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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 133-136

From flummoxed to focused: A mixed-methods study of preventive practices during the COVID-19 pandemic among intern doctors working in a rural tertiary care hospital of Maharashtra, India


1 Department of Community Medicine, Rural Medical College, PIMS (DU), Loni, Maharashtra, India
2 Intern Doctors, Rural Medical College, PIMS (DU), Loni, Maharashtra, India

Date of Submission05-Jul-2020
Date of Decision11-Aug-2020
Date of Acceptance12-Aug-2020
Date of Web Publication8-Sep-2020

Correspondence Address:
Mandar Baviskar
Department of Community Medicine, Rural Medical College, PIMS (DU), Loni, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SHB.SHB_48_20

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  Abstract 


Introduction: Intern doctors are important in the functioning of a teaching hospital. Their health and sanitation practices can, therefore, influence disease transmission rates. Methods: A simultaneous quantitative + qualitative study was conducted on 110 intern doctors working in a rural tertiary care hospital. Percentage values and Chi-square tests were used to compare responses in male and female interns and triangulation-incorporated qualitative inputs. Results: Overall, the practices were sound, but lapses in the protocol were reported, especially in areas with higher patient footfall. Females were more likely to follow proper hand hygiene (P = 0.042), use alcohol based sanitizer and keep it on their person (P = 0.017), use gloves as instructed (P = 0.02). And males diligently observed social distancing (P = 0.0001), and followed mobile phone hygiene (P = 0.003). Conclusion: Despite the scale of pandemic, interns have tried their best to follow guidelines and commonsense measures. Clear protocols, positive reinforcement, and monitoring can prevent lapses in preventive measures.

Keywords: COVID-19, India, intern doctors, rural, sanitation


How to cite this article:
Baviskar M, Kharde A, Gadekar S, Sheth S, Chordiya A. From flummoxed to focused: A mixed-methods study of preventive practices during the COVID-19 pandemic among intern doctors working in a rural tertiary care hospital of Maharashtra, India. Soc Health Behav 2020;3:133-6

How to cite this URL:
Baviskar M, Kharde A, Gadekar S, Sheth S, Chordiya A. From flummoxed to focused: A mixed-methods study of preventive practices during the COVID-19 pandemic among intern doctors working in a rural tertiary care hospital of Maharashtra, India. Soc Health Behav [serial online] 2020 [cited 2020 Sep 24];3:133-6. Available from: http://www.shbonweb.com/text.asp?2020/3/4/133/294537




  Introduction Top


The Indian medical undergraduate curriculum involves 4½ years of teaching and training after completion of which the students undergo 1-year rotatory internship posting in a hospital where they begin to ease into the role of young practitioners. This transition period is made more challenging as they have to simultaneously prepare for their postgraduate entrance examination that determines the trajectory of their careers. After successfully completing the internship, they are then issued a license to practice by the state medical council.

The COVID-19 pandemic came to India in February just as the new batch of intern doctors joined their postings. These relatively green doctors had little time to train before being sent to the metaphorical trenches to tackle the onslaught of cases. Although initially the urban regions of India bore the brunt of infection, the cases trickled down to rural areas soon. The Maharashtra state in western India is industrialized and connected globally by means of Mumbai which is the financial capital of the country.[1] It was, therefore, the worst affected by the pandemic.

Intern doctors play an important role in the day-to-day functioning of a teaching hospital. Their health and sanitation practices can, therefore, influence the disease transmission rates. It is in this background that we conducted a study among intern doctors working in a rural tertiary care hospital to study their adherence to health and sanitation guidelines with the intention to identify any shortcomings and overcome them.


  Methods Top


A simultaneous quantitative + qualitative study was conducted on all 110 intern doctors working in a 1200-bedded rural tertiary care hospital in the months of April and May 2020. Their mean age was 23.5 years (standard deviation [SD] = 1.163), and 44 (40%) interns were male, whereas 66 (60%) were female.

Prior approval of the institutional ethics committee was obtained (ref. no. RMC/UG-PG/2020/55). Prior to administering the questionnaire, ethical conditions for participating in the study were explained to the respondents. These included privacy, voluntary participation, anonymity, confidentiality, and protection from both psychological and physical harm. Written informed consent was taken from each respondent. Data collection was done with the help of a semi-structured questionnaire. The investigators personally administered the questionnaire with due precautions. Data collection was followed by sensitization regarding proper preventive measures to be followed in the COVID-19 pandemic.

Focus group discussion was conducted to get quality insights from eight randomly selected interns which included five females and three males (mean age 24 years, SD = 0.92) from obstetrics, general medicine, emergency medicine, community medicine, chest and tuberculosis, otorhinolaryngology, ophthalmology, and general surgery. Appropriate social distancing and use of face masks were implemented while conducting the focus group discussions. The transcripts were analyzed, the themes were isolated, and the responses were noted.

