|DR P C SEN BEST PAPER AWARD
|Year : 2016 | Volume
| Issue : 3 | Page : 181-187
Taking stocks of antimalarial activities: A study on knowledge and skill of health personnel at primary care setting in the state of West Bengal, India
AB Biswas1, Sarmila Mallik2, Dipta Kanti Mukhopadhyay3, Aditya Prasad Sarkar4, Susmita Nayak5, Asit Kumar Biswas6
1 Professor, Institute of Health and Family Welfare, Kolkata, West Bengal, India
2 Professor, Department of Community Medicine, Murshidabad Medical College and Hospital, Kolkata, West Bengal, India
3 Associate Professor, Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
4 Associate Professor, Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
5 Consultant, Institute of Health and Family Welfare, Kolkata, West Bengal, India
6 Chief Medical Officer of Health, Darjeeling, West Bengal, India
|Date of Web Publication||24-Aug-2016|
Dr. Sarmila Mallik
C/5, Ideal Association, VIP Road, Kolkata - 700 054, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Early diagnosis and effective treatment are the key areas in malaria control in India. Objective: The present study was carried out to assess the knowledge and skill of health personnel at primary care level and the logistic support related to the program at subcenter (SC) level. Methods: A cross-sectional, descriptive study was conducted among medical and paramedical personnel working at primary health-care institutions in two districts of West Bengal. Knowledge was assessed using a structured questionnaire while diagnostic skill and logistic support were assessed with structured checklists. Clinical skill was assessed with case vignettes. Results: Requisite knowledge on diagnostic procedure was found in two-third to three-fourth of health personnel while only 26.7% and 12.4%, respectively, knew the correct treatment of Plasmodium vivax and Plasmodium falciparum malaria. Median standardized score for knowledge was 50.0 while the scores for skill of preparing blood slide and for rapid diagnostic test were 70.0 and 57.1, respectively. Education and work experience were related to diagnostic skill but had little effect on knowledge. In clinical skill, medical personnel scored 50% or more in investigation and treatment aspects only. In another case vignette, health workers excelled over medical officers and other staff in all axes other than history taking and clinical examination although their performance was also suboptimal. Formal training on malaria did not show any bearing on median knowledge and skill score. Supply of diagnostics and drugs was insufficient in majority of SCs. Conclusion: Renewed efforts are needed to create competent workforce and ensure adequate logistic supply.
Keywords: Health personnel, India, knowledge, malaria, primary care, skill
|How to cite this article:|
Biswas A B, Mallik S, Mukhopadhyay DK, Sarkar AP, Nayak S, Biswas AK. Taking stocks of antimalarial activities: A study on knowledge and skill of health personnel at primary care setting in the state of West Bengal, India. Indian J Public Health 2016;60:181-7
|How to cite this URL:|
Biswas A B, Mallik S, Mukhopadhyay DK, Sarkar AP, Nayak S, Biswas AK. Taking stocks of antimalarial activities: A study on knowledge and skill of health personnel at primary care setting in the state of West Bengal, India. Indian J Public Health [serial online] 2016 [cited 2019 May 21];60:181-7. Available from: http://www.ijph.in/text.asp?2016/60/3/181/189003
| Introduction|| |
In spite of the gradual reduction in case load of malaria in India, it continues to be a major public health problem in the country.  About 27% of Indians live in areas with high transmission of malaria with annual parasite incidence (API) of 1 or more.  Totally, 15 states of India including the Northeastern states and West Bengal reported around 92% of all malaria cases of the country with 97% of deaths due to malaria.  In West Bengal, besides its capital city of Kolkata and the adjoining areas, the forest and the areas in proximity to forests in Terai and Dooars in Northern districts and the similar (Junglemahal) areas of Southwestern districts of the state were known for high transmission of malaria. 
Under the National Vector Borne Disease Control Programme (NVBDCP), one of the major thrust areas for control of malaria is on its early diagnosis with prompt, complete, and effective treatment.  Examination of blood smear has been the mainstay for diagnosis of Plasmodium species causing malaria. The government has introduced rapid diagnostic test (RDT) for easy and prompt diagnosis of malaria in high endemic areas. , Under the national programme (NVBDCP), health workers at subcenter (SC) level are primarily responsible for the diagnosis of malaria through blood smear or RDT and managing the disease based on the results of the tests. ,
Globally, it was noted that in providing good quality care for malaria, the stumbling blocks were increasing complexities in diagnosis and treatment as well as lack of the presence of appropriate skills in peripheral health workers. ,, However, there is a paucity of authentic and representative data regarding knowledge, skills, and practices of health personnel with regard to malaria in India in published literature. 
