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

ABSTRACT  Problem Statement: Acute respiratory infection (ARI) is the leading cause of morbidity and mortality of children under five years old in Indonesia, despite the availability of standard treatment guidelines (STGs) and a flow chart of diagnosis and treatment of ARI in health centers in Indonesia. Previous studies showed that treatment of ARI at the health center level did not always comply with the STGs, as indicated by the use of nonstandard drugs such as antibiotics, antihistamines, corticosteroids, and phenobarbital.  Objective: To reduce the use of nonstandard drugs for under-five ARI patients.  Design: Randomized controlled study.  Setting and Study Population: Twelve health centers from two districts were randomly assigned to receive the intervention (Group A), and another 12 from these districts acted as controls (Group B).  Interventions: A two-hour small group discussion (SGD) on the ARI STGs was conducted in each health center in Group A, facilitated by a senior paramedic who was trained by the study team to facilitate such a discussion. Agreement on how to treat ARI in each health center was reached in this discussion. Self- assessment discussions (SA1 after one month and SA2 after two months) were conducted at each health center to discuss the results of prescribing in the previous month and problems faced by paramedics in treating ARI. A feedback seminar (FBS) in which the results of the study were presented to both groups was conducted four months after SA2. Prescribing surveys were conducted at baseline, post-SGD, post- SA1, post-SA2, four months post-SA2, and monthly for three months post-FBS. Thirty prescriptions with ARI as a single diagnosis were collected from each health center each month.  Outcome Measures: Average number of drugs prescribed/encounter, percentage with an antibiotic prescribed, percentage with an antihistamine prescribed, percentage with a corticosteroid prescribed, and average drug cost/encounter.  Results: Comparing baseline to four months post-SA2, the average number of drugs prescribed/encounter decreased from 4.0 to 3.1 in Group A and increased slightly in Group B (3.8–4.0). Group A had a 41% drop in percentage receiving antibiotics (from 63–22%) compared to no change (stable at 67%) in Group B. Antihistamine use was reduced by 56% (79–23%) compared to 9% (75–64%), and corticosteroid use fell by 15% (21–6%) in Group A compared to a 2% increase (22–24%) in Group B. Average drug cost was reduced by 373 rupiahs (1,123 to 750) in Group A compared to 145 rupiahs (1,296 to 1,151) in Group B. Following the FBS, there were significant improvements in all outcomes in Group B of about one-third to one-half the levels observed in Group A during the intervention.  Conclusions: Small group interactive seminars conducted by senior paramedics followed by two self- assessment meetings are effective in reducing the use of nonstandard drugs for under-five ARI patients by health center paramedics. Providing feedback after an intervention can result in significant improvements in practices in the control group.

 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.  Efforts have been done to reduce antibiotics in ARI, but the use of nonstandard drugs was still practiced.  Innovative Strategies are needed to improve adherence to ARI treatment guidelines in health centers. BACKGROUND

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

METHODS (1) Location: Bantul and Magelang Districts, Indonesia Target Intervention: Health center paramedics Design: Randomized pre-post study 24 HCs were randomly assigned: 12 HCs to underwent series of intervention (SGD-SA1-SA2) 12 HCs acted as control

Methods(2): STUDY DESIGN: Randomized Pre – Post Study Small Group Discussion PRE INTERVENTIO N Post SGD Post SA1 Post SA2 Feedback Seminar (FBS) POST FBS Prescribing survey: FGD Self Assessment-1 POST INTERVENTIO N FGD 24 HCs in 2 districts Randomization 12 HCs underwent series of intervention 12 HCs acted as control Number of sample: 30 prescriptions per HC X 12 time points X 24 Hcs = 8640 prescriptions Self Assessment-2

OUTCOME MEASURES  Prescribing survey was conducted before the intervention (3 months), Post SGD, Post SA1, Post SA 2, and 4 months after SA2, 1 after FBS, 2 months after FBS, and 3 months after FBS  Number of sample: 30 prescriptions per HC per month  Total amount of sample: 8640 prescriptions Outcome measures  Percentage of ARI patient receiving antibiotics  Percentage of ARI patient receiving corticosteroids  Percentage of ARI patient receiving antihistamines  Percentage of ARI patient receiving phenobarbitals  Average cost of drugs per encounter in rupiah  Average number of drug per encounter Data CollectionMethods(3):

INTERVENTION SGDSA1SA2FBS Duration, time, and place 2-hour interactive discussion, conducted in each HC in group A 2-hour interactive discussion, conducted in each HC in group A, one month after SGD 2-hour interactive discussion, conducted in each HC in group A, one month after SA1 Half day interactive seminar, 6 months after SA2 Participants8-12 HC paramedics 1 paramedics and 1 doctor each HC, from 24 study HCs. Total: 48 participants FacilitatorParamedic Speaker: researchers, and Hcs with best and worst performance Resource Person HC doctor Experts in ARI and Clinical Pharmacology MaterialFlow chart and STG of ARI, booklet prepared by reseachers on how to treat ARI in HCs, result of FGD and baseline prescribing survey Result of prescribing survey: baseline and 1 month post SGD Result of prescribing survey: baseline, 1 month post SGD, 1 month post SA2, and result from other HCs Result of prescribing survey from all study Hcs at baseline, 1 month post SGD, 1 month post SA2, and 4 month Post SA2 Focus of discussion STG and evidences on its trustworthiness Problems faced in implementing SGD Problems faced in implementing SGD, comparison of performance with other HCs Sharing experience and knowledge on implementing STG of ARI Methods(4):

REDUCTION OF ANTIBIOTICS & ANTIHISTAMINE Result(1):  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)

REDUCTION OF CORTICOSTEROIDS & PHENOBARBITAL Result (2):  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)

AVERAGE DRUG COST AND POLYPHARMACY Result (3):  Marked reduction at drug cost per encounter (>30% reduction) is also shown by Paramedics underwent series of intervention.  Average number of drugs per encounter reduced from 4.1 to 3.0, meaning that on average, one drug disappeared from the prescription.

DISCUSSIONS  Small Group Discussion followed by Self Assessment discussion have been proven effective in improving prescribing practices for ARI patients in HCs.  The opportunities for paramedic to actively share their opinion and experience in the discussion, and the strength of the agreement achieved at the end of discussion are the factors of success to the improvement achieved.  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).

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.  T0 maintain the impact of intervention in long term period, reinforcements are needed.