Do memories of the Ebola virus disease outbreak influence post-Ebola health seeking behaviour in Guéckédou district (epicentre) in Guinea? A cross-sectional study of children with febrile illness.

BACKGROUND: The 2013-2015 Ebola Virus Disease (EVD) outbreak in Guinea resulted in community mistrust that influenced health care service utilization. This study aimed to assess whether EVD-related memories affect post-outbreak health-seeking behaviours for children under 5 years of age with febrile illnesses in Guéckédou district, Guinea. METHODS: This cross-sectional study was conducted by surveying caregivers of children under 5 years of age in the sub-district most affected by the EVD outbreak (Guèndembou) and the least affected sub-district (Bolodou) in Guéckédou district. Memories of the outbreak were referred to as EVD-related fears in the post-EVD period, which was based on a series of questions regarding current feelings. RESULTS: While the majority of caregivers sought care for their children with febrile illness in both districts, a statistically significantly higher proportion of caregivers in Guèndembou sought care, compared to caregivers in Bolodou.. More caregivers in Guèndembou (19.9%; n = 39) reported the death of family members or friends due to EVD compared to Bolodou (6.9%; n = 14; P < 0.001). The mean EVD fear score of caregivers was significantly higher in Guèndembou (3.0; SD: 3.0) than in Bolodou (2.0; SD: 1.1) (p < 0.001). Caregivers with a fear score above the median were 1.68 times more likely to seek care than those whose fear score was equal to or below the median; however, this difference was not statistically significant. Caregivers who reported family members' or friends' death due to EVD were also more likely to seek care (AOR = 2.12; 95%CI: 0.91-4.91), however, with no statistical significance. Only residing in the EVD-most affected sub-district of Guèndembou (AOR = 1.74; 95%CI: 1·09-2.79) was positively associated with seeking care. CONCLUSIONS: This study reveals that community members in the rural district of Guéckédou still live with fear related to EVD nearly 2 years after the outbreak. It calls for more efforts in the health domain to preserve communities' key values and address the psychosocial effect of EVD in rural Guinea.

Maternal and Child Health Services in the Context of the Ebola Virus Disease: Health Care Workers' Knowledge, Attitudes and Practices in Rural Guinea.

The objective of this study was to document maternal and child health care workers' knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved.

Factors affecting alcohol drinking behaviour among secondary school students in Vientiane Province, Lao People's Democratic Republic: a cross-sectional study.

BACKGROUND: This study investigated alcohol consumption prevalence among adolescents in school settings in Lao People's Democratic Republic and identified factors associated with alcohol consumption to establish better school-based interventions. METHODS: Self-administered questionnaires containing items assessing alcohol drinking behaviour and underlying factors were administered to 393 secondary school students ages 10-19 y. Multivariate logistic regression was used to predict factors associated with drinking behaviour. RESULTS: Fifty-eight percent of respondents reported ever drinking alcohol. Among the drinkers, 52.6% were light drinkers, 16.8% were moderate drinkers, 27.0% were heavy drinkers and 3.5% were very heavy drinkers. Older age group (adjusted odds ratio [AOR] 5.2 [95% confidence interval {CI} 2.6 to 10.1]); peer pressure, particularly when more than two-thirds of friends drank alcohol (AOR 8.0 [95% CI 2.2 to 29.5]); and siblings' drinking behaviour (AOR 2.8 [95% CI 1.4 to 5.5]) were positively associated with alcohol use, while no permission to drink at home (AOR 0.2 [95% CI 0.1 to 0.6]), uncertain of permission to drink at home (AOR 0.06 [95% CI 0.02 to 0.1]) and never attempting to buy alcohol (AOR 0.2 [95% CI 0.1 to 0.4]) were negatively associated with respondents' alcohol use. CONCLUSIONS: By the age of 19 y, most participating students had started drinking alcohol. One-third of them were permitted to drink by family members and drinking was strongly accelerated by peer pressure. Educational programmes are needed for adolescents attending school and their families that employ peer learning to raise awareness of the ill effects of alcohol use.

Effect of daily versus weekly home fortification with multiple micronutrient powder on haemoglobin concentration of young children in a rural area, Lao People's Democratic Republic: a randomised trial.

