Naturally durable heartwood: evidence for a proposed dual defensive function of the extractives.

We previously proposed that extractives in highly durable heartwood may protect wood against fungal colonization and subsequent degradation by dual mechanisms: the extractives have some fungicidal activity and are also free radical scavengers (antioxidants). In short-term laboratory decay tests using two different wood species and decay fungi, the antioxidant 2,6-dimethyl-di-tert-butyl-4-methylphenol (BHT) alone had little or no preservative effect. In contrast, the combination of BHT with different organic commercial biocides always showed an increase in efficacy compared to the organic biocide alone. Consequently, we conclude that the combination of a commercial antioxidant and biocide is synergistic. This implies that extractives may protect wood by more than simply being fungicidal.

Comparative validity of three methods for assessment of the quality of primary health care.

OBJECTIVE: This study compared the sensitivity and specificity of three assessment methods to detect the performance of key clinical tasks by health workers in a primary care setting. DESIGN: Health worker performance during patient encounters for acute respiratory infections, acute diarrhea and family planning counseling was assessed through checklist-based observation of the consultation, interview with the mother following the consultation, and review of the patient's clinical record. The results of each method regarding the performance of key tasks by health workers were compared to a 'gold standard', defined as the application of the observation checklist by observers with extensive quality assessment experience. Patient encounters were studied in three Ministry of Health facilities in the Department of Totonicapán, Guatemala, involving care by physicians, nurses and auxiliary staff RESULTS: The three methods showed reasonably high levels of sensitivity (generally about 70%) for the detection of failures in the performance of most health worker tasks. The greatest problem experienced by each method related to specificity, i.e. capacity to recognize quality successes and only detect real failures. CONCLUSION: Direct observation demonstrated the best overall balance of sensitivity and specificity. Exit interview of the mother demonstrated good sensitivity and better specificity than record review.

The Quality Assurance Project: introducing quality improvement to primary health care in less developed countries.

Persistently excessive morbidity and mortality rates in less developed countries (LDCs) served by primary health care systems suggest that the quality of services is inadequate. The PRICOR project, sponsored by the United States Agency for International Development, has designed and implemented methods for quality assessment and problem solving in LDC health systems. After developing comprehensive lists of essential activities and tasks, similar to practice parameters, for seven child survival interventions, PRICOR supported comprehensive quality assessment studies in twelve LDC countries. The studies, yielding over 6000 observations of health worker-client encounters, indicated highly prevalent, serious program deficiencies in areas including diagnosis, treatment, patient education and supervision. To facilitate corrective action, PRICOR assisted managers in conducting operations research to resolve priority problems revealed by the assessments. The recently initiated Quality Assurance Project is building on PRICOR techniques in designing and implementing sustainable continuous quality improvement programs for LDC health systems.

PIP: The PRICOR Project developed extensive lists of essential tasks and activities for the effective delivery of child survival interventions (PRICOR Thesaurus): case management of acute respiratory infection, malaria, and diarrhea; growth monitoring and promotion; maternal health; and child spacing. It later helped managers and researchers in the use of the Thesaurus to conduct comprehensive systems analyses of these interventions in Colombia, Costa Rica, Haiti, Niger, Indonesia, Pakistan, Peru, Philippine,s Senegal, Togo, Thailand, and Zaire. These analyses confirmed that researchers and program managers can indeed study service delivery through systematic review of health worker performance. Further this evaluation of primary health care (PHC) systems in 12 countries identified repeat program deficiencies. For example, counseling by health workers to clients was consistently weak. The tended to not explain to mothers proper home treatment, describe danger sings, or ask them to repeat instructions to assure that mothers understood them. Further health workers did not necessarily tell mothers during treatment about their child's nutritional status, type of vaccine being administered, of why they prescribed oral rehydration therapy. This lack of client education is especially significant since, in PHC, the health workers and the caregiver should be partners in achieving successful results. Deficiencies also existed with supervision. For instance, supervisors did not always monitor health workers, rectify errors, or solve problems. Further researchers compare supervisors' perceptions of health worker performance with actual performance. Supervisors tended to overstate performance. Nevertheless these analyses did identify practical solutions to many program deficiencies. In fact, most solutions did not depend on resources availability, PRICOR techniques to design and implement strategies for sustained improvement in PHC in developing countries.

