Summary of PHD thesis: Some epidemiological characteristics and intervention effeciency for respiratory infections in children under 5 years at cho moi districts in Bac Kan province

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Objective of the projec: identify several risk factors related to acute lower respiratory infectionsa; evaluate effectiveness of interventional measures for acute respiratory infections in the community.

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Nội dung Text: Summary of PHD thesis: Some epidemiological characteristics and intervention effeciency for respiratory infections in children under 5 years at cho moi districts in Bac Kan province

The work was completed in: THAI NGUYEN UNIVERSITY Medico-Pharmaceutical University - Thai Nguyen University UNIVERSITY OF MEDICINE AND PHARMACY Advisors: 1. Assoc. Prof.,PhD. Nguyen Thanh Trung ĐAM THI TUYET 2. Prof.,PhD. Trưong Viet Dung Opponent 1: .......................................................................................... SOME EPIDEMIOLOGICAL CHARACTERISTICS .......................................................................................... AND INTERVENTION EFFECIENCY FOR Opponent 2: .......................................................................................... RESPIRATORY INFECTIONS IN CHILDREN UNDER 5 YEARS .......................................................................................... AT CHO MOI DISTRICTS IN BAC KAN PROVINCE Opponent 3: .......................................................................................... .......................................................................................... Specialty: Social Hygiene and Health Organization The thesis will be protected in Thesis Committee in National Level Code: 62.72.73.15 held in Thai Nguyen Medico-Pharmaceutical University At .............in .............., ................, 20... SUMMARY OF PhD THESIS The information from this thesis can be found at: - National Library Thai Nguyen - Year 2010 - Learning Resource Center - Thai Nguyen University - Library of Thai Nguyen Medico-Pharmaceutical University
1 2 INTRODUCTION NEW CONTRIBUTIONS OF THE THESIS The thesis has identified a situation of acute respiratory Acute respiratory infections are very common diseases with the infections in children under 5 years old in Cho Moi District, Bac Kan highest morbidity and mortality in children, especially pneumonia province remaining high. among under-five children in developing countries. The study was carried out in mountainous areas, highlands, In Viet Nam, every year about 32 - 40 million episodes of disadvantaged areas, ethnic minorities. In there, people’s living children suffer from acute respiratory infections and about 22 – conditions remained poor, backward and less access to information, 24,000 children have died from pneumonia. In disadvantaged, remote and their awareness was slow, but if intervened by the health areas, pneumonia is still a cause of a leading death in children. Now, education communication with appropriate methods such as oral acute respiratory infections in children accounts for approximately propaganda in ethnic minority languages combining with posters, 39.7% in the community. In general, main causes of acute respiratory leaflets, video tapes, local simple terms, easily to understand would infections are due to viruses, bacteria, pulmonary tuberculosis in bring results and attract the community to participate children and fungus. In addition, owing to the impact of risk factors The intervention measure has mobilized local human such as environmental pollutions, cramped housing, smoke of the resources, attracted the participation of the community, close cooking, tobacco smoke, low birth weight, malnourished children, coordination between the commune health centers, village health diarrhea and climate changes. Mother’s early recognition of signs of workers and people, easily to mobilize, possible to work at all time, respiratory infections as well as how to care for children with any where. respiratory infections is still limited, especially mothers living in the The iinterventional measure has a horizontal impact and depth: mountainous, remote areas. Width: The health education communication for mothers with So, well done to prevent acute respiratory infections in children children under 5 years old or caregivers for detection, classification, will reduce the morbidity and mortality in children, particularly treatment, care , acute respiratory infection control in children. children under 5 years old and since that it will reduce funding to pay Depth: Medical care at Home: Children were followed up in for drugs, medical services in hospitals, reduce the overload by the households to detect and classify a disease and thus children were children with acute respiratory infections treated in the hospital, cared for at home, then