Single-centre descriptive study of adverse events reported after anti-COVID vaccination

 

Fabio Giancane1, Angelo Cianciulli1, Silvia De Chiara2, Alessandra Iannelli2,

Marika Finizio4, Rosetta Frammartino1, Andrea Lombardi1,

Domenico Ciro Cristiano1, Francesco Gravante3, Francesco Petrosino1*

 

1.Nurse, AOU ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno
2.Pharmacist, AOU ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno
3.Nurse, Local Health Unit of Aversa, Caserta
4.Nursing graduate, University of Salerno

*Corresponding author: Francesco Petrosino, AOU ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno. Email: f.petrosino75@gmail.com

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ABSTRACT

Introduction: In Italy, approximately 80.5% of the population has completed the primary anti-COVID vaccination cycle with approximately 141 million doses administered. With the introduction of new measures to counter the spread of COVID-19, including compulsory vaccination for certain categories of people, the population expressed fears about the safety and adverse effects of SARS-CoV-2 vaccines. Several factors, such as gender and age, could have influenced the outcomes associated with the vaccine. Our single-centre work seeks to provide such evidence with respect to Pfizer/BioNTech’s BNT162b2 (Comirnaty) and AstraZeneca’s AZD1222 (Vaxzevria) vaccines.

Materials and Methods: Single-centre descriptive study carried out on a sample of subjects who underwent anti-COVID vaccination at the ‘San Giovanni di Dio e Ruggi d’Aragona’ AOU vaccination centre in Salerno. Patients who reported a suspected adverse reaction after receiving a dose of vaccine were included in the study. The regional vaccine platform SORESA and the VigiFarmaco portal were used to collect the data.

Results: During the period covered by the study, 126,928 doses of SARS-CoV-2 vaccine were administered. The Pfizer-BioNTech vaccine group comprised 124,138 administrations. The AstraZeneca vaccine group consisted of 2,790 administrations. 287 post-vaccination adverse reaction reports entered in the National Pharmacovigilance Network were considered. In most of the reactions reported, for both vaccines considered, the symptomatology was attributable to local reactions at the injection site. At the systemic level, however, we noted the prevalence of non-specific events such as fever, headache and diffuse arthromyalgia.

Conclusions: Based on our results and comparison with the literature, the data collected on the vaccines considered in the study suggest a favourable safety profile for their large-scale use. The rate of minor adverse events turned out to be low, with similarly reassuring data compared to serious adverse events, such as not to justify hesitation towards vaccination for COVID-19 disease control.

Keywords: SARS-CoV-2; Surveillance system; COVID-19 vaccination; mRNA; Viral vector; Adverse events following immunisation

 

INTRODUCTION

Pathogenic viral outbreaks and complex interactions with humans and animals have, over the centuries, caused the transmission of viruses between different species (jumping), posing a great threat to human health and safety[1-3]. Globalisation has increasingly favoured pathogenic transmission between continents, causing different pandemics, in particular viral pandemics[4]. A new public health crisis that threatened the world in 2019 was the spread of the new coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) declared a pandemic by the World Health Organisation (WHO) in March 2020[5]. The rapid spread of the COVID-19 disease has focused researchers’ attention on the repurposing of existing approved drugs that inhibit viral entry, endocytosis, genome assembly, transmission and replication[6]. Most of the available information has been obtained through studies on other members of this family (SARS and MERS)[7]. Many researchers are currently working on the development of various types of specific drugs to treat this disease worldwide[8, 9]. Therefore, the current treatment given to COVID-19 patients is only based on their symptoms[10, 11]. Exposure to a pathogen such as SARS-CoV-2 generates an antibody response that changes over time and in different individuals (antibody kinetics)[12, 13]. It is believed that the limited pre-existing natural immunity to this virus was responsible for the explosive increase in cases[14, 15]. A previous infection, on the other hand, could play a key role in ensuring protection against new infections, and the literature can provide evidence of such protective correlations through longitudinal cohort studies[16-19]. In the absence of specific drugs, only global vaccination has made it possible to contain the spread of the virus, reducing the number of serious clinical cases and hospitalisations[20-22]. In December 2020, the first vaccines against COVID-19 developed with different technologies received Emergency Use Authorisation (EUA) from the US Food and Drug Administration (FDA). Subsequently, globally, they were licensed in 117 countries in North and South America, the United Kingdom, Europe, Africa, Asia and Oceania[23, 24].
In Italy, mRNA vaccines and the adenovirus vaccine AZD1222 have been widely administered. Time saving during the development of COVID-19 vaccines was achieved through unprecedented levels of public financial support, increased tolerance for risky investments in technology and process, and studies on mRNA transport methodology[25-27]. The Italian Medicines Agency defines pharmacovigilance and vaccine vigilance as “a complex set of activities aimed at continuously assessing all information relating to the safety of medicinal products and ensuring that the benefit/risk (B/R) ratio remains favourable over time.” Our country has a pharmacovigilance system that, for many years now, has devoted special attention and a special organisational structure precisely to monitoring what happens after a vaccine is administered. It is an open, dynamic system to which everyone (health professionals, patients, parents, citizens) can send their reports contributing to the monitoring of the safe use of vaccines and medicines in general. Furthermore, the system has full transparency and offers access to aggregated data, which can be queried on the AIFA website. The National Pharmacovigilance Network (NFP) suddenly came into the spotlight when several new vaccines received emergency authorisation and were launched on a large scale at the end of 2020. Vaccines have undergone rigorous clinical testing and evaluation by the authorities, but with the use of new technologies [28] and rapid, large-scale administration of vaccines, the importance of a well-functioning international system of post-marketing safety surveillance has been emphasised[29, 30]. The surveillance of vaccine safety and the collection of reports on suspected adverse events after immunisation (AEFI) [31] is the responsibility of national vaccine regulatory systems, including national regulatory authorities (NRAs) and national immunisation programmes (NIPs). Passive surveillance, defined as the collection and analysis of unsolicited reports of suspected adverse events in the form of individual case safety reports (ICSRs) that are sent to a central database or a health authority, is the basis of safety surveillance for immunisation programmes, in order to identify rare events, evaluate clusters of reports and detect safety signals for further and subsequent studies [32, 33]. Although the identification and quantification of adverse events related to anti-COVID vaccination is not always easy to understand, especially in such a broad context as a pandemic, the analysis of the available data can be an important moment for risk estimation and subsequent safety assessments[34-36].
This paper describes reports of reactions that were observed after administration of the COVID vaccine. Investigating the meaning and causes of these reactions is the task of pharmacovigilance. Investigating every event that appears after a vaccination serves to gather as much information as possible and increase the possibility of identifying truly suspicious events whose nature is important to understand, or which have never been observed before, with the aim of ascertaining whether there is a causal link with the vaccination. In this way, regulatory authorities such as AIFA can verify the safety of vaccines in the real world, confirming what has been observed in pre-authorisation studies and possibly identifying new potential adverse reactions, especially if they are rare (1 in 10,000) and very rare (less than 1 in 10,000). A large number of reports, therefore, does not imply that the vaccine is more dangerous, but is an indication of the high capacity of the pharmacovigilance system to monitor safety.
The anti-Sars-CoV-2 vaccination campaign, which started on 27 December 2020, saw the participation of the ‘San Giovanni di Dio e Ruggi d’Aragona’ AOU of Salerno in ‘Vaccine Day’, the symbolic start date of the vaccination campaign in Italy and across Europe. In what was analysed by this work, in order to make this event – historic for all healthcare worldwide – possible, an organisational and coordination process was implemented that ensured high daily vaccination numbers and minimal risks for users, in full compliance with the quality standards of Public Health.
Several factors, such as gender and age, may have influenced the clinical outcomes associated with the vaccine[37]. To date, in Italy, about 80.5% (48 million subjects) of the population have completed the COVID-19 primary vaccination cycle with about 141 million doses administered. This followed the introduction of new measures to combat the spread of COVID-19, including the compulsory vaccination of certain categories of persons[38].

