Medical practitioners’ knowledge and awareness of multiple myeloma at public hospitals, Gauteng, South Africa

Abstract

Background: Multiple myeloma (MM) is a plasma cell malignancy associated with morbidity and mortality worldwide, and most patients are referred for specialist care very late with complications. The low index of suspicion among medical practitioners is among the reasons for the delay in MM diagnosis and management. This study aimed to determine the level of awareness and knowledge of MM among medical practitioners working in public hospitals of Tshwane Municipality, Gauteng Province, South Africa.

Methods: A cross-sectional descriptive study on 74 doctors working in three district, one regional and one central hospital using a convenience sampling.

Results: Seventy-four medical practitioners participated in this study. Their median age was 37 years with an interquartile range of 43–30 years. The majority (85%) of the respondents were aware of MM, while 74% were knowledgeable regarding MM presentations and diagnostic investigations.

Conclusion: The findings highlighted a high level of awareness and knowledge of MM among the study population, but almost all of the participants requested an educational information brochure on MM.

Contribution: Medical practitioners have a high level of awareness of multiple myeloma; however, there is a discrepancy between this level of awareness and the delayed presentation of patients at the public hospitals. As primary healthcare in South Africa is nurse-driven, the study indicates that not all primary healthcare providers may be aware of this disease. Future awareness campaigns should target other primary healthcare providers, including nurses and private general practitioners.

