Assessment of Knowledge, Attitude, and Practice of Primary Care Physicians Regarding Common Dermatologic Conditions in Sudan 2024: A Cross Sectional Study
Conditions: Dermatological Disorders
Sponsor: Afifa Muhammad Alameen Khalifa Alshaykh

Assessment of knowledge, attitude, and 
practice of primary care physicians 
regarding the common dermatologic 
conditions in Sudan 2024: a cross-sectional 
study 
 
 
26/10/2024 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Introduction: 
Background  
Dermatological conditions represent a major health problem globally. Skin disorders were 
considered the 18th cause of global disability and ranked as the fourth cause of non-fatal disease 
burden worldwide in 2013. (1) 
According to the global skin and subcutaneous diseases burden report in 2019, 4,859,267,654 
new cases of skin disorders were reported. The majority of these disorders are attributed to fungal 
infections (34%) followed by bacterial skin infections accounting for 23% of the cases and the 
incidence of skin disorders is slightly higher in men. In addition to that, the number of deaths from 
skin conditions worldwide is 98.522, most of whom died of bacterial skin infections (72%). 
In fact, there has been a substantial increase in the mortality rate due to skin diseases globally in 
comparison to 1990 by 71%. Geographically, the highest morbidity and mortality rates as a 
consequence of skin conditions were in the South Asia region (25%) Regarding age, Skin and 
subcutaneous diseases affect all age groups; however, children are found to be the most affected 
age category as a result of the smoothness and softness of their skin. (1) Particularly those under 
4 years of age who represent the majority of new cases. Nevertheless, death is more prevalent 
in the older population who are aged above 80 years and both genders are affected equally. (2)  
In the region of western Sudan, the most common skin disorders are fungal skin infections 
account for 32.6% of cases which is similar to the report of global disease burden in 2019, followed 
by eczema at 10.5%, and bacterial skin infections labelled as the third common skin disorder at 
10.3%. (3) 
Although skin conditions are mostly benign and non-fatal, they significantly impact individuals’ 
quality of life, leading to long-term disability.  Mental, social and emotional well-being is negatively 
affected by skin disorders leading to social isolation. These adverse impacts extend beyond 
individuals, influencing their families, partners, and friends, especially for those patients with 
chronic and disfiguring skin conditions who are more likely to encounter psychological distress, 
depression along suicidal attempts. (1) 
In Africa, skin disorders impact 21- 87% of children and account for up to one-third of all outpatient 
consultations with paediatricians and dermatologists. (4) Furthermore, studies have indicated that 
a notable proportion, ranging from 6% to 24%, of primary care visits are attributed to skin 
conditions, positioning dermatological ailments as a prominent motive for seeking medical advice 
within the realm of primary healthcare. (5)  
Primary care physicians are the cornerstone of the health system since they play an essential 
role in the diagnosis of patients with common skin disorders. They represent a considerable 

percentage of the overall patients who attend primary health care centres and take on the 
responsibility of managing common skin conditions, in addition to referring patients who need 
further consultation and assessment by dermatologists. Therefore, primary health care physicians 
must be well informed and surprisingly knowledgeable about common dermatological conditions 
and competent in the recognition and management of those conditions. This will subsequently 
lead to faster diagnosis, a desirable patient outcome, and greater patient satisfaction. In addition 
to a lower referral rate to dermatologists, this necessarily reduces the burden on the health 
system. 
Since there are no available documents in Sudan and less attention is paid to skin conditions, we 
aim to assess the level of knowledge of recognition, diagnosis, and management of common skin 
conditions among primary health care physicians working in the primary care centres in Sudan, 
address the area of weakness and try to fill the gaps in practice regarding the management of 
common skin disorders. 
Problem statement   
 
