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A cross-sectional study to assess knowledge, attitude and practices regarding H1N1 among AYUSH practioners at Panvel taluka

Pandemic influenza occur when there is antigenic shift of the virus as a result of genetic reassortment or recombination of human virus with avian virus and animal virus, leading to novel subtype for which human population has no immunity. Novel H1N1 flu is an acute respiratory disease, caused by a strain of the influenza type A virus known as H1N1, officially referred as novel A/H1N1. The virus is a mixture of four known strains of influenza A virus: one endemic in humans, one endemic in birds and two endemic in pigs. Transmission of the new strain is human-to-human.

Three influenza viruses have caused major pandemics during the 20 th century: the 1918 H1N1 virus (Spanish influenza), the 1957 H2N2 virus (Asian influenza), and the 1968 H3N2 virus (Hong Kong influenza).Global pandemics with high mortality and morbidity occur when a virulent new viral strain emerges, against which the human population has no immunity. The pandemic influenza A H1N1 2009 virus (A/2009/H1N1) caused the first pandemic influenza of the new millennium, and has affected more than 214 countries and caused more than 18,449 deaths. 1 On August 13th, 2009, the World Health Organization reported that 1,82,166 laboratories confirmed cases of influenza A/H1N1, with 1799 deaths in 178 countries. In 2015, the incidence of swine flu increased substantially to reach 5-year highs with more than 10,000 cases and 774 deaths reported. 2 The number of H1N1 cases and deaths in India in recent years is good enough reason to declare it as a major emerging disease. 2 Like the multifaceted culture in our country, traditional medicines have evolved over centuries blessed with a plethora of traditional medicines and practices. Department of Indian Systems of Medicine and Homoeopathy (ISM&H) was renamed as Department of AYUSH (an acronym for -Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homoeopathy) in November 2003. 3 Bringing AYUSH into the mainstream health care delivery system of the country has long been a major policy objective of the Ministry. Under the NRHM, AYUSH facilities are being set up in PHCs and CHCs and are being manned by qualified AYUSH physicians appointed on contract basis. AYUSH practitioners has been newly integrated into the National Health Delivery System. 3 AYUSH practitioners are important key persons in delivering health services in case of epidemic as they are the first level of contact for the community and their correct knowledge, positive attitude and right practices can help in counteracting the spread of H1N1. Thus, with this background present study was conducted to assess knowledge, attitude and practices of AYUSH practitioners about H1N1.

Objective
To assess knowledge, attitude and practices regarding H1N1 among AYUSH practitioners at Panvel Taluka.

METHODS
There are total 18 tribal villages in Panvel taluka. Study was carried out among AYUSH practitioners practising at these tribal villages for a period of three months (October-December 2015). A list of all practitioners practising different system of medicine in the area was compiled from those available with local medical association and representatives of drug companies. Sample size was calculated using formula with finite population. n 1 =Nz 2 / p (1-p)/d 2 (N-1)+z 2 p(1-p) (Where n=sample size with finite population correction; N=population size; z=z statistics for a level of confidence; p=Expected [proportion]; d=precision (d=0.05)) By using this formula where p=70% sample size of 205 was calculated, considering 10% attrition sample size further calculated as (205+20)=225. 4 Therefore, a total of 225 AYUSH practitioners were included in the study.
Total sample size was again divided into strata by stratified probability proportional systematic random sampling.
Thus total of 121 BAMS practitioners, 101 BHMS practitioners, 2 Siddha and Unani practitioners, 1 Yoga practitioners were included in the study.
A predesigned pretested questionnaire was developed to assess the knowledge, attitude and practices of AYUSH practitioners for H1N1. Knowledge questions included transmission, incubation period, isolation period, clinical features, prevention and treatment of H1N1 infection. A predetermined scale was assessed to grade the participants as having good, average, poor knowledge. A knowledge scale of equally weighted sub questions was used. One point (1) was given for correct response and zero (0) for incorrect answer. Percentage of all marks was calculated for all practitioners. Those scoring >70% were graded as having good knowledge, 50-70% as average, <50% as poor knowledge. Response on attitude was measured on 4 point Likert's scale. Questionnaire on practice were used to assess the actual compliance and practices of preventive measures by AYUSH practitioners.
Those practitioners who gave the consent & those practitioners practising for more than 6 months in that area were included in study.
Those practitioners because of their busy schedule were not able to give time were followed up for 3 times and were then excluded from study.
Institutional Ethical committee approved the study protocol.
Statistical analysis was performed using SPSS version 21.

