BIOCHEMICAL ASSESSMENT


BIOCHEMICAL ASSESSMENT OF HOME MADE FLUIDS AND THEIR ACCEPTABILITY IN THE MANAGEMENT OF DIARRHEA IN CHILDREN IN THE GEZIRA STATE, SUDAN

Tahani El Faki, MSc, Hayder E. Babikir, MD, Khalid E. Ali, PhD Faculty of Medicine, Gezira University, Sudan

هدف الدراسة : تهدف هذه  الدراسة لإعداد محاليل منزلية مفيدة ، سهلة التحضير لمعالجة الإسهال عند الأطفال السودانيين بولاية الجزيرة وسط السودان .

طريقة الدراسة :المحاليل التي أجريت عليها الدراسة هي محلول الذرة المعروف بالنشا ومحلول الأرز أو ماء الأرز . أخذت عينة من النشا و 10 عينات من ماء الأرز من المنازل وأجريت عليها القياسات التالية : الأس الهيدروجيني و الكاربوهيدرات والدهون و الألياف و الرماد و الصوديوم والبوتاسيوم والكلورايد .

نتيجة الدراسة :وجد أن كل من محلول الذرة ( النشا ) ومحلول الأرز ( ماء الأرز ) يحوي كميات معتبرة من المواد الغذائية مما يجعل لهذين المحلولين قيمة غذائية . وقد وجد أن نسبة الصوديوم والكلوريد أقل من محتويات المحلول المقترح من هيئة الصحة العالمية واليونسيف ، ووجد أنه يمكن تعديل تكوين محلول النشا ومحلول الأرز بإضافة كلوريد الصوديوم ليشابه تكوين محلول الأرواء بالفم القياسي المقدم من هيئة الصحة العالمية واليونسف ، ويمكن ذلك بإضافة  3- 5و3 جرام كلوريد الصوديوم إلى لتر من محلول الذرة ( النشا ) وإضافة 3و2 – 6و2 جرام من كلوريد الصوديوم إلى لتر من محلول الأرز ( ماء الأرز ) .

الخلاصة :نخلص من هذه الدراسة بأن محلول الذرة ( النشا ) ومحلول الأرز ( ماء الأرز ) يمكن استعمالهما لمكافحة الجفاف ويمكن أيضا استعمالهما بعد إضافة كلوريد الصوديوم لمعالجة الجفاف الناتج من الإسهال كبديل لمحلول الأرواء بالفم القياسي ، وسيساعد ذلك في حل مشكلة عدم توفر المحلول مما يؤدي إلي خفض المراضة والوفيات بسبب الإسهال .

الكلمات المرجعية : نشا الذرة ، ماء الأرز ، الجفاف ، محلول الارواء بالفم .

Objectives:To determine the biochemical constitution of homemade fluids and assess their acceptability and efficacy for the management of acute diarrhea in Sudanese children.

Material and Methods:This is a cross-sectional study of 150 children selected randomly. The fluids studied were 36 samples of sorghum-based solutions (nasha) and 10 samples of rice water. Samples were randomly collected from households and analyzed to determine the pH, carbohydrates, proteins, fat, crude fiber, ash and electrolytes (Na+, K+ and Cl-).

Results: In addition to being very useful for rehydration, the two fluids were found to contain considerable amounts of nutrients. The sodium and chloride contents of homemade fluids were found to be much lower than those of the WHO/UNICEF ORS (oral rehydration solution). These electrolytes can be adjusted by adding table salt (3-3.5 g NaCl to one litre of sorghum-based solution and 2.3-2.6 g NaCl to one liter

Correspondence to:

Dr. Hayder E. Babikar, Faculty of Medicine, Gezira University, Sudan

of rice water) to bring them to concentration comparable to that of the standard ORS.

Conclusion:Homemade solutions can be modified by adding table salt to bring them to the standard ORS and can be used successfully to prevent dehydration. This will solve the problem of the availability of ORS and reduce morbidity and mortality from diarrhea.

Key Words: Acute diarrhea, dehydration, sorghum gruel, rice-water, ORS, Sudan.


 

INTRODUCTION

Acute diarrhea is a major cause of morbidity and mortality in young children all over the world. It is estimated that more than one billion episodes of acute diarrhea occur yearly in children in the developing world including Sudan.1 In 1900, it was estimated that 23% of all deaths of children under five, in the developing countries, were caused by diarrhea.2,3 A national survey in 1996 by the Diarrhoeal Disease Control Programme (CDD) in the northern states of Sudan showed a prevalence rate of 22% in the two weeks preceding the survey.4

                Orally administered fluids and electrolyte solutions have been effectively used world­wide to treat children with acute diarrhea.5 The physiologic basis for these solutions is the transport of glucose and/ or other organic solutes together with sodium to achieve enhanced absorption of salt and water.6

                The impact of oral rehydration solution (ORS) on dehydration case/fatality rate, and cost effectiveness is well documented.7-9 However, many logistic and economic prob­lems limit the availability and distribution of ORS to less than half the population of the developing world.10 Besides, since ORS does not reduce the volume, frequency or dur­a­tion of diarrhea,11 a frequently-mentioned source of dissatisfaction for mothers (and consequently for health care providers), there is a persistent desire to use antidiarrheal drugs and limit the amount of fluids given to dehydrated children. Cultural acceptance has often limited the use of ORS. The WHO estimates that <25% who could benefit from therapy are treated with ORS.12 The rate of ORS use is only 31%.

                One proposed approach for the development of an improved ORS, is to replace glucose, with glucose polymers e.g. d. hexoses, L. amino acids and their di- and tri- peptide forms.13 This makes it possible to increase the amount of glucose in the ORS formulation without increasing its osmolarity.

                The purpose of this research was to assess some locally used, primarily homemade fluids in the form of simple starch, containing glucose and di- and tri-peptides. These are readily available, easily prepared, have no adverse effects on children with diarrhea, and are culturally accepted by mothers.

MATERIAL AND METHODS

This is a cross-sectional house-to-house study. From Wad Medani (urban) and El Meilig (rural), central Sudan, 150 children aged 0-5 years, with diarrhea in the last 48 hours prior to the conduct of the study, were recruited by systematic random sampling. A questionnaire was used to determine the types and amounts of homemade fluids used for diarrhea, their methods of preparation, their effect on the status of dehydration and on the stool output, and the readiness with which the fluids were accepted by the children. The children were interviewed in their own homes by physicians and faculty members of Gezira University. The infor­mants were their mothers. A sub-sample of 36 specimens of sorghum-based solution (nasha) and 10 of rice water, the commonest fluids used, were obtained at random from the children's own homes, for laboratory analysis. The number of sub-samples was small on account of the limited resources available. 

                "Nasha" is a thin gruel, prepared from dif­ferent varieties of sorghum flour. Approxi­mately 130-135 grams of the flour is mixed with 300-400ml of water, left overnight to ferment, after which water is added to bring it up to 1000-1200ml. The solution is then decanted and boiled to a thin gruel to which 10 to 15g of sugar is usually added.

                Rice water is prepared by soaking about 120-130g of rice in 300-400ml of water for 1 to 2 hours, and then manually crushing it. One liter of water is added to it and de­canted, after which 2.5 – 5g of sugar is usu­ally added. Both solutions are administered orally. 100ml/kg body weight is given during the first 4 hours. The condition of the child is then re-assessed and management con­tinues with breast-feeding if there is im­prove­ment. If the condition has deteriorated, the child is referred to the hospital for i/v rehydration and  resuscitation if necessary.

                The samples were analyzed in duplicate, to determine their pH, electrolyte content (Na+, K+ and Cl-) and to proximate analysis. The pH was measured using Philip's PW 9410 Digital pH-meter. Moisture was determined by the vacuum oven method described by the Association of Official Ana­lyti­cal Chemists (AOAC, 1990).14 Protein contents were determined by the standard Kjedldahl method. Fat, ash, and crude fiber values were determined according to the AOAC (1990) methods. Sodium and potassium amounts were determined by flame photometry using the Corning400-flame photometer.14 The gravi­metric method described by AOAC (1990) was used to determine chloride contents. A pschnometer or density bottle was used to measure specific gravity. The means and stan­dard deviations were determined. More accurate and sensitive quantitative methods could have been used, but the methods used were the only ones available to the authors. How­ever, the authors believe that the methods used, despite their limitations, were appropriate for the purpose of this study.

                Improvement in the general condition of the child is assessed by the duration of diarrhea, stool consistency and increase in body weight.

                The SPSSpackage was used for the analysis of data.

RESULTS

Table 1 shows the general characteristics of the study group. Rural children comprised 52.7%, and urban children 47.3%. Those of low socio­economic status comprised 47.3%, middle class 38.7%, and of high socio­economic status 14%. Of the mothers, 32.7% were illiterate.

Table 2 shows the types of early manage­ment of diarrhea and their accept­ability. Of the mothers, 9.3% used the ORS, 75.4% used homemade fluids (HF), 6% used drugs and 9.3% used both ORS and HF. The acceptability of ORS among children was 57%,  compared  to  100%  for   homemade

Table 1:General characteristics of the study group

Characteristics

No (%)

Total No (%)

Residence

Rural

79 (52.7)

150 (100)

Urban

71 (47.3)

Socioeconomic status

Low

71 (47.3)

Middle

58 (38.7)

150 (100)

High

21 (14.0)

Education

Literate

101 (67.3)

150 (100)

Illiterate

49  (32.7)

Table 2: Types of early management of diarrhea and their acceptability

Variable

No(%)

Total No

Types of early management

ORS

14 (9.3)

150

Homemade fluids

113 (75.4)

Drugs

9 (6)

Combination(ORS+HF)

14 (9.3)

Child's acceptability

Homemade fluids

113

Accepted

113 (100)

Unaccepted

0

ORS

14

Accepted

8 (57)

Unaccepted

6 (43)

Drugs

9

Accepted

6 (66.7)

Unaccepted

3 (33.3)

Combination (ORS + HF)

14

Accepted

9 (64.3)

Unaccepted

5 (35.7)

fluids, 66.7% for drugs and 64.3% for a combination of ORS and HF.

                Table 3 shows some homemade fluids com­­monly used in the state of Gezira; 42.5% used sorghum, 20.3% used rice water. Other home­made fluids including Gonglias "Adan­sonia digitata", Hilba juice "Fenugreek", and custard were used by 7.2% and 15% used a combination of ORS and homemade fluids


 

.

