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Sociocultural and health system factors associated with mortality among febrile inpatients in Tanzania: a prospective social biopsy cohort study
  1. Michael E Snavely1,
  2. Michael J Maze2,
  3. Charles Muiruri1,
  4. Lilian Ngowi3,
  5. Flora Mboya3,
  6. Julia Beamesderfer4,
  7. Glory F Makupa5,
  8. Anthon G Mwingwa5,
  9. Bingileki F Lwezaula6,
  10. Blandina T Mmbaga3,
  11. Venance P Maro5,
  12. John A Crump2,
  13. Jan Ostermann7,
  14. Matthew P Rubach8
  1. 1 Duke Global Health Institute, Duke University, Durham, North Carolina, USA
  2. 2 Centre for International Health, University of Otago, Dunedin, New Zealand
  3. 3 KCMC-Duke Collaboration, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
  4. 4 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5 Kilimanjaro Christian Medical University College, Moshi, Tanzania
  6. 6 Mawenzi Regional Referral Hospital, Moshi, Tanzania
  7. 7 Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
  8. 8 Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
  1. Correspondence to Dr Matthew P Rubach; matthew.rubach{at}duke.edu

Abstract

Introduction Communicable diseases are the leading causes of death in Tanzania despite the existence of effective treatment tools. We aimed to assess the sociocultural and health system factors associated with mortality from febrile illness in northern Tanzania.

Methods We interviewed febrile inpatients to determine prevalence of barriers in seeking or receiving care and grouped these barriers using the Three Delays model (delays at home, in transport and at healthcare facilities). We assessed 6-week mortality and, after matching on age, gender and severity of illness, measured the association between delays and mortality using conditional logistic regression.

Results We enrolled 475 children, of whom 18 (3.8%) died, and 260 adults, of whom 34 (13.0%) died. For children, home delays were not associated with mortality. Among adults, a delay in care-seeking due to not recognising severe symptoms was associated with mortality (OR: 3.01; 95% CI 1.24 to 7.32). For transport delays, taking >1 hour to reach a facility increased odds of death in children (OR: 3.27; 95% CI 1.11 to 9.66) and adults (OR: 3.03; 95% CI 1.32 to 6.99). For health system delays, each additional facility visited was associated with mortality for children (OR: 1.59; 95% CI 1.06 to 2.38) and adults (OR: 2.00; 95% CI 1.17 to 3.41), as was spending >4 days between the first facility visit and reaching tertiary care (OR: 4.39; 95% CI 1.49 to 12.93).

Conclusion Our findings suggest that delays at home, in transport and in accessing tertiary care are risk factors for mortality from febrile illness in northern Tanzania. Interventions that may reduce mortality include community education regarding severe symptoms, expanding transportation infrastructure and streamlining referrals to tertiary care for the sickest patients.

  • fever
  • social determinants of health
  • health services accessibility

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000507

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    Footnotes

    • Transparency declaration The guarantor affirms that this manuscript is an honest, accurate and transparent account of the study being reported. No important aspects of the study have been omitted. Any discrepancies from the study as planned have been explained.

    • Handling editor Soumitra Bhuyan

    • Contributors Conceived and designed the study: MPR, JAC, JB and MJM. Performed the study: MJM, LN, FM, BTM, VPM, BFL, GFM and AGM. Analysed the data: MES, JO, CM, MJM and MPR. Wrote the manuscript: MES, MJM, CM, JB, BTM, VPM, JAC, JO and MPR. Sought and obtained funding: MPR, VPM, BTM and JAC. Guarantor: MES. All author contributions were made independently from any funding source.

    • Funding This study was supported by the US Health Resources and Services Administration through the Medical Education Partnership Initiative (T84HA21123), the US National Institutes of Allergy and Infectious Diseases through the Investigating Febrile Deaths in Tanzania (INDITe) grant (R01AI121378) and the Fogarty International Center through The Impact and Society Ecology of Bacterial Zoonoses in Northern Tanzania grant (R01TW009237). MPR received support from a National Institutes of Health Early Career Award (K23) grant (AI116869) and a Fogarty International Center Global Health Training Grant (R25TW009343). JB received support from Doris Duke International Clinical Research Fellowship. MJM received support from a University of Otago Frances G Cotter Scholarship.

    • Competing interests None declared.

    • Ethics approval This study was approved by the KCMC Research Ethics Committee, the Tanzania National Institute for Medical Research National Research Ethics Coordinating Committee and an institutional review board of Duke University Health System.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The full dataset and statistical code are available from the corresponding author at matthew.rubach@duke.edu. The presented data are anonymised, and risk of identification is low.