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COMMUNITY INTERVENTION TO PROMOTE RATIONAL TREATMENT OF ACUTE

RESPIRATORY INFECTION IN RURAL NEPAL

Karkee SB, Tamang AL, Gurung YB, Holloway KA, Kafle KK, Rai C, Pradhan R

Britain Nepal Medical Trust, WHO Geneva and INRUD, Nepal

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AbstractProblem Statement: Acute respiratory infection (ARI) is often inadequately treated in rural Nepal. Children under five years with severe ARI are undertreated and may die unnecessarily, whereas others take antimicrobials for mild ARI.Objectives: To evaluate the impact of a child-to-child school education program together with mother and drug retailer education in community treatment of ARI.Design: Randomized pre-post intervention study with control preceded by a formative qualitative investigation into community recognition and treatment of ARI. In the formative investigation, community case definitions for severe and mild ARI were identified by interviewing mothers of children diagnosed in hospitals and primary care facilities as severe or mild cases.Setting and Population: Household survey in 10 villages (in an area around a school and health facility) to find 800 children under five years with ARI in the past two weeks in both the intervention and control areas.Intervention: Child-to-child education program administered by teachers in schools, resulting in street theater performances in front of mother’s groups in the community and finally, interactive group discussions with mothers run by community health volunteers following a performance. Training of community leaders and drug retailers by paramedics was also conducted. All activities occurred in mid-2003.Outcome Measures: Percentage of children under 5 years with severe ARI treated in the community according to national guidelines (i.e., taken to the health facility, treated with appropriate antimicrobials, and given appropriate home treatment); percentage of people taking antimicrobials for the common cold.Preliminary Results: Key words and concepts used by mothers to define severe ARI included “pneumonia,” “sannipat,” fast/difficult breathing, chest in-drawing, and inability to suck milk. The baseline survey (December 2002–January 2003) showed that severe ARI in children under five years formed less than 25% of all cases of ARI. Of these children, less than 50% received an antimicrobial, and only 10% of their mothers/caretakers said that they would go to a health facility. A significant number of young children with ARI received inappropriate drugs without health worker consultation. A few people with common cold took antimicrobials. Drug retailer understanding of ARI was similar to that of mothers, and less than 75% of them stocked the antimicrobials recommended in the national guidelines for severe childhood ARI. Conclusions: On the evidence of the baseline results, main messages given during the intervention were that young children with signs of severe ARI must urgently be taken to the health facility and that drugs should only be taken on the advice of a health worker. A post-intervention survey was conducted from December 2003 to January 2004, and data entry and analysis is in progress.

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Introduction On average, each child suffers 5 to 6 episodes of

ARI every year in Nepal. Pneumonia among ARI cases increased from

39.8% in 1998/99 to 43.7% in 1999/2000. Of all deaths among under-five children, 30 to 35%

are related to Pneumonia. A study in PHC outlets of nine districts showed

about 14.3 % of pneumonia cases in children under-five were treated with antibiotics.

antibiotics were prescribed in about 70% of under five children with no pneumonia.

Another study showed about 23% of ARI surrogates reporting sign of pneumonia to retailers received cold preparations (i.e. combination of paracetamol and antihistamines) and 21% received antibacterial.

The above data suggest inappropriate and under-use of antibiotics and need for improving the practices in ARI.

This is the intervention study in districts where formative study was completed.

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Objective The overall objective of the study was to improve

community drug use practice in ARI.

Specific Objectives to find out consumers' knowledge and treatment

seeking practice for ARI to improve consumers' knowledge and practice

about under-five children in order to recognize the signs and symptoms of ARI visit health institutions for getting appropriate

treatment for pneumonia/severe disease visit drug vendors/retailers for getting

appropriate treatment for pneumonia/severe disease

use antibiotics appropriately in pneumonia/ severe disease (i.e full-course in right dose, on time and with appropriate method of administration)

reduce the use of antibiotics in no pneumonia.

