KNOWLEDGE, ATTITUDE


KNOWLEDGE, ATTITUDE AND PRACTICE OF PRIMARY HEALTH CARE DOCTORS AND NURSES IN HYPERTENSION      OF PREGNANCY

Mohammad B.S. Gandeh, FFCM*, Waleed A. Milaat, PhD†

*PHC Department, Ministry of Health, Jeddah, †Department of Family & Community Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

هدف الدراسة: تقييم مستوى المعلومة، الاتجاه، والسلوك لأطباء وممرضات الرعاية الصحية الأولية عن ارتفاع ضغط الدم في الحمل وتحديد العوامل المرتبطة بها بمدينة الخبر بالمملكة العربية السعودية.

طريقة الدراسة: تم تحديد مستوى المعلومة، الاتجاه، والسلوك عن ارتفاع ضغط الدم في الحمل باستعمال استبيان شامل لجميع الأطباء وهيئة التمريض المتواجدين في مراكز الرعاية الصحية الأولية في مدينة الخبر أثناء جمع معلومات البحث وقد سبق ذلك تقييم الاستبيان وعمل دراسة استطلاعية له كما تم وضع درجات لكل جزء من الاستبيان وعمل المعدل الحسابي لها وحددت العوامل المؤثرة في كل قسم باستعمال التحليل الإحصائي المتعدد.

نتائج الدراسة: بلغ عدد المشاركين في الدراسة 36 طبيبا و 91 ممرضة. وبلغت نسبة السعوديين من الأطباء 22.2% ونسبة السعوديات من الممرضات 47.3% . أما معدل سنوات التدريب بعد التخرج فقد كان 12.6 سنة للأطباء و 8.7 سنة للتمريض. كما وجد أن الممرضات السعوديات قضين فقط ثلاثة أسابيع في قسم النساء والولادة خلال فترة الامتياز وأن جميع الممرضات السعوديات كن يحملن دبلوم التمريض فقط وأن هناك نقصا في الدورات المعطاة عن مرض ارتفاع ضغط الدم عند الحوامل للأطباء والممرضات بعد تخرجهم. وكان سلوك الأطباء في التعامل مع مشكلة ارتفاع ضغط الدم ضعيفا خاصة في الإجراءات الواجب اتخاذها بعد الوصول للتشخيص وكذلك التوعية الصحية عن تناول ملح الطعام والتغذية بالإضافة إلى معلوماتهم كانت قليلة أيضا.أما بالنسبة للممرضات فقد كان سلوكهم مقبولا خاصة في أخذ التاريخ المرضي وفحص المرضي والإجراءات الواجب اتخاذها بعد التشخيص للحالة، بينما كان مستوى معلوماتهن ضعيفا. وكان اتجاه الأطباء والممرضات إيجابيا بصفة عامة عن مرض ارتفاع ضغط الدم أثناء الحمل، وكذلك كان اتجاههم نحو التوعية الصحية للمرض مقبولا. وقد وجد أن جنسية الممرضة ومدة التدريب التي قضتها بعد التخرج من أهم العوامل التي تؤثر على مستوى درجات الاتجاه والمعلومة للمرضة.

الاستنتاجات والتوصيات: أشارت الدراسة إلى ضعف مستوى المعلومة لدى العاملين في مراكز الرعاية الصحية الأولية في هذه المشكلة الصحية الشائعة وأوضحت قلة تدريب الأطباء والتمريض فيها أيضا. ويوصي بعمل دورات لتنشيط معلوماتهم ولرفع مستواهم في المشاكل الصحية الشائعة والخطيرة ومنها ارتفاع ضغط الدم وتمديد فترة التدريب في الإجراءات الواجب اتخاذها بعد اكتشاف الحالات للأطباء والممرضات العاملين في عيادات متابعة الحوامل لتحسين مستوى المعلومة والسلوك لديهم في مشكلة ارتفاع ضغط الدم أثناء الحمل.

الكلمات المرجعية: ارتفاع ضغط الدم، الحمل، معلومات، ممارسة، رعاية الحامل، الرعاية الصحية الأولية.

Correspondence to:

Dr. Mohammad Gandeh, P.O. Box 53306, Jeddah 21583, Saudi Arabia

Objective: To assess the status of knowledge, attitude and practice ( KAP) of doctors and nurses in Primary Health Care (PHC) centers with regard to hypertension in pregnancy and to identify factors associated with KAP in Al-Khobar, Saudi Arabia.

Methodology: Using a self-administered comprehensive questionnaire, all available doctors and nurses in PHC centers of the Al-Khobar area were approached to determine their knowledge, attitude and practice in hypertension during pregnancy. Questionnaires were validated and pilot tested. Each section of the questionnaire was scored and the mean scores calculated. Factors affecting each section were identified by means of multiple regression analysis.

Results: A total of 36 doctors and 91 nurses were enrolled in the study. Saudis formed 22.2% of the doctors and 47.3% of nurses. Mean years of practice after graduation were 12.6 and 8.7 years for doctors and nurses, respectively. Saudi nurses spend only 3 weeks in the obstetrics ward during the whole period of their internship. All Saudi nurses hold only diplomas and not many courses on the hypertensive disorder are offered to both doctors and nurses after graduation. The practice of doctors particularly in the management of patients after reaching a diagnosis and educating them on diet and salt intake was poor. Furthermore, their knowledge was also poor. Though their level of knowledge was poor, the nurses’ practice was satisfactory, particularly in taking history and physical examination. The attitude of both doctors and nurses towards hypertensive disorders was in general, positive and satisfactory towards health education. Nurses’ nationality and duration of post-internship training were the factors that influenced their attitude and scores on knowledge.

Conclusion and recommendation: The study revealed that both doctors and nurses working in the PHC lacked training and knowledge in this area of their work. It is therefore necessary to give PHC doctors and nurses refresher courses on common and serious problems like hypertension. A longer period of training in action management is needed to improve the knowledge and practice of doctors and nurses working in antenatal clinics in this area.

Key Words:Pregnancy hypertension, knowledge and practice, Antenatal care, Primary Health Care.


 

INTRODUCTION


 

Hypertension is one of the most common if not the commonest medical complication in pregnancy.1-9 Hyper-tensive disorders in pregnancy are found to be the greatest single cause of maternal mortality.9-11 It also causes a lot of prenatal mortality.12 Most of the complications caused by this problem could be reduced by early detection and proper management.13,14 Studies on the incidence of hypertensive disease in pregnancy in most developing countries, including Saudi Arabia, are scarce.15 Few of those studies, if any, have looked at the extent of knowledge, attitude or practice of doctors or nurses dealing with hypertensive pregnant mothers. Hence, the objective of this study was to determine the status of knowledge, attitude and practice ( KAP) of doctors and nurses in PHC centers with regard to hypertension in pregnancy and to analyze factors affecting KAP in the Al-Khobar area of the Eastern Provinceof the Kingdomof Saudi Arabia. Terms used to describe hypertension and its complications in pregnancy differ according to its presentation, gestational age of discovery and the presence of previous history of hypertension before pregnancy. The one defined by  the 1972 Committee on Terminology of the American Obstetricians and Gynecologists (ACOG)13,15-19 was adopted for the purpose of this KAP study.

METHODOLOGY

Doctors and female nurses working at all 8 PHC centers in Al-Khobar area were enrolled for the study. Two self-administered questionnaires structured to examine the essential knowledge, attitude, and practice of doctors and nurses in dealing with hypertensive disorders during pregnancy. Each questionnaire was divided into two parts. The first was intended to gather demographic characteristics and information on the respondent that might affect the KAP. These variables included age, sex, nationality, year of graduation, certification, training and experience in obstetrics, duration of work in PHC in the country and any in-service training received. The second part of the questionnaire consisted of 49 questions divided into three sections dealing with practice, attitude and knowledge. The practice sections included questions designed to test competence of doctors and nurses in the skills of measuring blood pressure, management of the hypertensive pregnant mother and practices of health education. The knowledge section was composed of 28 questions to test basic medical knowledge regarding blood pressure reading, management of the problem and its complications. Both questionnaires were given to three consultant obstetricians and two nurse educators for consent validity and elimination of non-essential questions. Both knowledge and practice areas were scored on a zero and one additive scoring system in which each correct answer or practice was given one scoreand no mark given for a wrong response. The attitude part included questions that measured attitudes of participants towards the seriousness and commonness of hypertension in pregnancy and their motivation to improve their knowledge on the subject. Attitude questions were scored using the Five-Point Likert scaling system. In this scale, a high attitude was assigned to the answer if the respondent’s answer was to “agree” or “strongly agree” to the question in the scale and a low attitude level for “Not Sure” or “Disagree”. Final scoring of the knowledge and practice section was satisfactory if the participant scored at least 60% of the total marks in these two sections. This was an arbitrary cut-off point based on the pilot study and judgment of the experts. On attitude, the questionnaire was handed over to five postgraduate doctors in general practice and their responses to attitude questions were used as a reference standard. The questionnaire for nurses was translated into Arabic for the Arabic-speaking nurses to make them clearer. Both versions of the questionnaire were pilot tested on a pilot group of 10 doctors and 22 nurses, selected randomly from PHC centers in a nearby city, Al-Dammam to assess level of difficulty, clarity, suitability and time required for their completion. Modifications and deletions based on the findings of the pilot study were subsequently made. Data were fed into a personal computer, cleaned and analyzed using EPI info and SPSS statistical packages. Frequency distribution tables were constructed and appropriate tests including the multiple regression analysis to identify significant independent factors were applied. The level of significance was considered at p-value of <0.05.

