INTRODUCTION:

Healthcare cost is growing at unsustainable rates. Several mechanisms were proposed to treat this challenging dilemma, such as quality improvement, organizational empowerment, and application of health information systems. The health systems face these problems for a long duration that has no absolute solution or a clear explanation of the implementation of the cost-conscious practice. The three dimensions of knowledge, practice, and attitudes (KAP) are collectively required to drive health workers toward more cost-oriented practice. This review literature study is commenced to recognize the most appropriate mechanism for behavior modification among healthcare practitioners.

The current study analyses 32 studies to identify the guidelines responsible for successful human behavioral change. The implication of this review is better understandings of health professionals’ attitudes toward cost-conscious care to strengthen the feasibility of managing the drivers of cost-effective practice. The three discussed domains are an overview of the main theories; clarifying human behavior mainly knowledge, practice, and attitudes (KAP), through analyzing related supportive and non-supportive studies.

The clinical recommendation to understand the reasons accountable for human practices provides the health sector stakeholders, health educators, and administrators with a broader view and stronger capability for behavior adjustment. The achievability of targeted outcomes from educational intervention through the application of the KAP model is a controversial issue. On the first hand, several types of researches support the idea of the practice related to the level of knowledge and positive attitudes. On another hand, multiple researchers validate the role of other determinants of behavior than knowledge and attitudes. Translating people's knowledge and attitudes into the preferred practice responsible for controlling healthcare expenditure has remained questionable. Several theories attempt to explain human behaviour, but no model is grasping all root causes dominating and guiding human behaviour. When planning for behavioural change towards cost-effective practices, it should keep in mind that the predictors, the drives, and the variables influence human behaviour. Considering all internal and external factors forming and modifying people practiced action guarantees, more attainment of pre-specified educational objectives.

The Health Belief Model (HBM) explain human predisposition for complication avoidance, applicable here that performing preventive practice impacting the human perception of susceptibility, risk of illness severity, expected benefits of action, and costs. Although HBM is criticized ignoring the determinants of preventive behaviour management, it guides the process of medical regimen adherence through identifying its potential predictors. Theory of Planned Behaviour stated that intention for performance is beliefs, motivation, and perceived control. Attitudes are responsible for determining human behaviour, which is not always following a logical sequence or a consequence of human intention to act. The Patient Empowerment Theory by Funnell et al. postulate that the action performer takes charge to decide lifestyle change. The KAP 1950s utilized extensive survey countries to research family planning practice. Knowledge is defined by Badran (1995) as the acquisition, retention, and use of information or skills that resulted from education and experience through the cognition process. According to Eagly and Chaiken, an attitude as a psychological tendency expressed to evaluate a particular entity with some degree of the favorable or unfavorable mindset that composed of cognition, affection, and conation,

While Practice represents knowledge acquisition and attitudes change translated into preventive behaviours [1].

Some researchers concluded the direct causal relationship. A study evaluates the knowledge, attitude, and practices about prescribing fixed dose combinations among resident doctors who came to the same conclusion. Despite the proved clinical advantages of prescribing fixed-dose combinations, lack of knowledge would cause irrational prescription, adverse drug reaction, and increased treatment cost [2] proposed that a better understanding of the KAP triad enables deep awareness of deficiencies and required to create targeted behaviour [2].

The author proposed that a better understanding of the KAP triad enables deep awareness of deficiencies and required to create targeted behaviour [2]. Okobia study (2006), confirmed similar results where women higher practice of breast self-exam associated with a higher level of knowledge in Nigeria. Women are more knowledgeable. Indeed they perform BSE three times more than men. And finally recommended a framework and policy guidelines for the organization as a mean of information dissemination since education is the primary determinant of knowledge level [3]. A scientific review aims to identify the causal specification of KAP Outcomes to confirm the positive influence of health education interventions on the three pillars of knowledge, attitude, and preventive practice, ultimately the outcomes represented in improvement in laboratory results among diabetes patients. Education indirectly lower hemoglobin A1C and low-density lipoprotein by enhancing the preventive practice [1].

