Rational use of antibiotics by community health workers and caregivers for children with suspected pneumonia in Zambia: a cross-sectional mixed methods study

Abstract

BackgroundAntibiotic resistance is an issue of growing global concern. One key strategy to minimise further development of resistance is the rational use of antibiotics, by providers and patients alike. Through integrated community case management (iCCM), children diagnosed with suspected pneumonia are treated with antibiotics; one component of an essential package to reduce child mortality and increase access to health care for remote populations. Through the use of clinical algorithms, supportive supervision and training, iCCM also offers the opportunity to improve the rational use of antibiotics and limit the spread of resistance in resource-poor contexts. This study provides evidence on antibiotic use by community health workers (CHWs) and caregivers to inform iCCM programmes, safeguarding current treatments whilst maximising access to care.Methods1497 CHW consultations were directly observed by non-clinical researchers, with measurement of respiratory rate by CHWs recorded by video. Videos were used to conduct a retrospective reference standard assessment of respiratory rate by experts. Fifty-five caregivers whose children were prescribed a 5-day course of antibiotics for suspected pneumonia were followed up on day six to assess adherence through structured interviews and pill counts. Six focus group discussions and nine in depth interviews were conducted with CHWs and caregivers to supplement quantitative findings.ResultsThe findings indicate that CHWs adhered to treatment guidelines for 92 % of children seen, prescribing treatment corresponding to their assessment. However, only 65 % of antibiotics prescribed were given for children with experts’ confirmed fast breathing pneumonia. Qualitative data indicates that CHWs have a good understanding of pneumonia diagnosis, and although caregivers sometimes applied pressure to receive drugs, CHWs stated that treatment decisions were not influenced. 46 % of caregivers were fully adherent and gave their child the full 5-day course of dispersible amoxicillin. If caregivers who gave treatment for 3 to 5 days were considered, adherence increased to 76 %.ConclusionsCHWs are capable of prescribing treatment corresponding to their assessment of respiratory rate. However, rational use of antibiotics could be strengthened through improved respiratory rate assessment, and better diagnostic tools. Furthermore, a shorter course of dispersible amoxicillin could potentially improve caregiver adherence, reducing risk of resistance and cost.

How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review

“…All observational studies reported on the use of healthcare information during consultations, which is reported in table 3 for nine studies involving a survey and in table 4 for the five qualitative studies. The most mentioned information sources used during consultations were books,7 19–23 leaflets,20 guidelines,7 20 21 24–28 a flip chart and reporting form aid,29 and the internet 7 21 24 26 30 31. A survey conducted in Harare, Zimbabwe, in 2006 found that 28 out of 46 community pharmacists (61%) used the internet for practice and 23 (50%) mentioned using Google 24.…”

“…A more recent survey in Nigeria in 2016 found that 46 out of 115 community pharmacists (40%) searched the internet several times a day for drug information and only 8 (7%) never searched the internet 30. A study observing community health worker consultations with children who had suspected pneumonia in Zambia found low use of the flip chart and reporting form aid and suggested this might be because community health workers were confident in their recall of the diagnostic integrated community case management algorithm 29. Reasons for not using books were that it took too much time to use them,7 23 prescribers felt confident in their decisions, were too busy or felt ashamed to use it in front of patients 23.…”

“…Our review fills this gap by providing evidence on tools and aids. The most mentioned information sources used during consultations were books,7 19–23 leaflets,20 guidelines,7 20 21 24–28 a flip chart and reporting form aid,29 and the internet 7 21 24 26 30 31. The nine intervention studies assessed tools such as electronic versions of algorithms for the management of childhood illness and mobile-based medicine and dosing tools for different diseases (general, respiratory disease, depression, cardiovascular disease).…”

Exploring the roles and factors influencing community health workers’ performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa

“…Therefore SA needs to set up a more comprehensive training program because CMAM alone requires advanced skills of routine growth monitoring, administering antibiotics and RUTF (Puett et al, Puett, Sadler, et al, ). Intervention‐based CHWs in and Zambia have proven capable of administering appropriate amounts of antibiotics for SAM and pneumonia and are thus not liable to errors that can cause future antibiotic resistance (Graham et al, ; Puett et al, Puett, Sadler, et al, ). Since prescribing antibiotics is a critical component of CMAM, it is unknown if CHWs in SA will be granted the rights to administer them.…”

Optimising adherence to childhood pneumonia treatment: the design and development of patient instructions and a job aid for amoxicillin dispersible tablets

“…Even when antibiotics are available, a third of children may not complete the full course of treatment 5. This illustrates an additional issue in delivering effective treatment for childhood pneumonia: ensuring adherence to the treatment regimen.…”