From the Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden ACCESS TO HEALTH CARE FOR CHILDREN IN AMAZONIAN PERU FOCUS ON ANTIBIOTIC USE AND RESISTANCE Charlotte Kristiansson Stockholm 2009 All previously published papers were reproduced with permission from the publishers. Published by Karolinska Institutet. Printed by Larserics © Charlotte Kristiansson, 2009 ISBN 978-91-7409-616-3 To my sister, my father and my mother For insisting that nothing is impossible i ii ABSTRACT Background: Infectious diseases remain a big problem in low and middle income countries (LMIC). Problems of access to adequate health care (including antibiotics) prevail despite the availability of many elaborate interventions. Antibiotic resistance further endangers access to effective infectious illness management. The Peruvian state insurance SIS, had formally granted full access to health care and antibiotics for children living within the study areas. Main objective: To assess health-seeking behaviour, antibiotic use and socioeconomic status for children aged 6 – 72 months in two communities of the Amazonian area of Peru. In addition, to study associations between antibiotic use and socioeconomic factors related to antibiotic resistance among the same study population. Methods: Two cross-sectional surveys of caregivers were carried out in the two urban Amazonian communities, Moyobamba and Yurimaguas, in 2002. A similar cross-sectional survey was carried out later in 2005, in Moyobamba only. Caregivers were interviewed on health care seeking strategies and medication for their children in relation to reported symptoms and socioeconomic status using a structured questionnaire. Self-reported symptoms were classified into illnesses based on the IMCI algorithm (Integrated Management of Childhood Illnesses). Wealth index was generated by Principal Component Analysis using household assets and characteristics and was used as a proxy for economic status. Faecal samples were collected from the children and the antibiotic susceptibility of E. coli was analysed by a rapid resistance screening method. Results: Many caregivers consulted health professionals for their children’s illnesses, (Yurimaguas 42% and Moyobamba 30%) in year 2002 but the poorest caregivers consulted health professionals less frequently (33%) than the least poor (71%) for severe illnesses such as pneumonia (I). In Moyobamba the number of caregivers that consulted health professionals (medical doctors, nurses or health technicians) decreased from 91% in 2002 to 74% in 2005 (p<0.001) (III). The majority of the antibiotics used were prescribed by health professionals (71%), but the amount of antibiotics recommended by pharmacy staff increased in 2005 (18%) as compared to 2002 (6%) in Moyobamba (III). Health professionals prescribed equally often, whether or not antibiotics were recommended for the illnesses. Pharmacists were more discriminatory (II). Caregivers self-caring for their children were restrictive with antibiotics for all illnesses. The amount of children receiving antibiotics free of charge through the SIS had decreased in 2005 as compared to 2002 (III). There were a high number of children carrying antibiotic resistant clones of E. coli in both communities, more commonly among the least poor children (IV). Discussion: The high affordability mediated by the SIS likely contributed to the high utilisation of the public health services. However, inequitable utilisation and under-use of health services for severe illnesses indicate that there are still barriers to access. Antibiotics were prescribed for illnesses where it is not indicated, wasting resources and potentially contributing to emerging antibiotic resistance. The high carriage of antibiotic resistance in the commensal bacterial flora, more commonly among the least poor than the poorest children, underlines the importance of including all groups in society in attempts to improve adequate use of antibiotics. Keywords: equitable access to health care, antibiotic use, health insurance, policy implementation, inequity, antibiotic resistance iii LIST OF PUBLICATIONS I. Kristiansson C, Gotuzzo E, Rodriguez H, Bartoloni A, Strohmeyer M, Tomson G and Hartvig P. Access to health care in relation to socioeconomic status in the Amazonian area of Peru. International Journal for Equity in Health 2009, 8:11 II. Kristiansson C, Reilly M, Gotuzzo E, Rodriguez H, Bartoloni A, Thorson A, Falkenberg T, Bartalesi F, Tomson G and Larsson M. Antibiotic use and health-seeking behaviour in an underprivileged area of Peru. Tropical Medicine and International Health 2008, 13:3, 434-441. III. Kristiansson C, Petzold M, Gotuzzo E, Pacheco L, Strohmeyer M, Hartvig P, Bartoloni A and Tomson G. Insurance does not ensure access: Problems in Amazonian Peru. Manuscript. IV. Kristiansson C, Grape M, Gotuzzo E, Samalvides F, Chauca J, Larsson M, Bartoloni A, Pallecchi L, Kronvall G and Petzold M. Socioeconomic factors and antibiotic use in relation to antimicrobial resistance in the Amazonian area of Peru. Scandinavian Journal of Infectious Diseases, 2009; 41: 303-312. These papers will be referred to in the text by their roman numerals, I-IV. iv CONTENTS 1 PREAMBLE ................................................................................................. 1 2 BACKGROUND .......................................................................................... 3 2.1 Child health ......................................................................................... 3 2.2 Health care and treatment ................................................................... 4 2.3 Health-seeking behaviour ................................................................... 6 2.4 Access to health care .......................................................................... 7 2.4.1 Inequity in health and in access to health care ...................... 9 2.5 Antibiotic use and resistance .............................................................. 9 2.5.1 Antibiotic use .......................................................................... 9 2.5.2 Antibiotic resistance and access to antibiotics .................... 10 2.5.3 Antibiotic resistance ............................................................. 11 2.6 Health systems .................................................................................. 12 2.7 Policy implementation ...................................................................... 14 2.8 Factors investigated .......................................................................... 16 2.9 Rationale ........................................................................................... 17 3 OBJECTIVES ............................................................................................. 18 3.1 General objective .............................................................................. 18 3.2 Specific objectives ............................................................................ 18 4 MATERIAL AND METHODS ................................................................. 19 4.1 Context .............................................................................................. 19 4.2 Study areas and population ............................................................... 23 4.3 Design, sampling and data collection .............................................. 24 4.3.1 Survey design and sampling ................................................ 24 4.3.2 Data collection ...................................................................... 25 4.3.3 Microbiological analysis ...................................................... 26 4.3.4 Classification of main variables ........................................... 27 4.3.5 Research management .......................................................... 30 4.3.6 Statistical analysis ................................................................ 31 5 MAIN RESULTS ....................................................................................... 32 5.1 Background data and morbidity ....................................................... 32 5.2 Use of health care and antibiotics .................................................... 32 5.2.1 Health-seeking behaviour .................................................... 32 5.2.2 Use of antibiotics .................................................................. 34 5.2.3 Cost incurred for public health services and for antibiotics 36 5.3 Antibiotic resistance ......................................................................... 37 5.3.1 Antibiotic resistance ............................................................. 37 5.3.2 Antibiotic resistance and influencing factors ...................... 38 6 DISCUSSION ............................................................................................. 40 6.1 Utilisation of public health care services ......................................... 40 6.2 Inequity in health care utilisation ..................................................... 40 6.3 Changes in health-seeking between 2002 and 2005 ........................ 41 6.4 Antibiotic use .................................................................................... 42 6.5 Antibiotic resistance associated with wealth and antibiotic use ...... 45 6.6 Methodological considerations ........................................................ 46 7 Conclusions and recommendations ............................................................ 50 8 ACKNOWLEDGEMENTS