| 61. |
- Kemetli, Levent, et al.
(författare)
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Temporal trends in the use of adjuvant systemic therapy in breast cancer : a population based study in Sweden 1976-2005.
- 2009
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Ingår i: Acta Oncologica. - : Informa UK Limited. - 0284-186X .- 1651-226X. ; 48:1, s. 59-66
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Both adjuvant therapy and mammography screening can decrease breast cancer mortality and there is a need of knowing to what extent those two modalities are used in the population. Screening coverage is well documented but there is a scarcity of population-based data on use of systemic adjuvant treatment. AIM: To describe the introduction, and trends in the use of adjuvant systemic therapy for breast cancer in two of six public health regions in Sweden. MATERIAL & METHODS: Population-based data on use of adjuvant therapy were available from databases with documented high quality and high coverage data for Stockholm (1976-2005) and North Sweden (1980-2003, and 2005). RESULTS: The use of systemic treatment was infrequent before the late 1980s in both regions, but increased during the 1990s. In 2005, the proportion of operable breast cancer patients treated with adjuvant endocrine therapy in the ages 40-59 was around 60 to 80%. The proportion adjuvant chemotherapy was less than 15% for the ages 70-74. For the north region the use of endocrine therapy increased successively over time, with an exception for age group 40-49 were a more rapidly increase occurred in the late 1990s. In Stockholm the increment was higher and more rapidly. There was no clear difference in chemotherapy use between the regions, and the use increased from the mid 1980s in age group 40-49, and in the early 1990s for women aged 50-59. In age group's 60-69 and 70-74 the use was relatively infrequent. CONCLUSIONS: Trends in, and levels of the use of adjuvant systemic therapy for breast cancer varied over time in the two study regions, particularly for endocrine therapy. We consider that the differences between the regions mainly reflect different interpretations of new scientific evidence. We stress the importance of a good documentation of all new treatment protocols.
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| 62. |
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| 63. |
- Kidanto, Hussein Lesio, et al.
(författare)
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Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania
- 2009
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Ingår i: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 9
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care. METHODS: We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care. RESULTS: Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time. CONCLUSION: Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.
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| 64. |
- Kidanto, Hussein Lesio, et al.
(författare)
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Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania : Bridging the quality gap
- 2012
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Ingår i: BMC Pregnancy and Childbirth. - : BioMed Central. - 1471-2393 .- 1471-2393. ; 12, s. Article nr 134-
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Tidskriftsartikel (refereegranskat)abstract
- Background: Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.Objective: The prevalence of eclampsia in MNH is high (approximate to 6%) with the majority of cases arriving after start of convulsions. In 2004-2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.Methods: A CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit.Results: There was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).Conclusion: CBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.
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| 65. |
- Kidanto, Hussein L, 1964-
(författare)
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Improving quality of perinatal care through clinical audit : a study from a tertiary hospital in Dar es Salaam, Tanzania
