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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 39-43

Medical officer's perspectives and professional challenges in handling poisoning cases in rural India


Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India

Date of Submission03-Jul-2021
Date of Decision16-Feb-2022
Date of Acceptance18-Feb-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Asawari Raut
Associate Professor and Head, Department of Clinical Pharmacy Pharm D Program, Poona College of Pharmacy Bharati Vidyapeeth (Deemed to be University) Erandwane, Pune - 411 038, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcfm.ijcfm_52_21

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  Abstract 


Introduction: Poisoning is a significant public health problem in developing countries, more so in rural areas. Very little is known about the treatment available for poisoning cases in the context of rural health care provision in India. This study explores the perceptions of the primary health care medical officers regarding the management of poisoning cases.
Material and Methods: A semistructured, self-designed survey form was used to interview the medical officers in Pune district. The interview focused on understanding rural hospital settings in terms of infrastructure, available facilities, and medical officers' perception of professional challenges in the management of poisoning cases.
Results: Underreporting of poisoning cases in these primary health centers (PHCs) and transferring to higher hospitals without basic first aid provided was noted through interviews.
Conclusion: Medical officers in rural PHCs lack the necessary training and knowledge required for the management of poisonings which is further worsened by lack of resources. There is a need to focus on poison management in continuous medical education. Training programs and education for medical officers are needs of the hour.

Keywords: Medical officers, poisoning, primary health care, rural health


How to cite this article:
Mahadik K, Raut A, Chowdhury M, Asad AH, More S. Medical officer's perspectives and professional challenges in handling poisoning cases in rural India. Indian J Community Fam Med 2022;8:39-43

How to cite this URL:
Mahadik K, Raut A, Chowdhury M, Asad AH, More S. Medical officer's perspectives and professional challenges in handling poisoning cases in rural India. Indian J Community Fam Med [serial online] 2022 [cited 2022 Nov 27];8:39-43. Available from: https://www.ijcfm.org/text.asp?2022/8/1/39/349385




  Introduction Top


Being an agrarian country, the incidence of poisoning, both intentional and unintentional, has been increasing in the rural parts of India due to easy access to pesticides. Each year, poisoning results in significant morbidity and mortality. According to the World Health Organization, India's poisoning death rate is 31.3 per 100,000 people. In spite of that, in the community health-care settings, diseases such as tuberculosis, cardiovascular disorders, traumas, etc., have always been highlighted and given more importance.[1],[2],[3]

The majority of patients with poisoning recieve their primary treatment in nearby Primary Health Centers (PHCs).[4] PHCs are the cornerstone of rural health services‒the first port of call to a certified doctor of the public sector in rural areas for the sick and those who directly report are referred from subcenters for curative, preventive, and promotive health care.[5] Nonspecialist and sometimes relatively junior doctors staff these hospitals. The delivery of care is also greatly impacted by the availability of treatment resources such as poison antidotes, gastric lavage, and resuscitation facilities which play a key role in reducing mortality.[6],[7] Although previous studies have examined clinicians' and nurses' perspectives toward poisoning patients in well-resourced tertiary care hospitals, there is no published research exploring medical officers' perspectives and expectations about the care and treatment of poisoning patients in rural, low-resource settings.[4]

Thus, the objective of the study was to explore the professional challenges faced by the medical officers for assessing and managing poisoning cases at the PHCs in the rural area of India. The study also assessed the availability of resources in PHCs from the medical officer's perspective.


  Material and Methods Top


A qualitative and quantitative study was carried out in which semistructured face-to-face interview with PHC medical officers was conducted for 6 months from September, 2019 to February, 2020 in Pune district, Maharashtra, India. The study was approved by the Bharati Vidyapeeth (Deemed to be University) Medical College Institutional Ethics Committee (Ref-BVDUMC/IEC/100E).

A total of 67 medical officers completed the survey and interview [Figure 1].
Figure 1: Methodology flow diagram

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Step 1: Survey questionnaires were filled by the medical officers, followed by segregating the PHCs into two: low incidence and moderate-to-high incidence of poisoning cases per month. Step 2: The faculty and Doctor of Pharmacy Interns of Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University) conducted a semistructured face-to-face interview with the medical officers who reported moderate-to-high incidence of poisoning cases in their PHCs. Interviews were around 10–15 min in duration.

The survey and interview comprised questions regarding common poisonings and its prevalence, treatment facilities, resources and infrastructure facilities of the PHCs, and challenges faced by the physicians.

A qualitative examination of the interview data provided an exploration of the doctors' experiences and perceptions about treating poisoning patients.


