| 1. |
- Bordás, Pál, 1955-
(författare)
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Evaluation of the effectiveness of mammography screening in Northern Sweden.
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Service screening with mammography was implemented in Northern Sweden between 1989 and 1998, covering 190,000 women aged 40-74 years constituting the target population in the area. The aim of this thesis was the evaluation of mammography screening in Northern Sweden with special focus on selected screening performance indicators and on the disease outcome. We analysed interval cancer (IC) incidence and episode sensitivity in the Norrbotten Mammography Screening Programme (NMSP) for the period 1989-2002. An overall IC rate at 1.1/1000 and IC rate ratio at 38% was found and epsiode sensitivity was estimated at 62-73%, in concert with reference values of the European guidelines. Radiological classification of the IC cases in three rounds of the NMSP showed that true, occult, missed and minimal signs IC, were present in 48%, 10%, 14% and 28% of the cases. We analysed early death from breast cancer (n=342) in Northern Sweden during the first five years of mammography service screening. Most fatal cases were advanced and incurable on diagnosis. In a few screen-detected cases with favourable prognostic factors the fatal outcome was unexpected. We estimated breast cancer survival by detection mode in 5120 women with breast cancer. We found a significantly favourable survival among IC cases compared to cases among uninvited. We studied breast cancer mortality in relation to mammography screening. Our findings indicated a long-term reduction of breast cancer mortality by 26-30% among women invited to screening and by 31-35% among women screened compared to not screened. We conclude from our evaluation of the mammography screening in Northern Sweden that women benefited from this public health intervention in form of improved survival and reduced mortality.
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| 2. |
- Frumence, Gasto, 1965-
(författare)
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The role of social capital in HIV prevention: experiences from the Kagera region of Tanzania
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background The role of social capital for promoting health has been extensively studied in recent years but there are few attempts to investigate the possible influence of social capital on HIV prevention,particularly in developing countries. The overall aims of this thesis are to investigate the links between social capital and HIV infection and to contribute to the theoretical framework of the role of social capital for HIV prevention. Methods Key informant interviews with leaders of organizations, networks, social groups and communities and focus group discussions with members and non-members of the social groups and networks were conducted to map out and characterize various forms of social capital that may influenceHIV prevention. A quantitative community survey was carried out in three case communities toestimate the influence of social capital on HIV risk behaviors. A cross-sectional survey was conducted to estimate the HIV prevalence in the urban district representing a high HIV prevalence zone to determine the association between social capital and HIV infection. Main findings In early 1990’s many of the social groups in Kagera region were formed because of poverty and many AIDS related deaths. This formation of groups enhanced people’s social and economic support to group members during bereavement and celebrations as well as provided loans that empowered members economically. The social groups also put in place strict rules of conduct, which helped to create new norms, values and trust, which influenced sexual health andthereby enhanced HIV prevention. Formal organizations worked together with social groups and facilitated networking and provided avenues for exchange of information including healtheducation on HIV/AIDS. Individuals who had access to high levels of structural and cognitive social capital were more likely to use condoms with their casual sex partners compared to individuals with access to low levels. Women with access to high levels of structural social capital were more likely to use condoms with casual sex partners compared to those with low levels. Individuals with access to low levels of structural social capital were less likely to be tested for HIV compared to those with access to high levels. However, there was no association between access to cognitive social capital and being tested for HIV. Individuals who had access to low levels of both structural and cognitive social capital were more likely to be HIV positive compared to individuals who had access to high levels with a similar pattern among men and women. Conclusion This thesis indicates that social capital in its structural and cognitive forms is protective to HIV infection and has played an important role in the observed decline in HIV trends in the Kagera region. Structural and cognitive social capital has enabled community members to decrease number of sexual partners, delay sexual debut for the young generation, reduce opportunities for casual sex and empower community members to demand or use condoms. It is recommended that policy makers and programme managers consider involving grassroots’ social groups and networks in the design and delivery of interventions strategies to reduce HIV transmission.
