Assessment of prevalence and determinants of posttraumatic stress disorder in survivors of earthquake in Pakistan using Davidson Trauma Scale.

INTRODUCTION: Pakistan's 2005 earthquake claimed almost 87,000 lives and displaced millions. The present study sought to assess PTSD prevalence among earthquake survivors, to evaluate its determinants, and to identify protective factors that suggest future interventions in the aftermath of disasters. METHODS: In a cross-sectional survey, three districts were selected based on their proximity to the epicenter and the presence, accessibility, and security of refugees, 300 earthquake survivors were enrolled. RESULTS: Analysis revealed that after 30months, PTSD prevalence was high. Being female, older, unmarried, head of the family, and currently unemployed and having low income and living in temporary housing confer higher risks of PTSD. Having a high social capital and religious inclination seem to have protective, buffer effect and increase resilience against PTSD. CONCLUSION: This is the first post-quake study in Pakistan that has utilized, adapted and validated Davidson Trauma Scale in the local context. Results imply the significance of continued psychological support, of drawing on resilience factors in PTSD management. Implications and directions for future research are discussed.

Needlestick and sharps injuries among health care workers at public tertiary hospitals in an urban community in Mongolia.

BACKGROUND: Needlestick and sharps injuries (NSSIs) are one of the major risk factors for blood-borne infections at healthcare facilities. This study examines the current situation of NSSIs among health care workers at public tertiary hospitals in an urban community in Mongolia and explores strategies for the prevention of these injuries. FINDINGS: A survey of 621 health care workers was undertaken in two public tertiary hospitals in Ulaanbaatar, Mongolia, in July 2006. A semi-structured and self-administered questionnaire was distributed to study injection practices and the occurrence of NSSIs. A multiple logistic regression analysis was performed to investigate factors associated with experiencing NSSIs. Among the 435 healthcare workers who returned a completed questionnaire, the incidence of NSSIs during the previous 3 months was 38.4%. Health care workers were more likely to report NSSIs if they worked longer than 35 hours per week (odds ratio, OR: 2.47; 95% confidence interval, CI: 1.31-4.66) and administered more than 10 injections per day (OR: 4.76; 95% CI: 1.97-11.49). The likelihood of self-reporting NSSIs significantly decreased if health care workers adhered to universal precautions (OR: 0.34; 95% CI: 0.17-0.68). CONCLUSIONS: NSSIs are a common public health problem at public tertiary hospitals in Mongolia. The promotion of adequate working conditions, elimination of excessive injection use, and adherence to universal precautions will be important for the future control of potential infections with blood-borne pathogens due to occupational exposures to sharps in this setting.

Predictors of exclusive breast-feeding in early infancy: a survey report from Phnom Penh, Cambodia.

BACKGROUND: Exclusive breast-feeding (EBF) is recommended in the first 6 months of an infant's life. This study aims to investigate the present status of infant feeding practices and identify factors that affect EBF practices during the first 6 months following infant birth in Phnom Penh, Cambodia. METHODS: A cross-sectional survey with a semistructured questionnaire was given to 312 mothers with children aged 6 to 24 months who visited the immunization clinic in the National Maternal and Child Health Centre in Phnom Penh, Cambodia, from December 2005 to February 2006. RESULTS: Eighty-three percent of mothers fed breast milk exclusively in the first month, whereas only 51.3% continued EBF in the first 6 months. Within 30 minutes after delivery, 39% of mothers began breast-feeding. Results from logistic regression analysis indicate that the lack of a maternal antenatal EBF plan (odds ratio [OR] = 10.01, 95% confidence interval [CI] = 3.68-27.24, p < .001), working mothers (OR = 4.71, 95% CI = 2.77-8.01, p < .001), and lack of paternal attendance at breast-feeding classes (OR = 1.93, 95% CI = 1.13-3.28, p < .05) have independently positive associations with cessation of EBF during the first 6 months of infant life. CONCLUSION: The findings have helped to identify some important factors affecting EBF practices in the study area in Cambodia. The findings revealed that it is important to educate pregnant mothers, probably through exposure to trained midwives and media, so they may recognize the significance of EBF and will develop intention and plan to feed their babies, keeping in mind the benefits it may yield. Paternal involvement in breast-feeding classes may increase their awareness and consequently complement EBF practices. Finally, development of conducive working environments and policies for working mothers should be carefully explored because it could have positive influence in better care and promotion of EBF.

