|Year : 2018 | Volume
| Issue : 1 | Page : 47-51
Knowledge and practices about animal bite management among government doctors posted at primary health-care settings of district Patiala in Punjab
Vishal Malhotra, Amarjit Singh, Rajinder Singh Balgir
Department of Community Medicine, Government Medical College, Patiala, Punjab, India
|Date of Submission||31-Oct-2017|
|Date of Acceptance||14-Feb-2018|
|Date of Web Publication||25-May-2018|
195-B Sewak Colony, Patiala - 147 001, Punjab
Source of Support: None, Conflict of Interest: None
Background: Approximately 36% of the world's rabies deaths occur in India, three-fourth of them in rural areas. Out-of-pocket expenses and lack of transportation from rural areas prevent many of the poorest people in India from accessing primary health-care services, leaving them to carry the burden of rabies. Rabies incidence in India has been constant for a decade, without any obvious declining trend, this situation is due to general lack of awareness of preventive measures, which includes insufficient dog vaccination, an uncontrolled canine population, poor knowledge of proper post-exposure prophylaxis on the part of many medical professionals, and an irregular supply of antirabies vaccine and immunoglobulin, particularly in primary-health-care facilities. The present study was done to assess the skill and knowledge about animal bite management among primary health care providers health-care providers at peripheral health institutes of district Patiala.
Materials and Methods: A cross-sectional survey was done using pretested and validated, self-administered questionnaire. Overall awareness was assessed based of sum score of each outcome according to blooms cutoff point, P < 0.05 was considered statistically significant.
Results: Out of 103 government doctors, rural medical officers (RMOs) constitute 32 (31%) and Punjab civil medical services (PCMS) 71 (69%). RMO Cadre has more mean age (34.06 ± 3.95), than PCMS (29.02 ± 5.98). Both cadres have many gaps in their knowledge. Median score of both groups is 13. Almost 45% have low knowledge-practice (K-P) score and the difference in K-P score of RMOS and PCMS are not statistically significant.
Conclusion: Both groups lack knowledge on how to manage common clinical scenarios frequently seen in rural areas. There is urgent need for upgrading the knowledge and skills of doctors working at the peripheral health facilities. State health department must coordinate with medical colleges for training by organizing continued medical education for the success of national rabies control programme.
Keywords: Awareness, Punjab civil medical services, rural medical officer
|How to cite this article:|
Malhotra V, Singh A, Balgir RS. Knowledge and practices about animal bite management among government doctors posted at primary health-care settings of district Patiala in Punjab. J Curr Res Sci Med 2018;4:47-51
|How to cite this URL:|
Malhotra V, Singh A, Balgir RS. Knowledge and practices about animal bite management among government doctors posted at primary health-care settings of district Patiala in Punjab. J Curr Res Sci Med [serial online] 2018 [cited 2018 Jul 18];4:47-51. Available from: http://www.jcrsmed.org/text.asp?2018/4/1/47/233201
| Introduction|| |
Out of an estimated global annual 55,000 rabies deaths, roughly 20,000 occur in India each year which account to 36% of the world rabies deaths. In India, three-quarters of rabies deaths occur in rural areas. One of the reasons the disease has been neglected is because “deaths are scattered” and never amount to the kind of emphasis that is given to an epidemic. According to the World Health Organization (WHO), the true burden of rabies in India is not known; the reported incidence is probably an underestimation because in India rabies is still not a notifiable disease. Out-of-pocket expenses and lack of transportation from rural areas prevent many of the poorest people in India from accessing primary health-care services, leaving them to carry the burden of rabies. In spite of considerable advances in the development and availability of efficient tools to control this disease, there has not been any substantial decrease in rabies incidence in the Southeast Asia region, except in Thailand and Sri Lanka. It continues to be a major public health problem throughout the region. According to the WHO, ending human deaths from dog-mediated rabies by 2030 will require an active role from India, which has a high concentration of the disease but is also empowered by its rich technical expertise and resources to drive cooperation of other countries in the region. Hence, the Government of India has launched national rabies control program under 12th 5-year plan in all states and UTs. The human component of this program includes training of health professionals, implementing use of intradermal route of inoculation of cell culture vaccines, strengthening surveillance of human rabies. Since three-quarters of cases comes from rural areas, it is of utmost importance that doctors who are providing services at primary health-care level in rural areas and at periphery should have the required competence, confidence, and practical hand-on skills, so that they can handle difficult class three bite cases. It has been seen that most of Class 3 bite cases particularly with lacerated wounds are referred to Government Rajindra Hospital by doctors posted at peripheral health institutions of Patiala district. It is very difficult for cases referred from rural areas to reach tertiary care facility due to poverty and transportation problems, and sometimes, they failed to reach on time leading to loss of precious life. The present study was conducted after taking approval from Institutional ethics committee and was done to assess awareness about animal bite management among rural medical officers (RMOs) and General duty Medical officers (GDMO) of Punjab civil medical services (PCMS) cadre working at rural dispensaries, primary health centers (PHCs) and community health centers (CHCs) level in rural health blocks of Patiala district. These doctors are the first point of contact for healthcare of these rural masses. Most of the previous studies were done to assess the awareness of private practitioners and very few have been conducted among government health-care providers, so this pilot study will provide baseline information to state health department and Zila-Parishads about level of awareness and training need for doctors working at primary health- care level.