BACKGROUND: Multiple micronutrient deficiencies, in particular iron deficiency anaemia (IDA) is a severe public health problem in Lao People's Democratic Republic (Lao PDR). Because of the practical difficulties encountered in improving the nutritional adequacy of traditional complementary foods and the limitations associated with the use of liquid iron supplementation for the treatment and prevention of IDA in infants and young children, recently, home-fortification with multivitamins and minerals sprinkles was recommended. This study aims to compare the effect of twice weekly versus daily supplementation with multivitamins and minerals powder (MMP) on anaemia prevalence, haemoglobin concentration, and growth in infants and young children in a rural community in Lao PDR. METHODS: A randomized trial was conducted in six rural communities. Children aged 6 to 52 months (n = 336) were randomly assigned to a control group (n = 110) or to one of two intervention groups receiving either two sachets per week (n = 115) or a daily sachet (n = 111) of MMP for 24 weeks; 331 children completed the study. A finger prick of blood was taken at baseline, at week 12, and again at week 24 to determine haemoglobin concentration. Anthropometric measurements were taken every 4 weeks. The McNemar test was used to assess within group differences at three time points in the study subjects with anaemia and one-way ANOVA was used to assess changes in mean haemoglobin concentration in the treatment groups. RESULTS: MMP supplementation resulted in significant improvements in haemoglobin concentration and in the reduction of anaemia prevalence in the two treatment groups compared with the control group (p <0.001). The severely to moderately anaemic children (Hb <100 g/L) on daily supplementation recovered faster than those on twice weekly supplementation. MMP was well accepted and compliance was high in both treatment groups. Overall, the improvement in the weight for age Z-score was very small and not statistically significant across the three study groups. CONCLUSIONS: MMP supplementation had positive effects in reduction of anaemia prevalence and in improving haemoglobin concentration. For severely to moderately anaemic children, daily MMP supplementation was more effective in improving haemoglobin concentration and reducing anaemia prevalence. A longer intervention period is probably needed to have a positive effect on growth.

Polarized nature of the COVID-19 pandemic in Japan: associations with population age structure and behaviours.

BACKGROUND: Although the scale of the coronavirus disease (COVID-19) pandemic was relatively small in Japan compared with the rest of the world, the polarisation of areas into high- and low-COVID-19-incidence areas was observed among the 47 prefectures. The aims of this study were not only identifying the factors associated with the polarised COVID-19 pandemic in Japan but also discussing effective preventive measures. METHODS: This was an ecological study using online survey data which was cross-sectionally conducted by the author. A total of 6000 respondents who resided in 10 low- and 10 high-COVID-19 incidence prefectures, with a wide gap in terms of COVID-19 incidence, in Japan were recruited. Data on COVID-19 cases and geodemographic information were obtained from official government sites. Statistical analyses were conducted to compare variables between the two areas and age groups. RESULTS: This study revealed that that age influenced people's behaviours and perceptions, except one behaviour of 'wearing facemasks'. The major factors significantly associated with the cumulative number of COVID-19 cases per 100,000 people were 'commuting by private automobile' (adjusted odds ratio [AOR], 0.444; 95% confidence interval [CI], 0.394-0.501), 'commuting by public transportation' (AOR, 6.813; 95% CI, 5.567-8.336), 'washing hands' (AOR, 1.233; 95% CI, 1.005-1.511), 'opening windows regularly' (AOR, 1.248; 95% CI, 1.104-1.412), 'avoiding crowded places (AOR, 0.757; 95% CI, 0.641-0.893), 'non-scheduled visits to drinking places' (AOR, 1.212; 95% CI, 1.054-1.392) and 'perceived risk of contracting COVID-19' (AOR, 1.380; 95% CI, 1.180-1.612). These factors were strongly associated with age groups. CONCLUSIONS: Effective preventive measures for COVID-19 transmission can be developed by understanding the characteristics of populated areas, such as public transportation infrastructure and younger people's movements and behaviours in relation to the population age structure to contain the current epidemic and protect the most vulnerable elderly people.

Prevalence of counterfeit anthelminthic medicines: a cross-sectional survey in Cambodia.

