Investigating socio-ecological factors influencing implementation of tuberculosis infection prevention and control in rural Papua New Guinea.

BACKGROUND: Tuberculosis (TB) is a highly transmissible infectious disease killing millions of people yearly, particularly in low-income countries. TB is most likely to be transmitted in healthcare settings with poor infection control practices. Implementing TB infection prevention and control (TB-IPC) is pivotal to preventing TB transmission in healthcare settings. This study investigated diverse stakeholders' perspectives relating to barriers and strategies for TB-IPC in rural hospitals in Papua New Guinea. METHODS: Multiple qualitative case studies were conducted with 32 key stakeholders with experience in TB services. Data collection drew on three primary sources to triangulate data: semi-structured interviews, document reviews and field notes. The data were analyzed using hybrid deductive-inductive thematic analysis. RESULTS: Our results reveal that key stakeholders perceive multiple interdependent factors that affect TB-IPC practice. The key emerging themes include strategic planning for and prioritizing TB-IPC guidelines; governance, leadership and accountability at the provincial level; community attitudes towards TB control; institutional capacity to deliver TB care, healthcare workers' safety, and long-term partnership and integration of TB-IPC programmes into the broad IPC programme. CONCLUSIONS: The evidence suggests that a multi-perspective approach is crucial for TB-IPC guidelines in healthcare institutions. Interventions focusing on addressing health systems strengthening may improve the implementation of TB-IPC guidelines.

Tuberculosis infection prevention and control in rural Papua New Guinea: an evaluation using the infection prevention and control assessment framework.

BACKGROUND: Papua New Guinea (PNG) is one of the 14 countries categorised as having a triple burden of tuberculosis (TB), multidrug-resistant TB (MDR TB), and TB-human immunodeficiency virus (HIV) co-infections. TB infection prevention and control (TB-IPC) guidelines were introduced in 2011 by the National Health Department of PNG. This study assesses the implementation of this policy in a sample of district hospitals in two regions of PNG. METHODS: The implementation of TB-IPC policy was assessed using a survey method based on the World Health Organization (WHO) IPC assessment framework (IPCAF) to implement the WHO's IPC core components. The study included facility assessment at ten district hospitals and validation observations of TB-IPC practices. RESULTS: Overall, implementation of IPC and TB-IPC guidelines was inadequate in participating facilities. Though 80% of facilities had an IPC program, many needed more clearly defined IPC objectives, budget allocation, and yearly work plans. In addition, they did not include senior facility managers in the IPC committee. 80% (n = 8 of 10) of hospitals had no IPC training and education; 90% had no IPC committee to support the IPC team; 70% had no surveillance protocols to monitor infections, and only 20% used multimodal strategies for IPC activities. Similarly, 70% of facilities had a TB-IPC program without a proper budget and did not include facility managers in the TB-IPC team; 80% indicated that patient flow poses a risk of TB transmission; 70% had poor ventilation systems; 90% had inadequate isolation rooms; and though 80% have personal protective equipment available, frequent shortages were reported. CONCLUSIONS: The WHO-recommended TB-IPC policy is not effectively implemented in most of the participating district hospitals. Improvements in implementing and disseminating TB-IPC guidelines, monitoring TB-IPC practices, and systematic healthcare worker training are essential to improve TB-IPC guidelines' operationalisation in health settings to reduce TB prevalence in PNG.

Knowledge among the rural parents about the vaccinations and vaccination coverage of children in the first year of life in Papua New Guinea - analysis of data provided by Christian health services.

Knowledge among the rural parents about the vaccinations and vaccination coverage of children in the first year of life in Papua New Guinea - analysis of data provided by Christian Health Services. BACKGROUND: This analysis aimed to assess rural parents' knowledge about the diseases prevented by vaccinations and establish vaccination coverage in PNG. METHODS: Knowledge of vaccinations was checked through a standard questionnaire (five closed questions). We analyzed data on vaccination coverage from 2016 to 2018 from all Catholic health facilities. Analyzed vaccinations were the pentavalent vaccine (DTaP-HiB-HepB) and measles vaccine given in the first year of life. Coverage was calculated based on the number of vaccines used compared to the number of eligible children. Analyzed vaccinations were the pentavalent vaccine (DTaP-HiB-HepB) and measles vaccine given in the first year of life. RESULTS: Fifty-six parents, including 52 mothers and four fathers, participated in the interview. Many parents (46%) understood that the vaccine prevents diseases. During the analyzed period, 25,502 doses of measles vaccine were given, 31,428 children were vaccinated with the pentavalent vaccine. In 2016, the measles vaccine coverage rate was 26.6 and 33.4% for the pentavalent vaccine. In 2017, measles and pentavalent vaccines' coverage rate was 12.5 and 16.6%, respectively. There were significant differences in immunization coverage between provinces. A decreasing trend in the number of administered vaccinations was observed. CONCLUSION: The results of this analysis demonstrate that in PNG, the majority of children are not fully immunized. There are significant differences in the vaccination coverage between provinces. As protection from diseases is low, there is a very high risk of an outbreak of the vaccine-preventable disease in the community. Delivery of vaccinations in PNG encounters many barriers, from access to healthcare services to natural disasters and inter-tribial conflicts.

