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Essential Medicines and Policy Department  (EDM)

International Conferences on Improving Use of Medicines (ICIUM)

Intervention trial to decrease unjustified use of pharmaceutical drugs in the treatment of childhood diarrhea, Lima, Peru

Paredes P, Yeager BAC, Montalvo J, Arana A

Instituto de Investigacion Nutricional and Universidad de Lima, Peru

 

 

Objective: A community-based intervention was implemented to address the unjustified use of pharmaceutical drugs in the treatment of acute, watery diarrhea in a peri-urban community of Lima, Peru.

Design: The intervention design was based on previous ethnographic research on the factors that influence treatment decisions at the household level and at the health facility level. The intended audiences were caretakers, physicians and the community overall. Mass media and interpersonal communication were combined and educational and persuasive strategies used. The main media for caretakers were interactive video sessions in community organizations, and a mock medicine box with recommendations of the campaign distributed after the sessions. Approximately 3,000 women caretakers and 1830 school children attended the video sessions. Distribution of explanatory pamphlets and broadcast of audio messages in market places were used to reach both caretakers and other members of the community. A diffusion effect of the campaign was also expected for the rest of the community members.

Physicians' intervention strategies aimed to increase physicians' awareness of the potential decrease of peoples' expectations for drug prescriptions, as a result of the intervention, and thus decrease unnecessary prescriptions. A project physician made weekly face-to-face visits to doctors, distributing booklets with scientific information about diarrhea case management. The personal visits and discussions in conjunction with distributing the materials were aimed at promoting their reading and reinforcing physicians' knowledge. Nutritional management was promoted as the alternative treatment to drugs for all audiences. The use of detailed food recipes aimed to promote its adoption by both caretakers and physicians.

Outcome Measures: The impact of the intervention was assessed through before-after cross sectional household surveys in the intervened community and in a comparison community. Data collected referred to the actual treatment provided for all diarrhea cases starting in the previous 15 days. Knowledge and attitudes toward drugs for diarrhea were also measured in caretakers and other community members.

Results: Comparison of pre-post intervention data in the intervened community showed a significant decrease in the overall use of drugs for diarrhea, and in the proportion of cases receiving a prescription when seen by a physician. The comparison community also showed a significant decrease in both indicators, but the changes in drug use were greater in the intervened community. The results suggest that the intervention was successful in changing behavior, even though final evaluation included data of treatment provided by new non-intervened physicians who replaced those who participated in the intervention at the local health facilities.

 

Justification

blueball.gif (959 bytes) Widespread use of antidiarrheoals and antimicrobials in the treatment of simple, watery cases of diarrhea.

blueball.gif (959 bytes) Increased resistance of microorganisms.

blueball.gif (959 bytes) Diverts attention of caretakers from adequate fluid replacement or seeking help outside the home.

blueball.gif (959 bytes) Deleterious effects of antidiarrheoals.

blueball.gif (959 bytes) Economic burden for poor population.

blueball.gif (959 bytes) Limitations of policy measures.

blueball.gif (959 bytes) Previous interventions with no behavioral measures or limited impact.

 

Background information

At community level:

Culturally determined beliefs about diarrhea causes and treatments.

blueball.gif (959 bytes) drugs acceptable (but not exclusive) for certain episodes

blueball.gif (959 bytes) the desire for a prompt resolution based on fear of consequences for the child and for caretakers' daily activities

blueball.gif (959 bytes) beliefs and perceptions are shared by other members of the community

support the use of drugs as a good alternative

support perceived image of a "good mother"

support perceived image of a "good doctor"

At medical practice:

blueball.gif (959 bytes) Physicians' knowledge of case management consistent with MOH norms

But, physicians are aware of:

blueball.gif (959 bytes) socially desirable drug treatment to "cure" diarrhea fast, and

blueball.gif (959 bytes) children are brought to consultation, because other attempts have failed

Also:

blueball.gif (959 bytes) physicians' treatment decisions influenced by their experience (or the experience of colleagues) in their training or practice setting.

blueball.gif (959 bytes) the prevailing attitude among physicians "although drugs may not be necessary, they rarely complicate cases

Dilemma:

blueball.gif (959 bytes) follow scientific guidelines - but at the risk of losing patients’ confidence in their treatment and thus prestige

blueball.gif (959 bytes) or satisfy caretakers’ expectations, thus promoting their compliance for other recommendations - but at the cost of unnecessary drug use.

 

Objective

To test the effectiveness of an aggressive, community-based intervention in decreasing the use of drugs for the treatment of uncomplicated, acute cases of watery diarrhea in children under five years old.

Theoretical framework

Ecological perspective:

    Integration of cognitive, social expectation and behaviorist models

    Incorporates the role of social and cultural factors influencing behavior.

"drug treatment is the result of a complex interaction of individual and social processes and reinforcements about the disease, its cultural interpretation, its biological characteristics, and the evaluations of treatment outcomes."

