Several epidemiological characteristics and interventional efficiency for acute respiratory infections in children under 5 years-old at Cho Moi district in Bac Kan pr

THAI NGUYEN UNIVERSITY
UNIVERSITY OF MEDICINE AND PHARMACY




AM THI TUYET



SOME EPIDEMIOLOGICAL CHARACTERISTICS
AND INTERVENTION EFFECIENCY FOR
RESPIRATORY INFECTIONS IN CHILDREN UNDER 5 YEARS
AT CHO MOI DISTRICTS IN BAC KAN PROVINCE





Specialty: Social Hygiene and Health Organization
Code: 62.72.73.15



SUMMARY OF PhD THESIS

Thai Nguyen - Year 2010


The work was completed in:
Medico-Pharmaceutical University - Thai Nguyen University




Advisors:
1. Assoc. Prof.,PhD. Nguyen Thanh Trung
2. Prof.,PhD. Trong Viet Dung

Opponent 1:

Opponent 2:

Opponent 3:



The thesis will be protected in Thesis Committee in National Level
held in Thai Nguyen Medico-Pharmaceutical University
At in
.
, , 20


The information from this thesis can be found at:

- National Library
- Learning Resource Center - Thai Nguyen University
- Library of Thai Nguyen Medico-Pharmaceutical University

1
INTRODUCTION

Acute respiratory infections are very common diseases with the
highest morbidity and mortality in children, especially pneumonia
among under-five children in developing countries.
In Viet Nam, every year about 32 - 40 million episodes of
children suffer from acute respiratory infections and about 22 –
24,000 children have died from pneumonia. In disadvantaged, remote
areas, pneumonia is still a cause of a leading death in children. Now,
acute respiratory infections in children accounts for approximately
39.7% in the community. In general, main causes of acute respiratory
infections are due to viruses, bacteria, pulmonary tuberculosis in
children and fungus. In addition, owing to the impact of risk factors
such as environmental pollutions, cramped housing, smoke of the
cooking, tobacco smoke, low birth weight, malnourished children,
diarrhea and climate changes. Mother’s early recognition of signs of
respiratory infections as well as how to care for children with
respiratory infections is still limited, especially mothers living in the
mountainous, remote areas.
So, well done to prevent acute respiratory infections in children
will reduce the morbidity and mortality in children, particularly
children under 5 years old and since that it will reduce funding to pay
for drugs, medical services in hospitals, reduce the overload by
children with acute respiratory infections treated in the hospital,
reducing time of mothers to leave work to care for sick children.

Therefore, we conducted the theme: “Several epidemiological
characteristics and interventional efficiency for acute respiratory
infections in children under 5 years old at Cho Moi district in
Bac Kan province”aiming at:
1. Describe several epidemiological characteristics and
interventional efficiency for acute respiratory infections in children
under 5 years old at Cho Moi district in Bac Kan province.
2. Identify several risk factors related to acute lower
respiratory infections .
3. Evaluate effectiveness of interventional measures for acute
respiratory infections in the community.


2
NEW CONTRIBUTIONS OF THE THESIS

The thesis has identified a situation of acute respiratory
infections in children under 5 years old in Cho Moi District, Bac Kan
province remaining high.
The study was carried out in mountainous areas, highlands,
disadvantaged areas, ethnic minorities. In there, people’s living
conditions remained poor, backward and less access to information,
and their awareness was slow, but if intervened by the health
education communication with appropriate methods such as oral
propaganda in ethnic minority languages combining with posters,
leaflets, video tapes, local simple terms, easily to understand would
bring results and attract the community to participate
The intervention measure has mobilized local human
resources, attracted the participation of the community, close
coordination between the commune health centers, village health

workers and people, easily to mobilize, possible to work at all time,
any where.
The iinterventional measure has a horizontal impact and depth:
Width: The health education communication for mothers with
children under 5 years old or caregivers for detection, classification,
treatment, care , acute respiratory infection control in children.
Depth: Medical care at Home: Children were followed up in
the households to detect and classify a disease and thus children were
cared for at home, then referred to the commune health center to
exam and treat if a severe disease. Educating knowledge, attitude,
practice for mothers aimed a change of mother’s behaviors in the
respiratory infection control among children.
The immune - enhancing drugs (Broncho-Vaxom) was firstly
used for acute respiratory infection control among children in the
mountainous community, highlands and ethnic minorities.
STRUCTURE OF THESIS
The thesis includes 107 pages, 45 tables, 8 figures, 2 photos, 3
diagrams and 147 references in which 76 are in Vietnamese and 71
are in English. Key parts of thesis: Introduction: 02 pages, Chapter 1.
Literature review: 18 pages, Chapter 2. Subjects and method: 19
pages, Chapter 3. Results: 37 pages, Chapter 4. Discussion : 28 pages
Conclusions and recommendations : 03 pages

