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Table of Contents
Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 170-176

Knowledge, attitude, confidence, and barriers in the practice of erectile dysfunction screening among primary health-care providers in Taiping Perak, Malaysia

1 Department of Primary Care Medicine, Simpang Health Clinic, Ministry of Health, District of Larut, Matang and Selama, Penang, Malaysia
2 Department of Public Health, Ministry of Health, District Health Office of Larut, Matang and Selama, Penang, Malaysia
3 Department of Surgery, Penang General Hospital, Ministry of Health, Penang, Malaysia
4 Department of Surgery, Taiping Hospital, Ministry of Health, Taiping Perak, Malaysia

Date of Submission05-Jan-2019
Date of Decision09-Mar-2019
Date of Acceptance29-Mar-2019
Date of Web Publication29-Jul-2019

Correspondence Address:
Chai Li Tay
Department of Primary Care Medicine, Simpang Health Clinic, Ministry of Health, District of Larut, Matang and Selama, Taiping Perak
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_1_19

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Background: Erectile dysfunction (ED) is a common health problem and has clinical importance. it is well documented that ED is associated with coronary heart disease. However, the practice of ED screening is poor in primary care settings. Objectives: To assess primary health-care providers' knowledge and attitude toward ED and to determine the confidence and barriers in the screening of ED. Materials and Methods: A cross-sectional study using self-administered questionnaires was conducted at 11 government health clinics in Taiping Perak in 2018 involving all health-care providers who run the outpatient and noncommunicable disease unit. SPSS (version 25) statistical package was used to analyze the data. Mann–Whitney U-test, Kruskal–Wallis test, and Chi-square test were employed. Results: A total of 77 primary health-care providers participated in this study. The median age of the participants was 31 years (interquartile range 7). A total of 38 (49.4%) participants scored above the median knowledge. Participants who were doctors, users of clinical practice guide in ED, confident in ED screening, and perceived adequate training scored higher in knowledge (P ≤ 0.05). Smoking as a cause of ED (98.7%) recorded the highest percentage of correct responses, whereas the prevalence of ED (18.2%) recorded the lowest. All participants perceived ED as an important health issue and felt that proper treatment is required. Only 16 (20.8%) participants had confidence in ED screening practice. Lack of training in ED screening and assessment was the barrier that significantly affects the confidence of practice (P = 0.012). Conclusion: The knowledge on ED and confidence in its screening were unsatisfactory among the primary health-care providers. Our work suggests the requirement to equip health-care professionals with adequate training on ED screening, assessment, and management for early prevention of cardiovascular disease and improvement of men's quality of life.

Keywords: Erectile dysfunction screening, Malaysia, primary health-care providers

How to cite this article:
Tay CL, Abdul Razak AR, Tan CK, Tan MZ. Knowledge, attitude, confidence, and barriers in the practice of erectile dysfunction screening among primary health-care providers in Taiping Perak, Malaysia. Urol Sci 2019;30:170-6

How to cite this URL:
Tay CL, Abdul Razak AR, Tan CK, Tan MZ. Knowledge, attitude, confidence, and barriers in the practice of erectile dysfunction screening among primary health-care providers in Taiping Perak, Malaysia. Urol Sci [serial online] 2019 [cited 2021 Jan 19];30:170-6. Available from: https://www.e-urol-sci.com/text.asp?2019/30/4/170/263644

  Introduction Top

Erectile dysfunction (ED) is defined as the persistent inability to maintain or achieve an erection of sufficient rigidity to have satisfying sexual activity for at least 3 months.[1] The prevalence of ED was 69.5% among men attending a primary care setting in Malaysia.[2] The problem of ED is mainly linked to age, as shown in a Malaysian study that the prevalence of ED increased from 49.7% of men in their 40s to 66.5%, 92.8%, and 93.9% of men in their 50s, 60s, and 70s, respectively.[2]

Men with ED are more likely to have coronary heart disease (CHD). ED and CHD share many risk factors such as diabetes mellitus, hypertension, smoking, dyslipidemia, and aging. Besides, the same vascular and endothelial changes that take place in the coronary arteries are likely to occur in the cavernosal arteries that supply the penile erectile tissue.[3] Although ED is a common health issue, only about one in ten men with ED between 18 and 59 years of age seek medical advice about their problem.[4] There are two major reasons for overlooking ED as a major health disorder. First, the majority of men with ED do not seek medical advice mainly because of social or religious factors; concerns about embarrassment; indifference; and fears about the side effects of treatment. Second, the majority of doctors do not explore enough to identify men with ED or encourage them to seek treatment.[5]

In the present study, the prevalence of ED among those with diabetes or heart disease was the highest (89.2%) followed by hypertension (80.4%).[2] However, ED screening for diabetic men was not executed well in our primary care setting. Out of the total 7472 diabetic men who frequented public primary care clinics in the districts of Larut, Matang, and Selama, Taiping Perak, only 1371 (18.3%) were screened and 38 (2.8%) were diagnosed to have ED in 2017.[6] Therefore, this study was conducted to determine the knowledge level on ED and its associated factors; to know the attitude, confidence, and barriers in the ED screening; and to determine the association between barriers and confidence in its practice.

