Factors Associated with Knowledge, Attitude, and Practices of Physicians related to Autism spectrum disorder in Romania

An inadequate level of general knowledge of physicians regarding mental health, including Autism Spectrum Disorder (ASD) not only could have adverse effects on affected individuals’ health and quality of life, but also could further delay its diagnosis and initiation of timely interventions. The purpose of this survey was to assess the level of knowledge, attitudes, and practices (KAP) of physicians regarding ASD in Romania and identify their associated factors. composite potential causes, behavior, and educational needs associated with ASD knowledge. We determined the variables associated additively or interactively with regarding by applying General Linear Models to the ve as dependent variables.

Several studies from different countries have assessed the knowledge, attitude, and practices of physicians regarding ASD [31][32][33][34][35], and studies from many countries such as Turkey [31,35], Pakistan [33,34], Nepal [36], and Nigeria [32] all noted a de ciency in ASD knowledge among physicians. Studies from Pakistan [33,34] also reported a signi cant degree of misconceptions regarding ASD among general practitioners and physicians. In addition, Minhas et al. highlighted a high degree of stigma, lack of available services, and the limited levels of ASD knowledge in general physicians in Pakistan and India, which takes a signi cant toll on parents and reduces their faith in the medical professional's ability to help children with ASD [37]. This study also noted that physicians specializing in ASD and other mental health conditions stay within urban areas, leaving rural populations with little to no support [37]. Some studies indicated a lack of formal training regarding ASD and the management of diagnosed children in terms of the available options [38,39]. On the other hand, other studies have also shown that physicians that specialized in ASD, and/or had experience with ASD scored higher in knowledge assessments regarding ASD [40,41], were able to understand the need for an early diagnosis [40,42], had a more positive attitudes towards those with ASD [40,43], and were able to better handle children with ASD in their practice [39].
Romania is an ethnically diverse, upper-middle-income country in Eastern Europe [44,45]. The 2002 reformations to the 1997 Romanian Social Health Insurance Act provided a more comprehensive health insurance [46], and comprehensively covers roughly 85% of the population [47]. Statistics from 2016 show that Romania has approximately 2.26 physicians per 1,000 population [44]. It is also estimated that there are approximately 1,018 new cases of mental disorders per 100,000 annually, and roughly 1% of the population in Romania suffer from mental disorders [48]. Additionally, the National Program for Health Evaluation, Health Promotion, and Health Education that is supported by the O ce of the United Nations High Commissioner for Human Rights (OHCHR) reported that the most frequent mental health disorders in children and adolescents in Romania are: anxiety disorders, depression, Attention De cit Hyperactivity Disorder (ADHD), aggressive behavior (bullying), and ASD [49]. Based on a 2016 cohort of over 9000 children from 122 regular schools and 95 schools for children with special education needs (SEN), researchers in Romania reported a prevalence of 14.3% for ASD in children aged 7-9 years old [50]. However, since the study population for this study involved children with SEN, this estimated prevalence of 14.3% is clearly an overestimate and suffers from a serious selection bias, and may not accurately represent the ASD prevalence of Romania's population. Additionally, Romania's relatively limited service infrastructure for ASD diagnosis and lack of services for adults with ASD in most regions of the country [51] may be contributing factors of underreporting and stigma toward ASD in the country.
A signi cant proportion (90.4%) of Romanian children who require psychiatric care initially visit a general physician for advice and guidance [52]. Many of the instruments used internationally for ASD assessment include ADOS [8], ADOS-2 [9], and ADI-R [10] that are considered as the gold standard for assessment of ASD are translated [53][54][55] [59]. For example, the Checklist for Autism in Toddlers (CHAT) and it's other versions are not available for assessment of ASD in Romania [59] but are used internationally to assess a broad range of developmental disorders including ASD in children under 3 years of age. In 2011, the Romanian Health Ministry developed the Screening Questionnaire for Autism Spectrum Disorders [Chestionarul de Screening pentru Tulburări de Spectru Autist (CS-TSA)] modeled after the CHAT to speci cally aid Romanian physicians in the early detection of ASD between the ages of 0-3 years.
[60]. Since 2016, CS-TSA has been included in the subsidized services of the National Health Insurance Company. Since then, it has become mandatory for family practitioners to administer the questionnaire. However, the Romanian medical school curriculum has not changed signi cantly since 1996. The current postgraduate curriculum requires one month of pediatric psychiatry training for family physicians in the residency program and three months of pediatric psychiatry training for pediatricians. Though the medical school curriculum regarding ASD hasn't changed in the past decade, access to more ASD cases, a greater awareness of the disorder in physicians other than specialists, and greater access to knowledge disseminated from other researchers and media (as a potential source for general knowledge about ASD in public) may have contributed to increase in ASD knowledge of Romanian physicians with pediatric psychiatry training.
In this cross-sectional study, we aim to assess the knowledge, attitude, and practices of physicians regarding ASD in Romania. In addition, we investigate factors associated with knowledge about ASD in Romanian physicians. Though a previous study has used factor analysis for a similar assessment [18], to the best of our knowledge, we are the rst study that has assessed association of various factors with knowledge, attitude, and practices of physicians regarding ASD.

