Objectives: To asses the knowledge, opinion and attitude of medical graduates regarding selected reproductive tract infections, diagnosis of sexual dysfunction, identification of sexual abuse and other sexual health issues in Fatima Baqai Hospital Gadap Town.
Methds: A cross sectional study conducted from January 2009 to July 2009 in Fatima Baqai Hospital Karachi. An anonymous, self administrated structured questionnaire was completed by medical graduates. Formal/ informal interviews were also arranged. The questionnaire and interviews addressed socio-demographic features, reproductive problems knowledge, attitudes and experience of those medical graduates. Descriptive statistics were analyzed by SPSS version 11.
Result: A total of 50 medical graduates participate in the study. Of the total nearly half scored less than 50% in the knowledge section. Attitude and practices assessment suggested a tendency to be judgmental, gender/ rights discriminatory and with little provision for enabling clients to make their own decision, so essential for quality sexual health provision.
Conclusion: The level of reproductive and sexual health knowledge among the participant medical graduates were lower than expected. Attitudes and opinions indicate judgmental approach and indicating lack of experience of training in dealing with sexuality issues.
Keywords: Sexual and reproductive health, Medical graduates, Developing countries, Medical training (JPMA 61:648; 2011).
Each year, it is estimated that over 585,000 women die world wide because of complications from pregnancy, birth, abortion and inappropriate conditions. On the other hand, the rate, cost, morbidity and challenges of unwanted pregnancy and sexually transmitted diseases (STD) are increasing each day around the world.1 Pakistan is included in the three south Asians countries, which have the highest numbers of maternal and perinatal deaths. Unfortunately due to societal stigma surrounding sex and sexuality in Pakistan there is very limited access to correct information, regarding normal physiological changes, sexual intercourse, healthy and unhealthy processes, safe behaviours and safe maternity services. Sexual rights are also commonly violated as a child and forced marriages are routine. Marital rape is a non existent concept and women are remaining in abusive relationships due to discriminatory law and policies.2 The majority of these inappropriate conditions, morbidities and mortalities can be prevented by educating people about proper reproductive/sexual health knowledge and by increasing the usage of maternity and family planning services. Effective sexual health messages and counseling can positively influence public and patient behaviour. The most notable example was the reversal of the Uganda HIV epidemic during the early 1990s.3 Sexual and reproductive health, as defined by ICPD ( International conference on population and development) is significantly under represented in basic educational curricula for medical and health professionals and the continuing medical education programmed for established practitioners in many developing countries.4,5 Many studies also found medical college training on sexuality issues to be lacking6,7 and analyzed that medical graduate training can be an important means of promoting the appropriate and effective assessment and management of sexual health problems in society. Importantly, continued medical education based on solid scientific evidence is not well recognized, yet not widely implemented and thus reducing the possible impact on health services in community and the consequences of its stagnation of the quality service delivery and ill health of the population in the developing world.8 So, we planned to determine the reproductive health training adequacy, attitude and opinions in our hospital and college medical graduates to highlight the behaviours of future public educators and to assess the existing curricula for undergraduate, postgraduate and continuing professional education sufficient?
Subjects and Methods
This cross-sectional study was conducted from June 2009 to July 2009 in Fatima Baqai hospital, Gadap town Karachi. House surgeons and postgraduate training of gynecology department, resident medical officers working in primary health center of Gadap town and 25 final year student who had completed their last posting in gynecology were included in the study. By taking these participants we assumed that we had a complete picture of Gadap town reproductive health providers. All participants were explained about the objective and potential benefit of the study and after ensuring the confidentiality of information, written consent was obtained. Data was collected using a pre-tested questionnaire administered by investigators. Two questionnaires were used; one for assessment of knowledge and another for assessment of attitude and opinion. Initial part of questionnaire consisted of socio-demographics information of the participant\'s age, gender, institution of graduation, qualification and working experience. While the remaining part consisted of questions regarding subject knowledge, attitudes and practices towards sexual/reproductive health. Attitude questionnaire were designed to asses the comfort of participants during sexual history taking, counseling regarding sexuality, respect for patients\' own decision and gender sensitivity that are important to provide quality health services in a non discriminatory environment. Knowledge questionnaire responses were coded as "Correctly answered" and "Incorrectly answered". Later on investigators calculated the percentage of corrected responses of each participant and individual question by entering data into Epi-info and SPSS version 11. A scale of 1 to 3 was used to grade responses of attitude questionnaire and the scale was later categorized into agreed, neutral and disagreed. After the participants had filled the questionnaire, a formal/informal interview was conducted to record their views and compare them with their opinions in the questionnaire.
In our study 35 (70%) participants were females and 15 (30%) were males. The mean age was 25Â±5 years. Most doctors (70%) had graduated from Baqai Medical College.