RESULTS

The total number of PHC doctors in Al-Khobar area was 44. Among those 36 (81.4%) who were present at time of data collection were enrolled in the study. Their ages ranged between 25-47 with mean of 37.1 years (SD ± 6.4) and 56% were in the 35-44 years group. Males constituted 58.3% of the doctors. Arab nationals other than Saudis including Egyptians, Palestinian, and Jordanian formed the majority of doctors (41.7%), while Saudis constituted 22.2% of the group and the rest were from the Indian subcontinent. The mean number of years in practice after graduation was 12.6 years (SD ± 7.38). Table 1 describes distribution according to number of years after graduation.

Table 1: Distribution of PHC doctors according to years of practice after graduation


 

Years of practice

Frequency

Percentage

1-4

  6

16.7

5-9

  6

16.7

10-14

11

30.7

15-19

  7

19.5

20-24

  3

8.4

25-29

  3

8.4

Total

36

100

   


 

he mean number of years working in PHC was 4.7 years (SD ± 3.4) and 17


 

doctors (47.2%) had worked for over 5 years in PHC centers. Only, 4 doctors (11.1%) had postgraduate qualifications; out of these only one held a diploma in Obstetrics. Five doctors (13.9%) had had 3-6 months post-internship training in Obstetrics but no certification. Of the entire group, only 2 doctors (5.6%) had had courses in hypertensive disorders in pregnancy in the course of their work.

In describing their general attitude towards managing hypertension in pregnancy, a majority of doctors (80%) stated clearly that they did not feel confident in managing hypertensive pregnant mothers and would prefer to see children or adult male patients in


 

their clinic. Nevertheless, the attitude of 34 doctors (94.4%) toward learning more about hypertension in pregnancy was positive. Out of the maximum attitude score of 45 marks, the mean score for the attitude questions for the group reached a reasonably high figure of 30.69 marks. Table 2 describes some of the attitude questions and their responses.


 


 

Table 2: Doctors attitudes towards hypertension in pregnancy


 

Statements

+ve (%)

-ve (%)

Hypertension in pregnancy is a common problem.

25 (69.4)

11 (30-6)

Measurement of blood pressure for every pregnant mother in each ANC visit is mandatory.

35 (97.2)

1 (2.8)

I need to know more about hypertension in pregnancy.

34 (94.4)

2 (3.6)

I believe, I can manage some patients with preeclampsia in my clinic.

17 (47.2)

19 (53.8)


 

Doctors’ management of hypertension in pregnancy was quite deficient as 16 doctors (44.4%) reported that they had not actually seen any hypertensive pregnant mother during last year. Around 53% of the doctors depended on BP measurement taken by a competent staff and did not check it. The doctors’ scores for practice was generally low, as only 60% of them got the correct answers to the skill of blood pressure measurement, a basic skill necessary for any medical graduate. In addition, almost all doctors wrongly reported that they had advised their pregnant hypertensive patients to lose weight and reduce their salt intake. Another major mistake noted among 25% of the doctors was that they said they would start treatment of hypertensive cases immediately after diagnosis in their clinic without considering referral. The scores on practice of 75% of the doctors were below the satisfactory cut-of point.

Again the doctors’ score of 58.3% on all areas of knowledge was unsatisfactory since this directly affected the diagnosis and quality of care for hypertensive mothers. Some of the responses dealt with normal and abnormal readings of blood pressure and the presenting symptoms of preeclampsia. Doctors’ mean score 12.1 marks out of a total score of 21 on knowledge was moderate.

The total number of PHC nurses in Al-Khobar area was 120. Among these, the 91 (75.8%) who were present at the time of data collection answered the questionnaire. Their mean age was 29.8 years (SD ± 6.3) ranging between 20-44 years, 74% of them fell within the 20-34 age group. Saudis constituted 47.3 of all nurses. Indians formed the second largest group (37.4%) followed by Filipinos (11%). According to their qualification, 14 nurses (15.4%) held Bachelor degrees and 77 (84.6%) had diplomas. All the Saudi nurses belonged to the latter group. Mean years of practice after registration was 8.7 (SD ± 5.4) and their distribution is shown in Table 3. Mean duration of work in PHC was 4.1 years (SD ± 2.8) and most nurses (69.2%) had spent < 5 years working in PHC in the country.

Table 3: Distribution of PHC nurses according to years of practice after registration


 

Years of practice

Frequency

Percentage

1-5

30

      33

6-10

25

27.5

11-15

25

27.5

16-20

9

       9.9

20

2

       9.9

Thirty-seven nurses (40.7%) had spent < 6 months in Obstetrics training and 10 nurses (11%) had spent 1 year. Most of


 

the group (48.3%), mainly the Saudis, had minimal training of 3 weeks in obstetrics ward during their internship period as required by the Saudi female health institution.

A majority of the nurses – 73 (80.2%) had not worked in a PHC setting before their current positions. Out of those who had had previous PHC experience, only 13 had had any experience in antenatal care. Nine of them had had courses in


 

hypertensive disorders in pregnancy during their work in PHC.

Table 4: Nurses attitude towards hypertension in pregnancy


 

Statements

+ve (%)

_ve (%)

Taking of blood pressure for almost every pregnant woman during each antenatal care visit is mandatory.

90 (89.9)

1 (1.1)

I should educate pregnant women about hypertension in pregnancy.

90 (98.9)

1 (1.1)

I should educate pregnant women about the importance of early antenatal care.

91 (100 )

0

I should educate pregnant hypertensive patients about the need for bed rest.

89 (97.8)

2 (2.2)

Hypertension in pregnancy is a common health problem.

78 (85.7)

13 (14.3)

I need to know more about hypertension in pregnancy.

91 (100)

0


 


 

In describing their general attitude towards hypertension in pregnancy, 86% of them reported that it was a common health problem and they were all positive about learning more. They were all keen to talk to pregnant women about their problem and advice them to take bed rest.


 

Out of the maximum attitude score of 35 marks, the highest mean score was 30.02 marks. Table 4 shows some of the attitude questions and their responses.

The nurses were quite good on practice in the area of hypertension in pregnancy, as 95.6% of them scored “Satisfactory”. Most of the questions related to the skill of measuring blood pressure. Questions on management were answered correctly by 86.1 and 9.7% of them. The mean score of this section on practice was quite high for nurses being 8.3 marks out of a total score of 12 marks.

The nurses’ level of knowledge was very low since only five of them (5.5%) scored “Satisfactory” on the questions in this section. The deficiencies were in areas dealing with diagnosis and quality of care for hypertensive mothers. The questions included simple definitions and associated symptoms of high blood pressure. Most of them (96.7%) wrongly considered salt restriction and weight reduction as important in the health education of hypertensive pregnant women. Mean scores on knowledge was 9.02 marks out of a total score of 20 marks which was quite low.

In the regression analysis of independent factors associated with KAP of doctors and nurses, all variables in the first part of the questionnaire such as age, nationality and certification were included in a series of multiple regression equations against each of the dependent variables, namely, scores on knowledge, attitude, and practice for doctors and nurses. There was a positive significant association of the doctors’ attitude with their sex i.e., male, nationality, being older and previous enrollment in a course on hypertension (R square = 0.26 p=0.02). Their knowledge was only associated with previous training in Obstetrics (R square = 0.14, p=0.02), while practices of both doctors and nurses were not associated with any of the factors under study. The attitude of nurses, on the other hand, showed different associations as non-Saudi nationals and training in Obstetrics had a positive significant effect on their attitude (R square = 0.08, p=0.02). Their knowledge was only associated significantly with being non-Saudi (R square = 0.19, p=0.001).

DISCUSSION

Hypertension in pregnancy is one of the major causes of prenatal morality and morbidity.20 It is responsible for about 18% of maternal mortality,10,21,22 Maternal mortality in hypertensive disorders of pregnancy is primarily due to low standard of care and delay in referral.14 Antenatal care (ANC) is a major part of maternal and child services in PHC. One of the most important functions of ANC is to detect high-risk pregnancies and to give them the necessary care. Early detection of hypertension in pregnancy is vital to its management. Findings from this study will help to identify the status KAP of workers in PHC on hypertensive disorders in pregnancy.

It was discovered in this study that the definition of raised blood pressure and its management was not standardized among doctors and nurses in PHC. This is not surprising as previous study by Bisson in Bristol23 in which a large group of general practitioners, hospital doctors, hospital midwives, community midwives and student midwives who were questioned, gave variety of action plans according to their understanding of diagnostic criteria. They considered the reading of 90 mmHg the model value of diastolic BP at which further action would be taken, whether proteinuria was present or absent. Edema was considered a useful indicator by 93% of the respondents and 49% would use ankle edema in their assessment. Another questionnaire-based survey by Hutton24 on the management of hypertension in pregnancy completed by 65 New Zealand Obstetricians found that 40 (61.5%) doctors considered the diastolic of 80-85 mmHg, the lowest abnormal reading, at 28 weeks, and by 18 (27.7%) doctors at 36-week gestation. However, 20 (30.8%) doctors considered the diastolic of 90 mmHg, at 28 weeks and 42 (64.6%) doctors at 36 weeks gestation, the lowest abnormal reading.

Around 47% of PHC doctors had spent more than 5 years in PHC service in KSA and only 14% of them had had post-internship training in Obstetrics but being males had not been involved in ANC activity in PHC. Only 2 had had courses in hypertensive disorders of pregnancy. This clearly points to a dearth of training courses in PHC.

