Family Physicians' Experiences, Behaviour, and Use of Personal Protection Equipment During the SARS Outbreak in Singapore: Do They Fit the Becker Health Belief Model?
Identifieur interne : 000015 ( Istex/Corpus ); précédent : 000014; suivant : 000016Family Physicians' Experiences, Behaviour, and Use of Personal Protection Equipment During the SARS Outbreak in Singapore: Do They Fit the Becker Health Belief Model?
Auteurs : Nc Tan ; Lg Goh ; Ss LeeSource :
- Asia Pacific Journal of Public Health [ 1010-5395 ] ; 2006-09.
English descriptors
- Teeft :
- Acute shortage, Adequate supply, Becker, Becker health belief model, Behaviour, Behaviour change, Behaviour modification, Bulk purchase, Clinic, Clinic staff, Clinical session, Early stage, Family physician, Family physicians, Family practice, Family practices, Fellow healthcare workers, Health authority, Health belief model, Health education monographs, Healthcare, Healthcare workers, Hong kong, Infectious disease, Initial draft, Mask, Mass media, Morbidity risks, Outbreak, Participant, Patient attendance, Personal protection equipment, Physical discomfort, Preventive measures, Primary healthcare workers, Private group practice, Private practices, Probable sars patients, Psychosocial reaction, Public health, Respiratory syndrome, Sars, Sars epidemic, Sars hospital, Sars infection, Sars outbreak, Sars patient, Sars patients, Sars virus, Singapore, Such equipment, Such family physicians, Surgical, Surgical mask, Surgical masks, Various sources.
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DOI: 10.1177/10105395060180030901
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Family
Physicians' Experiences, Behaviour, and Use of Personal Protection Equipment
During the SARS Outbreak in Singapore: Do They Fit the Becker Health Belief
Model?
SAGE Publications, Inc.2006DOI: 10.1177/10105395060180030901
NCTan
MMed, FCFPS
Family Physician, SingHealth Polyclinics, Singapore
LGGoh
FCFPS, FRAGP
Department of Community, Occupational and Family Medicine
National University of Singapore
SSLee
MMed, FCFPS
Family Physician, College of Family Physicians, Singapore
Introduction
T h e s e v e r e a c u t e r e s p i r a t o r y syndrome (SARS) outbreak
in 2003, began in Southern China. The clinical characteristics were fever,
then cough and later breathlessness. The chest X-ray at the breathless stage
will s h o w p a t c h y a r e a s o f a t y p i c a l pneumonia1. The etiological
agent is a novel coronavirus. A 23-year-old Singaporean female who travelled
to Hong Kong was infected there and spread the disease to Singapore upon her
return2. It took the health workers by surprise to find that the disease spread
rapidly to them from noso- comial transmission1.The outbreak resulted in 206
patients infected with SARS and 32 deaths3. Forty percent of the SARS patients
were healthcare workers in hospitals 3. A specific hospital was subsequently
designated a s a S A R S h o s p i t a l d u r i n g t h e outbreak to receive
and manage any
suspected
cases4. Current literature on the impact of SARS includies studies carried
out in hospital settings5,6,7. This paper examines the impact of SARS on family
physicians in the primary care settings, both in private clinics and in government-funded
polyclinics. The presence of SARS in patients manifested as fever cases with
cough and later breathlessness alerted family physicians that they need to
be aware of the possibilities of SARS in patients with such symptoms. In the
early stage of the SARS outbreak, family physicians, without any reliable
diagnostic investigations, relied entirely on patients' account of flu-like
symptoms with or without travel history to arrive at a probable diag- nosis
of SARS (suspected SARS). Media publicity initially resulted in public stigmatisation
of the disease and this made the patient reluctant to provide full disclosure
of their clinical
50
history.
Those patients with clinical history suggestive of SARS were also more likely
to seek consultation at the family practice rather than faced possible stigmatisation
and quarantine at the SARS hospital. Once the infectious nature of SARS was
known, the Ministry of Health (MOH) officials announced compulsory contact
tracing for every SARS patient admitted. Members of staff working in those
practices which referred these patients, were screened by the officials for
infectious disease control at the respective clinics and were subjected to
quarantine if the control measures were assessed to be inadequate. The media
publicised selected family practices, which had earlier encountered SARS patients.