Antenatal care among ethnic populations in Louang Namtha Province, Lao PDR.

One in 33 women in Lao PDR dies due to pregnancy-related causes, which is the highest in Southeast Asia. This study assessed ANC utilization rates and the determinants for these rates; it also explored rural maternal decision-making regarding the place of delivery and immunizations for their children under age five years. A cross-sectional study was carried out in Viengphukha District, Louang Namtha Province, Lao PDR in January 2008. Of 1,005 household representatives, 620 who had children age under five years were interviewed using a semi-structured questionnaire. Nearly one-quarter of mothers (23.4%) had at least one ANC visit during their most recent pregnancy, of which 4.5% had > or = 4 ANC visits. ANC visit rates among lowland and midland mothers were 3.6 and 7.6 times higher than highland mothers, respectively (p < 0.005 and p < 0.001). Mothers with no ANC were more likely to deliver at home (adjusted OR = 18.0; p < 0.0001). Home deliveries were more common among highland than lowland mothers (adjusted OR = 10.5; p < 0.05). Children born to mothers who had no ANC visit were more likely to not complete routine immunization than those who were born to mothers who had ANC visits (adjusted OR = 1.9; p < 0.01). Low ANC utilization rates in Lao PDR were observed among ethnic minority mothers who were less educated. ANC visits enhanced hospital deliveries and child immunizations. The promotion of ANC among women in remote rural communities is needed.

Factors influencing breastfeeding in children less than 2 years of age in Lao PDR.

AIM: This study aimed to investigate the prevalence of, and factors influencing, exclusive breastfeeding (EBF) at 6 months and continued breastfeeding (CBF) at 2 years. METHODS: Between January and February 2007, a cross-sectional study was conducted using a semi-structured questionnaire in 40 villages in the Vientiane capital and the Vientiane province of Lao PDR. A total of 400 mothers with children less than 2 years old were recruited by multistage random sampling. Based on the 1991 World Health Organization Breastfeeding Indicators, children were classified into three groups, 6-23-month-old children for assessing EBF at 6 months, 12-15-month-old children for CBF at 1 year and 20-23-month-old children for CBF at 2 years. RESULTS: The prevalence of EBF at 6 months and CBF at 2 years were 19.4% (n= 283) and 18.6% (n= 43), respectively. Some of the factors influencing EBF at 6 months in a univariate logistic regression model included: location of residence, (OR: 19.19, 95% CI 6.96-57.01), ethnicity (OR: 3.15, 95% CI 1.63-6.08), encouragement of the child's father (OR: 9.03, 95%CI 1.21-67.57) and inter-spousal communication (OR: 5.20, 95% CI 2.34-11.56). A majority of the mothers (75.0%) had watched television advertisements for infant formula from Thailand, and 48.4% reported that they wanted to buy formula milk after having watched them. CONCLUSION: This study showed a low prevalence of EBF at 6 months in the studied area in Lao PDR. Some of the factors that had a strong impact on EBF at 6 months included: location of residence, ethnicity, father's involvement, early breastfeeding plan, Mother's Card in antenatal care and television advertisement. There may be opportunities for government to review a range of policies relating to paternal involvement, antenatal care and formula advertising that could help to improve EBF rate.

Hospital medical waste management in Shandong Province, China.

Medical waste refers to those hazardous waste materials generated by healthcare activities, including a broad range of materials, and remains as an issue on both public health and environment. In China, there was inadequate information on the implementation of management systems in hospitals based on the national regulatory framework. The objectives of this study were to assess the current situation of medical waste management and to identify factors determining the implementation of a management system based on the national regulatory framework in hospitals. We investigated 23 general hospitals in both urban and rural areas of Shandong Province, China, by both quantitative and qualitative approaches. The medical waste generation rate was 0.744, 0.558 and 1.534 kg bed(-1) day(-1) in tertiary hospitals, urban secondary hospitals and county hospitals, respectively. There is a wide disparity between implementation in tertiary, secondary and county hospitals. With increasing financial, technological, and materials investment, a management system has been established in tertiary and secondary hospitals. Financial support and administrative monitoring by the government is urgently needed to build a sound management system in hospitals located at remote and less-developed areas. In those areas issues in the financial, administrative and technical aspects should be further examined.

Malnutrition among children in rural Malawian fish-farming households.