In such a perspective, the present study was planned to be undertaken among health personnel at primary care level in West Bengal with following objectives:
- To assess the knowledge of health personnel in West Bengal regarding diagnosis, management, and control of malaria as per NVBDCP
- To assess the skill of health personnel on diagnosis and management of malaria
- To assess the logistic support at SC level.
| Materials and Methods|| |
Design and period of study
We undertook a cross-sectional, descriptive study among health personnel serving at primary care level in West Bengal from March 2013 to April 2014. Field level data were collected in the month of August 2013.
West Bengal, the fourth most populous state of India with a population of 91 million, was the study area. It spreads over 80750 km 2 across 19 districts. In 2012, API of West Bengal was 0.61 with only one district having API more than two. 
They consisted of the medical officers (MOs) including block medical officer of health (BMOH), public health nurse (PHN), Gram Panchayat level health supervisor (HS), and frontline health workers consisting of health workers - male, health workers - female, and second auxiliary nurse midwife (ANM) working at the primary care level, i.e., block primary health center (PHC), PHC, and SC in the selected districts of West Bengal.
We used multistage sampling to select the sampling unit, i.e., SCs and its staff. Based on the state average of annual blood examination rate (ABER) (5.65%), we selected two districts of West Bengal: one above (Nadia) and one below (Birbhum) the average.  In each of the selected districts, we selected two blocks by simple random sampling. BMOH and PHN of all the blocks and all MOs, HSs, and frontline health workers of the selected blocks of both the districts were included for the assessment of knowledge on diagnosis, management, and control of malaria as well as their clinical skill.
In each block, 2 gram panchayat (GPs) and 2 SCs from each GP were selected randomly in the study. In addition to knowledge and clinical skill regarding malaria, GP level HSs of the selected GPs, all frontline health workers attached to selected SCs were assessed for diagnostic skill in the study. Logistic supply for malaria control activities to the selected SCs was also assessed.
The Institutional Ethics Committee of B.S. Medical College, Bankura, issued ethical clearance certificate. Questionnaire and clinical case vignette were prepared, pretested in a nearby district, and validated with the help of multidisciplinary experts. A team of public health experts validated the scheme of scoring utilized in observation checklists. We collected information on age, sex, designation, educational qualification, working experience in health sector, status of formal training on malaria, and knowledge of the health personnel regarding diagnosis, management, and control of malaria as per the national programme through a self-administered, structured questionnaire at the respective SCs/PHCs. An observation checklist with scoring was used to assess skill on the preparation of blood slides and use of rapid diagnostic kit (RDK). Investigators gave a score of "2" for each correct step in preparing blood smear or performing RDT and "0" for each incorrect step. Clinical case vignettes were used to assess malaria case management skill. In case vignette, each correct answer was awarded with "1" and each incorrect answer was given "0".
At the SCs, we assessed the availability of logistic supply vis-à-vis essential medicines (chloroquine, artemisinin-based combination therapy [ACT] primaquine, paracetamol), RDK, slides, lancet, reporting forms (M1 for report of surveillance by peripheral health worker/institution, M2 for laboratory request form for blood slide examination, M4, the monthly reporting form) etc., by a checklist. An item was considered to be available sufficiently if average stock for a month (based on consumption of last 3 months) of that item was present on the 1 st day of the month of survey, and was assessed from stock registers and through physical verification.
Data management and analysis
Field investigators for this study were either faculty members of different medical colleges or senior health officials of West Bengal. They were trained before the study for the purpose. Quality control was maintained by a group of experts. Data were entered in Microsoft Excel sheets and were analyzed. Total score attained in knowledge questionnaire and in a particular checklist was standardized by expressing it in the percentage of maximum attainable score. Box-Whisker plots were used to show the distribution of score of knowledge and diagnostic skills according to background characteristics of the health personnel. Radar chart was used to show the distribution of score of case management. The proportion of specific attributes was calculated and expressed in percentages.
| Results|| |
In the present study, 315 health personnel participated in the assessment of knowledge on malaria and skill of clinical case management. Of them, 16.5% were MOs, 14.3% were PHNs, 8.9% were HSs, and around 60% were frontline health workers including health workers - female (28.9%), second ANM (21.0%), and health workers - male (10.5%). More than one-fourth (27.3%) were graduate and around one-fifth (20.9%) had either postgraduate or medical degrees. More than half (58.7%) had a working experience of 5 years or more while around one-sixth (14.9%) joined the government health services within last 1 year. Almost half (49.8%) received at least one formal training on malaria and 49.0% of them received it within last 1 year. In total, 39 frontline health workers and HSs attached to 16 SCs participated in the assessment of diagnostic skills. Of them, 38.5% were health workers - female, 33.3% were second ANMs, and 18.0% were health workers - male. Slightly less than half of the participants had graduation/postgraduation (46.2%) and more than half (53.8%) received any training on malaria. Almost half of the participants (48.7%) had working experience of <5 years.
