INTRODUCTION
Acute respiratory infections (ARIs) are the first cause of diseases’
burden and the third cause of death among under-five-children in
Viet Nam. Delays in access to health services and inappropriate
treatment are the two main reasons causing deaths for children with
ARIs. From 1982, the Global Programme for Control of Acute
Respiratory Infections, with Viet Nam being a member has been
implementing many interventions mainly focusing on the public
health care system. After many years of implementation, the
mortality rate is decreased but incidences remain high. Unsafe drug
use for treatment of ARIs is common.
Among many interventions, Information- Education-
Communication (IEC) to provide knowledge, skills in care of ARI
children has always been the first approach recommended by the
World Health Organization (WHO). Coverage, targets of IEC are not
only limited to the health system but expanded to other people such
as care takers and drug sellers.
In Viet Nam, few research studies have been implemented to
explore IEC methods that are effective for prevention and control of
ARIs among under-five-children. Particularly, there was a lack of
pilot studies carrying out interventions targeting a wide range of
subjects aiming at major changes in all steps of the care-taking cycle
for children with ARIs.
We conducted the study: "Assessment of the effectiveness of
community interventions in management of Acute Respiratory
Infections among under-five-children in Dan Phuong and Ba Vi,
Ha Noi" with the following 3 objectives:
1. To assess effectiveness of interventions in changing knowledge,
practice of mothers in management of ARIs among under-five
children in Dan Phuong and Ba Vi from 2005 to 2008.
2. To assess effectiveness of interventions in changing knowledge,

Structure of the dissertation
The dissertation consists of 141 pages not including annexes, has
4 chapters, 33 tables, 8 figures, 142 Vietnamese and international
references and annexes. The dissertation includes: Introduction (2
pages); Overview (26 pages); Study subjects and methodology (25
pages); Results (42 pages); Discussions (42 pages); Conclusions (2
pages); Recommendation (1 page).
2
CHAPTER 1. OVERVIEW
1.1. Incidence and mortality of ARIs
In Viet Nam, ARIs are the leading cause of new infections and
deaths among under-five-children with an estimated 30 to 80 million
cases of all types of ARIs each year. ARIs have the highest
prevalence in hospitals. Among causes of childhood mortality,
pneumonia has the highest percentage.
1.3. The situation of mothers’ care for children with ARIs
Even though knowledge has been improved, mothers’ skills in
recognizing signs of diseases still have shortcomings. In 2008, in
Viet Nam, the percentage of mothers recognized signs of ARIs were
low: 5.0% for inability to drink, 4.1% for seizures and 3.4% could
recognize abnormally sleepy. For the 2 characteristic indicators of
pneumonia, only 37.3% recognized breathing signs and 0.9% knew
signs of chest indrawing.
Many skills in seeking health services for children with ARIs
needed improvement. In 2000, only 86% of parents believed that
pneumonia was a dangerous disease requiring consultation at health
care services. In 2003, the highest percentage (20.9%) was mothers
providing home care for children with ARIs. Lack of knowledge on
signs and management of diseased children has contributed to high
risks of death among children with ARIs. Among the death cases,

approximately 80.4%. Knowledge and practice of private providers is
also in need of improvement. Only about 77.5% of private physicians
knew that chest indrawing was a sign of severe pneumonia. Overuse
of antibiotics, prescriptions of inappropriate types or insufficient
dosage of antibiotics was main findings in the study on use of drugs
for ARIs treatment. The percentage of children using antibiotics for
treatment of non-pneumonia conditions was still high, accounting for
39%. In 2004, prescriptions of 2 antibiotics or more accounted for
11% and 20% of antibiotics used were injections. Health staff rarely
counsel patients on home care. Very few of mothers (5.6%) who
brought their children to physicians’ examination were counseled on
use of drugs at home. In 2008, 31% of mothers bringing their
children to examinations receive any information from the health
staff. Lack of training, not suitable treatment regimens, work
overload and profit-related factors had negative impacts on the
practice of health staff.
1.5. The situation of drug retail for children with ARIs
Inappropriate, unsafe selling of drugs is increasing. Drugs are
sold freely on the market, without instructions, even without
4
prescriptions, including those requiring physicians’ indications. A
large majority of children (91%) having ARIs received antibiotics.
Among those decided to use antibiotics, 67% households did so by
following suggestions of drug sellers, 11% decided by themselves
and only 22% followed physicians’ prescriptions. This means that
people have the risks of using drugs for wrong indications,
ineffective use, or even having health risks.
Professional practice skills of private pharmacies’ staff are
affected by many factors such as: professional knowledge, buyers’
demand, regulatory documents and profits.