 

MATERIAL AND METHODS

Study design

In this paper, we will provide a surveillance report on vaccines administered at the ‘San Giovanni di Dio e Ruggi d’Aragona’ University Hospital (AOU ‘Ruggi’) in Salerno with respect to specific targets:

1.to conduct a descriptive observational study of subjects undergoing vaccination with Pfizer/BioNTech’s BNT162b2 (Comirnaty) and AstraZeneca’s AZD1222 (Vaxzevria) between 27 December 2020 and 30 November 2021
2.to conduct a descriptive analysis of all reports of suspected adverse drug reactions attributed to COVID-19 vaccination (Adverse Events and Severe Adverse Events Following Immunisation, AEFI and sAEFI), collected through the AIFA form and/or the VigiFarmaco system of the Italian Drug Agency (severity, concomitant use of drugs, outcome)
3.to assess the role and statistical association between reported reactions and previously identified variables (age, gender, dose).

 

Participants

The descriptive observational study was carried out on a sample of subjects who received the vaccine at the ‘San Giovanni di Dio e Ruggi d’Aragona’ AOU vaccination centre in Salerno in the period between 27 December 2020 and 30 November 2021. Patients who reported a suspected adverse reaction after receiving a dose of vaccine were included in the study.

 

Sample Size

The sample size was evaluated using the GPower software version 3.1.9.7[39]. Power analysis was conducted for a two-tailed t-test, with an effect size = 0.50, a probability of type I error = 0.05, a test power = 0.95 and a sample size ratio of 1:1. The sample size for group 1 is 105 and for group 2 it is 105 for a total of 210 items. For the goodness-of-fit χ2 test, with an effect size = 0.3, a probability of the type 1 error = 0.05, a power of the test = 0.95 and GdL = 1, the sample size for the group is 143 (172 with 2 degrees of tolerance).

 

Data collection

For the vaccination population, data were obtained from the SINFONIA platform (Sistema Informativo Sanità Campania) and the VigiFarmaco portal for adverse event reporting. They were collected anonymously, formatted, narrowed down to the vaccines of interest for this study and entered into a database using Microsoft Corporation Excel software.

 

Data analysis

The collected data were processed with SPSS ® (Statistical Package for Social Science – Chicago, IL, USA) statistical software for Windows, version 26.0. A descriptive analysis of the general characteristics of the study population was performed, using absolute frequencies and percentages. Data were stratified by age group, gender and period of administration. For continuous variables, results were expressed as mean ± standard deviation (SD), and as median and Interquartile range (RIQ) for numeric variables. Paired and unpaired data were analysed using Student’s t-test. The Kolmogorov-Smirnov test, which is more appropriate when the sample size is >50, was used to check normality. The Q-Q diagram and the values of skewness and kurtosis were also evaluated. The categorical variables were summarised using frequencies and percentages, and we used the chi-square (χ2) test to compare the categorical variables between the groups.
The Phi coefficient was used to measure the strength of association between the dichotomous variables, while Pearson’s linear correlation coefficient was used to assess the degree of relationship between the variables age and severity.
All tests with p-value (p) < 0.05 were considered statistically significant.

 

Ethical consideration

Due to the nature of this study, no formal approval to the relevant Ethics Committee was required. The study was conducted in accordance with the principles of the Declaration of Helsinki. The data were extracted from databases for which the processing information had been signed in advance and analysed for the time strictly necessary to achieve the purposes for which they were collected, in compliance with the Regulation (EU) 2016/679 (GDPR) on privacy and guarantee of anonymity. Authorisation for their use was provided by the Corporate Privacy Officer and the legal representative of the organisation.

RESULTS

During the period covered by the study, 126,928 doses of SARS-CoV-2 vaccine were administered. Those who had already received the first dose went to the centre for the administration of the second dose of vaccine. Some of them also received the third dose.
In Table 1, the general trend of the Vaccination Centre is shown, while in Table 2, the trend per macro area (Vaccination Type and Dose) is shown.