As a result, these practices were stigmatised and faced immediate decline
in patient attendance and reduced income to the respective family physicians.
This s t i g m a t i s a t i o n r e s u l t e d i n t h e i r reluctance
to reveal their identity after their encounter with SARS patients, even if
they were not quarantined. It w a s t h u s v e r y d i ff i c u l t f o r
t h e investigators to measure the impact of SARS on family physicians. In
Singapore, family practices are located in the community with walk-in accessibility
to any patients. The “private” family physicians are self-employed,
either work alone (singleton practice) or together with one or more family
physicians in “group practices”. The polyclinic family physicians
work in small teams o f d o c t o r s i n t w o c l u s t e r s o f government-aided
polyclinics located in various parts of the island, where medical supplies
and resources are centrally procured and shared with their respective cluster
hospitals. Family physicians who worked on an a d - h o c h o u r l y r a
t e d b a s i s w e r e referred to as “locum” doctors. In 2003,
there were some 2000 family physicians out of 6500 doctors in the country.
It was only after the establishment of a hotline on 6 May 2003 by the C o
l l e g e o f F a m i l y P h y s i c i a n s
(COFPS)
that family physicians came forward to air their views, and family physicians
known in this way to have S A R S p a t i e n t s w e r e i n v i t e d t
o participate in the study. There were eight such family physicians and all
participated. Objective This qualitative study examined the family physicians'
experiences, the psychosocial reaction after their exposure to SARS patients
in family practice, as well as the prevailing PPE usage in their practice.
Methods Recruitment of participants In this study, family physicians, known
to have had exposure to SARS p a t i e n t s , w e r e i d e n t i f i e d
e i t h e r through self-revelation or through the COFPS hotline. Attempts
were made to collect a variety sample which i n c l u d e s t h e i d e n
t i f i e d f a m i l y physicians of both genders, a range of ages and years
of practices from both the public and private sectors respectively. However,
the sampling was restricted as both the sampling field and total number of
such family p h y s i c i a n s w a s u n k n o w n . T h e investigators
first contacted these family physicians by phone to invite them to participate
in the study. They were subsequently provided with study information letters
via the post or electronic mail. All invited family physicians participated
in the study. Conduct of interviews In-depth interviews were selected as a
mode of data collection to protect the anonymity of the participants. Two
of the three investigators took turns to interview each participant from July
to October 2003 in various localities, i n c l u d i n g t h e C O F P S ,
N a t i o n a l University of Singapore, cafés, local clubhouses, participant's
residence and the Singapore Medical Asso- ciation. The SARS outbreak began
on 1 March 2003 when the index case was admitted to hospital and the onset
of
the last case was on 5 May 2003. Singapore was declared SARS free on 31 May
2003. The purpose and objectives of the study were explained to the p a r
t i c i p a n t s a t t h e o n s e t o f t h e interview and a written consent
was obtained. Each interview was audio taped and was about 45-120 minutes
long. The interviews followed a semi- structured pre-planned discussion guideline.
The guideline covered the doctors' experience during their direct encounter
with the suspected SARS patients, including their clinical assessment and
management of their patients in their clinics, problems encountered, post-exposure
psycho- social reaction, use of PPE and other preventive measures. The tape-recorded
interviews were transcribed in their entirety into text files. The transcripts
were read and checked by the investigators to ensure consistency. Data analysis
The data was coded using qualitative data analysis software NUD*IST Version
6.0TM8. Broad themes were identified after standard content analysis of the
coded data was carried out. The quotations included in the results were typical
views expressed by the participants and were used to exemplify emergent themes.
One participant read the initial draft of the article to verify and validate
the themes listed by the investigators. Model fitting The investigators attempted
to fit the family physicians' behaviour, as revealed by the results, to the
Becker Health Belief Model9. This model has been in use since 1974 to explain
an i n d i v i d u a l 's b e h a v i o u r c h a n g e t o w a r d s p r
o t e c t i n g t h a t p e r s o n . Initially it had four elements – perceived vulnerability, perceived severity, perceived effectiveness, and
perceived barriers. Rosenstock 10 included one more element – cues
to action whilst the element of self- efficacy was added in 197711. The six
elements of the model are shown in
51
Table
2. It has found application in situations of changing behaviour towards reducing
risk, including its use in reducing risk of infection in HIV infection. Results
Socio-demographic background of participants and outcome of their patients
The participants were six male and two female family physicians, each declared
to have managed a single confirmed SARS patient. Their years of practice ranged
from 12 to 36 years with mean duration of 19.6 years. Their demographic profiles
and the outcomes of their patients were summarised in Table 1 below. The participants
were informed of their patients' outcome through their initiative to contact
the SARS hospital or via notification and contact tracing from MOH officials.
