Assessment of patient’s perception and knowledge towards anesthesia services at Dilla University Referral Hospital, South Ethiopia, 2021: a cross-sectional study : IJS Global Health

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Assessment of patient’s perception and knowledge towards anesthesia services at Dilla University Referral Hospital, South Ethiopia, 2021: a cross-sectional study

Hailu, Seyoum MSc; Girma, Timsel MSc; Regasa, Teshome MSc

Author Information
International Journal of Surgery: Global Health: September 2022 - Volume 5 - Issue 5 - p e79
doi: 10.1097/GH9.0000000000000079
  • Open

Abstract

From its beginnings in the nineteenth century, the practice of anesthesia had been in a state of continuous evolution1. There is no consistency as to the foremost suitable title for a specialist specializing in anesthesia with nations such as the United States referring to them as anesthesiologists, and other countries such as the United Kingdom (UK) referring to them as anesthetists. The term anesthetist is additionally not continuously saved for specialists as the United States refers to nurses trained in anesthesiology as anesthetists2,3. Currently, anesthesia is one of the most significant developments of modern medicine that allows treatment involving unbearable pain to be performed while the person is relaxed, asleep, and with no memory of the procedure. However, anesthesia is still being considered a behind the screen specialty, there is poor public understanding regarding the role of anesthetists in the various areas of a health care delivery system4–6.

In recent decades the practice of anesthesia is by far beyond the usual operation theaters, for which anesthetists are involved in crucial activities of pain management, critically ill and palliative care management, and are considered part of the resuscitation team all over the world7,8. Anesthetists are also proficient in cardiopulmonary resuscitation, basic and advanced life support, and disaster management9,10.

Even though significant successes observed in surgery are closely coupled to advances in anesthesia and anesthetic techniques, anesthesia has always been misunderstood as a “behind the scenes” specialty11,12. Some patients have misconceptions concerning anesthesia, which influences their decision to seek a surgical consult, and their willingness to undergo anesthesia and surgical interventions, especially in developing countries11,13,14. This may contribute to the delayed presentation of patients, which impacts negatively on outcomes and quality of health care15,16.

The poor public image of anesthetists, and their discipline, among both the medical and lay communities, has been a long-standing and common problem13,17. Anesthetists and their discipline have failed to thrive in the public eye, despite phenomenal growth in their scope of practice, efficacy, and safety. As a result, they continue to linger behind the screen as masked figures18,19. Increasing public awareness would be beneficial to both patients and service providers to improve the knowledge and perceptions among the wider society20,21.

Despite the advancements in anesthesia, there is inadequate public knowledge regarding the specialty and the scope of the functions of anesthetists, as well as the pivotal role anesthetists, play in the health care delivery system. Patients in developing nations have been reported to have less knowledge about anesthetists compared with those in developed countries12,22,23.

Improved public awareness may be beneficial to patients in areas ranging from perioperative anxiety to effective use of anesthetic services. In addition, anesthetists may derive a sense of validation by having their importance acknowledged by the public. Society can gain in-depth knowledge and understanding about anesthesia in different areas like education, media, and training. Efforts to maximize interactions with the un-anesthetized patient through the introduction of anesthetic clinics and routine preoperative and postoperative visits are expected to improve patient’s knowledge about anesthesia and anesthetists.

Although a considerable number of studies in anesthesia have been published worldwide, a limited number of studies have been done regarding the knowledge and perceptions of anesthesia and anesthetists in Africa. In Ethiopia anesthesia as a discipline and anesthetist as a professional is not well recognized by the public24.

Therefore, this study is aimed to assess the overall perceptions and knowledge of the patients towards anesthesia service in our institution.