Table 3: Homemade fluids used by mothers/ families in the state of Gezira (N=113)

Types of homemade fluids

No (%)

Sorghum (Nasha)

48 (42.5)

Rice water

23 (20.3)

Sugar salt solution

17 (15.5)

Other (Gongolais, hilba, custard)

8 (7.2)

Combination (Nasha + RW)

17 (15.0)


 

Table 4: Comparison of homemade fluids with ORS effects

Types of fluids

Stool output (%)

General condition (%)

Reduced

Increased

No effect

Improved

Not improved

Nasha

52.1

27.1

20.8

62.5

37.5

Rice water

60.8

30.4

8.8

65.2

34.8

Sugar salt solution

35.3

42.2

23.3

52.9

47.1

Other homemade fluid

37.5

35.2

25.0

62.5

37.5

Nasha + rice water

52.9

35.3

11.8

58.8

41.2

ORS

37.5

42.9

21.4

78.6

21.4

Homemade fluid

68.1

18.6

13.3

80.9

20.0

Table 5: Chemical composition and some characteristics of different fluids

Chemicals/

Characteristics

Sorghum solution

(n=36)

Rice water

(n=10)

Standard ORS

p-value

Carbohydrate (g/l)

80.37 ±19.77SD

50.25 ±12.67 SD

20.00 (glucose)

0.00004

Sodium (mmol/l)

37.37 ±3.50 SD

51.74 ±4.50 SD

90.00

<0.0001

Potassium (mmol/l)

11.71 ±3.50 SD

13.66 ±2.17 SD

20.00

0.102

Chloride (mmol/l)

18.24 ±3.33 SD

34.75 ±2.07 SD

80.00

<0.0001

Protein (g/l)

38.39 ±22.63 SD

25.00 ±6.36 SD

0.00

0.08

Fat (g/l)

6.53 ±2.93 SD

3.5 ±0.93 SD

0.00

0.026

Crude fiber (g/l)

6.49 ±2.91 SD

4.10 ±1.59 SD

0.00

0.017

Ash (g/l)

9.73 ±2.53 SD

7.56 ±1.81 SD

5.69

0.016

pH

4.33 ±0.48 SD

6.56 ±0.05 SD

7.00

0.0006

Specific gravity

1.04 ±0.02 SD

1.01 ±0.01 SD

-

0.016

Calculated energy (cal/l)

492 ±98 SD

333 ±76 SD

80.00

0.0002


 

                Table 4 presents the comparison of the effects of homemade fluids and ORS, on the stool output and the general condition of the children. Homemade fluids, in general, re­duced the stool output in 68.1%, increased it in 18.6%, and showed no effect in 13.3% of the children.  HF improved the general con­di­tion in 80% of the children. In compari­son, ORS reduced the stool output in 37.5%, increased it in 42.9%, and had no effect in 21.4% of the children. The general condi­tion improved in 78.6% of the children who received the standard ORS.

                The chemical combination and some characteristics of selected HF with that of ORS are presented in Table 5. The mean total soluble carbohydrate of sorghum-based solution was 80.74% +19.76 g/l and was 50.25 +12.67 g/l for rice water, whereas ORS contained 20g/l in the form of glucose. The mean sodium (Na+) was 37.37 +8.13 mmol/l, 51.74 +4.50 mmol/l, and 90 mmol/l for nasha, rice water and ORS, respectively. The mean potassium level was 11.71 +3.50 mmol/l, 13.66 +2.17 mmol/l, and 20 mmol/l for nasha, rice water and ORS, respectively. The chloride levels for these solutions were 18.24 +3.33 mmol/l, 34.75 +2.07 mmol/l, and 80 mmol/l respectively.

                The mean protein level was 38.39 +22.63 g/l for nasha, and 25.00 +6.36 g/l for rice water, while their mean fat was 6.53 + 2.93 g/l and 3.51 +0.93 g/l respectively. Crude fiber was 6.49 +2.91 g/l and 4.10 +1.59 g/l respectively. The mean ash level was 9.73 +2.53 g/l in nasha, 7.56 +1.81 g/l in rice water and 5.69 g/l in the standard ORS. The mean energy value of nasha was 492 +98 cal/l and 333 +76 cal/l in rice, whereas it was 80 cal/l in the standard ORS. The mean pH of nasha was 4.33 +0.48, 6.56 +0.05 in rice water and 7.00 in the standard ORS.

DISCUSSION

The majority of women in this study preferred homemade fluids to ORS. All the women (100%) accepted the homemade fluids as compared to 57% for ORS. This could be due to the greater palatability of HFs and that they are prepared from staple foods traditionally used in weaning. The homemade fluids reduced the stool output in 68.1% of the children compared to only 37.5% who used the ORS. This was the case in other communities where mothers' dis­satisfaction with ORS was evident.6 The effects of HFs on the stool output could be due to the starches (the polymeric forms of glucose) in these fluids which enhance water absorption and reduce the stool volume.16,17 The low acceptability of the ORS and its ineffectiveness in reducing stool output results in persistent desire to use antidiarheal drugs and discontinue rehydration. This sometimes necessitates hospital admission for proper rehydration.15

                The soluble carbohydrates, electrolyte contents and pH of sorghum-based solution and rice water which are comparable to that of ORS, were recommended as safe, efficient and reliable for rehydration during acute diarrhea.7 The pH of sorghum-based solution is low as a result of cereal fermen­tation. It has been reported that it has some anti-microbial effects but is without acidotic ill effects during diarrhea.18 The prevalence of diarrhea was also reduced among children who used lactic acid fermented cereal gruel in Tanzania.19 The pH of rice water is close to that of standard ORS.

                The addition of sucrose sugar to gruel, inhibits the build up of osmotic pressure, increases the salt and water absorption and reduces the stool volume.16 Proteins in ‘nasha’ and rice water hydrolyzed to amino acids and di-peptides enhanced the absorp­tion of sodium and water. The moisture contents of these fluids were similar to that of human and cow's milk.            

                Sodium chloride concentration in ‘nasha’ and rice water was low, both being around half that of ORS. This could be modified, with the addition of salt to compensate for the sodium loss during diarrhea. Potassium concentration of the two fluids was more than half of the standard ORS. To simulate the levels in ORS, 52.63 mmol (1.21 g) of sodium and 61.76 mmol (2.2 g) of chloride should be added to sorghum-based gruel, and it is recommended that 3 – 3.5g of table salt be added to one liter of ‘nasha’. Similarly, the addition of 2.3 – 2.6g of NaCl to one liter of rice water will adjust the concentration of both Na+ and Cl- to one similar to that of ORS.

CONCLUSION AND RECOMMENDATIONS

Apart from supplying the child with water, electrolyte and energy, homemade fluids also have the advantage of providing small amounts of other nutrients such as minerals and vitamins. Hence, the National Diarrhoea Control Programme has developed a stra­tegy to promote the use of homemade fluids to prevent dehydration. The fluids in the present study have considerable amounts of electrolytes, are accepted by the children and their mothers, and are readily available and easily prepared. As such, they can be successfully used after the recommended adjustment, both for rehydrating children with some degree of dehydration after epi­sodes of acute watery diarrhea, and also for the prevention of dehydration. These home­made fluids should be considered feasible alternatives to ORS where it is not readily available.

REFERENCES

1.             Synder JD, Merson MH. The magnitude of the global problem of acute diarrhoeal disease. A review of active surveillance data. Bull WHO 1982; 60:605-13.

2.             Grant JP. The state of the world children. UNICEF ( Switzerland): OxfordUniv Press;1988.

3.             WHO Diarrhoeal Disease Control Programme. A manual for treatment of acute diarrhea for use by physicians and other senior health workers. HO/CDD/8.2 ( Geneva): WHO Rev; 1984.

4.             National Diarrhea Disease Control Programme, Sudan. Household survey. Sudan: Ministry of Health; 1996.

5.             Levine MM, Edelman R. Acute diarrhoeal infections in infants-1-Epidemiology treatment and prospects for immunoprophylaxis. Hosp Pract 1979; 14:89-150.

6.             Hirschorn N. The treatment of acute diarrhoea in children, on historical and physiological perspec­tive. Am J Clin Nutr 1980; 33:637-63.

7.             WHO/UNICEF. The magnitude of diarrhoea and the use of oral rehydration therapy, 2nd ed. Geneva:  WHO; 1985.

8.             Mahalanabis D, Choudhuri AB, Bagehi NG, et al. Oral fluid therapy of cholera among Bangladesh refugees. John Hopkins Med J 1973; 132:191-205, cited by Synder JD, et al. Home base therapy for diarrhoea. J Pediatr Gastroenterol and Nutr 1990; 4:438-47.

9.             Listernik R, Ziesel E, David AT. Outpatient oral rehydration in the United States. Am J Dis Child 1985; 140:211-5.

10.   WHO Diarrhoeal Disease Control Programme. 5th Pro­gramme Report 1984-1985. WHO/CDD. Geneva: WHO; 1986.

11.   Sack DA, Chowdhurg A, Eusof A, et al. Oral hydration in rotavirus diarrhoea, a double-blind comparison of sucrose with glucose electrolyte solution. Lancet 1978; 2:280-3.

12.   Who Diarrhoeal Disease Control Programme. 6th Pro­gramme report, 1986-1987. WHO/CDD. Geneva: WHO; 1988.

13.   Patra FC, Mahalnabis D, Jalon KN. Stimulation of sodium and water. Absorption by sucrose in the rat small intestine. Acta Paediatr Scand 1982; 71:103-7.

14.   Association of Official Analytical Chemists (AOAC). Official methods of analysis. 14th ed. Arlington: USA; 1990.

15.   Synder JD, Molla AM, Cash RA. Home based therapy for diarrhoea. J Pediatr Gastroenterol and Nutr 1990; 4:438-47.

16.   Molla AM, Ahmed SM, Khatium M, Greenough WB. Rice-based oral rehydration solution de­creases the volume in acute diarrhoea. Bull WHO 1985; 63:751-6.

17.   Lepage P, Hitiman DG, Goethen CV, Ntaho­rutaba MN, Sengumuremyi F. Food based oral rehydration salt solution for acute childhood diarrhoea. Lancet 1989; II:898-9.

18.   Mensah PPA, Tomkins AM, Drasar BS, Harison TJ. Effect of fermentation of Ghanaian maize dough on the survival and proliferation of four strains of Shigella flexneri. Trans Roy Soc Trop Hyg 1988; 82:635-6.

19.   Lorri W, Svanberg U. Lower prevalence of diarrhoea in young children fed lactic acid fer­mented cereal grules. Food and Nutr Bull 1994; 15(2):57-63.


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UNDERGRADUATE STUDENTS


VIEWS OF UN DERGRADUATE STU DENTS ON OB JECTIVE STRUCTURED CLINICAL EXAMINATION IN NEUROLOGY: A PRELIMINARY REPORT

Hassan M. Ismail,MD,FRCP, King Fahd Hospitalof the University, Al-Khobar, Saudi Arabia

هدف الدراسة: التعرف على آراء طلاب مرحلة البكالوريوس حول  تقييمهم  لإختبار الأوسكى المكون من محطتين  فى كورس طب المخ و الأعصاب بكلية الطب، جامعة الملك فيصل.

