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ORIGINAL ARTICLE
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Treatment-seeking behavior of patients attending department of dermatology in a tertiary care hospital and their impact on disease


 People's College of Medial Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Date of Submission15-Feb-2021
Date of Decision06-May-2021
Date of Acceptance28-May-2021

Correspondence Address:
Animesh >Saxena,
OPD No. 8, C-Block Peoples Hospital, Bhanpur, Bhopal - 462 037, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_123_21

  Abstract 


Context: There has been a sharp rise in skin diseases in the past few decades part of which is definitely due to the extensive use of steroids for nearly every skin disorder which remains the major reason among others for this steep rise. Self-medication and unqualified doctors have played a pivotal role in the current menace, and due to a lack of strict laws, every self-proclaimed person with no legal degree in dermatology becomes a skin specialist and start his own skin clinic. The study was therefore conducted to determine the preferred source of treatment among patients with various skin diseases; to determine influencing factors among these patients in choosing the source of treatment; and to determine the impact outcome of medicine on skin diseases based on source of medication. Materials and Methods: A designed pro forma consisting of eight questions was prepared and provided to the patients who have taken any medication previously for the current disease. Results: In the current study, 300 patients were enrolled, out of which 264 had taken modern (allopathic) medicine and 36 took complementary and alternative medicine. One hundred and twenty-six patients (47.7%) took treatment directly from medical store, 85 patients (32.2%) consulted unqualified doctors, 40 (15.2%) visited qualified doctors (nondermatologists), and only 13 patients (4.9%) consulted a qualified dermatologist. Most of the patients who were advised treatment by medical store worsened, followed by unregistered doctors, qualified doctors, and least by dermatologist. Conclusion: Although modern medicine has gained considerable importance for the management of dermatological conditions, still the majority of patients seek care from medical store, unregistered doctors, and MBBS doctors. Care seeking from dermatologist is <5%. Self-medication and quackery significantly affect the outcome as symptoms worsened in the majority of patients.

Keywords: Complementary and alternative medicine, quackery, self-medication



How to cite this URL:
>Saxena A, Dey VK, Srivastava P, Hemnani S, Kushwaha S, Sharma S. Treatment-seeking behavior of patients attending department of dermatology in a tertiary care hospital and their impact on disease. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=335880




  Introduction Top


Skin diseases are responsible for huge disease burden all over the world, and delayed or inappropriate management has been associated with serious detrimental effect on quality of life.[1] Self-medication for majority of skin ailments is common in Indian scenario. Self-medication according to the World Health Organization has been defined as selection and consumption of one or more drugs without physician's advice.[2] It is usually a habit of the patients to use drugs prescribed to other family members or friends for the same type of illness to avoid doctors' consultation. Consultation with the local pharmacist is also common in India. On the other hand, quackery in India is a constant source of misdiagnosis and mismanagement, significantly affecting the course of illness and thus causing adverse outcome as well as financial burden on the patient.[3]

Nearly, every medicine in India is available as over the counter drug in India, though these drugs have proven safety and efficacy but patients lack the knowledge regarding their correct dose, duration, side effects, and drug interactions.[4],[5] Self-medication may have several benefits, i.e., patients may get immediate symptomatic relief, especially in cases with minor ailments and may be cost effective in some cases. However, self-medication, particularly in dermatological practice, may have certain potential risks such as incorrect self-diagnosis, progression of disease, delay in seeking health care, dangerous drug interactions, incorrect dose and manner of administration, masking severe disease, and risk of abuse.[6]

Verma et al. documented that topical corticosteroids are one of the most commonly used drugs in dermatology which is often misused by both medical and nonmedical personnel as they are easily available, low cost over-the-counter medication.[7] The topical steroid abuse is commonly observed even for wrong indications such as fungal infections and acne. Even, it is prescribed by a MBBS for wrong indication and wrong duration due to a lack of awareness and practice during their training.[8] The present study was therefore conducted at a tertiary care center with the broad aim to assess the impact of quackery, self-medication, and alternate medicine on skin diseases in the current scenario.

Objective

We conducted this study with the following objectives:

  1. To determine the preferred source of treatment among patients with various skin disease
  2. To determine influencing factors among these patients in choosing the source of treatment
  3. To determine the outcome of medicine on skin diseases based on source of medication.