 

Table 1. General performance of the Vaccination Centre

 

Table 2. Performance by macro area of the Vaccination Centre, with order of priority of categories

 

A proportion of the vaccinated subjects (404) switched from AstraZeneca to Pfizer-BioNTech due to changes in the Italian Regulatory Authority’s declarations [40] or because they had suffered increased D-dimer levels [41]after the first AZD dose.
The Pfizer-BioNTech vaccine group (BNT) comprised 124,138 administrations (47.8% men and 52.2% women) with a mean age of 49.11±20.94 years (range: 12-101) and a median age of 51 years (RIQ: 31-64).
The distribution is superimposable between first dose (50.6%) and second dose (47.2%). Only 2.2% of the subjects received the third dose.

 

Figure 1. Age distribution BNT Group

 

The AstraZeneca vaccine group (AZD) consisted of 2,790 administrations (57.7% men and 42.3% women), with a mean age of 47.46±11.77 (range: 18-76 years) and a median age of 49 years (RIQ: 38-57). 58.7% of the sample received the first dose and 41.3% the second dose.

 

Figure 2. Age distribution AZD Group

 

The enrolled population was stratified by age decades. The Pfizer-BioNTech group consisted predominantly (18.9%) of individuals aged between 60 and 69 years (Figure 3), whereas the AstraZeneca group comprised more people (23.1%) aged between 40 and 49 years (Figure 4). In particular, several subjects were unable to receive AstraZeneca mainly due to thrombotic risk (e.g. high D-dimer value, coagulation impairment, etc.) and age limitation (initially subjects over 18 years of age were eligible and later over 60 years of age), according to the recommendations in force in Italy. Our study therefore examined the AEFIs and sAEFIs attributed to the SARS-CoV-2 vaccination and recorded by the nursing staff or pharmacists responsible for vaccine preparation and pharmacovigilance at the AOU ‘San Giovanni di Dio e Ruggi d’Aragona’ Vaccine Centre.
At the time of its closure on 30 November 2021, we verified that 287 post-vaccination adverse reaction reports had been entered into the National Pharmacovigilance Network. The data show that the percentage of reported sAEFIs are significantly lower than the risks related to COVID-19 (data from the COVID-19 Integrated Surveillance in Italy).

 

Figure 3. Distribution by age group BNT Group

 

Figure 4. Age distribution AZD Group

 

Most of the reported adverse events were classified as non-serious (90.9%) and to a lesser extent as serious (9.1%); in most cases, the outcome was complete resolution or improvement of symptoms. The distribution of reports per type of vaccine follows the distribution of administrations (92% for Pfizer-BioNTech and 8% for AstraZeneca).
The average age of persons reporting a suspected adverse event was 62±22.21 years (range: 15-99). As already observed in the National Surveillance Reports on anti-COVID-19 vaccines, also in what was analysed by this work, the reporting rates for the 2nd dose are lower than for the 1st dose and significantly lower for the 3rd dose. Although these are not absolute incidence rates, the data indicate an overall absence of significant sAEFI events such as to be an alert for regulators to serious safety issues with administered vaccines. On the other hand, in contrast to the overlapping exposure between the genders (52% of doses administered in females and 48% in males), one can note the asymmetric distribution of reports with respect to gender, with 71.1% of reports concerning women and 27.9% concerning men, regardless of the vaccine and the dose administered.
In our statistical analysis, in order to determine whether there were age differences between those who reported a post-vaccination adverse reaction, we performed an independent samples t-test.
To test for normality, we used the Kolmogorov-Smirnov test with Lilliefors correction, which was non-significant for both men (p = 0.071) and women (p = 0.058). Visual inspection of the Q-Q plot shows that age is normally distributed, with a skewness of -0.445 (ES = 0.271, | z | = 1.64) and kurtosis of -0.634 (ES = 0.535) for men and a skewness of 0.006 (ES = 0.171, | z | = 0.035) and kurtosis -0.902 (ES = 0.341) for women[42-43]. Having ascertained the normality of the sample distribution, we evaluated the hypothesis of equality of variance by means of Levene’s test. This turns out to be statistically non-significant (F = 0.255, p = 0.614) and it is therefore possible to use the assumption of homogeneous variance of the age of males and females.
The results suggest that the difference in mean age between the two groups is not significantly different (t(279) = 1.769, p = 0.078). We then looked at whether the 287 subjects in our sample were as likely as the Italian population to have non-serious (81.8%) or serious (18.1%) reactions[44].
We conducted a χ2 test for goodness of fit against the theoretical distribution model. In this case, the results obtained suggest that the two categories do not distribute themselves according to the expected probability (χ2(1) = 15.88, p < 0.001). In particular, in our reference sample, non-serious reactions are more frequent (90.9%) than serious reactions (9.1%). We then conducted a χ2 test to test whether men and women were equally likely to have non-serious or serious reactions. The test results suggest that men and women were equally distributed within the two categories of the severity status variable (χ2(1) = 2.83, Phi = -0.100, p = 0.093). In other words, there is no evidence of linear dependence between gender and the occurrence of a serious adverse reaction, with a small linkage effect between the two variables, as suggested by the value close to 0 for the Phi coefficient. We also conducted a χ2 test to test whether there was a relationship between the number of doses received and the occurrence of a severe reaction. These results also suggest that the groups are equally distributed within the two categories of the severity status variable (χ2(2)= 0.418, p = 0.811, V = 0.038). In other words, dose and severity of the reaction are independent in distribution. Finally, Pearson’s linear correlation coefficient was calculated to investigate the correlation between the variables age and severity considering the reported adverse reaction (r = -0.279, p = 0.01).
The results suggest that as age decreases, there is a weak correlation with the presentation of a severe reaction. In this analysis, the source variable (severity) was coded into a nominal dichotomous qualitative variable with value 0 (no severe reaction) and 1 (severe reaction).
Below are some of the reactions detected and their incidence in relation to the total number of detections (Figure 5).
Figure 6 shows some detected reactions and their incidence for the Pfizer-BioNTech vaccine and Figure 7 for AstraZeneca.

 

Figure 5. All types of adverse events observed on our sample.

 

Figure 6. All types of adverse events observed by Comirnaty vaccine.

 

Figure 7. All types of adverse events observed by Vaxzevria vaccine.

 

Finally, Figure 8 shows the reports of sAEFI aggregated by symptomatology. It can be noted that,

 

Figure 8. All types of severe adverse events observed.

