Abstract
Background
Snakebite is a time decisive medical emergency requiring contact with health facility at the earliest. Many snakebite victims yet seek care from traditional healers (THs) or village quacks (VQs) before reaching an appropriate facility, which leads to adverse consequences. This study was conducted to assess care-seeking behaviour and pathways followed in reaching appropriate facilities among suspected snakebite cases and to identify associated factors.
Methods
A hospital-based cross-sectional study was conducted at a medical college in West Bengal. All suspected snakebite cases admitted during a reference period of two months were studied. Study subjects and/or accompanying persons were interviewed for care-seeking behaviours and pathways followed.
Results
Among the 393 study participants, most were ≤30 years of age, men, agricultural workers, of lower middle and lower socioeconomic class and only 69.5% had formal schooling. The commonest place of occurrence was the agricultural field (40.7%), and the commonest biting site was the lower extremity (77.6%). Only half of participants (55.2%) used immediate correct measures at the biting site. Incorrect practices included tourniquet application (29.5%), use of herbal preparation (7.1%), blade shaving at site (2.8%) etc. As first care-seeking points, 15% and 24.9% of cases visited THs and VQs, respectively. Pathway analysis revealed that unfavourable pathway was followed by 39.9% participants. Two unfavourable points were consulted by 3.8% of participants. The care-seeking pathway was significantly associated with religion, caste, education and socioeconomic class.
Conclusions
Findings of this study highlight the urgent need for behaviour change interventions addressing the myths and misconceptions of people regarding snakebite.
Keywords: Care-seeking, Pathway analysis, Snakebite
Introduction
Snakebite is one of the life-threatening time decisive medical emergency.1 It has been recently recognised by the World Health Organization as one of the neglected tropical diseases in 2017.2 indicating worldwide priority concern about this medical emergency. In venomous snakebite cases, outcomes depend on the species, the area of the body bitten, the amount of venom injected and the health conditions of the person bitten etc., while bites from nonvenomous snakes can also cause infection, often due to lacerations and abrasions. Symptoms may become more life-threatening over time developing into hypotension, tachypnoea, severe tachycardia, severe internal bleeding, altered sensorium, kidney failure, respiratory failure etc.3,4 But such adverse outcomes in many cases may be avoided by timely and appropriate interventions from the skilled health personnel.
On the contrary, till today snakebite cases used to seek care from diverse sources other than public health facilities. In Africa and Asia, it is very common to see that snakebite victims are going to traditional healers (THs), rather than going to health facilities to receive treatment.2 THs use venom stone,5 herbal preparations locally and/or a ring around the bitten limb.6 The indigenous treatments such as application of herbal medications7 over the bite site, nasal insufflations and oral liquid and solid forms are also given to the victims.8 Immediate intervention or remedy, such as application of a tourniquet, incision and suction of the bite site, may be harmful and dangerous.6,8
Again, the greatest burden of snakebite is in the resource-poor rural settings and areas with difficulty to reach to formal health care.9 The poorest of the poor, mostly in rural areas initially avoid formal health care because of the cost of medical care, as well as their lack of awareness and superstitions.2 These situations lead to unnecessary delay in first contact with formal health care and in administration of appropriate treatment, which ultimately increase the rate of complications or fatal outcome.2,10
Even in India, victims seek hospital care after consulting with the THs (ojhas, gunin, mantrik and tantrik).1,11 Lack of awareness and social diversity also increases the probability of using indigenous treatments. All these result in fatal outcome in snake bite cases. Based on hospital-reported data, it is estimated that 35,000 to 50,000 people die of snakebite every year in India.12 Although clinical profiles of envenoming by snakes have received focus in different studies,13, 14, 15, 16, 17 responses of the victims to snakebite is rarely discussed in health research in Indian context and in West Bengal also. Improved understanding of the diversity of victims’ responses is necessary to elicit the practicality of such a health problem regarding care-seeking behaviour of snakebite victims. With this backdrop, present study had been planned to assess care-seeking behaviours and pathways followed in reaching appropriate facilities among suspected snakebite cases admitted in a medical college in West Bengal and to identify some associated factors.
Materials and methods
The data were collected after ethical approval of the synopsis by concerned ethics committee of the medical college. The purpose and nature of the study was briefed to the study subjects and informed consent was obtained from the respondents before data collection. They were also assured about the confidentiality and anonymity of information.
