Preventive Health Evaluation in Underserved Occupational Environment: A Cross-Sectional Study of its Practice, Facilitators, Barriers, and Benefits among Medical Practitioners in Nigeria.

BACKGROUND: The health of medical doctors (MDs) has been the focus of global concern in addition to the recently modified physician oath now called "The Modern Physician Pledge." As a member of human family, MDs are also prone to diseases they manage in healthcare environment.
OBJECTIVES: The study was aimed at describing the practice, facilitators, barriers, and benefits of preventive health evaluation (PHE) in a cross-section of medical practitioners in Nigeria.
METHODOLOGY: A cross-sectional study done on 178 MDs in Nigeria. Data collection was done using pretested, self-administered questionnaire that elicited information on practice, facilitators, barriers, and benefits of PHE. Self-rated health status was also studied. Practice of PHE was inquired in previous one year.
RESULTS: The age of the respondents ranged from 25 to 72 (36 ± 10.2) years. There were 161 (90.5%) males. All the respondents were aware of PHE. One hundred and fifty-five (87.1%) respondents rated their overall health then as excellent; 142 (79.8%) rated their overall health compared to 6 months ago as excellent, while 169 (94.9%) rated their overall health compared to others of their age as excellent. Generally, in all ages and both sexes, the most common PHE was blood pressure (BP) measurements (100%). The commonest female sex-specific PHE was self-breast examinations (100%). Among the males, the most common male-specific PHE was testicular self-examinations (87.0%). The commonest facilitator and barrier were family history of hereditary diseases (100%) and financial restraints (82.0%), respectively. The most common benefit was early detection of diseases (100%).
CONCLUSION: Awareness of PHE was 100% but didn't translate to comparative practice orientation. The most common general PHE was BP checks. The commonest female and male sex-specific PHE was self-breast and testicular examinations respectively. The predominant facilitator and barrier were family history of hereditary diseases and financial restraints. The most common benefit was early detection of diseases. Copyright:

INTRODUCTION

The health of medical doctors (MDs) has been the focus of global concern in Nigeria.[1] and other parts of the world[23] in addition to the recently modified Physician Oath now called “The Modern Physician Pledge,” which states inter alia that “I WILL ATTEND TO my own health, wellness, and abilities in order to provide care of the highest standard.”[4] As a member of human family, MDs are also prone to diseases they manage in healthcare environment.[56] Of great interest is that the burden of preventable diseases among MDs is likely to be underestimated and sometimes overlooked due to self-medications and unwillingness of MDs to assume the role of patients.[78]

Preventive health evaluation (PHE) refers to measures taken for disease prevention which is used to identify persons with increased risk of preventable diseases before they have subjective complaints and objective findings.[910] Globally, several declarations have emphasized optimal health for everyone, everywhere leaving nobody behind including MDs as dictated in the Health For All,[11] Millennium Development Goals,[12] and Sustainable Development Goals.[13]

Research studies have reported various causes of diseases among MDs in different parts of the world and these include hypertension,[14] diabetes mellitus,[15] obesity,[16] metabolic syndrome,[16] and cancers.[17] Of great enthusiasms is the documentary reports of sudden deaths among MDs different parts of the world.[18192021] Aside work-life disparities and various degrees of burnout reported among MDs in various parts of the world,[22] research studies have shown the existence of inappropriate lifestyles and other risk factors of premature deaths among MDs.[1202123] Despite the development of guidelines[10] for PHE and evidence of benefits of preventive health services, factual uptake of PHE is low among MDs particularly in resource-constrained settings.[1724] The current trend of fatal and silent heart attacks, and strokes among MDs in different parts of the world[18192021] therefore opens the doors to preventive health evaluation and care.

Several factors have been documented to constitute barriers and facilitators to the uptake of PHE globally.[925] However, researchers have discussed the role of different levels of prevention in health–disease continuum with evidence of benefit predominantly documented.[925] However, in resource-constrained context of Nigeria where healthcare is driven by curative services with little emphasis on preventive health care; PHE among MDs is alarmingly suboptimal.[1] This study was therefore conducted to provide data that would help in the identification of specific groups of at risk MDs in whom PHE may be anticipated as well as providing valuable information that can be used to guide PHE particularly for those with inappropriately self-rated health status. It is based on this background that the authors studied the prevalence, facilitators, barriers, and benefits of PHE in a cross-section of MDs in Nigeria.

PARTICIPANTS AND METHODS

This was a cross-sectional study of 178 public and private medical doctors (MDs) who participated in Continuing Professional Development (CPD) program organized by Christian Medical and Dental Association (CMDA), Abia State chapter for MDs in Nigeria on 29th and 30th November 2018, and during the Annual General Meeting (AGM) of Association of Resident Doctors (ARD), Federal Medical Centre (FMC), Umuahia held on 8th December 2018.