Methods

Study design, settings, and participants

An institutional-based cross-sectional study was carried out at DURH through a questionnaire-based direct interview of the participants, in the period between September and December 2021. DURH is one of the public hospitals in the Gedeo Zone, Dilla town, which is located 360 km south of Addis Ababa, the capital city of Ethiopia, and 90 km from Hawassa the capital city of Sidama region which was established in 1985 GC as a zonal hospital and currently it is the only teaching and referral hospital in the Gedeo Zone. After obtaining an ethical exemption from the institutional review board of the college of medicine and health sciences all elective and emergence patients aged 18 years and above were directly interviewed during the preanesthetic evaluation period. Informed consent was taken from each participant and any participant who do not want to be part of the study was let to leave the study. Patients who were mentally incapacitated, physically or emotionally unstable, patients with pain score ≥4 on the visual analog scale, and those receiving any medications that can alter their decision-making were excluded from the study. Sociodemographic characteristics and previous anesthesia exposure were independent variables while patients’ knowledge and perceptions of anesthesia are dependent variables. This study was done in line with the World Medical Association Declaration of Helsinki’s Ethical Principles for Medical Research Involving Human Subjects25 and the work has been reported in line with the STROCSS 2021 criteria26. The study was also registered on the research registry with the unique identifying number of researchregistry7597 (https://www.researchregistry.com/browse-the-registry#home/).

Sampling and data collection procedures

The sample size was calculated using the single population proportion formula by considering the following assumption. It was calculated by considering the proportion of patients who heard about anesthesia 62.4% based on a study done in Ghana27.

n=(Zα/2)2×P(1P)d2,

where, d=margin of error (0.05), P=proportion of respondent that had good knowledge toward anesthesia (15.7%), Z=the standard score corresponding to 95% confidence interval.

n=(Zα/2)2×P(1P)d2n=(1.96)2×(0.624)(0.376)(0.05)2=360.

Considering, the 10% nonresponse rate, the final sample size became 360+36=396 is the final sample size to be collected.

Operational definition

Anesthetist

A health care professional trained to administer anesthesia.

Anesthesia

Loss of sensation, especially of pain, induced by drugs: called general anesthesia when consciousness is lost and local anesthesia when only a specific area of the body is involved.

Knowledge

The facts known by the participants gained by experience or learning.

Perceptions

The way the participants think about or understand someone or something.

Data collection instrument and methods

Data was collected by graduating class anesthesia students and postanesthesia care unit nurses. Training and orientation were given for data collectors on how to grasp information about patient sociodemographic characteristic and the relevant data by using developed questionnaires, which consists of four major parts. The first part questions Sociodemographic characteristics, the second part questions on patient’s knowledge about anesthesia, the third part questions on patient’s perception of anesthesia, and the fourth part are postoperative and outside-theater roles. Data quality was assured by doing a pretest on 5% of the sample size which was not included in this analysis. Regular checking for completeness and consistency of the collected data was done daily throughout the data collection period by the principal investigator.

Outcomes of the study

The main outcome of this study was to determine patients’ knowledge and perceptions of anesthesia service. We categorized knowledge and perception level into percentage scores as poor <50%, moderate 50%–75%, and good >75%.

Statistics and analysis

After data were checked for completeness, Statistical Analysis was done using SPSS (IBM) version 25 software. Descriptive statistics were used to summarize data using frequencies for nominal data and mean (±SD) for continuous variables.

Result

Sociodemographic characteristics of the respondent

A total of 396 respondents were included in the study while 27 patients declined to participate with a 93% response rate. The mean age of participants was 39.5±(14.9) years, and more than half of the respondents 225 (61%) were male. The majority of patients 230 (62.4%) were living in the urban area. Regarding the educational status, 47% of the respondents had attended secondary and above while 9.8% of the respondents had no formal education. Comparing the type of surgery involved 238 (64.6%) of the patients were emergency while the rest were elective surgery (Table 1).

Table 1 - Sociodemographic characteristics of respondents among patients admitted for surgery at DURH, 2021.
Variable (n=369) No. (%)
Age (y)
 18–40 208 (56.4)
 41–60 121 (32.9)
 >60 40 (10.7)
Sex
 Male 225 (61)
 Female 144 (39)
Residence
 Urban 230 (62.4)
 Rural 139 (37.6)
Educational status
 illiterate 36 (9.8)
 Read and write 55 (15)
 Primary school (1–8) 174 (47)
 Secondary and above 104 (28.2)
Marital status
 Married 319 (86.5)
 Single 30 (8.2)
 Widowed 13 (3.4)
 Divorced 7 (1.9)
Type of surgery
 Emergency 238 (64.6)
 Elective 131 (35.4)

