Situational analysis for diagnosis and treatment of cervical cancer in mainland Tanzania.

OBJECTIVE: To determine factors influencing early diagnosis and treatment of cervical cancer in Tanzania women. DESIGN: A cross-sectional study. SETTING: Forty primary health care facilities, twenty district/regional and four referral (tertiary) hospitals in mainland Tanzania. RESULTS: The most basic equipment for cytology-based cervical cancer were available at all health care facilities. However, screening against cervical cancer was appallingly inadequate at all levels of health care delivery system. Apart from medical doctors at tertiary level, other medical personnel including nurses were poorly or hardly utilised for cervical cancer screening. Treatment facilities for pre-cancerous lesions in most district, regional and even tertiary hospitals were inadequate or non-existent despite being very simple, cheap and yet very effective. There was total lack of organised institutional or national policy guidelines on cervical cancer screening in Tanzania. CONCLUSION: There is an urgent need to introduce systematic screening against cervical cancer and treatment of precursor lesions at all levels of health care delivery system in Tanzania. A national policy guideline should be urgently drawn addressing specifically frequency of screening and at what age to start screening.

Situation analysis for cervical cancer diagnosis and treatment in east, central and southern African countries.

OBJECTIVE: To determine the factors influencing cervical cancer diagnosis and treatment in countries of East, Central and Southern Africa (ECSA). METHODS: Data were collected from randomly selected primary health care centres, district and provincial hospitals, and tertiary hospitals in each participating country. Health care workers were interviewed, using a questionnaire; the facilities for screening, diagnosing, and treating cervical cancer in each institution were recorded, using a previously designed checklist. FINDINGS: Although 95% of institutions at all health care levels in ECSA countries had the basic infrastructure to carry out cervical cytology screening, only a small percentage of women were actually screened. Lack of policy guidelines, infrequent supply of basic materials, and a lack of suitable qualified staff were the most common reasons reported. CONCLUSIONS: This study demonstrates that there is an urgent need for more investment in the diagnosis and treatment of cervical cancer in ECSA countries. In these, and other countries with low resources, suitable screening programmes should be established.

Randomised trial of alternative malaria chemoprophylaxis strategies among pregnant women in Kigoma, Tanzania: I. Rationale and design.

OBJECTIVE: The objective of the study was to assess the effectiveness of alternative strategies of malaria chemoprophylaxis on the reduction of malaria episodes and prevalence of parasitaemia among pregnant women in Kigoma urban district in western Tanzania. DESIGN: Randomised antimalarial prophylactic trial. SETTING: The study was conducted in an urban maternal and child health (MCH) clinic in Kigoma town. SUBJECTS: All pregnant women attending antenatal care services at Kigoma urban MCH clinic were eligible. Informed consent was sought from each pregnant woman for participation in the study. INTERVENTION MEASURES: The intervention measures were intermittent and continuous malaria chemoprophylaxis using chloroquine and proguanil. MAIN OUTCOME MEASURES: Reduction of malaria episodes and parasitaemia and haemoglobin levels among participating pregnant women in Kigoma urban district. RESULTS: Baseline data indicates that the overall mean haemoglobin concentrations among the primigravidae and multigravidae women were similar within the intervention and comparison groups (F-test (df = 5, N = 701) = 1.27, P = 0.27). Similarly, no significant difference was observed in the prevalence of malaria parasitaemia within the primigravidae intervention and comparison groups (chi 2 test (df = 5, N = 701) = 5.4, P = 0.4). Hence, the process of randomisation produced comparable intervention and comparison groups with balanced characteristics. Specific results of the baseline studies are presented in the companion paper. CONCLUSION: We conclude that the process of randomisation resulted in comparable intervention and comparison groups. As malaria is a common cause of considerable morbidity and mortality among pregnant women in Tanzania, the present study provided useful data for improving reproductive health in Kigoma region, western Tanzania.