2.3. Duration of the study
From March 2005 to January 2008, wherein interventions were
carried out in a two-year period.
2.4. Terms, definitions used in the study
2.5. Study methods
2.5.1. Study design
Community based intervention study with control.
2.5.2. Sample size
2.5.2.1. Mothers
Using formula for sample size to compare two proportions:
{ }
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21
2
221112/1
)(
)1()1()1(2
pp
ppppzppz
n
−
−+−+−
=
−−
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Where: n: minimal sample size (number of mothers); p
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=46.2%;
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exceeding the age of five, analysis before and after interventions
included 625 mothers (301 in Ba Vi and 324 in Dan Phuong).
6
- Enrollment of all health providers and drug sellers in selected
communes.
2.5.4. Data collection methods
2.5.4.1. Techniques, tools for quantitative data
- Mothers were directly interviewed using questionnairre. All
mothers were assessed for knowledge. Practice of mothers whose
children had ARIs within 2 months before surveys were assessed.
- Health providers were interviewed for knowledge and observations
were made using checklist for their practice.
- Drug sellers were assessed for knowledge using direct interview
and for practice by drug buyers’ observations using checklist.
2.5.4.2. Techniques, tools for qualitative data
In each district, before and after interventions, focus group
discussions were made with mothers, active mother groups, health
providers, drug sellers, and managers.
2.5.5. Methods used to control biases
2.5.6. Data management methods
Quantitative data were entered using Epi-DATA and analyzed
using STATA to calculate percentages, means, test for hypotheses
and EI (Effectiveness Indicators).
Qualitative data were managed “ open-coded” by groups of themes
and cited in the report.
2.6. Design and implementation of interventions
Interventions were carried out in 5 selected communes in Ba Vi
with IEC activities during 12 months and support supervision for the
next 12 months. Steps of implementation included:
- Designing intervention materials: “Child health diary” for the

PI
n=301
p BL
n=324
PI
n=324
No sign 11.6 0.3 <0.001 13.9 13.3 -93.1
1 sign
29.2 4.0 <0.001 34.6 31.5
- 77.3
2 signs 32.6 9.6 <0.001 29.6 30.2 -72.6
3 signs 22.3 18.9 <0.001 17.3 17.0 -13.5
4 signs 3.7 39.5 <0.001 4.3 6.5 915.9
5 signs 0.3 21.7 <0.001 0.3 1.5 7729.0
6 signs 0.3 6.0 <0.001 0 0 1900.0
* No significant difference for any indicator among control group
At baseline, intervention group knowing two signs accounted for
the highest percentage (32.6%). Post-intervention, mothers knowing
4 signs had the highest percentage (39.53%).
3.1.2.2. Knowledge on management of sick children
The percentage in intervention group knowing to bring the child
for exams when there are signs indicating such a need increased from
13.8% to 93.0% (p<0.05). The percentage of mothers correctly
knowing children can be monitored at home increased to 23.9% in
the intervention group as compared to 1.3% at baseline (p<0.001).

8
Table 3.5: Comparisson of knowledge on management of children with
ARIs of mothers baseline-post intervention (%)
Management

Intervention Control*
BL
n=301
PI
n=301
p BL
n=324
PI
n=324
With
prescription 62.8 94.4 <0.001 55.2 58.0 45.2
Sufficient
duration
39.2 70.1 <0.001 47.8 42.6 91.1
No antibiotics
for cold 49.5 63.8 <0.05 50.0 47.5 33.8
* No significant difference for any indicator among control group
All 3 indicators for knowledge on antibiotics use of mothers post-
intervention in Ba Vi significantly increased in comparison to
baseline and were much higher than among controls as well.
3.1.2.3. Knowledge on care, follow-up of children
Post-intervention, the percentage of mothers having correct
knowledge on child care for each indicator increased by about 20%
or more. All four indicators increased significantly.
Post-intervention, the percentage in Ba Vi knowing needs for
monitoring of children increased by 16.8% with statistically
significant differences. Knowledge on re-examination (immediate
and scheduled) also increased significantly.
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Table 3.7: Comparison of mothers’ knowledge on child care and monitoring,