Perceived vulnerability and severity of infection The widely reported SARS-related
deaths
in various media kept the family physicians in constant vigil against infliction
with the SARS virus from patients with related symptoms during the consultation.
It was a novel virus and family physicians had hitherto not encountered such
a potential lethal infectious disease in primary care and had previously not
used any PPE in their routine clinical practice. The family physicians' learning
curve in the perception of susceptibility and severity of the infection was
steep as the SARS outbreak occurred over a period of weeks. The participants
received news about the deaths of fellow healthcare workers from SARS in the
mass media, which was very open. Being healthcare workers themselves who dealt
with patients suffering from fever and upper respiratory tract infection symptoms
similar to SARS, they regarded SARS as posing a threat not only to their life,
but also to that of their families, clinic staff and patients. In fact, the
participants expressed more concern about the
safety
of their loved ones at home than the threat to their own personal health.
It was the perceived vulnerability of the infection to spread to other persons
that motivated the participants to persist with the PPE in their practice.
FP1: “My fear is not only for myself. I am also afraid of what will
happen to my family and children should I spread the infection to them … and my staff in the clinic too are vulnerable to infection from a SARS patient.” Seeking information on PPE The participants felt helpless in the initial weeks
of the outbreak, as little information of the disease and the methods of control
were available from their previous education and training. They obtained piecemeal
information of PPE from various sources: the media such as news- papers, internet
and television news reports, personal phone calls to friends, local health
authorities and the COFPS and written notices and instructions from the Ministry
of Health (MOH). At the later stage of
Table
1. Profile of participating family physicians and the outcome of the SARS
whom they had initially treated
52
Table
2. Becker Health Belief Model – Concepts and applications
the
outbreak, a SARS seminar was organized by MOH and COFPS for fami ly p hy sic
ian s, wh ere more detailed information on PPE was disseminated. The COFPS
SARS h o t l i n e w a s p e r c e i v e d b y t h e participants to be an
effective channel of communication to address their concerns and queries on
PPE. Perception of effectiveness and benefits of PPE All the participants
had worn masks during their contact with the suspected SARS patients. They
singled out the mask as the key equipment that protected them from the corona
virus. FP6: “I am just relieved that at the time of contact, we were
already having an increased awareness about SARS and we were already wearing
the N95 mask.” However, a few participants admitted their earlier scepticism
on the effectiveness of the mask to prevent the droplet borne virus. They
expressed concerns, as they were not mask-fitted in the absence of proper
testing equipment in their clinic. They were eventually convinced of the mask's
effectiveness when infection
was
eliminated for all healthcare workers with the use of PPE in the SARS hospital
6. FP1: “I think PPE is absolutely essential and I think it should be
adopted very early. I feel it is better to overreact than under-react.” Even with the N95 mask, there was a general sense of insecurity as the participants
thought of potential or accidental contamination from s u b c o n s c i o
u s a c t i v i t i e s s u c h a s scratching the face or adjustment of the
masks. FP6: “We were definitely not sure whether they (PPE) were the
only things needed and we were definitely not sure whether they would definitely
protect us.” Two participants in this study wore surgical gowns during
their encounter with the suspected SARS patients. They used the gown as a
d d i t i o n a l p r o t e c t i o n t o a v o i d exposure of the SARS virus
on their clothing. The rest did not use the gown due to inadequate dissemination
of information and instruction from the health authority in the early stage
of outbreak, complacency or they had no gown, which were also in acute
shortage during the SARS outbreak. FP8: “I was masked. I was gowned.