Patient perception towards anesthesia

Out of the total respondents, 159 patients had undergone some surgery in the past. Still when asked “who gives you anesthesia” there was not much difference in the percentage of patients saying “anesthetist” with that of patients who did not undergo an operation before. Out of 369 respondents 42% perceived that surgeons stay with the patient, 20% knew that anesthetists stay with them, 15% of them responds as nurses stay with them while 23% of the respondents do not know who will stay with them in the operation theater. Although some of the primary roles of the anesthetist were described accurately by the patients, <15% knew about the roles of anesthetists like vital parameters monitoring and maintaining hemodynamics during the operation. One hundred eighty-nine patients (51.3%) thought that anesthetist does stay with them during the operation. Of 369, 59% of patients were not aware of the type of anesthesia while 37% of respondents correctly mention as they know regional anesthesia and only about 4% of the respondents know general anesthesia. Around 53.5% of patients could recall that they had been visited by their anesthetist at least once either in the outpatient department or in the ward (Table 2).

Table 2 - Patient perception towards anesthesia among patients admitted for surgery at DURH, 2021.
Variable (n=369) Frequency (%)
Had your anesthetist visited you after the operation?
 Yes 197 (53.5)
 No 172 (46.5)
What type of anesthesia do you know?
 General 15 (4)
 Region 137 (37)
 I do not know 218 (59)
In operation theaters, who is staying with you?
 Surgeon 155 (42)
 Nurse 55 (15)
 Anesthetist 74 (20)
 I do not know 85 (23)
What do you think the role of an anesthetist is?
 Resuscitation 70 (19)
 Vital parameters monitoring hemodynamics 55 (15)
 Putting patients to sleep and waking them up 133 (36)
 I do not know 111 (30)
Did the anesthetist stay with you throughout the operation?
 Yes 189 (51.3)
 No 180 (48.7)

Patient knowledge of anesthesia

Of the 369 participants, 56.8% of the clients received anesthesia for the first time and 159 (43.2%) had undergone operations in the past. About 53% had heard of the term anesthesia. Out of those who heard about anesthesia, 32% got their information from the anesthetist while 11% were informed by the surgeon (33.9%) of respondents listed the role of the anesthetist as putting patients to sleep, and (14.6%) mentioned offering pain relief.

Of 369 respondents, only 42% knew that anesthetist is the one who gives anesthesia and 38% knew that any doctor gives them anesthesia (Fig. 1).

F1
Figure 1:
Bar chart shows patient response on “who administers anesthesia?” Among patients admitted for surgery at DURH, 2021.

About 74% of the participants recognize that an anesthetic assessment before surgery is relevant; however, 46% were not even informed of the kind of operation that would be carried out. The findings also show that 65.4% did not know about the possible risk for complications from anesthesia whereas 128 (34.6%) of the patients had some knowledge about the complications of anesthesia, the worst listed was death or not waking up (34.6%).

Discussion

The results of this study showed that there is misunderstanding and misconception about the meaning of anesthesia as well as the role of the anesthetist. The majority of the patients in our study had poor knowledge of anesthesia and the role of anesthetist which is in line with a study conducted in India which stated patients globally, especially in less developed countries, have little or limited knowledge regarding anesthesia and limited access as there is a severe shortage of anesthetist and limited supply of anesthesia in low-resourced settings12. Findings of most surveys done in different parts of the world reveal that fewer than 2 of 3 patients know that anesthetists are physicians, with a seeming trend of patients in developing countries having poorer knowledge compared with those in developed countries9,11.

In our survey, most of the participants (59%) do not know the type of anesthesia that might deliver to patients which is comparable with another study done in northern Ethiopia which detects about 74% of the patient do not know the types of anesthesia24. Our result is by far different from a study done in Nepal which mentions most of their respondents (56.7%) knew that anesthesia techniques consisted of general and regional anesthesia, 24.2% knew only about general anesthesia, 5.8% knew about regional anesthesia, whereas 13.3% had no idea what the techniques were7. This discrepancy might be due to the poor public awareness regarding anesthetists and the anesthesia profession in general in our setup.

The study also found unfavorable perceptions toward anesthesia and in this <15% of the patient accurately perceived the role of anesthetists. The finding of this study was similar to that of a study done at a Medical College in Nepal which revealed that the role inside the theater and expanding role outside the theater is poorly known7.

