Am. J. Trop. Med. Hyg., 72(4), 2005, pp. 430–433 Copyright © 2005 by The American Society of Tropical Medicine and Hygiene
PERIPHERAL HEALTH WORKERS’ KNOWLEDGE AND PRACTICES RELATED TO FILARIAL LYMPHEDEMA CARE: A STUDY IN AN ENDEMIC DISTRICT OF ORISSA, INDIA KALYANI RATH, BASANTA K. SWAIN, SHALOUMY MISHRA, TRISHNA PATASAHANI, ANNA S. KERKETTA, AND BONTHA V. BABU Division of Clinical and Epidemiology, Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar, India
Abstract. The Global Program to Eliminate Lymphatic Filariasis (GPELF), which includes alleviation of disability and suffering of patients, is run primarily in India by the primary health care system. The present study assessed the knowledge and practices related to lymphedema care among peripheral health workers of the primary health care system in a filarial-endemic district of Orissa, India. A total of 41 health workers sampled across the district were subjected to in-depth interviews. The results showed that many lymphedema patients visit the peripheral health institutions mostly for the treatment of acute episodes of lymphangitis. Many health workers do not know the concept of foot care and its importance in lymphedema management. However, a few health workers advised the patients to follow some components of foot care. The knowledge levels and practices of peripheral health workers are not at desirable levels. The medical and paramedical staff of the peripheral health institutions should be oriented about the management of lymphedema and peripheral health workers should promote the foot care practices. For the GPELF as a whole to prove successful, the patients who already have lymphedema need to be cared for and have their morbidity relieved as much as possible. as a whole.19,20 Since foot care is the mainstay in the control of morbidity in LF,13,21 attempts should be made to promote foot care among lymphedema patients under the GPELF, which has been initiated in many endemic areas of India. The GPELF is primarily run by primary health care system and the peripheral health workers are expected to play a key role in promoting the foot care among the lymphedema cases. Thus, it is essential to know the current levels of knowledge and practices of health workers with regard to foot care and care of lymphedema patients. The present study, perhaps first of its kind, assesses knowledge and practices related to lymphedema care among peripheral health workers of primary health care system in a filarial endemic district of Orissa, India.
INTRODUCTION The Global Program to Eliminate Lymphatic Filariasis (GPELF) is based on the interruption of transmission and alleviation of disability and suffering among those who have the most common manifestation of lymphatic filariasis (LF).1 Although LF presents with chronic manifestations, i.e., lymphedema and hydrocele, acute attacks in the form of lymphangitis are more common. Repeated episodes of lymphangitis have a greater economic impact on the patient.2–4 They also lead to the progression from lymphedema to elephantiasis,5 which also has a significant socioeconomic impact on the patients.2,6–8 The lymphangitis is of two types: acute filarial lymphangitis, caused by the death of adult filarial worms, and acute dermatolymphangioadenitis (ADLA), the result of secondary bacterial infections.9 The role of bacteria in the pathogenesis of ADLA has been well established.10,11 Subsequently, Olszewski and others12 conducted bacteriologic studies on skin, tissue fluid, lymph, and lymph nodes from cases of filarial lymphedema, and explained the episodes of dermatolymphangioadenitis and their etiology. Stagnation of lymph, which occurs in affected limb, encourages growth of bacteria invading the region. Injuries, even trivial ones, resulting in wounds or abrasions, fungal or bacterial infections, fissuring of the skin, paronychia, and eczema are the lesions of the skin that favor entry of such bacteria into the tissue.11,13 Studies have also implicated pathogenic bacteria, mainly streptococci and occasionally other pathogens, as the causative agents of these episodes.14,15 In this process, secondary infection and the resultant inflammation seem to play major roles in skin changes in lymphedema, including the development of elephantiasis.16,17 Olszewski18 demonstrated that simple hygienic measures, supplemented with antibiotic treatment, have profound effect in preventing these acute episodes. Shenoy and others13 also demonstrated how well designed programs of foot care can significantly decrease the frequency of adenolymphangitis (ADL) attacks. In these programs, meticulous hygiene in treating the affected area needs to be incorporated with the creation of hope and understanding among the patients, their care providers, and the community
MATERIALS AND METHODS This study was conducted in Khurda district of Orissa, India. The district is endemic for Bancroftian filariasis.22,23 Ten primary health centers (PHCs) were selected by sampling one randomly from each block (administrative unit) of the district. From each PHC, at least four health workers (two who are stationed at the PHC and two who are attached to health sub-centers [HSCs]) were selected on random basis. Thus, 41 health workers were sampled. The mean ± SD age and total service in the endemic area of the sampled health workers were 41.7 ± 9.0 years and 16.5 ± 9.0 years, respectively. This project was reviewed and approved by the Ethical Committee of our institute. After verbal consent was obtained, each health worker was subjected to an in-depth interview using a structured questionnaire.24,25 Each health worker was asked how he or she dealt with lymphedema patients and probed about knowledge and practices of various foot care methods. The details of their age, sex, designation, place of work, and years of service in a filarial-endemic area were recorded. RESULTS The results are based on the qualitative data obtained through in-depth interviews. We also attempted to quantify
