Eastern Highlands Province Research Articles

Experiences of studying midwifery in the Eastern Highlands Province of Papua New Guinea

Introduction: Midwives have been shown to be the essential healthworker in improvinghealth formothers andnewborns. Papua New Guinea (PNG) suffers a critical shortage of qualified midwives. Exploring the reasons why people apply to study midwifery may assist future efforts to strengthen the midwifery workforce. Methods: 182midwifery students from four differentmidwifery schools or universities in Papua New Guinea commenced their training in 2012 and 2013. During the course of their studies, students were given a survey to complete regarding many aspects of their midwifery studies. 121 students completed the survey and 118 students gave a response to the question ‘Why did you choose to study midwifery?’ The answers were analysed using thematic analysis. Results: Three themes emerged from the responses: Recognising public need, recognising professional needs and recognising personal needs. The majority (50%) of responses recognised the high maternal mortality in PNG. Several of the students had witnessed maternal deaths and wanted to prevent this in the future. More than one quarter (28%) of respondents saw that their professional skills and knowledge needed to be improved and also cited the extreme shortage of midwives in the country as a motivating factor. A further one fifth (21%) stated that they had experience and interest in working in maternal health, with others in positions of supervision or education without midwifery qualifications. Conclusion: The concern about the number of women dying in PNG was the major single motivating factor for nurses commencingmidwifery studies in PNG. There is an urgent need to trainmore midwives in PNG to face the crisis of maternal deaths. The enthusiasm for saving lives needs to be garnered to improve the development of ‘supermidwives’who canmake vital differences to the lives of mothers and newborns in PNG.

Diversity of Mycobacterium tuberculosis and drug resistance in different provinces of Papua New Guinea.

BackgroundPapua New Guinea (PNG) is a high tuberculosis (TB) burden country of the WHO Western Pacific Region, but so far research on drug resistance (DR) and genotypes of Mycobacterium tuberculosis (M. tuberculosis) was only conducted in few provinces in the country. The aim of the present study was to obtain baseline data on the level of drug resistance and the genotypic diversity of circulating M. tuberculosis in additional provinces and to investigate the differences between three selected sites across PNG.ResultsGenotyping of 147 M. tuberculosis clinical isolates collected in Goroka, Eastern Highlands Province, in Alotau, Milne Bay Province and in Madang, Madang Province revealed three main lineages of M. tuberculosis: Lineage 4 (European-American lineage), Lineage 2 (East-Asian lineage) and Lineage 1 (Indo-Oceanic lineage). All three lineages were detected in all three sites, but the individual lineage compositions varied significantly between sites. In Madang Lineage 4 was the most prevalent lineage (76.6%), whereas in Goroka and Alotau Lineage 2 was dominating (60.5% and 84.4%, respectively) (p < 0.001). Overall, phenotypic drug susceptibility testing showed 10.8% resistance to at least one of the first-line drugs tested. Of all resistant strains (23/212) 30.4% were Streptomycin mono-resistant, 17.4% were Isoniazid mono-resistant and 13% were Rifampicin mono-resistant. Multi-drug resistant (MDR) TB was found in 2.8% of all tested cases (6/212). The highest amount of MDR TB was found in Alotau in Milne Bay Province (4.6%).ConclusionA large number of drug resistant TB infections are present in the country and MDR TB has already been detected in all three surveyed regions of PNG, highlighting the importance of monitoring drug resistance and making it a high priority for the National Control Program. Due to the high prevalence of Lineage 2 in Milne Bay Province and given the frequent association of this lineage with drug resistance, monitoring of the latter should especially be scaled up in that province.

Antibiotic resistant Shigella is a major cause of diarrhoea in the Highlands of Papua New Guinea.