3
CHAPTER 1:
LITERATURE REVIEW

1.1. Current status of acute respiratory infections
Currently, in developing countries, respiratory tract infectious
diseases are still a cause of a leading mortality and morbidity in

children under 5 years old, mainly due to pneumonia According to
the World Health Organization (WHO), every year, each child suffers
from acute respiratory infections from 4-9 times. Estimating globally,
each year about 2 billion episodes of children suffer from respiratory
infections, accounting for 19-20% of deaths in children under 5 years
old worldwide.
According to a research by Ruan I. (2005), estimating the
incidence of pneumonia episodes in children under 5 years on a
global scale showed that the incidence of pneumonia episodes in
developing countries was 0.29 episode per year per child. In
developed countries, this rate was 0.026 episode per year per child
and over 95% of pneumonia episodes in children in the world
occurred in developing countries
In 2003, a study on a situation and some main risk factors
related to respiratory infections in children under 5 years old at Thuy
Duong - Huong Thuy, Thua Thien Hue conducted by Nguyen Van
Thieu and Nguyen Huu Ky States showed that the prevalence of
acute respiratory infections in the community was still high (39.7%).
In 2007, the Central Tuberculosis and Lung Hospital and
Project of Acute Respiratory Infections in Children held a workshop
on “Deployment of project activity plan of acute respiratory
infections in children in key provinces in 2007 and the 2007-2010
period” and reported that the highest prevalence of acute respiratory
infections in recent years was in the mountainous provinces, followed
by Central Coast and Plains.
1.2. Causes and risk factors related to acute respiratory
infections
1.2.1. Causes of acute respiratory infections
Viruses were the most common causes resulting in acute lower
respiratory infections in children under 5 years old and was the

leading cause of hospitalization and death in children. The common

4
viruses included: respiratory syncytium virus (RSV), influenza virus,
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
acute respiratory infections and mainly bacteria were pneumococcus
and H. influenzae.
1.2.2. Risk factors related to acute respiratory infections
Risk factors related to acute respiratory infections in children
were: Socio-natural environment, health systems, mother’s
knowledge, attitude, practice (KAP) and biological factors. But in the
mountainous area, these risk factors are little considered and this is
an issue that we need to think.
1.3. Several intervention measures against respiratory infections
done in the world and Vietnam
- The group of intervention : Impact on knowledge, attitude
and practice of mothers or caregivers
- The group impacting on child care health systems
- The group impacting on the socio-natural environment
- The group impacting on biological factors.

Chapter 2
SUBJECTS AND METHODS

2.1. Study subjects
- Children under 5 years (from 60 months old or younger).
- Mothers with children under 5 years old or caregivers.
- Leaders of the community: Leaders of the commune, head of

Health Department.
- Commune health workers, village health workers.
2.2. Study setting and duration
2.2.1. Setting: Cho Moi District, Bac Kan Province
2.2.2. Duration: The study was carried out from December 2006 to
January 2009
2.3. Methodology
2.3.1. Study Design
- Descriptive study: A study conducted by a cross-sectional
survey to describe a real situation of acute respiratory infections and

5
at the same time to analyze to determine factors associated with acute
lower respiratory infections.
- Intervention study: Before - after intervention design with a
control group
2.3.2. Sampling method
* Sample size for a descriptive study: Calculated by the
following formula:
()
2
2
.
1
2
(.)
pq
nZ
p
α

ε
=−

n = 1038 children
The minimum sample size was 1038 children for the
descriptive study . In fact, we investigated 1152 children.
* Sample size for a intervention study: Calculated by the
following formula:
()
(
)
(
)
()
112 2
2
,
2
12
11ppp p
nZ
PP
−+ −
=
−
αβ

Changing data into the formula, we have: the intervention
sample size for mothers: n = 554 mothers.
The intervention sample size for children : n= 455 children

Thus, to make sure of ethics in research, we would conduct the
intervention in all mothers with children under 5 years and all
children aged 5 years in 4 intervened communes.
2.3.3. Study indicators
̊ Indicators on current status of acute respiratory infections
in under-five children in study settings before intervention: Clinical
examination
̊ Indicators on association between mother’s
knowledge,
practices and acute lower respiratory infections: Interviewing and
observing mother’s practices.

6
̊ Indicators on risk factors related to acute lower
respiratory infections: Interviewing and observing a housing
conditions and hygiene.
̊ Classification of related factors according to model of
logistic regression.
̊ Intervention efficiency index in research.
¬ Output index: Percentage of mothers with KAP changes
after intervention
¬ Impact index:
* Longitudinal follow-up index in the community:
- Incidence density by year, episodes of acute respiratory
infections by season, morbidity rate after using Broncho -Vaxom
during intervention.
- Morbidity of acute respiratory infections after using Broncho- Vaxom
- Rate of children using antibiotics after using Broncho- Vaxom
* Evaluation index after intervention in a intervention group
and a control group: The prevelence of acute respiratory infections

after intervention (Compared with the prevalance before intervention)
̊ Intervention efficiency index in qualitative research to
evaluate an acceptance of the community:
̊ In-depth interviews, group discussions: Leaders of the
community, mothers, village health workers, commune health workers
to evaluate an acceptability of the community for intervention measures
2.4. Intervention contents
Arragement of the community, deployment of health education
communication, longitudinal follow-up of acute respiratory infections in
children in the community, preventive intervention by immune-
enhancing drugs, evaluation after intervention.
2.5. Data processing and analyzing
Data were entered and processed and analyzed by using
SPSS16.0 , Epidata, EPI-INFO, EXCEL.

