|Year : 2013 | Volume
| Issue : 2 | Page : 108-113
Knowledge of Sri Lankan government medical practitioners and medical students on standard treatment guidelines; regional cross sectional survey
Lukshmy Menik Hettihewa, Inoka Wimalasena, Tharanga Dadallage
Department of Pharmacology, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
|Date of Submission||10-Apr-2012|
|Date of Acceptance||26-May-2012|
|Date of Web Publication||3-Jun-2013|
Lukshmy Menik Hettihewa
Department of Pharmacology, Molecular Science and Biomedical Unit, Faculty of Medicine, University of Ruhuna
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction of module of rational use of medicine (RUM) to pharmacology curriculum requires analysis of existing knowledge among health care workers. We conducted this study to evaluate the knowledge and attitude of medical practitioners (MPs) and medical students (MSs) on Standard Treatment Guidelines (STG) as an initial tread. 42 MPs and 120 MSs were selected and for this study and pretested structured questionnaire on STG and core policies of RUM were used to evaluate the key testing parameters. Results showed that only 78% of MPs were confident about their knowledge in STG and 7% of them were not attentive. Knowledge of MPs and MSs showed 78% and 84% on contents of STG while the knowledge in core policies was 73% and 34% respectively. More than 99% of MSs and 71% of MPs were attentive on the inclusion of clinical features of the illness in STG. Knowledge on updating and significance of STG as guidance for new prescribers of MPs were 84% and 88% respectively while 96% of MSs had acquainted in those two areas. Both groups had good knowledge on STG and they showed that STG were prepared with accordance with personnel experience (MPs-71%, MSs-74%). 80% of MSs and 75% MPs discerned that common treatment practices is not an inclusion criteria for STG. We found that MSs had good knowledge on contents of STG but skills in application in RUM were limited. MPs had good knowledge on core policies and application of STG but not familiar with principles of STG. We conclude that MPs need repetitive in-service training programs to ensure the adherence to STG and MSs are in need of skill development program to pertain STG in clinical practice.
Keywords: Core policies, knowledge on medical practitioners and Medical students, rational use of medicine, standard treatment guidelines
|How to cite this article:|
Hettihewa LM, Wimalasena I, Dadallage T. Knowledge of Sri Lankan government medical practitioners and medical students on standard treatment guidelines; regional cross sectional survey. Int J Nutr Pharmacol Neurol Dis 2013;3:108-13
|How to cite this URL:|
Hettihewa LM, Wimalasena I, Dadallage T. Knowledge of Sri Lankan government medical practitioners and medical students on standard treatment guidelines; regional cross sectional survey. Int J Nutr Pharmacol Neurol Dis [serial online] 2013 [cited 2020 Jun 5];3:108-13. Available from: http://www.ijnpnd.com/text.asp?2013/3/2/108/112830
| Introduction|| |
Standard treatment guidelines (STG) is also known as standard treatment schedules, standard treatment protocols, therapeutic guidelines, and so forth list the preferred drug and non drug treatments for common health problems, experienced by people in a specific health system. ,,,
According to the implications, STG should include the health problem, the name, dosage form, strength, average dose (pediatric and adult dose) number of doses per day, and the duration of treatment, diagnosis and advice to the patient.  Experience of most of the scientist's had shown that absence of STG applications in a ward can offer an ample opportunity to misuse drugs by improper treatment of common problems.  Therefore the sound knowledge on the application and formulation of standard treatment guidelines is a necessity for developing countries. Adherence to the STG by a particular country or a hospital can significantly maximize the benefits to patients from the scarce available resources especially in developing countries. 
Twelve core policies to promote rational use of drugs had been identified by the WHO. , They are establishing a mandated multi-disciplinary national body to coordinate medicine use policies, clinical guidelines, essential medicines list, drugs and therapeutics committees, Problem-based pharmacotherapy training in undergraduate curricula, continuing in-service medical education,supervision, audit and feedback,Independent information on medicines, public education,avoidance of perverse financial incentives, appropriate and enforced regulation, and sufficient government expenditure. STG had been identified as the important first step to ensure the quality, effective and economical health care system in a country. 
If a particular program can increase the knowledge of health care personals using the concept of RUM, it will invariably improve the cost effectiveness.  There were some studies showing that significant impact on the proper management of the patients in health institutes when the rules and regulations were formed to practice standard treatment guidelines. This has been observed after broad-based implementation of a malaria treatment protocol in a pediatric hospital, children received rational therapy before leaving the emergency department.  To evaluate the situation in our country, present study was planned to assess the knowledge of STG and the core policies on rational use of medicine by medical practitioners (MPs) and medical students (MSs).
