Children with palliative care needs in Papua New Guinea, and perspectives from their parents and health care workers: a qualitative study.

INTRODUCTION: The World Health Organisation defines paediatric palliative care (PPC) as caring for the child's body, mind, and spirit, and giving support to the family. In life-limiting conditions it is important that palliative support can be provided even when curative attempts are being utilised. In Papua New Guinea, as in other low- and middle-income countries there is a lack of services and training on PPC. This study aims to describe the characteristics of children with palliative care needs and to assess the perspectives of their parents and health care workers. METHODS: A descriptive qualitative study was carried out over 5 months in 2022 at the Port Moresby General Hospital children's wards. Clinical information was gathered from the admission charts of children with life threatening and life limiting conditions and a recorded interview was carried out with the children's parents. A focus group interview with 10 experienced nurses caring for these children was video recorded. The recorded interviews were subjected to thematic analysis. RESULTS: Twenty children and their parents were included in this study. Nine had a cancer diagnosis and 11 had a chronic progressive condition. The common clinical characteristics of children with palliative care needs were pain (n = 9) and shortness of breath (n = 9), and most children had more than one symptom. Several themes were identified in the parent interviews. Most parents could not name their child's diagnosis, but they were able to correctly describe their child's condition using their own terms. Most parents felt involved in their child's management and were satisfied with the care provided. Parents were psychologically affected by their child's situation but were hopeful that God and the medicines would heal their child. Ten nurses were involved in a focus-group interview. Most nurses' understanding of palliative care was from experience not from formal training, but most felt confident in identifying the physical, emotional, and spiritual needs of the children. Understanding of analgesia was limited, as was the availability of appropriate medications included in the WHO Analgesic Ladder. CONCLUSION: There is a need for a systematic approach to palliative care in Papua New Guinea. Palliative care can be integrated into an overall approach to quality of paediatric care. It is relevant to a broad section of children with severe chronic or malignant conditions and can be carried out with limited resources. It does require some resources, further training and education, and increased provision of basic drugs for symptom control.

Rural healthcare workers views on the introduction of solar power and oxygen concentrators in health facilities in Papua New Guinea: a qualitative study.

INTRODUCTION: A motivated, well supported rural health workforce is required to provide appropriate child health services to the rural population. This study explored the views of rural health workers in Papua New Guinea on the impact of a program to improve oxygen delivery systems and to provide reliable power to their health facilities. METHODS: A pre-tested, self-administered open question survey was carried out among rural health workers from 38 health facilities in which oxygen concentrators had been installed, including 30 with solar power. Thematic analysis was carried out on the responses. RESULTS: The program was highly appreciated. Benefits extended beyond the ability to treat children with a reliable source of oxygen. Participants reported the positive community response to improved patient care and avoiding patient referrals. They stressed their wish for further improvements in infrastructure and for continuing education. CONCLUSION: The program improved morale and job satisfaction. The views of rural health workers are important in assessing program effectiveness.

Living with thalassaemia in Papua New Guinea, the experience of children, adolescents and their families.

AIM: Thalassaemia, the commonest genetic blood disorder in Papua New Guinea (PNG) presents daunting challenges for the affected children, their parents and families, and the health system. We aimed to describe the quality of life of affected children and adolescents and the experience of and difficulties faced by their parents in the setting of a tertiary referral hospital in PNG. METHODS: A mixed-methods longitudinal study involving baseline questionnaire, then serial interviews with parents, children and adolescents living with ß-thalassaemia attending Port Moresby General Hospital. RESULTS: Twenty-one patients and their families were interviewed over a 6-month period. Most families originated outside the National Capital District and had migrated to be near the Port Moresby General Hospital and its blood bank services. Thirteen patients had at least one affected sibling and four families had experienced the death of at least one other affected child. No child was receiving chelating agents, and most had clinical evidence of iron overload. There were important impacts of thalassemia on quality of life, including very poor school attendance and some aspects of children's self-perception. Families faced significant burdens and made genuine sacrifices to care for their children. CONCLUSION: Regular blood transfusions increase the life-span of children with thalassaemia but there is a need to achieve a hyper-transfusion regimen coupled with chelation therapy. As for all chronic illness, a focused and holistic approach is needed to improve the quality of life for affected children and their families.

Oxygen saturation reference ranges and factors affecting SpO2 among children living at altitude.

