2. A FORMATIVE STUDY TO DESIGN AN INTERVENTION INVOLVING MOTHERS, DRUGS VENDORS AND HEALTH WORKERS IN A SELF-PROCESS OF BEHAVIORAL CHANGE FOR RATIONAL DRUG USE IN ARI TREATMENT PH Dung, NTK Kim Chuc and Dennis Ross Degan Funding by ARCH (Boston University)

3. ABSTRACT A FORMATIVE STUDY TO DESIGN AN INTERVENTION INVOLVING MOTHERS, DRUGS VENDORS AND HEALTH WORKERS IN A SELF-PROCESS OF BEHAVIORAL CHANGE FOR RATIONAL DRUG USE IN ARI TREATMENT Pham Huy Dung, Nguyen Thi Kim Chuc, Dennis Ross Degan et al. Institute for Health and Development, Vietnam Problem statement: The treatment of ARI, particularly the use of antibiotics in the treatment of ARI, was observed to be irrational at community level. According to some previous studies, antibiotics were used in 71.4% of non-pneumonia (acute naso-pharyngitis) cases. Objectives: This formative study aims at formulating an intervention for improving rational treatment of ARI at community level by (1) redefining the problem, (2) by identifying target groups for intervention, (3) by developing methods for measuring behavior, (4) by determining factors influencing behavior and (5) by defining key actors to make change in the intervention Design: Collection of qualitative and quantitative information from mothers of children under-5, drug vendors and physicians for the development of the intervention Setting and Population: Quantitative and qualitative data have been collected from the study of 4 communes in 2 districts Ba Vi and Dan Phuong of Ha Tay province Results: (1) Redefining the problem: about 80%-90% of mothers bought antibiotics without prescriptions at drug vendors. Many of those, who bought antibiotics with prescriptions, did not use antibiotics in compliance with prescriptions. Many mothers like to use unnecessary drugs (corticoids, vitamins, etc.). Drug vendors used to sell drugs on request of mothers without giving advice. Health workers used to prescribe drugs including antibiotics not in compliance with guidelines provided by the National ARI project for ARI treatment (2) Identifying target groups for intervention: all three actors to include mothers with children under-5, drugs vendors and physicians were identified to be target groups for intervention (3) Developing methods for measuring behavior: simulated clients, interview of exit patients, analysis of medical prescription encounters, checklist to evaluate providers' behavior, etc. were developed for measuring behavior (4) Determining factors influencing behavior: interactions between mothers, physicians and drug vendors as well as interactions among their peers were determined to be factors influencing their behavior (5) Defining key actors to make change: motivated women were defined to be key actors Conclusions: An intervention package was formulated to include a guideline for mothers, drug vendors and physicians in the treatment of ARI at community level based on interactions between them and among their peers. Improvement would be measured by behavioral changes of target groups. Key actors to make change would be motivated women working with an educational toolkit to be designed accordingly Study funded by: ARCH (Center for International Health, Boston University School of Public Health) and MSH

4. BACKGROUND & SETTING  Irrational management of ARI cases/ irrational of antibiotic in the treatment of ARI: -about 80%-90% of mothers bought antibiotics without prescriptions, -71.2% of prescribed encounters for naso-pharyngitis cases had some antibiotics, - many mothers did not use antibiotics in compliance with prescriptions for their ARI sick children -> Such situation requires some intervention for more appropriate management of ARI cases and more rational use of drugs in ARI treatment.  Four of the 48 communes in 2 districts, 2 communes in each district (Ba Vi and Dan Phuong), which had been chosen to be the site for the intervention, were selected randomly to be the site for the formative study. Commune Dan Phuong and commune Tho Xuan were chosen from Dan Phuong district. Commune Phong Van and commune Phu Chau were chosen from Ba Vi district

5. STUDY AIMS This study has To describe current behavior of key actors in community drug use for ARI treatment To identify problems of ARI treatment at community level related to behavior of key actors To identify factors influencing on the behavior of key actors To design intervention measures to change such behavior in order to improve rational drug use in ARI treatment at community level To identify motivated persons to keep running the intervention