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Page 1 of 6 Original Research
hps://www.safpj.co.za Open Access
South African Family Pracce
ISSN: (Online) 2078-6204, (Print) 2078-6190
Authors:
Andiswa M. Pooe1
Abegail N. Dlova1
Sam T. Ntuli2
Aliaons:
1Department of Haematology,
Faculty of Health Sciences,
Sefako Makgatho University,
Pretoria, South Africa
2Department of Stascs,
Faculty of Health Sciences,
Sefako Makgatho University,
Pretoria, South Africa
Corresponding author:
Andiswa Pooe
amtyobile@gmail.com
Dates:
Received: 01 Oct. 2022
Accepted: 29 Apr. 2023
Published: 27 June 2023
How to cite this arcle:
Pooe AM, Dlova AN, Ntuli ST.
Medical praconers’
knowledge and awareness
of mulple myeloma at
public hospitals, Gauteng,
South Africa. S Afr Fam Pract.
2023;65(1), a5644. hps://
doi.org/ 10.4102/safp.
v65i1.5644
Copyright:
© 2023. The Authors.
Licensee: AOSIS. This work
is licensed under the
Creave Commons
Aribuon License.
Introducon
Multiple myeloma (MM) is a haematological malignancy characterised by the accumulation
of malignant plasma cells in the bone marrow resulting in anaemia and other cytopenias,
bone lesions, hypercalcaemia, renal insufficiency and monoclonal gammopathy.1 The
incidence of MM in South Africa is 4.34, whereas in the rest of the world, it varies between
0.54 and 5.3 per 1 001 000 population.1 ,2 Multiple myeloma comprises about 1% of all malignant
tumours, accounts for 10% – 15% of all haematological malignancies2 and is a major cause of
morbidity and mortality in both developed and developing countries.3,4 The condition mainly
affects elderly people aged 65 years and older5,6,7,8 and, in most cases, develops as an
asymptomatic premalignant condition known as a monoclonal gammopathy of undetermined
significance (MGUS).9 The diagnosis of MM includes the presence of this monoclonal protein
in serum or urine, bone marrow clonal plasma cells and related organ or tissue impairment as
evidenced by hypercalcaemia, renal insufficiency, anaemia and/or bone lesions.2,9 As the
diagnostic criteria and management for MM have changed dramatically over the last few
years, one needs to have a high index of suspicion to make the diagnosis because of its
nonspecific clinical features.10
Globally, MM remains a major public health concern; the number of cases has increased 2.36 times
from 65 940 in 1990 to 155 688 in 2019, while the mortality rate increased 2.19-fold from 51 862 to
113 474.4 This could be indicative of an increasing global burden for MM as the world aging
population increases. In South Africa (SA), the National Cancer Registry indicates that of the
14 616 haematological malignancies reported between 2000 and 2006, MM is diagnosed in about
Background: Multiple myeloma (MM) is a plasma cell malignancy associated with morbidity
and mortality worldwide, and most patients are referred for specialist care very late with
complications. The low index of suspicion among medical practitioners is among the reasons
for the delay in MM diagnosis and management. This study aimed to determine the level of
awareness and knowledge of MM among medical practitioners working in public hospitals of
Tshwane Municipality, Gauteng Province, South Africa.
Methods: A cross-sectional descriptive study on 74 doctors working in three district, one
regional and one central hospital using a convenience sampling.
Results: Seventy-four medical practitioners participated in this study. Their median age was
37 years with an interquartile range of 43–30 years. The majority (85%) of the respondents were
aware of MM, while 74% were knowledgeable regarding MM presentations and diagnostic
investigations.
Conclusion: The findings highlighted a high level of awareness and knowledge of MM among
the study population, but almost all of the participants requested an educational information
brochure on MM.
Contribution: Medical practitioners have a high level of awareness of multiple myeloma;
however, there is a discrepancy between this level of awareness and the delayed presentation
of patients at the public hospitals. As primary healthcare in South Africa is nurse-driven,
the study indicates that not all primary healthcare providers may be aware of this disease.
Future awareness campaigns should target other primary healthcare providers, including
nurses and private general practitioners.
Keywords: multiple myeloma; awareness; knowledge; Gauteng Province; South Africa.
Medical praconers’ knowledge and awareness of
mulple myeloma at public hospitals,
Gauteng, South Africa
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1543 (10.6%) of the cases.11 In the Eastern Cape province of
