Safe sex, gender and responsible youth in Mozambique

Project period: 2007-2011

Project team:

Christian Groes-Green, Institute of Public Health, University of Copenhagen

 

Partner institutions:

Mailman School of Public Health, Columbia University, US
University Eduardo Mondlane, Mozambique

 

Project description:

It is widely documented that the large majority of youth in sub-Saharan Africa practice unsafe sex despite high risks of infection with HIV/AIDS. Nevertheless, despite the fact that the majority of youth underlie these constraints there is also a minority who challenges them and to different degrees practices safe sex. This study argues for shifting the focus towards this minority in order to understand how, against all odds, some youth develop identities and gender notions that are less constraining and different from those that lead to unprotected sex. In terms of policy the assumption is that a detailed understanding of the factors that facilitate safe sex will lead to new ways of targeting the large majority who practice unsafe sex despite high knowledge of HIV transmission.

The project aims to explore how emerging masculinities and femininities enhance safe sex practices among secondary school youth in Maputo, Mozambique. Among factors favoring alternative gender notions are exposure to school based peer education about sexual and reproductive health through a national program supported by Danida as well as the influence of national laws and global discourses promoting gender equality and women’s empowerment.

 

Specific objectives:

To develop an understanding of the ‘positive’ or ‘responsible’ practices of youth by exploring gender notions and external influences which motivate safe sex, in order for donors to improve future interventions in the area of HIV/AIDS prevention in Mozambique.

To enhance the theoretical understanding of alternative femininities and masculinities by identifying why some youth groups develop alternative gender notions favoring safe sex and in order to suggest new ways to empower women/girls and educate men/ boys in safe sex.

To suggest new methods of targeting adolescents through education by investigating to which extent peer education in Mozambique provides adolescents with a critical consciousness enabling them to oppose prevalent sexual norms and gender inequalities.

 

Budget: DKK 1.780.000

 

Contact

Christian Groes-Green:chgr@sund.ku.dk

Malaria infection during pregnancy: determining the time points of highest vulnerability – A project under STOPPAM (Strategies TO Prevent Pregnancy Associated Malaria)

Project period: 2008-2011

Project Team:

Christentze Schmiegelow, MD/PhD student, Centre for Medical Parasitology (CMP), Institute of International Health, Immunology and Microbiology (ISIM), University of Copenhagen and Department for Infectious Diseases, Rigshospitalet, Denmark
Professor Thor Theander, CMP, ISIM, University of Copenhagen and Department for Infections Diseases, Rigshospitalet, Denmark
Birgitte Bruun Nielsen, MD, PhD, Department of Obstetrics and Gynaecology, Aarhus University Hospital, Skejby, Denmark
Vibeke Rasch MD, PhD, DMSc, Department of Obstetrics and Gynaecology, Odense University Hospital and ISIM, University of Copenhagen

 

Partner Institutions:

National Institute for Medical Research, Tanga Region, Tanzania
Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
Department of Immunology, Wenner-Gren Institute, University of Stockholm, Sweden
Institut de Recherche pour le Développement (IRD), Paris, France
Research Unit 010 (UR010), Mother and Child Health in the Tropics, Development Research Institute (IRD), Cotonou, Benin
ALMA consulting group, France

 

Project description:

“Malaria infection during pregnancy – determining the time-points of highest vulnerability” is a PhD project and a specific subcomponent under the STOPPAM – Strategies TO Prevent Pregnancy Associated Malaria – project conducted in Tanzania and Benin. STOPPAM is a collaboration between CMP and the partner institutions mentioned above. The objective of STOPPAM is to map pregnancy-associated malaria (PAM) from a clinical, pathological, immunological and parasitological perspective. The knowledge gained will facilitate the development of a vaccine against PAM and optimisation of the prevention strategies currently existing.

The subcomponent “Malaria infection during pregnancy – determining the time-points of highest vulnerability” is specifically focusing on the clinical consequences of PAM.

 

Background: Malaria in pregnancy caused by Plasmodium falciparum has detrimental effects on both mother and offspring. It is a major cause of abortion, stillbirth, low birth weight and preterm delivery and increases the risk of maternal anaemia which contributes to maternal mortality. Recent studies have shown a possible link between PAM and the development of hypertensive disorders (pregnancy-induced hypertension and preeclampsia); disorders that, as PAM, are leading causes of maternal and foetal/infant mortality and morbidity in developing countries.

