Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers’ knowledge, practical competence and reported practice

Authors


Corresponding Author N. Q. Hoa, Karolinska Institutet, Stockholm, Sweden. E-mail: quynhhoa29@gmail.com; hoa_nq2002@yahoo.com

Summary

Objective  To assess knowledge, practical competence and reported practices among health-care providers about antibiotics to treat acute respiratory infections in children under five in rural Vietnam.

Method  Health-care providers prescribing or dispensing western drugs for children self-completed a structured questionnaire. Recommendations concerning antibiotic use from WHO and national guidelines were used to assess the appropriateness of reported treatment of acute respiratory infections.

Results  Ninety-six per cent of 409 eligible health care providers participated. Only 27% demonstrated correct knowledge regarding the consequences of resistance. Seventy-nine per cent would use antibiotics for common colds with fever, and 21% in cases with no fever. Nineteen per cent had overall knowledge compliant with recommended guidelines. Stated antibiotic use in written scenarios for common colds (81%) was not significantly different from that for non-referral cases of pneumonia (87%). The proportion of antibiotic use in the common cold scenario was significantly lower among health-care providers who had the correct overall knowledge. According to reported symptoms from the most recent encounter with a sick child, the diseases seen were 62% mild acute respiratory infections, 19% severe, and 19% non-respiratory infections. Among those, antibiotics, most commonly beta-lactams, were used in 90%, 87% and 78% of cases, respectively.

Conclusions  Antibiotics are often prescribed or dispensed to treat common colds. Interventions to change prescribing and dispensing practices should be developed and implemented in collaboration with local and national paediatricians. Continuous training of health-care providers, particularly drug sellers, is important.

Abstract

Objectif:  Evaluer les connaissances, les compétences pratiques et les pratiques rapportées par les prestataires de soins de santé, sur les antibiotiques pour le traitement des infections respiratoires aiguës chez les enfants de moins de cinq ans dans les zones rurales du Vietnam.

Méthode:  Les prestataires de soins de santé, prescrivant ou dispensant des médicaments occidentaux pour enfants, ont rempli un questionnaire structuré. Les recommandations de l’OMS et les directives nationales sur l’utilisation des antibiotiques ont été utilisées pour évaluer si les traitements rapportés pour les infections respiratoires aiguës étaient appropriés.

Résultats:  96% des 409 prestataires de soins de santééligibles ont participéà l’étude. Seuls 27% ont démontré des connaissances correctes sur les conséquences de la résistance. 79% utiliseraient des antibiotiques pour le rhume commun avec de la fièvre et 21% pour les cas sans fièvre. 19% avaient des connaissances générales conformes aux directives recommandées. L’utilisation d’antibiotiques dans des scénarios sur papier pour le rhume commun (81%) n’était pas significativement différente de celle pour des cas de pneumonie non référée (87%). La proportion des utilisations d’antibiotiques dans le scénario de rhume commun était sensiblement plus faible chez les prestataires de soins de santé avec une connaissance générale correcte. Selon les symptômes rapportés pour la plus récente visite d’enfant malade, la maladie observée était dans 62% des cas des infections respiratoires bénignes, dans 19% des cas, des infections respiratoires sévères et dans 19% des cas, des maladies respiratoires non-infectieuses. Parmi celles-ci, des antibiotiques, plus communément des bêta-lactames, ont été utilisés dans 90%, 87% et 78% des cas, respectivement.

Conclusions:  Les antibiotiques sont souvent prescrits ou dispensés pour traiter les rhumes. Des interventions visant à changer les pratiques de prescription et de dispense doivent être développées et implémentées en collaboration avec les pédiatres locaux et nationaux. La formation continue des prestataires de soins de santé est importante, notamment chez les vendeurs de médicaments.

Abstract

Objetivo:  Evaluar los conocimientos, as competencias en la práctica y las practicas reportadas por los proveedores sanitarios sobre los antibióticos para tratar infecciones respiratorias agudas en niños menores de cinco años en Vietnam rural.

Métodos:  Los proveedores sanitarios que prescribían o dispensaban medicamentos occidentales para niños completaron individualmente un cuestionario estructurado. Se utilizaron las recomendaciones de la OMS y las guías nacionales en lo concerniente al uso de antibióticos para evaluar la conveniencia del tratamiento reportado para infecciones respiratorias agudas.

