METHODS

Study Setting
A multi country cross-sectional study was conducted across six countries (Bahrain, Egypt, Iraq, Kuwait, Pakistan and Saudi Arabia) of the 22 countries of the Eastern Mediterranean Region (EMR), from September 2014 to March 2015. These countries were selected to obtain perceptions and practice of Family Physicians regarding health promotion, disease prevention including periodic screening and health checks.

Selection of participants
Family Physicians who were currently practicing in these six countries of EMR were invited to participate in the study. They were informed about the study protocol and were requested to participate in the study and return the filled questionnaire through email within a month. Reminders were sent every week to the Family Physicians who agreed to participate in the study.

Informed Consent
The information about the study protocol and consent forms were sent to each Family Physician who agreed to participate in the study, and they were asked to return the signed consent form. The study was conducted in accordance with the Helsinki Declaration and the Departmental Research Committee of the Aga Khan University reviewed and approved the study.

Study Questionnaire
A questionnaire was formulated after compiling important aspects of periodic health evaluation through extensive literature search and by taking expert suggestions. The questionnaire was initially prepared in English; however, it was also translated to Arabic, as it is a common language in the region. The questionnaire was pre-tested on five physicians and ambiguities found were removed. The questionnaire was composed of 2 sections: The first section covers demographic details of the participants, while the second section focuses on perceptions and practices of physicians regarding health promotion, disease prevention including periodic screening and health checks.

Statistical Analysis
Data was entered and analyzed in SPSS version 19.0. The analysis was completed in two stages i.e. descriptive and inferential. Frequencies of all the variables were reported in the descriptive analysis. In the 2nd stage, logistic regression analysis was performed to identify the factors that promote Family physicians to recommend periodic health evaluation to their patients. In the regression analysis the outcome was Family physicians who recommend health evaluation to their patients (Yes/No). Univariate analysis was carried out to obtain the independent effects of factors on the outcome. Since none of the variables were found to be significant at the Univariate level, therefore, multivariate regression was not performed. The results were reported in the form of unadjusted odds ratio along with their 95% confidence interval. Throughout the analysis a P value of < 0.05 was considered statistically significant.

RESULTS

Table 1: Baseline characteristics of Study Participants (n=100)

*Sum cannot be 100 as some FPs had more than 1 degree

The demographic characteristics of the participating physicians are presented in Table 1. A total of 100 Physicians returned completed questionnaires and were included in the final analysis. The response rate was 71% (100/140). The majority of the sample population were female physicians (76%) and 63% of them were between 25 to 35 years of age. About 87% of the physicians had a postgraduate training; 93% had done specialization in Family Medicine. Slightly over two-fifths (41%) were in their residency programs and 32% working in the public sector. On an average 57% see less than 25 patients per session and 47% spend at least 10 minutes with each patient during consultation. A vast majority of participants attended CME regularly; with 31% attending 20 to 50 CME credit hours per year. Of the total physicians sample, the majority were from Pakistan (31%), followed by Egypt (30%) and Iraq (30%).

Table 2: Family Physician questions asked in history and Physical examination


There are limited national screening programs in the surveyed countries which reflected poor quality of health service planning in these countries. Approximately 53% of the Family Physicians (FPs) responded that they always recommend periodic screening health checks to their patients. The clinical practice screening questions asked in history and in physical examination are given in Table 2. The FPs common health checks questions asked from patients in medical history were related to their blood pressure (86%), closely followed by family history of diabetes (85%) and tobacco use (77%). However, the least common questions asked from patients were about alcohol (25%), mental health status of patients (27%) and Body Mass Index (38%).

Table 3: Investigations & Health Education as part of Periodic Check Up


Clinical practice investigations as part of periodic physical examination are presented in Table 3. Over two thirds (67%) of the FPs responded that they always use hemoglobin as clinical marker in health evaluations. About 60% always order blood sugar and 50% request for lipid profile. 51% of them mentioned that they never advised patients for cervical smear, 73% of them never asked patients to get prostate specific antigen, and about 54% didn't ask about the travel vaccine status. The majority of them provide counseling to patients during periodic health checks on obesity and diet (81%), smoking (82%) and exercise (74%).

