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Knowledge, attitudes, and practices of primary health care physicians, junior doctors, and medical college students towards autism in Duhok, Iraq

Kurdistan toward autism spectrum disorder. Methods: A cross-sectional study was carried out from September 10 th until October 30 th , 2016. A self-administered questionnaire was used for data collection. Two hundred and two questionnaires were completed by the three participants’ groups. Data analysis was carried out using the statistical analysis system (SAS, version 9.4). Results: Of the 202 participants, 24.8% were sixth year medical students, others were junior doctors (35.6%) and primary health care physicians (39.6%). Of them, 51.5% were females and 48.5% were males. High percentages (90.1% and 91.1%) of respondents heard and knew about autism spectrum disorder, respectively. They showed poor information on identification and management. Primary health care physicians had more knowledge on the genetic basis of autism ( P <0.001) and behavioral therapy for autism ( P = 0.016). No significant differences in knowledge was found between both gender groups except that female participants had limited knowledge on its genetic basis ( P = 0.007). Conclusion: Although primary health care physicians, rotators, and medical students generally heard about autism spectrum disorder, they had limited knowledge of its diagnosis and management. It is recommended to introduce autistic disorders lectures to the medical college curriculum and training of physicians by experienced professionals.


Introduction
The general knowledge of mental health among general practitioners and primary health care (PHC) physicians is limited, as identified by more than 400 articles. 1 This gap in knowledge on mental illnesses could be filled with continuous medical education (CME). 2 In Arabian Gulf countries, including Iraq and Iraqi Kurdistan, primary care physicians are somewhat less efficacious in dealing with patients having psychiatric disorders. 3 One of the important challenges of child mental health nowadays is autistic disorders. Autism spectrum disorders (ASD) are disseminated, and lifelong neurodevelopmental disorder that has uncertain etiology. 4 It comprises a trio of impairments embodying delay and deviance in (a) social interaction and relationships, (b) communication and language, and (c) limited interests and repetitive behaviors that create a considerable effect on the child or young person and their family. 5,6 The last decades showed an obvious increase in the prevalence of ASD. 7 Many cases are missed and not diagnosed until school age. 8 Both the American Academy of Pediatrics (AAP) and the Royal Australian College of General Practitioners (RACGP) Background and objective: The knowledge of autism spectrum disorder among physicians and medical students is limited. This study aimed to find out the level of knowledge, attitudes, and practices of primary health care physicians, junior doctors, and 6 th year medical college students in Duhok province, Iraqi Kurdistan toward autism spectrum disorder. Methods: A cross-sectional study was carried out from September 10 th until October 30 th , 2016. A self-administered questionnaire was used for data collection. Two hundred and two questionnaires were completed by the three participants' groups. Data analysis was carried out using the statistical analysis system (SAS, version 9.4). Results: Of the 202 participants, 24.8% were sixth year medical students, others were junior doctors (35.6%) and primary health care physicians (39.6%). Of them, 51.5% were females and 48.5% were males. High percentages (90.1% and 91.1%) of respondents heard and knew about autism spectrum disorder, respectively. They showed poor information on identification and management. Primary health care physicians had more knowledge on the genetic basis of autism (P <0.001) and behavioral therapy for autism (P = 0.016). No significant differences in knowledge was found between both gender groups except that female participants had limited knowledge on its genetic basis (P = 0.007). Conclusion: Although primary health care physicians, rotators, and medical students generally heard about autism spectrum disorder, they had limited knowledge of its diagnosis and management. It is recommended to introduce autistic disorders lectures to the medical college curriculum and training of physicians by experienced professionals. Keywords: KAP; Physicians; Medical students; Autism.

Methods
The current study was performed to investigate the knowledge, attitude, and practice (KAP) toward ASD among PHC physicians, junior doctors, and 6 th year medical college students in Duhok province, Iraqi Kurdistan.
insisted on the important role of primary care providers in the early detection of autism. 9,10 The process of referring to specialist services is enhanced and strengthened by the perfect process of early detection of ASD, which consequently resulted in early intervention. 11,12 A survey in the United States of America showed differences in knowledge of autism between PHC providers and specialists like psychologists, psychiatrists, and speech therapists. 13 On another side of the world, misunderstandings about the etiology, treatment, and prognosis of ASD were found among health care workers in Sub-Saharan African subcultures. 14 In developing countries, the health staff concentrates more on tropical diseases with shortages in their knowledge concerned the developmental milestones field. 15,16 Intrinsically, the documented deficit of knowledge about ASD in between health care workers may be due to a flaw in the academic education system with the inadequacy of practical training and insufficient theoretical lectures provided in terms of pediatrics, psychiatry, and psychology. 17,18 For this reason, the level of knowledge on ASD among final year undergraduate medical, nursing, and psychology students should be well assessed. They will be future members of the multidisciplinary team responsible for taking care of autistic children. 19  Physicians in Akre city 9

Total 202
physician types and student responses. A P ≤0.05 was considered statistically significant, and a P <0.001 was considered highly significant. Likewise, Chi-square tests were performed to check for any significant differences by gender. Percentages for the correct answer of knowledge, identification, and management of autism were identified. Chi-square test was performed to check for any significant differences among the physician groups with regard to the percentages of correct answers. Data were analyzed using SAS version 9.4 (SAS Institute, Cary, NC).

