'To help them is to educate them': power and pedagogy in the prevention and treatment of malaria in Tanzania.

OBJECTIVES: Acknowledging that mothers are often the primary caregivers at the household level, malaria control efforts have emphasized educating women in its early recognition. This fails to consider the context in which knowledge will be transformed into action, as women lack decision-making responsibility and financial resources. We examine the knowledge and power dynamics of provider-patient interactions and the implications for malaria treatment of educating mothers during consultations. METHODS: We conducted in-depth interviews in Tanga, Tanzania, with 79 household participants over 2 years to explore knowledge and perceptions of febrile illness, its treatment and prevention. We also interviewed 55 clinicians at government and private healthcare facilities about their patients' knowledge and treatment-seeking behaviour. We analysed our data using a grounded theory approach. RESULTS: Informants had good knowledge of malaria aetiology, symptoms and treatment. Healthcare workers reported that mothers were able to give them sufficient information about their child for accurate diagnosis. However, health staff continued to see mothers who present 'late' as uneducated, intellectually incapable and lazy. Whilst evidence shows that decisions about treatment do not rest with mothers, but with male family members, it is women who continue to be blamed and targeted by health education. CONCLUSIONS: Aggressive didactic teaching methods used by health staff may be disempowering those already equipped with knowledge, yet unable to control treatment decisions within the household. This may lead to further delays in presentation at a healthcare facility. We propose a rethinking of health education that is context-sensitive, acknowledges class and gendered power relations, and targets men as well as women

Malaria treatment practices in the transition from sulfadoxine-pyrimethamine to artemether-lumefantrine: A pilot study in Temeke municipality, Tanzania

Background: Tanzania has changed its malaria treatment policy twice; in the first change Sulfadoxine - Pyrimethamine (SP) replaced chloroquine (CQ) in August 2001. In the second change Artemether –Lumefantrine (ALu) replaced SP in January 2007. It is not known how experiences with previous policies would influence the uptake the new policy.Objective: This study assessed malaria treatment practices in the transition from SP to ALu and the implications for the uptake of the new policy.Methods: Two months prior to change from SP to ALu a survey of randomly selected households (HHs) was carried out to explore the factors influencing malaria therapy choices and formulations of antimalarial drugs preferred. Perceptions on single versus multiple doses of antimalarial drugs, awareness on dosage calculation and compliance were also explored.Results: Two thirds of the respondents held the perceptions that childhood illness corresponding to malaria would require an antimalarial drug. However, about a quarter (24.3%) held the perception that childhood convulsion is not amenable by modern medicines. Half (50.7%) held the perception that high fever causes convulsions, however only a small percentage (5.8%) linked convulsions with severe malaria. SP was the most commonly available antimalarial drug (81.8%); followed by amodiaquine (35.4%), quinine (25.5%), artemisinin monotherapies (3.2%) and chloroquine (3.2%). The larger majority (85.9%) preferred antimalarial drugs syrup for children below 12 months old; about half (52.2%) also preferred syrup for children 1 – 5 years old. More than half (57.5%) preferred antimalarial drugs as tablets for older children and adults. Less than a quarter were aware that antimalarial drugs doses are calculated based on weight and age by about a half (48.5%). About three quarters (76.5%) were aware that SP is given as a single dose. About two thirds (63.8%) preferred antimalarial drugs as a single dose; only about a third (34.5%) preferred multiple dosages.Conclusions: For uncomplicated malaria, the community would seek antimalarial drugs while traditional medicines may initially be sought for severe malaria in the form of convulsions. Experiences with and preference of single SP dose may negatively influence compliance with multiple dose ALu therapy. The absence of ALu syrup formulation may negatively influence its acceptance for young children; while the absence of injectable formulation may negatively influence its acceptance to adult patients.Key words: malaria, community, policy changes, artemisinin based combination therapy, Tanzani

Epidemiology and Molecular Characterization of Cryptosporidium spp. in Humans, Wild Primates, and Domesticated Animals in the Greater Gombe Ecosystem, Tanzania

Cryptosporidium is an important zoonotic parasite globally. Few studies have examined the ecology and epidemiology of this pathogen in rural tropical systems characterized by high rates of overlap among humans, domesticated animals, and wildlife. We investigated risk factors for Cryptosporidium infection and assessed cross-species transmission potential among people, non-human primates, and domestic animals in the Gombe Ecosystem, Kigoma District, Tanzania. A cross-sectional survey was designed to determine the occurrence and risk factors for Cryptosporidium infection in humans, domestic animals and wildlife living in and around Gombe National Park. Diagnostic PCR revealed Cryptosporidium infection rates of 4.3% in humans, 16.0% in non-human primates, and 9.6% in livestock. Local streams sampled were negative. DNA sequencing uncovered a complex epidemiology for Cryptosporidium in this system, with humans, baboons and a subset of chimpanzees infected with C. hominis subtype IfA12G2; another subset of chimpanzees infected with C. suis; and all positive goats and sheep infected with C. xiaoi. For humans, residence location was associated with increased risk of infection in Mwamgongo village compared to one camp (Kasekela), and there was an increased odds for infection when living in a household with another positive person. Fecal consistency and other gastrointestinal signs did not predict Cryptosporidium infection. Despite a high degree of habitat overlap between village people and livestock, our results suggest that there are distinct Cryptosporidium transmission dynamics for humans and livestock in this system. The dominance of C. hominis subtype IfA12G2 among humans and non-human primates suggest cross-species transmission. Interestingly, a subset of chimpanzees was infected with C. suis. We hypothesize that there is cross-species transmission from bush pigs (Potaochoerus larvatus) to chimpanzees in Gombe forest, since domesticated pigs are regionally absent. Our findings demonstrate a complex nature of Cryptosporidium in sympatric primates, including humans, and stress the need for further studies