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the data by assessing the proportions of various responses to the total respondents (Table 1). The majority (92.7%) of health workers agreed that many lymphedema patients have visited PHCs/HSCs, mostly to get treatment for acute ADL episodes, and a few patients visited for treatment of swelling of limbs. Similarly, health workers were consulted by lymphedema patients during ADL episodes and patients also consulted health workers during related problems such as pain and heaviness in an affected limb and itching of the affected area. Some (39%) told that patients came with queries such as why their limb became swollen. Most of the time the health workers advised the patients to consult a physician. They also advised them to get their blood tested and take diethylcarbamazine (DEC) tablets or an injection of flourocide. On some occasions, they provided the patients with antepyretic drugs such as paracetamol. A few (7.3%) health workers said they often insisted that patients use a pressure bandage. It is important to note that although we surveyed an LF-endemic area, none of the health workers received any training on lymphedema care, except a half-day training session on drug distribution before the yearly mass drug administration (MDA) of the GPELF. However, a small proportion (17.1%) got instructions verbally from higher authorities to refer these cases to any hospital. Approximately two-thirds of the respondents said that there were no facilities in their institution to take care of lymphedema patients. Only three of the ten PHCs have facilities for blood testing. When health workers were asked whether something could be done to minimize the morbidity of lymphedema patients, many (60.98%) of them said that it can be minimized by medication. However, none indicated any information regarding foot care or foot hygiene. All health workers know that lymphedema patients have frequent acute episodes of ADL and they treat them with DEC and antipyretics. Approximately 17% of the respondents said that it could be
TABLE 1 Responses of peripheral health workers about management and care of lymphedema patients* Percent
Seen that lymphedema patients visit PHC/HSC Consulted by lymphedema patients Informed by higher authority on lymphedema care Agreed that PHC/HSC has no specific facilities/drugs for lymphedema care Think that something should be done for lymphedema patients Know that these patients have had acute ADL episodes Know the concept of foot care Advise lymphedema patient to wash the affected limb regularly Advise lymphedema patient to keep the affected limb dry Advise lymphedema patient to massage the affected area Advise lymphedema patient to use a bandage Advise lymphedema patient with regard to wounds and blisters Advise lymphedema patient to use some foot wear Advise lymphedema patient to elevate the affected limb during sleep/rest Advise lymphedema patient to exercise (move) the affected limb Advise other methods such as home remedies Advise patients with regard to food
92.7 95.1 17.1 61.0 80.5 100.0 36.6 68.3 56.1 48.8 68.3 70.7 85.4 65.9 56.1 29.3 75.6
* PHC/HSC ⳱ primary health center/health subcenter; ADL ⳱ adenolymphangitis.
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prevented by avoiding mosquitoes. Simultaneously, the health workers were probed to find out whether they are aware of the concept of foot care or foot hygiene. None of them reported a knowledge of this concept. However, approximately 25% said that by keeping the affected foot clean and by wearing proper footwear, patients can prevent injury and minimize morbidity. Moreover, when probed about practice of various methods of foot care, some health workers responded positively. These findings are shown in Table 1. Approximately 68% of the health workers advise patients to wash their affected limb regularly for the maintenance of cleanliness to avoid infections. Some (21.95%) health workers know the benefit of washing, but they did not advise this to the patient. A few have the misconception that the affected limb should be washed with warm salt water. More than 50% of health workers said they often told patients to keep their affected limb dry. Some (43.5%) said this practice will keep prevent fungal infections, but some (34.8%) advised the patients though they did not know the reason. Massaging was advised by approximately half of the health workers and they said that massaging would improve blood circulation, reduce swelling, make affected limb softer, and lessen the pain. Some (15%) health workers never suggested massaging although they knew of its benefits. Similarly, a bandage was advised by approximately 68% of the health workers. They knew that use of a bandage reduces swelling. A few (7.3%) health workers thought that use of a bandage would check the flow of blood and prevent blood accumulation in one specific area. Approximately 27% knew that use of a bandage would help in the reduction of swelling, but they never advised the patient to use it. Significantly, a high percentage (85.4%) of respondents suggested patients wear proper footwear, since they knew that the use of footwear prevents external injuries. Many recommended the use of soft spongy slippers, whereas approximately 6% of the health workers told patients that they should use special kind of footwear that would cover the entire affected foot. Many (66%) also advised elevation of the affected limb and some believed that blood circulation will be normal and swelling of foot would be reduced if the foot was elevated. More than half of the respondents advised exercise of the limb and believed that it would enhance blood circulation. A few thought that by doing exercise, the patient would get some relief from pain, but many of them do not know the reasons for elevation and exercising of the foot. Approximately 30% of health workers suggested home remedies such as herbal medicines. Interestingly, approximately 75% of the health workers advised lymphedema patients to avoid certain foods. Many of them prescribed various food taboos such as not eating watery rice (many people in this region preserve the previous days’ leftover rice by adding water to it and subsequent eat it for breakfast), plantain fruits, seafoods, and salty and sour foods.