A cross-sectional study was conducted from September to November 2017 among suspected snakebite cases admitted in the medical college. As per hospital policy of the medical college, all the suspected snakebite cases were admitted in the emergency ward, and then they were referred to the medicine ward and paediatric ward or discharged after observation. The emergency, medicine and paediatric ward of the medical college were visited every day throughout the study duration to include all the suspected snakebite patients in that time period (complete enumeration). Data regarding sociodemographic characteristics, snakebite event, immediate intervention to the biting site and care-seeking behaviour were collected using a predesigned, pretested schedule by interviewing the subjects. In case of patients with altered consciousness or having critical illness and children, accompanying persons (friends/relatives) were interviewed. Registers and available relevant records were reviewed.
The principal outcome variable was care-seeking behaviour and pathways followed among the study participants. THs are those persons who use past experiences, observations handed down from generation to generation and spirits of the ancestors to diagnose and prescribe medication incorporating plant-, animal- and mineral-based medicines, spiritual therapies etc., for different physiological, psychiatric and spiritual conditions.18 They are known as ojhas, gunin, mantrik and tantrik.1,11 Village quacks (VQs) are those unqualified persons who claim medical knowledge or other skills.19 Those study participants who consulted with THs or VQs at any time during their care-seeking pathway were considered as having unfavourable care-seeking pathway.
Collected data were checked for completeness and consistency and then entered in the computer on Excel data sheets (Microsoft Excel, 2013). Data were analysed using Statistical Package for Social Sciences (IBM SPSS Statistics 20.0, Windows, 2012). All the continuous variables were expressed as mean [standard deviation (SD)] or median (IQR) depending on the type of data and categorical variables in frequency and percentage. Factors influencing care-seeking pathway were assessed by chi-square test. Median time gap from bite to reaching to public health facilities among patients following different care-seeking pathway was compared using Kruskal-Wallis H test. A multivariable logistic regression was performed to find out the predictors of favourable care-seeking pathway. All the variables found to be significantly associated in the bivariate analysis were included in the final model using the forced entry method.
Results
A total of 424 suspected snakebite cases got admitted in the medical college from September to October 2017. Among them, 31 (7.3%) could not be studied as they were discharged on risk bond before the visit for data collection. Finally, 393 patients were interviewed and included in the analysis. Overall, 135 (31.8%) patients among the total admitted suspected snakebite cases were finally diagnosed as confirmed poisonous snakebite case and were administered antivenom serum. Among the total 393 study subjects, the mean age (SD) was 30.37 (±11.275) years, and the age group of ≤30 years (61.1%) comprised maximum. Among the study subjects, most were men (59%) and Hindu (78.4%) and from other backward caste (35.9%). Maximum subjects were with primary (class I-IV) education (32.6%) and from lower middle socioeconomic class (45.8%) according to modified BG Prasad scale. Among male study subjects, most (59.1%) were agricultural workers and 46% women were housewives/homemakers.
The commonest place of occurrence of suspected snakebite was in the agricultural field (40.7%), and the commonest site of bite was the lower extremity (77.6%). Most of the events occurred between 6 am and 12 noon (32.8%) and 6 pm and midnight (34.8%). Among the study participants, 52.2% had seen the offending snake (Table 1).
Table 1.
Profile of suspected snakebite cases (n = 393).
| Profile | Frequency | Percent |
|---|---|---|
| Place of occurrence | ||
| Home | 86 | 21.9 |
| Agricultural field | 160 | 40.7 |
| Street | 101 | 25.7 |
| At working place | 31 | 7.9 |
| Pond | 15 | 3.8 |
| Time of occurrence | ||
| Mid-night – 6 am | 58 | 14.8 |
| 6 am–12 noon | 129 | 32.8 |
| 12 noon to 6 pm | 69 | 17.6 |
| 6 pm to midnight | 137 | 34.8 |
| Site of occurrence | ||
| Lower extremity | 305 | 77.6 |
| Upper extremity | 68 | 17.3 |
| Trunk | 16 | 4.1 |
| Neck | 4 | 1.0 |
| Suspected snake seen by victims | ||
| Yes | 205 | 52.2 |
| No | 188 | 47.8 |
Only 217 (55.2%) participants used correct measures at the site of bite. Incorrect practices included application of tourniquet (29.5%), herbal preparation (7.1%), blade shaving at the site (2.8%) etc. In 42.3% participants, no immediate intervention was performed at the biting site, whereas 16.3% respondents reported that their wound was washed with only water.
