Knowledge, Attitudes, and Practices Regarding Epidemiology and Management of Travelers' Diarrhea: A Survey of Front-Line Providers in Iraq and Afghanistan

Military Medicine, Jun 2005 by Riddle, Mark S, Tribble, David R, Jobanputra, Nishith K, Jones, James J, Et al

To evaluate the relationship between medical knowledge and clinical practice, a survey on travelers' diarrhea was administered to military health care providers attending a professional development and trauma management conference. The survey was administered at the beginning of the conference and 58 of the 76 attendees participated by completing a questionnaire. Respondents were aware of the standard definition of travelers' diarrhea; however, their knowledge about the epidemiology and management of travelers' diarrhea was low. Less than one-third correctly answered questions on etiology and more than two-thirds made incorrect management choices in treatment of mild to moderate watery diarrhea and dysentery. Important knowledge gaps about gastroenteritis were identified and should serve as a basis to develop military-specific clinical guidelines and training programs.

Introduction

Research efforts by the Department of Defense have significantly increased our knowledge about the epidemiology and management of travelers' diarrhea.1-4 However, little has been done to study whether this knowledge has been effectively disseminated to operational health care providers. Although there are several published reports on provider's knowledge, attitudes, and practices in military settings, none have focused on infectious diseases.5-10 As part of a mid-deployment training conference in Doha, Qatar, we conducted a knowledge, attitudes, and practice assessment of current operational health care providers (primarily physician assistants) deployed in support of Operation Iraqi Freedom (Iraq) and Operation Enduring Freedom (Afghanistan) with regard to travelers' diarrhea epidemiology and management. In addition, we asked health care providers about their impression of the burden and impact and the adequacy of education and prevention with respect to travelers' diarrhea. The primary objective of the survey instrument was for educational purposes in a conference setting and secondarily to determine consistencies and gaps in each of these knowledge, attitude, and practice areas.

Methods

Seventy-six physicians, physician assistants, and medics attended a professional development and trauma management conference in Doha, Qatar, in December 2003. All attendees were health care providers assigned to forward-deployed combat units within Iraq and Afghanistan. A multiple-choice survey was developed by clinical researchers with expertise in travelers' diarrhea (TD). The survey assessed knowledge, attitudes, and practices related to diarrhea epidemiology and management. In addition, participants were asked to rank their impressions about the clinical frequency and operational impact of TD in their current practice, relative to other diseases and nonbattle injury (DNBI). The survey also assessed the health care provider's attitudes regarding adequacy of training and field preventive measures to manage and prevent TD. The survey included a number of question formats including ranking, multiple choice, and Likert-type scale. Multiple-choice questions on diagnosis and management were scenario based.

The survey was administered before conference participants receiving updates on the epidemiology and management of infectious diarrhea. The survey, which was primarily designed as a teaching tool for introducing the topic of travelers' diarrhea, was performed without collection of personal identifiers other than the medical level of the provider (i.e., physician, physician assistant, or medical technician).

Analysis of the survey was primarily descriptive. Composite rank scores of morbidity and operational impact were computed by summation of individual rank scores for each DNBl and battle injury categories. Multiple-choice questions were scored for correct/noncorrect and collapsed into composite scores for areas of epidemiology and management. Correct answers were developed by consensus among three clinicians with more than 30 years combined experience in research and clinical management of TD and were based on published treatment guidelines.11,12 The case presentation/management scenarios were designed to have a step-wise increase in complexity and/or severity. The choices of treatment and management, ranging from simple rehydration and follow-up, to management with antibiotics and antimotility agents, were identical for each of the clinical scenarios.

Analysis was conducted to determine whether there was a trend of increasing level of care associated with increasing severity of illness. For this analysis, the data set was expanded to include an individual observation for each of five (nondysentery and nonpersistent) diarrhea clinical scenarios of increasing severity and complexity. Each scenario question was assigned an ordinal ranking from 1 to 5 (from "mild" to "most severe"). Similarly, an ordinal ranking of four levels of care (from "minimal" to "more involved") was assigned for each choice in management. To evaluate whether there was an association between increasing severity of illness and increasing level of care, an ordinal logistic regression model was fit with level of care and severity of illness as the outcome and predictor variables, respectively. Because transformation of the data set generated multiple individual observations for each question, a cluster option was specified for each attendee to control for observations being independent across individual attendees (clusters) but not necessarily within individual attendees (e.g., control for repeated measures).13