referred to the commune health center to reducing time of mothers to leave work to care for sick children. exam and treat if a severe disease. Educating knowledge, attitude, Therefore, we conducted the theme: “Several epidemiological practice for mothers aimed a change of mother’s behaviors in the characteristics and interventional efficiency for acute respiratory respiratory infection control among children. infections in children under 5 years old at Cho Moi district in The immune - enhancing drugs (Broncho-Vaxom) was firstly Bac Kan province”aiming at: used for acute respiratory infection control among children in the 1. Describe several epidemiological characteristics and mountainous community, highlands and ethnic minorities. interventional efficiency for acute respiratory infections in children STRUCTURE OF THESIS under 5 years old at Cho Moi district in Bac Kan province. The thesis includes 107 pages, 45 tables, 8 figures, 2 photos, 3 2. Identify several risk factors related to acute lower diagrams and 147 references in which 76 are in Vietnamese and 71 respiratory infections . are in English. Key parts of thesis: Introduction: 02 pages, Chapter 1. 3. Evaluate effectiveness of interventional measures for acute Literature review: 18 pages, Chapter 2. Subjects and method: 19 respiratory infections in the community. pages, Chapter 3. Results: 37 pages, Chapter 4. Discussion : 28 pages Conclusions and recommendations : 03 pages
3 4 CHAPTER 1: viruses included: respiratory syncytium virus (RSV), influenza virus, LITERATURE REVIEW para influenza and adenovirus and in which RSV was the most important pathogenic agent for lower respiratory infection. In developing countries, bacteria played an important role in resulting in 1.1. Current status of acute respiratory infections acute respiratory infections and mainly bacteria were pneumococcus Currently, in developing countries, respiratory tract infectious and H. influenzae. diseases are still a cause of a leading mortality and morbidity in children under 5 years old, mainly due to pneumonia.. According to 1.2.2. Risk factors related to acute respiratory infections Risk factors related to acute respiratory infections in children the World Health Organization (WHO), every year, each child suffers were: Socio-natural environment, health systems, mother’s from acute respiratory infections from 4-9 times. Estimating globally, knowledge, attitude, practice (KAP) and biological factors. But in the each year about 2 billion episodes of children suffer from respiratory mountainous area, these risk factors are little considered and this is infections, accounting for 19-20% of deaths in children under 5 years an issue that we need to think. old worldwide. According to a research by Ruan I. (2005), estimating the 1.3. Several intervention measures against respiratory infections incidence of pneumonia episodes in children under 5 years on a done in the world and Vietnam - The group of intervention : Impact on knowledge, attitude global scale showed that the incidence of pneumonia episodes in and practice of mothers or caregivers developing countries was 0.29 episode per year per child. In - The group impacting on child care health systems developed countries, this rate was 0.026 episode per year per child and over 95% of pneumonia episodes in children in the world - The group impacting on the socio-natural environment occurred in developing countries - The group impacting on biological factors. In 2003, a study on a situation and some main risk factors related to respiratory infections in children under 5 years old at Thuy Chapter 2 Duong - Huong Thuy, Thua Thien Hue conducted by Nguyen Van SUBJECTS AND METHODS Thieu and Nguyen Huu Ky States showed that the prevalence of acute respiratory infections in the community was still high (39.7%). 2.1. Study subjects In 2007, the Central Tuberculosis and Lung Hospital and - Children under 5 years (from 60 months old or younger). Project of Acute Respiratory Infections in Children held a workshop - Mothers with children under 5 years old or caregivers. on “Deployment of project activity plan of acute respiratory - Leaders of the community: Leaders of the commune, head of infections in children in key provinces in 2007 and the 2007-2010 Health Department. period” and reported that the highest prevalence of acute respiratory - Commune health workers, village health workers. infections in recent years was in the mountainous provinces, followed 2.2. Study setting and duration by Central Coast and Plains. 2.2.1. Setting: Cho Moi District, Bac Kan Province 1.2. Causes and risk factors related to acute respiratory 2.2.2. Duration: The study was carried out from December 2006 to infections January 2009 1.2.1. Causes of acute respiratory infections 2.3. Methodology Viruses were the most common causes resulting in acute lower 2.3.1. Study Design respiratory infections in children under 5 years old and was the - Descriptive study: A study conducted by a cross-sectional leading cause of hospitalization and death in children. The common survey to describe a real situation of acute respiratory infections and