  Results Top


Practice environment

Fifty-five percent (37) of respondents worked at Type A PHCs and 45% (n = 30) worked at Type B PHCs. PHCs with a delivery load of <20 deliveries per month fall under the category of Type A, whereas those with a delivery load of 20 or more deliveries per month are Type B. The bed occupancy rate was <40% in 18, 40%–60% in 23, and >60% in 26 PHCs. The majority of the respondents were PHC medical officers from the north region of Pune district (25), followed by the west (13), south (12), and east (9) [Table 1].
Table 1: Practice Environment of the primary health centers

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“We have PHC set up in an old building in a remote village. We are provided with basic supplies such as oxygen cylinder, atropine, and anti-snake venom. No other medications are provided.” (MOS2).

The majority of the respondents (50) encountered around 1–5 poisoning cases per month at their PHCs. Ten respondents claimed that they get around 6–10 poisoning cases per month at their PHCs. Seven respondents answered that they encounter more than 10 cases per month. Animal bites and stings were the most commonly encountered poisoning cases, followed by pesticides, household agents, and drugs [Figure 2].
Figure 2: Commonly encountered poisoning cases

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“I cannot give an exact answer regarding the frequency of poisoning cases as we refer most cases directly to government hospitals. In recent times we have had only two such cases for which we gave basic first aid and referred the cases to the government hospital.” (MOW3).

Availability of resources

Majority of the physicians (30) claimed that antidotes are not regularly available for the management of poisoning cases at the PHCs. Sixteen respondents answered “yes,” whereas the remaining did not provide any answer for this question. Basic clinical assessment facilities were also limited which usually determine the further treatment plan [Table 2].
Table 2: Practice environment and resources available in the primary health centers

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“Resources like well-equipped ambulance should be provided. We have oxygen supply and anti-snake venom but transportation takes time. It will also be helpful while referring patients to higher hospitals.” (MON2).

On being questioned whether the current availability of resources is adequate for management of poisoning cases, a doctor answered saying:

“Resources are limited but we can't expect much from a PHC. Even if better resources are provided, we need trained technical staff for proper handling of such resources.” (MON5).

Other physicians stated that even when the health-care staff is well trained, limitations in physical settings such as insufficient equipment and medicine in the hospital constrained their ability to provide the necessary care to the pesticide poisoning patients.

“Resources are limited for sure. Gastric lavage facility should be made available. Suction machine is required so that we can at least perform first aid treatment and refer critical cases forward. If we have first aid-related medications and resources, it will be more than sufficient.” (MOE4).

Knowledge of primary health center staff and future directions

When asked whether in their work setting, they agree with the statement that “further knowledge/training is necessary to facilitate the management of poisoning cases,” 70% agreed, whereas 20% disagreed [Figure 3]. On being provided with various options for continuing education regarding the handling of poisoning cases, majority of the respondents preferred workshop, followed by lecture/online lecture, conference, modules, certificate programs, and newsletters.
Figure 3: Physicians' perceptions about resources, treatment guidelines, and training programs

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“Workshop will work wonders and give our staffs the basic idea of first aid and handling of such cases. It will give us practical knowledge rather than just listening to online lectures. We will be benefitted by your workshop.” (MOW6).

“Online lectures will be more beneficial as everyone will not be able to attend the workshop due to various reasons. It is difficult to gather everyone at the same place at one time.” (MOE2).

Lack of trained staff at the PHC was also reported by most of the respondents.

“We are not trained specifically for handling poisoning cases as such, but by our experience we handle such cases. However, it will be helpful if we get training in this area to reduce the risk and this will ensure better handling as we are the first ones to handle these poisoning cases in the rural areas. Hence it is essential for us to know the do's and don'ts” (MON7).

Other respondents provided similar answers:

“Staff at our PHCs requires training for the very basic first aid that should be given when handling a poisoned patient. They can't handle critical cases. Regular training is necessary to constantly update our knowledge regarding this.” (MOS1).

*MO: Medical officer; N: North; S: South; E: East; W: West


  Discussion Top


The study interview data were analyzed to help understand the strategies and practice of the rural PHC medical officers in regard to their practice environment, load of poisoning cases encountered by them in a month, availability of necessary resources for handling such cases, and the knowledge of the PHC staff.

The interview highlighted the lacunae in the working of the PHCs which are responsible for providing both preventive and essential curative services in rural areas. As per the Indian Public Health Standards, every PHC should have at least 4–6 beds for males and females. Fewer than 77% of Indian PHCs meet the minimum requirement of four beds.[5] A similar pattern was found in our study. Laboratory services are recommended as an essential component for the proper functioning of PHC. It was apparent that most of the PHCs have facilities for in-patient services; however, some important laboratory investigations to diagnose and understand the severity of organophosphate poisoning and snakebites, such as serum cholinesterase and bleeding time and clotting time were not available adequately. This indicates that despite the presence of in-patient facilities, poisoned patients would not be availed of the treatment required for their condition.

The most commonly encountered poisoning of snakebites and organophosphate in the study correspond to the farm workers' workplace having thick and dense grassland and occupational exposure to pesticides.[8],[9] The reporting of 1–5 cases/month could underestimate the exact prevalence of poisoning cases due to underreporting.