 

Figure 8 shows the reports of severe AEFIs aggregated by symptomatology. It can be seen that, in addition to overlapping with the AEFIs in terms of typology, they are characterised by events attributable to general pathologies. For all reported sAEFIs, the outcome was improvement of symptoms.

 

DISCUSSIONS

Our study examined AEFIs and sAEFIs spontaneously reported at the AOU ‘San Giovanni di Dio e Ruggi d’Aragona’ in Salerno through the AIFA pharmacovigilance system and attributed to anti-COVID vaccination. Our data, although related to a small sample, demonstrate the few reports of serious reactions and the low risk of outcomes when compared to historical pandemic data and in line with national data. In contrast to an overlapping exposure between the sexes with respect to total administrations, AEFIs were predominantly reported in the female sex (71%). The percentage of sAEFI is almost overlapping between the sexes, with a prevalence for Pfizer-BioNTech’s Comirnaty vaccine (78%) at the first dose (77%). In most of the AEFIs reported, for both vaccines considered, the symptomatology was attributable to local reactions at the injection site (e.g. pain, swelling, redness). At the systemic level, however, we noted the prevalence of non-specific events such as fever, headache and diffuse arthromyalgia. The same applies to reactions reported as serious; the latter, identified as such due to the prolonged observation period at the vaccination centre, in rare cases led to the hospitalisation of those involved. All these reports resulted in an improvement in symptoms. In line with the literature, our study showed that the onset of AEFI can be influenced by gender. This could be related to the opposite role of sex hormones [42] as well as pharmacokinetic parameters that may differ between males and females [43].
Disease control efforts by health authorities should seriously consider the relationship between the risks involved in immunising the population versus the benefits against the disease[45]. While there is no general acceptable risk threshold, the number of deaths worldwide from COVID-19, the risk of collapse of health systems, shutdowns and damage to economies, should lead epidemiologists, health organisations and governments to set this threshold as soon as possible.

CONCLUSIONS

Based on our results and the comparison with the literature[46, 47], both vaccines showed a favourable safety profile, with reassuring data that does not justify hesitation towards vaccination for COVID-19 disease control[48-50]. We therefore highlighted the few differences in the incidence and type of AEFI and sAEFI associated with Pfizer/BioNTech’s Comirnaty (BNT162b2) and AstraZeneca’s Vaxzevria (AZD1222). For these reasons, the guidelines issued by many countries, such as Italy, whose main objective is to increase the number of vaccinated persons with a ‘fourth dose’ to protect the over 60s and the frailest of the population. It is therefore necessary to disseminate surveillance and public health data to counter vaccination hesitancy in the general population and the reluctance of “no vax” subjects towards vaccinations, also in view of possible future pandemic events.

 

LIMITS

The study has some limitations. Pharmacovigilance information is based on a voluntary and passive reporting system that may not capture every single event related to AEFI and sAEFI. Direct verification is not always possible to determine whether every reported adverse reaction is actually related to the vaccine. In particular, the lack of reporting could lead to an underestimation of all the adverse events that actually occurred.
Another limitation of the study is that, to the exclusion of age and gender, other individual characteristics were not taken into account, such as underlying or previous diseases (myocarditis, autoimmune or immune-mediated diseases, oncological pathologies) or chronically taken medications, which might instead predispose vaccinated subjects to be susceptible to AEFIs and sAEFIs.

ACKNOWLEDGEMENTS

We thank Prof Francesco De Caro (UOC Risk Assessment Management and Reporting) and Dr Maria Grazia Lombardi (UOC Pharmacy), AOU ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno.

 

FUNDING

This research did not receive any external funding or support.

 

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest associated with the study.

 

AUTHORS’ CONTRIBUTION

FG and AC were responsible for the conception and design of the study; SDC and AI performed the data collection; FG and FP performed the data analysis; MF and RF were responsible for drafting the manuscript; AL and DCC made critical revisions to the article.

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by OPI Napoli

ANALYSIS OF PSYCHOSOCIAL STATUS AND QUALITY OF LIFE IN THE ELDERLY WITH OSTEOARTHRITIS DURING THE COVID-19 PANDEMIC: A CROSS SECTIONAL STUDY

 

Mohd Syukri1*, Dewi Masyitah1, Mashudi1, Lailatul Fadilah2

 

  1. Department of Nursing, Health Polytechnic, Ministry of Health Jambi, Indonesia

  2. Department of Nursing, Health Polytechnic, Ministry of Health Banten, Indonesia

 

* Corresponding author: Mohd Syukri, Jl. Dr. Tazar, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Orcid: https://orcid.org/0000-0003-2061-5531

Email: syukrimuh290@gmail.com

                                 

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ABSTRACT

Introduction: Along with increasing age, there will also be an increasing tendency to get sick and have physical limitations (disabilities) due to a drastic decline in physical abilities. These conditions are the leading cause of high mortality and morbidity in the elderly, especially during the Covid-19 pandemic. The current study aims to analyze the relationship between psychosocial status and the quality of life of the elderly with osteoarthritis during the Covid-19 pandemic.
Materials and Methods: This cross-sectional study was located at a nursing home in Jambi, involving 351 randomly selected participants. Measure the psychosocial status of the elderly using the Indonesian version of the Self Reporting Questionnaire (SRQ) and the quality of life using the Indonesian version of the World Health Organization Quality of Life-Old (WHOQOL – OLD) questionnaire.
Results: Most elderly have a good quality of life, as many as 229 (65.1%), while a poor quality of life, as many as 30 people (8.5%). In the psychosocial variables, most respondents did not experience mental health disorders, as many as 260 people (74.1%). The Mann-Whitney test showed a significant relationship between Quality of Life and Psychosocial Status, in particular we obserbed in subjects without mental disorders in comparison to subjects with mental disorders a better quality of life, i.e. the elderly who do not suffer from mental disorders will show a tendency for a good quality of life.
Conclusions: Psychosocial status related to quality of life in the elderly with osteoarthritis during the Covid-19 pandemic. The elderly who do not suffer from mental disorders will show a tendency for a good quality of life.

