A FORMATIVE STUDY TO DESIGN AN INTERVENTION INVOLVING MOTHERS, DRUGS VENDORS AND HEALTH WORKERS IN A

1
(No Transcript)
2
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)
3
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

4
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 -gt 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

5
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

6
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

7
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

8
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

9
RESULTS 2 INTERVIEW HEALTH WORKERS

• 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

10
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)

11
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

12
RESULTS 5 INTERVENTION DESIGN

• Mothers
• Motivated women
• Health workers
• Guidelines
• Drug vendors
• Regulation
• All three actors
• Information/ interactive action

13
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.

14
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