Health Education Program for Parents (HEPP)

Yayasan Orangtua Pedi Parents Best Friend

Compassion, Courage, Commitment

c/o Dr Purnamawati S Pujiarto, SpAK, MMPed web: www.milissehat.web.id

Children in Indonesia face health risks from their medical treatment that would not be acceptable to you. Doctors routinely prescribe mixtures of potent antibiotics and medicines with potentially serious side effects, for treatment of common illnesses. Where do parents find the information and support needed to challenge their doctors, and to receive unbiased and basic information on their childrens illnesses and how they can be managed? How can concerned parents and doctors provide this basic information and support in the face of opposition from the medical and pharmaceutical industry which thrives on purchase of high cost medicines? Yayasan Orang Tua Peduli (Concerned and Caring Parents) is trying to support and inform parents to become partners with their doctors in the care of their children.

1. BACKGROUND
1.1 Organisation Yayasan Orang Tua Peduli (YOP), is a non-profit, non-government organisation that was formed in Jakarta in November 2005. The organisation grew out of the education and advocacy efforts of Dr Purnamawati Pujiarto, a paediatric-hepatologist. Dr Purnamawati became aware of a rise in the number of children suffering from liver complaints and was concerned about a possible link to irrational use of drugs. In 2003, Dr Purnamawati started organising schools for parents to educate them on child health, illness prevention and appropriate medications which is structured as the Health Education Program for Parents (HEPP) [see below].

Health Education Program for Parents (HEPP)

1.2 What is HEPP? HEPP is a health education and promotion initiative that is driven by two broad aims:

To empower parents to become informed health consumers; and To promote the rational prescription and use of medicine.

HEPP is an integrated program and provides advice to parents on the following topics:

Common health problems in children; Rational use of drugs; Appropriate preventive measures; Breastfeeding; Appropriate feeding for infants and young children; Immunization; Growth and development and the rearing process; Relevant issues such as dengue fever, malaria, avian influenza, sex education in children, pregnancy, dental health.

2. RATIONALE
2.1 Why is HEPP needed? Empowered Consumers. As in many countries, the doctor to patient relationship in Indonesia is often unequal and few parents have basic understanding of the common causes of illness among children and simple, effective medications. Typically, parents will leave the treatment of their sick children in the health providers hands without question and expect instant relief or recovery for their child. In engendering better informed parents, HEPP is also working to encourage a culture of consultation between parents and doctors. By no means unique to Indonesia, medical consultations result in the prescription of medication. This results in unnecessary and over-prescribing and a dependency on curative services, both doctors and drugs, for healthcare. Rational Drug Use. The prescription and choice of medication (i.e. trademark versus generics) in Indonesia, especially in private practice, rests entirely with the doctor. HEPP is targeted to parents who use private sector health facilities where compliance with national treatment guidelines and rational drug policies is voluntary and not regulated. In private medical practice in Indonesia, evidence suggests a number of irregularities in prescribing practices. These are listed here and explained below: 1. Polypharmacy; 2. Overuse of antibiotics; 3. Overuse of steroids 4. Preference for trademark drugs and consequent cost; and 5. Unnecessary medicines. The summary of the study on prescribing habit is listed on Table 1 (see below). 1. Polypharmacy is the administration of several medicines together. Most health problems in children do not call for polypharmacy treatment. A widespread

Health Education Program for Parents (HEPP)

practice in Indonesia is to give children several medicines as a crushed mixture called puyer. These concoctions may include appetite stimulants, pain killers, antibiotics, steroids, tranquillizers, vitamins and rehydration solutions. An informal assessment of 204 clients in Jakarta revealed that almost 70% of cases received a minimum of four drugs in powder form. The side effects of the internal interaction of these drugs among children has not been studied. 2. Overuse of antibiotics is common. In fact, a focussed assessment undertaken in the early 1990s revealed that antibiotics consumed 46% of the central level health budget for drugs. Antibiotics are routinely prescribed for children with fever, diarrhoea, sore throats, respiratory and digestive complaints; these symptoms are caused by viral infections and do not need antibiotics. 3. Overuse of steroids is very common. Common health illnesses in children do not need steroid yet the side effects can be major. 4. Preference for trademark drugs over cheaper generic versions. The rate of generic drug prescription is very low, around 11% only. This unjustifiedly increases health care expenditure for parents, with a greater burden on the lower middle classes who prefer but struggle to afford private health services. 5. Unnecessary medicines. The dispensing of multi-drug mixtures is not taught in tertiary medical education in Indonesia and it has no basis in science. Inappropriate prescription-use of medication poses the risk of harm to the child and increased risk of antibiotic resistant bacteria. The preference for prescribing trademark drugs places a greater and unnecessary financial burden on families, as does inappropriate or inefficacious treatments which require repeat visits to the doctor. This combines to undermine the quality of health care and equitable access to it. Table 1. Overall picture of prescribing pattern URI (55) Fever (43) Diarrhea (27) 260 186 83 5 4 3 8 9 7 77.4 54.5 7 16.9 72.6 86.4 0 9.7 55.4 74.1 5 3.6

