Tropical Doctor, October 1992
172 Dr Harold Gaze, Pediatrician in Neuchatel for making available his files and data. REFERENCES
I 2 3 4 5 6 7 8
The Growth Chart. A tool for use in infant and child health care. Geneva: World Health Organization, 1986 Ebrahim GJ. Pediatric practice in developing countries. London: Macmillan, 1981 Prader A, Budliger H. Korpermasse, Wachstumsgeschwindigkeit und Knochenalter gesunder Kinder in den ersten zwolf Jahren. Helv Paed Acta 1977 (suppl 37) Butte NF, et al. Human milk intake and growth in exclusively breast-fed infants. J Pediatr 1984;104: 187 Paiva SL. Pattern of growth of selected groups of breastfed infants of Iowa City. Pediatrics 1953;11:38 Jackson RL, Westerfeld R, et al. Growth of wellborn American infants fed human and cow's milk. Pediatrics 1964;33:642 Ahn CH, MacLean WC. Growth of the exclusive breast-fed infant. Am J Clin Nutr 1980;33:183 Chandra RK. Physical growth of exclusively breast-fed infants. Nutr Res 1982;2:275
Multi-resistant typhoid fever in Nepal You have recently drawn attention in the abstracts section (Tropical Doctor October 1991, p 184) to the occurrence of multi-resistant typhoid fever in Pakistan and the warning that this may be a problem over a wider geographical areal. A recent study in Tansen has confirmed that this is a major problem in western Nepal: 80 out of 100 consecutive blood culture positive cases of Salmonella typhi were resistant to chloramphenicol and ampicillin-. While ciprofloxacin may be the treatment of choice in Britain 1, it is prohibitively expensive in rural Nepal. We are currently using norfloxacin, which is a quarter of the price, but still more expensive than chloramphenicol. This seems to be effective in most cases but there have been some treatment failures. In addition, there is widespread inappropriate use of inadequate courses of antibiotics in this area, and it will not surprise us to see norfloxacin resistant strains of Salmonella typhi appearing in the next few years. With only 10 adult medical beds and a case load of perhaps 1000 typhoid patients per year, it is impossible for us to admit most of them for inpatient management. We are therefore looking for an alternative treatment which must be cheap, effective and orally available. We would welcome any suggestions. JOHN
P
WATSON
Specialist Physician, United Mission Hospital, Tansen, Nepal
REFERENCES
I
Mandai BK. Treatment of multi-resistant typhoid fever (letter). Lancet 1990;336: 1383 2 Watson JP, Pettibone EC. Chloramphenicol and ampicillin resistant Salmonella typhi in Nepal. J Nepal Med Assoc 1991;29:259-61
Phenytoin and wound healing Abscesses are common problems and present late in rural third world settings. At this hospital, over a 16-week period, 63 abscesses were drained. Nine contained over 400 ml of pus and three over 800 ml. It has been well accepted practice to dress these with betadine or pro flavin packs on a daily basis and allow them to heal by granulation. This is a slow process. Open wounds and ulcers similarly present late and badly infected. Many are unsuitable for suturing but most, once clean, could be grafted. In developing countries circumstances often accumulate, preventing this ideal; lack of facilities, time, manpower and patient refusal to undergo 'an operation'. In these cases wounds must be healed with dressings. Again, a slow process. In all these situations we have been using phenytoin powder. At the initial drainage or debridement procedure a betadine pack or dressing is still used. This is changed as soon as the production of pus is minimal (usually 24-48 h later), to a dry dressing or pack onto which the phenytoin powder has been sprinkled. There has been a marked reduction in healing time with rapid drying and contraction of the wound. Also, owing to its simple, non-messy application, patients are able to manage their dressings at home easily, either alone or with a family member. This enables earlier discharge and we have not observed any adverse effect from this practice. One 100 mg capsule of phenytoin contains sufficient powder to cover the majority of wounds and abscesses, usually with plenty to spare, and costs 2 cents (US). We believe that these dressings are an inexpensive way of significantly reducing the duration of hospital stay and the load on nursing time. This use of phenytoin has been well described previously' and, there are controlled trials supporting its efficacy in wound healing-. We are convinced of the value of this method, especially in a busy rural setting where resources are limited. It does not appear, however, to be widely used. We would be interested to know if others have made use of this form of therapy, and whether they have found it to be beneficial. P M FLANAGAN A M FLANAGAN
St Apollinaris Hospital Private Bag 206 Creighton 4600, Natal, South Africa
REFERENCES
I
Smith B, Moore M, Jain K. First international conference on the use of phenytoin in dermatology. Int J Dermatol 1988;27:528-30 2 Lodha SC, Lohiya ML, Vyas MCR, Bhandari S, Goyal RR, Harsh MK. Role of phenytoin in healing of large abscess cavities. sr J Surg 1991;78:105-8
Family planning: KAP among rural women in Kabarole District, Uganda In May 1990, 198 women living in rural areas in Kabarole district, Western Uganda were interviewed to obtain baseline information regarding family planning need, knowledge and practice. This data was used in the planning and evaluation of the family planning programme
