Knowledge of health workers on snakes and snakebite management and treatment seeking behavior of snakebite victims in Bhutan

Author summary Snakebites affect people globally including Bhutan and snakes are source of fear and excitement. Major proportion (62.7%) of Bhutanese population who thrive on agro-farming, rearing livestock, and searching forest produces are at risk of snake envenomations. Deaths due to snakebites are dependent upon use of first aid type, provisions available with the health facilities, and health seeking behaviors of snakebite victims. This multi-center study was conducted to assess the level of knowledge of health workers and its association with their demographic features and health seeking behavior of snakebite victims as observed by health workers using investigator administered structured questionnaire. We included 12 hospitals and a Basic Health Unit (BHU) from 10 snakebite prone Dzongkhags with 962 (84%) snakebites from January 2013 to December 2017 in the country. Among 118 health workers interviewed, 27 (23%) had adequate level of knowledge with remaining 91 (77%) having inadequate knowledge. Male health workers and Doctors had better level of knowledge than other demographic groups. Health workers from Sarpang scored higher compared to those from other Dzongkhags. A total of 42% (n = 50) health workers scored below 60% (31 or less correct responses for 52 questions), which demands requirement of training and inclusion of practice-oriented courses in training curriculum of health professionals for snakebite management. Often, use of traditional medication and less frequent adherence to WHO recommended first aid measures was observed by 5% (n = 6) respondents. The adoption of non-recommended treatment practices seems to delay proper treatment resulting in gangrene and associated complications. Background Published information on snakebite is rare in Bhutan although remarkably higher number of snakebites and associated deaths are reported from other South Asian countries. Aims and methodology Structured questionnaire was used to collect knowledge of health workers in snakebite management and health seeking behavior of snakebite victims as observed by health workers. Study was conducted in purposively sampled 10 Dzongkhags (district level administrative units) with higher incidence of snakebites. Result Heath workers scored 27-91% (with an average of 63%, SD = 14) for 52 questions related to snake identification and snakebite management. Among 118 health workers interviewed, 23% had adequate knowledge on snakes and snakebite management while 77% had inadequate knowledge. Among 32 Doctors, 63% of them scored above or equal to 75%. Health workers from Sarpang scored higher (76%, SD = 11) than those from other Dzongkhags. Snakebite victim's visit to local (traditional) healers prior to seeking medical help from hospital was observed by 75 (63%) health workers. Fifty one percent of health workers observed patients treated with local methods such as the use of black stone called Jhhar Mauro (believed to absorb snake venom), application of honey, rubbing of green herbal paste made up of Khenpa Shing (Artemisia myriantha Wallich ex Besser var. paleocephala [Pamp] Ling) and consumption of fluid made up of Neem leaf (Azadirachta indica Juss). Use of tight tourniquet as a first aid to snakebite was observed by 80% of the health workers. Conclusion Health workers lack confidence in snakebite management. Snakebite victims are likely to suffer from harmful local practices and traditional beliefs on local treatment practices. Empowering health workers with adequate knowledge on snakebite management and making locals aware in pre-hospital care of snakebites are needed to improve the pre- and in-hospital management of snakebite in Bhutan.