PIP: This randomized antimalarial prophylactic trial assessed the effectiveness of alternative malaria chemoprophylaxis strategies on the reduction of malaria episodes and prevalence of parasitemia among pregnant women in urban Kigoma, Tanzania. All pregnant women attending antenatal care services at an urban maternal and child health clinic were randomly exposed to either intermittent or continuous malaria chemoprophylaxis using chloroquine and proguanil. The main outcome measures of the study were reduction of malaria episodes and parasitemia and hemoglobin levels among pregnant women. Baseline findings suggest that the overall mean hemoglobin concentrations among primigravida and multigravida women were similar within the intervention and comparison groups (P = 0.27). Similarly, no significant difference was observed in the prevalence of malaria parasitemia within the primigravida intervention and comparison groups (P = 0.4). Hence, the process of randomization produced comparable intervention and comparison groups with balanced characteristics. As malaria is a common cause of morbidity and mortality among pregnant women in Tanzania, this study provided useful data for improving reproductive health in the Kigoma region.

Randomised trial of alternative malaria chemoprophylaxis strategies among pregnant women in Kigoma, Tanzania: II. Results from baseline studies.

OBJECTIVE: To determine baseline data among pregnant women consenting to participate in a randomised trial of alternative strategies of malaria chemoprophylaxis in Kigoma urban district, western Tanzania. DESIGN: Cross-sectional study. SETTING: The study was conducted in an urban MCH clinic in Kigoma town in western Tanzania. SUBJECTS: All consenting pregnant women who fulfilled entry criteria were recruited into the study. BASELINE STUDIES: Baseline data were collected prior to randomisation of women to antimalarial prophylactic regimens. Baseline measurements included examination for blood depleting parasitic infections (stool and urine examinations), haemoglobin levels, haematocrit, sickling test, and blood slide for malaria parasites. RESULTS: A total of 728 pregnant women consented to participate in the interview and of these 705 participated in baseline studies constituting a participation rate of 96.8%. The age of participating women ranged from 14 to 45 years with a mean age of 23.7 years (standard deviation [SD] = 5.4) while the mean number of pregnancies ranged from 1 to 13 with a mean of 3.2 (SD = 2.2). The prevalence of malaria parasitaemia among the pregnant women examined was 9.4% (N = 705) while the prevalence of anaemia (defined as Hb < 8.5 gdl-1) was 12.4% (N = 579). No significant difference was observed in prevalence proportions of malaria parasitaemia in relation to age, parity, marital status and use of mosquito bednets. However the prevalence of anaemia among women in the age group 31-45 years was significantly lower than that observed among women in the age group 14-20 years (2.9% versus 18.9%; crude odds ratio [OR] = 0.13; 95% confidence interval [CI], 0.02-0.55). Sickle cell disease (HbAS) was found in 2.3% (N = 564) of the pregnant women examined. CONCLUSION: It is concluded that the prevalence of malaria parasitaemia and anaemia was very high in this population suggesting the need for interventions directed at controlling these major causes of maternal morbidity and mortality in Tanzania.

PIP: This cross-sectional study conducted in Kigoma urban district, western Tanzania, determined the baseline data among pregnant women consenting to participate in a randomized trial of alternative malaria chemoprophylaxis strategies. Baseline data were obtained prior to randomization of women to antimalarial prophylactic regimens (intermittent or continuous chloroquine and proguanil). Baseline measurements included examination for blood depleting parasitic infections (stool and urine examinations), hemoglobin levels, hematocrit, sickling test, and blood slide for malaria parasites. A total of 728 pregnant women consented to participate, and of these, 705 participated in baseline studies constituting a participation rate of 96.8%. The age range was 14-45 years, while the number of pregnancies ranged from 1 to 13. The prevalence of malaria parasitemia among the subjects was 9.4% (N = 705), while the prevalence of anemia was 12.4% (N = 579). There was no significant difference in prevalence proportions of malaria parasitemia in relation to age, parity, marital status and use of mosquito bednets. However, the prevalence of anemia among women aged 31-14 years was significantly lower than among women in the age group 14-20 years (2.9% vs. 18.9%; crude odds ratio = 0.13; 95% confidence interval, 0.02-0.55). Sickle cell disease (HbAS) was found in 2.3% (N = 564) of the pregnant women examined. The prevalence of malaria parasitemia and anemia was very high in this population, suggesting the need for effective disease control interventions.

Situation analysis for cervical cancer diagnosis and treatment in Zimbabwe.