The Global Burden of Diseases Study 2013 stated that Skin diseases were the 18th most common 
cause of global disability-adjusted life years and the fourth most common category of non-fatal 
disease. 
skin diseases are one of the most common human illnesses (6), Many patients present to the 
emergency department with skin conditions that are not true dermatologic emergencies (7) Urgent 
skin conditions caused by allergic drug reactions, severe immune-mediated diseases or 
infections, are uncommon and the conditions are rare, they can be sometimes challenging to 
diagnose. and non-dermatologists are responsible for their care (8). Early recognition and timely 
intervention are crucial to ensure the best outcome and prevent any complications (9). While the 
majority of ambulatory patient visits are seen by PCPs, it is estimated that 6–7% of all these visits 
are for dermatologic complaints (9,10). Despite the relatively high incidence of skin disorders, 
training for healthcare professionals in dermatology is often limited (11,12). Due to ecological 
variables, sanitation standards, social mores, and genetics, the pattern of skin disorders differs 
from nation to nation, and even from region to region within the same country,  some  studies 
focused only on diagnosing skin cancer using cross-sectional questionnaire assessment, 
concluding that many non-dermatologists face challenges in recognizing and diagnosing different 
stages of skin cancer (13) another study discussed the accuracy of non-dermatologists’ initial 
judgement on inpatient dermatologic conditions by comparing the non-dermatologist referring 
notes with the reviewing dermatologist response concluding that non-dermatologists misdiagnose 
many common and uncommon skin conditions respecting case rarity(14) , study from Yemen 
conclude that PCPs were not properly trained to diagnose and treat skin diseases. Dermatologic 
training and curricula at medical schools need a comprehensive evaluation (15). The different 
levels of experience between dermatologists and non-dermatologists may affect the quality of 
dermatologic care and may explain in part the greater expertise dermatologists have in diagnosing 
and treating skin disease. (16)   
 

 
Justification 
 
 
Primary care physicians (PCPs) represent the backbone of any health care system as they 
provide the basic health services demanded by the majority of patients. As a consequence, the 
exposure of primary care physicians (PCPs) to skin disorders has increased. However, 
information is lacking regarding the level of proficiency of PCPs in this field. Despite the fact that 
skin conditions have a lower fatality rate and consequently receive less attention than more 
serious medical conditions,4,5 their contribution to total morbidity occupies a significant cost on 
the community, imposing a burden on the health care resources and personnel. Few works of 
literature covered this topic throughout different decades because very little data were conducted 
and the study was never done in our region, we aim to conduct an online assessment using a 
questionnaire assessing the ability of non-dermatologists to recognize urgent skin diseases at 
Sudanese hospitals. 
 
 
 
 
 
 
 
 
 

Literature review: 
The structure and functions of the skin: 
Skin is considered to be the largest body organ (17). which comprises 15% of total body weight 
(18). It is composed of three layers epidermis, dermis, and subcutaneous tissue (18). The 
epidermis contains many types of cells keratinocytes predominate and also contain Langerhans 
cells, melanocytes, and Merkel cells (19). There are four layers in the epidermis basal layer, 
stratum spinosum, stratum granulosum, and stratum corneum respectively (20). The dermis is the 
intervening lamina of the skin. The main cell type in the dermis is fibroblast which produces 
collagen elastin and other proteins. It also contains neurovascular structures and sweat glands. 
The dermis comprises two layers papillary and reticular dermis (21). The subcutaneous tissue or 
hypodermis is composed of adipocytes, fibroblasts, and macrophages. It also contains 
substances like proteoglycan and glycosaminoglycans. It is involved in thermoregulation during 
cold and exercise (22).  
Functions of the skin: 
● protection against microbes and chemicals through the layer of stratum corneum. It also 
protects against dehydration and acts as a shock-absorbent (18). 
● sensory function through receptors that regulate the sensation there are two types of 
receptors located in the dermis bare nerve endings which are responsible for pain and 
temperature sensation and encapsulated mechanoreceptors which are responsible for 
touch and vibration. 
● Homeostasis: it prevents heat and water loss.  
● Vitamin D synthesis (19). 
● cosmetic effect (18). 
 
Diagnosis and classification of skin diseases: 
Most common skin diseases like skin carcinoma and leprosy if not diagnosed early can lead to 
death. Here are some examples of common skin disorders and how they are diagnosed: 
Malignant melanoma: is classified into squamous cell carcinoma and basal cell carcinoma which 
are mainly diagnosed by biopsy 
Leprosy: which is caused by mycobacterium leprea which produces skin and neurologic defects. 
It can be diagnosed by skin smears and skin biopsy. 
Viral skin diseases: like rubella, measles, herpes simplex virus, and human papillomavirus mainly 
are diagnosed clinically (23). 
Psoriasis: it is a genetic disease that causes hyperproliferation and abnormal differentiation of 
keratinocytes. It can be diagnosed clinically (24). 

