Imran Iqbal ( Departments of Paediatries, Nishtar Medical College, Multan. )
Shahid Pervez ( Community Medicine, Nishtar Medical College, Multan. )
Salim Baig ( Departments of Paediatries, Nishtar Medical College, Multan. )
knowledge, attitude and practices (K.A.P.) survey was conducted among doctors working as general practitioners (GP) in Multan, for diagnosis and management of acute respiratory infections (AR!) in children under five years of age. GPs in Multan were not familiar with national ARI control programme and rational drug use guidelines. They rarely asked about symptoms describing severity of disease while taking patient histories and did not look for signs of severe pneumonia during physical examinations. Most patients diagnosed as URTI (upper respiratory tract infection) received oral antibiotics and those with pneumonia received injectable antibiotics, Other drugs prescribed included cough syrups, antihistamines and antipyretics. The average number of drugs prescribed per patient was 3,4, The doctors were deficient in providing home care advice for sick children to the caretakers. Average time spent by doctors on each patient was two minutes and twenty-three seconds. A combination of biomedical and social factors help to perpetuate this irrational prescribing behaviour of the GPs. Continuing education program mes for doctors in general practice about AR! management in children and rational use of drugs and health education of the public may improve the current prescribing practices (JPMA 47:24, 1997).
Acute respiratory infections (AR!) are one of the major causes of morbidity and mortality in developing countries. Children under five years may suffer from 5-8 attacks of ARI annually1.. In Pakistan. children with A.RI constitute about one-third of the out-patient attendance for any doctor working in the community2. One-fourth to one-third of under-five mortality in developing countries has been shown to be attributable to AR! as an underlying or a contributing cause3. Most of these deaths are due to pneumonia and arc preventable with adequate antibio,tic treatment4. While many children with ART lack the benefit of essential antibiotic treatment, others are victims of indiscriminate and inappropriate use of antibiotics5. Research studies in Pakistan and other developing countries have shown that training of health personnel in the rational and effective management of ARI episodes can help to reduce mortalit due to ARI in the community5,6.
ARI Control Programmes initiated by WHO are developing and promoting effective and rational management of ARI episodes in children by the health care personnel worldwide5. The National ART Control Programme in Pakistan has also started training of doctors in the management of ARI Studies of health facility utilization patterns in the country have shown that self-employed general practitioners (GPs) working in the community see and treat the larger segment of ARI patients2,7-9, These GPs are registered doctors with MBBS (Bachelor of Medicine and Bachelor of Surgery’) qualifications. They typically have small community- based walk-in clinics. Most clinics have dispensing corners where prescribed medicines are dispensed to patients in the form of tablets, powders and mixtures and injections administered.
There is limited data available on health care practitioners KAP (knowledge, attitude and practice) regarding AR! management in children under five years of age10,11. We conducted this study to investigate the way in which GPs in Multan diagnosed and treated children under the age of five, presenting with ARI. The specific goals of the study were (1) to assess the knowledge and skills of the GPs regarding ART management, (2) to compare the way in which the doctors actually evaluated and treated children with standard case management guidelines. (3) To determine ways in which the National ARI Control Programme might intervene to promote effective and rational management of ARI episodes by the GPs.
Materials and Methods
Study area and subjects
Multan, located in south of Punjab, is a densely populated urban area housing about a million inhabitants. Population is largely middle to poor class. Children under five constitute about 15% of total population. Study subjects were GPs working in the city of Multan including its slums and suburbs.
There was no pre-existing list available of all GPs working in the city. A tentative list of 132 names was prepared after obtaining infonnation from local medical association, professional colleagues and pharmaceutical companies.One hundred and ten of these GPs were personally visited by our research physician to enlist theirparticipation in the study. The remaining GPs were not available on contact. The GPs were told that our intention was to study symptom reporting in children with AR! presenting to the doctors (to minimise observation bias). Permission was asked for two research physicians to observe the doctor taking the history and examining the patients. All of these doctors who were contacted consented to participate in the study. Data collection was started in Januaiy, 1993, initially with those GPs who were considered to enjoy more busy practices by an estimate of waiting crowd in the clinic at the time of initial contact. By the end of March, 1993, winter had ended and the number of ARI patients dropped significantly. Then data had been collected about 69 GPs. As it was not feasible to continue the study longer or during the next ARI season, these 69 GPs by default became our study sample.