Disease prevention is crucial for containing the cost of health treatment. Keeping a healthy diet is essential for fighting overweight and obesity and its related health problems as cardiovascular diseases, hypertension, and diabetes [4]. Including nutritional education into the higher learning of physical education, the curriculum was suggested to provide college students with multiple channels of nutrition information and boost comprehensive physical and mental health development. A study designed to assess KAP dimensions regarding nutritional habits among nutrition, and non-nutrition students at Hail University in Saudi Arabia insisted on the positive correlation between knowledge score and maintaining the healthy practice as taking breakfast and a healthy diet [4].

Mitigation of the effect of finite resources and ever-increasing demand is a difficult achievement. In spite of activating drug formularies or practice guidelines, some of the clinical policies that ground on the cost-effectiveness criteria, there are no clear guidelines on how physicians incorporate cost-effectiveness decisions at the bedside [5]. A Swedish study found that although generic drug substitution successful in cost reduction, it is might unintentionally lead to double medication and patients’ confusion, and this obstacle is manageable through pharmacist education to their patients. Finally, instead of cost-saving, this could lead to cost increment result from lower adherence and patient confusion [6].

Physicians are the key players in generic trade name substitution influenced by their knowledge about the therapeutic value and price difference. Recently, spending on drug prescriptions has noticed a dramatic increase to exceed 10% in Saudi Arabia; however, adoption of utilization review presents an effective strategy for cost curbing. Physicians reported quality assurance prescribing the drug, so it’s highly guaranteed and motivate shifting to generic prescription [7].

Alfahan’s study (2016) targeted to assess KAP in the main mean of infection prevention; hand hygiene in primary care settings in Riyadh, Kingdom of Saudi Arabia. It revealed that recent training was a significant determinant of knowledge score where staff had a higher knowledge score showed a higher level of hand rubbing. While environmental context, social pressure, and individual attitudes found to be an important variable affecting hand hygiene practice [8]. A cross-sectional study Jordanian nurse’s practice in pain management of pediatric patients confirms the previously hypothesized view that KAP elements are strong predictors of practices; about 69% of pain management practice is explainable by the KAP model [9].

A descriptive comparative pre and post-intervention survey research tell about the cost anesthesia medication in the operating room, which affected by anesthesia providers’ knowledge of medication cost and the attitude about cost-saving. Knowledge about cost increased from 2.6 to 3.8 after having the price list. Applicability of these findings for cost reduction necessity induced by health care reform and limited reimbursements need further search [4]. Hamdard and Haneef's, study intended to identify the change in KAP regarding some maternal health practices in Kabul city from 2013 to 2016; it showed that the proportion of women practicing birth spacing and antenatal visits, and under five years vaccination were significantly higher in the intervention group receiving maternal and child health intervention [11]. Basic life support training had significantly higher knowledge scores, but a high-level of knowledge remains insufficient if positive attitudes are lacking. Even positive attitudes make no difference if not enriched by updated knowledge and proper training. This study emphasizes on bring improvement of BLS education among Saudi females [12]. It is learned 34% of physicians reported being knowledgeable, take guidelines on the best intervention that resolve the problem of antimicrobial resistance and enhance the skill to prescribe well. And introduce that uncertain diagnosis, patients’ expectations, influences of pharmaceutical marketing, and unregulated antibiotic dispensing are manageable barriers through education [13]. For characterizing the personal attitudes and knowledge towards immunization practice, Italian occupational physicians interviewed through telephone regarding official Italian recommendation for health care workers, knowledge about vaccine practice, their propensity towards vaccines, risk perceived from vaccine-preventable infectious diseases. Knowledge about the vaccine and official recommendations significantly correlated with attitudes and relevant practices. Planning for specialized training educational courses is highly recommended [14].

AlAteeq's study (2016) investigated the impact of brief physician advice on smoking cessation among military personnel smokers in Saudi Arabia. Acquiring knowledge motivates physician positive attitudes and raises the probability of favourable practice. The lack of knowledge lacking among practicing physicians evidenced lessor percentage positive attitudes [15]. These outcomes validated by Alshammari (2014) when the positive attitudes that physicians in Eastern Saudi Arabia have led them to a reasonable level of interest participating in obesity prevention [16].