  Materials and Methods Top


This study was conducted as a cross-sectional study among patients seeking care for various ailments at outpatient department, department of dermatology during the study period of 3 months, i.e., from November 1, 2019 to January 31, 2020, after approval from the Institutional Ethical Committee (IEC-2019/59). A self-predesigned questionnaire in English and Hindi language was prepared, and a pilot study for 1 week was done, during which a total of twenty adult patients could be observed, and necessary changes were made in final questionnaire following pilot project. The patients enrolled in the pilot study were not included in final calculation of results.

As during the pilot study of 1 week, twenty eligible patients could be enrolled, and the final study was planned for 3 months. Estimating the patient's size of 20/week, a total of 300 patients during the study period of 3 months was calculated. All the 300 patients of all age groups who have been suffering from present illness for a minimum duration of 2 weeks were selected using convenient sampling. Two resident doctors were appointed to monitor and assist participants to fill the form whenever required.

Two separate sets of questionnaires were prepared, one for patients who received modern medicine and another for complementary and alternative medicine. Questionnaire for modern medicine included following variables other than demographic profile and general information.

  1. Source of medication was divided into four classes based on whose recommendation patient took medicine and was divided into four groups


    1. Qualified dermatologist
    2. Qualified doctors – which included MBBS and specialist from other branches (MD/MS/DNB)
    3. Unqualified doctors – doctors without any degree, doctors trained in alternate medicine such as Homeopathy/Ayurvedic/Unani/naturopathy practicing modern medicine
    4. Medical store personal.


  2. Outcome of previous treatment on current disease – it was divided into four subgroups based on the changes observed by the patient after minimum 2-week interval
  3. Source of information for previous treatment – patients were enquired about the source under whose influence patients take treatment from various sources.


Statistical analysis used

On completion of data collection, data were compiled using Microsoft Excel version 2013, and analysis was done using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA). Numerical data were expressed as mean and standard deviation, whereas categorical variables were expressed as frequency and proportions. Independent sample t-test was applied to assess the difference in mean between two groups, whereas Chi-square test was applied to assess the difference between proportions. P < 0.05 was considered statistically significant.


  Results Top


The present study was conducted on a total of 300 patients with skin diseases, out of them, 264 (88%) patients opted for modern treatment, whereas 36 (12%) patients received alternate medicine such as Ayurvedic, homeopathic, or Unani. The patients were aged between 6 years and 70 years with a mean age of 27.97 ± 10.44 years. About 54.9% of patients were male and 45.1% were females. Sociodemographic variables of our study are presented in [Table 1]. The mean age of patients receiving modern medicine was 28.1 ± 10.5 years, whereas the mean age of patients receiving alternate medicine was 27.3 ± 10.4 years. Test of significance (independent t-test) showed no significant difference in mean age between patients receiving modern and alternate medicine (P > 0.05). Chi-square test was applied to assess the difference in proportions between two groups of patients and showed no significant difference in sociodemographic variables (P > 0.05).
Table 1: Distribution of patients according to sociodemographic variables

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Out of 300 patients, 169 (56.3%) suffered from tinea out of which 151 (89.3) preferred modern medication and 18 (6%) preferred alternate medication. We observed no significant difference in clinical profile of patients seeking modern and alternative medicine (P > 0.05) [Table 2].
Table 2: Distribution according to clinical profile

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Out of 264 patients who took modern medicine, most of the patients (126%–47.7%) preferred buying medicines directly from medical store after consulting the pharmacist [Figure 1]. Most of the patients who were advised treatment by medical store worsened, followed by unregistered doctors, qualified doctors, and least by dermatologist [Figure 2].
Figure 1: Impact of previous treatment on current disease

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Figure 2: Source of modern medicine

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Our study documented significantly better awareness about qualified dermatologist among patients with upper class, followed by middle and lower class (P < 0.05) [Table 3].
Table 3: Source of medicine preferred by patients according to socioeconomic status

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Self-medication was seen in 47% of patients which were under influence from the information by self (based on advertisement or past treatment), friends, or pharmacist [Table 4].
Table 4: Influence to choose the previous treatment

