1 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

2 Abstract Problem 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 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.

3 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.

4 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.

5 Method Setting/ 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 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.

6 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 Post-intervention data collected at the end of 2003.

7 Results Features reported by mothers/ caretakers for children with ARI (n= 1899) Name/featuresChildren <5 % Runny nose94.2 Cough92.1 Fever77.3 Fast breathing23.6 Unable to eat/stopped taking feed/food 8.3 Common cold4.6 Pneumonia (sannipat)4 Chest in-drawing3.9 Irregular/ difficulty in breathing2.9

8 Categorisation by severe and mild ARI based on reported features CriteriaChildren < 5 % Pneumonia4.0 Fast breathing23.7 Unable to suck4.3 Difficulty in breathing1.0 Mild ARI91.8 Categorisation by treatment received CriteriaSafe Home Care % Antibiotics Treatment % Treatment from HIs % Pneumonia (n=74) Fast breathing (n=439) Unable to suck (n=79) Difficulty in breathing (n=19) Mild ARI (n=1701)

9 Source of Treatment for Children under five with ARI Place of TreatmentChildren<5 % Home68.9 Health institutions (HP, Sub-HP, or Hospital 22.7 Medicine shop or Private clinic6.1 Traditional healer9 Neighbour0.4 Others0.4

10 Treatment of under-five children with Prescriptions/ Medicines and without Prescriptions/ Medicines Source of Treatment Children<5 % Prescription or Medicine Available Prescription/ Medicine Not Available Health Post Medicine shops Private clinic Neighbour Others Home0.1 Sub-health- post 0.1

11 Drugs received by Children under five with ARI from Health Institutions Medicine with PrescriptionsChildren<5 % Paracetamol11.2 Co-trimoxazole7 Amoxycillin5.8 Cough Syrup1.5 Metronidazole1.4 Ampicillin1 Cloxacillin0.5 Chloramphenicol0.4 Iburpofen0.2 Acetylsalicyclic acid0.1 Benzyl penicillin0.1 Betamethasone0.1 Cephalexin0.1 Erythromycin0.1 Gentamicin0.1

12 Drugs received by children under five with ARI where prescriptions not available Medicine administration with Prescriptions Children<5 % Paracetamol4.7 Amoxycillin2.3 Ampicillin1.6 Co-trimoxazole1.1 Cough Syrup0.4 Multivitamin0.2 Vitamin B complex0.2 Chloramphenicol0.1 Iburpofen0.1

13 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.