knowledge and first aid practices regarding snake bites an ... · urban and rural community...

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ABSTRACT

OBJECTIVE: To assess the level of knowledge and first aid practices regarding Snake Bites in urban and rural settings of Bahawalpur. STUDY DESIGN: A Comparative cross sectional study

st stPLACE AND DURATION: Six months, from 1 August 2015 to 1 February 2016, in the urban and rural communities of Bahawalpur and Bahawal Victoria Hospital.METHODOLOGY: A close ended validated questionnaire translated in local language was used to interview 693 participants; adopting a two-stage cluster sampling strategy. Urban and rural community knowledge on snakes, snake bites and first aid measures was assessed. RESULTS: Majority of the participants (74%) whether urban or rural residents had the impression that all the snakes are poisonous. Around 79% participants had correct knowledge about the snake bite seasons. Incorrect knowledge of first aid techniques like use of tourniquet, herbs, sucking the blood and going to the faith healers/snake charmers were more seen in the rural areas. Around 56% of the urban population had the correct knowledge of anti-snake venom. CONCLUSION: This study points to certain lacunae in the knowledge and practices on snake bite and its first aid management between urban and rural population. There is a paucity of knowledge on snakebites and its first aid management predominantly in the rural areas. Comparing urban and rural population, people living in urban areas have better knowledge.KEY WORDS: Snake Bite, First Aid, Knowledge, Rural Population, Urban Population

HOW TO CITE THIS:Usman HB, Khan MA, Khalid M, Akram S. Knowledge and First Aid Practices Regarding Snake Bites- An Experience of Southern Punjab, Pakistan. Isra Med J. 2017; 9(4): 238-243.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 9 - Issue 4 | Jul - Aug 2017

INTRODUCTION

Snake bite is a life threatening medical emergency. Most of the 1,2snake bites are seen in the rural areas all over the world . There

are approximately 5.5 million snake bite victims each year 3worldwide . In Asia alone there are around 4 million victims per

year, which is a conservative incidence because of 4underreporting . Estimated annual deaths due to snakebites in

Asia are around 100,000 (major contributors are South Asian countries e.g. 1000 in Nepal, 1000 in Sri Lanka and around

520,000 each in India and Pakistan) . Snake bite is significantly overlooked as a public health problem in the world which is

5,6 evident from lack of reliable epidemiological data . There are around 2700 different known species of snakes, out of which

6only 500 are venomous .Snake bites are commonly seen in the rural areas where the risk

7increases because of farming/agriculture . The situation gets worse in the rural areas of developing countries because the patients do not have rapid access to life saving anti-snake

7,8venom . Similarly, studies reflect that a high proportion (80%) of snake bite victims, first consult the traditional healers before

9-11they get any proper medical treatment . First aid management of snake bite is very important which is usually

6done by the relatives, friends or co-workers . If proper first aid is given at the time of bite it can even delay the life-threatening effects. As most bites are from non-venomous snakes, only

8,9reassurance can bring the victims out of their shocked phase . Misconceptions like incision at the site of bite and sucking dirty blood out, applying onion or other herbs, going to the snake charmers or using tourniquet etc. are still common practices in

8,12,13rural areas of India and Pakistan .Pakistan is a developing country with limited resources. Snake

8bite is mainly a problem of rural area . Annual mortality rate due 12to snake bites in Pakistan is around 1.9/100000 population .

Better knowledge of the rural communities can help in the 8,10,13reduction of snake bites as well as the deaths because of it .

Specific treatment of snake bite is available in the hospitals in the form of anti-snake venom. Most of the people are unaware

8,13of this available treatment .