AIMS: To determine reference values for oxygen saturation (SpO2) among healthy children younger than 5 years living at moderately high altitude in Papua New Guinea and to determine other factors that influence oxygen saturation levels. METHODS: 266 well children living at 1810-2630 m above sea level were examined during immunisation clinic visits, and SpO2 was measured by pulse oximetry. Potential risk factors for hypoxaemia were recorded and analysed by multivariable analysis. RESULTS: The median SpO2 was 95% (IQR 93%-97%), with a normal range of 89%-99% (2.5-97.5 centiles). On multivariable analysis, younger children, children of parents who smoked, those asleep and babies carried in bilums, a traditional carry bag made of wool or string, had significantly lower SpO2. CONCLUSION: The reference range for healthy children living in the highlands of Papua New Guinea was established. Besides altitude, other factors are associated with lower SpO2. Some higher-risk infants (preterm, very low birth weight, recurrent acute lower respiratory infection or chronic respiratory problem) may be more prone to hypoxaemia if they have additive risk factors: if parents smoke or they are allowed to sleep a bilum, as their baseline oxygen saturation may be significantly lower, or their respiratory drive or respiratory function is impaired. These findings need further research to determine the clinical importance.

Medical Students at the School of Medicine and Health Sciences, University of Papua New Guinea: Predictors of Performance and Student Backgrounds.

BACKGROUND: Papua New Guinea, a lower middle income country with a population of around 8.5 million, the majority of whom live in rural areas, produces far fewer than the number of medical graduates required to meet the WHO-recommended doctor/population ratio. The School of Medicine and Health Sciences is under pressure to increase its output and ensure the graduates are able to function in rural settings. Through two studies, we aimed to determine the predictors of student performance and their socioeconomic and educational background to assist in determining admission policies and improve completion rates. METHODS: A retrospective study analysed data relating to student performance from six annual cohorts. A cross-sectional study among currently enrolled students sought information about their socioeconomic and educational background. RESULTS: Of the 300 students enrolled in the six cohorts, 176 (59%) completed the programme in the scheduled 4 years. There were no differences in completion rates by gender or route of entry to the programme. Grade point average at medical school entry predicted academic performance. Sixty-four per cent of the students who failed to complete in four years attributed their poor academic performance to social issues. Overall attrition was only 8%. Seventy-six per cent (162/214) of the enrolled students completed the cross-sectional survey. Most (79%) of students' fathers and 58% of mothers had postsecondary education. Seventy-three per cent of respondents indicated that they had been to preschool or elementary school. Thirty-six per cent had attended primary school in a village or government/mission station. Just over half (53%) of the students indicated that English had been the language most used in primary school. Males were more likely to have made a specific career choice than females. The majority (141/162, 88%) of the students indicated that they had experienced some academic difficulty during the years. CONCLUSION: Prior academic performance predicted timely completion of the MBBS programme. Just over a third of students had attended rural village primary schools. Social and domestic issues were common and adversely affected academic performance.

An outbreak of dengue fever in children in the National Capital District of Papua New Guinea in 2016.

BACKGROUND: The first documented outbreak of dengue which included cases with haemorrhage occurred in Papua New Guinea in 2016. AIM: To document the presentation and outcome of children with dengue in Port Moresby. METHODS: This prospective cross-sectional descriptive study was conducted in Port Moresby General Hospital during a 6-month period from 6 January to 6 July 2016. Altogether, 165 children aged 1-14 years who met the WHO criteria for probable dengue were assessed and treated. Clinical features, presence of warning signs and signs of severe dengue, date of onset, management and outcome were recorded. Blood specimens were collected for serological testing and full blood count. RESULTS: The median age was 6 years (interquartile range 3-8). Eighty-eight (53%) children had no warning signs and were managed as outpatients. Of the 165 patients, 42 (25%) had abdominal pain, 28 (17%) had bleeding and 3 (2%) had clinical evidence of fluid accumulation. The median (IQR) lowest platelet count in those tested was 34 × 109/L (22-54). Two children were transfused with packed red blood cells and one received a platelet transfusion. No child developed dengue shock and none died. Non-structural protein 1 (NS1) and dengue IgM were positive in 122/144 (85%) and 36/111 (32%) of blood samples, respectively. 150/151 blood samples tested for dengue were positive on one or more tests. CONCLUSION: There is the potential for future outbreaks of increased severity in Papua New Guinea. Surveillance, mosquito reduction initiatives and health education programmes are needed to reduce the impact of future outbreaks.

Oral Rehydration in Children with Acute Diarrhoea and Moderate Dehydration-Effectiveness of an ORS Tolerance Test.