Study design
For this survey, investigators at the University of Texas Health Science Center at Houston (UTHealth) and "Carol Davila" University of Medicine and Pharmacy (UMF) collaborated to develop a questionnaire by modifying a previously established questionnaire used in Pakistan [34] and Turkey [35], to assess the knowledge, attitude, and practices of physicians and specialists regarding ASD in Romania. The questionnaire was translated to Romanian and back translated to English by the Romania team to ensure the accuracy of the translations. The study protocol was approved by the Institutional Review Boards

Participants
Participants in this survey were selected from a listing of all the private practices and clinics of physicians in Romania. A volunteer team that included medical students from the "Professor Alexandru Obregia" Clinical Psychiatry Hospital were provided the aforementioned list such that they could assist with distribution and collection of completed questionnaire by physicians or specialists at each of their practices from January to July in 2017. As a result of this effort, they collected a total of 383 completed questionnaires.

Data Management and Quality Assurance of Data
The UTHealth team provided a Research Electronic Data Capture (REDCap) [61] bilingual (in Romanian and English) database for data entry from the questionnaires. We used double-data entry method to minimize discrepant data as part of quality assurance procedures. The Carol Davila team in Romania completed the rst set of data entry in the REDCap database. Then the questionnaires were sent to the UTHealth team in the US for a second round of data entry. Since physicians responded to the open-ended questions in Romanian, we identi ed a graduate student at UTHealth, who is a native Romanian speaker, to translate the responses into English, which were then entered into the REDCap database.

Instruments
The questionnaire for assessing knowledge, attitude, and practices of physicians about ASD The Questionnaire contained three sections. Section A had 19 questions focused on assessing socioeconomic and demographic information including age and sex. This section also inquired about the participant's background in the medical eld and their current practice (e.g., location of clinic, number of patients seen in a day in their practice, etc.). This section ended by asking if the physician personally knew someone with ASD.
Section B had six questions to assess the participants' knowledge and attitude about ASD. This section rst asked if the participant had ever heard of "Autism or Autism Spectrum Disorder." If the participant marked "Yes," then in the following question they were asked to provide the sources where they heard about ASD. All participants were then asked to provide an estimate for the prevalence of ASD in Romania, the US, and globally. The physicians were subsequently asked that out of every 100 children s/he sees in her/his practice how many children have ASD. At the end of this section there was a section comprised of 14 true or false statements that were prepared to assess various aspects of the knowledge, attitude, and practices of the physician about ASD in Romania, for which the response options were in a 5-point Likertscale: "Strongly agree," "Agree," "Undecided," "Disagree," and "Strongly disagree." Section C had six questions designed to assess the participants' practices about ASD. This section assessed the physician's knowledge of available tools to screen children for ASD. They were also asked to list the screening tools they had used in the past, if any. The physicians were then asked about early indicators of ASD in 2-year-old children and what they do when they suspect a child has ASD. Section C continued by asking the physicians about which ASD diagnostic tools they had used in the past ("Have you ever used any of the following to diagnose a child with autism or Autism Spectrum Disorder"). Next the physicians were presented with a 4-point Likert-scale question ("In diagnosing children with autism, the following symptoms are") comprised of 11 accurate or inaccurate symptoms used to diagnose ASD with response options of "Necessary," "Not necessary, but helpful," "Not helpful," and "Don't know." The last question in this section asked physicians to provide their opinion on ways to reduce the prevalence of ASD in Romania.

