Community intervention to promote rational treatment of acute respiratory infection in rural Nepal.

OBJECTIVE: To evaluate a community education program about treatment of acute respiratory infection (ARI). METHODS: First, community case definitions for severe and mild ARI were developed. The intervention was then evaluated using a controlled before-and-after design. Household surveys collected data about ARI treatment in 20 clusters, each based around a school and health facility. Treatment indicators included percentages of cases attending health facilities and receiving antibiotics. The intervention consisted of an education program in schools culminating in street theater performances, discussions with mothers after performances and training for community leaders and drug retailers by paramedics. The intervention was conducted in mid-2003. Indicators were measured before the intervention in Nov/Dec 2002 and again in Dec 2003/Jan 2004. RESULTS: Two thousand and seven hundred and nineteen households were surveyed and 3654 under-fives were identified, of whom 377 had severe ARI. After implementing the intervention, health post (HP) attendance rose by 13% in under-fives with severe ARI and fell by 9% in under-fives with mild ARI (test of interaction, P = 0.01). Use of prescribed antibiotics increased in under-fives with severe ARI by 21% but only by 1% in under-fives with mild ARI (test of interaction, P = 0.38). Irrespective of ARI severity, the use of non-prescribed antibiotics dropped by 5% (P = 0.002), and consultation with female community health volunteers (FCHVs)and use of safe home remedies increased by 6.7% (P not estimated) and 5.7% (P = 0.008) respectively. CONCLUSION: The intervention was implemented using local structures and in difficult circumstances, yet had a moderate impact. Thus it has the potential to effect large scale changes in behaviour and merits replication elsewhere.

Practical approach to lung health in Nepal: better prescribing and reduction of cost.

OBJECTIVES: To assess the impact of Practical Approach to Lung Health (PAL) guidelines on prescription behaviour and the total cost of prescription for patients with asthma, chronic obstructive pulmonary disease and pneumonia. METHODS: Pre- and post-intervention comparison in a cluster randomized trial of primary care facilities. Seven health posts and 33 subhealth posts in Nepal were stratified by type and randomized into intervention and control groups. Health workers from the intervention facilities received 5 days training on the adapted PAL guidelines and their use. To collect prescription details, we used carbon-copy prescription pads in both groups. To measure the impact of PAL guidelines we used the World Health Organization's rational use of drug indicators and drug cost indicators, in a multivariate regression analysis. RESULTS: The PAL guidelines led to fewer prescriptions of multiple drugs and to more prescriptions of generic and essential drugs. The guidelines also lowered average prescription cost and wastage by disease except for chronic obstructive pulmonary disease although not to a statistically significant degree. Similarly, the prescription of antibiotics and adherence to guidelines improved, albeit not statistically significant. CONCLUSION: There is evidence that the implementation of PAL guidelines promotes rational use of drugs for some respiratory diseases. The expected health effects of PAL guidelines should be compared with their implementation costs before continuing training on lung health, and strategies put in place to sustain the effects.