OBJECTIVES: To assess the prevalence of counterfeit anthelminthic medicines in Cambodia, and to determine influential factors. METHODS: Commonly used anthelminthic medicines were collected from private drug outlets. Medicines were carefully observed including their registration labelling, and their authenticity was investigated with the manufacturers and the Medicines Regulatory Authorities. Samples were analysed by High-Performance Liquid Chromatography at the National Health Product Quality Control Centre, Cambodia. RESULTS: Two hundred and three samples of anthelminthics were collected from 137 drug stores. Domestic products constituted 36.9%. Of 196 samples which were verified for registration, 15.8% were not registered. Of 165 samples successfully investigated for their authenticity, 7 (4.2%) were identified as counterfeit. All of these medicines were purchased in open packs or containers, and most of them were foreign manufactured and/or without registration. CONCLUSION: The results of our survey urge strict implementation of drug registration and vigilance on the availability of unregistered medicines to combat counterfeit medicines in Cambodia.

Antimicrobial therapy for water-associated wound infections in a disaster setting: gram-negative bacilli in an aquatic environment and lessons from Banda Aceh.

INTRODUCTION: As members of the Japan Disaster Relief (JDR) team in Banda Aceh, three of the authors treated 1,891 patients following the tsunami of 2004. Of the 367 cases with traumatic injuries, 216 cases required antimicrobial therapy. The medical services were continued by the Japan Self-Defense (JSD) Medical Team until mid-March 2005. Of the 216 cases initially treated by JDR, 54 required prolonged antimicrobial therapy for persistent symptoms despite repeated debridement. The aim of this study is to recommend an appropriate antimicrobial therapy for water-associated wound infections in the absence of laboratory services in disaster settings following tsunami. METHODS: The JDR and JSD treatment records were analyzed retrospectively. In August 2006, 19 months after the tsunami, the authors investigated pathogens in natural aquatic habitats in the affected area in Banda Aceh. At the same time, interviews with tsunami survivors were performed to determine the influential factors that facilitated wound infections after the tsunami. RESULTS: From the 49 water samples tested, Aeromonas sp., Vibrio sp., Klebsiella sp., and Proteus sp. were isolated from 24, 16, 15, and six samples, respectively. Regardless of the genus, almost all of the isolated gram-negative bacilli were sensitive to ciprofloxacin and gentamicin. CONCLUSIONS: From the microbiological test results and analyses of the medical records and interviews, the researchers recommend the following regimen when clinical microbiological tests are not available: initial treatment with beta"lactam penicillins for three days, followed, if the first antimicrobial is not effective, by ciprofloxacin or any other relevant new quinolones, with the addition of gentamicin if necessary.

Pharmaceutical supply for disaster victims who need chronic disease management in region with aging population based on lessons learned from the Noto Peninsula Earthquake in 2007.

The lessons from the Great Hanshin-Awaji Earthquake and Chuuetsu Earthquake showed us how difficult it is to keep chronic disease management for survivors of such large-scale earthquakes, particularly for elderly people. To solve the problem, an ordinance for enforcement on exceptional practices was issued for the Pharmaceutical Affairs Law Article 49 Clause 1. The law allows selling prescription medicines for patients with chronic diseases who have difficulties to continue their medications due to a large-scale disaster. To make it work, the patient should demonstrate that he or she continuously received the medication by presenting either Medication Notebook or prescription book recorded by the pharmacist. However, the Separation Rate of Prescription and Dispensing in Japan is still low; in particular, that in Ishikawa prefecture, where the Noto Peninsula Earthquake (M 6.9) occurred on March 25, 20007, is very low. It means that few victims hold a Medication Notebook. In consideration of this situation, we conducted a questionnaire survey of elderly victims of the Noto Peninsula Earthquake with a key-informant-interview during the period from July through August, 2007. This study revealed that: 1) Only 16% (18/110) of respondents kept a Medication Notebook; 2) 75% (82/110) had chronic diseases and received medication regularly; 3) Of 81 who had chronic diseases, 42% (34/91) were dispensed at the same pharmacy always, (The rest received from either clinic or changing pharmacy according to clinic location); and 4) Diseases that the respondents had were hypertension, cardiovascular diseases, diabetes, and so on. Based on these results, we discuss the establishment of a pharmaceutical supply system that can effectively distribute appropriate medicines to patients under difficult situations following a large-scale disaster in Japan.

Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study.

