Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan

This study explored the perceived value, role and reported use of clinical guidelines by clinicians in urban paediatric and maternity hospital settings, and the effect of current implementation strategies on clinician attitudes, knowledge and behaviour. A total of 63 clinicians from 7 paediatric and maternity hospitals in Kabul, Afghanistan participated in structured focus groups; content analysis methodology was used for identification and analysis of key themes. Seven sets of guidelines, protocols or standards were identified [including 5 WHO-endorsed guidelines]. However, most are failing to achieve high levels of use. Factors associated with guideline use included: clinician involvement in guideline development; multidisciplinary training; demonstrable results; and positive clinician perceptions regarding guideline quality and contextual appropriateness. Implementation activities should fulfil 3 major objectives: promote guideline awareness and access; stimulate motivation among clinical guideline users; and actively facilitate adherence to guidelines

Control measures and the outcome of the measles epidemic of 1999 in the Eastern Highlands Province

@#In the Eastern Highlands Province (EHP) of Papua New Guinea (PNG) measles outbreaks have occurred regularly every 3 to 4 years since 1980. The latest was between September 1998 and March 2000. Between July 1999 and March 2000 314 children with measles were reviewed at Goroka Base Hospital. The majority of these children were very young: 55% were under 1 year and 27% under 6 months. The median age of the measles cases was 11 months (range 10 days to 13 years). 40% of the children had a verifiable history of having received at least one dose of measles vaccine. The majority were vaccinated during the epidemic and included many children who either were below 6 months of age or who developed measles within 2 weeks of vaccination. Measles complications occurred in 82% of the children, the most common being pneumonia. Serious complications, particularly severe pneumonia, were more common among the unvaccinated children than in those who had received at least a single dose of the measles vaccine. No deaths occurred among 82 children who had received measles vaccine more than 2 weeks before the onset of clinical measles, compared with 10 deaths in 206 children who had never been vaccinated against measles or were vaccinated in the 2 weeks before presentation (p=0.067). The overall case fatality was 4%: 14% among the hospital-acquired and 2.5% in community-acquired measles. Improvement in the measles vaccination coverage and supplementary vaccination campaigns are required to prevent measles outbreaks in PNG. Intensified measles vaccination campaigns, such as the one conducted in EHP in 1999, are recommended during epidemics to minimize deaths due to measles and to rapidly control outbreaks. The efficacy of measles vaccination can only be measured in total mortality, not in the prevention of clinical measles.

Antibiotic-resistant bacterial sepsis in Papua New Guinea

@#Infections due to antibiotic-resistant bacteria, especially gram-negative bacteria, are a common cause of child mortality in Papua New Guinea. Antibiotic-resistant bacteria include the enteric gram-negative bacilli, especially Escherichia coli, Klebsiella and Enterobacter, and Haemophilus influenzae type b, a major respiratory tract pathogen and cause of meningitis. Among these bacteria there is now high-level resistance to standard antibiotics, including chloramphenicol, amoxycillin and cotrimoxazole. Reasons behind the increase in antibiotic-resistant bacterial infections are the widespread unregulated use of antibiotics and the very large burden of bacterial infections. Risk factors for development of resistant enteric gram-negative infections include village births, prolonged hospital stay, kwashiorkor in adopted children and previous treatment with broad-spectrum antibiotics. Cost-effective strategies to combat these pathogens will need to be broad and must focus on reducing the use of antibiotics for trivial illnesses, reducing the need to use antibiotics and reducing the risk factors for resistant bacterial sepsis. There must be stricter regulation of commercial pharmacies, education of health workers on how to avoid inappropriate antibiotic prescribing, a focus on the prevention of pneumonia by immunization with new vaccines, improvements in the quality and uptake of formal maternal care services and public health measures within villages. In addition there is a need for better surveillance for antibiotic-resistant bacteria within hospitals; this will require substantial improvements in laboratory facilities and carefully planned research collaboration. A national committee should be established to advise on these matters and coordinate interventions.

The role of non-government organizations in supporting and integrating interventions to improve child health

@#In Papua New Guinea there are many organizations providing sparsely spread and fragmented health services. Government health facilities are often relatively well functioning in urban and periurban areas, but sporadic or nonexistent in rural areas. In some remote areas churches are the major health service providers. Increasingly other community groups are providing village-based health services. Much financial support is now pledged by major international donors for community-based health services, but few people working at a district or community level have the management skills to access the funds or plan programs effectively, and few of the major donors have any significant presence in rural areas. Such a management skill gap also exists at the level of many provincial health offices and this seriously limits the effectiveness of all major donor projects. There is need for integration of health services to avoid replication and to extend services to areas where no effective services are currently provided. There is also a great need to train people at a community and district level in program planning and management. Non-government organizations (NGOs) working at a district or community level have the potential to bridge this skill gap and to help integrate community-based services with government institutions. This paper reports, as an example, the activities of Save the Children, an international NGO in Papua New Guinea. Essential for the success of community-based health projects is the development of local management skills, reliable funding, integration with established health institutions, objective evaluation and community support. Skilled NGOs working at a community, district or provincial level can have important roles in assisting local people to run effective and sustainable health programs.