Resultados:  Un 96% de los 409 proveedores sanitarios elegibles participaron. Solo un 27% demostró tener un conocimiento adecuado y correcto con respecto a las consecuencias de la resistencia a los antibióticos. Un 79% reportó que utilizaría antibióticos para tratar la gripe común con fiebre, y un 21% en casos sin fiebre. Un 19% tenía un conocimiento general que cumplía con lo recomendado por las guías. El uso de antibióticos reportado para un escenario de gripe común (81%) no fue significativamente diferente al de casos no referidos de neumonía (87%). La proporción de uso de antibióticos para el escenario de gripe común fue significativamente menor entre los proveedores sanitarios que tenían un conocimiento general correcto. De acuerdo con los síntomas reportados con referencia al encuentro más reciente con un niño enfermo, las enfermedades vistas fueron: infecciones respiratorias agudas leves en un 62%, en un 19% de los casos infecciones respiratorias severas, y en 19% infecciones no respiratorias. Entre estos se utilizaron antibióticos, principalmente betalactámicos, en un 90%, 87%, y 78% de los casos, respectivamente.

Conclusiones:  A menudo se prescriben antibióticos o son dispensados para tratar la gripe común. Se deberían desarrollar e implementar intervenciones para cambiar las prácticas de prescripción y dispensación, en colaboración con los pediatras locales y nacionales. El entrenamiento continuo de los proveedores sanitarios, particularmente los vendedores de medicamentos, es importante.

Introduction

Acute respiratory infections (ARIs) are among the leading causes of morbidity and mortality among children in low- and middle-income countries. Every year, severe ARIs, such as pneumonia, cause more than two million deaths among children under 5 years of age worldwide (UNICEF 2006). Antibacterials, commonly called antibiotics, play a crucial role in treating severe infections of bacterial origin, including respiratory infections. The widespread use of antibiotics, whether appropriate or inappropriate, has driven the emergence and spread of resistant bacteria (Okeke et al. 2005; van de Sande-Bruinsma et al. 2008).

Resistance to frequently used antibiotics among respiratory pathogens has become a common clinical problem (Song et al. 2004; Fuller et al. 2005). Irrational antibiotic use has been observed in various parts of the world among those involved in the prescribing, selling and taking of drugs (Van Duong et al. 1997; Kamat & Nichter 1998; Nash et al. 2002; Petersen & Hayward 2007). However, the level of knowledge and quality of practice of health-care providers (HCPs) related to the correct use of antibiotics has not been widely studied, especially not in low-income settings.

In Vietnam, ARI symptoms are the most common reason for seeking health-care for children (MOH 2003). Recommendations for rational antibiotic use for treatment of ARIs in children have been formulated internationally and adapted in national guidelines (Gove 1997; MOH 1998, 2006a). The national ARI programme (since 1984) and the Integrated Management of Childhood Illness (IMCI) programme (since 1998) have been implemented to address major child health problems in Vietnam, including ARIs. The implementing strategies focus on training health-care providers to apply standard management guidelines in classifying symptoms, identifying treatment and guiding mothers how to care for children at home. In a first-level health facility, the classification of pneumonia for a child is based on the main signs: fast breathing, chest in-drawing or stridor. A child with a cough but without any of the above pneumonia signs or general danger signs such as unconscious or sunken eyes is classified as having a common cold (Gove 1997). The majority of ARI cases are common colds, with symptoms such as cough, runny nose and fever. These cases are generally self-limiting viral illnesses that do not require antibiotic treatment (Rosenstein et al. 1998). Generally in children, only pneumonia or severe pneumonia should be treated with antibiotics (Gove 1997; Kabra et al. 2006).

The aim of this study was to assess fact-based knowledge (knowledge) and applied knowledge through the use of written clinical scenarios (practical competence) and reported practices among HCPs regarding use of antibiotics for treatment of ARIs in children under five in rural Vietnam. Understanding these factors can help to develop suitable intervention strategies to improve antibiotic prescribing and dispensing practices and curb the further spread of antibiotic resistance.

Materials and methods

Study setting and participants

A cross-sectional study was conducted from June to July 2007 in Bavi district, 60 km west of Hanoi City. The district is divided into three regions, i.e. lowland, highland and mountainous area. The population of Bavi is approximately 250 000 persons, of which 8% are children under five. The basic public health-care system includes a district hospital with 150 beds, three regional polyclinics and 32 commune health stations (CHSs). Each public health facility has one drugstore administered by health staff. In addition, there are private health facilities, including a wide range of more than 200 private providers comprising private pharmacies, drug outlets, private clinics and traditional healers.