SA, 3603 incident cases of haematological malignancies were
identified between 2004 and 2013 and MM accounted for 465
(13%) of the cases.12
At Steve Biko Academic Hospital, a retrospective study was
conducted between May 2005 and September 2008; MM was
reported in 6.7% (n = 39) of 582 patients in which protein
electrophoresis was performed.13 An earlier study conducted
among 145 patients diagnosed with haematological
malignancies at Dr George Mukhari Academic Hospital
(DGMAH) between January 1998 and December 1998 found
that MM accounted for 26% of the cases and most of these
patients were referred and diagnosed late (unpublished
findings).14
Various efforts have been made to develop standard
management protocols for MM;15,16,17 however, the diagnosis
and management of MM patients remain a challenge.18
Several factors may have contributed to the challenges,
including the late presentation of patients to a healthcare
facility,13,19,20 the inadequacy of diagnostic facilities20 and MM
patients experiencing multiple consultations in the primary
care before being referred to the tertiary facility.20,21,22 Visser
et al. in their study at Steve Biko Academic Hospital reported
that the majority of the MM cases were diagnosed at a very
late stage of the disease and concluded that this could be
related to a low index of suspicion among referring medical
practitioners.13 This finding is supported by many
studies.21,22,23,24
Studies have been conducted in developed countries that
assessed the level of awareness and knowledge of MM
practices among haematology healthcare professionals25 and
general practitioners,26 but these studies were on MGUS and
highlighted a lack of awareness and understanding with
mean scores of 2.1 and a standard deviation of ± 1.09. The
studies were done using an online questionnaire. In sub-
Saharan African countries, there is a paucity of information
on the awareness and knowledge of MM among medical
practitioners, but in Kenya27 and Nigeria,28 researchers
reported very low awareness of MM among practitioners
without conducting formal research. This was based on the
observed increase in patient enrolment to the MM diagnosis
and management program after the training of medical
students and healthcare practitioners. In our institution, the
number of patients with MM is on the increase. These
patients present late, and 22% of them were aged less than 40
years, which might be one of the reasons for a low index of
suspicion among referring medical practitioners.14 Multiple
myeloma is known to be preceded by pre-existing MGUS.29,30
Despite this, the level of awareness and knowledge of MM
practices among medical practitioners remains unresolved
worldwide. Therefore, this study aimed to determine the
level of awareness and knowledge of medical practitioners
regarding MM in Tshwane Municipality, Gauteng province,
SA. This study will assist medical practitioners to have a
high index of suspicion when patients present for the first
time with symptoms, leading to early diagnosis thus
preventing complications.
Methods
Study design and seng
A cross-sectional descriptive study was carried out among
medical practitioners in three district, one regional and one
central hospitals. The tertiary hospital was used as a pilot
site, and the data obtained was included in the main data as
there were no changes made. Communication was sent via
emails and telephonically to four district and one regional
hospitals. After engaging with management for all five
hospitals for more than a year, permission was only
obtained from four of them. Data were collected over
3 months from 04 March 2019 to 31 May 2019, and during
the study period, the selected hospitals had 157 medical
practitioners (Table 1).
The bed capacity for the district and regional hospitals ranges
from 50 to 414 beds. There are, on average, 53 clinics that are
referring to these hospitals. The average distance from these
hospitals to a higher level of care is approximately 30 km.31
Study populaon, inclusion and exclusion
criteria
The study population included all qualified medical
practitioners such as interns, community service officers,
medical officers, registrars and specialists in other disciplines
working at the selected hospitals. The study excluded all
clinical managers because the majority do administrative
duties.
TABLE 1: Summary of the number of doctors per hospital.
Hospitals Number of doctors Sample size proporonal to size
A 40 19
B60 28
C27 13
D 10 5
E20 9
Total 157 74
FIGURE 1: Level of awareness and knowledge about mulple myeloma.
0
10
20
30
40
50
60
70
80
90
100
Yes No Yes No
Awareness Knowledgeable
Percentage

