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Asthma at Muhimbili: a clinical and laboratory study of pattern of presentation, provoking and aggravating agents, and complicating factors.
(Diss. University of Dar es Salaam, 1977) Kilonzo, Gad P.
The purpose of this study was to examine asthma patients presenting at Muhimbili Hospital with the view to: 1. Describe social and psychological features associated with asthma patient presenting at Muhimbili. 2. Describe the pattern of the disease here and compare this with that described in other parts of the worlds, with paticular emphasis on atopic disease. 3. Find out what agents provoke and influence severity of illness. 4. Determine the clinical status of these patients 5. Find out what complications accompany the disease with special attention paid to the cardiopulmanary system.50 asthma patients and a group of 44 non-asthmatic control patients presenting at Muhimbili were studied. Asthma patients referred to Muhimbili casualty department and those admitted through medical outpatient clinics during September, October and November 1976 were included. Cases were taken consecutively as far as possible. They were interviewed, examined and investigated. The methods included (i) Personal interview with the patient using a check list. (ii) General physical examination with emphasis placed on cardio-resperatory system, and in particular noting signs of chronic chest hyper-inflamation due to chronic airway obstruction. (iii) Investigations were done to asthmatic patients. Only those investigations which required to be controlled were done to control patients, mainly stool examination, and serum estimation for IgE. The results showed late onset of asthma more marked among the females with crippling social and psychological stresses which accompany the disease. Accompanying a topic illnesses were high resembling the picture seen in temperate countries, and unlike that reported in several tropical countries. History was not a good indicator of offending allergens, and skin testing is suggested as a better method of identifying sensitizing allergens. Asthma in Muhimbili resembled other tropical countries in having a high eosinophil count, but this count was not higher than that of control patients. Asthma patients also have lower intestinal parasite load than a group of control patients. Patients with severe asthma have significant dehydration at the time of hospital admission. Chest radiographic changes were similar to the observations of other clinical workers in tropical countries and consisted of signs of chronic hyperinflation and tuberculosis reactivation. Results of skin testing identified two major allergens, house dust mites and mixed threshings. House dust mites and their secretions in dust were more important. Implications for management and therapy include the following: (a) Severe asthma patients should be rehydrated with at least 2 litres of fluid. This may be given as a vehicle for bronchodilators. (b) Asthma patients on corticosteraids whether continuous or intermittent should receive prophylactic anti-tuberculous therapy or followed closely with chest radiographs and sputum culture. (c) On the basis of sensitivity pattern tetracycline is the drug of choice at the first instance in cases of asthma complicated by infection before culture and sensitivity are available. The author concludes that major clinical conditions accompanying asthma are few, and complications of asthma are dehydration, reactivated tuberculosis, and chest deformities.
The cultural perspective of therapeutic relationship ‐ a viewpoint from Africa
(Acta Psychiatrica Scandinavica, 1985) Kilonzo, Gad P.
Therapeutic relationship has been considered an important ingredient of all psychotherapies. In communities in which no familiar conventions of such a relationship are available, the therapeutic encounter poses very different problems from those in the West, where such conventions freely prevail. This study has been carried out by five therapists representing three widely disparate cultures, but all working together in Tanzania. It brings together their perceptions of these problems and the strategies they employed to resolve them while working with African patients. In their view, in spite of great disparity between the world view behind Western psychotherapy and that of African communities, it is not impossible to forge a therapeutic relationship if empathic understanding and cultural sensitivity are added to the attitude of acceptance. After all, the therapist must attract and keep the patient before he can expect anything from him. The authors describe how this can be done with African patients.
Witchcraft and Psychotherapy
(British Journal of Psychiatry, 1986) Kilonzo, Gad P.
Belief in witchcraft, which serves a variety of social functions and personal defences, is bound to emerge in psychotherapy with individuals from a culture that holds such beliefs; endeavouring to understand it can open up new therapeutic possibilities. The nature of witchcraft, the profiles with which it intrudes into therapy, and the socio-psychological functions it fulfills are considered. Referring such patients to witchdoctors is morally unjustifiable, but the witchdoctor's folk-image provides a floating transference, around which the therapeutic relationship can be built. In dealing with witchcraft-ideation, understanding is based as much on cultural as on personal empathy, and to enhance its relevance, therapy may appropriate some of the functional dynamics of the witchcraft system into its own therapeutic manoeuvres.
