assessment of the effectiveness of community interventions in management of acute respiratory infections among under-five-children in dan phuong and ba vi, ha noi

To assess effectiveness of interventions in changing knowledge,practice of mothers in management of ARIs among under-fivechildren in Dan Phuong and Ba Vi from 2005 to 2008.. To assess ef

Acute respiratory infections (ARIs) are the first cause of diseases’burden and the third cause of death among under-five-children inViet Nam Delays in access to health services and inappropriatetreatment are the two main reasons causing deaths for children withARIs From 1982, the Global Programme for Control of AcuteRespiratory Infections, with Viet Nam being a member has beenimplementing many interventions mainly focusing on the publichealth care system After many years of implementation, themortality rate is decreased but incidences remain high Unsafe druguse for treatment of ARIs is common

Among many interventions, Information- Communication (IEC) to provide knowledge, skills in care of ARIchildren has always been the first approach recommended by theWorld Health Organization (WHO) Coverage, targets of IEC are notonly limited to the health system but expanded to other people such

Education-as care takers and drug sellers

In Viet Nam, few research studies have been implemented toexplore IEC methods that are effective for prevention and control ofARIs among under-five-children Particularly, there was a lack ofpilot studies carrying out interventions targeting a wide range ofsubjects aiming at major changes in all steps of the care-taking cyclefor children with ARIs

We conducted the study: " Assessment of the effectiveness of community interventions in management of Acute Respiratory Infections among under-five-children in Dan Phuong and Ba Vi,

Ha Noi" with the following 3 objectives:

1 To assess effectiveness of interventions in changing knowledge,practice of mothers in management of ARIs among under-fivechildren in Dan Phuong and Ba Vi from 2005 to 2008

2 To assess effectiveness of interventions in changing knowledge,practice of health providers in management of ARIs among under-five children in Dan Phuong and Ba Vi from 2005 to 2008

3 To assess effectiveness of interventions in changing knowledge,practice of drug sellers in drug retail for under-five children withARIs in Dan Phuong and Ba Vi from 2005 to 2008

New contributions of the study

1 This study has designed, implemented community basedinterventions effective in changing knowledge, practice in care ofchildren with ARIs in rural areas with its targets being also peoplewho established and implemented the interventions Beside thebenefits of having utilized available resources, communityparticipation also improve activeness and responsibility ofbeneficiaries towards family and community health

2 The interventions differed from many other preceding studies inhaving targeted all three main groups related to, and having animpact on the whole care taking cycle for children with ARIs

3 This study was able to select and focus interventions on priorityissues according to the needs of the target groups without having to

be spread over all contents

4 To improve effectiveness, the study selected a combination ofmany IEC approaches (home communication, groups meetings,during consultations, selling of drugs, skills training, etc.) and manyforms of supervisions (within and between groups and from higherlevels) to create an intervention package

5 The study has successfully assessed effectiveness in measuringchanges in knowledge, practice of target groups of interventions,thereby provided evidence that combining IEC interventions withsupport supervision and active participation of target groups willachieve high effectiveness, be suitable and sustainable

Structure of the dissertation

The dissertation consists of 141 pages not including annexes, has

4 chapters, 33 tables, 8 figures, 142 Vietnamese and internationalreferences and annexes The dissertation includes: Introduction (2pages); Overview (26 pages); Study subjects and methodology (25pages); Results (42 pages); Discussions (42 pages); Conclusions (2pages); Recommendation (1 page)

CHAPTER 1 OVERVIEW 1.1 Incidence and mortality of ARIs

In Viet Nam, ARIs are the leading cause of new infections anddeaths among under-five-children with an estimated 30 to 80 millioncases of all types of ARIs each year ARIs have the highestprevalence in hospitals Among causes of childhood mortality,pneumonia has the highest percentage

1.3 The situation of mothers’ care for children with ARIs

Even though knowledge has been improved, mothers’ skills inrecognizing signs of diseases still have shortcomings In 2008, inViet Nam, the percentage of mothers recognized signs of ARIs werelow: 5.0% for inability to drink, 4.1% for seizures and 3.4% couldrecognize abnormally sleepy For the 2 characteristic indicators ofpneumonia, only 37.3% recognized breathing signs and 0.9% knewsigns of chest indrawing