Comparison of methods for estimating the frequency of paralytic poliomyelitis in developing countries.

Standard reporting systems have proved to be unreliable in estimating the frequency of paralytic poliomyelitis in many developing countries. The effectiveness of three survey methods for estimating the prevalence of lameness attributable to poliomyelitis were compared in the Danfa Health Project district of rural Ghana. Lameness was studied because it is easily identified by inexpensive survey techniques. A postal survey of school headteachers was the least costly and most accurate method, giving a prevalence of lameness attributable to poliomyelitis of 7.2 per 1000 schoolchildren. This method is recommended for countries with an extensive network of primary schools. Medical examinations in a village health survey yielded a prevalence of 4.6 per 1000 children aged 6-15 years. This method was relatively expensive but could be justified if the survey was multipurpose. A question added to the annual district census showed a prevalence of 2.2 per 1000 children, a rate still many times higher than estimates from national statistics. The inclusion of such a question in a census or other national survey entails little additional cost and with more careful questioning results should improve. Repeated surveys can be used to assess the success of poliomyelitis vaccination programmes.

An evaluation of male contraceptive acceptance in rural Ghana.

To evaluate the effect of male contraceptive acceptance on fertility, the Danfa Family Planning Project in rural Ghana studied a sample of its male family planning acceptors. The findings show that half of the survey respondents accepted foam for use by their partners and half accepted the condom. The continuation rate (69 percent at 12 months) and use-effectiveness rate (80 percent at 12 months) reported by men were higher than those reported by women program acceptors. It is felt that men can play a significant role in affecting fertility through their influence on a couple's choosing to use contraception and as a result of their motivation to obtain contraception and see that it is used. It is urged that increasing emphasis be placed on providing family planning services for men in African programs.

PIP: Report of a follow-up survey of male family planning acceptors in the Danfa program. A sample of 100 men from each of 3 project areas (representing 47% of all male acceptors as of July 1974) was obtained, with 227 acceptors ultimately interviewed. A sample of female acceptors was also interviewed, using a similar questionnaire. 84% of the males were between ages 20-44. The mean age for the sampled females was 29. 19% of the males and 5% of the females reported ever using contraception before accepting it from the program. 80% of males were literate and 39% of females, the importance of literacy for males further underscored by the fact that while only 36% of their spouses were literate, the female respondents claimed 72% of their spouses to be literate. Controlling for other factors, religion was also important, with Christians most likely to accept family planning. 70% of male acceptors were married at the time of acceptance and 25% of those unmarried at time of acceptance were married by the time of the interview. 76% had at least one living child. 55% of the married men and 44% of the unmarried men claimed to have only one sexual partner. 78% of married men claimed to have discussed family planning with their wives. 66% reported that they used the accepted method only with their wives, 20% only with the other partner, and 12% with both partners. The most common reason given for acceptance was the health of their children. 52% of the male acceptors had first learned about family planning from the project health staff and 24% through mass media. 64% of the male respondents reported having tried to persuade another to accept family planning, compared with 40% of the females. Half of the men had chosen the condom, and half contraceptive foam for their partners. 16% of foam and 6% of condom acceptors had never used the methods. The large number of foam acceptors and users indicates the important role of males in acceptance of family planning. Self reporting indicated 81% of acceptors used their methods correctly. Continuation rates were higher for the male acceptors surveyed than for the women, which may be a reflection of their extra- and pre-marital relations. Among those not continuing, the major reasons were the desire for a child (28%) and inability to get supplies (18%). Accidental pregnancies were fewer among the partners of the male respondents than among women in the project in general, and the extended use-effectiveness was greater. These again may reflect the extra-marital and pre-marital sexual activities.

Impact of family planning information on acceptance at a Ghanaian rural health post.