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Sample size and sampling procedures
A minimum sample size of 74 medical practitioners was
required for this study, considering a study population of
157, a 95% confidence interval and a sampling error of 5%.
The calculation of the sample size was performed in the Epi-
Info program version 3.01 and allocated proportionally to the
selected hospitals based on the number of medical
practitioners (Table 1). The medical practitioners were
recruited using a non-random convenience sample, and all
(N = 157) received an invitation to participate in the study
through their clinical managers, with a weekly follow-up
reminder. The medical practitioners available during the
facility visits were included in the study.
Data collecon
The self-administered questionnaire was used to collect the
data. The researchers developed the questionnaire by
reviewing relevant literature.25,26,27,28 The questionnaire has
four parts. Section A is about respondents’ demographic data
such as age, gender, rank, year in which the medical degree
was completed, discipline and three yes and no questions on
the education obtained on multiple myeloma. Section B and
C consist of four (4) questions that assessed awareness and
nine (9) questions for knowledge of MM. The answers to the
questions were true or false and do not know, and the correct
answers were coded as 1, incorrect and do not know as 0.
The score was calculated for each participant by summing up
the points of all the questions and the score ranged from 0 to
4 for awareness and 0–9 for knowledge. Participants whose
scores were 50% or more were considered to be aware and
knowledgeable of MM practices. The questionnaire content
validation and relevance were performed by a panel of
independent consultants in the discipline of haematological
pathology and piloted at DGMAH. Section D covered the
respondents’ exposure and need for training.
Data analysis
The data were entered into Microsoft Excel 2016 (Microsoft
Corporation, Redmond, Washington, DC, United States) and
analysed using SPSS® statistical software (version 13.0 SPSS
Inc, Chicago, Illinois) respectively. The percentages and
numbers were used to present categorical data such as gender
(i.e., male/female), years completed medical degree (i.e., ≤ 5,
6–10, 11–19 and 20+), rank (medical interns, community
service officer (CSO), medical officer (MO), registrar, family
physician, other speciality specified) and discipline, whereas
median and interquartile ranges were used for the continuous
variables (i.e., age, awareness and knowledge score for MM).
Logistic regression was used to determine associations
between dependent variables (i.e., medical practitioners’
awareness and knowledge regarding MM) and independent
variables (i.e., age, gender, years completed medical degree
and rank). In a bivariate logistic regression analysis, a
p-value of less than 0.05 was considered statistically
significant.
Ethical consideraons
The study obtained ethical approval from Sefako Makgatho
Health Sciences University Research Ethics Committee
(Ref: SMUREC/M/178/2017). The permission to conduct
the study was obtained from the Gauteng Provincial
Department of Health and the superintendents of each
hospital. All the participants completed the informed
consent before completing the questionnaire and were
assured of anonymity.
Results
Demographic characteriscs
Seventy-four medical practitioners participated in this study
(response rate: 100%). Their median age was 37 years, with an
interquartile range (IQR) of 43–30 years. More than half of the
doctors were medical officers aged < 40 years. Fifty-two
percent of the doctors were ≤ 10 years of experience post-
medical degree. Males and females were equally distributed
(Table 2).
Level of awareness and knowledge of mulple
myeloma
The median score for awareness of MM was 4 (IQR: 4–3), and
85% of the respondents were aware of MM as a medical
condition. The median score for knowledge of MM was 6
(IQR: 7–4). Seventy-four percent of the respondents were
knowledgeable about MM presentation and diagnostic
investigations (Figure 1).
TABLE 2: Demographic characteriscs of the respondents (N = 74).
Variable n%
Age (years)
< 30 17 23
30–39 22 30
40–49 24 32
50+ 8 11
Missing 3 4
Gender
Male 36 49
Female 36 49
Missing 2 2
Rank
Medical interns 9 12
CSO 3 4
MO 40 54
Registrar 11 15
Specialist 9 12
Missing 23
Years completed a medical degree
≤ 5 25 34
6–10 13 18
> 10 30 40
Missing 6 8
Discipline
Family Medicine 7 78
Obstetric and Gynaecology 1 11
Paediatric 1 11
CSO, community service ocer; MO, Medical ocer.