7
Chapter 3
STUDY RESULTS

3.2. Some epidemiological characteristics of acute respiratory
infections in children under 5 years old at the study sites
- The prevalence rate of acute respiratory infections in children
before intervention was 43.9%, acute upper respiratory infections
(36.1%), acute lower respiratory infections (7.8%). The prevalence of
acute upper respiratory infections (AURI) in a group of children aged
36-60 months was highest (41.0%), higher than a group of children
aged 2 - <12 months (27.1%), with p <0.01. The prevalence of acute
lower respiratory infections (ALRI) in a group of children aged 2 -
<12 months was highest (11.0%), higher than a group of children 36-
60 months (4.7%), with p <0.01.

- The prevalence of acute lower respiratory infections in the
H
’
Mong ethnic minority children was highest (26.3%), followed by
the Dao ethnic minority children (9.9%), the Nung (9.6%), the Tay
(7.0% ) and the Kinh majority children was the lowest (6.7%). The
difference in the prevalence between the H
’
Mong children and the
Tay and the Kinh was statistically significant, with p<0.01. (Table 3.6)
3.3.2. Factors related to acute lower respiratory infections
- A type of temporary house and a desolate, damp condition of
house, indoor stoves, animal sheds near the house, indoor smoking
were factors associated with acute lower respiratory infections in
children. A group of children living in conditions of above –
mentioned poor housing hygiene had a higher risk of respiratory
infections from 2.28 times to 3.44 times, with p <0.05 (Table 3.12)
- The time of weaned children closely related to the situation of
acute lower respiratory infections. A group of children weaned early
(<12 months) had a risk of respiratory infections to be 7.82 times
higher than a weaned group of children (>18 months), with p<0.01.
Immunization status was also closely related to the situation of acute
lower respiratory infections in children. Children who were not fully
vaccinated or were fully vaccinated but an incorrect schedule had a
risk of acute lower respiratory infections to be 8.24 times higher than
the children who were fully vaccinated and according to a correct
schedule, with p <0.01 (Table 3.13).

8
- Mother’s knowledge on child care was closely related to

acute lower respiratory infections. Children of mothers with poor
knowledge had a risk of acute lower respiratory infections to be 3.69
times higher than children of mothers with a good and average
knowledge , with p <0.01 (Table 3.14)
- Mother’s child care practices were closely related to acute
lower respiratory infections in children. Children of mothers with
poor practices had a risk of acute lower respiratory infections to be
5.18 times higher than children of mothers with a very good and
average practices, with p <0.01 (Table 3.15).

Table 3.16. Assessing related factors according to models of logistic
regression
Related factors included in
regression models
Crude OR
( 95% CI)
Adjusted OR
( 95%CI)
p
(adjusted)
Not fully vaccinated or fully
but incorrect schedule
8.24
{4.34-15.66}
10.8
{3.96-29.85}
<0.01
Early weaned < 12 months
old
7.82

{3.06-17.97}
4.39
{1.82-10.56}
<0.01
Poor child care practice
5.18
{2.06-13.01}
4.61
{1.82-11.67}
< 0.01
Poor child care knowledge
3.69
{1.58-8.65}
3.38
{1.43-7.9}
< 0.01
Type of temporary house
3.44
{1.03-11.42}
1.47
{0.83-2.62}
> 0.05
Damp condition of house
3.08
{1.94-4.89}
1.85
{1.2-3.41}
< 0.05
Animal sheds near the house
2.51

{1.46-4.32}
2.0
{1.14-3.52}
< 0.05
Mother’s education
≤ primary school
2.46
{1.07-5.70}
1.43
{0.89-2.29}
> 0.05
Smoking
2.43
{1.34-4.40}
3.29
{1.52-7.13}
< 0.01
Indoor stoves
2.28
{1.46-3.57}
1.75
{1.01-3.03}
< 0.05

9
Table 3.16 showed that the leading related factor was
children’s vaccination (adjusted OR = 10.80), the second was the
child care practice (adjusted OR = 4.61), the third was time of
weaned children (adjusted OR = 4.39), followed by knowledge
(adjusted OR = 3.38). A family with smokers, animal sheds near the

house, damp conditions of the house, indoor stoves, mother's
education and a housing type were confounding factors.
3.4. Intervention effectiveness for acute respiratory infection
control in children
3.4.2. Effectiveness of intervention model
3.4.2.1. Output results of intervention
Results of intervention for mother’s KAP change :
* Impact of intervention for mother’s knowledge change
Table 3.23. Efficiency of intervention for mother’s knowledge change
Intervened group Control
Before
interventi
on (1)
(n = 593)
After
interventi
on (2)
(n = 627)
First
Survey (3)
(n = 456)
Final
survey (4)
(n = 450)
Site