Diarrhoea remains a major cause of illness in Papua New Guinea (PNG); however, little is known about its aetiology. As a result of the cholera outbreak that spread throughout PNG in 2009-2011, we conducted diarrhoeal surveillance in Eastern Highlands Province. Following informed consent and a brief questionnaire, participants provided a stool sample or duplicate rectal swabs. Samples were tested for common bacterial pathogens Salmonella spp., Shigella spp., Vibrio spp., Campylobacter spp. and Yersinia enterocolitica using established culture methods. Enteric parasites were detected using microscopy. A total of 216 participants were enrolled; where age was recorded, 42% were under 5 years of age, 6.7% were 5 to 17 years of age and 51.3% ≥18 years of age. One or more pathogens were detected in 68 (31.5%) participants, with Shigella (primarily S. flexneri) being the most commonly isolated (47 of 216 participants). Enteric parasites were detected in 23 of the 216 participants, occurring as a co-infection with another pathogen in 12 of 23 cases. No Vibrio cholerae was detected. Shigella isolates were commonly resistant to ampicillin, tetracycline, co-trimoxazole and chloramphenicol. Shigellae, specifically S. flexneri, are important pathogens in the highlands of PNG. While most studies in low-income settings focus on childhood aetiology, we have demonstrated the importance of Shigella in both children and adults. Enteric parasites remain present and presumably contribute to the burden of gastrointestinal illness. While improvements in sanitation and hygiene would help lower the burden of all aetiologies of infectious diarrhoea, additional control strategies targeting Shigella may also be warranted.

Childbirth in a rural highlands community in Papua New Guinea: A descriptive study

Objectivesto explore men׳s and women׳s experiences, beliefs and practices surrounding childbirth in a rural highlands community in Papua New Guinea. Designa qualitative study comprising focus group discussions, key informant and in depth interviews. Settingthe study was undertaken in a rural community in Eastern Highlands Province, Papua New Guinea. Participants51 women and 26 men participated in 11 focus group discussions. Key informant and in depth interviews were undertaken with 21 women and five men. Findingsboth women and men recognised the importance of health facility births, linking village births with maternal and newborn deaths. Despite this, many women chose to give birth in the community in circumstances influenced by cultural and customary beliefs and practices. Women giving birth in the community frequently gave birth in an isolated location. Traditional beliefs surrounding reasons for difficult births, including spiritual beliefs were reported along with the use of traditional methods used to help prolonged and difficult births. Conclusionswhile the importance of health facility births is recognised in this rural community many women continue to give birth in the village. Identifying and understanding local customs, beliefs and practices, particularly those that may be harmful to women and their newborn infants, is critical to the development of locally-appropriate community-based strategies for improving maternal and infant health in rural communities in PNG and other resource-limited, high burden settings.

Hospital admission following induced abortion in Eastern Highlands Province, Papua New Guinea--a descriptive study.

BackgroundIn Papua New Guinea abortion is restricted under the Criminal Code Act. While safe abortions should available in certain situations, frequently they are not available to the majority of women. Sepsis from unsafe abortion is a leading cause of maternal mortality. Our findings form part of a wider, mixed methods study designed to identify complications requiring hospital treatment for post abortion care and to explore the circumstances surrounding unsafe abortion.MethodsThrough a six month prospective study we identified all women presenting to the Eastern Highlands Provincial Hospital following spontaneous and induced abortions. We undertook semi-structured interviews with women and reviewed individual case notes, extracting demographic and clinical information.FindingsCase notes were reviewed for 56% (67/119) of women presenting for post abortion care. At least 24% (28/119) of these admissions were due to induced abortion. Women presenting following induced abortions were significantly more likely to be younger, single, in education at the time of the abortion and report that the baby was unplanned and unwanted, compared to those reporting spontaneous abortion. Obtained illegally, misoprostol was the method most frequently used to end the pregnancy. Physical and mechanical means and traditional herbs were also widely reported.ConclusionIn a country with a low contraceptive prevalence rate and high unmet need for family planning, all reproductive age women need access to contraceptive information and services to avoid, postpone or space pregnancies. In the absence of this, women are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk and putting an increased strain on an already struggling health system. Women in this setting need access to safe, effective means of abortion.