طريقة الدراسة: أستخدم اختبار الأوسكى في اختبار طلاب و طالبات السنة الخامسة الذين يؤدون كورس طب المخ و الأعصاب بالفصل الأول للعلم الدراسى 1420-1421هـ. و قد تم اختبار كل طالب على مريضين لكل 7 دقائق. و بعد الإنتهاء من الإختبارمباشرة قام كل طالب و طالبة بإكمال إستبيان من 6 أسئلة حول تغطية الحالات لما درسوه أثناء الكورس و وضوح الأسئلة و كفاية الزمن المخصص للإجابة و نوع الحالات مقارنة بما نوقش أثناء الكورس و الإستفادة التعليمية من الإختبار و تنظيم الإختبار.

نتائج الدراسة: جلس للإمتحان 30 طالبا و 18 طالبة. إستغرق وقت الإمتحان فى المتوسط ساعتين للمجموعة المكونة من 16 طالبا. و كانت الإجابات فى الإستبيان إيجابية حول وضوح الأسئلة و التنظيم 41 طالبا (85%) و الوقت 36 طالبا (75%). وأجاب اثنان و ثلاثون طالبا (67%) بأن الإختبار كان يمثل تجربة تعليمية مفيدة بينما عبر نصفهم عن عدم التغطية الكافية لما درس أثناء الكورس و أيضاً بالنسبة لعدد المرضى بالإختبار وطالب 11 طالبا( 22%) بزيادة وقت الإمتحان بكل محطة.

الخلاصة:  وضحت نتائج الإستبيان  قبولا من الطلاب لإختبار الأوسكى للمهارات السريرية فى طب المخ و الأعصاب و لكن هناك حاجة  لزيادة عدد المرضى و الوقت الممنوح لكل حالة للحصول على نتائج أفضل من حيث تغطية المادة و مراعاة تقليل العبء الواقع على المشاركين من المرضى.

مفتاح الكلمات: طب الأعصاب، التعليم الطبى، مرحلة البكالوريس، أوسكى، المملكة العربية السعودية.

Objective:Obtain the undergraduate medical students’ evaluation of an objective structured clinical examination (OSCE) formed by two stations in neurology.

Methods:The fifth-year medical students taking the neurology course at King Faisal Universityduring the first rotation of academic year 1420-1421H (2000-2001G) made the evaluation. The time for each station was seven minutes. After finishing the exami­­nation, each student completed a six-item questionnaire on coverage, question clarity, time, patients, educational usefulness and organization of the examination with yes, no or don’t know responses.

Results:A total of 48 students (30 males and 18 females) took the examination. The average time to complete the examination for a group of 16 students was 2 hours. The responses were positive for clarity of questions and organization of the examination 41(85%), and allotted time 36(75%). Thirty-two students (67%) found the structured

Correspondence to:

Dr. Hassan M. Ismail, P.O. Box 40152, Al-Khobar 31952, Saudi Arabia

exami­nation a useful educational experience. About half the students expressed their concern about the coverage of taught material and the number of patients seen in the examination as representative of those seen during the course, and 11 students (23%) requested more time.

Conclusions:The students’ response to the use of the structured clinical examination as an objective tool for evaluation of clinical skills in neurology was favorable and com­parable to reports from other parts of the world. Improvement is required in the number of patients, coverage and allotted time to optimize outcome by improving content vali­dity and reducing stress on participating patients.

Key Words:Neurology, undergraduate, medical education, OSCE, Saudi Arabia.


 

INTRODUCTION

The Department of Neurology in King Faisal Universityis the first academic department of neurology in the Kingdomof Saudi Arabia. The department offers a three-week clinical rota­tion in neurology (course MDNL506) to fifth-year medical students. Since the depart­ment was established the rotating students have been evaluated at the end of the course by a conventional long-case clinical examina­tion. The Objective Structured Clini­cal Exami­na­tion (OSCE) is presently the pre­domi­nant method for formative and sum­mative evaluation of clinical skills and competencies in undergraduate medical edu­ca­tion.1-4 OSCE has been recently used for evaluation of undergraduate and postgraduate students in various sub-specialty departments including radiology,5 dentistry,6,7 rheu­mato­logy,8 urology,9 critical care medicine10 and surgery.11 Experience with the use of OSCE in neurology has been limited.12,13 The neurology course objectives focus primarily on teaching clinical skills; thus, at the end of the course students are expected to be able to perform a neuro­logical examination com­petent­ly, and interpret the clinical signs in terms of neuro­-anatomical localization of neu­ro­logical disease.  In order to improve ob­jec­tivity in evaluating our students it was decided to give OSCE a trial for fifth year students rotating during the first semester of academic year 1420-1421H (2000-2001G). This paper presents a preliminary report of the students' views on the trial of OSCE.

METHODS

The students were divided into two male groups and one female group who rotated in neurology for three-week blocks. The examination was composed of two stations, each with a patient having neurological signs similar to those covered during the course. The time given for each station was seven minutes. Each student answered a question­naire of six items immediately after finishing the examination. The first ques­tion was on the coverage of the examination for the clinical material that was taught during the course. The second question was on the clarity of the examination questions. The third was on the adequacy of the allocated tine for each station. The fourth was on whether the patients seen in the examination were representative of those seen during the course. The fifth was on whether the examination could be viewed as a useful educational clinical experience, and the last question was on whether the organization of the examination was satisfactory. The students had to answer yes, no or don’t know.

RESULTS

A total of 48 students took the OSCE, 30 males and 18 female students. The average time taken to com­plete the OSCE for a group of 16 students was two hours. Figure 1 shows a bar chart of students' responses for the questionnaire items, including cover­age of material taught, clarity of questions, adequacy of time per station, given patients as representative of those seen during the course, usefulness of the examination as an educational clinical experience, and organi­za­tion of the examination. Forty-one students (85%) were satisfied with the clari­ty of the questions and organization of the examination. Thirty-six students (75%) were satisfied with the allotted time, but 11 (23%) suggested increasing the time to 10 minutes per station. Thirty-two students (67%) found the examination a useful edu­ca­tional clinical experience. Around half of the students found the coverage of the clinical material taught and the number of patients inadequate.

DISCUSSION

Evaluation of students in undergraduate medi­cal education is a measurement of student learning and is directed towards assessment of knowledge, and of clinical and communica­tion skills. Data analysis and data interpre­tation are the two most popular methods for assessing knowledge, whereas OSCE and case presentation are the most used methods for assessing clinical skills.1 OSCE was introduced first as a new test for clinical com­petence.14-19 It has been widely accepted as a means of objectively assessing the acquisition of clinical skills and clinical competence with greater reliability and validity1,5-21 and is now considered worldwide as the standard form of examination for the clinical assessment of both under- and post-graduate students.1-13 The students in previous reports felt that OSCE is a fairer system than the other forms of examination and preferred it as a method of clinical assessment.22,23

                Although the overall response to using OSCE as an objective tool for evaluating neurology students was favorable, the salient shortcomings included the coverage of the examination for the clinical material taught, the number of patients, and to a lesser extent the allotted time per station. Improvement in coverage and increase in the number of patients requires an increase in the number of stations to improve content validity, but will also increase the total time of the exami­nation. Thus, the addition of a third patient and an increase of time to eight minutes per station will increase the examination time to three hours, which is still shorter than the time taken to examine the same number of students using the conventional interactive bedside assessment method. That method requires, on average, four hours for the same number of students. Furthermore, the stress to the participating patients has to be taken into consideration.

                Although using a different set of patients may resolve this issue, it will certainly affect that important factor in favor of OSCE regarding objectivity, uniformity and fairness of the student evaluation process. Similar prob­lems were previously noted on using OSCE in neurology.12,13

                The present preliminary results of using OSCE in neurology were favorable and are comparable to reports from other parts of the world. Improvement, however, in the number of patients, material coverage and allotted time per patient is required to optimize the outcome by improving content validity and reducing stress to participating patients.

REFERENCES

1.     Fowell SL, Maudsley G, Maguire P, Leinster SJH, Bligh J. Student assessment in undergraduate medical education in the United Kingdom, 1998. Med Educ 2000;34(Suppl.1):1-49.

2.     Bradley P, Humphris G. Assessing the ability of medical students to apply evidence in practice: the potential of OSCE. Med Educ 1999;33(11):815-7.

3.     Duerson MC, Romrell LJ, Stevens CR. Impacting faculty teaching and student performance: nine years' experience with the Objective Structured Clinical Examination. Teach Learn Med 2000; 12(4): 176-82.

4.     Carraccio C, Englander R. The objective structured clinical examination: a step in the direction of competency-based evaluation. Arch Pediatr Adolesc Med 2000;154(7):736-41.

5.     Morag E, Lieberman G, Volkan K, Shaffer K, Novelline R, Lang EV. Clinical competence assess­ment in radiology: introduction of an objective structured clinical examination in the medical school curriculum. Acad Radiol 2001;8(1):74-8.

6.     Brown G, Manogue M, Martin M. The validity and reliability of OSCE in dentistry. Eur J Dent Educ 1999;3(3):117-25.

7.     Manogue M, Brown G. Developing and imple­menting an OSCE in dentistry. Eur J Dent Educ 1998;2(2):51-7.

8.     Smith MD, Henry-Edwards S, Shanahan EM, Ahern MJ. Evaluation of patient partners in the teaching of the musculoskeletal examination. J Rheumatol 2000;27(6):1533-7.

9.     Sibert L, Grand'Maison P, Doucet J, Weber J, Grise P. Initial experience of an objective structured clinical examination in evaluating urology residents. Eur Urol 2000;37(5):621-7.

10.   Rogers PL, Jacob H, Thomas EA, Harwell M, Willenkin RL, Pinsky MR. Medical students can learn the basic application, analytic, evaluative and psychomotor skills of critical care medicine. Crit Care Med  2000;28(2):550-4.

11.   Merrick HW, Nowacek G, Boyer J, Robertson J. Comparison of the objective structured clinical exami­nation with the performance of the third-year medi­cal students in surgery. Am  J Surg 2000;79(4): 286-8.

12.   Anderson DC, Harris IB, Allen S, Satran L, Bland CJ, Davis-Feickert JA, Poland GA, Miller WJ. Comparing students' feedback about clinical instruc­tion with their performance. Acad Med 1991;66(1): 29-34.

13.   Gledhill RF, Capatos D. Factors affecting the reliability of an objective structured clinical exami­na­tion (OSCE) test in neurology. S AfrMed J 1985; 67(12):463-7.

14.   Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ 1979;13(1):41-54.

15.   Cuschieri A, Gleeson FA, Harden RM, Wood RA. A new approach to final examination in surgery. Use of objective structured clinical examination. Ann R Coll Surg Eng 1979;61(5):400-5.

16.   Watson AR, HoustonIB, Close GC. Evaluation of an objective structured clinical examination. Arch Dis Child 1982;57(5):390-2.

17.   Kirby RL, Curry L. Introduction of an objective structured clinical examination (OSCE) to an undergraduate clinical skills programme. Med Educ 1982; 16(6):362-4.