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About 36 patients (12%) took alternate medicine, of them, 58.4% got them from qualified alternate medicine doctors, whereas 16.7% bought them after advice from medical store pharmacist and 25% took home remedy which included application of garlic, turmeric, and paste of multiple herbs usually used for cooking. None of the patient reported improvement from alternate medicine that was probable reason to shift to modern medicine and visit tertiary care hospital [Table 5].
Table 5: Impact of complementary and alternative medicine on present disease

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  Discussion Top


Dermatology has seen its own trend toward complementary and alternative therapies.[9] Although modern medicine and alternative medicine both have a role in the management of dermatological diseases, the roles of the different professions are poorly coordinated.[10] Due to shortage of MBBS doctors in India, Ayurvedic, Homeopathic, and Unani (AYUSH) doctors openly practice modern medicine and are only doctors at rural areas, even Government appoint AYUSH doctors at public health center as a medical officer who take cares of patients and even performs postmortems which is illegal as AYUSH doctors have no training to perform any procedure or prescribe modern medicine.[11]

Our study aimed at assessing the care-seeking behavior of patients with skin ailments. The study also stressed on assessing the factors responsible for opting treatment at sources other than medical professional and outcome following seeking care at various sources. To the best of our knowledge, none of the previous studies emphasized on assessing such associations. We observed that maximum patients opted for modern treatment (88%), whereas only 12% opted for alternate medicine such as Ayurvedic, Homeopathic, or Unani for the management of skin conditions. No significant difference in sociodemographic profile and clinical profile could be observed between patients seeking modern medicine and alternative medicine. Although modern medicine has gained importance all over the world, complementary and alternative practices have their roots since ancient times and are adjuncts to modern medicine. Pandey et al. documented that various factors determine the health-seeking behavior of patients, which include social, cultural, economic, and literacy. Economic factor is one of the major determinants of choosing source of medication as alternative medicine is usually cheaper than modern medicine.[12] Apart from this, Debas et al. highlighted patient's faith, belief, confidence in the treatment, ease of access, and convenience as other important factors which are important determinant of health-seeking behavior.[13]

Patients opting for modern medicine and alternative medicine were further categorized based on the source of medication in our study. Among patients opting for modern medicine, about 47.7% of patients preferred buying medicines directly from medical store after consulting the pharmacist. However, 32.2% of patients sought care with unqualified doctors and 15.2% of cases visited qualified doctor. Only 4.9% of cases received care from dermatologists. The findings of the present study were supported by findings of Kumar, in which the authors documented that, in India, the role of specialist is negligible in health care as most of patients self-medicate under influence of a friend, family member, or a medical store personal or visit an unqualified doctor.[14] Significantly better outcome was observed in patients who took treatment from professional doctor, whereas outcome was significantly poor among patients seeking care from medical store and unregistered doctor (P < 0.05). Quackery is often the primary source of medical facility, especially in rural areas.[14] Kamat and Nichter documented that medical store plays a pivotal role in self-medication, patients consider medical store personals a learned person with information of drugs and diseases, but 60% of the pharmacies are run by unqualified personals with no training or degree in pharmacy for the sole purpose of cost-cutting qualified pharmacist are not employed and only exist on paper, even big pharmacies employee 8-10 personals, and none are qualified pharmacist.[15] According to Verma et al., topical corticosteroids are commonly prescribed for majority of skin ailments, and this drug is often misused by both medical and nonmedical personnel as they are easily available, low cost over-the-counter medication.[7] Meena et al. concluded that even MBBS doctor prescribe these medicines for wrong indication and wrong duration affecting the outcome.[8]

Self-medication was common among patients with skin disease under the influence of advertisement or past treatment, friends, or pharmacist. Furthermore, socioeconomic status was observed to be an important determinant of seeking care from the professionals. Our study findings were supported by findings of Pandey et al.[12] and Debas et al.,[13] i.e. economic factor is one of the major factors which helps in determining the source of medication as dermatologist consultation charges are higher as compared to MBBS doctor. Seeking care from unregistered practitioner and pharmacist may appear cheaper in terms of money but may increase the suffering of patients and thus contribute to higher cost in long run.