6. METHODS I: QUANTITATIVE Interview was conducted in all 4 chosen communes with the participation of  231 women  15 drug vendors  25 health workers providing medical prescriptions

7. METHODS 2: QUALITATIVE Twelve focus groups were implemented, 3 in each commune:  One with the participation of mothers  One with the participation of drug vendors  One with the participation of health workers  About 435 medical prescription encounters were collected for analysis

8. RESULTS1: INTERVIEW MOTHERS  84% of interviewed mothers had heard about acute respiratory infections (Information that mothers received came mainly from TIVI and radio channels, health workers and drug vendors)  More than half of interviewed mothers stated that cough, fever and dyspnea are symptoms of ARI, and more than half stated that they have to bring their children for consultations when they have severe symptoms of ARI  35.9% of mothers stated that they use antibiotics for their children when they have only cough and cold  6% of mothers stated that they did not have a medical consultation for their children who have pneumonia

9. RESULTS 2: INTERVIEW HEALTH WORKERS  40.7% stated that they had attended to some courses for the training on ARI of more than 3 days a course  74.1% stated that they were aware that Vietnam had national guidelines for the treatment of ARI  52% stated that guidelines are very necessary  two tiers to three quarter stated that they would refer the child to higher care level when the child has dyspnea, lethargy and feeding refusal  One third of interviewed health workers stated that they would use antibiotics for chronic otitis  Almost half stated that they would not use antibiotic for streptococcal pharyngitis; 15% did not state that pneumonia is in the ARI group; 35% did not state that upper respiratory infections are in the ARI group  Some of them stated that they should refer pneumonia and severe pneumonia to higher care level

10. RESULTS 3: INTERVIEW DRUG VENDORS  60% stated that frequent drugs on sell for ARI patients were antibiotics; 66.7% stated that these are traditional antitussic or any anti cough medicine; 53.3% stated that these are vitamins · 40% stated that they gave advices to their clients on how to use medicines; 47% stated that they gave advices to their clients about sides effects of medicines; 20% stated that they gave advices to their clients about symptoms of severe pneumonia for their clients to take into consideration of the matter; 20% stated that they gave advices to their clients to go for medical consultations for medical prescriptions · 73.3% stated that it is very necessary to have medical prescriptions for the purchase of antibiotics; 20% stated that it is necessary; and 6.7% stated that it is not necessary (6.7%)

11. RESULTS 4: FOCUS GROUPS  Focus groups of mothers  Wrong ARI case management home  Having information on ARI from other women, health workers and drug vendors  Focus groups of health workers  Wrong decisions in antibiotic use and referral for ARI cases  Having information from guidelines  Focus groups of drug vendors  Wrong management of cases without medical prescriptions  Having information from drug companies

12. RESULTS 5: INTERVENTION DESIGN  Mothers  Motivated women  Health workers  Guidelines  Drug vendors  Regulation  All three actors  Information/ interactive action

13. SUMMARY This formative study has described current behavior of mothers, health workers and drug vendors in community drug use for ARI treatment. From this description, the study has identified problems to be solved for improving rational community drug use. Problems were that mothers did not have right decisions when they could keep their children with ARI home using home remedies or OTC drugs, when they should bring them for medical consultations and when they should bring them for emergency care in hospitals; that health workers did not have rational prescriptions for children with ARI when they could only give them OTC drugs, when they should give them antibiotics and when they should refer them to hospitals; and that drug vendors did not have appropriate case management of their clients with ARI when they could sell drugs to them when they should not but only giving them advices The intervention could be developed on consideration of influencing factors on behavior of target groups (mothers, health workers and drug vendors) to include the sources of information they used to receive and their knowledge about ARI and the management of ARI cases.

14. CONCLUSION AND POLICY IMPLICATIONS  Three key actors in community rational use for the treatment of ARI did not have high rate of right decisions on when to do what for an ARI case  The formative study could provide information for the design of interventions to decisions of these key actors  Combined intervention measures targeting at many actors (mothers, health workers and drug vendors) require an integrated management at operational level