HCPs prescribing or dispensing western drugs for children under five in the district were eligible for participation in the study. Western drug is the term used to differentiate between ‘modern medicines’ and traditional medicines (herbal medicines). The list of HCPs used for this study was compiled from information provided by the Bavi district health office and from surveyors of the Epidemiological Field Laboratory (Filabavi), an ongoing epidemiological cohort study (Chuc & Diwan 2003). HCPs who provided neither health services nor western drugs for children under five were not included in the study. To check the completeness of the list, communal health staff and Filabavi surveyors travelled around the commune to double-check. In all, of the 457 health-care providers in the list, 48 were ineligible due to incorrect address, not treating children, or using only herbal medicines for treatment.

Data collection and instruments

Data was collected using a structured questionnaire divided into four parts: (i) information on demographic characteristics; (ii) knowledge about and perceptions of antibiotic resistance; (iii) knowledge and practical competence related to the management of children under five with ARIs; (iv) symptoms and named drugs given regarding their latest management encounter with a child under five (Box 1). In the third part, knowledge was assessed using the questions directly addressing the need for antibiotics to treat specific ARI symptoms. Practical competence was evaluated using two written clinical scenarios, a ‘common cold scenario’ and a ‘pneumonia scenario’. The scenarios were formulated following the IMCI guidelines and discussed with two experienced paediatricians. In addition, we conducted several in-depth interviews with health-care providers and revised the scenarios to be applicable in primary healthcare facilities. The questionnaire was pre-tested outside the study area several times in order to optimize its clarity for self-completion.

Table Box 1.   Main questions and scenarios used in the paper
  1. The full questionnaire is available in Vietnamese and English from the first author.

I. General information
Age; Sex; Level of education; Professional training; Working place; Average service hours.
II. Perception, knowledge of antibiotic resistance
Have you heard about antibiotic resistance? (Yes/No)
How do you understand the term ‘antibiotic resistance’? (Open)
What are the leading causes of antibiotic resistance? (Multiple choices)
 Irrational prescribing of antibiotics by physicians
 Arbitrary antibiotic use by patients (self-medication, non-compliance)
 Violation of regulations for selling antibiotics by drug dispensers
 Other factors
What is consequence of antibiotic resistance? (One choice)
 Not any consequence in patients and other persons
 Treatment failure in patients, not in other persons seeking treatment of infectious diseases
 Treatment failure in patients and future effects on other persons seeking treatment of infectious diseases because bacterium are not susceptible to antibiotics
 Do not know
III. Perception, knowledge and practice in use antibiotic for children under 5
Knowledge: In case of having respiratory infectious symptoms, when does the child need antibiotic?
1. Cough, stuffy nose or runny nose without fever (Yes/No)
2. Cough, stuffy nose or runny nose with fever (Yes/No)
3. Including one of the following symptoms: fast breathing, chest in-drawing or stridor (Yes/No)
4. Other respiratory symptoms (Yes/No) Respondents asked to present details.
Scenario of common cold:“A parent or guardian comes to you and describes the symptoms or brings a child under 5 years old who has cough, runny nose and fever, but no sign of fast breathing, chest in-drawing or stridor. He/she asks for examination or to buy drugs. How do you deal with this scenario? What advice do you give to the child’s parent/guardian? Do you recommend or dispense any kind of drugs to treat the child? If yes, please write name and dose of drugs you could use for treatment of this child”.
Scenario of pneumonia:“A parent or guardian comes to you and describes the symptoms or brings a child under 5 years old who has cough, runny nose, fever above 38,5 °C, and fast breathing. He/she asks for examination or to buy drugs. How do you deal with this scenario? What advice do you give to the child’s parent/guardian? Do you recommend or dispense any kind of drugs to treat the child? If yes, please write name and dose of drugs you could use for treatment of this child”.
IV. Reported practice of treatment for the most recent child under 5 encounter
When was your most recent encounter with a child under 5 for examination or drug prescription?
Please list all the symptoms of from this encounter.
Please describe in detail the actions you took for treatment in this most recent encounter.
Did you prescribe or dispense any kind of drugs to treat the child?
If yes, please write name of drugs you prescribed or dispensed for treatment of the child?