Ingredients and contaminants of traditional alcoholic beverages in Tanzania
(Transactions of the Royal Society of Tropical Medicine and Hygiene, 1991) Kilonzo, Gad P.
Abstract Home-made but commercially available alcoholic beverages were collected in Dar es Salaam, Tanzania and analysed for their congener alcohol, additive, aflatoxin and heavy metal contents. Ethanol concen- trations of the 15 brewed samples ranged from 2.2 to 8.5% w/v whilst the 2 distilled samples contained ethanol 24.2 and 29.3% w/v. Aflatoxin Bl was found in 9 brewed beverages, suggesting the use of con- taminated grain or fruit for their production. The amount of zinc in 4 samples was double the World Health Organization recommended maximum for drinking water (5 mg/litre). One brewed beverage contained toxic amount of manganese (12.8 mg/litre). Both distilled spirits were rich in fuse1 alcohols and one was fortified by caffeine. The results suggested that impurities and contaminants possibly associated with severe health risks, including carcinogens, are often found in traditional alcoholic beverages. Con- tinuous daily drinking of these beverages is certain to increase health risks. Contaminated grain or fruit rejected from foodstuff production should not be used for the production of alcoholic beverages.
Prevalence and Incidence of Epilepsy in Ulanga, a Rural Tanzanian District: A Community‐Based Study
(Epilepsia, 1992) Kilonzo, Gad P.
A random cluster sample survey of approximately 18,000 people in 11 villages was performed in Ulanga, a Tanzanian district with a population of approximately 139,000 people. Well‐instructed fourth‐year medical students and neurologic and psychiatry nurses identified persons with epilepsy using a screening questionnaire and sent them to a neurologist for detailed evaluation. Identified were 207 subjects in 1,000. Prevalence among villages varied, ranging from 5.1 to 37.1 in 1,000 accounted for 58% and partial seizures accounted for 31.9%, whereas in 10.1% seizures were unclassifiable. Of the partial seizures, secondarily generalized seizures were the most common. Possible etiologic or associated factors were identifiable in only 25.3% of cases. Febrile convulsions were associated in 13.4 of cases. Other associated factors included unspecified encephalitis
Knowledge, Attitude, and Practice Toward Epilepsy Among Rural Tanzanian Residents
(Epilepsia, 1993) Kilonzo, Gad P.
Before a health education program can be established, one must first know what the target population believes and does with respect to the disease in question. Therefore, we performed a study among Tanzanian rural inhabitants to identify their knowledge, attitude, and practice (KAP) toward epilepsy: 3,256 heads of households (mean age 40.2 years, range 15–90 years; M/F ratio 1:1) were interviewed. Of the respondents, 32.9% said they had never seen a seizure; 67.7% said they did not know the cause of epilepsy; 33.3% mentioned various causes including heredity, witchcraft, infection of the spinal cord, hernia; 40.6% believed epilepsy was infectious through physical contact, flatus, breath, excretions, sharing food; 36.8% believed epilepsy could not be cured and 17.1% believed it could not even be controlled; 45.3% believed epilepsy could be treated by traditional healers, and only 50.8% believed hospital drugs were of any use; and 62.7% of the respondents would not allow an epileptic child to go to school for various reasons, including mental sub normality (54.0%), fear of the child falling while alone (65.9%), and fear that the epileptic child would infect other children (11.2%). Concerning what is to be done when a seizure occurs, 33.5% of the respondents would keep away and not touch the person; 16.5% would take some potentially harmful measure such as forcing a mouth gag or forcing a drink such as water (1 even mentioned urine); 5.2% would take unnecessary measures such as rushing the patient to a hospital. Only 35.7% of respondents would perform at least some of the currently recommended first‐aid measures. Therefore, there is a need for health education on epilepsy in Tanzania, and these results are forming the base for design and execution of a health education and a primary health care program in epilepsy control.
The family and substance abuse in the United Republic of Tanzania
(Bulletin on narcotics, 1994) Kilonzo, Gad P.