Score
scale

n % n % n % n %
p


Efficiency index
(%)
Effectiveness of
intervention
(%)
Poor 514 86.7 40 6.4 376 82.5 349 77.6
p
1&2
< 0.01
p
3&4
> 0.05
p
2&4
< 0.01
Interventio
n: 92.61
Control:
5.94
86.67
Average 79 13.3 356 56.8 80 17.5 99 22.0
p
1&2
< 0.01

p
3&4
> 0.05
p
2&4
< 0.01
Interventio
n: 327.06
Control:
25,71
301.35
Fair,
well
0 0 231 36.8 0 0 2 0.4
p
1&2
< 0.01


p
3&4
> 0.05
p
2&4
< 0.01
Interventio
n: 36.8
Control:
0.4
36.40

10
Table 3.23. showed that :
After 2 years of intervention, mother’s knowledge on acute
respiratory infections was markedly improved:
Poor knowledge in a intervention group decreased to 6.4%
(after intervention) from 86.7% ( before intervention) , 77,6% (in the
control), efficiency of intervention was 86.67%, with p < 0.01.
An average and good knowledge in the intervention group was
increased as compared to before intervention and a control group.
Effectiveness of intervention for the average knowledge was 301.35%
and for the fair and good knowledge was 36.40%, with p < 0.01.
* Impact of intervention for mother’s child care at home
Table 3.25. Results to change mother’s healthcare service
Intervention group Control
Before
interventi
on (1)
(n = 593)
After
interventi
on (2)
(n = 627)
First
survey (3)
(n = 456)
Final
survey (4)

(n= 450)
Study site
Indicator
n % n % n % n %
p


Untreated at
home
17 2.9 7 1.1 13 2.9 12 2.6
p
1 & 2
< 0.05
p
3 & 4
> 0.05
p
2 & 4
> 0.05
Self- buy medicines
and self- treated
at home
87 14.7 22 3.3 49 10.7 51 11.3
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p

2 & 4
< 0.01
To see healers 10 1.7 1 0.2 9 2.0 8 1.8
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.05
To see village
health workers
1 0.2 300 47.8 5 1.1 4 0.9
p
1 & 2
< 0.01

p
3 & 4
> 0.05
p
2 & 4
< 0.01
To commune
health center
(CHC)
407 68.6 532 84.8 312 68.4 316 70.2
p

1 &2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.01
Worship 210 35.4 101 16.1 160 35.1 163 36.2
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.01

11

The Table 3.25.revealed that:
After intervention, the use of health services for mother’s
children had changed markedly: The rate of mothers in the
intervention group took their children to village health staffs more:
from 0.2% (before intervention) up to 47.8% (after intervention) and
0.9% (in the control). Taking children to commune health centers
also increased: from 68.6% (before intervention) up to 84.8% (after
intervention) and 70.2% (in the control). Worship also reduced more
: from 35.4% (before intervention) to 16.1% (after intervention) and

36.2% (in the control).
Table 3.28. Effectiveness of intervention for mother’s child
care practice
Intervention group Control
Before
interventi
on ( 3)
(n=593)
After
interventi
on (4)
(n=627)
First
survey (1)
(n=456)
Final
survey (2)
(n=450)
Time
period




Level
n % n % n % n %
p

Efficiency index
(%)

Effectiveness of
Intervention (%)
Poor 482 81.3 91 14.5 350 76.8 343 76.2
p
1 & 2
<0.01
p
3&4
> 0.05
p
2 & 4
<0.05
CT:82,16
C: 0,78
81.38
Average 73 12.3 139 22.2 71 15.6 76 16.9
p
1 & 2
<0.01
p
3&4
>0.05
p
2 & 4
<0.05
CT:80,49
C:8,33
72.16
Fair ,
well

38 6.4 397 63.3 35 7.7 31 6.9
p
1& 2
<0.01
p
3&4
>0.05
p
2 & 4
<0.01
CT:889,06
C:10,39
878.67

The table 3.28 found that:
After 2 years of intervention, mother’s child care practices on
ARI were improved considerably:
Poor practices in the intervention group dropped from 81.3%
(before intervention) 14.5% (after intervention), 76,2% (in the
control) with p < 0.01, efficiency of intervention was 81.38%, with
p < 0.01.

12
The average and good practices after intervention were
increased as compared to before intervention and the control,
efficiency of intervention was 81.38%, 72.16% and 878.67%,
respectively, with p < 0.01.
3.4.2.2. Impact results
¬ Results of longitudinal follow-up for acute respiratory
infections in children at households by village health staff during

intervention in the intervention group :No child died in the community.
* Incidence density of acute respiratory infections in intervened areas
Table 3.29. Incidence density of acute respiratory infections episode
by year
No pneumonia: Cough
or cold
Pneumonia; Severe
pneumonia
Indicator

Year
Sum of
person-
year at
risk
Episode
Incidence
(Year)
Incidence
/1000
Child-
years
Episode
Incidence
(Year)
Incidence/
1000
Child-
years
2007

758 4118 5.43 5430 533 0.70 700
2008
750 2635 3.51 3510 232 0.31 310
Efficiency
index(%)
35.36 55.71

The Table 3.29 point out that:
- The incidence density according to episodes of no
pneumonia: Cough or cold in 2008 (3.51 episodes/year/child,
equivalent to 3510 episodes/1000 child- years) was lower than that in
2007 (5.43 episodes/year per child, equivalent to the 5430
episodes/1000 child- years), efficiency index reached 35.36%. Thus,
episodes of disease in 2008 decreased as compared to episodes in
2007 was 35.36%.
- The incidence density according to episodes of pneumonia;
severe pneumonia in 2008 (0.31 episode per year per child,
equivalent to 310 episodes /1000 child - years) was lower than that in
2007 (0.70 episode per year child, equivalent to 700 episodes/1000
child - years , efficiency index reached 55.71%. Thus, episodes of
disease in 2008 decreased as compared to episodes in 2007 to be 55.71%.

