1. Problem Statement: In Kenya, despite the development of national standard treatment guidelines (STGs) for the management of acute respiratory infections (ARI) and malaria and the dissemination of those guidelines for use by health care providers, the irrational use of antibiotics continue to be a problem in the quality of services in most health facilities. Among those health facilities, mission hospitals that provide over 50% of the entire national health services are also dealing with problem of irrational prescribing for ARI and malaria. The Lack of adherence to the STGs, lack of monitoring and supervisory systems and mechanisms to control prescribing practices are factors that continue to contribute to over use of antibiotics in the treatment of children under five years. Objectives: To assess the effectiveness of an educational intervention in improving prescribing practices in the treatment of non- pneumonia ARI and malaria in children under five in mission hospitals in Kenya. Design and Setting : Retrospective randomized control study design with pre-post intervention study periods. The study used qualitative and quantitative methods and was conducted in 6 mission hospitals in central and eastern provinces of Kenya. It involved the analysis of a total of 2465 prescriptions for ARI and malaria from the treatment records of the study hospitals (200 prescriptions each), and surveys of 56 key informants Interventions: An educational intervention was conducted at each hospital based on the baseline results. The training curriculum included drug management functions, the role of the participants in drug management, importance of appropriate prescribing, good prescribing practices and the role of P & T C in promoting proper prescribing. The STGs for the study conditions were issued to the prescribers. P&TC members were recommended to actively participate in promoting rational prescribing for the study conditions. Outcome measures: Average number of drugs per case, % of drugs in generic, % of antibiotics prescribed, average cost of treatment per encounter, % injections prescribed per case, % prescription conforming to the standard treatment guideline. Results: Compliance to STGs for ARI improved after the intervention. Moderate changes were observed for injection and antibiotic prescribing for ARI and malaria cases while overall prescriptions of generics improved for both conditions. The number of drugs per prescription did not change significantly. Hospitals with an active P& TC had a better improvement in prescribing for ARI and malaria than those with non-active committees. Conclusions: The educational intervention supported by P&TC activities poorly influenced the use of antibiotics in the treatment of non-pneumonia ARI and malaria in mission hospitals. In addition to re-enforcing the role of P&TC in hospital settings, regular training supported by distribution of materials may yield to more significant improvement in prescribing behavior. Funding source: Applied Research on Child Health (ARCH) ABSTRACT

2. Effect of an Educational Intervetion on Antibiotic Use in the Treatment of ARI and Malaria in Six Mission Hospitals in Kenya Gitau L, Kiambuthi J

3. Background and Setting In Kenya high infant mortality rates are attributed to ARI and malaria in children under five years Mission hospitals are important in the provision of primary care serving over 50% of rural population Treatment practices for the treatment of ARI and malaria is characterized by inappropriate prescribing which includes ─ Polypharmacy ─ Multiple drugs ─ Inappropriate use of injections ─ Use of branded products

4. Study Objectives Objective: To assess the effectiveness of an educational program with supportive activities of Pharmacy and Therapeutic (P&TC) on prescribing for non-pneumonia ARI and malaria in children under five in six mission hospitals in Kenya. Specific Objectives: 1. To determine prescribing practices for non-pneumonia ARI and Malaria in children under five 2. To determine the effect of an intervention to improve prescribing of antibiotics for non-pneumonia ARI and malaria.

5. Methods Design: - Quasi Experimental design with comparison groups and a pre-post intervention study periods. - Use of quantitative and qualitative analytical methods. Setting: Six mission hospitals in Central and Eastern provinces in Kenya. Intervention: - An educational training on prescribing of non-pneumonia ARI and malaria - Development of Pharmacy and Therapeutics Committees at each of the hospitals - Distribution of supporting educational materials

6. Methods (continued) Quantitative Analysis - Outpatient clinics of 6 missions hospitals - Analysis of prescribing patterns for ARI and malaria  999 prescriptions for ARI cases  1465 prescriptions for malaria cases Qualitative Analysis - Survey of 156 key informants - Exit interview of 120 caregivers - In-depth interview of 36 prescribers and P&TC members

7. Results Moderate changes observed in injection and antibiotic prescribing for ARI and malaria. – General use of injections decreased from 22% baseline to 18% after the intervention – General use of antibiotics decreased by 2% after the intervention Overall prescriptions of generics for ARI and malaria increased by 13% – Generic prescribing for ARI improved by 11% (88% before Vs 99% after) – Generic prescribing for malaria improved by 14% (83% before Vs 97% after)

8. Results (continued) Hospitals with an active P&TC committees had a better improvement in prescribing for ARI and malaria than those with non-active committees Smaller increases in treatment costs observed in hospitals with active P&TC. - For malaria: prescription costs increased by 41Ksh in hospitals with active P&TC compared to Ksh 110.17 in hospitals with inactive P&TC - For ARI: treatment costs increased by 26Ksh compared to 66.74 Ksh in hospitals with inactive P&TC.

9. Results 4

12. Summary and Conclusions The educational intervention supported by P&TC activities poorly influenced the use of antibiotics in the treatment of non pneumonia ARI and malaria in the mission hospitals. The intervention did result in improving the use of generics and in controlling increases in prescription costs. Antibiotic use changed moderately, but less expensive antibiotics were being prescribed. Generic use increased in treatment of ARI and malaria Smaller increased in treatment costs observed in intervention hospitals.

13. Considerations Education program and P&TC activities with adequate support in mission hospital settings can improve prescribing for ARI and malaria in children The role of P&TC needs to be reinforced and extended in the hospital settings to promote rational prescribing of medicines for childhood illnesses Regular training of healthcare providers and P&TC activities supported by distribution of materials may yield a greater improvement in prescribing behavior. Educational programs supported by active P&TC may be more efficient in public health facilities where prescribing patterns also need improvement Government should consider the implementation of such initiatives throughout public health facilities in order to improve rational drug use in Kenya. Given the importance and the role of mission hospitals in Kenya, the Government should support those institutions in their initiatives.