Keywords: Elderly; Covid-19; Psychosocial; Quality of life

INTRODUCTION

Qualified elderly are elderly who, through the aging process, remain healthy and optimal physically, socially, and mentally to remain prosperous throughout life and participate in improving the quality of life as members of society [1,2]—osteoarthritis in the elderly results in limitations in carrying out daily activities independently. A study revealed that 2.6% of the elderly experienced total dependence, 1.2% with moderate support, and 96.3% with mild reliance [3]. Dependence, coupled with lifestyle changes, is one of the factors causing stress in the elderly [4,5].
The elderly with osteoarthritis who experience stress tend to experience sadness, and the body becomes weak, with reduced appetite and interest in all things [6,7]. As a result, they will experience delays in treatment, especially in the second year of the Covid-19 pandemic, where there is a statistical increase in cases in various parts of the world, including some areas in Indonesia, where the elderly are a group that is vulnerable to infection. The number of deaths continues to increase, especially in the elderly group [8–10]. If this condition is allowed to drag on, it will trigger depression. In addition, the elderly will find it difficult to motivate themselves to recover. The adaptation process that must undertake to all the changes experienced makes the elderly vulnerable to psychological disorders such as unstable emotional conditions, depression, or anxiety, and it may reduce the quality of life of the elderly [11,12].
Crisis in the elderly can be expressed as a condition of psychosocial disorders with characteristics including dependence on others, isolating themselves, or withdrawing from social activities for various reasons. The reasons include undergoing retirement, severe and prolonged illness, the death of a spouse, and undergoing health protocols during the Covid-19 period, where everyone must keep their distance and isolate themselves [6,13]. For the elderly, changing roles in the family, socio-economic, and social community resulted in setbacks in adapting to the new environment and interacting with the social environment [11,14].
Quality of life is a strategic issue that reflects the condition of the elderly in enjoying the rest of their life and preparing to die peacefully. Therefore, factors affecting the quality of life of the elderly should be accommodated by the elderly, families, and health providers [15,16]. One of the health service providers on the first line is the Public Health Center (PHC). PHC as a health service provider and acting as a center for community health development in its working area should develop health programs based on problems that develop in the community [17,18].
Psychological factors, as assessed by the Geriatric Depression Scale, and sociodemographic characteristics, such as marital status, income and leisure activities, had an impact on quality of life [19]. Other studies show that apart from social demographic factors, social organization and social support affect the quality of life of the elderly [20], and the ability to perform daily routine activities is the strongest predictor [21]. In addition to the aforementioned factors, it is necessary to explore the effects of the psychosocial status of the elderly during the Covid-19 pandemic because the elderly are prone to depression. Preliminary research shows an increase in depression, post-traumatic anxiety, and adjustment disorders in the elderly, and the risk of suicide increases sharply. Stress can also lower the body's immunity, worsening the condition of the elderly who are already physically weak. Patients with a previous psychiatric disorder will tend to experience worsening [3,20].
The elderly group is very vulnerable to contracting Covid-19, plus declining physical health conditions are increasingly impacting the decline in the quality of life of the elderly, increasing mortality rates in the elderly group. For this reason, it is necessary to survey psychosocial health status, response, and quality of life during the Covid-19 pandemic. This study explores the psychosocial problems of the elderly with osteoarthritis during the Covid-19 pandemic.

   

MATERIALS AND METHODS

Study design

The type of research is analytic observational using the research design is cross sectional study.

 

Study Population

This study was conducted at the Jambi Nursing Home involving 351 randomly selected participants with the following sample criteria including age 55 years, living in Jambi Nursing Home for at least one year.

 

Instruments

Psychosocial status was measured using the Indonesian version of the Self-Reporting Questionnaire (SRQ), which consisted of 29 questions about the respondent's condition during the last 30 days [21]. The Indonesian version of the SRQ-20 has 5 dimensions, namely energy, cognitive, depression, physiology, and anxiety. The YES answers to items 1 to 20 (symptoms of neurosis) indicated a psychological problem, and item number 21 meant using a psychoactive substance. One YES answer from items 22 to 24 (psychotic symptoms) indicates a severe problem and needs further treatment. One YES answer to items 25-29 indicates the presence of symptoms of PTSD (Post Traumatic Stress Disorder).
Psychosocial status was categorized into suffering and not suffering from mental disorders. A mental disorder is declared if at least 5 neurotic symptoms are found or there is at least 1 psychotic or PTSD (Post Traumatic Stress Disorder) symptom on the Self-Reporting Questionnaire (SRQ). Meanwhile, it is declared not suffering from mental disorders if there are only 4 items of neurotic symptoms and there are no psychotic symptoms or PTSD (Post Traumatic Stress Disorder) symptom on the Self-Reporting Questionnaire (SRQ). The variable “Psychosocial status” assigning the scores: 1 = suffering and 0 = not suffering for mental disorders.
Measurement of quality of life used the Indonesian version of the World Health Organization Quality of Life-Old (WHOQOL – OLD) questionnaire, which contains the respondents' living conditions in the last four weeks consisting of 26 questions [22].  The variable “Quality of Life”, assigning the scores: 1 = poor, 2= moderate, 3 = good, and 4 = very good for each subject.
The Indonesian version of the World Health Organization Quality of Life-Old (WHOQOL – OLD) questionnaire consists of the Herth Hope Index, Perceived Social Support from Friends (PSS-Fr), Perceived Social Support from Family (PSS-Fa) [22]. The Indonesian version of the WHOQOL-BREFF questionnaire has been tested for validity and reliability by Priastana et al. [22] with a rcount value (0.361) and a Cronbach Alpha value = 0.965, so researchers do not need to test the validity and reliability again.

 

Sample size

The number of samples involved was 351 participants who were randomly selected from the population. Calculating the number of samples is determined using the Slovin formula [23], where from 2.880 people in the population, d = 0.05, the number of samples is 351.

 

Ethical Consideration

No economic incentives were offered or provided for participation in this study. The study protocol matched the Declaration of Helsinki ethical guidelines for clinical studies. This research has been approved by the Health Research Ethics Commission of the Health Polytechnic of the Jambi Ministry of Health with the number LB.02.06/2/111/2022.