13
Resuls of longiuidinal follow-up for children who had a
recurrent acute respiratory infections many times in the intervention
group were taken Broncho- Vaxom done by village health staff
Table 3.33. Intervention results to the average number of diseased –
child times before and after medication
Time period
Indicator

Before
intervention
(n = 52)
After
intervention
(n = 52)
p


Decreased as
compared to
before
intervention
Overall ARI
(Episode)
12.46 ± 3.60 3.54 ± 2.38 <0.01 8.92 ± 3.97
AURI (Episode) 8.15 ± 3.71 2.56 ± 2.12 <0.01 5.59 ± 4.03
ALRI (Episode) 4.31 ± 1.05 0.98 ± 0.77 <0.01 3.33 ± 0.90
Average day with ARI 6.40 ± 2.32 2.79 ± 1.71 <0.01 3.61 ± 2.69
The table 3.33 showed that:
- For children using Broncho- Vaxom, the average number of
episodes of ARI, acute upper respiratory infections, acute lower
respiratory infections were dropped. For ARI : After intervention
(3.54 ± 2.38), before intervention(12.46 ± 3.60), decreased more as
compared to before intervention of 8.92 ± 3.97, with p <0.01.
- For the average duration of ARI in children: After
intervention (2.79 ± 1.71 days), before intervention (6.40 ± 2.32
days), decreased more as compared to before intervention of 3.61 ±
2.69 days, with p < 0.01.
Table 3.36. Impact of intervention for using antibiotics in children

before and after taking Broncho- Vaxom
Time period
Indicator
Before
intervention
(n = 52)
After
intervention
(n = 52)
p

Decreased
as
compared
to before
intervention
Number of antibiotic
episodes used
4.15 ± 1.22 1.04 ± 0.81 < 0.01 3.12 ± 1.25
Antibiotics used 52 (100 %) 35 (67.3 %) < 0.01 32.7 (%)

14
The Table 3.36 revealed that:
For children using Broncho-Vaxom, the use of antibiotics in
children with ARI was dropped as compared to before using
Broncho-Vaxom :
- The average episode of using antibiotics in children after
intervention (1.04 ± 0.81), before intervention (4.15 ± 1.22),
decreased as compared before intervention of (3.12 ± 1.25), with p < 0.01.
- The percentage of children using antibiotics after

intervention (67.3 %), before intervention (100%), decreased as
compared to before intervention of 32,7%, with p<0.01.
¬ Assessing a situation of acute respiratory infections in
children after intervention
Table 3.40. Efficiency of intervention for status of ARI in children
Intervention
group
Control
Before
intervent
ion (1)
(n= 654)
After
intervent
ion (2)
(n= 684)
First
survey
(3)
(n= 498)
Final
survey
(4)
(n= 468)
Site
Level
n % n % n % n %
p

Efficiency index

(%)
Effectiveness of
intervention (%)
General
ARI
276 42.2 166 24.3 230 46.2 214 45.7
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.01
Intervention:
42.42
Control:
1.08
41.34
AURI 221 33.8 152 22.2 195 39.2 182 38.9
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.01

Intervention:
34.32
Control:
0.77
33.55
ALRI 55 8.4 14 2.0 35 7.0 32 6.8
p
1 & 2
< 0.01
p
3 & 4
> 0.05
p
2 & 4
< 0.01
Intervention:
76.19
Control:
2.86
73.33
The Table 3.40 showed that : After 2 years of intervention, the
situation of ARI in children was markedly improved:
ARI in the intervention group decreased from 42.2% (before
intervention) to 24.3% (after intervention) and in the control was 45.7%,

15
with p <0.01. Effectiveness of intervention was 41.34%. Thus, due to
intervention, the prevalence of ARI decreased by 41.34%.
Evaluation of the community acceptance for intervention
measures in the qualitative research

Ending the intervention stage, the researchers conducted in-
depth interviews, focus group discussions of mothers or caregivers,
village health staff, commune health workers, community leaders in
order to: assessing the community acceptance with the intervention
measures was implemented locally, the intervention measures were
accepted by the community. The practical efficiencies: Mother’s
knowledge and practice were improved, reducing the incidence, the
recurrence rate and the level of disease and from that it had promoted
the community to accept and to take part actively.

Chapter 4:
DISCUSSION

4.1. Current status of acute respiratory infections in children
under 5 years old at Cho Moi district, Bac Kan province
4.1.1. General situation of acute respiratory infections
The prevalence of acute upper respiratory infections in children
was 36.1%, the prevalence of acute lower respiratory infections in
children was 7.8% . The overall prevalence of acute respiratory
infections in children in this area was 43.9%. The above results
demonstrated that acute respiratory infections in children under 5
years old in the community remained high. Cho Moi - a mountainous
district of Bac Kan province was still difficult in socio-economic,
cultural life. 80% of populations were ethnic minorities. People’s
living conditions in here still faced up with many difficulties,
mothers were lacking in knowledge and child care practices. Our
study results was much higher than the study results conducted by
Prietsch S. O (2008) in the city of Rio Grande, Southern Brazil, by
Nguyen Van Thieu and Nguyen Huu Ky (2003) in Huong Thuy -
Thua Thien Hue. However, our study results were relatively

