Toward Improving Rational Use of Antibiotics in Peru

1. Toward Improving Rational Use of Antibiotics in Peru Kristiansson C1, Larsson M1, Thorson A1, Gotuzzo E2, Pacheco L3, Rodriguez Ferrucci H4, Reilly M1, Carvallo E4, Bartoloni A5, Bartalesi F5, Strohmeyer M5, Bechini A6, Paradisi F5, Falkenberg T1 1. IHCAR, Karolinska Institutet, Sweden 2. Inst. Med. Trop. A. von Humboldt, Universidad Peruana Cayetano Heredia, Peru. 3. Health Directorate of San Martin, Peru 4. Health Directorate of Loreto, Peru 5. UFDID, University of Florence, Italy. 6. UFDPH, University of Florence, Italy.

2. Problem statement Antibiotics are among the most commonly used types of drugs and have had a significant impact to decrease morbidity and mortality in infectious diseases. However, irrational use of antibiotics leads to resistance, treatment failure, and waste of scarce resources. Irrational prescribing of antibiotics in Peru, partly related to fulfilmentof social expectations rather than doctors’ lack of knowledge, has been described (Paredes et al, 1996). With health care systems in constant change it is important to continuously monitor the rationality of antibiotic use, in order to evaluate policy changes and provide a knowledge basis for development of new interventions.

3. Objective of study To investigate morbidity pattern, health seeking behaviour and antibiotic use among households with children aged 6 - 72 months in the urban community Yurimaguas, Alto Amazonas, Peru.

4. Methods The caregivers of 800 children aged 6–72 months were interviewed using a pre-tested validated questionnaire. The questionnaire included questions regarding the children’s episodes of illness and health seeking behaviour the previous two weeks, including details on use of antibiotics. Fifteen focus group discussions (FGDs), with 6–8 participants per group, were performed with health workers and caregivers, including mothers, fathers, and grandmothers. Issues of health seeking behaviour and concepts of health and illness were discussed.

5. Consult health care provider Self treatment No action taken Graph 1. Health seeking behaviour related to symptom clusters 1. Children’s symptoms previous two weeks, as reported by caregivers, was clustered into Diarrhoea- Dysentery and ARI-like clusters. Average number of symptoms per child: 3,6 (1-12). 250 200 Self treatment + consult hc provider 150 Number of children 100 50 0 Other Diarrhoea Upper ARI Dysentery Lower ARI Mix diarrhoea upper ARI Mix dysentery upper ARI Mix diarrhoea-lower ARI Mix dysentery lower ARI

6. Graph 2. Health seeking behaviour related to antimicrobial consumption 250 200 150 Number of children 100 70 60 50 50 40 0 30 Number of children 20 Consult Other No action taken Self treatment + Consult Health care provider Consult Nurse/Obst. 10 Consult Public doctor Exclusive Self-treatment Consult private pharmacy Consult Public pharmacy Consult Health technician 0 1. Health seeking behaviour and antibiotic consumption No Antibiotics used Antibiotics used 2. Type of health care provider combined with self treatment Antimicrobial consumption for mixed health seeking behaviour (self medication + consultation) Other Public doctor Nurse/Obst. Private doctor Health technician Public pharmacy Private pharmacy

7. Table 1. Prescriber and place of purchase of antibiotics Place of purchase of the antibiotic prescribed

8. 250 No antibiotics 200 Self treatment Other 150 Curandero Pharmacist 100 Health technician Nurse 50 Doctor 0 Diarrhoea Upper ARI Lower ARI Mix up.ARI + Dysentery Mix up.ARI + Diarrhoea Mix low.ARI + Dysentery Mix low.ARI + Diarrhoea Graph 3. Antibiotic treatment and antibiotic provider relative to symptom clusters* number of children Other Dysentery * Children’s symptoms previous two weeks, as reported by caregivers, was clustered into Diarrhoea- Dysenteryand ARI-like clusters. Average number of symptoms per child: 3,6 (1-12).

