Knowledge and practices of epistaxis in Eastern Tanzania: A cross-sectional study of an emergency in otorhinolaryngology

Abstract

Introduction

Epistaxis is the commonest otorhinolaryngological emergency encountered by primary care and emergency physicians and it causes anxiety to both patients and health care providers [1], [2], [3], [4]. It has a bimodal distribution since most cases are seen in the 2–10 or 50–70 year-old age groups and it also affect up to 60% of the population in their lifetime, with 6% requiring medical attention [1,5]. Epistaxis ranges from mild to severe form and considered as a life-threatening condition when it occurs since its course remains unpredictable [1,2].

Epistaxis has been causing a significant workload in accident and emergency departments [4,6]. There are variable causes of epistaxis and can be local or systemic and the reported incidence varies from 10% to 60% of individuals [7] and being more common in males than females and with an increasing incidence with age [4,6]. Epistaxis is common among young adults and children and rare among neonates but in terms of its peak incidence, it reaches peak in the sixth decade [8].

The diagnosis of idiopathic epistaxis requires a careful history, physical examination, and laboratory workups to rule out any possible etiologies [3,8]. In most of the cases, epistaxis usually occurs outside hospital setting and therefore it is crucial for the general population particularly non-health professionals to understand basic aspects regarding epistaxis including first aid measures and practices on epistaxis management. Provision of first aid in refractory epistaxis is of paramount importance to prevent its associated morbidity and mortality [9,10].

Determining knowledge on the causes, first aid management and practices of epistaxis is of significance if efforts to prevent and to provide prompt treatment of epistaxis including first aid at the scene of an event are to be advocated. There has been variable knowledge and practices of epistaxis among the studied participants in different parts of the world. Majority of the participants in the study done in Saudi Arabia did not know whether chronic diseases (82%) or medications (74%) were risk factors for epistaxis and on the other hand, almost two-thirds believed manipulation of the nose and environmental factors to be risk factors for epistaxis [11]. On the other hand, 67.4% of the participants knew epistaxis management while 32.6% did not know in a study that was done in Saudi Arabia [6]. Another study from the same country pertaining knowledge, attitude and practices of epistaxis among the general population found about one-third (34.8%) of the cases knew that chronic diseases cause epistaxis, 42.2% stated that drugs could cause epistaxis and 68.9% knew excess nose manipulation to be one of the causes of epistaxis. More than half of the cases (55.6%) knew that pressing the nose could also stop epistaxis [4].

Despite the few reported studies on knowledge on the causes and first aid management of epistaxis in other parts of the world, there are limited studies done in Tanzania on the same topic. The objective of this study is to determine knowledge on the causes, first aid management and practices of epistaxis among patients attending a health facility in Eastern Tanzania

Methods

A hospital based cross sectional study was conducted from March to June 2022 in an outpatient department of a health facility in Ifakara Township that is located in Morogoro Region in the Eastern part of Tanzania. Convenience sampling technique was utilized to recruit three hundred and seventy one patients using Kish and Leslie formula. Individuals aged <18 years had their consent being obtained from their guardians/caretakers. Those who met the inclusion criteria but had no readiness to provide the required details were excluded. A Swahili translated structured questionnaire adopted from previously published studies and thereafter modified to fit the current study was used to collect data [5,4,16]. Cronbach's alpha was used to determine the validity and reliability of the data collection tool. An item was considered reliable with Cronbach's alpha score being between 0.6–0.8.

Data was analyzed using SPSS version 23 software package and Chi-square test was performed to establish relationship between the selected independent and dependent variables. An independent variable with p-value <0.05 was regarded to be statistically significant. The ethical committee of the University of Dodoma gave the ethical approval for this study being dated 28th October 2021 under the approval number MA.84/261/02/’A’/.