| Materials and Methods|| |
There are approximately 45 RMOs posted in rural dispensaries who are under the jurisdiction of Zila Parishads, headed and supervised by additional deputy commissioner for rural development and 80 GDMO posted at PHCs and CHCs of the rural health blocks of Patiala district who are under PCMS cadre, supervised by chief medical officer of the district. Both groups are M.B.B.S doctors but differ by cadre and supervising authority. Hence, total of approximately 125 medical officers who are providing primary healthcare to rural masses were included in the study. Awareness regarding rabies and animal bite management by doctors was assessed using pretested and validated, self-administered knowledge, attitude, and practices questionnaire. The Department of Community Medicine faculty, who were not directly involved in the study, checked the face/content validity and then statistician of the Government Medical College was consulted for his feedback on validation of the tool. It was than pretested on 20 medical officers of urban settings and after making desired modification it was used for assessment. Based on this pilot testing, 30 min was considered appropriate period for answering the questionnaire by medical officers. Questionnaire consisted of 22 questions on various aspects of rabies and animal bite management and each question had one correct answer. Local health authorities were contacted and it was decided to get the questionnaire filled by RMOs, during their monthly meeting with district health authorities. During meeting, the RMOs were explained about the purpose of the study by the senior faculty of community medicine department and those who gave verbal informed consent were given questionnaire to be filled in front of senior faculty of community medicine department and other district health authorities without discussing with each other. Thirty-two RMOs ultimately showed willingness and participated in the study. Similarly, during training workshops of GDMO in the Government Medical College, Patiala, they were explained about the purpose of the study and 71 GDMO participated in the study, so total of 103 medical officers participated in the study, keeping an overall response rate of more than 80%. Participants overall knowledge and practices were assessed using the sum score of each outcome based on Bloom's cutoff point (60%–80%).,,
There are total 22 questions with one correct answer, so maximum score is 22, and based on below mention score range, medical officer's level of awareness was assessed.
- 18–22 (80%–100%) high levels
- 13–17 (60%–80%) moderate levels
- <13 (<59%) low levels.
Having a score above the cutoff point was equated with having high levels of knowledge and good practice. Epi-Info version 7 from CDC (Centers for Disease Control and Prevention) Epi Info™ and Microsoft Excel 2010 were used to analyze the data from duly filled questionnaire. Box–whisker plots were used to show the distribution of knowledge-Practice (K-P) score of study participants.
| Results|| |
In our study, 103 medical officers participated, where RMO, constituted 32 (31%) and PCMS 71 (69%), with RMOs having more mean age of (34.06 years ± 3.95) and service experience (6.25 ± 2.83) when compared with PCMS cadre doctors with mean age of (29.02 ± 5.98) and service experience (2.2 ± 3.2) working at peripheral health institutions. There was no statistically significant difference between the two cadres of doctors working in peripheral health institutions.
[Table 1] shows that RMOs have better knowledge about rabies and its epidemiological determinants as compared to PCMS doctors, although very few doctors of both cadre, RMO (28%) and PCMS (26%) knew about incubation period of disease. Majority of the PCMS (69%) and RMOs (60%) do not know that rabies can be transmitted by body fluids of infected patients. The fact that rabies is a 100% fatal disease is not known to 32% PCMS and 25% RMOs respectively. PCMS (54%) and RMO (35%) doctors do not know about reservoir of rabies.
|Table 1: Knowledge of Punjab civil medical services and rural medical officer cadre doctors about rabies and management of animal bite|
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When it comes to knowledge about first-aid measures such as wound washing and banding/suturing of wounds, 65% PCMS cadre doctors knew about duration of wound washing whereas just 40% RMOs knew about this fact. More PCMs doctors (83%) knew about delayed wound suturing than RMOs (78%).