Sample Size Justi cation and Statistical Power
In order to estimate the proportion of physicians and specialists who are knowledgeable about ASD within a margin of error of 5% with 95% con dence, we needed to survey at least 384 physicians or specialists. Considering that around 5% of the surveys were expected to be incomplete, we planned to survey 400 physicians at the conference. In our survey a total of 383 physicians completed the survey. This sample size is also su cient to detect an effect size of 0.3 or greater with at least 80% power at a 5% signi cance level, assuming the ratio of physicians in the two groups compared (e.g., male vs. female physicians) with respect to their knowledge sub-score ranged from 0.40 to 0.60.

Descriptive Analysis
We used descriptive statistics to summarize various characteristics of the study population, including age and gender of the participants. Some of the open-ended questions were categorized before analysis.
Physicians' age was categorized as a dichotomous variable with categories of ≤ 35 & > 35 years. Since we received a variety of responses for names of the medical schools where the physicians earned their degrees, these responses were reduced to three categories: 1) Carol Davila University of Medicine and Pharmacy, 2) Grigore T. Popa University of Medicine and Pharmacy, and 3) Other Medical Schools. The physicians that responded to the survey had clinics in various cities of Romania, and the responses were categorized based on the number of survey responses received for each city, leaving us with four categories: Bucharest, Suçeava, Brăila, and Other cities. We also asked physicians to write the year in which they completed their most recent continuing education course, for which the responses were divided into: before 2007, between 2007 and 2014, and after 2014. The physicians were also asked to write down how many years they had been practicing medicine, and the answers were reported as more than 30 years, between 16 and 30 years, and 15 years or less.
The responses for the average number of patients each physician saw in his/her practice daily and the average number of patients under the age of 12 seen by each physician in a day were categorized as: ≤ 20 patients, 21-40 patients, and > 40 patients per day. The self-reported responses for the average time a physician spent at his/her practice each day were categorized based on an 8-hour workday (≤ 8 hours and > 8 hours per day). Likewise, responses for the average time a physician spent with each patient was classi ed as ≤ 15 minutes and > 15 minutes. Only binary (yes or no) responses were allowed for other variables such as whether the physician completed speci c ward rotations in or after medical school, and if the physicians had heard of ASD in the past and were reported as such.
All physicians were asked whether they had heard of ASD in the past. If a physician left this question blank, we interpreted that the physician did not know, hence included this in the group that have not heard of ASD. Physicians were then asked to mark where they had heard of ASD as their source of ASD knowledge (SAK). The 10 SAK options provided for selection were: medical school, continuing education, conferences, primary literature, colleagues, television, newspaper, internet, radio, and other sources not included in the list. Physicians were allowed to choose more than one SAK. Responses to the SAK question from physicians that had indicated that they had not heard of ASD or did not respond to the question were included in the analysis as an additional category. This resulted in a three-level variable for each SAK: those who heard of ASD from the selected SAK (Yes); those who heard of ASD but did not hear of ASD from this SAK (No); and those who had not heard of ASD.