To assess knowledge dimension on the causes and practices of management of epistaxis, a rating scale type was utilized as follows; Nine items on the knowledge dimension on the causes of epistaxis were assessed using a five-point Likert scale ranging from 1 to 5 (1=very unconfident, 2=fairly unconfident, 3=neutral, 4=fairly confident and 5=very confident). Higher scores represented better knowledge. The six items on the knowledge dimension on the first aid management of epistaxis were evaluated on a five-point Likert scale ranging from 1 to 5 (1=very unconfident, 2=fairly unconfident, 3=neutral, 4=fairly confident and 5=very confident). Higher scores similarly represented better knowledge. The seven items on practices of management of epistaxis were evaluated on a three-point Likert scale ranging from 1 to 3 (1=don't know, 2=no, 3=yes). Higher scores indicated good management practices of epistaxis.

Results

Discussion

Prompt management of patients with epistaxis is of paramount importance so as to prevent its associated morbidity and mortality. This study aimed to explore knowledge and practices of epistaxis among patients in Eastern Tanzania.

Good knowledge on the causes of epistaxis among individuals in the general population is of importance if people are well equipped with it and in our study majority of the participants (60.9%) had good knowledge regarding causes of epistaxis. On the other hand, excessive nose manipulation (95.1%), changes in climatic conditions (90.0%), nasal foreign bodies (81.7%), malignant/neoplastic tumors (81.1%) and hypertension (63.3%) were the major known causes of epistaxis while 37.2%, 51.5% and 41.5% did not know if some medications, chronic liver disease and infections such as typhoid fever respectively can cause epistaxis. Our finding appear to be similar to those by Alhejaily et al. where 34.8% of the participants knew that chronic diseases cause epistaxis, 42.2% stated that some drugs can cause epistaxis and 68.9% knew that excessive nose manipulation can cause epistaxis [4]. Similarity can also be depicted in the findings from Almulhim et al. where 15.3% knew chronic disease could be the cause of epistaxis, 11.5% stated some medicines can cause epistaxis and 77.9% knew environmental factors may be the cause of epistaxis [6]. On the other hand Al radhwan et al. had similar findings where 7% knew chronic disease as the risk factor for epistaxis, 11.3% knew some medicines could cause epistaxis and 68.2% thought environmental factors may be the cause of epistaxis [11]. Such similarity from the studies under comparison with our study may be because most of the study participants were literate by majority having college/university and above as their level of education.

There are variable sources of information about epistaxis that has been reported globally and regarding such sources, our study has found relatives or friends to be the most common sources (34.8%), other common sources were radios (19.1%), educational facilities (18.3%) and television (13.8%) while the least sources were internets (7.5%), doctors/nurses (4.5%) and newspapers/magazines (1.9%). Such findings appears to be similar to those from the study done in Saudi Arabia where the most common sources of information were relatives or friends (15.7%), internet (14.5%), first aid course (12.1%), leaflets (11.1%) and television (10.6%) [12]. This finding has relevance since it would inform policy makers on where to lay emphasis in terms of publicizing information on epistaxis so that people are well informed on epistaxis including its management. On the other hand, the similarity in the findings may be due to almost similar studied strata of the population in terms of similar socio-demographic characteristics where most of the participants in our study and in the study under comparison were married and had college/university educational level and therefore friends/partners may be the source of information.

