Current Knowledge Attitudes, and Practices of Healthcare Providers about Leprosy in Assam, India

Background: Leprosy is a chronic infectious disease that is associated with serious morbidity and is a disease of public health concern because of the case load and the social stigma attached to the disease. Aim: To understand the knowledge of, and attitudes towards, leprosy amongst healthcare providers in Assam, India. Settings and Design: This cross-sectional study was conducted during March to June 2007 in different health institutions of the Kamrup district of Assam. Results: Among the program managers interviewed, only half were organizing training sessions, and 37.5% were involved in supervision of the program activities at the periphery level. Among the program managers who were involved with leprosy elimination, only half were organizing training session and 37.5% were involved in supervision of the program activities at the periphery level. Medical officers consistently demonstrated higher knowledge about leprosy, followed by health supervisors and multipurpose workers (MPWs), including nursing staff. Regarding training status with regard to leprosy, 90% of medical officers, 80% of health supervisors and around 87% of MPWs (83% of male MPWs and 89% of female MPWs) had attended training programs on leprosy. Regarding WHO MDT, 80% of health supervisors, 84.8% of male MPWs and 86.2% of female MPWs had an idea of MDT and treatment duration of various categories of patients. Conclusions: These observations suggest that there appear to be adequate knowledge and positive behavior among healthcare providers with regard to leprosy in this part of India. However, there is still a need to organize training programs at regular intervals to train new recruits, as well as reinforce and update the knowledge of those already trained.


INTRODUCTION
L eprosy is still prevalent in certain parts of the world, particularly India and South America. [1] Social stigma and prejudices associated with leprosy still remain major obstacles for its eradication.
After India had declared the goal of elimination of leprosy, it was no longer cost effective to rely on rapid surveys, population surveys and contact tracing for case detection, and since then most new cases have been diagnosed by the General Health Service staff; and since 2001, MDT services were integrated with the general healthcare delivery system. [2] Human resource development of general healthcare system (GHS) is a vital preparatory action for successful integration of leprosy into GHS. District-level technical support teams (DTSTs) have been formed with responsibility for building up the capacity of medical and paramedical staff working at various levels of the system. [3]  Studies indicated that in the currently declining phase of leprosy endemicity, employing a conventionally trained, salaried class of paramedical staff for field surveys is prohibitively expensive in view of the high cost per case detected. Involving primary healthcare workers and community-derived workers is cost effective. [4] Integration of the vertical leprosy program with the existing horizontal health program poses various administrative and operational challenges for program managers. [5] In this context, it is necessary to know the current levels of knowledge, attitude and practices (KAP) prevailing among healthcare personnel with regard to leprosy at a given point in time, so that required knowledge and skills can be imparted. This study was carried out to identify the healthproviding behavior of healthcare personnel working in an endemic region of Kamrup district of Assam under the MDT-implementation and leprosy-elimination program.

MATERIALS AND METHODS
This cross-sectional study was based on both quantitative and qualitative parameters with review of relevant documents, records and literature at Kamrup district of Assam, India, from March 2007 to June 2007. To assess the training status and program management at the community level, it was decided to interview the medical officers and health workers working in various health institutions in the district. The district has two divisions: urban and rural. Rural Kamrup had 14 block primary health centers (PHCs). Keeping in view the operational feasibility and manpower constraints, we took up about 25% of these PHCs, i.e., four. These four PHCs were selected randomly from the set. The following block PHCs got selected, viz., Uparhali block PHC, Boko block PHC, Sonapur block PHC and Hajo block PHC.
For urban representation, we had taken into consideration major government health institutions. The Upgraded Urban Leprosy Centre attached to the dermatology clinic of Guwahati Medical College, and the Urban Leprosy Centre attached to Mohendra Mohan Hospital (MMH) were the primary sources of data.
Secondary data, i.e., data regarding the manpower involved in delivering healthcare in these selected centers, was collected from the office of the Director of Health Services.
The data collection tool used for the study was an interview schedule that was developed at the institute with the assistance from the faculty members and other experts. Different information modalities were sought from different groups of health personnel. The questionnaire was discussed among the faculty of Department of Community Medicine, Guwahati Medical College, and it was also shared with the zonal officers of the district dealing with leprosy. The schedule was then pre-tested in the field to rule out operational constraints. The pilot study was carried out at the institute among general healthcare personnel, following which some of the questions from the interview schedule were modified.
This pre-designed and pre-tested questionnaire contained questions relating to the information on designation of the staff; his/ her training status in leprosy; the presence or absence of knowledge about leprosy, its categorization, its treatment modalities; and individual involvement in the National Leprosy Eradication Programme The study was approved by the institutional ethics committee of Guwahati Medical College. All the healthcare providers present during the study period were included. Those on leave or transferred to another district were excluded from the study. Accordingly, 50 medical officers, 40 health supervisors, 66 male multipurpose health workers and nonmedical assistants, 65 female multipurpose health workers and auxiliary nurse midwives, along with 8 policy makers at the district headquarters, were selected for study. All the participants were explained about the purpose of the study and were ensured strict confidentiality, and then informed consent was taken from each of them. They were given the option of not participating in the study if they so desired.

