Doctoral Degrees (Health Systems and Public Health)

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Browsing Doctoral Degrees (Health Systems and Public Health) by Author "Enarson, Penelope Marjorie"

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    Improving the quality of care for inpatient management of childhood pneumonia at the first level referral hospital : a country wide programme
    (Stellenbosch : Stellenbosch University, 2015-04) Enarson, Penelope Marjorie; Gie, Robert Peter; Cameron, Neil A.; Graham, Stephen Michael; Stellenbosch University. Faculty of Health Sciences. Interdisciplinary Health Sciences. Community Health
    ENGLISH ABSTRACT: Pneumonia is the greatest single cause of mortality in children less than five years of age throughout the world causing more deaths than those due to AIDS, malaria and tuberculosis combined. Approximately 50% of all childhood pneumonia deaths occur in sub-Saharan Africa. Children in developing countries being treated for pneumonia frequently have one or more comorbid conditions which increases their risk of dying. The proper management of the child with severe or very severe pneumonia is essential to reduce case fatality. Standard case management (SCM) of pneumonia, has been shown to be an effective intervention to reduce deaths from pneumonia, but what is lacking is a means of delivering it in low-resource/high burden countries. A major barrier to wide application of this intervention in low-income countries is weak health-care systems with insufficient human and financial resources for implementing SCM to a sufficient number of children at a level of quality and coverage that would result in a significant impact. The objective of this dissertation is to address this issue by investigating ways of improving delivery of standard case management of pneumonia in district hospitals throughout Malawi, a high HIV-prevalent country which would result in a decrease in the in-hospital case fatality rates (CFR) from pneumonia in children less than five years of age. We reviewed the evidence base for SCM. Then we evaluated the development and implementation of a national Child Lung Health Programme (CLHP) to deliver SCM of severe and very severe pneumonia and a programme to provide uninterrupted oxygen supply in all paediatric wards at District Hospitals throughout Malawi. We demonstrated that it was feasible to implement and maintain both programmes country-wide. Thirdly we evaluated the trend in case fatality rates in infants and young children (0 to 59 months of age) hospitalized and treated for severe and very severe pneumonia over the course of the implementation of the CLHP. The findings from this study showed that in the majority (64%) of cases, who were aged 2-59 months with severe pneumonia there was a significant effect of the intervention that was sustained over time whereas in the same age group children treated for very severe pneumonia there was no interventional benefit. No benefit was observed for neonates. Fourthly we investigated factors associated with poor outcome reported in the previous study, in a subset of this cohort to determine the individual factors including demographics of the study population, recognised co-morbidities and clinical management that were associated with inpatient death. This study identified a number of factors associated with poor pneumonia-related outcomes in young infants and children with very severe pneumonia. They included co-morbidities of malaria, malnutrition, severe anaemia and HIV infection. The study found that the majority of reported comorbid conditions were based on clinical signs alone indicating a need for more accurate diagnosis and improved management of these comorbidities that may lead to improved outcomes. Other identified factors included a number of potentially modifiable aspects of care where adjustments to the implementation of SCM are indicated. These included enhancing correct classification of the severity of the disease, the use of correct antibiotics according to standard case management, more extensive availability and use of oxygen together with oximetry to guide its use,. Finally recommendations were made to address the identified reasons for poor outcomes and suggested future research.