Currently PAM is tackled through treatment of identified cases and prevention strategies comprising of intermittent prophylactic treatment (IPTp) and bednets. Even though PAM is often asymptomatic, consequences of the infection are seen later in pregnancy and upon delivery. Increasing resistance to the drugs used for prevention strategies is also an ever-present challenge. The current strategies to prevent the consequences of PAM are therefore insufficient.

To overcome PAM, optimisation of the current prevention strategies and a vaccine are needed. This is only possible if the pathogenesis of PAM is better understood and the time-points of highest vulnerability to the infection are identified.

 

Aim: To contribute to a better understanding of PAM from a clinical point-of-view. The overall objective of the PhD study is to measure birth outcome, monitor maternal health (including the development of hypertensive disorders) and assess intrauterine growth by ultrasound investigations and relate these findings to knowledge about parasite exposure during the pregnancy.

 

Methodology: A cohort of 1000 pregnant women residing in Korogwe District, North-East Tanzania is followed from their first antenatal booking until delivery. They are screened for malaria infection, anaemia, hypertensive disorders and signs of foetal/infant compromise at regular visits in the Reproductive and Child Health clinic as well as upon delivery. To identify foetal compromise and to further characterise the origin of low birth weight ultrasound investigations will be performed regularly during the pregnancy. This will enable us to identify the occurrence and timing of intra-uterine growth retardation in respect to parasite exposure.

Upon delivery, birth anthropometry will be measured, the mother’s health will be assessed with special focus on malaria infection and hypertensive disorders and placental specimens will be collected to further characterise the exposure to malaria and signs of inflammatory reactions.

 

 

Funding: European Union Framework 7 and University of Copenhagen.

 

Contact

Christentze Schmiegelow, MD, PhD student, Centre for Medical Parasitology, University of Copenhagen

christentzeschmiegelow@hotmail.com

www.cmp.dk / www.stoppam.org

Primary and secondary prevention of cervical cancer in Tanzania

Project period: 2008-2011

Project team:

Main Researcher Denmark: Myassa Dartell, PhD student, Dept. International Health, Immunology and Microbiology (ISIM), Copenhagen School of Global Health, Faculty of Health Sciences, University of Copenhagen and Dept. Virus, Hormones and Cancer, Danish Cancer society (Kræftens Bekæmpelse).
Main Researcher Tanzania: Crispine Kahesa, PhD student, Ocean Road Cancer Institute (ORCI), Tanzania and Dept. International Health, Immunology and Microbiology (ISIM), Copenhagen School of Global Health, Faculty of Health Sciences, University of Copenhagen.
Main Supervisor: Vibeke Rasch, MD, PhD, ISIM and Odense University Hospital
External Supervisor: Susanne Kjaer, MD, Prof, PhD, chief of department, Virus, Hormones and Cancer, Danish Cancer society (Kræftens Bekæmpelse
External Supervisor: Christian Munk, MD, PhD, co-leader of department, Virus, Hormones and Cancer, Danish Cancer society (Kræftens Bekæmpelse)
External Supervisor: Julius Mwaiselage, MD, PhD, chief of department, Cancer prevention and screening, Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania.

 

Partner institutions:

Ocean Road Institute, Dar es Salam, Tanzania
Institute of Virology, Tuebingen, Germany
Centre for International Health, University of Copenhagen
Danish Cancer Association

 

Project description:

Each year 500,000 new cases of invasive cervical cancer are diagnosed and 250,000 women die annually from this disease. The vast majority of cervical cancer cases (99,7%) are linked to genital infection with HPV. Vaccines against this virus are likely to be highly effective in preventing cervical cancer. Characterization of the HPV types from different geographical areas is essential in the development of an effective vaccine. However, in Tanzania the different subtypes of HPV and their epidemiology is largely unknown. There is therefore a great need of information about the different HPV subtypes being present in Tanzania. The impact of a vaccine on reducing cervical cancer mortality will, however, not be measurable for decades to come and vaccine initiatives need to be introduced in conjunction with other prevention strategies, such as screening and treatment of pre-cancerous lesions.

It is the aim of the study to assess the prevalence and type distributions of HPV in rural and urban Tanzania and to describe the coverage level and characteristics of underserved women on an existing screening programme in Dar es Salaam.