Statistical analysis
The data collected were thoroughly screened and entered into MS-Excel spreadsheets, and analysis was carried out. The procedures involved were transcription, preliminary data inspection, content analysis and interpretation. Percentages were used in this study to analyze study variables.

RESULTS
Among the program managers interviewed, only half were organizing training sessions, and 37.5% were involved in supervision of the program activities at the periphery level [ Table 1].
Regarding training status in leprosy, 90% of medical officers, 80% of health supervisors and around 87% of MPWs (83% of male MPWs and 89% of female MPWs) had attended training programs on leprosy [ Table 2].
The health-providing behavior of the programimplementing personnel was also studied. Sixty percent of the medical officers had a role to play in Information Education Communication (IEC). Among the health supervisors, 90% were aware of the cause of leprosy, while 92.5% were aware of the diagnosis, categorization of patients and treatment according to category. All the  Table 3].

DISCUSSION
Our study revealed a diverse yet good knowledge and attitudes towards leprosy among the 'MDT (multidrug therapy)'-implementing personnel. Medical officers consistently demonstrated higher knowledge about leprosy in comparison with health supervisors and multipurpose workers, including nursing staff.
In a study from Hyderabad city, conducted in Government Health Services dispensaries in Hyderabad in order to assess KAP and some operational parameters, medical officers consistently demonstrated higher knowledge about leprosy, followed by nursing staff and paramedical workers.
More than half of the study subjects did not have specific training in leprosy. [3] A study was undertaken as part of operational research by the Ministry of Health and Family Welfare, Government of India, to assess the level of integration of leprosy services into general healthcare system in 24 low or moderately endemic states/ union territories. The data in this study included training status of general healthcare staff with regard to leprosy. About half (53.2%) of the existing medical officers, 83.9% of health supervisors and 96.8% of multipurpose workers were found to be trained in leprosy.
The study emphasized the need for training; as only 31.3% of medical officers were able to diagnose leprosy, and most of them were relying on vertical staff and skin specialists for confirmation. [6] Assam reported a higher level (97%) of training of medical officers in leprosy. Training of health supervisors and multipurpose workers was better than that of medical officers in most of the states. Tripura reported negligible training of all the health functionaries because of specific local problems. In Assam and Maharashtra, medical officers in all (100%) health facilities were diagnosing and treating leprosy cases, as compared with Himachal Pradesh (30%). However, lower involvement of GHS staff in recording and reporting was noted in Assam (both 0%, respectively), Andhra Pradesh (10% and 30%, respectively). [7] An investigation into the attitudes, beliefs and behavior of 730 primary healthcare (PHC) workers with regard to MDT was carried out in Yangzhou and Dongtai districts of China, which revealed that only half of the PHC workers had a basic knowledge of MDT and a desire to participate in MDT implementation. [8] The knowledge and attitude of health workers in northwestern Botswana with regard to leprosy were determined by interviewing 99 health workers from various health institutions. Knowledge on causation of leprosy was generally lacking. Although majority of respondents knew that the disease is curable, less than half knew the correct duration of treatment. [9] A study conducted by the Regional Leprosy Training and Research Institute, Lalpur, Raipur, Chhattisgarh, India, revealed that 45% of medical officers, 71% of health supervisors and 75% of multipurpose workers were trained in leprosy. [10] CONCLUSION To sum up, these observations suggest that there appear to be adequate knowledge and positive behavior of healthcare providers with regard to leprosy in this part of India. However, there is still a need to organize training programs at regular intervals to train new recruits, as well as reinforce and update the knowledge of those already trained. In view of the changing logistics, it is very necessary that manpower training and reinforcements should be given serious consideration by health planners.