BACKGROUND: The 2014 west African epidemic of Ebola virus disease posed a major threat to the health systems of the countries affected. We sought to quantify the consequences of Ebola virus disease on maternal and child health services in the highly-affected Forest region of Guinea. METHODS: We did a retrospective, observational cohort study of women and children attending public health facilities for antenatal care, institutional delivery, and immunisation services in six of seven health districts in the Forest region (Beyla, Guéckédou, Kissidougou, Lola, Macenta, and N'Zérékoré). We examined monthly service use data for eight maternal and child health services indicators: antenatal care (≥1 antenatal care visit and ≥3 antenatal care visits), institutional delivery, and receipt of five infant vaccines: polio, pentavalent (diphtheria, tetanus, pertussis, hepatitis B virus, and Haemophilus influenzae type b), yellow fever, measles, and tuberculosis. We used interrupted time series models to estimate trends in each indicator across three time periods: pre-Ebola virus disease epidemic (January, 2013, to February, 2014), during-epidemic (March, 2014, to February, 2015) and post-epidemic (March, 2015, to Feb, 2016). We used segmented ordinary least-squares (OLS) regression using Newey-West standard errors to accommodate for serial autocorrelation, and adjusted for any potential effect of birth seasonality on our outcomes. FINDINGS: In the months before the Ebola virus disease outbreak, all three maternal indicators showed a significantly positive change in trend, ranging from a monthly average increase of 61 (95% CI 38-84) institutional deliveries to 119 (95% CI 79-158) women achieving at least three antenatal care visits. These increasing trends were reversed during the epidemic: fewer institutional deliveries occurred (-240, 95% CI -293 to -187), and fewer women achieved at least one antenatal care visit (-418, 95% CI -535 to -300) or at least three antenatal care visits (-363, 95% CI -485 to -242) per month (p<0·0001 for all). Compared with the negative trend during the outbreak, the change in trend during the post-outbreak period showed that 173 more women per month (95% CI 51-294; p=0·0074) had at least one antenatal care visit, 257 more (95% CI 117-398; p=0·0010) had at least three antenatal care visits and 149 more (95% CI 91-206; p<0·0001) had institutional deliveries. However, although the numbers for these indicators increased in the post-epidemic period, the trends for all stagnated. Similarly, the increasing trend in child vaccination completion during the pre-epidemic period was followed by significant immediate and trend reductions across most vaccine types. Before the outbreak, the number of children younger than 12 months who had completed each vaccination ranged from 5752 (95% CI 2821-8682) for tuberculosis to 8043 (95% CI 7621-8464) for yellow fever. Immediately after the outbreak, significant reductions occurred in the level of all vaccinations except for yellow fever for which the reduction was marginal. The greatest reductions were noted for polio and tuberculosis at -3594 (95% CI -4811 to -2377; p<0·0001) and -3048 (95% CI -5879 to -216; p=0·0362) fewer vaccines administered, respectively. Compared with pre-Ebola virus disease outbreak trends, significant decreases occurred for all vaccines except polio, with the trend of monthly decreases in the number of children vaccinated ranging from -419 (95% CI -683 to -155; p=0·0034) fewer for BCG to -313 (95% CI-446 to -179; p<0·0001) fewer for pentavalent during the outbreak. In the post-Ebola virus disease outbreak period, vaccination coverage for polio, measles, and yellow fever continued to decrease, whereas the trend in coverage for tuberculosis and pentavalent did not significantly differ from zero. INTERPRETATION: Most maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions. FUNDING: University of Conakry and Centre National de Formation et Recherche de Maferinyah (Guinea).

Effect of the 2014/2015 Ebola outbreak on reproductive health services in a rural district of Guinea: an ecological study.

Background: The 2014/2015 Ebola outbreak was the most sustained in history. In Guinea, we compared trends in family planning, antenatal care, and institutional deliveries over the period before, during and after the outbreak. Methods: We carried out an ecological study involving all the health facilities during pre-Ebola (1 March 2013 to 28 February 2014), intra-Ebola (1 March 2014 to 28 February 2015) and post-Ebola (1 March to 31 July 2016) periods in Macenta district. Results: Utilization of family planning declined from a monthly average of 531 visits during the pre-Ebola period to 242 visits in the peak month of the Ebola outbreak (51% decline) but recovered in the post-Ebola period. From a monthly average of 2053 visits pre-Ebola, antenatal care visits declined by 41% during Ebola and then recovered to only 63% of the pre-Ebola level (recovery gap of 37%, p<0.001). From a monthly average of 1223 deliveries pre-Ebola, institutional deliveries also declined during Ebola and then recovered to only 66% of the pre-Ebola level (p<0.001). Conclusions: All services assessed were affected by Ebola. Family planning recovered post-Ebola; however, shortfalls were observed in recovery of antenatal care and institutional deliveries. We call for stronger political will, international support and generous funding to change the current state of affairs.