Knowledge and First Aid Practices Regarding Snake BitesAn Experience of Southern Punjab, Pakistan

1 2 3 4Hassan Bin Usman Shah , Muhammad Ahmed Khan , Muhammad Khalid , Sumera Akram

1. Assistant Professor of Community Medicine Yusra Medical & Dental College, Islamabad 2. ENT Specialist, CMH Bahawalpur 3. Public Health Specialist, Islamabad4. Bahawal Victoria Hospital Bahawalpur

Correspondence to:Hassan Bin Usman ShahAssistant Professor of Community Medicine, Yusra Medical & Dental College, Islamabad Email: [email protected]

Received for Publication: 28-06-16Accepted for Publication: 20-07-17

Hassan Bin Usman Shah et al. ISRA MEDICAL JOURNAL | Volume 9 - Issue 4 | Jul - Aug 2017

selected. SPSS version 22 was used to analyze the data. Standard descriptive and analytical statistics were used for data analysis. Chi-square test was used to establish the association between categorical variables, 95% confidence intervals (95% CI) and p value less than 0.05 was considered significant. Ethical approval: Approval was taken from Ethical review board of Yusra Medical and dental college.

RESULTS

A total of 693 participants were interviewed in District Bahawalpur. The mean age of the participants was 37.2 + 17.6 years. There were 353 rural and 340 urban participants, majority were males 562 (81%). The education status was better in the urban population (table- I). Most of the participants hailing from the rural areas were farmers while majority of the study participants from the urban areas were government employees. With regards to socioeconomic status of the participants, it is pertinent to note that almost three times higher proportion of the participants from the urban areas compared to rural areas belonged to the highest income group i.e. 60% in the urban areas whereas 20% in the rural areas earned more than Rs. 30,000 a month. Other demographics are given in the table - I. below. Knowledge about the common snake seasons and common bite site was good both in the urban and the rural areas. Rural population experiencing more snake bites, have better understanding about non-poisonous snakes (p=0.000). A marked difference was noted in the urban and rural participant's knowledge once the snake bites. Majority (n=160, 45.3%) rural participants were of the opinion that the victim will die immediately (p =0.000). Knowledge about measures to reduce snake bites was almost same in both the groups. Other knowledge items about snakes, snake bites and measures how to reduce snake bites are given in the table - II.

The aim of this study was to compare the knowledge and first aid practices regarding snake bite of people living in rural and urban areas of Bahawalpur, a district of southern Punjab, Pakistan. This would help to assess the population's perception about the snake bite management and thus guide the design and implementation of health promotion and public awareness programs.

METHODOLOGY

This comparative cross sectional study was conducted with a 6 st stmonths' duration from 1 August 2015 to 1 February 2016 in

Bahawal Victoria Hospital and local communities of that region. To conduct the survey, sample size was calculated, with the use of open Epi software. This calculation was conducted in a manner to yield results in accordance with the specified objectives of estimating the current knowledge, attitudes and practices regarding snake bite among target communities of district Bahawalpur. However, due to non-availability of the data for the key variables of interest, it was assumed that the knowledge and awareness of snake bite and its first aid management would be 50% among the target population. The sampling frame of all the listed union councils was utilized to derive the clusters within the district. To conduct the survey of at-least 686 participants, a two-stage cluster sampling strategy was adopted. These would include the calculation of the number of village locations to be selected based on the criteria of 20 respondents per village location, selection of these villages in the district through simple random sample selection

stapproach (1 stage), and selection of households within villages nd(2 stage) through systematic sampling with a random start

approach.Knowledge on snakes, snake bites and first aid measures was assessed using a structured close ended questionnaire in local language was developed adapted with some improvement

13from Kumar et al research done in India. Residents of the selected area above 15 years of age, willing to participate were

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TABLE - I: DEMOGRAPHIC PROFILE (N=693)

ISRA MEDICAL JOURNAL | Volume 9 - Issue 4 | Jul - Aug 2017Hassan Bin Usman Shah et al.

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TABLE - II: KNOWLEDGE ABOUT THE SNAKES AND SNAKE BITES (N=693)

Marked difference was seen in the knowledge of first aid measures after snake bites. Rural population being more at risk were in favor of applying tourniquet, cutting and sucking blood form the bite site (p=0.000). Wrong practices of going to the faith healers and application of herbs and other things (like

onion) on the bite site was also common in rural population (p-0.000). Rural population also had less knowledge about immobilization (p=0.000) and availability of anti-snake serum. Table III shows the responses of the participants regarding first aid and specific management of the snake bite cases.