Tropical Doctor, October 1992
173
in the district. Official family planning services in the district are scanty and concentrated in the few urban centres. The total population in Kabarole district is 741 000 people, growing at a rate of 3.30/0 (National census 1991). Ninety-five percent of these people live in rural areas. Literacy rate in the district is about 40% for adult females. Sampling for the survey was done as follows: nine out of 34 peripheral health facilities were randomly selected; for each health facility two villages (each with 300-700 people) were selected, taking the nearest and the most far (at least 8 km away). In each village a list of households was compiled, eight households selected using systematic random sampling, and all women aged 15-49 years (n = 198) interviewed about their fertility preferences, knowledge, and practices regarding family planning. Eighteen per cent of respondents were aged below 20 years while 80% fell in the range 20-44 years. One fifth of women were single, three-quarters were in marital union (married or living together) and the rest were divorced or widowed. Forty-five per cent of the single respondents were below the age of 20. Average age for women at first entry into a marital union was 16.7 years. Thirty-seven per cent of all respondents had no formal education, 50% had some primary education, and 13% had attended secondary school. Most (75%) of the people were peasant farmers and traders (14%). The average number of living children per respondent was three, ranging from one for the age group 15-19, to seven children for those 45-49 years. Several (17%) said they would produce as many children as God decides for them. The most frequent ideal number of children for the remaining respondents was six. Most (67%) respondents were in need of family planning: ie they either did not want to produce any more children or preferred to wait over 2 years before their next child. None,
however, was using any contraceptive. Of all respondents, 73% could list one or more methods of contraception, 17% had ever used modern contraceptives (Table 1), and only 48% knew a source of family plannnng services. Current use of modern contraceptive methods is still low (4%). Although 71% of women believed that family planning can lead to improved maternal and child health, misconceptions about side effects of modern contraceptives were widespread. Of the 145 women who knew a contraceptive method, fears of side effects were: none (30%), do not know (27%), prolonged or irregular menses (21%), deformed babies (16%), abdominal pain (8%), weight gain (8%), infertility (7%), headaches (5%), hypertension (5%) and promiscuity (4%). The above results are similar to those obtained for the western region during a demographic and health survey in 1988/89. Of those women who knew a contraceptive method, 28% reported their sexual partner's acceptance of contraceptive use, 44% reported opposition, while 28% did not know their partners' attitudes and 7% had no sexual partners. However, only one third of women whose partners accepted family planning had ever used modern contraceptives. Lack of adequate information and low accessibility of family planning services must be addressed. We suggest that men must be involved in family planning, and programmes must include efforts to reach them. To minimize misconceptions about the pill requires an effective information campaign, emphasizing the low risks and the health benefits of oral contraceptives.
Table 1. Percentage distribution of 198 women by contraceptive method known, and ever used
Attitudes to hearing aid use in Nigerian patients A study of the attitude of hearing impaired Nigerians to the use of hearing aids was conducted over a 5-year period between 1984 and 1989 at the General Hospital, Owerri. Of the 201 patients who needed a hearing aid, only 40 (20%) agreed to use one (28 women and 12 men). Of these, the majority (21) accepted a behind-the-ear aid. Various factors affected the acceptance and rejection of hearing aids. Eighty per cent (161)of those who needed to use hearing aids rejected them outright. The rejectors fell within the age group of 20-45 years while the acceptors were mainly below 20 years and above 45 years of age. The reasons for rejection included psychological, socio-cultural and financial factors. Some rejectors thought the aids to be cumbersome 'foreign bodies'; others feared embarrassment and ridicule when the stigma of their disability was revealed in public. The prohibitive cost of aids was a significant cause for non-acceptance. In 1989 in Nigeria an in-the-ear aid cost about W5000 (about $500); a behind-the-ear aid cost W2000-W3000
Know method (%)
Ever used
Contraceptive method Any method Any modern method Pill Condom Injection Female sterilization Male sterilization Diaphragm/foam/jelly IUD Any traditional method Periodic abstinence Prolonged breastfeeding Withdrawal Herbs Others
73.2 69.7 58.1 11.6 4.5 16.7 0.0 0.0 0.0 21.2 7.6 10.6 1.0 7.1 1.5
18.2 16.7 15.7 0.0 3.0 0.0 0.0 0.0 0.0 6.1 4.5 2.5 0.0 1.0 0.5
(%)
W KIPP
E M
KWERED
B K SSEMPEBWA
Deutsche Gesellschaft fuer Technische Zusammenarbeit (GTZ), Fort Portal, Uganda Ministry of Health, Fort Portal Uganda