18.   Newble DI. Eight years experience with structured clinical examination. Med Teacher 1988;22:200-4.

19.   Newble DI, Swanson DB. Psychometric charac­teristics of the objective structured clinical examina­tion. Med Educ 1988;22:325-34.

20.   Rothman AI, Cohen R. Understanding the objective structured clinical examination (OSCE): issues and options. Ann R Col Phys Surg Can 1995;28:283-7.

21.   Newble DI, Dauphinee D, Dawson-Saunders B, Macdonald M, Mulloholland H, Page G, et al. Guidelines for the development of effective pro­cedures for the measurement of clinical com­petence. In: The certification and recertification of doctors: issues on the assessment of clinical com­petence. Ed. Newble DI, Jolly BJ, Wakeford RE. Cambridge UniversityPress, Cambridge1993; pp 69-91.

22.   Smith LJ, Price DA, HoustonIB. Objective structured clinical examination compared with other forms of student assessment. Arch Dis Child 1984; 59(12):1173-6.

23.   Lazarus J, Kent AP. Student attitudes towards the objective structured clinical examination (OSCE) and conventional methods of assessment. S AfrMed J 1983;64(11):390-4.


-0001-11-30

SCREENING MAMMOGRAPHY


KNOWLEDGE AND ATTITUDE TOWARDS SCREENING MAMMOGRAPHY AMONG 400 WOMEN IN THE EASTERN PROVINCEOF SAUDI ARABIA

Fatma A. Al-Mulhim, MD, College of Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة :تقييم مدى المعرفة والموقف تجاه الفحص الإشعاعي للثدي وسط النساء السعوديات.

طريقة الدراسة :تمت مقابلة عينة تضم أربعمائة امرأة سعودية باستخدام استبيان محدد.

نتائج الدراسة :كان التاريخ المرضي الأسري الإيجابي لسرطان الثدي هو العامل الأبرز المرتبط بمعرفة وموقف المرأة تجاه الفحص الإشعاعي للثدي ولم تكن هنالك علاقة واضحة بالمستوى التعليمي ولوحظ ضعف المعرفة والفهم وسط ( 8. 41%) لجميع المشاركات وخصوصاً فيما يتعلق بعدم عمل وعدم الرغبة في عمل تصوير إشعاعي للثدي وكان هنالك عدد 51 امرأة من المشاركات  ( 8 .12 %) ممن لم يقمن بعمل تصوير إشعاعي للثدي ولكنهن يرغبن في عمله وأن 25 امرأة من المشاركات ( 3. 6 %) لا يعرفن ماذا يفعلن فيما يتعلقن بقرارهن  لعمل  فحص إشعاعي للثدي في المستقبل بينما أوضحت 67 مشاركة (8. 16% ) أنهن  يرغبن في عمل تصوير إشعاعي للثدي كل عام أو كل عامين .

الخلاصة :توضح هذه الدراسة مدى قصور المعرفة والفهم تجاه عمل تصوير إشعاعي للثدي حتى وسط ذوات التعليم العالي وتشير إلى الحاجة إلى تنفيذ برنامج تثقيف صحي عن فائدة هذا الفحص .

الكلمات المرجعية :التصوير الإشعاعي للثدي ، المعرفة ، الموقف ، المملكة العربية السعودية   

Objective: Assess knowledge and attitude of Saudi females towards screening mammography.

Material and Methods:A sample of four hundred Saudi females were interviewed using a structured questionnaire.

Results:Positive family history of breast cancer was the most significant factor that was positively associated with individual knowledge and attitude towards screening mammography (p<0.00001). There was no significant association with the level of education. Poor knowledge and attitude were observed among 41.8% of all participants, especially in relation to not having mammography done or not wishing to have it done. There were 51 (12.8%) participants who had not had mam­mography done, but wished to have it, 25 (6.3%) participants who were undecided about having mammography done in the future, while 67 (16.8%) wished to have it done every one to two years.

Conclusion:This study showed that there has been deficient knowledge and attitude towards screening mammography even among the highly educated, and stressed the need for health education on the importance of screening.

Key Words: Screening, mammography, breast cancer, Saudi Arabia.

Correspondence to:

Dr. Fatma A.K. Al-Mulhim,  Department of Radiology, King Fahd Hospital of the University, P.O. Box 40044, Al-Khobar 31952, Saudi Arabia


 

INTRODUCTION

Screening mammography (SM) is an impor­tant tool for detecting early breast cancer. SM refers to x-ray examination of the breast for women who are asymptomatic, that is, have no apparent breast problems.1 Esti­mates of SM sensitivity range from 75 to 90%, with specificity ranging from 90 to 95%.2                 The positive predictive value of SM for breast cancer ranges from 20% in women under the age of 50 years, to 60 and up to 80% in women aged 50-69 years. Ran­domized clinical trials have demonstrated a 30% reduction in breast cancer mortality in women 50-69 years who are screened annually or biannually with mammograms. The data on women under age 50 years are less clear.2 Conclusions on the value of SM in these women have been hampered by in­adequately designed studies, including the failure of randomization and inadequate sample size, low compliance in the inter­vention group, and high screening rates (cross-over) in the control groups.3,4 A few studies have suggested adverse effects on mortality in the early years after screening implementation, but both the occurrence and potential etiology of these effects are poorly understood.4,5                 In many countries, screening programs are mandatory for women over 50 years of age. This is due to the higher incidence of breast cancer in older women there, consideration of cost-benefit ratio, and past fears about radiation risks in younger women.6,7 One review discounts the last factor, indicating that even in women as young as 25, the benefits of mammographic screening far outweigh any risks.8 Given the fact that the majority of breast cancer patients in Saudi Arabia are younger than those in the West, mainly because of the nature of the population pyramid of Saudi Arabia, the right population for screening needs to be defined and access to spe­cialized medical services must be assured.9 The lack of public knowledge about cancer is a potential barrier preventing people from participating in such studies and in cancer control activities.10,11 The aim of  this study is to assess the knowledge and attitude of Saudi females about SM as the first step towards the early detection of breast cancer.

MATERIAL AND METHODS

This study was conducted in the period January-to-June, 2000. The study population was women in the 30-65 year age group working in schools in the Eastern province. The total number of  women was about 2000, and was composed of teachers, clerks, and those in administrative and miscellan­eous jobs. A simple random sampling approach was adopted and a 25% target sample size was set. Thus, the estimated  sample size was 500 women. Participants were interviewed using a structured questionnaire, consisting of the "yes" or "no", and "uncertain" question format.

                The variables in the questionnaire con­cerned: marital status, number of children, level of education, occupation, history of pre­vious mammography, family history of breast cancer, number of mammography tests done, who made the decision about mam­mog­raphy, motive for doing mam­mog­raphy, rea­sons for not doing mammography, sources of knowledge about mammography, and a series of seven questions describing the positive, or negative attitude towards mammography screening. 

                The data was analyzed using the Statistical Package for Social Sciences ( SPSSPC). Frequency distribution tables were generated and a chi-squared test was done to assess the significance of dif­ferences between categories. Significant variables were further analyzed using multiple logistic regression with the attitude towards screening mammography as the dependent variable. A p-value of 0.05 or less was considered as indicative of statistical significance.

    

RESULTS

The total number of females who par­ticipated in the study was 500, with a response rate of 80.0%. The reasons for non-response were that 100 women were excluded from the study: 75 had not heard about SM, 15 were below the age of 30, and 10 with incomplete questionnaires were rejected.

                The mean age of the sample was 35.9  ± 5.7 years, with a range of 30-65 years. The majority of participants (92.8%) were within the age groups 30-44 years. Schoolteachers constituted 74.5% of the sample, while housewives, university teachers and others formed 14.5%, 2,5% and 8.5%, respective­ly. The majority of participants (90.5%) were married (Table 1).

Table 1: Socio-demographic variables

Variable

No (%)

Age:

30 – 34

180 (45.0)

35 – 44

191 (47.8)

45 – 65

29 (7.3)

Occupation:

Teacher

298 (74.5)

Miscellaneous jobs

102 (25.5)

Marital status:

Married

362 (90.5)

Not married

38 (9.5)

Number of children:

None

  91 (22.8)

1 – 4

196 (49.0)

5+

113 (28.3)

                Regarding experience with mammog­raphy, 58 (14.5%) women had previous experience with mammography. Of these, 36 (62.1%) had had it done once, 18 (31.0%) two times, and 4 (6.9%) three times. The decision for mammography had been made by 28 (48.3%) of the participants them­selves, while for the remaining number the decision had been made by others.

                A total of 89 (22.3%) participants were motivated to have mammography done, 56 (62.9%) of whom had it done for fear of cancer and 14 (15.7%) because they knew of people who had cancer.

Table 2: Experience with mammography

Experience

No (%)

Previous mammography:

Done

58 (14.5)

None done

342 (85.5)

No. of mammography tests done (Total 58):

Once

36 (62.1)

Twice

18 (31.0)

Three times and more

4 (6.9)

Decision about mammography:

Made by me

28 (48.3)

Made by another person

30 (51.7)

Motive for doing mammography (Total 89):

Fear of cancer

56 (62.9)

Knowledge of cancer in others

14 (15.7)

Myself having cancer

1 (1.1)

Other reasons

18 (20.2)

Reasons for not doing mammography (Total 371):

Having no breast problem(s)

248 (66.9)

Fear of discovering cancer

49 (13.2)

Not being old enough

11 (3.0)

High test cost

  1 (0.3)

Too busy to do test

37 (10.0)

Fear of radiological hazards

8 (2.2)

Not convinced about benefit of test

9 (2.4)

Other reasons

8 (2.2)

Source of knowledge about mammography (Total 129):

Mass media

40 (31.3)

Private doctor

21 (16.4)

Own knowledge and conviction

52 (40.6)

My husband

9 (7.0)

Another relative

6 (4.7)

However, 371 (92.8%) participants had had no motivation for mammography. The reasons for non-motivation were that they


 

Table 3: Attitude towards mammography

Attitude

No (%)

1. Did not do mammography and do not wish to do it

167 (41.8)

2.  Did mammography before and do not wish to do it again

  8 (2.0)

3.  I do not know what to do for having mammography in future

25 (6.3)

4.  I have to discuss mammography with my doctor first

  50 (12.5)

5.  Did not do mammography but wish to do it

  51 (12.8)

6.  I did mammography before and wish to do it again

13 (3.3)

7.  I intend to do mammography every 1-2 years

  67 (16.8)

Table 4: Variables affecting attitudes towards mammography

Variable

Total

Attitude

Chi-

p-value

Positive (%)

Negative (%)

squared

Age:

30 – 34

174

  69 (39.7)

105 (60.3)

35 – 44

178

  95 (53.4)

  83 (46.6)

45 – 65

17

  17 (58.6)

  12 (41.4)

8.192

0.01

Educational level:

Below secondary

  36

  18 (50.0)

  18 (50.0)

Secondary

  80

  37 (46.3)

  43 (53.8)

University

233

108 (46.4)

125 (53.6)

Postgraduate

  32

  18 (56.3)

  14 (43.8)

Family history of breast cancer:

Positive

  55

  41 (76.4)

  13 (23.6)

21.464

0.0001

Negative

326

139 (42.6)

187 (57.4)

Martial status:

Married

344

163 (47.4)

181 (52.6)

Not married

  35

  17 (48.6)

  18 (51.4)

Number of children:

None

  86

34 (39.5)

52 (60.5)

1- 4

188

93 (49.5)

95 (50.5)

5+

107

54 (50.5)

53 (49.5)

Occupation:

Teachers

312

143 (45.8)

169 (54.2)

Miscellaneous jobs

  69

  38 (55.1)

  31 (44.9)


 

had had no breast problems (66.9%), were afraid of discovering that they had cancer (13.2%),  or were too busy (10.0%). Among the rest, the reasons were that they were not old enough, could not afford the cost, were afraid of radiological hazards, or uncertain of its benefits.