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TABLE - III: KNOWLEDGE ABOUT THE FIRST AID MEASURES AND SPECIFIC TREATMENT (N=693)

Majority participants were not in favor of giving anything extra in diet but things like desi ghee, milk, onion and imli etc. were few options in which rural population was mostly interested (Figure -1).

DISCUSSION

Snake bite is a neglected public health issue which results in at least 100,000 deaths each year globally that can be prevented if

9proper first aid management is given to the victims. Community based studies regarding the knowledge and

10practices on this subject are rare. Our study shows that the awareness regarding snake bite, its first aid and treatment measures was very low among the study participants. However, there was a difference between urban and rural population, urban being more educated had better knowledge also. Lack of knowledge was also seen in studies conducted in rural Bengal

13,14and Maharastra, India . A lower proportion of the urban participants (18%) were of the opinion that non-poisonous snakes are more common compared to one third (30%) of the rural participants. The better knowledge of the rural area participants regarding type of the snakes (poisonous or non-poisonous) compared to urban areas is probably due to high exposure to snakes and snake bites in rural areas. Regardless of having this knowledge, majority (45%) of the rural participants thought that snake bite victim will die immediately after the

6bite. Participants of study conducted by Joseph et al. were also FIGURE -1: KNOWLEDGE/PERCEPTION ABOUT

GIVING SPECIAL DIET AFTER SNAKE BITE (N=693)


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13,14 findings of studies conducted in India (77%) and Srilanka 15(86%) . Similar lack of knowledge (55%) about vaccination was

8also observed in other parts of Pakistan . About 50% of our study participants whether urban or rural, do not believe in taking the victims immediately to the hospitals, this delay must be discouraged as life saving time would be lost.

CONCLUSION

This study points to certain lacunae in the knowledge and practices on snake bite and its first aid management between urban and rural population. There is a paucity of knowledge on snakebites and its first aid management predominantly in the rural areas. Comparing urban and rural population, people living in urban areas have better knowledge.

Contribution of Author:Usman HB: Literature search, Manuscript writing, Data analysisKhan MA: Data Collection and literature reviewKhalid M: Data analysis and Proof reading Akram S: Data Collection and literature review

Disclaimer: None.Conflict of Interest: None.Source of Funding: None.

REFERENCES

1. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008; 5(11):218.

2. Warrell DA. Snake bite. The Lancet. 2010; 375(9708):77-88.3. Kadir MF, Karmoker JR, Alam MR, Jahan SR, Mahbub S, Mia

M. Ethnopharmacological Survey of Medicinal Plants Used by Traditional Healers and Indigenous People in Chittagong Hill Tracts, Bangladesh, for the Treatment of Snakebite. Evid Based Complement Alternat Med. 2015: 871675. doi: 10.1155/2015/871675

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of the same opinion. Majority urban participants (96%) cannot differentiate between poisonous and non-poisonous snakes, this ratio is slightly better in rural population where around 14% can differentiate. In a study conducted in rural India around 26%

13people could differentiate between the two .A high proportion of rural participants were aware of the practices that reduce snake bites, both in and outside of the house, possibly due to high exposure to snakes and snake bite in rural areas. The most cited preventive measure was cleaning weeds, bushes etc. near participant's houses, a finding which relates closely with the findings of another study conducted in

13,14 15rural India while much less than what Srilankans suggest (98%). An overwhelming majority of the study participants (90%) were aware that wearing long boots would protect them from snake bites but they hardly adopt such measure. Similar

15findings were also seen in a study carried out by Silva et al. and Kasturiratne 16 et al. , where farmers despite having the knowledge prefer going barefooted in the fields. Suboptimal knowledge regarding first aid management was seen especially in the participants of rural areas. The knowledge about the most important first aid management procedure i.e. immobilization was less prevalent in the rural areas. A vast majority of the urban participants (90%) were aware that immobilization of the bite site/limb was the initial first aid measure, a finding that is similar to the 89% of rural Srilankan