Oral rehydration solution (ORS) is the mainstay of treatment of acute watery diarrhoea, but it is underutilized in many hospitals, resulting in children with moderate degrees of dehydration being unnecessarily hospitalized and receiving intravenous fluids. We aimed to assess the utility of an ORS tolerance test on initial presentation to an emergency department, and determine the volume of ORS a child with diarrhoea and moderate dehydration needed to tolerate to be successfully managed at home. One hundred and twenty-nine children with acute watery diarrhoea and moderate dehydration were given ORS and observed in a Children's Emergency Department (CED) over a period of 2-4 h. Patients were admitted, kept in the CED for further management or discharged, based on the assessment of oral intake and the clinical judgement of the treating health workers. Seventy-nine (61.2%) patients tolerated ORS well. They drank a median [interquartile range (IQR)] of 24.4 ml (IQR 12.5-28.8) ml/kg, were judged to have passed the ORS test and were discharged to continue oral rehydration treatment at home. At follow-up on days 2 and 5, 63/79 (79.7%) children had improved, were adequately hydrated and the diarrhoea had reduced. Sixteen of the 79 (20.3%) failed oral home treatment, with persisting diarrhoea, vomiting, hypokalaemia and/or weakness. The 63 who succeeded had tolerated a median of 25.8 (IQR 18.4-30.0) ml/kg of ORS in the CED, whilst the 16 who failed oral home treatment had tolerated 11.1 (IQR 9.1-23.0) ml/kg ORS (p < 0.001).

Epilepsy in Papua New Guinea: a longitudinal cohort study.

Epilepsy affects up to 1-4% of children living in low income and middle countries, however there are few studies of the problems faced by children with epilepsy in such settings. We aimed to document the situation for children with epilepsy in Port Moresby, an urban area in Papua New Guinea, a low-middle income country in the Western Pacific region. We conducted longitudinal cohort study using mixed methods, with serial data collected over 2 years which assessed seizure control, neurodevelopment, and structured interviews with children and parents. For quantitative data descriptive statistics are reported; for qualitative data common responses, themes, experiences and perceptions were grouped and reported in narrative. Forty-seven children with epilepsy were followed for a median of 18 months. Twenty six (55%) children had some associated neurodevelopmental disability. Children gave detailed and vivid descriptions of their experience of seizures. Most children and parents had a positive view of the future but faced many challenges including financial difficulties, fear of having seizures especially at school, restriction of activity that isolated them from peers, and significant stigma and discrimination. Seizure control improved over time for some children, but inconsistent supply of phenobarbitone hindered better control. Comprehensive care for children with epilepsy requires a good knowledge of the individual patient -including their seizure type and comorbidities, their family, and their strengths and vulnerabilities. Children with epilepsy face many problems that can lead to isolation, discrimination and restricted opportunities.

Safety, Effectiveness and Feasibility of Outpatient Management of Children with Pneumonia with Chest Indrawing at Port Moresby General Hospital, Papua New Guinea.

Implementing the World Health Organization (WHO) recommendations on home-based management of pneumonia with chest indrawing is challenging in many settings. In Papua New Guinea, 120 children presenting with the WHO definition of pneumonia were screened for danger signs, comorbidities and hypoxaemia using pulse oximetry; 117 were appropriate for home care. We taught mothers about danger signs and when to return, using structured teaching materials and a video. The children were given a single dose of intramuscular benzylpenicillin, then sent home on oral amoxicillin for 5 days, with follow-up at Days 2 and 6. During the course of treatment, five (4%) of the 117 children were admitted and 15 (13%) were lost to follow-up. There were no deaths. Treating children with pneumonia with chest indrawing but no danger signs is feasible as long as safeguards are in place-excluding high-risk patients, checking for danger signs and hypoxemia and providing education for mothers and follow-up.

Simplified management protocol for term neonates after prolonged rupture of membranes in a setting with high rates of neonatal sepsis and mortality: a quality improvement study.

In low-income and middle-income countries, courses of antibiotics are routinely given to term newborns whose mothers had prolonged rupture of membranes (PROM). Rational antibiotic use is vital given rising rates of antimicrobial resistance and potential adverse effects of antibiotic exposure in newborns. However missing cases of sepsis can be life-threatening.This is a quality improvement evaluation of a protocol for minimal or no antibiotics in term babies born after PROM in Papua New Guinea. Asymptomatic, term babies born to women with PROM >12 hours prior to birth were given a stat dose of antibiotics, or no antibiotics if the mother had received intrapartum antibiotics, reviewed and discharged at 48-72 hours with follow-up. Clinical signs of sepsis within the first week and the neonatal period were assessed. Of 170 newborns whose mothers had PROM, 133 were assessed at 7 days: signs of sepsis occurred in 10 babies (7.5%; 95% CI 4.4% to 13.2%) in the first week. Five had isolated fever, four had skin pustules and one had fever with periumbilical erythema. An additional four (3%) had any sign of sepsis between 8 and 28 days. There was one case of bacteraemia and no deaths. 37 were lost to follow-up, but hospital records did not identify any subsequent admissions for infection. A rate of sepsis was documented that was comparable with other studies in low-income countries. This protocol may reduce antimicrobial resistance and consequences of antibiotic exposure in newborns, provided safeguards are in place to monitor for signs of sepsis.