Tow sub-studies will be conducted: sub-study I, which will describe HPV prevalence and HPV typology among 2000 women living in Dar es Salaam and 2000 women living in Mwanza and; sub-study II, which will describe the coverage level of the existing screening programme in Dar es Salaam, the characteristics of underserved women and barriers to women’s participation in screening. A combined quantitative and qualitative approach will be utilised. Laboratory analyses will be used to assess the HPV prevalence and HPV typology. Structured questionnaire interviews will be used to obtain information about socioeconomic situation, reproductive history, STIs/HIV and distance to health facility. A case control approach will be applied, in which women who are attending the screening programme will comprise the case group in comparison with women who are attending the program. The qualitative part will rely on in-depth interviews performed among women who are not attending and women who are attending the program as well as among key persons involved in the cervical cancer screening program.

 

 

Budget: DKK 3.157.000

 

Contact

Vibeke Rasch: vira@sund.ku.dk

Wired mothers – use of mobile phones to improve maternal and neonatal health in Zanzibar

Project period: January 2009 – December 2010

Project team:

Stine Lund (MD, principal investigator)
Maryam Hemed (MD, Gynaecologist)
Khadija S. Said (MD, Gynaecologist)
Rashid Kombo (Statistician)
Azzah Said (AMO coordinator reproductive and child health, Ministry of Health and Social Welfare, Zanzibar)
Mkoko Makundu (MD, Zonal Medical Officer, Ministry of Health and Social Welfare, Zanzibar)
Associate Professor Vibeke Rasch (MD, PhD, University of Copenhagen, supervisor)
Birgitte Bruun Nielsen (MD. PhD University of Copenhagen, supervisor)

 

Partner institutions:

Ministry of Health and Social Welfare, Zanzibar, Tanzania
Health Sector Programme Support Zanzibar
University of Copenhagen

 

Project description:

The study aims to examine the beneficial impact of use of mobile phones for health care on maternal and neonatal morbidity and mortality, and to seek innovative ways to ensure access to skilled attendance at delivery through an intervention called “wired mothers”. Wired mothers are pregnant women linked to a primary health care unit through use of mobile phones receiving standard sms reminders for care appointments and who can call the primary provider in case of acute or non acute problems. It is also the aim to study the health system’s response in relation to obstetric emergencies when using mobile phones to strengthen communication between different levels (from TBA to referral hospital).

 

Specific objectives:

To investigate attendance to routine primary health care appointments amongst wired and non wired women;
To investigate the level of facility based deliveries amongst wired and non-wired women.
To investigate the morbidity amongst wired and non-wired women
To investigate the quality of services provided to wired and non-wired women
To investigate neonatal morbidity and mortality amongst children born by wired and non-wired mothers.

 

Budget: DKK 3,305,192

 

Contact

Stine Lund: stine_lund@dadlnet.dk

Strengthening Population & Reproductive Health Research in Vietnam (REACH): A Capacity-Building and Interdisciplinary Research Project

Project period: 2005-2009

Project team:

Director Quoc Anh
Director Chien
Vibeke Rasch, MD, PhD, Dr Med Sci
Ass Professor Tine Gammeltoft
External Lecturer Lise Rosendal Østergaard

 

Partner institutions:

International Health Unit, Institute for International Health, Immunology and Microbiology, University of Copenhagen
Institute of Anthropology, University of Copenhagen
General Office for Population and Family Planning, Vietnam
Hanoi Medical University, Vietnam

 

Project description:

The REACH project is part of the Bilateral Programme Enhancement of Research Capacity in Developing Countries (ENRECA) funded by the Danish development agency Danida. It is a partnership arrangement between University of Copenhagen and the Vietnamese Commission for Population, Family and Children (VCPFC).

The purpose of the REACH project is to enhance the research capacity in Vietnam within the field of Sexual and Reproductive Health and Rights and HIV/AIDS. This is done through close co-operation between Vietnamese and Danish researchers as a twinning-arrangement between two partner institutions: the Vietnamese Commission for Population, Family and Children and University of Copenhagen. The project is funded by the Danish Ministry of Foreign Affairs.