  Materials and Methods Top

There were a total of 14 government health clinics in Taiping Perak. After excluding three small health clinics without noncommunicable disease (NCD) unit, this cross-sectional study was conducted at 11 government health clinics from August 15, 2018, to October 15, 2018. By universal sampling, all doctors and paramedics from these health clinics, including family medicine specialists (FMS), medical officers, medical assistants, and nurses who run the outpatient and NCD unit, were invited to participate. Those health-care providers who only run the maternal child health unit, general practitioners from private clinics, and support staff were excluded from the study.

A questionnaire with total 107 items was designed to collect information on the demographic data of the recruited primary health-care providers (12 items), knowledge (76 items), attitudes towards ED (5 items), confidence (1 item), practices (3 items), and barriers (10 items) in the screening of ED at the primary care setting. There were three options in the knowledge section of a nominal Likert scale (true, false, and don't know). There were five options in the attitude section (strongly agree, agree, neutral, disagree, and strongly disagree). The confidence level in ED screening was evaluated using a Likert scale from 1 to 5, ranging from not confident at all, not confident, neutral, confident, to very confident.

The questionnaire was designed by the principal investigator based on the Malaysian Erectile Dysfunction guidelines and literature search. For content validity, the questionnaire was modified after reviewed by four experts: two surgeons and two FMS. In order to ensure the reliability of the questionnaire on knowledge, internal consistency was tested using Cronbach's alpha on each knowledge question. The Cronbach's alpha coefficient ranged from 0.90 to 0.91. The maximum score for knowledge was 76 marks. One mark was given for the correct answer and zero mark for the wrong or don't know answer. A single open-ended question was provided for the participants to mention barriers that were not stated in the options.

The questionnaires were distributed to the participants at the respective health clinics. Written consent was obtained from the participants. They were given protected time to answer the questionnaires which were collected upon completion. Incomplete questionnaires were excluded.

Statistical analysis was done using the IBM SPSS Statistics for Windows, Version 25.0. (IBM Corp., Armonk, NY, USA) statistical package. Nonparametric data were presented as median with interquartile ranges (IQRs). Categorical data were presented as frequency with percentages. Mann–Whitney U-test and Kruskal–Wallis test were used to compare the knowledge of ED with the participants' characteristics, attitudes, confidence, and practice. Chi-square test was employed to determine the association between barriers and confidence in the screening of ED. The level of significance was set at 0.05.

The approval to conduct this study was obtained from the district health officer of Larut, Matang and Selama, and the Medical Research and Ethics Committee (MREC) of the Ministry of Health, Malaysia via the National Medical Research Registry (NMRR) with assigned number NMRR-17-3157-39132.

  Results Top

Sociodemographic data

A total of 78 participants were approached for this study and all consented to participate. After excluding one incomplete questionnaire, 77 questionnaires from 58 (75.3%) doctors, 14 (18.2%) medical assistants, and five (6.5%) nurses were analyzed, and the response rate was 98.7%. The median age of the participants was 31 years (IQR 7), with the youngest being 25 and the oldest being 57 years old. Majority of the participants were females (53.2%), married (76.6%), and doctors (75.3%). Most of them had no working experience in surgical department (59.7%) and <10-year working experience at health clinics (83.1%). Only seven (9.1%) and three (3.9%) doctors achieved diploma and master in family medicine, respectively. Merely six (31.6%) paramedics received post diploma basic training [Table 1].
Table 1: Association between knowledge score and demography (n=77)

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Knowledge score

The median knowledge score on ED was 48 (IQR 14.5), and 38 (49.4%) participants scored above the median [Table 2]. The presence of sexual desire among men with ED (88.3%) recorded the highest percentage of correct responses for general information on ED, whereas the prevalence of ED recorded the lowest (18.2%). For the causes of ED, smoking (98.7%) recorded the highest percentage of correct responses and urinary tract infection recorded the lowest (31.2%). As for the medication-associated ED, beta-blockers (76.6%) recorded the highest percentage of correct responses, whereas hyoscine (24.7%) recorded the lowest [Table 3]. Nearly 50%–70% of the participants had a misconception that methyldopa, spironolactone, nonsteroidal anti-inflammatory drugs, and ketoconazole are not associated with ED. Almost 32%–39% of the participants disconcerted that metformin, gliclazide, and insulin are associated with ED.
Table 2: Description on the knowledge score (n=77)