Dermatophyte infections: like tinea capitis, tinea pedis, tinea ungium, and tinea cruris are common 
in developing countries. Can be diagnosed by clinical examination, microscopy, culture, and 
polymerase chain reaction (25). 
Scabies: is a parasitic infection that affects only humans. It exists in many forms and causes 
severe pruritus. It is mainly diagnosed clinically also by microscopy and dermoscopy (26). 
Common dermatologic conditions worldwide: 
The most common dermatologic conditions occurring worldwide are as follows: dermatitis, acne 
vulgaris, urticaria, psoriasis, viral skin diseases, fungal skin diseases, scabies, melanoma, 
pyoderma,cellulitis, keratinocyte malignancy, decubitus ulcer, alopecia areata, itchiness, with the 
remaining dermatoses falling under the heterogenous ‘Other skin and subcutaneous diseases’ 
category (27). 
Common dermatologic conditions in Africa: 
The most common dermatologic conditions in Africa are as follow: Atopic Dermatitis (7.49%), 
Tinea Versicolor (4.94%), Acne Vulgaris (3.73%), Papular Urticaria (3.47%), Tinea (2.94%), 
irritant Contact Dermatitis ( 2.94%), Scabies ( 2.76%), Seborrheic Dermatitis ( 2.50%), Pityriasis 
Rosea (2.26%), Urticaria (2.18%), Viral Warts (1.85%), dermatophytes of the scalp ( 1.80%), 
Lichen Planus (1.77%), Vitiligo (1.77%) and Lichen Simplex Chronicus ( 1.45%) (27).  
Common dermatologic conditions in Sudan: 
The information about the prevalence and incidence of common skin diseases in the Sudanese 
population is insufficient and lacks data about the burden of dermatologic conditions on the 
Sudanese population. A study conducted in Nyala in western Sudan about the most common 
dermatologic conditions in this area showed that the prevalence of skin conditions in children 
under 18 years was 96% compared to 88.3% in adults with a total prevalence of 92.6%. The top 
13 dermatologic disorders in Nyala were as follows: fungal infections (32.6%), dermatitis/eczema 
(10.5%), bacterial skin infections (10.3%), disorders of skin appendages (8.7%), parasitic 
infections (7.7%), atrophic skin disorders (7.4%), pigmentation disorders (7.4%), hypertrophic 
skin disorders (6.4%), viral infections (5.8), benign neoplasm (1.9%), dermatoses due to animal 
injury (0.4%), bullous dermatoses (0.1%), and malignant neoplasm (0.1%) (28). 
Another study published in 2023 investigating fungal infections among Sudanese populations 
proposed that tinea capitis affects 3.22% of school children in Sudan with 17% occurring in the 
eastern part of the country (29). Kafi et al showed that the prevalence of vulvovaginal candidiasis 
is 10.1% (30) while in pregnant women who are at higher risk, the recorded prevalence was 16.6% 
and 32.6% according to Nemery et al. and Abdelaziz et al. (31), correspondingly. 
Sudan is considered highly endemic with mycetoma that causes a huge impact on patient’s 
health, the community, and the entire health system (32). Abbott’s study in 1952 estimated the 
prevalence of mycetoma to be 4.6 per 100,000 inhabitants based on a cohort of 1,231 mycetoma 
patients admitted to hospitals throughout the country (33). lately in 2014, a huge meta-analysis 
conducted by van de Sande et al. estimated that the mycetoma prevalence in Sudan was 1.81 
cases per 100,000 inhabitants (34).  