 

Statistical analysis

Data are presented as number and percentage for categorical variables, and continuous data expressed as the mean ± standard deviation (SD) or median with Interquartile Range (IQR). The results of data normality analysis using the Kolmogorov Smirnov test showed that the data were not normally distributed. We found the relationship between Quality of Life and Mental disorders using the Mann–Whitney test (ordinal data vs dichotomous).
We considered all tests with P-value< 0.05 as significant. The statistical analysis was performed by SPSS software version 16.0.

 

RESULTS

The distribution of the characteristics of the research respondents is presented in table 1.

 

Table 1. Distribution of the Respondents characteristics

 

Table 1 show that most respondents were 55-64 years, as many as 186 (53%). Most sexes are male, with as many as 225 (64.1%) respondents. Most respondents had a high school education, with 227 (64.7%).
Table 2 shows that most elderly have a good quality of life, as many as 229 (65.1%), while a poor quality of life, as many as 30 people (8.5%).
In the psychosocial variables, most respondents did not experience mental health disorders, as many as 260 people (74.1%).

 

Table 2. Distribution of study variables

 

Table 3 shows that of the 91 respondents who do have mental disorders, there are 46 respondents with a moderate quality of life category. Of the 260 respondents with not mental disorders, there are 218 respondents have a good quality of life category

 


Table 3. Relationship between Psychosocial Status and Quality of Life in the Elderly

 

The Mann-Whitney test showed a significant relationship between Quality of Life and Psychosocial Status, in particular we obserbed in subjects without mental disorders in comparison to subjects with mental disorders a better quality of life (median: 3 vs 2, p<0.0001), i.e. the elderly who do not suffer from mental disorders will show a tendency for a good quality of life.

 

DISCUSSION

Elderly stress arises from anxiety about various diseases, including Covid-19. The current study aims to analyze the relationship between psychosocial conditions and the quality of life of the elderly with osteoarthritis during the Covid-19 pandemic.
The results of this study reported that on the psychosocial variables of the elderly, most of the elderly did not experience mental health disorders, as many as 260 people (74.1%) and the elderly and around 25.9% of the elderly experienced mental disorders ranging from PTSD (Post Traumatic Stress Disorder), neurotic and psychotic. Mental disorders experienced by the elderly include the elderly avoiding interacting with other people, decreasing interest in routine activities, always remembering the impact of Covid-19 and feeling disturbed, lack of appetite, not sleeping well, and feeling anxious. Symptoms of this health disorder significantly interfere with the quality of life of the elderly [24].
Anxiety, as a symptom of stress in the elderly in the Covid-19 pandemic situation, should receive support from spouses and family members by being willing to listen to the complaints of the elderly, being able and having time always to be near and accompany the elderly. Elderly family members are also responsible and act as friends of the elderly in dealing with their day-to-day. Likewise, in elderly stress, there is family support to maintain health by supporting the health of the elderly [25].
The increasing number of Covid-19 cases harms everyone's mentality, especially the elderly. SARS-CoV-2 is highly contagious. Even some cases develop into respiratory failure, which will progress to death. Deterioration of the patient's condition is more common in the elderly and those with previous co morbidities (hypertension, diabetes, heart disease) [26,27]. The elderly group (elderly) has physical and psychological weaknesses during the Covid-19 pandemic. About 20% of deaths with Covid-19 in China are over 60 years old [28].
The effects of quarantine are loneliness, sadness, and prolonged stress. Preliminary research suggests an increase in depression, post-traumatic stress, adjustment disorders in the elderly, and the risk of suicide [29]. Stress lowers immunity. This situation can worsen the condition of the elderly, who are already physically weak. Patients with previous psychiatric conditions will tend to experience worsening, one of which is the problem of osteoarthritis [30].
The main problem often experienced by the elderly with osteoarthritis is joint pain. Pain will increase when doing activities, which limits a person's activities. The decrease in physical activity will affect the patient's daily life activities and the quality of his life. A further consequence of osteoarthritis is decreased functional activity, especially difficulty rising to a sitting position, walking, and going up and down stairs [31,32]. The elderly with osteoarthritis will experience joint and muscle dysfunction, so they will experience limited movement, decreased strength, and muscle balance. About 18% experience difficulties and limitations in activities, loss of function of work capacity, and decreased quality of life [33,34].
According to Hong's study [35], the elderly with osteoarthritis have a poorer quality of life than the elderly without osteoarthritis. This condition is associated with decreased physical function due to joint inflammation caused by joint damage. Therefore, it is highly recommended that families take care of the mental health of the elderly during Covid-19 so that it does not affect their physical health. Maintaining the mental health of the elderly during the Covid-19 pandemic requires assistance from all parties. Families, health workers, the government, and the elderly must cooperate. In addition, the knowledge, attitude, and behavior of the elderly need to be improved to deal with the Covid-19 pandemic. Adaptation and survival are the keys to overcoming this pandemic condition [29].
The primary strategy is to ensure that the elderly always maintain physical distance, wash their hands, use masks, eat nutritious foods, and do light exercise [36,37]. Other activities that can be done indoors, such as reading books, painting, or watching movies, can still be done. Explanations should be given as concisely as possible to the elderly. If the elderly understand, they will feel safe and peaceful and improve their quality of life. Social relations with family and friends must still be carried out through communication tools. Emotional support is crucial for the elderly who live alone. They are prone to anxiety and confusion during this uncertain period [9,38].
Visits to the doctor should be replaced with telemedicine. Patients can consult via Whatsapp, telephone, short message, Zoom, or any application. All planned surgeries should be postponed, such as cataracts, hernias, and kneecap replacements [38]. Any redundant information about Covid-19 should be reduced to prevent panic and misunderstanding. Information should focus on preventive measures, not on myths alone. Health information, updates about Covid-19, and psychological consultations should be provided by telephone or online by the government [30,39]. Although the elderly may appear weak from the outside, the family must try to give them a sense of freedom, respect, and genuine care. The elderly must still be involved in decision-making [40].
The World Health Organization (WHO) emphasizes the importance of psychosocial needs for the elderly [38]. The government is expected to provide basic needs for the elderly, especially those less well off financially and psychologically. The items that is important to prepare including food, medicines, and disinfectants. The need for security is essential and should not be ignored [41].
The strength of this study is that the two questionnaires used, namely the Self Reporting Questionnaire (SRQ) and the World Health Organization Quality of Life-Old (WHOQOL – OLD) questionnaire, have used the Indonesian version of the questionnaire to reduce research bias.

