International Journal of Anesthesiology & Pain Medicine

Keywords

Knowledge; Attitudes; Anesthesia services; Arsi university asella referral; Teaching hospital

Introduction

Anesthesia (From Greek "without sensation"), a word that millions of tongues speak daily around the globe, was irst used by Greek philosopher dioscorides in the irst century AD to describe the narcotic like effects of the plant mandragora. It is a state of a controlled, reversible loss of sensation or awareness that is induced for medical purposes. It may include some or all of the analgesia (relief or prevention of pain), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness. It enables the painless performance of surgical procedures that would otherwise cause severe pain to the patient or would be technically unfeasible [1,2].

Modern anesthesia was not discovered until the midnineteenth century, in which the specialty of anesthesia began a ter its irst successful public demonstration in 1846 and became irmly established in the following century. Following its irst public demonstration, anesthesia has become one of the most advanced specialties in modern health care, particularly in the last several decades [3-5]. However, the roles of anesthesia services in the health care system particularly the anesthetist's role have long been suffering from low appraisal and poor recognition among patients and general population [6-9]. A 2009 worldwide meta-analysis showed that less than two-thirds of patients knew that anesthetists are physicians [10].

Nowadays, anesthetists are responsible for the well-being of patients undergoing complex and invasive surgical procedures. Anesthetists play a very crucial role in a patient’s medical care and in regulating critical leif functions that arnge from perioperative patient management to critical and palliative care. However, very few patients know these roles and responsibilities. A recent study in India found that most of the patients (44.5 %) knew that operating surgeons were anesthesia providers, while only 22% of patients correctly knew anesthesia providers as anesthetists.

Anesthetist’s duty also extended to outside the operating room, with a leading role in the management of trauma resuscitation, providing labor analgesia, and pain management. They are involved in running the intensive care unit and are an integral part of the resuscitation team in most hospiatls. Surprisingly, a 2013 study found that only 22% of the patients knew correctly that an anesthetist is a person who will resuscitate the patients if any mishap occurs in ORT. It was observed that 63% of the cases felt that the role of the anesthetist in the operation theater is to put the patient to sleep [11].

Poor knowledge about anesthesia services is not limited to the public and patients. One tsudy showed that even other healthcare personnel and academic staff do not know the current depth of anesthetic practice and the teaching potential of anesthetists [12].A 2011 study in Israel conducted on paramedical staff found very shocking results; only 49.20% of respondents knew anesthesia was a different specialty and only 5.8% knew about regional anesthesia [13].

Most works of the literature showed that the possible reasons for limited knowledge and negative attitudes about anesthesia services were due to lower educational level, lack of previous pre-anesthetic teaching and health information, and the city where a person lives i.e., rural [14]. Previous exposure to anesthesia and surgery also affects knowledge about anesthesia. One study showed that out of 103 patients who had previous exposure to anesthesia, 64 patients answered correctly about different types of anesthesia techniques while 81 patients, who had no previous exposure to anesthesia, answered incorrectly [15].

Generally, with the changing healthcare environment and advancements in anesthesia, the patients and public need to be educated and involved. It is important to determine and promote patients' knowledge and attitudes toward anesthesia services that would be beneficial to both patients and service providers.

Materials and Methods

Multi-center based cross-sectional study was conducted at three South-Eastern referral hospitals of Ethiopia; Arsi University Asella Referral and Teaching Hospital (AUARTH), Shashemene Referral Hospital, and Adama Referral Hospital and Medical College from December 1, 2020, to April 1, 2021, G.C. The Source population consisted of all adult patients who were admitted to undergo surgery in referral hospitals of South- Eastern Ethiopia. The study population included all surgical elective patients who were admitted and scheduled for elective surgery in referral hospitals of South Eastern Ethiopia during the study period. Inclusion criteria were; patients who were posted for elective surgery and patients with an age of more than 18 years were included. Conversely, uncooperative patients, unable to speak, with severe medical or surgical conditions (ASA Grade 3 and above), and patients who underwent emergency surgery were excluded. The formula for calculating sample size (estimation of population proportion) is:

Where: n=Sample size=334, C.I=95%, a=0.05, D=Precision=0.05, P=68.2% (patients who have poor knowledge and attitudes otward anesthesia services, taken form the previous study at Tikur Anbessa specialized hospital, Ethiopia [16]. Non-respondent rate (10%)=35. Therefore, the total sample size=369.