 
Primary Healthcare and Primary Healthcare Doctors: 
Primary healthcare is a wide range of health services provided for the community. It is main pillar 
is to support the health needs of the society throughout their life in an inclusive, equal, easily 
accessible and cost-effective way. It encompasses health promotion and disease prevention, 
community empowering and education, rehabilitation and interdisciplinary teamwork. The 
workforce is composed of general healthcare practitioners, nurses and pharmacists and other 
supporting providers. Primary healthcare doctors vary in their duties, names and level of 
education across different health systems, but one unified fact is that most of the time they are 
the first responders in the health system hence their role in the system is crucial (35,36).  
Patients frequently present to primary healthcare for skin and skin appendages related problems 
(37), and primary care doctors play a vital role in diagnosing, managing and referring these 
conditions.  Therefore, regular training is required to meet this need (38).  However, a significant 
proportion of patients apply directly to secondary and tertiary care for their skin problems therefore 
there is a need to promote dermatologic consultation in primary care to reduce the pressure of 
the higher levels of care (39). This can be achieved by providing regular training and courses 
which proved to have a significant impact on the knowledge level of practising doctors which in 
turn is directly reflected on patient care (40). 
 
Primary Healthcare in Sudan: 
 No sufficient data is available regarding the current healthcare in Sudan. Sudan first adopted 
primary healthcare in 1972.  The working sites include primary healthcare centres and rural 
hospitals as well as other smaller health units which in turn refer to them, and there are plenty of 
non-profit and private organisations providing different levels of healthcare. All of which are 
managed by the State and Federal Ministries of Health. The workforce is distributed -yet 
differently- among these sites and comprises community health workers, nurses, medical 
assistants and doctors. (41) 
 
Similar studies: 
A study was done in the Jouf region in Saudi Arabia to assess primary care physician’s expertise 
of common dermatological conditions with respect to their recognition, management and referral 
as well as the factors influencing their practice in an attempt to identify the weaknesses in handling 
these conditions. The study used a cross-sectional survey and interviews targeting all primary 
care physicians working in the Jouf region (n=103) over four months. Standardised photos from 
DermNetNZ.org and American Academy of Family Physicians standards were used. 61 
participants completed the survey of which 27 were general practitioners and 34 were family 
medicine specialists.  Mean years in practice was 12 (±7) and mean number of consultations per 
month were 27(±25). On a scale of 10; 7.08(±1.3) was the mean overall knowledge level and the 

highest scores were significant for those with five years or more experience. The highest overall 
knowledge score (87.3%) was for skin appendages disorders. The mean diagnostic score was 
7.01(±1.51) and the mean management score was 7.14(±1.3).  There was a weak negative 
correlation between higher knowledge, correct diagnosis and correct management with referral 
decisions. The study concluded that most primary care physicians showed sufficient knowledge 
and more clinical years and exposure lead to better knowledge and fewer referral cases with a 
potential for further optimization. (42) 
Another study in Jeddah, Saudi Arabia was conducted at the tertiary care centre King Abdulaziz 
University Hospital  to assess non-dermatologists ability to recognize urgent skin disease , the 
161 participants included consultants, specialists and residents from different specialties actively 
working in the hospital the Google Form questionnaire was distributed via email and by two 
dermatology consultants, it was composed of a socio-demographic section and assessment 
section the  latter contains case scenarios and pictures of urgent dermatological conditions and 
participants were asked to rate  their confidence level while answering each question on a scale 
from one to ten. The most recognized urgent skin condition was herpes zoster which was 
recognized by 88.8% of the participants with 49.1% confidence score followed by cellulitis 80.1% 
and Pemphigus vulgaris what the least recognized, only by 28% out of which 12.4% were 
confident some diseases were recognized correctly at high percentage despite the physicians 
being not confident about diagnosing them reflecting a varied relation between the correct 
answers and level of confidence. The accuracy percentage was 61.33% however it decreased to 
25.3% when it was recalculated with respect to full confidence level educational level and gender 
didn’t significantly affect the ability to answer correctly. In general, the study demonstrated that 
physicians face some difficulties in recognizing urgent skin diseases and highlights the need for 
more dermatological courses and training. (43) 
In the Philippines another cross-sectional study was conducted to determine the knowledge, 
attitudes, perception and practice of Primary Care Physicians regarding common dermatologic 
conditions in rural areas (Doctors to the Barrios DTTBs) with respect to their diagnosis and 
management and to assess the level of service delivery network and referral protocols.  Of the 
118 DTTBs who were included 65.77% had less than one year of experience as DTTBs. The 
results showed no association between age, educational level and clinical experience regarding 
the knowledge of common skin diseases. Despite 6% of the consultations being for skin diseases 
per week; only 25% of the doctors can access dermatological consultation leaving them with the 
burden to diagnose and manage the majority of presenting cases. The study also demonstrates 
that the most commonly diagnosed disease was dermatitis followed by superficial infections. 55% 
of the physicians have insufficient knowledge with scores less than 60% while most doctors rated 
their competency in recognition and treatment of skin diseases as average to bad and about half 
of them refer patients when they are unsure about the diagnosis.   Also, the majority of the 
physicians showed an interest in learning more about skin diseases and acknowledged the 
importance of acquiring adequate knowledge. (44) 
A cross-sectional study was conducted to assess the knowledge, attitude and practice of primary 
health care doctors about common dermatology conditions in Abha City, Saudi Arabia in 2017 
using a validated self-administered questionnaire. It included GPs and family physicians working 

