Transcript Poster presentation

A FORMATIVE STUDY TO DESIGN AN
INTERVENTION INVOLVING MOTHERS,
DRUGS VENDORS AND HEALTH WORKERS IN A
SELF-PROCESS OF BEHAVIORAL CHANGE FOR
RATIONAL DRUG USE IN ARI TREATMENT
PH Dung, NTK Kim Chuc and Dennis Ross Degan
Funding by ARCH (Boston University)
ABSTRACT
A FORMATIVE STUDY
TO DESIGN AN INTERVENTION INVOLVING MOTHERS, DRUGS VENDORS AND
HEALTH WORKERS IN A SELF-PROCESS OF BEHAVIORAL CHANGE FOR RATIONAL DRUG USE IN
ARI TREATMENT
Pham Huy Dung, Nguyen Thi Kim Chuc, Dennis Ross Degan et al.
Institute for Health and Development, Vietnam
Problem statement: The treatment of ARI, particularly the use of antibiotics in the treatment of ARI, was observed to be
irrational at community level. According to some previous studies, antibiotics were used in 71.4% of non-pneumonia (acute
naso-pharyngitis) cases.
Objectives: This formative study aims at formulating an intervention for improving rational treatment of ARI at community level
by (1) redefining the problem, (2) by identifying target groups for intervention, (3) by developing methods for measuring
behavior, (4) by determining factors influencing behavior and (5) by defining key actors to make change in the intervention
Design: Collection of qualitative and quantitative information from mothers of children under-5, drug vendors and physicians for
the development of the intervention
Setting and Population: Quantitative and qualitative data have been collected from the study of 4 communes in 2 districts Ba Vi
and Dan Phuong of Ha Tay province
Results: (1) Redefining the problem: about 80%-90% of mothers bought antibiotics without prescriptions
at drug vendors. Many of those, who bought antibiotics with prescriptions, did not use antibiotics
in compliance with prescriptions. Many mothers like to use unnecessary drugs (corticoids, vitamins,
etc.). Drug vendors used to sell drugs on request of mothers without giving advice. Health workers
used to prescribe drugs including antibiotics not in compliance with guidelines provided by the
National ARI project for ARI treatment (2) Identifying target groups for intervention: all three
actors to include mothers with children under-5, drugs vendors and physicians were identified to be
target groups for intervention (3) Developing methods for measuring behavior: simulated clients,
interview of exit patients, analysis of medical prescription encounters, checklist to evaluate
providers' behavior, etc. were developed for measuring behavior (4) Determining factors influencing
behavior: interactions between mothers, physicians and drug vendors as well as interactions among
their peers were determined to be factors influencing their behavior (5) Defining key actors to
make change: motivated women were defined to be key actors
Conclusions: An intervention package was formulated to include a guideline for mothers, drug vendors and
physicians in the treatment of ARI at community level based on interactions between them and among
their peers. Improvement would be measured by behavioral changes of target groups. Key actors to
make change would be motivated women working with an educational toolkit to be designed accordingly
Study funded by: ARCH (Center for International Health, Boston University School of Public Health) and MSH
BACKGROUND & SETTING
 Irrational management of ARI cases/ irrational of antibiotic in
the treatment of ARI: -about 80%-90% of mothers bought
antibiotics without prescriptions, -71.2% of prescribed
encounters for naso-pharyngitis cases had some antibiotics, many mothers did not use antibiotics in compliance with
prescriptions for their ARI sick children -> Such situation
requires some intervention for more appropriate management
of ARI cases and more rational use of drugs in ARI treatment.
 Four of the 48 communes in 2 districts, 2 communes in each
district (Ba Vi and Dan Phuong), which had been chosen to be
the site for the intervention, were selected randomly to be the
site for the formative study. Commune Dan Phuong and
commune Tho Xuan were chosen from Dan Phuong district.
