Assessment of quality of life for hypertensive patients: Integrative review for Potential of Novel Assessment Tools of quality of life
La Ode Alifariki1*, Sri Susanty2, Heriviyatno Julika Siagian3, Daryono Daryono4
1Department of Epidemiology, Medical School, Halu Oleo University, Kendari, Indonesia
2Department of Nursing, Medical School, Halu Oleo University, Kendari, Indonesia
3Department of Medical Surgical Nursing, College of Science and Technology, Sembilanbelas November University, Kolaka, Indonesia
4Nursing Department, Health Polytechnic Ministry of Health Jambi, Indonesia
Corresponding author: La Ode Alifariki, Kampus Hijau Bumi Tridharma, Anduonohu, Kec. Kambu, Kota Kendari, Sulawesi Tenggara 93232, Indonesia. Orcid: https://orcid.org/0000-0003-4120-7465. Email: ners_riki@yahoo.co.id
Cite this article
ABSTRACT
Background & Aim: The body of literature on QoL has steadily grown over recent years, spurred by the promotion of research and the cross-cultural adaptation and validation of assessment instruments in different languages. However, limited information exists on the most commonly used instruments against the backdrop of current demographic and epidemiological trends. The aim this study to evaluate QoL assessment instruments used in hypertensive patients.
Methods & Materials: This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases used including Sciencedirect, Cochrane library, Pubmed, Proquest, and the Wiley Online Library, utilizing keywords that are tailored to the Mesh Terms. Systolic Blood Pressure (SBP) value at least 140 mmHg and/or Diastolic Blood Pressure (DBP) value at least 90 mmHg, or the patient had a history of hypertension and was administered with antihypertensive drugs, English version, observational studies that presented Health-Related Quality of Life (HRQoL) scores in hypertensive individuals using varied assessment tools (WHOQoL BREF, SF-36, MINICHAL, etc) where these tools assess the situation of the patient's quality of life based on the domain of life (physiological, psychological, social interaction, etc.) in the form of numbers, and published between January 2000 to December 2021 were inclusion criteria of the study. Relevant studies were read critically, analyzed, and described in detail. Survey data were processed in the form of comparative tables.
Results: A total of 2,287,348 references were found through databases, and for the final screening, twenty-two articles were finally designated as articles to be reviewed. The SF-36 (SF-8, SF-12), WHOQoL BREF, MINICHAL, and PECVEC are assessment tools used in the studies included in this review. The SF-36 was the most widely used tool in the studies included in this review. One of the critical domains to assess is spiritual, where none of the studies included this domain.
Conclusion: The SF-36 is the most frequently used assessment tool. However, this form is a general form that is not explicitly intended to assess the quality of life in hypertension only. The spiritual domain is one of the important items that need to be included in the QoL assessment tool.
Keyword: Quality of life, assessment tool, hypertension
INTRODUCTION
Hypertension is one of the most common chronic diseases that threaten the health of human beings. Poor adherence to treatment and low control rate of hypertension are the risk factors for coronary heart disease, stroke, and renal insufficiency, causing a great disease burden worldwide [1–3]. For a long time, the evaluation for the health condition of hypertension patients is usually based on the control of patients’ blood pressure (BP) or the degree of damage to the target organ [4–6]. As the medical model has changed from the biological medical model to the biological–psychosocial medical model, it is difficult to comprehensively and accurately assess chronic diseases (such as hypertension) in terms of incidence, death rate, cure rate, and life expectancy. Thus, the health-related quality of life (HRQoL) has gradually arisen with great attention in the world [7–9].
Quality of Life (QoL) is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment[10]. Health related QoL (HRQoL) is emerging as an important outcome in hypertension and can be adversely affected by hypertension itself and side-effects of antihypertensive drugs. However reports of HRQoL among hypertensive individuals have been conflicting, with some studies finding worse HRQoL among hypertensive compared to the general population, while Moum T et al reported no impact of hypertension on HRQoL in some / all domains. There is a paucity of studies reporting QoL in Indian hypertensive patients [8,11,12]. Assessing QoL is of essence, as this concept serves as an indicator in clinical trials for specific diseases, assesses the physical and psychosocial impact that the disorders may have on affected individuals, allowing a better knowledge about the patient and their adaptation to their unhealthy condition. Roca-Cusachs et al reported that hypertensive patients had a significant reduction in QoL compared to normotensive patient [13,14].
Scales measuring HRQoL of hypertensive patients include EuroQOL five-dimension questionnaire, WHO QoL-100 (the well-being questionnaire), SF-36 (the Medical Outcomes 36 Item Short-form Health Survey), and so on. SF-36 is the most widely used scale for assessing HRQoL, which has high reliability. In addition, SF-12, the shorter form of SF-36, is an effective alternative to the SF-36 in hypertension. Although many articles showed a significantly lower HRQoL of hypertension patients, some still present no difference in many domains [7,15,16].
Another quality of life assessment form that is starting to be widely used is MINICHAL. MINICHAL, an assessment tool focusing on people with hypertension, was formed in 2002 by a group from Spain [13], and it was shown to be effective in the measurement of HRQoL of elderly people with hypertension linked to the supplementary health sector and evidenced a lower impairment in HRQoL among the elderly practicing physical activity [17].
The body of literature on QoL has steadily grown over recent years, spurred by the promotion of research and the cross-cultural adaptation and validation of assessment instruments in different languages. However, limited information exists on the most commonly used instruments against the backdrop of current demographic and epidemiological trends. In light of the above, the aim of this study was to evaluate QoL assessment instruments used in hypertensive patients.
METHODS
Review Protocol
This integrative review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [18]. The current study tries to evaluate QoL assessment instruments used in hypertensive patients from articles that have been published in the period January 2000 to December 2021.
Searching strategy
Relevant articles were searched and collected using Sciencedirect, Cochrane library, Pubmed, Proquest, and the Wiley Online Library, with a publication time between 2000 and 2021. The search keywords were adjusted according to the Mesh terms for health research. The keywords used vary, depending on the search engine used. In general, the keywords focus on Quality of life OR HRQoL AND Hypertension AND Measurement AND Assessment tool OR WHOQoL OR SF-36 OR MINICHAL. Summary of keywords used in each databases are reported in table 1.
Table 1. Search string in databases
Study eligibility
Inclusion criteria: Hypertension is defined as Systolic Blood Pressure value at least 140 mmHg and/or Diastolic Blood Pressure value at least 90 mmHg, or the patient had a history of hypertension and was administered with antihypertensive drugs. Language was restricted to English. All observational studies that presented Health Related Quality of Life (HRQoL) scores in hypertensive individuals using varied assessment tools (WHOQoL BREF, SF-36, MINICHAL, etc) where these tools assess the situation of the patient's quality of life based on the domain of life (physiological, psychological, social interaction, etc.) in the form of numbers, published between January 2000 to December 2021. In addition, we manually searched the cited reference of potentially eligible articles and published reviews.
Studies were excluded if they were carried out in special groups (armies, a pasturing area, etc.) and cannot represent the general population; they compared HRQoL of individuals randomized to different antihypertensive agents or placebo or other interventions.
Study selection and data analyses
After a further authentication of the articles, cross sectional, and case-control study design were chosen for final analysis. Relevant studies were read critically, analyzed, and described in detail. The methodological quality of studies was evaluated using National Institute of Health (NIH) for observational cohort and cross sectional studies. The checklist has 14 questions including Q1: Was the research question or objective in this paper clearly stated?; Q2: Was the study population clearly specified and defined?; Q3: Was the participation rate of eligible persons at least 50%?; Q4: Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?; Q5: Was a sample size justification, power description, or variance and effect estimates provided?; Q6: For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?; Q7: Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?; Q8: For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome?; Q9: Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?; Q10: Was the exposure(s) assessed more than once over time?; Q11: Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?; Q12: Were the outcome assessors blinded to the exposure status of participants?; Q13: Was loss to follow-up after baseline 20% or less?; Q14: Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? relating to the research question, selection of study subjects, statistical analysis and measurement and selection of timeframe between exposure and outcome to see an effect. The quality grading of studies was done as Good (G) if the overall rating was at least 70%, Fair (F) if rating was at least 50% and poor (P) if the rating was less than 50% . The table assists in identifying the key characteristics of each study included in this review, with quality of life in patients with hypertension theme.
Table 2. Summary of quality assessment
RESULTS
Search Results
Combining the output of the searches in the various databases, a total of 2,287,348 references were found. After duplicates were removed, 1,918,891 potentially relevant references remained from the database searches. 1,918,854 articles removed by reasons of irrelevant, review/report, not full text, book chapter. 22 articles were finally designated as articles to be reviewed. The main focus of this integrative review is the evaluation of quality of life assessment tools used in hypertensive patients.
The authors developed tables for data analysis with the study design, participants characteristics including the number, assessment tools used, domain of measurements, measurement method, and the main results of Quality of Life assessment tools. PRISMA flow chart for study selection, can be seen in figure 1.
Figure 1. PRISMA flowchart for Study selection
Characteristics of the studies
The studies included in this review are from several countries globally, including China (n=7), Brazil (n=5), and one study each in Pakitan, Turkey, Greece, Lebanon, Sweden, Spain, Finland, and India. The study design used mainly was cross-sectional, which focused on the relationship between hypertension and the quality of life. The assessment tools used vary, including WHOQoL-BREF, SF-36, SF-12, SF-8, MINICHAL, and PECVEC. Several studies used a control group to compare the quality of life of people with hypertension with people who did not suffer from hypertension. Self-reported and face-to-face interviews measure the quality of life through a questionnaire format. Several studies included in this review also did not determine the degree of hypertension which was the inclusion criteria in the study conducted. Overall, 140 mmHg for systolic blood pressure is the standard for patients with hypertension.
Table 3. Characteristics of the studies included
Quality of Life Domains
Based on the assessment tool used, the assessment domains for hypertension sufferers include general health, physical, psychological, social relationship, and environment (WHOQoL-BREF), mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (EuroQoL EQ 5D), Physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health (SF-36, SF-12, SF-8), mental, and somatic (MINICHAL), the physical, psychological, and social dimensions (PECVEC). Most studies conducted in non-English countries translate the assessment items into the language of each country to make it easier for participants to answer the question items in each assessment tool.
QoL measurement results
In general, the assessment results of the quality of life in patients with hypertension on all the assessment tools used show a low score, which means the quality of life is low. The results of the quality of life assessment based on each assessment tool can be described as follows:
In studies using the 5D EQ, the problems found in the quality of life domain include mobility, pain, anxiety [19], while other studies indicate a decrease in scores in all domains in the 5D EQ [7,28,30]. Meanwhile, for the study conducted by Qin et al. [36], which compared the quality of life between patients with hypertension and those without hypertension, it was found that only the pain/discomfort dimension showed a very significant difference in scores.
In the studies using SF-36, -12, and -8, it was found that the duration of suffering from hypertension affected general health and vitality dimensions. The amount of consumption of antihypertensive drugs is related to the role emotional dimension, and controlled blood pressure has a significantly better effect on the quality of life, especially in the domains of role-physical, social functioning, and role emotional [20]. One study revealed that physical health and mental health domains had a strong positive influence on adherence to hypertension therapy [21]. Studies in Greece revealed that women had lower BP, SF, RE, and VT scores. Increased age was independently associated with lower scores on PF and RE [22,25]. Saboya et al. [23] found that the depression index affects the quality of life outcomes. One study in China revealed that patients who were aware of hypertension had lower scores (Poor QoL) than patients who were unaware of hypertension and normotensive [24]. Lower educational level, higher body mass index, and lower muscle strength showed the worse quality of life in the functional capacity domain. Higher systolic blood pressure was related to higher values in the physical aspects domain. Women presented worse quality of life in the pain domain than men, and educational level was directly related to social aspects [26]. Decreases in physical functioning and general health scores occurred in hypertensive patients aware of their condition [29]. A study in Brazil found that patients with hypertension had a lower quality of life than normotensive participants in all measurement domains [31,32,34,35]. Another study in Spain noted that people with hypertension had a low quality of life, especially in physical function, general health, vitality, and mental health.
Another measurement used MINICHAL, which consists of two domains, namely mental state and somatic manifestations. Oza et al. [27] found that the mental domain had more impact than the somatic domain. Meanwhile, in a study in Brazil, it was found that women have a better quality of life compared to men in the mental state domain.
DISCUSSION
This integrative review was carried out as our first step in conducting future projects to measure the quality of life of people with hypertension. Differences in culture, race, economic situation, geographical location, and so on in the world underlie our thinking to explore the possibility of imbalances in the assessment tool used internationally and has been tested for validity. However, some of the literature in this study has modified the item assessment tool used primarily for language. We realize that it is not enough to generalize its reliability and feasibility, especially in Indonesia and other countries in the Asian continent, which has extreme contrasts in culture with countries on the continent of Europe, America, and others.
The WHOQoL-BREF is one of the most commonly used generic Quality of Life (QoL) questionnaire which was developed simultaneously across a broad range of member countries, assuring that it could be used more multi-culturally and multi-lingually than any other existing QoL tool. It emphasises subjective response rather than objective life condition, with assessment made over the preceding two weeks [25]. WHOQoL-BREF consists of four main domains including physical health, psychological, social relationship, and environment. The aspects included in these domains include the physical health domain consisting of Activities of daily living, Dependence on medicinal substances and medical aids, Energy and fatigue, Mobility, Pain and discomfort, Sleep and rest, and Work Capacity [40]. The psychological domain consists of Body image and appearance, Negative feelings, Positive feelings, Self-esteem, Spirituality / Religion / Personal beliefs, thinking, learning, memory, and concentration. The social relationship domain consists of Personal relationships, Social support, and Sexual activity. Domain environment consists of financial resources, Freedom, physical safety and security, health and social care: accessibility and quality, Home environment, Opportunities for acquiring new information and skills, Participation in and opportunities for recreation/leisure activities, Physical environment (pollution/noise/traffic/climate), and Transport [41,42].
The 3-level version of EQ-5D (EQ-5D-3L) was introduced in 1990 by the EuroQol Group. The EQ-5D-3L essentially consists of 2 pages: the EQ-5D descriptive system. The EQ-5D-3L descriptive system comprises the following five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 3 levels: no problems, some problems, and extreme problems. The patient is asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. This decision results into a 1-digit number that expresses the level selected for that dimension. The digits for the five dimensions can be combined into a 5-digit number that describes the patient’s health state. The 5-level EQ-5D version (EQ-5D-5L) was introduced by the EuroQol Group in 2009 to improve the instrument’s sensitivity and to reduce ceiling effects, as compared to the EQ-5D-3L. The EQ-5D-5L essentially consists of 2 pages: the EQ-5D descriptive system. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The patient is asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. This decision results in a 1-digit number that expresses the level selected for that dimension. The digits for the five dimensions can be combined into a 5-digit number that describes the patient’s health state [28,43,44].
The Short Form (SF) -36, -12, -8 is a health status profile originally designed to measure health status of patients and outcomes of patients. Health status could be compared between groups of patients by type of intervention, disease, or type of health insurance. The original target population was individuals living in the community. The SF-36 is used today in outpatient settings and with community-dwelling older adults. The 36 questions on the SF-36 are meant to reflect 8 domains of health, including physical functioning, physical role, pain, general health, vitality, social function, emotional role, and mental health. The categories of physical role and emotional role reflect performance at the activity and participation levels [45,46].
MINICHAL consists of the short version of Calidad de Vida em la Hipertensión Arterial (CHAL), developed and validated in Spain. This is a self-administered instrument comprised of 16 items divided into the Mental Status (1 to 10) and Somatic Manifestations (11 to 16) dimensions. The mental domain includes questions one to nine and score ranges from 0 to 27 points. The somatic domain includes questions 10 to 16 and score ranges from 0 to 21 points. Last question is related to the overall impact of hypertension on the QoL. The score scale is Likert scale with four possible answers (0 = No, not at all; 1 = yes, somewhat; 2 = yes, a lot; 3 = yes, very much). Total points range from 0 (best level of health) to 51 (worst level of health) [47,48].
PECVEC considers the physical, psychological and social dimensions of QoL. Patients performance and well-being are assessed in each dimension. The physical dimension is measured according to two scales: lists of symptoms (17 items) and physical functions (eight items). The psychological dimension is measured according to three scales: psychological function (eight items), positive state of mind (five items) and negative state of mind (eight items). The social dimension is measured according to two scales: social function (six items) and social well-being (five items). The items are Likert-scaled from 0 (worst) to 4 (best) [37,49].
Quality of life is a reflection of holistic aspects of human well-being. Holistic health care includes biological, psychological, sociological, and spiritual aspects, so to assess the quality of life of a person with hypertension, it is obligatory to fully represent the items from the holistic aspect of the assessment. Differences in culture, economic status, race, geographical situation make it difficult to generalize an assessment tool.
In the results of the QoL measurement, there are several differences in the problems that most bother hypertensive patients. Studies that measured QoL using the 5DEQ showed that the most disturbing domains were mobility, pain, and anxiety. However, in another study, the pain was the main difference between hypertensive and non-hypertensive patients. There are possible factors that play a role in influencing the 5DEQ score in patients with hypertension, as shown in a study in China in the community during the COVID 19 pandemic, where the most frequently reported problems were pain/discomfort, followed by anxiety/depression, and self-care were the least frequently reported problem. The study also revealed that Men were more likely to report problems in mobility than women. Meanwhile, the above 60 years group reported the most problems in mobility, usual activities, pain/discomfort, and anxiety/depression [50].
In the results of the QoL measurement, there are several differences in the problems that most bother hypertensive patients. Studies that measured QoL using the 5DEQ showed that the most disturbing domains were mobility, pain, and anxiety. However, in another study, the pain was the main difference between hypertensive and non-hypertensive patients. There are possible factors that play a role in influencing the 5DEQ score in patients with hypertension, as shown in a study in China in the community during the COVID 19 pandemic, where the most frequently reported problems were pain/discomfort, followed by anxiety/depression, and self-care were the least frequently reported problem. The study also revealed that Men were more likely to report problems in mobility than women. Meanwhile, the above 60 years group reported the most problems in mobility, usual activities, pain/discomfort, and anxiety/depression [50].
CONCLUSION
Overall, the existing assessment tools have been recognized for their validity and reliability. The SF-36 is the most frequently used assessment tool, because it is considered the easiest to use and in accordance with conditions in several regions of the world. However, this form is a general form that is not explicitly intended to assess the quality of life in hypertension only. Holistically, the existing assessment tools have not touched the spiritual domain, where this domain in some countries is an essential factor in daily life.
Limitations
Our main limitation is access to reputable databases, as this is our main barrier in all articles assessing hypertensive patients' quality of life using various tools. The results of this review is probably suitable only in Indonesia and some Asian countries which have similar cultural issue.
Acknowledgement
We would like to express our gratitude to all parties, particularly the dean of the medical college of Haluoleo University and the dean of Science and Technology College of Sembilanbelas November University.
Conflict of interest
There is no conflict of interest.
Authors’ contribution
All authors equally contributed to preparing this article.
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Music-based intervention in Covid-19 hospitalization: a perspective through Consolidated Framework for Implementation Research (CFIR)
Alessio Pesce1
1Department of internal Medicine, ASL2, Savona, Italy
Corresponding Author: Alessio Pesce, MSN, Local Health Authority (ASL2), Piazza Sandro Pertini n. 10, 17100 Savona, Italy, Email: al.pesce@asl2.liguria.it
https://orcid.org/0000-0003-2702-4101
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Abstract
COVID-19 patients survive in isolation with stringent measures of infection containment, leading to anxiety, fear, stress, loneliness, and depression. Music is recognized as useful to promote multiple health outcomes, including anxiolytic effects, pain-relieving, and relaxing effects that favour well-being and social interaction in healthcare settings. The Consolidated Framework for Implementation Research (CFIR) allows to implement music in hospital, restricting methodological weaknesses. The importance of exploring the in-patients’ preferences, usages, and feelings for COVID-19 before initiating a music-based intervention is crucial.
Keywords: Music-Therapy, Covid-19, Patient preference, Nursing
Introduction
Music represents an interdisciplinary topic, transversal to medicine and human sciences. It constitutes a non-pharmacological intervention aimed at multiple health outcomes, including anxiolytic effects, pain-relieving, and relaxing effects that promote well-being and social interaction in healthcare settings [1,2,3]. Music-based interventions, therefore, can also be used to relieve psycho-social need in COVID-19 patients [1]. Clinical observation has revealed that patients with COVID-19 may experience diarrhea, nausea, decreased appetite, rash, and other adverse reactions during antiviral treatments [1]. Similarly, hospitalized patients survive in isolation with stringent measures of infection containment, leading to anxiety, fear, stress, loneliness, and depression, even to the point of evoking obsessive thoughts; in severe cases these effects compromise prognoses impacting on mortality and adverse events. There is ample evidence of the need for interventions, with greater relevance on health determinants in the community and hospital context, such as loneliness and social isolation that are fundamental for anxiety and depression development. Furthermore, in percentage terms, loneliness is associated with a 50% increase in the risk of developing dementia and a 30% increase in the risk of heart disease and stroke [4]. Since the early 1900s, music has been used as a mean to improve the psychological well-being of people experiencing situations of isolation or detention; this area of interest is currently at the forefront of scientific research.
Discussion
Music is recognized as useful to promote social interactions and emotional regulation, strongly improving people well-being in a pandemic context [5]. To date, research protocols are available in the hypothesis that music can reduce anxiety, depression or improve quality of life in COVID-19 patients [6]. However, to provide scientific evidence, studies are needed to explore patients' perspectives and determine the effects of music-based intervention during hospitalization. Some authors [7] remark how essential is the compatibility between proposed music pieces and people's preferences, and how these may vary depending on expectations at a specific time, health conditions, or healthcare environment. A crucial aspect in music-based interventions is the proper selection of music pieces. Listening to specific types / genres of favorite music or sounds is likely to have an emotional impact based on patients' clinical condition. Systematic reviews show that patients' music background and listening habits were drastically underestimated, reported in only 7.7% of studies conducted [8]. In only about 25% of the studies, patient feedbacks on music interventions were explored [8]. In UK [9], a scientific framework was used to integrate music in hospital. Through the Consolidated Framework for Implementation Research (CFIR), a protocol has been developed to integrate the patient's preferred music into the care pathway by providing in-ear music players. The CFIR presents five domains that must be satisfied in order to support the implementation of the intervention. Domains include: Characteristics of intervention, Individuals involved, Outer and Inner setting and Implementation process [9].
The CFIR constructs starts from the evidence of efficacy in music-based intervention available in literature, proceeding through its feasibility analysis, considering socio-political, organizational and applicability domains in healthcare setting, through systematic surveys among patients and healthcare professionals. Carter et Al [9], applying CIFR, defined pre-recorded music-based intervention as easy to be implemented in the treatment protocol and sustainable in economic and training terms, through programming with a qualified music expert. Personality variables, cognitive-affective components [10] and the patient's clinical condition, especially respiratory system efficiency and symptom burden, show a close correlation with music preferences [7], stated even before COVID-19 disease. Therefore, the importance of exploring the in-patients’ preferences, usages, and feelings for COVID-19 before initiating a music-based intervention is crucial. This knowledge, would allow health and music professionals to personalize the intervention and to explore important correlations between habitual music preferences and attitudes than those experienced by the patient as result of proposed music listening. Studies uniquely states methodological weaknesses in music-based interventions [8,11]. There is a lack of scientific rigor in music selection, involvement of music experts, and objective reporting and description of the music pieces used [11]. Music, also, was rarely selected to achieve specific effects according to reference frameworks [8,11]. Patients often selected pieces without a scientific rationale, resulting a little directional effect. The opportunity to identify music mechanisms for action would allow researchers to advance beyond basic questions about efficacy and begin to answer questions about how, why, and for whom an intervention works [11].
