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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 2  |  Page : 516-521

Predictors of poor knowledge, attitude, and practice among primary care physicians toward end-of-life care


Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission23-May-2021
Date of Decision24-Jul-2021
Date of Acceptance27-Jul-2021
Date of Web Publication27-Jul-2022

Correspondence Address:
Shimaa M. A. Ammar
Tanta, Gharbia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_101_21

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  Abstract 


Background
The prevalence of multiple chronic conditions in elderly people rises recently. Establishing comprehensive end-of-life (EOL) care to improve their quality of life and avoid any unnecessary suffering is mandatory. Being the first point of contact with the health care system, primary care physicians' knowledge, attitude, and practice (KAP) toward EOL care is evidently considered.
Objectives
To assess KAP among primary care physicians and the predictors of poor KAP regarding EOL care.
Aim
To improve the EOL services among primary care physicians.
Patients and methods
A cross-sectional study was conducted on randomly selected 300 primary care physicians from the 1st of May to the end of November 2019. The selected participants were interviewed through a semistructured self-administered questionnaire composed of four parts inquiring about their sociodemographic data, KAP level toward EOL care.
Results
The majority of the studied participants had poor knowledge (94.7%) and practice (96.3%) about EOL care. Only 37.7% of them had a negative attitude. Being female (P = 0.03) and general practitioner (P = 0.02) were the most affecting factors of poor knowledge. General practitioner was the most influencing factor on poor attitude (P = 0.04). There was a positive correlation between knowledge score and attitude score (P < 0.001), and the same with knowledge score and practice score (P < 0.001).
Conclusion
Although more than half of the physicians had positive attitude as regards EOL care, their knowledge and practice levels were poor. Being a female and general practitioner expressed more poor knowledge. Being a general practitioner showed poor attitude, while working in rural areas was the main affecting factor on poor practice.
Recommendation
EOL care should be integrated in both undergraduate and postgraduate studies.

Keywords: attitude, end-of-life care, knowledge, practice, primary care physicians


How to cite this article:
Shaheen HM, Salama AA, Ammar SM, Mohasseb MM. Predictors of poor knowledge, attitude, and practice among primary care physicians toward end-of-life care. Menoufia Med J 2022;35:516-21

How to cite this URL:
Shaheen HM, Salama AA, Ammar SM, Mohasseb MM. Predictors of poor knowledge, attitude, and practice among primary care physicians toward end-of-life care. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:516-21. Available from: http://www.mmj.eg.net/text.asp?2022/35/2/516/352113




  Introduction Top


Over 40 million individuals live with incurable diseases in need for end-of-life (EOL) care. About 78% of them live in low-income and middle-income countries with poor access to EOL care[1].

EOL care is the care that is provided for persons whose illness is no longer responding to curative treatments through an interdisciplinary team. Such care includes physical, emotional, social, and spiritual support for patients and their families[2].

The WHO classifies EOL care as a top priority for global health care and has characterized the need for EOL care as 'an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases'[3].

EOL care includes physical, emotional, social, and spiritual support for patients and their families. It is referred to as palliative care, hospice care, holistic care, and terminal care. Even though a difference was found between these terms, there was a misconception in using these terminologies[4].

Integrating EOL care early in the disease trajectory can result not only in good control of such symptoms and better quality of life for those patients and their families, but also in their illness perception, goals of care discussion, acceptance of advanced care planning, and overall survival. Moreover, it decreases emergency department visits and costs of care[5].

There are a lot of barriers to developing EOL care worldwide as a misperception about terminology, inaccessibility of service, lack of knowledge, family barriers, financial burden, conflict with spiritual beliefs, desire for aggressive care, medical mistrust, bad communication skills, and nonreferral or late referral[6].

Globally, there are limited guidelines for establishing EOL care programs and their availability in low-income and middle-income countries is also unknown[7].

The status of EOL care in developing countries is alarming. Very little research in EOL care has been published in such countries[8].