While remaining were graduates of Chandka Medical College, Bolan Medical College and Dow Medical College. None of the participants had post house job experience of more than 3 years. Out of 10 postgraduate trainees, 3 (6%) were also private practitioners.
Eleven (22%) scored less than 50%, 31 (62%) scored between 51%-69% and 5 (10%) doctors scored over 70% in the knowledge/training assessment test. Knowledge score for individual participants ranged from 10% to 90% for incorrect responses (Table-3).
Doctors particularly females (20%) reported discomfort in taking sexual history; especially from very young or elderly patients. Although 60% were neutral in opinion, however, during interview they reported hesitation in taking sexual history. Almost all (90%) participants felt it is appropriate to counsel patients about sexuality, risky behaviours and risk reduction strategies. Eighty (80%) of the respondents were of the opinion that the present medical curriculum is insufficient to prepare doctors to deal with sexual health problems. Specific practices to ensure confidentiality and encouraging patients to make responsible decisions were assessed to be deficient.
It is known that knowledge, opinions and attitudes are related to behaviours, as reproductive health training and attitude are predictive factors for reproductive behaviours.9 In our analysis, the over all knowledge score of all candidates indicate that the participants lacked the basic knowledge for managing cases of sexual and reproductive health effectively. An important reason of this as expressed by majority of candidates (80%) in informal interviews that sexual and reproductive health care is significantly under-represented in the basic educational curriculum for medical and other health professionals as well as in continuing medical education programmes for professional development of practicing physicians. Others have also reported the lack of integration of sexual health related topics in health care professionals\' education.10,11 According to WHO, "Reproductive and sexual health accounts for 20% of the global burden of ill health for women and 14% for men".12 Unfortunately a wrong perception among Pakistani community is that sexuality issues are not a problem in our population.
This study has identified deficiencies pertaining to sexual health training. It is observed that female doctors have generally scored better than their male counterparts. This may be due to the fact that they deal with such cases more frequently then male doctors. The scores of knowledge/training assessment questionnaire (Table-3) indicate that most of the participants (70%) correctly answered the first three questions. Those who did not were all males. This may also point to the general attitude of males towards such issues, as not being their problem and hence, a barrier in management of their spouses with conditions like STD which requires stringent partner management.13
When we saw the scores of questions 15, 20, 22 we found that only (10%-20%) of participants correctly answered this questions. This indicates a severe lack of knowledge related to female reproductive health issues. Most of candidates considered home delivery unsafe for all types of pregnant ladies. ICPD (International conference for population and development5 has also pointed out this issue that many of the health care providers have fixed unbendable approach towards community health care delivery. It is suggested to bring changes in undergraduate medical curriculum to develop a better attitude towards working in community.14
Sexual history taking can be influenced by medical college training, cultural brought-up, attitudes towards sexual orientation and patient and doctor gender.15,16 It is therefore not surprising that many doctors in our sample reported being uncomfortable when taking sexual histories, particularly from the young and elderly patients. A lack of appropriate vocabulary of words for sexual and reproductive parts in the local languages is also an important reason for the discomfort in taking a comprehensive history. One crucial skill for effective and proper management of patient is that a doctor should be fully aware of the local resources, ethical norms of society and law. Health care providers should know the ethical guidelines specially about the patients\' rights regarding disposal of information, confidentiality and informed consent. These issues are particularly important in providing sexual and reproductive health services, however participants of our study showed poor knowledge in this area.
About 20% of participants disagreed with the thought for giving referral for safe medical abortion, another 30% gave controversial opinion showing the judgmental (as opposed to professional) attitude towards abortion. These practices contribute to an increase in the incidence of unsafe abortion and associated complications.17,18
Sexual health problems significantly impact the quality of life of millions of individuals. It is necessary that public healthcare providers should be experienced and sensitive when dealing with patients with sexuality issues. Respect of all categories of patients with reproductive health issues is vitally important, but is rarely discussed as a public health or medical issues.
This study pointed out that students had insufficient training about reproductive/sexual health before coming into clinical practice. Reproductive/sexual health training should be provided at undergraduate as well as at postgraduate level with refresher courses for continuing medical education.
Traditional education in obstetric and gynaecology rarely give students adequate training in understanding the sexuality problems of patients throughout the clinical practice. There should be a module on sexuality, which develops emerging doctor\'s awareness about the need of community sexuality and its impact on care of patients and understanding of male and female sexual responses. In addition, it should help students to understand social, physiological and emotional influences on sexual function and dysfunction, different modes of sexual expression and the implication of body image and self esteem. They should be fully trained with the legality issues (like informed consent) for reproductive and sexual health. Finally there is utmost need of refresher courses as continued medical educations for doctors working in community, to improve community sexual health management by properly trained doctors.
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