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Perinatal audit has been tested and proved an important tool for reduction of perinatal mortality and assessment of quality of perinatal care. At Muhimbili National Hospital (MNH), a tertiary hospital in Dar es salaam, Tanzania we performed a retrospective cross-sectional study using data from an obstetrics database to classify all perinatal deaths during 1999-2003. We also determined the prevalence of anaemia in pregnancy and its impact on perinatal outcome. Furthermore, we conducted a perinatal audit to study potential determinants and causes of perinatal and neonatal deaths and their avoidability. We also assessed the quality of care of patients admitted with eclampsia using a criteria based audit. Stillbirth, early neonatal and perinatal mortality rates (PMR) were 96, 27 and 124 respectively. A large proportion of foetuses (38%) had no audible foetal heart beat on admission at MNH labour ward and the majority of the neonatal deaths were asphyxiated at delivery. The PMR for multiples and singletons were 269 and 118 respectively resulting in a rate ratio of 2.4 (95%CI: 2.1-2.4). The prevalence of anaemia and severe anaemia was 68% and 5.8%, respectively. Severity of anaemia increased the risk of preterm delivery with ORs of 1.4, 1.4 and 4.1 for women with mild, moderate and severe anaemia as compared to women with normal haemoglobin levels. The corresponding risks for LBW and VLBW were 1.2, 1.7 and 3.8, and 1.5, 1.9 and 4.2 respectively. The prevalence of preterm delivery and LBW was 17% and 14% respectively. The hospital-based incidence of eclampsia was 504 per 10,000 women or 5.1 % of all mothers admitted. Suboptimal care were identified on criteria regarding management plan by senior staff, review of the plans by specialist obstetrician, delay on caesarean section, monitoring patients on magnesium sulphate and inadequate use of the laboratory. Two out of three patients requiring operation were not operated within set standards. Birth asphyxia was the main cause of intrapartum fresh stillbirth (47%) and early neonatal deaths (51%), whereas eclampsia (25%) and preeclampsia (8.3%) were main maternal medical conditions. The majority of stillbirths were fresh, indicating foetal demise during labour or just before delivery. The audit study identified suboptimal care in about 80% of audited cases out of which about 50% were found to be the likely cause of the adverse perinatal outcome. Inadequate maternal and foetal monitoring during labour were the main suboptimal factors, though delay in referral and operative interventions were also prominent. Based on these studies, we conclude that: The perinatal mortality (PMR) in this study was higher than the national average. About one in four perinatal deaths at MNH can be attributed to avoidable factors linked to obstetric care Main causes of perinatal and neonatal deaths were intrapartum birth asphyxia, immaturity related and infections Management of patients in labour needs to be improved Suboptimal care that is essentially avoidable included: inadequate monitoring of patients during labour, delay of care, e.g. long decision to surgery interval, and delayed referral of patients fromprimary hospitals The prevalence of anaemia in pregnancy was very high; and low birth weight and preterm delivery was independently associated with severity of anaemia The prevalence of eclampsia at MNH was high and the case management needs to be improved
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| 66. |
- Kidanto, Hussein L, 1964-, et al.
(författare)
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Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania
- 2009
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Ingår i: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 9, s. 45-
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).METHODS: From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.RESULTS: The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.CONCLUSION: There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.
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| 67. |
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| 68. |
- Kisanga, Felix, et al.
(författare)
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Child Sexual Abuse: Community Concerns in Urban Tanzania
- 2011
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Ingår i: Journal of Child Sexual Abuse. - : Informa UK Limited. - 1053-8712 .- 1547-0679. ; 20:2, s. 196-217
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to explore community perceptions about child sexual abuse in Tanzania. Thirteen focus group discussions were conducted with adult community members. The core category, children's rights challenged by lack of agency, was supported by eight categories. Aware but distressed portrayed feelings of hopelessness, lack of trust in the healthcare and legal systems reflected perceived malpractice, decreased respect for children's rights referred to poor parental care and substance abuse, myths justifying CSA illustrated cultural beliefs to rationalize child sexual abuse, disclosure threatened by fear of stigma and discrimination aligned the manifestations that prevent disclosure, actions driven by economic circumstances described the economical dependence of victims, urging a change in procedures reflected informants' wish to ally with local governance and pressure groups, and willingness to act indicated the community's role in supporting victims. The study showed how lack of agency calls for efforts to increase children's human rights at all levels.
