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Salmonella enterica serotype Typhi (S. Typhi) was estimated to cause over 200,000 deaths and more than 21 million illnesses worldwide, including over 400,000 illnesses in Africa. The current study was conducted in four villages on Pemba Island, Zanzibar, in 2010. We present data on policy makers’, health administrators’, and village residents’ and leaders’ perceptions of typhoid fever, and hypothetical and actual health care use among village residents for typhoid fever. Qualitative data provided descriptions of home-based treatment practices and use of western pharmaceuticals, and actual healthcare use for culture-confirmed typhoid fever. Survey data indicate health facility use was associated with gender, education, residency, and perceptions of severity for symptoms associated with typhoid fever. Data have implications for education of policy makers and health administrators, design and implementation of surveillance studies, and community-based interventions to prevent disease outbreaks, decrease risks of complications, and provide information about disease recognition, diagnosis, and treatment. Copyright © 2013 by The American Society of Tropical Medicine and Hygiene.
Data were collected in two phases. The first phase included qualitative one-on-one interviews with policy makers, healthcare administrators, local village leaders (shehas), and residents. These qualitative interviews were designed to explore participants’ experiences and perceptions regarding typhoid fever, other infectious disease, and use of treatments and health facilities. The qualitative interviews provided contextual data, which was used independently and a supplement to the survey data. The second phase included a randomized household survey focused on healthcare utilization and accessibility, engagement in safe water and sanitation practices, knowledge of typhoid fever, and vaccine desirability. The survey provided more generalizable data, and the ability to determine potential associations between variables, e.g., demographics and perceptions of typhoid fever and healthcare utilization. Zanzibar is located off the coast of Tanzania and includes two main islands, Unguja and Pemba. Although part of the Republic of Tanzania and Zanzibar, Zanzibar remains semi-autonomous with an independent government, including executive and legislative bodies, and various ministries, e.g., Ministry of Health and Social Welfare. Zanzibar’s economy is primarily agriculture-based though in recent years tourism has been an increasingly significant component of the local economy.14 In the Republic of Tanzania and Zanzibar, the 2009 Gross National Income per capita was US$500. In 2007, over 33% of the population was living below the national poverty line. Average life expectancy is 56 years.15 The under 5 years of age mortality rate in 2009 was 107.9, which is lower compared with the overall sub-Saharan region (117.7) and other low-income countries (129.6). Fertility rates remain relatively high, with 6.3 children per woman in 2002. In 2008, 45% of the rural population had access to safe water, which is comparable to the general sub-Saharan region (46.8%), but lower than the global average for low income countries (55.6%).15 The current research was conducted on Pemba Island. However, qualitative interviews with government policy makers and administrators were conducted on the neighboring island of Unguja. In the 2002 census, Pemba Island’s population was ∼350,000 with over 80% of the residents living in rural areas. According to the 2002 census, 44% of the population is younger than 15 years of age.16 Four research villages in the southern region of Pemba were purposively selected by the local and international research teams. Two villages (Pujini and Uwandani) had recent blood culture-confirmed cases of typhoid fever, whereas two villages (Matale and Umangani) had no confirmed cases. The villages differ in distance and ease of access to the administrative center, Chake Chake. Pujini is the most remote and ∼10 km from Chake Chake with a significant portion of travel time off paved roads; Uwandani is situated immediately off the main road. Qualitative interviews were conducted in Pujini and Matale with residents and local leaders (Sheha and assistant Sheha). The household surveys were conducted in all four villages. Healthcare in Zanzibar includes both public and private facilities with oversight through the Ministry of Health and Social Welfare (MOHSW). Private facilities on Pemba Island include over-the-counter shops and pharmacies. Public facilities include first and second line Primary Health Care Units (PHCU) at the village level, Primary Health Care Centers (PHCC) or “cottage hospitals” at 30-bed capacity, and district hospitals. First line PHCU services focus on basic health care, maternal-child care, outreach and health education services, immunization programs, and water sanitation efforts. Second line PHCU also includes laboratory facilities and dental services. PHCC include in-patient basic medical and surgical care, emergency obstetric services, psychiatric assessments, and ambulance services.17 On Pemba Island there are 58 PHCU, two cottage hospitals (PHCC), and three public district hospitals with capacity of 80–120 beds.18 One of the three district hospitals is located in Chake Chake. The research population included all residents 16 years of age and older and currently living in the four research villages. Through contact between the local research team members and the village Sheha (leaders), residents were purposively selected for the qualitative interviews based on criteria including experience with typhoid fever and socio-economic status. The Sheha or assistant Sheha were also interviewed in Matale and Pujini. For the household survey, the research team was able to use lists of assigned household numbers in each village for randomization purposes. These numbers were assigned to and marked on all village housing structures as a part of the Public Health