5.2
* No significant difference for any indicator among control group
Post-intervention, most of the intervention group (92%) brought
children to examination upon detection of signs of severe disease in
need of examination (p<0.001) (Table 3.8).
Figure 3.2: Comparison of practice for children with cough, cold at
baseline and post-intervention (%)
For children having cough, cold, the percentage of mothers in Ba
Vi with correct management significantly increased as compared to
baseline. Main reason for the increase was an increase of those who
follow their children at home by 14.7% compared to baseline with an
EI of more than 472.4% (Figure 3.2).
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3.1.3.2. Practice of drug use
Table 3.9: Comparison of mothers’ antibiotics use practice for children
baseline-post intervention
Antibiotics
use
Intervention Control*
EI
BL PI p BL PI
n=178 n=113 n=172 n=160
With
prescription 53.4 70.8 >0.05 50.0 53.1 26.4
Sufficient
duration
25.3 63.7 <0.001 33.1 41.9 125.2
Both 18.0 47.8 <0.001 19.8 24.4 142.2
* No significant difference for any indicator among control group
There was a positive change in antibiotics use among the

24.6 32.8 <0.05 33.3 31.2 33.9
Monitoring
46.4 59.1 <0.001 47.4 45.0
50.6
32.7 40.9 >0.05 49.1 51.9 19.4
* No significant difference for any indicator among control group
11
Post-intervention, the percentage who did each of the essential
care tasks at home clearly increased, with the exception of indicator
for monitoring which increased but not significantly.
Post-intervention, the percentage of mothers bringing their
children to re-examination after 2-3 days of antibiotics use increased
to 38.2% (p<0.001). Intervention EI was 599.4%.
3.2. Effects of interventions in changing providers’ knowledge,
practice in care of children with ARIs.
3.2.1. Characteristics of health providers
Two groups of providers in two districts had similarity in some
basis characteristics such as age, years in occupation, professional
level, and types of health facility (private /public). There was no
statistically significant difference between two groups in above
mentioned data. Average age was 40. The majority (74.68%) were
assistant doctors. The number of private providers was twice as high
as commune health station staff. The majority provided examination
and treatment for more than 10.
3.2.2. Effectiveness in changing providers’ knowledge
3.2.2.1. Knowledge to recognize signs of diseases
For very severe diseases, providers need to remember 11 signs (6
for children under 2 months of age and 5 for children from 2 months
to 5 years). At baseline in both districts, most providers only
remembered between 4 and 6 signs. A few did not know any. No

its signs increased from 66.7% to 100%, knowing raised respiratory
rate, an indicator for pneumonia increased from 47.2% to 83.3%.
3.2.2.2. Knowledge in management and prescription of drugs
Table 3.14: Comparison of knowledge on pneumonia signs at baseline and
post-intervention (%)
Signs of severe
Intervention Control*
BL
n=36
PI
n=36
p
BL
n=43
PI
n=43
Fast breaths 66.7 100
<0.001
65.1 55.6 64.7
Raised resp. rate 47.2 83.3
<0.001
48.8 46.5 81.3
* No significant difference for any indicator among control group
For pneumonia: the percentage in intervention group having
knowledge on correct management increased significantly with an EI
of 1,062.0%. That of those knowing to use proper types of antibiotics
increased significantly while for those knowing to use for a sufficient
number of days did not (Table 3.14).
For children with cough, cold: the percentage of providers in Ba
Vi with correct knowledge (no antibiotics) increased significantly