16
consistent with a study conducted by Nizami S. Q in the outskirts of
Karachi city, Parkistan (2006)
* The prevalence of acute respiratory infections in children by
ethnic group
In our study area, there were many ethnic minorities such as
Tay, Nung, Dao, H'mong, Hoa, San Chi, San Diu, Cao Lan, Muong
Results showed that the prevalence of acute lower respiratory
infections among ethnic children was very different. This rate in Tay
children was 7.0% and in Kinh was 6.7%, in Nung was 9.6%, in Dao
was 9.9%, and in H'mong was 26.3%. The rate of acute lower
respiratory infections in H'mong children was higher than that in
Kinh children and other minorities children (p <0.01). Why was the
rate of acute lower respiratory infections in H'mong children 3 times
higher than this rate in other ethnic children. It could be possible that
the H
’
mong people had their own customs, they never worked and
contacted with other ethnic groups in the same area, they lived in
separate villages, mainly cultivating in burnt – over lands, stoves
between house, animal shed near the house, H'mong mother’s child
care knowledge and living habits were poorer than the Kinh and Tay
mothers. Therefore, social factors such as child care knowledge and
habits were the problems that needed to be paid a special attention to
in acute respiratory infection control.
4.2. Factors related to acute lower respiratory infection
* Association between mother’s knowledge, practice and acute
lower respiratory infections
Results demonstrated that mother’s knowledge and practice

were closely related to acute lower respiratory infections. Children in
a group of mothers with poor knowledge were at risk of acute lower
respiratory infections, 3.69 times higher than children in a group of
mothers with an average and good knowledge, with p <0.01. When
analyzing factors of mother’s child care practices with ARI program
also obtained similar results, acute lower respiratory infections in
children was closely related to mother’s child care practices. Children
in a group of mothers with poor practices were at risk of acute lower

17
respiratory infections, 5.18 times higher than children in a group of
mothers with the average and good practices, with p <0.01. This was
appropriate because the area where we conducted the study was the
mountainous area, highlands, mainly the ethnic minorities, difficulties in
traveling, backward customs, inhabitant’s life mainly relying on
cultivating in burnt-over lands. Therefore, they less accessed to
information. This problem was also referred to in a study in Bac
Giang, Ha Tinh, Quang Tri by Han Trung Dien and by G. Chan C et
al (2006) in Malaysia.
4.3. Effectiveness of community intervention in prevention
and control of acute respiratory infections in children
¬ Impact of intervention for changing mother’s knowledge
and practices
After 2 years of intervention, mother’s knowledge and
practices for acute respiratory infections in the intervention group
were markedly improved. Mother’s knowledge level after
intervention presented in Table 3.23 showed that the mothers with a
poor knowledge decreased from 86.7% (before intervention) to 6.4%
(after intervention). Mother’s average and fair, good knowledge was
increased in the intervention group as compared to before

intervention and the control. Mothers when they had knowledge, they
needed to apply it in child care in reality: After intervention, mother’s
child care practices at home were clearly improved. Mother’s poor
practice in the intervention group decreased from 81.3% (before
intervention) to 14.5% (after intervention), 76.2% (in the control)
with p < 0.01. Effectiveness of intervention was 81.38%.
The results of our study were consistent with studies done by
several authors in the country and in the world: Study on acute
respiratory infections in children under 1 year in the community and
impact of health education communication in some communes in Bac
Giang, Ha Tinh, Quang Tri provinces by Han Trung ien (2002 and
study on mother’s KAP for respiratory infections in Kenya by Simiyu
D. E. (2003).

18
4.3.2. Effectiveness of intervention in prevention and control of
acute respiratory infections
4.3.2.1. Evaluation of situation of acute respiratory infections
through longitudinal follow-up at household
¬ The incidence density of acute respiratory infections at
intervened communes
In order to evaluate the incidence of acute respiratory
infections, we conducted a longitudinal follow-up of children in 2
years of intervention. The Table 3.29 showed that the incidence of
episodes: No pneumonia, cough or cold in 2008 (3.51 episodes/ year
/child, equivalent to 3510 episodes/1000 child - years) was lower
than that in 2007 (5.43 episodes/year/child, equivalent to 5430
episodes/1000 child - years). The incidence of episodes: Pneumonia;
severe pneumonia in 2008 (0.31 episode/year/child, equivalent to 310
episodes/1000 child - years) was lower than that in 2007 (0.70

episode/year/child, equivalent to 700 episodes/1000 child - years). In
the first year, the intervention contents included the health education
communication, follow-up and treatment at home, at commune health
centers if severe, patients were referred to high levels. In the second
year, we also conducted above –mentioned measures and using
Broncho- Vaxom for children who were relapsed several times. That
helped the mothers understand what they needed to do to solve health
problems and diseases of their children by their efforts and the
support from outside. Since then the mothers had decided to make the
most appropriate action to protect and to improve health for
themselves, their families and the community in general and for
children in particular. The incidence of acute respiratory infections in
children in the second year had decreased as compared to that in the
first year. Our study results in the first year were higher than results
done by Ruan I. (2005): A global estimate of the rate of pneumonia
in children under 5 years showed that: The incidence of pneumonia
episodes in developing countries was 0.29 episode/year/child. Ending
the second year of intervention, the incidence of pneumonia episodes
in our study as compared to the study result by Ruan I was

