Knowledge of healthcare professionals about poliomyelitis and postpoliomyelitis: a cross-sectional study

ABSTRACT BACKGROUND: Postpoliomyelitis syndrome is a clinical condition that can affect poliomyelitis survivors. OBJECTIVE: Our aim was to evaluate knowledge of poliomyelitis and postpoliomyelitis syndrome among Brazilian healthcare professionals. DESIGN AND SETTING: Cross-sectional study conducted at a Brazilian public higher education institution located in the state of Goiás. METHODS: The participants (n = 578) were Brazilian physicians, physical therapists, nurses, nutritionists and psychologists. A self-administered questionnaire (30 questions) was designed to probe knowledge about poliomyelitis and postpoliomyelitis syndrome. From the questionnaire, we created a structured test to objectively evaluate the knowledge of these professionals. The test was composed of 20 questions and was scored over a range from 0 (totally ill-informed) to 20 (totally well-informed). RESULTS: In general, the physicians, physical therapists and nurses demonstrated better understanding of poliomyelitis and postpoliomyelitis syndrome. The healthcare professionals who had received previous information about poliomyelitis and postpoliomyelitis syndrome had significantly higher scores than those who had never received information (P < 0.001). On average, this difference was approximately 28.6%. CONCLUSIONS: The findings from the present study indicate that there is a critical need for improvement of knowledge about postpoliomyelitis syndrome among Brazilian healthcare professionals. The services provided by these professionals may therefore become compromised. Furthermore, public healthcare initiatives should be implemented to improve knowledge among healthcare professionals.


INTRODUCTION
Poliomyelitis is an infectious viral disease that may attack people at any age. It affects the nervous system, resulting in paralysis and muscle spasms, and in some cases encephalitis. 1,2 There are several regions in the world that are certified as free from poliomyelitis. 3 However, there are some endemic countries, such as Afghanistan, Nigeria and Pakistan, and there are records of imported cases in some African countries. 3 In Brazil, even though poliomyelitis has been eradicated, according to the Brazilian Health Ministry, 312 Brazilian municipalities have polio vaccine coverage of below 50%. This creates a state of alert and threatens the eradication of the disease. Therefore, there is a need to maintain permanent and effective actions of disease surveillance and adequate levels of immunological protection for the population. 4 Postpoliomyelitis syndrome (PPS) is the term used to describe a collection of signs and symptoms that may be experienced by individuals afflicted by paralytic poliomyelitis after years of clinical and functional stability. 5 The signs and symptoms that characterize PPS are new muscle weakness, muscle fatigue, muscle atrophy, muscle and joint pain, sleep disturbances, intolerance to cold, respiratory and swallowing difficulties and a recent increase in body mass. [6][7][8] It is a slowly progressive disease, usually insidious, with subacute onset, sometimes resulting in significant restrictions of activities associated with everyday life. 7,[9][10][11][12][13][14][15][16] Although the pathophysiology of PPS is unclear, different mechanisms have been proposed.
The most accepted mechanism postulates that degeneration or dysfunction of giant motor units, https://orcid.org/0000-0001-9200-3185 the disease, which include: muscle disuse, the normal loss of motor units with age, predisposition to motor neuron degeneration due to glial vascular and lymphatic damage, reactivation of the virus or persistent infection, immunological factors related to poliomyelitis, 9,15,[18][19][20] the effect of growth hormone and the combined effect of overuse, disuse, pain, body mass gain or other diseases. 9,18,20 Regarding the diagnostic criteria for PPS, a clinical approach aimed at ruling out other neurological diseases, orthopedic conditions, psychiatric disorders or even consequences linked to the aging process is required, since these conditions could develop the same signs and symptoms as seen in PPS. 9,21 Therefore, it is extremely important that patients should be managed by a multidisciplinary healthcare professional team that includes neurologists, rheumatologists, orthopedists, pulmonologists, physical education professionals, physical therapists, nutritionists, nurses and psychologists. 9,22,23 Despite the significant decline in the incidence of paralytic poliomyelitis, 3 PPS will remain a major health problem for many years. In western countries, where the last large epidemics date back to the 1940s and 1950s, many survivors of paralytic poliomyelitis are now aged between 70 and 80 years. 24 In Brazil, the last major outbreak was in 1984. 24 Therefore, the future outlook is for continued or even increased need for rehabilitation programs and management of people with PPS. 9

OBJECTIVE
The aim of this study was to verify the knowledge of health professionals about poliomyelitis and PPS regarding the pathophysiology, etiology, symptomatology and forms of treatment of PPS.