5 6 at the same time to analyze to determine factors associated with acute Indicators on risk factors related to acute lower lower respiratory infections. respiratory infections: Interviewing and observing a housing - Intervention study: Before - after intervention design with a conditions and hygiene. control group Classification of related factors according to model of 2.3.2. Sampling method logistic regression. * Sample size for a descriptive study: Calculated by the following formula: Intervention efficiency index in research. n = Z 2 1−α ( p .q ) 2 ( p .ε ) 2 Output index: Percentage of mothers with KAP changes after intervention n = 1038 children Impact index: * Longitudinal follow-up index in the community: The minimum sample size was 1038 children for the - Incidence density by year, episodes of acute respiratory descriptive study . In fact, we investigated 1152 children. infections by season, morbidity rate after using Broncho -Vaxom * Sample size for a intervention study: Calculated by the during intervention. following formula: - Morbidity of acute respiratory infections after using Broncho- Vaxom p 1 (1 − p 1 ) + p 2 (1 − p 2 ) - Rate of children using antibiotics after using Broncho- Vaxom n = Z (2α , β ) ( P1 ) 2 − P2 * Evaluation index after intervention in a intervention group and a control group: The prevelence of acute respiratory infections Changing data into the formula, we have: the intervention after intervention (Compared with the prevalance before intervention) sample size for mothers: n = 554 mothers. Intervention efficiency index in qualitative research to The intervention sample size for children : n= 455 children evaluate an acceptance of the community: Thus, to make sure of ethics in research, we would conduct the In-depth interviews, group discussions: Leaders of the intervention in all mothers with children under 5 years and all community, mothers, village health workers, commune health workers children aged 5 years in 4 intervened communes. to evaluate an acceptability of the community for intervention measures 2.3.3. Study indicators 2.4. Intervention contents Indicators on current status of acute respiratory infections Arragement of the community, deployment of health education in under-five children in study settings before intervention: Clinical communication, longitudinal follow-up of acute respiratory infections in examination children in the community, preventive intervention by immune- Indicators on association between mother’s knowledge, enhancing drugs, evaluation after intervention. practices and acute lower respiratory infections: Interviewing and 2.5. Data processing and analyzing observing mother’s practices. Data were entered and processed and analyzed by using SPSS16.0 , Epidata, EPI-INFO, EXCEL.
7 8 Chapter 3 - Mother’s knowledge on child care was closely related to STUDY RESULTS acute lower respiratory infections. Children of mothers with poor knowledge had a risk of acute lower respiratory infections to be 3.69 3.2. Some epidemiological characteristics of acute respiratory times higher than children of mothers with a good and average infections in children under 5 years old at the study sites knowledge , with p
9 10 Table 3.16 showed that the leading related factor was Table 3.23. showed that : children’s vaccination (adjusted OR = 10.80), the second was the After 2 years of intervention, mother’s knowledge on acute child care practice (adjusted OR = 4.61), the third was time of respiratory infections was markedly improved: weaned children (adjusted OR = 4.39), followed by knowledge Poor knowledge in a intervention group decreased to 6.4% (adjusted OR = 3.38). A family with smokers, animal sheds near the (after intervention) from 86.7% ( before intervention) , 77,6% (in the house, damp conditions of the house, indoor stoves, mother's control), efficiency of intervention was 86.67%, with p < 0.01. education and a housing type were confounding factors. An average and good knowledge in the intervention group was 3.4. Intervention effectiveness for acute respiratory infection increased as compared to before intervention and a control group. control in children Effectiveness of intervention for the average knowledge was 301.35% 3.4.2. Effectiveness of intervention model and for the fair and good knowledge was 36.40%, with p < 0.01. 