The proportion of health personnel who correctly knew the volume of blood needed to prepare both thick and thin blood smears and could interpret the results of RDT from schematic diagram was (199/315) 63.2% and (241/315) 76.5%, respectively. It was found in [Table 1] that the proportion of frontline health workers knowing those aspects was significantly higher than those of MOs, PHNs, and HSs. There was no significant difference in the proportion of different categories of health personnel knowing complete treatment of Plasmodium vivax and Plasmodium falciparum malaria. Although, it was noted that only (84/315) 26.6% and (39/315) 12.4% of health personnel knew the complete treatment of P. vivax and P. falciparum malaria, respectively.
|Table 1: Distribution of health personnel according to their knowledge on diagnosis and treatment of malaria |
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It was also noted in the present study that (162/315) 51.4% of the participants knew the contraindications of primaquine. Correct duration of antimalarial effectiveness of insecticidal residual spray with dichlorodiphenyltrichloroethane and long-lasting insecticidal net was known to only (13/315) 4.1% and (28/315) 8.9% participants, respectively.
Median standardized knowledge score for all health personnel was 50.0. [Figure 1] shows that median standardized knowledge score was highest in health workers - male followed by MOs and female frontline workers (health workers - female and second ANM) and lowest in PHN and HSs. Standardized knowledge score showed little variation depending on education or work experience. Health personnel who did not receive any formal training on malaria had a slightly lower median score with wider intragroup variation than those who received it.
|Figure 1: Distribution of standardized knowledge score of health personnel according to designation, education, work experience, and formal training on malaria|
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The median standardized skill score for the preparation of blood slide for all health personnel was 70.0. [Figure 2] reveals that the median standardized skill score was highest in health workers - male followed by female frontline health workers. HSs had lowest median score with wider intragroup variation. Health personnel having graduation/postgraduation and working experience of 5 years or more had higher median standardized skill score with smaller intragroup variations than their counterparts. Receipt of any formal training on malaria did not show any change on median skill score although those who did not receive training showed wider intragroup variation. On further analysis, it was noted that waiting for spontaneous blood flow, offering whole edge of spreader slide, correct angle, and shape of the smear were the weakest areas in preparing blood smear where health workers - male superseded others.
|Figure 2: Distribution of standardized skill score of health personnel for preparation of blood slide according to designation, education, work experience, and formal training on malaria|
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The median standardized skill score for conduction of RDT for all health personnel was 57.1. As shown in [Figure 3], second ANM ranked best followed by HS. Health workers - male and female had lowest median score. Health personnel who had graduation/postgraduation or having working experience of <5 years had higher score than their counterparts. However, those having working experience of <5 years showed wider intragroup variation. Health personnel had similar score irrespective of receipt of training. On further analysis, it was found that checking for the expiry date, keeping the kit on level surface, and checking result after 15-20 min were the most commonly neglected skills.
|Figure 3: Distribution of standardized skill score of health personnel for conduction of rapid diagnostic test according to designation, education, work experience, and formal training on malaria|
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[Figure 4]a shows that in case vignette for MOs only, they scored more than 50% in only investigation and treatment axes, and in other three axes, they scored 40% or below. In another case vignette, although in all axes other than history taking and clinical examination, frontline health workers performed better than MOs, PHNs, and HSs, even they scored 50% or more in the only investigation and follow-up axes [Figure 4]b.
|Figure 4: Radar chart showing case management skill among different categories of health personnel|
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Around one-third of SCs had sufficient quality of blood slides (37.5%), lancet (31.3%), and RDK (37.5%). The majority of the SCs had stock of chloroquine (93.8%), ACT (87.5%), and primaquine (81.3%) although not in sufficient quantity. More than 90% SCs had an adequate quantity of M2 form; however, M1 and M4 forms were available in 56.3% SCs.
| Discussion|| |
In both public and private health systems worldwide, health personnel are increasingly been considered as the key resources as they are critical for delivering health services. , In this study, we want to emphasize the knowledge and skill of health personnel regarding malaria. Although 80.0% of the frontline health workers were aware of diagnostic procedures for malaria, the complete treatment of P. vivax and P. falciparum malaria was known to nearly one-fourth and one-seventh of health workers, respectively. In Odisha, around 80% of frontline health workers could correctly interpret RDT.  The knowledge of PHNs and HSs on both diagnosis and treatment of malaria was low. Even the MOs who were not only responsible for the diagnosis and treatment at primary care level but also had the responsibility of supervising all paramedics were having suboptimal knowledge. Lack of knowledge among key health personnel about the complete treatment of malaria may decelerate the attainment of the objectives of the national program. Poor awareness of health personnel regarding contraindications of common antimalarial drugs may pose hindrance in effective control of malaria.