The interviews also revealed that most of the poisoning cases brought to the PHCs are transferred to tertiary care hospitals for treatment. The fact is supported by a study conducted by Prasadi et al., which reported that the majority of poisoning cases coming to tertiary care hospitals are referred from PHCs.[10] In some cases, only basic first aid is provided before transferring to the higher hospitals. The patient transfer should be limited to cases in which the patient's acute medical condition has been resolved; the medical advantages of the transfer outweigh the potential risks, including informed consent of the patient and agreement between the transferring and receiving hospital to authorize the transfer within its available capacity. It is important that a systematic approach be followed in this process of patient transfer, beginning with the decision to move, via pretransfer stabilization and then the management of the transition itself. Moreover, such patients' transfer further increases the time lag between consumption of poisoning and receiving initial treatment, which is also responsible for high mortality.

The difficulties faced in diagnosis and treating the various cases of poisoning coming to the PHCs are usually attributed to a lack of specially trained medical and paramedical staff, specific antidotes, and lifesaving drugs.[11]

Respondents expressed how this significant shortage of trained professionals and other resources in the rural hospital setting will not help the professional growth of rural hospital physicians.

The physicians urged on the need for continuing medical education (CME) for understanding the recent advances in the management of poisoning cases. They also shared that CME does not adequately emphasize toxicology and its related advances. The obstacles in the way of continuing professional education could be seen as delivering treatment to poisoning cases in hospitals not only far from ideal but also leading to an inevitable transfer of poisoning patients to secondary and/or tertiary hospitals.


  Conclusion Top


Understanding the lacunae and ground reality of functioning of PHCs in rural areas is vital to provide them with necessary and suitable resources for the management of poisoning cases. Poorly designed health systems and deficits of training and resources lead to the transfer of poisoning cases to secondary and/or tertiary care hospital which in turn increases the time lag between consumption of poison and receiving treatment. Regular refresher courses should be conducted for the medical officers working in the PHCs as a part of the CME program to update their knowledge regarding the toxicological crisis. The CME should focus on first aid and emergency management of poisoned patients.

Financial support and sponsorship

This study was financially supported by the All India Council for Technical Education - Unnat Bharat Abhiyan Funding.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blanchard J, Feltes M, Kim JY, Pousson A, Douglass K. Experience of Indian emergency physicians in management of acute poisonings. Toxicol Commun 2019;3:54-60.  Back to cited text no. 1
    
2.
Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: Systematic review. BMC Public Health 2007;7:357.  Back to cited text no. 2
    
3.
Jesslin J, Adepu R, Churi S. Assessment of prevalence and mortality incidences due to poisoning in a South Indian tertiary care teaching hospital. Indian J Pharm Sci 2010;72:587-91.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Senarathna L, Adams J, De Silva D, Buckley NA, Dawson AH. Personal and professional challenges in the management of deliberate self-poisoning patients in rural Sri Lanka: A qualitative study of rural hospital doctors' experiences and perceptions. BMC Public Health 2008;8:373.  Back to cited text no. 4
    
5.
Directorate General of Health Services. Indian public health standards (IPHS) guidelines for primary health centers.  Back to cited text no. 5
    
6.
Van der Hoek W, Konradsen F, Athukorala K, Wanigadewa T. Pesticide poisoning: A major health problem in Sri Lanka. Soc Sci Med 1998;46:495-504.  Back to cited text no. 6
    
7.
Senarathna DL. How the Level of Resources and Hospital Staff Attitude in Primary Care Hospitals in Rural Sri Lanka Affect Poisoning Patient Outcome University of Newcastle. Newcastle: University of Newcastle; 2006.  Back to cited text no. 7
    
8.
Kalantri S, Singh A, Joshi R, Malamba S, Ho C, Ezoua J, et al. Clinical predictors of in-hospital mortality in patients with snake bite: A retrospective study from a rural hospital in central India. Trop Med Int Health 2006;11:22-30.  Back to cited text no. 8
    
9.
Dash SK, Mohanty MK, Mohanty S, Patnaik KK. Organophosphorus poisoning: Victim specific analysis of mortality and morbidity. Med Sci Law 2008;48:241-5.  Back to cited text no. 9
    
10.
Prasadi GA, Mohamed F, Senarathna L, Cairns R, Pushpakumara PH, Dawson AH. Paediatric poisoning in rural Sri Lanka: An epidemiological study. BMC Public Health 2018;18:1349.  Back to cited text no. 10
    
11.
Sharma BR, Harish D, Sharma AK, Bangar S, Gupta M, Gupta N, et al. Toxicological emergencies and their management at different health care levels in Northern India – An overview. J Pharmacol Toxicol 2010;5:418-30.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Material and Methods
Results
Discussion
Conclusion
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