This document outlines a research proposal to evaluate adherence to Afghanistan's National Standard Treatment Guidelines for Primary Level (NSTG-PL) in the treatment of acute diarrheal diseases at four district hospitals in Kabul. The study aims to determine if antibiotics and oral rehydration salts are prescribed according to the NSTG-PL by analyzing prescriptions from April to September 2018. A retrospective cross-sectional study design is proposed to randomly select 378 prescriptions proportionately from the four hospitals. Data will be analyzed to measure adherence rates and rational medicine use. Results will help assess treatment quality and inform efforts to improve healthcare practices and curb antimicrobial resistance in Afghanistan.

1. Maulana Azad University, Jodhpur
Department Of Public Health
Research Proposal
Evaluation Treatment Of Acute Diarrhoeal Diseases In Kabul
Four District Hospitals OPD Wards
Name: Esmatullah Shafaq
Enrollment No: 17035351100008
Date: January 12, 2019
Presented in partial fulfillment of the master’s in public health (MPH) program
Supervisors
Ms. Bhawna Sati
Co-Supervisor
Dr. Abdul Saboor Saber

2. Table of content
 Research summary/abstract
 Background /introduction and rational
 Literature review
 Research question/hypothesis
 Objectives
 Study design
 Research methodology
 Data analysis
 Ethical consideration
 Limitation of the study
 Expected benefits & outcomes
 Tables and figures
 Reference
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3. 2. Research Summary/Abstract
 The national standard treatment guideline for primary level (NSTG-PL) 2013 reflects the
recommended state-of-the treatments
 ADDs are caused by viruses, bacteria or parasites and caused loss of water and electrolytes from
the body. decrease blood volume and cardiovascular collapse and death if not treated promptly.
 Utilization of antibiotics has increased and some physicians prescribe the antibiotics without
considering the recommended Oral Rehydration Salts (ORS) are not prescribed.
 Hence this study will be carried out in Kabul BPHS four District hospital’s OPD wards prescriptions
aiming to identify:
 1) Adherence to NSTG-PL in Diarrhoeal diseases treatment,
 Result will be present in frequencies, percentages, ratio, mean, standard division..,
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4. 3. Background /Introduction and Rational
 Acute Diarrheal Disease(ADDs)is the second most frequent illness after ARI (*)
 The % ADDs has been increasing significantly from 2010 to 2016
 Antibiotics are irrationally prescribed.
 Patient received incorrect medicine and not cured
 ORS, Zink not prescribed
 Antimicrobial resistance is one of the global issue
 The selected four DHs cover about 24% of Kabul BPHS population
 located in difference region of Kabul province
 The selection period ((April 01, 2018 to September 30, 2018) High number of incident
 May las years experience shows the irrationally prescription of antibiotics ae prescribed in HFs
4 * ATLAS Diseases under surveillance in Afghanitan-2016
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5. 4. Literature review
 25 Journal articles and literature reviewed based on that 7 were exacted useful in my study.
 Study done in 2012 by SPS in 62 health facilities in 13 provinces of Afghanistan and from RMU assessments
done 2016 in 12 national hospitals in Kabul,
 52 % of OPD patient with Diarrhea are not receiving ORS,
 32 % of prescribed antibiotics are not confirmed by NSTG-PL
 AfDH2015 shows that 29% of children under age 5 had diarrhoea in the 2 weeks before the study and only
41% continued feeding and were given ORS or increased fluids and only 6.2% given Zinc supplements.
 Antibiotics prescription in OPD of hospital is practiced up to 60% ,the use is double the WHO
recommendation of30%. **
 A study on Assessment of Antibiotic Utilization in Treatment of Acute Diarrhoea Diseases in Bishoftu
General Hospital, Oromia Ethiopi , Aril 2016 indicate that (86.8%) patients received antibiotics. Based on
the presence of blood in stools, 14.5% of cases were of invasive bacterial type. According to the
recommendations of WHO, the rate of overuse of antibiotics was 72.3%***
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** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533508/
*** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954943/