The implementation of CFIR would also provide a new methodological approach in clinical practice, promoting a personalised music-based intervention, according to the needs of the institutional settings and the patient's preferences. Music promotes early weaning to invasive mechanical ventilation [12], social interaction [13], quality of life and sleep [14,15], mood and well-being in healing environment [16]; reducing procedural stress and the need for anxiolytic and sedative drugs [17,18]. Significant psycho-physical benefits, in condition of clinical stability or instability, represent important outcomes in COVID-19 hospitalization. Relaxation, distraction, entertainment and emotional support of listening to music, according to the patient's preferences through the CFIR framework, can also contribute, with scientific rationale, to cope loneliness, isolation, fear and psychopathological states resulting from COVID-19 disease.
Conflict of interest
The Author declare that there is no conflict of interest.
Funding
The author states that he has not obtained any funding or financial sponsors.
References
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2. Bradt J, Dileo C, Myers-Coffman K, Biondo J. Music interventions for improving psychological and physical outcomes in people with cancer. Cochrane Database Syst Rev. 2021;10(10):CD006911.
3. Kakar E, Billar RJ, van Rosmalen J, Klimek M, Takkenberg JJM, Jeekel J. Music intervention to relieve anxiety and pain in adults undergoing cardiac surgery: a systematic review and meta-analysis. Open Heart. 2021;8(1):e001474.
4. Rico L., Caballero F., Martìn M., Cabello M., Ayuso-Mateos, Miret M. Association of loneliness with all-cause Mortality. A meta-analysis. PLoS One. 2018; 13(1):e0190033.
5. Cabedo-Mas A, Arriaga-Sanz C, Moliner-Miravet L. Uses and Perceptions of Music in Times of COVID-19: A Spanish Population Survey. Front Psychol. 2021; 11:606180.
6. Chen X, Li H, Zheng X, Huang J. Effects of music therapy on COVID-19 patients' anxiety, depression, and life quality: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2021 Jul 2;100(26):e26419.
7. Liwka A, Pilinski R, Przybyszowski M, Pieniazek M, Marciniak K, Wloch T, et al. The influence of asthma severity on patients' music preferences: Hints for music therapists. Complement Ther Clin Pract. 2018; 33:177-183.
8. Williams C, Hine T. An investigation into the use of recorded music as a surgical intervention: A systematic, critical review of methodologies used in recent adult controlled trials. Complement Ther Med. 2018; 37:110-126.
9. Carter JE, Pyati S, Kanach FA, Maxwell AMW, Belden CM, Shea CM, et al. Implementation of Perioperative Music Using the Consolidated Framework for Implementation Research. Anesth Analg. 2018; 127(3):623-631.
10. Greenberg DM, Baron-Cohen S, Stillwell DJ, Kosinski M, Rentfrow PJ. Musical Preferences are Linked to Cognitive Styles. PLoS One. 2015; 10(7):e0131151.
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17. Walter S, Gruss S, Neidlinger J, Stross I, Hann A, Wagner M, et al. Evaluation of an Objective Measurement Tool for Stress Level Reduction by Individually Chosen Music During Colonoscopy-Results From the Study "ColoRelaxTone". Front Med (Lausanne). 2020 Sep 15;7:525.
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LEARNING MODEL METHODS EMOTIONAL DEMONSTRATION (EMO DEMO) IN PREVENTION OF NON-COMMUNICABLE DISEASES: QUASI-EXPERIMENTAL STUDY
Winda Triana*, Pahrur Razi, Ervon Veriza, Solihin Sayuti
Department of Health Promotion, Health Polytechnic of Ministry of Health Jambi, Indonesia
* Corresponding author: Winda Triana, Jl. Prof DR GA Siwabessy No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36122Department of Midwifery, Health Polytechnic of Jambi, Indonesia.Orcid :https://orcid.org/0000-0003-0574-7915. Email: trianawinda146@gmail.com
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ABSTRACT
Background. The development of science and technology in the field of medicine encourages experts to always conduct research on various diseases, including one of them is the incidence of infectious diseases in order to overcome suffering and death due to these diseases.This study aimed to analyze the effectiveness of the emo demo method in increasing knowledge and skills about the prevention of non-communicable diseases.
Methods. This quasi-experimental study using two groups of pretest-posttest design involved 100 participants, whose data were collected using a questionnaire and tested using the Wilcoxon test.
Results. Both knowledge and skills variables show differences before and after the intervention of providing education, namely there is an increase in knowledge and skills to prevent non-communicable diseases. There are different mean values between pre-test and post-test knowledge and skills, meaning that mathematically indicates there are differences in knowledge and skills before and after Emo Demo.
Conclusion. The Demonstration Emotional Method learning model is effective in increasing students' knowledge and skills about preventing non-communicable diseases.
Keyword: Counseling, Learning, Student, Knowledge, Skill
INTRODUCTION
Addressing Non Communicable Disease (NCDs) is integral to the 2030 Agenda for Sustainable Development [1]. Sustainable Development Goal (SDG) target 3.4 calls for a one-third reduction in premature mortality from NCDs by 2030. Many other SDG 3 targets are important for NCDs. Achieving the NCD-related SDG 3 targets can deliver shared gains across the development agenda, given the multidirectional relationship between NCDs, poverty, inequalities, economic growth, climate action and other SDG goals and targets [2].
Globally, non-communicable diseases, including cardiovascular disease, accounted for greater than 70% of all deaths in 2017 [3]. Non-Communicable Disease (NCD) is a catastrophic disease with the highest cause of death in Indonesia [4,5]. The National Health Research and Development Agency shows an increase in the development of NCDs in Indonesia due to the NCD trend followed by a shift in disease patterns [6].
An unhealthy lifestyle causes the high prevalence of NCD in Indonesia. The shift in the condition of NCD disease is expected to have a significant impact on Indonesia's human resources and economy in 2030-2040. Indonesia will face a demographic bonus where the productive age is much higher than the non-productive age group [7].
A 2018 National Basic Health Research (Riskesdas) results show that 95.5% of Indonesians consume fewer vegetables and fruit. 33.5% of people lack physical activity, 29.3% of people of productive age smoke every day, 31% have central obesity, and 21.8% are obese adults [6]. Lifestyle changes should be made as early as possible as an investment in future health. Controlling risk factors must also be done as early as possible. People must have health awareness to know their body condition to make it easier to treat before too late[8].
Emotional Demonstration (Emo Demo) is a behaviour change communication strategy that uses the incorporation of Behavior Communication Change (BCC) and Behavior Communication Definition (BCD). BCC is an interactive process between individuals, groups, or communities to develop communication strategies to achieve positive behaviour change. BCD is a communication process which makes direct use of individual psychological constructs involving feelings, needs and thoughts. It is one of the methods that is being widespread and gaining attention[9–12].
The Global Alliance for Improved Nutrition (GAIN) is a Swiss-based foundation first launched at the United Nations Headquarters in 2002 to address nutrition issues. Indonesia encourages changes in feeding behaviour to prevent stunting in children through the Emo-Demo Program. The Emo-Demo targets one essential behaviour that we change: exclusive breastfeeding and a steady and balanced diet, healthy snacks and balanced, complementary foods, and washing hands with soap[13–15].
Developing an NCD prevention control model in the younger generation is very important so that they become productive, academically intelligent, and healthy. Avoiding healthy adolescents with NCD can be combined with efforts that have been carried out in the community. Through Integrated Development Post-NCD (IDP-NCD), prevention of NCD risk factors can be done as soon as possible so that the incidence of NCD in the community can be suppressed[7].
IDP-NCD risk factor surveillance has been carried out in every health centre in Jambi City (20 health centres). NCD risk factors found through the implementation of IDP in Jambi City have increased in the period 2016 to 2019. The NCD risk factors are smoking, lack of physical activity, fewer vegetables and fruit, and being overweight[16]. Based on the 2019 annual report, the five most prominent diseases at the Jambi City Health Center were hypertension at 47.42%, the most aged >59 years (19,223) cases. Diabetes Mellitus by 20%, Myalgia by 20%, Coronary Heart disease by 2.8%, and an increase in the age of 45-59 years with 1,528 cases[16].
The Simpang IV Sipin Health Center is one of the Telanaipura District Health Centers, Jambi City, with the results of risk factor screening at the NCDIDP in 2019 of 15.34%. This value is far from the MSS target of 100%. NCDIDP is a part of Community Based Health Efforts (UKBM). The target population aged 15-59 in 2019 in 21,935 people in the Telanaipura District Health Center Work Area. SMAN 5 is located in the work area of the Simpang IV Sipin Health Center, with 1200 students, where the senior high school age is in the range of 15 years and over. This high school age is very vulnerable to early disease if there is no early detection and regular monitoring is in the risk factor category. NCD includes smoking, consumption of alcoholic beverages, unhealthy eating patterns, and lack of physical activity, obesity, stress, hypertension, hyperglycemia, and hypercholesterolemia.
Considering the impact of the emergence of NCD, it is necessary to establish an NCD IDP and Utilize IDP with the emo demo method. It is hoped that with the formation of IDP-NCD volunteers in SMAN 5, all students will be interested in using IDP-NCD through the Emotional Demonstration Method Learning Model in Prevention of Non-Communicable Diseases at IDP NCD SMAN 5 Jambi City.
METHODS
Trial design
This research is a quasi-experimental study using two groups of pretest-posttest design
Participants
This study involved 100 participants, who were carried out in September-October 2020 at SMAN 5 (High school) Jambi City, involving high school students who were randomly selected with the inclusion criteria of students who had never received health education about non-communicable disease emodemos; grade Fourth, Fifth, and Lower Sixth, while students who were sick during the study were not included in the study.
Intervention
The research variables are students' knowledge and skills. Before the intervention was given, the researcher first measured the level of knowledge and skills of the students/participants (pre-test). After being given the intervention, the researcher again measured the level of knowledge and skills of the students/participants (post-test). In this study, the intervention model given is the emotional demonstration learning model (emo demo) which is carried out once with a duration of 1 hour, which is 45 minutes of material delivery and 15 minutes of discussion). In this study, the researchers provided an explanation of non-communicable diseases to participants, accompanied by games about pictures and stickers of people with non-communicable diseases. the next step is for participants to try to explain about the pictures and stickers they get.
The knowledge and skills questionnaire consists of 22 questions with right and wrong answer choices. If the student answers correctly, he is given a score of 1, and if the answer is wrong, he is given a score of 0. The range of scores obtained is between 0-22. Both questionnaires use the Guttman scale. Meanwhile, students' skills were measured using a questionnaire consisting of 8 questions with right and wrong answer choices. If the mother answered correctly, she was given a score of 1, and if the answer was wrong, she was given a score of 0. The range of scores obtained was between 0-8. Both questionnaires use the Guttman scale.
The Guttman scale has an important characteristic, which is that it is a cumulative scale and measures only one dimension of a multi-dimensional variable, so that this scale has an undimensional nature. The data obtained are in the form of interval data or dichotomy ratios (two alternatives) [17].
Researchers have worked as lecturers and researchers between 10-15 years and have academic degrees Masteral Degree and Doctorate. Researchers have done much research in the health sector and have compiled many questionnaires, so the researchers have prepared the questionnaires in this study. Before the research was conducted, the questionnaire was piloted on ten students, and the results showed that two questions had to be replaced because they were invalid. The knowledge questionnaire contains the respondent's understanding of non-communicable diseases ranging from understanding, to overcoming them, while the skills questionnaire contains activities carried out in detecting and preventing non-communicable diseases.
Outcomes
This study compares the knowledge and skills of students in preventing the incidence of non-communicable diseases after being given an intervention in the form of an emo demo.
Sample size
This study involved 100 participants who were taken randomly using simple random sampling technique and sourced from three high school classes, namely grades Fourth, Fifth, and Lower Sixth.
Ethical Consideration
No economic incentives were offered or provided for participation in this study. In this study, because the subject was still a minor so the researcher had asked for and obtained parental consent so that their child could participate in the study. The study was performed in accordance with the ethical considerations of the Helsinki Declaration. This study obtained ethical feasibility under the Health Research Ethics Commission of the Ministry of Health, Jambi, and registration number: LB.02.06/2/153/2020.
Statistical analysis
Data are presented as numbers and percentages for categorical variables. Continuous data were expressed as mean ± standard deviation (SD) or median with Interquartile Range (IQR). Then proceed with bivariate analysis using the Wilcoxon test. The Wilcoxon test was used to determine the effect of the emo demo intervention on knowledge and skills. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.
RESULTS
The characteristics of respondents in this study include age, gender and class level. The following is the frequency distribution of the respondents' characteristics in this study:
Table 1. Frequency Distribution of Respondents Characteristics
In Table 1 it is known that respondents in this study were female dominant as much as 58%, the most age was ]13, 14] years as much as 36% and the students came from class Fourth dominant.
Students' knowledge before being given the Emotional Demonstration Method learning model in the prevention of non-communicable diseases, is presented in table 2.
Table 2. Distribution of Respondents based on students' knowledge before being given the Emotional Demonstration Method learning model in the prevention of NCD
Table 2 shows that 92% did not know the abbreviation of IDP, 93% did not know what diseases were included in NCD 96%, students did not know the function of IDP, 89% of students did not know the symptoms of NCD.
Knowledge after being given the Demonstration Emotional Method learning model about prevention of non-communicable diseases at IDP-NCD SMAN 5 Jambi City, can be seen in table 3.
Description: an asterisk (*) is the correct answer
Table 3. Distribution of respondents based on knowledge after being given the Emotional Demonstration Method learning model in the prevention of non-communicable diseases
Table 3 shows that there are 100% of respondents who answered correctly about the function of the NCD IDP, 99% answered TRUE that IDP can be done aged 15 years and over, and 99% answered TRUE that the types of diseases included in the NCD are stroke, diabetes, cancer, 97% answered It is true that NCD is a non-communicable disease and is not caused by viruses or bacteria, but is caused more by behaviour and lifestyle.
Skills before being given the Emotional Demonstration Method learning model in preventing non-communicable diseases at IDP NCD SMAN 5 Jambi City in 2021 can be seen in table 4.
Description: an asterisk (*) is the correct answer
Table 4. Distribution of Respondents based on student skills before being given the Emotional Demonstration Method learning model in the prevention of non-communicable diseases
Table 4 shows that 98% did not conduct interviews to gather information, 86% did not weigh weight, 64%, and 61% did not measure BMI.
Skills after being given the Emotional Demonstration Method learning model in preventing non-communicable diseases at IDP NCD SMAN 5 Jambi City in 2021, can be seen in table 5,
Table 5. Distribution of Respondents based on student skills after being given the Emotional Demonstration Method learning model in the prevention of non-communicable diseases
Table 5 shows that 100% of them were able to conduct interviews to dig up information, weigh weight, measure height, measure abdominal circumference, and measure blood pressure.
Table 6 shows that the Kolmogorov Smirnov statistical test results obtained a significant value of knowledge and skills both at the pre-test and post-test Emo Demo, each less than 0.05.
Table 6. Normality Test Results of Knowledge and Skills pre test and post test Emo Demo
The knowledge and skills data at the pre-test and post-test Emo Demo are not normally distributed. Therefore, the statistical difference test was tested using Wilcoxon (table 7).
Table 7. Average Knowledge and Skills Pre and Post-test Emo Demo
Table 7 shows that there are different mean values between pre-test and post-test knowledge and skills, meaning that mathematically indicates there are differences in knowledge and skills before and after Emo Demo.
DISCUSSION
Based on the study results, it was known that the participant's level of knowledge and skills regarding the prevention of non-communicable diseases was deficient prior to the intervention. It may be influenced by the low level of education and material on non-communicable diseases that are not included in the high school education curriculum.
The success of health education for school-age children is determined by the selection of educational methods following the characteristics of school-age children and the factors that will be influenced as a result of the education carried out [10,12,13].
Change can only happen in response to something new, exciting and fun. Health education methods usually used tend to instil knowledge before forming new behaviours. The emo demo method was carried out as an intervention using the behavioural-centred design (BCD) approach. This approach seeks to include psychological elements as innovations to change individual behaviour. The combination of science and creativity in the preparation of messages makes this method able to transfer behaviour change messages that are more readily accepted by the target [14,15,18].
In line with previous research by Padila [19] at Aisyiyah 1 Kindergarten, Bengkulu City, it was found that before the intervention was given, most of them received a one-star category as many as 27 people (90%), while the number of respondents after the intervention mostly experienced an increase in ability and received a four-star category, totaled 23 people (76.7%). Similarly, Aisyah's research [20] at Al Kautsar Integrated Kindergarten, Mojokerto, Indonesia, found a change in knowledge after receiving material through demonstration media (emo demo) on washing hands in 7 steps.
The results of this study reject the null hypothesis regarding the effect of the emotional demonstration method on how to prevent non-communicable diseases by school students. The results of this study are in line with Aisyah's research [20] which states that the emo demo method improves children's knowledge, behaviour, and habits to wash their hands properly and correctly. Fermi Avissa [21] also found that the demonstration method improved the knowledge and skills of handwashing in preschool children at TK Flamboyan Platuk Surabaya.
Another study aims to apply the Emo Demo education method in reinforcing the mother's intentions and actions in providing vegetable and fruit menus for the family. The results showed an increase in the intention of homemakers in the intervention group by 6.8 points with a p-value = 0.003, while in the control group, the opposite occurred in the form of a decrease in score by 6.8 (p = 0.229)[12].
Emo Demo is a highly participatory activity guide that aims to convey a simple message in a fun and emotional way, thus making it memorable and impactful compared to other conventional behaviour change strategies [4,11,22].
Emo Demo connects three crucial components in learning: allowing people to learn firsthand through experimentation, providing information, involving other parts of the brain, and touching emotions. In addition, the delivery of the Emo Demo is carried out using teaching aids to make the Emo Demo easy to remember and the message conveyed is accurate so that the message is more easily absorbed and the target is willing to try new behaviours [4,14,15,23].
Giving lessons to students through the emotional demonstration method is considered effective in increasing students' knowledge and skills. Through this method, students are given education by delivering material accompanied by animated videos. After that, students can do direct practice on ways to control non-communicable diseases. Such as measuring blood pressure, weighing weight and height, carrying out counselling, exercising together and others so that the lesson material is memorable in students' memories and hard to forget. It is proven that the dominant skills of students after being given skills lessons, it is seen that almost 100 students get a score of 100.
In general, the study results found that the knowledge and skills of respondents increased after the intervention. However, some respondents did not change after receiving education through emo demos and video media. It might be due to their poor memory.
CONCLUSION
The Demonstration Emotional Method learning model is effective in increasing students' knowledge and skills about preventing non-communicable diseases.
LIMITATION
The limitations of this study include the minimal number of samples, and this study only involved one country, namely Indonesia, so the results may be different when comparing the effects of emo demos and intervention videos on students in other countries or even in the European countries.
FUNDING STATEMENT
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
CONFLICT OF INTEREST
The authors report no conflict of interest.
ACKNOWLEDGEMENT
We would like to thank the director of the Department of Health Promotion, Jambi Health Polytechnic for supporting this research.
AUTHOR CONTRIBUTIONS
WT and PR were responsible for the study conception and design; EV performed the data collection; PR and SS performed the data analysis; WT, PR, and SS were responsible for the drafting of the manuscript; WT and PR made critical revisions to the paper for important intellectual content.
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RELATIONSHIP OF KNOWLEDGE, DEFECATION BEHAVIOR AND FLY DENSITY WITH INCIDENCE OF DIARRHEA ON CHILDREN: A CASE CONTROL STUDY
Suparmi Suparmi *, Rina Fauziah
Department of Sanitation, Health Polytechnic of Jambi, Indonesia
* Corresponding author: Suparmi, Jl. Dr. Tazar, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Department of Sanitation, Health Polytechnic of Jambi, Indonesia. Orcid : https://orcid.org/ 0000-0002-0695-9496. Email: suparmi.poltekkes@gmail.com
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Abstract
Introduction: Diarrhea is a significant public health problem because it is the third major contributor to child morbidity and mortality in various countries, including Indonesia. This study aimed to determine the relationship between the density of flies in the geographic area, the knowledge of the mothers, their defecation behavior, and the presence of diarrhea in children in Jambi City, Indonesia
Materials and Methods: This type of research is a quantitative study with a case-control approach involving 76 children under five, namely 38 cases and 38 control groups. The research data were analyzed using the Odds Ratio test.
Results: Mothers who have less knowledge are 12 times more likely to have a toddler suffering from diarrhea than mothers who have good knowledge. Mothers with poor behavior in dealing with toddlers' defecation habits will have a 5 times greater risk of having a toddler with diarrhea problems; on the other hand, if mothers behave well in dealing with children's defecation problems, then the toddler will not be at risk of having diarrhea. The density of flies does not provide a significant risk for the incidence of diarrhea in infants.
Conclusion: the incidence of diarrhea in children under five in the Putri Ayu Public Health Center in Jambi City is influenced by low parental knowledge and bad defecation behavior
Keyword: Availability of latrines, Behavior, Knowledge, Diarrhea, Children
Introduction
Diarrhea is the expulsion of feces with increasing frequency (three times a day) and changes in the consistency to become soft or watery, with or without blood/mucus [1–5]. Diarrhea is also a public health problem in developing countries like Indonesia because of its high morbidity and mortality. Diarrhea is an endemic disease and a potentially extraordinary disease often associated with death [6–8]. Of all deaths of children under five due to diarrheal diseases, 78% occur in Africa and Southeast Asia [9,10]. In 2019 cases in Indonesia were 4,485,513 people with diarrhea services for toddlers 40%. In 2016, people with diarrhea of all ages served at health facilities amounted to 3,176,079 people, and in 2017 it increased to 4,274,790 people. In that year, there have been 21 outbreaks spread across 12 provinces and 17 districts/cities. In 2017, the coverage of services for children with diarrhea in Indonesia was 40.07%, with the highest being West Nusa Tenggara (96.94%) [11].
Diarrhea is a symptom of infection in the intestinal tract, which can be caused by various bacterial, viral and parasitic infections. Infection is spread through contaminated food and drink, or from person to person as a result of poor sanitation. Diarrhea is usually transmitted through food and drink contaminated with feces and vomit from people with diarrhea. Transmission of diarrhea can also be caused by the behavior of defecating in any place, not washing hands after defecating, not washing hands before and after eating [12–14].
The formation of behavior starts from the knowledge or information that has just been obtained. The individual must first know the benefits and advantages of the knowledge or information they get before adopting it in behavior. The more information obtained, the stronger a person's attitude will change. A person becomes healthy if his daily behavior is healthy and sound. Otherwise, if someone is sick, his daily behavior is wrong or unhealthy [15–17].
The relationship between fly density and the incidence of diarrhea is that the higher the density of flies, the higher the incidence of diarrhea. Transmission routes of the diarrheal disease include water and food, and mechanical arthropods [18].
Toddlers are an age group that is vulnerable to nutrition and prone to disease, especially infectious diseases, one of which is diarrhea. Diarrhea attacks many toddlers because their immune systems are weak, so they are very susceptible to viruses that cause diarrhea. Toddlers who suffer from diarrhea tend to be more at risk of becoming dehydrated quickly. This condition is hazardous and has a negative impact because it can inhibit child growth and development, which can reduce the quality of life [17,19,20].
The prevalence of diarrhea in children in Jambi Province in 2018 was around 7.7%. In 2016 from 11 districts/cities, the incidence of diarrhea in Jambi city has increased. The highest number of sufferers from 2014, as many as 10,491 cases. In 2015, as many as 15,429 cases compared to other districts/cities in Jambi Province, while the incidence of diarrhea was 1,005 cases in 2019 in the Putri Ayu Health Center Work Area, Jambi City [21].
Based on this phenomenon, conducted this study to determine the relationship between knowledge, public defecation behavior, and fly density with diarrhea incidence.