That was the instructions given but I know some doctors, like my partner,
did not. I had to scold my nurses (for not wearing PPE), because they could
not believe it could happen (infected).” Half of the participants inter-
viewed wore disposable latex gloves during their consultation with the probable
SARS patients. In com- parison to the mask and gown, the disposable gloves
were not in short supplies. It was also relatively cheaper than the mask and
gown. Those who did not wear gloves indicated that they did not receive instructions
from the health authority to do so or they would wash their hands very frequently
or used hand antiseptic rub to avoid p o t e n t i a l c o n t a m i n a t
i o n . O n e participant pointed out that wearing gloves would be more appropriate
if surgical procedures were conducted during their patient consultation. FP2: “wearing
gloves, I don't think it was really helpful, unless you are talking about
doing a procedure, but at that time, we were informed not to do any procedure.”
53
Two
participants indicated that they used the goggles or visual sheath only in
their encounter with their probable SARS patients. Several participants highlighted
that they did not have such equipment in their clinic and a few had bought
them after their encounter or after the outbreak. FP1: “For myself,
I felt it was a very serious matter; I was actually fully masked, gowned,
capped and “flexiglassed” (type of spectacles) myself at least
one week prior to my exposure.” Difficulty and coping strategies in
using the PPE The participants highlighted the physical discomfort during
prolonged use of the N95 mask, ranging from breathing difficulty, headache
to the development of allergic facial rash around the mask. One participant
resorted to the use of three-ply surgical mask due to dyspnoea with the use
of the N95 mask. The other participant used the surgical mask due to unawareness
in the very early stage of the outbreak but subsequently switched to N95 mask
after the encounter with the SARS patient. The mask muffled their speech and
the participants needed to raise their voice and yet they could only drink
at the end of the clinical session. The discomfort from the N95 mask had severely
impaired the ability to carry out the consultation had resulted in one participant
switching to the triple ply surgical mask. FP1: “It took a lot of getting
used to the PPE especially the masks…. they were very uncomfortable
and very difficult to breathe.” One participant highlighted the importance
of behaviour modification after putting on the mask to avoid contamination.
It included avoidance of hand contact with the mask such as subconscious scratching
of the face or adjustment of the spectacles and avoidance of drinking till
the disposal of the mask at the end of the clinical session. Practice pattern
was also modified as one participant decided t o t a l k l e s s a n d h a
s t e n e d t h e
consultation
in view of the dyspnoea. There were moments of complacency when the participants
felt all right to remove the mask intermittently to a l l o w “ n o
r m a l ” b r e a t h i n g b u t compliance was improved after the
death of their doctor friend from SARS in the hospital. In retrospect, at
least two participants pointed out that the mask also protected them from
the common cold and flu. T h e p a r t i c i p a n t s , w h o w o r e gowns,
pointed out the inconvenience during toilet breaks. The gowns needed to be
handled carefully during their removal to avoid contamination to the person's
own clothing. This was especially pertinent for participants who re-used the
gowns after their break time in view of the acute shortage of the gowns. One
participant pointed out that the gown needed to be worn appropriately; he
observed that his doctor colleague had their collars exposed despite wearing
the gown and thus could still be exposed to the virus. FP2: “It doesn't
make sense if you wear a gown and the collar was exposed. What makes you so
sure the virus does not stick to the neck?” Perceived barrier to PPE – shortage, cost and adverse patient's reaction The shortage of PPE heightened
the sense of insecurity. The participants from private practices resorted
to prolonged use or recycled the PPE as a desperate means to conserve these
items. Even in the government aided polyclinics, the supply was severely limited
and rationing was put in place. The participants inevitably faced higher operating
cost yet diminishing revenue due to declining patient a t t e n d a n c e
. N o n e t h e l e s s a l l t h e participants persisted in their PPE whilst
managing their then suspected SARS patients professionally, relying entirely
on their PPE as their only barrier and protection against the SARS virus.
They also had to handle some of their other patients' adverse p e r c e p
t i o n o f t h e i r P P E w i t h reassurance and explanation.
FP1: “I
think most of them came i n a n d s a w m e d r e s s e d l i k e a n astronaut.
