LONG-TERM IMPACT OF AN MTP APPROACH TO REDUCE INAPPROPRIATE USE OF ANTIBIOTICS

1. LONG-TERM IMPACT OF AN MTP APPROACH TO REDUCE INAPPROPRIATE USE OF ANTIBIOTICS IN ACUTE RESPIRATORY-TRACT INFECTION Yudatiningsih I.,Sunartono H. Sleman District Health Office, Indonesia

2. ABSTRACT Problem Statement: An MTP (Monitoring-Training-Planning) approach is an innovative new way to change behavior through an adult-learning, problem-based intervention. The MTP approach includes the use of indicators to measure the magnitude of the problem (monitoring component), discussion about underlying factors and how to improve the situation (training component), and setting the improvement target (planning component). Because MTP is a self-learning activity involving all providers in health facilities, it is expected that the impact will be sustainable. Objectives: To evaluate the long-term impact of an MTP approach to reducing inappropriate antibiotic use in acute respiratory infections (ARIs). Disigns: A time-series pre and post-intervention without a control group. Twenty-four health centers were involved, and each conducted an MTP activity for antibiotic overuse in ARI in August 1999. Feedback was given in October, 2000 (14 months post-intervention), February 2002 (30 months), and May 2003 (45 months), followed by serial data collection. The percentage of patients receiving antibiotics was calculated based on 30 prescriptions/month randomly selected from each facility. Study Population: Children aged 0–14 years with ARI as a single diagnosis. Interventions: MTP and feedback. Outcome Measure: Percentage of children with ARI receiving antibiotics. Results: All facilities reported that MTP reduced inappropriate antibiotic use, from an average of 50%–20%. In month 44, data showed that the average percentage of antibiotic use was 17%, which further decreased to 13% in month 48. In parallel to the activity to reduce antibiotic use in ARI, all health centers also used the MTP approach to address other problems in medicine use, such as reducing inappropriate use of antibiotics in children with acute diarrhea, increasing the appropriateness of antibiotic use in selected cases, reducing inappropriate use of corticosteroids in children with ARI, and reducing polypharmacy. The cost to conduct MTP activities was affordable for the health centers. It was recognized from the feedback meetings that all prescribers were very optimistic and took an active role in proposing solutions. Conclusions: An MTP approach, in combination with feedback, significantly reduced the inappropriate use of antibiotics in ARI, and the impact was sustained after almost four years. With intensive discussion and self-learning activities during the process, MTP sensitized prescribers to be more proactive in promoting appropriate drug use.

3. BACKGROUND • Acute respiratory tract infection (ARI) is still a leading cause of childhood morbidity in developing countries. In Indonesia, the prevalence of ARI is about 21.4 per 1000 population, with >60 % of cases in the under-five age group. • The problem that related to ARI treatment is inappropriate antibiotics medications. Percentage of antibiotics used for ARI treatment in children achieves 68%, while pneumonia cases are only 2% of the total ARI cases.

4. EFFORTS IN IMPROVING DRUG USE PRACTICES • Inappropriate drug use practices are leading to medically ineffective, unsafe and economically inefficient use of pharmaceuticals (Santoso, 1998) • A study done in 1999 by Santoso et al.,however, showed that a MTP approach was effective in improving the rational use of antibiotics. Field test of the MTP approach were conducted in public hospital, private hospital, and health centers • MTP approach is a new innovative approach to change the behaviour by adopting adult-learning problem based approach. It includes the use ofindicator to measure the magnitude of the problem (Monitoring component), discussion on underlying factors and how to improve the situation (Training component) and setting the target of improvement (Planning component) • The research experience in Gunung Kidul showed that the continuity of the self-monitoring process was guaranteed by a regular feedback (Sunartono and Darminto, 1995) • Various interventions have been conducted in Sleman, including MTP and small group discussions. Are the interventions impact as expected? Are the intervention impacts suistainable?

5. OBJECTIVE To evaluate the long-term impact of MTP approach in reducing inappropriate antibiotic use in acute respiratory tract infections (ARIs)

6. METHODS • Design: retrospective, descriptive-analytical • Time-series data collection on prescribing practices • Involving 24 HCs in Sleman District, Yogyakarta, Indonesia

7. DESCRIPTION OF ACTIVITIES 1999-2003 • MTP activity involved all prescribers in 24 HCs, consisted of doctors, nurses, and midwives. Each HC conducted MTP activity in August to October,1999. • 24 health centers (HCs) were involved, each underwent MTP activity in Aug-Oct, 1999. The MTP approach was carried out by each HC and a HC doctor as the MTP team leader • Feedbacks were given in 3 occasions, ie,in October 2000(month 14), February 2002 (month 30), and April 2003 (month 45), each followed by serial data collection by health office staff • The feedbacks were carried out by district health office staff, by showing the results of data collections at pre-MTP, post-MTP and pre-feedback to feedbacks • The feedbacks were conducted in district health office, and each lasted in 2 hours

8. TIME-LINE OF ACTIVITIES MTP 24 HCs Feedback in month 14 Feedback in month 30 Feedback in month 45 pre post pre post pre post pre post Aug’99 Oct’00 Feb’02 April ‘03 1999 2001 2002 2003 2000

9. DATA COLLECTION • % patients receiving antibiotics for ARI treatment (0 - 14 years old) was calculated based on 30 randomly selected prescriptions per month at each HC • This prescribing surve covered the period 1 months before and during MTP period, 6 months before and after feedback in month 14 (Apr 2000 – Apr 2001), 3 months before and after the feedback in month 30 (Nov 2001 - May 2002), and 3 month before and after the feedback in month 45 (Jan-Jul, 2003) • Data were collected by staff from the district health office who had been trained in data collection methods as recommended by WHO.

10. RESULTS: ANTIBIOTIC USE • 24 HCs reported that MTP reduced inappropriate antibiotic use in ARI treatment, from an average of 50% to 20% • In month 13, data on antibiotics use tended to increase (from 20% to 35%). However, compared to the MTP results, the pre-feedback data on antibiotics use tended to increase, although did not achieve the level of significance (p>0.05). This means that the impact of MTP still exist after a long period of time. • In month 14, data showed that the average % antibiotics was further decreased to 26%.

11. MTP at 24 HCs Feedback in month-14 Feedback in month-30 Feedback in month-45 ANTIBIOTICS USE OVERTIME % patient receiving antibiotics

12. DISCUSSIONS • In month 44, data showed that the average % antibiotics was 17%, and further decreasing to 13% in month 48. This means that the feedback is shown by the study to be effective in reducing the use of ABs in the ARI treatment. • In parallel to the activity to reduce AB use in ARI, all HCs have also been conducted MTP approach to address other problems in medicine use e.g.,reducing inappropriate use of AB in children with acute diarrhoea, increasing the appropriateness of AB use in selected cases, reducing inappropriate use of corticosteroids in children with ARI, reducing polypharmacy, etc. Moreover, cost to conduct MTP activities was affordable to each HC • It was recognised from the feedback meeting, that all prescribers were very positive and took an active role in proposing solutions

13. CONCLUSIONS • MTP approach, enforced by feedback, significantly reduced the inappropriate use of antibiotics in acute respiratory tract infection • 4 years after its implementation, MTP activities are still going on in health centers. In fact, MTP has been used by HC not only for ARI, but also for addressing other drug use problems • Because the MTP approach is effective, easy to implement, less costly, and promotes capacity building in HCs, it currently becomes an integral part of the district stategies to improve the quality of health services