Methods
Design
This research is a quantitative research with a Case-Control study approach
Participants
This research was conducted in Legok Village, Jambi City, Indonesia. The research was carried out in January-April 2020, involving 76 mothers with a ratio of the number of cases and controls being 1:1; in this study, the number of case groups was 38 respondents, and the control group was 38 respondents with matching mothers education. The case group is mothers who have children suffering from diarrhea while in the control group are mothers who have children who do not suffer from diarrhea.
The minimum sample size required for this study was calculated using the G*Power program, considering effect size of 0.3, α-value of 0.05, power of 0.85, and sample group ratio of 1 [22].
The selection of research samples was carried out randomly with inclusion criteria such as mothers who have toddlers and mothers who have never been respondents in previous studies with the theme of diarrhea.
Intervention
In this study, there are three independent variables: mother's knowledge, fly density, and defecation behavior, with diarrhea incidence as the dependent variable. All questions in the study used a dichotomous scale so that the scale used was the Guttman scale [23].
The density of flies has the objective criteria of dense and less dense and was measured using a Guttman scale questionnaire with 10-item questions and a rating range of 0-10, if the respondent answered yes was given a score of 1 and the answer was not given a score of 0.
Defecation behavior variables have good objective criteria and are not measured using a Guttman scale questionnaire with 10-item questions and a rating range of 0-10, if the respondent answered yes was given a score of 1 and the answer was not given a score of 0.
Mother's knowledge has the objective criteria of dense and less dense and was measured using a Guttman scale questionnaire with 10-item questions and a rating range, if the respondent answered correctly was given a score of 1 and the wrong answer was given a score of 0. The incidence of diarrhea varies, but there are objective criteria for cases and controls, which are measured using a Guttman scale questionnaire.
The variable incidence of diarrhea has objective criteria for cases and controls measured using a Guttman scale questionnaire with 10 item questions with a rating range of 0-10, if the respondent answered yes was given a score of 1 and the answer was not given a score of 0.
Blinding
In this study, 2 enumerators were used to collect research data. The previous enumerators did not know the participants because they were students who had been trained by the researcher before collecting data.
Ethical Consideration
No economic incentives were offered or provided for participation in this study. Before carrying out data collection, the researcher first took care of ethical permission.
The authors state that this study followed all ethical clearance processes and was approved by the health research ethics committee of Jambi University, Faculty of Medicine and Health Sciences, and registration number: LB.03.02./3.5/121/2019.
Statistical analysis
Data were presented as numbers or percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). The Odds Ratio was used to evaluate significant differences of proportions or percentages between two groups. If the OR value is more than 1.0 then it is considered significant or the variable is considered a risk factor. Statistical analysis was performed using the SPSS version 16.0 application. All tests with p-value (p) < 0.05 were considered significant.
Results
The characteristics of the respondents in this study can be seen in table 1 below.
Table 1. Distribution of respondent characteristics
Table 1 shows that the age group of 26-30 years dominated the respondents as much as 76.3% in the case group. The elementary education level was 39.5%, the dominant working mother was 57.9%, and primiparas were 60.5%. While in the control group, the age group of 26-30 years dominated the respondents as much as 76.3%, the elementary education level was 39.5%, the dominant working mothers were 52.6%, and multiparas were 68.4%. In the case group, the median age of children was 59.5 while in the control group it was 52, and the frequency was almost the same.
Table 2 shows that mothers who have less knowledge are 12 times more likely to have a toddler suffering from diarrhea than mothers who have good knowledge.
Mothers with poor behavior in dealing with toddlers' defecation habits will have a 5 times greater risk of having a toddler with diarrhea problems; on the other hand, if mothers behave well in dealing with children's defecation problems, then the toddler will not be at risk of having diarrhea.
The density of flies does not provide a significant risk for the incidence of diarrhea in toddler.
Table 2. Frequency Distribution of Respondents Based on Research Variables
Discussion
This study aimed to determine the relationship between the density of flies in the geographic area, the knowledge of the mothers, their defecation behavior, and the presence of diarrhea in children in Jambi City, Indonesia. Knowledge results from 'knowing,' which occurs after people have sensed a particular object. Sensing occurs through the five human senses, namely the senses of sight, hearing, smell, taste, and touch. Most human knowledge is obtained through the eyes and ears [24]. Knowledge of cognition is an essential domain for forming one's actions (overt behavior). Based on experience and research, behavior based on knowledge will be more lasting than behavior that is not based on knowledge [25]. The results of statistical tests show that mothers who have less knowledge are 12 times more likely to have a toddler suffering from diarrhea than mothers who have good knowledge. The results of this study are in line with the results of research conducted by Hartati [26], namely there is a significant relationship between respondents' knowledge and the incidence of diarrhea with a p-value of 0.001. also in line with research conducted by Palancoi [18], namely there is a significant relationship between respondents' knowledge and the incidence of diarrhea with a p-value of 0.010.
Based on the data obtained, some respondents have a low level of knowledge about diarrhea. A mother tends to find it challenging to protect and prevent her toddler from transmitting diarrhea. This low knowledge of mothers is due to the lack of information or counseling provided by health workers, making it difficult to prevent and take action when a child has diarrhea. The author suggests that health workers at the Putri Ayu Health Center increase the socialization of maternal and child health books and counseling about diarrhea so that public knowledge about diarrhea increases. Defecation-prone mothers are five times less likely to have a toddler who has diarrhea than mothers who have normal bowel habits. The findings of this study are consistent with those of Ambar and Suci [27], who found a significant association between defecation behavior and the occurrence of diarrhea with a p-value of 0.002. From the data at the research location, it is known that there are respondents who have poor defecation behavior. The behavior of open defecation reflects a culture of public ignorance, which can be interpreted as an attitude of not caring about anything. In this case, the community does not care about the detrimental effects of open defecation on themselves and others. Clean and healthy living behavior has a close relationship with diarrhea incidence. The behavior of washing hands before eating, feeding the baby, and defecating is a factor in breaking the chain of transmission of diarrheal diseases.
Based on the author's observations, it is known that most of the sewerage facilities (latrines) in the research location do not meet the requirements, such as not having a septic tank. Family restrooms that do not meet the requirements cause environmental pollution, including soil pollution, water pollution, food contamination, and the breeding of flies. The author suggests changing the habit of open defecation (BAB) into clean and healthy living behavior (PHBS) and seeking latrines that meet sanitary requirements, among others, by having a septic tank and maintaining the cleanliness of the feces disposal site to avoid diarrhea. Flies are one type of nuisance insect and can be disease-transmitting insects to human health that can spread disease. The presence of flies in an area can be used to indicate that the area is not clean or hygienic [28]. One of the causes of diarrhea is the contamination of food and drink by bacteria carried by house flies. This fly is considered a nuisance because it perches in damp and dirty places, such as garbage. If microorganisms contaminate the food infested by house flies, bacteria, protozoa, eggs/larvae of worms, or even viruses that are carried and removed from the mouths of flies and, when eaten by humans, can cause diarrheal disease [17,29]. The eradication of flies affects the entire community. Garbage is linked to the emergence and reproduction of flies. Insecticides can also eradicate flies, albeit this is less effective. Keeping the house clean, not littering, utilizing sanitary latrines (water-sealed latrines), and leading a clean and healthy lifestyle are all actions that must be taken to remove flies [14]. The number of flies does not appear to be a substantial risk factor for diarrhea in toddlers. The findings of this study agree with those of Firmansyah [1], who found that there is no significant link between fly density and diarrhea incidence, with a P-value of 0.080. The findings of the field investigation revealed that some respondents had a high degree of fly density. The researchers saw a lot of waste surrounding the house, which was tossed haphazardly, resulting in the appearance of flies. The presence of a large number of flies might be caused by poor or unclean housing cleanliness. If the house is in the high category, flies will land wherever, including food and drinks that are not covered in the house, and there will be bacterial contamination from flies to food and drinks for toddlers, causing digestive system disorders and diarrhea in many toddlers. Because of their good understanding of food processing, such as covering food after cooking or washing hands before cooking, many of the respondents were aware of the dangers of flies as a cause of diarrhea.
Conclusion
The incidence of diarrhea in children under five in the Putri Ayu Public Health Center in Jambi City is influenced by low parental knowledge and bad defecation behavior. The author recommends that individuals pay attention to the cleanliness of their homes, particularly their rubbish, because flies are intimately associated to garbage because garbage serves as a breeding place for them. It is expected that the community will further improve clean and healthy living behavior, especially by taking steps to prevent diarrhea, such as washing hands after defecating and before eating with soap and seeking latrines that meet sanitation requirements. Sanitation requirements include having a septic tank and maintaining the cleanliness of the waste disposal site, and not getting used to defecating in the river.
Limitations
The limitation of this research is the number of samples is very limited and does not compare the variables studied in the community between countries, in the future research must be carried out involving a larger community with coverage between countries.
Acknowledgement
We would like to thank the director of the Department of Health Sanitasion, Jambi Health Polytechnic for supporting this research.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
Competing interests statement
There are no competing interests for this study.
Author’s Contributions
SP and RF were responsible for the study conception and design; performed the data collection; and performed the data analysis; were responsible for the drafting of the manuscript; SP made critical revisions to the paper for important intellectual content.
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Nurses’ knowledge of Diagnostic-Therapeutic Care Pathways (DTCP): A cross-sectional study
Ubaldino Ubaldi1*, Valentina Accinno2, Margherita Ascione3, Concetta Pane4
- Department of Ageing, Neurological, Orthopaedic and Head and Neck Sciences C.E.M.I, IRCCS - Fondazione Policlinico Gemelli - Rome (Italy)
- Department of Women's and Children's Health Sciences and Public Health DH Clinical Pharmacology, IRCCS - Fondazione Policlinico Gemelli - Rome (Italy)
- Integrated Operative Unit Maternal and Childhood Coordination - ASL Napoli 3 SUD, Naples (Italy)
- Integrated Operative Unit Maternal and Childhood Coordination - ASL Napoli 3 SUD, Naples (Italy)
*Corresponding Author: Ubaldino Ubaldi, Clinical Nurse, IRCCS - Fondazione Policlinico Gemelli - Rome. Nurses Department of Ageing, Neurological, Orthopaedic and Head and Neck Sciences C.E.M.I
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ABSTRACT
Introduction: Management by processes and clinical care pathways are now fundamental and indispensable requirements for quality improvement in healthcare organisations. The basic idea is to design a system that allows for continuous improvement in the way in which the key player in healthcare, i.e. the patient, is managed. If this were to happen, the best experiences to date tell us, it would definitively improve outcomes, efficiency and appropriateness. Moreover, patients perceive and appreciate this difference, allowing health professionals to operate at their best.
Objective: To assess the knowledge and application of the DTCPs by the nursing staff.
Materials and methods: The cross-sectional study took place in the period between June and September 2019 at the Operative Units of digestive surgery, hepatobiliary surgery, breast surgery and gynaecological surgery of the “Fondazione Policlinico Gemelli IRCCS in Rome”. A questionnaire was administered only to permanent nurses.
Results: A total of 64 questionnaires were administered of which 27 were correctly completed (response rate 42.1%) and considered valid for analysis. The sample of respondents was predominantly female (74.07%), 81.48% held a Bachelor's degree and 40.74% held a Master's degree. 55.56% knew what DTCPs were, but there was no in-depth knowledge of them in the sample. In fact, 55.56% knew whether there were active DTCPs in their region; 7.41% that nurses cannot participate in DTCPs and only 11.11% that nurses cannot participate in the review of individual DTCPs, while 59.26% were aware of the professional figures involved in the drafting and review of DTCPs. 25.93% knew what the diagnostic phase was based on and 14.81% that there were no active memoranda of understanding with public or private facilities in the diagnostic phase. Finally, only 25.93% were aware that the user could not be used in the evaluation of the outcome.
Conclusions: Although the interviewees were familiar with clinical care pathways, for most of them there had never been active involvement, they agreed on user involvement instead.
Keywords: nursing care, clinical care pathways, patient safety, diagnostic-therapeutic care pathways
INTRODUCTION
The reorganisation of the hospital network (Ministerial Decree 70/2015) and the reorganisation of Primary Care (Law 189/2012 - Balduzzi Decree) have brought about a profound and structural change in patient care and treatment in the Italian National Health Service [1-2]. The reorganisation of Primary Care, with the establishment of the AFTs (Regional Functional Aggregations) and the UCCPs (Complex Units of Primary Care), has meant tackling the problem of chronicity, with patient care, according to the Chronic Care Model and the model of integrated and structured Clinical Networks. It is a process of structural change and as such entails the need for a new culture in the definition, management and verification of the process of taking care of chronic patients: all this represents the real 'Reform'. The operational tool for treating chronic patients and co-morbidities is the Diagnostic-Therapeutic Care Pathways (DTCPs), which therefore represent the lintel of the new system [3-4].
Clinical/healthcare pathways predefine an optimal scheme of the sequence of behaviours in relation to the diagnostic, therapeutic and care pathway to be activated in the face of a typical clinical situation, in order to maximise the effectiveness and efficiency of activities [5]. DTCPs represent multidisciplinary care management technologies that map activities in a healthcare pathway, which are now considered fundamental and indispensable requirements for improving the quality of healthcare organisations in accordance with the logic of clinical governance [6]. The aim is to increase the quality of care across the continuum, improving risk-adjusted patient outcomes, promoting patient safety, increasing user satisfaction and optimising the use of resources [7].
In the entirety of its definition, construction, implementation and monitoring phases, it makes it possible to structure and integrate activities and interventions involved in the active and global care of citizens presenting health problems through a process approach, in a multidisciplinary context and on different areas of intervention (hospital, region, etc.), making it possible to assess the appropriateness of the activities carried out with regard to the objectives, the reference recommendations (Guidelines, good practices) and available resources [8]. It also allows for a measurement of activities and a comparison of results with specific indicators, leading to an improvement in each intervention in terms of effectiveness and efficiency. The need to find a shared theoretical and operational reference on what is meant by 'diagnostic therapeutic care pathway' is common among those who, at different levels and with different roles, deal with the planning of healthcare and social-health services and for those who work in them [9-10] .
The organisation of care by DTCPs is indirectly referred to by the 'Gelli' Legislative Decree (No 24/2017), the aim of which is to improve the quality of the National Health System, seeking to do so also by acting on the pillar of appropriateness of healthcare intervention, in particular, Article 5 of the aforementioned law regulates the way in which the healthcare profession is exercised, obliging healthcare professionals (doctors, nurses, physiotherapists, etc.) to adhere to the use of official guidelines and good clinical care practices [11]. Hence the need to investigate nurses' knowledge of DTCPs.
Objective
Assessing nurses' knowledge and perceptions of DTCPs
MATERIALS AND METHODS
The cross-sectional study was conducted during June-September 2019 at the Operative Units of digestive surgery, hepatobiliary surgery, breast surgery and gynaecological surgery at the “Fondazione Policlinico Gemelli Istituto di Ricovero e Cura a Carattere Scientifico in Rome (IT)”. Authorisation was requested and obtained from SITRA (Servizio Infermieristico Tecnico Riabilitazione Aziendale - Company Rehabilitation Technical Nursing Service) to proceed with the administration of a questionnaire, filled out anonymously, to the nurses on duty in the above-mentioned operational units.
The distribution took place after an interview with the nursing coordinators, providing verbal information on the questionnaire and confirmation of the processing of the data in aggregate form, not resulting in any distribution by name. After the distribution of the questionnaires to the nurses in the operating units by the coordinators, the latter collected them and placed them in a single container, which was then returned to the authors of the study.
All nurses who took part in the study well understood and signed the consent form, in which the purpose of the study and the methodology of conducting it were explained, and the personal data processing form.
The questionnaire, created ad hoc, was structured after a thorough literature search and listed in Appendix A, after the references section. The questionnaire was validated on a sub-sample of 10 nurses from the investigated sample, i.e. the questionnaire was submitted to them twice, at a minimum time interval of three days, and the statistical correlation between the two sets of answers was assessed, using the two-proportion test, with the two answers being statistically correlated if p-value >0.05 (i.e. the answers given, particularly with regard to the DTCP, were consistent at two different time points).
The questionnaire consists of 21 multiple-choice items structured as follows:
- 5 items on biographical characteristics: years of service, assigned operational unit, gender, educational qualification, post basic training;
- 16 items on DTCPs: what is a DTCP; participation of nurses in DTCP training courses; existence of DTCPs in their region and which types; whether clinical audits are planned and how often and others.
Informed consent was signed by all patients included in this study and anonymity was guaranteed. No economic incentives were offered or provided for participation in this study. The study was performed following the ethical considerations of the Helsinki Declaration[12].
Inclusion and exclusion criteria
All nurses of both sexes with a permanent contract type, who speak and understand Italian well, were included in this study, while all nurses temporarily assigned by the cooperatives (fixed-term and/or temporary assignment) were excluded from the study. However, this is a sample study with probabilistic sample selection (the only common element of inclusion is the existence of an open-ended contract).
Statistical analysis
Data was presented as numbers or percentages for categorical variables. Continuous data is expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR).
A binomial test was performed to compare two mutually exclusive proportions or percentages in groups. The chi square test and Fisher's exact test were performed to evaluate significant differences in proportions or percentages between two groups. Particularly Fisher’s exact test was used where the chi-square test was not appropriate. The multiple comparison chi-square tests were used to define significant differences between percentages. In this case, if the chi-square test was significant (α level: 0.05), the residual analysis with the Z-test was performed. All tests with p-value(p) <0.05 were considered significant. The statistical analysis was performed by Matlab statistical toolbox version 2008 (MathWorks, Natick, MA, USA).
RESULTS
A total of 64 questionnaires were administered, 13 in digestive surgery, 14 in hepatobiliary surgery, 21 in breast surgery and 16 in cancer surgery. Only 27 questionnaires (42.8%) were returned and completed. Specifically:
- digestive surgery, 13 questionnaires delivered, 5 returned completed (38.4%).
- general surgery - hepatobiliary, 14 questionnaires delivered, 9 returned completed (64.2%);
- retroperitoneal cancer surgery, 21 questionnaires delivered, 6 returned completed (28.5%);
- gynaecological oncology, 16 questionnaires delivered, 7 returned and completed (43.7%);
In Table 1 below, we have reported the characteristics of our sample of nurses
Table 1. Characteristics of the 27 subjects participating in this study Items 1-5 of the questionnaire
Table 1 shows that the sample has a length of service ranging from 11 to 20 years (44%), is predominantly female (74%) and holds a bachelor’s degree (81%), while 40.7% of the respondents hold a Master's degree.
Table 2 shows the interviewees' knowledge of the Diagnostic-Therapeutic Care Pathway (DTCP).
Table 2. Knowledge of the interviewees about the DTCP. Items 6-15 of the questionnaire. The correct answer is indicated in bold and with an asterisk.
Table 3 shows the interviewees’ knowledge of the DTCP Protocols.
Table 3. Knowledge of the interviewees about the DTCP Protocols. Items 16-18 of the questionnaire The correct answer is indicated in bold and with an asterisk.
Table 4 shows the monitoring associated with the DTCP
Table 4. Knowledge of the interviewees about the monitoring associated with the DTCP. Items 19-22 of the questionnaire The correct answer is indicated in bold and with an asterisk.
Finally, Table 5 shows all the statistical tests performed in this study
Table 5. Statistical tests performed in this study. Unanswered questions were not considered in the statistical analysis for each item. The correct answer in the questionnaire is indicated in bold
From Table 5, it can be seen that in our sample, there was no significant difference by seniority of service (p=0.368) and by medical area (p=0.730), while there was a significant presence of female gender (74.07%, p<0.0001) and of subjects with a Bachelor's degree (81.48%, p<0.0001). On the other hand, with regard to postgraduate education, subjects with a Master's degree were significantly more present (40.74%, p<0.0001), together with the option 'Other' (25.93%, p=0.0013).
With regard to knowledge of DTCP courses, the most frequent answer was Answer A: 'DTCP describes the pathway that a person with health problems takes between one or more health organisations and defines the best sequence of actions necessary to achieve the health objectives identified a priori' (55.56%, p<0.0001), whereas when asked about participation in DTCP courses, the answer 'No' was the significantly most frequent (74.08%, p<0.0001). Regarding knowledge of active DTCP courses in one's region, the most frequent answer was 'YES' (55.56%, p<0.0001).
When asked about knowledge of which DTCPs were active (Item 9) and of DTCPs for neurodegenerative diseases (Item 10), there was no significant difference between the answers.
In Item 11, concerning 'nurse participation', Answer C: 'partly' was the most frequent (55.56%, p<0.0001), similarly for Item 12 (Answer C: 70.37%, p<0.0001).
With regard to the clinical audit (Item 13), there was no significant difference between the various answers. In contrast, for audit cadence (Item 14), Answer D: '1/year' was the most frequent (55.56%, p<0.0001).
With regard to knowledge of published audits (Item 15), there was no significant difference between the various answers.
With regard to Item 16 (Other professional figures), the significantly more frequent answer was Answer C: 'all professional, rehabilitation medical figures provided in the multidisciplinary teams specific to that clinical condition' (59.26%, p<0.0001).
For Item 17 (DTCP phases), the most frequent answer was 'YES' (48.15%,p=0.0084). Similarly for Item 18 (SI: 51.85%, p<0.0001).
There was no significant difference between the responses associated with Items 19, 20 and 21, whereas for Item 22 (user involvement), the 'YES' response was the significantly more present (48.15%, p=0.0084),
DISCUSSION
The cross-sectional study was conducted with the aim of exploring and assessing the knowledge of DTCPs by nurses in service at the Fondazione Policlinico Gemelli (IRCCS) assigned to the Operative Units of digestive surgery, hepatobiliary surgery, breast surgery and gynaecological surgery through the administration of a questionnaire.
Almost half of the nurses interviewed to date, despite having completed a Bachelor's and a Master's degree, are not aware of the importance of DTCPs in terms of quality of care and the achievement of health outcomes: all organisations, including health care organisations, are composed of a series of processes or sets of actions, oriented towards creating value for those who know and use them [13]. It is likely that the study of Guidelines, Protocols, Procedures and DTCPs undertaken in the 1st year programme should also be taken up in the following years in the degree course, combining theory with practice.
Almost all of the nurses (74.08%), who participated in the study, were never involved in participating in the drafting of such pathways, without considering the importance of a broadly participatory approach of all components (management and technical-professional) of the organisation and the use of decision-support techniques (use of scientific evidence, audits between professionals) [14].
Healthcare institutions can use DTCPs and promote evidence-based practice to benefit quality and reduce costs [15]; however, research suggests that compliance with the use of DTCPs is low [16].
Another barrier could be resistance to the practice of change in working environments
[17], however with a proper implementation and evaluation process, change in healthcare is achievable [18].
The nurses' thoughts on user involvement are significant: in the light of these results, it can be stated that the attempt to introduce a multidisciplinary logic in healthcare organisations is hindered by the very peculiarity of the context, which is of a professional nature, in which management cannot impose itself on professionals, but must instead involve them. The task of management today is to succeed in creating those conditions that actively involve health professionals in spontaneously innovating clinical practice [19].
CONCLUSION
The implementation of DTCPs can offer the patient timely and real continuity of care, through the identification of qualified care and the integration of all professional figures. The study conducted included the assessment of nurses' knowledge on DTCPs. The results obtained show a gap in nurses' knowledge of DTCPs and this preliminary study provides several insights to improve the knowledge of DTCPs among nurses in order to ensure better continuity of patient care.
Strengths and Limitations of the study
The study has some limitations. In particular, the sample examined is a monocentric and small sample; a larger sample could have provided additional insights, reducing the possibility of statistical bias.
The study could be a preliminary step to a larger one including other operating units, not previously taken into account, so as to offer new insights given the importance of the topic for nurses.
Funding
This research did not receive any form of funding.
Conflict of interest
The authors declare that they have no conflicts of interest associated with this study.