Ethical Consideration
This study was approved by the ethics committee of the College of Medicine, University of Dohuk. Informed written consent was obtained from all participants, and an information leaflet has been provided at the time of implementing the study.

505
The total number of participants in this survey was 202; 51.5% were females, and 48.5% were males. Most of the respondents were between the age of 25 and 34 years (68.8%). Fifty of them were 6 th year medical students (24.8%), the 72 junior doctors were 35.6%, and the PHC physicians were 80 making 39.6%. About 75.3%of the physicians had 1-5 years of experience. Nearly half of the participants have taken a training course on ASD, 45.1% included in the college curriculum and 11.9% outside the college, as shown in Table 2.

Study Instruments
A questionnaire was designed by the authors to assess KAP toward ASD among participants who are physicians and medical college students. The instrument was designed in such a way as to cover all aspects of KAP. The first part included some demographic data of the participant like gender, age, place of work, number of years of experience. The second part of the study tool composed of 20 questions covering areas of KAP toward ASD including the three main domains of clinical information and etiology, diagnosis, and treatment of ASD. The validity of the research tool was done by presenting the instrument to four specialists, including two psychiatrists and two community medicine specialists, to review it and give their valuable notes, which were applied to the original questionnaire.

The Pilot Study
Then a pilot study that lasted for seven days was conducted after discussions with experts. It has been conducted through using a small group of respondents consists of 10 PHC physicians, five junior doctors, and five medical college students of 6 th year, those who were not included in the study. The investigators did their pilot study to train on the questionnaire, achieve more practice, and estimate the appropriate time required to complete the survey.    Table 3 shows the number and percentages of correct responses about knowledge, identification, and management of autism by physicians' types and 6 th year medical students, separately and totally. of the management is whether the participant has any idea about an applicable scientifically practical concerned programs, was wrongly answered by most of the respondents i.e., only 18.8% of them answered it correctly. The last two questions on management were providing multiple choices and were also mostly answered wrongly. The question of final treatment decision and the preferable center of referral of autistic patients were answered correctly by only 19.3% and 16.8%, respectively. The pattern of distribution of correct responses among the physicians and students is also clarified in Table 3. The three groups had similar responses in most areas of the questionnaire except for three questions: one is concerned with knowledge, and the other two were concerned with management. Regarding the genetic bases as etiology of autism, there was a highly significant difference between the responses of the three groups (P <0.001). PHC doctors and sixth year medical students had more correct answers percentages than the junior doctors, 46.3% and 42%, in contrast to 16.7%. Although most of the responses about whether the respondents have an idea about an applicable scientific practical concerned program used in behavioral therapy were negative, the PHC doctors showed more positive answers (26.3%) in comparison to 19.4% and 6% of the other two groups. Regarding referral to specific centers of autism management and rehabilitation, the question was more correctly answered by 6 th year medical students (30%) in comparison to 15% and 9.7% of other groups. Differences between gender groups are shown in Table 4. There were no significant differences between the male and female respondents except the question concerning the genetic etiological factors of autism which was answered correctly by males 43.9% vs. only 26% of females (P = 0.008).  24 The majority of medical doctors in Siri Lanka (61.9%) regarded themselves as incapable of diagnosing autism. 25 Although most of the respondents in our study knew the age of diagnosis of autism which is at three years, physicians in other countries have different percentages of correct answers. 26 In Pakistan, only 56.2% of them recognized that the onset of symptoms of autism should be before 36 months. 27 Around third of the participants in this study could define autism as a neurodevelopmental disorder. This was lesser than what doctors of Colombo south teaching hospital reported, in which 64.2% of them regarded autism as a neurodevelopmental disorder. 25 In Lahore, Pakistan, 51% of physicians considered autism a developmental disorder. 27 Less than half of the participants believe that autism is a curable condition. This was close to the opinions of Nigerian health care workers in which 54.5% and 32.1% of them subscribed that autism is a treatable and preventable condition, respectively. 24 The three groups of respondents were not knowledgeable about treatment options, including the concerned treatment programs, treatment decisions, and referral to specified centers. The correct answers were chosen by only 16.8% and 19.3% of all participants together. This may be due to the deficiency of services and centers specialized for ASD treatment in our locality. Other studies provided similar findings; only15-34% gave advice on medical or educational programs, and 6% advised referral to ASD specialists. 22 The exception was the agreement of most respondents of our study on behavioral therapy to be the best treatment options. The gender variation on knowledge about autism was not seen in this study in most areas of assessment.

Data Analysis
Bakare MO et al. study showed no significant gender differences in Autism knowledge. 16 The only significant association with gender was one item related to the etiology of autism. Male doctors and medical students were significantly more likely to recognize the genetic basis of autism. The knowledge gap in this study and other similar studies could view the deficient autism education in the medical academic discipline and in the professional formative practice. Insufficient knowledge in these areas may lead to delay recognition, identification, or

Conclusion
The majority of participants knows and heard about ASD, but they showed poor information on its definition, identification, and management. PHC physicians' knowledge of genetic etiological factors of autism and behavioral therapy was better compared to the other two groups. It is recommended to introduce autistic disorders lectures to the medical college curriculum and more medical training for physicians. This may enhance better access to care for autistic children in their early stages and improve parents' care by education.