Emerging co-infection of HIV and hepatitis B virus in far western Nepal.

We detected a prevalence (11%) of hepatitis B virus (HBV) infection among male adult villagers (n = 149) in far western Nepal where migration to India is common. Although only one migrant-returnee was infected with both HBV and HIV, co-infection may occur more frequently in future as the HIV prevalence is high (8%).

Use of medicines and adherence to standard treatment guidelines in rural community health centers, Timor-Leste.

The use of medicines and nurses'/midwives' adherence to standard treatment guidelines (STGs) were examined in Timor-Leste during the early stage of the nation's new health system development. A cross-sectional study was conducted as the quantitative element of mixed methods research. Retrospective samples from patient registration books and prospective observations were obtained in 20 randomly selected rural community health centers. The medicines use indicators, in particular the level of injection use, in Timor-Leste did not suggest overprescription. Prescribers with clinical nurse training prescribed significantly fewer antibiotics than those without such training (P < .01). The adjusted odds ratio of prescribing adherence for clinical nurse training, after accounting for confounders and prescriber clustering, was 6.6 (P < .01). STGs for nonphysician health professionals at the primary health care level have potential value in basic health care delivery, including appropriate use of medicines, in resource-limited communities when strategically developed and introduced.

Drug utilisation and self-medication in rural communities in Vietnam.

Reportedly 40-60% of people in Vietnam depend on self-medication. To assess the current situation of self-medication practices as compared with medication given by health professionals in rural areas in Vietnam, we conducted a cross sectional survey at household level. A total of 505 women with at least one child younger than 5 years of age were interviewed in their homes about their drug utilisation practices and attitudes toward medication, by using structured questionnaires. Of the 505 households, 138 stocked drugs for anticipated illness in the future. A total of 96 different antibiotics (in terms of generic type) were kept at 76 households. These antibiotics were kept mainly for coughs and diarrhoea. The self-medication group was twice as likely to use antibiotics than the other group. In addition, self-medication practice was increased when a mother kept medicines in the house. This study revealed that mistaken beliefs about medicines and undesirable attitudes toward medication were prevalent. Mothers used antibiotics as if such drugs were panaceas. In this context, there was insufficient public health education, no control over pharmaceutical promotion, and no efficient drug policy and regulation. More attention should be given to consumers and patients as the ultimate users of drugs so that they can access accurate information, assess the reliability of information and ask necessary questions.

Effect of isotonic and hypotonic lactated ringer's solutions with dextrose intravenously administered to dehydrated heifers.

To determine the effects of rapid infusion of essential fluids in a volume of hypotonic lactated Ringer's solution, the central venous pressure (CVP) and acid-base equilibrium were investigated in to mildly dehydrated heifers. Mild dehydration was induced in 9 Holstein heifers by withholding food and water until 7.0+/-5.7% of plasma volume had been lost. The heifers were randomly assigned to the ILG (lactated Ringer's + 5% dextrose), HLG (1/2 lactated Ringer's + 2.2% dextrose) or HRG (1/2 Ringer's + 2.5% dextrose) groups with 3 heifers in each group. Heifers received 30 ml/kg of one of the fluids, at a flow rate of 20 ml/kg/hr. The rapid intravenous (IV) infusions of HLG and HRG used in this study were found to be safe and effective in increasing plasma volume without increasing CVP, even though the infusion was given to the jugular vein at a dosage of 30 ml/kg. However, ILG infusion induced progressive increases in CVP, reaching 9.0+/-2.0 mmHg. No clinical signs, such as moist rales on auscultation, moist cough, jugular vein congestion, ophthalmoptosis, salivation or arrhythmia, were observed throughout the fluid infusion. The relative changes in base excess (rBE) for the ILG and HRG groups were significantly decreased until the end of fluid infusion. As for the HLG group, rBE slightly decreased until the end of the fluid infusion. Then the values significantly increased and exceeded the pre-infusion value at the end of the experiment. While IV infusion of HLG inhibited acidification caused by dilution, HRG infusion induced diluted acidification. It is suggested that HLG infusion should be examined as a treatment for cattle with dehydration and moderate metabolic acidosis, since rapid infusion of HLG may be more beneficial for rehydrating cattle with metabolic acidosis than current treatment.