REFERENCES
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- Janicek M., Casi clinici ed evidence – based medicine, Roma 2001.
- Atwal A., Caldwell K., Do multidisciplinary integrated care pathways improve interprofessional collaboration, Scandinavian Journal of Caring Sciences, 16(4):360-7,2002.
- Croce D., Sebastiano A., Castiglioni Rusconi M., Carenzi A., I PDT/PDTA nelle organizzazioni sanitarie: una meta-analisi della letteratura internazionale, economia e management “s.d” pp38-39 [online]Casati G., La gestione per processi in sanità, QA Vol 13. 1, (2002).
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Appendix A
COGNITIVE QUESTIONNAIRE ON NURSES' PERCEPTIONS OF DTCPs.
Dear colleague,
We are two nurses who work at the Fondazione Policlinico Gemelli and we are conducting a cognitive survey, with the aim of surveying the knowledge of health workers on the subject of Diagnostic-Therapeutic Care Pathways.
We ask you to take a few minutes of your time to answer the questions in the questionnaire, assuring you that the results will be treated absolutely anonymously and used for statistical purposes only.
Thank you for your participation.
1. Years of service:
A. less than 10
B. 11-20
C. More than 20
2. In which area are you assigned?
A. critical area
B. medicine
C. surgery
D. Other......
3. Gender:
A. M
B. F
4. Basic qualification:
A. Qualifying title
B. University diploma
C. Bachelor's degree
5. Post-basic training (multiple answers possible)
A. Advanced training courses.....................................................
B. Master's degree (one or more) .............................................
C. Master's/Specialist Degree
D. Level II Master's degree (one or more).............................................
E. Other...........................
6. What is a Diagnostic-Therapeutic Care Pathway (DTCP)?
A. The DTCP describes the 'journey' that a person with health problems takes between one or morehealth organisations and defines the best sequence of actions necessary to achieve thehealth objectives identified a priori.
B. The DTCP is a set of guidelines, protocols and procedures
C. The DTCP is a structured pathway of healthcare acts
7. Have you ever participated in DTCP training courses?
A. Yes
B. No
C. I have never been contacted
8. Are there active DTCPs in your region?
A. Yes
B. No
C. In the planning stage for implementation
9. If you answered 'Yes' to the previous question, which one?
A. Single integrated rehabilitation pathway for the stroke patient
B. Pathway for the care and rehabilitation of patients with disorders of consciousness due to severe acquired brain injury
C. Diagnostic and therapeutic care pathway for chronic obstructive pulmonary disease
D. Definition of the pathway for early detection of suspected cases of DSA and indication for diagnosis and certification
E. Operational guidelines for the implementation in the regional network of social and health services and integrated pathways for adults with SLA
F. Operational guidelines for the prevention, diagnosis, treatment and care of people with dementia
G. Other DTCPs …………………………………………………………………………………………………………………………………………………………………
10. In your Regional Health Agency, have DTCPs been activated that may affect Neurodegenerative and Neurodevelopmental diseases?
A. Yes
B. No
C. They are in the planning stage
11. Does the professional figure of the nurse participate, and to what extent, in the drafting of the specific DTCP?
A. Yes
B. No
C. Partially
D. Participates in specific regional technical tables as a representative of the professional association
12. Does the nurse participate, and to what extent, in the review of individual DTCPs?
A. Yes
B. No
C. Only partially
13. Are clinical audits of individual DTCPs planned?
A. YES
B. NO
C. Partially
14. How often are specific audits planned for each DTCP?
A. One/month
B. One/every two months
C. One/semester
D. One/year
E. Other...
15. Are the DTCPs published on the company website or in the appropriate sections and therefore consultable by the various professionals?
A. YES
B. No
C. Only partially
16. What other professional figures are envisaged in the drafting/revision of individual DTCPs?
A. Only doctors
B. Only physiotherapists
C. All the professional, medical and rehabilitation figures foreseen in the multidisciplinary teams specific to that clinical condition
17. The DTCP envisages a Diagnostic phase and a Therapeutic-Assistance phase: are PACC, PIC and Day Service envisaged in the diagnostic phase?
A. Yes
B. No
18. Are memoranda of understanding currently in place with accredited public and/or private healthcare facilities in the Diagnostic phase?
A. Yes
B. No
C. Partially (please specify)………………………………………………….
19. In DTCPs, is the outcome used, and in what way, as a check on the effectiveness, efficiency, cost-effectiveness and appropriateness of the Pathway?
A. Yes
B. No
C. Through outcome measures and specific performance indicators set out in individual documents
20. To what extent does the nurse participate in pathway monitoring activities?
A. Not participating
B. Meetings in the working group
C. Meeting in the working group of the regional technical table
21. Are teleconsultation, telemonitoring and teleassistance activities provided for within the individual DTCPs?
A. Yes
B. No
C. In part (specify)………………………………………………….
22. Is user involvement in outcome assessment foreseen in the DTCPs?
A. Yes
B. No
Authorisation for data processing for statistical purposes consent
□ ………………………………………………………….
□ ………………………………………………………….
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Attribution-NonCommercial-NoDerivatives 4.0 International License.
THE IMPACT OF HEALTH EDUCATION ON KNOWLEDGE, ATTITUDE, PRACTICE, AND PREVENTION OF IRON DEFICIENCY ANEMIA AMONG ADOLESCENT FEMALES: A SYSTEMATIC REVIEW
Sarinah Siregar*1, Asni Johari2, Muhammad Rusdi2, Syahrial2
1Health Polytechnic, Jambi Ministry of Health, Jambi, Indonesia
2 Jambi University, Indonesia
Corresponding author: Sarinah Siregar, Prof DR GA Siwabessystreet, No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36122, Phone :+62 813-6685-5307
Email: sarinah.siregar.poltekkes@gmail.com
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ABSTRACT
Introduction: Women in reproductive age are at high risk of iron deficiency anemia during the menstrual cycle. Adequate knowledge, attitudes, practices, and prevention towards anemia are necessary. There is a dearth of information on the evaluation of study characteristics and the overall quality of evidence of intervention studies in improving knowledge, attitudes and practices of anemia among adolescents.
Aim: The purpose of this study is to examine the impact of health education interventions on the knowledge, attitudes, practices, and prevention towards anemia in adolescent girls. Therefore, the review question are “What health education methods are best used to improve knowledge, attitudes, practices, and prevention of adolescent?”, “What is the effect of health education interventions on anemia in adolescent girls?”
Methods: This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) Checklist whichinvolved studies published between 2000 to 2021 through the databases of PubMed, ScienceDirect, Willey online Library, Cochrane, in English version. Study quality assessed using the National Institutes of Health (NIH) on controlled intervention studies. The risk of bias of the studies included assessed using The Cochrane Risk of Bias Assessment Tool.Data of the studies included were synthesized thematically in order to understand the effectiveness of mobile application. At identification stage, there are 1,414 publications were discovered through backward searching of relevant papers. The full-text screening was conducted on 34 articles and the finding 22 articles failed to meet eligibility criteria at the full-text screening stage, and only 12 articles were finally eligible for further analysis. There are twelve studies included in this study, strengthening the components of health education and increasing Iron-Folic Acid (IFA) knowledge among adolescent girls is beneficial in reducing iron deficiency anemia in adolescent girls
Results: The results of the review article showed that health education interventions, giving iron supplements and multivitamins were effective in overcoming iron deficiency anemia in adolescent girls. Educational interventions also increase the knowledge of young women about iron deficiency anemia
Conclusions: Health Education intervention for the treatment of iron deficiency anemia among adolescent female improved their knowledge, attitude, practice,and prevention
Keywords: adolescent girl, health education, iron deficiency anemia, anemia
INTRODUCTION
Anemia is a medical complication in which the number and size of red blood cells, or the hemoglobin concentration, falls below the reference range. It has the potential consequence of impairing or reducing the capacity of the blood to transport oxygen throughout the body [1–3]. Anemia is resulting from both poor nutritional status and/or poor health condition. Globally the most significant cause of anaemia is iron-deficiency (ID). The onset of anemia secondary to iron deficiency is generally assumed to account 50% of anemia occurred in the world [4].
Women of reproductive age (adolescent girls) are at a high-risk group so that 25% of students suffer iron deficiency anemia during the menstrual cycle [5,6]. Because in a period of growth and development, they need iron every day is more than 3 times that of young men [7]. The results study by Gunatmaningsih [8] showed that respondents in a period of menstruating have 1.842 times greater risk of anemia, the duration of menstruation is a predictor of anemia [9]. Blood loss during menstruation can lead the iron deficiency anemia. The amount of blood lost during one menstrual period ranges from 20-25 cc, iron loss 12.5-15 mg/month, or 0.4-0.5 mg/day. If this is added to the basal loss of 1.25 mg/day, then the total amount of iron lost is 1.25 mg/day. The volume of blood that comes out more than 80 ml occurs in adolescents who have long menstrual periods [10]. Menstrual problems can interfere the school activities and daily activities too [11].
Another factor that can exacerbate anemia in adolescent girls is the lack of iron intake, where iron in adolescent girls is needed to accelerate growth and development. The results of Shalini's research in India found that the intake of iron-rich foods low was 72% [12]. Tangerang indicated that the total iron intake in girls aged 10–12 years who suffered from anemia was only 5.4 mg/day or 25%, which is lower than the daily requirement of 20 mg/day according to the 2013 Nutritional Adequacy Ratio (RDA) [13].
Anemia causes fatigue, decreased learning concentration that impact learning achievement, can reduce work productivity [14] and quality of life in adults [15]. Anemia can reduce the body's resistance so which can increase the risk of infection. The high prevalence of anemia among adolescents if not handled properly will continue into adulthood and contributed greatly to the increase in maternal mortality (MMR), the risk of giving birth to babies with low birth weight (LBW), and stunting [14,16].
WHO (2014), has a target in 2025 to reduce the prevalence of anemia in women of childbearing age by 50% [5]. In WHO (2011) recommendations for the prevention of anemia for adolescent girls and women of childbearing age by focusing on promotive and preventive activities, through efforts to increase consumption of nutrients that contain lots of Fe, provide blood-added tablets, and increase fortification of foodstuffs with iron and acid folate. Blood supplement tablets are iron folate tablets where each tablet contained 200 mg of ferrous sulfate as well as 60 mg of elemental iron and 0.025 mg of folic acid [17].
A few studies have shown that supplementation of tablets containing 200 mg of ferrous sulfate and 0.25 mg of folic acid that increases in average Hb in adolescent girls after being given treatment [18,19]. The results of the Singh RS research (2018), effective nutritional counseling and supplements play an important role in preventing nutritional deficiencies, such as anemia [20]. Education/counseling to parents increases the cure rate for anemia in preschool-aged children, through increasing adherence to IFA consumption [21]. Adolescence also is an unique point of intervention as people of this age group are more receptive to changes in lifestyle that may determine their life course later [22]. Previous studies showed that adolescents have poor knowledge, attitudes and practices about malnutrition and dietary intake [23],[24],[25],[26]. Providing them with knowledge about iron deficiency could prevent them from anemia and the impact later in life. Enhancing health education interventions on knowledge, attitudes and practices, especially among adolescents, is potentially important in reducing anemia and mitigating short and long term consequences associated with health outcomes and those of their future offspring. There is a dearth of information on the evaluation of study characteristics and the overall quality of evidence of intervention studies in improving knowledge, attitudes and practices among adolescents especially in Asia region. Since the mid-1800s, when nursing was first acknowledged as a unique discipline, the responsibility for teaching has been recognized as an important role of nurses as caregivers. The focus of nurses’ teaching efforts is on the care of the sick and promotion of the health of the well public. In accordance to this review topic, a nurse has a great responsibility to teach people regarding nutritional anaemia. This systematic review aimed to examine the impact of health education interventions on the knowledge, attitude, practice, and prevention of iron deficiency anemia among Asian adolescent girls. This review provides an overview of the importance of educational interventions, and nurses may play an important role in educating families about anaemia and empowering them to achieve the best possible outcomes for adolescent.
MATERIAL AND METHODS
Review Protocol
We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement 2020 in conducting this study [27]. The study analyzed the effectiveness of health education in preventing anemia among adolescent females based on peer-reviewed studies published from 2000 to 2021. The participants, intervention, comparator, outcome, and study design (PICOS) criteria outlined in Table 1 were used to select studies for inclusion in this review.
Table 1. Studies Criteria based on PICOS
Searching strategy
Databases used in collecting relevant literature include Sciencedirect, Cochrane library (Central), Pubmed, and the Wiley Online Library. We could not use other databases due to limited access or are not free access. The defined keywords adhere to the Mesh term for health research. The keywords being used are varied because they are tailored to the search engine. The keywords focus on nutritional education, empowering, Educational intervention, peer education, health promotion OR Health information AND iron deficiency anemia OR anemia AND adolescent girls OR female students. A summary of keywords combination used in each database used is reported in Table 2.
Table 2. Search strings in databases
Eligibility Criteria
We included all studies with evidence reporting the effectiveness of educational interventions in reducing and preventing iron deficiency anaemia, published from January 2000 to December 2021, written in English, and published in peer-reviewed journals. All studies using adolescent female or female students in either school or community-based settings are included in this review. Health education in any methods, intervention duration of three days at minimum, and followed up on a week, month, or year are also included in this study. Studies that reported incomplete information were excluded from duplicate publications, systematic reviews, commentaries, and letters to editors that did not provide primary data.
Information Source
After compiling keywords that match the Mesh terms, the next step is to start searching the database with free access status. The time span determined by the authors has been mutually agreed upon and is considered sufficient to describe the theme raised. Literature searches on Sciencedirect were conducted in June 2021, Cochrane library in November and December 2021, Pubmed in May 2021, and the Wiley Online Library in December 2021. We also carried out a hand search of articles, comments, letters to editors, and proceedings. The articles obtained are then collected into separate folders, for further screening. We also got several articles from the results of a bibliography search in the article.
Selection Process
Two authors independently screened each record (title/abstract), disagreement between the authors resolved by first author. Screening is done by adjusting the title, objectives, and conclusions. Other required information is obtained from the main body of the study. The screening focus was based on the inclusion criteria of this systematic review.
Study Quality
Methodologically, article quality assessment used tools from the National Institutes of Health (NIH) on controlled intervention studies. There is an assessment sheet for assessing the methodology and compliance with the inclusion criteria of this study. Scores <30% of the criteria were classified as "poor", scores between 30 and 70% were classified as "moderate", and scores >70% were classified as "good" study quality. We agreed to include articles that fall into the "fair" and "good" categories.
Risk of bias
The Cochrane Risk of Bias Assessment Tool was used to evaluate the types of bias in each of the studies. The Cochrane Collaboration Risk of Bias Tool scale contains 12 items, which assess the internal and external validity of studies. The review evaluated and rated the 12 items. Items rated ‘yes’ were scored as ‘1′, while no or unable to determine or unclear or non-applicable were all scored as ‘0′. Higher scores and percentages indicate a lower risk of bias. The level of bias within each category for each study was rated as ‘high risk’ or ‘low risk’. Each criterion had equal weight, or the same value; the total score was calculated as the percentage of the maximum value obtained. Studies with scores above the mean score were considered to have a low risk of bias, while studies below the mean value are considered to have a high risk of bias.
Data Extraction and synthesis
An independent author (SS, AJ) conducted the extraction. Discrepancies among those two authors are resolved by consensus after consulting with other investigators (MR) when failed to meet an agreement.
The extraction items consist of First author/year, country, study design (Quasi-experimental, Randomized Controlled Trial), sample size, age, type of intervention, outcomes.
RESULTS
Study Selection
A systematic electronic search identified that 1,414 publications were discovered through backward searching of relevant papers. The full-text screening was conducted on 34 articles. A total of 22 articles failed to meet eligibility criteria at the full-text screening stage, and only 12 articles were finally eligible for further analysis. The search results follow the PRISMA 2020 flow diagram (Fig. 1).
Figure 1. PRISMA flow diagram for literature search
Table 3. Characteristics of the studies included
Study characteristics
Of the 12 studies that met the criteria for this review, 5 were studies conducted in India, 4 were studies in Iran, and one was conducted in Sri Lanka, Jordan, and Palestine. The study designs used were also quite varied, but most of the studies used a quasi-experimental design with a case-control approach (n= 10), and each study used an RCT and cross-sectional intervention design.
Quality Assessment
Assessment of the methodological quality of studies resulted in 6 studies with a good quality score [38] and 6 studies with a fair quality score [28].
Table 4. Summary of studies quality assessment based on NIH
*Y: yes; NA: not applicable; NR: not reported
Risk of Bias
Figure 2. The Risk of Bias summary
Study setting and participants
Only 1 out of 12 studies met the inclusion criteria using a community-based setting [30]. Participants involved in the whole study were in the age range between 12-19 years old (First grade to twelfth grade), which was categorized into adolescence. Furthermore, for the gender of the participants, many of the studies we excluded were using male and female participants.
Types of intervention
The following interventions alone or in any combination were reviewed, such as Health education [28–31,33,36], Nutrition education [32,34,35,37,38], health information [39], and micronutrient supplementation (Iron) and dietary advice [28,32,34]. The shortest intervention duration was 45 minutes [29,31–33] while the longest duration was three months [34].
Types of Outcomes
We included all studies that met the inclusion criteria and limited access to relevant studies in other databases meant that we could not continue this review in the meta-analysis. For primary outcomes determined are Knowledge [31–33,35], Attitude, practice [29,30,34,38]. Meanwhile, secondary outcomes include decreased anaemia prevalence [28,30], improved prevention behaviour [33,36,37,39].
Knowledge, Attitude, Practice
In their study, Chaluvaraj et al. explained that despite numerous health education sessions in school, most female adolescents lack knowledge about anemia, its causes, prevention, and management. The study's overall findings indicated that female adolescents' knowledge, attitudes, and practices were moving in a desirable direction after the intervention. Adolescent healthcare services and facilities must be improved. Comprehensive nutritional education about anemia and its consequences for adolescents can pay considerable dividends in women's future lives [29].
According to the Kamalaja et al. study, rural adolescent girls lack essential health, food, and nutrition information. It could be due to a lack of purchasing power, access to nutritious food, false beliefs and taboos, and a lack of mass media such as TV, radio, and newspapers. Those methods provide information on good nutrition and a lack of government and non-government programs available for the health and well-being of adolescents. The health and nutrition education intervention significantly impacted subjects' nutrition knowledge [30].
Adolescent girls in the Gandhi study had moderately sufficient knowledge, attitude, practice of anemia prior to the teaching program. The majority (76.6 percent) of the adolescent children's knowledge became adequate after the structured video teaching program. Furthermore, there was no correlation between knowledge level and selected demographic variables such as age, gender, education, family type, father's job, mother's job, and monthly income [31].
Balshod et al. discovered that a single educational session significantly improves adolescent girls' knowledge of anemia. Such education interventions are to be carried out regularly in order to improve their knowledge. It encourages them to live healthy lifestyles, preventing anemia and other micronutrient deficiencies [33].
Iron deficient female adolescents in Gaza were discovered to have insufficient nutrition knowledge, attitude, and practice which could contribute to their haemoglobin and ferritin levels. Normal ferritin and hemoglobin levels, on the other hand, necessitate good knowledge, a positive attitude, and good practice. A nutrition education intervention was found to significantly improve knowledge, attitude, and practice [34].
Amani and Soflaei study aimed to improve knowledge of adolescent through the nutrition campaign. The intervention resulted in a significant change in nutritional knowledge and food-group scores consumption of adolescent girls taking part in the public education campaign [35].
Abu-Baker et al. found that more than half of the participants had adequate overall knowledge, attitude, and practice of IDA, many had insufficient knowledge of related issues, such as prior knowledge of anemia, its consequences, or foods that increase iron absorption. Implementing a nutrition education program would effectively improve female adolescents' knowledge, attitude, and practice regarding IDA. The intervention group significantly improved in these aspects after the intervention compared to the control group. Prior research has shown that implementing a structured and comprehensive educational program, even if it is a short-term program, is an effective strategy for improving knowledge, attitude, and practice among adolescents [38].
Prevention, Behavioral changes
Kotecha et al. In their study conducted IFA supplementation intervention once a week. It has proved its potential of not only improving haemoglobin but also improvement of iron stores. The serum ferritin data of over 800 girls confirmed the validity and consistency of the finding. Thus, this strategy of once a week IFA supplementation when given under supervision was effective [28].
The PRECEDE educational model was used in the Sharifirad et al. study. The PRECEDE educational model emphasizes self-care, incentives, and self-reliance through training. This method was the most effective in increasing participant knowledge and changing their attitudes toward behavior change. The PRECEDE framework is a systematic health education process that has been used in numerous studies to help organize a procedure for systematically developing programs. The main advantage of using this framework is that it delineates the factors associated with healthy behavior. It was discovered that educational programs based on the PRECEDE model were effective in controlling IDA and achieving success in other fields of study [36].
DISCUSSION
This review summarizes findings from a total of 12 studies and including 5,355 participants. Most of the studies included in this review were Quasi experimental and assessed the impact of educational intervention on the knowledge and health status among adolescents regarding iron deficiency anemia (IDA). The interventions included Nutrition education, health information, dietary advice, and supplementary micronutrient (Iron).
Given the WHO building block framework, the service delivery platform in all included studies was schools. The nutrition intervention was delivered through school teachers, student classroom monitors, and the research team. None of the included studies detailed details relating to health information systems. In all included studies, researchers provided nutritional supplements, and various non-profit organizations provided some funding. In all included studies, the investigator directly led the intervention. High school girls are one of the most important high-risk groups regarding IDA. That is why this age group was considered as a study subject.
Among the main results, we can confirm that educational intervention can positively impact knowledge, attitudes, practices, behaviour, awareness, and improvement of anaemia conditions in participants with anaemia. Giving daily or weekly iron supplements reduced the severity of anaemia experienced by participants. Only a small number of studies have provided participants with iron supplementation in addition to providing education or health information, so we cannot fully believe in the effectiveness of micronutrient supplementation. These findings require caution in interpretation since there have been very few studies, and because the quality of the results is low or very low, so they can only be seen as preliminary findings.
Booklets are the most widely used media in the studies included in this review [29,34,36,37,39]. These media used by combining several other media such as videos, power points, pamphlets, in channelling or transferring knowledge about anaemia, the results obtained show a positive effect where KAP has increased [29,34].
The overall quality of evidence-based was moderate. It indicates the reliability of the overall intervention approach and determination. The results propose the need to (i) improve the standards and procedures in intervention strategy and outcome apprising in randomized controlled trials to pinpoint actual outcomes relevant to the study population. (ii) Identify the outcomes that tend to improve the significance of health/nutrition education interventions. (iii) To enable the comparison of the methodology of the study in order to determine the factors that promote the effectiveness of health/nutrition education interventions among adolescents. Improving the methodological quality, such as random sequence generators, allocation concealment, blinding of participants, managing the dropout, including matter-of-fact reporting, and follow-up after the intervention will increase the study's quality and the overall quality outcome. More detailed and appropriate studies should focus on middle and low-income countries as they bear more global malnutrition and early marriage burden, especially adolescent females. In low- and middle-income countries, most adolescent girls have become mothers with inadequate knowledge concerning malnutrition and its consequences. Focusing on young women is crucial for themselves and their children in a short time in preventing the intergenerational cycle of IDA transmission.
The limitations of the review include limited access to the several databases which make we were unable to gain possible relevant studies. We are unable to continue with meta analysis because we only collect very few studies with moderate quality. Randomized controlled trials should be followed up to ensure continuity of the intervention. Future studies are expected to include follow-up in their research protocol. Furthermore, future studies should focus on underprivileged low- and middle-income populations through either school-based or community-based interventions.
CONCLUSIONS
Based on the studies in the review, it showed that Educational intervention for the treatment of iron deficiency anemia among adolescent female give positive impact on knowledge, attitude, practice, behavior, and awareness
Acknowledgments
We would like to thank the director of the Jambi Health Polytechnic for supporting this research.