Laboratory-Ivo de Carneri/Johns Hopkins University database. A total of 487 households were selected based on an estimated = 0.05). At completion, 435 (89.3%) households participated in the survey. Primary reasons for not participating were absenteeism during the data collection days, a household number could not be located, or a structure had been abandoned. Interview guides for policy makers and administrators, and residents and local leaders were developed for the qualitative interviews. The guides for policy makers and administrators included questions about the national and local level health infrastructure, knowledge and perceptions about typhoid fever, issues of water safety and sanitation, health outreach and education, and experiences with the Expanded Program for Immunization (EPI) and other vaccination programs. The guides for residents and local leaders focused on utilization and accessibility to healthcare facilities, water use practices, knowledge, perceptions, and experience of typhoid fever, experience with vaccination programs, and desirability for a typhoid vaccine in the future. The household survey was developed based on typhoid fever pre-vaccination survey instruments previously used in Hue, Viet Nam, and Kolkata, India.19,20 Modifications were made to the survey questions and response items based on local socio-cultural context and the qualitative interview data. The final survey included five sections: 1) demographics; 2) general healthcare utilization and accessibility; 3) hypothetical healthcare use for symptoms associated with typhoid fever; 4) knowledge, experience with, and perceptions of typhoid fever (including vulnerability, severity, prevention, treatment); 5) participation in EPI and vaccine desirability. The survey was field piloted, minor revisions were incorporated, and final checks were conducted to ensure accurate translation of the survey from English to Swahili. Both qualitative and survey data were collected in September and October 2010. Qualitative data were audiotaped. Extensive notes were also taken during all of the interviews to allow more immediate access to the data. Qualitative interviews with policy makers and administrators were conducted primarily in English by one of the U.S. team members, with a translator available to clarify questions and responses. Interviews were conducted in the offices of the respondents. Qualitative interviews with local leaders and residents were conducted at the respondents’ homes in Pujini and Matale. Interviews were conducted by a member of the U.S. team with a trained English-Swahili bilingual translator. Household survey data were collected during three consecutive days in each village. Before data collection, the local village Sheha or assistant Sheha were provided with information about the survey and were asked to assist with locating the randomly selected households. Trained data collectors were provided with the lists of selected households. The U.S. team members and the local project coordinator supervised data collection to ensure that the correct households were identified, that questions were asked as designed, and responses correctly recorded. Data collectors read the survey questions and as determined by the specific question either read responses or asked for a spontaneous answer. Responses were recorded on a survey form with a unique individual identification number. Each survey took ∼30 minutes. Respondents were given a package of laundry soap for their time. Qualitative data were transcribed and translated into English. Texts were coded for traditional medicine, general and symptom-specific healthcare utilization, accessibility of healthcare, and knowledge, perceptions, and experience with typhoid fever. As needed, terms for local medicines were researched to determine the plant species and literature regarding use of those plants for treatment of specific symptoms. Coded texts were reviewed for patterns and consistencies in relation to the research questions. Two members of the research team were involved in the coding and analysis of the qualitative data. In addition, the qualitative data were triangulated with the household survey data to further assess consistencies as well as possible contradictions between data sets. Demographic data from residents and local leaders were entered into SPSS (SPSS, Inc., Chicago, IL). Analysis of these data followed the same procedures as described below for the household survey data. Household survey data were double entered into Microsoft FoxPro 7.0 (Microsoft, Seattle, WA) by trained local staff. Raw data were reviewed and corrections were made as necessary. The raw data were converted to and analyzed in SPSS version 11.5 and frequencies, means, and ranges were run for further data cleaning. A variable was created from a scale of questions about perceived severity of typhoid fever for infants, children, adults, and elderly. Descriptive analysis provided information on demographics, healthcare utilization, and knowledge and perceptions of typhoid fever. Bivariate analysis included use of Pearson’s χ2s (categorical) and independent t tests and analysis of variance (continuous) for testing significance. Multinomial logistic regression analysis was used to determine independent association of residency (village), gender, age, and education for beliefs about cause of typhoid fever, perceived household vulnerability to typhoid fever, and symptom-specific (sustained fever for 3 days and abdominal pain) hypothetical healthcare utilization for respondent (self) and his/her child. The protocol and instruments (interview guides and survey) were approved by the ethics board at the International Vaccine Institute, Seoul, Korea, and through the Zanzibar Research Council Ethics Committee. Consents were read to respondents and respondents either signed or imprinted a fingerprint with a witness’s signature to acknowledge consent. Data collectors were trained in research ethics and consenting procedures.
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