About 44% of the doctors had not seen any cases of hypertensive pregnant mothers during the last year. Questions asked were concerned with four aspects namely, techniques of blood pressure measurements, history and physical examination, health education practice and action management to be taken by the PHC doctors on discovered cases. The practice of 75% of doctors was unsatisfactory in all these areas. Nevertheless, better scores were achieved in techniques of blood pressure measurement. This was considered a basic skill routinely used by doctors in their clinics. It is obvious that having such little contact with hypertensive cases and lacking the basic training or refresher courses, their management skills will be inadequate.

Since hypertension is one of the commonest medical complications in pregnancy, it is important to educate the pregnant mother about it. Almost all doctors report that they advise hypertensive mothers on the need for bed rest. This is an important non-pharmacological measure in the management of the problem.25 On the other hand, almost all doctors report that they advise their patients to restrict their salt intake and to go on a weight-reducing diet. This is wrong practice, which is unfortunately quite common. Salt restriction in hypertensive non-pregnant women can be effective but in pregnancy may aggravate the condition. Moreover, diet restriction in pregnancy can lead to delivery of small-for-date fetus.25 Similar findings of wrong advice were reported in other studies by Trudinger26 and Bisson.23

Around 85% of PHC doctors reported that they would not refer hypertensive cases after diagnosis and 25% of them would start medication immediately after diagnosis. This is unacceptable by PHC standards. In fact, the cornerstone of management of hypertensive cases starts in the PHC center with accurate diagnosis and undelayed referral of these cases from the PHC to the specialist or hospital.16,21 PHC doctors should be aware of their limitation in the management of these cases and not to jeopardize the health of the mother and her fetus.

The responses of PHC doctors to the questions on attitude were variable. Around 31% did not recognize this is a common health problem in pregnancy, while 97% of them stressed the importance of taking blood pressure reading at each ANC visit. That 53% of PHC doctors depended on blood pressure measurement taken by clinical staff without confirming it, the reading themselves is an alarming negative attitude as well as wrong practice. The diagnosis of hypertension in general or in pregnancy in any patient is not an easy task and proper management and modifications depend on it. It is therefore, important that the person responsible for the management, namely, the doctor, should confirm the reading again.

In looking for factors affecting the attitude of doctors, it was found that gender i.e., male, Arab, older and previous training in a course on hypertension were factors associated with higher scores. Longer experience in PHC work, being male and older and the absence of a language barrier for Arabic speakers, including Saudis, might explain to some extent their better attitude scores as compared to those of the females and younger doctors.

The knowledge of about 58% of doctors on questions that bare on the diagnosis and quality of care of hypertensive mothers as well as the definition of high blood pressure and associated symptoms was unsatisfactory. This clearly indicates the importance of continuing medical education.

Nurses provide most of the vital ANC services in the PHC. Around 53% of the PHC nurses were non-Saudis and non-Arabic speakers and the language barrier adversely affects the health education in hypertensive cases. It is obvious from the results that there is a shortage of specialized courses for nurses. None of the Saudi nurses had more than a diploma in nursing and there didn’t seem to be any arrangements for their further movement at Universities. A period of 3 weeks in an obstetrics ward for new graduate nurses as part of an internship period is not enough to give clear, pragmatic information on ANC services in a PHC setting. About 31% of the nurses have spent 5 years in the PHC centers in the KSA, but only 10% had taken courses in hypertension. This clearly, demonstrates the necessity of a better arrangement for on-job training classes for them.

Nearly 96% of the nurses scored “satisfactory” in the practice section. Their responses to the question of history and physical examinations were 87% correct and about 90% of them responded correctly to the questions on health education. Their erroneous responses were on the items on restriction on salt intake and weight reduction. These good scores indicate that except for their wrong ideas on salt and diet restriction, which should be corrected at refresher courses, the correct procedure have been learnt.

Although the PHC nurses were very good with practice in general, around 95% of them had poor knowledge. Practice leads to the perfection of psychomotor skills. Knowledge and facts, on the other hand, need to be updated by continuous education.

Their general attitude, towards hypertensive disorders in pregnancy was positive. Around 86% of them felt that it was a common health problem and reported that they needed to know more about it. They were all interested in spending time to inform hypertensive cases on their disease. The importance of a Health Education as a vital task for nurses cannot be ignored. The presence of these cases in the clinic, therefore, provides a good opportunity for the performance of this task. The nurses’ positive attitude is indicative of their high motivation for self-improvement.

There was a strong positive association of attitude of nurses to non-Saudi nationality and training in obstetrics. Knowledge scores were also significantly associated with being non-Saudi. These findings can be related to the difference in educational level. While all Saudi nurses hold Diplomas, about 30% of the non-Saudi nurses have Bachelors degrees. There is a masked difference in the type, duration and content of curriculum at the pre-graduate level for both groups and non-Saudi nurses had higher knowledge scores than Saudis. The implication of these findings clearly points out the need to improve the knowledge and attitude of PHC nurses through refresher courses.

CONCLUSION AND RECOMMENDATIONS

In conclusion, PHC doctors had scored “Good” in attitude questions but had low scores on the practice and knowledge component of the questionnaire. The nurses scored high on practice and attitude but had low scores on the knowledge  component. It is

recommended that appropriate regular refresher courses on common and serious problems like hypertension be organized for doctors and nurses in the PHCs. There should be opportunities for effective training of reasonable duration with clearly defined objectives under proper supervision in good hospitals to improve their knowledge and practice. It would be also appropriate to offer Saudi doctors extra incentives for postgraduate study in family medicine to deal with these common problems, and to institute a suitable program of continuing medical education within the health centers for both doctors and nurses. It is also vital to review the curriculum of the female nursing institutions to update both its theoretical and practical content, and extend the duration of training in such common problems as hypertension in obstetrics.

ACKNOWLEDGMENT

The author acknowledges the extensive help of Professor Mohamad Awadalla Salih, Chairman of the Educational Department, Dhahran Armed Forces Hospital, in the conduct of the survey. We would also like to thank Dr. Mohammad Hanif Mian, of the Family and Community Medicine Department in King Faisal University for his statistical help.

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22.Zeeman GC, Dekker GA.Pathogenesis of Preeclampsia: A Hypothesis. Clin Obstet Gynecol 1992;35:317-37.

23.Bisson DL, Macgillivary I, Thomas P, Stirrat GM. Assessment and management of hypertensive disorders in pregnancy by health professionals in the Avondistrict. Br J Gen Pract 1991;41:23-5.

24.Hutton JD, Ngan Kee DG, Wilcox FL. New ZealandObstetricians Management of Hypertension in Pregnancy. A Questionnaire Survey. Aust NZ J Obstet Gynecol 1987; 29:5-8.

25.Brown MA. Non-pharmacological management of pregnancy-induced hypertension. J Hypertens 1990;8:295-301

26.Trudinger BJ, Parik I.Attitude to the Management of Hypertension in Pregnancy: A Survey of Australian Fellows. Aust NZ J Obstet Gynecol 1980; 2:191-97.


-0001-11-30

ABILITY OF ADULT PATIENTS


ABILITY OF ADULT PATIENTS TO PREDICT ABSENCE OR PRESENCE OF FEVER IN AN EMERGENCY DEPARTMENT TRIAGE CLINIC

Sameeh M. Al-Almaie, FFCM (KFU), Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

مقدمة: تعتبر درجة الحرارة المرتفعة من أكثر مظاهر المرض التي يمكن قياسها والتي تثير عادة توقعات علاجية عالية. وقد يلتمس المرضى المشورة الطبية لأنهم يعتقدون انهم يعانون من المرض والحرارة المرتفعة، أما إذا كان لديهم شعوراً بأنهم مرضى ولكن دون أن يقترن ذلك بارتفاع في درجة الحرارة فقد لا يلجؤون في هذه الحالة إلى طلب المشورة الطبية. إن ارتفاع درجة الحرارة الذاتية (subjective) قد يعتبر كذلك مؤشراً هاماً لإجراء تقييم إضافي لحالة المريض.

هدف الدراسة: الهدف من هذه الدراسة هو عمل تقييم لمصداقية المرضى البالغين للتنبؤ بغياب أو وجود ارتفاع في درجة الحرارة في عيادة تصنيف الحالات بقسم الطوارئ.

طريقة الدراسة: تم إجراء الدراسة على 1241 مريض من المرضي البالغين القادرين على المشي   ( الذين تزيد أعمارهم عن 12 سنة) واستمرت الدراسة ثلاث أسابيع. وقد تم سؤال جميع المرضى عما إذا كانوا يعانون أم لا من ارتفاع في درجة الحرارة أو عما لو كانوا يعانون من هذا الشعور أو كان هناك ارتفاع في درجة حرارتهم عندما تم قياس درجة حرارتهم بواسطة جهاز IVACالرقمي. وقد تم أخذ قياسات درجات الحرارة في مجموعتين وذلك من أجل تحديد الارتفاع الشديد في درجة الحرارة بالنسبة لدرجة الحرارة 37.8 مئوية أو أعلى، ودرجة الحرارة 38 مئوية أو أعلى.

نتائج الدراسة: كانت حساسية ونوعية الاستبيان عن ارتفاع درجة الحرارة بالطريقة الذاتية 89.6% و 94.5% بالنسبة للرجال و90% و94.8% بالنسبة للسيدات. كان معدل الدقة 93.9% و 94.6% على التوالي. كانت نسبة عدد حالات ارتفاع درجة الحرارة الموضوعية (objective fever) 8.7% وكانت تحدث مقادير تنبئية إيجابية وسلبية عامة نسبتها 80.9% و 98.9% مع معدل دقة نسبته 94.2%.