Funding Source
This research did not receive any outside funding or support.
Authors contribution
All authors equally contributed to preparing this article
Conflict of interests
The authors declared no conflict of interest.
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The Influence of Consuming Sauropus Androgynus L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels on Breastfeeding Mothers: Randomized Controlled Trial
Ajeng Galuh Wuryandari1*, Indarmien Netty Ariasih1, Julaecha2
1Department of Midwifery, Health Polytechnic Jambi, Jambi, Indonesia
2Baiturrahim of College of Health Sciences, Jambi, Indonesia
Corresponding author: Ajeng Galuh Wuryandari, dr. Tazar Street, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Orcid :https://orcid.org/ 0000-0002-7513-4666, Phone: +62 812-7978-0909, Email: wuryandariajenggaluh@gmail.com
Cita questo articolo
Background: Much scientific evidence shows the benefits of L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels. The leaves of these plants can be easily found in almost all of Indonesia and are a local food ingredient for Indonesian people. This study analyses the effect of the consumption of Sauropus Androgynus L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels on increasing the production of breastmilk while breastfeeding.
Methods: The research design used in this study was one group pretest-posttest design. The sample was taken by purposive sampling with 37 breastfeeding mothers with children aged <40 days who met the inclusion criteria. The intervention was to provide products processed as daily dishes, namely " sayur bening "with a composition of 150 grams of each plants (L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels), then measure the milk production by looking at how much the amount of breast milk increases after consuming the product for five days in a row, with the same seasonings. Data analysis using Wilcoxon test.
Results: The number of respondents in the study was 37 people with an age range between 19-39 years, with a child age range of 4-40 days, and the number of children owned by the respondents between 1-5 people. Analysis using the Wilcoxon test, it was found that all respondents (100%) experienced an increase in breastfeeding with p-value < 0.05, the same result was also shown in the comparison of birth weight with children's body weight after being given the intervention.
Conclusion: Consumption of Sauropus Androgynus L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels was statistically proven to differ in the amount of breast milk expenditure significantly. Kathree processing is adapted to everyday cooking so that postpartum nursing mothers can easily accept the taste and appearance.
Keywords: Sauropus Androgynus L. Merr, Moringa Oleifera Lam, Vigna Cylindrica (L) Skeels, Breastfeeding, Mothers
Introduction
Breast milk makes the world healthier, smarter, and more equal [1–3]. The benefits of breastfeeding can reduce the incidence of infection, increase intelligence, possibly protect against overweight and diabetes, and prevent cancer for mothers [4,5]. The Lancet report on maternal and child nutrition states that 800,000 child deaths can be prevented through breastfeeding and calls for breastfeeding support, but says that almost worldwide report a decrease in the rate of exclusive breastfeeding, including Indonesia. The reasons why women avoid or stop breastfeeding range from medical, cultural, and psychological reasons to physical discomfort and discomfort [6,7]. These things are not trivial, and many mothers without support turn to bottle feeding of formula. Multiplying across populations and involving multinational commercial interests, this situation has catastrophic consequences at the level of breastfeeding and the next generation's health [8–10].
The mother's nutritional status during breastfeeding is an effect of the nutritional status of the mother before pregnancy and during pregnancy (weight gain during pregnancy). Maternal weight gain during pregnancy depends on the nutritional status of the mother before pregnancy [11,12]. One of the most common factors associated with the failure of exclusive breastfeeding is the factor of breastfeeding that has not come out in the first week after delivery and the mother's view that her milk production is not enough. Exclusive breastfeeding for six months is one of the global strategies to improve infants' growth, development, health, and survival. Although there are many benefits of exclusive breastfeeding for babies, mothers, families and communities, its coverage is still low in various countries, including Indonesia [13,14]. The Basic of Health Research 2010 data shows that the coverage of exclusive breastfeeding for infants up to six months is only 15.3% [10].
Hereditary habits that have become local cultural wisdom in the Danau Sipin District area are various vegetables that are believed to increase breast milk, including banana hearts, long bean leaves, katu leaves, moringa leaves and many more. While in 2019, Lake Sipin was chosen to be the winner of the National Clean and Healthy Behavior Competition, the vegetables above have become regional local wisdom, with a variety of dishes derived from moringa, katu, long beans, kates. Danau Sipin District consists of 5 Kelurahan. There is 1 community health centre, namely the Putri Ayu Community Health Center. For January - September 2019, the target number of exclusive breastfeeding was 458 mothers, who gave exclusive breastfeeding 256 mothers, who did not give exclusive breastfeeding 49 for various reasons, while those who did not visit 153.
Various studies have been conducted to increase breast milk, including by giving oxytocin massage and the results are also significant. The culture of eating various vegetables such as katu leaves, Lembayung leaves (long beans) and banana flower, moringa and green beans related to their function as lactagogues is still focused on extracting and scientifically proving the function of long bean leaves and katu, moringa and kates leaves as lactagogue Traditionally processed form, namely as clear or boiled vegetables, stir-fry [5,15].
Danau Sipin sub-district in the work area of Putri Ayu Community Health Center which has a work area of 5 sub-districts. There is one coordinating midwife who is ready to participate in this research. Likewise, the head of the Driving the Empowerment of Family Welfare and his team and cadres. The leaves of long beans, katuk, and moringa are very potential to be developed both in terms of their benefits as lactagogues and the nature of these plants, which are very easy to grow with a short harvest life. Its use is still limited among Javanese and Malay tribesmen, with the processed form only as clear vegetables or boiled alone or mixed. However, not all villages have Moringa leaves, or Long bean leaves, all the time.
So far, breastfeeding mothers only consume L.Merr leaves which are used as laktagogums, whereas L.Merr leaves or also known as lavender leaves have greater benefits. Likewise, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels leaves both contain laktagogums and saponins as well as polyphenols that can increase prolactin levels. Prolactin is a hormone that plays a major role in breast milk production [16-20]. Therefore, the development of functional supplementary food products for nursing mothers containing kathree leaves, namely Lembayung, katu, and moringa in the form of ready-to-eat products.
This study aims to analyze the effect of consumption of Kathree (Sauropus Androgynus L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels) on increasing the production of breast milk in postpartum mothers.
Materials and Methods
Trial design
The Randomized Controlled Trial with design of this study was one group's pretest-posttest design, namely a research design that contained a pretest before being given treatment and a posttest after being given treatment.
Participants
The sample is mothers who have babies aged < 40 days in the working area of Putri Ayu Health Center. Sampling was done by purposive sampling with 37 mothers who breastfed children aged <40 days who met the inclusion criteria. The inclusion criteria for the sample were healthy mothers and babies, primigravida mothers, while the exclusion criteria were mothers suffering from depression. The sample of this study was randomly selected from 105 postpartum mothers who visited the community health center polyclinic.
The data used in this study is secondary data from the documentation of quarterly reports at the Putri Ayu Health Center and the Jambi City Health Service which was carried out in December 2019-September 2020. The dependent variable of the study was the production of breast milk, measured by criteria 1) Frequency of urination, newborns who get enough Breast milk then urinate for 24 hours at least 6-8 time. 2) Characteristics of urination, clear yellow urine color. 3) Frequency of bowel movements, bowel patterns 2-5 times per day. 4) Color and characteristics of bowel movements, in the first 24 hours the baby excretes bowel movements which is dark green, thick and sticky, which is called meconium and beyond is golden yellow, not too runny and not too thick 5) The number of hours of sleep for babies who have enough breast milk for 2-4 hours. 6) Baby's weight. Signs of adequacy of breast milk in infants are: weight gain of more than 10% in the first week. As explained earlier that the questionnaire on breast milk production uses 6 question items, if the respondent answers yes, he will be given a score of 1 and if he answers no, he will be given a score of zero. Breast milk production questionnaire using the Guttman scale with a score range of 0-1. Breast milk production is said to be smooth if at least 4 of the 6 indicators observed in infants. If the value is less than 4 it is said no smoothly.
Intervention
Participants were given an intervention in the form of food consisting of 150 grams of each plant (L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels (Herbarium Medanense (Meda). The dose of food (vegetables) was determined based on the daily requirement of vitamins and minerals for postpartum mothers, namely 150 grams of vegetables consumed. 3 times a day for 7 days, if toxic effects occur during consumption of vegetables, the mother and baby will be referred to the clinic. Input (Q1) is the production of breast milk, then the mother is given Kathree vegetables (X) as an intervention, after that comes the output (Q2) in this case changes in breast milk production.
Randomisation
Sample selection using a simple random method
Blinding
In this study, 3 enumerators were used to collect research data. The previous enumerators did not know the participants because they were students who had been trained by the researcher before collecting data.
Statistical methods
Data were presented as numbers or percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). The data obtained were analyzed by univariate and bivariate, from the normality test (Kolmogorov Smirnov) obtained abnormal data so that the analysis used the Wilcoxon test.
All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.
Ethical Consideration
Registered prospective respondents have signed an informed consent and there is no incentive to participate in the study and the anonymity of participants is guaranteed. Before carrying out data collection, the researcher first took care of ethical permission. The authors state that this study followed all ethical clearance processes and was approved by the health research ethics committee of Ministry of Health Polytechnic of Jambi, Indonesia, and registration number: LB.02.06/2/18/2019.
Results
The results of the univariate analysis, which aims to determine the frequency of each variable studied, can be seen in the table 1.
Table 1 shows that most respondents in group aged 20-30 years amounted to 14 people (37.8%).
Majority of respondents’education level is low education as much as 70.3%, the dominant occupation of respondents is housewives as much as 51.4%.
Table 1. Frequency Distribution of Respondents' Characteristics
The normality test results showed that the data on the measurement of the amount of breast milk expenditure before and after the intervention was abnormal data. The results showed that all respondents (100%) experienced an increase in breastfeeding with p-value < 0.05. Statistically, there is a significant difference between before giving Kathree and after. The results can be clearer as in the table below.
Table 2. Wilcoxon Test Analysis Results about Breast Milk Production
According to the Wilcoxon test, 37 respondents experienced an increase in the amount of milk expulsion. The results of this study prove that dietary factors such as L. Merr, Moringa Oleifera Lam, and Vigna Cylindrica (L) Skeels, with a p-value < 0.05. Based on the results of this study, out of the five respondents, the baby's body weight increased by around 300 - 400 grams for 7 days of administration of purple leaf. Thus it can be stated that the provision of processed mauve leaves affects the increase in breast milk production for postpartum mothers.
Figure 1. Description of milk production
Figure 1 shows the fluctuation of post partum breast milk production before giving Kathree and an increase in milk production after the intervention.
Discussion
This study proves that food factors have a significant effect on breast milk production in addition to psychological factors and baby's suction power. Kathree gift which consists of Moringa leaves, katuk leaves, and long bean leaves, also known as mauve leaves.
Moringa oleifera Lam (synonym: Moringa pterygosperma Gaertner), commonly known as Moringa, is the most popular Moringacae clan species. Moringa oleifera grows in the form of three and is long-lived (perennial) with a height of 7-12 meters. It also has sympodial branches that point upward or oblique and tend to grow in line and lengthwise. Can grow both in the lowlands and highlands to an altitude of ± 1000 m above sea level, often planted as a barrier or fence in the yard or field.
Moringa oleifera is a local food ingredient that can be developed in the culinary of breastfeeding mothers because it contains phytosterol compounds that function to increase and accelerate milk production (lactagogum effect). Increased breast milk production, increased nutritional intake of infants, which is expected to impact the nutritional status of infants [21-22].
Moringa leaves contain high amounts of vitamin A, vitamin C, B vitamins, calcium, potassium, iron and protein which are easily consumed and assimilated by the human body. In addition, Moringa is also known to contain more than 40 anti-oxidants [23]. This content is needed by postpartum mothers who breastfeed. Breastfeeding mothers need more nutrients than during pregnancy. During breastfeeding, she needs extra energy to restore her health condition after giving birth, daily activities such as breast milk formation. In the first month after giving birth, milk production is generally abundant so that it comes out a lot and is sucked by the baby, so the mother is hungry and thirsty faster. In order for the number of calories to be balanced with the needs, adequate nutrition is needed because the energy will be reprocessed to form breast milk. During breastfeeding, the mother produces about 800-1000cc of breast milk [9,24,25].
Breast milk also contains protective compounds that can prevent babies from infectious diseases. Breastfeeding also has a tremendous emotional effect that can affect the inner relationship between mother and baby and affect the psychological development of the baby. Exclusive breastfeeding can optimize the baby's growth. Factors that influence breastfeeding are mothers who are well supported by their families and lactation education which can increase their knowledge, attitudes and behavior to provide exclusive breastfeeding for up to 6 months [24,26-28].
Previous research conducted by Zakaria [21] in Maros District on 70 breastfeeding mothers 6 weeks after giving birth showed that giving Moringa leaf extract and powder could increase breast milk volume, but the increase in the group that received the extract was higher than the group, get powder, but does not affect the quality of breast milk (iron, vitamin C and vitamin E).
Moringa oleifera is one of the alternative plants that are believed to have the potential to reduce malnutrition, hunger, prevent low birth weight, increase maternal hb levels, prevent DNA damage due to stress and prevent anemia in pregnant women [25].
Research by Situmorang [29] by giving katuk leaf stew to nursing mothers as much as 3x1 with 150 cc of katuk leaf stew. Katuk leaves are useful for increasing breast milk, for fever, and many other things. Based on research, katuk leaf infusion can increase milk production in mice. Katuk leaf root infusion has a diuretic effect at a dose of 72 mg / 100 g BW. Katuk vegetable consumption for nursing mothers can prolong the time to breastfeed the baby. The process of boiling katuk leaves can eliminate anti-protozoa properties. Katuk leaf infusion levels of 20%, 40%, and 80% in mice did not cause congenital defects and did not cause reabsorption. Raw katuk leaf juice is used for natural body slimming in Taiwan. The protein content in katuk leaves is nutritious to stimulate the release of breast milk. While the steroid and polyphenol content in it can function to increase prolactin levels. Thus the production of breast milk can increase. The steroids together with vitamin A also promote the proliferation of new alveolar-alveolar epithelium. Thus, there will be an increase in the number of elveoli in the gland which will automatically increase milk production. One of the reasons women do not give breast milk to their babies is that there is not enough milk to not be satisfied with breastfeeding. This is one of the factors that exclusive breastfeeding fails so that the mother gives formula milk to her child [12].
From the research results of Rahmawati [24] conducted a study on giving katuk leaves on increasing the production of sheep's milk. From the results of these studies, it turns out that the 20% katuk leaf extract solution given in vitro can increase milk production> 20%. The milk composition did not change, there was an increase in glucose metabolism activity by> 50%.
Suyanti & Anggraeni, [30] also states that giving katuk leaf decoction which is drunk 3 times a day (150cc in 1x drink) for 7 days can increase milk production by 50-120 ml. The Man Whitney statistical test p value <0.05 showed a significant effect of katuk leaf decoction on breast milk production based on the baby's weight gain. Mothers with sufficient breast milk can be seen from the frequency of weight gain for babies on day 10 [27].
Long bean plant (Vigna cylindrica (L) Skeels) is one plant that people believe can enlarge breasts and increase milk production. This plant has a proliferative effect on breast cells because it contains phytoestrogens, which are natural estrogens found in plants. This compound can stimulate proliferation if it binds to estrogen receptors. Long bean leaves contain 34 kilocalories of energy, 4.1 grams of protein, 5.8 grams of carbohydrates, 0.4 grams of fat, 134 milligrams of calcium, 145 milligrams of phosphorus, and 6 milligrams of iron. In addition, the Long Bean Leaves also contain as much vitamin A as 5240 IU, vitamin B1 0.28 milligrams and vitamin C 29 milligrams [5,31].
In the future, the plants from this research can be used as an alternative therapy for pregnant women who lack milk production. In addition to the effects or side effects that have not been widely reported, these three plants are very easy to find and inexpensive.
Conclusion
Moringa leaves, katuk leaves and long bean leaves were statistically proven to have significant differences in the amount of breastfeeding. Kathree processing is adapted to the form of everyday cooking so that postpartum nursing mothers can easily accept the taste and appearance. Kathree can easily be found in almost all over Indonesia, and is the local wisdom of the Indonesian people.
Study limitations
In our research, it has limitations such as the number of participants being fewer, and in this study there were 3 types of plants used for the intervention and no data analysis was carried out on each type of plant so that the efficacy of each plant could not be known, so in the future it is necessary further research
Author contributions
AGW and J contributed on concepting and designing the research. AGW and INA searched literature, analyze and interpret the data. AGW and J contributed to the paper's conceptualization, critical revision, and edited the overall improvement. All authors drafting manuscript, read and approved the final submitted paper.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Conflict of interest
There is no conflict of interest to declare.
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Technological innovations in cardiac electrostimulation: Professional updating and cultural evolution of nurses
Carlo Uran1, Pasquale Piscitelli2, Mariuccia falco3, Giovanna Bombace3, Palma Eterno3
1 Interventional cardiologist. Cardiology and Intensive Care Unit, “San Giuseppe e Melorio” Hospital, Santa Maria Capua Vetere, Italy
2 Registered nurse. Cardiology and Intensive Care Unit, “San Giuseppe e Melorio” Hospital, Santa Maria Capua Vetere, Italy
3 Graduate nurse. Cardiology and Intensive Care Unit, “San Giuseppe e Melorio” Hospital, Santa Maria Capua Vetere, Italy
Corresponding author: Dr. Carlo. Uran, Cardiology and Intensive Care Unit, “San Giuseppe e Melorio” Hospital, Santa Maria Capua Vetere, Italy. Email: carlura@libero.it
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Abstract
Cardiology made enormous advances in the treatment of extremely severe diseases such as heart failure. Specifically, interventional cardiology has been enriched, over the years, with increasingly complex aids that have contributed in improving the quality of life and survival of patients suffering from this disease. These advances in technique compel the interventional cardiologist being constantly updated on new procedures and therapy. As a result, both the ward nurses and those supporting the cardiologist in the surgery room, must acquire the knowledge that allows them to be always in step with the fast-changing times.
The aim of this commentary is to underlining the importance of a continuous updating of nurses by emphasizing that their role has been changing over the years and that these professionals, along with the physicians, must stay up-to-date regarding technological innovations, within the limits of their specific skills.
Keywords: Heart failure; Cardiac Contractility Modulation; Nurse updating
Introduction
Nurses of interventional Cardiology unit must acquire more and more skills because of the evolution of technology and subsequently of the complexity of implantable devices. The acquisition of skills is a continuous process and requires constant effort. Therefore, not only the physician, who remains the main operator, must constantly update himself on new techniques and procedures, but also nurses who assist him in and out the operating room, must acquire the scientific mentality that allows them to get highly specialized technical knowledges. In the field of interventional cardiology, advances in technology made care approach increasingly complex, before, during and after an interventional procedure. In such a large and constantly evolving field, nurses should necessarily acquire all the skills for the assistance process and should consequently have the ability to analyze, decide and execute the most appropriate and safe care services, supported by solid evidence of effectiveness. Cardiac Contractility Modulation (CCM) therapy, delivered by OPTIMIZER SMART®, is part of the non-pharmacological therapy for treatment of heart failure with reduced or moderately reduced ejection fraction, in symptomatic patients (NYHA class II-IV) despite optimized medical therapy [1]. It is an important technological innovation for the treatment of this severe disease. The CCM acts by delivering a high-energy non-excitatory bipolar signal, synchronized with local electrical activity, in the ventricular absolute refractory period, by means of two active-fixation leads, placed on the IVS and spaced from each other by no more than 1 cm. Both leads can have a sensing and therapy delivery function. In the implantation phase, is very important to be meticulous in positioning the leads so that they have a sensing greater than 4 mV at the PSA. In the short and long term, this treatment increases left ventricular contractility. As result, the CCM therapy improves clinical status, functional capacity, quality of life and prevents hospital admissions of carefully selected patients [2]. The selection of the patient to whom implant this device, takes place by evaluating his quality of life and the frequency of hospitalizations for heart failure. Quality of life is assessed by the MLWHFQ questionnaire. A score over 30 in a patient in NYHA II class is indicative of severe lack of autonomy and is a significant element in the decision to implant such device (Fig. 1). The interventional procedure does not differ from those implemented for the implantation of other cardiac devices. The difference is about the periodic checking of the implanted device, performed by the cardiologist with the help of a biomedical engineer, who analyze the data by a portable computer loaded with a specific software, by which, electrical parameters and therapy delivery time are tested. The therapy delivery time must be at least 7 hours per day and a parameter to pay attention to is the percentage of therapy delivery, which must be as high as possible and not fall below 80%. [3].
Discussion
Many papers describe implantation procedure and the role of nurses [4-5-6]. After the surgery, nurse takes the patient back to the ward and performs an ECG. Nurses who record the ECG should be able to understand whether the device is properly working or not. The typical ECG of a patient implanted with a CCM device shows a ‘spike’ in the absolute refractory period of cardiac cycle: the ‘R wave’ of QRS complex. (Fig. 2). Nurses should know that the presence of a ‘spike’ on the ‘R wave’ of the QRS complex is not a non-capturing sign or a sensing defect: it is the proper operating of the device itself. This knowledge is important in order not to alarm the patient and inappropriately alert the cardiologist. The day after implantation, nurses should check the surgical wound, evaluate whether there is a hematoma or not and if medical attention is required. Then the patient can undergo to a chest x-ray to evaluate the position of the leads and to exclude a PNx, if the subclavian vein puncture has been performed without echo guide [7]. OPTIMIZER SMART® is powered by a weekly-rechargeable battery through an induction mini-charger, rechargeable itself, delivered to the patient. At bedside, physician and nurses instruct the patient, with the assistance of biomedical engineer, regarding its use. It is important, in this phase, that nurses as well assist the patient and reassure him about the easiness of device recharging procedure. Patient should charge the device battery weekly and it is advisable to suggest him to always recharging the device on the same day and at the same time, specifying however that it is not a life-saving device, but an electrical therapy provider. This avoids the worry of postponing or anticipating the charging process. Nurses get involved in many ways in interventional procedures: they manage the pre-operation care and technical setup; help the physician in the surgical room; check the correct functioning of the device and, if complications are detected, alert the physician and look for a quick solution to them. In order to perform these tasks, nurses should know how the device acts and which complications might occur after intervention, so they can be able to deal with them without any anxiety. In 2014 in order to assess critical care nurses' knowledge and practice regarding implantable cardiac devices in Egypt, was published a paper by which authors showed that Critical care nurses have inadequate knowledge and practice regarding implantable cardiac devices [8]. Unfortunately, things have not changed over the years. In 2017, in order to assess cardiology nurses' knowledge and confidence in providing education and support to ICD recipients, Steffes et al. published a paper. The result was surprising: authors proved that the ICD knowledge of US nurses in 2015 was similar to that reported in the United Kingdom in 2004 [9-10], with limited knowledge about the complexities of modern ICD devices. Such deficits in knowledge may affect the quality of education provided to ICD recipients in preparing them to live safely with an ICD. A survey published in 2021 by Fitzimons et al, showed that many nurses felt not being living up to their job and emphasize the importance of in continuing cardiovascular nursing education and of their professional updating[11]. Nowadays, the nurses should be a complete professional and should have the technical and care skills required to obtain the best result in interventional procedures, as regard the new generation devices as well. Consequently, the interventional cardiology/electrostimulation nurses are required to have not only care skills, but also the knowledge of devices. In CCM therapy, electrical stimulation is delivered to the cardiac muscle during the absolute refractory period. In this phase, the electrical signals activate the mobilization of calcium ions in the cardiomyocytes. The mechanism of action of the CCM can be summarizing as follows: CCM signals applied during the absolute refractory period cause an increase of cytosolic calcium during the systole, resulting in improving the cardiac contraction [12]. The mechanism of action explains the typical ECG of a patient with CCM and the nurses must be able to recognize it in order not urgently alert the doctor. This is the reason why nurses as well should know it. Furthermore, nurses have to be aware about the effects of such therapy. A few seconds after the delivery of the therapy, normalization of the activity of the proteins that are involved in regulation of intracellular calcium, occurs. After a few hours, there is a progressive normalization of the abnormal expression of fetal gene program, which is a characteristic of heart failure. Reverse remodeling has been demonstrated within 3 months, with reduction of mechanical and neuro-hormonal stress and increase of left ventricular ejection fraction. CCM restores the structure and function of damaged cells to their normal state [13]. Due to this action, CCM improves clinical outcomes in terms of exercise tolerance and QOL at 6 months [14], and this is the reason why guidelines published in 2016 and the Consensus HFA ESC 2019, state that CCM can be considering in selected patients with HF [15]. In 2020, Giallauria et al. evaluated the three currently available randomized controlled trials of CCM therapy for treatment for patients with heart failure. This comprehensive meta-analysis made the authors conclude that CCM provides statistically significant and clinically meaningful benefits in measures of functional capacity and HF-related quality of life [16]. The latest ESC guidelines on heart failure (2021) suspend the judgment on CCM ('under evaluation'), since its effect on the long-term mortality rates of patients with heart failure has not evaluated yet in a randomized controlled multicenter trial [17]. However, it is noteworthy that some preliminary studies showed that CCM improves clinical outcome in terms of exercise tolerance and QOL. Besides, it improves long-term survival, compared with the mortality predicted by the Sattle Heart Failure Model Score and reduces hospitalizations by 75%. [18]. Due to these considerations, we highlighted that the cardiology nurses have not an adequate preparation. Because of this, patient care inevitably suffers. This is the reason why we believe that it is mandatory for the nurse to be updated both about procedures and about devices. They should have adequate knowledge about the indications and the mechanism of action of devices. Furthermore, as regard the CCM, it is mandatory for the cardiology nurses, the knowledge of the typical ECG of a patient implanted with such device.
