining determinants of anemia among pregnant women using Stata 15. Results: The burden of anemia among pregnant women in Tanzania has remained unprecedently high, and vary between regions. Despite such variation, there was no significant decline of anemia in general between the two periods [AOR=0.964, p=0.747). Anemia is currently prevalent in 57% of pregnant women in Tanzania. The burden is more likely to be higher among women aged 15-19 years than those aged between 20-34 years. It is more likely to be prevalent among those within large families, with no formal education, food insecurity, lack of health insurance, had no antimalaria during pregnancy, and had low frequency of ANC attendance. On the other hand, delivery in a health facility was protective against anemia.Conclusions: Anemia in pregnancy remained persistently high and prevalent among 57% of pregnant women in Tanzania. Efforts to address anemia is crucial and need to be focused in regions with increasing burden of anemia among pregnant women. It is imperative to address important risk factors such as food insecurity, strengthening universal health coverage, empowering women of reproductive age with education and especially nutritional knowledge and advocating for early antenatal booking, attendance, and facility delivery.</jats:p