| Materials and Methods|| |
It was a descriptive cross sectional survey. The study was carried out at the Teaching Hospital, Karapitiya and Faculty of Medicine, University of Ruhuna. Knowledge on STG was assessed in 42 MPs and 120 MSs. The ethical clearance was granted by the ethics and review committee of the institution. The Knowledge was tested using a pretested structured questionnaire prepared by WHO related to contents of STG and the core policies in RUM. All the MPS who gave the informed consent were taken to the study. Questionnaire was sent to all MPs in the selected hospital and Faculty of Medicine and only responded data were collected. MSs were selected after they completed the pharmacology syllabus in undergraduate curriculum. Questionnaire is given in [Table 1].
|Table 1: Questionnaire on assessment of knowledge on rational use of medicine of health personnel|
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Analysis was done using microcal origin statistical package SPSS package 16.
| Results|| |
Percentage of MP's knowledge on STG, EDL, drug and therapeutic committees and drug information sources
We analyzed the level of knowledge of MPs on key policies of RUM; standard treatment guideline (STG)(A), EDL-(B), national formulary/hospital formulary (NF/HF)-(C), drugs and therapeutic committees (DTC)-(D) and reliable drug information sources (RDIS)-(E) [Figure 1].
|Figure 1: The levels of knowledge in key policies on RUM of MPs were assessed. The percentages of MPs who were confi dent on their knowledge. Knowledge was categorized as good, fair or don't know. Knowledge on STG, EDL, NF/HF, DTC and RDIS were represented as A, B, C, D and E 27%, 29%, 24%, 10% and 29% respectively. Some of MPs were not aware of STG (7%), EDL (17%), NF/HF (19%), DTC (58%) and RDIS (12%). values were given as percentages|
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Our results shows that majority of MPs were confident on the knowledge of STG, EDL, NF/HF, DTC and RDIS.
Assessment of knowledge of MPs and MSs on rational use of drugs
We extended our study to compare the knowledge between MPS and MSs on Key policies of RUM designed by the WHO. Key policies were the knowledge on STG and the need of in-service intervention for improving prescribing practices.
Percentage of knowledge on contents of STG among MPs and MSs
After identification of knowledge in different major components of RUM, we further analyzed the contents in each component. First we concentrated on the major components in STG.Assessment of STG in MPs and MSs were done and the following subcomponents were tested; whether STG includes clinical features (A) it is necessary to update STG(B)whether STG includes common treatment practices but not the best practices (C) whether STG provides a goodguidance to new prescriber (D) whether the STG is prepared considering personal practice (E) [Figure 2]a shows the percentage of knowledge in these five components in STG among MPs in our study group. We analyzed the knowledge on contents of STG in MPs. [Figure 2]a shows that more than 71% of MPs agreed the STG is included of clinical features, 84% of them had agreed for the necessity of updating STG.
|Figure 2: The percentage of MPs giving correct answers for different subcomponents in STG. More than 71% of MPs and 99% of MSs say inclusion of clinical features (A), 84% of MPs and 95% of MSs decide the necessity of updating STG (B), 76% of MPs and 80% of MSs show STG should be made considering the common treatment practice (C), 88% of MPs and 97% of MSs say STG is a useful guidance to new prescriber (D) and finally, 71% of MPs and 74% of MSs shows STG is to be prepared according to personal practice (E)|
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In addition to that majority of MPs decided that STG is prepared according to the common treatment practice and they indicated that STG is a useful guidance to new prescribers it is prepared according to personal practice. Further to that we analyzed the same knowledge of STG in MSs. [Figure 2]b shows that most of the medical students agreed the STG should consist of clinical features, and the importance of updating STG. Majority of students had indicated that STG is prepared according to the common treatment practice and STG is a useful guidance to new prescribers. But 74% of also showed that STG is prepared according to personal practice.
Difference between the knowledge on STG by self evaluation and by a pre-tested structured questionnaire among MPs
27% of MPs had there self confident about the knowledge on components of STG. But we found that 79% of them are aware about the inclusion criteria on STG by using the questionnaire [Figure 3].We further identified that 52% of MPs were not on a correct evaluation about their knowledge on STG.
|Figure 3: Gap analysis of the knowledge on STG between self analysis (27%) and by structured questionnaire (79%) in MPs|
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Knowledge on core policies of rational use of medicine among medical practitioners
As the quality of basic training in pharmacology and therapeutics for undergraduate medical and paramedical students can significantly influence future prescribing, existing knowledge on core policies on RUM was analyzed as an initial step. Following promoting factors were checked in our study group: EDL (A), STG (B), need of restricting the prescription (C), need of cross sectional supervision (D) and requirement of sufficient government money (E).