172 Dr Harold Gaze, Pediatrician in Neuchatel for making available his files and data. REFERENCES
I 2 3 4 5 6 7 8
The Growth Chart. A tool for use in infant and child health care. Geneva: World Health Organization, 1986 Ebrahim GJ. Pediatric practice in developing countries. London: Macmillan, 1981 Prader A, Budliger H. Korpermasse, Wachstumsgeschwindigkeit und Knochenalter gesunder Kinder in den ersten zwolf Jahren. Helv Paed Acta 1977 (suppl 37) Butte NF, et al. Human milk intake and growth in exclusively breast-fed infants. J Pediatr 1984;104: 187 Paiva SL. Pattern of growth of selected groups of breastfed infants of Iowa City. Pediatrics 1953;11:38 Jackson RL, Westerfeld R, et al. Growth of wellborn American infants fed human and cow's milk. Pediatrics 1964;33:642 Ahn CH, MacLean WC. Growth of the exclusive breast-fed infant. Am J Clin Nutr 1980;33:183 Chandra RK. Physical growth of exclusively breast-fed infants. Nutr Res 1982;2:275
Multi-resistant typhoid fever in Nepal You have recently drawn attention in the abstracts section (Tropical Doctor October 1991, p 184) to the occurrence of multi-resistant typhoid fever in Pakistan and the warning that this may be a problem over a wider geographical areal. A recent study in Tansen has confirmed that this is a major problem in western Nepal: 80 out of 100 consecutive blood culture positive cases of Salmonella typhi were resistant to chloramphenicol and ampicillin-. While ciprofloxacin may be the treatment of choice in Britain 1, it is prohibitively expensive in rural Nepal. We are currently using norfloxacin, which is a quarter of the price, but still more expensive than chloramphenicol. This seems to be effective in most cases but there have been some treatment failures. In addition, there is widespread inappropriate use of inadequate courses of antibiotics in this area, and it will not surprise us to see norfloxacin resistant strains of Salmonella typhi appearing in the next few years. With only 10 adult medical beds and a case load of perhaps 1000 typhoid patients per year, it is impossible for us to admit most of them for inpatient management. We are therefore looking for an alternative treatment which must be cheap, effective and orally available. We would welcome any suggestions. JOHN
P
WATSON
Specialist Physician, United Mission Hospital, Tansen, Nepal
REFERENCES
I
Mandai BK. Treatment of multi-resistant typhoid fever (letter). Lancet 1990;336: 1383 2 Watson JP, Pettibone EC. Chloramphenicol and ampicillin resistant Salmonella typhi in Nepal. J Nepal Med Assoc 1991;29:259-61
Phenytoin and wound healing Abscesses are common problems and present late in rural third world settings. At this hospital, over a 16-week period, 63 abscesses were drained. Nine contained over 400 ml of pus and three over 800 ml. It has been well accepted practice to dress these with betadine or pro flavin packs on a daily basis and allow them to heal by granulation. This is a slow process. Open wounds and ulcers similarly present late and badly infected. Many are unsuitable for suturing but most, once clean, could be grafted. In developing countries circumstances often accumulate, preventing this ideal; lack of facilities, time, manpower and patient refusal to undergo 'an operation'. In these cases wounds must be healed with dressings. Again, a slow process. In all these situations we have been using phenytoin powder. At the initial drainage or debridement procedure a betadine pack or dressing is still used. This is changed as soon as the production of pus is minimal (usually 24-48 h later), to a dry dressing or pack onto which the phenytoin powder has been sprinkled. There has been a marked reduction in healing time with rapid drying and contraction of the wound. Also, owing to its simple, non-messy application, patients are able to manage their dressings at home easily, either alone or with a family member. This enables earlier discharge and we have not observed any adverse effect from this practice. One 100 mg capsule of phenytoin contains sufficient powder to cover the majority of wounds and abscesses, usually with plenty to spare, and costs 2 cents (US). We believe that these dressings are an inexpensive way of significantly reducing the duration of hospital stay and the load on nursing time. This use of phenytoin has been well described previously' and, there are controlled trials supporting its efficacy in wound healing-. We are convinced of the value of this method, especially in a busy rural setting where resources are limited. It does not appear, however, to be widely used. We would be interested to know if others have made use of this form of therapy, and whether they have found it to be beneficial. P M FLANAGAN A M FLANAGAN
St Apollinaris Hospital Private Bag 206 Creighton 4600, Natal, South Africa
REFERENCES
I
Smith B, Moore M, Jain K. First international conference on the use of phenytoin in dermatology. Int J Dermatol 1988;27:528-30 2 Lodha SC, Lohiya ML, Vyas MCR, Bhandari S, Goyal RR, Harsh MK. Role of phenytoin in healing of large abscess cavities. sr J Surg 1991;78:105-8
Family planning: KAP among rural women in Kabarole District, Uganda In May 1990, 198 women living in rural areas in Kabarole district, Western Uganda were interviewed to obtain baseline information regarding family planning need, knowledge and practice. This data was used in the planning and evaluation of the family planning programme