The family in the United Republic of Tanzania has traditionally been a paramount institution invested with important functions of socialization. It provided spiritual guidance, emotional and social support systems, security and education, and defined the moral and ethical system in which the community was intricately bound together. The institution is weakening under the impact of modernization at a pace that far exceeds the pace at which newer institutions are emerging to assume those responsibilities. Drug abuse is becoming an unwelcome guest under those circumstances. It is proposed that active measures should be taken at the community and national policy level to strengthen and employ the family for the purpose of promoting a drug-free lifestyle.
Determination of appropriate clomipramine dosage among depressed African outpatients in Dar es Salaam, Tanzania
(The Central African Journal of Medicine, 1994) Kilonzo, Gad P.
In an open clomipramine dose finding study, 33 depressed indigenous African outpatients were randomly assigned to two regimens of treatment with 125 mg and 75 mg oral medications daily. At the end of eight weeks of treatment, 16 patients (48,5 pc) were on the 75 mg regime, and 17 (54,8 pc) were on 125 mg. 178 Analysis of depression scores cm the Beck-Rafaelsen scale indicated improvements of depression in both regimes of equal magnitude. Analysis of variance showed no statistically significant difference on dose response between the two regimes. The higher doses, however, were associated with more drowsiness and tremulousness. It is suggested that Black African patients respond to tricyclic antidepressants in much lower doses than those recommended in Western textbooks. It is also apparent that side effects of tricyclic antidepressants, which have been implicated in non-compliance to medication, could be avoided without compromising treatment outcome
Psychiatric co-morbidity in medical patients with aids: some considerations for clinicians and counselors in Tanzania June 1997
(Tanzania Med J, 1997) Kilonzo, Gad P.
Clinical experience indicates that psychiatric patient populations are being neglected in HIV preventive work and furthermore the psychiatric problems of persons with AIDS are often undetected and under reported. This paper explores the reasons for this observation and discusses the implications for clinicians and counselors. This review focuses on two issues: the urgent need for preventive efforts geared to the psychiatric patient population; and for the early detection of psychiatric problems in HIV positive medical patients by primary care physicians and counselors.
Development of mental health services in Tanzania: A reappraisal for the future
(Social science & medicine, 1998) Kilonzo, Gad P.
The article traces the historical development of mental health services in Tanzania from traditional practices through custodial institutions during the colonial period, efforts towards decentralization, including the development of innovative agricultural rehabilitation villages during the 60s and the introduction of primary mental health care during the 80s right up to the present. Available resources in Tanzania, including the traditional healing system, the family and ample arable land were examined as to how these might be used in the care of mental patients and the promotion of mental health in general. The article points to real opportunities and a possible course of action for the future.
Traditional African Mourning Practices Are Abridged in Response to the AIDS Epidemic: Implications for Mental Health
(Transcultural Psychiatry, 1999) Kilonzo, Gad P.
This paper examines the psychological significance of traditional African mourning practices in the context of the HIV/AIDS epidemic. In Tanzania, untimely multiple losses through AIDS increasingly force communities to forgo traditionally prescribed mourning practices and rituals. An increase in psychiatric and psychological problems associated with incomplete mourning and unresolved grief has been observed in clinical settings. This may be due to the psychosocial inadequacy of these abridged mourning processes. It is unlikely that western forms of grief counseling can replace traditional mourning rituals, at least in terms of psychological efficacy. An approach is suggested that permits a wider elaboration of cultural psychic processes through the creation of new rituals.
Is care and support associated with preventive behaviour among people with HIV?
(AIDS care, 1999) Kilonzo, Gad P.
Care and support should play a critical role in assisting people who are HIV-positive to understand the need for prevention and to enable them to protect others. Differences in sexual risk reduction among 154 newly diagnosed HIV-positive individuals from semi-urban Tanzania were examined using a randomized control design, which assigned a control group to regular health services and an experimental group to enhanced care and support. Data were collected at baseline, three months and six months on self-reported sexual risk behaviours, disclosure of serostatus, reproductive health and psychosocial support. Over the six-month period, significant risk reduction occurred among both groups, with most of the behaviour change occurring during the first three months, e.g. 86 respondents (56%) reported condom use at last intercourse at 3 months compared with 24(16%) at baseline (p = 0.05). Extra care and support did not lead to increased risk reduction among the experimental group. The study population as a whole significantly changed their behaviour, suggesting that in the short term, learning one is HIV-positive has an impact on risk reduction.
