Knowledge about childhood bronchial asthma among primary health care personnel in eastern Saudi Arabia

Background: Bronchial asthma (BA) is a chronic non-communicable disease affecting children and adults. Despite the availability of written guidelines for diagnosis and management, yet still knowledge and application were inadequate. The aim of this study was to assess asthma knowledge of primary health care centers (PHCCs) personnel in Dammam city, eastern Saudi Arabia. Materials and Methods: This was a cross-sectional study conducted in 22 PHCCs. The sample consisted of 194 personnel (50 physicians and 144 nurses). Data was collected through a self-administered questionnaire which contained 58 questions. Knowledge score about asthma was coded as good and poor. Descriptive statistics, paired t-test and logistic regression were used for statistical analysis. Results: The majority of PHCCs personnel (96.9%) had no postgraduate studies and 78.4% of them didn’t receive any training about BA. More than half (55.2%) of the PHCCs personnel showed good total knowledge score about BA. Also, 81.8% of the physicians and 52.7% of the nurses had good total knowledge level regarding the total aspects of BA in children. Physicians had statistically higher mean knowledge score than nurses regarding all components and total knowledge scores. Knowledge about role of exercise and prognosis was inadequate. Being a physician, female, younger, less years of work in PHCCs were statistically signifi cant and associated with good knowledge level. Conclusions: There are still some defi ciencies in knowledge about different aspects related to bronchial asthma. It is recommended that both physicians and nurses receive training about national asthma guidelines through continuing medical education.


INTRODUCTION
[6][7] The majority of asthma patients in KSA are managed by primary health care (PHC) physicians at primary health care centers (PHCCs).Knowledge of physicians about diagnosis and management of bronchial asthma is essential for better patient care.5] The aim of this study was to assess the knowledge of PHCCs personnel (physicians and nurses pilot study was conducted to test the validity and the logistics of administering the questionnaire in one of the PHCCs.Personnel in the pilot study were excluded.

Data collection
Data collection was accomplished through a self-administered questionnaire constructed by the investigators.All the questions were close-ended and the questionnaire consisted of two main parts: 1. Personnel's socio-demographic characteristics: Occupation, nationality, gender, marital status, years of experience since graduation, duration of work in PHC, and training about bronchial asthma.2. Fifty eight (58) questions to assess the knowledge about bronchial asthma in children divided into seven components namely; magnitude, defi nition and causes, risk factors, associated diseases, role of exercise, clinical picture, management, and prognosis.
A scoring system was used, giving a score of one to each correct answer and a score of zero to the wrong answers or do not know.The knowledge score was calculated by summation of the right answers, scores.The maximum total knowledge score was 58.The knowledge score of the components as well as the total knowledge score were divided into two groups namely, good and poor knowledge according to the cut-off points which were determined according to the mean of the distribution.Personnel who scored less than the cut-off point were considered as poor and those above the cut-off point were considered as good.
Necessary permissions to conduct the study were obtained from concerned authorities and confi dentiality of the information was strictly adhered to by assuring the participants that no details about their status will be released and data will be only used for research purpose.

Statistical analysis
The collected data were reviewed, coded, verifi ed and statistically analyzed using the Statistical Package for Social Sciences (SPSS) software version 16.Descriptive statistics for all studied variables and paired t-test were used.Logistic regression analysis was used to fi nd the association between the characteristics of the PHCCs personnel (Independent variables) and the knowledge level about bronchial asthma (Dependant variable).A P-value level of < 0.05 was considered signifi cant throughout the study.
[Figure 1] shows that 81.8% of the physicians and 52.7% of the nurses had good total knowledge level regarding the total aspects of bronchial asthma in children.
According to [Table 3], it was evident that physicians had higher mean knowledge score regarding all the components and the total knowledge scores of bronchial asthma in children and the differences were found to be statistically signifi cant except for the knowledge about prognosis.The results of the logistic regression analysis