الاستنتاجات: وجد أن مصداقية المرضى البالغين، المراجعون لعيادة تصنيف الحالات، في تقييم ارتفاع الحرارة الذاتية (subjective fever) تعتبر جيدة. وجد في الواقع أن نسبة أربعة من بين كل خمسة من المرضى الذين قالوا أن درجة حرارتهم الموضوعية (objective temperature) كانت مرتفعة (38 درجة مئوية أو أكثر). وهذا يعني أن الشكوى من ارتفاع درجة الحرارة الذاتية     ( subjective temperature) يجب أن تؤخذ بجدية أكثر من قبل الأطباء في مجتمعنا.  

الكلمات المرجعية: درجة الحرارة، التوقع ، المصداقية،البالغين ، قسم الطوارئ.

Introduction: Fever is the most appreciated manifestation of disease which usually raises high therapeutic expectations. Patients seek medical advice because they think they are sick and feverish. If they feel that they are sick but not feverish, they may not seek medical advice. Subjective fever may also be an important clue to further evaluation of the patient.

Objective: The aim of this study was to assess the reliability of adult patients to predict absence or presence of fever in Emergency Department triage clinic.

Correspondence to:

Dr. Sameeh M. Al-Almaie, P.O. Box 40072, Al-Khobar 31952, Saudi Arabia

Methods: A prospective study of 1241 ambulatory adult patients (above 12 years of  age) was  carried  out  over  a three-week period. All patients were asked whether or

not they had fever or felt they had fever or were running a temperature before oral temperature was taken with an IVAC digital machine. Two sets of temperature readings were taken to define fever as 37.8oC or greater, and 38.0oC or greater.

Results: The sensitivity and specificity of detecting fever by subjective means was 89.6% and 94.5% for male and 90.0% and 94.8% for female. The accuracy rates were 93.9% and 94.6% respectively. The prevalence of objective fever was 8.7% yielding general positive and negative predictive values of 80.9% and 98.9% with an accuracy rate of 94.2%.

Conclusion: The reliability of adult patients attending triage clinic in assessing subjective fever was found to be good. Four out of five of our patients who believed they had a fever were actually found to have an objective temperature increase (38.0oC or greater). This means that medical staff should take a complaint of subjective fever in our population more seriously.

Key Words: Fever, subjective fever, adult patient, emergency department and reliability


 

INTRODUCTION

Fever is the most appreciated manifestation of disease.1 Although nonspecific, it may indicate the presence of a spectrum of illnesses ranging from a self-limiting viral syndrome to life-threatening bacterial disease of malignancy.2 Fever is one of the most frequent complaints encountered in an Emergency Department. People identify fever as a sign of illness more readily than they recognize the importance of most other symptoms.

Patients come to the Emergency Department (ED) because they think they are sick and feverish. If they feel that they are sick but not feverish, they may not come to ED. In addition to causing concern, the presence of fever usually raises high therapeutic expectations.3 Medical staff may over – or underestimate the patient’s complaint of fever. Overestimation of subjective fever by medical staff, even if not proven on examination, may  influence  them to order unnecessary investigations or medications.4

As some of the endemic diseases such as malaria, brucellosis and Tuberculosis (TB) prevalent in our area may present early as intermittent fever, the patient may feel feverish at night or at some point but be afebrile on presentation at the ED. Fever in elderly persons even in the absence of other manifestations of disease, may indicate the presence of serious infection, most often caused by bacteria or a non-infectious disease; such as connective tissue disorders or a malignancy.5

Subjective fever may, therefore, be an important clue for further evaluation of the patient. It is therefore important that the patients’ ability to detect the presence or absence of fever be better characterized.

Since the reliability of patients in Saudi Arabia to predict absence or presence of fever has not been studied before, the objective of this study is to assess the reliability of subjective fever in triage of adult patients in the ED and to compare their assessment with temperature measurement on the IVAC digital machine.

METHODS

A prospective study was carried out over a three-week period on all ambulatory adult patients (above 12 years of age) of both genders, attending a triage clinic in the ED of King Fahd Hospital of the University in Al-Khobar, Saudi Arabia. This is a 440-bed hospital with 130,000 patient visits to the ED per year. Injured and trauma patients, those with a respiratory rate above 30 per minute, those with altered mental status and all patients attending obstetric and gynecology triage room were excluded from the study. The physician in the triage room asked each patient whether or not he or she had fever or felt feverish before oral temperature was taken with the IVAC digital machine.

Two sets of temperature readings were taken to define fever as 37.8oC or greater and 38.0oC  or greater. The clinical diagnosis of the patient’s complaints was also recorded and grouped by gender for 996 patients.

A single standard 2x2 table was constructed according to the patient’s subjective sensation of fever and the measured oral temperature. Sensitivity, specificity and positive and negative predictive values with 95% confidence intervals (95% CI) were calculated.

Data was entered into a personal computer using SPSS/PC version 6.0 statistical package. The method of chi-square was applied to calculate significant and non-significant values.

RESULTS

The total number of adult patients in this study was 1241 patients, 540 (43.5%) males and 701 (56.5%) females. The mean age (± SD) of males was 30.75 ± 14.1 years and the mean age of females was, 32.9 ± 13.6 years.

The sensitivity of male and female patient detection of fever by subjective means was 89.6% and 90.0% respectively, while the specificity was 94.5% and 94.8% respectively (Table 1). The accuracy rates were 93.9% and 94.6% respectively (Table 2).

The positive predictive value (PPV) and negative predictive value (NPV) with 95% CI for male patients was 69.8% (63.5 - 76.1) and 98.5% (97.5 – 99.6) and for the female patients was 52.1% (36.8 – 67.4) and 99.4% (98.6 – 99.9) respectively.

The prevalence of objective fever was 8.7% yielding general positive and negative predictive values of 80.9% and 98.9% with an accuracy rate of 94.2% (Table 2).

Other calculations were made when fever was defined as a temperature of 37.8oC or above. Table 2 shows sensitivity, specificity, positive and negative predictive values and accuracy rate in subjectively predicting objective oral temperature of 37.8oC or greater in comparison with temperature of 38.0oC or greater. The clinical diagnoses according to gender for 996 patients are illustrated in Table 3.


 


 

Table 1: Sensitivity and specificity of adult patients in subjectively predicting oral temperature increase

Category

Sensitivity

95% CI

Specificity

95% CI

X2

p-value

Males

³38.0oC

89.6%

82.3 – 96.9%

94.5%

92.5 – 96.5%

309.67

< .00001

Males

³37.8oC

83.3%

75.3 – 91.3%

96.5%

94.8 – 98.2%

337.56

< .00001

Females

³38.0oC

90.2%

81.2 – 99.2%

94.8%

93.2 – 96.4%

297.78

< .00001

Females

³37.8oC

79.7%

69.4 – 90.0%

96.3%

78.2 – 81.2%

342.18

<.00001

Table 2: Sensitivity, specificity, positive predictive value, negative predictive value and accuracy rate of ability of adult patients to subjectively predict objective oral temperature increase

Category

True Sensitivity

(+ve’s)

True Specificity

(-ve’s)

No. (PPV)

No.  (NPV)

No. (Accuracy Rate)

Male ³  38oC (540)

67 (89.6%)

473 (94.5%)

86 (69.8%)

454 (98.5%)

540 (93.9%)

Male ³37.8oC (540)

84 (83.3%)

456 (96.5%)

86 (81.4%)

454 (96.9%)

540 (94.4%)

Female ³38oC (701)

41 (90.2%)

660 (94.8%)

71 (52.1%)

630 (99.4%)

701 (94.6%)

Female ³37.8oC (701)

59 (79.7%)

642 (96.2%)

71 (66.2%)

630 (98.1%)

701 (94.9%)

Cum. ³  38oC (1241)

108 (89.9%)

1133 (94.7%)

157 (80.9%)

1084 (98.8%)

1241 (94.2%)

Cum. ³37.8oC (1241)

143 (81.5%)

1098 (96.4%)

157 (73.8%)

1084 (97.5%)

1241 (95.4%)

Table 3: Clinical diagnoses for 996 adult patients seen in Emergency Department according to their gender

Diagnosis

Female (%)

Male (%)

Total (%)

p-value (X2)

Cardiovascular

37 (5.6)

10 (3.0)

47 (4.7)

0.0208

Respiratory

33 (5.0)

17 (5.1)

50 (5.0)

0.9204

Gastrointestinal

102 (15.5)

32 (9.5)

134 (13.5)

0.0064

Hematology/Oncology

24 (3.6)

10 (3.0)

34 (3.4)

0.4066

Endocrinology

11 (1.7)

3 (0.9)

14 (1.4)

0.1870

Genitourinary

51 (7.7)

31 (9.2)

82 (8.2)

0.6030

Musculoskeletal

104 (15.8)

62 (18.5)

166 (16.7)

0.1336

Neurologic

34 (5.2)

13 (3.9)

47 (4.7)

0.4654

Dermatological

19 (2.9)

2 (0.6)

21 (2.1)

0.0188

Ophthalmologic

9 (1.4)

8 (2.3)

17 (1.7)

0.3422

Ear, Nose and Throat

119 (18.0)

74 (22.0)

193 (19.4)

0.1388

Psychiatric

19 (2.9)

6 (1.8)

25 (2.5)

0.2628

Infectious Disease

4 (0.6)

4 (1.2)

8 (0.8)

0.3682

Trauma and Injury

50 (7.6)

43 (12.8)

93 (9.3)

0.0124

Others

44 (6.7)

21 (6.3)

65 (6.5)

0.8104

Total

660 (66.3)

336 (33.7)

996 (100)

0.0078


 

DISCUSSION

The normal body core temperature ranges between 36.2oC and 37.8oC and is influenced by several factors: age (infants less than one year have higher baseline temperature), times of day (temperature generally elevates in the afternoon),

exercise, metabolic rate, environmental temperature and bundling. Fever is generally, albeit arbitrarily, considered as a rectal temperature of 38.0oC or greater.2

Usually, documentation of actual recording of elevated temperature is required before a patient is considered feverish and further action taken. Nevertheless, a history of subjective fever may influence the differential diagnosis and the plan of action drawn by the treating physicians.