You can see the anxiety and concern in their faces.” Availability and
cost of PPE The participants from private practice were frustrated, as they
were unable to secure adequate N95 masks due to acute shortage during the
outbreak. The price of the N95 mask increased drastically during the SARS
outbreak. There were media reports about the public rushing to obtain the
N95 mask for personal protection and this further i n f l a t e d t h e p
r i c e s . D e s p i t e t h e increased cost, the participants' many attempts
to purchase the mask from various sources were not always successful. FP7: “I
was pretty upset…We are doctors out in the frontline and we don't even
get any kits, which I think is totally ridiculous.” (The SARS kit is
a local term used by healthcare workers to refer to PPE) The participants
also felt obliged to provide masks for their clinic staff as they dealt directly
with the patients as well as to their febrile patients with flu symptoms who
could potentially be SARS patients. However, many of the clinic assistants
wore surgical masks due to the shortage of N95 masks. Patients with SARS related
symptoms were also provided with surgical masks to reduce infectivity. This
further increased their operating cost of their clinic. The participants conserved
the N95 masks by prolonging the usage, instead of discarding them after every
change of attire. They were also concerned with the rising expenditure from
the use of the masks and other PPE and the declining attendance at their clinics
with resultant fall in revenue. The public was advised to avoid unnecessary
visits to healthcare institutions during the outbreak to reduce infection
and this had led to a decline of patient attendance to the family practice
clinics. This caused two participants to directly appeal to the government
and
54
the
Singapore Medical Association to obtain the N95 masks through bulk purchase.
Another participant had extended his assistance to other family physicians
through bulk purchase of the masks through his family contact with the supplier.
Patient perception of the PPE The participants claimed that their patients'
reactions to the PPE were varied and ranged from amusement to apprehension.
They believed that patients recognized the various PPE from the media coverage
of the outbreak, which advised the public to wear mask if they developed flu.
The participants highlighted the initial concern expressed by some of their
patients when they saw their doctors and nurses wearing the PPE. The patients
perceived the wearing of PPE by their family physicians as a s i g n t h a
t t h e y c o u l d h a v e b e e n exposed to SARS patients and thus taking
up these precautions. The patients inferred that their family physicians,
in turn could endanger their health by transmitting the SARS virus to them.
. FP1: “My two GP friends too, who adopted this gear, they actually
reported a drop in attendance rate. It does affect practice because of anxiety
and fear.” One participant highlighted the need to explain to patients
the use of PPE to rectify any erroneous perception. He made it clear to his
patients that wearing the PPE would be a key measure to safeguard their health
with mutual benefits. The participants reported that the patients gradually
accepted the PPE as an integral component of their doctor c o n s u l t a
t i o n a n d a t t r i b u t e d t o widespread media education and publicity.
FP5: “Some patients were a bit fearful; I explain to them that by wearing
a mask, I am protecting myself so that I do not infect you. That works both
ways and they should understand that. Some people don't, unfortunately, but
that's part of the learning process.”
E v
e n a f t e r S i n g a p o r e w a s declared to be free of SARS outbreak,
the participants indicated that they would put on the PPE if they were alerted
to any future infectious disease epidemic. Those from the private practices
would also check on their PPE stocks in their clinic regularly to ensure adequate
supply. Discussion The SARS epidemic had an unprecedented impact on the entire
healthcare system in Singapore. The s u s c e p t i b i l i t y o f t h e
h e a l t h c a r e workers to infection and the serious consequences were
initially not recognised. During the SARS outbreak, the centre of action was
in hospitals, and the primary healthcare workers were initially left to handle
the situation on their own. By nature of their relatively small practices
compared to the hospitals, the family physicians were potentially disadvantaged
to handle the highly contagious and potentially lethal disease. Their stocks
of PPE were limited and rapidly depleted and new supplies were diminished
due to high demand and escalating prices. In Hong Kong, the perceived inadequacy
of PPE supply, infection control training and inconsistent use of PPE when
in contact with SARS patients w e r e s h o w n t o b e s i g n i f i c a
n t independent risk factors for SARS infection 7. Although initially there
was no f o r m a l g u i d e l i n e i n p r e v e n t i v e measures against
SARS, CDC and W H O s u b s e q u e n t l y u rg e d a l l healthcare workers
examining any person with febrile illnesses to wear gloves, gowns, goggles
and N95 or equivalent respirators 2,7(N/R/ P 95/ 99/100 or FFP 2/3 or an equivalent
national manufacturing standard (NIOSH or N, R, P 95,99,100) or European CE
