Knowledge , attitude , and practice of family physicians regarding diabetic neuropathy in family practice centers : Suez Canal University

The World Health Organization (WHO) describes diabetes mellitus (DM) as the most common endocrine disease in the world. In the year 2000, diabetes affects more than 230 million people worldwide, and according to the most recent projections, it is expected to affect 370 million people by the year 2030.[1] For Egypt, the total projected number of people with diabetes is about 6.7 million (9%).[2] Diabetic neuropathy (DN) is a debilitating disorder that occurs in nearly 50% of patients with diabetes. It is a late fi nding in type 1 diabetes, but can be an early fi nding in type 2 diabetes. Neuropathy is estimated to be present in 7.5% of patients at the time of diabetes diagnosis.[3-7]

some instances, patients with DN have few complaints, but their physical examination reveals mild to moderately severe sensory loss.0][11] In the past 3 decades, despite considerable advances in treatment modalities of diabetes, it has been shown considerable gaps between patient's outcome and acceptable treatment in developed and also in developing countries.
Different reasons are proposed in failure to achieve therapeutic goals such as poor adherence to treatment regimens by patients or malpractice by physicians. [12]It has been observed that in addition to physicians' knowledge; their attitude about treatment was important to achieve goals.In other words, physicians' belief was important factor in their success for treatment of diabetes. [13]On the other hand, the knowledge and practice of diabetic patients to follow therapeutic principles showed a direct relationship with the attitude of physicians to diabetes care.This study was conducted to assess family physician's (FPs) knowledge, attitude, and practice regarding DN for further educational interventions that will improve their quality of care for diabetics.

MATERIALS AND METHODS
This study was designed as cross-sectional descriptive study including all FPs working in family medicine centers affi liated to Faculty of Medicine, Suez Canal University.The number of the physician was 60.Only 18.3% of them were female, average age was 28.4 years, and 31.7% had medical experience for more than 5 years.These demographic data are presented in Table 1.There are nine family medicine centers distributed in Ismailia (Abo-khalifa, El-Mahsama, and Fanara), Port Said (Port-Fouad and El-Salam), and Suez (El-Omda, Amer, El-Gabaliat, and 24 October) Governorates.
All the FPs under training in (Diploma, Master degree, and Fellowship) working in family medicine practice centers (FMC) affiliated to Suez Canal University was included.The study population was subjected to self-administrative semi-structured questionnaire which was developed by the researchers, revised by two experts in the fi eld of diabetes and community medicine and validated according to pilot study by 10 FPs.The questionnaire was composed of three parts: A) Part I: Sociodemographic of FPs; including gender, age, qualifi cation, experience years in family medicine, practice location, and the number of diabetic patients seen per week; in addition to some questions regarding their opinions on sources of their knowledge about diabetes and their perception regarding their knowledge and training in DN.
B) Part II: Multiple choice questions and two patient problems for assessing knowledge, attitude, and practice of FPs regarding DN.The scoring system was: • Knowledge score: One point for each correct answer of total 15 points.The cut off point to pass the evaluation for knowledge considered 50% for correct answers of the total score.Not passed knowledge if <50 and passed knowledge if ≥50.• Attitude score: A score of 5 was given for "strongly agree", 4 for "agree", 3 for "unsure", 2 for "disagree", and 1 for "strongly disagree"; of total 20 points.The cut off point to pass the evaluation for attitude considered 80% for correct answers of the total score.Favorable attitude if ≥80% and unfavorable attitude if <80%.• Practice score: A score of 3 was given for "always", 2 for "sometimes", 1 for "rarely", and 0 for "never"; giving total of 60 points.Also, one point for each correct answer of total 6 points in the patient problems.The total practice scoring was 66 points.The cut off point to pass the evaluation for practice considered 60% for correct answers of the total score.Appropriate if ≥60% and inappropriate if <60%.
C) Part III: Two questions about the greatest barriers faced by physicians in DN management and their recommendations to improve their practice at family medicine level.