In this study, the reliability of our adult patients attending triage clinic in assessing subjective fever was tested. Their ability to predict the presence or absence of an objective fever of 38.0oC or greater was found to be good.

The ability of our patients to predict the presence or absence of an objective fever seems to be better than the US patients studied by Buckley.4 The sensitivity and specificity in US patients were 83% each, while in our study, the sensitivity and specificity were 89.9% and 94.7% respectively.

The denials of subjective fever by the patient in our study and Buckley’s study4 were almost the same, where it was highly predictive of not having an objective increase in oral temperature (NPV 98.9% and 99.0% respectively).

On the other hand, the PPV of the complaints of subjective fever was only 25.0% in Buckley’s4 study compared to 80.9% in our study. This means, four out of five of our patients who believed they had a fever were actually found to have objective temperature increase, compared to one out of four patients in Buckley’s4 study. Medical staff should therefore, take the complaint of subjective fever in our population more seriously.

The results of our study showed that the ability of females to predict presence or absence of subjective fever (38oC or greater) is higher than males (92.1% for females and 69.8% for males). This could be explained by the fact that women make better nurses then men. On the other hand, further investigation may be required on this difference.

When the set of definition of an objective fever is put at 37.8oC or above, the sensitivity and PPV of the ability of the patient to predict presence or absence of fever drops from 89.9% and 80.9% to 81.4% and 73.8% respectively and the specificity increases from 94.7% to 96.4%. Though the difference in objective temperature between the two readings was only 0.2oC it is still statistically significant (p-value <0.01).

The clinical diagnosis of 996 adult patients out of the whole sample was recorded as seen in Table 3. The written diagnoses indicate the diagnosis of the current encounter for this particular visit to ED.

Ear, Nose and Throat (ENT) and Musculoskeletal problems were the most frequent presentations encountered in the triage clinic (19.4% and 16.7% respectively). Since this study was carried out towards the end of June and early July, the high presentation of both diagnoses cannot be attributed to cold weather or winter viral illnesses.

There were significant differences between male and female in the overall clinical diagnoses (chi = 29.92 p-value = 0.0078). More female patients presented with Cardiovascular and Gastrointestinal diseases than the male patients (p-value = 0.0208 and 0.0069 respectively). On the other hand, more males presented with Dermatological disease, Trauma and Injury than females (p-value = 0.0188 and 0.0124 respectively).

These differences may be due to the fact that males in our community at work or at leisure are more exposed than females to the risk of contact with different chemical and allergic agents, to trauma and injury.

In conclusion, this study showed that adult patients were reasonably reliable in their assessment of subjective fever. Four out of five of those who stated that they had fever were correct. Females were more accurate in this regard than males. Therefore, medical staff should take the complaints of subjective fever in our community more seriously.

REFERENCES

1.Parry MF, Neu HC. Infectious diseases. In           Rakel RE. Textbook of Family Practice, 4th ed. Saunders company; 1990.

2.Manno MM. Fever. In Aghababian R.V. Emergency Medicine - The core Curriculum, 1st ed., Lippincott - Rave, 1998.

3.  Simon HB. Evaluation of fever. In Goroll AH, May LA, Mulley AG.  Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 5th ed., J.B. Lippincott, 1998.

4.Buckley RG, Conine M. Reliability of subjective Fever in Triage of Adult Patients. Ann Emerg Med 1996; 27:693-5

5.  Norman DC, Yoshikawa TT.  Fever in the elderly (Review).  Inf Dis Clin Nor  Am  1996; 10 (1):     93-9.


-0001-11-30

PEAK EXPIRATORY


PEAK EXPIRATORY FLOW RATE IN A S AMPLE OF NORMAL SAUDI MALES AT RIYADH, SAUDI ARABIA

Ahmed A. Al-Taweel, ABFM, Khalid A. Kalantan, ABFM, Hamza A. Ghani, ABFM

Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

هدف الدراسة: هو إيجاد المعدل الطبيعي للقدرة القصوى على الزفير للسعوديين البالغين مـــن الرجال ومقارنته بالمعدل الطبيعي لدى البريطانيين.

طريقة البحث : عملت دراسة مقطعية في خمسة مراكز صحية أولية تمثل مدينة الرياض في الفترة من 15 نوفمبر إلى نهاية ديسمبر 1993م. ستمائة وثمانين رجلا سعوديا والذيـن انطبقت عليهم صفات سترنجنت للأشخاص الطبيعيين تضمنتهم هذه الدراسة معظمهم تحت سن 54 عاما (4ر94%).

نتائج البحث: كان معدل ومعامل التشتت للعمر والطول للمشاركين في هذه الدراسة هما 28.4    ±13 و 167.6 ±6.4 على التوالي. وعمل تحليل للنتائج بخطوات متعددة لتحديد طبيعة خط الانحدار للقدرة القصوى على الزفير بحسب العمر والطول. رسمت خطوط الانحدار ووجد أن القدرة القصوى على الزفير لا تبدأ بالنزول حتى سن 25 عاما. وكلما زاد الطول تزداد القدرة القصوى على الزفير بعلاقة طردية.

الاستنتاجات : وجد في هذه الدراسة أن معدلات القدرة على الزفير لدى السعوديين أقل مقارنــة بالبريطانيين. هذه النتائج ستخدم كقاعدة لإيجاد المعدلات الطبيعية للقدرة القصوى على الزفير لسكان المملكة.

الكلمات المرجعية : القدرة القصوى على الزفير، الربو الشعبي، المملكة العربية السعودية.

Objective: To find out the normal peak expiratory flow rate for adult Saudi males and to compare our standards with British standards.

Methods: A cross-sectional study was carried out in five primary health care centers representing Riyadh city in the period between 15th November through December 1993. Six hundred and eighty Saudi men who satisfied stringent criteria of normality were included in the study.

Results: The mean and standard deviation of the subjects’ age and height were 28.4 ± 13 and 167.6 ± 6.4 respectively. Linear regression analysis was performed through step-wise procedure to determine the form of regression of peak expiratory flow on age and height. Regression curves were obtained and it was found that peak expiratory flow rate did not begin to decline until about the age of 25 years; and as height increased the peak expiratory flow rate increased in a linear relationship.

Conclusion: It was demonstrated that our study group had lower peak expiratory flow rate compared with British people. These findings will serve as a basis for preparing flow rate values for our population.

Key Words: Peak expiratory flow rate, Bronchial asthma, Saudi Arabia.

Correspondence to:

Dr. Hamza Abdul Ghani, Consultant Family Physician, Department of Family & Community Medicine (34), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia


INTRODUCTION

Bronchial asthma is one of the most important and highly prevalent problems in Saudi Arabia. The prevalence of asthma in Saudi Arabia ranges between 10-17% (10% in Riyadh, 13% in Jeddah and Qassim and 17% in Abha); which is higher than the range reported in Western countries.1,2

Pulmonary function tests are important in the detection and evaluation of pulmonary dysfunction. Peak expiratory flow rate (PEFR) is the simplest estimate for lung functions. It indicates the severity of airflow limitation.3,4 Peak expiratory flow rate is measured by peak expiratory flow meter (PEFM) which is a simple and relatively cheap device (cost ranges from 25-40 US dollars). It has a great diagnostic and prognostic value in patients with hyperactive air-way disease.5-7 It is widely used in general practice in the UK and in family practice in the USA with proved importance in evaluating and monitoring patients with bronchial asthma.6 Although PEFM is a simple, practical and effective tool for use in the primary health care (PHC) setting, few of PHC practitioners in Saudi Arabia seem to use it.8

Many factors can affect the reading of peak expiratory flow rate (PEFR). The age, sex and height are important variables upon which peak expiratory flow depends.9 Other factors include the diurnal variation10 and ethnic differences.11 The degree to which both the instructor and the patient understand the technique of using the flow meter is important and can greatly affect the result. Widely used standard peak flow rates have not been established for our population and the PEFR tables in use are based on studies in the Western countries. Not many local studies on the PEFR of Saudis in PHC clinics have been done.12,13 The objective of the current study was to identify the normal peak expiratory flow rate for a sample of Saudi males and to compare the findings with British standards.

MATERIAL AND METHODS

Riyadh (the capital of Saudi Arabia) is divided into five main sectors for the provision of the Health Services (i.e., North,  South, East, West and Central). A number was given to each center in all sectors, and five primary health care centers were randomly selected to represent different geographical areas. Within each center, patients were enrolled randomly in a systematic way to ensure a good non-biased presentation. The sample size for the centers was nearly the same to make the allocation equal. Subjects included in the study were Saudi males aged 15 years and above, non-smokers who satisfied stringent criteria of normality.10 These were as follows 1) had never smoked; 2) were not subject to recurrent or persistent expectoration; 3) were not subject to wheezing nor had had an episode of acute bronchitis; 4) had not had asthma or recurrent bronchitis during their childhood; 5) had not had any serious respiratory disease.

Since it was difficult for the subjects to recall one attack of acute bronchitis, this criterion was not used to exclude any.  The number of subjects included in this study was 680. Each center was provided with mini-Wright peak flow meter (product of Ciement Clarke International Ltd, England), with disposable mouth pieces. All the mini-Wright peak expiratory flow meters were new and had been calibrated to make sure that they had similar readings. Only males were included in the study to ensure accessibility so that we could deal directly with the subjects and supervise more closely. It was agreed that all the tests be done in the afternoon sessions ( 4 -8 p.m.) to avoid the effect of the diurnal variation of peak expiratory flow10 and get more volunteers.