Antibiotic use in the management of children with the common cold at a provincial hospital in Papua New Guinea: a point-prevalence study.

BACKGROUND: Antibiotic prescribing for self-limiting viral infections such as the common cold or viral upper respiratory tract infection (URTI) is irrational and increases the risk of antibiotic resistance. However, such a practice is widespread and is likely to be as common in Papua New Guinea as in many other countries. METHODS: In a cross-sectional descriptive study, children were recruited who had been diagnosed with a common cold or URTI by attending clinical staff-mostly nurses-in a provincial hospital's children's outpatient department using a standard definition. The frequency of antibiotic prescribing was determined and the clinical knowledge and practices of nurses, health extension officers, community health workers and doctors working in the children's outpatients department regarding the common cold and its management was assessed. RESULTS: One hundred and eight children diagnosed with the common cold were enrolled; 89 (82.4%) were prescribed antibiotics. Children with fever on examination, those older than 12 months and those whose symptoms lasted ≥7 days were more likely to be prescribed antibiotics. Of the health workers surveyed, 95% knew that viruses were the cause of the common cold, but 30% thought that antibiotics were needed for treatment. CONCLUSIONS: Although among healthcare workers, there was a gap between knowledge of aetiology and knowledge of appropriate management of the common cold, there was a larger apparent gap between that knowledge and practice. Findings from this study could be used to identify interventions promoting rational antibiotic use, targeting both health-care workers and the community.

Evaluation of Xpert MTB/RIF assay in children with presumed pulmonary tuberculosis in Papua New Guinea.

BACKGROUND: The Gene Xpert MTB/ RIF assay (Xpert) is used for rapid, simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin resistance. This study examined the accuracy of Xpert in children with suspected pulmonary tuberculosis (PTB). METHODS: Children admitted to Port Moresby General Hospital with suspected PTB were prospectively enrolled between September 2014 and March 2015. They were classified into probable, possible and TB-unlikely groups. Sputum or gastric aspirates were tested by Xpert and smear microscopy; mycobacterial culture was undertaken on a subset. Children were diagnosed with TB on the basis of standard criteria which were used as the primary reference standard. Xpert, smear for acid-fast bacilli (AFB) and the Edwards TB score were compared with the primary reference standard. RESULTS: A total of 93 children ≤14 years with suspected PTB were enrolled; 67 (72%) were classified as probable, 21 (22%) possible and 5 (5.4%) TB-unlikely. Eighty were treated for TB based on the primary reference standard. Xpert was positive in 26/93 (28%) MTB cases overall, including 22/67 (33%) with probable TB and 4/21 (19%) with possible TB. Three (13%) samples identified rifampicin resistance. Xpert confirmed more cases of TB than AFB smear (26 vs 13, p = 0.019). The sensitivity of Xpert, AFB smear and an Edwards TB score of ≥7 was 31% (25/80), 16% (13/80) and 90% (72/80), respectively, and the specificity was 92% (12/13), 100% (13/13) and 31% (4/13), respectively, when compared with the primary reference standard. CONCLUSION: Xpert sensitivity is sub-optimal and cannot be relied upon for diagnosing TB, although a positive result is confirmatory. A detailed history and examination, standardised clinical criteria, radiographs and available tests remain the most appropriate way of diagnosing TB in children in resource-limited countries. Xpert helps confirm PTB better than AFB smear, and identifies rifampicin resistance. Practical guidelines should be used to identify children who will benefit from an Xpert assay.

Risk factors for malnutrition in children at Port Moresby General Hospital, Papua New Guinea: a case-control study.

Fifty children admitted for malnutrition were age matched with 50 admitted for other reasons. These children were more likely to be female (p = 0.003), born low birth weight (p = 0.02), after a short birth interval (p = 0.014) and to be incompletely vaccinated (p < 0.001) than control children, and to be living in rural villages or settlement housing (p < 0.001) with inadequate water supply (p < 0.001) and sanitation (p = 0.037), with overcrowding (p = 0.016) and low household income (p = 0.04). Their parents were more likely to have had no or only rudimentary education than parents of control children [Odds ratio (OR) 3.58 for mothers, 4.12 for fathers]. Parental consumption of alcohol as well as smoking in the mother was more common in the malnourished children. Running water in the house was an independent protective factor (OR 0.23) and the fathers' poor employment status (OR 4.12) an independent risk factor. The solution to malnutrition involves improving community understanding of nutrition and in reducing social inequalities.

