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THE IMPORTANCE OF FEEDBACK TO
ENHANCE THE IMPACT OF EFFECTIVE
INTERVENTIONS TO REDUCE
ANTIBIOTICS IN ACUTE RESPIRATORYTRACT INFECTION
Yudatiningsih I.1,Sunartono H.1,SuryawatiS.2
1Sleman District Health Office,
2 Center for Clinical Pharmacology and Drug
Policy Studies, Gadjah Mada University,
Yogyakarta, Indonesia
ABSTRACT
Problem Statement: To gain a maximum impact, efforts to improve rational use of medicine should be
continuously conducted, especially at the primary health service level. The Sleman District Health Office
conducted a managerial intervention using Monitoring-Training-Planning (MTP)strategy at 31 health centers
(HCs) in 1999. The MTP activity reduced antibiotic use for acute respiratory infection (ARI) from 50% to 20%.
One year after MTP, antibiotic use was measured again, and the result showed that it varied among HCs
from 12% to 53%. This finding indicated that the antibiotic use after MTP could increase again, and therefore
enforcement efforts should be conducted. References indicated that feedback is effective in enforcing the
impact of interventions
Objectives: To evaluate whether feedback could maintain the effect of MTP in reducing the use of antibiotics.
Design: Randomized controlled study with parallel design .
Setting and Populations: Twelve of 25 HCs were randomly selected to participate in the study. They were
randomly assigned into two groups: the test group (6 HCs) received feedback and the control group (6HCs)
did not receive feedback. Data collection was conducted at 6 month before and 6-month after the feedback
sessions.
Intervention: Feedback was carried out by district health office staff in a single 2-hour meeting at the district
health office, including the presentation of pre-MTP, post-MTP and pre-feedback data. Participants in the
feedback meeting consisted of doctors, nurses, and midwives from 6 HCs.
Outcome Measures: % antibiotics given and average number of drugs per encounter for ARI treatment in
children 0-14 years old.
Results: Compared with the MTP results, the pre-feedback data on antibiotic use showed an increase,
although it did not achieve the level o significance (p>0.05). After feedback, the test group showed a
significant decrease in % antibiotics given (from 34% to 11% ) and the average number of drugs per
encounter (from 3.5 to 3.2), while the control group showed a significant increase in % antibiotics (from 35%
to 40%) and average number of drugs per encounter (from 3.6 to 3.7). This means that MTP has a lasting
impact, but the feedback enhanced the impact significantly.
Conclusions: Feedback enhances the impact of even an effective intervention such as MTP.
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.
BACKGROUND (Con’t)

In 1999, Sleman district health office conducted a
managerial intervention using Monitoring-TrainingPlanning (MTP) strategy to improve use of medicine at
31 HCs

The MTP activity reduced the antibiotics use for ARI
from 50% to 20%.

One year after MTP, the antibiotics use was reevaluated. The result showed that it varied among
HCs, from 12% to 53%

This finding indicated that the antibiotics use after MTP
increased, therefore enforcement should be
conducted. Previous studies suggested that feedback
is effective to enforce the impact of interventions
OBJECTIVES
To evaluate whether a
feedback could maintain
the effect of MTP
(Monitoring - Training Planning) in reducing
the use of antibiotics
DESIGN AND SAMPLE SELECTION

Design: randomised control study with parallel design

It involved 12 HCs in Sleman district, Yogyakarta, Indonesia

Prescribers included physicians, nurses and midwife per HC

12 of 25 HCs underwent MTP were randomly selected to
participate in the study

12 HCs were randomly assigned into 2 groups: the test group
(6 HCs) received feedback and the control group (6HCs) did
not receive feedback

Data collections were conducted for 6 month before and 6
month after feedback
FEEDBACK INTERVENTION

The feedback was carried out in October, 2000. The
prescribers consist of 1 doctor, 1 nurses, and 1 midwife in
each health centers (test group) were involved in the study.
They were invited to feedback meeting in health office of
Sleman district

The feedback was conducted one time only for the test
group, and lasted in 2 hours. The meeting were conducted
in the formal setting in district health office

In this study, the feedback was carried out by district health
office staff to show them the data collections displayed
their pre-MTP, post-MTP and pre-feedback performances
THE RESEARCH ACTIVITY
This Study
Feedback
pre
6
25
HCs
6
5
4
post
3
2
1
1
2
3
4
5
6
Test Group
12
Analysis
HCs
6
Control Group
Underwent
MTP
May Jun Jul Aug Sep Okt Nop Des
1999
2000
Jan Feb Mrt Apr
2001
ANALYSIS

The percentage patients receiving antibiotics and average
number of drug per encounter for ARI treatment in children 0
- 14 years old were calculated based on 100 randomly
selected prescriptions/ month at each HC

This survey covered the period of 6 months before the
feedback (April - September, 2000) and 6 months after the
feedback (November, 2000 - April, 2001). Data were
collected by staff from the district health office who had been
trained in methods recommended by WHO

The pre-post change of the study outcomes was then
computed, and Student’s t-test were applied to test the
difference between the average change in the test group
and the control group
RESULTS

The study and control groups were similar during the baseline period in
rate of antibiotics use (34% of patients in the test group vs. 35%
among control), and in the number of drugs prescribed per patient
encounter 3.5 vs 3.6. Non of these differences was statistically
significant

Compare 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 MTP has a long –term impact

After feedback, the test group showed a significant decrease of
antibiotic use (from 34% to 11%) and the average number of drug per
encounter (from 3.5 to 3.2), while the control group showed significant
increases in antibiotic use (from 35% to 40%) and average number of
drug per encounter (from 3.6 to 3.7). This means that the feedback is
effective in further reducing the use of ABs in the ARI treatment.
ANTIBIOTIC
TREATMENT
USE
IN
ARI
100
80
This Study
60
Control Group
Underwent
MTP
40
20
Test Group
Feedback
0
9
s' 9
Ag
p '9
Se
9
Ok
9
t'9
9
p'9
No
s
De
'9 9
0
n '0
Ja
Fe
0
b'0
t '0
Mr
0
0
r'0
Ap
i'
Me
00
0
n '0
Ju
0
l '0
Ju
g '0
Au
0
p '0
Se
0
0
p'0
No
s
De
'0 0
1
n '0
Ja
Fe
1
b'0
t '0
Mr
1
1
r'0
Ap
THE NUMBER OF DRUGS
PRESCRIBED PER PATIENT
10
8
This Study
6
Control Group
Underwent
MTP
4
Test Group
2
Feedback
0
9
s' 9
g
A
p '9
Se
9
Ok
9
t'9
9
p'9
o
N
s
De
'9 9
0
n '0
Ja
Fe
0
b'0
t '0
Mr
0
0
r'0
Ap
i'
Me
00
0
n '0
Ju
0
l '0
Ju
g '0
Au
0
p '0
Se
0
0
p'0
o
N
s
De
'0 0
1
n '0
Ja
Fe
1
b'0
t '0
Mr
1
1
r'0
Ap
CONCLUSIONS
Feedback
is proven effective to
strengthen an intervention to
reduce the use of antibiotics in
health centers
Feedback
enhances the impact of
even an effective intervention such
as MTP