Yudatiningsih I. 1 ,Sunartono H. 1 ,SuryawatiS. 2 1 Sleman District Health Office,

1. THE IMPORTANCE OF FEEDBACK TO ENHANCE THE IMPACT OF EFFECTIVE INTERVENTIONS TO REDUCE ANTIBIOTICS IN ACUTE RESPIRATORY-TRACT INFECTION Yudatiningsih I.1,Sunartono H.1,SuryawatiS.2 1Sleman District Health Office, 2 Center for Clinical Pharmacology and Drug Policy Studies, Gadjah Mada University, Yogyakarta, Indonesia

2. ABSTRACT Problem Statement: To gain a maximum impact, efforts to improve rational use of medicine should be continuously conducted, especially at the primary health service level. The Sleman District Health Office conducted a managerial intervention using Monitoring-Training-Planning (MTP)strategy at 31 health centers (HCs) in 1999. The MTP activity reduced antibiotic use for acute respiratory infection (ARI) from 50% to 20%. One year after MTP, antibiotic use was measured again, and the result showed that it varied among HCs from 12% to 53%. This finding indicated that the antibiotic use after MTP could increase again, and therefore enforcement efforts should be conducted. References indicated that feedback is effective in enforcing the impact of interventions Objectives: To evaluate whether feedback could maintain the effect of MTP in reducing the use of antibiotics. Design: Randomized controlled study with parallel design . Setting and Populations: Twelve of 25 HCs were randomly selected to participate in the study. They were randomly assigned into two groups: the test group (6 HCs) received feedback and the control group (6HCs) did not receive feedback. Data collection was conducted at 6 month before and 6-month after the feedback sessions. Intervention: Feedback was carried out by district health office staff in a single 2-hour meeting at the district health office, including the presentation of pre-MTP, post-MTP and pre-feedback data. Participants in the feedback meeting consisted of doctors, nurses, and midwives from 6 HCs. Outcome Measures: % antibiotics given and average number of drugs per encounter for ARI treatment in children 0-14 years old. Results: Compared with the MTP results, the pre-feedback data on antibiotic use showed an increase, although it did not achieve the level o significance (p>0.05). After feedback, the test group showed a significant decrease in % antibiotics given (from 34% to 11% ) and the average number of drugs per encounter (from 3.5 to 3.2), while the control group showed a significant increase in % antibiotics (from 35% to 40%) and average number of drugs per encounter (from 3.6 to 3.7). This means that MTP has a lasting impact, but the feedback enhanced the impact significantly. Conclusions: Feedback enhances the impact of even an effective intervention such as MTP.

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. BACKGROUND (Con’t) • In 1999, Sleman district health office conducted a managerial intervention using Monitoring-Training-Planning (MTP) strategy to improve use of medicine at 31 HCs • The MTP activity reduced the antibiotics use for ARI from 50% to 20%. • One year after MTP, the antibiotics use was re-evaluated. The result showed that it varied among HCs, from 12% to 53% • This finding indicated that the antibiotics use after MTP increased, therefore enforcement should be conducted. Previous studies suggested that feedback is effective to enforce the impact of interventions

5. OBJECTIVES To evaluate whether a feedback could maintain the effect of MTP (Monitoring - Training - Planning) in reducing the use of antibiotics

6. DESIGN AND SAMPLE SELECTION • Design: randomised control study with parallel design • It involved 12 HCs in Sleman district, Yogyakarta, Indonesia • Prescribers included physicians, nurses and midwife per HC • 12 of 25 HCs underwent MTP were randomly selected to participate in the study • 12 HCs were randomly assigned into 2 groups: the test group (6 HCs) received feedback and the control group (6HCs) did not receive feedback • Data collections were conducted for 6 month before and 6 month after feedback

7. FEEDBACK INTERVENTION • The feedback was carried out in October, 2000. The prescribers consist of 1 doctor, 1 nurses, and 1 midwife in each health centers (test group) were involved in the study. They were invited to feedback meeting in health office of Sleman district • The feedback was conducted one time only for the test group, and lasted in 2 hours. The meeting were conducted in the formal setting in district health office • In this study, the feedback was carried out by district health office staff to show them the data collections displayed their pre-MTP, post-MTP and pre-feedback performances

8. THE RESEARCH ACTIVITY This Study Feedback pre post 6 5 4 3 2 1 1 2 3 4 5 6 6 Test Group 25 HCs 12 HCs Analysis 6 Control Group Underwent MTP May Jun Jul Aug Sep Okt Nop Des Jan Feb Mrt Apr 1999 2000 2001

9. ANALYSIS • The percentage patients receiving antibiotics and average number of drug per encounter for ARI treatment in children 0 - 14 years old were calculated based on 100 randomly selected prescriptions/ month at each HC • This survey covered the period of 6 months before the feedback (April - September, 2000) and 6 months after the feedback (November, 2000 - April, 2001). Data were collected by staff from the district health office who had been trained in methods recommended by WHO • The pre-post change of the study outcomes was then computed, and Student’s t-test were applied to test the difference between the average change in the test group and the control group

10. RESULTS • The study and control groups were similar during the baseline period in rate of antibiotics use (34% of patients in the test group vs. 35% among control), and in the number of drugs prescribed per patient encounter 3.5 vs 3.6. Non of these differences was statistically significant • Compare 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 MTP has a long –term impact • After feedback, the test group showed a significant decrease of antibiotic use (from 34% to 11%) and the average number of drug per encounter (from 3.5 to 3.2), while the control group showed significant increases in antibiotic use (from 35% to 40%) and average number of drug per encounter (from 3.6 to 3.7). This means that the feedback is effective in further reducing the use of ABs in the ARI treatment.

11. ANTIBIOTIC USE IN ARI TREATMENT % of patient receiving antibiotics This Study Control Group Underwent MTP Test Group Feedback

12. THE NUMBER OF DRUGS PRESCRIBED PER PATIENT No. of drugs prescribed per patient of ARI This Study Control Group Underwent MTP Test Group Feedback

13. CONCLUSIONS • Feedback is proven effective to strengthen an intervention to reduce the use of antibiotics in health centers • Feedback enhances the impact of even an effective intervention such as MTP