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, Wahlstrom R, Freudenthal S, Stalsby Lundborg C, Eriksson B, Tomson G Ministry of Health, Lao PDR; IHCAR, Karolinska Institutet, Sweden Problem Statement: Self-medication (SM) of antibiotics (AB) for reproductive tract infections (RTI), including sexually transmitted diseases (STD), was suspected to be high in Laos, but no studies had been performed. Inappropriate self-medication could contribute to the continuing increase in antibiotic resistance. Objectives: To describe AB use as SM for RTI and to explore the perceptions and understanding of health information, among the adult population in two provinces of Lao PDR in order to improve drug use and Information, Education and Communication (IEC) components. Design: Cross-sectional population based study. Structured interviews (household survey) and focus group discussions. Setting and Population: A total of 500 subjects, who had self-medicated for RTI were recruited from 827 households in the Vientiane Municipality (VTM) and the Champasack province (CPS), half in urban and half in rural areas. Intervention: The study was part of an information and education strategy to gain more knowledge about prevalence and attitudes. Outcome Measures: Percentage of people using AB as SM for RTI, percentage of advisers for using AB, percentage of kind of AB used, percentage of sources of information received, and qualitative aspects on information material (pamphlet). Results: In total, 16 percent stated use of AB as SM for RTI (28% in women and 2.5% in men) in both study sites, significantly higher among people in VTM (women 32%, men 3.7%) than among people in CPS (women 25%, men 1.5%). Drugstores were the first place for seeking treatment. Advice was reported to be sought from drug sellers or friends or relatives or following previous treatment. Ampicillin and tetracycline dominated. More than half of the respondents of both sexes had little knowledge of antibiotics, many using antibiotics 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 due to some technical terms or foreign language. Most people understood the messages in the printed pamphlet, except for some technical terms used, but reported that the photographs were confusing and needed to be changed. Conclusions: Great efforts are needed to improve people’s knowledge on rational use of antibiotics, on prevention and seeking treatment for RTI and STD by improving health messages including IEC. Study funded by: Sida and Ministry of Health, Laos

Introduction Self-medication with antibiotics: commonly found in many countries. Inappropriate self-medication could contribute to: - antibiotic resistance - treatment failure/chronic diseases - drug side-effects/allergic reaction/toxic poisoning Reproductive Tract Infections ( RTI ) including Sexually Transmitted Diseases ( STD ) : - remain a very common problem worldwide - impose a burden of morbidity/mortality - facilitate HIV transmission => RTI/STD prevention in combination with appropriate treatment and health education => major public health importance No study on self-medication with antibiotics for RTI performed in Laos No evaluation of a pamphlet “STD can be prevented“ published by L-J SHIP (Lao-Japan Sethathirath Hospital Improvement Project) => 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/STD in countries neighboring Laos

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 “STD can be prevented” among the adult population in two provinces of Laos To provide essential information for future interventions 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 “STD 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 “STD can be prevented” Study sites: Vientiane Municipality (VTM) and 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 household with 3056 family members. Inclusion criteria : Women and men aged 18 or more who had used an antibiotic as self-medication for RTI in the last one year, and who were willing to participate Sampling method : Multistage sampling Data collection: Data collected in March Four FGD conducted in the urban areas of VTM and 4 FGD in the remote areas of CPS. Eight to ten 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 (2) Intervention IEC activities like radio, television, newspaper or pamphlet health information Pamphlet “STD 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/STD Project Description of the content and pictures of the pamphlet: The size of the pamphlet is 30x20 cm, folded into three sections to make it small enough for people to take with them. The paper is thick and of good quality. Photo 1: Close up of the inside of a vagina with an abnormal vaginal discharge Photo 2: Close up of a penis with urethral discharge Photo 3: Close up of a penis with genital ulcer Photo 4: Close up of scrotum swelling and a doctor’s fingers with gloves on that are holding it Picture 5: Close up of a baby with inflammatory eyes and a doctor’s fingers trying to open it.

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 48% had completed 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 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%) More than 66% of respondents used antibiotics for inappropriate duration Only 9% of them knew the dosage of antibiotics used

Results (3)

Results (4) 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 Of the 496 respondents who had ever gone to hospital, 59% replied that the services of medical staff were polite/good, 37% said that they were fair, but 4% said that some medical staff were impolite/rude/bad Health information 91% of respondents had ever heard any information of RTI 10% of them had difficulties of understanding the information, mostly due to misunderstanding of technical terms or foreign languages or unclear explanation After getting the health information, 39% reported change of behaviour, but only 17% of all respondents had ever used a condom Respondents in VTM used more condom than those in CPS (25% VS 9%, p < 0.01) Sources of information: - Radio and television 31% - Drug sellers and friends 18%

Results (5) Focus group discussions (FGD) Knowledge and attitudes regarding STD prevention and seeking treatment: Most participants in all FGD had ever heard about STD/AIDS Some had very little knowledge about prevention, treatment and ways of transmission Main sources of information regarding STD: 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 Perception on the services of medical staff: Most FGD participants reported that “ the services of medical staff are good “ However, few of them said: “the provision of treatment and care from some medical staff are not as good as expected”

Conclusion More self-medication with antibiotics for RTI among people in the VTM (women 32%, men 4%) than among people in CPS (women 25%, men 2%) Drugstores: the first place for seeking treatment Advice sought from drug sellers or friends or relatives 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 The common reasons for self-medication were habit, no time to see a physician, following advice of others or drug advertisement Most people had access to health messages for RTI, largely by radio and television Some information was difficult to understand due to some technical terms or foreign language Most people understood the messages of the pamphlet, except for some technical terms used The photographs were confusing and needed to be changed

Implications The irrational use of antibiotics for self-treatment of RTI could have serious adverse effects resulting in antibiotic resistance, treatment failure, serious complications and sequelae In the short term, there is a need to: - improve people’s knowledge on rational use of antibiotics, on prevention and seeking treatment for RTI/STD by improving health messages including IEC - train drug sellers to improve their awareness of selling antibiotics for self-treatment of STD - improve the pamphlet “STD can be prevented” by changing the photographs and using less technical terms in the text 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