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| 3. |
- 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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| 4. |
- 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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| 5. |
- Laisser, Rose Mjawa, 1956-
(författare)
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Prevention of intimate partner violence : community and healthcare workers´ perceptions in urban Tanzania
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Intimate partner violence (IPV) against women is public health and human rights concern. The studies forming this thesis seek to understand healthcare worker and community attitudes and perceptions about IPV; their role in support, care and prevention of IPV, and the feasibility of introducing routine screening for IPV among women attending healthcare. Methods: Four interrelated studies were conducted in Temeke District, Dar es Salaam, Tanzania: 1) a content analysis of 16 in-depth interviews with healthcare workers about their experiences of meeting IPV clients, 2) a grounded theory analysis of seven focus group discussions that explore community perceptions, 3) a cross sectional study of 657 healthcare workers and students to understand their attitudes and perceptions about IPV and future roles in care and support, and 4) evaluation of a pilot intervention that introduces routine screening in an outpatient department. The pilot intervention included screening of 102 women, ten observations of healthcare worker interactions with women clients, three focus group discussions, and five narratives written by healthcare workers about their experiences with the screening tools. Results: Gender inequalities, attitudes, and poverty intersect in the explanation of IPV. Healthcare workers view low economic status among women, rigid gender norms, and stigma that influences women to stay in violent relationships. Alcohol abuse, multiple sexual partners and low levels of income among men were cited as triggers for IPV episodes. Between 20-67% of healthcare workers and students report meeting IPV clients at work. More than 9o% observed clients with unexplained feelings of sadness and/or loss of confidence. Resource and training limitations, heavy workloads and low salaries constrain services. A strong desire to make a difference in the care and support of IPV clients was present, but violence as a hidden agenda with a client resistance to disclosure was a challenge. The community study shows a transition in gender norms is making violence against women less acceptable. Conclusions and suggestions: Healthcare workers and the community strongly wish and are committed to support IPV prevention. Both groups understood the meaning, provocative factors and some IPV effects. This awareness contributes to their desire to be part of a change. At the central level, prevention of IPV should be on the governments’ policy agenda and should be prioritised. Education about gender-based violence must be incorporated into the curricula of healthcare workers. At community level, advocacy is necessary for changing harmful gender norms and measures to combat women’s poverty. Men should be engaged at all levels. Provision of information on the human rights perspectives of IPV should be strengthened and related to other types of violence.
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| 6. |
- Majoko, Franz, 1955-
(författare)
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Assessing Antenatal Care in Rural Zimbabwe
- 2005
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Antenatal care has been associated with improved maternal and perinatal outcomes but there is no agreement on the most effective model in terms of content as well as the number and timing of visits. A cluster randomised controlled trial was conducted in a rural area of Zimbabwe to assess a 5-visit goal-oriented antenatal care model against standard care. In the same population was also determined the sensitivity of factors used for risk screening to predict pregnancy complications and the effectiveness of the referral system in managing women with identified risk markers or pregnancy complications. Pregnancy records of 10 572 out of total 13 517 recruited women were available for analysis. The new model did not change the number of visits but resulted in better use of health care. The classical risk screening system had low predictive value and identified too large a risk group for referral. Nulliparous women had an increased risk for pregnancy complications whereas women with previous uncomplicated pregnancies were at low risk of complications even with high parity. Multiparous women with previous complications had an increased risk of complications but better utilisation of health care services for delivery reduced adverse perinatal outcomes. There was a functional referral system in Gutu and women complied with referral indications but efficiency of the system was reduced by failure of care providers to comply with referral recommendations. Antenatal care can be improved in a rural setting through a focussed programme and the unpredictability of many pregnancy complications limits the value of antenatal risk screening. Until universal access to essential obstetric care facilities is attained in low resource settings, a critical re-examination of risk factors could avoid overburdening the referral system.
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| 7. |
- Mgaya, Andrew Hans
(författare)
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Improving the quality of caesarean section in a low-resource setting : An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes.This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process. In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.