Seizures 33.3 66.7 <0.05 41.7 34.9 116.6
Fever 44.4% 52.8 >0.05 32.6 25.6 40.2
* No significant difference for any indicator among control group
Post-intervention, the percentage of providers in Ba Vi who
asked for seizures and fluid intake increased significantly (p<0.05),
that of simple questions (age and fever) increased not significantly.
Table 3.19: Comparison of providers’ examination practice baseline-post
intervention
Examination
Intervention Control*
BL
n=36
PI
n=36
p BL
n=43
PI
n=43
Chest indrawing 38.9 80.6 <0.05 37.2 41.9 94.6
Counting of
Respiratory rate 22.2 55.6 <0.05 23.3 27.9 170.2
* No significant difference for any indicator among control group
Post-intervention assessment showed that the percentage of
providers observing chest indrawing and respiratory rate increased
significantly.
3.2.3.2. Practice in drug prescription
For pneumonia cases in Ba Vi: at baseline, all were referred.
Post-intervention, all 5 cases were correctly managed by receiving
antibiotics prescriptions and were not referred.
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Home care 33.3 75.0
<0.01
18.6 20.9
112.5
Monitor ARIs 22.2 63.9
<0.001
14.0 23.3
120.8
Re-visit appointment 33.3 63.9
>0.05
34.9 41.9 71.7
* No significant difference for any indicator among control group
In Ba Vi, post-intervention, percentages of providers providing
counseling on each content increased. Instruction for home care and
monitoring increased significantly with corresponding EI of 112.5%
and 120.8%, respectively.
3.3. Effectiveness of interventions in changing drug sellers’
knowledge, practice for ARIs.
3.3.1. Characteristics of drug sellers
Demographic characteristics of intervention and control groups
are similar in: average age, professional, educational levels, and
duration of work.
3.3.2. Effects in changing drug sellers’ knowledge
3.3.2.1. Knowledge in ARIs history taking before selling
Post-intervention, only knowledge on questions about
abnormal breathing and prescription increased significantly with
intervention EI of 137.5% and 200.0%, respectively.
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Table 3.24: Comparison of history taking knowledge before selling of
drugs, baseline-post intervention

Intervention Control*
EI
BL
n=23
PI
n=23
P BL
n=24
PI
n=24
Age 73.9 100 >0.05 62.5 66.7 28.6
Prescription 30.4 91.3 <0.01 33.3 33.3 200.0
Duration of cough 43.5 73.9 >0.05 70.8 62.5 81.6
Ability to drink 39.1 69.6 >0.05 45.8 41.7 87.0
Abnormal breathing 30.4 78.3 <0.05 20.8 25.0 137.5
Feel tired 52.2 78.3 >0.05 45.8 58.3 22.1
High fever 82.6 91.3 >0.05 75.0 79.2 4.9
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3.3.2.3. Knowledge on counseling after drug retail
Post-intervention, knowledge of need to counsel on drug use
in Ba Vi increased, with the percentages of 2 issues: monitor signs
for immediate exam and advise to seek examination clearly increased
(p<0.01 and p<0.05), while others increased but not significantly.
Table 3.26: Comparison of drug sellers’ knowledge on counseling, baseline-
post intervention (%)
Counseling
contents
Intervention Control*
BL
n=23

PI
n=24
Child’s age
56.5 82.6 >0.05 54.2 50.0 54.0
Prescription
4.3 34.8 <0.05 8.3 8.3 709.3
Duration of
cough 43.5 52.2 >0.05 41.7 37.5 30.1
Ability to drink
26.1 65.2 <0.05 41.7 37.5 159.8
Abnormal
breathing 17.4 52.2 <0.05 8.3 0 200.0
Feeling tired
30.4 52.2 >0.05 33.3 29.2 74.0
High fever
60.9 78.3 >0.05 45.8 41.7 37.6
* No significant difference for any indicator among control group
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3.3.3.2. Drug selling Practice for ARIs
Table 3.28: Comparison of drug selling practice for ARIs, baseline-post
intervention (%)
Intervention Control*
EI
BL
n=23
PI
n=23
P BL
n=24
PI

thought that interventions were easily sustainable.
3.4.2. Interventions for health providers
100% providers participated in training and meetings for
experience exchange. Supportive supervision from higher levels was
considered ‘irregular’ by 44.4%. Over 90% providers believe that
contents for knowledge, skills were useful. All 3 interventions were
assessed as easily sustainable by more than 80% of providers.
3.4.3. Interventions for drug sellers
Percentage of intervention beneficiaries was 100%. Knowledge,
skills in history taking and counseling on drug usage was very useful
for most sellers; the exception being ‘drug selling practice’ which
was not useful for 39.1%. Peer supervision was ‘very easily
sustainable’ for the majority (78.3%). Two others, training and higher
level supervision was only seen as “easily sustainable”.
CHAPTER 4. DISCUSSION
4.1. Effectiveness in changing mothers’ knowledge, practice in
care for ARIs
4.1.1. Characteristics of mothers
4.1.2. Effects in changing mothers’ knowledge
4.1.3. Effects in changing mothers’ practice
Post-intervention, most of the intervention group brought their
children to examination when there were signs of severe diseases. In
this study, the percentage of correct knowledge was similar to that of
correct practice. This indicates that knowledge acquired was also
applied in the mothers’ practice. In parallel to receiving knowledge,
they also had a supporting environment to easily change behavior.
Self taking care and monitor of the sick child was a new term for
the mothers. Post-intervention, the percentage in intervention group
providing home care increased six folds. Still, nearly 40% bought
drugs for treatment by themselves (wrong practice) even though only