 

Read more: www.inthealth.ku.dk/reach/

 

Contact

Vibeke Rasch, MD, PhD, Dr Med Sci, Department of Obstetric and Gynaecology, Odense University Hospital and ISIM, University of Copenhagen

Email: vira@sund.ku.dk

 

PRegnancy Outcome and MIcronutrient Supplementation in Ethiopia (PROMISE). The effect of perinatal micronutrient supplementation: A randomised study.

Project period: 2008-2011

Project team:

Professor Henrik Friis, Dept Human Nutrition, KU-LIFE, Denmark
Assistant Professor Tsinuel Girma, Dept of Paediatrics, Jimma University, Ethiopia
Partner institutions: Jimma University, Ethiopia

 

Project Description:

Background: Pregnant women are considered at increased risk of micronutrient deficiencies because nutritional needs are increased during pregnancy. UNICEF ten years ago suggested changing the recommendations for prenatal micronutrient supplementation from the existing iron and folic acid supplement to multi-micronutrients. However, results from trials testing the suggested supplement containing 1 DRI (daily recommended intake) are disappointing with relatively small effects on BW which was apparently not accompanied by a reduction in neonatal mortality as expected. The main outcome in most studies was birth weight which may be too rough to predict survival. Body composition is most likely a better predictor of survival than is body weight. Further, few studies have obtained promising results of micronutrient supplementation in high doses, particularly vitamins B, C and E (BCE). In the PROMISE study we will assess the effect of perinatal supplementation with BCE in addition to other essential micronutrients.

 

Aim: To evaluate the effect of high dose perinatal multi-micronutrient supplementation on birth weight and body composition. Further, the effects on infant morbidity and mortality, motor milestones, and prevalence of maternal anaemia will be assessed. Analyses will be stratified by HIV status.

 

Methodology: The study is a randomised, controlled trial in which two different high dose micronutrient supplements are compared with the standard of care in antenatal supplementation (iron and folic acid). A total of 8000 pregnant women are given a daily supplement of A) 2 DRI of 15 micronutrients including iron and folic acid, B) the same as A, but with higher doses of BCE from first antenatal contact until three months after delivery, or C) iron and folic acid until delivery followed by placebo until three months after delivery. Birth anthropometry will be measured using standard methods and body composition of newborns will be measured using air displacement plethysmography (Peapod). Infants and mothers will be followed closely during the first year of life during which growth, change in body composition, hospitalisations and mortality will be assessed.

 

Scope of study: This study will provide knowledge to support the decision whether public multi-micronutrient supplementation should be part of the international recommendations for antenatal care.

 

Project budget: Total 12.7 mio DKK (Danida, FØSU, Novo, Forskningsrådet for Sundhed og Sygdom).

 

Contact

Henrik Friis, MD, PhD
Professor of International Nutrition and Health
Dept of Human Nutrition, University of Copenhagen
hfr@life.ku.dk

Development of a strategy for improved Antenatal Care in low income settings – experiences from Jimma town health facilities, Ethiopia

Project period: 2008-2011

Project team:

PhD student Sarah Fredsted Villadsen
Professor Henrik Friis, Dept Human Nutrition, KU-LIFE, Denmark
MD/PhD Vibeke Rasch, Institute of International Health, Immunology, and Microbiology, Denmark
Assistant Professor Dereje Negussie, Dept of Gynaecology and Obstetrics, Jimma University, Ethiopia.

 

Partner institution: Jimma University, Ethiopia

 

Project description:

Background: Pregnancy and child birth are major health challenges, and reduction in maternal mortality is one of the Millennium Development Goals. Despite being high on the political agenda, little progress have been made, and in developing countries complications during pregnancy and childbirth are leading causes of disability and death among women in reproductive age. In Ethiopia the maternal and infant mortality are among the highest in the world. Many studies have investigated barriers for not using antenatal care (ANC) and delivery services as well as poor health outcomes of mother and child, but little is known about what interventions implemented within the frames of public financed health facilities in low income countries, could have positive effect on mother and child health. Evaluation of interventions for improved maternal and infant health and survival in public financed health care systems are thus needed.

 

Aim: To develop a participatory strategy to improve utilization and quality of ANC services in a low income setting.