Four years of retrospective randomize control trial conducted to determine the intervention on hand hygiene capability; that controls insurance claims on hygiene preventable infections, absenteeism and subjective impact on employees. After the provision of brief hand hygiene education, over 20% reduction in healthcare claims, absenteeism, and an increase in employee satisfaction [17]. Kharkar and Bowalekar, KAP 2012 survey assessed the reporting of adverse effects of drugs to government agencies by Indian physicians. Despite 55% of the physicians having the knowledge and positive attitudes to reporting adverse drug reactions, low reporting rate in documentation because of complex reporting, lack of electronic reporting access, unavailability of toll-free reporting number, and a wary of government agencies evidenced. Another Investigation curried on pregnant women in 2005 discover that whilst Rwanda women have positive attitudes and knowledge about the negative malaria effects on pregnancy, the recorded percentage of an insecticide-treated bed net was only 8.3%. [1]. Vasconcelos et al., study come out with a contradictory result, low knowledge in study sample evidenced low positive attitudes [28%] toward Pap test, Brazilian women sample unexpectedly resulted in 67% level of practicing pap testing because of accessibility of clinic and living with a partner

According to Lundberg's study 2013, Physicians can guide the provision of medical treatment but not cost-effective practice. As a result, individualized instruction, followed by feedback and peer-review programs, administrative changes programmed, such as participation, penalties, and rewards as a cost-containment measure. The reasons for economic inflation represented in the provision of expensive products or sophisticated technology, new drugs, new staff, increased utilization, broader access for the continuously older population are not the sole causes for cost increment. Based on these findings, the university education programs criticize of insufficient control cost without post-graduation workshops, case reviews, mortality conferences [18].

The length of time in knowledge attainment process appeared as a differential factor regulating the following attitudes and practice. A study of the influence of the dental education program on knowledge, frequency of sugar intake, and brushing frequency on 2678 school students revealed that there is no difference in frequency brushing between two groups after the intervention. Perhaps, among two groups of student one is provided intervention for brushing timefor12 months and another for 6 months [19].

A study conducted at Shiraz University Medical Sciences indicated the duration of knowledge acquisition plays a role in the magnitude of influence on the practice of different medical staff categories in Iran. Instructors and nursing students who have relatively similar values of knowledge about standard isolation (6.85,6.71) and similar attitudes (34.43,34.63) observed in different levels of practicing infection control precautions (4.41, 3.52). At the same time, auxiliary nursing and midwifery students having close degrees of knowledge and attitudes reported the same level of practicing [20].

David's study (2017) aimed t determine the attitudes of physicians and trainees toward cost-effectiveness and equity in clinical decision making. Practicing physicians and medical students tend to be more egalitarian, and utilitarian respectively, to cost-effectiveness. Balanced cost-effectiveness with equity defined as uniformity between the distribution of resources and access to care helps in shaping treatment guidelines, screening recommendations, and government healthcare policies [21]. Hunderfund et al, inquiry in 2018 interested in the same mission where students illustrated concern about society's cost and more denial of costly but beneficial treatment than physicians [22]. In a survey, identify the physician's views and barriers to cost-effective. Although a physician is responsible to use the cost-effectiveness criteria to formulate policies of drug formularies or practice guidelines incorporating cost-effectiveness decision at the bedside is still poorly known [23].

The interdependence relationship and dynamic interaction between the three pillars of the KAP triad are not sufficient enough to fully explain the human practice, and an in-depth understanding of how to adjust the medical staff's care has more adhered to cost-effective practices. Interference from a conglomerate of all impacting elements as information, education, communication, and human resources, the socio humanistic aspects, modern technologies, and environmental factors create a challenging complexity to understand accurately the human behaviour [24]. To enhance public awareness about the prevention of dental diseases risks factors, a cross-sectional study aims to evaluate the conventional KAP health education model among school children in the Galicia region in Spain. A questionnaire assessing oral health knowledge, attitudes, and practices completed by dentist’s guidance reveals an association between three model basics in terms of oral hygiene. However, findings questionable to a simple direct association where attitudes were not purely acting as intermediate factors in knowledge practice causal chain. This fact is evidenced by the impression of the sociocultural background and economic level of the population on health practice [25].

