Assessment of Knowledge, Attitudes, and Practices of Physicians working at private dispensaries and hospitals in Riyadh city towards the Surveillance System

Effective surveillance is the key to effective disease control. Once an infectious disease has been detected (or suspected) it should be notified to the local health authority, whose responsibility is to put into operation control and preventive measures. In addition to the government health system, the private health care system constitutes an essential part of surveillance mechanism. However, the knowledge of reporting requirements and responsibilities among physicians working in private health care has not been adequately examined as a cause of underreporting. This study was designed to assess the knowledge, attitudes, and practices of physicians in Riyadh private hospitals and dispensaries about disease surveillance.

The study was conducted as a cross sectional study using self-administered questionnaires. Private health care in Riyadh city is provided through a widespread network of around 237 private dispensaries and 17 private hospitals. A multistage stratified random cluster sampling technique was used to identify the physicians to be recruited into the study. A total of 45 dispensaries and 6 hospitals were selected. All physicians working in these selected private dispensaries and hospitals who encounter patients with communicable diseases (General Practitioners, Physicians in Medicine, Pediatrics, ENT, Dermatologists, Emergency, and Laboratory doctors) were included in this study.

A total of 255 physicians were included in this study, 76.5% of them were male, 46.7% were in the 36-45 years age group, and almost all were non Saudis. Of all participating physicians, 76.9% were working in private dispensaries; 14.9% of them had one year experience in the health field in Saudi Arabia; and 45.5% were working as medical or pediatric physicians.

About 43.5% of physicians had good knowledge of the definition and components of surveillance system and scored more than 70% of the total score, and only 9.4% had good knowledge about the time of notification for the 36 notifiable diseases in Saudi Arabia, and scored more than 70% of the total score (i.e. > 26 of 36), the remaining 90.6% scored under 70% (i.e. < 25 of 36).

In the assessment of physicians attitudes toward different components of the surveillance system, 76.1% agreed that the case definition is clear, 63.5% agreed that the operating surveillance system is good, 67.4% agreed that the notifiable diseases are sufficient, 56.1% didn't agree that some diseases should be added, 56.4% didn't agree that some diseases should be removed, 95.7% agreed that the Ministry of Health (MOH) should arrange training courses in surveillance, and 87.1% agreed that they would like to attend such courses.

About 41% of participating physicians had a clear manual about the surveillance system, and 92% of them claimed that they were following the MOH strategy. Only 6% had attended training courses in surveillance system. About 80% of all participants read about surveillance system, ranging from always 3.9% to rarely 22.4%. Journals were reported as the main source of reading about surveillance among 46.7% of the physicians.

In case of detecting any notifiable disease or outbreak, 78% of participating physicians notified this disease or outbreak to the MOH. Among those who did notification for communicable disease, 27.6% never faced any difficulties during notification, and 72.4% faced difficulties ranging from always 4.5% to rarely 19.6%. Some of these difficulties were related to patients' such as lack of cooperation in giving the information (43.7%) and patient not knowing his address (18.1%). Other difficulties were related to the health facility, which included that there wasn't enough time for recording the information due to too many patients (21.6%), no health inspector (28.6%), or the health inspector is there but not always present (22.1%). The difficulties related to the surveillance system included that the notification system is not clear (36.7%), and that there was too much information to record (21.6%).

Of all participating physicians, 71.4% took control measures in case of detecting any notifiable disease or any outbreak, 20.3% of those conducting control measures did not have any difficulties in conducting the control measures, 35.2% faced difficulties due to uncooperative patient's contacts, 26.9% due to unclear control measures for some diseases, and 18.7% due to unknown patient's address.

Out of all physicians, 46.7% never received any feedback, 4.5% always received feedback, 8.6% received it mostly, 24.1% received it sometimes, and 16.1% rarely received feedback. Regarding feedback types, letters were received by 34.2%, Journals/ Bulletin by 23.1%, Report by 16.1%, Symposium by 3%, and periodic meetings 1%. The feedback was received via mail (27%), fax (25%), or hand carried (21.6%).

There was no statistically significant difference in the knowledge of physicians according to their characteristics. The only statistically significant difference was found between physicians due to difference in their place of work, those working in hospitals had a proportion of good knowledge about surveillance definition (P=0.013) and notification time (P= <0.0001) higher than those working in dispensaries.

It was concluded that knowledge about disease notification among doctors working in Riyadh private hospitals and dispensaries was poor, which can affect disease surveillance. Most participating physicians had not received any training courses about surveillance system, and most of them claimed not to have received any feedback on infectious disease surveillance. The training and retraining of physicians responsible for data generation, collection and forwarding in health facilities on disease notification, regular feedback on diseases reported and provision of forms were recommended in order to improve the disease surveillance system.

Surveillance is an important source of epidemiological information. In this study, it was observed that although under half of the participant physicians had a good knowledge of disease notification about 78% were reporting notifiable diseases to the MOH. However, under the circumstances we have no idea about the completeness, presence, or accuracy of personal and disease data, and whether they are reporting on time. A study conducted in Jeddah to assess the reporting system of communicable diseases found that the reporting rate was 74%, but its usefulness was diminished because of the incomplete, absent or incorrect personal and disease data.[1]

Worldwide, notifiable disease surveillance often suffers from incomplete reporting; many difficulties can be faced by physicians during reporting which can lead to underreporting, some of these difficulties may be related to physicians themselves, some related to patients, and some related to the surveillance system.[2] In this study, the most frequent difficulties faced by physicians during reporting were due to uncooperative patients in giving the correct information about the disease, unclear notification system, the time for recording the information is not enough, and the patient didn't know his address; these difficulties were similar to that found in many other studies done worldwide. In one study two primary barriers to reporting were not knowing what diseases were reportable, and the perception that the reporting process required too much time and effort.[3] In another study the major barriers to reporting most frequently identified included time required for notification, lack of knowledge regarding which diseases are reportable, and a belief that many notifiable diseases are too common or unimportant to merit the effort of reporting.[4]

Poor attitude has been attributed to physician assumption that someone else will report, concerns regarding the effort required for reporting, insufficient compensation for doing so, and a view that no useful action is taken on notifications.[5] Feedback to doctors, showing them that preventive action is taken as a result of notification, may be an effective way to improve notification practices. However, this study showed that few doctors received any feedback.[6] Only 6% of physicians working in private hospitals and dispensaries had attended training courses in surveillance, which indicates lack of coordination with MOH, and needs to be taken care of if the surveillance system is to be improved.