The Director of each health center allocated one of the male nurses to work with the investigators. To ensure a unified correct procedure, all the nurses were instructed and trained by the assigned investigator on the technique of using the device. A group of subjects were instructed to do the test in front of both the nurse and the investigator to ensure that they perform it correctly and to use this as demonstration for the nurse.

The instructions adopted14 for using the peak flow meter were as follows: 1) Every subject was asked to do the test three times. 2) Take a full deep breath in. 3) Hold the peak flow meter horizontally and close the lips tightly round the mouth piece. 4) Blow out as hard and as fast as you can in a short sharp blow. 5) Wait one minute between each blow. Take the best of 3 readings. This was recorded on the table along with subject’s age and height.

Data were analyzed using Stat Pac Gold statistical analysis package. Linear regression step-wise analysis was performed. The mean was expressed as mean ± 1 standard deviation.

RESULTS

The age distribution of a total of 680 subjects included in this study is shown in Table 1. The mean and standard deviation of their age and height were 28.4 ± 13 and 167.6 ± 6.4 respectively.

Linear regression analysis was performed through step-wise procedure to determine the form of regression of peak expiratory flow on age and height (Table 2). When the data was plotted it became evident that the relation between the variables was curvilinear (Figure 1). It showed that as age increased the PEFR decreased (b = -0.5, T = -2.5, p-value 0.012). However, it showed a positive association between height of the study population and PEFR (b=4.3, T=11.7, p-value < 0.0001). From the multiple regression equation R2 = 21% and F-ratio + 46%, p-value = <0.0001, i.e., about 21% variability of the PEFR can be determined by the factors in the equation.

Table 1: Age distribution of subjects in series

Age in years

Number

%

       < 25

358

52.6

25 – 34

142

20.9

35 – 44

93

13.7

45 – 54

49

7.2

55 – 64

25

3.7

       ³ 65

13

1.9

Total

680

100

Table 2: Regression Equations

Parameter

Coefficient

Value

Constant

bo

-338.5

   Age

b1

        20.3

   Age2

b2

         -0.55

   Age3

b3

          0.004

   Height

b4

          3.81

Equation: PEF (L/min) = -338.5 + 9 + 20.3 age – 0.55 age2 + 0.004 age3 + 3.81 height. R2=21%, p-value <0.0001.

The regression curves were drawn for six heights, and standardized to 167 cm (Figure 1). The peak expiratory flow began to decline around the age of 25 (Figure 2). The height was plotted versus the peak expiratory flow and showed that there was a relatively linear relationship

DISCUSSION

We found that as the age increased beyond 25 years the PEFR significantly decreased. In calculating regression equations for peak expiratory flow on age and height, it was assumed that there was a linear relation between the fall of peak expiratory flow and advancing age. A similar assumption was made by most investigators who have published normal values of peak expiratory flow including Gregg and Nunn.10

In this study, it was clearly shown that a linear fall of peak expiratory flow occurred only after the age at which maximal peak expiratory flow was attained and if adolescents were included in the series the shape of regression became curvilinear. This finding is supported by a study done by Graff-lonnevig et al for Saudi children aged 6-16 years.12 Our findings suggest that peak expiratory flow began to decline at the age of 25 years while the decline occurred at the age of 35 years in British reports.10 Since our series contained too few subjects over 65 years of age (1.9%) the regression curves had a high peak expiratory flow rate for that particular age group. Studies of peak expiratory flow rate in the elderly have shown that the rate in elderly had a lower standard than younger age groups.15,16

The comparison of the peak expiratory flow rates in this study with that of Gregg and Nunn10 demonstrated clearly that peak expiratory flow rates for Saudi males were lower than those of British males. This is supported by other local studies for other respiratory functions.13 Graff-Lonneving et al found that peak expiratory flow rate measured in Saudi children by means of the mini-Wright peak flow meter were significantly lower than in children from Europe and North America.12

However, a significant positive association was found between the height of the study population and the PEFR. The multiple regression equation R2 = 21% and fraction = 46% with p-value <0.0001, indicates a significant dependency of the PEFR of the study population on their age and height.

One limitation of the current study was the non-inclusion of female subjects since certain cultural difficulties in performing the measurements were envisaged. The other limitation was that the computed equation was reliable in predicting only 21%, for the whole range of age groups. However, this study has shown that Saudi Arabian male adults living in Riyadhhave lower peak expiratory flow rate than adults of different racial origins living in UK.

There is a need for baseline normal values for peak expiratory flow rate for both children and adults in Saudi Arabia, and the data obtained from this study can be used as a base-line for future studies for the preparation of standard charts for our population. Further studies without the limitations of this study i.e., to include females and a wide range of patient characteristics are required.

ACKNOWLEDGMENT

The authors are grateful to Prof. Jamal S. Jarallah for reviewing the manuscript and Dr. Fayek Khwsky for his statistical comments. We would also like to thank the Directors of all PHCC and nurses assigned to do and supervise the project.

REFERENCES

1.Al Frayh A, Bener A, Al-Jawadi TQ.  Prevalence of asthma among Saudi school - children. Saudi Med J 1992; 13 (6): 521-4.

2.Al Frayh A. Prevalence of asthma and allergic rhinitis in the Kingdomof Saudi Arabia. Proceeding of the first annual meeting of the Saudi Society of Allergy and Immunology Jan 1994.

3.Charlton I, Charton G, Broomfield J, Mullee M. Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice. BMJ 1990; 301: 1355-9.

4.Cochrane GM. Asthma: diagnosis and role of PEFR monitoring. Update 1987; 8: 585-89.

5.British Thoracic Association.  Death from asthma in two regions of England. BMJ 1982; 285: 1251-5.

6.Katz DN. The Mini Wright peak flow meter for evaluating airway obstruction in a family practice. J Fam Pract 1983;  17: 51-7.

7.Battu K, Collins-Williams C, Zaleskey C. Evaluation of home monitoring of asthmatic children with the mini-wright peak flow meter. J Asthma 1982; 19 (1): 33-7.

8.Khoja Ta, Al-Ansari LA.Asthma in Saudi Arabia: is the system appropriate for optimal case? J Public Health Management Practice 1998, 4(3): 64-72.

9.British Thoracic Society, Research Unit of the Royal Collegeof Physicians of London. Guidelines for the management of asthma in adults chronic persistent asthma. BMJ 1990; 301: 651-3.

10.Gregg I, Nunn A.J. Peakexpiratory flow in normal subjects. BMJ 1973; 3: 282-4.

11.Cinkotai FF, Sharpe TC, Gibbs AC. Circadian rhythms in peak expiratory flow rate in workers exposed to cotton dust. Thorax 1984; 39 (10): 759-65.

12.Graff-Lonnevig V, Harfi H, Tipirneni P. Peakexpiratory flow rates in healthy Saudi Arabian children living in Riyadh. Ann Allergy 1993; 71        (5): 446-50.

13.Al Fayez SF, Kassimi MA, Ardawi MS. Normal spirometry values in Saudi Nationals in Western Region of Saudi Arabia. Saudi Med Journal; 1989: 56: 227-34.

14.Catterall J, Shapiro C. Noctarual asthma. BMJ 1993; 306: 1189-93.

15.Koenigsberg M, Holden DM. Peakexpiratory flow rate in the elderly. J Fam Pract 1989;  29 :503-6.

16.Cook NR, Evans DA, Scherr PA, Speizer FE, Vedal S, Branch LG.  Peak expiratory flow rate in an elderly population. Am J  Epidemiol 1989; 130 (1): 66-78.


-0001-11-30

IMPACT OF HEALTH EDUCATION


IMPACT OF HEALTH EDUCATION PROGRAM ON KNOWLEDGE ABOUT AIDS AND HIV TRANSMISSION IN STUDENTS OF SECONDARY SCHOOLS IN BURAIDAH CITY, SAUDI ARABIA:    AN EXPLORATORY STUDY

Mahmoud A. Saleh, MD*, Yasser S. Al-Ghamdi,MRCP ( UK)*, Omer A. Al-Yahia, ABFM, Tariq M. Shaqran, JBFM, Ahmed R. Mosa, ABFM

* Medical Education & Research Centerand †Primary Health Care Administration, Directorate of Health Affairs, Al-Gassim Region, Saudi Arabia

مقدمــة: تعتبر المعلومات الدقيقة عن متلازمة العوز المناعي المكتسب ( الإيدز )  وفيروس العوز المناعي البشري ضرورية للوقاية 0

هدف الدراسة: أعدت هذه الدراسة للتعرف على مدى معرفة طلاب المرحلة الثانوية في مدينة بريدة عن مرض الإيدز ومدى تأثير برنامج للتثقيف الصحي على معلوماتهم عن المرض بصفة عامة ، وطرق انتقال فيروس العوز المناعي البشري، ومدى الفهم الخاطئ لديهم عن انتقال المرض خلال مخالطة المصاب0

طريقة البحث: تضمنت الدراسة برنامج تثقيف صحي لعدد 483 طالب ثانوي من مدارس مدينة بريدة خلال العام الدراسي 1997م ، استخدمت فيه وسائل الاتصال الشخصي والوسائط المرئية ، وتم استبيانهم قبل وبعد البرنامج لقياس معرفتهم عن الإيدز.