To estimate the impact of fish farming operated at household level on nutritional status among children 6-59 months of age, a cross-sectional study was conducted in Zomba district, Malawi. Anthropometric measurements of 66 children in each type of household (fish-farming and non-fish-farming households) and structured interviews with their parents were undertaken. A total of 21 background variables were employed and examined using bivariate and multivariate analyses. Overall, a lower prevalence of malnutrition was detected among the children in fish-farming households than those in non-fish-farming households in all the malnutrition indicators, i.e. stunting, underweight and wasting. In particular, a significantly lower prevalence was detected among the children in fish-farming households than those in non-fish-farming households in both severe (P=0.045) and global underweight (P=0.042). 'Higher proportion of income from fish farming to total income', 'more frequent intake of oil and fats other than never/seldom' and 'breastfeeding practice for the appropriate duration' are the protective factors against being underweight. Household fish farming may have indirectly contributed to lower prevalence of underweight through increasing frequency of intake of oil and fats by strengthening households' purchasing power. The study supports 12 months as the threshold for appropriate breastfeeding duration.

Scaling up interventions to eliminate neonatal tetanus: factors associated with the coverage of tetanus toxoid and clean deliveries among women in Vientiane, Lao PDR.

The Lao People's Democratic Republic (PDR) is one of seven countries that have not eliminated maternal and neonatal tetanus in more than 50% of districts. We conducted a community-based household survey to assess the achievements of strategies towards maternal and neonatal tetanus elimination in the capital province. The coverage of tetanus toxoid (TT) was 79.7% by the protection-at-birth (PAB) method. The percentages of deliveries attended by skilled personnel and of deliveries at a health facility were 68.4% and 63.7%, respectively. The progress towards eliminating neonatal tetanus in Lao PDR is not sufficient despite the study sites being placed in the capital province. The lack of continuum of care for mothers and newborns is the major obstacle to scale up the tetanus toxoid coverage and PAB as well as clean deliveries.

Physicians' knowledge regarding the recommended anti-tuberculosis prescribed medication regimen: a cross-sectional survey from Lucknow, India.

We conducted a cross-sectional, descriptive survey among 141 medical physicians treating tuberculosis (TB) patients, registered with local chest physicians association in Lucknow District, India. A semi-structured questionnaire was used to evaluate the physicians' knowledge of anti-tuberculosis prescribed medication regimens. Sixty percent of eligible physicians had Revised National Tuberculosis Control Program training, mostly in the public sector. Only two-thirds of physicians could correctly state the recommended TB drugs. Physicians, especially in the private sector, had inadequate knowledge of the approved anti-tuberculosis prescribed medication regimen. This study demonstrates the need for adequate training in both public and private sectors regarding the correct anti-tuberculosis treatment regimens.

Monitoring malaria control in Khammouane province, Laos: an active case detection survey of Plasmodium falciparum malaria using the Paracheck rapid diagnostic test.

In Khammouane province, Laos, over 5000 slide-positive malaria cases were reported at local health facilities in 1997. To combat the spread of malaria, insecticide-treated nets (ITNs) and community health education were provided to the people in this province by the Lao Ministry of Health and the Japan International Cooperation Agency. In order to document the current malaria situation, an active case detection (ACD) survey using rapid diagnostic tests was conducted at 23 sites from June to July, the rainy season, in 2005. A total of 1711 villagers from 403 households participated in the survey. The proportion of positive cases was 0.7% (12/1711) with a range in each village of 0-8.2%. The low infection rate observed in this ACD survey was consistent with the decrease in the number of slide-positive malaria cases at local health facilities (from over 5000 cases to 536 cases), indicating the substantial progress made in malaria control. Although the reduction of malaria cases can be attributed to multiple factors, continued promotion of the proper use of ITNs as well as community-based testing and treatment services, especially in remote areas, may lead to a further reduction of malaria cases in the province.

Emergency obstetric care in Punjab, Pakistan: improvement needed.

INTRODUCTION: This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services. METHODS: In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis. RESULTS: No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality. CONCLUSION: The study may be taken as a baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications.

Challenges in access to and utilization of reproductive health care in Pakistan.