 

CONCLUSION

Psychosocial status related to quality of life in the elderly with osteoarthritis during the Covid-19 pandemic. The elderly who do not suffer from mental disorders will show a tendency for a good quality of life.

 

LIMITATIONS

The research location only involves 1 place so that it cannot compare the results of similar studies in different populations, so in the future research must be carried out involving several regions. Another limitation is the cross-sectional research design because it only measures the current condition of the variables, so it can cause research results to be biased.

 

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.

 

AUTHORS’ CONTRIBUTION 

All authors equally contributed to preparing this article.

 

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by OPI Napoli

Cardiopulmonary Resuscitation (CPR) during COVID-19 Pandemic

 

Aprianto Daniel Pailaha1*

1 Professional Nurse Study Program, Department of Nursing, Faculty of Health Sciences, Brawijaya University, Malang, Indonesia

*Corresponding Author: Ns. Aprianto Daniel Pailaha, S.Kep., Professional Nurse Study Program, Department of Nursing, Faculty of Health Sciences, Brawijaya University, Malang, Indonesia. Email: apriantodanielpp@gmail.com

      ORCHID ID: https://orcid.org/0000-0002-9456-6616

 

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ABSTRACT

Introduction: The COVID-19 infection has a high rate of mortality and morbidity and is extremely contagious. COVID-19 has raised attention to safety issues involving healthcare workers who perform CPR. The risk of transmission produces a dilemma to perform cardiopulmonary resuscitation (CPR) within the COVID-19 pandemic. Additionally, patient and/or family preferences, as a factor associated with Do-Not-Resuscitate (DNR). This commentary wants to provide an overview or other perspectives that may be the subject of further research so that there will be evidence base practice for health workers, especially nurses in code blue situations.
Discussion: COVID-19 pandemic has clearly had a significant impact on the epidemiology and outcome of cardiac arrest in both out-of-hospital and in-hospital settings. All potential COVID-19 patients should be offered the advantage of CPR by attempting to revive them after taking all required safety precautions, and the patient should only be confirmed dead after CPR has been performed. Provision of further information regarding CPR to patients and/or families for consideration, including the advantages and disadvantages of CPR, before making a final decision regarding the administration of CPR. COVID-19 patients with a poor prognosis might benefit from Do-Not-Resuscitate (DNR) but this is causes dilemmas in nursing profession.
Conclusion: Although the survival rate for COVID-19 patients is poor, it is anticipated that CPR attempts will still be performed during the COVID-19 pandemic by following several guidelines. COVID-19 patients with a poor prognosis might benefit from Do-Not-Resuscitate (DNR) if the patient and/or family who are accountable provide their approval and everything is in order. As a nurse, we must respect the decisions that patients or families make because it is their right and their authority.

Keywords: CPR; Cardiac Arrest; DNR; COVID-19; Nursing

 

INTRODUCTION

The COVID-19 pandemic is extremely challenging health care systems worldwide and increasing principal ethical issues, especially concerning a prospect need for health care in the context of scarce resources and crisis capacity. Cardiac arrest is defined as the sudden cessation of cardiac mechanical activity, confirmed by the absence of signs of circulation. Lack of blood flow to the brain and other vital organs can cause loss of consciousness, powerlessness, or death if not treated properly [1]. Cardiac arrest is associated with pneumonia in COVID-19 patients, myocardial injury has a poor percentage of outcomes, whereas other Cardiovascular Disease (CVD) cases without myocardial injury are relatively vulnerable [1,2]. The COVID-19 patients may experience respiratory dysfunction and a subsequent change in tissue oxygenation that directly affects the cardiovascular system and results in serious issues including myocarditis, myocardial injuries, acute myocardial infarction, heart failure, cardiac dysrhythmia, and thromboembolism [3]. COVID-19 infection has a high mortality and morbidity rate and is highly contagious. COVID-19 has raised attention to safety issues involving healthcare workers attempting CPR. Among the several aerosol-producing procedures performed on patients, CPR is strongly associated with a variety of aerosol-generating procedures, including chest compression, positive pressure ventilation, and the respiratory tract maneuver. This will trigger extremely concerned about being infected with COVID-19 because considering that the COVID-19 virus is very dangerous for vulnerable populations.
Several inpatients experiencing cardiac arrest are administered cardiopulmonary resuscitation (CPR), provided advance instructions are available or the patient has a documented Do-Not-Resuscitate (DNR) status [4]. Despite the fact that attitudes regarding CPR have changed due to the COVID-19 pandemic, the majority of respondents reported that they would be prepared to do CPR if they encountered a cardiac arrest incident. Notably, independent of usual circumstances, people are more inclined to perform CPR without mouth-to-mouth resuscitation. There were other factors that affected CPR during the COVID-19 pandemic, however the two of that had been determined to be of considerable increasing significance were the fear of contracting COVID-19 and the fear of spreading COVID-19 to others, which were assessed at 78% and 29%, respectively [5,6]. This is a separate consideration for health workers, especially nurses in implementing CPR in cases of cardiac arrest during the COVID-19 pandemic.
When a new pandemic begins, the infection in healthcare facilities spreads easily. In April 2020, as many as 22,073 cases of COVID-19 among healthcare professionals were reported to the WHO. On February 2020, there were 1716 healthcare professionals in China who had contracted SARS-CoV-2. As many as 3300 people were infected as of early March, and at least 22 of them died in China. As of March 2020, about 2600 people were infected in Italy, and 13 of them had died [7]. When performing CPR during the COVID-19 pandemic, there are several factors that need to be considered carefully to ensure the safety of the rescuers, the patients, and the surroundings. The purpose of writing comments on this article is to provide an opinion regarding the administration of CPR in cardiac arrest in patients with COVID-19 or during this COVID-19 pandemic.
The resuscitation guidelines, in force considering 2015, have consequently been adapted to this new situation, e.g., for Basic Life Support (BLS), mouth-to-mouth ventilation in addition to chest compression are encouraged to bystanders. For Advanced Life Support (ALS), bag-masks or Supraglottic Airway (SGA) ventilation are considered appropriate options to tracheal intubation [8]. Recently, updates have been issued, considerably with the aid of using the International Liaison Committee on Resuscitation (ILCOR), European Resuscitation Council (ERC), and the American Heart Association (AHA). Briefly, the principle modifications advise that lay rescuers have to consider chest compressions only, except for children, and all life support providers must use PPE all through resuscitation and favor early tracheal intubation to minimize aerosols.
The risk of transmission of the SARS-CoV-2 virus to initial responders performing cardiopulmonary resuscitation (CPR) produce a dilemmas to manage CPR within the COVID-19 pandemic. A better knowledge of this could enable identification of which individuals are less likely to benefit from CPR, and inform discussion of a Do Not Resuscitate (DNR). This aims to provide an overview or other perspectives that may be the subject of further research so that there will be evidence base practice for health workers, especially nurses in code blue situations.