                On the source of knowledge about mammography, 128 (32.0%) of the participants stated the source of their knowledge. The sources consisted of the mass media (31.3%), private doctors (16.4%), personal knowledge and convic­tion (40.6%), husband (7.0%), and another relative (4.7%) (Table 2).

                Table 3 shows the attitude towards SM. Almost half of the sample had a positive attitude towards mammography. This atti­tude was expressed in the wish to have mam­mog­raphy done, having had mammog­raphy done before and the desire to have it done every 1-2 years. The other half who had a negative attitude towards mammog­raphy stated that they had not had mam­mography done and had no wish to have it done, were not decided what to do in the future, or would discuss the matter first with the doctor.

                On the effect of variables on participants' attitudes, significantly more younger partici­pants had a positive attitude than older ones (P<0.01). Also, significantly more partici­pants with a positive family history of breast cancer displayed a positive attitude than those with a negative family history (P< 0.0001). However, no significant relation­ship was observed on the positive attitude towards SM with any of the other variables studied (Table 4). Multiple logistic re­gres­sion analysis revealed that the only variable that was significantly and positively asso­ciated with a positive attitude towards mam­mography was a positive family history of breast cancer (P < 0.00001).

DISCUSSION

Mammography, a screening procedure, is an x-ray examination of the breast that has decreased the risk of death from breast cancer by 25 to 30%. It can detect breast can­cer or carcinoma in situ at 5 to 10 mm in diameter. Most physicians cannot reliably detect lesions smaller than 10 mm on physical examination, and patients generally seek medical attention for lesions that are 25 mm or larger.12

                Early breast cancer is potentially curable; in Saudi Arabiait is the most common cancer in women. However, our experience indicates that the pattern of the disease is different than that reported in the litera­ture.9,13 Published data from the Saudi National Cancer Registry indicate that breast cancer is the most frequent malig­nancy in adult women, accounting for 18% of the total. A review of studies on the relationship of age to the incidence of breast cancer in North Americaand Europeshows that the incidence in women younger than 40 years ranges from 8 to 15%, as compared with the 35% observed in King Faisal Spe­cialist Hospital. The low frequency of early stage disease reflects delayed presentation and referral, and is a cause for serious con­cern. The delay may be due to ignorance of the disease, little education and/or the in­accessability of specialized medical care.9

                The evaluation of public awareness and misperception about cancer is of funda­mental importance for the successful imple­men­tation of activities on cancer control.10,14

                        This study shows that there is poor knowl­edge and considerable negative atti­tude towards mammography in all identified age groups, and on all educational levels. Little work has been done by the media or pri­vate doctors on community education for disease prevention. Participants with per­sonal or family experience with cancer were more aware of the importance of screening for the disease. The data also suggest that for effective cancer control in Saudi Arabiathere should be comprehensive cancer health education.

                A joint effort by the primary care physician and community oncologist in this task will be necessary and the development of more widespread screening and educational programs will be of benefit to the women of the Kingdom. The develop­ment and implementation of a comprehen­sive Breast Cancer Program in which additional resources are allocated towards its control would be an important first step towards raising the national consciousness on this disease.

              

ACKNOWLEDGMENT

I am grateful to Dr. A. G. Elzubier, FRCP, Assistant Professor, for his invaluable assistance and help in the statistical analysis.

REFERENCES

1.     Ferrini R, Mannino E, Ramsdell E,Hill L, Screening mammography for breast cancer: American college of preventive medicine September/October 1996;12(5):340-41. 

2.     Elwood JM, Cox B, Richardson AK, The effectiveness of breast cancer screening by mammography in younger women. Online J Clin Tril 1993;2:Doc no 32.

3.     Miller AB, Baines CJ, To T, et al. Canadian national breast screening study 1: breast cancer detection and death rates among women ages 40-49 years. Can Med Assoc J 1992;147:1459-98.

4.     Nyyystrom L, Rutqvist I, Wall S, et al. Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet 1993;341:973-8.

5.     Vogel V. Screening younger women for breast cancer. J Natl Cancer Inst 1994; 16:55-60.

6.     Fox SA, Klos DS, Tsou CV. Underuse of screening mammography by family physicians. Radiology 1988;166: 431-3. 

7.     American Cancer Society. 1989 survey of physi­cians attitudes and practices in early cancer detection. CA Cancer J Clin 1990;40:77-101.

8.     Mattler FA, Upton AC, Kesey CA, et al. Benefits versus risks from mammography. Cancer 1996;77:903-9.

9.     Ezzat A, Raja M, Rostom A, Zwaan F, Ingemansson S, AL-Abdulkareem A. An over­view of breast cancer. Annals of Saudi Medicine 1997;17(1): 10-5.

10.   Luther SL, Price JH. Measuring common public misperception about cancer. J Cancer Ed 1987; 2(3):177-87.

11.   Ibrahim EM, AL-Muhana FA, Saied I, et al. Public knowledge, misperception, and attitude about cancer in Saudi Arabia. Annals of Saudi Medicine 1991; 11(5): 518-23.

12.   Anman K, Shea S. Screening mammography under age 50. Jama 1999; 28(281):1470-2.

13.   El-Hassan AY,AL-Mulhim FA, Ibrahim EM, Al-Awami M. Retrospective appraisal of 3300 con­secutive mammograms. Annals of Saudi Medi­cine 1990; 10(3):285-90.

14.National survey on breast cancer: a Measure of progressing public understanding Washington DC. US Government Printing Office. Dept. of Health Education and Welfare publication 1980; 81:2306.


-0001-11-30

PARASITIC INFECTION


PATTERN OF INTESTINAL PA RASITIC INFECTION AMONG FOODHANDLERS IN RIYADH, SAUDI ARABIA

Khalid A. Kalantan, ABFM, Eiad A. Al-Faris, MRCGP, Ahmed A. Al-Taweel, ABFM

Collegeof Medicine, King Saud University, Riyadh, Saudi Arabia

أهداف الدراسة: تهدف هذه الدراسة للتعرف على أنواع الطفيليات المعوية و معدل انتشارها بين عمال المطاعم و كذلك لتقويم مدى فعالية نظام المسح الطبي الحالي للعمال قبل السماح لهم بمزاولة المهنة.

طريقة الدراسة:تم اجراء دراسة مقطعية في مناطق الخدمة التابعة لعدد سبع مراكز صحية تمثل النواحي المختلفة لمدينة الرياض. و تم اختيار 700 عامل ، بطريقة عشوائية ، يعملون في المطابخ و المطاعم التجارية العامة. ثم طُلب من العمال تعبئة النموذج المعد للدراسة و من ثم احضار عينة طازجة من البراز لفحصها في مختبر المركز الصحي التابع للمنطقة.

نتائج الدراسة: أوضحت الدراسة أن 66% من العمال استجابوا لاحضار العينات. كما تبين 12.8%من العينات ايجابية للطفيليات المعوية. و كشفت الدراسة أيضاً عن وجود علاقة ذات دلالة احصائية ، بين جنسية العامل و فرصة اصابته بعدوى الطفيليات المعوية. ولهذا فإن أعلى معدلات الإصابة وجدت بين العمال البنجلاديشيين و الهنود . بينما وُجد أن أقلها بين العمال الوافدين من الدول العربية و الأتراك. و بالنسبة لأنواع الطفيليات ، كشفت الدراسة أن أكثرها انتشاراً الجياردية اللمبلية (33.8%) ثم السرمية الدويدية (27.4%). و يبدو أن نظام المسح الطبي للعمالة المطبق حالياً غير فعال حيث ثبت أن 81% من المصابين بالطفيليات يحملون شهادات صحية تثبت خلوهم من الطفيليات و سارية المفعول ايضاً.

الخلاصة: على الرغم من وجود نظام يلزم عمال المطاعم بحمل شهادة صحية سارية المفعول قبل العمل في المطاعم و المطابخ العامة ، غير أن معدل انتشار الطفيليات المعوية لا يزال مرتفعاً. ناقشت الدراسة بعض الحلول المقترحة للتغلب على هذه المشكلة.

الكلمات المرجعية: الطفيليات المعوية ، عمال المطاعم ، المملكة العربية السعودية.

Objective:Identify the types and prevalence of intestinal parasites among food handlers, and test the effectiveness of the current pre-employment screening policy.

Methods:A cross sectional survey was carried out in the catchment areas of seven primary health care centres (PHCCs) to represent various sections of Riyadhcity. A total of 700 food handlers working in restaurants were randomly selected from the study area. All study subjects were asked to complete a data collection form and to bring a fresh stool specimen on the specified day to the designated PHCC.

Results:About 66% of the selected subjects complied in bringing fresh stool specimens. Fifty nine (12.8%) of the specimens were positive for parasites. There was a significant association between the food handler’s nationality and the likelihood  of  a  positive  specimen  result, being  highest   among  the  Bangladeshis

Correspondence to:

Dr. Khalid A. Kalantan, Assistant Professor, Department of Family & C ommunity Medicine (34), College of Medicine King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia

(20.2%) and Indians (18.5%) and the lowest among the Arabs (3.4%) and the Turks (10%). The commonest intestinal parasites isolated were Giardia lamblia (33.8%), followed by Enterobius vermicularis (27.4%). The current screening policy does not seem effective, as there was an absence of significant association between holding a valid PEHC and the test result, with 81% of the positive results from persons holding valid pre-employment health certificates (PEHCs). 

Conclusions:Though it is obligatory for food handlers to hold a PEHC in Saudi Arabia, the prevalence of intestinal parasites remains high. Possible solutions include health education on hygiene, more frequent stool tests, and assessment of the current annual screening procedure.

Key Words: Intestinal parasites, health education, foodhandlers, Saudi Arabia.