Participants
This was a cross-sectional study in which a total of 578 participants (454 women and 124 men) were recruited. This was done using different sources of advertisement (i.e. internet, local newspapers, magazines and billboards in universities, clinics, hospitals and gyms). The inclusion criterion for the study was that the participants should be professionals with at least an undergraduate degree in medicine, physical therapy, nursing, nutrition or psychology. Healthcare professionals with specialization in neurology and/or neuromuscular disorders were excluded from the study.
All the participants were informed of the aim of the study and experimental procedures, and written informed consent was obtained from each participant before any data were collected. All procedures involved in this study were approved by the The questions are shown in Tables 2 and 3.
In addition, a knowledge assessment test was created.
This aimed to objectively show the knowledge of the professionals interviewed. The test comprised 20 questions within the questionnaire, which were analyzed as a score for correct responses, ranging from 0 to 20 points. These questions are marked with an asterisk in Tables 2 and 3.

Statistical analysis
Descriptive statistics were used to analyze the findings (mean, standard deviation and absolute and relative frequencies). only had an undergraduate degree and two (0.2%) did not report their highest graduation level. The other characteristics of the participants are presented in Table 1.

Knowledge about poliomyelitis
The first part of the questionnaire was designed to assess knowl- Regarding epidemiology, between 60 and 80% of the healthcare professionals knew that poliomyelitis is a disease that has not been eradicated worldwide. The chi-square test did not reveal any significant association between healthcare professional categories and knowing that poliomyelitis is a disease that has not been eradicated around the world (P = 0.406). Also, there was no significant association between health professional category with regard to knowing that a poliomyelitis vaccine is available (P = 0.133).
Indeed, more than 90% of the healthcare professionals knew that a vaccine is available to prevent poliomyelitis.
With regard to treatment, 94.2% of the physicians, 78.8% of the physical therapists, 73.7% of the nurses, 33.3% of the nutritionists                  Table 3). The chi-square test did not reveal any association between healthcare professional category and these topics (P < 0.001).

Knowledge of the professionals about paralytic poliomyelitis and PPS
With regard to the questionnaire that was created, the professionals scored on average 11.0 ± 4.4 (which corresponded to   approximately 55% of the total score), out of a maximum score of 20. Specifically, the Kruskal-Wallis test [X 2 (4) = 107.500; P < 0.001] demonstrated that the knowledge of the physicians, physical therapists and nurses was significantly higher than that of the nutritionists and psychologists (P < 0.05, Figure 1); and that the knowledge of the physicians and physical therapists was significantly higher than that of the nurses, nutritionists and psychologists (P < 0.05).
We also found that healthcare professionals who had received previous information about poliomyelitis and PPS had significantly higher scores than those who had never received information (P < 0.001). On average, this difference was approximately 28.6% (Figure 2). Five volunteers did not respond to this question. which had been successful in eliminating polio from Syria in 1995. 38 Specifically in Brazil, the authorities reported difficulties in attaining vaccine coverage in the 2018 campaign against paralytic poliomyelitis. 39 For this reason, the Brazilian authorities have launched another vaccine campaign in order to reach the vaccine coverage recommended by the WHO. 39 Altogether, this information highlights the need to improve knowledge about poliomyelitis and PPS among healthcare professionals.

DISCUSSION
Our study had some limitations. Firstly, like all studies in which questionnaires are used, the present results rely on the honesty and level of recall of the respondents. Secondly, the reliability and validity of the instrument used to gather the data for this study has not been determined, although the questionnaire was previously evaluated by two experienced researchers. Nevertheless, we believe that these limitations do not prevent us from drawing conclusions from this study.

CONCLUSION
Our study showed that, overall, there is a lack of knowledge about PPS and poliomyelitis, especially among psychologists and nutritionists. Therefore, the services provided by these professionals may become compromised. Furthermore, government initiatives should be implemented to increase knowledge among healthcare professionals.