Knowledge and Attitudes Towards Abortion and Euthanasia Among Health Students in Papua New Guinea.

PURPOSE: The purpose of this study was to explore knowledge and attitudes of health program students towards ethical issues pertaining to the beginning and the end of human life, and associations between these attitudes and demographic variables. PARTICIPANTS AND METHODS: The study took a mixed-method approach with self-administered survey questionnaires and in-depth interviews. A total of 88 students participated in the survey, and 10 students participated in interviews. The study was conducted among students in the Health Extension Program at a Christian university in Papua New Guinea. RESULTS: Students showed a higher acceptance of abortion than euthanasia. More year-4 students presented significantly deeper knowledge of euthanasia and abortion compared to year-1 students. There were no gender differences regarding knowledge and attitude towards these two bioethical issues. The majority of students opposed the idea of women's right to abortion, which is attributed mainly to socio-cultural reasons. The qualitative analysis indicated a very strong perception that having children 'defines' womanhood and also revealed general disapproval of any form of euthanasia. A low level of acceptance of various forms of euthanasia is associated with a respect for older people in Melanesian society and beliefs that ancestors' support is required for achieving prosperity in life. CONCLUSION: The study offered a comprehensive description and analysis of students' knowledge and attitudes towards ethical issues pertaining to the beginning and the end of human life. Presented a low level of knowledge towards bioethical issues, together with a small proportion of the knowledge gained from lectures and tutorials, indicated inadequate teaching of bioethics and calls for further improvement. In the perspective of rapid social and cultural changes in the Papua New Guinea society, further studies on changing attitudes towards bioethics issues would be valuable.

Ultrasound-guided pediatric forearm fracture reductions in a resource-limited ED.

BACKGROUND: Pediatric forearm fractures are a common presentation in emergency departments in Papua New Guinea. Often these children undergo "blind" closed reduction with reduction adequacy assessed by standard radiographs. This study aims to demonstrate the safety and efficacy of ultrasound (US) in guiding closed reduction of pediatric forearm fractures in a resource-limited setting. METHODS: We recruited consecutive children with closed forearm fractures requiring reduction. A US scanner was used to visualize and aid fracture reductions. The outcome measures were the rate of successful reductions (ie, adequate alignment without the need for a second procedure or further surgical intervention), length of stay in hospital, and adverse events during each procedure and at follow-up after 6 weeks. RESULTS: Of 47 children recruited, there were 44 (94%) successful reductions, whereas 3 (6%) required repeated reduction. The mean (SD) length of stay in hospital of the successful cases was 8.77 (3.66) hours. Two patients had tight plaster casts during early follow-up which were immediately addressed. Of the 44 successful cases, only 38 were retrieved for the final review. No further adverse events were observed in the latter. CONCLUSIONS: This small-scale study has demonstrated the safe and efficacious use of US-guided close reduction of pediatric forearm fractures in a low-resource setting. Using US, real-time visualization of reduction efforts can reassure the clinician in decision making, thus reducing the rate of repeated reductions and allowing shorter hospital stay.

Knowledge, attitude and practice related to infant feeding among women in rural Papua New Guinea: a descriptive, mixed method study.

BACKGROUND: Despite the well-recognized effectiveness of exclusive breastfeeding for the first six months of an infant life for reducing infant mortality, adherence to this practice is not widespread in the developing world. Although several studies on infant nutrition practices have been conducted in urban settings of Papua New Guinea (PNG), there is only scant information on infant feeding practices in rural settings. Therefore, this study aimed to investigate knowledge, attitude and practice associated with exclusive breastfeeding in various locations in rural PNG. METHODS: A mixed method study using interviews based on a semi-structured questionnaire (n = 140) and Focus Group Discussions (FGDs) was conducted among mothers in rural PNG between August and September 2012. Participants were selected using convenience sampling. Included in the study were both primiparous and multiparous mothers with a child below the age of two years. Content analysis was used for qualitative data and descriptive statistics were used for quantitative data. RESULTS: Whereas most women indicated breastfeeding as a better way to feed babies, knowledge of the reasons for its superiority over infant formula was generally poor. Only 17% of mothers practiced exclusive breastfeeding for the first six months postpartum. Our study showed that the size of the gap between exclusive breastfeeding practice and global recommendations was striking. Taking into account the low educational profile of the participants, the disparity may be explained by the fact that most of the mothers in this study had no formal education on infant feeding. CONCLUSIONS: This study showed a lack of understanding of the importance of and poor adherence to exclusive breastfeeding for the first six months postpartum among rural mothers. As exclusive breastfeeding promotion has been proved to be one of most effective ways to improve infant survival, more attention should be given to it, especially targeting the large proportion of women who missed formal education on infant feeding in school. A proper community-based program including the tools for monitoring its implementation and effectiveness needs to be developed to transform policy recommendations into action in rural PNG.