PIP: Evaluation of the effect of a clinic-based educational program on utilization of family planning services at a rural health post in Ghana had two major objectives: 1) to measure to what extent immediate change in family planning knowledge, attitudes and behavior could be brought about by the provision of family planning information; and 2) to demonstrate that by means of on-going evaluation of the educational presentation on family planning, by providing adequate feedback to the educator, and through continual revision of the educational content, increased understanding of family planning information would result at successive information sessions. The study was limited to female clinic attendees aged 15-44. The family planning presentation was followed by a question and answer period and shortly thereafter, individual interviews. The 2 major study objectives lend themselves to quantitative testing of specific programme hypotheses as follows: 1) the number of women who accept a family planning method at the clinic will be significantly greater on days when family planning information is provided than on days when it is not; and 2) as a result of the informational input, ongoing evaluation and feedback, family planning knowledge levels for selected topics will be significantly higher among health clinic attendees. Results showed that the first hypothesis was substantiated by data which revealed that there were significantly more acceptors on days when family planning information was offered. The second hypothesis, however, was not supported. In general, it would appear that family planning education provided in a health facility adjacent to a family planning clinic can have a significant impact on initial adoption of family planning mthods. Follow-up of acceptors was not carried out, and thus data on continuation of use were not available for this study.^ieng

Haematological values in a rural Ghanaian population.

Early in 1973 residents of 20 randomly selected rural villages in southern Ghana were studied to determine the prevalence of anaemia. Laboratory tests were conducted to learn what haemoglobin phenotypes were present and the distribution of white blood cell counts. Moderate anaemia (below 10 g%) was fairly common, particularly in children and 15--29 year old women, but severe anaemia (below 7 g%) was rare. Malaria infection and diets with low iron content were major factors affecting haemoglobin level, while hookworm infestation and high parity had little effect. Neutropenia (about two-thirds of Caucasian values) and the distribution of haemoglobin types (AS 16.3%; AC 11.1%) were similar to findings in earlier studies. To improve haemoglobin levels in children and young women, low-cost intervention programmes based on volunteer village workers are recommended.

The training of traditional birth attendants in Ghana: experience of the Danfa Rural Health Project.

Three quarters of deliveries in Ghana are still attended by untrained personnel, including traditional birth attendants (TBA's), and maternal mortality remains high. The Ministry of Health is exploring ways of improving this situation. Recently, training traditional birth attendants to improve maternal and child health practices and promote family planning has been considered. Most TBA's in rural Ghana are elderly illiterate farmers. The Danfa Project has identified and trained 57 of these TBA's with the objective of developing a programme that might be replicated elsewhere in the country. This paper describes the design of the programme and problems encountered and makes recommendations to others who may be considering similar programmes in other countries.

PIP: 57 traditional birth attendants were identified and trained by the Danfa Project in rural Ghana in an effort to improve maternal and child health practices and promote family planning. A plan was also developed for follow-up and continuing education of these traditional birth attendants (TBAs). The Danfa Comprehensive Rural Health and Family Planning Project is a 9-year research, service, and teaching project undertaken jointly by the University of Ghana Medical School and the University of California at Los Angeles. The following objectives of the TBA training program were defined: 1) to motivate and train the TBAs to monitor women during the antepartum period and to recognize and refer high risk woman or those with serious complications of pregnancy or delivery; 2) to train the TBAs to perform safer deliveries; 3) to train the TBAs in the proper care of the cord; and 4) to enlist the aid of the TBA in the promotion of improved maternal and child health practices and family planning in their villages. The syllabus - outlined here - emphasizes the teaching skills which are needed to meet the stated objectives. The most important aspect of the training program is the continuing support and supervision of the trained TBAs. Problem areas of the program are related to supervision, transportation, non-participation, age of the TBAs, and remuneration. The following were included among the recommendations to those contemplating the training of TBAs in Africa: 1) training should be continuous; 2) emphasis should be on motivating the younger TBAs and those who perform the greatest number of deliveries; and 3) the training program should be simple and emphasize only those basic scientific midwifery skills which would help the TBAs gain self-confidence and make deliveries safer.

Outside Europe. Is poliomyelitis a serious problem in developing countries?--the Danfa experience.