Pilot study
The questionnaire was pretested on FPs before the beginning of data collection to determine if the questions asked were understood by the respondents or not, perform any modifi cations needed, and determine the required time for the questionnaire.

Data analysis
The data were coded and organized.The fi nal study results were stated by using the Statistical Package for Social Sciences (SPSS) program, version 15.Statistical signifi cance was considered at P-values < 0.05 and a higher signifi cance at P-values < 0.001.

Ethical consideration
The study protocol was approved by the faculty committee of research ethics.The data were collected after taking a written consent from the study participants and their names were omitted (anonymous).All data were confi dential and used only for scientifi c research purposes.

RESULTS
Results of physicians' knowledge, attitude, and practices are presented in Table 2. 48.3, 66.7, and 43.3% of the evaluated FPs passed the knowledge, attitude, and practice assessment, respectively.Also, 85% of physicians felt that they need more knowledge and training in DN management.FPs qualifi cation was a signifi cant variable in passing the knowledge test (P = 0.037), but qualifi cation and experience years (P = 0.007 and 0.035, respectively) were signifi cant variables in passing the practice test, while no statistically significant relation was observed between sociodemographic characteristics and attitude scoring.There was a positive, signifi cant (P = 0.021) correlation between practice score and knowledge score.
The physicians' recommendations are summarized in Table 3.
Providing physicians with standardized guidelines, continuous medical education seminars, and training courses came at the top of recommendations to improve DN care by FPs.