All HCPs on the list were invited to participate in the study by telephone or were directly contacted at their facility. The questionnaire was administered in a series of meetings at the district health office with about 20–30 HCPs participating each time. In these meetings, questions were first clarified and participants were instructed how to fill in the questionnaire. The participants completed the questionnaire individually, usually within 30–45 min, under supervision of research staff. Those who did not come to the meetings after three invitations were asked to self-complete the questionnaire at their health facility or at home. Six Filabavi supervisors, specifically trained for this study, were responsible for distributing, guiding and supervising the self-completion process of the questionnaire following a standardized data collection procedure.

Data management and analysis

To assess the appropriateness of prescribing or dispensing antibiotics among HCPs, we used recommendations concerning antibiotic use from the WHO (Gove 1997) and national guidelines (MOH 2006a). Overall knowledge was considered as correct if the HCP provided answers to knowledge questions in accordance with the guidelines for all three stated ARI symptoms, i.e. ‘No’ for questions 1, 2, 4 and ‘Yes’ for question 3 (Box 1). Practical competence and reported practice regarding antibiotic use were evaluated based on whether HCPs prescribed or dispensed a specific antibiotic in the written treatment scenarios and in their most recent encounter with a child under five.

Reported symptoms of the most recent child seeking health-care service were classified following the IMCI guidelines as: (i) mild ARIs if including any of following symptoms: cough, stuffy nose, runny nose, sore throat, without pneumonia signs; (ii) severe ARIs, if included at least one of the pneumonia signs: fast breathing, chest in-drawing or stridor; (iii) non-ARI, if the child had any other symptom such as watery feces, bloody stools, vomit, ear ache, injury, abdominal pain, skin rash, toothache.

Professional education of the participants was classified into three levels: (i) basic, if HCP had up to 1 year of pharmaceutical or medical training after high school, such as basic drug seller, basic nurse, village health worker or no medical training; (ii) intermediate, if she/he had medical or pharmaceutical training for 2–3 years, i.e. assistant doctor, assistant pharmacist, middle nurse; (iii) university, if she/he had 5–6 years of medical or pharmaceutical training, i.e. medical doctor or pharmacist.

Practice types (working place) were grouped as: (i) drugstore, if the HCP dispensed drugs in drug outlet, private pharmacy, CHS drugstore or public drugstore, without examination; (ii) private clinic, if the HCP examined or consulted in a private place and then either prescribed or dispensed drugs; (iii) CHS, including HCPs working in CHS and prescribing drugs; (iv) hospitals, including HCPs working in hospitals or regional polyclinics, and prescribing drugs. Of those individuals working in two places, practice type was classified as the place where they spent the majority of their daily working time.

Drugs prescribed or dispensed for these cases were classified according to the Anatomical Therapeutic Chemical (ATC) classification system (WHO 2004), with the help of VN-pharmacy software (HUP 2004). This study includes antibiotics that are classified as antibacterials for systemic use and aggregated at the level of the active ingredient (level 5 of the ATC class J01) (WHO 2004).

Frequencies and estimated proportions of stated antibiotic use with corresponding 95% confidence interval (95% CI) were used to describe the differences between socio-demographic groups of the providers. Multiple logistic regression was used to examine the correlations between the following independent variables: HCP’s sex (women vs. men), age (50– years, 40–49 years, 30–39 years, vs.−29 years), education level (university, intermediate, vs. basic), practice type (hospitals, CHS, private clinic, vs. drugstores), region (mountain, highland, vs. lowland) and frequency of seeing patients (daily, weekly, vs. sometimes) and the following dependent variables: overall knowledge and practical competence of antibiotic use. In the model with practical competence, overall knowledge of antibiotic use for ARIs was considered as an additional independent variable.

Ethical considerations

This study was approved by the ethical review board of Hanoi Medical University. Informed consent of all the participants was sought after introduction of the study. Confidentiality was assured and participants were informed that they had the right to withdraw from the study at any time without explanation.

Results

Background characteristics of health-care providers

Of the 409 eligible HCPs, 392 (96%) consented to participate in the study. Among them, 276 self-completed the questionnaire in the group meetings at the district health office and 116 self-completed the questionnaire at home or at their facility.