to 40% with significant differences. This is an evidence for positive
impact of interventions in changing health providers’ practice.
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Baseline assessment showed that, because of fear for
accountability and limited training, all pneumonia cases were
referred to higher level. Reduction of unnecessary referral will
benefit both service providers and users. Post-intervention, all of the
5 observed pneumonia cases in Ba Vi were prescribed antibiotics and
received treatment at community level. Comparison results in
antibiotics prescription practice for cough and colds showed that
interventions were not highly effective. Percentage of correct practice
increased not significantly, only by 13%.
Post-intervention, providers’ percentages having counseled on
home care and child monitoring both increased significantly by about
40%. That of re-examination appointment did not clearly increase.
In sum, behavior changes were possible through provision and
regular refreshing of knowledge if they were did not require time or
affect incomes but increased providers’ reputation. Time consuming
or income affecting changes are more difficult even if sufficient
knowledge was provided. For them, a legal environment with
specific regulations and mechanisms could support more actively.
4.3. Effectiveness in changing drug sellers’ knowledge, practice
4.3.1. Characteristics of drug sellers
4.3.3. Effect in changing drug seller’s knowledge
4.3.3. Effect in changing drug seller’s practice
Post-intervention, the percentage of sellers having asked about
prescriptions and breathing signs in Ba Vi substantially increased
with corresponding EI of 200% and 700% and significant
differences. Sustaining supervision and regular provision of
knowledge was able to change sellers’ habits.

toward the health of them, their families and surrounding
communities; thereby contributed to improvement of feasibility and
sustainability of the interventions.
CONCLUSIONS
The study has successfully designed, piloted interventions
and assessed their effectiveness in changing knowledge, practice of
key target groups - namely mothers of children under five, commune
health workers and drug sellers - in the process of providing care for
children with acute respiratory infections. The intervention area was
5 communes in Ba Vi district with control being 5 communes in Dan
Phuong from March 2005 to January 2008. It provided evidence that
combinations of information- education-communication interventions
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with support supervision and active participation of target groups are
highly effective, suitable and sustainable interventions for changing
knowledge and practice; specifically:
1. Effectiveness of interventions for mothers
- Interventions had substantial effects in changing mothers’ knowledge in all
four content areas provided to them, specifically: (1) Recognition of signs
of diseases; (2)Appropriate initial management for pneumonia, cough,
colds; (3)Use of antibiotics for correct indications, sufficient duration
and correct types; (4)Care, monitor and re-examination of children.
- Interventions were effective in improving some mothers’ practices:
(1)Initial management(seeking health facilities for children having
signs requiring examinations; self monitoring of cough, colds); (2)
Antibiotics use (correct types and sufficient duration); (3) Care and
re-examination (practice to give more foods, more fluids, make
airway free, keep warm/cool and re-examination for children).
- Interventions were not very effective in changing some practices:
(1)Antibiotics use for children with cough, colds; (2) Regular

counseling on side effects, monitoring and re-examination by danger
signs).
- Interventions were not effective in reducing unnecessary sell of
antibiotics:(1) Not to sell antibiotics for upper ARIs such as cough,
colds.
RECOMMENDATIONS
From experiences of this intervention study with controls in two
districts Ba Vi and Dan Phuong, we have the following
recommendations:
1. Community based interventions successfully piloted in this study
need to be continued to be assessed and pilot-implemented in
rural areas with similar conditions with adjustments in contents
and approach to be suitable to local conditions.
2. For interventions to be effective in improving care and treatment
of children with ARIs, attentions are needed for some conditions:
- Emphasizing an active role and participation of individuals,
families, services providers and the community in order to
create possitive comprehensive changes in the whole care
taking cycle for children with ARIs. Encouragment of active
participation of all groups during the whole intervention
process, from designing, implementating to supervision.
- Regular implementation of IEC activities providing
knowledge and support supervision for all subjects
participating in care of children with ARIs.
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- Interventions’ forms (active mother groups, self supervision,
etc.) or contents (home care and monitor of sick child,
counseling after service, etc.) that had positive impacts in this
study need to be considered for expansion, continuously
assessed and adjusted when implemented in other areas.