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

1 INTRODUCTION Acute respiratory infections (ARIs) are the first cause of diseases’ burden and the third cause of death among under-five-children in Viet Nam Delays in access to health services and inappropriate treatment are the two main reasons causing deaths for children with ARIs From 1982, the Global Programme for Control of Acute Respiratory Infections, with Viet Nam being a member has been implementing many interventions mainly focusing on the public health care system After many years of implementation, the mortality rate is decreased but incidences remain high Unsafe drug use for treatment of ARIs is common Among many interventions, InformationEducationCommunication (IEC) to provide knowledge, skills in care of ARI children has always been the first approach recommended by the World Health Organization (WHO) Coverage, targets of IEC are not only limited to the health system but expanded to other people such as care takers and drug sellers In Viet Nam, few research studies have been implemented to explore IEC methods that are effective for prevention and control of ARIs among under-five-children Particularly, there was a lack of pilot studies carrying out interventions targeting a wide range of subjects aiming at major changes in all steps of the care-taking cycle for 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 objectives: To assess effectiveness of interventions in changing knowledge, practice of mothers in management of ARIs among under-five children in Dan Phuong and Ba Vi from 2005 to 2008 To assess effectiveness of interventions in changing knowledge, practice of health providers in management of ARIs among underfive children in Dan Phuong and Ba Vi from 2005 to 2008 To assess effectiveness of interventions in changing knowledge, practice of drug sellers in drug retail for under-five children with ARIs in Dan Phuong and Ba Vi from 2005 to 2008 New contributions of the study This study has designed, implemented community based interventions effective in changing knowledge, practice in care of children with ARIs in rural areas with its targets being also people who established and implemented the interventions Beside the benefits of having utilized available resources, community participation also improve activeness and responsibility of beneficiaries towards family and community health The interventions differed from many other preceding studies in having targeted all three main groups related to, and having an impact on the whole care taking cycle for children with ARIs This study was able to select and focus interventions on priority issues according to the needs of the target groups without having to be spread over all contents To improve effectiveness, the study selected a combination of many IEC approaches (home communication, groups meetings, during consultations, selling of drugs, skills training, etc.) and many forms of supervisions (within and between groups and from higher levels) to create an intervention package The study has successfully assessed effectiveness in measuring changes in knowledge, practice of target groups of interventions, thereby provided evidence that combining IEC interventions with support supervision and active participation of target groups will achieve high effectiveness, be suitable and sustainable Structure of the dissertation The dissertation consists of 141 pages not including annexes, has chapters, 33 tables, figures, 142 Vietnamese and international references and annexes The dissertation includes: Introduction (2 pages); Overview (26 pages); Study subjects and methodology (25 pages); Results (42 pages); Discussions (42 pages); Conclusions (2 pages); Recommendation (1 page) 3 CHAPTER OVERVIEW 1.1 Incidence and mortality of ARIs In Viet Nam, ARIs are the leading cause of new infections and deaths among under-five-children with an estimated 30 to 80 million cases of all types of ARIs each year ARIs have the highest prevalence 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 in recognizing signs of diseases still have shortcomings In 2008, in Viet Nam, the percentage of mothers recognized signs of ARIs were low: 5.0% for inability to drink, 4.1% for seizures and 3.4% could recognize abnormally sleepy For the characteristic indicators of pneumonia, only 37.3% recognized breathing signs and 0.9% knew signs of chest indrawing Many skills in seeking health services for children with ARIs needed improvement In 2000, only 86% of parents believed that pneumonia was a dangerous disease requiring consultation at health care services In 2003, the highest percentage (20.9%) was mothers providing home care for children with ARIs Lack of knowledge on signs and management of diseased children has contributed to high risks of death among children with ARIs Among the death cases, 5.3% children with ARIs were brought to health centers in lifethreatening conditions, 39.2% with severe disease and 26.1% of the children 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 with lack 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 more tasty foods, 56.8% knew to keep the children warm in winter and cool in summer Only 54.6% knew to provide more to drink Making the 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 health services Comfort (29.0%) and proximity to home (27.1%) were most important factors in selection of health facilities, good quality ranked as third factor Mass media channels were most important sources providing information to mothers For rural women, commune health staff 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 and districts in the whole country, skills of commune health staff in examination 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 The percentage of health staff correctly differentiated diseases was approximately 80.4% Knowledge and practice of private providers is also in need of improvement Only about 77.5% of private physicians knew that chest indrawing was a sign of severe pneumonia Overuse of antibiotics, prescriptions of inappropriate types or insufficient dosage of antibiotics