Retention Among ART Patients in the Highlands of Papua New Guinea

Despite more than 10,000 patients on antiretroviral therapy (ART), there remains a dearth of operational research in Papua New Guinea related to HIV service delivery. This study examined the effectiveness of a locally developed model of HIV service delivery called PAPUA (Patient and Provider Unified Approach) in the Highlands of Papua New Guinea. The model emphasizes coordinated patient and provider support along with decentralized services to rural districts in the Highlands. We conducted a chart review among HIV-infected adults on ART at clinics in Eastern Highlands Province, where the PAPUA model was implemented in addition to the standard of care, and in Western Highlands Province, where the standard of care was implemented. We calculated yearly retention rates and used multivariable Cox proportional hazards regression analyses to compare retention rates across the provinces. Data for 2457 patients from the 2 provinces were analyzed. Among patients receiving ART under the PAPUA model in Eastern Highlands, the 12-, 24-, 36-, and 48-month retention proportions were 0.79, 0.73, 0.68, and 0.63, respectively. When we compared retention probabilities across the 2 provinces, patients receiving care under the PAPUA model had a 15% lower rate of attrition from care during the first 4 years of ART (hazard ratio, 0.85; 95% confidence interval: 0.74 to 0.99; P = 0.03), after adjusting for age, gender, and year of enrollment. The PAPUA model seems to be a promising intervention although it is inextricably linked to the limitations posed by a resource-constrained health system.

Improving Health Worker Adherence to Malaria Treatment Guidelines in Papua New Guinea: Feasibility and Acceptability of a Text Message Reminder Service

The aim of this study is to assess whether a text message reminder service designed to support health worker adherence to a revised malaria treatment protocol is feasible and acceptable in Papua New Guinea (PNG). The study took place in six purposively selected health facilities located in the Eastern Highlands Province (EHP) of PNG. Ten text messages designed to remind participants of key elements of the new NMTP were transmitted to 42 health workers twice over a two week period (two text messages per day, Monday to Friday) via the country’s largest mobile network provider. The feasibility and acceptability of the text message reminder service was assessed by transmission reports, participant diaries and group discussions. Findings indicate that the vast majority of text messages were successfully transmitted, participants’ had regular mobile phone access and that most text messages were read most of the time and were considered both acceptable and clinically useful. Nevertheless, the study found that PNG health workers may tire of the service if the same messages are repeated too many times and that health workers may be reluctant to utilize more comprehensive, yet complementary, resources. In conclusion, a text message reminder service to support health worker adherence to the new malaria treatment protocol is feasible and acceptable in PNG. A rigorous pragmatic, effectiveness trial would be justified on the basis of these findings.

Exploring women's perspectives of access to care during pregnancy and childbirth: A qualitative study from rural Papua New Guinea

Objectivesto explore women's perceptions and experiences of pregnancy and childbirth in a rural community in PNG. Designa qualitative, descriptive study comprising focus group discussions (FGDs) and in depth interviews. Settingthis study took place in a rural community in Eastern Highlands Province, PNG. Participants51 women participated in seven focus group discussions. In depth interviews were undertaken with 21 women, including women recruited at the antenatal clinic, women purposively selected in the community and three key informants in the community. Findingsthe majority of women mentioned the benefits of receiving antenatal care at the health facility and the importance of a supervised, facility birth. Women faced numerous challenges with regards to accessing these services, including geographical, financial and language barriers. Cultural and customary beliefs surrounding childbirth and lack of decision making powers also impacted on whether women had a supervised birth. Key conclusions and implications for practicedistance, terrain and transport as well as decision making processes and customary beliefs influenced whether a woman did or did not reach a health facility to give birth. While the wider issue of availability and location of health services and health system strengthening is addressed shorter term, community based interventions could be of benefit. These interventions should include safe motherhood and birth preparedness messages disseminated to women, men and key family and community members.