Acknowledgement
The authors warmly thank Serena Costanza Uran for her collaboration in the translation
Funding statement
This paper did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
Competing interest statement
There are no competing interests for this study.
Authors’ contribution
Dr. C. Uran: Investigation, conceptualization, resources, preparation and translation of the paper. Dr. M Falco; P. Piscitelli; Dr. G. Bombace; Dr. P. Eterno: Preparation
References
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- Abraham WT, Smith SA. Devices in the management of advanced, chronic heart failure. Nat Rev Cardiol. 2013;10(2):98-110.
- Abraham W.T et al. A Randomized Controlled Trial to Evaluate the Safety and Efficacy of Cardiac Contractility Modulation. J Am Coll Cardiol HF 2018;
- Kim Rajappan, Cardiac Department, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK; Education in Heart Arrhythmias. Permanent pacemaker implantation technique: part I; http://dx.doi.org/10.1136/hrt.2007.132753
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- Porfili A. Protocollo infermieristico per procedure di elettrostimolazione: impianto o sostituzione di Pacemker, Defibrillatori, Dispositivi per la terapia di re sincronizzazione cardiaca (CTR) Linee guida AIAC 10.2018
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- Nahla Shaaban Ali; Warda Youssef; Abdo Mohamed; Ali Hussein Nurses' knowledge and practice regarding implantable cardiac devices in Egypt. British Journal of Cardiac Nursing 10, No. 1. Published Online:26 Dec 2014https://doi.org/10.12968/bjca.2015.10.1.34
- Steffes SS, Thompson EA, Bridges EM, Dougherty CM. Knowledge of Implantable Cardioverter Defibrillator Purpose and Function Among Nurses in the United States. J Cardiovasc Nurs. 2017;32(3):304-310. doi:10.1097/JCN.0000000000000339
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- Donna Fitzsimons, Matthew A Carson, Tina B Hansen, Lis Neubeck, Mu’ath I Tanash, Loreena Hill, The varied role, scope of practice, and education of cardiovascular nurses in ESC-affiliated countries: an ACNAP survey, European Journal of Cardiovascular Nursing, Volume 20, Issue 6, August 2021, Pages 572–579, https://doi.org/10.1093/eurjcn/zvab027
- Borggrefe, M.; D. Burkhoff (Jul 2012). “Clinical effects of cardiac contractility modulation (CCM) as a treatment for chronic heart failure”. Eur J Heart Fail. 14 (7): 703–712.
- Butter, C.; et al. (May 2008). “Cardiac Contractility Modulation Electrical Signals Improve Myocardial Gene Expression in Patients With Heart Failure” (PDF). J Am Coll Cardiol. 51 (18):1784–1789.
- Kuschyk et al. Cardiac Contractility Modulation treatment in patients with symptomatic heart failure despite optimal medical therapy and cardiac resynchronization therapy (CRT) International Journal of Cardiology 277 (2019) 173-177 .
- Petar M. Seferovic et al ”Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of The Heart Failure Association of the European Society of Cardiology.
- Giallauria F, Cuomo G, Parlato A, Raval NY, Kuschyk J, Stewart Coats AJ. A comprehensive individual patient data meta-analysis of the effects of cardiac contractility modulation on functional capacity and heart failure-related quality of life. ESC Heart Fail. 2020;7(5):2922-2932.
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [published correction appears in Eur Heart J. 2021 Oct 14;:]. Eur Heart J. 2021;42(36):3599-3726.
- “MAGGIC” Heart Failure Risc Calculator according to Pocock et al. Predicting survival in heart failure: a risk score based on 39372 patients from 30 studies, Eur Heart J (2013) 34(19) 1404-1413.
Figure 1. The Minnesota questionnarie 21 items
Figure 2. ECG of a patient with a CRT-D system, implanted with the CCM device
Table of abbreviations
Sleep Quality Related to Vigilance Among Nurses in Hospital: A Cross Sectional Study
Debbie Nomiko1*, Ernawati1, Bettywaty Eliezer1
1Nursing Department, Health Polytechnic Ministry of Health Jambi, Indonesia
Corresponding author: Debbie Nomiko, dr. Tazar Street, BuluranKenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Orcid :https://orcid.org/0000-0002-3623-7937, Phone: +62 812-7897-981, Email: debbiedebbienomiko@gmail.com
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ABSTRACT
Introduction: Sleep quality disorders may cause a decrease in concentration and work performance of individual. It is also believed that nurses with work shifts as health workers may run into sleep quality disorders. Several researches have shown the relationship between sleep quality and the work performance of nurses in shifts duty. This study aimed to determine the relationship of sleep quality and vigilance of nurses in shifts duty in Raden Mattaher hospital Jambi.
Methods: A cross sectional study was performed recruiting 97 nurses working shifts in 3 inpatients wards of the Raden Mattaher Hospital Jambi. Socio-demographic details and data nurses alertness were collected using ad hoc questionnaires, data sleep quality were collected using the Pittsburgh Sleep Quality Index. Relationships among sleep patterns and alertness variables were investigated. Data were analyzed by univariate and chi-square test (CI 95%). Statistical analysis was performed using the SPSS version 16.0.
Results: Results showed an average of 29.4 years of age. Respondents were mostly female, married with working time <5 years. The results of the bivariate analysis show there was not relationship between sleep quality and vigilance of nurses who undergoing shifts in Raden Mattaher hospital Jambi with p-value 0.35.
Conclusion: There was not a relationship between sleep quality and vigilance among nurses undergoing a shift in patients' rooms
Keywords: Nurses, Sleep Quality, Wakefulness, Shift Work Schedule
INTRODUCTION
The prevalence of sleep quality disorders every year tends to increase, one of the causes is fatigue due to excessive work volume [1–4]. Poor sleep quality may cause adverse effects workers physical and psychological health leading to negative consequence workplace such as mistakes and reduced performances [5–8]. Health professionals have been known to experience fatigue at times. The condition has also long been associated with reduced patient safety [9,10]; decreased satisfaction, health and well-being [11–13]; more conflict among team members [14]; risk of needle stick injuries [14,15] and increased staff turnover [10]. Nurses, the largest group of healthcare providers, are prone to relatively high acute burnout, chronic fatigue, and recovery from fatigue after shift changes [16]. It is closely related to the demands they face throughout the working day, such as physical, mental, emotional demands and pressures associated with shift and non-standard work schedules. These factors place hospital nurses very vulnerable to burnout and its accompanying effects [17].
Nurses are professional workers who use a shift work system, so it can be ascertained that sleep quality disorders can also occur in nurses who undergo shifts [18–20]. Shift work has an impact on disturbances in circadian rhythms [21], and the main one being sleep pattern disturbances that cause sleep deprivation and fatigue [22,23].
Vigilance is degree of readiness of a person in responding to something [24] A person's level of vigilance is needed at work. Accidents occur as a result of decreased levels of alertness [25]. Variables that affect the level of alertness are monotonous state, level of sleepiness, psychophysiology, distraction, and work fatigue. In the variable of sleepiness level, there are 3 indicator variables, namely, circadian rhythm, sleep quality, and sleep time [26,27]. Research results show that 78% of nurses who work shifts experience changes in sleep quality. Furthermore, poor sleep quality is one of the contributing factors to medical errors that occur in health services [28–30]. The impact of poor sleep quality has been widely studied. Sleep absence is an important predictive factor influencing the occurrence of various chronic diseases such as hypertension [31] and cardiovascular disease [32], and diabetes [33]. Nurses' inconsistent sleep habits can have a severe impact on their health as well as their ability to do their jobs [34,35].
METHODS
Trial design
A cross-sectional study was made at the Raden Mattaher Hospital Jambi.
Participants
The population in this study was all shift nurses in 3 inpatient installations at Raden Mattaher Hospital Jambi with a total sample of 97 people with the criteria of nurses in the inpatient installation, not leave, having at least a minimum nursing diploma.
Intervention
A study questionnaire was made to collect socio-demographic details and a 24 items questionnaire was implemented to collect nurses’ alertness data. to four point scored Likert scales (always, often, sometimes and never) were used for the self-assessment of nurses’ alertness before, during and after care activities, with particular attention to missed cares, mistakes and documentation management. Nurses’ sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) tool [36]. Authors declare that the PSQI (Indonesian version) permission to use was obtained by the copyright property.
The PSQI is widely considered the gold standard tool for sleep patterns evaluation and quality of sleep assessment. It provides a global score ranged from 0 to 21 where scores higher than 5 means poor sleep quality. Furthermore, it provides 7 sub-scores assessing sleep patterns: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunctions. The PSQI questionnaire was translated into Indonesian and
tested for reliability with Cronbachs alpha result of 0.753. Data were collected by three interviewers who were unknown to the participants before the study.
Blinding
In this study, 3 enumerators were used to collect research data. The previous enumerators did not know the participants because they were students who had been trained by the researcher before collecting data.
Ethical Consideration
Before carrying out data collection, the researcher first took care of ethical permission. The authors state that this study followed all ethical clearance processes and was approved by the health research ethics committee of Jambi Universitys Faculty of Medicine and Health Sciences.
Statistical methods
Data were presented as numbers or percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). The chi square test and Fisher's exact test were performed to evaluate significant differences of proportions or percentages between two groups. Particularly Fisher's exact test was used where the chi square test was not appropriate. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.
RESULTS
Ninety-seven out of one hundred twenty-two nurses working shifts in 3 wards) qualified nurses
completed their studies. The results of this study presented in the table 1.
Table 1. Demographic Data of Nurses Undergoing Shift
Most of respondents were female (71.1%), married (71.1%) and have working of period < 5 years (55.7%). These results showed the average age of the respondents was 29.40 years, and the age range was between 21-51 years (SD 5.85).
Table 2 shows the results of the assessment of the seven components of the respondent's sleep quality, it was found that the component of the use of sleeping pills (using pills) had the highest score in terms of not using, namely 97.93%, the second highest score was the component of the subject's sleep quality, namely the subjective average of respondents stated 86.6% had good sleep quality. The results also showed that most of the respondents had sleep disturbances as much as 65%, and as many as 40% had sleep efficiency in the range of 75-84%.
That most nurses (86.6%) have good sleep quality based on subjective sleep quality. In the second component (sleep latency), most of the respondents (51.5%) had a sleep latency of 1-2 hours, and merely a small portion (7.2%) had a sleep latency of 5-6 hours.
Table 2. Sleep Quality Components: Subjective and Objective Sleep Quality measures
In the third component (sleep duration), most of the respondents, as many as 32% of respondents, had sleep duration < 5 hours and only five respondents (5.2%) had sleep duration > 7 hours. Furthermore, 26.8% of the fourth component had a daily sleep efficiency > 85%, and only 14 respondents (14.4%) had a daily sleep efficiency of 14.4%. This result is slightly different from the previous study [49], which showed that 73.5% of nurses have sleep efficiency >85%.
Sleep quality in terms of sleep disturbance components shows that most of the respondents (67%) have sleep disorders with a score of 1-9, then for the use of sleeping pills, most of the respondents (97.93%) have never used sleeping pills at all.
Table 3. The Correlation Between Sleep Quality and Vigilance Among Nurses undergoing Shift
The results of statistical tests obtained a p-value = 0.35, so it can be concluded that there was not a
significant relationship between sleep quality and vigilance among nurses who undergoing a shift in
the hospital.
DISCUSSION
Statistically it was found that in this study, there was no relationship between sleep quality and nurses' work alertness, although descriptively it can be reported that Nurses with good sleep quality tend to have good vigilance, and contrarily, nurses who have poor sleep quality tend to have less vigilance (see table 3). It significantly affects the productivity of nurses at work, where nurses in carrying out their work with good vigilance will work with good performance compared to nurses who are less alert.
Nurses who work night and rotating hours have been proven to have more trouble staying awake on duty and make twice as many mistakes as those who work day and evening shifts. More than 20% of workers in industrialized countries work shifts, and about 10% of them are diagnosed with sleep disorders [37]. Many factors affect sleep quality, one of which is shift work. Individuals who work shifts or shifts have difficulty adjusting to changing sleep schedules [6].
Poor sleep quality mainly occurs in nurses who use shift work systems. A study by Murphy et al., [38] found that shift work was significantly associated with poor sleep quality after controlling for variables of age, gender, and length of work.
This study also found almost the same proportion of respondents between respondents who had good and bad sleep quality, while most of the respondents had the desired of vigilance, which was around 67%. A systematic review study conducted by Dall’Ora et al. [39] found that shift characteristics are related to employee performance, and having sufficient rest time positively affects employee vigilance. Furthermore, Wahyuni [40] found a decrease in vigilance in night shift nurses with a proportion of decreased vigilance of 71.1%. However, statistically, it was not proven
to have a significant effect. The factor that influences the level of alertness before office hours is the
sleep quality. Lack of sleep results in a person's condition is less energetic and not enthusiastic [41].
We report that research data show that nurses predominately have a sleep latency of 1-2 hours, and only a small proportion (7.2%) have a sleep latency of 5-6 hours. Sleep latency is the length of sleep from start to fall asleep [42,43]. One of the factors that can affect sleep latency is bedtime habits that can disrupt a person's sleep and have an impact on increasing sleep latency [44].
This result is in line with the results of a previous study [45] that most respondents (60.3%) shift nurses experienced sleep disturbances less than once a week. Of all the sleep quality components, the sleep disturbance component had the highest mean of 1.44 with a standard deviation of 0.90 in a study of nurses undergoing shifts in Jordan [46].
Nurses’ poor sleep quality leads to a number of negative health outcomes. Nurses suffering from
poor sleep quality were more prone to develop burnout [47], depression and anxiety [48]. In addition, poor sleep could impair cognitive performance, such as concentration and memory, which may lead to poor work performance and even affect patients’ safety [49-51].
Effective measures, such as education on sleep hygiene [48], yoga [52] and cognitive-behavioral therapy for insomnia [53], should be considered to improve nurses’ sleep quality, quality of life, and patients’ safety.
CONCLUSION
The current study found that sleep quality was not a significant factor contributing to nurses' vigilance and medical error. Nevertheless, we still suggest that hospital managers should apply a 15-30 minute rest period during work shifts for nurses and pay attention to work rotation times, especially night shifts as a strategy to increase vigilance to prevent fatigue, sleepiness, and work errors.
LIMITATION OF STUDY
This study was only conducted in 3 hospital wards, so it cannot be compared with the same conditions in different hospitals. No intervention was carried out in this study to improve nurses' sleep quality and increase alertness while working. Other factors that influence Precautions, such as lighting conditions, environment, pills, caffeine, and other ingredients, were not studied.
Authors’ contribution
All authors equally contributed to preparing this article.
Acknowledgement
We express our gratitude to the director Director of Health Polytechnic, Ministry of Health Jambi, Indonesia for its support for the implementation of this research
Funding
This research received funding from the Development and Empowerment of Human Resources in Public Health (BPPSDMK) Indonesia
Conflict Of Interest
The authors declare that there was no conflict of interest in this research.
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DEVELOPMENT AND EFFECTIVENESS OF AUGMENTED REALITY-BASED LEARNING FOR HEALTH SCIENCE STUDENTS: A SYSTEMATIC REVIEW
Lia Artika Sari1, Muhammad Rusdi2, Asrial2, Herlambang2
1 Doctorate student in Education MIPA Jambi University, Indonesia
2 Jambi University, Indonesia
Corresponding author: Lia Artika Sari Jl. Prof DR GA Siwabessy No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36122, Indonesia, Tel: +6282196687959, Email: liaartikasari57@gmail.com, Orcid : https://orcid.org/0000-0002-5285-5356
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ABSTRACT
Background and Objective. The rapid development of technology makes it easier for teachers to continue to be interactively connected with students, for example, by using Augmented Reality technology. We conducted this review intending to investigate the diffusion and the effectiveness of AR technology as a learning media for students from various health fields.
Materials and Method. This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) Checklist. We used some databases including PubMed, Google Scholar, Wiley Online Library, and Sciencedirect to search relevant literature with eligibility criteria, namely articles published in the period 201-2021, and discuss the development of Augmented Reality -based applications for learning students in the field of health
Results. The studies included are on the development of AR-based learning applications carried out to improve the clinical skills of health students (Medicine, Nursing, and Midwifery). Various types of application development are carried out including anatomy, Endotracheal Intubation, AR Prototype for Medical Surgery, Intravascular Neurosurgery, injection skills, and Laparoscopic.
Conclusion. The use of Augmented Reality as a learning medium really helps improve the understanding and skills of students majoring in health sciences.
Keywords: Development, Augmented Reality, Health-Science, Students
INTRODUCTION
The use of technology in the education of health science students has evolved over the years. These trends are mainly evolving in response to the challenges facing health education [1]. The use of simulation in health education has been applied in the last 50 years [2]. Augmented reality technology is an example of virtual reality technology developing rapidly in nursing education [3].
Augmented Reality (AR) technology refers to virtual elements to display the actual physical environment to create mixed-reality files in real-time. It complements and enhances the perceptions that humans acquire through their senses in the real world [4]. AR provides various levels of understanding and interaction, which can help students in e-learning activities [5]. For example, in an AR learning environment, motivational factors related to attention and learning satisfaction are rated higher than slide-based learning [6]. Today's development of smartphone technology makes AR technology more accessible to students and lecturers; for example, mobile learning (m-learning) using AR has become a trend [7].
Simulations using AR technology can replicate real-world aspects so that a safe learning environment is available for students where they can practice until the expected skill competencies are achieved [8]. Simulation has become an integral part of nursing curricula [9], which involves using patient simulators, trained people, real-life virtual environments, and role play [10].
Technological advances over time have increased the realism and authenticity of the simulated environment, leading to increased reactions, satisfaction, learning attitudes, cognitive and affective outcomes among health students in general [11].
Clinical health services have also used AR because it provides an internal picture of the patient, without the need for invasive procedures [12–15]. Medical students and professionals need more situational experience in clinical care, especially for patient safety, so this shows that there is a real need to continue developing the use of AR in health education.
The focus of studies on AR in recent years [16,17] has highlighted the belief that AR provides medical students with rich contextual learning to help achieve core competencies, such as decision making, work for effective teams, and creative adaptation of global resources to address local priorities [18], AR provides more authentic and engaging learning opportunities for various learning styles, providing students with a more personalized and exploratory learning experience [19]. The security of the patient will also be awake if an error occurs during skills training with AR [20].
Objective
This review was conducted to describe the development of AR technology as a learning medium for students from various health fields. This study is expected to be a reference material for teachers in learning strategies.
METHOD
Review Protocol
The research design is a Systematic Review, using the PRISMA-P 2009 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) Checklist.
Searching strategy
To search for literature using the PubMed database, Google Scholar, Wiley Online Library, and Sciencedirect using the keywords "Developing" AND "Augmented Reality" AND "Clinical practice" AND (Medical OR Nurse OR Midewifery) "College student".
We categorize the search into five categories that are considered to represent the topic of Augmented Reality development, namely AR typology, AR features and advantages, AR user perceptions, AR effectiveness in supporting learning, and AR design. Each category was analyzed to identify the best lessons, experiences, and evidence related to the design and development of AR.
Eligibility Criteria
The articles included in this review use the development method, with the subject of the trial being health students. In addition, the articles used are in English and full text, published in the period 2010–2020. Furthermore, the data obtained are then analyzed using quantitative descriptive methods and a narrative is produced that explains the study results.
The study results were documented to identify the effectiveness of using augmented reality in student health learning.
Study Type
The studies included in the criteria for this review are only limited to studies on the development
of Augmented Reality technology for student learning in the health sector. Articles entered are in English, full text, and is not a thesis or dissertation.
Type of Participant/Population Target
The participants used were health students (Medicine, Nursing, Midwifery) who did clinical practicum (Clinical Skill). There are no restrictions on age, gender, level/semester, as long as participants do clinical practicum learning (clinical skills).
Article Quality
Quality assessment was carried out on six journals that met the inclusion and exclusion criteria using the JBI Critical Appraisal Checklist criteria. Journals are good if they meet at least 80%, moderate if they meet 50–80% and weak if they meet less than 50% of the criteria. Articles are used in good to moderate categories for further data synthesis, namely, grouping similar extracted data according to the results to be measured to conclude.
RESULTS
Literature Identification and Selection
There were 319 articles identified from four databases (Pubmed, Google Scholar, ScienceDirect, and Wiley Online Library) relevant to the review topic, where the assessment or screening was based on the title and abstract of the articles obtained. 66 studies were removed because they were duplicate. After screening the title and abstract, 219 studies were removed due to irrelevant theme, not AR topic, and proceeding types. At the eligibility stage, 28 studies were not fit the inclusion criterias.
Critical Appraisal
Based on the JBI Critical Appraisal Checklist, six pieces of literature are in the excellent category, and two pieces of literature are in the weak category.
To maintain the quality of the literature studies made, this review only uses six good-quality journals, and then data extraction will be carried out (Figure 1).
Figure 1. PRISMA Flowchart: Strategy for Searching for Development of Augmented Reality in Educational Situations for Health-Science Students
After bearing the assessment, screening, and feasibility, the authors agreed to include six studies in this systematic review of the literature. Furthermore, the extraction of data from each of the included literature we describe in the following table displays the critical information needed with the theme of the study.
Table 1. Data Extraction on Included Articles
Characteristics of the studies included
The articles included in the inclusion criteria were six from several countries, including the USA as many as two articles, Canada 1 article, Sweden 1 article, Ireland 1 article, and Japan 1 article. Overall, the article taken is a study on the development of AR-based learning applications carried out to improve the clinical skills of health students (Medicine, Nursing, and Midwifery). Various types of application development are carried out including anatomy, Endotracheal Intubation, AR Prototype for Medical Surgery, Intravascular Neurosurgery, injection skills, and Laparoscopic.