6. 5.Research Question/Hypothesis
Research question:
 Is the standard of Diarrhea treatment recommended by NSTG_PL followed at the Kabul BPHS/
four district hospital OPD wards during April 01, 2018 To September 30, 2018?
Hypothesis:
 The NSTG-PL is followed by prescriber during treatment of diarrhea recommended treatment
(Ho).
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7. 6 Objectives
6.1 General Objectives
 To evaluate adherence to NSTG-PL in treatment of ADDs in Kabul 4 district hospitals
6.2 Specific objectives
 To determine adherence to NSTG-PL in the treatment of acute diarrheal diseases in Kabul
four district hospitals OPD wards during specific time period
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8. 7 Study Design
 A retrospective, quantitative, cross-sectional study to evaluate the adherence to
NSTG-PL prescribing practices in Kabul four district hospital’s OPD wards.
 A total 378 (95%CI, 5% Alpha) sample prescriptions will be randomly selected from
the outpatient prescriptions retained in pharmacy.
 The study period will be cover six month (April 01, 2018 To September 30, 2018).
 Result will be presented in frequencies. Percentages, ratios, mean, standard
division.
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9. 8 Research Methodology
Sample Selection criteria:
 Prescriptions should be available in targeted Kabul BPHS 4 District hospitals
 The prescriptions will be form the period of (April 01, 2018 To September 30, 2018)
 The prescription should have diagnosis of Acute Diarrhoeal Diseases (Acute Watery Diarrhoea
Acute Watery Diarrhea with Dehydration, Acute Bloody Diarrhea, Dysentery..,)
 The diagnosis of proscriptions should be readable
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10. 8. Research Methodology…
 The sample size will selected based on online “Sample Size Calculator by Raosoft, Inc.”
 A total 378 ((95%CI, 5% Alpha) calculated form total population 20316**** (prescriptions)
samle will be randomly selected from the outpatient prescriptions retained in pharmacy
 Simple random sampling consider proportionate sample size based on HMIS report
 Qara Bagh DH (28.4.%)
 Chahar Asyab DH (27.5%)
 Surobi District DH (34.6%)
 Mirbacha Kot DH (9.5%)
 The Data’s quality will be controlled and the primary data will be collected
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10 **** HMIS data reported ADD conditions (April 01 To September 30 2018 ) by 4 DH of Kabul BPHS

11. 9.Data Analysis
The collected data will be analyzed to obtain information regarding:
1. The adherence to NSTG-PL by prescriber
2. Interpretation of rational medicine use and antibiotics use in the diarrhea disease.
3. When the data has been gathered the data will be enters to a software and to clean data,
analyzed by using EpiInfo.exe, Ms. Excel
4. The specific interpretation and analysis will be done in order to obtained selected indicators
results
5. Result will be present in frequencies, percentages, ratios, mean, standard division
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12. 10. Ethical consideration
 Ethical approval will be obtained from the Institutional Review Board (IRB) of Afghanistan and the
University of Maulana Azad ethics committee based in Jodhpur, India
 I will meet the Afghanistan Public Health Institute APHI, General Directorate of Pharmaceutical
Services (GDPS) and implementer NGO, I will to officially start to collect the data from selected
HFs
 The official approval from BPHS Implementer NGO (Move Welfare Organization) has taken for
collection & using the data for my research purpose.
The result of my research will be a very useful document to the GDPS, MoPH of Afghanistan and as
well for implementer NGOs.
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13. 11.Limitation of the study
 There are not any significant limitation for the study.
however, some limitation like:
 Quality of the data
 Information biases
 Selection biases
 Behavior of health facilities personnel
 Resource limitation as well, since this research will be conducted by my
own resources and budget.
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14. 13.Expected benefits & outcomes
I will complete the research and will share the result and explore the current practice and come to:
 General Directorate of Pharmaceutical Services (GDPS)
 Ministry of Public Health MoPH
 Implementer NGOs
1. In order take corrective actions to enhance adhere to NSTG_PL,
2. Right medicine to right patient
3. Improve patient satisfaction form health facilities
4. Improve cost effectiveness and prevent prolong of illness or death
5. Impact of NSTG-PL on prevention to antimicrobial resistance
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15. Tables and Figures
 I will draw tables for showing the ADD conditions and determine their treatment
conformity with standard treatment guideline and special interpretation to each indicator.
 the following documents are used for support of research.
 Work plan for thesis ( data collection, analysis, interpretation, reporting…)
 Attendance work certificate under site supervisor guide for thesis research proposal
 Consent letter for thesis research proposal from implementer NGO
 Consent letter from site supervisor for thesis research proposal
 Data collection questionnaire for thesis research proposal
 Data collection form for medicine availability
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16. Reference
 1. NationalStandardTreatmentGuidelinesforthePrimaryLevel411201473415510553325325.pdf
[Internet]. [cited 2018 Oct 27]. Available from:
http://gdpa.gov.af/Content/Media/Documents/NationalStandardTreatmentGuidelinesforthePrimar
yLevel411201473415510553325325.pdf
 2. AFDHS_Final Report.pdf [Internet]. [cited 2018 Oct 13]. Available from:
http://cso.gov.af/Content/files/Afghanistan%20DHS%202015%20KIR/AFDHS_Final%20Report.pdf
 3. Ayoub D, Lopetuso LR, Chamseddine F, Dajani A, Lahiri K, Mahmoud H, et al.
Epidemiological evaluation of acute gastroenteritis and therapeutic approaches in Middle East
Countries. Eur Rev Med Pharmacol Sci. 2016;20(18):3891–901.
 4. s21744en.pdf [Internet]. [cited 2018 Oct 27]. Available from:
http://apps.who.int/medicinedocs/documents/s21744en/s21744en.pdf
 5. AfghanistanNationalFormularyEnglish-recentversion1611201581950470553325325.pdf
[Internet]. [cited 2018 Oct 27]. Available from:
http://gdpa.gov.af/Content/Media/Documents/AfghanistanNationalFormularyEnglish-
recentversion1611201581950470553325325.pdf
 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533508/
 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954943/
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17. Thank you for your attention
Any question??
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