Women's barriers to HIV-1 testing and disclosure: Challenges for HIV-1 voluntary counseling and testing
(AIDS care, 2001) Kilonzo, Gad P.
In view of the ever-increasing HIV/AIDS epidemic in sub-Saharan Africa, the expansion of HIV-1 voluntary counselling and testing (VCT) as an integral part of prevention strategies and medical research is both a reality and an urgent need. As the availability of HIV-1 VCT grows two limitations need to be addressed, namely: low rates of HIV-1 serostatus disclosure to sexual partners and negative outcomes of serostatus disclosure. Results from a study among men, women and couples at an HIV-1 VCT clinic in Dar es Salaam, Tanzania are presented. The individual, relational and environmental factors that influence the decision to test for HIV-1 and to share test results with partners are described. The most salient barriers to HIV-1 testing and serostatus disclosure described by women include fear of partners' reaction, decision-making and communication patterns between partners, and partners' attitudes towards HIV-1 testing. Perception of personal risk for HIV-1 is the major factor driving women to overcome barriers to HIV-1 testing. The implications of findings for the promotion of HIV-1 VCT programmes, the implementation of partner notification policies and the development of post-test support services are discussed.
Risk factors for epilepsy in a rural Area in Tanzania. a community based case-control study
(Neuroepidemiology, 2001) Kilonzo, Gad P.
Background and Methods: The high prevalence of epilepsy detected in rural Tanzania by Dr. Jilek-Aall since 1960, was verified by the World Health Organization (WHO) survey on neurological and seizure disorders. Neurologists and psychiatrists further interviewed both patients and controls using standard methods. The presence of possible risk factors was complemented by corroborative evidence through interviewing close relatives and scrutinizing medical records. Seizures were classified based on clinical symptoms and the use of EEG. Results: A family history of epilepsy in first-degree relatives was found in 46.6% of patients, but in only 19.6% of controls. The odds ratio for family history with epilepsy was 3.52 (95% confidence interval, CI 2.4–5.74, p < 0.001). A past history of febrile convulsion was found in 44% of patients in comparison to 23% of the control group which was significant (odds ratio 2.4, 95% CI 1.5–3.8; p < 0.001). A history of intrapartum complications was found in 12.1% of patients and 1.8% of controls (odds ratio 7.3, 95% CI 2.5–25.2; p < 0.002). Head injury was not a significant risk factor for epilepsy in this rural community. Conclusion: The results indicated a strongly independent association between four factors and the risk of developing epilepsy. It would seem more likely that previous brain insults/diseases play a significant major role in the cause of epilepsy in the Mahenge area. However, a genetic predisposition to low threshold for convulsions cannot be excluded.
HIV and Partner Violence: Implications for HIV Voluntary Counseling and Testing Programs in Dar es Salaam, Tanzania
(2001) Kilonzo, Gad P.
This study explored the links between HIV infection, serostatus disclosure, and partner violence among women attending a VCT clinic in Dar es Salaam, Tanzania. Men and women both perceive HIV testing as a way to plan for the future but are motivated to undergo testing by a number of different individual, relationship, and environmental factors. The women in our study described more barriers to HIV testing than did men, and women who have communicated with their partners about VCT before seeking services are significantly more likely to share their HIV test results than those who have not talked with their partners. Findings from this study led to a number of recommendations that could reduce the barriers women face in getting tested for HIV and in disclosing their serostatus to their partners, as well as reduce levels of partner violence. These recommendations pertain to VCT services as well as to the wider community and policy environment.
Substance use by Students in South Africa - Tanzania and Zimbabwe
(Afr. J. Drug Alcohol Stud, 2001) Kilonzo, Gad P.
The study aimed to compare substance use of students in South Africa. Tanzania. and Zimbabwe. Multistage sampling produced samples of 2946. 2491 and 183 students aged 13-14 In Cape Town, Dar es Salaam (DAR) Harare respectively. Questionnaires were administered in classrooms. High prevalence rates of tobacco, alcohol and solvent use and site differences were noted - among males in the previous year, 23.5% in Cape Town had smoked cigarettes, J 5.2% in DAR had inhaled solvents and 29.5% in Harare had drunk alcohol. Lifetime prevalence rates for cannab ts were low. Except for solvents, rates were lowest. in DAR. Gender differences were noted in Harare and DAR for certain substances. The importance oftransnational research using comparable methodologies and analytical designs Is emphasized.
HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing Clinic in Dar Es Salaam, Tanzania
(American journal of public health, 2002) Kilonzo, Gad P.
Objectives: Experiences of partner violence were compared between HIV-positive and HIV-negative women. Methods: Of 340 women enrolled 245 (72%) were followed and interviewed 3 months after HIV testing to estimate the prevalence and identify the correlates of violence. Results: The odds of reporting at least 1 violent event was significantly higher among HIV-positive women than among HIV-negative women (physical violence odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.23, 5.63; sexual violence OR = 2.39; 95% CI = 1.21, 4.73). Odds of reporting partner violence was 10 times higher among younger (< 30 years) HIV-positive women than among younger HIV-negative women (OR = 9.99; 95% CI = 2.67, 37.37). Conclusions: Violence is a risk factor for HIV infection that must be addressed through multilevel prevention approaches.
High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania
(AIDS and Behavior, 2003) Kilonzo, Gad P.
The rates, barriers, and outcomes of HIV serostatus disclosure to sexual partners are described for 245 female voluntary counseling and testing (VCT) clients in Dar es Salaam, Tanzania. VCT clients were surveyed 3 months after HIV testing to describe their HIV-serostatus disclosure experiences. Sixty-four percent of HIV-positive women and 79.5% of HIV-negative women (p = 0.028) reported that they had shared HIV test results with their partners. Among women who did not disclose, 52% reported the reason as fear of their partner's reaction. Both 81.9% of HIV-negative women and 48.9% of HIV-positive women reported that their partner reacted supportively to disclosure (p < 0.001). Less than 5% of women reported any negative reactions following disclosure. VCT should continue to be widely promoted. However, intervention approaches such as development of screening tools and new counseling approaches are important to ensure the safety of women who want to safely disclose HIV serostatus to their sexual partners.
Disentangling HIV and AIDS stigma in Ethiopia, Tanzania and Zambia
(LSHTM Research Online, 2003) Kilonzo, Gad P.
The International Center for Research on Women (ICRW), in partnership with organizations in Ethiopia,Tanzania, and Zambia, led a study of HIV and AIDS-related stigma and discrimination in these three countries.This project, conducted from April 2001 to September 2003, unraveled the complexities around stigma by investigating the causes, manifestations and consequences of HIV and AIDS-related stigma and discrimination in sub-Saharan Africa. It then uses this analysis to suggest program interventions. Structured text analysis of 730 qualitative transcripts (650 interviews and 80 focus group discussions) and quantitative analysis of 400 survey respondents from rural and urban areas in these countries revealed the following main insights about the causes, context, experience and consequences of stigma: 1. The main causes of stigma relate to incomplete knowledge, fears of death and disease, sexual norms and a lack of recognition of stigma. Insufficient and inaccurate knowledge combines with fears of death and disease to perpetuate beliefs in casual transmission and, thereby, avoidance of those with HIV.The knowledge that HIV can be transmitted sexually combines with an association of HIV with socially“improper”sex, such that people with HIV are stigmatized for their perceived immoral behavior. Finally, people often do not recognize that their words or actions are stigmatizing. 2. Socio-economic status, age and gender all influence the experience of stigma.The poor are blamed less for their infection than the rich, yet they face greater stigma because they have fewer resources to hide an HIV-positive status. Youth are blamed in all three countries for spreading HIV through what is perceived as their highly risky sexual behavior.While both men and women are stigmatized for breaking sexual norms, gender-based power results in women being blamed more easily. At the same time, the consequences of HIV infection, disclosure, stigma and the burden of care are higher for women than for men. 3. People living with HIV and AIDS face physical and social isolation from family, friends, and community; gossip, name-calling and voyeurism; and a loss of rights, decision-making power and access to resources and livelihoods. People with HIV internalize these experiences and consequently feel guilty, ashamed and inferior.They may, as a result, isolate themselves and lose hope.Those associated with people with HIV and AIDS, especially family members, friends and caregivers, face many of these same experiences in the form of secondary stigma. 