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Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improveobstetric practices.
BJOG: An International Journal of Obstetrics and Gynaecology. 2007 Jan; 114(1):16-23.We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices. Design: Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385. Settings: Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand. The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention. The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner. The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8- 65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries. The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop. (author's)
Hospital care for children in developing countries: clinical guidelines and the need for evidence [editorial]
Journal of Tropical Pediatrics. 2006 Feb; 52(1):1-2.Throughout most of the world, nurses, paramedical workers and non-specialist doctors provide the care of critically ill children who present to hospitals. While most seriously ill children in developing countries present to district and peripheral hospitals, a large proportion of hospital funding and resources is allocated to tertiary institutions. As a consequence, most critically ill children are cared for where resources are inadequate, support from central agencies is lacking, there is poor access to information, there is little ongoing professional development or staff training, and staff morale is invariably low. The quality of care provided in these hospitals has an impact on the health and lives of millions of children each year. Until relatively recently, little attention was paid to this issue, perhaps because many children in developing countries die before reaching hospital, or due to concern that promoting hospitals might detract from primary care. Whatever the reasons, the quality of paediatric care in peripheral hospitals has been somewhat neglected by many organisations. With recent evidence that there is considerable scope for improvement, there is a need for a serious coordinated global approach and locally appropriate interventions. Improvements in triage, diagnosis, treatment guidelines, supportive care, monitoring and follow-up would reduce hospital mortality and iatrogenic complications. These are public health as well as clinical problems; and demand approaches that can be brought to national scale. (excerpt)
Demographer John Caldwell and the Addis Ababa Fistula Hospital win 2004 United Nations Population Award.
Population 2005. 2004 Jun; 6(2):12.Well-known Australian demographer, John C. Caldwell, and the Addis Ababa Fistula Hospital, a pioneer in the treatment of childbirth injuries, have won the 2004 United Nations Population Award. The Award is given annually to individuals and institutions for their outstanding work in the field of population and in the improvement of the health and welfare of individuals. The Award Committee, chaired by Ambassador Iftekhar Ahmed Chowdhury of Bangladesh, selected the two winners after a review of nominations received from around the world. The Committee is made up of Member States of the United Nations, with UNFPA, the United Nations Population Fund, serving as its secretariat. Each winner will receive a certificate, a gold medal and an equal share of a monetary prize. Awards will be presented to winners in July at a ceremony at the United Nations Headquarters, New York. (excerpt)
Chapel Hill, North Carolina, University of North Carolina at Chapel Hill, Carolina Population Center [CPC], MEASURE Evaluation, 2003 Aug.  p. (USAID Cooperative Agreement No. HRN-A-00-97-00018-00)This report describes a study of the content and use of routinely collected data from maternity registers for the purposes of monitoring for maternal and newborn health at the health facility level in two departments of Benin. Specifically, the objectives of the study are to: Describe the scope, quality, completeness and use of the information collected in maternity registers in the departments of Atlantique and Zou; Calculate indicators which reflect clinical practices and outcome, such as: the cesarean section rate (for health facilities with surgical capacity), the referral rate, the rate of referred patients who are treated at the referral site, the episiotomy rate, the rate of “directed” deliveries (i.e., deliveries where oxytocics were used) and stillbirth and maternal death rates in health facilities in the departments of Atlantique and Zou; Validate the data regarding cesarean section operations recorded in the delivery register against that recorded in the surgical register; Describe the process by which data are recorded in the maternity registers. (excerpt)
WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors.