Page 4 of 6 Original Research
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Regarding individual items for awareness and knowledge
of MM, the most frequent response was that MM is a
malignant plasma cell disorder, not an infectious condition
and can be diagnosed by markedly elevated erythrocyte
sedimentation rate (ESR) and pathological fractures. The level
of awareness and knowledge by rank is shown in Table 3.
As shown in Table 4, male medical practitioners, ≥ 10 years of
experience were more aware of MM when compared to
other categories of doctors.
Although male medical practitioner, medical officers, registrar
and who had 10 or more years of experience were more
knowledgeable than the other groups, the results were not
statistically significant (p < 0.05; Table 5).
Regarding training on MM diagnosis, 69% of the participants
said they received training about MM practices as
undergraduate students, but few (8%) said they had
attended an educational event on MM after qualifying
(Table 6). Nearly all (98.7%) participants said they would
benefit from an educational event and information brochure
on MM.
Discussion
This is the first study to investigate the level of awareness
and knowledge of MM and associated factors among
medical practitioners in public hospitals in SA. The findings
show that more than two-thirds of the participants had a
high level of awareness and knowledge of MM. Studies
conducted in the United Kingdom (UK) found that under
60% of the general practitioners (GPs) or trainees (n = 58)26
and haematology healthcare professionals (n = 55),25
had knowledge and awareness, but these studies
assessed the level of awareness and knowledge of MGUS.
In Kenya27 and Nigeria,28 researchers reported very low
awareness of the signs and symptoms of MM among doctors
without conducting formal surveys. The reason for the
higher level of awareness and knowledge in our study is
not clear, but it could be that individual practitioners may
have seen more MM cases throughout their careers given
that MGUS is mainly diagnosed by pathologists when
patients do not meet diagnostic criteria for MM.11,12,13
Interestingly, even though our findings revealed a high level
of awareness and knowledge of MM as compared to UK,
Kenya and Nigeria, nearly all (98.7%) of the medical
practitioners in our study requested an educational brochure
on MM practices. This is supported by the high number of
MM patients referred to our tertiary setting with advanced
stage of the disease, which could be related to the low index
of suspicion of MM among medical practitioners.13,21,22,23,24
General practitioners and medical officers at district hospitals
need to be aware of the disease as the majority of the patients
with non-specific symptoms of MM get to be seen by them as
their first point of call from the clinics. This will save many
patients from developing complications such as pathological
fractures.
TABLE 6: Educaon on mulple myeloma.
Variable Yes No
n%n%
Received training about MM as an
undergraduate student?
51 69.0 24 31.0
Ever aended an educaonal event on
MM post-graduaon?
68.0 68 92.0
Would you benet from an educaonal
event/informaon brochure on
mulple myeloma?
73 98.7 11.3
MM, mulple myeloma.
TABLE 3: Awareness and knowledge of mulple myeloma by ranks.
Rank NAware*Knowledgeable**
n%n%
Medical interns 9 9 100 4 44
CSO 3 3 100 3 100
MO 40 34 85 31 78
Registrar 11 982 982
Specialist 9 667 667
CSO, community service ocer; MO, medical ocer.
*, p = 0.496; **, p = 0.324.
TABLE 4 : Associaon between awareness of mulple myeloma and demographics.
Variable Aware Bivariate logisc regression
Yes No OR 95% CI p
n%n%
Age (years) 0.736
< 40 34 87 5 13 Ref - -
40+ 27 84 5 16 0.8 0.2; 3.0 -
Gender 0.057
Female 28 78 8 22 Ref - -
Male 34 94 2 6 4.9 0.9; 24.7 -
Rank
Specialist 667 3 33 Ref - -
MO 34 85 615 2.8 0.5; 14.5 0.212
Registrar 982 2 18 2.3 0.2; 17.8 0.442
CSO/Interns 12 100 0 0 1.0 0.3; 1.2 0.550
Years since compleng a medical degree 0.164
≤ 10 34 90 4 10 Ref - -
> 10 23 77 7 23 0.4 0.1; 1.5 -
CSO, community service ocer; MO, medical ocer; CI, condence interval.
TABLE 5 : Associaon between knowledge of mulple myeloma and demographics.
Variable Knowledgeable Bivariate logisc regression
Yes No OR 95% CI p
n%n%
Age (years) 0.543
< 40 28 72 11 28 Ref - -
40+ 25 78 7 22 1.4 0.5; 4.2 -
Gender 0.789
Female 26 72 10 28 Ref - -
Male 27 75 9 25 1.2 0.4; 3.3 -
Job category
Specialist 667 3 33 Ref - -
MO 31 78 9 22 1.7 0.4; 8.2 0.498
Registrar 9 82 2 18 2.3 0.3; 17.8 0.442
CSO/Interns 7 58 5 42 0.7 0.1; 4.2 0.698
Years since compleng a medical degree 0.835
≤ 10 27 71 11 29 Ref - -
> 10 22 73 827 1.1 0.4; 3.3 -
CSO, community service ocer; MO, medical ocer; CI, condence interval.