EN 149: 2001 (FFP2,3) and EN143:2000P2). The N95 mask, referring to 95% filter
efficiency of 0.3 micron sized aerosols respiratory particles, was considered
the minimal standard in respiratory protection
d
u r i n g t h e o u t b r e a k . R e p o r t s 3,5 showed that wearing the
N95 masks significantly decreased the risk of SARS infection with an adjusted
odds ratio of 0.1. However, it must be fitted according to the person's facial
size and contours and not all makes are suitable for each individual. Such
fit test kit was not available to most of the family physicians, especially
those in private practices. The shortage of PPE did not allow the family physicians
any options in mask fitting and selection. Furthermore, proper instruction
of wearing and removing the mask to avoid contamination of the body with t
h e u s e d m a s k w a s n o t w i d e l y disseminated in the initial period
of outbreak. This exposed the family physicians and their clinic staff to
the risk of SARS infection in view of their clinic infrastructure and resource
constraints. Nonetheless, there were no primary healthcare workers in Singapore
being infected from their patients. The perceived mortality and morbidity
risks to themselves and their families motivated them to continue the PPE
despite personal discomfort, inconveniences and expenses. The f a m i l y
p h y s i c i a n s s e l f - r e p o r t e d experience, behaviour and use
of the PPE in the SARS outbreak appear to fit into the Becker Health Belief
Model very well. (Table 2) The Becker Health Belief Model is often used to
illustrate personal behavioural changes in the face of an a d v e r s e h
e a l t h e v e n t t o p r o t e c t oneself. The “person” is
often the patient but the investigators attempt t o a p p l y t h i s m o
d e l t o f a m i l y physicians who had been exposed to the risk of a life-threatening
infectious disease. Firstly, the perceived vulnerability of the family doctors
was reinforced by the reports of infection of health care workers in Singapore
and in other areas of epidemic – Hong Kong, Taiwan and Vancouver 1,2.
Health care workers comprise forty percent of the cases of SARS in hospitals.
Secondly, the perceived severity was
55
not
in doubt. In Singapore, amongst the 32 deaths, 5 were healthcare workers,
including 3 doctors4,6. These two elements of the Becker Health Belief Model
drove the behaviour of family physicians towards the use of PPE during their
consultation due to perceived effectiveness: protection from infection by
the SARS virus. In the same vein, the shortage of PPE, p a r t i c u l a r
l y t h e m a s k , c r e a t e d annoyance and active search for supplies
of such equipment. Finally, the perceived effectiveness clearly outweighed
the perceived barriers, which included shortage, cost and discomfort for the
wearer. Not only d i d t h e y e n d u r e t h e p h y s i c a l discomfort,
they also modified their behaviour to cope with the problem. The study revealed
that participants had moments of complacency in using P P E b u t p r o m
p t l y c o r r e c t e d themselves upon learning about the deaths of fellow
healthcare workers in hospitals. This change of behaviour was further enhanced
amongst the participants, whose patients they initially treated in their clinics,
died later of SARS. The use of gloves, gowns and goggles was perceived to
be less beneficial in the protection against SARS in the outpatient setting.
Thus only two participants in the study wore all these PPE. This could likely
be due to supply exigency and empirical understanding of the risk of infection.
Unlike surgeons and hospital-based doctors, practical procedures are less
commonly carried out in family practices, thus the perceived need that to
put on gloves, gowns and goggles was small. An open system of updating p a
t i e n t s a n d t h e i r h e a l t h c a r e providers through the public
media will fulfill the two add-ons to the original Becker Health Belief Model.
The cues to action in the SARS outbreaks were widespread media reports, which
reinforced the need and benefits of wearing masks from t h e a d v i s o r
y a n d i n f o r m a t i o n disseminated from MOH.
Self-efficacy
was enhanced in the outbreak as family physicians became conversant on how
to wear the PPE correctly and at the right time. This was reinforced by training
sessions conducted by MOH to help doctors dev el op se lf-e ffic acy sk il
ls . To m a i n t a i n s e l f - e ff i c a c y, f a m i l y physicians should
maintain adequate supply of PPE at all times and these items should be included
in periodical audits of the clinic or during audit checks of new clinics prior
to issue of operation license by MOH. The successful termination of the SARS
epidemic was attributed to PPE and confidence of its protective barrier to
the virus. Masks were used universally, the gowns and gloves are used in high
risk places and patients in the later stages of the epidemic. These were continued
cues to action. Thus, the Becker Health Belief Model provides a good model
to e x p l a i n t h e S i n g a p o r e f a m i l y physicians self-disclosed
behaviour in dealing with the SARS outbreak. The model can be used to guide
learning by healthcare workers in putting on appropriate barriers during their
encounter with unknown pathogens that can result in disease outbreaks. As
the participants related, their PPE was viewed with apprehension by the public.