Integrated package approach in delivering interventions during immunisation campaigns in a complex environment in Papua New Guinea: a case study.

Papua New Guinea's difficult and varied topography, poor transport infrastructure, changing dynamics of population and economy in recent times and understaffed and poorly financed health service present major challenges for successful delivery of vaccination and other preventative health interventions to both the rural majority and urban populations, thereby posing risks for vaccine preventable disease outbreaks in the country. The country has struggled to meet the vaccination coverage targets required for the eradication of poliomyelitis and elimination of measles. Escalation of inter and intra country migration resulting from major industrial developments, particularly in extraction industries, has substantially increased the risk of infectious disease importation. This case study documents the evolution of immunisation programmes since the introduction of supplementary immunisation activities (SIAs). Single antigen SIAs have advantages and disadvantages. In situations in which the delivery of preventative health interventions is difficult, it is likely that the cost benefit is greater for multiple than for single intervention. The lessons learned from the conduct of single antigen SIAs can be effectively used for programmes delivering multiple SIA antigens, routine immunisations, and other health interventions. This paper describes a successful and cost effective multiple intervention programme in Papua New Guinea. The review of the last SIA in Papua New Guinea showed relatively high coverage of all the interventions and demonstrated the operational feasibility of delivering multiple interventions in resource constrained settings. Studies in other developing countries such as Lesotho and Ethiopia have also successfully integrated health interventions with SIA. In settings such as Papua New Guinea there is a strong case for integrating supplementary immunisation activity with routine immunisation and other health interventions through a comprehensive outreach programme.

Male involvement in sexual and reproductive health in the Mendi district, Southern Highlands province of Papua New Guinea: a descriptive study.

BACKGROUND: Lack of male involvement and support for sexual and reproductive health services is seen by many Papua New Guinean women as a barrier to accessing services. Poor utilization of services by both men and women is reflected in high maternal mortality and high rates of HIV/AIDS and sexually transmitted infections in the Southern Highlands Province. It is therefore important to understand the type of services provided, men's perceptions of these services and the Health Sector's capacity to involve men in its programs. METHODS: Information from interviews of married men, officers in charge of health facilities, and information from a focus group discussion with village leaders was collected to assess possible constraints to reproductive and sexual health care delivery. RESULTS: Although many men had heard about antenatal care, supervised births, family planning and sexually transmitted infections including, HIV/AIDS, many were unaware of their importance and of the types of services provided to address these issues. There was a very strong association between men's literacy and their knowledge of Sexual and Reproductive Health (SRH) issues, their discussion of these issues with their wives and their wives' utilisation of sexual and reproductive health services. Some men considered SRH services to be important but gave priority to social obligations. Although men made most decisions for sexual and reproductive issues, pregnancy, child birth and rearing of children were regarded as women's responsibilities. Knowledge of HIV/AIDS appeared to have changed sexual behaviour in some men. Services for men in this rural setting were inadequate and service providers lacked the capacity to involve men in reproductive health issues. CONCLUSION: Poor knowledge, socio-cultural factors and inadequate and inappropriate services for men hampered utilization of services and impaired support for their wives' service utilization. Programmatic and policy initiatives should focus on improving service delivery to accommodate men in sexual and reproductive health.

Evaluation of an interferon-gamma release assay in children with suspected tuberculosis in Papua New Guinea.

There are few data from tuberculosis (TB) endemic settings of the performance and outcome predictors of the QuantiFERON-TB Gold in Tube assay (QFT) in children with suspected TB. A prospective cross-sectional study was conducted in Papua New Guinea children with suspected TB evaluated at Port Moresby General Hospital (Port Moresby, Papua New Guinea). Two hundred sixteen children were enrolled including 106 probable TB, 87 possible TB and 23 without TB. Concordance between QFT and tuberculin skin test results was 86% (P < 0.001, κ = 0.70). QFT was significantly more likely to be positive than tuberculin skin test, overall and within the probable or possible TB categories, with no difference in prevalence of positivity between these 2 categories. The role of QFT in supporting the clinical diagnosis of TB in endemic settings, where resources are limited, remains uncertain especially as cost and technical requirements remain considerable.