Page 5 of 6 Original Research
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Concerning the demographics, more than half (54%) of
respondents were MOs, which shows the significant role
played by these health workers in the diagnostic referral
pathways of MM. This concurs with the findings of previous
studies, which show that the majority of MM patients
initially consulted a GP outside the haematology unit.23,32,33,34
Therefore, appropriate awareness and knowledge of MM
among GPs are essential for early diagnosis and referral of
MM cases. In our study, slightly one-third (34%) of the
participants had completed their medical degree within the
last 5 years, which is lower than 43.1% reported in a UK
study that showed lower awareness and knowledge of
MGUS among GPs and/or primary care physicians.26
Elliss-Brookes and colleagues in their UK study found that
many MM cases (37%) were diagnosed within the emergency
department, 13% in other outpatient departments and 27%
were GP referrals.35 In contrast, a retrospective study carried
out among 582 patients at the Steve Biko Academic Hospital
in SA found that the majority of the MM patients were
commonly diagnosed in orthopaedic and internal medicine.13
Interestingly, in the present study, the majority (63%) of the
medical practitioners were stationed in family medicine,
internal medicine, general surgery, orthopaedic and
emergency department. Thus, the medical practitioners in
these disciplines are more likely to have seen more MM
cases, which supports the high level of awareness and
knowledge of MM observed in this study. Our findings
showed that male practitioners were five times more likely to
be aware of the MM than females, and this could be because
males (61%) made up the majority of the GPs compared to
39% of females, of which GPs are the most common
practitioners patients initially consult.17,36,37 Our finding also
found that participants with six or more years post-medical
degrees were aware of MM, which shows that most of the
respondents in our study were experienced.
The Tackling Early Morbidity and Mortality in Multiple
Myeloma (TEAMM) trial undertaken in the UK evaluated
the routes to diagnosis in patients with myeloma and the
relationship between diagnostic pathways, time to diagnosis
and disease severity among 915 patients. This UK study
found that 51% of the patients were diagnosed by direct
referral from primary care to haematology, while 29% and
20% were diagnosed and referred via acute services and
other specialities, respectively.38 The TEAMM trial also noted
that patients diagnosed via other secondary care specialities
significantly had a longer diagnostic interval38 and most of
these patients were found to experience the highest frequency
of complications.23,38 Although our findings showed a good
level of awareness and knowledge about MM, the late
presentation of patients to a healthcare facility 13,19,20 because
of a low level of suspicion by clinicians,13 the inadequacy of
diagnostic infrastructure in the facilities,20 diagnostic and
referral delays of MM among GPs24 remains a challenge in
sub-Saharan African countries. Therefore, there is a need to
raise awareness of this condition among the general public,
address diagnostic infrastructural deficiencies in healthcare
facilities and improve referral pathways from primary care
physicians to a haematologist.
This study has several limitations. It is a single time point
study, with a small sample size and involved medical
practitioners in one of the three municipalities in Gauteng
Province; therefore, the results cannot be generalised to all
medical practitioners working in hospitals in the province.
The limitation of this study is also acknowledged for not
assessing the medical practitioners’ practices of MM, which
could assist in determining the reasons for the low suspicion
index of MM among clinicians resulting in patients’ initial
symptoms being ignored or missed.
The other limitation of the study is that the level of awareness
and knowledge was not shown at different levels of care
(district, regional and central hospitals). This finding would
give an idea if where the patients present first there was a
lack of awareness or knowledge or vice versa. Despite these
limitations, this study established a high awareness and
knowledge of MM in public hospitals in the Tshwane region.
Factors associated with awareness include gender and years
of completing a medical degree.
Conclusion
In conclusion, our findings have highlighted a higher
proportion of the participants had a high level of awareness
and knowledge of MM. Despite this, MM patients referred to
our tertiary setting were found in the advanced stage of the
disease. Given the challenges in suspecting MM in patients in
a primary care setting and the worse disease-free survival rate
with debilitating complications seen in our patients, our study
recommends continuous training of medical practitioners
through continued professional development (CPD) meetings
at the district hospitals, to increase their index of suspicion
for MM.
In addition, medical practitioners from referring institutions
without comprehensive cancer treatment facilities should be
encouraged to timely refer MM patients to haematological
services on time. Further studies with a larger sample are
required to assess the level and identify factors associated
with awareness, knowledge and practices of MM among
medical practitioners. Moreover, other studies are required
to assess healthcare professionals that work at non-specialised
units such as casualty as well as primary care nurses as most
primary health care clinics in South Africa are nurse-driven.
Acknowledgements
We would like to acknowledge Dr Janin Alanin for the
contribution to the study.
Compeng interests
The authors declare that they have no financial or personal
relationships that may have inappropriately influenced
them in writing this article.

Page 6 of 6 Original Research
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Authors’ contribuons
A.M.P and A.N.D. drafted the protocol write-up, applied
for ethical clearance, collected data and participated in
writing and editing the manuscript. S.T.N. analysed data
and wrote the manuscript for submission.
Funding informaon
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Data availability
The authors confirm that the data supporting the findings
of this study are available within the article. Table 1, Table 2,
and Table 3 in the article have associated raw data.
Disclaimer
The views and opinions expressed in this article are those of
the authors and do not necessarily reflect the official policy
or position of any affiliated agency of the authors.
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