«LOCAL UNDERSTANDING AND PRACTICES RELATED TO IMCI INTERVENTIONS IN EASTERN TANZANIA INAUGURALDISSERTATION Zur Erlangung der Würde eines Doktor der ...»
LOCAL UNDERSTANDING AND PRACTICES RELATED TO IMCI
INTERVENTIONS IN EASTERN TANZANIA
Erlangung der Würde eines Doktor der Philosophie
Der Universtät Basel
Charles Chrisostom Mayombana
aus Ngara, Tanzania
Basel, September 2004
Genehmigt von der Philosophish-Naturwissenschaftlichen Fakultät der Universität Basel auf Antrag von Herrn Prof. Dr. Marcel Tanner, PD Dr. Brigit Oberist und Dr. Don de Savigny Basel, September 2004 Prof. Dr. Tanner Dedicated to
MY WIFE, CALISTER MAYOMBANAAND
MY CHILDREN JULLIET AND JONSTON MAYOMBANATable of Contents Table of Contents Table of Contents
Table of Figures
Table of Tables
1.1 The Tanzania Essential Health Intervention Project (TEHIP)................1
1.2 Integrated Management of Childhood Illness (IMCI)
1.3.1 Malaria as a worldwide problem
1.3.2 The situation of malaria in Tanzania
1.3.3 Social Science Research on Malaria in Tanzania
1.3.4 key issues in Social science research on IMCI and malaria... 19
1.4 Scope and framework of our study
1.4.1 Study scope
1.4.2 Conceptual framework
1.4.3 Overview of chapters
2. Goal and Objectives
2.2 Specific Objectives
2.3 Research Questions
3. Study Setting and Methods
3.1 Study Setting
3.1.1 Study area
3.1.2 Illness burden and health care system of the study districts... 37 3.1.3 Traditional Healing in Tanzania
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3. 2 Methodology
3.2.1 Sampling and methods
3.2.2 Data management and analysis
4. Findings: Illness Concepts, Illness Aetiology, Care-Seeking, Impact............... 47
4.1 Illness Concepts: Local Terminology and Ranking of IMCI Related Illness in Morogoro Rural and Rufiji Districts, Eastern Tanzania.......... 49 Abstract
Study setting and methods
4.2 Illness Concepts: Fuzzy Concepts: Local Recognition and Labeling of IMCI-Targeted Conditions in Eastern Tanzania
Materials and methods
4.3 Illness aetiology: Explaining IMCI Related Illness: Intra-cultural Variation in Eastern Tanzania
4.4 Impact: Care-Seeking Patterns for Fatal Malaria in Tanzania.......... 129 Abstract
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4.5 Illness Aetiology: Pragmatic Ambivalence as Barrier to Effective Household and Community IMCI in Eastern Tanzania
Materials and methods
4.6 Care-seeking: Searching for Best Care. Family and Community IMCI in Eastern Tanzania
6. Conclusions and Recommendations
For future research
For practical intervention
Table of Figures Figure 1. Map of the study area of Morogoro Rural and Rufiji Districts in Tanzania
Figure 2. The conceptual framework for TEHIP research
Figure 3. “The Ears of the Hippopotamus” where malaria patients are managed … and die (Breman 2001)
Figure 4. Mapping Malaria Risk in Africa: Tanzania – Length of Transmission Season
Figure 5. Location of social science research on Malaria in Tanzania.
.......... 17 Figure 6. The conceptual framework of this study
Figure 7. Study villages, Morogoro Rural District
Figure 8. Ethnic groups of the study area (Swantz 1986:430)
Figure 9. Study villages, Rufiji District
Figure 10. Overlap of the biomedical category" malaria" and related illness concepts
Figure 11. Conceptual links of Degedege
Figure 12. Risk of malaria transmission.
Length of malaria transmission season in Tanzania based on the MARA climate model. (Source, Ministry of Health TEHIP and MARA-Tanzania).
Figure 13 Initial care-seeking patterns. Care of forst resort sought during the final illness by 320 fatal “malaria” cases in children less than five years of age in the Rufiji DSS sebtinel area, 1999-2001
Figure 14. Frequency of care-seeking events.
Distribution of frequency of care-seeking events at differing categories of provider among those who sought care during the final illness in fatal episodes of malaria in 320 children under five years of age with (dark shading) and without convulsions (light shading).
Figure 15. Loyalty to first provider.
Comparison of loyalty to first provider of modern or traditional care during the final illness in fatal cases (all ages) that saw two or more providers.
Figure 16. Drugs purchased from retail and drug shops for home use (1999)
Table of Tables Table 1. Zones and villages in study district
Table 2. IMCI conditions and local illness terminology, Morogoro Rural District
Table 3. IMCI conditions and local illness terminology, Rufiji District.
................. 58 Table 4. Eight core conditions
Table 5. List of signs and symptoms for the Morogoro District
Table 6. List of signs and symptoms for the Rufiji District
Table 7. Qualitative ranking of severity of IMCI related illnesses in both districts
Table 8. Ranking of illness with respect to percieved threat, Morogoro rural (top) and Rufiji Districts (bottom)
Table 9. Symptoms recognized by caregivers for homa, malaria, degedege and nimonia in Morogoro Rural (M) and Rufiji (R) Districts (based on case studies)
Table 10. Comparison of labels used for degedege in IMCI guidelines and those mentioned by caregivers in interviews, FGDs and case studies.
...... 91 Table 11. Comparison of danger signs for nimonia mentioned by caregivers with those used in IMCI guidelines
Table 12. Qualitative range of explanation of causes of IMCI related illnesses
Table 13. Causes by frequency of mentioning in percentage (%), Morogoro Rural District
Table 14. Causes by frequency of mentioning in percentage (%), Rufiji District.
