|Year : 2021 | Volume
| Issue : 5 | Page : 1882-1889
Knowledge, attitude and practices of PHC physicians in Aseer region regarding management of acute asthma
Hassan Ahmed Assiri1, Yahia Matter Alkhaldi2, Safar Abadi Alsaleem3, Hassan Mohammad Alqarni1
1 Abha Health Sector, General Directorate of Health Affairs, Aseer Region, Abha, Kingdom of Saudi Arabia
2 Department of Research and Studies, GDHA, Aseer Region, Abha, Kingdom of Saudi Arabia
3 Department of Family and Community Medicine, KKU, Abha, Kingdom of Saudi Arabia
|Date of Submission||11-Jul-2020|
|Date of Decision||17-Sep-2020|
|Date of Acceptance||04-Oct-2020|
|Date of Web Publication||31-May-2021|
Dr. Hassan Ahmed Assiri
Abha Health Sector, General Directorate of Health Affairs, Aseer Region
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Objectives: This study aims to explore knowledge, attitude and practices of physicians working at primary health care (PHC) in Abha, KSA, regarding assessment and management of acute bronchial asthma. Subjects and Methods: This is a cross-sectional study that was conducted among PHC physicians in Abha, Khamis Mushayt and Ahad Rufeida cities, Aseer region KSA in 2018. A questionnaire that was constructed by the investigators was used to assess the knowledge, attitude and practices of PHC physicians regarding the diagnosis and management of patients with acute asthma. The questionnaire was distributed under the supervision of the first investigator. Data management was carried out using SPSS version 23. Results: A total of 200 PHC physicians participated in this study. About two-thirds of them (63.5%) had good grade of knowledge regarding acute asthma management, whereas 44% had positive attitude toward acute asthma management. The main knowledge gaps were doses of drugs used in the management of acute severe asthma attack (36%), and diagnosis of acute severe asthma attack (51.5%). Physicians' main source of knowledge on asthma included textbooks (26%) and guidelines (61.5%). Physicians' practice grades were significantly higher among those with less experience in PHC (p = 0.011). Almost all PHC centers (PHCC) (98%) had oxygen and nebulizers, 72.5% had steroids, 71.5% had salbutamol, 50.5% had ipratropium and 41% had peak flow meter, whereas 73.5% had the Saudi Initiative for Asthma (SINA) guidelines. Conclusion: This study revealed that knowledge of PHC physicians regarding the management of bronchial asthma was suboptimal, their attitude is not completely positive, and their adherence to asthma management guidelines is quite low. Some PHCCs were lacking important drugs and equipment for management acute asthma that should be provided. Well-structured training of PHCC doctors on SINA is mandatory to upgrade their knowledge, promote their attitude and improve their skills.
Keywords: Acute asthma, Aseer region, attitude and practice, knowledge, primary health care, Saudi Arabia
|How to cite this article:|
Assiri HA, Alkhaldi YM, Alsaleem SA, Alqarni HM. Knowledge, attitude and practices of PHC physicians in Aseer region regarding management of acute asthma. J Family Med Prim Care 2021;10:1882-9
|How to cite this URL:|
Assiri HA, Alkhaldi YM, Alsaleem SA, Alqarni HM. Knowledge, attitude and practices of PHC physicians in Aseer region regarding management of acute asthma. J Family Med Prim Care [serial online] 2021 [cited 2021 Sep 26];10:1882-9. Available from: https://www.jfmpc.com/text.asp?2021/10/5/1882/317267
| Introduction|| |
Bronchial asthma (BA) is one of the most common chronic health problems. It affects up to 300 million people worldwide, and it is estimated that an additional 100 million people will suffer from BA by 2025. BA is a chronic inflammatory airway disease in which the airway occasionally constricts in response to one or more triggers such as exposure to environmental stimulants, allergens, cold air, exertion, or emotional stress and produce an inflammatory reaction with intermittent airways obstruction.
The prevalence of BA varies from one country to another and ranges from 1.1 to 9.9% in adults.. In KSA, Al-Frayh et al. found that the magnitude of BA increased significantly from 8% in 1986 to 23% in 1995. Despite the high prevalence and severity of asthma, Verleden and De in Belgium, found that only 37.5% of the asthma patients seemed to be controlled and correctly treated.