A systematic random sampling technique was employed to approach the study participants. The sampling interval (K^th) was calculated using population seiz and total sample size. Population size (N) is taken from the average number of adult elective operations performed as of the surgical registration book for the last five years, and the total sample size (n) is calculated using population proportion. Therefore, sampling fraction or interval (K^th)=N/n=738/369=2. Accordingly, every other patient posted for pre-operative evaluation and scheduled for elective surgery was selected to participate in the study until the required sample size was achieved.

The study was conducted by interviewing patients using a structured questionnaire, which was prepared in English and then translated into Amharic and Afan Oromo. The checklist was also used to obtain the patient’s information from the chart. Two data collectors were selected and 5 days of training were given on how to complete data and supervised by the investigators during data collection. Patients were asked by data collectors to self-report on socio demographic characteristics and other independent factors. They were also asked to respond to their opinion for questions to assess knowledge and attitudes. On the other hand, the proposed type of surgery was obtained from the patient's chart and pre-operative schedule format.

Knowledge is a patient's state of knowing, familiarity, and understanding of anesthesia services. In this study, the patient will be considered as having good knowledge, if he/she answers correctly more than half of the 12 knowledge questions provided (≥ 6). Attitude ias set offe elings, beliefs, characteristics, andb ehaviors of patients toward anesthesia services. Similarly, as for knowledge, the patient will be considered as having a good attitude, if she/he answers correctly more than half of the 12 attitude questions provided (≥ 6). Generally, a patient wilbl e considered ash aving good knowledge and attitude if she/he answered more than half of the knowledge and attitude questions provided (≥ 12).

During data collection, regular supervision and follow-up were made by the researchers and cross-checked for completeness and consistency of collected data daily. Once the data was collected and checked for completeness, consistency, and accuracy, it was sorted and categorized. Then, the data were entered into the computer using a developed data entry format, coded for each category of variables, and cross-checked for errors. Univariate analyses such as frequency and percentage were computed for variables such as age, gender, type of surgery, education level, occupation, previous history of anesthesia or surgery, and knowledge and attitude related questions. A logistic regression model and odds ratio was used to measure the association of independent and dependent variables. A p-value of less than 0.05 was considered to constitute a statistically significant difference.

Results

Description of sociodemographic characteristics

Out of a total of 369 participants included in the analysis, 52.3% were male and 47.7% were female. Most of the patients (22.8%) were aged between 46 and 55 years. Consequently, patients who came from rural areas and were illiterate accounted for 75.6% and 43.9%, respectively. Most of the participants (65.3%) run their life by agriculture (Table 1).

Table 1: Description of sociodemographic and patient factors among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Knowledge of anesthesia provision: In the knowledge assessment, out of 369 respondents, most of the patients (74.5%) believed that anesthesia is necessary for surgery. When asked about ways of anesthetic administration, 15.7% of them did not know how it is provided. Only 36.9% of them know ways of anesthetic administration. In the assessment of the type of foods allowed two hours before surgery, most patients (43.4%) think nothing should be eaten. Only 127 (34.4%) of them were known as liquid foods. One hundred thirtythree of the respondents knew what anesthesia is about, and 34.1% of them have no idea about anesthesia (Table 2).

Table 2: Description of patient’s knowledge toward anesthesia provision among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

In the assessment of patients' knowledge of complications of anesthesia, 36.04% of them know complications of anesthesia and 32.52% have no idea about complications of anesthesia (Figure 1).