 

Methodology: This study will be conducted with an interdisciplinary approach combining quantitative and qualitative methods. A local situation analysis of the ANC and delivery service will be conducted by study of routine data, field observation and qualitative interviews. By participatory methods ideas for improved service will be sought among the health staff responsible for the maternal and neonatal health. Further, the needs, experiences and wishes regarding the health system of the mothers with newborns will be analysed through qualitative interviews. On behalf of these input an intervention will be designed and implemented. Indicators of the study outcomes will be measured before and after intervention in routine data from the health facilities combined with a community based survey. The data will be collected in several study sites to evaluate the change in outcomes in settings with and without intervention.

 

Project budget: DKK 2,5 mill as part of a larger research collaboration with Jimma University, Ethiopia.

 

Contact

Sarah Fredsted Villadsen: sfv@life.ku.d

Quality of emergency obstetric and neonatal care in Kagera Region, Tanzania

Project period: 15 June 2007 – 14 June 2010  

Project team (PhD study):

Main Reasearcher: Bjarke Lund Sørensen, MD, Dept. International Health, Immunology and Microbiology (ISIM), Copenhagen School of Global Health, Faculty of Health Sciences, University of Copenhagen
Main Supervisor: Vibeke Rasch, MD, PhD, ISIM and Odense University Hospital
External Supervisor: Birgitte Bruun Nielsen, MD, PhD, consultant OB-GYN, Aarhus University Hospital, Skejby
External Supervisor: Peter Elsass, professor of Psychology, Dr.Med., Dept. of Psycology, University of Copenhagen
External Supervisor: Siriel Massawe, MD, PhD, consultant OB-GYN, MUHAS, Dar es-Salaam, Tanzania

 

Partner institutions:

Copenhagen School of Global Health, University of Copenhagen
Dept. of Psychology, University of Copenhagen
Odense University Hospital
Aarhus University Hospital, Skejby
Muhimbili University of Health and Allied Sciences (MUHAS), Dar es-Salaam, Tanzania
Regional Medical Officer, Kagera Region, Tanzania
Advanced Life Support in Obstetrics (ALSO) Tanzania, Malawi, UK and Internationational Advisory Board

 

Project description:

Background: Why mothers come late for emergency obstetric care?
I went to Tanzania in 2007 to do my PhD study and find out why pregnant women come too late for treatment when they suffer complications. In Tanzania, the risk of women dying in relation to pregnancy and childbirth is hundred times higher as in Denmark. UN fifth millennium development goal is to reduce maternal mortality 75% by 2015. The strategy for achieving this goal is to get 90% of all births to take place with a “skilled delivery attendant” – a midwife or a doctor. Half of the women in Tanzania give birth at home and the aim of my study was in the beginning to clarify why many women do not seek the services of the health system. I observed births at home, at small health posts and the large regional hospital and spoke with the families and the involved birth attendants. Doctors and midwives said that many women are “indifferent” to their health, they are “ignorant” and “lazy” or that there are “cultural barriers”. This image was difficult to recover when I spoke to the women and their families, they explained that it was first and foremost economic conditions that could prevent them from reaching the health post or hospital. I examined the preparedness to deal with birth complications at the health posts in the villages – it proved to be very sparingly. During the month I spent at the regional hospital several maternal deaths took place, all of which could easily have been avoided.

 

Maternal deaths at Kagera Regional Hospital
I will never forget the Saturday morning I arrived at a chaotic labour ward where two midwives struggled desperately. A woman who was delivered two hours previously, lay unconscious bleeding heavily. The floor sailed in her blood. I quickly got a white coat and gloves on and had compressed the uterus so that the bleeding stopped. I got intravenous access, got a saline drip running and administered medications to contract the uterus. I could not feel the woman’s pulse and the blood pressure was immeasurable. Her mucous membranes were snow-white as a sign that she had lost most of her blood. The staff of the blood bank had not met at work yet, so we got no blood. The woman had cardiac arrest and we began resuscitation. The oxygen concentrator did not work, because there was a power cut and the emergency generator was not deployed. The mask and the balloon to blow air into her lungs were old and leaking and practically useless – there was nothing we could do. We had to give up and go the heavy way out to her husband and tell that his wife had not survived the birth – he practically melted in the hands of me – fell lax on the stairs and wept as he shook. Two daughters were in their finest dresses to say congratulations to their mother – I will never forget their sweet, expectant smile, with a stroke turned to deep despair and horror – they wept and screamed and ran around wild, while they tore the clothes off the washing from dry rope outside the maternity ward. At this moment the doctor in call arrived, three hours after he had been summoned. “This is life at a hospital,” he said with a smile, “Shit happens”. I was not able to answer him. While I was at the hospital a second woman died in the same way from exsanguinations, a third of eclampsia (hypertensive disorder of pregnancy) after being treated wrong and too late, a fourth had a retained placenta, which was not removed in seventeen hours, so she died of severe infection, a fifth had an infected illegal abortion that did not get the evacuation of the uterus that could have saved her life.