Many skills in seeking health services for children with ARIsneeded improvement In 2000, only 86% of parents believed thatpneumonia was a dangerous disease requiring consultation at healthcare services In 2003, the highest percentage (20.9%) was mothersproviding home care for children with ARIs Lack of knowledge onsigns and management of diseased children has contributed to highrisks of death among children with ARIs Among the death cases,5.3% children with ARIs were brought to health centers in life-threatening conditions, 39.2% with severe disease and 26.1% of thechildren already died at home

The objectives of Viet Nam’s ARI program are to reduce the rate

of incidence of ARIs and safe use of drugs for children with ARIs.The widespread retail of antibiotics, lack of controls together withlack of knowledge in drug use has been hindering the program.Antibiotics abuse for mild ARIs as well as insufficient dosage,inappropriate types of antibiotics used were common

The practice of home care for children also was inappropriate.For children having diseases, 67.4% of mothers knew to give moretasty foods, 56.8% knew to keep the children warm in winter and

cool in summer Only 54.6% knew to provide more to drink Makingthe airway free was the method that the least mothers knew (23.8%) Factors related to knowledge and skills of mothers included:severity of disease and income was related to selection of healthservices Comfort (29.0%) and proximity to home (27.1%) were mostimportant factors in selection of health facilities, good quality ranked

as third factor Mass media channels were most important sourcesproviding information to mothers For rural women, commune healthstaff and local loudspeakers played very important roles.Misperceptions of users were related to inappropriate drug use

1.4 The situation of management of ARIs by health staff

Even though the ARIs program covered 100% of communes anddistricts in the whole country, skills of commune health staff inexamination and diseases classification are still having shortcomings.Health staff very often did not explore all signs of severe diseases.Skills in counting respiratory frequency were less than required Thepercentage of health staff correctly differentiated diseases wasapproximately 80.4% Knowledge and practice of private providers isalso in need of improvement Only about 77.5% of private physiciansknew that chest indrawing was a sign of severe pneumonia Overuse

of antibiotics, prescriptions of inappropriate types or insufficientdosage of antibiotics was main findings in the study on use of drugsfor ARIs treatment The percentage of children using antibiotics fortreatment of non-pneumonia conditions was still high, accounting for39% In 2004, prescriptions of 2 antibiotics or more accounted for11% and 20% of antibiotics used were injections Health staff rarelycounsel patients on home care Very few of mothers (5.6%) whobrought their children to physicians’ examination were counseled onuse of drugs at home In 2008, 31% of mothers bringing theirchildren to examinations receive any information from the healthstaff Lack of training, not suitable treatment regimens, workoverload and profit-related factors had negative impacts on thepractice of health staff

1.5 The situation of drug retail for children with ARIs

Inappropriate, unsafe selling of drugs is increasing Drugs aresold freely on the market, without instructions, even without

prescriptions, including those requiring physicians’ indications Alarge majority of children (91%) having ARIs received antibiotics.Among those decided to use antibiotics, 67% households did so byfollowing suggestions of drug sellers, 11% decided by themselvesand only 22% followed physicians’ prescriptions This means thatpeople have the risks of using drugs for wrong indications,ineffective use, or even having health risks.

Professional practice skills of private pharmacies’ staff areaffected by many factors such as: professional knowledge, buyers’demand, regulatory documents and profits

1.6 Interventions to change behaviors in care of ARIs children

Because of IEC efforts combined with other interventions,prevention and control of ARIs has achieved promising results Somestudies have suggested the need to implement interventions to changebehaviors of all subjects related to the care taking cycles for sickchildren

There have been only few studies providing IEC interventionsfor mothers Pilot interventions included: health staff providing directcommunication for mothers groups, video instructions at communehealth stations, educational messages on commune loudspeakers.Contents of IEC messages were usually provided by professionals.For health staff, there were pilot interventions with lower levelhealth staff constructing treatment regimens for themselves to bemore suitable to local conditions but they did not have higheffectiveness due to lack of on-site self-supervision or peersupervision Training of lower level health staff at higher levels alsowas not effective because of differences in diseases patterns andconditions between different levels

For drug sellers, interventions focused on the practice of drugretail and counseling on appropriate use of drugs for some diseasesincluding ARIs but the few interventions were in urban areas only

CHAPTER 2 LOCATION AND METHODS OF THE STUDY 2.1 Study subjects

Mothers having a child under five (who were mothers having achild less than three years old at baseline survey, were followed for 2

years until study ended); health staff and drug sellers at communehealth stations and private providers in selected communes

