Health professionals’ over estimation of knowledge on snakebite management, a threat to survival of snake bite victims - A cross-sectional study in Ghana

Background According to the World Health Organization, snakebites, a common occupational hazard in developing countries accounts an annual loss of between 81,000 and 139, 000 lives following 5 million of bites of which 2.7 million results in envenomation. Since snakebite associated morbidity and mortality is more prevalent in agriculture economies such as Ghana, health professionals should be optimally knowledgeable on how to manage incidence of snakebites. Lack of knowledge or overestimation of a professional’s knowledge can be affects heath delivery especially for emergency situations such as snakebites. The three (3) Tongu districts South Eastern Ghana which are rurally situated with agriculture as the major source of livelihood for their inhabitants are prone to snakebite incidence hence the need to assess whether the health professionals in these districts are well equipped by way of knowledge to handle such emergencies and whether they are able to rightly estimate their knowledge with regards to snakebite management. Methodology/Principal findings Data was collected using a de novo semi-structured questionnaire administered through google form whose link was sent via to 186 health workers made up of nurses, midwives, physician assistants, medical doctors, pharmacists, and pharmacy technicians. This data was analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Association between variables was determined using the appropriate tools where necessary, using a confidence interval of 95% and significance assumed when p ≤ 0.05. This study found male health workers significantly more knowledgeable about snakebite management (11.53±5.67 vrs 9.64±5.46; p = 0.022) but it was the females who overestimated their knowledge level (27.9% vrs 24.1%). The medical doctors exhibited the best knowledge on snakebite management with the registered general nurses least knowledgeable. Although most professionals overestimated their knowledge, the registered general nurses were the worst at that (53.7%). Overall knowledge of health care professionals on snakebite management was below average [10.60±5.62/22 (48.2%)] but previous in-service training and involvement in management of snakebite were associated with better knowledge. Respondents who had no previous training overestimated their knowledge level compared to those who had some post qualification training on snakebite management (7.5% vrs 38.1%). Greatest knowledge deficit of respondents was on the management of ASV associated adverse reactions. Conclusion Health workers in rural Ghana overestimated their knowledge about snakebite management although their knowledge was low. Training schools therefore need to incorporate snakebite management in their curriculum and health authorities should also expose health workers to more in-service training on this neglected tropical disease. Author summary World Health Organization estimates that every year between 81,000 and 139,000 die due snake bites across the world. Mismanagement of snakebites can result in increased disabilities and death if not handled by knowledgeable health workers. This study assessed if various categories of health workers made up of professionals from the medical, pharmaceutical and nursing categories in the three neighbouring Tongu districts in Ghana have the appropriate level of knowledge on snakebite management. Using a newly developed questionnaire, data was collected from the respondents using google forms sent to their WhatsApp platforms. Data was then analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Results were presented in the form of tables and association between the variables also determined. The level of knowledge of sampled health workers on snakebite was below average especially among the nursing professionals. However, those who had some previous post qualification training on snakebite management exhibited a significant superior knowledge and least overestimated their knowledge hence policy makers should through workshops equip health workers especially the nurses on snakebites so that rural dwellers whose health care needs are mainly attended to by nurses can be better managed when they suffer snakebites.

Ocean such as Tuvalu and Nauru [1]. It is estimated that there are more than 3,700 species of 85 snakes on earth [2]. As snakes also makes efforts to survive in the ecosystem, there are bound to 86 come into conflict with humans and mostly as a defensive mechanism some of them bite. This 87 human-snake conflict is estimated to results in between 4.5 and 5.4 million snakebites annually 88 [3]. It is estimated that about 600 snakes whenever they bite, they inject toxins substances referred 5 89 to as venoms into their victims hence they are classified as being venomous while the vast majority 90 are non-venomous [4]. The number of persons bitten by venomous snakes cannot be exactly 91 known but it is believed that 1.8 to 2.7 million people globally suffer the effects of their bites out 92 of which 81,000 to 138,000 of victims die although the mortality would have been higher had it 93 not been because about 50% of venomous snakebites do not lead to envenoming [4,5]. 94 Notwithstanding this high level of snakebite incidence, reports across the world found that quite a 95 number of victims seek remedies from traditional medicine practitioners than hospitals. A study 96 in India found that only 22.2% of snakebite victims report at the hospitals [6]. Two hospital-based   Study design 122 A cross-sectional study design was applied in this study which was conducted within the months 123 of May and June, 2019. 125 The study population were health care providers namely; pharmacists, physician/medical 126 assistants, medical doctors, pharmacy technicians as well as midwives and nurses of various 127 categories who work in hospitals, health centres and CHPS compounds in the study area.

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Study sample size determination 129 The sample size for this study was calculated using the Cochran formula, 0 = 2 ( )( ) With an estimated overall knowledge of health care providers in the study area on management 132 of snakebites as 50%, p (the estimated proportion of an attribute that is present in the population) 133 = 0.5 hence q is 1-p = 0.5.

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Sociodemographic characteristics of respondents Training on and management of snakebite       Table 5 shows the comparison between the perceived and actual knowledge scores of respondents    can be due to the more exposed those in CHPS zones are to snakebite issues than those in the 428 hospitals. This results then places snakebite victims that are sent or referred to these higher-level victims as they will be inappropriately more confident as they even administer or manage such 448 cases wrongly. The effect of high confidence level on the knowledge of respondents was succinctly 449 exhibited when differences between perceived and actual knowledge scores were analyzed. The 450 more confidence a health worker expresses, the higher the over estimation of knowledge; those 451 not confident (6.6%) and very confident (52.7%). Although the overall knowledge on snakebite 452 management may be low, there were some areas where they showed some good knowledge 453 especially those about the 20 minutes whole blood count test, anti-snake venom being the only specific antidote for envenomation and the best route for administering being intravascular.

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Management of ASV adverse drug reaction (ADR) was rather poorly answered. For more than 456 half (51.6%) of respondents to opt for hydrocortisone rather than adrenaline (22.0%) as their 1 st 457 choice in the management of ASV associated adverse drug reaction is a source of worry. This

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The authors declare that there is no conflict of interest regarding the publication of this paper.

FUNDING STATEMENT
Funding of the study was by the authors. This research did not receive any specific grant from 502 funding agencies in the public, commercial, or not-for-profit sectors. 503 504 ACKNOWLEDGEMENT 505 We wish to acknowledge the support of heads of health facilities where the data were collected. 506 We also acknowledge the support given the team of researchers by health workers in the North, 507 Central and South Tongu districts of the Volta region.