In Saudi Arabia, Al-Dawood found that the rate of hospital emergency visit was 65% while hospital admission was 12% among children.
The Saudi Initiative for Asthma (SINA) has been performed excellent efforts to improve the quality of BA care at all levels including primary health care center (PHCC). They issued and updated national asthma guideline and make it accessible to use in different formats. Despite this valuable effort, the gaps between theory and practice is still expected to be huge as reflected with a high percentage of uncontrolled BA and their frequent visit to ER departments in hospitals.
Primary care center and their health care professionals are the first lines to manage acute BA; however the data about knowledge, attitude, practice and essential drugs, equipment availability were not adequately explored in this regard.
This study aims to explore knowledge, attitude and practices of physicians working at PHC in Aseer region regarding assessment and management of acute asthma.
| Subjects and Methods|| |
This cross-sectional study was conducted in the three main cities of Aseer Region: Abha, Khamis Mushayt and Ahad Rufeida during 2018. All physicians at PHCCs within these cities were constituted the study population and were invited to participate in this study. The expected number of physicians who should participate in the study was around 240 PHC physicians.
Based on the thorough review of relevant literature, a questionnaire has been designed by the researchers.,,,,,,, The questionnaire consisted of the following sections:
- Personal characteristics: Age, gender, nationality, qualification, position, experience in PHC, experience with asthma management.
- Knowledge: Participants' level of knowledge about diagnosis and management of acute asthma was assessed by relevant questions derived from the SINA Guidelines, which comprises eight questions (True/False) type and six multiple choice types. Each question was given a score of (1) for a correct response, or a score of (0) for an incorrect response or if the participant does not know the answer. Participants' knowledge grades were classified as follows: “Very knowledgeable” (≥85%), “Knowledgeable” (70-84%), or “Poor” (<70%).
- Attitude: Participants' attitude was assessed by asking 15 questions. It was assessed by Likert scale of three points (i.e., Agree, Neutral, or Disagree). An attitude was considered positive when the participant's total score was more than 20 points, negative if participant's total score was less than 15 points, or neutral if the total score was 15-20 points.
- Practices: Participants' practices about diagnosis and management of acute asthma were assessed by 12 relevant activities. Each statement was assessed as following: (4 = always, 3 = often, 2 = sometimes, 1 = rare, and zero = never). Practice regarding management of acute asthma was considered as “Good practice” if the total score was ≥75% and poor if less than 74.9%. Prior to start of data collection, the study tool was tested through a pilot study. This pilot study was applied to 15 physicians (who were not included into the main study) to test the validity and clarity of the questionnaire. To test the validity of the questionnaire, two consultants (family medicine consultant and Chest Diseases consultant) were invited to read the questionnaire and submit their comments and suggestions which were considered in the final version of the questionnaire. The ethical approval was obtained from the research ethical committee, College of Medicine, King Khalid University-Abha, KSA, under the number of REC# 2018-01-08 on 8/1/2018G. The consents of participants were obtained before distributing the questionnaire.
The questionnaire was distributed and collected by the investigator in arrangement with technical supervisors of the three health sectors during the study period (2017-2018).
The Statistical Package for Social Sciences (SPSS version 23.0) was used for data entry and analysis. Descriptive statistics (i.e., frequency, percentage, mean and standard deviation) was calculated and the appropriate test of significance (e.g., χ2) was applied. A statistically significant level was considered when P < 0.05.
| Results|| |
A total of 200 out of 240 PHCC doctors participated in this study giving a response rate of (83%). [Table 1] depicts the personal characteristics of PHC physicians, 64.5% of physicians aged 30-35 years. More than half of the PHC physicians (57.5%) were males, and 45.5% were Saudi. About two-thirds of the physicians (60%) had less than 5 years' experience in PHC. More than half of the physicians (53%) had a diploma or master degree, 44.5% had MBBS degree, while 2.5% had Doctorate or Fellowship degree. General practitioners constituted 47.5% of physicians, while specialists and consultants constituted 52.5%. About two-thirds of the physicians (60%) received training on asthma management. Physicians' main source of knowledge on asthma included textbooks (26%), clinical guidelines (61.5%), and workshops (11.5%).