Care-seeking behaviour of the study participants revealed that 59 (15%) and 98 (24.9%) had sought first care seeking from THs and VQ, respectively. Again, 157 (39.9%) had followed unfavourable health-seeking pathway. As described in Fig 1 also, overall 62 (15.8%) and 110 (27.9%) participants consulted THs and VQs, respectively. Fifteen (3.8%) of them consulted with both THs and VQs.
Fig. 1.
Care-seeking pathway among study subjects from bite to admission in Medical College.
Besides assessing care-seeking behaviour of participants, reasons were also explored for availing local help, i.e., TH, VQ or both, among the participants with unfavourable pathway. Easy and near availability of local help (49 [31.2%]) was noted to be the most influencing factor among the participants with unfavourable pathway. Being driven from traditional belief, 41 (26.1%) participants sought local help to know primarily whether the suspected snake was poisonous one or not. While ignorance to suspected bite (thinking that it was not from a poisonous snake) was noted among 47 (29.9%) participants, 21 (13.4%) participants availed local help as they thought that they will get quick and assured services. Financial reason was also noted among 14 (8.9%) participants who availed local help to avoid the high cost to access public health facility. Further questioning revealed that one-third of participants [53 (33.7%)] consciously choose TH, VQ or both even when public healthcare facilities were available nearby.
The median time gap from bite to reaching first public health facility (Medical College/Sub Divisional Hospital/Community Health Centre/Primary Health Centre) among patients with different health-seeking pathway was elicited in this study. The time gap for those subjects who consulted with TH was 125 (105–245) minute and for VQs it was 85 (70–110) minute. The maximum time gap 265 (175–445) (in minute) was seen among those consulting with both THs and VQs, whereas it was lowest among patients with favourable care-seeking pathway 30 (25–40) minute. Using Kruskal-Wallis H test, the time gap among patients following different care-seeking pathway was found to be significantly different (<0.001).
It was found that patients older than 30 years and who were men, Hindu, belonging to tribes/other backward community, not having formal education, agricultural workers and belonging from poorer socioeconomic status were more likely to choose unfavourable pathway. Bivariate analysis showed that the care-seeking pathway among study subjects was significantly associated with age [odds ratio {OR} (95% confidence interval {CI}) = 1.621 (1.072–2.450)], religion [OR (95% CI) = 1.679 (1.005–2.807)], caste [OR (95% CI) = 2.256 (1.364–3.732)], education [OR (95% CI) = 6.780 (4.208–10.922)], occupation [OR (95% CI) = 2.064 (1.369–3.111)] and socioeconomic class [OR (95% CI) = 3.187 (1.953–5.201)] but not with gender [OR (95% CI) = 1.107 (0.734–1.671)].
Finally religion [AOR (95% CI) = 1.825 (1.003–3.320)], caste [AOR (95% CI) = 2.026 (1.107–3.706)], education [AOR (95% CI) = 6.257 (3.673–10.659)] and socioeconomic class [AOR (95% CI) = 3.286 (1.862–5.800)] remained significant in the adjusted model (Table 2). Other variables lost their significance. The model explained 30.9% variance and it was depicted by Negelkerke R2 value of 0.309. Hosmer and Lemeshow was not significant (0.199) indicating that the model was fit.
Table 2.
Factors associated with favourable care-seeking pathway (n = 393).
| Factors | Number | Favourable pathway n (%) | OR (95% CI) | AOR (95% CI) |
|---|---|---|---|---|
| Age (in years) | ||||
| >30 | 153 | 81 (52.9) | 1 | 1 |
| ≤30 | 240 | 155 (64.6) | 1.621(1.072–2.450) | 1.072 (0.651–1.766) |
| Gender | ||||
| Male | 232 | 137 (59.1) | 1 | 1 |
| Female | 161 | 99 (61.5) | 1.107 (0.734–1.671) | 1.063 (0.642–1.758) |
| Religion | ||||
| Hindu | 308 | 177 (57.5) | 1 | 1 |
| Muslim | 85 | 59 (69.4) | 1.679(1.005–2.807) | 1.825(1.003–3.320) |
| Caste | ||||
| SC, ST & OBC | 294 | 163 (55.4) | 1 | 1 |
| General | 99 | 73 (73.7) | 2.256(1.364–3.732) | 2.026(1.107–3.706) |
| Education | ||||
| Illiterate/nonformal education | 120 | 35 (29.2) | 1 | 1 |
| Formal schooling | 273 | 201 (73.6) | 6.780(4.208–10.922) | 6.257(3.673–10.659) |
| Occupation | ||||
| Agricultural worker | 188 | 96 (51.1) | 1 | 1 |
| Others group | 205 | 140 (68.3) | 2.064(1.369–3.111) | 1.300 (0.790–2.139) |
| SESa | ||||
| Lower middle & lower class | 272 | 142 (52.2) | 1 | 1 |
| Upper, upper middle & middle class | 121 | 94 (77.7) | 3.187(1.953–5.201) | 3.286(1.862–5.800) |
Socioeconomic class: BG Prasad scale [CPI (IW) September, 2017: 270]. Statistical significance at 95% Confidence interval is indicated in bold.