Children were examined for lameness in the Danfa Project district of rural Ghana to assess the impact of endemic poliomyelitis and to test a widely held hypothesis that paralytic poliomyelitis is relatively rare in such districts (less than 1 per 1000 children affected). The observed prevalence of lameness attributable to poliomyelitis was 7 per 1000 school-aged children, and the annual incidence is estimated to be at least 28 per 100 000 population. Although no evidence for an epidemic was found, these rates are comparable with those in the USA and Europe during the years of severe epidemics and indicate that a high price is being paid in the Danfa district for the natural acquisition of immunity. As a result, immunisation against poliomyelitis has been given high priority. A teacher questionnaire was also tested for use in postal surveys as a rapid means of estimating the prevalence of lamenes attributable to poliomyelitis in countries with a reasonable network of primary schools.

Is poliomyelitis a serious problem in developing countries?--lameness in Ghanaian schools.

A postal survey of lameness in schools throughout Ghana showed an estimated prevalence of lameness attributable to poliomyetitis of 5-8 per 1000 school-aged children and an estimated mean annual incidence of paralytic poliomyelitis of 23 per 100 000 population. Official reported incidence rates range from 0-1 to 2-1 per 100 000 population, indicating that at least 90% of cases are not reported. No evidence of epidemics was found to account for these high rates. These suggest that mean annual incidence rates in tropical endemic countries have always been as great, if not greater, than those experienced by temperate countries during epidemic periods in the twentieth century and that the total number of cases of paralytic poliomyelitis occurring in the world each year has been reduced by only 25% since the advent of polio vaccine. Immunisation against poliomyelitis must have a high priority in Ghana and other tropical countries where the disease is endemic.

The Danfa family planning program in rural Ghana.

PIP: The objectives of the Danfa Family Planning Program in rural Ghana are to provide family planning services to the people in the region and to conduct research into ways of making these services as effective and accessible as possible within given resource limitations. The effort is made to describe the planning and operating experience of the program during its 1st 2 1/2 years. In order to test the hypotheses and satisfy service, research, and teaching objectives, the region in which the project operates was divided into 4 areas with each area receiving different service inputs. This division was related to the following arguments with the 4th area used as a control area to learn how much family planning occurs in the absence of special health, education, and family planning programs: 1) couples will want to limit the number of their children only if they perceive that they need no longer fear that several of them will die before reaching adulthood; 2) the most cost-effective approach is to provide family planning services in conjunction with an intensive educational program promoting good health practices and family planning but without comprehensive health services; and 3) by amking family planning services available without concern for comprehensive health services or a special education program, adequate acceptance of family planning and a favorable fertility change at minimum cost will be achieved. The 4 research areas covering about 200 square miles are located in a rural region 8-50 miles north of Accra, the capital of Ghana, and have a population of 60,000. It was learned that it is easier to operate a family planning program in this region of rural Ghana than had originally been anticipated and that education about the benefits of family planning and the methods available along with accessibility to services are 2 elements that are crucial to the success of a family planning program in this setting.^ieng

Attitudes and practices of traditional birth attendents in rural Ghana: implications for training in Africa.

PIP: In the Danfa Project area of rural Ghana a survey of the characteristics, attitudes, and practices of traditional birth attendants was conducted. In 1973, 6 months following the start of the family planning program, a questionnaire was administered to a sample of the traditional birth attendants registered. Interviews were carried out in the local language by public health nurses familiar with the area. 82 interviews were completed. Differences in interview responses between areas were negligible and combined results are reported for the 3 areas surveyed. There were 2 types of traditional birth attendants -- herbalists who engaged in midwifery as only part of their medical practice and those who limited their practice to midwifery. The traditional birth attendants usually gave correct or neutral advice and most recognized the benefits of rapid referral to hospitals for seious problems. They were supportive of family planning and very interested in improving their skills. However, a number of factors must be considered in organizing training programs. Special adult educational methods must be used. In order to achieve adequate coverage 1 must train large numbers of traditional birth attendants who perform an average on only 7 deliveries per year and who are widely scattered in remote rural villages. This creates extensive problems, particularly in transportation and follow-up supervision. Combining training of traditional birth attendants with other village health programs or community development projects could be the answer.^ieng