Critical Appraisal
Based on the JBI Critical Appraisal Checklist, six pieces of literature are in the excellent category, and two pieces of literature are in the weak category. To maintain the quality of the literature studies made, this review only uses six good-quality journals, and then data extraction will be carried out.
Table 2. Summary of Critical appraisal based on JBI checklist
AR system design
In Majimas’ work, the learners can learn experts’ nursing skills without moving their lines of sight. When practicing skills training, learners can learn skills by following and imitating (tracing) the images of experts’ techniques that are dis-played transparently in front of them in real time. The prototype system verified that training is possible by overlaying images on a simulation arm model.
Chien and colleague The system is based on a complete structure of the skull which can be decomposed and reassembled. To be an effective training tool, the system has to provide correct information to the students, the skull includes zygomatic bone, temporal bone, sphenoid bone, mandible, maxilla, ethimoid bone, parietal bone, frontal bone, occipital bone, nasal bone, lacrimal bone, palatine, vomer, and inferior nasal concha.
Torregrosa and team developed an ARBOOK which includes a standard part of descriptive anatomy of the lower limb including osteology, arthrology, myology, nerve and vascular supply. Each part of the book includes bi-dimensional images and text about the muscles: origin insertion, vascular and nerve supply or action. It also includes a card for each anatomical figure that can be recognized by a digital webcam connected to a computer. The users can modify the actual position of the virtual structure by moving the card. To develop the ARBOOK, more than 100 TC images were needed and the images were processed by OsiriX software and 3D constructed. LabHuman and VMV3D companies performed the animation.
Drapkin study, an open-source T1 and T2 weighted simulated MRI dataset of a normal human brain constructed from a composite of 27 volumetric datasets of the same living subject was obtained from the BrainWeb simulated brain database. This dataset was viewed using GEHC MicroView software, version 2.1.2 (General Electric Healthcare, Little Chalfont, Buckinghamshire, UK). 3D models were constructed using MicroView to create isosurfaces based on gray scale values within a given region of interest to create a 3D mesh approximating the shape of a given internal brain structure. These computer graphic object composites were exported as a VTK PolyData file and edited using Maya software, version 2010 (Autodesk, San Rafael, CA) and were examined by two neuroanatomists and one neurologist for accuracy and compared to the Netter’s Atlas of Human Neuroscience. The final edited versions were imported back into MicroView 2.1.2 as Wavefront OBJ files and overlaid on top of the original MRI dataset. The final product was a set of digital 3D models of internal brain structures that can be freely rotated and zoomed by the user. To fabricate the 3D-printed models in Licci study, anonymized CT data set of a patient with enlarged CSF spaces was first downloaded from the picture archiving and communication system (PACS) and further processed with the medical segmentation software Materialise Mimics (Mimics Innovation Suite v20; Materialise). The DICOM CT data set consisted of native cross-sectional slices of bone and soft-tissue windows to display the relevant anatomical features. Further processing and segmentation of several anatomical structures according to tissue density (Hounsfield units) was worked out. The virtual cranial vault was designed with the help of the modeling software Materialise 3-Matics to be removable and equipped with realistic, neurosurgical burr holes for endoscopic access. The osseous skull was printed completely (2 parts) with a consumer Replicator+ 3D printer (MakerBot Industries) from polylactic acid (PLA; light gray), and the corresponding ventricle spaces were divided into 2 parts with a wall thickness of 3 mm in transparent PLA material. After printing a total of 5 skull models, the support structures were manually removed, and the two halves of the ventricular system were glued together. These were inserted into the skull model, and the cavity between the ventricular system and the bony skull was filled with 2-component silicone for stabilization.
In the Islam study, they proposed a novel video-based approach for observing continuous, long sequence of surgeon’s hand and surgical tool movements in both surgical operation or surgical training, and then modeling and evaluating the skill demonstrated in the observation. Hand movement of entire surgical procedure is captured using inexpensive video camera. Video data of the tool movement can also be obtained for minimal invasive surgery (MIS). Both of the video data are analyzed using computer vision algorithm and then integrated to correlate with user’s skill level.
For modeling the surgical skill, a stochastic approach is proposed that uses simple arithmetic mean and standard deviation of the processed data. Using this technique, observer-independent models can be developed through objective and quantitative measurement of surgical skills. Because of the non-contact nature of the tracking technique, the system is free from sterile issue and there is minimal interference with the skill execution, unlike other methods that employ instrumented gloves or sensor-based surgical tools.
AR for Nursing skills
There is one study that developed the teaching skills of nurses using AR technology. The skill learned in the study was performing intravenous injections [21].
AR for Anatomy learning
Three studies [22] developed learning methods based on AR technology. AR technology was used to create an interactive learning environment, which allows students to understand the 3D skull structure with visual support [14]. One of the studies gave their app the name ARBOOK, which can be presented in both, printed or electronic version. ARBOOK includes a standard part of descriptive anatomy of the lower limb including osteology, arthrology, myology, nerve and vascular supply [15]. Another study developed 3D Neuroanatomy Teaching Tool. The models were created of the ventricular system, thalamus, hypothalamus, pituitary gland, hippocam-pus, amygdala, fornix, caudate, putamen, globus pallidus, brainstem, cerebral peduncles, and cerebellar peduncles [16].
AR for Surgical training
There are two studies that develop training based on AR technology. The first study involved a neuroendoscopic ventricular lesion removal training [17], and the second study provided two laparoscopic graspers and performed the pegboard transfer exercise on the FLS [18].
DISCUSSION
It is undeniable that the advancement of Augmented Reality technology has had a significant impact on the health sciences. Professions requiring high precision and good psychomotor abilities certainly require more time to practice carrying out their actions. The presence of Augmented Reality technology in its various forms is proven to increase students' abilities and interests in dealing with the learning process.
Under certain conditions, especially during pandemic times where large-scale restrictions are imposed, direct meetings to carry out laboratory practicums are deemed possible, so there must be changes in strategies or effective learning methods for students in dealing with curriculum demands related to learning outcomes. A total of 6 eligible articles have been extracted to provide an overview of the development of Augmented Reality technology-based tools/tools in many health science fields, including Medicine, Nursing,/Midwifery. From the article, the discussion will be described based on the field of development, software and hardware used,
Development area
Anatomy Learning
Two articles develop applications for learning body anatomy based on Augmented Reality [18]. Tried to develop a 3D interactive learning environment of bone structure with visual support. This application is equipped with pop up labels and interactive displays in 3D to make it easier for users to see the position of each bone at various angles. In addition, users are also facilitated with the help of each label with information about the bone so that students no longer need to open books to look for information about the designated bone. To use this 3D application, students/users need hardware devices such as laptops/PCs equipped with cameras and pointers. For testing this device, Chien and colleagues used 30 medical students who had never taken anatomy courses to hope that the participants' responses to this application would be of better quality. At the evaluation stage, participants revealed that the developed application was fascinating because it could provide a complete picture of the displayed bone structure and explain each pop-up label, making it easier to understand and memorize. In addition, another exciting thing is that the reassembled function in the application allows students to see the inner structure of the bone.
Another application developed by Torregrosa and colleagues in 2014 called ARBOOK (Augmented Reality Book) focuses on the anatomical structure of the lower extremities. For its development, 100 TC photos/images are needed, then the images are processed using OsiriX software and 3D object creation. For validation, the questionnaire compiled for the ARBOOK evaluation consists of the categories of task motivation and attention, autonomous work, comprehensive spatial orientation, and 3D interpretation. . Next, an expert assessment will be carried out. Application testing involves first-year health students who have never taken an anatomy course. The test results show a significant difference between learning using ARBOOK and conventional learning. As has been stated in previous studies that the use of virtual materials in anatomy learning can provide good benefits for student learning achievement, especially regarding motivation and independence [27,28].
Augmented Reality technology was also developed in Neuroanatomy learning for MRI exercises developed by Drapkin and colleagues in 2015. The developed application makes the brain image display into a 3D shape. This 3D model begins by using MicroView to form a primary image in the form of isosurfaces and then form a 3D model similar to the shape of the actual brain. The graph is then exported in VTK PolyData file format and edited using Maya software. The editing results are then given to neuroanatomists and neuroscientists to assess the accuracy of the image shape and compared with images on the ATLAS neuroscience Netter. The final image is then placed on top of the actual brain image from the MRI. Next, we entered the pilot phase, which was conducted on participants who were medical students at level 1. The trials showed that this 3D neuroanatomy teaching tool effectively trains medical students to read brain MRI and effectively teach students to identify internal brain structures.
Surgery training
In contrast to learning the body's anatomical structure, surgical skills in surgery require hand-eye coordination, which can be achieved with continuous practice [29]. In surgery, one is not enough to see what other people are doing when performing surgery; that is, to become skilled, it is necessary to "watch and do" [30].
One of the six articles included in this review is an Augmented Reality-based simulation development study for Neuroendoscopic Ventricular Removal exercises [25]. In this development study, a 3D-printed model of synthetic body tissue was created. The idea is based on the limited material for practical surgery such as tumour removal. By using this 3D-printed model, it is hoped that it can accommodate all residents to do exercises repeatedly because this model is reusable.
Overall, the surveyed participants agreed or strongly agreed (Likert scores of 4 and 5) on the realistic nature of the anatomical model of the skull and ventricular system, the technical suitability of the model, the camera view, which was similar to the actual surgical view. Participants also agreed or strongly agreed that the content validity of the simulator is a valuable tool for enhancing surgical competence for neuro-endoscopic procedures that helps develop coordinating skills and represent an excellent practical exercise tool for ventricular tumour removal.
Other Augmented Reality-based surgical simulations are also included in this study. The development study conducted by Islam et al. [26] aims to create a video-based approach to observing surgeon hands and surgical instrument movements in surgery and surgical training. The data is captured with a video camera and then explored using a computer vision algorithm. Furthermore, by analyzing the basic statistical parameters, observer-independent performs objective and quantitative measurements of the surgical skills of the trainees. Computer vision is done through two steps, namely Glove/object detection and motion capture. This application is very suitable for remote assessment of student skills. Between the rater and the assessed, it is possible not to be in the room together; this allows the assessed participants to be calmer in the face of the assessment. Students can also receive virtual and interactive demonstrations of surgical procedures with surgeons carrying out the surgery so that students can experience real situations in the operating room.
Nursing skills
Majima, et all [21] developed a practicum learning system for nursing students based on Augmented Reality, especially in the act of taking blood specimens. In certain types of blood vessels, beginners find it difficult to insert the needle. It is the basis for this research. Through this development, beginners can learn the "art" in the veins and imitate the images displayed in front of them. In injection skills education, both instructors and students are usually very interested in holding a syringe. However, in reality, the teaching given is limited to fixation, and the left finger technique is taught, which is tailored to the characteristics of each patient's blood vessels that are difficult to insert a needle. How to repair and lengthen unstable blood vessels has not been entirely taught.
When practising skills training, students can learn skills by following and imitating (tracing) expert technical drawings transparently displayed in front of them in real-time. The prototype system verifies that training can be performed by overlaying the image on a simulated arm model.
CONCLUSION
The use of Augmented Reality as a learning medium really helps improve the understanding and skills of students majoring in health sciences. The many choices of models in application development provide opportunities for researchers to continue to innovate. Augmented Reality-based learning applications in the future become an absolute thing along with the increasing development of technology.
Limitation
Many databases not used in this review, such as Scopus, Ebsco, IEEE, and others, are very
credible for searching literature/articles. It is due to limited access to these databases. The use of gray literature such as google scholar conducted carefully with agreement of all authors.
The author also has limitations in understanding the software and programming languages used in the articles reviewed, so the authors cannot further discuss the application development process in the six articles reviewed.
Recommendation
This study provides a broad overview of the Augmented Reality-based application development process so that it can be a reference material for future teachers or researchers to be able to innovate in the development of Augmented Reality-based learning applications, for example, in the process of guiding final project students, or multiplying nursing action tutorials that are currently available. Not yet fully available in the form of an Augmented Reality application.
Funding
This systematic review does not get funding.
Conflict of Interest
The author declares there is no conflict of interest in this study.
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KNOWLEDGE AND ATTITUDES BETWEEN NURSES, MIDWIVES AND STUDENTS ABOUT VOLUNTARY TERMINATION OF PREGNANCY: A SCOPING REVIEW OF THE LITERATURE
Sofia Di Mario1, Andrea Minciullo2 & Lucia Filomeno3*
- RN, MSN, PhD Student; Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
- RN, MSN, Gastroenterology and Digestive Endoscopy Unit, Campus Bio-Medico, 00128, Rome, Italy,
- RN, MSN, PhD Student; AOU Policlinico Umberto I – Department of Neurosciences and Mental Health, Viale dell’Università, 30, 00185, Rome, Italy.
* Corresponding author: Lucia Filomeno, Department of Neurosciences and Mental Health, AOU Policlinico Umberto I, Rome. E-mail: lucia.filomeno@uniroma1.it
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ABSTRACT
Background: Voluntary termination of pregnancy (VTP) is influenced by ethical convictions, religious orientations and knowledge of the law. The latter is essential for students to be improved in University curricula, in order to develop attitudes among future nurses and midwives with the objective to reduce stigma and reluctance in providing VTP. Previous research has shown that nursing and midwifery students' attitudes and knowledge can be improved.
Aim: The aim of this study is to describe literature regarding knowledge and perception about abortion and voluntary termination of pregnancy in several countries of the world among nurses, midwives and university students.
Methods: This is a scoping review of the literature conducted by following the recommendations of the PRISMA-ScR Statement. The authors selected studies in MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC, published in English and Italian in the last decade. Quality assessment was performed using the Jadad scale.
Results: Initially, 434 studies were selected. A total of 11 articles met the inclusion criteria. The articles included in the scoping review deal with the issue of abortion from different perspectives. From the analysis it emerged that the barriers for VTP are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the procedure.
Conclusions: Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. Therefore, it is recommended to implement university curricula on the topic.
Keywords: knowledge, attitudes, voluntary termination of pregnancy, nurses, midwives, students.
INTRODUCTION
Abortion, originated as birth control, is the termination of pregnancy before 20 weeks of gestation or with the foetus weight less than 500 gr at birth [1,2]. It can happen when at least three events occur: spontaneous or habitual abortion (also called Voluntary Termination of Pregnancy - VTP), criminal or illegal abortion, and therapeutic or legal abortion [3]. In the last decades of the 20th century, many countries all over the world legalised this practice. The World Health Organization (WHO) states that 3 out of 10 (29%) of all pregnancies, and 6 out of 10 (61%) of all unintended pregnancies, ended in an induced abortion [4]. In many societies, a deep conflict about the legality and morality of abortions manifests itself in restrictive laws and strong antiabortion attitudes. Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access a safe one. Barriers to accessing safe VTP include: restrictive laws, poor availability of services, high cost, stigma, conscientious objection of health-care providers and unnecessary requirements, such as mandatory waiting periods, mandatory counselling, provision of misleading information, third-party authorization, and medically unnecessary tests that delay care [5,6]. Kumar et al. [7], defined abortion stigma as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to the ideals of womanhood”. According to this definition, women who experience VTP challenge social norms regarding female sexuality and maternity, and their doing so elicits stigmatising responses from the community. Where opposition to abortion is widespread, abortion-related stigma is likely to negatively influence women’s abortion experience.
Increased knowledge and improved attitudes among health care providers and university students have the potential to reduce stigma and reluctance to provide abortion [6]. In a recent study conducted by O'Shaughnessy et al. [8], it was reported that “low levels of knowledge among staff suggests that training is required to ensure the provision of a safe and effective VTP service”. Midwifery and Nursing schools do not provide termination of pregnancy education or, if they do, it is inadequate and so, most staff were left to navigate this procedure without support or prior practice.
Termination is only possible in the rarest of cases: when the pregnancy poses a serious risk to the woman’s life or in the event of foetal malformations [7]. In Italy, as in many countries, it is set at 12 weeks’ gestation according to the law No. 194 enacted on May 22nd, 1978. Before that date, VTP was considered illegal by the criminal code [9]. The law regulates VTP with the aim of guaranteeing the bio-psycho-social integrity and well-being of women. A woman can have an abortion within the first 90 days, or within the fourth and fifth months only for therapeutic reasons [9]. Conscientious objection status does not exempt the professional from assisting the woman before and after the procedure, but from carrying out only those procedures directed towards and aimed at the termination [10-13]. The nurse can raise a conscientious objection to assisting the VTP with a declaration that can be withdrawn at any time [9]. Termination is a woman’s right, and the staff involved must act in accordance with the law and the woman’s right to free choice. A better understanding of factors influencing perceptions may be useful in determining the curricula of university programs and in giving nurses and midwives the tools to cope with their own beliefs towards late abortions [14-16]. Thus, this review seeks to contribute to research on abortion stigma by exploring literature regarding attitude, knowledge and perception differences toward abortion among nursing, midwifery and students, assessing the scientific evidence available to date and thereby delineating directions for future research.
METHODS
Identification of Relevant Studies
A scoping review was chosen as the research methodology [17]. This supports what is referred to as a systematic approach to the synthesis of evidence, helping to identify gaps for future studies. In this case, the goal is to determine the strength of the evidence using a consistent best practice approach. The search of the international literature was conducted in accordance with the PRISMA-ScR Statement (PRISMA extension for Scoping Reviews)[18] and was conducted within some main databases of biomedical interest: MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC. The review was carried out from October 2021 to February 2022. The keywords used were “knowledge; attitude; perception; nurse; student; abortion; midwife and questionnaire”. The latter were useful in formulating the research question according to the PCC (Population, Concept and Context) methodology (Table 1).
Table 1. Clinical research question identified through the PCC methodology
Study Selection and Eligibility Criteria
Research question: “What are the differences in knowledge and attitudes between nursing and midwifery staff and the corresponding university students?”. The search string was created using the Boolean operators (AND and OR), the terms MeshTerms and the truncation function, to ensure maximum search sensitivity and specificity:
(Knowledge OR Attitude OR Perception) AND (Abortion) AND (Nurse OR Midwife OR Student) AND (Questionnaire OR Assessment)
The study population were nurses, midwives and nursing and midwifery students. The primary studies concerning the assessment of attitudes, perceptions and knowledge about abortion between the two groups and the efficacy and validity of these arguments within the degree programs were considered eligible. The studies included experimental or quasi-experimental studies and observational studies. Since grey literature (i.e., unpublished conference proceedings or theses or dissertations) was not considered, other potentially relevant studies were not included in this review.
The selection criteria listed below were met to identify suitable studies for the purpose of this review.
Inclusion criteria
- Literature from the last 10 years.
- Italian or English language.
- Experimental and observational studies: RCT (Randomised Controlled Trial), quasi-experimental research designs, pretest-posttest, cross-sectional.
- Nurses, midwives and corresponding university students.
Exclusion criteria
- Other healthcare professionals, physicians, medical students or students of other healthcare professionals.
- Grey
- Qualitative and mixed-methods studies.
Data Extraction
In the first phase, the results obtained from the research were imported into a software for the management of bibliographic references and duplicates were eliminated. In the second phase, each article uploaded to the database was carefully and independently examined. Initially, they were analysed by reading their title and abstract and, according to the previously established eligibility criteria, the irrelevant ones were excluded, while those relevant for full-text reading were selected. Thanks to the in-depth reading, it was possible to exclude the articles that did not answer the research questions. Two reviewers worked independently. The following data was collected for each article: study title, first author, year of publication, study sample and study design, objective, assessment and a summary of the results. The approach used to group the articles was thematic: the main objective of the thematic analysis is to identify similar concepts in the collected dataset, exploring their relationships of meaning. These reports can be used to further develop and corroborate the interpretation of theories that seek to investigate the phenomena studied [19].
Quality Assessment
The quality of the studies was assessed usingthe Jadad Scale [20], focusing on methods for random allocation, double blinding, and withdrawals and dropouts. Total scores ranged from 0 to 5 points, where studies with 0-2 points were considered poor quality and those with 3-5 points represented high-quality evidence [20].
RESULTS
Initially, 434 articles were selected with duplicates removed (Figure1). Of these, 11 met the inclusion criteria and underwent the review process. The main information of the relevant articles was organised in a data extraction table (Table 2). Studies were conducted in 11 different countries: Belgium, Ghana, Iran, Brazil, Israel, Spain, Ethiopia, Finland, Canada, Pakistan and South Korea. This demonstrates a notable absence of literature in Italy. The studies included a sample ranging from a minimum of 74 to a maximum of 647 participants. The most recent one dates to 2020, while the oldest one dates to 2010. From the analysis it emerged that the barriers for abortion treatment are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the intervention [21-24]. The possession of skills is often not enough as in the study by Romina et al. [22] where it emerged that there was no significant relationship between the knowledge of the law and the care performance of health professionals while a statistically significant relationship was observed between their opinion of abortion and their active collaboration[22].
Figure 1. - PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.
Personal and religious beliefs have been considered to have a profound influence on opinion and behaviour, in some cases resulting in the inability to take care of the patient for fear of remorse [21; 25-27]. The presence of moral and / or religious values in health workers was significantly correlated with the occurrence of the request for conscientious objection (CO) [21-26].
Table 2. Data Extraction Table.
In South Korea, where about half of the population declared themselves irreligious, Chung Mee Ko et al. [26] assessed the opinions of 167 nurses regarding CO; the majority replied that patients’ rights to health care should take priority over nurses’ right to refuse health care, concluding that the nursing profession should seriously consider whether it is necessary to insist on nurses’ right to CO and should be actively involved in the determination process of new abortion laws and related policies [26]. Nieminen et al. [6] studied CO among Finnish nursing students and practitioners. Most of them seemed to consider the continuation of adequate services to patients in the event of the introduction of CO as crucial, while emphasising the surgical act over patient support. Despite their views and beliefs, health workers sometimes faced a conflict with their commitment to care; in the work of Ben Natan et al. [15], they stated that bioethical dilemmas, as well as the reasons for abortion, influenced their ability to actively collaborate during the termination of pregnancy [15]. Nurses attitude and ability to actively participate in late abortions were found to be strongly conditioned by the level of religious observance [21-22]. The study by Roets et al. [28] found that in several neonatal intensive care units in Belgium, healthcare workers practicing late abortion had a high degree of tolerance towards late termination of pregnancy, regardless of the patient’s socio-demographic factors, so much so that they asked the institutions to provide for a change in legislation [28].
Ben Natan et al. [15], however, found that nursing students had more prejudices towards late abortions than experienced nurses, evidence in line with the study conducted by Assefa et al. [24] where it turned out that a predictor of a positive attitude towards VTP was seniority [24]. The role of health workers is very important, especially on a psychological level, even more so when they must help women to deal with a negative event such as a miscarriage. To this end, Engel et al. [27] suggested that health workers should receive specific training to be able to support women and their families [27]. Previous research has shown that university education programs do not provide the tools necessary to achieve the objectivity required in preparation for abortion and that this may have contributed to anti-abortion attitudes and misconceptions about legal regulations that are common among students10. Same results emerged from the work of Baig et al. [29] who studied the knowledge, attitudes and practices of midwives in post-abortion care services [29]. The work highlighted the need to provide comprehensive training and mentoring to midwives and students, building strong networks to enable the development of broader initiatives to reduce the stigma of abortion.
DISCUSSION
Although the total number of studies investigating abortion stigma among undergraduate students and nurses and midwives such as nurses and midwives is low, results indicate that knowledge, personal and religious beliefs significantly affect attitudes about VTP. This is in line with the findings by Madziyire et al. [10] where incomplete comprehension of abortion laws highlights the urgent need for providers education as a key step in reducing stigma and mortality associated with unsafe abortion [10]. Additionally, the lack of expertise evidenced by most of the studies, suggest that even nurses and midwives who have good intentions may unwittingly disseminate misinformation. One study underlined the fact that type of profession and seniority were important in providers’ knowledge about abortion. Also, being male and having high knowledge significantly influenced providers’ attitude. The same findings were highlighted by Hammarstedt et al. [30] who stated that gynaecologists and midwives were less restrictive towards legal abortion the more experience they had, being especially influenced by recently obtained experience within the last year [30]. Claims of conscientious objection must be ethically justified, and not become a strategy to hide prejudices or fear of lawsuits and moral accusations. Such an instrument cannot be an obstacle for women to have access to abortion [31]. Humanized care in the abortion process is part of the reproductive and sexual rights of women, and ensuring it is a duty of all health professionals.