Standard Affi case management guidelines
The Pakistan National ARI Control Programme recommends standard case management based on WHO developed criteria for children with ART by the health personne12 This protocol requires the doctor to ask a specific set of questions while taking the history and to perfonn specific physical examination (Table I).
The classification of severe pneumonia, pneumonia or cough and cold is made on the basis of the clinical findings (Table II).
The case management piDlocol recommends hospitalisation of children suffering from very severe disease and severe pneumonia, oral antibiotics at home for children with pneumonia and no antibiotics for those with simple cough and cold. It also recommends to give specific home care advice pertaining to fluids, feeding, home remedies and warning signs of pneumonia to the caretakers of the patients treated at home (Table III).
Keeping in view the standard case management guidelines, the following three measuring instruments were developed and pre- tested to study research questions.
1. An observational checklist for recording direct clinical observation of GPs while examining children in their clinics. Specific items included: presenting complaints described by the caretaker or asked by the doctor, clinical examination performed by the doctor, home care advice given by doctor and duration of doctor-patient interaction.
2. A semi-structured interview data collection instrument which recorded details of GP’s clinical practice and his knowledge of important clinical features in patients suffering fmm ARI.
3. A self-administered questionnaire for the GPs asking about their patient management in different ART diseases.
Two research physicians with experience in ART case management of children were hired for data collection. Clinical practice of each GP was observed fora session of two to four hours. All the children under five years of age presenting with ART to the doctor during this period were included in the study. The GP’s clinical behaviour was recorded on observational checklist while he was examining the child. At the end of the consultation, they asked the GP about his diagnosis for the child and the treatment prescribed. This was necessary as the GPs in Multan usually wrote their prescriptions in codes deciphered by employees who dispense the medicines accordingly. At the end of the session, the doctor was requested to answer a few questions (semi-structured interview) and to complete a written self-administered questionnaire.
All the datacollection forms were kept confidential. The data was coded and entered into the computer and later used for data analysis. The computer software used was Epi info 5.01. developed by the World Health Organisation. Geneva and Centre for Disease Control, Atlanta, USA.
Sixty-nine GPs were included in the study. Number of ARI patients examined by each of them during the observation period varied from one to eight, data was collected for 255 doctor-patient encounters.
The mean age of GPs 38±8 years (range, 28-60). They had obtained their medical qualifications from 3 to 34 years ago (median >10 years). The mean period for practicing clinical medicine was 8±8 years (range 1-33). Thirty-eight doctors (55%) worked fulltime in their clinics (morning and evening), while 3 1 (45%) were employed elsewhere in the morning hours and worked in their clinics during the evening only. Eighteen GPs (26%) also provided simple laboratory services, such as routine blood and urine examinations. Five GPs (7%) had admission facilities in their clinics. Their practice load varied considerably, by self reports they saw from 4 to 70 patients a day (median 20, mean24+4).
Comparison of reported knowledge/practice and observed practices of the GPs
Doctors’ replies to the questionnaires represented reported knowledge/practice while data obtained from observational checklists revealed observed practices of the GPs. Points of importance with respect to the standard ARI case management protocol were compared. For the purposes of this comparative analysis, the first patient which came to the doctor during the observation session, if fulfilling the entty criteria, was selected. This makes the data in the reported and observed columns of following tables directly comparable as each doctor replying to the questionnaire about a specific problem/disease contributed only one observation while examining/treating a patient suffering from the same problem/disease.
Table IV compares reported and observed clinical skills of the GPs. Most of them said and were observed to ask about fever and cough, but fewer asked about difficulty in breathing and ver few counted respiratory rates or looked for chest indrawing.
Most depended on their stethoscopes during examination. Treatment and advice for 23 cough and cold doctor-patient encounters is shown in Thble V The majority of children were treated with oral and injectable antibiotics in addition tantipyretics and antihistamines. Very few patients were provided home care advice.
Table VI compares treatment and home care advice forpatients withpneumonia. Most were prescribed antibiotic injections and there was marked variation between reported and observed prescribing practices.
Drugs and duration
Number of drugs prescribed per patient ranged from none to seven, with a median of 3.0 (mean=3.4+1.0). In 156 encounters, time of patient-doctor interaction was recorded. It ranged from ten seconds to six minutes, with a median of 2.0 minutes (mean=2.23+1 .43 minutes with seconds).