3.4.2.1. Output results of intervention * Impact of intervention for mother’s child care at home Results of intervention for mother’s KAP change : * Impact of intervention for mother’s knowledge change Table 3.25. Results to change mother’s healthcare service Table 3.23. Efficiency of intervention for mother’s knowledge change Intervention group Control Before After Site Study site First Final interventi interventi p Intervened group Control survey (3) survey (4) Effectiveness of Efficiency index on (1) on (2) intervention Indicator (n = 456) (n= 450) Before After (n = 593) (n = 627) First Final p (%) (%) interventi interventi n % n % n % n % Score Survey (3) survey (4) p1 & 2 < 0.05 on (1) on (2) Untreated at scale (n = 456) (n = 450) 17 2.9 7 1.1 13 2.9 12 2.6 p3 & 4 > 0.05 (n = 593) (n = 627) home n % n % n % n % p2 & 4 > 0.05 Self- buy medicines p1 & 2 < 0.01 p1&2< 0.01 Interventio and self- treated 87 14.7 22 3.3 49 10.7 51 11.3 p3 & 4 > 0.05 n: 92.61 Poor 514 86.7 40 6.4 376 82.5 349 77.6 p3&4> 0.05 86.67 at home p2 & 4 < 0.01 Control: p2&4< 0.01 5.94 p1 & 2 < 0.01 To see healers 10 1.7 1 0.2 9 2.0 8 1.8 p3 & 4 > 0.05 p1&2< 0.01 Interventio p2 & 4 < 0.05 n: 327.06 Average 79 13.3 356 56.8 80 17.5 99 22.0 p3&4> 0.05 301.35 p1 & 2 < 0.01 Control: To see village p2&4< 0.01 25,71 1 0.2 300 47.8 5 1.1 4 0.9 p3 & 4 > 0.05 health workers p2 & 4 < 0.01 p1&2< 0.01 Interventio To commune p1 &2 < 0.01 Fair, n: 36.8 0 0 231 36.8 0 0 2 0.4 p3&4> 0.05 36.40 health center 407 68.6 532 84.8 312 68.4 316 70.2 p3 & 4 > 0.05 well Control: p2&4< 0.01 0.4 (CHC) p2 & 4 < 0.01 p1 & 2 < 0.01 Worship 210 35.4 101 16.1 160 35.1 163 36.2 p3 & 4 > 0.05 p2 & 4 < 0.01
11 12 The average and good practices after intervention were The Table 3.25.revealed that: increased as compared to before intervention and the control, After intervention, the use of health services for mother’s efficiency of intervention was 81.38%, 72.16% and 878.67%, children had changed markedly: The rate of mothers in the respectively, with p < 0.01. intervention group took their children to village health staffs more: 3.4.2.2. Impact results from 0.2% (before intervention) up to 47.8% (after intervention) and Results of longitudinal follow-up for acute respiratory 0.9% (in the control). Taking children to commune health centers infections in children at households by village health staff during also increased: from 68.6% (before intervention) up to 84.8% (after intervention in the intervention group :No child died in the community. intervention) and 70.2% (in the control). Worship also reduced more * Incidence density of acute respiratory infections in intervened areas : from 35.4% (before intervention) to 16.1% (after intervention) and Table 3.29. Incidence density of acute respiratory infections episode 36.2% (in the control). by year Table 3.28. Effectiveness of intervention for mother’s child No pneumonia: Cough Pneumonia; Severe Indicator care practice Sum of or cold pneumonia Time person- Incidence Incidence/ Intervention (%) period Intervention group Control Efficiency index Effectiveness of year at Incidence /1000 Incidence 1000 Episode Episode Before After risk (Year) Child- (Year) Child- First Final Year (%) interventi interventi p years years survey (1) survey (2) 2007 on ( 3) on (4) 758 4118 5.43 5430 533 0.70 700 (n=456) (n=450) (n=593) (n=627) 2008 750 2635 3.51 3510 232 0.31 310 Level n % n % n % n % Efficiency p1 & 2 0.05 81.38 ĐC: 0,78 p2 & 4
13 14 Resuls of longiuidinal follow-up for children who had a The Table 3.36 revealed that: recurrent acute respiratory infections many times in the intervention For children using Broncho-Vaxom, the use of antibiotics in group were taken Broncho- Vaxom done by village health staff children with ARI was dropped as compared to before using Table 3.33. Intervention results to the average number of diseased – Broncho-Vaxom : child times before and after medication - The average episode of using antibiotics in children after intervention (1.04 ± 0.81), before intervention (4.15 ± 1.22), Decreased as decreased as compared before intervention of (3.12 ± 1.25), with p < 0.01. Time period Before After p compared to intervention intervention - The percentage of children using antibiotics after before Indicator (n = 52) (n = 52) intervention (67.3 %), before intervention (100%), decreased as intervention Overall ARI compared to before intervention of 32,7%, with p
15 16 with p
17 18 respiratory infections, 5.18 times higher than children in a group of 4.3.2. Effectiveness of intervention in prevention and control of mothers with the average and good practices, with p