Regional differences in the growing incidence of dengue Fever in Vietnam explained by weather variability.

Dengue fever is a major health problem in Vietnam, but its incidence differs from province to province. To understand this at the local level, we assessed the effect of four weather components (humidity, rainfall, temperature and sunshine) on the number of dengue cases in nine provinces of Vietnam. Monthly data from 1999 to 2009 were analysed by time-series regression using negative binomial models. A test for heterogeneity was applied to assess the weather-dengue association in the provinces. Those associations were significantly heterogeneous (for temperature, humidity, and sunshine: P < 0.001 heterogeneity test; for rainfall: P = 0.018 heterogeneity test). This confirms that weather components strongly affect dengue transmission at a lag time of 0 to 3 months, with considerable variation in their influence among different areas in Vietnam. This finding may promote the strategic prevention of dengue disease by suggesting specific plans at the local level, rather than a nationally unified approach.

Steps towards preventive HIV treatment in Fujian, China: problems identified via an assessment of initial antiretroviral therapy provision.

BACKGROUND: At the end of 2009, a total of 501 AIDS patients were receiving antiretroviral therapy (ART) in Fujian Province in China, yet there were no assessments to determine treatment efficacy and HIV-1 preventive potency under the current health care delivery system. METHODS: During the period of 2005-2009, we assessed the outcomes of initial ART by following up 381 patients for 12 months in Fujian Province. CD4⁺ T-lymphocyte (CD4) count, plasma viral load (VL), and patient characteristics were analysed. The results were compared between 4 groups divided by the baseline CD4 values at the 25, 50 (median), and 75 percentiles. FINDINGS: Over three-quarters of the subjects reported heterosexual contact as the probable route of transmission. After 12 months of ART, CD4 recovery varied between the 4 groups (P < 0.001), but VL sharply declined regardless of the baseline CD4 count (P = 0.136). Although this VL decline indicates the potency of ART as an HIV-1 prevention tool, the time between positive diagnosis and ART initiation suggests serious delay in both diagnosis and treatment; the medians of periods for the lowest and highest baseline CD4 quartiles were 1.2 and 9.6 months, respectively. CONCLUSION: Current limitations in VL determination make it difficult to assess the efficacy of initial ART, and delays in diagnosis and treatment suggest that subjects contributed to HIV-1 transmission while they were not receiving ART. The current National Free ART scheme does not provide free treatment for sexually transmitted infection (STI), and there is no link between ART and the STI care delivery system. This may interfere with the HIV-1 preventive potency of ART. We highly recommend establishing a collaborating mechanism with STI care, strengthening the VL determination system, and promoting HIV tests and early ART initiation.

Application of standard treatment guidelines in rural community health centres, Timor-Leste.

OBJECTIVE: To analyse nurses' and midwives' knowledge of and attitudes towards standard treatment guidelines (STGs), which were developed to help their practices at rural community health centres (CHCs) in Timor-Leste. METHODS: Fifty-five nurses and midwives were individually interviewed. Data were analysed qualitatively using the Framework approach. RESULTS: Overall, the standard treatments for acute respiratory tract infections, malaria and diarrhoea were well known by the respondents. Clinical nurses showed precise and detailed knowledge, especially for antibiotic use. The respondents were willing to use STGs and believed that they 'should' follow them. This feeling arose due to their self-awareness as frontline health workers and, at the same time, as peripheral civil servants. The changes brought about by the introduction of STGs were positively perceived. Three components of the change were observed: the concept, daily practice and perceived patient satisfaction. The respondents had previously felt a lack of confidence and hoped to improve their capacity as health care workers; they became confident in their practices by using STGs. Self-confidence was identified more clearly in the clinical nurse interviews. Few difficulties in using STGs were indicated, and the respondents suggested ways to deal with these difficulties. DISCUSSION: By using the STGs, the nurses/midwives gained knowledge and self-confidence. The positive perception of the changes promoted further use of the STGs. Clinical nurse training positively influenced the knowledge of and attitudes towards the STGs. Few difficulties in applying STGs in daily practice were identified, which is contrary to previous studies that targeted physicians in the Western world. Development of STGs within a health policy framework was considered a key factor. The STGs exist across related policies and various programmes, which are interconnected. The Timor-Leste experience indicates the value of STGs for non-physician health care providers at the primary health care level.