9. Results from survey • The symptoms that each child had shown the last two weeks, as reported by the caregivers, were grouped into ARI- Diarrhoea- and Dysentery-like symptom clusters. Upper ARI-like symptom cluster were the most prevalent, followed by a mix of upper ARI and diarrhoeal symptoms, (graph 1). • The majority of the caregivers (44%) of the 504 children with symptoms were exclusively treating the children at home, without advice from health professionals. For health problems resembling lower ARI and for mixes of symptoms caregivers were more prone to consult health providers, (graph 1). • The majority of antibiotics were obtained through the health care sector. Of 177 children medicated with antibiotics 71% had their antibiotics prescribed by a health care professional, 8% had consulted a pharmacist and 19% had self-medicatedwithout consulting a health care supplier, (table 1).

10. Results from survey • Children whose caregivers have consulted a health care provider are more likely to be treated with antibiotics than children that have been exclusively self medicated by their caregivers, (graph 2). • Of the children with upper ARI-like symptoms, 28% was treated with antibiotics. A higher percentage of the children with ARI-diarrhoea mixes (38% resp 46%), lower ARI (50%) and diarrhoea (44%) received antibiotics, (graph 3). • For most symptom clusters, the majority of the antibiotics were prescribed by the health care system, (graph 3) Diarrhoea being the exception, 26% of the children were self medicated with antibiotics while 16% obtained the antibiotic from the health care sector.

11. Focus Group Discussion (FGD) results • Healthseeking behaviour • Most caregivers attempt to cure their children at home and the use of traditional medicine is widespread. If the child does not improve within some days they turn to the health center. • Some caregivers seeks help at Pharmacies or buy medicine at markets before they turn to the health center, or after, if they are not satisfied with the advice of the health providers. • The traditional healer is consulted for chronic diseases or diseases like ”susto”, (”fear”), incurable by a medical doctor. • Time, economical resources and traditional beliefs effects the health seeking behaviour. Caregivers have elaborated theories on diseases and their origins and appropriate treatment.

12. Healthseeking behaviour • Many caregivers frequently seek help for their children at the health care centers as the public health insurance ” Seguro Integral de Salud - SIS”, which includes all children, makes it accessible. For the adults self-medication seems to be more widespread. • However, caregivers also express doubts about the insurance, they say that not all medicines are available and the doctors prescribe the same medicines for different diseases; what they have, not what you need. The generic antibiotics of the public health sector are said to be of lower quality. • Antibiotics • Antibiotics are perceived as strong medicines. They affects the red blood cells, and should be used with caution. Caregivers express doubts about taking the full course. • Traditional medicine is sometimes mixed with antibiotics, for example to cure some types of Diarrhoea.

13. Conclusions The survey results shows that the majority of the antibiotics are obtained from the health sector. The self medication with antibiotics is relative low but considering the symptom clusters certain problem areas can be identified (e.g. diarrhoea). The results show example of potential irrational use of antibiotics for children in Yurimaguas, e.g. short courses, over-prescribing, self medication etc. The FGD results point out that the problem of irrational use can be even more widespread among the adults.

14. Discussion The public health insurance ”Seguro Integral de Salud - SIS”, which provides all children with health care free of charge, is likely to be an important reason for the high attendance of health care institutions in Yurimaguas. The treatment guidelines and systems of monitoring included in the SIS are likely to have influenced the antibiotic prescribing practices, illustrated for example by the low prescribing of antibiotics for diarrhoea by the health care sector. Bad compliance and self medication with antibiotics seems to be a result of lack of communication between patient and health care providers as well as a result of economical constrains and traditional beliefs.

15. Recommendations Interventions aiming at rationalise the antibiotic use are recommended to address the health care sector as well as the community. As the majority of the antibiotics were obtained through the health sector, a high impact may be achieved through rational prescribing mediated by contextualized educational programs and peer-review strategiesaddressing the problems identified (Chuc et al 2002), including issues of patient/doctor communication.

16. Recommendations, continuing The impact of the intervention might be higher if the community members, being the ultimate decision makers regarding health seeking behaviour and compliance with antibiotic treatments, are addressed by the intervention as well as they are invited to the planning and implementation of it. SIS, the public health insurance, has likely had a high impact on health seeking behaviour and medication patterns. Changes of SIS, like those now being implemented as a result of economical constrains, may result in changes in health seeking behaviour, something that must be considered in intervention planning.

17. Reference list 1. Paredes P, de la Pena M, Flores-Guerra E, Diaz J, Trostle J. Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: knowledge may not be the clue. Soc Sci Med. 1996 Apr;42(8):1141-53. 2. Chuc NT, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T. Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol. 2002 Nov;55(11):1148-55.