2.2 Location

Dan Phuong and Ba Vi districts, Ha Noi (formerly Ha Tay province)

2.3 Duration of the study

From March 2005 to January 2008, wherein interventions werecarried out in a two-year period

2.4 Terms, definitions used in the study

2 2 2 1 1 1 2

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) (

) 1 ( ) 1 ( )

1 ( 2

p p

p p p p z p p z

The calculated sample size was 157 (each group) To ensure

sufficient sample for analysis, a sample of 300 was selected for eachgroup, giving a total of 600 mothers

2.5.2.2 Health service providers

Enrolment of all health providers (commune stations and private)and drug sellers in communes receiving interventions for mothers

2.5.3 Sample selection

- Multi-stage sampling was used After the baseline, two districtswere randomly selected to be intervention and control districts

- Random selection of 5 out of 10 similar commune pairs

- Random selection of 3 villages in each commune for the study

- All mothers having a child under 3 year old were selected forfollow-up during the two-year-intervention and assessment afterinterventions (at a time all had their children under 5 years) After 2years, with exception of few withdrawals and a few childrenexceeding the age of five, analysis before and after interventionsincluded 625 mothers (301 in Ba Vi and 324 in Dan Phuong)

- Enrollment of all health providers and drug sellers in selectedcommunes

2.5.4 Data collection methods

2.5.4.1 Techniques, tools for quantitative data

- Mothers were directly interviewed using questionnairre Allmothers were assessed for knowledge Practice of mothers whosechildren had ARIs within 2 months before surveys were assessed

- Health providers were interviewed for knowledge and observationswere made using checklist for their practice

- Drug sellers were assessed for knowledge using direct interviewand for practice by drug buyers’ observations using checklist

2.5.4.2 Techniques, tools for qualitative data

In each district, before and after interventions, focus groupdiscussions were made with mothers, active mother groups, healthproviders, drug sellers, and managers

2.5.5 Methods used to control biases

2.5.6 Data management methods

Quantitative data were entered using Epi-DATA and analyzedusing STATA to calculate percentages, means, test for hypothesesand EI (Effectiveness Indicators)

Qualitative data were managed “ open-coded” by groups of themesand cited in the report

2.6 Design and implementation of interventions

Interventions were carried out in 5 selected communes in Ba Viwith IEC activities during 12 months and support supervision for thenext 12 months Steps of implementation included:

- Designing intervention materials: “Child health diary” for themothers, treatment instructions for health providers and drug sellinginstructions for drug sellers

- Implementation of IEC interventions for mothers (counselingprovided by active mothers, group meetings, counseling duringconsultations and drug purchase) and skills training for groupsproviding health services

- Supervision (from higher level, between and within groups) forchanging practices and monitor sustainability

2.7 Ethical issues

CHAPTER 3 RESULTS 3.1 Effectiveness in changing knowledge, practice of mothers in taking care of children with ARIs.

3.1.1 Some characteristics of mothers

Average age was 27.6±4.9 Mothers in agriculture and havingsecondary school attainment had the highest proportions There was

no significant difference in average age, occupations, educationalattainment and households characteristics between two groups

3.1.2 Effect of interventions on mothers’ knowledge

3.1.2.1 Recognition of signs of diseases

The distribution of mothers by number of diseases signs theycould recognize post-intervention (PI) differed from baseline (BL)significantly

Table 3.3: Comparison by number of signs mothers knew indicating

need for examination baseline-post intervention (%)

Number of

signs

BLn=301

PIn=301

n=324

PIn=324

* No significant difference for any indicator among control group

At baseline, intervention group knowing two signs accounted forthe highest percentage (32.6%) Post-intervention, mothers knowing

4 signs had the highest percentage (39.53%)

3.1.2.2 Knowledge on management of sick children

The percentage in intervention group knowing to bring the childfor exams when there are signs indicating such a need increased from13.8% to 93.0% (p<0.05) The percentage of mothers correctlyknowing children can be monitored at home increased to 23.9% inthe intervention group as compared to 1.3% at baseline (p<0.001)

Table 3.5: Comparisson of knowledge on management of children with

ARIs of mothers baseline-post intervention (%)

BLn=301 n=301PI p BL

Correct

management 51.5 77.1 <0.001 49.4 51.5 45.4

* No significant difference for any indicator among control group

3.1.2.3 Knowledge on drug use

Table 3.6: Comparison of mothers' knowledge on the use of antibiotics for

children with ARIs, baseline-post intervention (%)