in primary healthcare centres. The study showed that more than two thirds (69.5%) of the 
participants had insufficient knowledge whereas 21.9% and 4.8% had good and excellent 
knowledge respectively. Physicians who had higher than bachelor degrees, more than three 
months experience and physicians who attended training courses in dermatology (30%) had 
significantly higher levels of knowledge. The majority of doctors agreed that they should have a 
role in the management of common dermatologic conditions. (45) 
A study was done to assess Primary care physicians’ knowledge and self-perception of 
competency in dermatology in Yemen conducted by Salma et al, Mona et al and Raed et al (46). 
It was a cross-sectional study; a simple random sample was obtained and data was collected 
through a self-administered questionnaire which contained three sections: sociodemographic 
data, attitude and perception, and knowledge section. Data were analyzed using SPSS v19 (IBM: 
Armonk, New York). The response rate was 80% most of them were females at a rate of 85%. 
Regarding self-perception of competency in dermatology: (37.5%) perceived their ability to 
diagnose skin diseases as very good/good and (40.0%) PCPs perceived their ability to treat skin 
diseases as very good/good. The average score of PCPs’ ability to classify skin lesions was 7.48 
(±1.2) (out of 10).  It also found that two-thirds of PCPs thought that patients receive better care 
in private clinics than public clinics so the rate of referral to dermatologists was higher among 
them. They concluded that there was no relationship between the ability to classify skin lesions 
and PCP's perception of self-competency in dermatology. They found that PCPs were not well 
trained to deal with common dermatologic diseases so they recommended that the dermatology 
curriculum in medical schools should be revised and strengthened to make PCPs more 
competent. 
Another study was done to assess the ability of primary care physicians to recognize common 
dermatoses was conducted by Ramsy et al and Alissa et al (47). It involved 285 PCPs divided 
into four groups each group received different medical training. The first two groups received pre 
and post-test examinations while the other two received pretest examinations to assess their 
ability. The exam was in the form of 20 coloured slides about the most common skin diseases 
and candidates were asked about the diagnosis. The overall performance in the pretest exam 
was a mean score of 54% and only 16% of PCPs recognized lichen planus and 49% recognized 
acne. They recommended that wider studies should be done to address the causes of PCPs 
being unable to recognize common dermatologic conditions. They also recommended that there 
should be dermatology specialists available in primary care setting for better handling of 
dermatologic patients. They strengthened the point that PCPs should receive better medical 
training to enhance their ability to deal with patients. 
Another study was done to investigate the diagnosis of skin disease in primary care by Mary et 
al, Maximilian et al, Erika et al, and Stefan et al (48). It was a qualitative study. Data was collected 
through semi-structured interviews. Data was analysed by MAXQDA-10. A total of 45 GPs were 
approached; only 14 of them agreed to participate in the study and most of them were females. 
Most of the participants were found to be able to give spot diagnoses, especially for 
morphologically distinct conditions but some of them depend on both history and examination to 
diagnose the condition of the patient. Most of the GPs tend to exclude the life-threatening 
condition and then address the presenting complaint. They concluded that GPs encounter a wide 

range of skin conditions and they use different techniques to reach diagnosis. They recommended 
that more research should be done on the diagnosis of skin conditions in primary care to develop 
simple tools for GPs to diagnose skin conditions. They also recommended that GPs should 
receive regular training regarding the diagnosis and management of skin diseases. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Objectives 
General Objective: 
To assess the knowledge, attitude and practice of primary health care doctors regarding 
the diagnosis and management of common dermatological conditions in Sudan. 
 