النتائج والتوصيات: أشارت النتائج إلى التحسن الكبير في معرفة طلاب المدارس الثانوية عن المرض0  ونوصي بنشر برامج التثقيف الصحي  عن متلازمة العوز المناعي المكتسب ( الإيدز)  بين قطاع طلاب المدارس الثانوية لتوضيح  كيفية انتقال المرض وطرق الوقاية منه ، وكذلك تطبيق التجربة على فئات المجتمع الأخرى المعرضة للخطورة 0

الكلمات المرجعية: متلازمة العوز المناعي المكتسب ( الإيدز )، المعرفة، الانتقال، الفهم الخاطئ، طلاب.

Background:Accurate information about Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) is important for their prevention.

Objectives: This study is intended to assess knowledge on AIDS in students of secondary schools in Buraidah city and to measure the effect of a health education program on their knowledge about AIDS in general, modes of HIV transmission and the degree of their misperception about the transmission of the disease through casual contact.

Methodology: A well-designed health education program using personal communication and visual media techniques was conducted for 483 secondary school students in Buraidah secondary schools during the year 1997. Pre and post-tests were done to examine their knowledge about AIDS.

Results and recommendations: The results of this study pointed out that a health education program on AIDS for students of secondary schools greatly and significantly improved  their  scores  on  general  knowledge  on  AIDS  views  on  its

Correspondence to:

Dr. Mahmoud A. Saleh, Medical Education and Research Center, King Fahad Specialist Hospital, P.O. Box 2290, Buraidah, Al-Qassim, Saudi Arabia

transmission and misperception of AIDS (p<0.01). Continuous in-service programs for secondary students are recommended.

Key Words: AIDS, Knowledge, Transmission, Misperception, Students


 

INTRODUCTION

Acquired Immunodeficiency Syndrome (AIDS) is one of the chief public health issue of the twentieth century. It has attracted unprecedented attention all over the world and has become a focus for priority attention by politicians, public health workers and the general public. This is because in addition to being a new disease with a fatal outcome and a certain amount of mystery surrounding it there is no specific drug for its treatment. Moreover, since it is related to sex,1,2 young people are increasingly at risk3 in many countries and with the emotional and peer pressure and physical violence often used to force many young people into unwanted sex, there is an urgent need for young people to protect themselves against HIV.4

                                Accurate information about AIDS is important for its prevention. Much of the effort towards this end has focused on educating both the general public and specific high risk groups.5 Periodic evaluation of this effort is therefore important in determining its success and to examine factors that influence the knowledge acquired.6,7

                                This study was intended to assess knowledge about AIDS in general, modes of transmission of human immuno-deficiency virus (HIV) and the degree of misperception among secondary school students in Buraidah about transmission of the disease through casual contact. It also aimed at finding out how much influence the health education program had had on their knowledge.

SUBJECTS AND METHODS

This study was carried out on 483 students from the Secondary Institute of Commerce (the only institute of commerce in the city), the Secondary Institute of Islamic Science (the only Islamic Science Secondary Institute in the city), Al-Amir Sultan Teaching Compound (the biggest general school for boys in the city) and the 19th secondary school for girls (this is the only girls’ secondary school accessible for this study). The different types of schools for secondary education in Buraidah city during the year 1997 (Technical, Islamic Science and General Education respectively) were represented in the study. The health education program on AIDS was implemented in these institutes. All students in each institute were invited to participate in the program and random cluster samples were chosen from those attending as the study population.

The standard questionnaire administered was used in the U.S. National Health Interview Survey of AIDS knowledge. It was designed to assess knowledge about AIDS and mode of HIV transmission.7,8 The questionnaire was modified to comply with the culture of our community, translated into Arabic and tested before being used.

The questionnaire contained three scales reflecting knowledge of AIDS: general knowledge, transmission knowledge and misperception scores. Seven statements were used to assess general knowledge on AIDS and the number of correct responses was summed up to yield a general knowledge score ranging from 0 to 7. Also, three questions were used to assess knowledge about recognized modes of HIV transmission (sexual, perinatal, and parenteral) and the number of correct responses was summed up to produce a transmission knowledge score ranging from 0 to 3. Higher scores indicate more knowledge. Seven other questions were used to assess perception about HIV transmission through casual contact, the sum of incorrect responses yielding a misperception score that ranged from 0 to 7. A higher score indicates greater misperception.

Every participant in this work was asked to give his personal data including; age, sex, and school grade as well as type of education. The questionnaire was distributed twice. The first time was considered a pre-test before the health education program was launched. This program was designed to improve the knowledge of the target group with regard to general information, modes of transmission and to reduce the degree of misperception about transmission of HIV through casual contact. The strategy adopted relied on a mix of communication methods including health talks, discussions, posters as well as booklets and pamphlets (in Arabic). At the end of the course, the same questionnaire was used as a post-test to evaluate the effectiveness of the program.

Statistical analysis was done using the SPSS/Win Release 6 statistical package.9 The data were grouped and tabulated. Means, standard deviation, student’s t-test, paired t-test and F-value of analysis of variance were calculated.

RESULTS AND DISCUSSION

The age of the target sample ranged from 15 to 27 years, and the mode was 17 years. The majority of the students approached were males (81.8%). Grade 2 secondary students formed 39.3% of the sample, 33.6% were grade I and 27.1% were grade III. Moreover, about half of the sample (45.3%) approached were general secondary students, 41% were commercial secondary students, and 13.7% were affiliated to Institute of Islamic Science.

Table 1 clearly shows that the mean values of knowledge scores among the studied sample were 4.1 + 1.3 for general knowledge, 2.6 + 0.7 for transmission knowledge and 4.6 + 2.2 for misperception. These scores greatly improved after the program of health education to 5.0 + 1.3; 2.9 + 0.3 and 1.1 + 1.6 respectively. The differences observed were statistically significant (p<0.01). McCaig et al (1990)7 found that among US adult population, the mean values of the same scores were 4.80 + 1.02, 2.80 + 0.01 and 2.90 + 0.03 respectively. St. Lawrence et al (1989)10 reported that successful efforts to educate the population could result in an increased knowledge of the disease, as well as lowered misperceptions.

It was noted that among the three age groups, knowledge scores had improved significantly by the end of the course (p<0.01) (Table 2). When the different age groups were compared in their pre-test as well as post-test scores, no significant differences were observed in any of the different components of the questionnaire except for general knowledge score after education which was significantly lower in those 18 years of age than the other two age groups (4.7 + 1.4, 5.0 + 1.1 and 5.2 + 1.3 respectively) (Table 3). Wassif et al (1993)11 found no significant differences in any of the different components of the questionnaire among the different age groups. However, Diclemente et al (1988),12 Keeter and Bradford (1988)13 and Hardy et al (1989)14 reported that older persons were less knowledgeable about AIDS.

Table 2 reveals that among females, the mean values of knowledge scores were significantly higher in the post-test than in the pre-test and the misperception score was significantly reduced (P<0.01). The same pattern was observed among males. In the pre-test, no significant differences were


 


 

Table 1: AIDS knowledge among the studied-group before and after health education program

Time

Score of AIDS Knowledge

GK Score (0-7)

TK Score (0-3)

MP score (0-7)

    X        ±      SD

    X       ±      SD

     X       ±     SD

Before education (n=483)

4.1

1.3

2.6

0.7

4.6

2.2

After education (n=483)

5.0

1.3

2.9

0.3

1.1

1.6

Paired t-test

11.3

6.3

29.5

p-value

<0.01

<0.01

<0.01

GK = General Knowledge, TK = Transmission Knowledge, MP = Misperception

Table 2: Comparison of AIDS knowledge among the studied-group before and after health education program according to some demographic variables

Variable

AIDS Knowledge

GK Score

TK Score

MP Score

Before ed.  X + SD

After ed. X + SD

Paired t-test

Before ed.  X + SD

After ed. X + SD

Paired t-test

Before ed.  X + SD

After ed. X + SD

Paired t-test

Age group:

<17 (n=124)

3.9+1.3

5.0+1.1

7.7*

2.6+0.8

2.9+0.2

4.7*

4.5+2.2

0.9+1.3

17.1*

17-18 (n=209)

4.0+1.4

5.2+1.3

8.2*

2.7+0.7

2.9+0.3

4.4*

4.6+2.2

1.0+1.6

19.8*

18 (n=150)

4.1+1.2

4.7+1.4

4.1*

2.7+0.5

2.8+0.4

1.5*

4.8+2.2

1.3+1.8

14.5*

Sex:

Female (n=88)

3.9+1.3

5.2+1.3

6.8*

2.6+0.7

2.9+0.5

3.4*

4.7+2.3

0.7+1.1

15.5*

Male (n=395)

4.1+1.3

4.8+1.3

9.4*

2.7+0.6

2.8+0.6

5.3*

4.6+2.2

1.1+1.7

25.5*

School grade:

Gr. 1 (n=162)

4.0+1.4

4.8+1.1

5.9*

2.6+0.8

2.9+0.2

4.7*

4.7+2.3

1.1+1.7

15.8*

Gr. 2 (n=190)

4.1+1.3

5.3+1.3

9.6*

2.6+0.7

2.9+0.2

4.9*

4.6+2.1

0.8+1.4

21.5*

Gr. 3 (n=131)

4.2+1.3

4.7+1.3

3.9*

2.7+0.4

2.8+0.5

0.4

4.5+2.3

1.3+1.7

13.9*

* Denotes statistical significant (p<0.01)  

GK = General Knowledge, TK = Transmission Knowledge, MP = Misperception

Table 3: AIDS knowledge among the studied-group according to some demographic variables

Variable

AIDS Knowledge

GK Score

TK Score

MP Score

Before ed.

X +SD

After ed.

X +SD

Before ed.

X +SD

After ed.

X +SD

Before ed.

X +SD

After ed.