|Table 1: Personal characteristics of PHC physicians in Aseer region, KSA |
Click here to view
[Table 2] summarizes the knowledge of participants regarding BA. The main points of knowledge gaps regarding acute BA management: doses of drugs (36%), diagnosis (51.5%), initial steps in the management asthmatic children (52.5%), signs of acute severe asthma (56%) and the appreciation of appropriate time to respond after initial treatment (57%).
|Table 2: Knowledge of acute asthma among PHC physicians in Aseer region, KSA |
Click here to view
[Table 3] depicts the attitudes of participants. All participants agreed that BA greatly affects patients' quality of life, and the majority agreed that the diagnosis of BA is their responsibility (96.5%). On the other hand, most participants disagreed that the patient should refer a case of suspected BA to a chest specialist (85.5%) and that providing health education for caregivers of patients with asthma is a difficult task (83%).
|Table 3: Attitude of PHC physicians in Aseer region, KSA regarding acute asthma, KSA, 2017 |
Click here to view
[Table 4] shows that the most frequent activities practiced by PHC doctor for management of acute asthma are counseling smoker for smoking cessation, and educating patients about symptoms and signs suggesting worsening of asthma control, whereas the least practiced activity was providing inhaled corticosteroid as initial treatment during asthma exacerbation.
|Table 4: Practice of PHC physicians regarding management of acute asthma in Aseer region, KSA KSA, 2017 |
Click here to view
[Table 5] shows the association between knowledge of participants and their characteristics regarding acute asthma management. It was found that those aged 30-35 years had a higher score compared to those aged above 35 years (P= 0.013). The knowledge grades were better among males compared to females 28% versus 17% (P = 0.029). Knowledge grades regarding asthma management were significantly better among non-Saudi physicians (P < 0.001) and those with high qualifications compared with those holding MBBS (69% vs. 19%; P = 0.001). However, physicians' knowledge grades did not differ significantly according to their years of experience in primary care or receiving training on asthma management.
|Table 5: Physicians' knowledge grades regarding acute asthma management according to their personal characteristics, KSA, 2017 |
Click here to view
[Table 6] and [Table 7] show the association between the attitude/practices of participants and their characteristics regarding acute asthma management. It is obvious there were no significant associations except for those with less experience in PHC had significantly better practice (p = 0.011).
|Table 6: Physicians' attitude toward acute asthma management according to their personal characteristics, KSA, 2017|
Click here to view
|Table 7: Physicians' practice grades regarding acute asthma management according to their personal characteristics, KSA, 2017|
Click here to view
[Table 8] shows that almost all PHCCs (98%) have oxygen and nebulizers, 72.5% have steroids, 71.5% have salbutamol, 50.5% have Ipratropium and 41% have peak flow meter; whereas 73.5% have the SINA guidelines.
|Table 8: Availability of material and medications related to asthma management at PHCCs, KSA,2017 |
Click here to view
| Discussion|| |
In the Kingdom of Saudi Arabia, most asthmatic patients are managed at primary care centers by primary care physicians. Knowledge of primary care physicians about the diagnosis and management of BA is essential for better patient care.
The present study aimed to explore knowledge, attitude and practices of PHC physicians in Aseer region regarding the assessment and management of acute asthma.
Findings of the present study revealed that the perception of participant PHC physicians is suboptimal, with about one-fourth of them having poor knowledge grade, about one-third had a negative attitude toward asthma management, while almost half of participants were non-adherent to the SINA guidelines when managing acute asthma at PHCC.
In the previous study conducted by Abudahish and Bella, they reported low knowledge scores among PHC physicians in Aseer Region many years ago. In Al-Khobar City, KSA, Yousef et al. reported that 41% of PHC physicians had poor knowledge regarding BA, while Taha et al. in Dammam, Saudi Arabia, reported that about half of primary care personnel showed poor knowledge regarding BA.,
In Kuwait State, Almutawa et al. reported a poor adherence among primary care physicians to the National Asthma Management Guidelines as only 37.2% of them strictly adhering to it. Poor compliance with asthma guidelines was also reported by many other studies in different counties.,,
The lack of knowledge and poor practice of primary care physicians regarding management of BA may be explained by the finding that only 60% of primary care physicians attended training courses on asthma management. However, those who attended the training courses did not have significantly better knowledge, attitude or practice compared to those who attended the training courses, indicating that “casual” training or awareness through brief training courses may not be effective.