 

INTRODUCTION

Intestinal parasitic infection is considered as one of the most common tropical dis­eases in developing countries, where the prevalence rate ranges between 30 and 60%.1-3 The prevalence of almost all parasites depends on climatic and socio-environmental conditions.4 In a Bangla­desh slum, over 80% of the population have one or more parasites.5 In some parts of India (Madras), Trichuris Trichiura was found among 62.3% of the children.6 In Pakistan, the prevalence of parasites in diarrhoeal patients was found to be 71%, with a high rate of Giardia Lamblia.7 Asympto­matic carriers of intestinal para­sities are a particular public health hazard, especially if they work in catering facili­ties, where they may become a source of infection for others.8

Expatriates account for more than one fourth of the total population in Saudi Arabia. Most catering staff come from South-East Asia and the Indian subconti­nent. Pre-employment stool examinations are mandatory for food handlers in Saudi Arabia before they can get their pre-employment health certificates (PEHCs). One stool specimen annually is needed.

Several studies have been conducted on the prevalence of intestinal parasites in patients,4,9,10 food handlers in a military hospital,11 and food handlers in communi­ties other than Riyadh city.8,12 To the best of our knowledge no community-based study was carried out on the prevalence of food handlers in Riyadh, the Capital of Saudi Arabia.

The objective of the current study is to identify the type and prevalence of intes­tinal parasites among food handlers in Riyadh city, and to test the effectiveness of the current pre-employment screening policy.

MATERIALS AND METHOD

Seven primary health care centres (PHCCs) were randomly selected to repre­sent the geographical parts of Riyadh city. Their catchment areas were taken as the study area, which included 669 different kitchens and public restaurants employing 2245 food handlers. A total of 700 food handlers were randomly selected as the study sample. The study was conducted during the period between April 1st and June 28th, 1995.

Specimen Collection

All study subjects were given a tight-lid plastic container and instructed to bring a stool specimen fresh within half an hour on the specified day, to allow an even work­load for the laboratory of the designated PHCC. They were also asked to complete a data collection form with the help of trained health inspectors; it included the demographic characteristics of the worker, any related symptoms, e.g. diarrhoea, date of last PEHC (if present). Those who failed to bring the bottle were reminded with phone calls from the designated research assistant.

Stool Analysis Technique

All specimens were examined grossly by qualified laboratory technicians for con­sistency and presence of blood or mucus. Direct faecal smears were prepared for micro­scopic assessment for the presence of tropho­zoites and cysts within 15 minutes of receipt under magnifications of 10 and 40x.

Data Analysis

The data were entered into a PC micro­computer and were analysed using Stat Pac Gold statistical analysis package. The asso­ci­a­tion between two categories was tested for significance using chi-square test, and p value less than 0.05 was considered significant.

RESULTS

Of the 700 food handlers selected for the study, 461 (65.8%) responded. All food handlers working in kitchens and public restaurants in the study area were non-Saudi men, ranging in age from 21 to 48 years. They represented 11 different coun­tries, the majority of them (65.9%) from South East Asian countries and the Indian subcontinent (Table 1). There was a signi­fi­cant association between the nation­ality of the food handler and the likelihood of his having a positive stool specimen for parasites (P = 0.006). The highest preva­lence was among the Bangladeshis (20.5%), followed by the Indians (18.5%); the least was among the Arabs (3.4%) and the Turks (10%) (Table 1).

Table 1: Prevalence of intestinal parasitic infections in various nationalities in Riyadh, Saudi Arabia(N=461)

Nationality

Stool specimens (%)

Positive specimens (%)

Indian

119 (25.8)

22 (18.5)*

Arab countries

87 (18.9)

3 (3.4)

Bangladeshi

83 (18.0)

17 (20.5)

Pakistani

83 (18.0)

10 (12.0)

Turkish

70 (15.2)

7 (10)*

Others†

19 (4.1)

2 (10.5)

p-value 0.006(calculated after excluding others)

*Include double infection

†Including Filipinos, Srilankans, Afghanistanis

                Of the 461 stool specimens examined, 59 (12.8%) were found to be positive for para­sites. Giardia lamblia constituted 33.8% of total positive specimens; 42.9% of which were found among Indians, followed by Bangladeshis (33.3%), Pakistanis (14.3%), and Turks (9.5%). No parasites were found among Arabs and the other nationalities (Table 2). Enterobius vermicularis was the second most common parasite (27.4%) of the total positive specimens; 43.8% of which were found among Indians, followed by Bangladeshis, Turks and Pakistanis (18.8, 18.8, and 12.3% respec­tive­ly) Table 2. Entamblia histolytica constituted 19.4% and was equally prevalent among Arabs, Pakistanis, Turks and others 16.8% (Table 2). Only 8.4% of the Arab food handlers had positive results, compared to 14.97% of the non-Arab ones (Table 3).

                Of 59 positive subjects, 81.4% had a valid PEHC. Furthermore, there was no significant difference between the subjects who had or did not have a valid PEHC, and the likelihood of having a positive test for parasites (p=0.13). Two specimens (3.4%).


 

Table 2:Distribution of the most common intestinal parasites according to nationality in Riyadh

Nationality

G. Lamblia

No (%)

E.Vermicularis

No (%)

E. Histolytica

No (%)

Others*

No (%)

Indians

    9 (42.9) †

  7 (43.8)

1 (4.7)

   5 (41.7) †

Arab countries

-

1 (6.3)

  2 (16.8)

-

Bangladeshis

7 (33.3)

  3 (18.8)

  3 (25.0)

4 (33.0)

Pakistanis

3 (14.3)

  2 (12.3)

  2 (16.8)

3 (25.0)

Turks

2 (9.5) †

  3 (18.8)

     2 (16.8) †

-

Others

-

-

  2 (16.8)

-

Total

21 (100)

16 (100)

12 (100)

12 (100)

*E. Coli, T. Trichiura, Hook worm, Ascaris and Strongyloid

†Including double infections

‡Including Filipinos, Srilankans and Afghanistanis

Table 3: Prevalence of the most common intestinal parasites in food handlers according to nationality

Nationality

Total sample size

Total positive

No (%)

G. Lamblia

No (%)

E. Histolytica

No (%)

Non-Arab

374

56 (14.97)

11 (2.9)

10 (2.6)

Arab

87

3 (3.4)

-

-

Total

461

59 (12.8)

11

10


 

(3.4%) were found to have double infec­tion. The majority of infected persons were asymptomatic 45 (76.3%); whereas (23.7%) complained of diarrhoea at the time of the study (Figure 1). Sixty-six percent of the infected persons with Giardiases were found to be asymptomatic. The preva­lence of each type of intestinal parasite is shown in Figure 2.

DISCUSSION

Although the study subjects were reassured that  the  test   would  not   influence   their

among food handlers in Riyadh, Saudi Arabia

ability to continue their jobs and defaulters were reminded and rescheduled, only 65.8% of the subjects complied. Two fresh stool samples two days apart per patient were reported to increase the yield of isola­tion.13-15

                The technique used in this study, microscopy of a single fresh faecal smear, is recognised as having low sensitivity in detecting most intestinal parasites and will only have detected those that were abun­dant in the particular faecal sample sup­plied. However, our one-sample-per-sub­ject policy was employed due to sche­duling difficulties and concern over col­lection of additional samples being un­acceptable by the study subjects. This policy may lead to under-estimation of the problem size. Use of a magnification of 10x and 40x means that crypto­sporldium SPP will have missed. Moreover,  Microsporldia SPP, in particular, need special stain which is not available in the labs. We also realise that for adequate sensitivity strongloides SPP require concentration or culture which is not available in the basic laboratory of PHCCs. The prevalence of intestinal parasites in this study (13%), is similar to the figure (14.2%) of a similar study in Al-Madina (in the West of Saudi Arabia).12 A lower pre­va­lence rate (7.6%)8 was reported among food handlers in the Eastern Prov­ince, although food handlers attending a pre-employment examination were studied.

                Giardiasis is endemic in many parts of the world, including Europe and the USA.9,16) Consumption of faecally con­tami­nated water is the main mode of trans­mis­sion, followed by direct person-to-person contact. On a few occasions food has been implicated as a source of infec­tion.13,17 Giardia lamblia was the most common parasite (33.8%) isolated in this study. The prevalence rate of Giardia lamblia has had a wide range in different Saudi studies, namely 3.1-30%.4,8,12 The finding that three quarters of the positive-testing workers were asymptomatic could not be explained totally by the high pro­portion of Giardiasis (only 66% were asymp­tomatic), as it was suggested by a few studies.18

                This study was consistent with the findings of previous studies7-12,20-25which recog­nized that intestinal parasitic infection among food handlers is still an important public health problem in the Kingdom of Saudi Arabia.

CONCLUSIONS AND RECOMMENDATIONS          

The finding of a higher prevalence among the Bangladeshis and Indians who have a high prevalence rate in their own countries5-7,19indicates that more rigorous strategies should be directed to these high risk groups. The Indians represent a high proportion of the total sample size (26%) and 18.5% of positive specimens. They need health education regarding certain hygienic measures to avoid spreading of the infection and more frequent stool tests, especially upon arrival from travel to their countries.

                The finding of 81% positive results among the subjects who had a valid PEHC and the absence of significant asso­ci­a­tion between a valid PEHC and test result call into question the effectiveness of the annual screening procedure. Reinfec­tion is another possible cause of these results because some of the subjects might have had a holiday in an endemic area and come back carrying the infection or been in contact with some one who had the infection.

                Re-evaluation of the process of pre-employment examinations, especially those in the catering trade is highly recom­mended. Biannual screening of two stool samples two days apart per food handler is also recommended, as is a re-examination checkup upon arrival after holiday, parti­cularly for those coming from high prevalence countries.

ACKNOWLEDGMENT

The authors are grateful to Drs. Jamal Jar­al­lah, Sulaiman Al-Shammari, and Fayek S. El Khwsky from the Department of Family and Community Medicine, College of Medicine, King Saud Univer­sity for their constructive comments, and Mr. Mohamed Eijaz for secretarial assistance.

REFERENCES

1.     Musaiger AO, Gregory WB. Change in parasitic infections among school children in Bahrain, 1980-1986: A preliminary study 1990. Saudi Med J 1990;11(2):113-5.

2.     World Health Organization 1987. Prevention and control of intestinal parasitic infections. Geneva: WHO, Tech. Rep. 749:7-18.

3.     Al-Shammari S, Khoja T, Al-Khwasky F, Gad A. Intestinal Parasitic diseases in Riyadh, Saudi Arabia: Prevalence, Sociodemographic and en­viron­mental associates. Tropical Medicine and Inter­national Health 2001;6(3):184-9.

4.     Khan MU, Amir SE, Eid OM, Aggrewal S. Parasitic infestation in expatriates in Riyadh, Saudi Arabia. Ann Saudi Med 1989;9(5):471-4.

5.     Khan MU, Shahidullah M, Barua DK, Begum T. Efficacy of periodic deworming in an urban Slum population for parasite control. IndJ Med Res 1984;83:82-8.

6.     ElKins DB. A survey of intestinal helminthes among children of different social communities in Madras, India. Transa Roya Soci Trop Med Hyg 1984;78:132-3.

