Awareness and Attitude of Healthcare Workers to Cosmetic Surgery in Osogbo, Nigeria

This study aimed at understanding the level of awareness and elucidates the attitude and disposition of healthcare workers to cosmetic surgery in Osogbo, Nigeria. A questionnaire-based survey was done at LAUTECH Teaching Hospital, Osogbo, in 2012. Questionnaires were administered to 213 workers and students in the hospital. These were then analysed using SPSS version 16.0 with frequencies, means, and so forth. Respondents were 33 doctors, 32 nurses, 79 medical students, 60 nursing students, 4 administrative staff, 1 pharmacist, and 4 ward maids. There is fair awareness about cosmetic surgery generally with 94.5% and its availability in Nigeria with 67.0%. A fewer proportion of the respondents (44.5%) were aware of the facility for cosmetic surgery in their locality. A large percentage (86.5%) favorably considers facilities outside Nigeria when making choice of facility to have cosmetic surgery done. 85.5% considered the information about cosmetic surgery reliable while 19.0% objected going for cosmetic surgery of their choice even if done free. Only 34.0% consider cosmetic surgery socially acceptable. Although the awareness of health workers about cosmetic surgery is high, their disposition to it is low. There is a need to increase the awareness in order to increase cosmetic surgery practice in Nigeria.


Introduction
The concern of people about their appearance is gradually on the increase both in the developed and the developing world; thus there is an increase in the number of cosmetic surgeries done annually. In the United States, for instance, 11.7 million cosmetic procedures were performed in 2007, with the vast majority being minimally invasive procedures [1]. Even though the rate of rise is not as high as that in the developing countries, the fact still remains that people are getting more concerned with their appearance especially with the increasing standard of living. In Asia, cosmetic surgery has become an accepted practice, and countries such as China and India have become Asia's biggest cosmetic surgery market [2]. It may not appear that plastic and reconstructive surgeries in children are of high priority in a country like Uganda. However, plastic surgery cases may constitute up to 20% of the surgical workload of a rural hospital in sub-Saharan Africa [3], and lack of surgical provision commits otherwise healthy individuals to lifelong disfigurement and functional impairment, as well as educational and social exclusion [4]. A number of factors may underscore the increase in the popularity of cosmetic surgery.
These include the growing importance of physical appearance in contemporary western culture [5,6] which has served to normalize the pursuit of appearance-enhancing behaviours [7]. Higher disposable incomes among patients, advances in surgical procedures (particularly in terms of safety), and the lower cost of treatments have also served to reduce patient anxiety about cosmetic procedures [8].
In spite of the tremendous advancements in the field of plastic surgery, it seems that limited knowledge among the general public exists regarding the spectrum of plastic surgery especially cosmetic surgery. Has the medical community been well informed about cosmetic surgery? The knowledge of the general public about cosmetic plastic surgery will increase in proportion to the knowledge of the health workers who are likely to inform or misinform the general public 2 Surgery Research and Practice about these surgical procedures. These people contribute considerably to the health care of the public.
This study is an attempt to establish the knowledge of the health community in a developing country on cosmetic surgery aspect of plastic surgery and their attitude to this subspecialty.
Understanding the attitude and perception of our medical colleagues and other health workers will be more vital than assessing the knowledge of the public. Students in the clinical years were also involved in this study as a means to have an idea of the awareness and disposition of these professionals to be and thus taking a peep into the future of cosmetic surgery in the country.

Materials and Method
We conducted a questionnaire-based study among a selected group of healthcare providers in a teaching hospital in Nigeria. These include doctors, nurses, medical students, nursing students, pharmacist, administrative workers, and ward maids/assistants to assess their knowledge, attitude, and perception of cosmetic surgery. A well-structured set of questionnaires was administered to this group of selected individuals, and responses were sought and analyzed. Only students that spent at least a year in the clinical part of their training were included. Two hundred and twenty questionnaires were administered.
The questionnaire has 3 parts; the first part assesses biodata and the second assesses the knowledge and awareness of cosmetic surgery while the third part assesses the attitude and disposition of the respondents to cosmetic surgery.
A good number of respondents 101 (47.4%) rated the Nigerian facility to be average with about 147 (69.0%) preferring facilities abroad over Nigerian facilities. One hundred and twenty-six (59.2%) of them feel that the outcome of cosmetic surgeries done outside Nigeria is better than that done in Nigeria.
One hundred and thirty-nine (65.3%) of the respondents considered cosmetic surgery necessary while 103 (60.1%) were ready to advice close relations or associates to go for cosmetic surgery of their choice when need arises. Of all the itemized cosmetic surgery, only cleft surgery was considered a necessary cosmetic surgery by 117 (54.9%) of the respondents.
If cosmetic surgeries were to be done free, only 43 (20.2%) of the respondents would go for cosmetic surgery of their choice. Seventy-six (35.7%) of the respondents felt that people's disposition will change towards them if they went for any cosmetic surgery.
Seventy-four (34.7%) of the respondents consider cosmetic surgery socially acceptable in Nigeria while 64 (30.0%) of them thought it was averagely acceptable. However, 94 (44.1%) and 128 (60.1%) of respondents considered cities and megacities, respectively, as environments where cosmetic surgeries were more acceptable. One hundred and seventy-five (82.2%) felt that cosmetic surgery was more acceptable with those in high socioeconomic class while 142 (66.7%) felt that they were more acceptable to the literates.
Awareness about cosmetic surgery was considered low by 89 (41.8%) of the respondents while 47 (22.1%) of the respondents considered awareness of cosmetic surgery as very low. One hundred and forty-nine (70.0%) of the respondents recommended the need for more awareness of cosmetic surgery in the society.
When considering their religious beliefs and cosmetic surgery, 85 (39.9%) of respondents considered cosmetic surgery to be godly and 175 (82.2%) of respondents were not aware of any beliefs against or taboo about cosmetic surgery.
There is significant statistical relationship between the occupation of respondents and their awareness about cosmetic surgery ( = 0.000); however, there is no relationship between their awareness and their readiness to go for cosmetic surgery ( = 0.877). There is no statistical relationship between the reliability of the information about cosmetic surgery and their readiness to go for cosmetic surgery of their choice ( = 0.368). There is a statistical relationship between the religious background of our respondents and their awareness about cosmetic surgery ( = 0.000). Also the estimation of Nigerian facilities showed statistical relationship with their preference for facilities outside Nigeria ( < 0.000). Sex shows no statistical relationship with the choice of going for cosmetic surgery ( > 0.329); however, females (11.3%) are more likely to consider cosmetic surgery than men (8.9%). This study reported a positive association between openness and choice of going for cosmetic surgery ( < 0.000).