Total meds Median Max % Puyer % Antibiotics (% generics) % Generics

Coughs (41) 186 4 11 87 46.3 10.5 19.4 \ 60.9 36.6 14.6 17.1 2.4

% prescribed med - Steroid - Anti histamine - Anti Convulsion - Anti Pyretis - Supplement

61.8 50.9 16.4 36.4 21.8

41.9 53.5 55.8 79.1 34.9

44.4 18.5 11.1 29.6 51.9

Health Education Program for Parents (HEPP)

Picture: Preparation of puyer

This prescription is for a toddler with URI. All those medications are mixed together and crushed in to powdery form then divided by eyes into small paper/sachet. 2.2 What are the benefits of HEPP? HEPP is currently in contact with close on 9800 members or Concerned Parents across Indonesia. HEPP is empathic to parents and understands the position and

Health Education Program for Parents (HEPP)

prerogatives of the medical profession at the same time, providing vital information to concerned parents in order for them to support themselves and each other. HEPP works to generate the following benefits in the area of infant and child health: Enabling parents to make informed decisions about treatment options; Increased appreciation of the health and immunity benefits of exclusive breastfeeding; Reduce child exposure to and dependence on medications; Cost savings from reduced pharmaceutical consumption and fewer visits to the doctor.

3. HEPP PROGRAM
3.1 Current Activities In the interests of reach and accessibility, YOP undertakes a range of educational activities delivered through classroom-based sessions, as well as electronic and national media. 1. Group education sessions: YOP holds interactive information sessions for parent groups. This was the foundation work of YOP and is structured around practical scenarios and topics that encourage parent sharing and participation. YOP staff serve as facilitators and reference points for medical information and sources. The packaged courses consists of 4 7 meetings (on Saturdays and Sundays). YOP has also done such packaged education for private companies or any other parties. YOP also does a sporadic (non packaged [topic is based on request, mostly related to RUD] sessions). Recently, YOP also goes to schools, both for teachers as well as for parents. The group education sessions are an extremely effective entry point for reaching and building rapport and solidarity among concerned parents. Graduates of the sessions commonly remain in contact with YOP through the mailing list and have been instrumental in raising demand for more courses to be delivered in Jakarta and other provincial locations. Some of the graduates become co-facilitators. We also have breastfeeding classes for pregnant women and working mothers once a month in Jakarta and several other cities. The education sessions are also requested by companies. List of cities where a package of courses plus the boosters have been conducted are: - Aceh, Medan, Batam - Jakarta, Bekasi, Tangerang, Depok - Bogor, Bandung, Solo, Semarang, Jogja, Purworedjo, Surabaya, Sidoardjo - Balikpapan, Samarinda, Makasar In Jakarta, we have conducted 11 packaged (now is the 12th packaged). Total participants from Jakarta 2680; Sumatera 489, East Java 980 (Bodetabek 920, Bandung 369), Central Java 948, East Java 290; others 468. Total participants of HEPP (excluded participants listed in health education below) are 7146 for PESAT only. List of companies where packaged plus boosters of health education sessions have been conducted - Oil and gas: BP, Vico Indonesia, Conoco Phillips, Medco, Chevron - Mining: Arutmin, Indocement, Inco

Health Education Program for Parents (HEPP)

Banking: Standard Chartered Bank, Central Bank of Indonesia, Permata Bank Services: PWC, Law firms, religious events Manufacturer/Retail: Unilever, Mattel, Astra Honda Insurance: Axxa, AIG, LOMA Society Academic: Cikal, Mentari, AlIzhar, Hans Gretzel,