19
approximately 1/1. However, our result was higher than the result
done by Ruan I. when evaluating the incidence of pneumonia in
children under 5 years in developed countries (0.026 episode/year/
child). This difference could be possible that children in developed
countries were more comprehensively care for in all fields such as
economic, socio-cultural and health care etc. So children in
developed countries suffered from diseases less than children in
developing countries.
Evaluating Broncho – Vaxom’s efficacy and safety when using

for children who had current acute respiratory infections several
times in the intervention group.
* Reducing a number of diseased times
Since in practice, we found some young children due to
features such as: premature, allergies, deformities, malnutrition etc,
so their resistance was week. Although these young children were
well cared by their parents, they still suffered from ARI a lot of
times. One of the main points in this study was that if after one year
was intervened by the health education communication, children still
suffered from ARI many times ( AURI ≥10 times/year or ALRI = at
least 3 times/year), these children would be asked to use Broncho-
Vaxom. The result found that children had used Broncho- Vaxom ,
recurrent acute respiratory infections were clearly dropped (Table
3.33). It was shown by a decrease in the general episodes of ARI
after using Broncho- Vaxom (3.54 ± 2.38) as compared to before
using Broncho- Vaxom (12.46 ± 3.60), with p<0.01. In which a
average number of episodes of AURI after using Broncho- Vaxom
was 2.56 ± 2.12) as compared to before using Broncho- Vaxom of
8.15±3.71, with (p<0.01). Similarly, a average number of episodes of
ALRI after using Broncho- Vaxom was 0.98 ± 0.77) as compared to
before using Broncho- Vaxom of 4.31±1.05), with p<0.01. The study
results showed that Broncho-Vaxom worked to reduce a frequency of ARI.
* Reducing use of antibiotics
For a follow-up of use antibiotics, in our study, Table 3.36
showed that 32.7% of children who used Broncho-Vaxom did not use

20
antibiotics for one year of follow-up. Whereas, before using
Broncho- Vaxom, any children also had to use antibiotics. Difference
was statistically significant (p< 0.01). The average number of

episodes to use antibiotics after using Broncho- Vaxom was 1.04 ±
0.81), as compared to before using Broncho- Vaxom of 4.15 ± 1.22),
with p< 0.01. The study results showed that Broncho- Vaxom worked
to reduce a use of antibiotics in children with recurrent acute
respiratory infections.
* Safety and acceptance of community fori Broncho – Vaxom.
This drug was safe and well tolerated because out of 52 cases,
that used Broncho- Vaxom, did not have any cases with side-effects.
In addition to health efficiency, we also found that it had a social
efficiency: the acceptance of community and the information
obtaining from interviews, focus group discussions of mothers also
showed that it was very difficult for mothers to approach at first stage
of implementation because mothers had not noticed the effects of
drug, were afraid of letting kids use drug for a long time and in many
times. However, after several months, mothers responded
enthusiastically. After using Broncho- Vaxom, many children did not
suffer from ARI or less relapsed and had a mild illness. In addition to
the prophylactic benefits for children, economic aspects and the
satisfaction of the families also were considered when children were
given drugs against ARI. It was estimated that total cost for care and
treatment per one ill episode ranged from 200,000 VND to 2 millions
VND, including traveling, care and drugs etc. Because the
calculation was quite comprehensive in terms of health, costs and
people’s satisfaction. So that, people responded well to use children’s
Broncho- Vaxom, even though they had to pay money to buy drugs
with a price of 250,000VND at that time. This contrasted completely
with the assumption of the research team and local health officials
before conducting intervention: “a high cost for buying immune-
enhancing drugs would be obstacles for people living in the mountainous,
remote areas where people’s living conditions were still difficult and

backward”.

21
Our study results were consistent with recent studies on
efficacy and safety of Broncho- Vaxom in prevention of ARI in
children conducted by Nguyen Tien Dung, Le Thi Hoan et al (2007),
Pham Thu Hien, ao Minh Tuan (2010), Zielnik-Jurkiewicz B (2005).
4.3.2.2. Impact of intervention to reduce the prevalence of ARI
in children in the community.
Our study results showed that in the intervened and the control
sites during both before and after intervention, the prevalence of ARI
in children was significantly different, presented in Table 3.40. Table
3.40 showed that the prevalence of ARI in the intervention group
decreased from 42.2% (before intervention) to 24.3% (after
intervention), 45.7% (in the control), with p<0.01, the efficiency of
intervention was 41.34%. With the research results, we found that
initial intervention measures in the community had the impact on the
prevalence of ARI in children in a 2 year-intervention with the health
education communication and giving children to take immune-
enhancing drugs. It was possible that sustained measures done in the
community impacted on a reduce in the prevalence of ARI in
children. This was suitable with the information obtained from
interviews of mothers: Their children were better cared, suffered
from less illness and the severity was also dropped. Some studies in
the world also given the similar comments such as : Studies by Vitolo
M. R. in Brazil (2008), Khin Myat Tun, Han Win (2005).
4.3.2.3 Acceptance of the community with intervention models
of ARI control at study sites
Ending intervention, researchers conducted in-depth interviews,
focus group discussions of mothers, caregivers, village health staff,

commune health workers, community leaders to evaluate the acceptance
of the community with intervention measures implemented in the
localities and the following results:
The intervention solutions of ARI control for children under 5
years of age at Cho Moi district in Bac Kan province were accepted
by the community. Through in-depth interviews and group
discussions, we got the consensus of community leaders, commune
health officials and people here and especially accepted by mothers
raising young children. They said that when they participated in the
program, their knowledge and child care practices were improved.