New species (130) of the hyperdiverse aquatic beetle genus Hydraena Kugelann from Papua New Guinea, and a preliminary analysis of areas of endemism (Coleoptera: Hydraenidae)

New species (130) of the hyperdiverse aquatic beetle genus Hydraena Kugelann from Papua New Guinea, and a preliminary analysis of areas of endemism (Coleoptera: Hydraenidae)

Gendered talk about sex, sexual relationships and HIV among young people in Papua New Guinea

This paper presents findings from a qualitative study carried out in three secondary schools in Eastern Highlands Province, Papua New Guinea (PNG). Seventy-three Year 12 students took part in eight gender-specific focus group discussions (three female and five male). Irrespective of gender, respondents predominately understood sex as being for the sole purpose of reproduction within marriage. When discussing sex and sexual relationships, young men used explicit language and referred specifically to sexual organs and activities. Young women did not. Less concerned for privacy, young men talked in public spaces and in groups with same-sex peers about sex and sexual expression, whereas young women discussed such matters one-on-one and in private. These gender differences provide useful entry points for developing appropriate sex and HIV education programmes involving young people in PNG.

A review of maternal deaths at Goroka General Hospital, Papua New Guinea 2005–2008

Papua New Guinea is a developing country with a population of six million, facing significant geographical, cultural and economic barriers to the provision of antenatal and intrapartum care. The maternal mortality ratio (MMR) is an internationally regarded index of the quality of a country's maternity services; the most recently reported MMR for Papua New Guinea of 773 deaths per 100 000 births is one of the highest in the world. To review information about women who died from pregnancy-related causes, both direct and indirect, in the Goroka General Hospital (GGH) during the period 1st January 2005 to 31st May 2008. A retrospective review was undertaken of the charts of women recorded as dying in the Obstetrics and Gynecology (O&G) ward of GGH in the study period. The charts of 21 women who died from pregnancy-related causes were reviewed and information collated. Puerperal sepsis and sepsis complicating unsafe abortion were the most common causes of maternal death accounting for 48% deaths. Other causes included ectopic pregnancy and postpartum haemorrhage. Contributing factors included residence in a rural area, geographical and transport difficulties accessing care, non-use of family planning services, non-booking for antenatal care and late presentation in pregnancy or labour, and under-resourcing of services at GGH. The socio-economic status of most of the women was low, and where educational attainments were recorded these were also low. 71% of women identified themselves as practising Christians. Better outreach services to provide health information and antenatal care, with specific counselling about the need for supervised delivery, are urgently required in the Eastern Highlands Province that GGH serves if numbers of maternal deaths are to be reduced. Working through churches in the region may be the most appropriate way to provide information and services to women because a majority of women adhere to Christianity and can be reached in this way.

Do Palm Cockatoos (Probosciger aterrimus) have long enough lifespans to support their low reproductive success?

As an order, Parrots (Psittaciformes) are both the longest lived birds and among the most endangered. Palm Cockatoos (Probosciger aterrimus) have an extremely slow life history, including one of the lowest rates of breeding success reported for parrots. Here we use population viability analysis (PVA) to examine whether populations of Palm Cockatoos are viable in the long term with such low rates of reproduction. We built PVA models for two field sites with robust data on reproductive success and availability of nest-hollows: Iron Range on Cape York Peninsula (Queensland, Australia) and Crater Mountain (Eastern Highlands Province, Papua New Guinea). Our Iron Range models incorporate a fluctuating resource base of nest-hollows resulting from natural losses from fire, wind and tree decay and natural replenishment through tree breakages in tropical cyclones. The number of females allowed to breed each year in the simulations was limited by the availability of hollows. Our Iron Range models suggest that the population is only viable if juvenile and adult mortality rates are very low, and that at least some birds in the population live to 100 years old. Based on known maximum lifespans in the Cacatuidae, we conclude that Palm Cockatoos at Iron Range are unlikely to live for long enough on average to support their low rates of reproduction, and highlight the possibility that the population may be in decline. At Crater Mountain, where nestlings are harvested for food by local people, the models suggest that the reported current rate of 40% of nestlings taken is not sustainable.