Lancet. 2004 Apr 3; 363(9415):1110-1115.WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals. All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April, 2000 to April, 2001, were studied and their case fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors. At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs 77%, p<0·0001), antibiotics with gram-negative cover (15% vs 46%, p=0·0003), and vitamin A (76% vs 91%, p=0·018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000–01 were due to doctor error and 28% to nurse error. Weaknesses within the health system—especially doctor training, and nurse supervision and support—compromised quality of care. Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths. (author's)
Cluster randomized trial of an active, multifaceted information dissemination intervention based on the WHO Reproductive Health Library to change obstetric practices: methods and design issues [ISRCTN14055385]. [Estudio clínico aleatorizado por grupos de una intervención activa y multifacética de difusión de información basada en la Biblioteca de Salud Reproductiva de la OMS y destinada a la modificación de prácticas obstétricas: aspectos metodológicos y de diseño (ISRCTN14055385)]
BMC Medical Research Methodology. 2004 Jan 15; 4: p..Effective strategies for implementing best practices in low and middle income countries are needed. RHL is an annually updated electronic publication containing Cochrane systematic reviews, commentaries and practical recommendations on how to implement evidence-based practices. We are conducting a trial to evaluate the improvement in obstetric practices using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library (RHL). A cluster randomized trial to improve obstetric practices in 40 hospitals in Mexico and Thailand is conducted. The trial uses a stratified random allocation based on country, size and type of hospitals. The core intervention consists of three interactive workshops delivered over a period of six months. The main outcome measures are changes in clinical practices that are recommended in RHL measured approximately a year after the first workshop. The design and implementation of a complex intervention using a cluster randomized trial design is discussed. Designing the intervention, choosing outcome variables and implementing the protocol in two diverse settings has been a time-consuming and challenging process. We hope that sharing this experience will help others planning similar projects and improve our ability to implement change. (author's)
Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult. [La prise en charge au niveau des installations sanitaires de premier niveau des enfants gravement malades, en Afrique sub-saharienne, en cas de difficulté d'orientation vers d'autres structures]
Bulletin of the World Health Organization. 2003 Jul; 81(7):522-531.Objectives: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub- Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. Methods: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3–5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. Findings: We studied 7195 children aged 2–59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. Conclusion: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children. (author's)
Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. [Pour de meilleures pratiques de surveillance des infections dans le cas des aiguilles à injections intradermiques, sous-cutanées et intramusculaires]
Bulletin of the World Health Organization. 2003 Jul; 81(7):491-500.Objective: To draw up evidence-based guidelines to make injections safer. Methods: A development group summarized evidence-based best practices for preventing injection-associated infections in resource-limited settings. The development process included a breakdown of the WHO reference definition of a safe injection into a list of potentially critical steps, a review of the literature for each of these steps, the formulation of best practices, and the submission of the draft document to peer review. Findings: Eliminating unnecessary injections is the highest priority in preventing injection-associated infections. However, when intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles. Conclusion: The availability of best infection control practices for intradermal, subcutaneous, and intramuscular injections will provide a reference for global efforts to achieve the goal of safe and appropriate use of injections. WHO will revise the best practices five years after initial development, i.e. in 2005. (author's)
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1989; 67(5):577-82.The findings of a project initiated in 1988 by the World Health Organization's Global Program on AIDS on HIV transmission in health care settings indicate that strict adherence to infection control practices can greatly reduce the already minimal risk. There have been no cases reported of transmission from health workers with HIV infection to patients; 66 UK patients operated on by a UK surgeon with AIDS and 615 patients of a US surgeon with AIDS tested over 90 days after exposure were seronegative. On the other hand, prospective studies from the US, UK, France, Martinique, and Italy have identified 18 seroconversions in health care workers who had parenteral or mucus membrane exposure to blood from an HIV-infected patient. The majority (13) of these 18 cases involved needlestick injuries or cuts with a sharp object. Always problematic is the determination of whether infection in health care workers was occupationally acquired or a result of other high-risk activities. Patient-to-patient transmission of HIV infection has been the most commonly reported phenomenon and can occur through HIV-infected blood products, organs, tissues, and semen or contaminated equipment. HEre, the risk can be substantially reduced by proper instrument sterilization, use of disposable needles, screening of potential donors, and heat treatment of Factors VIII or IX.