Developing sub-scores to quantify various aspects of physicians' knowledge about ASD As part of the questionnaire, a 14-statement Likert-scale question was used to assess the physicians' knowledge about ASD. The responses were initially coded on a 5-point scale: 1-"Strongly agree," 2-"Agree," 3-"Undecided," 4-"Disagree," and 5-"Strongly disagree." Depending on whether the statement in the question was true or false, the "Undecided" groups were merged either with the "Agree" or "Disagree" groups. Since question 2, "Autism is a possible result of neglect by the parents," is false, the physicians who marked "Undecided" for question 2 were merged with the "Agree" and "Strongly agree" groups. Conversely, because question 8, "Children with autism require special education," is true, the physicians who marked "Undecided" for question 8 were merged with the "Disagree" and "Strongly disagree" groups. As a result of this reclassi cation, we derived binary variables based on whether the statements in the question were true or false. Since questions 1, 6, 8, 9, 10, 11, and 12 are true, we recoded "Strongly agree" and "Agree" as 1, and "Undecided", "Disagree" and "Strongly disagree" as 0. For questions 2, 3, 4, 5, 7, and14, which are false, "Strongly agree", "Agree", and "Undecided" were recoded as 0, and "Disagree" and "Strongly disagree" were recoded as 1. We determined that the responses to Question 13, "Parents in Romania tend to think their children are at risk for autism," may not be reliable because the prevalence or risk of ASD in Romania is currently unknown. Additionally, we determined that the responses to Question 9, "Children with autism deliberately misbehave," may not be reliable as they could uctuate depending on how the physicians interpreted the statement. Due to their ambiguous nature, Questions 9 and 13 were excluded from further analyses.
Originally, the 14-statement Likert-scale question was designed to provide an overall score of the physicians' knowledge; however, the resulting scores suggested the possibility of involvement of independent sub-domains in the overall knowledge score. Since the underlying factors in the scale could negate each other's scores, we used Factor Analysis, as described in Samanic,et al. [62], to determine these latent factors. Factors with an Eigenvalue of 1.00 (i.e., % of variance explained by each factor is equivalent to the variance explained by only one variable) or more were retained for the analysis and questions with absolute value of factor loadings of ≥ 0.40 was used for inclusion of that variable in the composite score (weighted score or factor score) for further analysis. Questions 9 and 13 were excluded from this analysis since the responses were deemed unreliable as stated previously. The Factor Analysis resulted in ve composite scores with factor-like sub-scores derived from the questions included in each factor with equal weights of 1. The ve sub-scores used for subsequent analyses are listed and described in Table 1.

Results
Descriptive analysis of demographic and socioeconomic characteristics from the 383 questionnaires revealed that about 75% of the participating physicians who responded were female and more than 80% were over the age of 30. Though all participants graduated from universities in Romania, more than half of the physicians graduated from UMFs (54.3%). Majority of the physicians completed the following rotations during their medical school years: Family medicine (65.8%); Pediatrics (89.3%); and Psychiatry (78.1%). Most participants practiced medicine within the capital city of Bucharest (57.2%) with patients mainly coming from urban areas (72.5%). More than 60% of physicians had practiced medicine for more than 15 years at the time of participating in the survey.

Discussion
To our knowledge, this is the rst study that assessed the knowledge of physicians in Romania about ASD. Also, although there are very few other surveys that have used factor analysis to de ne latent structures (domains), this is the rst survey that has used Factor Analysis to identify ve independent domains for describing different aspects of the knowledge of physicians about ASD. In the following, we will discuss our ndings in the context of each of these important issues.