Host use and crop impacts of Oribius Marshall species (Coleoptera: Curculionidae) in Eastern Highlands Province, Papua New Guinea

Oribius species are small flightless weevils endemic to the island of New Guinea and far northern Cape York, Australia. The adults feed externally on leaves, developing fruit and green bark, but their impact as pests and general host use patterns are poorly known. Working in Eastern Highlands Province, Papua New Guinea, we carried out structured host use surveys, farmer surveys, shade-house growth trials and on-farm and on-station impact trials to: (i) estimate the host range of the local Oribius species; (ii) understand adult daily activity patterns; (iii) elucidate feeding habits of the soil dwelling larvae; and (iv) quantify the impacts of adult feeding damage. Oribius inimicus and O. destructor accounted for nearly all the Oribius species encountered locally, of these two O. inimicus was the most abundant. Weevils were collected from 31 of 33 plants surveyed in the Aiyura Valley, and a combination of farmer interviews and literature records provided evidence for the beetles being pestiferous on 43 crops currently or previously grown in the Highlands. Adult weevils had a distinct diurnal pattern of being in the upper plant canopy early in the morning and, to a lesser extent, again late in the afternoon. For the remainder of the day, beetles resided within the canopy, or possibly off the plant. Movement of adults between plants appeared frequent. Pot trials confirmed the larvae are root feeders. Quantified impact studies showed that the weevils are damaging to a range of vegetable and orchard crops (broccoli, capsicum, celery, French bean, Irish potato, lettuce, orange and strawberry), causing average yield losses of around 30-40%, but up to 100% on citrus. Oribius weevils pose a significant and, apparently, growing problem for Highland's agriculture.

‘Today I am so happy to see friends I once worked with many years ago’

I was approximately 16 years old when I first met Dr Carleton Gajdusek in Wanitabi village, situated south of Okapa in the Eastern Highlands Province. I worked with Shirley Lindenbaum when she came to live in our village, and I helped Michael Alpers with his research. I was asked to work as a

Introduction

Introduction

Some recollections about kuru in a patient at Rabaul in 1978, and subsequent experiences with prion diseases

I first heard about kuru when I was undertaking the six-month full-time Diploma in Tropical Medicine and Hygiene (DTM&H) course at Edinburgh University in 1970–1971. The Head of the Department of Infectious and Tropical Diseases, the eminent Dr Frederick J. Wright, had visited Papua New Guinea and

High Prevalence of Sexually Transmitted Infections Among Female Sex Workers in the Eastern Highlands Province of Papua New Guinea: Correlates and Recommendations

More than 200 female sex workers (FSWs) participating in commercial sex along the Highlands Highway of Papua New Guinea were identified in a previous survey. This has implications for the spread of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) to areas and population groups serviced by the road. The goal of this study was to estimate the prevalence of gonorrhea, chlamydia, syphilis, trichomoniasis, and HIV among FSWs in Goroka and Kainantu in the Eastern Highlands Province (EHP) and to identify correlates that could be considered in intervention and control. Self-identified FSWs recruited through the Goroka Sex Workers Peer-Mediated Programme were invited to participate. All consenting FSWs underwent pretest counseling and provided sociodemographic and behavioral data using a structured questionnaire. The women were also asked to self-collect vaginal specimens and to provide peripheral blood to detect the respective STIs and HIV. Results were available for 211 FSWs. None of the women were positive for HIV. The overall estimated rates for gonorrhea, chlamydia, syphilis, and trichomoniasis were 21%, 19%, 24%, and 51%, respectively. Seventy-four percent were positive for at least 1 STI and 43% had multiple STI infections. High-risk sexual behaviors were found to be common among the women, including low and inconsistent use of condoms, with most of them attributing this to unavailability, dislike by or familiarity with clients, and being drunk and/or high on marijuana. STIs are prevalent among FSWs in Goroka and Kainantu in the EHP and are maintained by widespread high-risk sexual behaviors, including low use of condoms. Implications for their spread through the highway warrants increased efforts in intervention. Apart from a need to promote condom acceptance, distribution, and use, other high-risk sexual behavior and correlates identified in this study provide important considerations for intervention and control in this population.