7.     Baqai R, Zuberi SJ. Prevalence of intestinal para­sites in Diarrhoeal patients. J Pak Med Assoc 1986;36: 7-11.

8.     Khan ZA, Al-Jama AA, Madan I. Parasitic infec­tions among food handlers in Dammam and Al-Khobar, Saudi Arabia. Ann Saudi Med 1987; 7(1): 47-50.

9.     Hussain Qadri SM, Khalil SH. Intestinal para­sites: Incidence and etiology in over 1,000 patients at King Faisal specialist hospital in Riyadh. Ann Saudi Med 1987;7(3):207-11.

10.   Al-Fayez SF, Khogheer YA. A follow up study on prevalence of parasitic infections among pa­tients attending King Abdulaziz University Hos­pital, Jeddah. Saudi Med J 1989;10(3):193-7.

11.  Abu Al-Saud AS. Faecal parasites in non-Saudi catering and domestic staff at the Riyadh Military hospital. Saudi Med J 1983;4(3):259-62.

12.   Ali SI, Jamal K, Hussain Qadri SM. Prevalence of intestinal parasites among food handlers in Al-Madinah. Ann Saudi Med 1992;12(1):63-6.

13.   Al-Ballaa SR, Al-Sekeit M, Al-Ballaa SR, et al. Prevalence of pathogenic intestinal parasites among preschool children in Al-Madina District, Saudi Arabia. Ann Saudi Med 1993; 13(3): 259-63.

14.   Healy GR. Diagnostic techniques for stool samples. In: Amebiasis: Human Infection by Entameba histolytica. Ravin JI, ed. New York: Churchill Livingstone 1988; 495-510.

15.   Mathur TN, Kaur J. The frequency of excretion of cysts of E. histolytica in known cases of non-diagnostic amebic colitis based on 21 stool exami­nations. IndJ Med Res 1993; 61:330-4.

16.   Knight R. Epidemiology and transmission of giardiasis. Transa Roya Soci Trop Med Hyg 1980;74(4): 433-5.

15.   Petersen LR, Cartter ML, Hadler J. A food-Borue outbreak of Giardia Lamblia. J Infect Dis 1988;157(4):846-8.

18.   Meyer EA, Jarroll EL. Reviews and Commentary – Giardiasis. Am J Epidemiol 1980;111(1):  1-12.

19.   Ibrahim OMG, Bener A, Shalabi A. Prevalence of Intestinal Parasites among expatriate Woncers in Al-Ain, United Arab Emirates. Ann Saudi Med 1993;13(2):126-9.

20.   Abdel-Hafez MA, El-Kady N, Noah MS, Bolbol AS, Baknina MH. Parasitic infestation in expatriates in Riyadh Saudi Arabia. Ann Saudi Med 1987;7(3):202-6.

21.   Bolbol AS, Mohmoud AA. Laboratory and clinical study of intesdtinal pathogenic parasites among the Riyadhpopulation. Saudi Med J 1984;5:159-66.

22.   Abu Al-Saud AS. A survey of the pattern of parasitic infestation in Saudi Arabia. Saudi Med J 1983; 4(2):117-22.

23.   Al-Madani AA, Omar MS, Abu-Zeid HA and Abdulla SA. Intestinal parasites in urban and rural communities of Abha, Saudi Arabia. Ann Saudi Med 1989;9(2):182-5.

24.   Abu-Zeid HA, Khan MU, Omar MS, Al-Madani AA. Relationship of intestinal parasites in urban communities in Abha to socio-economic mental factors. Saudi Med J 1989;10(6):477-80.

25.   Siddiqui MA. The prevalence of human intestinal parasites in Al-Baha, Saudi Arabia: a preliminary survey. Annals of Tropical Medicine and Parasitology 1981; 75(5):565-6.


-0001-11-30

PATIENTS' SATISFACTION


PATIENTS' SATISFACTION WITH PRIMARY HEALTH CARECENTERS SERVICES IN KUWAIT CITY, KUWAIT

Abdullah H. Al-Doghaither, PhD, Badreldin M. Abdelrhman, PhD, Abdalla A.W. Saeed, MD, Abdullah A. Al-Kamil, MCommH, Mohieldin M. Majzoub, MD

College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة :قياس مستوى رضا المراجعين عن الخدمات التي تقدمها مراكز الرعاية الصحية الأولية بمدينة الكويت ودراسة العوامل الاجتماعية والديمغرافية المرتبطة برضا المراجعين .

طريقة الدراسة :دراسة مسحية مقطعية لمدة شهر واحد في خمس مراكز صحية بمدينة الكويت تم اختيارها من المناطق الجغرافية عن طريق العينة العشوائية البسيطة ، وتم اختيار المراجعين عن طريق العينة العشوائية المنتظمة من المراجعين عمر 18 سنة فما فوق ، وجمعت المعلومات عن طريق استبانه احتوت على العوامل الجغرافية والديمغرافية للمراجعين والخدمات التي تقدمها المراكز الصحية ومستوى رضا المراجعين عنها ، تم قياس مستوى الرضا على مقياس ليكرت ( Likert )المكون من خمس درجات ، الدرجة الأدنى تعنى درجة رضا أدنى .

نتائج الدراسة :كان 56% من المراجعين من الإناث ، 59% متزوجون ، أكثر من 50% أكملوا المرحلة المتوسطة أو الثانوية وحوالي 70% يعملون كموظفين ، وأكثر من 60% دخلهم الشهري أقل من 900 دينار كويتي وبلغ مستوى الرضا العام الذي أخذ في الاعتبار كل الخدمات المقدمة 31. 3درجة من 5 درجات . كان أعلى مستوى رضا لخدمات المختبر 64. 3 درجة وأدناها لخدمات الأطباء 12. 2 درجة وكان أعلى رضا للنساء المنخفضة من الدخل والتعليم والعاطلين عن العمل . كان أعلى مستوى لرضا الأطباء مهارات الاتصال 23. 2 ، وتوفر الدواء للصيدلية 01. 4 ، وتواجد المعدات اللازمة بالمعامل 73. 3 وعدم طول الانتظار لخدمات الأشعة 73. 3 ، وتواجد أطباء أسنان لخدمات الأسنان (27. 3).

الخلاصة:بعض  الخدمات تحتاج للتدخل التصحيحي حتى تكون أكثر رضا للمراجعين كما يحتاج المراجعين لبرنامج تعليمي عن أهداف الرعاية الصحية الأولية.

الكلمات المرجعية:الرعاية الأولية، رضا المريض، العوامل الديمغرافية والاجتماعية، الكويت.

Background: Assessment of patient satisfaction offers a way of optimizing health status and prevents waste of medical resources. The direct measurement of patient satisfaction is a new phenomenon in Kuwait. 

Objective: Assess patient satisfaction with respect to primary health care services and study any patterns of association of sociodemographic variables on the patient satisfaction level.

Methods: The sample consisted of 301 patients selected systematically from five primary health care centers to represent various geographic areas in Kuwait City. Just over 56% of the sample were females, 59% were married, the great majority (70.4%) were government employees, more than 60% had a monthly income of less

Correspondence to:

Dr. Abdullah H. Al-Doghaither, Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia

than 900 KD, more than 54% were intermediate and high secondary school graduates, and 37% were university graduates or had advanced degrees. The data was collected by personal interview using structured questionnaire.

Results: The overall mean satisfaction was 3.1 points out of five (62%). The mean satisfaction scores were 3.64, 3.29, 3.08, 3.05, 2.21 for laboratory, pharmacy, radiology, dental and physician services, respectively. The highest mean score for physician services was obtained for communication skills (2.23); for pharmacy services, the availability of medicine (4.01); for laboratory services, the availability of lab materials (3.73); for radiology services, the waiting time for x-ray (3.60); and for dental services, the adequacy of dentists (3.27). The results indicated that gender, income, marital status and occupation were the most consistent demographic predictors of satisfaction, with females, those with lower income, lower education levels and the unemployed having higher mean satisfaction scores.

Conclusion:There is a need for corrective intervention in some service areas and for an educational program to inform patients of the objectives and limitations of primary health services.

                 

Key Words: Primary care, satisfaction, sociodemographics, Kuwait


 

INTRODUCTION

Primary Health Care is defined by the World Health Organization as essential health care made universally accessible to individuals and families in the community by means acceptable to them. Its objective is to deliver integrated health services.  This new system abolished its former health offices, maternal and child health centers and dispensaries, amalgamating their ser­vices into health care centers which provide both curative and preventative aspects of care. Studies of patients attitudes towards health services, health personnel and resources constitute important elements in the extent to which the health services have met the consumers’ expectations and needs, and hence can be viewed as a means of judging the degree of their satisfaction with the services.1,2 The degree of patient satis­faction can be used as means of assessing the quality of health care and the personnel. It reflects the ability of the provider to meet patients’ needs. Satisfied patients are more likely than unsatisfied ones to continue using health care services, maintain their relation­ships with specific health care pro­viders, and comply with care regimens.3 Satisfaction studies have been done mostly in developed countries. In developing countries, such studies are scarce and of  a general nature. In the Gulf Region, some studies on satisfaction with ambulatory care were conducted in countries like Saudi Arabia,4,5  the United Arab Emirates6 and Qatar.7 The authors are not aware of similar published studies for Kuwait. The current study will start the process of evaluation with the hope of delineating areas of strength and weakness in Primary Health Care centers (PHCCs) to pave the way for appropriate planning strategies for improve­ment. This article is intended to stimulate further research in this area.

PATIENTS AND METHOD

This is a facilty-based study of the PHCCs in Kuwait City, the capital of Kuwait. The study population consisted of all Kuwaiti patients who visited (PHCCs) in Kuwait Cityduring the study period  (September,  1998). Because direct interviews are con­sidered to yield the best information and re­sult in a higher response rate from patients, it was selected as the appropriate methodo­­lo­gy. The satisfaction questionnaire was based on the standardized Likert scale of 1-5 points; the higher the score, the higher the satisfaction with the service offered. The ques­tionnaire addressed two main com­po­nents: patients’ sociodemographic (gen­der, marital status, education, age, income, and job) and general satisfaction with physi­cian, and dental, pharmacy, laboratory and radio­logy services. The internal consistency of the questionnaire was examined using Cronbach’s alpha. The alpha coefficient was 0.868, which is considered as a good measure for reliability. The study was conducted in five PHCCs randomly selected to represent various geographic areas of the capital, Kuwait City. The sample consisted of 80 patients chosen systematically from each center making a total of 400 patients. Every 10th Kuwaiti patient 18 years old and above who visited the PHCCduring the study period was selected. Participation was voluntary and confidentiality was assured to the respondents. Subjects were informed about the study objectives and procedures, and that data collected would be used only for the stated research purposes. The ques­tionnaire was administered by a trained final-year Kuwaiti student in the Health Service Administration Programme of the Department of Community Health Sciences, Collegeof Applied Medical Sciences, King Saud Universityin Riyadh, who was also available to answer patients’ queries and help illiterate patients. The data was checked manually for completeness.