Discussion
This study revealed that unfavourable health behaviour was prevalent among the study participants. It was also observed that the patients have strong belief in traditional remedies. Grossly unscientific and incorrect practices such as applying tourniquet, washing with soap and water, local application of herbal medicine, self-medication with pain killer ointment and blade shaving at the biting site were also noted in this study. These remedies can precipitate toxicity.3 The use of venom stone which was observed by Majumder et al5 in their study in South 24 Parganas, West Bengal, was not found in this present study. In a Srilankan study,8 the incising site of bite was found in 0.4% participants, which was found to be much more (2.8%) in this study. Application of a tourniquet was 35% and 29.5% in the aforementioned study and present study, respectively. The use of herbal medications at the site of bite was low (3% vs 7.1%) in the Srilankan study.8 Other unscientific practices such as oral suction of the site of bite, snakestone kept over the site of bite, ingestion of herbal decoctions, elevation of the bitten limb, removal of bangles and rings on the bitten limb were noted in the aforementioned study8 but not in present study. Unfortunately, none of the patients had immobilised the bitten limb by splinting in the present study.
Hati et al11 in an epidemiological study in West Bengal noted that among patients bit with a snake, 65.47% went to the THs (ojhas) and 22.14% persons received hospital treatment, while only 8.46% persons went to the hospital after consulting the ojhas. In this study, we have seen that before attending to health facility, patients often consult with THs and VQs (15% and 24.9% cases, respectively). The participants’ belief in THs and VQs along with the cost, transportation difficulties, as well as their easy and nearer availability explain the reason.
A key limitation of this study is that it is a hospital-based study. The care-seeking behaviour noted in this study may not reflect that in community. Ideally such study should be conducted at community level irrespective of subjects going to any public health facility or not. Moreover, decision-making delay for public health facility, distance of public health facility, transportation available for public health facility and road condition were not elicited in this study. There is also possibility of recall bias at mentioning the time gap by study.
This study revealed that significant proportion of patients followed unfavourable pathway for care-seeking including consultation with THs and VQs. The very first care-seeking point must be a public health facility at the earliest for proper management of snakebite. This decision must be made quickly without any consultation with THs and VQs. Such consultations considerably slow the process of reaching a public health facility,9 thereby deteriorating prognosis. Moreover improper management of biting site was also found among a considerable number of patients in this study, which reflects lack of awareness along with myths and misconception prevalent among the study participants. Therefore, population-based behaviour change communication methods should be launched to achieve correct approach in dealing with snakebite cases.
Conflicts of interest
The authors have none to declare.
Acknowledgements
The authors are grateful to Dr. Soumalya Roy, Dr. Avishek Pal, Dr. Suman Chatterjee, Department of Community Medicine, Burdwan Medical College for their valuable inputs during planning and execution of the study. The authors sincerely acknowledge all the medical and nursing staff of the emergency, medicine and paediatrics ward of the Burdwan Medical College and Hospital for their sincere cooperation during conducting the study. The authors are also thankful to the study participants whose constant cooperation was utmost important in the conduction of the study successfully.