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Table 3: Important questions and results of knowledge on erectile dysfunction (n=77)

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For the type of ED, the highest percentage of correct responses was gradual deterioration in organic ED (80.5%) and the lowest was the presence of morning penile stiffness in psychogenic ED (46.8%). For ED assessment, only 19.5% and 39% of the participants answered correctly on the number of grading of Erection Hardness Score (EHS) and the number of items in the International Index of Erectile Function (IIEF) questionnaire, respectively. For the investigations of ED, the highest percentage of correct responses was fasting blood glucose and serum testosterone (89.6%) and only 31.2% correctly answered that serum estradiol was an unnecessary test [Table 3]. There were 92.2%-94.8% of the participants correctly answered that quit smoking and weight reduction were nonpharmacological management for ED.

For pharmacological therapy, 72.7% and 83.1% of the participants correctly answered that phosphodiesterase-5 inhibitors (PDE-5i) are contraindicated in patients with stroke and unstable angina, respectively, whereas only 23.4% correctly answered that PDE-5i cannot initiate erection. For the side effects of PDE-5i, the highest percentage of correct responses was headache (83.1%) and the lowest was rhinitis (33.8%). The highest percentage of correct responses on the other treatment options of ED were testosterone replacement therapy (71.4%), intracavernosal injection therapy (70.1%), vacuum device therapy (66.2%) and the lowest was venous ligation surgery (35.1%) [Table 3].

Associated factors of knowledge score

Overall, doctors had significantly higher scores compared to paramedics with regard to the knowledge on ED (P = 0.002). However, there was no significant association between working duration at health clinic, previous working experience at surgical department, academic achievement for doctors or paramedics, and the knowledge score (P > 0.05) [Table 1].

Participants mostly received information regarding ED from the NCD course in our district that included 30-min lecture on ED (62.3%), from colleagues (41.6%), and from clinical practice guide (CPG) in ED (40.3%). Participants who received the information from CPG had higher knowledge on ED (median score 51.0) compared to those non-CPG users (median score 46.5) (P = 0.008) [Table 4].
Table 4: Knowledge score and source of information (n=77)

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All participants agreed that ED is an important health issue and patients with ED should get proper treatment. Around 97.4% of the participants agreed that ED screening is beneficial for patients. More than 80% of the participants agreed that ED is preventable in most men. Nearly 10.4% of the participants who agreed that their training on ED screening and assessment was adequate had higher knowledge score on ED (P = 0.004) [Table 5].
Table 5: Knowledge score, attitude, confidence, and practice in erectile dysfunction screening (n=77)

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Only 52 (67.5%) participants had previous practice on ED screening with a median of 10 (IQR 18) patients for the past one year. The majority screening target was diabetic patients (98.1%). The screening tools used were International Index of Erectile Function (IIEF-5) questionnaire (76.9%) and Men's Health Screening Form, Ministry of Health Malaysia (BSSK/L/2008 Pind1/2014) (15.4%).

Barriers and confidence in erectile dysfunction screening

Only 16 (20.8%) participants were confident to screen patients for ED. Participants with higher level of confidence in the practice of screening of ED had significantly higher knowledge on ED (P = 0.05) [Table 5]. Participants mostly perceived the barriers of practicing ED screening to be participants' lack of training on ED screening (83.1%), shortage of consultation time (77.9%), patients' refusal for ED screening (77.9%), elderly age (64.9%), coexisting medical comorbidities (62.3%), and no sexual partner (51.9%). Less than 50% of the participants perceived health-care providers' younger age, female gender, taboo, and lower socioeconomic status as the barriers of ED screening practice. Lack of training on ED screening was the only barrier that was significantly associated with lower confidence among the primary health-care providers in the practice of ED screening (P = 0.012) [Table 6].
Table 6: Barriers and confidence in erectile dysfunction screening (n=77)

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  Discussion Top

Vasculogenic ED, especially in younger men with no cardiac symptoms, should be regarded as a harbinger of future cardiovascular disease (CVD). The interval of development of ED with the presentation of CHD symptoms and a fatal cardiovascular event (stroke and myocardial infarction) is 2–3 years and 3–5 years, respectively.[7] Some prospective studies have also shown that ED is a marker of cardiovascular risk; hence, an appropriate cardiology work-up and identification of any risk factors should be mitigated.[8] There is limited data on the benefits of ED screening to all men. Thus, in the primary care setting, health-care providers mainly screen diabetic men for ED because patients with diabetes are found to be at least three times more likely to develop ED than patients without diabetes.[9]

