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Dermatological services in South Asia: Harnessing the non-dermatologists
Skin diseases cause an enormous burden in the developing world.
Consultant Dermatologist and Member of Board of Directors, International Skincare Group, Varanasi, India
Corresponding author: V Kaur (drvineet11@gmail.com)
Various studies worldwide1-4 have demonstrated the impact of skin diseases on morbidity in all age groups. However, with few healthcare resources, poor infrastructure, poverty and overcrowding, the impact is compounded. As skin diseases are not considered life threatening, they are not top priority for policymakers and are seldom mentioned in healthcare budget allocations. Yet they cause substantial loss of work hours and earnings.
The developed world has recognised the loss of quality of life and work and economic productivity in people suffering from skin diseases, especially chronic skin disorders. Currently there are various initiatives at different levels of healthcare delivery designed to address this problem. While dermatologists man hospital outpatient departments, wards and private practices, nurses are expanding their roles and are now integral members of dermatology teams. Some have even taken on independent roles as nurse practitioners with prescribing rights and others run nurse-led clinics and are in charge of daycare units.
However, two key issues are fundamental to this change: recognising the need to involve other healthcare providers in skincare delivery, and sensitising the dermatologist fraternity to this need. There have been many pioneers, both among dermatologists and nurses, who have led this change and helped to create models for others to replicate. However, every community and its needs are unique; this is the biggest challenge as no single blueprint will apply to all.
In South Asia, the challenges include large populations, poverty, poor resources, poor healthcare delivery infrastructure and lack of education. In India, for example, most dermatologists are based in the cities and towns, but almost 70% of the population live in villages. Although there are primary healthcare centres in the villages, these are often manned only by an auxiliary nurse midwife (ANM) and are occasionally visited by a junior doctor. Dermatologists almost never visit these centres. Therefore, when the need for skincare arises, whether from an acute infection or because of a chronic skin condition, patients have to travel long distances, often over difficult terrain, to see a specialist in a city or town, incurring loss of earnings and expenditure. In most situations, people therefore choose to take advice from local quacks and traditional healers, further jeopardising their health. Dermatologists, on the other hand, although aware of this situation, are able to do little to help change the scene, because of very busy clinical consultation commitments.
The need of the hour is to begin to use other health providers and to train them in basic skin care, and recognition and management of common skin conditions. As nurses form the largest such workforce, attempts have been made to sensitise them towards the need for training in this field. Empowering them with knowledge and skills is likely to go a long way in reducing the burden of skin disease in rural communities through their inputs.
The learning needs of nurses in the community also need to be addressed. A project to train ANMs in skincare in a rural health centre run by Christian missionaries was conducted.5 Twenty-five ANMs working in a government primary health centre were recruited on a first-come basis to undergo a 6-month training programme (2 sessions per month) in skincare. Diagnosis and management of 10 common skin diseases were taught using flash cards and clinical photographs supplemented by clinical cases brought in by the ANMs from their communities. The importance of skin hygiene and the use of indigenously available medicines were emphasised. An ongoing assessment of their acquired skills was made from their approach to diagnosis and management of cases. Their level of interest was assessed based on their attendance and their efforts to bring cases from their communities for discussion, while pre- and post-testing questionnaires were used to evaluate their knowledge acquired. This assessment was made using a 3-grade scale for each ANM. The long-term usefulness was assessed on the basis of records of patients seen, diagnosed, managed, and referred by each trained ANM.
The International Skincare Nursing Group (ISNG), the only international nursing body that works with local organisations globally to improve standards of skin health, has been greatly instrumental in bringing about a change in attitude and approach to skin healthcare in the region. Through various workshops organised from time to time in India and Nepal, ISNG members have shown the impact of such training in resource-poor developing countries. The board of ISNG consists of pioneering nurses from different countries and continents, who have showcased the role trained nurses can play in impacting skin health outcomes while improving quality of care and reducing healthcare costs.
Taking a lead nationally, the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) set up a Special Interest Group (SIG) on dermatology nursing to further this mission in various parts of the country. The SIG consists of international advisors (both dermatologists and nurses) and committed dermatologists as members who, through training workshops around the country, expose nurses and allied healthcare professionals to the need to know basic skincare and disease recognition/management. A curriculum6 has been drawn up as a guide to what nurses in South Asia must know about skincare. Many workshops have been successfully conducted at various centres (mostly attached to medical and nursing colleges) around the country, and the response has been overwhelming (Fig. 1).
Fig. 1. Participants at the IX SODVELONCON, Kathmandu, Nepal.
One such workshop is showcased below. A 2-day workshop on basic skincare was organised at the Father Muller Medical College in Mangalore, South India. A total of 270 nurses, including student nurses of different levels, nurse tutors and physiotherapists, attended the workshop. The faculty consisted of a very senior nurse, Barbara Page from Scotland; Professor G Singh, a senior dermatologist from India; Professor Ramesh Bhatt, a senior dermatologist; Professor Y Marfatia, a senior dermatologist; and the author. The programme was held as a zonal workshop on basic skincare for nurses, on 7 and 8 January 2012 (Fig. 2).
The programme is outlined above.
Fig. 2. A zonal workshop in Mangalore.
The success of this workshop and the positive feedback have led to more such teaching initiatives and workshops in other medical colleges in Ahmedabad and New Delhi.
Dermatology nursing has travelled thus far in this part of the world. The ball has been set rolling and is gaining momentum. The future demands that, to achieve the goal of making skin healthcare available to all, healthcare providers at all levels must become active players in the game. The light at the end of the tunnel is certainly bright.
References
1. Kaur P, Singh G. Community dermatology in India. Int J Dermatol 1995;34:322. [http://dx.doi.org/10.1111/j.1365-4362.1995.tb03611.x]
2. Grover S, Ranyal RK, Bedi MK. A cross section of skin diseases in rural Allahabad. Indian J Dermatol 2008;53:179-181. [http://dx.doi.org/10.4103/0019-5154.44789]
3. Dogra S, Kumar B. Epidemiology of skin diseases in school children: A study from northern India. Pediatr Dermatol 2003;20:470-473. [http://dx.doi.org/10.1111/j.1525-1470.2003.20602.x]
4. Lowell BA, Froelich CW, Federman DG, Kirsner RS. Dermatology in primary care: Prevalence and patient disposition. J Am Acad Dermatol 2001;45:250-255. [http://dx.doi.org/10.1067/mjd.2001.114598]
5. Kaur V. Dermatology service through auxiliary nurse midwives: An Indian model. Dermatol Nurs 2003;2:18-19.
6. Kaur V. Skincare Nursing for South Asian Nurses – A Framework Curriculum. 1st ed. Varanasi: Jauhari Printers, 2010.
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