Abortion laws and practice differ between cultures, religions and countries. The Finnish healthcare system is relatively liberal regarding the right for induced abortion until the 12° gestational week. Despite lively discussion, there is no legislation in this country on the possibility of CO [32]. Post-abortion care is important especially in countries like Pakistan, where half of pregnancies are unintended. Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement [33]. This has been reported in other surveys in other countries. In Ghana, for example, only 45% of surveyed physicians said that they would perform abortions, whereas another 36% said that they would provide counselling prior to abortion but not the procedure itself [33]. Women deserve a well-prepared, informed personnel and similarly, students deserve a thoughtfully inclusive curriculum that accurately addresses ethical topics, as most programs do not require sexual health courses as a part of their curriculum [34-35].
CONCLUSION
The role of the health professional assisting the woman who decides to undergo a voluntary termination of pregnancy is very important, especially in the phases before and after the intervention. Assistance must always be provided with respect for the woman’s dignity, confidentiality and freedom of choice. Nurses need to provide a source of support for the woman by establishing a relationship based on trust. Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. It is important that the health professional realises the crucial importance of their role in the woman’s grieving process to ensure good care.
Limitations of the study
Our study has some limitations that should be mentioned. In our analysis, only research articles published in English and Italian were included, which may have produced a language bias regarding the conclusion, as some scientific papers were published in other languages. Additionally, only studies published in peer-reviewed journals were included; this criterion was meant to ensure reporting quality but may mean that relevant grey literature was missed.
Practical implication
Nurse sneed to have adequate training in the bereavement context: they should know what interventions implement and what to avoid. The aim of the scoping review was to analyze the international panorama regarding abortion as a point of departure on which to develop an Italian study to compare legislation knowledge, attitudes and perspective differences among students and nurses and midwives. Therefore, it is recommended to implement university curricula on the topic.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
The authors declared no conflict of interest.
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NUTRITION EDUCATION MODELS IN PREGNANCY TO INCREASE KNOWLEDGE AND DIETARY PATTERNS: A SYSTEMATIC REVIEW
Suryani*1, Muhammad Rusdi1, Asni Johari1, Solha Elrifda1
- Post-Graduate Program of Mathematic and Natural Science Education College, Jambi University, Indonesia
Correspondence: Suryani, Address : Dr. Tazar Street, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Email : suryanipoltekkes3@gmail.com, Orcid : 0000-0001-6540-2607
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ABSTRACT
Background. The misconception of nutritional principles causes dietary oversight, resulting in an excess or deficit of energy and specific nutrients essential for the proper course of pregnancy and a child's healthy growth. This review aims to evaluate the effectiveness of nutrition education in improving knowledge and dietary change conducted in pregnant women.
Methods. This review study complies with the 2009 PRISMA guidelines. The studies included in this review are mainly studies with experimental designs. Databases used in searching relevant literatures such as PubMed, ScienceDirect, Willey online Library, Web of Science, Cochrane, and Proquest that were published from 2010 to 2021, full text, English version, experimental studies. Two review authors conducted studies screening based on the eligibility criteria, and extracted important points in the studies included. Quality of the studies included were assessed using EPHPP.
Results. A total of 10 studies were identified in this review. Six studies in the high quality, and four studies in moderate quality. Overall outcomes of the studies included are Knowledge, Attitude, practice, dietary practice, awareness, hemoglobin blood level, and Gestational Weight Gain (GWG).
Conclusion. Nutrition education in many methods has a power to improve knowledge, and dietary change of pregnant women. It implies the need for future large high quality trials using a standardized approach to measuring and reporting similar findings across studies.
Keywords : Pregnancy, Pregnant women, Education, Nutrition
INTRODUCTION
Pregnancy is one of the most notable moments in a person's life, and at that time, diet is essential [1]. So far, maternal malnutrition or failure to meet nutritional needs has caused specific health problems for both mothers and newborns [2]. Due to insufficient and unbalanced nutrition, problems such as anemia, osteomalacia, and pregnancy toxemia often arise, and the chances of stillbirth in newborns, premature delivery, congenital abnormalities, and mental retardation increase [3,4]. Furthermore, poor maternal nutritional quality causes developmental maladaptation in the fetus [5]. This results in long-term structural, physiological and metabolic changes and an increased risk of cardiovascular, metabolic, and endocrine diseases in adults [6].
Poor eating habits are a leading contributor to the development of overweight and obesity across the world [7,8]. The frequency of home-cooked meals has decreased over the last five decades, while consumption of foods produced outside the house (i.e., fast food and restaurant food), often higher in calories, fat, and salt, has grown [9,10]. Consumption of home-cooked meals regularly is linked to better diet quality over the lifespan [11,12]. As a result, increasing the frequency of home-prepared meal intake is a significant health habit to target for preventing overweight and obesity in adults and children, and it has been the topic of extensive research over the last two decades [13,14].
International authorities define pregnancy as a moment of highly nutritional needs to promote mother and fetal growth [15]. Nutritional support needed in pregnancy includes carbohydrates, fiber, protein, and micronutrients, such as vitamin A, vitamin B complex folate, and iron [16]. However, a study in Canada found that people have insufficient micronutrients through food, such as high levels of iron (97 percent), vitamin D (96 percent), and folate (70 percent) intake [17]. Therefore, stakeholders intended to present food and nutrition education to encourage a balanced diet based on food culture's valorization [18]. Food and nutrition education is an essential strategy for upgrading health because it encourages people to identify and tolerate their cultural discrepancies and empowers them to complete decisions concerning their health care [19]. Antenatal nutrition education is related to better eating patterns and a healthier pregnancy [20]. Healthy fetal growth and development, cognitive capacity, and immunological function are promoted by optimal nutrition throughout pregnancy [21]. Pregnant women's adherence to dietary guidelines decreases due to a lack of nutrition expertise and insufficient information from health providers [22]. Before and during pregnancy, the mother's behavior becomes a determining factor for both the mother and her child [23,24]. Many dietary mistakes can be caused by a lack of understanding of nutritional principles, resulting in an excess or deficit of energy and specific nutrients essential for the proper course of pregnancy and a child's healthy growth [25,26]. Adequate diet, in combination with sufficient physical activity and the avoidance of harmful habits, enhances the chances of a healthy pregnancy [27,28]. One of the previous systematic reviews on pregnant women's compliance in following dietary guidelines during pregnancy stated that knowledge was an essential predictor concerning adherence to the given nutritional guidelines [29].
It is essential to assess how successful nutrition educations are in improving the nutritional status of pregnant women especially their knowledge and dietary.
This systematic review aimed to assess the efficacy of nutrition education in knowledge and dietary change during pregnancy and their implications for future research. Therefore, the question for this review is, "what kind of nutritional education model is good for increasing knowledge and changes in the diet of pregnant women?".
METHODS
Design
When reporting this systematic review, the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed [30].
Eligibility Criteria
The participants, intervention, comparator, outcome, and study design (PICOS) criteria outlined in Table 1 were used to select studies for inclusion in this review.
Table 1. Studies Criteria based on PICOS
Type of Studies
The studies included in this review use experimental designs such as Randomized Controlled trials (RCT) and Quasi-experimental. Participants in the study should be pregnant women in any trimester of pregnancy.
Search Strategy
The following databases (platforms) were searched: PubMed, ScienceDirect, Willey online Library, Web of Science, Cochrane, and Proquest in the time frame between 2010 to 2021. We also searched the gray literature database for additional information such as Google Scholar, conference proceedings, and BASE. The keywords used are based on the Medical Subject Headings (MeSH) standard. Using Boolean operators and a combination of keywords used, namely: ((("pregnancy nutrition"[Title/Abstract]) OR ("pregnancy nutrition knowledge"[Title/Abstract])) AND ((("health education"[Title/Abstract]) OR ("nutritional education"[Title/Abstract])) OR ("health promotion"[Title/Abstract]))) AND (((("knowledge"[Title/Abstract]) OR ("attitude"[Title/Abstract])) OR ("practice"[Title/Abstract])) OR ("awareness"[Title/Abstract])).
Study selection
Two review authors independently assessed the titles and abstracts of the retrieved studies to see if they met the eligibility criteria (RUS and ASJ). The full-text publications for the remaining studies were obtained and evaluated for eligibility which obtained and read full texts of the studies that potentially met the inclusion criteria. The first ineligibility criterion from the following list determines why a publication was excluded: study design, population, intervention, and results. The first authors decided disagreements from review authors regarding the feasibility of the study (SUR and SOE), and this procedure was followed throughout the review.
Data Extraction and Quality Assessment
Two authors (SUR and SOE) independently extracted data in duplicate from studies that met the
inclusion criteria to avoid any chance of misinterpretation of conceptualizations in each study.
Data were synthesized in two ways: (1) research design and intervention strategies were presented. (2) the findings of each study were analyzed qualitatively by collecting the main findings with the design and intervention applied. Furthermore, data extraction was carried out to provide a brief description of the articles' substance, such as the characteristics of the respondents and the characteristics of the study. Data extracted included author, year, country, participant, study design, Intervention, outcome, and main findings. The researchers then examined each extraction and any discrepancies were discussed until consensus was reached.
The quality of the articles included was measured using an assessment tool for the Effective Public Healthcare Panacea Project (EPHPP) [31] which allows experts to apply this tool to articles on any public health topics. This tool uses STRONG, MODERATE, and WEAK categorizations based on the assessment results on eight components, namely Selection Bias, Study Design, Confounders, Blinding, Data Collection Methods, Withdrawals, and Drop-outs, Intervention Integrity, and Analyzes. Articles in the STRONG category are the article reached four strong from the EPHPP component without any of the components being considered weak, the MODERATE category if four components reach strong. One component is rated "weak," and for the WEAK category, it is given if two or more components reach a "weak" value.
Data synthesis
Data from the included studies could not be pooled for meta-analysis because to the substantial diversity in the methodological design of the investigations. Consequently, the narrative synthesis of the included study findings was provided using the Synthesis without Meta-analysis in Systematic Reviews: Reporting Guideline [32].
RESULTS
Search Results
The process of searching for articles up to the determination of articles that meet the inclusion requirements can be illustrated in Figure 1.
Figure 1. PRISMA Flowchart for Literature Search
Search results from five databases yielded 486 articles according to the keywords applied, and then 159 articles were eliminated because they were duplicates, leaving 327 articles. Furthermore, the screening stage was carried out on the remaining articles; as many as 295 articles were excluded because they did not discuss the nutrition status in pregnancy. At the end of the screening, ten articles met the inclusion criteria (Table 2). Those were included in the moderate and robust categories based on the EPHPP assessment tool for article quality assessment.
Table 2. Extraction of Literature Included
Description of studies included
The articles reviewed in this study are located in several countries such as Iran [37], Ethiopia [34], USA [41], Brazil [33], Palestine [36], and Somalia [39]. Study design including Randomized Controlled Trial (RCT) [33–35,38,39,42], and Quasy experimental [36],[37,40,41].
Characteristics of participants
All reviewed studies included pregnant women with variations in gestational age including below 36 weeks (Oliveira et al., 2018), below 16 weeks [34,35] below 20 weeks [41,42], 14-16 weeks [36], 6-10 weeks [38], 18 – 24 weeks [40], 14-20 [41]. Two studies were not applied the gestational age [37,39].
Description of interventions
Some studies provided booklet regarding Healthy Diet during Pregnancy [33], Counseling regarding dietary practice [34], Nutrition education (theoretical session, poster, brochures, flipchart, and whiteboard) [35,37,40], theoretical and practical [36], the nutrition‑education intervention based on Pender’s HPM [38], video health information [39], exercise, self-monitoring, facebook private group [41], web-based health information [42].
A booklet entitled “Healthy Diet during Pregnancy with Regional Foods (Alimentação Saudável na Gravidez com os Alimentos Regionais)” was used as the main intervention which contains the concept of healthy nutrition, allowed and avoided foods during pregnancy, the benefits of healthy dietary habits for mothers and babies, food hygiene, and recipes with regional foods. The intervention group participated in the individual intervention in a private room, in a single session, with an average duration of 20 minutes. During the meeting, the booklet was introduced, read, and the patients kept a copy to take home [33].
The counseling model has also been used in a study in Ethiopia. The intervention package was community-based guided counseling using the HBM and the TPB. The core content of counseling guide including meal frequency, portion size with increasing gestational age and taking diversified meals, consumption of iron/folic acid supplementation, iodized salt use, reducing of a heavy workload, taking day rest, use of impregnated bed nets, and health services. Counseling was given monthly using a counseling guide and leaflets with core contents. Individual Nutrition counseling was given through a home visit on non-working days. Each counseling session lasted for 40 to 60 minutes. Participants attended four counseling sessions during pregnancy. The first counseling was given before 16 weeks of gestation, the second and third counseling sessions were given during the second trimester of pregnancy, the fourth counseling was given during the early third trimester of pregnancy. The control group received nutrition education given by the health system [34].
Nutrition education intervention recorded in three studies was given to pregnant women between 1 and 4 months at baseline. The education was given every 15 days for 5 consecutive months. For intervention group, education intervention was given based on Health Belief Model theory: (1) susceptibility of the pregnant women and fetus to malnutrition due to inappropriate dietary practices nutrient deficiency or over nutrient intake; (2) severity of malnutrition such as wasting/thinness and overweight/obesity and high risk of fetus to intrauterine growth retardation, brain development, and cognitive function due to macro- and micronutrient deficiency; (3) benefits of right eating or dietary practices on women nutritional status and fetus health, (4) barriers to practice appropriate good dietary practices; and (5) self-confidence/efficacy to follow right dietary practices. The education was provided using theoretical session, poster, brochures, flipchart, and whiteboard. For the control group, nutrition education was given by trained community health volunteers based on the general usual nutrition education which is currently provided by health extension workers [35]. Fallah et al [37] conducted face-to-face nutritional education which contains two to four lessons based on a nutrition package by Iranian ministry of health. Another study by Shakeri [40] nutrition education conducted in groups of 12 people, held in 8 sessions each planned for three sections taking 90 minutes. An educational CD, educational booklet, tract, and pamphlet about the advantages of good nutrition for mothers and embryo, appropriate ways of doing activities during pregnancy, and false beliefs were given to the participants. Furthermore, lecture, question and answer, group discussion, and film screening methods were used to educate the patients. Paticipants in control group received the routine prenatal instructions [40].
The complementary nutritional intervention (CNI) program proposed by Al-Tell and colleague, it was developed based on the educational principles using the principles of health belief model that aimed to behavior change. The program composed of two parts that were presented within 16 hours and through 8 grouped sessions, in addition to another 2 individualized/ follow-up session for each woman. The content of the theoretical part consisted of 60% of program hours, and the practical part consisted of 40% of program hours. The study also used educational booklet for additional materials. It included information regard iron deficiency anemia in term of causes, complication, treatment inhibitors and promoters of iron absorption and examples of prepared meals rich of iron [36].
Khoigani and colleague conducted nutritional education based on the Pender’s HPM for intervention group, included three 45 – 60 minutes training sessions in 6 – 10, 18, and 26 weeks of pregnancy. Each participant had a meeting with the study nutritionist at the time of enrollment for nutritional assessment. In the first session, the dietary pattern, including the average daily servings of five food groups, was explained to the participants. In the second session, practical steps (goal‑setting techniques) to increase self‑efficacy [38].
Destephano et al evaluated the use of DVD to spread information about caesarean birth, episiotomy, nutrition and exercise, the father’s role, preparation and prevention, and pregnancy myths and facts. Each video topic ranged from 3 to 4 min in length, incorporated
traditional songs and poetry, and had English subtitles [39].
Baruth et al used the social cognitive theory to develop SELF intervention (Supporting hEaLthy Futures: Creating a Healthy Family by Investing in YourSELF). The intervention included four key components: Exercise is Medicine™, self-monitoring, opportunities for support, and walking groups (optional). In self monitoring, Participants were given a FitBit Charge to monitor their physical activity (daily) and an Eat Smart Precision digital scale (model ESBS-01) to monitor their weight. Participants were instructed to weigh themselves once a week using the scale provided, and enter their weight into their FitBit account [41].
Participants (control and intervention groups) in Olson et al [42] trials given access to the intervention website and to the placebo control website. The self-directed, integrated online and mobile phone behavioral intervention was designed using the Integrative Model of Behavior Prediction and the Behavior Model for Persuasive Design based on a non-electronic pregnancy lifestyle intervention. Participants in intervention group received access to three behavior change tools including a weight gain tracker, a diet and a physical activity goal-setting and self-monitoring tool, as well as, health information including tips, articles, frequently asked questions; a description of pregnancy and parenting-related resources available in the local community; a blogging tool; and an event and appointment reminder [42].
Quality Assessment
Assessment of the methodological quality of studies resulted in 6 studies with a high quality score [33–35,38,41,42] and 4 studies with a moderate quality score [36,37,39,40].
Description of Outcomes
Outcome measures reported in the included studies were Knowledge, attitude, practice [33–35,37,39,40], Dietary practices [34,35,38], Gestational Weight Gain (GWG) [41,43], behavior change [42], Hemoglobin blood level [36]. One study collected the result of outcomes measurement immediately after the intervention [39], Three studies conducted the evaluation in two times for 6 weeks [40], 5 months [36], and 8 months [42]. The rest of the studies evaluated the outcomes in the range of one to five months [33–35,37,38,41].
As mentioned in Oliveira et al study, the knowledge was considered adequate when used to prepare varied meals and/or juices, knew three or more types of regional foods, and mentioned at least two types of meals prepared with regional foods. The attitude was considered adequate when pregnant women prefer to use regional foods and know the advantages. The practice was considered adequate when pregnant women referred to use regional foods at least twice a day [33]. In Diddana study, knowledge measurement is based on the Health Belief Model consists of 15 nutrition question [35]. In Fallah study, Knowledge as a primary outcome was measured before the intervention and two posttests within three weeks interval [37]. Another study in Iran with knowledge and attitude as primary outcome completed the evaluation immediately and 6 weeks after the educational intervention for the samples of experimental and control groups [40].
For dietary practice outcome, assessment used a food frequency questionnaire (FFQ) collected between 36 to 37 weeks of gestation. Women who didn’t attend all counseling sessions were considered non-adherent to the guideline. But, women who withdraw from participating in the study were labeled as lost to follow up [34]. In Diddana study, dietary practice variable was collected by using 17 dietary habit questions [35].
DISCUSSION
Overview study included
This review provides evidence that interventions with a health education on pregnancy issue can improve pregnant women knowledge, attitude, practice, dietary pattern, awareness, hemoglobin level, and weight gain outcomes. There is somewhat more persuasive evidence that health education interventions are favorably linked with healthy living change during pregnancy of pregnant women as participants due to the number of RCTs that revealed significant findings. Because of the high variability of research designs and methodology utilized in the included papers, meta-analysis cannot be conducted. Furthermore, the goal of this evaluation was to serve as a first step in identifying evidence-based treatments that would help transfer prenatal nutrition research and guidelines into practice. Although the evidence highlighting the importance of nutritional status during pregnancy has been documented, and numerous practice guidelines, including the recently consolidated inter-professional practice guidelines, have existed for some time, there is still a significant gap in translating this evidence to pregnant women through health promotion efforts. Overall, there are few dietary promotion treatments during pregnancy, and only 10 interventions have been assessed on specified health outcomes, according to this analysis.
Overall, the studies comprised a wide range of pregnant women from six different nations, resulting in some findings. Furthermore, all of the research was done in a communal context. A previous evaluation noted that complete prenatal care treatments should be available in remote regions or with less infrastructure and that their duties and those of trained CHWs should be harmonized across nations to assure basic levels of care [44]. Pregnant women who did not take advantage of offered interventions, so missing out on the possibility of a better pregnancy outcome, exemplified the lack of access to services in remote regions [45].
We recommend that maternal and family health service managers at the national, state, and local levels devote resources to adapting and testing existing culinary nutrition programs or, as appropriate, developing new culinary nutrition programs tailored to these life stages, as a result of the potential benefits of culinary nutrition interventions during pregnancy and postpartum identified in this review. Culinary nutrition programs for pregnant or postpartum women might be incorporated into existing health education programs or offered separately. A workforce with culinary nutrition expertise in maternity and family health care would be required to support such initiatives.
Nutrition Education
For this group is included in the demographic group prone to nutrition and health concerns, nutrition education is crucial during pregnancy [46]. According to cross-sectional research, pregnant women's understanding of nutrition during pregnancy went from 53.9 percent to 97 percent after receiving nutrition education, while their pregnancy-specific dietary practices increased from 46.8 percent to 83.7 percent [47].
Besides knowledge, GWG is also an important issue to be discussed In both the short and long term, excessive GWG is linked to unfavorable health outcomes for mother and child health [48]. Excess GWG is linked to an increased risk of hypertensive disorders [49], glucose intolerance [50] and and poor delivery outcomes during pregnancy [51]. It also predicts more significant baby morbidity and fetal development, such as birth weight, big for gestational age, and macrosomia, among other things [52].
Olson et al., [42] In their experiment, a self-directed, integrated online and mobile phone behavior modification intervention failed to show a beneficial effect on the proportion of the sample with excessive total GWG when compared to an information-only placebo control condition (which is included in this review). It was most likely discovered because the intervention was self-directed. That may have been a wrong decision. Structured, personalized treatments were more likely to be successful in promoting dietary change, according to a recent assessment of the research on e-behavioral nutrition interventions [42].
One research included in this review, which focuses on the hemoglobin blood level as an outcome, was done in Palestine. Compared to the control group, the study found a substantial beneficial link between dietary behaviors and improved hemoglobin levels. Compared to the control group, there was also a good connection between maternal hemoglobin levels in the third trimester and tiredness levels in the study group [36]. According to review research, nutrition education such as counseling, web-based, and text messages may enhance pregnant women's adherence to iron supplements. The research also stressed the significance of a more extended trial period to assess the intervention's effectiveness correctly [53].
According to the World Health Organization, pregnant women who reside in areas with high nutritional deficits should get some primary nutritional treatment. Nutrition counseling on a healthy diet, energy and protein dietary supplements, iron and folic acid supplementation (all settings), calcium supplementation to reduce the risk of pre-eclampsia in settings where dietary calcium intake is low. Zinc supplementation is only recommended for pregnant women in the context of rigorous research, and multiple micronutrient supplementation is all recommended in settings where 20% or more of women are underweight. Nonetheless, in areas where nutritional shortages are common, several micronutrient supplements include iron and folic acid, may be recommended for maternal health [54].
CONCLUSION
Nutrition education in many methods has a power to improve knowledge, and dietary change of pregnant women. However, there is a need for future large high quality trials using a standardized approach to measuring and reporting similar findings across studies. A future study might use a double-blind RCT approach with larger sample size and a variety of nutritional outcomes. Longer duration in implementing the trials will improve the outcomes of the study as expected.
Limitation
Our study has several flaws, including a lack of access to the most often recommended databases for searching relevant literature and, ultimately, trial trials. Some research relied on self-reported outcome measures, which might be vulnerable to various biases (e.g., recall bias and response bias). Because some of the studies are of intermediate quality, their conclusions should be read with care. We should also consider that non-English paper were not considered and included in this review, with a potential bias to not identify as many eligible studies as possible.
Conflict of interest statement
The author(s) declares no conflict of interest.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
Acknowledgements
We express our gratitude to the director of Jambi University for its support for the implementation of this research and President of Jambi University, Indonesia
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