Figure 1: Distribution of patient knowledge toward complications of anesthesia among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Knowledge toward anesthetists: In patients' knowledge assessment of anesthetists, shockingly, more than half of the total respondents (56.6%) believed that surgeons are responsible for administering anesthesia to surgical patients. Only 124 (33.65) known anesthetists will provide anesthesia for surgery. Similarly, the majority of the patients (60.2%) knew the surgeon decides if a patient is fit for anesthesia or not and 55%of them think surgeons will determine if a patient can eat before surgery. Regarding the role of making sure patients recover after anesthesia, in the same way, most of the patients (43.6%) think it's the role of surgeons while only 18.43% of them knew anesthetists estimate and transfuse blood in the operation theater. On the other hand, most patients (59.6%) know the anesthetist's responsibility (anesthetizing and taking care of the patient's vital signs) in the operation theater (Table 3).

Table 3: Description of knowledge of patients toward anesthetists among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Generally, in this study among 369 patients, only 24.66% have a good knowledge and the remaining 75.34% have poor knowledge of anesthesia services (Figure 2).

Figure 2: Percentage of patient knowledge among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Patient’s attitude

Assessment of the patient's attitude was addressed as agree, disagree, or neither of the two for the questions provided. Out of 369 respondents, the majority of patients (88.1%) agreed positively about meeting the anesthetist before an operation and 71% of them prefer the less they know about anesthesia the better it would be. Similarly, most of the respondents (79.7%) agreed that anesthetists should tell them all the complications no matter what. One hundred seventy-six (47.7%) patients were not afraid, more about the anesthetic than the surgery. Regarding information on anesthesia services, 58.5% of them preferred anesthetists to explain to them than read about it. One hundred twenty-four (70.3%) patients do not care about the anesthetic, so long as it is a smooth operation. The most feared risk of anesthesia is feeling pain (39.30%) (Table 4).

Table 4: Description of patient’s attitude toward anesthesia services among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Generally, in this study among 369 patients, only 82.66% have a positive attitude and the remaining 17.34% have a negative attitude toward anesthesia services (Figure 3).

Figure 3: Percentage of patient’s attitude among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Patient’s knowledge and attitude

According to our findings, out of 369 patients, 57.18% of them have poor knowledge and attitude while 42.82% of them have good knowledge and attitude toward anesthesia services (Figure 4).

Figure 4: Percentage of patient’s overall knowledge and attitude among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Associated factors of poor knowledge and attitude

The output of binary logistic regression analysis identifies the following sociodemographic and patient factors that are significantly associated with poor knowledge and attitude (with p-value <0.05); Rural residence 7.014 (4.049-12.152), agriculture occupation 5.084 (2.804-9.218), housewife occupation 7.579 (2.769-20.745), patients with income of less than 1000 birr 5.867 (1.485-23.175), patients with the previous history of anesthetic exposure 3.242 (1.596-6.585) and patients with nongeneral surgery proposed type of procedure 0.244 (0.132-0.449). On the other hand, sociodemographic and patient-related factors such as sex, age, and type of anesthesia are not significantly associated with poor knowledge and attitude (Table 5).

Table 5: Associated factors of poor knowledge and attitude toward anesthesia services among surgical patients in referral hospitals of South Eastern, Ethiopia, from December 1, 2020, to April 1, 2021, G.C.

Discussion

Knowledge and attitude toward anesthesia services

This study was designed to assess patient's knowledge and attitudes toward anesthesia services to ascertain the degree of patient satisaction in this dramatically advancing anesthesia specialty. Regarding knowledge assessment, among 369 respondents, only 24.66% have good knowledge and the remaining 75.34% have poor knowledge of anesthesia services. Almost similar results were observed in a recent study in Saudi Arabia, where out of a total of 200 respondents, only 26% of participants were known about anesthesia services, and most of the patients were not aware of their roles [17]. This is in agreement with a 2009 worldwide meta-analysis that showed that less than two-thirds of patients knew anesthesia services. On the other hand, a 2016 study in India found a lower percentage of poor knowledge. Out of 180 participants, only 40% have poor knowledge of anesthesia services [18]. This might be because, in India, the patients have good inormation and knowledge about anesthesia services.

