Experiments conducted on gilt at growth stages results of monitoring of nitrogen, sulfur ingested and excreted in urine and faeces are presented in table 3.19 and figure 3.9; 3.10. research results showed that nitrogen, sulfur emissions in the feces and u

Experiments conducted on gilt at growth stages. Results of monitoring of nitrogen, sulfur ingested and excreted in urine and faeces are presented in Table 3.19 and Figure 3.9; 3.10. Research results showed that nitrogen, sulfur emissions in the feces and urine were reduced under way to reduce the rate of protein and amino acid levels. For pigs fed diets with different protein ratio while maintaining the same level of four essential amino acids is the first release of nitrogen in dung and urine decreased substantially. At the amino acid lysine is 11g/kg by food, the amount of nitrogen excreted in feces (g / head / day) by way of reducing the rate of protein, decreased from 9,12 - 8.21 to 7.47 (corresponding lots 1a, 2a and 3a, a decline from 9.97 to 18.09% when compared lot 2a, 3a with 1a). Similarly, at the amino acid lysine is 10g/kg by food, the amount of nitrogen excreted in feces (g / head / day) 20 decreased from 8,31 - 6.90 to 5.92 (with lots of 1b, 2b and 3b, a decline from 16.67 to 28.76% when compared lot 2b, 3b with 1b) at the amino acid lysine by a 9 g / kg feed from 6,66 - 5.92 to 5.95 (with lots of 1c, 2c and 3c, the decrease 11.11 - 10.66% when compared lot 2c, 3c to 1c) the difference in the amount of nitrogen discharged in the middle of the diets is statistically significant (P <0.05) except at 9 g / kg feed.

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THAI NGUYEN UNIVERSITY UNIVERSITY OF MEDICINE AND PHARMACY ĐAM 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. Trưong 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 ( . )p qn Z pα 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: ( ) ( ) ( ) ( ) 1 1 2 22 , 2 1 2 1 1p p p p n Z P P − + −= −α β 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 E f f i c i e n c y i n d e x ( % ) E f f e c t i v e n e s s o f i n t e r v e n t i o n ( % ) 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 p3 & 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 E f f i c i e n c y i n d e x ( % ) E f f e c t i v e n e s s o f I n t e r v e n t i o n ( % ) Poor 482 81.3 91 14.5 350 76.8 343 76.2 p1 & 2 <0.01 p 3&4 > 0.05 p 2 & 4 <0.05 CT:82,16 ĐC: 0,78 81.38 Average 73 12.3 139 22.2 71 15.6 76 16.9 p1 & 2 <0.01 p 3&4 >0.05 p 2 & 4 <0.05 CT:80,49 ĐC:8,33 72.16 Fair , well 38 6.4 397 63.3 35 7.7 31 6.9 p1& 2 <0.01 p 3&4 >0.05 p 2 & 4 <0.01 CT:889,06 ĐC: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 E f f i c i e n c y i n d e x ( % ) E f f e c t i v e n e s s o f i n t e r v e n t i o n ( % ) 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 Đien (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, Đao 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. ơ 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.

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