Majority of doctors (71%) of both cadres were aware about class of bite. Postexposure vaccine regime was known to 66% of PCMS and 68% of RMO. Route and site of administration of modern antirabies vaccine was answered correctly by 87% PCMS and 84% RMOs. However. most of them do not know about the management of common cases encountered in rural areas like treatment in case of consumption of raw milk of rabid milch animals where just 20% of PCMS and 28% of RMOs, responded correctly. Another clinical scenario in rural areas that is bite of horse, donkey, and mongoose was answered correctly by 25% of PCMS and 21% of RMOs. Majority of the PCMS (47%) and RMOs (66%) lack knowledge about animals for whom 10 days observation period is recommended, whereas, 63% PCMS and 31% RMOs knew about correct dosage of rabies immunoglobulin. Statistically significant difference was present in the knowledge among PCMS and RMOs cadre doctors about fact that rabies immunoglobulin can be given within 7 days and its correct dosage.
Both cadre doctors (50%) do not know what would be case management where dog was untraceable. PCMS (43%) and RMO (56%) doctors do not know about preexposure prophylaxis. Very few doctors have knowledge about reexposure prophylaxis, where just 19% PCMS and 3% RMOs correctly responded and this difference was statistically significant between two cadres of doctors.
[Table 2] showed mean K–P score of PCMS doctors (12. 69 ± 2. 74) is slightly more than RMOs (12.56 ± 2.13). This K–P score is based on both knowledge and practices aspect though it was not statistically significant. Based on blooms cutoff, more than 40% government doctors have low score and remaining scored moderately, with just 4% PCMS doctors have high knowledge about animal bite management. In Box–whisker Plot, minimum score of doctors comes out to be 7 and maximum 20 though Median, 25th percentile, 75th percentile of both cadres was same [Figure 1] and [Figure 2].
|Figure 1: Distribution of knowledge-practice score of government doctors|
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|Figure 2: Distribution of knowledge-practice score of medical officers of both cadres (n = 103)|
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| Discussion|| |
There are many gaps in the knowledge of government doctors working in peripheral health institutions, i.e., rural dispensary, PHCs, and CHCs. Their knowledge at the most was of moderate level. Most doctors knew about cause of rabies; however, reservoir of rabies is known to 52% doctors as against 92% in study done in Rohtak in Haryana, contrasting results have been reported in studies done in Jamnagar  and Belgaum, where 24% and 11% doctors were aware of animal reservoirs, respectively. It was astonishing that in our study 66% doctors were not known to the fact that rabies can be transmitted by body secretions of case of rabies which was higher than a study done in Ambala on private practitioners. In the current study, 54% doctors knew about minimum duration of wound washing which was higher than study done in Ambala. Immediate Bandaging/suturing was recommended by 18% doctors in the current study, similar results were reported by other studies done in Jamnagar  and Bangalore.
In our study, 67% doctors know about post-exposure and 47% about pre-exposure schedule which was in concordance with study done in Delhi  and higher than what was reported in other studies., Route and site of administration of modern antirabies vaccine was not known to about 13% doctors in current study, in contrast to 45% doctors in study done in Jamnagar. In the current study, 59% doctors recommended rabies immune globulin 7 days after bite and 47% doctors do not know about the dosage of rabies immunoglobulin which was lower than a study done in Ambala. In our study, 77% do not know about reexposure prophylaxis and the difference was statistically significant between two cadres, in contrast to study done in Delhi where 40.4% doctors were aware of this.
In our study, 53% doctors lack knowledge about which animals are to be observed for 10 days after their bite and 51% about management of cases where animal is untraceable; these aspects have not been explored in other studies. RMOs and PCMS doctors are working in rural areas where bite by donkeys/mongoose/horse is quite common and people frequently come to consult doctors after drinking the raw milk of milch animals bitten by rabid dogs. However, it was very surprising and unfortunate that majority of government doctors do not know how to manage these miscellaneous clinical scenarios. In addition, lacerated Class 3 wounds, particularly in rural children, are frequently referred to district hospital and medical colleges. The paucity of money and transportation facility leads to delay in seeking much-desired treatment, and at times poor people went to quacks leading to loss of precious life.
| Conclusion|| |
There is lack of knowledge in both cadres of government doctors. There is an urgent need for upgrading the knowledge and skills of doctors who are providing primary healthcare at the peripheral health facilities. State health department must coordinate with tertiary care institutes and medical colleges for training of doctors by organizing continued medical education on annual basis for the success of national rabies control program and for achieving the WHO target of ending human deaths from dog-mediated rabies by 2030.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]