Individual explanation and the mass media are modalities to educate the public
to accept the healthcare providers' use of PPE. The Becker Health Belief model
could also be applied for patients to adopt positive behaviour, which is publicly
and socially desirable: such as to continue to seek medical help during infections
and comply with preventive measures expected of responsible citizens to minimize
spread of infection. Limitations The investigators recognised the limitation
of the study as a result of a single participant reading the initial draft
to validate the results. The small n u m b e r o f t h e p a r t i c i p a
n t s w a s another limiting factor. Thus, the
results
represented the experiences and views of this group of family physicians who
had been exposed to S A R S p a t i e n t s a n d m a y n o t b e generalisable
to family practice in Singapore. However, the analysis of the qualitative
data from the eight participants revealed many similarities in their experiences
and post-exposure b e h a v i o u r a l m o d i f i c a t i o n s . T h e
investigators believed that the Becker Health Belief model could be applied.
Whether the model could still be applicable after a lapse of time after the
acute feeling of vulnerability generated by the outbreak remains to be tested
against the real world when a n o t h e r n o v e l i n f e c t i o u s
a g e n t presents itself in the future. Conclusion Perceived mortality and
morbidity risks from SARS motivated the family physicians in their use of
PPE. They a d o p t e d v a r i o u s m e a s u r e s a n d changed their
behaviour to cope w i t h t h e d i s c o m f o r t , c o s t a n d inconvenience.
Their behaviour can be fitted into the Becker Health Belief Model both for
understanding, as well as a road map for behaviour modification to assist
the effective management of unknown epidemics in the future. Acknowledgement
The authors were thankful to all the participating family physicians, who
had contributed to the study and to the research coordinator for diligently
transcribing all the voice recordings.
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<name name-style="western"><surname>Rosenstock I.</surname></name>, <name name-style="western"><surname>Stretcher V.</surname></name>, <name name-style="western"><surname>Becker M.</surname></name> (<year>1994</year>). <source>The health belief model and HIV risk behavior change.In:DiClementeR. (Editor.)PreventingAIDS: TheoriesandMethodsof Behavioural Interventions</source>. <publisher-loc>New York</publisher-loc>: <publisher-name>Plenum Press</publisher-name>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Family Physicians' Experiences, Behaviour, and Use of Personal Protection Equipment During the SARS Outbreak in Singapore: Do They Fit the Becker Health Belief Model?</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Family Physicians' Experiences, Behaviour, and Use of Personal Protection Equipment During the SARS Outbreak in Singapore: Do They Fit the Becker Health Belief Model?</title></titleInfo><name type="personal"><namePart type="given">NC</namePart><namePart type="family">Tan</namePart><affiliation>Family Physician, SingHealth Polyclinics, Singapore</affiliation><affiliation>Family Physician, SingHealth Polyclinics, Singapore</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">LG</namePart><namePart type="family">Goh</namePart><affiliation>Department of Community, Occupational and Family Medicine National University of Singapore</affiliation><affiliation>Department of Community, Occupational and Family Medicine National University of Singapore</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">SS</namePart><namePart type="family">Lee</namePart><affiliation>Family Physician, College of Family Physicians, Singapore</affiliation><affiliation>Family Physician, College of Family Physicians, Singapore</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Los Angeles, CA</placeTerm></place><dateIssued encoding="w3cdtf">2006-09</dateIssued><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><relatedItem type="host"><titleInfo><title>Asia Pacific Journal of Public Health</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1010-5395</identifier><identifier type="eISSN"></identifier><identifier type="PublisherID">APH</identifier><identifier type="PublisherID-hwp">spaph</identifier><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>18</number></detail><detail type="issue"><caption>no.</caption><number>3</number></detail><extent unit="pages"><start>49</start><end>56</end></extent></part></relatedItem><identifier type="istex">9DFE7DF0C41037B21E3893338E93A490DBDB10FA</identifier><identifier type="ark">ark:/67375/M70-F9231PLL-T</identifier><identifier type="DOI">10.1177/10105395060180030901</identifier><identifier type="ArticleID">10.1177_10105395060180030901</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/ark:/67375/M70-F9231PLL-T/record.json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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