Table 4: Perceptions of Family Physicians regarding Periodic Health Check Up (n=100)


Almost all (99%) FPs were of the view that periodic heath evaluations should be conducted by them while 43% believed that they should be conducted by nurses. Besides that, 98% of them responded that the evaluation should be conducted in primary health center clinics. As far as frequency of periodic health evaluations is concerned, 73% of them would recommend health evaluations every year, whereas, 17% recommend it every two years and 10% every three years. 62% of the Family physicians agree that ongoing opportunistic check is as important as periodic health evaluations. About one third of them believed that preventive health practices do not interfere with ongoing disease treatment and care (Table 4).

Figure 1: Factors that promote Family Physicians Periodic Health Evaluations Practice

Univariate logistic regression analysis
*Attendance in CME significant at p value < 0.05

Figure 1 depicts the factors that motivate FPs to recommend periodic screening health checks to their patients. Those who had a postgraduate training in Family Medicine (OR: 0.5; 95% CI: 0.39-1.67) are more likely to recommend health evaluations to their patients. Likewise, those who attend CME sessions regularly (OR: 0.11; 95% CI: 0.01-0.93) and those who are working as trained Family physicians (OR: 0.88; 95% CI: 0.39-1.9) are promoters of periodic screening health checks.

DISCUSSION

This is probably among the first studies from the East Mediterranean region that looks at health promotion, disease prevention including periodic screening health checks and the perception and practice of Family Physicians in the Region. The sample was limited to 100 respondents; the majority of them were women, in residency training or with postgraduate qualifications and undertaking Continuing Medication Education on a regular basis. Therefore, it will not be possible to generalize results of this study to Family Physicians practicing in EMR. Even with this limitation, results of our study do offer insight into the knowledge, attitude and practices of Family Physicians with regards to health promotion, disease prevention including periodic screening health checks in the region.

Half of respondents in this study recommend periodic screening and health checks to their patients. Yet it is disappointing to note a much smaller number of patients request these important health services from their doctors. In Eastern Mediterranean Countries, an earlier study showed that 90% of the Physicians recommend periodic health evaluation to patients.(12)
It has been noted that patient's preference for preventive strategies depends on household income and education.(13) It is again encouraging to note that a significant number of respondents ask about smoking, exercise and diet in the history and check for blood pressure, yet a much smaller number actually look at body weight and BMI.

It is also encouraging to note that a substantial number of respondents recommend blood sugar, lipid profile, hemoglobin, serum creatinine and LFTs for their patients during these health checks encounters. A need exists to focus on adult and travel vaccination for disease prevention. A recent study has shown that adult immunization coverage is less than satisfactory, even in those who have insurance coverage.(14) It is again encouraging to note respondent's recommendation for lifestyle related patient education and counseling.

The recommendation by most respondents that such periodic screening and health checks should be provided in primary care settings is more than welcomed, even though a substantial number of them feel that it interferes with provision of ongoing disease treatment and care. It has been earlier reported that need for acute and chronic disease treatment and care interferes with the provision of promotive and preventive health interventions.(15) It is no surprise that respondents with postgraduate training in Family Medicine and those undertaking CME activities recommended periodic screening and health checks more often to their patients.

The study indirectly highlighted the shortcoming in the health systems of EMR countries; the lack of national systematic approaches to periodic screening and health checks to target population based on best evidence. Promotion and prevention interventions at community (routine) and individuals (opportunistic) can be achieved for the benefits of the people without universal health coverage through comprehensive primary care services for all.(2)

Research is required to demonstrate long-term benefits of delivering several preventive interventions during preventive health examinations. It is also required to assess such interventions in the context of different populations needs, defining comparisons to "routine care" and carefully evaluate intermediate outcomes, harms and costs.(16)

CONCLUSION

Health services are becoming complex and expensive. With the availability of new intervention modalities and an increasing ageing population, it is becoming challenging to provide adequate health service coverage. Given this background, health promotion, disease prevention including periodic health examinations will reduce healthcare costs and provide funds to promote access to healthcare to the majority of those who need it and with equity. We have found support for health promotion, disease prevention including periodic screening and health checks in this study and recommend its practice in Eastern Mediterranean region.

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