Discussion
People in today's world are more health conscious, and awareness of the different medical specialties is on the increase. Despite the tremendous advancements in the field of plastic surgery, there seems to be a limited knowledge among the general public and also among medical professionals regarding the spectrum of plastic surgery. As a medical specialty, plastic surgery is poorly understood by both the general public and some medical professionals as well. In this study, the level of awareness was noted to be about 94.4%. However, there are varying levels of awareness about various forms of cosmetic surgery. In a similar study done in India, 12% of participants felt that plastic surgery and cosmetic surgery are the same, and 80% felt that cosmetic surgery is a part of plastic surgery. Of the 100 participants, 83% did not know why plastic surgery is called plastic surgery, 5% felt that it is called plastic surgery because it involves use of plastic, and 4% felt that it is called plastic surgery because face looks shiny like plastic after the surgery [9].
Information about cosmetic surgery among the respondents showed that more than half (126 (59.2%)) of the respondents got their information on cosmetic surgery from television and radio. This suggests the role of mass media in educating the public and disseminating information about cosmetic surgery. In a similar study done in India, nurses got their information mainly from television or magazines, although 27% of nurses gained the information through work; medical students learned about plastic surgery from all sources, but television and magazines were the main source [9].
In the Indian study [10], 37% of them believed that plastic surgery is an expensive surgery and meant for the rich and the famous. This is similar to what was obtained among the respondents in the current study who felt that cosmetic surgery is expensive and that cities and megacities were the environment where cosmetic surgeries are more acceptable among the high social economic class.
This study reported a positive association between openness and choice of going for cosmetic surgery, although previous work has reported a similar positive association between openness and positive self-evaluations of appearance [11].
Our results showed that women were more likely than men to consider having cosmetic surgery, which is consistent with previous work in which participants were asked to rate their likelihood of having various cosmetic procedures [12][13][14][15]. As discussed elsewhere, this sex difference may reflect the greater sociocultural pressure that women experience to live up to idealized images of physical perfection [5,6].
Although 94% of the respondents in this study were aware of cosmetic surgery, 41.8% of them believed that awareness of cosmetic surgery was low (41.8%) while 22.1% of them considered the awareness as very low. This may mean that the respondents believed that the awareness of cosmetic surgery is low among the general public. Indeed 70% of them recommend the need to raise more awareness about cosmetic surgery in the environment. Since television and radio were the major sources through which majority of the respondents knew about cosmetic surgery, these sources will serve as a good source of enlightening others in the public. Health talks on cosmetic surgery, debates, and question and answers on the radio and television about these developing areas of plastic surgery will assist in educating the public and correcting any misgivings on cosmetic surgery.
It should be noted that 139 (65.3%) considered cosmetic surgery necessary while 128 (60.1%) were ready to advice close relations or associates to go for cosmetic surgery of their choice when need arose. However, cleft surgery seemed to be the only form of cosmetic surgery considered necessary by 117 (54.9%) of the respondents. This quietly suggests an unannounced turning down of other forms of cosmetic surgeries and thus low acceptance.
It should also be noted that no particular religious or cultural taboo or belief was noted against cosmetic surgery.

Conclusion
The awareness and disposition of health workers to cosmetic surgery are still low in developing countries like Nigeria. This is evidenced from the fact that the awareness and disposition among health care workers in a tertiary institution are rather low and many would prefer treatment outside the country when there is a need for such treatment overtreatment in the country. The health care workers are the first source of education and raising of awareness of any health procedures among the populace. The low level of this group of people therefore attests to the possible lower level still among the populace. Despite the rapid progress that has occurred in the field of plastic surgery, a large portion of the population is still unaware of the specialty. Therefore, they may not be taking advantage of the optimal care that is already available. If patients are to receive the best treatment available, it is essential to institute programs to educate healthcare consumers and providers about plastic surgery and its different subspecialties, especially the cosmetic procedures and their role within the healthcare system.

Questionnaire: Awareness and Attitude of Health Workers to Cosmetic Surgery in Osogbo, Nigeria
This questionnaire was designed to obtain information concerning your awareness and attitude concerning cosmetic surgery. Please note that your participation is voluntary and that the information given will be treated as confidential and anonymous. Please sign below if you understand the details information given about the study and you are willing to participate in the study.