Sample size was determined using online sample size calculating software [available at www.surveysystem.com]. The input criteria for sample size estimation was set at 95% confidence level, and accessible sample of 300 MDs based on the previous summative CMDA, Abia State CPD and ARD, FMC Umuahia AGM attendance registers. The calculated sample size was 169 participants. The sample size calculating software assumed maximum possible proportion of 50% (0.50). To deal with incomplete response to the items on the questionnaire the estimated sample size was increased by 5% incomplete response proportion, thus sample size = n/1-incomplete response proportion at 5%. This gave a sample size of 177 respondents. However, 178 participants were used for the study. The eligible MDs were consecutively recruited for the study.

The questionnaire consisted of sections on demographic characteristics, information on practice, facilitators, barriers, and benefits of PHE. Self-rated health (SRH) status was also studied. Practice of PHE was inquired in previous year. The questions on practice, facilitators, barriers, and benefits of PHE sections of the questionnaire were designed by the researchers to suit Nigerian environment through review of relevant literature on PHE.[1781024] Self-rated health (SRH) status was studied using 3-item pre-validated SRH questionnaire which elicited responses in a 6-point Likert responses of excellent, very good, good, fair, poor, and very poor with respect to overall health then, overall health in the past 6 months and overall health compare to others of the same age.[26]

The ethical clearance was obtained from Health Research and Ethics Committee of FMC, Umuahia dated 15th October 2018 referenced FMC/QEH/G.596/Vol.10/410. Informed written consent was also obtained from the participants included in the study.

Data were analyzed using Statistical Package for Social Sciences (IBM SPSS) version 21, New York, USA for the calculation of frequencies and proportions for categorical variables and mean for continuous variables.

RESULTS

Of the 178 MDs who participated in the study, 105 (59.0%) were young adults, 64 (39.0%) were middle-aged adults, and 9 (5.0%) were older persons aged ≥60 years. The age of the respondents ranged from 25 to 72 (36 ± 10.2) years. There were 161 (90.5%) males and 17 (9.5%) females. Ninety-six (53.9%) of the participants had years of practice <10 years while 82 (46.1%) had years of practice of ≥10 years.

All the respondents were aware of PHE. One hundred and fifty-five (87.1%) respondents rated their overall health then as excellent then; 142 (79.8%) rated their overall health compared to 6 months ago as excellent, while 169 (94.9%) rated their overall health compared to others of their age as excellent [Table 1].

Table 1

Self-rated health status of the respondents (n=178)

Variable	Number	Percentage
Self-rated health status then
Excellent	155	87.1
Very good	23	12.9
Good/fair/poor/very poor	0	0.0
Self-rated health status in the previous 6 months
Excellent	142	79.8
Very good	36	20.2
Good/fair/poor/very poor	0	0.0
Self-rated health status compared to others of the same age
Excellent	169	94.9
Very good	9	5.1
Good/fair/poor/very poor	0	0.0

The most common PHE in all ages and both sexes was BP measurements (100%). The most common male-specific PHE was testicular self-examination (87.0%) while the commonest female sex-specific PHE was self-breast examination (100%) [Table 2].

Table 2

General, male-specific and female-specific preventive health evaluation

Variable	Number	Percentage
*General preventive health practices in the previous 1 year (n=178)
Blood pressure checks	178	100.0
Weight measurements	142	79.8
Waist circumference	140	78.7
Body mass index	95	53.3
Blood glucose checks	83	46.6
Colonoscopy	6	3.4
*Male-specific preventive health practices in the previous 1 year (n=161)
Testicular self-examination	140	87.0
Prostate specific antigen assay	22	13.7
Digital rectal examination	13	8.1
*Female-specific preventive health practices in the previous 1 year (n=17)
Self-breast examination	17	100.0
Pap smear	10	58.9
Mammosonography	8	47.1
Clinical breast examination	6	35.3
Mammogram	3	17.6

*Multiple responses

The commonest facilitator for PHE was family history of hereditary diseases (100%). The most common barrier to PHE was financial restraints (82.0%) while the most common benefit of PHE was early detection of diseases (100%) [Table 3].

Table 3

Facilitators, barriers and benefits of preventive health evaluation (n=178)

Variable	Number	Percentage
*Facilitators of PHE
Family history of hereditary diseases	178	100.0
Personal belief in the effectiveness of PHE	175	98.3
Positive attitude to PHE	175	98.3
Institutional responsibility to offer PHE	139	78.1
*Barriers to PHE
Financial restraints	146	82.0
Time constraints	143	80.3
Physicians inertia	140	78.7
Fear of getting positive results	84	47.2
Confidentiality issues and concerns	82	46.1
Conflicting recommendations on effectiveness of PHE	39	21.9
*Benefits to PHE
Early detection of diseases	178	100.0
Safer and easier than curative services	175	98.3
Relatively better cost-benefit ratio than curative services	170	95.5
Evaluation of health status	170	95.5
Reassurance for those with negative results	153	86.0