OBJECTIVE: To establish factors influencing early diagnosis and treatment of cervical cancer in Zimbabwean women. DESIGN: A cross sectional study. SETTING: A random selection of 29 primary health care facilities, 11 district/provincial and four tertiary hospitals in Zimbabwe. RESULTS: All the institutions at primary health care, district, provincial and tertiary levels had the basic infrastructure to perform exfoliative cytology screening (Pap. smear). An average of only nine pap. smears per month were performed at primary health clinics and at district/provincial and tertiary levels seven and 23 Pap. smears per week were done respectively. Infrequent supplies of consumable materials and lack of policy guidelines were the most common reasons for not screening women. Surgical treatment for cervical cancer was offered in all tertiary hospitals but only 22% of provincial hospital had facilities to perform hysterectomy. CONCLUSION AND RECOMMENDATIONS: There is an urgent need to improve screening for cervical pre-cancer in Zimbabwean women with emphasis to provide adequate treatment facilities especially at district and provincial Hospitals. A national policy guideline should be drawn to address specific ages and frequency of screening for cervical cancer.

Zimbabwean teenagers' knowledge of AIDS and other sexually transmitted diseases.

A cross sectional anonymously administered questionnaire was used amongst 1689 secondary school girls and boys to determine their knowledge of AIDS and other sexually transmitted diseases (STDs). Their knowledge was found to be very low. While 80% could name an STD in an open question, only 16% could recognise the important symptoms of the common and treatable diseases such as gonorrhoea and syphilis. This finding is worrying in view of the fact that these common STDs facilitate transmission of HIV/AIDS. The awareness of AIDs was high but when it came to the mode of transmission of AIDS the large majority were not aware of the risk of intercourse with an infected person. Furthermore, despite an intensive AIDS awareness campaign programme mounted by the government of Zimbabwe a large number of students thought that one can contract HIV/AIDS by shaking hands, sharing a toilet and witchcraft. Misconceptions on transmission abound. The data show that there is a need to review strategies of disseminating information to teenagers regarding STD, including AIDS, reproductive biology, sexuality and contraception. The best strategy may be the introduction of a reproductive health education curriculum in all schools starting at an early age.

Factors that determine utilization of modern contraceptives in East, Central and southern Africa.

A cross-sectional study to determine modern contraceptives utilization among women aged between 15 and 19 years was performed between September and October, 1991 in 5 countries of East Central and Southern Africa. The study involved both rural and urban area of Kenya, Uganda, Mauritius, Swaziland and Zambia. A total of 4513 women were interviewed of whom 2418 (53.6%) were from the urban areas while 2096 (46.4% were from the rural areas. The percentage distribution of contraceptive users was 33.2% in urban and 48.9% in rural areas. The proportion of users of traditional/natural contraception was 38.5%. Overall the prevalence of contraceptive use was 29.5%. Thus the natural/traditional methods were most popular in the region. The user rate of modern contraceptive methods ranged from 6.8% for Zambia to 60% for Mauritius. The study revealed that contraceptive prevalence rates were higher among women in urban areas (60%) than in rural areas (40%). The main factors influencing contraceptive use in order of importance included distance from residence to clinics, level of education attained, parity, marital status, approval by husbands/boyfriends and knowledge of family planning methods. Contraceptive use was highest in the age group of 20 to 34 years while it was lowest among young women aged 15-19 years.

Community health assessment index content and face validation studies.

The objective of the study was to evaluate content and face validity of Community Health Assessment Index (CHAI). Two independent groups of experts convened in Dar-es-salaam and Eldoret after having had a chance to study CHAI for two or more weeks in order for them to make written evaluations on the index. Twelve and 11 experts representing a broad range of interest in community health in the African context convened in Dar-es-salaam and Eldoret respectively. Most of these were nominated by their respective institutions, namely, ministries of health, academic and research institutions and non-governmental and multilateral organisations. The findings of the two groups of experts were very similar. The consensus was that CHAI has face and content validity. However, both groups suggested that (i) total adult mortality instead of male adult mortality be used; and (ii) that a 5 km rather than 10 km radius be used to define accessibility to health care. Regarding to questionnaire the consensus was that (a) the questions were both clear and culturally appropriate; (b) apart from the part which concerns a description of health services policy and community participation, the questionnaire could be administered by literate primary health care workers after appropriate training and translation; and (c) in addition to generating CHAI scores, the data gathered with this instrument could be used for planning and evaluation at the local community level. Overall the questionnaire was judged as "good" by 19 while the remaining 4 judged it as being "very good". Several suggestions in wording were made. Also a few additional questions were suggested. This evaluation provides justifications for further studies to assess the remaining measurement properties of this index.