Commune Phong Van and commune Phu Chau were chosen
from Ba Vi district
STUDY AIMS
This study has
•
To describe current behavior of key actors in
community drug use for ARI treatment
•
To identify problems of ARI treatment at
community level related to behavior of key actors
•
To identify factors influencing on the behavior of
key actors
•
To design intervention measures to change such
behavior in order to improve rational drug use in
ARI treatment at community level
•
To identify motivated persons to keep running the
intervention
METHODS I: QUANTITATIVE
Interview was conducted in all 4 chosen
communes with the participation of
 231 women
 15 drug vendors
 25 health workers providing medical
prescriptions
METHODS 2: QUALITATIVE
Twelve focus groups were implemented, 3 in
each commune:
 One with the participation of mothers
 One with the participation of drug vendors
 One with the participation of health workers
 About 435 medical prescription encounters
were collected for analysis
RESULTS1: INTERVIEW MOTHERS
 84% of interviewed mothers had heard about acute
respiratory infections (Information that mothers received
came mainly from TIVI and radio channels, health workers
and drug vendors)
 More than half of interviewed mothers stated that cough,
fever and dyspnea are symptoms of ARI, and more than half
stated that they have to bring their children for consultations
when they have severe symptoms of ARI
 35.9% of mothers stated that they use antibiotics for their
children when they have only cough and cold
 6% of mothers stated that they did not have a medical
consultation for their children who have pneumonia
RESULTS 2: INTERVIEW HEALTH WORKERS
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40.7% stated that they had attended to some courses for the training
on ARI of more than 3 days a course
74.1% stated that they were aware that Vietnam had national
guidelines for the treatment of ARI
52% stated that guidelines are very necessary
two tiers to three quarter stated that they would refer the child to
higher care level when the child has dyspnea, lethargy and feeding
refusal
One third of interviewed health workers stated that they would use
antibiotics for chronic otitis
Almost half stated that they would not use antibiotic for streptococcal
pharyngitis; 15% did not state that pneumonia is in the ARI group;
35% did not state that upper respiratory infections are in the ARI
group
Some of them stated that they should refer pneumonia and severe
pneumonia to higher care level
RESULTS 3: INTERVIEW DRUG VENDORS
60% stated that frequent drugs on sell for ARI patients were
antibiotics; 66.7% stated that these are traditional antitussic or any
anti cough medicine; 53.3% stated that these are vitamins
· 40% stated that they gave advices to their clients on how to use
medicines; 47% stated that they gave advices to their clients about
sides effects of medicines; 20% stated that they gave advices to
their clients about symptoms of severe pneumonia for their clients
to take into consideration of the matter; 20% stated that they gave
advices to their clients to go for medical consultations for medical
prescriptions
· 73.3% stated that it is very necessary to have medical prescriptions
for the purchase of antibiotics; 20% stated that it is necessary; and
6.7% stated that it is not necessary (6.7%)
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RESULTS 4: FOCUS GROUPS
 Focus groups of mothers
 Wrong ARI case management home
 Having information on ARI from other women, health
workers and drug vendors
 Focus groups of health workers
 Wrong decisions in antibiotic use and referral for ARI cases
 Having information from guidelines
 Focus groups of drug vendors
 Wrong management of cases without medical prescriptions
 Having information from drug companies
RESULTS 5: INTERVENTION DESIGN
 Mothers
 Motivated women
 Health workers
 Guidelines
 Drug vendors
 Regulation
 All three actors
 Information/ interactive action
SUMMARY
This formative study has described current behavior of mothers, health
workers and drug vendors in community drug use for ARI treatment. From this
description, the study has identified problems to be solved for improving
rational community drug use.
Problems were that mothers did not have right decisions when they could keep
their children with ARI home using home remedies or OTC drugs, when they
should bring them for medical consultations and when they should bring them
for emergency care in hospitals; that health workers did not have rational
prescriptions for children with ARI when they could only give them OTC drugs,
when they should give them antibiotics and when they should refer them to
hospitals; and that drug vendors did not have appropriate case management of
their clients with ARI when they could sell drugs to them when they should not
but only giving them advices
The intervention could be developed on consideration of influencing factors on
behavior of target groups (mothers, health workers and drug vendors) to
include the sources of information they used to receive and their knowledge
about ARI and the management of ARI cases.
CONCLUSION AND POLICY IMPLICATIONS
 Three key actors in community rational use for
the treatment of ARI did not have high rate of
right decisions on when to do what for an ARI
case
 The formative study could provide information
for the design of interventions to decisions of
these key actors
 Combined intervention measures targeting at
many actors (mothers, health workers and drug
vendors) require an integrated management at
operational level