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| 69. |
- Kisanga, Felix, 1953-
(författare)
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Child sexual abuse in urban Tanzania : possibilities and barriers for prevention
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Child sexual abuse is a global public health and human rights concern. Despite beinga crime in most countries, and with well-known physical and mental health consequences, the majority of sexual offences are not reported. Child sexual abuse is a maltreatment form characterized by contact or non-contact acts perpetrated by adults or older children toward younger children who have little power to resist. This thesis aims to understand the social context of child sexualabuse, and the perceived roles of parents, community, and key professionals in handling such incidents in urban Tanzania.Methods: A combination of qualitative and quantitative research designs were applied to four sub-studies performed in Temeke district, Dar es Salaam. Qualititative content analysis was conducted on 23 in-depth interviews to describe the perceptions of key professionals and their experiencesof handling cases of child sexual abuse, in addition, eight in-depth interviews with parents to capture their experiences of legal reporting of child sexual abuse incidents. Grounded theory was used to analyse 13 focus group discussions held with male and female community members to explore norm systems and community awareness related to child sexual abuse. Findings from these exploratory sub-studies paved the way for a school survey among 1359 students from 23 randomly selected secondary schools. Using descriptive statistics and multivariate regression analyses, prevalence, risk factors, and health consequences of child sexual abuse were estimated.Results: Lack of working tools and financial support were perceived as major problems among the key professionals. Corruption at community and institutional levels was seen as jeopardizing justice. Community passivity and lack of knowledge about laws regulating sexual offences were identifiedas additional challenges for conducting fair investigations. The community perspective illustrated that children’s rights were challenged by lack of agency. Community awareness about child sexual abuse was clear but there was also a lack of trust in that the healthcare and legal systems were capable of handling such cases. Myths and cultural beliefs justified abuse. Disclosure of abuse was threatened by fear of stigma and discrimination. Parental interviews identified four types of sexual abuse incidents. The type most strongly associated with a determination to seek justice was one with an innocent child. The youth who was forced into sex elicited feelings of parental betrayal. The consenting, curious youth created uncertainty in how to proceed, while the transactional sex youth evoked feelings of parental powerlessness. Shame and stigma, but also fear of perpetrator retaliation and breach of confidentiality, were seen as challenges for disclosure. The school survey showed that 28% (boys=30%, girls=26%) of the students were exposed to child sexual abuse, with boys more often affected than girls. Twenty-six per cent of boys and 19% of girls reported being forced to look at pornography. Forced sexual intercourse was experienced by 9.8% of boys and 8.7% of girls. Abuse increased with age and diminished self-rated health. Perpetrators were most often neighbours, teachers and peers. In contrast, survivor confidants were most often teachers, family members and friends. Most survivors did not want any action taken for the abuse. Proportions of students who perceived having fair/poor health increased with severity of abuse comparing the none-abused (7.0% and 6.3% of boys and girls respectively) with the ever abused (26% and 41% of boys and girls respectively) and those reporting penetrative sex (35% and 53% of boys and girls respectively). Likewise, suicidal ideation and attempts increased with severity of abuse when compared with those not abused.Conclusions and recommendations: Sexual abuse of children poses a devastating social, and public health challenge. In Tanzania neither the community nor the health or legal institutions are adequately prepared to handle these cases. Educating the community, economically empowering women and strengthening the medico-legal system are needed to increase the opportunity for human,legal and fair investigations and reactions. A national child protection system is needed to address the complexities of abuse at different levels and to safeguard the rights of children in Tanzania.
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| 70. |
- Kisanga, Felix, et al.
(författare)
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Parents' Experiences of Reporting Child Sexual Abuse in Urban Tanzania
- 2013
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Ingår i: Journal of Child Sexual Abuse. - : Informa UK Limited. - 1053-8712 .- 1547-0679. ; 22:5, s. 481-498
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Tidskriftsartikel (refereegranskat)abstract
- This article reports parental experiences of legally reporting child sexual abuse in Tanzania. Based on in-depth interviews, four types of sexual abuse incidents are portrayed. Each evokes different reactions from parents and the community. An incident characterized as the innocent child was associated with a determination to seek justice. The forced-sex youth elicited feelings of parental betrayal of their child. The consenting curious youth resulted in uncertainty of how to proceed, while the transactional-sex youth evoked a sense of parental powerlessness to control the child because of low economic status. Differentiating between types of sexual abuse incidents may increase awareness of the complexities of child sexual abuse reporting. Education on laws regulating sexual offenses and a functional national child protection system are needed to address child sexual abuse complexities and safeguard the rights of children in Tanzania.
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