In a study conducted by Taha et al., it was reported that most PHC personnel in PHCCs in Dammam City, KSA (78.4%) did not receive any training about BA.
Grunfeld et al. argued that well-trained physicians are usually more likely to have a good impact to assess and manage asthmatic patients, whereas Al-Kanderi et al. stated that the lack of training is one of the main barriers for providing medical care to asthmatics. They added that guidelines for the management of BA can be readily accepted if they are combined with task-based training.,
Compliance with clinical guidelines could be affected by many reasons. Almutawa et al. found that, although primary care physicians were aware of the existence of asthma guidelines, it seems that casual awareness may not guarantee familiarity with the guidelines. Other studies reported many reasons that included the poor understanding for estimating severity of asthma, underutilization of inhaled corticosteroids, difficult implementation, difficult dissemination, and shortage of staff at PHCC.,,,
In Karachi, Pakistan, Bhulani et al. reported that only one-fourth of general practitioners had adequate knowledge about concepts of asthma while only 10.4% had adequate practice in asthma management.
In the current study, we found that those with high qualifications were having better knowledge about management of acute asthma and such findings are expected. Bhulani et al. reported that knowledge and practice scores were significantly associated with primary care physicians' qualifications, which proved to be significant predictors for their adherence to asthma guidelines.
Findings of the present study revealed that oxygen and nebulizers were available in almost all PHCCs. To a lesser extent, steroids, salbutamol, and ipratropium are present in most centers.
In Kuwait, Al-Kanderi et al. reported the lack of essential medications of asthma in PHCCs, while Almutawa et al. reported that only 17.2% of physicians admitted that they are aware about the availability of spirometers at their primary care centers.,
Despite the importance of peak flow-meter in management of acute asthma, we found that only 41% of PHCCs were provided with this diagnostic tool. Such shortage should be managed in all PHCCs and all doctors to be trained how to use and interpret it appropriately as suggested by Rabe et al. In this regard, Nguyena et al. noted that the availability of spirometers/peak flow meters is usually lacking at primary care centers, especially in developing countries.
The present study showed that although 44% of PHC physicians had a positive attitude regarding management of BA, yet practice of 40% of physicians regarding adherence to practice guidelines was quite poor.
This finding is in accordance with that reported by Almutawa et al. who stated that, although PHC physicians had a positive attitude toward the outcome of adherence to asthma guidelines yet, they had a low actual adherence rate, low knowledge and practice scores.
Some studies emphasized that the role of the primary care service regarding BA management demands that primary care physicians should be adequately equipped with positive attitude, sound knowledge, and adequate practices.,,
Results of this study revealed that poor knowledge about BA management was significantly more among physicians who are females, Saudi and general practitioners. However, physicians' attitude did not differ significantly according to their personal characteristics, while those with more experience in PHC had significantly poor practice.
These findings are partially by those of Taha et al. in Dammam, Saudi Arabia, who reported that being a male, with less years of experience in PHC were statistically significant and associated with good knowledge level.
The lower knowledge grade among Saudi PHC physicians regarding the management of acute BA may be explained by the fact that non-Saudi physicians are usually properly selected as the best of those who apply for a position to work in Saudi Arabia. Nevertheless, this “selection” process does not apply to Saudi PHC physicians.
Moreover, the observed better knowledge among specialists/consultants than general practitioners in addition to the lower practice among those with more experience in PHC may indicate that senior physicians at PHC centers do not play their role in transmitting the knowledge and experience to their junior colleagues.
Based on the findings of the present study, the investigators emphasize on the following practical recommendations:
- Proper training of all PHC physicians on management of BA.
- Provision of the necessary medications and peak flow-meters to all PHCCs.
- Senior physicians at PHCCs should be encouraged to train their junior colleagues regarding the management of acute BA.
- Further studies are needed to explore the barriers that can face primary care physicians' adherence to primary care physicians' management of asthma guidelines.
- Frequent audit of asthma care in PHCC is strongly recommended.
| Conclusion|| |
This study revealed that knowledge, attitude, and practice of PHCC doctors in Aseer region regarding management acute asthma are suboptimal, there was a shortage of essential drugs and equipment which should be provided, training of all doctors are mandatory with a regular evaluation regarding its impact on asthma care.
Declaration of patient consent
The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Chapter 1: Definition and overview, 2006; p. 4.