Factors that Determine Utilisation of Mordern Contraceptives in East; Central and Southern Africa

A cross-sectional study to determine modern contraceptives utilization among women aged between 15 and 19 years was performed between September and October; 1991 in 5 countries of East Central and Southern Africa. The study involved both rural and urban area of Kenya; Uganda; Mauritius; Swaziland and Zambia. A total of 4513 women were interviewed of whom 2418 (53.6) were from the urban areas while 2096 (46.4were from the rural areas. The percentage distribution of contraceptive users was 33.2in urban and 48.9in rural areas. The proportion of users of traditional/natural contraception was 38.5. Overall the prevalence of contraceptive use was 29.5. Thus the natural/traditional methods were most popular in the region. The user rate of modern contraceptive methods ranged from 6.8for Zambia to 60for Mauritius. The study revealed that contraceptive prevalence rates were higher among women in urban areas (60) than in rural areas (40). The main factors influencing contraceptive use in order of importance included distance from residence to clinics; level of education attained; parity; marital status; approval by husbands/boyfriends and knowledge of family planning methods. Contraceptive use was highest in the age group of 20 to 34 years while it was lowest among young women aged 15-19 years

Reproductive biology knowledge, and behaviour of teenagers in East, Central and Southern Africa: the Zimbabwe case study.

Sexuality in the teenager is often complicated by unplanned/unwanted pregnancy, abortion and the risks of STDs including AIDS. There is therefore a need for improved understanding of factors affecting adolescent sexuality and the implementation of programmes designed to improve their knowledge, risk awareness and subsequent behavioural outcomes. A multicentre study of reproductive health knowledge and behaviour followed by a health education intervention was undertaken amongst teenagers in selected countries of East, Central and Southern Africa. Reported here are findings at baseline derived from the Zimbabwe component on reproductive biology knowledge and behavior. A self-administered questionnaire was used among 1 689 adolescent pupils drawn from rural, urban, co-education, single sex, boarding and day secondary schools in Zimbabwe. Correct knowledge on reproductive biology as measured by the meaning and interpretation of menstruation and wet dreams varied by school from 68 pc to 86 pc, with a significant trend (p < 0,01) based on level of education at baseline. The reported mean age at which menarche took place was 13,5 years +/- 1,3 (mean +/- SD). First coitus was reported to have taken place at the mean age of 12 years for boys and 13,6 years for girls. Seventeen pc of the adolescent pupils reported that they were sexually experienced and 33,2 had relationships. There were misconceptions reported on menstruation with 23 pc reporting that it was an illness. Peers, followed by magazines were the first sources of information on various aspects of reproductive biology, both of which might not provide the correct first information. Among pupils reporting that they were sexually experienced, the largest proportion (56 pc) had unprotected sex. The findings point to the need for targeting the adolescent pupils for information on reproductive biology and increased awareness on the risks of pregnancy, STDs and HIV.

PIP: A multicenter study of reproductive health knowledge and behavior followed by a health education intervention was undertaken among teenagers in selected countries of eastern, central, and southern Africa. Baseline findings are reported from the Zimbabwe component of the study. 1689 adolescents from rural, urban, coeducational, single sex, boarding, and day secondary schools in Zimbabwe participated in the study. 789 were aged 10-14 years, 872 were aged 15-19, 10 were older than 19, and 18 did not offer their age. 48.4% of participants were male. Correct knowledge on reproductive biology was measured by the meaning and interpretation of menstruation and wet dreams as indicated by responses to self-administered questionnaires. That knowledge varied by school from 68% to 86%, with a significant trend based upon the level of education at baseline. Menarche occurred at the reported mean age of 13.5 years, with first coitus occurring at the mean ages of 12 years for boys and 13.6 years for girls. 17% reported being sexually experienced and 33.2% were involved in relationships. 23% believed menstruation to be an illness. Peers, followed by magazines, were the main sources of information on reproductive biology. 56% of the respondents who reported being sexually experienced had unprotected sex. These findings point to the need to target adolescent students with information on reproductive biology and increased awareness on the risks of pregnancy, sexually transmitted diseases, and HIV.