Diversification economies and specialisation efficiencies in a mixed food and coffee smallholder farming system in Papua New Guinea

AbstractSmallholder farming systems in Papua New Guinea are characterised by an integrated set of cash cropping and subsistence food cropping activities. In the Highlands provinces, the subsistence food crop sub‐system is dominated by sweet potato production. Coffee dominates the cash cropping sub‐system, but a limited number of food crops are also grown for cash sale. The dynamics between sub‐systems can influence the scope for complementarity between, and technical efficiency of, their operations, especially in light of the seasonality of demand for household labour and management inputs within the farming system. A crucial element of these dynamic processes is diversification into commercial agricultural production, which can influence factor productivity and the efficiency of crop production where smallholders maintain a strong production base in subsistence foods.In this study we use survey data from households engaged in coffee and food crop production in the Benabena district of Eastern Highlands Province to derive technical efficiency indices for each household over two years. A stochastic input distance function approach is used to establish whether diversification economies exist and whether specialisation in coffee, subsistence food or cash food production significantly influences technical efficiency on the sampled smallholdings.Diversification economies are weakly evident between subsistence food production and both coffee and cash food production, but diseconomies of diversification are discerned between coffee and cash food production. A number of factors are tested for their effects on technical efficiency. Significant technical efficiency gains are made from diversification among broad cropping enterprises.

Diversification economies and specialisation efficiencies in a mixed food and coffee smallholder farming system in Papua New Guinea

Smallholder farming systems in Papua New Guinea are characterised by an integrated set of cash cropping and subsistence food cropping activities. In the Highlands provinces, the subsistence food crop sub-system is dominated by sweet potato production. Coffee dominates the cash cropping sub-system, but a limited number of food crops are also grown for cash sale. The dynamics between sub-systems can influence the scope for complementarity between, and technical efficiency of, their operations, especially in light of the seasonality of demand for household labour and management inputs within the farming system. A crucial element of these dynamic processes is diversification into commercial agricultural production, which can influence factor productivity and the efficiency of crop production where smallholders maintain a strong production base in subsistence foods. In this study we use survey data from households engaged in coffee and food crop production in the Benabena district of Eastern Highlands Province to derive technical efficiency indices for each household over two years. A stochastic input distance function approach is used to establish whether diversification economies exist and whether specialisation in coffee, subsistence food or cash food production significantly influences technical efficiency on the sampled smallholdings. Diversification economies are weakly evident between subsistence food production and both coffee and cash food production, but diseconomies of diversification are discerned between coffee and cash food production. A number of factors are tested for their effects on technical efficiency. Significant technical efficiency gains are made from diversification among broad cropping enterprises.

Bodies and Methods in Motion

As a cultural anthropologist who specializes in gender and sexuality research in Papua New Guinea (PNG), I was honored to become Senior Research Fellow of the Operational Research Unit (ORU) at the Papua New Guinea Institute of Medical Research (IMR) in Goroka, capital of Eastern Highlands Province. I now head the Anthropology Section thereof. Although I am the only anthropologist there, even our new behavioral health nursing officer can't seem to get enough tape transcription and use of Atlas.ti, a qualitative data software program! The anthropology bug that bit me long ago was spawned by qualitative parents. It infected me with a missionary zeal about qualitative methods and perspectives that I have tried to instill in our new ORU as we have taken on exciting new projects. As well, I have returned four times to the site of Ph.D. dissertation research I conducted over one decade ago—Daru, capital of PNG's Western Province. Adding to this, on August 2, 2003, I got married PNG-style (yep—bridewealth, pigs, and everything), to my longtime companion (Urakume Mahala, nee Cassandra Lee) who also fell in love with PNG.