Level of knowledge of practicing physicians in Romania about ASD
Although the nding from our descriptive analysis indicate that the Romanian physicians are knowledgeable about basic issues related to ASD, the overall responses from different parts of the survey suggest that majority of the Romanian physicians may bene t from additional training or continuing medical education in certain aspects of ASD including assessment and causes of ASD. In the following, we discuss these issues.
Findings from descriptive analysis related to knowledge of Romanian Physician about ASD in Factor Analysis. The ve sub-scores used for subsequent analyses are listed and described in Table 1.
We then used General Linear Models to determine characteristics of physicians associated with these ve sub-scores. It is important to keep in mind that in this kind of situation a single overall knowledge score is not meaningful because the underlying factors in the scale could negate each other's scores, which makes it very di cult to interpret.
Factors associated with knowledge of physicians related to each of the ve domains Furthermore, there are few studies that highlight the stigmatizing views of physicians related to ASD, and no studies that assess the potential sources and in uences of these attitudes in physicians. However, a study of 93 Youth and Family Center physicians from the Netherlands reported that the Dutch physicians who participated in the study had higher stigmatizing attitude toward ASD compared to Western physicians, but lower than non-western physicians [64]. However, the authors found no association between stigma and ASD knowledge. Unfortunately, it is di cult to compare this study to ours as the measurement tools and analysis methods vary signi cantly.
Additionally, stigmatizing attitude regarding ASD and mental illness not only effect service delivery but also may potentially deter medical students from perusing psychiatry as a career choice. A study of 68 psychiatrists, 194 pre-clinical medical students, and 354 post-clinical medical students found that preclinical medical students were more likely to agree that psychiatrists are not real physicians, and that the level of stigmatizing attitudes decreased with increased exposure to the eld of psychiatry [70].
Factors associated with physicians' knowledge of potential cause(s) of ASD (Factor 2) Our ndings from analysis of Factor 2 indicate that younger physicians (≤ 35 years old) were more aware about the potential causes of ASD (AMS difference = 0.72). Similarly, a survey of 348 general physicians in Pakistan reported that physicians less than 30 years of age were more knowledgeable about ASD than their older counterparts [34], and a study of 313 family medicine residents in Turkey also reported that physicians over the age of 35 were less knowledgeable about ASD than the younger residents [35]. This nding may be a result of the continuously expanding pool of research surrounding ASD, and the inclusion of new ndings in school curricula as new knowledge is uncovered. However, this nding also suggests that more efforts are needed to bring awareness about the potential causes of ASD to older physicians through formal continuing education programs. Additionally, physicians who saw 20 or less patients in a day were signi cantly less knowledgeable about potential causes of ASD than physicians who saw more than 40 patients in a day (AMS difference: -0.99), as were physicians that saw between 21 and 40 patients per day (AMS difference: -0.68). Physicians' general knowledge about various disorders including ASD may also increase as medical knowledge expands, and physicians' practices grow and they come across patients with a variety of ailments. [41] Factors associated with physicians' knowledge of the behavior of children with ASD (Factor 3) Older physicians (> 35 years) were more knowledgeable about the behavior of children with ASD than younger physicians (AMS difference = -0.26). Physicians who attended a public medical school were more knowledgeable about the behaviors of children with ASD private school counterparts (AMS difference = -0.57). Experience dealing with children with ASD gained over the years of their practice may provide physicians with a better understanding of the behaviors displayed by ASD children. Additionally, physicians with clinics in Suceava were signi cantly less knowledgeable than their colleagues that had clinics in Bucharest about the behavior of children with ASD (AMS difference = -0.68). Since larger cities, like the Romanian capital of Bucharest, usually house many of the larger educational institutes in the country compared to the smaller cities, physicians from larger cities may have access to more resources and the most up-to-date information about the behavior of children with ASD. Physicians from larger cities may also have more knowledge of this factor as they may be more likely to be exposed to children with ASD than physicians in smaller cities.
Factors associated with the physicians' knowledge of misconceptions about ASD (Factor 4) Though we analyzed various variables using GLM models to determine factors association with physicians' knowledge of misconceptions regarding ASD, we found no signi cant additive or interactive effects for this factor. Even though there were no associations found using basic GLM analyses, future exploratory analyses may be needed to analyze the relationship between this factor and other variables. to qualitatively assess how articles present ASD to the public. The authors found that 110 out of 210 articles reported information in simple and concise clinical language to educate the public about ASD.
Though this study does not assess levels of knowledge for any population, we can see through this paper that newspapers can be a good source of ASD knowledge as long as readers keep in mind that the articles may present ASD knowledge with some bias. [71] It is necessary to assess the knowledge, attitude, and practices of physicians about ASD as their views and background regarding ASD will potentially affect their practice and their diagnosis of children with ASD. Greater knowledge of physicians about ASD is essential for various reasons such as better service delivery [16,72] for ASD children and earlier identi cation of cases for appropriate therapies [34] that rely heavily on physicians' knowledge of ASD. Additionally, greater knowledge of ASD among physicians can also increase the trust between parents, patients, and their physician [37]. Furthermore, as knowledge increases among physicians, they will be able to better educate future generations of physicians. As a result, this may help to decrease the stigma amongst medical students, and hopefully increases the number of students pursuing psychiatry or psychology, further bene tting the Romanian population as well.
While it may be easier to assume that the knowledge score about ASD are additive, further analysis of interactive relationships may help further clarify relationships between factors associated with the subscores. We recommend exploring interactions in other knowledge assessment studies as well to determine variables that may have synergistic effects in in uencing the physicians' knowledge, attitude, and practices about ASD for a deeper and a more precise understanding of the related issues in the context of physicians' knowledge about a complex disorder such as ASD.