The individual can be expected to change an unhealthy habit to a healthy one in the light of information on the health benefits of that change. Considering the sociocultural context might be the solution for the health education program and Awareness campaigns to bridge the gaps of the KAP model and maximize its potentials and efficiency. Attitudes and practice statistically do not differ regarding weak and strong oral care, the knowledge groups, although higher average attitude and average practice scores, were associated with better oral health knowledge. Moreover, the indirect association is supported when the higher educational level of mothers and living in urban areas found to be associated with better oral hygiene and compliance and accessibility of healthcare service. In this way, these three variables do not classify the subject. The attitudes change do not always follow the behavior change, thus viewing attitude expressed in behavioural practice is not valid. If no other subject in to perform a brush or no brush, the translation of attitudes into practice will be less [25].

Furthermore, the lack of resources to guide discussions was pointed out as the main barrier for cancer physicians to discuss cost with patients. Overall, 60% reported addressing costs frequently or always in the clinic and concluded that discussion should base on optimal resource use and efficiency data [26]. The alarming worldwide and drastically increase in the prevalence of cardiovascular diseases was the primary drive for carrying out a study, evaluating the healthy lifestyle in terms of a healthy diet and physical activity. This remarkable study includes mothers from two villages in Nepal who revealed unexpected results evidenced by 57% and 44.6% of respondent’s good knowledge and attitude, further showed 90% poor healthy life practice. The high cost of healthy food, taste preference, and lack of relevant knowledge recorded as the main barriers to healthy eating habits and lack of leisure time, absence of parks, caring for family members, and embarrassment recognized as barriers for physical activity [27]. A cross-sectional survey for 1406 cardiac outpatients aimed to analyse the KAP factors influencing behaviour, focusing on gender differences is correlated, in knowledge and practice, knowledge and attitudes, but the former one was not correlated. The author’s inferring that it’s helpful for future campaigns to adopt gender-specific strategies [28]. The powerful way to contain cost is limiting access to expensive treatments with fewer benefits.

Three-quarters of physicians reported they are fully aware of the cost of medical treatment and tests, and viewed clinical guidelines core necessary of cost reduction; it should be implemented and adhered to [5]. Generic drug information influences attitudes and prescription practice brand-generic medicine substitutions extensively promote administrative measures as national e-prescription system regulations and rules [29]. Cost-effective care practiced by family physicians attributed to physician's attitudes and skills, and knowledge of the whole patient; more cost-effective practice is obtainable from individualized management, but not strictly adhering to guidelines [23]. Chinnasamy Alagesan (2019) studied KAP among Victorian oral health professionals in terms of Type 2 Diabetes Mellitus (T2DM) screening in dental settings. A differential result showed that the issue of DM screening for asymptomatic individuals is not strictly limited to KAP elements, rather a best-utilized screening tool, that should combine clinical and cost-effectiveness. Consequently, the drawbacks of diabetes risk screening tools were high cost; poor predictability, sensitivity, and unnecessary referral were not justified [31]

In the state of Selangor, Malaysia (2012), cross-sectional research investigated the KAP parameters, and it’s associating factors among university students reached supportive results, which summarized the association between attitude depending place of living and food pyramids; between practice and family income [32]. Previous study results evidence a significant difference in the nutrition knowledge, Attitude and practice scores, breakfast eating habits, and the concept of a balanced diet among the nutrition and non-nutrition students. Total breakfast skipping was more common among the non-nutrition students [4].

CONCLUSION:

The acquisition of relevant knowledge itself leads to improvement to knowledge level but insufficient to determine the resulted behaviour. On the second hand, the findings of several studies pointed to the urgent need for a more comprehensive and insightful model for interpretation of human behaviour. Health preventive practices not always associated with the process of good knowledge and attitudes score evidenced in the literature studies. Accessing knowledge from education and experience enhance positive attitudes, perhaps, not totally beneficial behaviour practicing. There are other extraneous factors involved in the decision taken, and the action performed as availability or accessibility of essential resources. It is time to change the inadequate and limited view of the role of knowledge in promoting attitudes and changing behaviour. Preventive, screening, and commitment to already proved cost-effective practices require a comprehensive education program. Effectiveness of any health training or campaign is possible and guaranteed if consider the educational background, duration of education, gender sensitivity, accessibility, or resources, following policies and clinical guidelines that encourage spending curbing alongside the appropriate implementation of the KAP model.

CONFLICT OF INTEREST:

The authors declare that there is no conflict of interest.

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Received on 07.11.2019 Modified on 19.12.2019

Research J. Pharm. and Tech. 2020; 13(11):5595-5600.

DOI: 10.5958/0974-360X.2020.00976.2