                Analysis of variance using Man-Whitney U-test and Kruskal-Wallis test was carried out to examine the differences on the mean scores of satisfaction within socio­demo­graphic variables. Multiple regression analysis was undertaken, with overall mean satisfaction score being the dependent variable and the sociodemographic charac­ter­is­tics being the independent variable. Summary satisfaction scores were done for all services according to the socio­demo­graphic variables studied. Data was ana­lyzed using SPSS package, version 9.

RESULTS

Data was obtained for 301 patients, a re­sponse rate of 75%. The sample was composed of 130 males (44.2%, mean age=31.38 years, range 15-71) and 171 females (56.2%, mean age =31.59, range =15-56). The two groups did not differ sig­ni­fi­cantly in age (P= 0.19). The majority of the patients were married (59.1%), aged less than 50 years (93%). For education, 2.2% reported they did not have formal education, 5.3% were primary school graduates, 54.3% intermediate and high school graduates, and 37% university graduatesand beyond.  Incomes ranged from less than 450 Kuwaiti

Table 1: Mean satisfaction score fo physician, dental, pharmacy, laboratory and radiology services

Items

Mean satisfaction

Physician

Communication skills

2.23

Clinical skills

2.21

Satisfying patients' wishes

Pharmacy

Ability to explain (pharmacist)

3.12

Convenience of prescription filling

3.40

Availability of medication

4.01

Conveniently and logically located

2.64

Laboratory

Availability of lab materials

3.73

Waiting time for lab results

3.54

Adequacy of lab staff

3.63

Radiology

Time taken for x-ray

3.60

Equipment condition

2.56

Dental

Appointments

3.24

Equipment condition

2.63

Adequacy of dentists

3.27


 

Table 2:Mean satisfaction score according to patients' demographic variables

Variables

Physicians

Pharmacy

Laboratory

Dentistry

Radiology

Mean

Gender

Male

2.17

3.47

3.40

2.93

2.97

2.99

Female

2.33

3.81

3.85

3.16

3.18

3.27

Education

Illiterate

2.33

3.81

3.74

3.54

3.23

3.33

Elementary

2.11

4.03

3.84

3.67

3.44

3.42

Intermediate & school

2.24

3.52

3.51

3.02

2.71

3.00

University & above

2.12

3.48

3.64

2.88

2.83

2.99

Marital status

Married

2.23

3.51

3.41

2.93

3.00

3.02

Single

2.38

3.77

3.90

3.20

3.11

3.27

Age

15-29

2.04

3.62

3.64

3.05

3.14

3.10

30-49

2.21

3.59

3.60

2.99

2.98

3.07

50

2.33

3.95

3.67

3.46

3.17

3.32

Income (KD)+

<450

2.27

3.88

3.80

3.21

3.28

3.29

<600

2.22

3.69

3.76

3.03

3.05

3.15

<900

2.24

3.44

3.39

2.81

3.02

2.97

<900+

2.35

3.54

3.62

3.05

2.96

3.12

Occupation

Government employee

2.28

3.58

3.63

3.00

3.04

3.11

Private

2.01

3.75

3.48

3.31

3.14

3.14

Labor

2.64

3.68

3.86

3.10

3.14

3.28

Student

2.41

3.68

3.46

2.69

3.12

3.07

Unemployment

1.89

3.88

4.05

3.46

3.29

3.31


 

Dinar (KD) for 22.6%, up to less than 900 KD for 27.2%. The majority of the patients (70.4%) were government em­ployees, 9.3% worked in the private sector, 2.3 were laborers, 11% were students and 7% were unemployed. The overall mean satisfaction with all services provided was 3.1 points out of 5 points (62%).

                Table 1 shows mean satisfaction scores for physi­cian, dental and allied medical services. The mean satisfaction with physi­cians’ services was 2.21 points (44.2%), 3.05 (61%) for dental services, 3.29 (65.8%) for pharmacy services, 3.64 (72.8%) for laboratory ser­vices and 3.08 (61.6%) for x-ray services. For all the services offered, the lowest mean satisfaction score was obtained for satis­fying patients’ desires by physicians (2.18 points, 43.6%) and the highest was for availability of medications in the pharmacy (4 points, 80%).

                Mean satisfaction scores for physicians’ and allied medical services according to the demographic variables are shown in Table 2. For all services, a significant difference was observed for all groups. Females were more satisfied (3.27) than males (2.99). Regarding marital status, singles reported a higher level of satisfac­tion (3.27) than marrieds (3.02). For age, elderly patients showed a higher level of satisfaction (3.32) than other groups. Pa­tients with lower edu­ca­tional levels (illiter­ate, 3.33; and elemen­tary, 3.42) showed a high level of satisfac­tion. Low-income groups showed higher levels of satisfaction than higher income groups. For occupation, the unemployed exhibited the highest level of satisfaction (3.31). It should be noted that physicians' services exhibited the lowest mean satisfac­tion scores for all variables.

                Table 3 shows the results of multiple regression of sociodemographic variables, predictors of satisfaction with services pro­vided. The first variable to influence mean score satisfaction was gender. Females had higher mean satisfaction scores (0.189) than males. The second variable to influence satisfaction was marital status, with singles reporting higher mean satisfaction scores (0.174) than married. The third variable was in­come, with lower income levels predicting  higher satisfaction; and the fourth variable was occupation, with unemployment pre­dicting higher satisfaction. Age and edu­ca­tion were not significant predictors for satis­fac­tion with services provided. The set of in­dependent variables included accounted for 44% of the variation in mean satisfaction.

Table 3: Standardized regression coefficient of demographic variables on mean satisfaction scores for physicians' and allied medical services

Variable

Regression coefficient

Sex

    0.189*

Marital status

    0.174†

Age

-0.058

Education

  0.026

Income

    0.129†

Occupation

  -0.118†

*significant at 0.01

†significant at 0.05

DISCUSSION

The measurement of patient satisfaction has become a common way to ellicit patients’ views about the health care delivered, and hence has received considerable attention in recent years. This is the age of health care consumerism and researchers are compiling hard data on outcome and consumer satis­fac­tion. The focus of all these activities is the patient.8,9 This study is an effort to evaluate patient satisfaction for a better patient focus. The overall satisfaction score in Kuwait Citywas 62%, with individual scores ranging from 61 to 72.8% for all ser­vices offered, except physician services which scored only 44.2%. These satisfaction scores are comparable to similar studies conducted in Riyadhand Jeddah cities, Saudi Arabia10,11 but are much lower than the reported findings of many worldwide studies which ranged from 61 to 97%.6,7,12,13

               It is difficult to interpret these wide differ­ences in range without adequate information about many aspects, such as study methodo­logy and populations; health sys­tems; char­ac­­teristics, sociocultural values and atti­tudes; and whether primary care training of health team is being regularly performed.14

                        The lowest satisfaction score in this study was for physician services. This needs urgent examination. Physicians are the traditional leaders of the health team and their performance and patients’ satisfaction with them is crucial to utilization and suc­cess of the services provided. Physicians may be overburdened by a high patient load, administrative duties, and other commit­ments which may affect their performance.

                Studies have shown that about 36% of the patients’ complaints were related to physi­cians’ attitude, conduct and communica­tion.15

                About two thirds of the patients in a study in neighboring Saudi Arabiathought that careful listening by the doctor to his patients’ complaints is an important charac­teris­tic for an ideal physician4.

                Other studies have shown that physicians’ communi­ca­tion skills and the length of time they spend talking, explaining and respon­ding to their patients’ queries and offering reassurance, support, and involving patients in decision-making, and discussing test results and findings from physical examina­tions were strong and important correlates of patients’ satisfaction.16-18

                Possible measures for boosting patients’ satisfaction with physicians’ services in­clude training of physicians in communi­cation skills following their undergraduate education. Post graduate training in com­muni­cation skills and their psychological aspects tend to increase open discussion about feelings and emotions and may also produce greater physician sensitivity to patients’ satisfaction.

                The low mean satis­faction score for satisfying patients’ desire to undergo lab tests and for offering request referral to hospital is understandable. Patients’ desires, particularly for laboratory tests and referral to secondary care, may not be professionally justified. Patients need to be educated about the objectives and limits of primary health care and be assured that if need arises all efforts will be done to offer the most appro­priate professional care at the primary or secondary level.Patients were more satis­fied with pharmacy services, particularly the availability of drugs. Kuwait, a rich country, appears to be successful in providing necessary drugs free of charge to all  Kuwaiti citizens. This is comparable to satis­faction with pharmacy services in developed countries, with reported satisfaction of 3.7 points  (74%), as found in the USA.19 Absolute or relative lack of drugs was frequently cited as a cause of dissatisfaction in many studies.4,10,20

                The most important concern of patients in Kuwait was for the location of the pharmacy within the Health Center. Some of the PHCCs may be rented buildings not ori­ginally designed as PHCCs; hence the area selected as a pharmacy may not be ideally situated. Similar findings were reported from neighboring Saudi Arabia.10 Satisfac­tion with pharmacy services could be aug­mented by further improvement in the communication skills of pharmacists, as shown in some studies.19

                Dissatisfaction with dental services was mostly related to equipment that may have been old or inadequate. However, patients sometimes expect to have dental services and equipment similar to that found in specialized dental centers. This may also explain the low satisfaction for radiological services, and seems similar to findings of studies showing that patients expected PHCCs to offer the same range of laboratory services provided by hospitals20.

                There seems to be a genuine need for educating patients about the broader objectives and limits of PHCCs.

               As for the patients’ sociodemographic correlates of satisfaction with the services offered, only gender, income, occupation and marital status appear to be correlated with satisfaction. Studies have reported vari­able associations of satisfaction according to the sociodemographic characteristics of patients. The findings of these studies did not reveal a consistent pattern and at times reported contradictory patterns in many countries in the Gulf Region, such as the UAE, Qatar and Saudi Arabia.6,7,10,11 Our data appear to indicate that higher satisfac­tion with physicians’ and allied medical services was significantly associated with patients who were female, single,  and un­employed, with lower education and income levels. The findings of the present study point to low satisfaction scores with physi­cian services, site of pharmacy, radiological and dental equipment. The aspects of the physician/patient relationship which are re­lated to greater patient satisfaction include clarity of physician' communication with their patients and involving patients in decision-making. Physicians’ services need to be improved in certain areas to boost patients’ satisfaction. An educational pro­gram for all consumers is needed to inform them about the philosophy, objectives, stra­tegies and limitations of Primary Health Services. This is an important aspect for increasing levels of utilization and satisfac­tion with primary health services. We hope that other studies will be carried out in a larger sample of subjects and PHCCs covering the other aspects of health services offered. The results of such studies can be valuable in planning new services and ex­panding and reorganizing current services.

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