Antibiotics use

EI

BLn=301

PIn=301

n=324

PIn=324With

prescription 62.8 94.4 <0.001 55.2 58.0 45.2Sufficient

duration 39.2 70.1 <0.001 47.8 42.6 91.1

No antibiotics

for cold 49.5 63.8 <0.05 50.0 47.5 33.8

* No significant difference for any indicator among control group

All 3 indicators for knowledge on antibiotics use of mothers intervention in Ba Vi significantly increased in comparison tobaseline and were much higher than among controls as well

post-3.1.2.3 Knowledge on care, follow-up of children

Post-intervention, the percentage of mothers having correctknowledge on child care for each indicator increased by about 20%

or more All four indicators increased significantly

Post-intervention, the percentage in Ba Vi knowing needs formonitoring of children increased by 16.8% with statisticallysignificant differences Knowledge on re-examination (immediateand scheduled) also increased significantly

Table 3.7: Comparison of mothers’ knowledge on child care and monitoring,

* No significant difference for any indicator among control group

3.1.3 Effects of interventions on mothers’ practice

3.1.3.1 Practice in management of sick child

Table 3.8: Comparison of mothers’ management of children having signs

indicating need for exams baseline-post intervention (%)

Managemen

Seek exams 74.1 92.1 <0.001 57.1 68.0 5.2

* No significant difference for any indicator among control group

Post-intervention, most of the intervention group (92%) broughtchildren to examination upon detection of signs of severe disease inneed of examination (p<0.001) (Table 3.8)

43.5

18.0 3.3

46.7 42.1

Figure 3.2: Comparison of practice for children with cough, cold at

baseline and post-intervention (%)

For children having cough, cold, the percentage of mothers in Ba

Vi with correct management significantly increased as compared tobaseline Main reason for the increase was an increase of those whofollow their children at home by 14.7% compared to baseline with an

EI of more than 472.4% (Figure 3.2)

3.1.3.2 Practice of drug use

Table 3.9: Comparison of mothers’ antibiotics use practice for children

duration

25.3 63.7 <0.001 33.1 41.9 125.2

* No significant difference for any indicator among control group

There was a positive change in antibiotics use among theintervention group The percentage using antibiotics with prescriptionand for sufficient duration increased from 18.0% to 47.8% (p<0.001)with an EI of interventions reaching 142.2%

Table 3.10: Comparison of drugs buying practice for children with cough,

cold baseline-post intervention (%)

* No significant difference for any indicator among control group

For cough and cold, the percentage of mothers with correctpractice post-intervention in Ba Vi increased but not significantly

3.1.3.4 Practice in care, follow-up of children

Table 3.11: Comparison of mothers’ practice in child care baseline-post

Post-intervention, the percentage who did each of the essentialcare tasks at home clearly increased, with the exception of indicatorfor monitoring which increased but not significantly.

Post-intervention, the percentage of mothers bringing theirchildren to re-examination after 2-3 days of antibiotics use increased

to 38.2% (p<0.001) Intervention EI was 599.4%

3.2 Effects of interventions in changing providers’ knowledge, practice in care of children with ARIs.

3.2.1 Characteristics of health providers

Two groups of providers in two districts had similarity in somebasis characteristics such as age, years in occupation, professionallevel, and types of health facility (private /public) There was nostatistically significant difference between two groups in abovementioned data Average age was 40 The majority (74.68%) wereassistant doctors The number of private providers was twice as high

as commune health station staff The majority provided examinationand treatment for more than 10

3.2.2 Effectiveness in changing providers’ knowledge

3.2.2.1 Knowledge to recognize signs of diseases

For very severe diseases, providers need to remember 11 signs (6for children under 2 months of age and 5 for children from 2 months

to 5 years) At baseline in both districts, most providers onlyremembered between 4 and 6 signs A few did not know any No

provider remembered all signs Post-intervention, most providers in

Ba Vi knew from seven to nine signs, no one knew less than 4 signsand 11% knew all 11 signs

Table 3.13: Comparison of providers’ knowledge on signs of severe

pneumonia baseline and post-intervention (%)

Children from 2 months to 5 years

Chest indrawing 55.6 88.9 <0.01 67.4 72.1 53.1

* No significant difference for any indicator among control group