RESULTS
The sociodemographic characteristics of practitioners are shown in Table 1. Majority of practitioners were in age  As seen in Figure 1, only 16.44% practitioners had good knowledge, 76.44% had average knowledge and 7.12% had poor knowledge about H1N1. The level of attitude of AYUSH practitioners regarding H1N1 shown in Table 3

5) No of practitioners correctly prescribe drugs for prophylaxis and treatment of H1N1
134 59.55

DISCUSSION
The results of present study offer insight about knowledge, attitude and practices towards Influenza A/ H1N1 infection among AYUSH practitioners which will help us to provide scientific support to assist health sector authorities in developing strategies and health education campaign to prevent transmission of H1N1.
AYUSH practitioners are important key persons in delivering the health services in case of epidemic as they come in first contact with patient. To deliver the health services in an effective manner, they should have sound knowledge and practices regarding the disease. There are very few studies available on this topic among AYUSH practitioners from India.
Finding of our study suggested that knowledge among AYUSH practitioners was fairly good. On an encouraging note, our research finding revealed that all practitioners knew about transmitting agent and mode of transmission of disease. This finding is similar to a study conducted by Rajora et al which was conducted in multispecialty teaching hospital in Delhi, India where in all resident doctors knew that influenza was caused by virus and is transmitted by droplets. 5 Our finding on awareness of causative agent of the disease was more than a study done by Datta, et al at Pondicherry which was conducted among paramedical workers in an tertiary care hospital where in 91% workers knew about the agent and mode of transmission of H1N1. 6 A study by Sharma et al showed that symptoms of H1N1 were known to only half of the interns which is very less compared to our general practitioners (75%). 7 The difference in knowledge may be because of case found in and around Mumbai. Also the difference in group of health care worker does not allow true comparison.
The period of infectivity of H1N1 begins the day before the onset of illness and can persist up to 5-7 days. It is of concern that in our study AYUSH practitioners lacked sufficient knowledge about the period of infectivity [44%]. Our findings are almost similar to study among dental practitioners in Nellore of AP conducted by Kappa et al. 8 56.7% AYUSH practitioners knew the correct incubation period of H1N1, Our finding was much less than that was observed in 93.2% doctors and 68.8%nurses in a study of swine flu (H1N1) epidemic among health care provider of a medical college of new Delhi. 5 Regarding attitude towards H1N1 in our study, 78.66% practitioners agreed that they are at risk of getting infection by H1N1 virus which is much higher than the perception by dental practitioners at Nellore District. 8 The difference might be probably due to number of cases reported in their community.
AYUSH practitioners in our study had favourable attitude towards the curability of disease. Most of practitioners believe that H1N1 is mild disease and doesn't cause mortality. This finding almost similar to study conducted among dental practitioners in Nellore district of Andhra Pradesh. 8 Current study also shed light on AYUSH practitioners H1N1 vaccine coverage. Health care workers have greater exposure to influenza cases as compared to general population. It is therefore important for them to where vaccinated against H1N1 which is consistent with survey finding in Turkey with vaccination coverage of (23.1%). 9 By contrast, the figure is very low compare to other study conducted among Dutch general practitioners where in general practitioners where vaccinated against H1N1. 10 This difference might be due to the practitioners belief on lack of effectiveness of H1N1 vaccine.
In our study very few practitioners i.e. (14%) use N95 mask all the time at clinic. Our finding is almost same to a study carried out among interns at tertiary care hospitals Pune where 12.76% interns used N95 mask all the time during their duty hours. 11 Two anti viral drugs Tami flu (Osaltamivir) and Relanza (Zanamivir) are recommended for treatment and for prophylaxis of H1N1. In our study uses of these drugs was known to more than 50% practitioners. Our finding was lower than study conducted among doctors of medical college hospital of Delhi where 95% doctors knew about drugs. 5 These differences might be due the fact that practitioners might not be trained for the same.

CONCLUSION
AYUSH Practitioners knowledge, attitude and practices about the Influenza disease are important due to their role model to general population. Our study indicated that practitioners had average knowledge and poor practices about H1N1 prevention.

Recommendations
Knowledge and poor practices about H1N1 prevention can be further improved by continuing medical education programme. Communication and provision of updated information will also help in improving vigilance & preparedness to delay the epidemic. There is also an immediate need for spreading awareness about the vaccine and its role in preventing H1N1 among AYUSH practitioners.