Not only for modern medicine, quackery, and self-medication is also observed in alternative medicine. Out of 36 patients who took alternate medicine, majority, i.e., 58.4% sought treatment from qualified alternate medicine doctors, whereas 16.7% bought them after advice from medical store pharmacist and 25% took home remedy. Number of patients getting medicine from qualified alternate medicine doctors is high as most alternate medicine doctors self-dispense medicines after formulation.


  Conclusion Top


Modern medicine as well as alternative medicine both is opted by patients depending on availability, sociocultural factors, and beliefs of patients. Although modern medicine has gained considerable importance for the management of dermatological conditions, still the majority of patients seek care from medical store, unregistered doctors, and MBBS doctors. Care seeking from dermatologist is <5%. Socioeconomic factors and influence from friends, advertisement, and pharmacist are significantly associated with source of medication. Self-medication and quackery significantly affect the outcome as symptoms worsened in majority of patients. General public is not yet aware of importance of specialty clinics which is resulting into steroid-induced adverse effects, drug resistance, and prolong illness. There is a need to control unqualified doctors and medical stores for drug dispensing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tizek L, Schielein MC, Seifert F, Biedermann T, Böhner A, Zink A. Skin diseases are more common than we think: Screening results of an unreferred population at the Munich Oktoberfest. J Eur Acad Dermatol Venereol 2019;33:1421-8.  Back to cited text no. 1
    
2.
World Health Organization. The Role of the Pharmacist in Self-Care and Self-Medication. Geneva: World Health Organization; 2011. Available from: http://apps.who.int//medicinedocs/en/d/whozip32e/. [Last accessed on 2021 Apr 14].  Back to cited text no. 2
    
3.
Bapat RV. Quackery in India. Ind Med Gaz 1909;44:158.  Back to cited text no. 3
    
4.
Murray MD, Callahan CM. Improving medication use for older adults: An integrated research agenda. Ann Intern Med 2003;139:425-9.  Back to cited text no. 4
    
5.
Choonara I, Gill A, Nunn A. Drug toxicity and surveillance in children. Br J Clin Pharmacol 1996;42:407-10.  Back to cited text no. 5
    
6.
Pandya P, Pandya I. Prevalence and patterns of self-medication for skin diseases among medical undergraduate students. Int J Res Dermatol 2018;4:162-7.  Back to cited text no. 6
    
7.
Verma P, Pathania S, Suvirya S, Shukla P. Knowledge attitude and practice survey in medical graduates regarding topical corticosteroids: A cross sectional study conducted at medical university of North India. Indian J Clin Exp Dermatol 2019;5:133-6.  Back to cited text no. 7
    
8.
Meena S, Gupta LK, Khare AK, Balai M, Mittal A, Mehta S, et al. Topical corticosteroids abuse: A clinical study of cutaneous adverse effects. Indian J Dermatol 2017;62:675.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Landis ET, Davis SA, Feldman SR, Taylor S. Complementary and alternative medicine use in dermatology in the United States. J Altern Complement Med 2014;20:392-8.  Back to cited text no. 9
    
10.
Lindblad AK, Kjellgren KI, Ring L, Maroti M, Serup J. The role of dermatologists, nurses and pharmacists in chronic dermatological treatment: Patient and provider views and experiences. Acta Derm Venereol 2006;86:202-8.  Back to cited text no. 10
    
11.
Bansode M, Rai J, George M. AYUSH and health services. Econ Polit Wkly 2018;53:21.  Back to cited text no. 11
    
12.
Pandey MM, Rastogi S, Rawat AK. Indian traditional ayurvedic system of medicine and nutritional supplementation. Evid Based Complement Alternat Med. 2013;2013:376327. doi: 10.1155/2013/376327. Epub 2013 Jun 23. PMID: 23864888; PMCID: PMC3705899.  Back to cited text no. 12
    
13.
Debas HT, Laxminarayan R, Straus SE. Complementary and Alternative Medicine. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 69. Co-published by Oxford University Press, New York.  Back to cited text no. 13
    
14.
Kumar S. Much health care in rural India comes from unqualified practitioners. BMJ 2004;328:975.  Back to cited text no. 14
    
15.
Kamat VR, Nichter M. Pharmacies, self-medication and pharmaceutical marketing in Bombay, India. Soc Sci Med 1998;47:779-94.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

 
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