Statistical analysis

Descriptive statistical analysis included percentage values of responses. Chi-square test was applied to compare responses in male and female intern doctors. Triangulation was done incorporating qualitative inputs.


  Results Top


The overall health and sanitation measures were good, but lapses in protocol were reported, especially in areas with higher patient footfall. Female interns were more likely to follow proper hand hygiene (χ 2 = 6.316, df = 2, P = 0.042), use alcohol based sanitizer and keep it on their person (χ 2 = 6.602, df = 1, P = 0.017), wear and change gloves as instructed (χ 2 = 5.398, df = 1, P = 0.020). And male interns diligently observed social distancing (χ 2 = 15.469, df = 1, P = 0.0001), and followed mobile phone hygiene (χ 2 = 15.469, df = 1, P = 0.003) [Table 1].
Table 1: Sex-wise comparison of preventive practices among interns

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The focus group discussions revealed that interns understood the seriousness of the situation. They felt that proper arrangements while serving food, in-campus availability of essential goods, availability of personal protective equipment (PPEs), in campus testing and isolation facilities were positive factors that enabled safety. Shared dorms by interns posted in different departments, sharing of instruments, and improper masking techniques were negative factors. Invariable crowding in certain areas of hospitals, discomfort due to prolonged use of PPEs in hot or humid climate, variability in duty hours, and having to move around the hospital campus togetthingsdone were barriers in following proper precautions [Table 2].
Table 2: Summary findings of focus group discussion

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The interns also reported being more comfortable using face shield, opining that it soaks the sweat on the forehead, lets you breathe, and psychologically also having a shield in front of the face helps. People maintain social distance knowing that you are a doctor and feel that proximity to doctors' increases risk of getting infected. Having a calmauthoritativedemeanor, keeping calm, and having signs in local language displayed clearly across hospitals were reported to have helped. A workshop was conducted for the interns, and they reported that it was helpful in helping them focus on adhering to preventive practices.


  Discussion Top


The COVID-19 pandemic has tested the resolve of even the most seasoned practitioners. The interns initially might have become flummoxed due to the flood of information, variable guidelines, and uncertainty surrounding the COVID-19 pandemic. The study was able to identify the issues faced by interns and recommend corrective measures which were implemented at the local level. Incremental improvements in preventive behaviors have shown to cause a dramatic improvement in preventing the likelihood of disease transmission.[2] Use of intelligent design to control footfall in hospitals and behavioral nudges to promote good practices has also been deemed to be useful.[3] Innovation in PPEs to make them suitable for local conditions is needed.[4]

Positive reinforcement rather than compulsions and restrictions is more likely to be effective in bringing about behavioral change in interns working under stress.[5] Addressing systemic supply-and-demand inadequacies in the Indian health system should be pursued aggressively by policymakers. Measures enabling patient care through stakeholder involvement need to be taken at local levels as well.[6]


  Conclusion Top


Despite the scale of pandemic, intern doctors have tried their best to follow guidelines and commonsense measures. We believe that clear protocols, regular monitoring, and positive reinforcement can prevent lapses in preventive measures.

Acknowledgment

We thank the Management and Directorate of Research, Pravara Institute of Medical Sciences (Deemed University), for their support.

Financial support

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaw A. Emerging Patterns of Urban Growth in India. Economic and Political Weekly; April 1999. Available from: https://www.jstor.org/stable/4407880?seq=1. [Last accessed on 2020 May 08].  Back to cited text no. 1
    
2.
World Health Organization. Water, Sanitation, Hygiene, and Waste Management for SARS-CoV-2, the Virus that Causes COVID-19: Interim Guidance, 29 July 2020. World Health Organization; 2020.  Back to cited text no. 2
    
3.
Bavel JJV, Baicker K, Boggio PS, Capraro V, Cichocka A, Cikara M, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav 2020;4:460-71.  Back to cited text no. 3
    
4.
Livingston E, Desai A, Berkwits M. Sourcing personal protective equipment during the COVID-19 pandemic. JAMA 2020;323:1912-4.  Back to cited text no. 4
    
5.
Wulf J, Nelson ML. Experienced psychologists' recollections of internship supervision and its contributions to their development. Clin Superv 2001;19:123-45.  Back to cited text no. 5
    
6.
Zodpey S, Negandhi H, Dua A, Vasudevan A, Raja M. Our fight against the rapidly evolving COVID-19 pandemic: A review of India's actions and proposed way forward. Indian J Community Med 2020;45:117.  Back to cited text no. 6
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