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LONG-TERM IMPACT OF AN MTP APPROACH
TO REDUCE INAPPROPRIATE USE OF
ANTIBIOTICS
IN ACUTE RESPIRATORY-TRACT INFECTION
Yudatiningsih I.,Sunartono
H.
Sleman District Health
Office, Indonesia
ABSTRACT
Problem Statement: An MTP (Monitoring-Training-Planning) approach is an innovative new way to change
behavior through an adult-learning, problem-based intervention. The MTP approach includes the use of
indicators to measure the magnitude of the problem (monitoring component), discussion about underlying
factors and how to improve the situation (training component), and setting the improvement target (planning
component). Because MTP is a self-learning activity involving all providers in health facilities, it is expected
that the impact will be sustainable.
Objectives: To evaluate the long-term impact of an MTP approach to reducing inappropriate antibiotic use in
acute respiratory infections (ARIs).
Disigns: A time-series pre and post-intervention without a control group. Twenty-four health centers were
involved, and each conducted an MTP activity for antibiotic overuse in ARI in August 1999. Feedback was
given in October, 2000 (14 months post-intervention), February 2002 (30 months), and May 2003 (45
months), followed by serial data collection. The percentage of patients receiving antibiotics was calculated
based on 30 prescriptions/month randomly selected from each facility.
Study Population: Children aged 0–14 years with ARI as a single diagnosis.
Interventions: MTP and feedback.
Outcome Measure: Percentage of children with ARI receiving antibiotics.
Results: All facilities reported that MTP reduced inappropriate antibiotic use, from an average of 50%–20%.
In month 44, data showed that the average percentage of antibiotic use was 17%, which further decreased to
13% in month 48. In parallel to the activity to reduce antibiotic use in ARI, all health centers also used the
MTP approach to address other problems in medicine use, such as reducing inappropriate use of antibiotics
in children with acute diarrhea, increasing the appropriateness of antibiotic use in selected cases, reducing
inappropriate use of corticosteroids in children with ARI, and reducing polypharmacy. The cost to conduct
MTP activities was affordable for the health centers. It was recognized from the feedback meetings that all
prescribers were very optimistic and took an active role in proposing solutions.
Conclusions: An MTP approach, in combination with feedback, significantly reduced the inappropriate use of
antibiotics in ARI, and the impact was sustained after almost four years. With intensive discussion and selflearning activities during the process, MTP sensitized prescribers to be more proactive in promoting
appropriate drug use.
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.
EFFORTS IN IMPROVING DRUG
USE PRACTICES

Inappropriate drug use practices are leading to medically ineffective, unsafe and
economically inefficient use of pharmaceuticals (Santoso, 1998)

A study done in 1999 by Santoso et al.,however, showed that a MTP approach was
effective in improving the rational use of antibiotics. Field test of the MTP approach
were conducted in public hospital, private hospital, and health centers

MTP approach is a new innovative approach to change the behaviour by adopting
adult-learning problem based approach. It includes the use of indicator to measure
the magnitude of the problem (Monitoring component), discussion on underlying
factors and how to improve the situation (Training component) and setting the
target of improvement (Planning component)

The research experience in Gunung Kidul showed that the continuity of the selfmonitoring process was guaranteed by a regular feedback (Sunartono and
Darminto, 1995)

Various interventions have been conducted in Sleman, including MTP and small
group discussions. Are the interventions impact as expected? Are the intervention
impacts suistainable?
OBJECTIVE
To evaluate the long-term
impact of MTP approach
in reducing inappropriate
antibiotic use in acute
respiratory tract infections
(ARIs)
METHODS
Design:
retrospective,
descriptive-analytical
Time-series
data collection on
prescribing practices
Involving
24 HCs in Sleman
District, Yogyakarta, Indonesia
DESCRIPTION OF ACTIVITIES 19992003

MTP activity involved all prescribers in 24 HCs, consisted of
doctors, nurses, and midwives. Each HC conducted MTP
activity in August to October,1999.

24 health centers (HCs) were involved, each underwent MTP
activity in Aug-Oct, 1999. The MTP approach was carried out
by each HC and a HC doctor as the MTP team leader

Feedbacks were given in 3 occasions, ie,in October
2000(month 14), February 2002 (month 30), and April 2003
(month 45), each followed by serial data collection by health
office staff

The feedbacks were carried out by district health office staff,
by showing the results of data collections at pre-MTP, postMTP and pre-feedback to feedbacks

The feedbacks were conducted in district health office, and
each lasted in 2 hours
TIME-LINE OF
ACTIVITIES
MTP
24
HCs
pre
post
Aug’99
1999
Feedba
ck
in
month
14
pre
Feedba
ck
in
month
30
post
pre
Oct’00
2000
Feedbac
k
in month
45
post
Feb’02
2001
pre
post
April ‘03
2002
2003
DATA COLLECTION

% patients receiving antibiotics for ARI treatment (0 14 years old) was calculated based on 30 randomly
selected prescriptions per month at each HC

This prescribing surve covered the period 1 months
before and during MTP period, 6 months before and
after feedback in month 14 (Apr 2000 – Apr 2001), 3
months before and after the feedback in month 30
(Nov 2001 - May 2002), and 3 month before and
after the feedback in month 45 (Jan-Jul, 2003)

Data were collected by staff from the district health
office who had been trained in data collection
methods as recommended by WHO.
RESULTS: ANTIBIOTIC USE

24 HCs reported that MTP reduced inappropriate
antibiotic use in ARI treatment, from an average of
50% to 20%

In month 13, data on antibiotics use tended to
increase (from 20% to 35%). However, compared to
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 the impact of MTP still exist after a long
period of time.

In month 14, data showed that the average %
antibiotics was further decreased to 26%.
ANTIBIOTICS USE
OVERTIME
100
80
60
MTP
at 24 HCs
Feedback
in month-14
Feedback
in month-30
Feedback
in month-45
40
20
0
Ags99 Nop99 Feb-00 Mei00 Ags00 Des00 Mrt01 Jun01. Sep01. Des01. Apr02. Jul02. Okt02. Jan03. Apr03. Ags03.
DISCUSSIONS

In month 44, data showed that the average % antibiotics was 17%, and
further decreasing to 13% in month 48. This means that the feedback is
shown by the study to be effective in reducing the use of ABs in the ARI
treatment.

In parallel to the activity to reduce AB use in ARI, all HCs have also been
conducted MTP approach to address other problems in medicine use
e.g.,reducing inappropriate use of AB in children with acute diarrhoea,
increasing the appropriateness of AB use in selected cases, reducing
inappropriate use of corticosteroids in children with ARI, reducing
polypharmacy, etc. Moreover, cost to conduct MTP activities was
affordable to each HC

It was recognised from the feedback meeting, that all prescribers were
very positive and took an active role in proposing solutions
CONCLUSIONS

MTP approach, enforced by feedback, significantly reduced
the inappropriate use of antibiotics in acute respiratory tract
infection

4 years after its implementation, MTP activities are still going
on in health centers. In fact, MTP has been used by HC not
only for ARI, but also for addressing other drug use problems

Because the MTP approach is effective, easy to implement,
less costly, and promotes capacity building in HCs, it currently
becomes an integral part of the district stategies to improve
the quality of health services