1. Sri Hidayati, Siti Munawaroh INRUD Yogya/INDONESIA
SMALL GROUP DISCUSSION AMONG PARAMEDICS AT HEALTH CENTER LEVEL TO IMPROVE ADHERENCE TO STANDARD TREATMENT GUIDELINES OF ACUTE RESPIRATORY TRACT INFECTIONS
Sri Hidayati, Siti Munawaroh
INRUD Yogya/INDONESIA

2. BACKGROUND
Standard Treatment Guidelines (STG) and flow chart of diagnosis and treatment of Acute Respiratory Infection (ARI) have been available in health centres all over Indonesia
Previous studies showed that treatment of ARI at health centre level did not always comply to the guideline, as indicated by the indiscriminate use of nonstandard drugs such as antibiotics, antihistamines, corticosteroids, phenobarbital,etc.
Innovative Strategies are needed to improve adherence to ARI treatment guidelines in health centers.
Ladies and gentleman, good morning

3. OBJECTIVES General: To improve adherence to STG of ARI Specific :
To reduce the number of drugs per encounter for ARI patients
To reduce unnecessary drugs such as antibiotics, antihistamines, corticosteroids, and phenobarbitals in ARI in health centers
To reduce cost of drugs in ARI patients

4. STUDY DESIGN: Randomized pre – post study
12 HCs underwent series of intervention
Small Group Discussion
Self Assessment-1
Self Assessment-2
24 HCs in 2 districts
Randomization
Feedback Seminar (FBS)
12 HCs acted as control
Focus Group Discussion
Focus Group Discussion
Prescribing survey:
Number of sample: 30 prescriptions per HC X 12 time points X 24 Hcs = 8640 prescriptions
POST INTERVENTION
POST FBS
PRE INTERVENTION
Post SGD
Post SA1
Post SA2

5. REDUCTION OF ANTIBIOTICS & ANTIHISTAMINE
Paramedics underwent series of intervention showed dramatic reduction (>50%) in antibiotics and antihistamine use.
These improvements were maintained at low level until after feedback seminar (FBS)

6. REDUCTION OF CORTICOSTEROIDS & PHENOBARBITAL
Paramedics underwent series of intervention showed drastic reduction (>50%) in corticosteroids and phenobarbital use.
These reductions sustained after feedback seminar.

7. POLYPHARMACY AND AVERAGE DRUG COST
Average number of drugs per encounter reduced from 4.1 to 3.0, meaning that on average, one drug disappeared from the prescription.
Marked reduction at drug cost per encounter (>30% reduction) is also shown by Paramedics underwent series of intervention.

8. DISCUSSIONS
Small Group Discussion followed by Self Assessment discussion have been proven effective in improving prescribing practices for ARI patients in HCs.
The mixed intervention, i.e., small group discussion, self-assessment discussion, and feedback given in large group feedback seminar, contributes to the sustainable improvement. However, enforcements might be repeated to maintain long-term impact.
Previous studies showed that replacement of drugs usually occurred as the adverse effect of intervention. This study however, showed that the elimination of nonstandard drugs was not replaced by others as indicated by the reduction of the number of drugs per encounter (4.1 – 3.0).

9. CONCLUSIONS
Repeated Small Group Discussions reduces the use of nonstandard drugs in the treatment of ARI in children in Health Centers.
Small Group Discussions among paramedics with trained paramedics acted as a facilitators and doctors as resource persons are feasible to organize in health centers.
To maintain the impact of intervention in long term period, reinforcements are needed.