*Multiple responses; PHE=Preventive Health Evaluation

DISCUSSION

This study has demonstrated the pattern of self-rated health (SRH) status among the study participants. The finding of larger number of respondents reporting their health status as excellent then, in the previous 6 months and compared to others of the same age despite the fact that some of the medical doctors (MDs) could have one form of health condition or the other is probably a reflection of health optimism among MDs.[178] Admittedly, MDs have a seeming culture that discourages admission of vulnerability to preventable health conditions with self-treatment being the norm.[17827] Thus an unhealthy medical doctor (MD) may claim excellent health status when in reality they are ill amidst patients and societal perceptions that MDs are immune from diseases. PHE among MDs is therefore a need of the moment since their well-being is considered an important public health challenge in the recently modified Physician Oath which states inter alia that “I WILL ATTEND TO my own health, wellness and abilities in order to provide care of the highest standard.”[4]

The most commonly practiced general PHE was blood pressure (BP) checks. This could be a reflection of the fact that hypertension is the most prevalent personal and family health condition in the study area with majority of the respondents having family history of hypertension.[28] Hypertension is usually asymptomatic and due to its high prevalence, BP checks should be done more frequently particularly among MDs with a high-normal BP values, family history of hypertension, and personal history of cardio-metabolic risk factors that frequently cluster with hypertension.[141628] Agreeably, when the health of a MD is compromised due to hypertensive disorder and its complications, so may the quality of care provided by the affected MD.[22] MDs shouldn't spend time measuring BP of patients and forget to measure their own BP regularly.

The commonest male-specific PHE was testicular self-examinations (TSE). As a reproductive health tumor, the prevalence of testicular tumors is rare among black males but the healthcare evaluation for testicular tumor is for every male as early stages of testicular cancers are symptomless.[29] TSE helps in identifying early testicular tumors when treatment is more effective and beneficial. It is recommended that all men from pubertal age should practice TSE at least once a month.[29]

TThe commonest female specific PHE was self breast examination (SBE). The finding of this study is in tandem with previous reports that SBE is routinely performed by women.[1030] The finding could be a reflection of the fact that breast cancer is the most common cancer among the females with high morbidity and mortality reported particularly in resource-poor environment.[30] Although there are several recommendations for screening for breast cancer among the females but women at high risk should begin early and continue as long as they are in good health.[30] Breasts cancer have multi-factorial etiologies involving cascade of events that unfold months to years prior to manifestations. The performance of SBE among female MDs is safe, effective, and practical alternative to mammosonography, mammogram, and biopsy studies especially in a resource-constrained environment.

The most common facilitator of PHE was family history of hereditary diseases. Although the parameters for PHE depend on the MDs age, gender, and individual risk factors but the good news is that preventable familial diseases lend itself to strategic control at primary and secondary levels of prevention.[1025] PHE among MDs with family history of hereditary disease can be used to identify individuals with risk factors of diseases aimed at altering the course of the disease through targeted health promotion.[25] There is need for MDs with family history of diseases to undergo appropriate PHE to enable them remain in state of wellness throughout the period of practice of medicine and beyond. This is the need of the moment in the face of reported increasing and alarming sudden death among MDs,[1718192021] although nothing in human life lasts forever but PHE increases the delivery of PHC and should never be dismissed with a wave of hand that it is not my portion.

The commonest barrier to PHE was financial restraint. The finding of this study is in contradiction with reports from developed nations where time constraint was the commonest barrier to PHE among MDs.[23] Of great concern is that despite the financial barrier and other constraints such as time for PHE, MDs in Nigeria are reluctant to engage in PHE and tend to delay seeking PHC as well as find it difficult to adopt the role of persons with risk factors of preventable diseases.[1] Of mindboggling is that the financial restraint to PHE could also augment the decision to delay seeking timely medical care for overt medical conditions as well as promote the culture of the MD working through ailments.[1378] As MDs endeavor to achieve excellence in medical career, they shouldn't forget that the most important aspect of professional life is optimal health without which they wouldn't be able to achieve work-life balance.

The commonest benefit of PHE was early detection of diseases. Although patients' care takes central stage in medical practice but the epitome of best medical practice depends on how MDs take care of their health in order to provide high quality care to the patients. As dictated in The Modern Physician pledge, “THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration.”[4] MDs should constantly remind himself that he is a human being first and a physician secondly and are not immune to diseases that befall humans. MDs should always attend to their duty of patient care but should never forget to do PHE and other relevant medical care as and when due.

Limitations of the study

The study was based on participant's subjective responses. The list of PHE services is not exhaustive and individual clinical decisions should be made based on a person to person basis. However, high risk MDs may require additional PHE beyond that recommended for the general population.

CONCLUSION

Awareness of PHE was 100% but didn't translate to comparative general practice orientation in the previous 1 year. The most common PHE was BP measurements. The commonest preventive female and male sex-specific PHE was self-breast and testicular examinations respectively. The predominant facilitator and barrier to PHE were family history of hereditary diseases and financial restraints. The most common benefit was early detection of diseases.

Declaration of participant's consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.