Sri Hidayati, Siti Munawaroh INRUD Yogya/INDONESIA

1. 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

2. BACKGROUND • 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. • Innovative Strategies are needed to improve adherence to ARI treatment guidelines in health centers.

3. 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

4. STUDY DESIGN: Randomized pre – post study 12 HCs underwent series of intervention Small Group Discussion Self Assessment-1 Self Assessment-2 24 HCs in 2 districts Feedback Seminar (FBS) Randomization 12 HCs acted as control Focus Group Discussion Focus Group Discussion Prescribing survey: Number of sample: 30 prescriptions per HC X 12 time points X 24 Hcs = 8640 prescriptions POST INTERVENTION POST FBS Post SGD PRE INTERVENTION Post SA2 Post SA1

5. REDUCTION OF ANTIBIOTICS & ANTIHISTAMINE • 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)

6. REDUCTION OF CORTICOSTEROIDS & PHENOBARBITAL • Paramedics underwent series of intervention showed drastic reduction (>50%) in corticosteroids and phenobarbital use. • These reductions sustained after feedback seminar.

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

8. DISCUSSIONS • Small Group Discussion followed by Self Assessment discussion have been proven effective in improving prescribing practices for ARI patients in HCs. • 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).

9. 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. • To maintain the impact of intervention in long term period, reinforcements are needed.