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Assessment of Knowledge, Attitude, and Practices of Ministry of Health physicians toward surveillance system in Riyadh region

Over the past few years, new diseases such as Avian flu, Severe Acute Respiratory Syndrome (SARS) have emerged, while other diseases that were once thought in decline such as Tuberculosis (TB) have reemerged after having developed resistance to known antimicrobial drugs. As a result, fears from disease outbreaks have increased in both number and complexity.
A cross sectional descriptive self-administered question based survey was conducted. This part involved only Riyadh region as part of a national study including all MOH physicians working in notifying disease in both governmental Primary Health Care Centers (PHCC's) and hospitals. The study sample involved 970 physicians. Only completely filled records were included [760 (78.4%)].
There was a total of 550 (72.4%) physicians from 205 PHCCs and 210 (27.6%) from 21 hospitals. The physicians' ages ranged from 25 to 60 years. The majority were in the 30-45 years age group (62.4%). Their mean age ± Standard Deviation (S.D) was 41.6 ± 7.8 years. The majority were males 545 (71.7%). Saudi nationality constituted only 4.3%, and Egyptian physicians were the most common among non-Saudis (33%). More than half (66.2%) had been working for MOH for 11-20 years. General practitioners (GPs) comprised the majority of physicians (78.9%), followed by specialists (19.3%), and consultants (1.8%).
Poor knowledge in general surveillance information was found among over half the respondents (58.3%), most (87.1%) scored poor knowledge in the notifiable diseases, and none achieved 100% correct answers in disease notification.
Over half (61.7%) agreed that the case definition in the surveillance system was clear, and 63.1% agreed that the operating surveillance system was good. Sixty percent agreed that the current notifiable diseases were sufficient, 70.1% were not sure if another disease should be added, 21.7% thought that some diseases (eg. HIV/AIDS, Chicken pox, rubella) should be added; 13.8% suggested removing some notifiable diseases such as: poliomyelitis, Gillian Barre Syndrome, suspected polio, and measles.
Sixty one percent strongly agreed that MOH should arrange training courses in surveillance, and 57.3% strongly agreed to attend such courses. The majority (88.2%) hadn't attended any surveillance system training courses, and only 38.9% had a clear manual about surveillance. Seventy percent stated that they faced difficulties in notifying communicable diseases ranging from always to rarely. Difficulties reported were: patients uncooperative in giving information (55.9%), health inspector not always present (44.1%), insufficient time due to high patient load (35%), too much information to record (28.6%), patient not knowing his address (26.5%), communication system either busy or out of order (20.7%), and other reasons such as language barrier, staff not cooperative, patient didn't care, and results come late (14.4%).
Physicians who reported difficulties in conducting control measures constituted (30.1%). The most common reasons were: uncooperative contacts (90%), no communication system with patient (84.7%), unclear control measures of the diagnosed disease (81.7%), unknown patient's address (76.8%), transportation difficulties (75.1 %), uncooperative non-governmental hospitals (44.1%), the information required to fill was not clear (37.1%), physicians' lack of knowledge of the control measures of the diagnosed disease (35.8%), and other reasons (14.4%).
Physicians who had read about surveillance system comprised 85.8%, ranging from always to rarely. Journals and/or bulletins were the most common sources (60.7%), books (48.2%), internet (25%), and other sources (eg. MOH memo, mass media, symposia) (11.3%).
More than half (62.4%) stated that they received feedback from the directorate or regional district: always (11.6%), mostly (22.8%), sometimes (43.9%), and rarely (21.7%). Feedback was received in the form of letters (46.6%), reports (39.7%), journals and/ or bulletins (25.1 %), periodic meetings (5.1 %), other means (eg. phone, through health inspector) (5.1 %), and symposia (4.4%). Feedback was received via: Fax (43.9%),mail (37.8%), by hand (32.3%), and others (eg. hospital administration, regional director, newspaper) (7.8%).
Over half (55.7%) gave suggestions for improving the surveillance system, such as: periodic training courses, particularly directed at new physicians. Courses should be in English for non-Arabic speaking doctors, accredited from the Saudi council, and they should be held in a nearby place to minimize transportation and guarantee their appearance. Suggestions to improve the feedback system included: internet access and developing a website for feedback, more cooperation from referring hospitals, cooperative coordinators between the hospitals and the PHCCs.
Physician's good knowledge was significantly higher among non-Saudis (100%)(P-value=0.01),male physicians (77.6%) compared to females (22.4%) (P-value=0.002), and GPs (78.6%) compared to specialists (20.4%) and consultants (1%) (P-value < 0.001). In addition, physicians working in PHCCs scored significantly higher knowledge score (63.3%) compared to hospital physicians (37.6%), P-value< 0.001.
There was no effect of physician's attitude toward attending training courses in surveillance on their knowledge of the notifiable diseases (p-value=0.05). Physicians who had a clear manual and those who had read about surveillance scored significantly higher knowledge levels (P-values <0.001 and 0.03 respectively).
Difficulties faced by physicians in communicable disease notification was significantly lower among those who had attended training courses on surveillance (P-value <0.05), and those who had a clear manual (P-value =0.005).

Editorial note:

An epidemiological surveillance system is a set of interconnected elements and activities. It is well-known as a central part of health care system in order to monitor priority health events known to be taking place in the population and contributes to the achievement of surveillance objectives.[1]
Early detection of disease outbreaks through notification helps health authorities plan preventive measures in order to control their spread. Despite this, notification suffers some obstacles as shown by worldwide studies. One of these obstacles is underreporting even with the clear directions from MOH requiring medical providers to report notifiable infectious diseases to their regional directorate.[2,3]
It is crucial for many diseases to be reported on time as timeliness is a key surveillance system metric in order to implement the control measures and prevent the disease spread and should be periodically evaluated. As a result, the knowledge of the physicians about the correct timing is crucial. Furthermore, it is mandatory for these physicians to report on time and be aware of the control measures of each disease and overcome the difficulties that they may face. Physicians' good knowledge constituted only 12.9% in terms of identifying the time for reporting the 36 notifiable diseases. This is similar to the knowledge of disease notification among doctors in government hospitals in Benin City, Edo State, Nigeria (11.9%), and indicating poor doctor's knowledge.[4]
Lack of sufficient training and lack of clear written manuals may explain the poor knowledge of the physicians, and calls for periodic training courses in surveillance.
Difficulties faced by the physicians in notification in addition to their low Steps taken to overcome such difficulties may include undergraduate education on surveillance, training courses, clear written manuals, and multidisciplinary cooperation to improve communication with patients. Simple, short and readily accessible forms may help improve reporting rate.
Feedback in response to notification, ensures its effectiveness. The low level of feedback needs to be studied separately, to determine factors that affect the feedback system and ways to overcome the difficulties.
  1. WHO Regional Office for the Eastern Mediterranean. Surveillance of communicable diseases a training manual. Alexandria: 1998 WHO-EM/ CDS/52/E/L/06.98/2000.
  2. Guidelines for evaluating surveillance systems. MMWR 1988, 37(S-5);1-18.
  3. Bakarman MA, Al-Raddadi RM. Assessment of reporting and recording system of communicable diseases in Jeddah Region. SMJ 2000;21(8):751-754
  4. Ofili AN, Ugwu EN, Ziregbe A, Richars R, Salami S. Knowledge of disease notification among doctors in government hospitals in Benin City Edo State, Nigeria. Public Health 2003, 117(3):214-7.