Limitations
We acknowledge that for this study we did not select a random sample of physicians who could represent all physicians in Romania. Instead, we used a convenient sampling of physicians who attended the Annual Conference of the Academic Society of Family Medicine in Romania, hence our study may have been in uenced by selection bias and may not be representative of a random sample of physicians practicing in Romania. Since physicians that are interested in ASD are more likely to participate in the study, the responses may be skewed towards physicians that had existing knowledge of ASD. The results may also be in uenced by the non-response bias for some questions. For examples, for some questions e.g., when the questions asked whether they have heard of ASD those who answered "Yes" were identi ed but the remaining answers were left blank. Therefore, for some limited variables it is not clear whether the response to the remaining questions is "No" or other than these two responses. Additionally, due to the nature of some questions such as the practitioner's year of graduation, the study may also have been affected by recall bias. Our study was also dependent on self-reported data regarding knowledge, practice, and attitude of physicians in Romania regrading ASD.

Conclusions
In this study we characterized ve latent domains related to Romanian physicians' knowledge about ASD that include stigma, potential causes, behavior in ASD children, special education needs, and misconceptions related to ASD. Though practicing physicians in Romania have adequate general knowledge about ASD, greater focus is needed on increased awareness of stigma and misconception surrounding this disorder, as well as its symptoms and potential causes. Further studies are needed to analyze the effects of the speci c factors identi ed in this study on ASD knowledge on physicians' perceptions and practices related to ASD.

Availability of data and material
The datasets used for the current survey will not be publicly available due to the identi ability of the individual sources or the location of physicians' practice. However, these data are fully secured and could become available under certain circumstances from the corresponding author based on a reasonable and a justi ed request.
Ethics approval and consent to participate Informed consent was obtained from all participants in the following manner. On the cover page of the questionnaire it is stated that, "By completing this questionnaire, you agree to participate in this study.
The decision to participate is voluntary and you can choose to stop at any time during the project. Any information collected by completing the questionnaire prior to your withdrawal from the study will be destroyed upon request." This project was reviewed and approved by the Commission for the Protection of Human Subjects (CPHS) of the University of Texas Health Science Center of Houston (UTHealth) as Table 1. Distribution of physicians' responses to several statements used for assessing knowledge, attitude, and practices of physicians in Romania about Autism Spectrum Disorder (ASD) and information about the ve sub-scores representing physicians' knowledge about ASD in Romania identi ed based on