DISCUSSION
The majority of PHCCs personnel were young females.This is mainly due to the predominance of nurses who were mainly females, refl ecting the usual pattern in KSA.Physicians in the sample were mainly general practitioners who had no post-graduate qualifi cations and no training in bronchial asthma.The total knowledge score of PHCCs personnel and the knowledge about causes and management of bronchial asthma were generally good.][17] A study of the level of knowledge about childhood asthma showed that general practitioners scored well in most questions but had some defi ciencies particularly in distinguishing preventive therapy from symptom-relieving medication. [10]Pediatric nurses in the previous study had poor knowledge of exerciseinduced asthma, which is similar to the result of the present study.Al-Kabba et al., in their study of primary care physicians knowledge about bronchial asthma using a true or false self-administered questionnaire, reported that only 39% of the of the 44 physicians passed the test as a whole, with 66% passed in general knowledge, 70% in diagnosis, 48% in classifi cation of severity, and 59% in the management of asthma. [13]A study of the prevalence of asthma in a prevalence of physician-diagnosed asthma in the three areas of 13.9%, 2.2% and 13.7% respectively. [7]milar results were shown by Lageriov et al., study among 698 general practitioners in fi ve European countries assessing their knowledge, attitudes, and prescribing behavior.It showed that most doctors were in agreement with guideline recommendations. [9]In practice, however, the proportion of asthma patients receiving inhaled steroids varied almost two-fold, ranging 31% in Germany to 58% in the Netherlands. [9]r study was also in agreement with Coates et al., study among 127 South Australian general practitioners concerning knowledge and reported asthma management, [14] which revealed defi ciencies in their knowledge and management practices of asthma and suggest that ideal asthma management was not being attained.
In this study physicians had better total knowledge compared to nurses.This result was similar to Lemay et al., study who reported that 32% of pediatric residents, 12% of family medicine residents and 72% of pediatric nurses failed to identify all three main symptoms of asthma (wheezing, cough, dyspnea). [16]In Lemay et al., study, 25% of pediatric residents, 52% of family medicine residents and 81% of pediatric nurses were unable to name at least two preventive asthma medications. [16]However, another study in Aseer Region, Saudi Arabia, showed poor knowledge of PHC physicians on asthma care, where they got 37.7% of the total scoring of case scenarios on asthma care. [16] this study there were defi ciencies in knowledge mainly concerning the role of exercise and management of asthma.Continuing medical education should focus on these areas especially for nurses who had unsatisfactory knowledge as shown by the signifi cantly lower mean knowledge compared to physicians.Tomson et al., study reported that there were changes in knowledge, attitudes and actual practice of Swedish primary care physicians after intervention messages concerning management of bronchial asthma. [11]A similar study by Rovithis et al., demonstrated an improvement in knowledge of PHC physicians serving a rural population on the island of Crete after a one-day educational course on bronchial asthma clinical guidelines. [8]These results stress the need for interventions in the form of frequent courses and continuing education to improve knowledge and practice of health care personnel about asthma and disease management.
In the present study, physicians had good knowledge in all aspects of bronchial asthma as shown by the logistic regression analysis.Female health care personnel were 4.2 times more likely to have good knowledge about bronchial asthma compared to males.This result was similar to Soyer et al., study in Turkey. [18]They reported that even though self-perceived overall asthma knowledge did not differ between genders (P = 0.098), female physicians recorded more frequent use of inhaled steroids for chronic asthma (3.72 ± 0.08 vs. 3.43 ± 0.07, respectively, P = 0.006) while male physicians scored higher than females for inhaled steroids for acute asthma (2.8 ± 0.12 vs. 2.17 ± 0.2, respectively, P = 0.007).Female physicians' scoring for 'symptom control' as the main aim of asthma management was higher than that of their male counterparts (3.88 ± 0.04 vs. 3.65 ± 0.06, respectively, P = 0.002).
In their study of clinicians adherence to asthma guidelines, Salama et al., showed that agreement with asthma guidelines was present in 76.2% of the studied physicians and there was positive signifi cant correlation between qualification and knowledge, (P < 0.01), positive signifi cant correlation between qualifi cation and practice, (P < 0.01), and positive signifi cant correlation between qualifi cation and attitude, (P < 0.01). [19]In the current study, the fact that younger health care personnel and those with less than 5-years experience of work in PHCCs had signifi cantly good knowledge which may possibly be due to their being newly graduated physicians with recent knowledge from their medical school studies.Nurses were still having some defi ciencies in knowledge of bronchial asthma compared to physicians.

CONCLUSIONS
This study showed that the majority of health care personnel had good knowledge about bronchial asthma.However, there are still some deficiencies about management and the role of exercise in asthma.Being a physician, a female, of young age, and with less years of work in PHCCs were significantly associated with good knowledge of bronchial asthma.It is recommended that both physicians and nurses should be informed and continuously reminded of the diagnosis and management of bronchial asthma according to the National Guidelines.This can be done through continuing medical education in the form of seminars, workshops and clinical teaching using patients with asthma.In addition, assessment of actual practice of physicians and nurses is greatly needed so that knowledge can be reflected on better patient care.

Limitations of the study
This study depends on self-reporting which might have resulted in over-or under-reporting of some aspects of asthma knowledge.This was a cross-sectional study done at a point in time.Therefore, cause and effect cannot be defi nitely assumed regarding factors predicting knowledge of asthma.Further studies on the effects of health care personnel practice in improving care of patients with asthma are needed.
) in Dammam city, eastern Saudi Arabia, and to determine factors affecting their knowledge.International Journal of Medicine and Public Health | Jul-Sep 2014 | Vol 4 | Issue 3 Yanbu industrial city and two non-industrial villages in KSA reported International Journal of Medicine and Public Health | Jul-Sep 2014 | Vol 4 | Issue 3

Table 1 : Socio-demographic characteristics of the PHC personnel
bronchial asthma in children.Moreover, 71.6% of PHC personnel had good knowledge regarding magnitude, defi nition and causes, risk factors (64.4%), associated diseases (57.2%), clinical picture (61.3%), management (59.8%), and prognosis (76.8%).On the other hand, 57.7% of the PHC personnel had poor knowledge level about the role of exercise in bronchial asthma [Table

Table 3 : Mean scores for different components of PHC personnel's' knowledge about bronchial asthma according to their occupation Knowledge Components Physicians
(n = 44) Nurses (n = 150) t-test P-value * Mean, ** Standard deviation

Table 4 : Logistic regression analysis of signifi cant factors predicting knowledge level about bronchial asthma in children among PHC personnel
2odel X2(14) = 38.251,P < 0.001, Figure 1: Distribution of PHC personnel according to their level of total knowledge score about bronchial asthma