There is a widespread misconception of the role of anesthetists all over the world, and there is considerable confusion in the public mind about what the anesthetist does in the operation theater. In our study, a higher percentage (59.6%) of patients taught anesthetists intraoperatively monitor heart, blood pressure, and breathing. On the other hand, a study done in Hong Kong and Korea showed only 25% and 18.8% of patients, respectively, thought anesthetists have the responsibility for these vital sign monitoring [19]. For the responsibility of estimating and transfusing blood intraoperatively, 18.43% of patients responded to an anesthetist, which was a higher result when compared to a study done by the Korean Association of anesthesiologists.

Our study also showed that only 33.6% of them know that anesthetists are in charge of anesthesia during the surgery. This is lower when compared with the study in Addis Ababa where 42% of the patients knew, anesthesia was provided by the anesthetists. This might be due to the study conducted in Tibur Anbessa Specialized Hospital (TASH) which is at the very top of the referral system in our country and located in the capital city, Addis Ababa. It has provided a variety of informed patients from every corner of Ethiopia. However, this study showed a better result than a study done in Nigeria which was 19%.

In this study, only 33.3% of the patients believed that anesthetists are responsible for making sure that the patient is it for anesthesia. Most of them (60.2%) believed it's the responsibility of surgeons. This may be because anesthetists are often busy in operating theaters with little and limited time to interact with their patients pre and post operatively.

Knowledge of the route of general anesthesia administration was correctly answered by 36.9% of the patients, which was very low. It is comparable with the study done in Pakistan. This might be due to these countries being categorized as the third world, which sets a high illiteracy rate. Regarding, the risk of anesthesia in high-risk patients like patients with hypertension and DM, 73.4% responded it has increased risk which was a higher finding than the study done in India (41%).

For the responsibility of making sure smooth recovery in postop, 25.7% of our patients believed anesthetists are responsible while in the study done in Hong Kong it was 65%. The reason for this significant difference could be most of our patients are sedated intraoperatively therefore; they know less about the role of anesthetists during this period. In the case of Hong Kong, as they have an advanced setup, they could use modern anesthetic techniques such as ultrasound-guided regional anesthesia that will reduce the use of sedative agents. Regarding complications of anesthesia, 32.52% of our patients believed anesthesia has no complications. This is comparable with the study done in India, which found that 31% of patients thought it has no complication.

In the knowledge assessment of who will estimate and transfuse blood in the operation theater, shockingly; the majority of patients (65.85%) believed all responsibilities belong to surgeons. Out of 369 respondents, only 18.43% knew anesthetists to estimate and transfuse blood in the operation theater. This might be because in most Ethiopian hospitals physicians are working closely with the patients starting from OPD up to admission, preparation, diagnosis, and post-operative management which might have misled the patients.

Regarding attitude assessment, among 369 patients, 82.66% have a positive attitude and the remaining 17.34% have a negative attitude toward anesthesia services. This might show the positivity of our community toward any profession. Most of our patients would like to meet their anesthetist preoperatively (88.1%) which is a little bit higher than the study done in Hong Kong (77%) [19]. This might be due to, although our patients have poor knowledge, they have a positive attitude toward anesthesia services. On the contrary, in Hong Kong, a patient's better knowledge negatively affects their attitude. Seventy-one percent (71%) of our patients think that the less they know about the anesthetic the better, which is a similar result when compared to the study done in Hong Kong.

In this study, seventy-four percent of patients also agreed all they needed to know was what their surgeon tells them. This might be due to surgeons spending more time with the patients in the ward and clinic, patients may think the surgeon gives them all the information they need to know. Regarding the importance of the anesthetist's explanation, of what is going to happen to the patient, 58.5 % agreed and 39% disagreed. This shows that most of the patients do not know how anesthetists work and do not expect an explanation from them.

Eighty-one percent of patients from this study would like to see their anesthetist postoperatively, and 33.6% of the patients do not care about the anesthesia as long as the operation went smoothly. However, the findings from Hong Kong revealed a different value, which was 42% and 13%, respectively. This result showed a large number of our patients do not care and are concerned about anesthesia services.

Generally, according to our findings, out of 369 patients, 57.18% of them have poor knowledge and attitude while 42.82% of them have good knowledge and attitude toward anesthesia services.