BACKGROUND: Pakistan's maternal mortality rate is high, and adequate and timely emergency services could prevent most maternal deaths. A woman's right to life-saving services of skilled health care providers in childbirth is undeniable. This paper examines factors restricting women's access to emergency obstetric care services in Pakistan. METHOD: This cross-sectional survey on emergency obstetric care services collected information at the health facility level using UN process indicators. The study enrolled 170 health facilities from nineteen randomly selected districts in Punjab and NWFP. RESULTS: Diverse factors limit women's access to Emergency Obstetric Care (EmOC) services. EmOC services were unavailable in most health facilities surveyed. Staff absenteeism, geographic remoteness, delayed access, and ambulance shortages jeopardize the transferral of seriously ill patients to higher level care facilities. Cultural norms dictate that women should be examined by women doctors, whose dearth makes these services inaccessible. CONCLUSION: Many maternal deaths would be avoidable if EmOC health services were accessible. The geographic obstacles to timely access, poor hospital infrastructure, and high staff absenteeism rates require immediate attention. Health facilities' working hours were inconsistent with the provision of around-the-clock essential services, depriving and endangering the lives of many in need. It is imperative to increase skilled female workers capable of managing EmOC problems through proper incentives. A focused approach at local levels through proper supervision, motivation, and management would unquestionably save women's lives.

The reality of health information systems: challenges for standardization.

Health information systems (HISs) serve as an indispensable foundation for developing health policy and strategies and improving delivery of routine health services in an evidence-based manner. In developing countries, HISs are not adequately functioning in spite of their important role such as monitoring tools for the progress of the Millennium Development Goals. This paper attempts to classify the HISs into four types according to their data sources. Information requirement by the diseases-specific funds (e.g. Global Fund to Fight AIDS, Tuberculosis and Malaria) and projects implemented by development agencies increase the workloads of health professionals at facility level and subsequently compromise data quality. For the data quality assurance and comparability of data across countries overtime of major health indicators, standardization of HISs are the urgent task.

A social marketing approach to quality improvement in family planning services: a case study from Rawalpindi, Pakistan.

In the 1990s, social marketing approach was introduced in Pakistan to improve the quality and accessibility of family planning methods involving private practitioners. This study measured six quality elements using a Bruce-Jain framework. Cross-sectional survey data were collected from 29 randomly selected Green Star clinics. The study's four components were 1) an inventory of each outlet (infrastructure, equipment, and supplies); 2) an observation guide for interaction between family planning clients and service providers; 3) exit interviews with clients attending the outlet; and 4) interviews with providers at the outlet. Of the 29 clients participating in the exit interviews, 72% were new users of family planning. The clients' mean age was 32 years; all clients were married; 93% had received formal education. Housework was the principal activity of 93% of clients. The mean number of children reported was three. Both hormonal and intrauterine contraceptives (IUCDs) were available in all facilities; 86% of the clients reported being able to obtain their contraceptive of choice. Most facilities had the equipment and supplies needed to deliver services; service personnel were trained and regularly supervised; the service outlets emphasized mechanisms to ensure continuity of use. Notable shortcomings included a shortage of information on alternative methods, contraindications, and side-effect management, as well as a dearth of registration records. In conclusion, this is a good example of public-private partnership involving private practitioners using a social marketing approach. The quality components of a Bruce-Jain framework were achieved, resulting in a satisfied clientele. Involvement of private service outlets increased the accessibility and enhanced the use of services. Social marketing may be expanded to improve quality and access by involving further components of health care.

Assessment of hepatitis B vaccine-induced seroprotection among children 5-10 years old in Ulaanbaatar, Mongolia.

Hepatitis B virus infection is a serious public health problem. Mongolia is one of the countries with the highest rates of hepatitis B virus infection in the world. The routine immunization with the hepatitis B vaccine began nationwide in 1991. The purpose of this study was to determine the persistence of seroprotection (anti-HBs >or= 10 mlU/mL) in children 5-10 years old that were immunized with the hepatitis B vaccine as infants. In total, 438 children were selected from six health facilities in Ulaanbaatar through a multistage random sampling method. Vaccination information was confirmed by checking the vaccination records kept in the health facilities. A blood sample was obtained from each child for anti-HBs, HBsAg and anti-HBc. Of 438 children, five (1.1%) were HBsAg positive and 58 (13.2%) were anti-HBc positive. Sixty infected children were excluded and a total of 378 (86.3%) sera were evaluated. The seroprotective antibodies were detected in only one-fourth of the children at the age of ten. Titres of anti-HBs decreased significantly with age (Linear regression p = 0.01). This decrease is primarily due to the rapid decrease in children living in ger areas (p < 0.001) compared to children living in apartment areas (p = 0.152). On the other hand, children living with higher socio-economic status had more exposure to blood-borne pathogens, probably due to inappropriate health-seeking behaviors.