Only 20% of the patients know who is staying with them during the operation mentioning it as an anesthetist while most of them (42%) respond as the surgeon is the one who is staying with them. This finding is poor as compared to a study done in Ghana where the majority of patients (62.4%) had heard about anesthesia. Most (85%) knew that specially trained doctors or nurses were responsible for the delivery of anesthesia27.

Of 369 respondents, only 42% knew that anesthetist is the one who gives anesthesia and 38% knew that any doctor does. A study done in Addis Ababa shows that 42.1% of the respondents say anesthetists were responsible for administering anesthesia while the other surgeons (18.5%), nurses (8.2%), and 31.3% of the participants do not know who administers anesthesia28. This variability is most likely related to a better understanding of the public as far as their residence is in big cities like Addis Ababa.

The majority of our study participants (74%) of the participants revealed that anesthetic assessment before surgery is relevant; however, 65.4% of the respondents did not know about the possible risk for complications from anesthesia.

The knowledge of the roles of anesthetists outside the operation room, management of clinically ill patients in the intensive care unit, and management of acute and chronic pain is poor in our survey as has been indicated in (Table 3) above. This finding is comparable to a study done in West Africa which detects <15% of patients knew the role of anesthetists outside the confines of the operating theater suites27, while it is lower than a study done in Jordan9. Even though most of our study participants are urban residents and at least can able to read or write, the overall knowledge and their perceptions of anesthesia and anesthetist are poor. This may be elaborated may be due to the routine working environment of anesthetists which is confined to the operation theater and the less time the anesthetist had with their unanesthetized patients. The findings of our study have the future implications of the need for more awareness creation and continuous education for the wider community regarding anesthesia service, therefore patients will have more perception and knowledge of anesthesia, and anesthetists.

Table 3 - Patients’ responses to postoperative and outside-theater roles.
Variable (n=369) Frequency (%)
Escorting patient to the PACU
 Surgeon 48 (13)
 Nurse 151 (40.9)
 Anesthetist 90 (24.4)
 I do not know 80 (21.7)
Who is treating any complications in the PACU
 Surgeon 232 (62.8)
 Nurse 57 (15.4)
 Anesthetist 70 (19)
 I do not know 10 (2.7)
Managing patients in the ICU
 Surgeon 219 (59.4)
 Nurse 67 (18.2)
 Anesthetist 51 (13.8)
 I do not know 32 (8.7)
Chronic and acute pain management
 Surgeon 258 (69.9)
 Nurse 43 (11.7)
 Anesthetist 54 (14.6)
 I do not know 14 (3.8)
ICU indicates intensive care unit; PACU, postanesthesia care unit.

Conclusion

The perception of most patients is that anesthesia is all about “putting patients to sleep and waking them up.” There was poor knowledge of patients regarding the role of anesthetists beyond the confines of the operating theater. Therefore, there is a need for intensified public education on the importance of anesthesia and the diverse roles anesthetists play in ensuring holistic health care delivery.

Limitations

The study was conducted as a descriptive cross-section design. It needs adding an analytical part to further determine the associated factors. Findings may differ with the population sub-type studied and the type of facility in which the study was conducted.

Challenges encountered

The major challenge we faced during the data collection process was difficulty in translating some of the medical terms in the questionnaire into the local languages. This was effectively overcome by consultation with language experts.

Recommendation

The perception and knowledge about the role of the anesthetist in the operation theater, in the intensive care unit, in acute and chronic pain management, and emergency care areas should be highlighted to all at large. We recommend a multicenter study with a larger sample size.

Ethical approval

This research has been exempted by the Institutional Review Board of Dilla University College of Medicine and Health Science from requiring ethical approval as it does not involve interventional human participants.

Ethical clearance was exempted by the DURH institutional ethical review board.

Sources of funding

None.

Author contribution

All authors equally contributed to the study concept or design, data collection, data analysis or interpretation, and writing the paper.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

7597.

Guarantor

Seyoum Hailu.

Consent from participants

Well, informed consent was taken from study participants after informing them of the purpose of the study, the benefit, and harm of participating in the study, and they have been told they can withdraw from the study at any step if they feel so.

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Keywords:

anesthesia; anesthetist; knowledge; perceptions; patient; Dilla

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