So:

    Multiple levels of intervention

    Multiple levels of interactions and information exchange (individual, family, social network, institutions, organizations)

    Multiple levels of analysis

 

Intervention strategies

Community based Involved leaders, and used existing organizations and institutions as channels
Education-Information-Communication Integration of mass media and interpersonal communication
Audience segmentation Caretakers

Other community members

Physicians in health facilities

Social marketing Persuasive, motivational strategies to promote adequate treatment through simple messages
Culturally appropriate Messages consistent with cultural beliefs

The campaign was launched under the logo:

"Tratamiento TAL

        Tiempo

Alimentacion

                Liquidos

Cura el Estomago Flojo o Diarrea sin Usar Remedios"

(Treatment TAL: Time, Feeding and Fluids- cures estomago flojo or diarrhea without using remedies)

 

Communication strategies

Materials

Intended audience

Channels

Purpose

Interactive Video

Caretakers of children < 5

Community organizations

Education, motivation Facilitate communication

     

Improve attention, retention and understanding of messages

Self-identification

Affective arousal

Cues for action

Promote I-P communication

Mock medicine box of recipes

Same

Same

Promotional

Audio messages

Caretakers & market places general public

Promotional

Cues for action

Enable use

Pamphlets

Caretakers & Market places

Education/ information

general public

As a reminder to audience exposed to video

For physicians

Materials

Channels

Purpose

Booklets

Weekly face-to-face visits

To increase physicians scientific knowledge

Prescription pad

same

Promote adequate process of diagnosis and treatment

Video and printed

Institutional meeting

Increase awareness of potential change of community expectations

 

Weekly visits

Interpersonal communication and stimulate reading of materials

 

Evaluation Design

KAP survey + interviews at health facilities

Intervention Period & Monitoring

Final KAP survey + interviews at health facilities

 

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Intervention---------------------

X X X X

-----------------OOOOOO

Comparison----------------------------------------OOOOOO

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KAP survey + Interviews at health facilities

Final KAP survey + interviews at health facilities

 

Results

  Intervention community Comparison community
Change in drug use arrow.gif (877 bytes)9.8 %** arrow.gif (877 bytes)6.8% *
Relative change arrow.gif (877 bytes)22.74% arrow.gif (877 bytes)13.96%
Change in physician’s Rx arrow.gif (877 bytes) 9.7 %** arrow.gif (877 bytes)0.44%
Relative change arrow.gif (877 bytes)10.23% arrow.gif (877 bytes)0.8%

Change in knowledge about drug use for diarrhoea

Caretakers (sick child) arrowup.gif (873 bytes)21.2%*** arrowup.gif (873 bytes) 16.7%**
Caretakers (healthy child) arrowup.gif (873 bytes)21.6%*** arrowup.gif (873 bytes) 13.4%***
Adults arrowup.gif (873 bytes)21.1%*** arrowup.gif (873 bytes) 11.5%***

Change in attitudes toward drug use for diarrhoea

Caretakers (sick child) arrowup.gif (873 bytes)23.9%*** arrowup.gif (873 bytes)4.5%
Caretakers (healthy child) arrowup.gif (873 bytes)20.7%*** arrowup.gif (873 bytes)7.7%
Adults arrowup.gif (873 bytes)15.0%*** arrowup.gif (873 bytes)3.3%

* p< 0.05

** p< 0.01

*** p< 0.001

Model of factors explaining drug use at baseline in the intervention community

Variables Log likelihood Significance
Caretaker's knowledge (drugs) -206.27 .0094
Caretaker's attitude to drugs -207.61 .0022
Duration of episode -207.02 .0041
Vomiting -206.44 .0079
Medical visit -205.58 .0207
Drug received by prescription -212.14 .0000
Score of severity -205.14 .0342

Model of factors explaining drug use after the intervention

Variables Log likelihood Significance
Caretaker's knowledge -186.58 .0000
Caretaker's attitude to drugs -175.62 .0429
Knowledge of adults in cluster -175.55 .0467
Frequency of loose stools -184.69 .0000
Fever -190.95 .0000
Drug received by prescription -209.57 .0000

Model of factors explaining drug use at baseline in comparison community

Variables Log likelihood Significance
Caretaker's knowledge of drugs -265.226 .0006
Fever -266.666 .0001
Age of the child in months -265.023 .0007
Drug received by prescription -312.900 .0000
Score of severity -270.986 .0000

Model of factors explaining drug use at final time in comparison community

Variables Log likelihood Significance
Caretaker's attitude to drugs -143.050 .0000
Age of caretaker -136.159 .0038
Blood in stools -134.213 .0346
Score of severity -150.546 .0000
Drug received by prescription -137.527 .0009

 

Conclusions

Results suggest that the intervention was successful in decreasing the use of drugs at home and prescriptions. Changes observed in the comparison community can be explained by a nutritional intervention at community kitchens in this area.

