Self-medication with antibiotics for Reproductive Tract Infections in Lao PDR: use, attitudes and understanding of information Sihavong A, Gneunphonsavath S, Chanthavong K, Visathep A, Choumkhamphanh S, Xayyavong S, Akkhavong K, Freudenthal S, Stalsby Lundborg C, Eriksson B, Wahlstrom R, Tomson G Ministry of Health, Lao PDR; IHCAR, Karolinska Institutet, Sweden 

Background Self-medication with antibiotics: Commonly found in many countries Inappropriate self-medication could contribute to antibiotic resistance/treatment failure/drug side-effects Reproductive Tract Infections (RTI) including Sexually Transmitted Infections (STI): - remain a very common problem worldwide - impose a burden of morbidity/mortality - facilitate HIV transmission => RTI/STI prevention with appropriate treatment and health education: major public health importance

Rationale  No study on self-medication with antibiotics for RTI performed in Laos  No evaluation of a pamphlet “STI can be prevented” published by L-J SHIP Highly relevant study to the nation as a response to: an awareness of the continuing increase in antibiotic resistance due to irrational drug use the high levels of HIV/STI in countries neighboring Laos (In this study Self-medication with antibiotics is defined as antibiotic use without prescription by a physician)

General objective To describe, in a comprehensive way, the utilization, knowledge and attitudes on self- medication with antibiotics for RTI To explore the understanding of a pamphlet “STI can be prevented” among the adult population in two provinces of Laos To provide essential information for future intervention to improve drug use and IEC components

Specific objectives 1. To describe the use of antibiotics as self-medication for RTI in adults 2. To explore people’s knowledge and attitudes regarding the use of antibiotics as self-medication for RTI 3. To explore people’s knowledge and attitudes regarding health information on the use of antibiotics for RTI 4. To explore people’s understanding of the pamphlet “STI can be prevented” and their views regarding community intervention for correct treatment and prevention of RTI

Methods (1) Study design: Cross-sectional population based study Methods used: * Structured interviews (household survey): To collect background information, knowledge and attitudes and health information * Focus group discussions: To explore people’s understanding and views on the pamphlet “STI can be prevented” Study sites: - Vientiane Municipality (VTM) - Champasack Province (CPS) Half in urban and half in rural areas Sample size: A total of 500 subjects self-medicated with antibiotics for RTI recruited from 827 households

Methods (2) Inclusion criteria: - Women and men aged 18 or more - Using an antibiotic as self-medication for RTI in the last one year - Willing to participate Sampling method: Multistage sampling Data collection: Data collected in March 2002 4 FGD conducted in the urban areas of VTM and 4 FGD in the remote areas of CPS 8 to 10 participants in each FGD Data analysis: Data entered by Epi Info (version 6.04) and analyzed by SPSS (version 10) FGD analyzed by qualitative method

Methods (3) Intervention Description of the content of the pamphlet IEC activities like radio, television, newspaper or pamphlet health information Pamphlet “STI can be prevented” produced in 2001 by the cooperation between: Sethathirath Hospital L-J SHIP Health Department of VTM and Ministry of Health/European Union/STI/Project Description of the content of the pamphlet Size of pamphlet: 30x20 cm; folded into three sections Paper is thick and of good quality

and classified by gender and areas Results (1) Percentage of people using antibiotics as self-medication for RTI in relation to all sampled family members and classified by gender and areas

Results (2) Social-demographic characteristics of people using antibiotics self-medication for RTI  Mean age of study participants: 34.8 (Std  9.5)  85% were married, 32% were housewives  48% had completed only primary school and 42% had completed secondary school  78% of female respondents had symptoms of both vaginal discharge and lower abdominal pain  85% of male respondents had symptoms of urethral discharge

Results (3) Knowledge and attitudes regarding the use of antibiotics for RTI among people with self-medication  54% of respondents did not understand what an antibiotic means  33% of the antibiotics used were ampicillin  58 percent were mixed antibiotics, most common combinations with ampicillin and tetracycline (28%)  66% of respondents used antibiotics for 3 to 5 days, 13% for 2 days or less  Only 9% of them knew the dosage of antibiotics used

Results (4)

Results (5) Health seeking  Of all respondents, 50% replied that they treated themselves for RTI because of habit, 36% had no time to see physician  More than 18% followed advice of others or drug advertisement, either directly (12%) or combined with other reasons Health information  91% of respondents had ever heard any information of RTI  10% of them had difficulties of understanding the information  After getting the health information, 39% of them reported change of behaviour, but only 17% of all respondents had ever used a condom  Sources of information: - radio and television 31% - drug sellers and friends 18%

Results (6) Focus group discussions (FGD) Knowledge and attitudes regarding STI prevention and seeking treatment:  Most participants in all FGD had ever heard about STI and AIDS  Some had very little knowledge about prevention, treatment and ways of transmission  Main sources of information regarding STI: drug sellers, friends, relatives, radio and television Perception and understanding of the pamphlet information:  For most women and men, the pamphlet’s size was good with useful messages and easy to keep. Most people understood its messages except for some technical terms used  The photographs were confusing and needed to be changed.

Conclusion  More self-medication with antibiotics for RTI among people in VTM (women 32%, men 3.7%) than among people in CPS (women 25%, men 1.5%)  Drugstores: the first place for seeking treatment  Advice sought from drug sellers or friends or relative or following previous treatment  More than half of respondents of both sexes had little knowledge of antibiotics, and used them with incorrect duration and dosage  Most people had access to health messages for RTI, largely by radio and television, but some information was difficult to understand  Most people understood the messages in the printed pamphlet, except for some technical terms used  The photographs were confusing and needed to be changed

Implications  Irrational use of antibiotics for self-treatment of RTI could contribute to the continuing increase in antibiotic resistance/treatment failure  In the short term, there is a need to: - improve people’s knowledge on rational use of antibiotics for RTI by improving health messages/IEC - train drug sellers to improve their awareness of selling antibiotics for self-treatment of STI - improve the pamphlet “STI can be prevented” by changing the photographs and using less technical terms  In the long term, there is a need to: - consider drug regulation to promote appropriate selling of antibiotics with or without a prescription - evaluate other published pamphlets regarding people’s understanding and views on health information for future community interventions

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