DISCUSSION
Out of 60 FPs, 65% of them aged less than 30 years old and 68.3% had less than 5 years' experience in clinical practice.This is not consistent with a study of Shera et al., conducted in Pakistan, 2002; about diabetes related knowledge, attitude, and practices of FPs.They demonstrated the average age of physicians as 42.18 years and the mean duration of clinical practice as 13.41 years. [14]so, the present study demonstrates that female physicians are the majority (81.7%); while males form only 18.3%.This is inconsistent with a study of Khan et al., conducted in Al Hasa district of Saudi Arabia, 2010; about knowledge, attitude, and practice of primary health care physicians in the management of type 2 DM, which demonstrate that the number of male physicians was much higher than that of female physicians: 72.73 and 27.27%, respectively. [15] addition, there was about one-third qualifi ed FPs; while 65% physicians are involved in the training programs of (diploma, master, and fellowship), with no other specialties included in the study except FPs.This is inconsistent with a study of Peimani et al., conducted in Iran, 2010; about knowledge, attitude, and practice of physicians in the fi eld of diabetes and its complications.They showed that about 37.7% of the participants were general physicians, while 15.9 and 46.4% were internist and other specialties, respectively. [16]e current study demonstrates that about 48.3 and 43.4% of the studied FPs have good knowledge and practice scores, respectively regarding DN management.However, these results showed better knowledge and practice scores than a similar same study of Peimani et al., which revealed that 29% of total physicians had good knowledge score in the fi eld of diabetes and its complications and 36.2% of physicians had acceptable practice in control and prevention of diabetes complications. [16]e difference between these results and the current results may be explained by the availability of continuous educational programs for postgraduate FPs that has been conducted regularly in the Family Medicine Department of Suez Canal University.
By studying some factors affecting the results (passed or not passed) of FPs, the current data revealed that qualifi cation of FPs is the main factor signifi cantly affecting their knowledge results, while qualifi cation and experience years in family medicine signifi cantly affecting their practice results (P < 0.05).
As well, FPs with experience ≥5 years signifi cantly scored better in the practice segment than those with experience less than 5 years (P = 0.035), but there is no statistically signifi cant relations in the segments of knowledge and attitude (P = 0.313 and 0.844, respectively).This is inconsistent with the study of Shera et al. [14] They demonstrated that, doctors with practice duration of 6-10 years provided more correct answers in the segment of knowledge and attitude, than those with either less or more (P = 0.01).Also inconsistent with the study of Khan et al., demonstrated that the means of overall scores were signifi cantly higher for physicians with 1-5 years of experience, than those with >5 years of practice (P < 0.05). [15]e present study demonstrates that there is no difference between FPs practicing in the urban areas and those practicing in the rural areas in the attitude segment (50 vs 50%, P = 0.715), but there is a slight difference in the knowledge part (51.7 vs 48.3%, P = 0.993), and in the practice part (38.5 vs 61.5%, P = 0.073).These however  did not achieve any statistical signifi cance.This is inconsistent with the study of Shera et al., [14] that demonstrated doctors practicing in the urban areas gave more correct answers in the segment of attitude (53 vs 43%, P = 0.05) and practice (52 vs 41% P = 0.03).In the knowledge variable, the doctors of the rural areas scored better (62 vs 56% P = 0.2).Also inconsistent with the study of Khan et al., [15] which demonstrated that the scores of rural general practitioners (GPs) were higher than that of GPs practicing in urban areas, which was statistically signifi cant (P = 0.003).
The difference between these results and the current results may be explained that there is no fi xed place for work and our physicians are in rotation all the time with some minimal exceptions.Also our physicians working in the rural and urban areas undergo the same educational programs and the same courses and modules that applied to postgraduate FPs who attend weekly in the scientifi c day in the Family Medicine Department of Suez Canal University.
In the present study, postgraduate knowledge form the commonest source for DN knowledge (78.3%), followed by internet (51.7%), and text books (50%); while dated papers from journals, courses or activities, and conferences and meetings accounts only for 31.7,26.7, and 25%, respectively.This is inconsistent with the study of Khan et al., which demonstrated that the source of information of the GPs on diabetes management was the clinical practice guidelines (15.2%), scientifi c meetings (12.1%), educational programs (19.2%), and medical journals (2%). [15]Also inconsistent with the study of Peimani et al., that demonstrated they did not have any information about whether the physicians had experiences in diabetes clinics, or they participated in workshops and diabetes training courses as a source of information. [16]ncerning the physicians' self-reported barriers regarding DN management, the present study shows that the highest percentage of FPs agree with barriers focused on inadequate physician tools regarding diabetic peripheral neuropathy assessment (80%), while 88.3% disagree that diabetic patients refuse examinations to assess neuropathy.Other studies show that poor practice of physicians is associated with extensive health problems in the community such as increasing the incidence of medical errors, patient dissatisfaction, lack of control of many chronic diseases, delay in diagnosis, and the illegitimate use of drugs. [14,17,18]ncerning to the physicians' recommendations to improve DN management in family practice centers, the majority (81.7%) of their recommendations focused on providing physicians with standardized guidelines, while 76.7% focused on continuous medical education seminars and training courses.The role of the healthcare provider, in the case of chronic illness is different than that of seasonal, episodic, and temporary ailments.For the successful treatment of a diabetic, the FPs have to acquire the understanding, cooperation, and involvement of other family members. [19]This will demand more of the doctor's time along with a sympathetic approach.The ideal method would be a team work, where the education of the diabetics is shared and coordinated by medical education and continuing medical education programs play an important role in enabling the healthcare providers to treat diabetics in a most effi cient and economical manner. [20]mple size is the main limitation of the study, while the variations of participants and work places are the main strength.However, further studies are required with a relatively larger sample size to detect the impact of the current data on the quality of diabetes health care delivered by FPs for DN.

CONCLUSION AND RECOMMENDATION
About half of the FPs passed the knowledge and have favorable attitude, while about two-thirds have appropriate practice regarding DN.Providing FPs with standardized guidelines, continuous medical education seminars and training courses came at the top of physician's recommendations to improve DN care by FPs.This study has identifi ed the need for further improvement in family medicine physician practices for treating and educating diabetics and recommended that awareness and educational programs are necessary to update the FPs on screening, effective treatment of diabetes, and prevention of DN.This should be the scope of any future health plans and programs for target populations.
International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4

Table 1 : Demographic data of the studied physicians
n = Number of studied physician

Table 2 : Knowledge, attitude, and practice results
n = Number of studied physician

Table 3 : Physicians' recommendations to improve diabetic care
n = Number of studied physician International Journal of Medicine and Public Health | Oct-Dec 2013 | Vol 3 | Issue 4