[Figure 4]a and b showed that the percentage of MPs and MSs who submitted the correct answers. Majority of the MPS had decided the correct answer about the core policies of RUM except that they were not convinced about the essential drug list was identified as a core policy.
|Figure 4: (a and b) The percentage of MPs and MSs who submitted the correct answers. 84%, 23% of MPs and MSs decided EDL is a promoting factor, 95%, 26% of them as STG, 61%, 55% of them decided that promoting the restriction of prescriptions is helpful for RUM and 95%, 29% of them decided that cross section super vision is a promoting factor respectively. 32% of MPs and 29% of MSs had decided that effective practice of RUM needs suffi cient government money. Values were given as percentages|
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In contrast MSs had given different types of answers about the core policies of rational use of medicine.Most of the medical students had not given the correct answer to the core policies except the answer C which indicate the need of restricting the unnecessary prescription.
Comparison of knowledge of MPs and MSs on contents in STG and promoting factors in RUM
We compared the level of knowledge of MPs and MSs on contents of STG. [Figure 5] shows that majority of MPs and MSs were aware about the correct promoting factors of STG. In addition to that we further compared the knowledge in promoting factors in rational use of medicine.
|Figure 5: (a) Percentage of MPs and MSs who were aware about the contents of STG (MPs MSs were78%, 89%), (b) percentage of MPs and MSs who had a knowledge on the promoting factors in rational use of medicine (MPs and MSs were 73.4%, 33.8%)|
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| Discussion|| |
Recent studies related to the RUM and STG had shown the possibility of introducing the prescribing policies into general medical practice and found that the compliance of such policies is dependent on active involvement of the prescriber concerned in government hospitals.  Some studies had shown that the regular feed back and assessment of prescriber and their practice had helped to reduce the health cost to the country and implement RUM policies.  All of us are aware that prescribing practice related to the STG cannot be defined without a method of measurement and references standard, knowledge of the prescriber has been considered in our study as an output measure of interventions.
In this study we concentrated on the knowledge related to the promoting factors of RUM, core policies and principles of STG in medically qualified personnel. We found that the overall level of knowledge on principles of STG in MSs were more than MPs. Significant knowledge in medical students can be explained by recent introduction of lectures in STG to the undergraduate medical curriculum and in addition to that inclusion of questions based on these guidelines.Suboptimum knowledge and awareness about STG by medical practitioners can be due to that currently employed MPs were not augmented with concept of STG during the undergraduate period with lack of in-service training program. We found that the knowledge on STG in MPs is not adequate about its principles and its clinical application.
In addition to that our results show that the knowledge on core policies in promoting more rational use of drugs among MPs (mean = 73%) was higher than MSs (mean = 33%). We found that the knowledge on core policies such as EDL, STG, cross section supervision, audits and feedback were more than 80%. In contrast MSs Knowledge in same area was less than 30%. Also 61% MPs had knowledge on prescriber restriction where as 55% MSs had that knowledge. 36% of MSs had identified that the sufficient government money as a core policy, but only 32% MPs had identified it. It was noticeable that though MSs had sound knowledge on contents of STG, they were not recognized it as a core policy (26%). Also in our previous study  on EDL we noted that MSs has had good knowledge about contents of the EDL (86%) but they didn't have adequate amount of knowledge about application, especially criteria for selection (32%). This observation can be due to inadequate experience as well as they didn't have opportunity to convey their knowledge to the practice.
According to the WHO strategies there are educational, managerial, financial and regulatory strategies to improve rational drug usage.  Educational strategy in the core curriculum of undergraduate medical students is the most important for prescribers and consumers.  We foundhere that the knowledge is insufficient despite the availability of STG charts, flow charts, news letters, and drug bulletins in the working environment. In Yemen, introduction of STG into practice for malaria had resulted in sharp drop in use of unnecessary quinine.  There are only very few studies found inrelation to the knowledge of STG among doctors and medical students in the world. There was a study related to the impact of drug bulletin  on prescribing but not about the STG. Some of the studies had focused on the define daily doses of the commonly used drugs but not on the attitudes and knowledge to change the adherence to the standard treatment guidelines.  As there are no interventions related to the STG application were planned for prescriber in our country, the knowledge in core policies had been found low. We suggest implementing these interventions program at regular basis and need sufficient government money as an important determining factor in practicing RUM.
Our study shows that only <40% of both MPs and MSs were aware STG as a core policy. That sounds both groups had no idea about either national health budget or national health policy.
This is an important finding and a documentary evidence to initiate necessary program by administration authorities with in service guidance program. It has to be instigated at regional level and should be expanded to the whole country because there is no a single in-service program about STG and its clinical application practicing now in our country. We believe that it is important to consider this issue and initiate the implementation program by the government authorities basically for the reduction of the national budget for health system.
Finally we find that MPs are need of in-service programs at a regular interval to ensure their adherence to the guidelines.
Also MSs should be skilled on applicability of guidelines and core policies more thoroughly by improving their curriculum in pharmacology. New teaching learning techniques in practical programs, assignments can be planned for better achievements. These two measures will be helpful to achieve more suitable national health cost to the country.
| Acknowledgment|| |
We would acknowledge all the staff members in the Department of Pharmacology in the Faculty of Medicine for their enormous help given during this research work.
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