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| 8. |
- Muganyizi, c, 1961-
(författare)
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Rape against Women in Tanzania : Studies of Social Reactions and Barriers to Disclosure
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis assessed responses toward rape against women as experienced by the victims and victim supporters in the context of the interaction between victims, supporters, and formal agencies in Tanzania. The overall research design was based on triangulation with a combination of qualitative and quantitative methods. A semi-qualitative study, in which free listings and semi-structured questionnaires were used, explored social reactions from 44 community nurses and 50 rape victims (Paper I). A tool developed from this first study was utilized for collecting data on people’s attitudes and their behavior toward rape and rape victims from a representative community sample of 1505 men and women aged 18-65 years (Paper II). Both studies helped to access suitable rape victims and supporters who participated in the third study to share experiences on the process of rape disclosure to formal and informal social networks (Papers III and IV). The results highlighted the salient social reactions and how rape victims perceived the impact of these reactions. Half of the participants interpreted rape situations based on social relationships, circumstances, and social status of the woman, rather than the legal definition. Two-thirds of the adults explained they would express negative social reactions toward a victim in some rape scenarios, and this correlated with their attitudes towards rape and rape victims. A variety of barriers in the informal and formal networks with potentially negative impacts on rape reporting, service utilization and, health outcomes were identified. In conclusion, successful interventions aimed at improving people’s response to rape, rape disclosure and, health outcomes in Tanzania should assume a holistic approach to address the negative factors identified at the individual, family and, community levels without forgetting the normative context that appears to underlie most decisions and practice.
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| 9. |
- Numan Hellquist, Barbro, 1982-
(författare)
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Breast cancer screening with mammography of women 40-49 years in Sweden
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background The debate regarding the lower age limit for mammography service screening is old and lively; a product in part of the lower breast cancer risk in younger ages as well as the limited data available for studies of the younger age group. Recently the idea of inviting only high risk groups has gained momentum, however high risk might not be equivalent to greater benefit from screening. Therefore, there is a need for information on effectiveness of screening as it relates to young women and to specific risk groups. To this end, this thesis evaluates mammography screening for the age group – 40 to 49 year old women – in terms of breast cancer mortality reduction in total and in subgroups based on breast cancer risk factors. Overdiagnosis of mammography screening is also evaluated for women 40 to 49 years old. In addition, this thesis presents a statistical method to estimate this effectiveness and to test for differences in effectiveness between subgroups adjusted for non-compliance and contamination.Methods The studies of this thesis are based on data from the Screening of Young Women (SCRY) database. The SCRY database consists of detailed information on diagnosis, death, screening exposure and risk factors for breast cancer cases and population size by year (between 1986 and 2005) and municipality for women in Sweden between 40 and 49 years old. The material was divided into a study group consisting of the counties that invited women in the age group 40-49 years to mammography screening, and a contemporaneous control group consisting of the counties that did not. Effectiveness was estimated in terms of rate ratios for two different exposures (invitation to and participation in screening), and overdiagnosis for subsequent screening was estimated adjusting for lead time bias. Defining a reference period enabled adjustment for possible underlying differences in breast cancer mortality and incidence. A statistical model for adjusting for non-compliance and contamination in randomised controlled trials was further developed to allow for adjustment in cohort studies using a Poisson model with log-linear structure for exposure and background risk.Results During the study period (1986-2005), there were 619 and 1205 breast cancer deaths and 6047 and 7790 breast cancer cases in the study group and the control groups, respectively. For women between 40 and 49 years old, the breast cancer mortality reduction was estimated at 26% [95% CI, 17 to 34%] for invited to screening and 29% [95% CI, 20 to 38%] for attending screening. The RR estimates for the high-risk groups based on the risk factors parity, age at birth of first child, and socio-economic status were equal to or higher than that of the low risk groups. The new statistical method showed that the decrease in effectiveness with parity was not a statistically significant trend. The overdiagnosis from subsequent screening for 40 to 49 year old women was estimated at 1% [95 % CI, -6 to 8 %] (i.e., not statistically significant).Conclusion Subgroup specific effectiveness was also estimated. The relative effectiveness of screening for breast cancer with mammography for women age 40 to 49 years appears to be comparable to that for older women. These findings and the fact that there was no statistically significant overdiagnosis from subsequent screening speak for inviting women 40 to 49 years old to screening. High-risk screening for nulliparous women aged 40 to 49 years, for example, might be an alternative in countries where population-based screening for all women between 40 and 49 years old is not possible. However, the matter of risk factors and the effect of their combinations is complex and risk group screening presents ethical and practical difficulties. The new statistical model is a useful tool for analysing cohorts with exposed and non-exposed populations where non-compliance and contamination is a potential source of bias.
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| 10. |
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