(*ear discharge, bird, bad weather, early pregnancy, god)........... 115 Table 15. General household-level characteristics of Coast Region in comparison to Tanzania rural mainland
Table 16. Level and source of initial care in fatal acute febrile illness / malaria by age group in the Rufiji DSS sentinel area, 1999-2001.
............ 147 Table 17. Type and provider of initial care in fatal acute febrile Illness / malaria by age group, sex, socio-economic status, and type of illness in
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the Rufiji DSS sentinel area, 1999-2001
Table 18. Level and source of accumulative care in fatal acute febrile illness / malaria, all ages, in the Rufiji DSS sentinel area, 1999-2001.
................. 152 Table 19. Causes attributed to homa, malaria, degedege and nimonia by caregivers in Morogoro Rural (M) and Rufiji (R) Districts in the case studies
Table 20. Causes attributed to homa, malaria, degedege and nimonia by caregivers in percentage (%) in Morogoro Rural District
Table 21. Causes attributed to homa, malaria, degedege and nimonia by caregivers in percentage (%) in Rufiji District
Table 22. Proportion (%) of health care options used in malaria-related illness
Acknowledgements I would like to acknowledge the financial support from the International Development Research Centre (IDRC, Canada) without which the project would not have been carried out and also for financial contribution to support my thesis writing. Thanks to TEHIP staff in particular to Dr. Don de Savigny, Dr. Conrad Mbuya, Dr.Graham Reid, Dr. Harun Kasale and Mr. Honorathy Masanja for various technical and management support availed to the research project.
My heart felt thanks go to the people and their leaders of both Morogoro Rural and Rufiji District and in particular to the mothers of young children and other informants who participated in the study. They responded to our often lengthy and repeated interviews, allowed us to document some sensitive cultural rituals related to child health and development while some became hosts to our field staff offering their houses for accommodation. Their contribution and hospitality is highly appreciated.
The collaboration and cooperation of the District Medical Officers of Morogoro Rural District, Dr. Harun Machibya, and of Rufiji District, Dr. Said Mkikima, and all the members of Council Health Management Team is highly appreciated. It would have been difficult to accomplish the project without their support and interest. The District Executive Directors (DED) of both Rufiji and Morogoro rural are highly acknowledged for their support. Their contributions and challenges brought forward during interactive research feedback meetings with the CHMTs were highly useful and encouraging.
I am deeply grateful to my supervisors Professor Marcel Tanner, Dr. Brigit Obrist and Dr. Don de Savigny. Their great encouragement, ideas and support is highly appreciated. Special thanks however are due to Dr. Brigit Obrist who was my main supervisor and for the intensive editing made to my thesis. I also thank Suzanne Tanner and Jenny de Savigny for their hospitality and encouragement throughout my stay in Switzerland.
At the Swiss Tropical Institute a number of staff members, students and friends supported me in various ways. Sincere thanks to Professor Mitchell Weiss, the Head, Department of Epidemiology and Public Health for his support and
guidance in the data management and analysis. Many thanks to Christine Walliser for various support rendered to me during my entire stay in Switzerland.
She was concerned with my wellbeing and health that permitted to finish my thesis successfully. I would like to thank Eliane Ghilardi for her repeated support throughout my studies. I would like to extend my heartfelt thanks to fellow students in particular Stefanie Granado, Karin Gross, Monica Daigl, Collins Arholu for various help and encouragement. I would like to mention my sincere gratitude to Miriam Cohn, Esther Schelling and Daniel Anderegg for their kind assistance in editing my thesis. Many other people at STI assisted me in many ways. I acknowledge the hospitality and support of my friends and colleagues Dr.
Christoph Hartz and his wife Christine, Dr. Christian Lengeler, Elizabeth Escher and Dr. Adrian Zumstein. I would also like to mention the encouragement and hospitality I received from Dr. Reto Suter and his family.
I thank all the project staff in Tanzania, in particular the office staff in Morogoro and Rufiji, the research assistants, enumerators and all participated in various ways for the courage and the good job done in quite difficult and often dangerous working circumstances. Due to bad roads and technical problems, some staff members spent nights in the forest, others in a boat floating on the Indian Ocean.
Worse, others were attacked by armed bandits in an attempt to hijack the project vehicle. Their courage, enthusiasm and tolerance are highly appreciated. Some of them even married and named their children after the project “TEHIP”.
Last but not least I acknowledge the kind assistance and support of my colleagues in Ifakara, in particular to Dr. Hassan Mshinda, for the encouragement and support. I am deeply indebted to my wife Calister, my children Juliet and Johnson who suffered through my long absence, for their encouragement and support.
Glossary Household An aggregate of persons, generally but not necessarily bound by ties of kinship, which live together under the same roof and eat together or share in common the household food. Members comprise the head of the household, relatives living with him, and other persons who share the community life for reasons of work or other consideration. A person who lives alone is considered a separate household. (National Statistics Office) Modern care/western medicine Scientific or cosmopolitan medicine refers to the medicine developed by in the western world since the Enlightenment. It starts from the Cartesian dichotomy of body and mind and is characterized by understanding of disease as a fundamentally biological process Illness A condition of poor health perceived or felt by an individual and interpreted by the social group Traditional/folk medicine/care The WHO has delineated a working definition of traditional medicine as "including diverse health practices, approaches, knowledge and beliefs incorporating plant, animal, and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness" Treatment/care-seeking Refers to a process followed by individuals and/or social group for restoring health by using medical resources of all kinds Self treatmentPerformance of activities or tasks to take care of oneself or one's family and friends during illness.