Associated factors of poor knowledge and attitude

The output of binary logistic regression analysis identifies the following sociodemographic and patient factors as a significant predictor of poor knowledge and attitude toward anesthesia services (with p-value < 0.05); rural residence with OR of 7.014 (4.049-12.152), agriculture occupation with OR of 5.084 (2.804-9.218), housewife occupation with OR of 7.579 (2.769-20.745), patients with income of less than 1000 birr with OR of 5.867 (1.485-23.175), patients with no previous history of anesthetic exposure with OR of 3.242 (1.596-6.585) and patients with non-general surgery proposed type of procedure with OR of 0.244 (0.132-0.449).

According to this study finding, patients who live in rural areas have poorer knowledge and attitude than patients who live in urban areas. Among patients who live in rural areas, 68.1% of them have poor knowledge and attitude, compared to 23.3% in urban areas. According to logistic regression output, the likelihood of poor knowledge and attitude in patients from rural areas was seven times more likely than in urban areas, with an OR of 7.014 (4.049-12.152). The same findings were observed in a study done in Saudi Arabia and Nigeria. In our country, it is known that people who live in urban areas are more likely to be educated than the people who live in rural areas according to the 2011 Ethiopia demographic and health survey. It is also known that more educated people tend to read and have better general knowledge than those who do not.

In this study, it was also found that patients who had no previous experience of anesthesia have poor knowledge and attitude compared to those who had exposure. Among patients who had no previous anesthesia exposure, 63.5% of them had poor knowledge and attitude, compared to 35.7% of patients with no exposure. According to logistic regression output, patients who had no previous experience with anesthesia have poor knowledge and attitude three times more likely compared to those who had exposure with OR of 3.242 (1.596-6.585). Similarly, a 2018 study in Nepal found, a statistically significant correlation between past exposure to anesthesia and knowledge about anesthesia. A 2011 study by de Oliveira, et al. also established a significant positive correlation between prior anesthetic experience and patients' knowledge of anesthesia service. This might be due to those patients being well-informed by anesthetists during their previous exposure to anesthesia and surgery.

Patients with agriculture and housewife occupation have poor knowledge and attitude compared to government employees. According to logistic regression output, patients with agriculture occupations have poor knowledge and attitudes five times with OR of 5.084 (2.804-9.218) and patients with housewife occupations eight times with OR of 7.579 (2.769-20.745) more likely than government employed, respectively. According to logistic regression, it was also found that patients with an income of less than 1000 birr have poor knowledge and attitude compared with patients with >2000-birr income. They were six times more likely to have poor knowledge and attitude, with an OR of 5.867 (1.485-23.175). This is similar to a study in Addis Ababa, where higher income correlated well with knowledge of anesthesia services. Other sociodemographic and patientrelated factors such as sex, age category, type of anesthesia was not statistically significant with poor knowledge and attitude (with a p-value greater than 0.05).

Conclusion

This study result showed a large number of our patients have poor knowledge and attitudes toward anesthesia services, which are worthy of the attention of anesthetists and all health care providers involved in the care of surgical patients. Anesthetists and stakeholders should have to work hand in hand and improve Ethiopian patient’s health information regarding anesthesia services and bring about a positive attitude towards the profession.

Declarations

Ethical approval and consent to participate: Not applicable

Consent for publication: Not applicable

Availability of data and materials: Data will be available based on reasonable requests of corresponding authors.

Competing interests: We declared that we had no competing interests.

Author’s contribution: DC.E and MS. O were involved in the conception, study design, execution, acquisition of data, analysis, and interpretation of data, took part in drafting the article or revising it critically for important intellectual content. AH.G, MA.G, BT.G, EN.T, NG.W, AB.W, and KM.A were involved in study design, execution, acquisition of data, analysis, interpretation, drafted, and final manuscript writing. All authors reviewed and agreed on all versions of the manuscript before submission, agreed to submit to the current journal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work.

Acknowledgment

We would like to extend our deepest thanks to Arsi University for its material support.

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