was main findings in the study on use of drugs for ARIs treatment The percentage of children using antibiotics for treatment of non-pneumonia conditions was still high, accounting for 39% In 2004, prescriptions of antibiotics or more accounted for 11% and 20% of antibiotics used were injections Health staff rarely counsel patients on home care Very few of mothers (5.6%) who brought their children to physicians’ examination were counseled on use of drugs at home In 2008, 31% of mothers bringing their children to examinations receive any information from the health staff Lack of training, not suitable treatment regimens, work overload and profit-related factors had negative impacts on the practice of health staff 1.5 The situation of drug retail for children with ARIs Inappropriate, unsafe selling of drugs is increasing Drugs are sold freely on the market, without instructions, even without prescriptions, including those requiring physicians’ indications A large majority of children (91%) having ARIs received antibiotics Among those decided to use antibiotics, 67% households did so by following suggestions of drug sellers, 11% decided by themselves and only 22% followed physicians’ prescriptions This means that people have the risks of using drugs for wrong indications, ineffective use, or even having health risks Professional practice skills of private pharmacies’ staff are affected 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 Some studies have suggested the need to implement interventions to change behaviors of all subjects related to the care taking cycles for sick children There have been only few studies providing IEC interventions for mothers Pilot interventions included: health staff providing direct communication for mothers groups, video instructions at commune health stations, educational messages on commune loudspeakers Contents of IEC messages were usually provided by professionals For health staff, there were pilot interventions with lower level health staff constructing treatment regimens for themselves to be more suitable to local conditions but they did not have high effectiveness due to lack of on-site self-supervision or peer supervision Training of lower level health staff at higher levels also was not effective because of differences in diseases patterns and conditions between different levels For drug sellers, interventions focused on the practice of drug retail and counseling on appropriate use of drugs for some diseases including ARIs but the few interventions were in urban areas only CHAPTER LOCATION AND METHODS OF THE STUDY 2.1 Study subjects Mothers having a child under five (who were mothers having a child less than three years old at baseline survey, were followed for years until study ended); health staff and drug sellers at commune health 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 were carried out in a two-year period 2.4 Terms, definitions used in the study 2.5 Study methods 2.5.1 Study design Community based intervention study with control 2.5.2 Sample size 2.5.2.1 Mothers Using formula for sample size to compare two proportions: {z n= 1−α / 2 p (1 − p ) + z1− β p1 (1 − p1 ) + p (1 − p ) ( p1 − p ) } Where: n: minimal sample size (number of mothers); p1=46.2%; p2=60%; p =(p1+p2)/2 ; Z1-α/2=1.96 with α=0.5%; Z1-β=0.84 (β=80%) The calculated sample size was 157 (each group) To ensure sufficient sample for analysis, a sample of 300 was selected for each group, 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 districts were randomly selected to be intervention and control districts - Random selection of out of 10 similar commune pairs - Random selection of villages in each commune for the study - All mothers having a child under year old were selected for follow-up during the two-year-intervention and assessment after interventions (at a time all had their children under years) After years, with exception of few withdrawals and a few children exceeding the age of five, analysis before and after interventions included 625 mothers (301 in Ba Vi and 324 in Dan Phuong) 7 - Enrollment of all health providers and drug sellers in selected communes 2.5.4 Data collection methods 2.5.4.1 Techniques, tools for quantitative data - Mothers were directly interviewed using questionnairre All mothers were assessed for knowledge Practice of mothers whose children had ARIs within months before surveys were assessed - Health providers were interviewed for knowledge and observations were made using checklist for their practice - Drug sellers were assessed for knowledge using direct interview and 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 group discussions were made with mothers, active mother groups, health providers, 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 analyzed using STATA to calculate percentages, means, test for hypotheses and EI (Effectiveness Indicators) Qualitative data were managed “ open-coded” by groups of themes and cited in the report 2.6 Design and implementation of interventions Interventions were carried out in selected communes in Ba Vi with IEC activities during 12 months and support supervision for the next 12 months Steps of implementation included: - Designing intervention materials: “Child health diary” for the mothers, treatment instructions for health providers and drug selling instructions for drug sellers - Implementation of IEC interventions for mothers (counseling provided by active mothers, group meetings, counseling during consultations and drug purchase) and skills training for groups providing health services - Supervision (from higher level, between and within groups) for changing practices and monitor sustainability 2.7 Ethical issues CHAPTER 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 having secondary school attainment had the highest proportions There was no significant difference in average age, occupations, educational attainment 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 they could 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 No sign sign signs signs signs signs signs Intervention BL PI p n=301 n=301 11.6 0.3