Zhao J, Takamura M, Yamaoka A, Odajima Y, Iikura Y. Altered eosinophil levels as a result of viral infection in asthma exacerbation in childhood. J Pediatr Allergy Immunol 2002;13:47-50.
Holgate ST, Price D, Valovirta E. Asthma out of control? A structured review of recent patient surveys. BMC Pulm Med 2006;6(Suppl 1):S2.
Al-Frayh AR, Shakoor Z, Gad El Rab MO, Hasnain SM. Increased prevalence of asthma in Saudi Arabia. Ann Allergy Asthma Immunol 2001;86:292-6.
Verleden GM, De VP. Assessment of asthma severity and treatment by GPs in Belgium: An Asthma Drug Utilization Research (ADUR) study. Respir Med 2002;96:170-7.
Al-Dawood KM. Risk factors associated with hospital emergency visits among asthmatic schoolboys in Saudi Arabia. East Mediterr Health J 2002;8:31-41.
Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, et al
. The Saudi Initiative for Asthma-2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016;11:3-42.
] [Full text]
Taha AZ, Sabra AA, Al Hamed JH. Knowledge about childhood bronchial asthma among primary health care personnel in eastern Saudi Arabia. Int J Med Public Health 2014;4:222-6. [Full text]
Abudahish A, Bella H. Adherence of primary care physicians in Aseer region, Saudi Arabia to the National protocol for the management of asthma. East Mediterr Health J 2010;16:171-5.
Yousef HA, Koura M, Yousef AA. Knowledge about bronchial asthma management in primary health care physicians in AlKhobar City, Saudi Arabia. J Family Community Med 2015;22:1-7.
Almutawa FN, Al-Mutairy G, Al-Arada N, Kamel MI. Perception of primary care physicians about guidelines of bronchial asthma. Alexandria J Med 2014;50:17-24.
Scribano PV, Lerer T, Kennedy D, Cloutier M. Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department. Acad Emerg Med 2001;8:1147-52.
Sun YH, Eun BW, Sim SY, Cho KH, Ryoo E, Cho DY, et al
. Poor adherence and reasons for non-adherence to the asthma guidelines among pediatricians in Korea. Asian Pac J Allergy Immunol 2010;28:147-54.
Rovithis E, Lionis C, Schiza SE, Bouros D, Karokis A, Vlachonikolis I, et al
. Assessing the knowledge of bronchial asthma among primary health care physicians in Crete: A pre- and post-test following an educational course. BMC Med Educ 2001;1:2-6.
Grunfeld A, Beveridge RC, Berkowitx J, FitzGerald JM. Management of acute asthma in Canada: An assessment of emergency physician behavior. J Emerg Med 1997;15:547-56.
Al-Kanderi BM, Al-Muhaileej FA, Al-Khalaf T. Evaluation of asthma clinics in primary care in Kuwait. Eur J Gen Med 2006;3:159-66.
Finkelstein JA, Lozano P, Shulruff R, Inui TS, Soumerai SB, Ng M, et al
. Self-reported physician practices for children with asthma: Are national guidelines followed? Pediatrics 2000;106:886-96.
Ait-Khaled N, Enarson DA, Bencharif N, Boulahdib F, Camara E, Dagli E, et al
. Implementation of asthma guidelines in health centres of several developing countries. Int J Tuberc Lung Dis 2006;10:104-9.
Graff L, Stevens C, Spaite D, Foody JA. Measuring and improving quality in emergency medicine. Acad Emerg Med 2002;9:1091-107.
Bhulani N, Lalani S, Ahmed A, Jan Y, Faheem U, Khan A, et al
. Knowledge of asthma management by general practitioners in Karachi, Pakistan: Comparison with international guidelines. Prim Care Respir J 2011;20:448–51.
Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: The Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000;16:802-7.
Nguyena VN, Chavannesb N, Le LT, Priced D. The Asthma Control Test (ACT) as an alternative tool to Global Initiative for Asthma (GINA) guideline criteria for assessing asthma control in Vietnamese outpatients. Prim Care Respir J 2012;21:85-9.
Uluç NN, Özdemir Ö. The attitude, knowledge, and behavior of family physicians about childhood asthma in Sakarya province. Turk Pediatri Ars 2019;54:225–37.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]