19 20 approximately 1/1. However, our result was higher than the result antibiotics for one year of follow-up. Whereas, before using done by Ruan I. when evaluating the incidence of pneumonia in Broncho- Vaxom, any children also had to use antibiotics. Difference children under 5 years in developed countries (0.026 episode/year/ was statistically significant (p< 0.01). The average number of child). This difference could be possible that children in developed episodes to use antibiotics after using Broncho- Vaxom was 1.04 ± countries were more comprehensively care for in all fields such as 0.81), as compared to before using Broncho- Vaxom of 4.15 ± 1.22), economic, socio-cultural and health care...etc. So children in with p< 0.01. The study results showed that Broncho- Vaxom worked developed countries suffered from diseases less than children in to reduce a use of antibiotics in children with recurrent acute developing countries. respiratory infections. Evaluating Broncho – Vaxom’s efficacy and safety when using * Safety and acceptance of community fori Broncho – Vaxom. for children who had current acute respiratory infections several This drug was safe and well tolerated because out of 52 cases, times in the intervention group. that used Broncho- Vaxom, did not have any cases with side-effects. * Reducing a number of diseased times In addition to health efficiency, we also found that it had a social Since in practice, we found some young children due to efficiency: the acceptance of community and the information features such as: premature, allergies, deformities, malnutrition ...etc, obtaining from interviews, focus group discussions of mothers also so their resistance was week. Although these young children were showed that it was very difficult for mothers to approach at first stage well cared by their parents, they still suffered from ARI a lot of of implementation because mothers had not noticed the effects of times. One of the main points in this study was that if after one year drug, were afraid of letting kids use drug for a long time and in many was intervened by the health education communication, children still times. However, after several months, mothers responded suffered from ARI many times ( AURI ≥10 times/year or ALRI = at enthusiastically. After using Broncho- Vaxom, many children did not least 3 times/year), these children would be asked to use Broncho- suffer from ARI or less relapsed and had a mild illness. In addition to Vaxom. The result found that children had used Broncho- Vaxom , the prophylactic benefits for children, economic aspects and the recurrent acute respiratory infections were clearly dropped (Table satisfaction of the families also were considered when children were 3.33). It was shown by a decrease in the general episodes of ARI given drugs against ARI. It was estimated that total cost for care and after using Broncho- Vaxom (3.54 ± 2.38) as compared to before treatment per one ill episode ranged from 200,000 VND to 2 millions using Broncho- Vaxom (12.46 ± 3.60), with p
21 22 Our study results were consistent with recent studies on For children: the incidence, the recurrent rate and the severity of efficacy and safety of Broncho- Vaxom in prevention of ARI in disease were deceased. That motivated the community to receive and children conducted by Nguyen Tien Dung, Le Thi Hoan et al (2007), to actively participate. The acceptance of community to intervention Pham Thu Hien, Đao Minh Tuan (2010), Zielnik-Jurkiewicz B (2005). models of ARI control in children was embodied in the voluntary 4.3.2.2. Impact of intervention to reduce the prevalence of ARI participation and the technology transfer of the theme for a local in children in the community. authority and that was the sustainability of intervention measure. Our study results showed that in the intervened and the control sites during both before and after intervention, the prevalence of ARI ơ CONCLUSIONS in children was significantly different, presented in Table 3.40. Table 3.40 showed that the prevalence of ARI in the intervention group 1. Some epidemiological characteristics of acute respiratory infections decreased from 42.2% (before intervention) to 24.3% (after in children under 5 years old at the study sites before the intervention. intervention), 45.7% (in the control), with p
23 24 - Mother’s poor practice in the intervention group decreased * Results of following up children taking Broncho-Vaxom were from 81.3% (before intervention) to 14.5% (after intervention), better than before taking Broncho-Vaxom. 76.2% (in the control) with p
LIST OF REPORTED WORKS RELATED TO THESIS 1. Dam Thi Tuyet, Nguyen Thanh Trung (2009), "The acceptance by the community for intervention measures in prevention of control of acute respiratory infections in children under 5 years in Cho Moi District, Bac Kan province", Journal of Practical Medicine, Hanoi, 40 (680), Pg: 50 - 55. 2. Dam Thi Tuyet, Mai Anh Tuan, Nguyen Thanh Trung (2010), "The impact of health education communication to the knowledge, attitude and practice in prevention and control of acute respiratory infection of mothers with children under age 5 in Cho Moi District, Bac Kan Province”, Journal of Practical Medicine, Hanoi, 2 (705), Pg: 79 - 83. 3. Dam Thi Tuyet, Nguyen Thanh Trung, Truong Viet Dung (2010), "Efficacy and safety of Broncho-Vaxom in the prevention of acute respiratory infections in children under 5 years old in Cho Moi District, Bac Kan province", Journal of Practical Medicine, Hanoi, 8 (730), Pg: 31- 34.