The general characteristics of the respondents are presented in Table 1. The mean age of the respondents was 42.5 years (SD = 13.3). There were more female than male HCPs (58%). Most of the HCPs had an intermediate educational level (57%). The majority of basic HCPs worked in drugstores (65%) and most of them were female. Only one respondent reported no medical training. There were 26 respondents who reported working both in the public and private sector: 20 were working in hospitals and six in CHSs. Of those working at private clinics, 76% reported having drugs available to dispense for patients. HCPs in the lowland area were more likely to work in private clinics and less likely in hospital. 56% of the respondents reported encountering children under five daily.

Table 1.   Socio-demographic characteristics of the 392 participating health-care providers (HCPs) in Bavi district presented by practice type
CharacteristicsPercentage within practice typeTotal (n = 392)
Drugstore (n = 139)Private clinic (= 70)CHS (n = 128)Hospital (n = 55)
Age (years)
–29291302424
30–39264332524
40–492413273124
50–2182102028
Sex
Female7624625158
Male2476384942
Professional education
Basic5224121328
Intermediate4660763858
University216124914
Region
Lowland224634728
Highland5030455345
Mountain2824214027
Frequency of seeing children
Sometimes294051621
Weekly2839111823
Daily4321846656

Knowledge and perceptions of HCPs regarding factors enhancing antibiotic resistance and consequences of antibiotic resistance

Of all the respondents, 97% stated that they had heard about antibiotic resistance (Table 2). However, only 27% demonstrated correct knowledge regarding the consequences of resistance, such as treatment failure of patients and possible future effects on other persons seeking treatment for infectious diseases. Almost all respondents (88%) believed that patient-related factors such as self-medication and poor adherence to antibiotic regimens contribute to the problems of antibacterial resistance. Many respondents considered inappropriate prescribing and dispensing of antibiotics among HCPs as a factor contributing to development of resistance (Table 2).

Table 2.   Estimated percentage of providers agreed with the statements about knowledge of antibiotic resistance by practice type
StatementsPercentage of HCPs within practice type that agreed with statements
Drugstore (n = 139)Private clinic (n = 70)CHS (n = 128)Hospital (n = 55)Total (n = 392)
Have heard about antibiotic resistance93979910097
Of the factors below, which enhance antibiotic resistance
Irrational prescribing of antibiotics by physicians4560658659
Arbitrary antibiotic use by patients (self-medication, non-compliance)8090968788
Violation of regulations for selling antibiotics by drug dispensers4860818265
Other factors67224
Your opinion regarding consequences of antibiotic resistance on the effect of treatment     
Not any consequence41203
Treatment failure in patients, not in other persons seeking treatment of infectious diseases6671764267
Treatment failure both in patients and other persons seeking treatment of infectious diseases because bacterium are not susceptible to antibiotic923215827
Do not know94104

Knowledge and practical competence of HCPs regarding antibiotic use for treatment of ARIs in children

In response to the knowledge questions, 21% stated that antibiotics should be used if the child has a cough, or runny nose without fever and 79% if the child has the same symptoms but also fever. Compared to other providers, drug sellers were significantly more likely to provide antibiotics in cases of cough without fever, and significantly less likely in cases with pneumonia signs than other providers. Only 19% of HCPs demonstrated, according to treatment guidelines, correct overall knowledge about use of antibiotics for treatment of ARIs among children under five. This knowledge was significantly better among HCPs who were in the highland and mountainous areas than in the lowland area (Table 3). Also, HCPs aged 30–49 years had better overall knowledge than those under 30 or over 50 years old.

Table 3.   Knowledge and practical competence in clinical scenarios of antibiotic use in treatment of acute respiratory infection (ARI) among children under 5: estimated percentages of correct answers and results of multiple logistic regression analyses
CharacteristicsnPercentage stating antibiotic needed for specified ARI symptomsCorrect overall knowledge of antibiotic use for ARIAntibiotic specified in treatment of common cold scenario†Antibiotic specified in treatment of pneumonia scenario‡
Cough, no feverCough, and feverPneumonia signs§ OR** (95% CI) OR** (95% CI) OR** (95% CI)
  1. *Significant different between groups using chi-square test (< 0.05).

  2. †Common cold scenario: cough, runny nose and fever, no sign of difficult breathing.

  3. ‡Pneumonia scenario: cough, runny nose, fever over 38 °C, and fast breathing (excluding 197 referral cases).