Reduction in cases attending health facilities in both communities may be explained by seasonality which, although not affecting incidence, influences severity of episodes. Evaluation of the impact of the intervention on prescribing by individual physicians was limited by high mobility and reduction of cases visiting health facilities. High turnover and variable time schedules are persistent problems in assessing the effectiveness of training and quality of care in health centers.

The decrease in prescriptions in the comparison community may be due to physicians' awareness of our presence in the area. Also, diffusion of the intervention to the comparison community cannot be ruled out. This may be an example of the "competing response", that is improvement of performances in non-intervened groups, in an attempt to show that they are as efficient as those intervened, seen in other settings.

One limitation in the interpretation of these results is the lack of data about the economic variables associated with drug use. Drug prices were not collected before or after the intervention, nor were the consumer price index or wages. These factors could explain the decline in drug use in both communities, but not the changes in knowledge and attitudes observed in the intervention community.

The promoted treatment (continue feeding) did not show significant change, although knowledge and attitudes about this topic did show improvement. A possible explanation is that people's definitions and perceptions about the continued feeding changed due to the educational intervention. Thus, answers to the final survey are guided by different definitions and do not necessarily reflect an objective comparison.

Due to budget constraints the evaluation occurred immediately after the completion of the intervention. Some authors recognize that changes do not occur so fast, rather the adoption of the promoted behavior depends on the stage of change in which the different audiences are at the moment of the intervention. The effect of the positive reinforcement created by the first trials of adoption of the behavior can not be measured at such an early stage. The data collected for the final evaluation therefore, may reflect only the change of early adopters of the behavior and not the full potential for behavior change promoted by the intervention.

Results show the importance of considering an integral approach when designing health interventions, especially when behaviors depend on strongly rooted cultural perceptions. The use of culturally appropriate information and theory-driven communication techniques, the involvement of local organizations, and the recognition that individuals are not isolated entities but their decisions affect, and are affected by, other dimensions of their environment, may have been the key to success. Understanding how the hypotheses guiding the design were involved in producing the expected changes, is relevant for academic purposes (to understand the processes and effects of communications), and also may be useful for local MOH authorities, public health officials and international and local agencies in their effort to improve diarrhea case management.

 

Characteristics of drug treatment

Type of drugs received by sick children in Intervention community at baseline and after the intervention

Type of drug

 Baseline (n=420)

 Final

(n =442)

 Difference Post-Pre1

 P-value

 

Any drug

 

43.1

 

33.3

 

- 9.8

 

.00294

 

Antibiotics

 

25.5

 

17.9

 

- 7.6

 

.00668

 

Antibiotics (CDD)

 

13.3

 

9.5

 

- 3.8

 

.07654

 

Other Antibiotics

 

14.3

 

9.0

 

- 4.3

 

.01642

 

Antidiarrheoals

 

7.6

 

9.7

 

+ 2.1

 

.27205

1 Pre-intervention values subtracted from post-intervention values

Type of drugs received by sick children in comparison community at baseline and after the intervention

Type of drug

Baseline (n=519)

 Final

(n=453)

 Difference Post-Pre1

 P -value

 

Any drug

 

48.7

 

41.9

 

- 6.8

 

.03359

 

Antibiotics

 

29.3

 

21.4

 

- 7.9

 

.00502

 

Antibiotics (CDD)

 

17.1

 

13.7

 

- 3.4

 

.13720

 

Other antibiotics

 

14.6

 

8.2

 

- 6.4

 

.00168

 

Antidiarrheoals

 

10.4

 

10.6

 

+ .2

 

.92262

1 Pre-intervention values subtracted from post-intervention values

Comparison between communities of type of drugs received at baseline and after the intervention

Type of drug

 Difference I-C baseline

 P-value

 Difference I-C final

 P-value

 Any drug

 - 5.6

 .08411

 - 8.6

 .00734

 Antibiotics

 - 3.8

 .19389

 - 3.5

 .18287

 Antibiotics (CDD)

 + 3.8

 .10771

 - 4.2

 .05083

 Other Antibiotics

 - 0.3

 .87689

 + 0.8

 .63803

Antidiarrheoals

 - 2.8

 .14118

 - 0.9

 .66767

 

  Intervention community Comparison community
Adequate feeding practice arrow.gif (877 bytes)5.6%** arrowup.gif (873 bytes)3.1%**
Seeking medical attention arrow.gif (877 bytes)5.6%* arrow.gif (877 bytes)6.5%**
Antibiotic use arrow.gif (877 bytes)7.6%** arrow.gif (877 bytes)7.9%**
Antibiotic not in CDD guides arrow.gif (877 bytes)4.3%* arrow.gif (877 bytes)6.4%**
Drug use (any community member except physician)