This study serves as a baseline survey of ARI Inanagement by the GPs in Multan. Observations indicate that the usual clinical practices of the GPs in Multandifferfrom the standard ARI case managetnent guidelines. There appear to be multiple reasons behind this prescribing behaviour of the doctors. Most of the GPs in the city were not familiar with the recent developlnents in the ARI case management. There was no formal training programme for the continuing education of doctors in general practice. Only two GPs in our sample, had attended the recently starfed ARI case management training courses. This lack of appropriate knowledge and skills is probably the major factor behind inappropriate management of ARI cases. But in addition, the difference between reported and observed practice among GPs could be due to social, financial and time constraints.
From a sociological view, a low level of general literacy in Pakistan and kick of health education has led to misconceptions about drug use and its benefits. It is a common belief that taking medicines improves the health of both the sick and the healthy people. Multiple drugs are considered better than single. Injections are expected and perceived as more effective than oral drugs11. Such beliefs are reinforced by the very large number of unqualified and unregistered practitioners practicing medicine all over Pakistan. The doctors’ prescribing practices are also influenced by this public attitude towards drugs. The parents are satisfied by the doctors’ mere use of stethoscope, believing that their child has been adequately examined13. Similarly, an injection and a bottle of medicine makes them believe that they are getting proper treatment. Overall, doctor is considered as a provider of medicine and not someone who gives medical advice11. These prescribing practices persist because they seem to satisfy the needs of both the patient and the doctor14,15.
Economic factors play a role because the doctors running general practice clinics are not prepared to risk any treatment failure for fear of losing their patients. Competitive business makes themfeel constrained to accede to the patient’s desire of an immediate improvement in his symptoms and early recovery. As a result, they excessively use antibiotics and other symptomatic relief drugs such as cough remedies and antipyretics. The clinics of sonic of the GPs were crowded with a large number of patients waiting for them. The patients were coming to the doctor’s table one by one as he was hurriedly writing prescriptions for them. This situation did not allow the doctor to talk to the patients or even to do an adequate physical examination. Froni previous experience. patients also expect the doctor to provide medicines, not just a consultation11.
A more recent country-wide survey involving government physicians has also brought, out unnecessary antibiotic use and lack of communication between the doctors and the child caretakers16. Similar prescribing behaviour of the doctors seems to be widely prevalent in other countries of the region2,15 and in rest of the developing world17-19, A study of drug utilization pattern in Sri Lanka showed that average number of drugs per consultation was 3.415. A survey in Indonesia has shown that 85% of the ARI patients seen by general practitioners and pediatricians were prescribed antibiotics and on an average. 3.5 drugs were prescribed per patient17. A WHO study on rational use of drugs in 12 developing countries of Asia, Africa and Latin America showed that the average number of drugs per prescription in different countries was 1.3 to 2.2. The same study revealed that the avenge time given by the doctor to each of the patients in these countries varied from 1.0 to 6.3 minutes18.
A number of strategies have been suggested and applied with variable amount of success to effect a change in physicians19 practices20,21. Generally, educational methods have been more successful as compared to the administrative and regulatoiy measures20. If the subjects are deficient in knowledge and skills are needed, teaching and training of the requisite skills would be necessary. If significant knowledge and required skills are there with lack of adequate performance, bringing changes in work environment facilitating the appropriate behaviours would be required22. Any simplified model would be inadequate to explain the observed prescribing behaviour of the GPs in our study. More research is needed to understand the interplay of economic, social and cultural forces which promote non-scientific prescribing behaviour of the health providers23. There is a need of educational programmes for the doctors with emphasis on rational prescribing and better communication with the patients. This educational process is best started during the undergraduate training years24. At the same time, continuing education programmes for the doctors would be needed. Any measures taken to change the prescribing behaviour of the GPs should be planned in consultation with them20,25. In addition, parents and caretakers of children need to be made more infonued about the dangers of excessive and unnecessary usage of drugs, so that an environment of demand can be generated for more rational prescribing by the doctors11.
Financial support for this research was provided by the Applied Diarrhoeal Disease Research Project at Harvard University by means of a Cooperative Agreement with the United States Agency for International Development (USAID).