References
- 1.Ministry of Health & Family Welfare . 2016 January. Government of India. Standard Treatment Guidelines. Management of Snake Bite. Quick Reference Guide. Available from: http://nhm.gov.in/monitoring/mission-steering-group.html?layout=edit&id=520. [Google Scholar]
- 2.Chippaux J.P. Snakebite envenomation turns again into a neglected tropical disease! J Venom Anim Toxins Incl Trop Dis. 2017;23:38. doi: 10.1186/s40409-017-0127-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Feitosa E.S., Sampaio V., Sachett J. Snakebites as a largely neglected problem in the Brazilian Amazon: highlights of the epidemiological trends in the State of Amazonas. Rev Soc Bras Med Trop. 2015;48(suppl I):34–41. doi: 10.1590/0037-8682-0105-2013. [DOI] [PubMed] [Google Scholar]
- 4.Gold B.S., Dart R.C., Barish R.A. Bites of venomous snakes. N Engl J Med. 2002;347:347–356. doi: 10.1056/NEJMra013477. [DOI] [PubMed] [Google Scholar]
- 5.Majumder D., Sinha A., Bhattacharya S.K. Epidemiological profile of snake bite in South 24 Parganas district of West Bengal with focus on underreporting of snake bite deaths. Indian J Public Health. 2014 January-March;58:17–21. doi: 10.4103/0019-557X.128158. [DOI] [PubMed] [Google Scholar]
- 6.Snow R.W., Bronzan R., Roques T. The prevalence and morbidity of snake bite and treatment seekingbehaviour among a rural Kenyan population. Ann Trop Med Parasitol. 1994 December;88:665–671. doi: 10.1080/00034983.1994.11812919. [DOI] [PubMed] [Google Scholar]
- 7.Dey A., De J.N. Traditional use of plants against snakebite in Indian subcontinent: a review of the recent literature. Dey and De Afr J Tradit Complement Altern Med. 2012;9:153–174. doi: 10.4314/ajtcam.v9i1.20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Kularatne A.M., Silva A., Maduwage K. Victims' response to snakebite and socio-epidemiological factors of 1018 snakebites in a tertiary care hospital in Sri Lanka. Wilderness Environ Med. 2014:35–40. doi: 10.1016/j.wem.2013.10.009. [DOI] [PubMed] [Google Scholar]
- 9.Mohapatra B., Warrell D.A., Suraweera W. Snakebite mortality in India: a nationally representative mortality survey. PLoSNegl Trop Dis. 2011;5(4):1018. doi: 10.1371/journal.pntd.0001018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sloan D.J., Dedicoat M.J., Lalloo D.G. Healthcare-seeking behaviour and use of traditional healers after snakebite in Hlabisa sub-district, KwaZulu Natal. Trop Med Int Health. 2007 November;12:1386–1390. doi: 10.1111/j.1365-3156.2007.01924.x. [DOI] [PubMed] [Google Scholar]
- 11.Hati A.K., Mandal M., De M.K. Epidemiology of snake bite in the district of Burdwan, West Bengal. J Indian Med Assoc. 1992 Jun;90:145–147. [PubMed] [Google Scholar]
- 12.Warrell D.A. Clinical management of snake bite in Southeast Asian region. Southeast Asian J Trop Med Public Health. 1999;30:1–84. [PubMed] [Google Scholar]
- 13.Chauhan V., Thakur S. The North-South divide in snake bite envenomation in India. J Emergencies, Trauma, Shock. 2016 Oct-Dec;9:151–154. doi: 10.4103/0974-2700.193350. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bawaskar H.S., Bawaskar P.H., Punde D.P. Profile of snakebite envenoming in rural Maharashtra, India. J Assoc Phys India. 2008;56:88–95. [PubMed] [Google Scholar]
- 15.Monteiro F.N., Kanchan T., Bhagavath P. Clinico-epidemiological features of viper bite envenomation: a study from Manipal, South India. Singap Med J. 2012 Mar;53:203–207. [PubMed] [Google Scholar]
- 16.Ahmed S.M., Qureshi U.A., RasoolA Snake bite envenomation in children in Kashmir. Indian Pediatr. 2011 Jan;48:66–67. doi: 10.1007/s13312-011-0013-1. [DOI] [PubMed] [Google Scholar]
- 17.Warrell D.A., Gutiérrez J.M., Calvete J.J. New approaches & technologies of venomics to meet the challenge of human envenoming by snakebites in India. Indian J Med Res. 2013;138:38–59. [PMC free article] [PubMed] [Google Scholar]
- 18.Mokgobi M.G. Understanding traditional African healing. Afr J Phys Health Educ Recreat Dance (AJPHERD) 2014 September;20(suppl 2):24–34. [PMC free article] [PubMed] [Google Scholar]
- 19.Definition and meaning, collins English dictionary. Available from: https://www.collinsdictionary.com/dictionary/english/quack-doctor(Last accessed on August 20, 2017).