  4. §Pneumonia signs: fast breathing, chest in-drawing or stridor, with or without fever.

  5. ¶Percentage within socio-demographic groups.

  6. **Adjusted OR were based on multiple logistic regression analysis.

  7. ††95% CI percentage of antibiotic prescribed and dispensed rate for common colds scenario.

  8. ‡‡95% CI percentage of antibiotic prescribed and dispensed rate for pneumonia scenario.

Age (years)
–299239*87*80*9*1861811
30–399521*78*88*21*2.94 (1.21–7.35)810.78 (0.33–1.80)850.71 (0.17–2.84)
40–499416*69*97*28*4.10 (1.70–9.85)800.80 (0.34–1.83)912.90 (0.64–13.17)
50–11112*82*96*17*2.32 (0.85–6.28)780.75 (0.31–1.82)861.85 (0.36–9.53)
Sex
Female22927*7987*18186*1831
Male16314*7996*201.01 (0.55–1.86)74*0.37 (0.20–0.68)922.55 (0.80–8.14)
Professional education
Basic11129*8185*181791771
Intermediate22521*8091*160.77 (0.39–1.50)821.27 (0.65–2.45)881.26 (0.39–4.03)
University569*71100*291.09 (0.41–2.85)802.50 (0.86–7.30)941.20 (0.14–10.15)
Practice type
Drugstore13930*8178*15*181172*1
Private clinic7014*81100*17*1.33 (0.51–3.48)801.62 (0.64–4.11)83*1.46 (0.23–9.34)
CHS12818*8196*17*1.33 (0.62–2.86)851.00 (0.46–2.18)91*3.79 (1.06–13.54)
Hospitals5518*6798*33*2.18 (0.91–5.22)750.59 (0.23–1.51)95*5.76 (0.79–42.12)
Region
Lowland1112988* 9310*185190*1
Highland1761878* 9021*2.39 (1.12–5.09)770.70 (0.36–1.38)81*0.36 (0.11–1.16)
Mountain1052071* 8924*2.76 (1.23–6.18)841.14 (0.52–2.51)96*2.47 (0.39–15.33)
Frequency of seeing children
Sometimes841886 8814176*160*1
Weekly902476 89211.76 (0.77–4.03)74*0.95 (0.46–1.96)83*3.83 (0.89–16.48)
Daily2182278 92191.27 (0.57–2.81)86*2.23 (1.07–4.64)93*8.29 (2.16–31.72)
Overall knowledge
Incorrect319     84*1861
Correct73     67*0.39 (0.21–0.73)880.81 (0.23–2.80)
Total3922179 9119 81(77–85)††87‡(82–91)‡‡

Table 3 shows that in the ‘common cold scenario’, many respondents mentioned that specific antibiotics should be used for treatment. In the ‘pneumonia scenario’, half of the respondents stated that they would refer the child to higher level health services without using any kind of drugs for treatment. Excluding these referral cases, the percentage of antibiotics provided for the ‘pneumonia scenario’ was not significantly different from that for the ‘common cold scenario’.

In the logistic regression analysis of ‘practical competence’ in the ‘common cold scenario’, the proportion of antibiotic use among HCPs who had ‘correct antibiotic overall knowledge’ was significantly lower than for those who had not (Table 3). It was higher but not statistically significant in the ‘pneumonia scenario’. Notably, HCPs encountering children daily were consistently more likely to prescribe or dispense antibiotics for treatment of ARIs regardless of disease severity. There was no significant difference in knowledge and practical competence between the HCPs who self-completed in the group meetings and others.

Antibiotics use among HCPs for treatment in most recent encounter with children under five

All the respondents reported about their most recent encounter with a child under five. 71% had encountered children under five during the previous week. The most prevalent symptoms reported for the latest child encounter were consistent with mild ARIs (62%), severe ARIs (19%) or other diseases (19%). Of these 11%, 24% and 34%, respectively, had been referred to a higher level. Figure 1 shows that patients commonly seek care at drugstores and CHSs in cases of mild ARIs. For severe ARIs, treatment was more commonly sought in hospitals and CHSs. Drugs were given in 95% of all cases. Among those, antibiotics accounted for 92%. The percentage of antibiotic use for treatment of mild ARIs, 90% (95% CI: 86.2–93.8%) was not significantly different from those for severe ARIs, 87% (95% CI: 79.0–94.4%), or other diseases 78% (95% CI: 68.2–87.0%). Regarding treatment of mild ARIs, ‘not using antibiotics’ was most common among private providers and least common among CHS staff.