The health management information system of Pakistan under devolution: health managers' perceptions.

Devolution implies that use of data for decision making starts at the level of data generation. However under a newly decentralized system, managers may face different hurdles in utilizing the preexisting Health Management Information System (HMIS). This qualitative research explores the perceptions of health managers regarding HMIS under the devolution reforms enacted in 2001 in Pakistan. The study was carried out by interviewing 26 managers at various levels in seven selected districts in all provinces. There was general dissatisfaction and confusion over roles and responsibility: respondents reported that the overall atmosphere was characterized by the reluctance of provincial managers to release data under their authority, the absence of prerequisite human resources, and conflicts of interests between political and administrative leadership. The devolution didn't bring immediate good effects for the HMIS. Treated as a least priority area, staff was distributed from provincial HMIS cells, causing overburdening of remaining staff and jeopardizing data analysis. Reporting regularity from the districts was also compromised secondary to political interference and loss of provincial control. The present HMIS is in need of redesigning so that it may keep pace with the devolved system. The HMIS reforms are needed to improve information systems at the district level, capacity building of district managers, political commitment, and administrative ownership of the system and to earmark and make available resource and promote evidence-based decision making. Change in the public administration culture towards encouraging initiative taking at lower levels, introduction of performance incentives, inculcating work ethics, encouraging local accountability, and good governance are all essential.

Risk of sharps exposure among health science students in northeast China.

Previous studies have demonstrated that sharps-related infectious disease is a global concern. Several papers have also reported that students are at a higher risk than healthcare workers. The prevalence of sharps exposure in China, however, is unknown. This study explored the incidence of sharps exposure and its related risk factors among students in all academic years and majors at a medical university in China. This cross sectional study was conducted at a Chinese medical university in May 2005. Stratified random sampling was used. Students in all five academic years (Y1-Y5) who were majoring in clinical medicine, nursing, dentistry, medical technology, pharmacology, acupuncture/massage, and public affairs management were provided questionnaires. Nine hundred seventy of 1,070 (90.7%) students completed the questionnaire. One hundred twenty-two of 968 (12.6%) students reported a total of 131 sharps exposures during the previous 12 months. Of these exposures, 24.7% occurred in academic year five (Y5) students, followed by 23.4% in academic year four (Y4) students. Dental students had the highest incidence rate at 20.6%, followed by medical students (16.0%), nursing students (12.2%), and acupuncture/massage students (5.0%). Only 45 (34.4%) of sharps exposures were reported to a supervisor, and the students displayed a general lack of knowledge of occupational exposure standards (OES). In conclusion, sharps exposures most frequently occurred among students from 3 majors: dentistry, nursing, and clinical medicine. Sharps exposures were underreported to supervisors. Effective OES educational programs need to be developed and should be implemented early in health science students' education.

UXO victims and health status of populations living in Xiengkhuang Province, Lao PDR: A household-based survey.

During the Vietnam War from 1964 to 1973, over 2 million tons of bombs were dropped on Laos. Approximately 30% of the bombs did not explode and have posed a continued threat to civilians throughout the country. Approximately 200 casualties per year have been reported nationwide. Therefore, we conducted a household survey to better understand magnitude of UXO victims, accessibility to the MCH services and child healthcare seeking behaviors of the population in the Xiengkhuang province. The household-based survey was carried out in February 2006 among 6 of 541 villages. 283 household representatives were interviewed. The cumulative number of UXO victims identified from 1973 to 2005 was 45 casualties, of which 9 (20.0%) occurred in the year 2005. 37.5% reported knowledge of danger zones for UXO contamination. Among the 91 children under the age of 5 years, households on average reported 1.7 episodes per year for diarrhea, 2.7 for respiratory disease, 2.3 for fever and 1.7 for measles. 69.4% of children under five were completed the routine immunization program, 62.6% of mothers used ANC service for their most recent pregnancy, 58.2% accessed family planning services, and 28.6% delivered their most recent child at a healthcare facility. UXO victims in the targeted villages sharply increased in 2005. Insufficient knowledge about UXO danger and MRE seems to be a central factor in the high rate of UXO-associated accidents. Diarrhea, respiratory disease and measles remained health problems for children under 5 years. MCH services utilization were higher than Laos nationally.