Studies assessing EOL knowledge, attitude, and practice (KAP) of physicians in developed countries are not representative of the overall reality due to small samples and local studies[9].

In Egypt, there are no data about EOL care knowledge and practice among physicians[10].

The aim of this work was to improve the EOL services among primary care physicians.


  Participants and methods Top


A cross-sectional study was conducted during the period from the first of May 2019 to the end of December 2020 in Menoufia governorate, Egypt.

Out of 1172 primary care physicians working in Menoufia health directorate, 300 participants were selected by proportional allocation method from the nine health administrations and then data were collected from the physicians by simple random sampling technique.

The sample size was calculated, based on the total number of physicians, prevalence (50%) being the highest frequency to calculate the largest possible sample size as the prevalence is unknown, and power of the study (80%), and confidence level of 95% to be 289 physicians that was increased by 10% to be 317 to overcome the incomplete questionnaires.

The selected participants were interviewed through a semistructured self-administered questionnaire composed of four parts inquiring about their sociodemographic data, KAP level toward EOL care.

The first part of the questionnaire included data about the personal characteristics of the physicians: age, sex, years of practice, qualification, and workplace. The second part addressed the knowledge about EOL care, their understanding of its terms using questions, for example, hospice care definition and its availability, difference between EOL care and palliative care. The third section asks about the attitude toward EOL care using questions, for example, their beliefs about terminal illness, spiritual care importance, decision making, and breaking bad news.

The last part was for assessment of the practice using questions as availability of terminal illness services, any involvement in such care, number of their terminal ill patients in the previous year, pain assessment, psychological issue involvement, and obstacles in providing such care.

The questionnaire was tested by being submitted to a panel of three experts to test its validity. Content-validity index of the designed questionnaire was calculated. It was 90% for the questionnaire used in the study. Cronbach's α was calculated, and it equaled 0.93.

The pilot study was conducted before the beginning of the field work; the study included 30 primary care physicians that were excluded from the study after modification of the questionnaire according to the results of the pilot study, such as reduction of its questions to avoid annoying participants by too many questions, change some answers that were not conclusive, and explain some expressions in detail as the word euthanasia that means mercy killing.

All the collected information was manually reviewed, verified, and coded before entry of the data. Variables were presented as number and percent.

The median score was calculated to assess good and poor scores. The median score for knowledge 30, attitude 34, and practice 36. Above that, median score is considered good and below is considered poor.

The research proposal was approved by the Ethical Committee in Menoufia Faculty of Medicine. Written consent was obtained from the participants recruited in the study after an explanation of the objectives of the study.

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM personal computer with Statistical Package of Social Science (SPSS), version 22 (SPSS Inc., Chicago, Illinois, USA).

Quantitative data were presented in the form of the mean, SD, and qualitative data were presented in the form of numbers and percentages, and were compared using the χ test and Fisher exact test. Pearson correlation was used to determine the correlation between parametric quantitative variables and the stepwise binary logistic regression to identify the most affecting factor. P value less than 0.05 was set as statistically significant and P value less than 0.001 was set as highly significant.


  Results Top


This study was conducted on 300 participants. In total, 204 of the studied participants were females, 219 of them work in rural places, and 206 were general practitioners. According to years of practice, only 43 of the studied participants had more than 5 years of practice, 205 of them had MBBCH as the highest degree of qualification, and 159 of them would continue medical education training programs [Table 1].
Table 1: Factors affecting poor knowledge score towards End-of-Life care among the studied participants

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The majority of the studied participants (95 and 96%) had poor knowledge and practice, respectively, while 38% only had poor attitudes toward EOL care [Figure 1].
Figure 1: Knowledge, attitude, and practice scores among participants.