Figure 1.

 Absolute numbers of antibiotics prescribed or dispensed by HCPs in the latest child encounter, stratified by diseases and practice type.

In the most recent child encounter, HCPs had in most cases given beta-lactam antibiotics in two doses for a 5-day course regardless of the severity of disease (Figure 1). Cephalosporins were more often used for severe ARIs than mild ARIs. Table 4 shows that, in the ‘pneumonia scenario’, amoxicillin was most commonly used, followed by cephalexin. However, in the severe ARI cases, cephalexin was most commonly used. Gentamycin and co-trimoxazole were frequently mentioned as a combination of antibiotics for treatment of severe ARIs. Only a few HCPs reported giving penicillin V to treat severe ARIs in children under five.

Table 4.   Percentage antibiotics named by HCPs for treatment in the ARI clinical scenarios and the latest child encounter
Antibiotic agentsATC codePercentage specific antibiotic named for treatment in ARI clinical scenariosPercentage specific antibiotic named in the latest child encounter
Common colds (n = 318)Pneumonia (n = 209)Mild ARIs (n = 217)Severe ARIs (n = 65)Other diseases (n = 59)Total (n = 341)
  1. Including 14 referral cases in which antibiotics still named.

CloramphenicolJ01BA01000051
AmpicillinJ01CA01697526
AmoxicillinJ01CA04612364515159
Benzyl penicillinJ01CE01051322
Phenoxymethyl penicillinJ01CE02100000
CephalexinJ01DA01163513181414
CefuroximJ01DA06210020.5
CefaclorJ01DA0838311126
CefadroxilJ01DA09250.5000.5
CefotaximJ01DA10071301
CefiximJ01DA23010200.5
Erythromycin + co-trimoxazolJ01EC20636676
Co-trimoxazoleJ01EE01226676
ErythromycinJ01FA01217386
SpiramycinJ01FA02441553
LincomycinJ01FF020.510.5201
GentamycinJ01GB03060.5802
MetronidazolJ01XD01000051
Total antibiotics namedJ01104111111122119114

Discussion

To our knowledge, this is the first assessment of knowledge, practical competence and reported practice regarding antibiotic use for treatment of ARI in children among both prescribers and dispensers at the district-level in Vietnam. Most HCPs reported that they had prescribed or dispensed antibiotics for symptoms of common colds. According to their knowledge, this practice was the correct case management of ARI. Such misconceptions and subsequent practice of providing antibiotics may be important factors behind the increasing antibiotic resistance (Quagliarello et al. 2003; van de Sande-Bruinsma et al. 2008).

Only 21% of HCPs knew that antibiotics are not indicated for treatment of mild ARIs with fever. Correct response for practical competence in clinical scenario (19%) and reported practice (10%) were even lower. In this study, reported antibiotic prescribing was more frequent than in any European country (Muller et al. 2007), but less frequent than one study in India (Bharathiraja et al. 2005). An unexpected and worrying finding is that the estimated percentage of antibiotic use for mild ARI cases was not significantly different from the use for severe ARIs. This indicates a serious lack of knowledge regarding the pathogeneses of ARIs and the ability to recognize the signs for pneumonia. We found that the presence of fever increased antibiotic prescribing, although this sign does not necessarily indicate a bacterial infection (Schmitt 1984). It is crucial to develop and implement educational programmes that target HCPs’ ability to accurately differentiate mild ARIs from pneumonia cases and that symptomatic treatment only should be given for common colds (Chuc et al. 2002; Perz et al. 2002; Finkelstein et al. 2008). In particular, HCPs should be reminded that it is not recommended to routinely administer antibiotics for all febrile respiratory illnesses.