2. Mailing list: Given the size and geography of Indonesia, YOP initiated an emailbased advice service and exchange so that parents in remote locations could seek advice of YOP staff and parents. The mailing list has close to 9506 (18 May 2010) subscribers and now almost 12,000 members with at least 300 emails daily on issues ranging from the verification of medical advice, to queries on medication and home based care for children with minor symptoms.
Picture: HEPP membership across Indonesia

Members spread from - Sumatera: Banda Ace, Lhokseumawe, Lhokseukon, Medan, Padang, Pakan Baru, Duri Riau, Palembang, Batam, Riau islands - Borneo: Pontianak, Balikpapan, Samarinda, - Java: o Jakarta, Cilegon, Serang, Banten, Tangerang, Bogor, Bekasi, Cirebon, Bandung, Garut, o Tegal, Semarang, Kudus, Jogja, Solo, Purworedjo, Cilacap o Surabaya, Sidoardjo, Malang, Kediri, Bondowoso - Sulawesi: Makasar, Palu, Manado - Lain-Lain: DenPasar, Mataram, Ambon, Timika Since November, we also develop a twitter account and we spread news/issue every Monday. Since January we also develop a facebook. 3. Radio programs: Since February 2004, Dr Purnamawati and HEPP colleagues have had regular, hourlong talkshow spots at prime time on two FM stations. o Radio Delta: middle to upper class of population, professionals including doctors (fortnightly); and o Radio Utan Kayu: middle to lower class of the population (weekly). Both stations relay the talk shows to several cities in Indonesia and has been instrumental in expanding the HEPP membership base in these cities.

Health Education Program for Parents (HEPP)

HEPP has developed a series of child health sessions to guide the talk show programming over the year and they broach a diverse range of topics: Physiology (common problems in children, bacteria versus virus, symptoms and disease, when hospitalization is needed);

Basic Medical Philosophy (informed consent and the right to information) Rational Prescribing (antibiotic overuse and sensible use of antibiotics); Doctor-Patient Relationship (art of asking questions, the meaning of consultation, communication between patient and doctor); Development Issues (global infant and maternal morbidity, womens welfare, safe motherhood); and Consumer Education (reading medication labels, medical references on the internet, individual questions from listeners hotline).

4. Publications: In its efforts to provide medical information in a format that is accessible and digestible for parents across Indonesia, HEPP has published hard bound and electronic educational materials. Published Works: 1. My Baby, My Child, a digest on child health for parents was published by HEPP in August 2005; 2. Books no. 2 are based on Q&A correspondence between parents and HEPP over the mailing list. It is called Q & A. Smart parents for healthy children. 3. Resident Paediatrician for a Readers Consultation Column in the monthly magazine Parenting; 4. Articles for high circulation Indonesian press including for Kompass, Jakarta Post, Republika and various national magazines. Web-based Publications: Since the launch of the HEPP website in August 2005 (www.sehatgroup.web.id but since February 2010, our web is www.milissehat.web.id ), HEPP has moderated a mailing list and published an expanding library on child health resources. Resources on the HEPP website include: 1. Guidelines on fever, febrile convulsion, UTI, Otitis, fever of unknown origin, TB, IVFD, colic, diarrhoea, atopic dermatitis, varicella, etc; 2. Immunization schedule; 3. Dietary and nutrition advice, growth charts 4. Drug information 5. Highlight for each month (March 2011, the highlight is related to antibiotic resistance)

5. Model Clinic: Aims: Provide a demonstration of responsible paediatric care; site for training and research; Provide a cost effective health service for the parents. Could become self funding in time

Health Education Program for Parents (HEPP)

It starts last August (2007) and majority of the patients are from mid-low SES. However, it still needs a lot of support.

6. Studies: We did some studies on 1. Prescribing habit (email based) on common health illnesses 2. Prescribing habit on common health illnesses particularly URI and acute GE. Based on posted prescription by parents 3. Survey on the impact of our mailing list 4. Survey on baby friendly hospital 5. Survey on violation to breastfeeding practices

Contact Information: Web: - Handadi: ghozan10032005@gmail.com - Dr Yulianto: anto_sk@yahoo.com - Dr Windhi: windhi_krn@yahoo.com Mailing list: - Moderator: sehat-owner@yahoogroups.com YOP: - Indira Hadi: indirahadi@hotmail.com - Nia Kurniawati: niapurnama@yahoo.com - Dr Purnamawati S Pujiarto: purnamawati.spak@cbn.net.id