1. Nichter, M. Social lessons from diarrhoea and their application to ARI. Hum. Organis.. 1993;52:53-67.
2. Khan,M.A., Rehman, G.N. and Qazi, S.A. Control ofacute respiratory infection in Pakistan present status and future developments. lslsmabsd, Federal ARI Cell. Childrai’s Hospital, 1990.
3. Gadomski, A. Epidemiology and etiology of acute reapirstory infections, particularly pneumonia, in developing countries WHO technical paper. EM/Inc. MTQ. ARU3, Geneva, World Health Organization, 1989.
4. Shrine, F Pneumonia in children: A neglected cause of death. World l-tcalth Forum. 1985;6:143-145.
5. WHO/UNICEF, Basic principles for control of acute respiratory infections in children in developing countries. A joint WHO/UNICEF statement. Geneva, World Health Organisation, 1986.
6. Than, A.J. Acute respiratory infections in children: A case management intervention in Abbottabad district of Pakistan. Hull. WHO, 1990;68:577.
7. Goldmann, H., Ravji, R., Limprethct, N. et at. Using information systems to improve management of primary health care systems. Pak. Pediatr. 3., 1989,13.145-158.
8. Perver, A., Choudary, N.A., Choudsry, F.M. et at. Medication attitudes Household survey ofFaisalabad Tehsil. 3. Pak.Med. Assoc., 1989;39:290-291.
9. Marsh, DR., Haq, I., Qureshi, AR et at. Childhood acute respiratory infection in Pakistan. 3. Pak. Med. Assoc,, 1993;43:14-20.
10. Redd, S., Moteetee, M. and Waldman, R. Diagnosis and management of acute respiratory infection in Lesotho. Health Policy Plan., 1990;5 :255.
11. Mull, D.S. and Mull, 3D. Insights from community based research on child pneumonia in Pakistan. Mcd. Anthropol., 1994; 15:335-352.
12. Ministry of Health, Government of Pakistan. Management of the young child with an acute respiratory infection. Islamsbsd, Federal ARI Cell, Children Hospital, 1994.
13. Kundi, M.Z.M., Anjum, M., Mull, D.S. et at. Matemal perceptions of pneumonia and pneumonia signs in Pakistani children. Soc. 5cr. Med., 1993;37:649-660.
14. Shwartz, R.K., Soumersi, SB. and Avom, 3. Physician motivations for non-scientific drug prescribing. Soc. 5cr. Med., 1989;28:577- 582..
15. Sacs, L. and Tomson, 0. Medicines and culture-s double perspective on drug utilization ins developing country. Soc. Sci. Med., 1992;34:307-31-5.
16. National ARI Control Progrsm. Report on ARI Health Facility Survey. ARI News (Pakistan edition) 1994;28:9-10.
17. Dwiprahasto, 1. Antibiotic utilization in the treatment of acute respiratory infection in children under 10 years seen in private practires. Paper delivered at the international clinical epidemiology. Cairo, Egypt, Network (INLEN) conference, 1993.
18. Hogerzeil, H. V. and Ross-Degnan, B. Field tests for rational drug use in twelve developing countries. Lancet, 1993;342: 1408-1410.
19. Habib, 0.5. and Ehrahim, SM. Acute respiratory infections: A study on case management in Basrah Health Centres. Health Policy Plan., 1994;9:2 13-217.
20. Greco, P. J and Eisenbcrg, J.M. Changing physicisnspractiecs. N. EngI. 3. Med., 1993;329: 1271.1274.
21. Soumerai, S.B. Principles of educational outreach (academic detailing) to improve clinical decision making. JAMA, 1990;263:549-556.
22. Graef, J.A., Elder, JR. and Booth, E.M. Communication for health and behavior change. San Francisco, The Jossey-Bass Inc., 1993, p. 71.
23. Nichtcr, NI. Introduction (Acute respiratory infection) Mcd. Anthropol., 1994;1 5.3 19-334.
24 Ahmad, SR. and Bhutta, Z.A. A survey ofpacdistric prescribing and dispensing in Karachi. J,Pak, Med. Assoc., 1990;40:126-130.
25. Oshiname, FO. and Briegcr, W.R. Primary care training for patent medicine vmders in rural Nigeria. Soc. Sci. Med., 1992;35:1477- 1484.