A wide range factors might influence the very high level of antibiotic prescribing and dispensing for treatment of mild ARIs among the HCPs. Conceptions among physicians, e.g. that antibiotics should be used to prevent secondary bacterial infections and complications of disease, has been reported (Bauchner et al. 1999). In addition, several other studies reported that although physicians know the correct indications, they still prescribe antibiotics unnecessarily (Choa et al. 2004; Mangione-Smith et al. 2006). The fact that overall knowledge was better among those aged 30–49 years than others may be explained by higher participation in continuous training combined with clinical experience. A worrisome finding is that university level providers hardly performed better than others in the scenarios. In the district, most of the medical doctors encountering children were not pediatricians, i.e. many of them have not been specifically trained regarding ARI in children. Differences in educational level and working place among female and lowland HCPs compared to other HCPs may explain their poor knowledge. Future studies should aim to better understand the determinants of prescribing and dispensing antibiotics for children. It is necessary to develop and implement an intervention in collaboration with local and national pediatricians (Gouws et al. 2004).

We found that drug sellers were more likely to give inappropriate antibiotic treatment compared to other HCPs. Similar findings were reported in other studies (Akkerman et al. 2005; Cadieux et al. 2007). As drug sellers commonly serve as the first point of contact for those seeking health-care and commonly dispense drugs without prescription in Vietnam (Chuc et al. 2001; Olsson et al. 2002), it is necessary to reflect on their involvement in management of ARIs to contain antibiotic resistance (Chuc et al. 2002). The prescription regulation states that drug dispensers must sell antibiotics only on prescription (MOH 2008). Currently, both private and public health services are convenient and accessible in both urban and rural setting which may lead to unnecessary visits and use of antibiotics for common colds (MOH 2003; Hoa et al. 2007). Evidence has suggested that reduced prescribing could be achieved if fewer patients consulted doctors for common infections (Lee et al. 2003; Ashworth et al. 2006). Greater enforcement of the prescription regulations in drug stores would reduce irrational dispensing of antibiotics.

Most HCPs reported providing extended-spectrum antibiotics such as amoxicillin, cephalexin and ampicillin for children under five, irrespective of symptom severity. This is different from findings in several north and central European countries, where the use of narrow-spectrum such as penicillin V is more common (Ferech et al. 2006). In the current therapeutic strategies, oral ampicillin was not recommended due to very low absorption, but it is still frequently used (MOH 2006b; Aspa et al. 2008). Frequent use of oral ampicillin as well as other extended-spectrum antibiotics can increase antibiotic resistance in the region (Song et al. 2006). In empiric treatment of pneumonia, short-course high-dose oral amoxicillin is recently recommended to overcome in vitro resistance of pneumococcal pathogens (Hazir et al. 2008).

The strength of our study is the inclusion of all HCPs who provided health services for children in public and private health facilities in the area. Furthermore, the study had a high response rate. However, there are some limitations. Some providers may have been missed despite the fact that the list was generated from several data sources. However, the list was checked for completeness by communal health staff and Filabavi surveyors, who are familiar with the area, we thus assume that omissions were unlikely. We did not assess knowledge and practice of HCPs in the diagnostic process, although we recognize that errors in diagnosis may contribute to inappropriate antibiotic prescribing. Scenarios do not completely reflect the real situation since a clinical examination could not be done. However, as compared to clinical examination, the use of IMCI guidelines showed high sensitivity and specificity (Cao et al. 2004). Moreover, we relied on respondents’ self-reporting, and did not assess actual practice by observing HCPs’ clinical performance or by using a simulated client method.

Conclusions and recommendations

Knowledge about antibiotic use was not in line with guidelines and was associated with inappropriate ARI management among HCPs. It was also reported that antibiotics are often prescribed or dispensed to treat common colds. Continuous training of HCPs, especially of drug sellers, in accurately identifying severe signs and in giving appropriate empiric antibiotic treatment is important. Interventions should preferably be developed and implemented in collaboration with local and national paediatricians.

Acknowledgements

We would like to acknowledge and thank the health-care providers from Bavi district who gave time to answer our question and shared their experiences with us. We gratefully acknowledge the Health System Research Programme, Filabavi, field supervisors and officials of Bavi district health office, Bavi district hospital for their assistance to the study. We are also very grateful to Ho Dang Phuc from the National Institute of Mathematics, Hanoi, Vietnam for the statistical support and to Dr. Nguyen Thi Thanh Mai, Dr Nguyen Thi Viet Ha, who are paediatricians of National Children Hospital as well as lecturers from Hanoi Medical University for their consultation and contribution to the study. The study was supported by the Health Systems Research Project in Vietnam, funded by Sida/SAREC, Sweden and Ministry of Science and Technology, Vietnam.

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