DISCUSSION The knowledge level and current practices of peripheral health workers with regard to lymphedema care are not at desirable levels in Orissa, India. It is understood that many lymphedema patients visited peripheral health institutions and sought treatment for both acute lymphangitis episodes
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and limb swelling. It is known that lymphedema patients in this endemic area know little about foot care and their practices are poor (Nayak AN, unpublished data). Thus, it is expected that peripheral health workers should promote foot care and encourage patients to adopt foot care by explaining its benefits in terms of relieving their morbidity. This activity should be undertaken during regular visits of health workers to the community, as well as during patients’ visits to health institutions. This group of health care providers should possess appropriate knowledge and technical skills to demonstrate foot care methods to the patients. They should make the best possible use of locally available resources and advise the patients to do likewise. The washing and drying of the affected limb regularly should be promoted. Attention should be given to the skin between toes, skin folds, and wounds while washing and drying. Dreyer and others26 recommended washing the affected limb regularly with soap and clean water to avoid the progression of lymphedema to elephantiasis. In the present study area, patients use various oils, such as coconut oil and mustard oil, for massaging. However, they do not wash off the oil, which facilitates the accumulation of dust, before they go out. Thus, they should be advised appropriately regarding this practice. Elevation of the affected limb during sleep and leisure time should be promoted because it prevents the accumulation of fluid in the affected area and provides considerable relief.26 Similarly, the movement or exercise of affected limb should be promoted because it increases the flow of blood and lymph through the limb (prevents lymphostasis).27 Use of a bandage should also be demonstrated as a good method for relief, particularly among patients with the early stage of lymphedema. The patient can be encouraged to use a simple cloth strip instead of a commercially available bandage. Many (60%) patients in this area use normal footwear, which may not provide any additional protection. Since no specially designed footwear is commercially available in the study area, patients should be advised to use larger size footwear. This improves foot hygiene and prevents injuries and infections when they go outdoors to work. These foot care practices should be carried out regularly for many years. Such long-term care is feasible if it is carried out in the homes of the patients by themselves or by their family members with locally available resources. It has been established that each acute episode among lymphedema patients causes considerable economic loss to the family and increases the risk of more episodes and further worsening of the condition. It has also been demonstrated that improving skin hygiene and treatment with topical antibiotics and anti-fungal creams can prevent acute attacks among lymphedema patients.11,13,28,29 The mainstay in the prevention of acute episodes is local care of the affected limbs.13,21 The study district has been covered by the MDA of DEC and albendazole under the GPELF. Although the alleviation of disability and control of morbidity is one of the two components of the GPELF, few attempts have been made in this direction. Thus, the program has failed to support persons with lymphedema. Unlike young people who are presently uninfected and may hope to remain uninfected as a result of MDA, those already infected will not benefit from the reduction in transmission achieved by the GPELF. For the GPELF to be successful and sustainable, those persons already with lymphedema need to be cared for and have their morbidity
relieved as much as possible. Thus, the medical and paramedical staff of these peripheral institutions should be instructed about recent developments in the clinical management of LF and the peripheral health workers should promote various foot care practices. Optimal disease prevention at the community level requires development of simple, reliable, and effective strategies to control secondary infections because these infections are essential cofactors in the development of filarial lymphedema and the further progression of elephantiasis.20 Appropriate care at an early stage can help in prevention or reversal of the progression of the disease. Although home-based foot care relies on the patients and their families, its promotion is the responsibility of peripheral health workers. These workers should take the lead in encouraging patients to modify their behavior to adopt appropriate foot care practices. Thus, much can be done at the peripheral level, and much can be achieved in disability prevention with little financial cost to the patient. Received June 2, 2004. Accepted for publication July 16, 2004. Acknowledgments: We thank Dr. S.K. Kar (Director, Regional Medical Research Centre) for his cooperation. Thanks are also due to medical officers and health workers of the PHCs studied for their cooperation and courtesy extended throughout the study. Financial support: Funding and infrastructure support were provided by the Regional Medical Research Centre (Indian Council of Medical Research), Bhubaneswar, India. Authors’ address: Kalyani Rath, Basanta K. Swain, Shaloumy Mishra, Trishna Patasahani, Anna S. Kerketta, and Bontha V. Babu, Division of Clinical and Epidemiology, Regional Medical Research Centre, Indian Council of Medical Research, SE Rly Project Complex (Post), Bhubaneswar 751 023, India, Telephone: 91-674-2303002/ 2301310, Fax: 91-674-2301351, E-mail:
[email protected].
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