22
For children: the incidence, the recurrent rate and the severity of
disease were deceased. That motivated the community to receive and
to actively participate. The acceptance of community to intervention
models of ARI control in children was embodied in the voluntary
participation and the technology transfer of the theme for a local
authority and that was the sustainability of intervention measure.


CONCLUSIONS

1. Some epidemiological characteristics of acute respiratory infections
in children under 5 years old at the study sites before the intervention.
- The prevalence rate of acute respiratory infections in under-
five children before intervention was high (43.9%), acute upper
respiratory infections (36.1%), acute lower respiratory infections (7.8%).
- The prevalence rate of lower respiratory infections in the
H
’

mong children was 26.3%, higher than that in the Kinh children
(6.7%) and also higher than the Tay children (7.0%), with p <0.01.
2. Factors related to acute lower respiratory infection
There were many factors related to acute lower respiratory
infections in children in the mountainous areas: not full vaccinated or
full vaccinated but incorrect schedule (adjusted OR: 10.8). Mother’s
child care practice care was poor (adjusted OR: 4.61). Early weaned
under 12 months (adjusted OR: 4.39). Mothers lacking in child care
knowledge (adjusted OR: 3.38). Families with smokers in the house,
near children (adjusted OR: 3.29). Animal sheds near the home
(adjusted OR: 2.0). The damp status of house (adjusted OR: 1.85).
Stoves in the home (adjusted OR: 1.75).
3.

Effectiveness of intervention measures for acute respiratory
infections in the community.
* Mother’s knowledge and practices were better after
intervention
- Mother’s poor knowledge in the intervention group decreased
from 86.7% (before intervention) to 6.4% (after intervention), 77.6%
(in the control). Effectiveness of intervention reached 86.67%, with p <0.01.

23
- Mother’s poor practice in the intervention group decreased
from 81.3% (before intervention) to 14.5% (after intervention),
76.2% (in the control) with p <0.01. Effectiveness of interventions
was 81.38, with p <0.01.
* More appropriate utilization of health services and decreased
morbidity:
- The average number of acute lower respiratory infection

episodes in children taken to commune health centers in intervention
communes was 0.67 ± 0.26, much more than those in the control
(0.39 ± 0.35), with p< 0.01
- The rate of using antibiotics in intervention communes was
64.6%, lower than that in the control (89.6%), with p<0.01.
Instruction of treatment at home in intervention communes was
92.9%, higher than that in the control (74.2%), with p< 0.01.
- Acute respiratory infections in the intervention communes
decreased from 42.2% (before intervention) to 24.3% (after
intervention), 45.7% (in the control), with p <0.01. Effectiveness of
intervention reached 41.34%.
* The incidence density of acute respiratory infections during
the intervention:
- No pneumonia: Cough or cold decreased after intervention
+ The incidence density of episode of acute respiratory
infections: In 2008 (3.51 episodes per year per child, equivalent to
3510 episodes/1000 child – years) was lower than that in 2007 (5.43
episodes per year per child, equivalent to 5430/1000 child- years).
The efficiency index was 35.36% .
- Pneumonia, severe pneumonia dropped after intervention
+ The incidence density of episode of acute respiratory
infections: In 2008 (0.31episode per year per child, equivalent to 310
episodes/1000 child- years ) was lower than that in 2007 (0.70
episode per year per child, equivalent to 700 episodes/1000 child - years).
The efficiency index reached 55.71%.

24
* Results of following up children taking Broncho-Vaxom were
better than before taking Broncho-Vaxom.
- The number of average episodes of acute respiratory

infections:
After intervention (3.54 ± 2.38), before intervention (12.46 ± 3.60),
decreased by 8.92 ± 3.97 as compared to before the intervention ,
with p <0.01.
- The average use of antibiotics after children taking Broncho-Vaxom
was 1.04 ± 0.81, significantly reduced as compared as before
taking Broncho-Vaxom (4.15 ± 1.22), with p <0.01.
- The percentage of children using antibiotics after taking
Broncho-Vaxom was 67.3%, before using Broncho-Vaxom was
100%, dropping by 32.7% as compared to before using Broncho-
Vaxom , with p <0.01.

RECOMMENDATIONS

1. Party Committee, People's Committee of commune and
branches, coordination with health centers, village health workers
strengthened the health education communication activities by many
ways, contents suitable for people living in the remote, mountainous
community and ethnic minorities one. Mobilizing the participation of
the community in prevention and control of illness in general, and of
acute respiratory infections in particular. Improving the housing
hygiene conditions suitable with local and familial resources in order
to minimize the factors related to acute respiratory infections in
children. Child health care in the community has to cooperate well
between the community leaders, health workers and families
2. Using the immune enhancing drug (Broncho-Vaxom) for
groups of children suffered from recurrent respiratory infections
several times by socialization.
3. The intervention model was effective in the ethnic minority
communities, mountainous areas and uplands. It should be expanded

to other areas to enhance the benefit of the community.


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.