Diabetic foot ulcers in Port Moresby General Hospital 2003-2008: review of the principles of effective prevention and management of diabetic foot.

BACKGROUND: In the recent decade in Papua New Guinea and other Pacific countries there has been an increasing trend of lifestyle diseases, including obesity associated with diabetes mellitus. Foot ulceration and infection leading to amputation are common and feared complications of diabetes. Yet these are potentially the most preventable of all complications in diabetic patients. Several studies have shown that half of all diabetic foot ulcers can be prevented by education and simple foot care. The primary goal of this study was to depict the scale of the diabetic foot as a community health problem. The secondary goal was to review the current literature on diabetic foot in order to develop a more effective preventive strategy. METHODOLOGY: A retrospective study on the patients with diabetic foot admitted to the surgical unit at Port Moresby General Hospital (PMGH) in 2003 and 2008 was conducted. We also carried out an extensive online search on the prevention and management of diabetic foot ulcers. RESULTS: Our study showed an increasing trend of diabetic foot ulcers and infections from 1.4 to 2.2% of all surgical patients at PMGH over a 5-year period. Interestingly, over that period the representation of females increased from one-third to almost half of all patients with diabetic foot. Furthermore, the patients with diabetic foot complications showed a lower average hospital stay of 35 days in 2008 compared to 54 days in 2003. The literature review showed that the introduction of a diabetic podiatric team service providing simple education to diabetic patients in the form of one teaching session and/or preventive written materials, with a short explanation of diabetic foot pathology and simple preventive measures, reduced the number of amputations by half. RECOMMENDATION: The introduction of a comprehensive foot care education program and organizing a specialist foot clinic for diabetic patients can reduce bed occupancy and health expenditure on diabetic patients as well as the number of amputations and subsequent disability.

Conservative management of splenic injury in the tropics.

We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.

Randomized clinical trial to compare the length of hospital stay and morbidity for early feeding with opioid-sparing analgesia versus traditional care after open appendectomy.

BACKGROUND & AIMS: Fast track protocols have been successfully used in abdominal surgery but there are no randomized trials on fast track after appendectomy. The aim of this study was to evaluate the safety and feasibility of fast track perioperative care protocol including early feeding with opioid-sparing analgesia after open appendectomy. METHODS: We randomly allocated 62 consecutive patients who underwent appendectomy to an early feeding with opioid-sparing analgesia and traditional care group. The study was not blinded regarding the mode of postoperative rehabilitation. Clinical primary endpoint was length of postoperative hospital stay. Secondary endpoints were morbidity rate, time to bowel sounds and passage of flatus or stools, tolerance of solid diet and facial visual pain score. RESULTS: The mean length of primary hospital stay was significantly shorter in the early feeding with opioid-sparing analgesia than in traditional care group (2.2 versus 4.0 days, P<0.001). No significant differences were seen between groups regarding demographics, degree of pathological changes in the appendix, and in the secondary endpoints such as morbidity, frequency of vomiting, visual facial pain score, time to first flatus or stools, resumption of bowel sounds and toleration of solid diet. CONCLUSIONS: This study indicates that early feeding and opioid-sparing analgesia after open appendectomy is safe and reduces length of hospital stay without deterioration of pain control.

Primary repair of colonic injuries at the Kundiawa and Madang General Hospitals, Papua New Guinea.

In this study, we evaluated the safety of primary repair of colon injury in a low-volume tropical hospital setting. Between 1998 and 2005, 18 consecutive patients who underwent emergency operation for civilian traumatic colon injury were studied. The main outcome measures were the mortality and morbidity rates and the total length of the hospital stay. The mean hospital stay for one-stage repair was 12 days versus 29 days for the two-stage procedure, which was a significant difference (p = 0.009). There was no death reported from this study. There was no significant difference in postoperative septic complications between the one-stage and two-stage procedures. One-stage repair of colonic injury is a safe and cost-effective option for selected patients in the tropical hospital setting.