A qualitative study indicated that perception of ED as “less important disease” was a major barrier in the treatment of ED.[10] All participants in our study had good perception that ED is an important health issue and proper treatment is required. This positive attitude is essential to ensure that those who have ED should seek proper treatment. The perception by all participants that ED is an important health issue could be influenced by our NCD unit that included the data collection on ED screening in all diabetic men. This perception could be exaggerated as ED may not affect all men's lives, especially those without sexual partners. Majority felt that ED screening is beneficial and ED is preventable. This is because ED predicts acute coronary syndrome, supporting the artery-size hypothesis and the role of ED screening for preventing a subsequent CVD event, especially in men with hypertension, diabetes mellitus, and dyslipidemia.[11] The gender distribution was almost equal, and majority of the participants were married in our study. Gender and marital status did not significantly affect the knowledge scores, reflecting that social and cultural factors may not account for the significant gap in the participants' knowledge on ED.

Despite good attitude, the overall knowledge scores for the primary health-care providers were below the expected standard. Participants who were doctors, those retrieved information from the CPG in ED, confident in ED screening, and perceived adequate training in ED screening and assessment had higher knowledge score. Comprehensive information on ED in the CPG equipped the participants with better knowledge. Only one-fifth of the participants were confident in the practice of ED screening. Lack of training is the only barrier that significantly affects the confidence and the knowledge level on ED screening.

Almost all the participants perceived that smoking can cause ED. ED screening could be considered for those smokers who smoke more than 10 cigarettes per day or for more than 10 years as supported by a meta-analysis by Cao et al. who indicated that the risk of ED increases from 14% to 15% significantly in these groups of smokers.[12] The Hallyn longitudinal study showed that there was a significant association between the severity of lower urinary tract (LUT) disorders and prevalence of ED.[13] Majority of our participants were unaware that LUT infection is one of the causes of ED. Education on the link of LUT infection and ED should be imparted to the health-care providers. In this study, the fact that there is presence of morning penile stiffness was not well understood by most of the patients with psychogenic ED. There is an association between depression and ED; therefore, patients reporting with ED should be routinely screened for depression and vice versa.[14] The components of IIEF questionnaire and EHS were not well comprehended by the participants probably because of lack of training and practice in ED screening.

The first-line therapy for the majority of patients with ED is the use of selective PDE5i, which is associated with an efficacy of 60%–70%.[15] However, we need to educate the health-care providers and patients that PDE5i is not effective for all patients and the underlying cause should be treated. Majority of the participants had a misconception that PDE5i can initiate erection; in fact, PDE5i could not initiate erection and hence sexual stimulation is still needed.[16] Primary care settings emerge to be more comprehensive centers from screening to management and some have equipped with men's health services. Adequate training on ED screening, assessment, investigation, and management should be imposed on our primary health-care providers to improve the knowledge and practice so that men's health quality would be further improved.

More than half of the participants perceived that patients' refusal, coexisting medical conditions, older age, and absence of sexual partner were barriers to ED screening. In general, health-care providers prioritize on physical health instead of sexual health due to the limited consultation time and lack of training without realizing that sexual activity does not disappear with age; 45.9% of men aged between 50 and 89 years have sex at least twice a month.[17] We need to educate that the onset of ED in an elderly man is an accurate marker of reduced life expectancy at 7 years and a biomarker of increased risk of mortality.[18] Health-care providers' younger age and female gender were the contributing barriers, and a study also reported that this group of providers were less likely to take sexual histories of patients.[19] Training in communicating with men on this sensitive topic is needed, especially for this group of providers.

Treating ED encompasses more than simply restoring sexual satisfaction, but also restores better self-esteem, quality of life including CVD prevention and mental health, loving family life, and social relation.[20] The ability to predict atherosclerotic involvement of coronary arteries within 2–5 years via ED screening enables us to escalate early modification of risk factors of CHD. Therefore, ED is a crucial men's health issue that needs to be incorporated into all risk-screening programs in primary care settings for better quality of care.

Strengths and limitations

  • This study indicates poor knowledge and low confidence in the practice of ED screening among primary health-care providers, implying that effort should be made to provide adequate training which include the use of CPG in ED to improve their knowledge and confidence
  • This study was conducted at government primary care centers in Taiping; hence, these findings are not generalizable to the whole of Malaysia.

  Conclusion Top

We recommend that undergraduate and postgraduate training programs on ED should be modified with full CPG in ED utilization by primary care doctors and paramedics to emphasize knowledge on early detection, evaluation, and management of ED. Health policy planners should plan to improve the public awareness regarding the importance of early diagnosis and treatment of ED, especially for men with NCD and chronic smokers.


The authors would like to thank Professor Dr. Chirk Jenn Ng for his inspiring guidance in men's health research and surgeons Mr. Voon Yen Fong, Dr. Samuel Leong Kheng Wong, and Dr. Peter Jerampang, FMS, in the help of questionnaire review.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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