4. People living with HIV and AIDS and their families develop various strategies to cope with stigma. Decisions around disclosure depend on whether or not disclosing would help to cope (through care) or make the situation worse (through added stigma). Some cope by participating in networks of people with HIV and actively working in the field of HIV or by confronting stigma in their communities. Others look for alternative explanations for HIV besides sexual transmission and seek comfort, often turning to religion to do so. 5. Stigma impedes various programmatic efforts. Testing, disclosure, prevention and care and support for people with HIV are advocated, but are impeded by stigma.Testing and disclosure are recognized as difficult because of stigma, and prevention is hampered because preventive methods such as condom use or discussing safe sex are considered indications of HIV infection or immoral behaviors and are thus stigmatized. Available care and support are accompanied by judgmental attitudes and isolating behavior, which can result in people with HIV delaying care until absolutely necessary. 6. There are also many positive aspects of the way people deal with HIV and stigma. People express good intentions to not stigmatize those with HIV. Many recognize that their limited knowledge has a role in perpetuating stigma and are keen to learn more. Families, religious organizations and communities provide care, empathy and support for people with HIV and AIDS. Finally, people with HIV themselves overcome the stigma they face to challenge stigmatizing social norms. Our study points to five critical elements that programs aiming to tackle stigma need to address: - Create greater recognition of stigma and discrimination - Foster in-depth, applied knowledge about all aspects of HIV and AIDS through a participatory and interactive process - Provide safe spaces to discuss the values and beliefs about sex, morality and death that underlie stigma - Find common language to talk about stigma - Ensure a central, contextually-appropriate and ethically-responsible role for people with HIV and AIDS While all individuals and groups have a role in reducing stigma, policymakers and programmers can start with certain key groups that our study suggests are a priority: - Families caring for people living with HIV and AIDS: programs can help families both to cope with the burden of care and also to recognize and modify their own stigmatizing behavior - NGOs and other community-based organizations: NGOs can train their own staff to recognize and deal with stigma, incorporate ways to reduce stigma in all activities, and critically examine their communication methods and materials - Religious and faith-based organizations: these can be supportive of people living with HIV and AIDS in their role as religious leaders and can incorporate ways to reduce stigma in their community service activities - Health care institutions: medical training can include issues of stigma for both new and experienced providers, while at the same time, risks faced by providers need to be acknowledged and minimized - Media: media professionals can examine and modify their language to be non-stigmatizing, provide accurate, up-to-date information on HIV, and limit misperceptions and incorrect information about HIV and people living with HIV and AIDS The complexity of stigma means that these and other approaches to reduce stigma and discrimination will face many challenges, but, at the same time, there exist many entry points and strong, positive foundations for change that interventions can immediately build on.
Pilot Study on Patterns of Consumption of Nonindustrial Alcohol Beverages in Selected Sites, Dar es Salaam, Tanzania
(Brunner-Routledge, New York, 2004) Kilonzo, Gad P.
The United Republic of Tanzania is a developing country in East Africa. It covers an area 945,000 square kilometers and has 1,424 kilometers of marine coastline on the eastern border. It has long land borders with Kenya, Uganda, Rwanda, Burundi, Democratic Republic of Congo, Zambia, Malawi, and Mozambique, and it bestrides a number of inland waters. The wide variation in altitude offers a range of climates, from the humid and hot tropical climates on the coast to the warm savanna grasslands, the warm highlands, the temperate mountains, and the alpine climate on the slopes of the high mountains such as Kilimanjaro. It has a population of 34.6 million people and a population density of 39 per square kilometer (Tanzanian Bureau of Statistics, 2002). The country has about 120 ethnic groups; a common language, Kiswahili, facilitates easy communication between people. There was a slow but steady increase in life expectancy at birth from 41.7 years in 1962 to a peak of 52 years in 1992, but this trend has been reversed over the past 10 years with a decline to a life expectancy of 48 years by 1998. The AIDS epidemic is one major factor associated with this decline (UNAIDS, 2000). Sustained per-capita income growth has been evident since 1995, with a steady increase from 0.6% per annum to an estimated 2.5% by 1999 (Bigsten & Danielson, 2001). Despite this overall increase, there are indications that income distribution has worsened over the years, and income has declined in absolute terms in the face of currency devaluation. It is estimated that 50% of the population live in poverty, most of them in rural areas (Mutalemwa, Noni, & Wangwe, 1998).

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