Practicing the essential steps of preparing a blood slide was done best by the health workers - males and their experience was reflected in their score in this regard. HSs, who did the poorest in this scoring, must refine their skill by sustained practicing. The finding of median score of seventy among all participants was not a disclosure of sorts as such a finding was obtained in Ethiopia as well, where at least half of the peripheral public laboratories did not fit the standard procedure of preparation and staining of blood smears. 
The median standardized skill score of all participants for conduction of RDT was just above 50.0. Second ANMs, the newly recruited cadre in the health service, have excelled in this skill. Inclusion of RDT in their preservice training and joining in government health services when RDT had been gradually inducted might have helped them to score higher in this skill compared to other categories of health personnel with smaller intragroup variation. A more systematic approach toward this diagnostic procedure such as checking of the expiry date, reading the result after optimum time needs to be inculcated in the health personnel. Problems in conducting RDT were reported by Blanas et al.  However, studies from Zambia and Uganda reported effective use of RDT by health workers. ,
MOs could not score even 50% of maximum attainable score in three axes; for example, history taking and clinical examination, of the designated case vignette for MOs. Infrequent clinical examination and limited history taking by health personnel were also noted by Nsimba et al.  Poor quality of malaria case management was also reported by Selemani et al. and Steinhardt et al. , Comparatively low score of the MOs in the case vignette for all health personnel compared to other categories of staff might be an obstacle in providing quality care for malaria at primary care level. Better performance of health workers with shorter training was also noted in several earlier studies in Kenya, India, and Tanzania. ,,,
Educational status of health personnel did not seem to influence their knowledge. However, education might have helped to internalize the skills of preparing blood smear and conducting RDT; a probable explanation of the finding of higher score for skill and smaller intragroup variation of the score among health personnel with graduation/postgraduation. The working experience was not associated with any difference in knowledge. However, as blood slide examination was the mainstay of diagnosing malaria and frontline health workers were always given a target on collection of blood slide, those with working experience in excess of 5 years were more skillful in drawing blood smear compared to their less experienced counterparts. However, it would not be very easy for health personnel who were of higher age group and with longer working experience to have inducted a new technique. Health personnel who were recruited in health system more than 5 years back scored lower in standardized skill score for RDT. In Odisha, educational status and working experience were not found to be significantly associated with knowledge and practice of health workers. 
In majority of the studies in India and Africa, in-service training failed to show any improvement in skill and practice of health workers although a few studies emphasized its role. ,,,,,, In the present study, formal training could not show any significant change in knowledge and diagnostic skills of malaria among the study population. In Kenya, Zurovac et al. noted that neither in-service training nor possession of guideline document per se showed any effect on the practice of health workers.  A sizeable portion of health workers in Senegal failed to use RDT and ACT even after training.  Off-site training, frequently used in resource-poor setting to upgrade knowledge and skill of health workers, was not found to be effective in earlier research. ,, "On the job supportive supervision" can be a feasible alternative. ,
Supply of the majority of the essential logistics for diagnosis and treatment of malaria was not very regular or planned in the SCs. A similar finding was also noted in Senegal.  Stock-out of essential antimalarial drugs in public health facilities was also reported from Odisha and some African countries. ,, Even the reporting forms were not present in sufficient quantity in all SCs.
| Conclusion|| |
Successful implementation of any program needs competent workforce and uninterrupted, optimum supply of logistics. Regarding malaria, there was enough scope for improvement in both the areas at a primary health-care setting in West Bengal. MOs, although having had undergone, presumably, the most intensive training on health care, lagged behind in knowledge and skill than other health personnel. Although education and working experience had a certain amount of positive influence on diagnostic skills of health personnel, training of the health personnel should be introspected and reviewed so that it brings about desirable changes in knowledge and skill of health personnel in the diagnosis and treatment of malaria in the primary health-care setting.
The authors gratefully acknowledge the financial support of the National Rural Health Mission, Government of West Bengal, for conduction of the study. The authors would also like to thank Prof. Krishnangshu Ray, Director, IHFW, Salt Lake, and Dr. Sujishnu Mukhopadhyay, Associate Professor, Community Medicine, Malda Medical College, West Bengal, India, for the intellectual input of on draft manuscript.
Financial support and sponsorship
The authors gratefully acknowledge the financial support of NRHM, Department of Health and Family Welfare, Government of West Bengal, Kolkata, West Bengal, India.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]