Management of epistaxis entails good knowledge in terms of instituting first aid on prompt basis as it prevents associated morbidity and mortality. Our study has found 77.6% of the participants to have good knowledge regarding first aid management of epistaxis which is comparable to the study which was done in Saudi Arabia which reported that 89.6% of the study participants had knowledge on first aid management of epistaxis [4] and another study from the same country reported 67.4% of participants to have known about epistaxis management [6]. On top of that, the study has found 88.4% of the participants knew that pressing the nose can stop epistaxis while 44.2% knew that the best position to stop epistaxis was to tilt the head forward and those participants who had history of epistaxis 73.2% pinched the nose as the first aid. Similarly in our study, 81.7% of the participants thought cartilaginous part the nose has to be compressed, 48.8% of the participants thought 5–10 min was the ideal time for nose compression and 76.3% of participants thought mouth breathing was the ideal breathing modality when one is having epistaxis. Such findings correlate to those from studies that were done in Saudi Arabia and the United Kingdom [4,11,[13], [14], [15]]. Ideally it is recommended to compress the cartilaginous part of the nose for 5–10 min while exercising mouth breathing as the first aid modality in patients with epistaxis. Similarity in terms of good knowledge regarding first aid management of epistaxis in our study and in studies under comparison that were done in Saudi Arabia and the United Kingdom may be because most of the study participants were literate by having college level/above as their highest level of education.

In terms of the discrepancy that 60.9% of participants had good knowledge on the cause of epistaxis in this study while 77.6% of the participants had good knowledge on its management, there may be such possibility since one may have lesser knowledge on the causes of epistaxis but may be well knowledgeable on its management and this may depend on whether one has been occasionally involved in provision of first aid to patients with epistaxis.

In terms of the association between knowledge and socio-demographic characteristics, this study has found a statistically significant association between overall knowledge on first aid management of epistaxis and some socio-demographic characteristics like age and educational level (p-values < 0.05). Age as a correlate for good knowledge on first aid management of epistaxis may be confounded by the fact that the prevalence of epistaxis is common in adults unlike younger people and one may have experienced several episodes of epistaxis during his or her lifetime as one tend to age and therefore with a positive impact on knowledge on first aid management of epistaxis. No association was found between overall knowledge and marital status (p value=0.064), place of residence (p value=0.682), and gender (p value=0.9300, Such findings appear to be similar to what has been reported in the study that was done in Saudi Arabia, where a statistically significant association was found between the level of knowledge about first-aid management of epistaxis and the age, gender and educational level (p values = 0.000) [16] but dissimilar to those from the study which was done in the same country where there was no association between socio-demographic characteristics and knowledge on first aid management of epistaxis [12]. Such association between socio-demographic characteristics and knowledge about first aid management of epistaxis has significance to policy makers or health planners as it will inform them on which strata of the population has to receive more efforts as per imparting knowledge on epistaxis.

Regarding practices on modalities of management of epistaxis, our study has found 48.5% of the participants to have reported both nonsurgical and surgical treatments modalities while 39.9% of the participants reported nonsurgical treatment modalities of epistaxis. However, topical vasoconstrictors (85.4%) and anterior nasal packing (83.8%) were the most reported treatment modalities while the least reported method was electro cauterization (26.1%). Such finding appears to correlate somehow with what was found in the study from Kenya among accident and emergency clinical staffs where nonsurgical treatment modality (cauterization) was reported by 26.9% of the participants [17]. The results from the study that was done in Kenya may be influenced by the type of study participants since they were ‘clinical staffs’ unlike our participants who were ‘patients’. On the other hand, anterior nasal packing was known by 83.8% of the participants and this may be because it is the commonly applied method to control epistaxis even in facilities located at remote places and patients may at times apply such methods by soaking cottons and packing the anterior part of the nose to control nose bleeding at home premises.

Regarding study limitations, individuals who ever experienced epistaxis might have had bias in terms of their responses to the various set questions aiming to determine their knowledge and practices on management of epistaxis.

Conclusion

The study has found majority of the participants to have good knowledge of the causes and first aid management of epistaxis. Health care institutions, health administrators together with health care authorities should foster public education on epistaxis by involving family members (relatives) or friends and educational facilities of the Ifakara Township population since they were the commonest sources of information pertaining first aid management of epistaxis.

Authors’ contributions

Authors contributed as follows to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: ZSA 50%, OCF 25%, AAK 25%. All authors approved the version to be published and agreed to be accountable for all aspects of the work

Declaration of competing interest

The authors declare no further conflicts of interests

References