X +SD

Age group:

<17 (n=124)

3.9+1.3

5.0+1.1

2.6+0.8

2.9+0.2

4.5+2.2

0.9+1.3

17-18 (n=209)

4.0+1.4

5.2+1.3

2.7+0.7

2.9+0.3

4.6+2.2

1.0+1.6

18 (n=150)

4.1+1.2

4.7+1.4

2.7+0.5

2.8+0.4

4.8+2.2

1.3+1.8

F-test

0.6

5.1

2.81

1.2

0.5

2.3

p-value

0.05

<0.01

0.05

0.05

0.05

0.05

Sex:

Female (n=88)

3.9+1.3

5.2+1.3

2.6+0.7

2.9+0.5

4.7+2.3

0.7+1.1

Male (n=395)

4.1+1.3

4.8+1.3

2.7+0.6

2.8+0.6

4.6+2.2

1.1+1.7

t-test

1.3

2.6

1.2

1.6

0.4

2.7

p-value

0.05

<0.05

0.05

0.05

0.05

<0.01

School grade:

Gr. 1 (n=162)

4.0+1.4

4.8+1.1

2.6+0.8

2.9+0.2

4.7+2.3

1.1+1.7

Gr. 2 (n=190)

4.1+1.3

5.3+1.3

2.6+0.7

2.9+0.2

4.6+2.1

0.8+1.4

Gr. 3 (n=131)

4.2+1.3

4.7+1.3

2.7+0.4

2.8+0.5

4.5+2.3

1.3+1.7

F-test

0.3

12.4

4.4

2.1

0.3

4.9

p-value

0.05

<0.01

<0.05

0.05

0.05

<0.05

GK = General Knowledge, TK = Transmission Knowledge, MP = Misperception

Table 4: Comparison of AIDS knowledge among the studied-group before and after health education program according to type of school

Type of School (Sc.)

AIDS Knowledge

GK Score

TK Score

MP Score

Before ed.  X + SD

After ed. X + SD

Paired t-test

Before ed.  X + SD

After ed. X + SD

Paired t-test

Before ed.  X + SD

After ed. X + SD

Paired t-test

General Secondary Sc. (n=219)

3.9+1.3

5.0+1.1

9.1*

2.6+0.7

2.9+0.2

6.0*

4.5+2.2

0.9+1.2

22.4*

Commercial Secondary Sc. (n=198)

4.1+1.2

4.6+1.3

3.5*

2.7+0.6

2.8+0.4

1.7

4.7+2.3

1.5+2.0

14.7*

Islamic Science Secondary Sc. (n=66)

4.2+1.5

6.2+0.9

9.8*

2.6+0.7

2.8+0.2

2.9*

4.9+1.9

0.2+0.7

18.6*

* Denotes statistical significant (p<0.01)  

GK = General Knowledge, TK = Transmission Knowledge, MP = Misperception

Table 5: AIDS knowledge among the studied-group according to type of school

Type of School (Sc.)

AIDS Knowledge

GK Score

TK Score

MP Score

Before ed.

X +SD

After ed.

X + SD

Before ed.

X + SD

After ed.

X + SD

Before ed.

X + SD

After ed.

X + SD

General Secondary Sc. (n=219)

3.9+1.3

5.0+1.1

2.6+0.7

2.9+0.2

4.5+2.2

0.9+1.2

Commercial Secondary Sc. (n=198)

4.1+1.2

4.6+1.3

2.7+0.6

2.8+0.4

4.7+2.3

1.5+2.0

Islamic Secondary Sc. (n=66)

4.2+1.5

6.2+0.9

2.6+0.7

2.8+0.2

4.9+1.9

0.2+0.7

F-test

1.0

49.9

1.8

4.7

1.0

20.4

p-value

0.05

<0.01

0.05

<0.05

0.05

<0.01

GK = General Knowledge, TK = Transmission Knowledge, MP = Misperception


 

observed between males and females regarding all the components of the questionnaire (p0.05). On examination of the results of the post-test, it was found that females had become more knowledgeable than males, but the difference was only significant in the general knowledge scores (p0.05). Also, the misperception score was significantly more improved in females than in males (0.7 ± 1.1 and 1.1 ± 1.7 respectively) (Table 3).

Grade 1 and Grade II students showed significantly higher scores of general and transmission knowledge as well as significantly lower misperception score in the post-test than in the pre-test results (Table 2). However, Grade III group showed a significant improvement in their general knowledge and misperception scores, while the change in their transmission knowledge score  was   not  statistically  significant (Table 2).

Before the health education program, Grade III students had higher scores in general knowledge (4.2 ± 1.3) and transmission knowledge (2.7 ± 0.4) as well as lower misperception score (4.5 ± 2.3) than Grade I and Grade II groups (Table 3) the only significant difference being the transmission scoring (p<0.05). At the end of the program the Grade III group showed the least improvement of the three grades in their knowledge and misperception scores. They had significantly lower general knowledge score as well as significantly higher misperception score than the other two groups (Table 3).

The health education program on AIDS significantly improved the general knowledge, transmission knowledge and misperception scores among students affiliated to general and Islamic science secondary education (p<0.01) (Table 4). However, the effect of the program among those in commercial secondary education was statistically significant on general knowledge and misperception scores, but not for transmission knowledge score (Table 4).

Before conducting the program, students of Islamic science education had higher scores of general knowledge and misperception than general and commercial education groups, as commercial secondary students had the higher transmission knowledge score. However, the differences in the scores for all components of pre-test questionnaire were not statistically significant (p0.05). By the end of the program, however, students of Islamic Science Education had the highest score for general knowledge (6.2 ± 0.9) and the lowest score for misperception (0.2 ± 0.7) among the three groups, as those in general secondary education had the highest score of transmission knowledge (2.9 ± 0.2). These differences were statistically significant (p<0.05) (Table 5).

We concluded that health education program on AIDS had greatly improved the knowledge and misperception scores for students of secondary schools varying according to their level and their individual ability. Individual demographic characteristics, beliefs of the problem, motivation to acquire knowledge, etc., are important factors in health education.15-16

The present study recommends the setting up of extra-curricular activities such as school counseling services, health clubs and discussion groups in secondary schools to talk about AIDS, explain in detail the modes of transmission and the precautions that could be taken against it. Research among other high-risk groups is also recommended.

REFERENCES

1.     W.H.O. Epidemiology of Acquired Immunodeficiency Syndrome, 2nd Edition EM/AIDS/14-E 1991 : 1-7.

2.     Drotman DP, Curran JW. Epidemiology & Prevention of  acquired immunodeficiency syndrome. Cited in Maxy. Public Health & Preventive Medicine, 13th ed.. Rosenau-last.  Prentice-Hall International  Inc. 1992  : 115 - 124.

3.     Walter HJ,  Vaughan RD, Gladis MM, Rgin DF, Kasen S, Cohall AT. Factors associated with AIDS risk behaviours among high School Students in an AIDS Epicenter. AM J Public Health, 1992 ; 82(4) : 528 – 32.

4.     AIDS Action (The international newsletter on AIDS prevention and care). Young people first. AHRTAG 1994 ; Issue 25 June – August :1-3

5.     W.H.O. Epidemiology of Acquired Immuno-deficiency Syndrome, 5th Edition EM/GPA/ 014/E/L 1993: 25-9.

6.     Blake SM, Arkin EB. A  summary  of  national  public  opinion surveys on AIDS : 1983 through 1986. AIDS information Monitor.  Washington, DC. American Red Cross 1986.

7.     McCaig LF,  Hardy  AM,  Deborah MW. Knowledge about AIDS and HIV in the U.S.adult population: Influence of the Local Incidence  of  AIDS. Am J Public Health 1991;  81(12 ): 1591-5.

8.     C.D.C. (Centers for Disease Control). AIDS and human immunodeficiency virus  infection  in the United States: Update.  MMWR  1988; 38  (suppl. 4): 1-38.

9.     SPSSInc. 444 N. Michigan Avenue Chicago, Illinois 60611, USA, 1993.

10.   St. Lawrence JS,  Hood HV,  Brasfield T,  Kelly JA. Differences in men’s  AIDS  risk  knowledge  and  behavior   patterns  in   high   and  low  AIDS prevalence cities. Public Health Report  1989; 104: 391-5.

11.   Wassif OM, El-Gendy MF, Saleh MA, El-Sawaf EM. Effect of Health Education Program on knowledge about AIDS and HIV Transmission  in Paramedical personnel working in Benha Hospitals. The Journal of Egyptian Public Health Association 1993; Vol. LXVIII (No. 1,2) : 143-159.           

12.   Diclemente RJ, Boyer DB, Moraies ES. Minorities and AIDS : knowledge, attitudes and misperceptions among Black and Latin adolescents. Am J Public Health 1988;78: 55-7.

13.   Keeter S, Bradford JB. knowledge of AIDS and related  behavior change among unmarried adults in a low prevalence city. Am J  Prev Med 1988;  4: 146-152.

14.   Hardy AM,  Dawson  DA. AIDS knowledge and attitudes. Provisional data from the National Health Interview Survey. Advance data from  vital and health statistics, No. 175. Hyattsville, M.D.; National Centerfor Health Statistics  1989.

15.   Park K. Health Education and Communication. Park’s Textbook of Preventive and Social Medicine. 15th edition M/s. Banarsidas Bhanot Publishers 1167, PREM NAGAR Jabalpur, 482 001 ( India), 1997: 586-92.

16.   Kelly RB,  Falvo DR.Patient Education. Cited by Rakel RE. Textbook of Family Practice. 5th edition. W-B. Saunders Company. A Division of Harcourt Brace Company. Philadelphia; 1995 : 278-90.


 


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