Specific objectives: 
1. To identify the level of knowledge of primary health care doctors regarding the 
diagnosis and management of common dermatological conditions in Sudan. 
 
2. To explore the attitude of primary health care doctors regarding the diagnosis and 
management of common dermatological conditions in Sudan. 
  
3. To investigate the practices of primary health care doctors regarding the diagnosis 
and management of common dermatological conditions in Sudan. 
 
 
 
 
 
 
 
 
 
 
 
 

Methodology: 
Objective: 
To evaluate the knowledge, attitude and practices of primary health care physicians 
regarding the diagnosis and management of common skin diseases in Sudan. 
Study Design: 
 
The research employed an observational cross-sectional study design. 
Study Area: 
The study will be conducted in the Republic of Sudan, which is located in northeastern 
Africa It is bordered by North is Bordered by Egypt , Northeast Has a coastline along the 
Red Sea ,East Shares borders with Eritrea and Ethiopia ,South Bordered by South 
Sudan ’Southwest Borders the Central African Republic ’West Shares a border with 
Chad ’Northwest Bordered by Libya ,It has 18 states Blue Nile, Central Darfur, East 
Darfur, Gedaref, Gezira, Kassala, Khartoum (the capital), North Darfur, North Kordofan, 
Northern, Red Sea, River Nile, Sinnar ,South Darfur, South Kordofan, West Darfur, West 
Kordofan, White Nile This number is after the secession of South Sudan, which occurred 
on July 9, 2011. 
Sudan is the third largest country in Africa, covering an area of approximately 1,886,068 
square kilometers (728,215 square miles), The population in July 2015 was an estimated 
36.1 million people, according to recent estimates, the population of Sudan will reach 
approximately 49 million people in 2024. Sudan is considered the 31st most populous 
country in the world. (1) 
Study Population: 
The study population consists of Sudanese general practitioners (GPs) working in primary 
health care centers across different states in Sudan. 
Inclusion Criteria: 
Participants must meet the following criteria: 
1. Sudanese nationality 
2. Age above 23 years 
3. General practitioner 
4. Currently working in primary care centers 
5. Residing in Sudan during the study period 
Exclusion Criteria: 
Individuals who do not meet the following criteria will be excluded: 
1. Non-Sudanese 

2. Age below 23 years 
3. Non-general practitioners 
4. Not working in primary care centers 
5. Not residing in Sudan during the study period 
 
Sample Size Calculation: 
The sample size will be calculated using the following formula  
       Sample Size = [z2 * p(1-p)] / e2 
z = z-score corresponding to the desired confidence interval, at 95% Confidence Level 
Z = 1.96. 
e = desired margin of error, which is a 5% confidence limit. 
p = estimated proportion of population with the characteristic of interest p = 0.5 is used 
for maximum variability 
the sample size was calculated as 211  
Data collection: 
Sampling: The study will utilize multistage sampling technique to select the participants. 
whereby, In the first stage, the 18 states will be clustered into 5 main areas. Then, the 
participants will be sampled conveniently from within these areas due to accessibility 
challenges. 
Ethical consideration:  consent will be obtained from each participant, and personal 
identifying data are excluded from the questionnaire to ensure privacy. 
Data collection tool: self-administered questionnaire designed through Google Forms 
to collect facts from the selected participants. The questionnaire captured applicable 
factors related to dermatology, knowledge, attitudes, and practices. 
Several 211 questionnaires were collected, divided equally into five regions in Sudan: 
East, North, South, West, and Central 
Data Analysis:  
● Data Description:  
Mean, median, frequency, and standard deviation will be used to express for the 
descriptive analysis to display the knowledge and attitude scores. 
● Software: 
Retrieved data will be analyzed using the statistical software package SPSS version 21 
 
● Statistical tests: 

We will use Chi-square test and Spearman correlation tests to examine for the association 
and correlation, and T- test, Kruskal-Wallis and Mann-Whitney U tests to explore the 
differences between variables depending on the normality of data. 0.05 is chosen as the 
cut-off point of significance for the p-value.    
● Handling Missing Data: 
Missing data will be handled using available case analysis (pairwise deletion).   
● Presentation of Results 
         The data will be presented using graphs and tables to present the key findings. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

  Time frame: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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