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MethodSetting/ sample Four hill/mountain districts of eastern Nepal with

BNMT Drug Scheme. Two districts randomly selected for intervention

and the remaining two as control. In each district, clusters containing schools, health

posts and retailers were listed and five clusters randomly selected.

The cluster included all households within the radius of 2 hours walking distance from the school for students of 10-15 years.

Each cluster mapped into five sub-clusters, each sub-cluster not less than 60 households.

At least 16 ARI under-five cases from each sub-cluster sampled. A total of 1,899 cases (last two weeks/ at the day of visit) from 1,407 households.

One health post and at least one retailer from each cluster making a total of 20 health post and 31 retailers.

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Data collection Interviewed using structured questionnaires for

households and retailers. Carbon Copy Prescriptions (CCPs) collected from

health posts. Systematic random sampling used to select one in 10 prescriptions. 14,966 prescriptions analysed.

Drug availability of health institutions collected quarterly by supervisors using a structured format.

Intervention- TOTs at district level for teachers and health

workers.- Trainings for students and community leaders

including health volunteers.- Street theatre performance for mothers and

community people by trained students in each sub-cluster.

- Question answer session with mothers by community leaders following the performance.

- Interventions in mid-2003. - Post-intervention data collected at the end of 2003.

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Results

Features reported by mothers/ caretakers for children with ARI

(n= 1899)

Name/features Children <5 %

Runny nose 94.2

Cough 92.1

Fever 77.3

Fast breathing 23.6

Unable to eat/stopped taking feed/food

8.3

Common cold 4.6

Pneumonia (sannipat) 4

Chest in-drawing 3.9

Irregular/ difficulty in breathing 2.9

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Categorisation by severe and mild ARI based on reported features

Criteria Children < 5 %Pneumonia 4.0Fast breathing 23.7Unable to suck 4.3Difficulty in breathing 1.0Mild ARI 91.8

Categorisation by treatment receivedCriteria Safe

Home Care %

Antibiotics Treatment

%

Treatment from HIs

%Pneumonia (n=74)

32.5 32.0 4.1

Fast breathing (n=439)

38.3 28.0 1.4

Unable to suck (n=79)

58.2 42.0 1.3

Difficulty in breathing (n=19)

68.4 26.0 5.3

Mild ARI (n=1701)

- 13.4 -

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Source of Treatment for Children under five with ARI

Place of Treatment Children<5 %

Home 68.9

Health institutions (HP, Sub-HP, or Hospital

22.7

Medicine shop or Private clinic 6.1

Traditional healer 9

Neighbour 0.4

Others 0.4

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Treatment of under-five children with Prescriptions/ Medicines and without Prescriptions/ Medicines Source of Treatment

Children<5 % Prescription or

Medicine Available

Prescription/ Medicine Not

AvailableHealth Post 11 10.2

Medicine shops

6.1 4.7

Private clinic 1.1 0.8Neighbour 0.2 0.4Others 0.1 0.3Home 0.1 0.1Sub-health-post

0.1 0.1

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Drugs received by Children under five with ARI from Health InstitutionsMedicine with Prescriptions Children<5

%Paracetamol 11.2Co-trimoxazole 7Amoxycillin 5.8Cough Syrup 1.5Metronidazole 1.4Ampicillin 1Cloxacillin 0.5Chloramphenicol 0.4Iburpofen 0.2Acetylsalicyclic acid 0.1Benzyl penicillin 0.1Betamethasone 0.1Cephalexin 0.1Erythromycin 0.1Gentamicin 0.1

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Drugs received by children under five with ARI where prescriptions not available

Medicine administration with Prescriptions

Children<5%

Paracetamol 4.7Amoxycillin 2.3Ampicillin 1.6Co-trimoxazole 1.1Cough Syrup 0.4Multivitamin 0.2Vitamin B complex 0.2Chloramphenicol 0.1Iburpofen 0.1

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Conclusion

On the evidence of the baseline results, main messages given during the intervention were that young children with signs of severe ARI

must urgently be taken to the health facility and that drugs should only be taken on the advice

of a health worker. A post-intervention survey was conducted from

December 2003 to January 2004, and data entry and analysis is in progress.