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According to age, poor knowledge was more among participants with this age 27.7 ± 2.6, poor attitude was more among participants with this age 27.5 ± 2.5, and there was poor practice in this age 27.5 ± 2.5 [Table 1],[Table 2],[Table 3].
Table 2: Factors affecting poor attitude score towards End-of-Life care among the studied participants

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Table 3: Factors affecting poor practice score towards End-of-Life care among the studied participants

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There were more poor KAP with female physicians by about 67, 66, and 68%, respectively, which was statistically significant (P = 0.02) associated with poor knowledge. Primary care physicians who were working in rural areas had also a more poor level of KAP by about 74, 71, and 72%, respectively. This was the statistically significant factor (P = 0.04) associated with poor practice [Table 1],[Table 2],[Table 3].

General practitioners had also poor KAP by about 72, 77, and 69%, respectively. This was statistically highly significant (P = 0.0001) associated with both poor knowledge and attitude. Poor KAP were with primary care physicians who were qualified only with bachelor's degrees by about 71, 75, and 69%, respectively, which was statistically significantly associated with poor knowledge and attitude, respectively [Table 1],[Table 2],[Table 3].

Being female and general practitioners were the most affecting factors in predicting EOL poor knowledge and general practitioner was the most affecting factor in assessing the EOL poor attitude among the studied participants [Table 4].
Table 4: Multivariate binary logistic regression for factors affecting poor knowledge and attitude

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There was a strong significant correlation between knowledge score and attitude score, and the same was found with knowledge score and practice score [Figure 2]a and [Figure 2]b.
Figure 2: (a) Correlation of knowledge of end-of-life care and attitude. (b) Correlation of knowledge of end-of-life care and practice.

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  Discussion Top


The study revealed that about 95% of the studied physicians had poor knowledge about EOL care. This was consistent with a study conducted in Northern Ireland where about 85% of physicians had poor knowledge[11]. In contrast, research conducted in Japan showed that about 72% of physicians had sufficient knowledge because they were providing EOL care as part of their general practice, and were developing a multidisciplinary support system to provide EOL care for patients[12].

More than 96% of the practice was poor, which may be explained by having poor knowledge about such topic.

But only about 38% of participants had a negative attitude toward EOL care. This was consistent with a study in Japan that declared that 37% of physicians had negative attitudes[13].

In the current study, female physicians had the main percentage with poor knowledge by about 67%. This is inconsistent with a study conducted by Taber et al.[14], which stated that being a female increased the knowledge of EOL care, which was explained by their interest in EOL care and geriatric medicine as a subspecialty. Also, no difference by sex was observed in Italy where both males and females had the same chances of learning, practice about EOL care, and sharing the same interest in it[15].

The study recorded that more than two-thirds of poor knowledge was with general practitioners, this may be because it is not adequately integrated into the undergraduate curriculum. That was consistent with the study of Paal et al.[16] where about 65% of general practitioners had poor knowledge.

Also, about 77% of negative attitude was with general practitioners, which was explained by their beliefs in EOL as they did not get more sufficient information about EOL care. Mostly, 80% of negative attitude was found in bachelor's degree qualifications, which was nearly in agreement with a study in Turkey declaring that about 78% of bachelor's degree holders had negative attitudes[17].

Mainly, the poor practice was found among the participants in the rural workplace. This may be because of the cultural and spiritual perspectives that are different in the rural areas.

The study showed a strong significant correlation between knowledge score and attitude score (P = 0.0001), and the same with knowledge score and practice score (P = 0.0001). These results are nearly in agreement with previous studies in Saudi Arabia[18] and Vietnam[19].

Strengths and limitations

EOL care research is a new topic in Egypt. To the best of our knowledge, the previous studies in Egypt are so limited. The study was conducted on primary care physicians from the whole governorate. However, the study was conducted in only one governorate. Future studies should be applied in other governorates to provide more ideas about EOL care.


  Conclusion and recommendation Top


Primary care physicians' knowledge and practice about EOL care were poor, but their attitude was relatively positive. Being female physicians, general practitioners, and working in rural areas were the most affecting factors for KAP. So EOL care should be integrated in both undergraduate and postgraduate studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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