Tropical Doctor, October 1992
173
in the district. Official family planning services in the district are scanty and concentrated in the few urban centres. The total population in Kabarole district is 741 000 people, growing at a rate of 3.30/0 (National census 1991). Ninety-five percent of these people live in rural areas. Literacy rate in the district is about 40% for adult females. Sampling for the survey was done as follows: nine out of 34 peripheral health facilities were randomly selected; for each health facility two villages (each with 300-700 people) were selected, taking the nearest and the most far (at least 8 km away). In each village a list of households was compiled, eight households selected using systematic random sampling, and all women aged 15-49 years (n = 198) interviewed about their fertility preferences, knowledge, and practices regarding family planning. Eighteen per cent of respondents were aged below 20 years while 80% fell in the range 20-44 years. One fifth of women were single, three-quarters were in marital union (married or living together) and the rest were divorced or widowed. Forty-five per cent of the single respondents were below the age of 20. Average age for women at first entry into a marital union was 16.7 years. Thirty-seven per cent of all respondents had no formal education, 50% had some primary education, and 13% had attended secondary school. Most (75%) of the people were peasant farmers and traders (14%). The average number of living children per respondent was three, ranging from one for the age group 15-19, to seven children for those 45-49 years. Several (17%) said they would produce as many children as God decides for them. The most frequent ideal number of children for the remaining respondents was six. Most (67%) respondents were in need of family planning: ie they either did not want to produce any more children or preferred to wait over 2 years before their next child. None,
however, was using any contraceptive. Of all respondents, 73% could list one or more methods of contraception, 17% had ever used modern contraceptives (Table 1), and only 48% knew a source of family plannnng services. Current use of modern contraceptive methods is still low (4%). Although 71% of women believed that family planning can lead to improved maternal and child health, misconceptions about side effects of modern contraceptives were widespread. Of the 145 women who knew a contraceptive method, fears of side effects were: none (30%), do not know (27%), prolonged or irregular menses (21%), deformed babies (16%), abdominal pain (8%), weight gain (8%), infertility (7%), headaches (5%), hypertension (5%) and promiscuity (4%). The above results are similar to those obtained for the western region during a demographic and health survey in 1988/89. Of those women who knew a contraceptive method, 28% reported their sexual partner's acceptance of contraceptive use, 44% reported opposition, while 28% did not know their partners' attitudes and 7% had no sexual partners. However, only one third of women whose partners accepted family planning had ever used modern contraceptives. Lack of adequate information and low accessibility of family planning services must be addressed. We suggest that men must be involved in family planning, and programmes must include efforts to reach them. To minimize misconceptions about the pill requires an effective information campaign, emphasizing the low risks and the health benefits of oral contraceptives.
Table 1. Percentage distribution of 198 women by contraceptive method known, and ever used
Attitudes to hearing aid use in Nigerian patients A study of the attitude of hearing impaired Nigerians to the use of hearing aids was conducted over a 5-year period between 1984 and 1989 at the General Hospital, Owerri. Of the 201 patients who needed a hearing aid, only 40 (20%) agreed to use one (28 women and 12 men). Of these, the majority (21) accepted a behind-the-ear aid. Various factors affected the acceptance and rejection of hearing aids. Eighty per cent (161)of those who needed to use hearing aids rejected them outright. The rejectors fell within the age group of 20-45 years while the acceptors were mainly below 20 years and above 45 years of age. The reasons for rejection included psychological, socio-cultural and financial factors. Some rejectors thought the aids to be cumbersome 'foreign bodies'; others feared embarrassment and ridicule when the stigma of their disability was revealed in public. The prohibitive cost of aids was a significant cause for non-acceptance. In 1989 in Nigeria an in-the-ear aid cost about W5000 (about $500); a behind-the-ear aid cost W2000-W3000
Know method (%)
Ever used
Contraceptive method Any method Any modern method Pill Condom Injection Female sterilization Male sterilization Diaphragm/foam/jelly IUD Any traditional method Periodic abstinence Prolonged breastfeeding Withdrawal Herbs Others
73.2 69.7 58.1 11.6 4.5 16.7 0.0 0.0 0.0 21.2 7.6 10.6 1.0 7.1 1.5
18.2 16.7 15.7 0.0 3.0 0.0 0.0 0.0 0.0 6.1 4.5 2.5 0.0 1.0 0.5
(%)
W KIPP
E M
KWERED
B K SSEMPEBWA
Deutsche Gesellschaft fuer Technische Zusammenarbeit (GTZ), Fort Portal, Uganda Ministry of Health, Fort Portal Uganda