15study . While this knowledge of immobilization was less prevalent in our rural population (68%), it was almost

13comparable to a study conducted in India . Application of tourniquet proximal to the bite site was considered as an important first aid measure both in the urban (67%) and rural (72%) participants in our study. These findings are similar to the findings of the studies conducted by Silva et

15 8al. and Chandio et al. , but are different from the findings of 13Kumar et al. ,in which a high proportion of the study

participants were aware of the preventive measure(around 96%). A common misconception about cutting and sucking blood from the bite site was more prevalent in rural population (57%),

13however, less than a study conducted in rural India (69%) . In this regard, a low proportion of participants (23%) of the urban areas favored this preventive measure, a finding almost similar

8to the findings of another study conducted in Sindh (29%) . Some rural participants (38%) were in favor of applying onion on the bite site and also adding things in victim's diet like desi ghee, onion, imli etc. Application of onion and herbs were seen in few

14,17cases in India and Kenya . Inclination of going to a faith healer for the management of snake bite was more prevalent in our rural areas (56%) which

13 15was not seen in Indian and Srilankan rural population, where they preferred going to a hospital (77%). In a study conducted in Kenya, treatment provided by the local herbal preparation was

17common (68%) for the snake bite victims . Our study participant especially of the rural areas (39%) would also like to treat their patients with herbs. Regarding specific snake bite treatment i.e. anti-snake vaccination, our study participants whether urban or rural had less knowledge (56% and 49% respectively) as compared to the


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8. Chandio AM, Sandelo P, Rahu AA, Ahmed ST, Dahri AH, Bhatti R. Snake bite: Treatment seeking behaviour among Sindh rural population. J of Ayub Med College. 2000; 12(3):3-5.

9. Rahman R, Faiz MA, Selim S, Rahman B, Basher A, Jones A, et al. Annual incidence of snake bite in rural Bangladesh. PLoS Negl Trop Dis. 2010; 4(10):e860.

10. Majumder D, Sinha A, Bhattacharya SK, Ram R, Dasgupta U, Ram A. Epidemiological profile of snake bite in south 24 Parganas district of West Bengal with focus on underreporting of snake bite deaths. Indian J Public Health. 2014;58(1):17-21.

11. Simpson ID. A study of the current knowledge base in treating snake bite amongst doctors in the high-risk countries of India and Pakistan: does snake bite treatment training reflect local requirements? Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008; 102(11):1108-14.

12. Quadir, G, Memon S. Snake bite. in: M. Iliyas (Ed.) Public Health and Community Medicine. 7th ed. Time Publisher,

Karachi, Pakistan; 2006: 475–8513. Kumar A, Dasgupta A, Biswas D, Sahoo S, Das S, Preeti P.

Knowledge regarding snake bite in rural Bengal–Are they still lingering on myths and misconceptions. Int Archives of Integrated Med. 2015; 2(7): 36-41.

14. Chincholikar SV, Bandana P, Swati R. Awareness of Snake bite and its first aid management in rural areas of Maharashtra. Indian J of Comm Health. 2014;26(3):311-15.

15. Silva A, Marikar F, Murugananthan A, Agampodi S. Awareness and perceptions on prevention, first aid and treatment of snakebites among Sri Lankan farmers: a knowledge practice mismatch? J of Occup Med & Toxicolo. 2014;9(1):1.

16. Kasturiratne A, Pathmeswaran A, Foseka M, Lalloo D. Estimates of disease burden due to land-snake bite in Sri Lankan Hospitals. Southeast Asian J of Tro Med and Public Health. 2005;36(3):733.

17. Owuor BO, Mulemi BA, Kokwaro JO. Indigenous snake bite remedies of the Luo of western Kenya. J of Ethn. 2005;25(1):129-41.

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