 

Facility delays in emergency obstetric care
It appeared to me that I might have looked in the wrong place searching for why women with birth complications were treated too late. It was perhaps not the women who were “indifferent” and “came too late” – but the health system that failed. I went through the health statistics. In Kagera region virtually every registered maternal death occurred in a hospital. I found the case files, went through the record books and operation records and interviewed staff, and the picture was becoming clear. Five out of six maternal deaths at the regional hospital occurred because of missing or significantly delayed treatment. Half of the women who died had been hospitalized two days or more before they died.

 

Advanced Life support in Obstetrics (ALSO)
I decided to change my study focus and try to see what impact it would have to train staffs in Emergency Obstetrics Care – the basic skills to handle pregnancy and childbirth complications. I chose to work with Advanced Life Support in Obstetrics (ALSO), which is the most common obstetric emergency training course in the world – I was in the U.S. and got the green light to start the course in Tanzania, went to England and was trained as ALSO instructor and managed to get together a good team of trainers. I revised the course content so that it matched African conditions.

In September 2008, we carried out the first ALSO courses in Tanzania for the staff at Kagera Regional Hospital. I had been very curious about how everything would go, but the reception was overwhelmingly positive. With a team of research assistants I had followed the deliveries at the maternity ward in the months leading up to training. All women had the bleeding after birth measured – it turned out that every third woman was bleeding too much, more than half a litre. At the ALSO course, we used role-playing and training mannequins to practice the simple skills that can stop any bleeding before it becomes life threatening. In the months after the training the number of women bleeding more than half a litre was reduced by 50%. Bleeding after childbirth is the most frequent cause of maternal deaths and with the ALSO training we showed that short, intensive training can improve the health of personnel handling considerably. The course lasting two days also addressed a number of other important maternal and neonatal complications and had a positive impact on other topics than bleeding complications. For example was neonatal mortality reduced. The courses were a great success and since then four more courses were conducted and a number of Tanzanian instructors trained. More courses are planned and we have now established a network among ALSO groups in Kenya, Rwanda, Malawi and Tanzania with the aim to document, develop and disseminate the course.

 

Contact

Bjarke Lund Sørensen:
bjarkebjarke@yahoo.dk

The ePartogram System for improving maternal and perinatal health

Nanna Maaløe, MD, PhD student, ISIM, University of Copenhagen

The ePartogram System for improving maternal and perinatal health
-an assessment of its effectiveness and feasibility in reducing adverse pregnancy outcomes in an East African referral hospital

Overall objectiveTo analyze the effect on quality of care during active labour of applying first a paper-based partogram system and later an electronic partogram system in an East African low resourced referral hospital, and – if effective – to stimulate adaption and up scaling of the system(s) to other settings, such as secondary and other tertiary hospitals.
Interventions 1. WHO paper partograms and a centrally located blackboard with an overview of women in labour (the P-Partogram System).
2. Jhpiego’s electronic partograms and a centrally located digital screen showing an overview of the ePartogram data on women in labour (the E-Partogram System).
Design Two intervention-based pre vs. post studies.
Setting Department of Obstetrics and Gynecology, Mnazi Mmoja Hospital, Zanzibar.
Population Labouring women and their offspring as well as health providers at the Department.
Sample size All deliveries at the Department from October 2014 to April 2017. Also, initial participant observations in September 2014.
Duration Pregnant women and their offspring will be enrolled at/after unset of labour and followed until discharge.
Endpoints The primary endpoint is perinatal mortality. Secondary endpoints include: maternal and perinatal outcome variables; process indicators of care during active labour; indicators of health providers’ knowledge, work satisfaction, and clinical performance; level of satisfaction among patients; and the cost of health adjusted life years gained.
Study time Data collection from September 2014 to April 2017. This requires that ethical clearance and permission from Zanzibar Medical Research and Ethics Committee is in place.