 

DISCUSSION

    1. CPR and COVID-19 Additional Considerations

The new regulations for performing high-quality CPR during the COVID-19 pandemic have been introduced to lower the risk of COVID-19 transmission. In order, the American Heart Association (AHA), European Resuscitation Council (ERC), International Liaison Committee on Resuscitation (ILCOR), and other resuscitation associations have been released a modification guidelines or recommendations for the COVID-19 pandemic concerns into account [9-11]. Several modification and recommendation implemented since the COVID-19 pandemic:

1) International Liaison Committee on Resuscitation (ILCOR)

    Treatment recommendations from ILCOR for performing CPR to address cardiac arrest problems in patients with COVID-19 [12].

    a) Cardiopulmonary resuscitation and chest compressions may produce aerosol.

    b) Rescuers consider public-access defibrillation and compression-only.

    c) Rescuers who are committed, competent, and trained may choose to give children rescue breaths in addition to chest compressions (good practice statement).

    d) Should wear personal protection equipment during resuscitation

    e) Rescuers consider defibrillation before donning aerosol-generating personal protection equipment.

2) European Resuscitation Council (ERC)

    The following new recommendation of Basic Life Support (BLS) are advised by the European Resuscitation Council for patients with confirmed or suspected COVID-19 [12,13].

    a) Should have prior training in appropriate use of PPE

    b) Consider to compression-only CPR if bag-mask ventilation is difficult or not available

    c) Use a high-efficiency particulate air (HEPA) filter during bag-mask ventilation

    d) Use two hands to hold the mask and the person doing compressions can squeeze the bag when they pause after 30 compressions

    e) Use PPE (surgical mask, eye protection, apron, and gloves) before defibrillation because not an aerosol-generating procedure

3) American Heart Association (AHA)

    The American Heart Association (AHA) introduced new recommendation for Basic Life Support (BLS) in COVID-19 patients both in‑and out‑of‑hospital cardiac arrest [13].

    a) Significantly reduce the risk of infection with vaccination and boosters.

    b) CPR is considered to be an aerosol-generating procedure (AGP) such as hest compressions, defibrillation, bag-valve-mask (BVM) ventilation, intubation, and positive pressure ventilation.

    c) Should wear PPE such as N95 mask, gloves, gown, eye protection, positive pressure ventilation.

    d) PPE must be donned before performing components of resuscitation.

If patients have any signs and symptoms, bystanders should give defibrillation only and without chest compression unless they have PPE. As a result, the estimated death rates for CPR are extremely low, and the use of barriers such as PPE was strongly recommended to reduce the risk of COVID-19 transmission. Cardiopulmonary Resuscitation (CPR) attempts such as chest compression only and defibrillation only as procedures with an increased risk of COVID-19 transmission. Tracheal intubation and mouth-to-mouth or mouth-to-mask ventilation were associated with a high risk of COVID-19 transmission. Although previous research has shown that compression-only CPR is as effective as combined compressions and ventilations, this could not be the case for COVID-19 patients because they suffer from primary respiratory failure.
The European Resuscitation Council (ERC) COVID-19 guidelines encourage continuing resuscitation efforts for cardiac arrests that occur both inside and outside of hospitals while also attempting to reduce risk to the person providing treatment. The COVID-19 guidelines focus specifically on patients with COVID-19. Those providing treatment should conduct a dynamic risk assessment, which may include current COVID-19 prevalence, the patient's presentation, the probability that treatment will be effective and efficient, the accessibility of personal protective equipment (PPE), and personal risks for those providing treatment [14]. The proportion of patients with shockable rhythms decreased, as did the use of automated external defibrillators. The use of supraglottic airways increased, while the rate of intubation decreased. Overall, there was a increase rates return of spontaneous circulation, survival to admission, and survival to discharge.

 

    2. CPR Outcomes during COVID-19 Pandemic

According to recent research, in-hospital cardiac arrest (IHCA) among COVID-19 patients was 9.39%, with 9% ROSC and 2% survival to hospital discharge. Accordingly, the average rate of out-of-hospital cardiac arrest (OHCA) survival to discharge is 8.8% [15]. But among COVID-19 patients, two more investigations on both in- and out-of-hospital CA showed a 0% survival rate to hospital discharge rate [16,17]. The primary CPR success rate among COVID-19 patients was low, especially for those with asystole or bradycardia [3,18]. This harmful infection has influenced the CPR efficacy because there are additional considerations for the CPR attempt. Therefore, the COVID-19 pandemic has largely influenced CPR procedures. Apart from the various factors involved in performing CPR, another thing that must be considered is the ability and capability to perform CPR through training [19]. Participation in training such as Basic Trauma Cardiac Life Support (BTCLS) or Advanced Cardiac Life Support (ACLS) will help nurses gain more knowledge, experience, and skills when it comes to performing CPR on cardiac arrest patients.
Continuous cardiopulmonary resuscitation (CPR) training and quality control systems, such as monitoring morbidity and mortality, are also recommended [20]. Every nurse, especially those working in emergency room, needs to have the necessary training to administer first aid in accordance with protocol. As a result, nurses may feel more confident and competent to provide CPR in situations of cardiac arrest.
Data from in-hospital cardiac arrests caused by COVID-19 are less commonly reported. According to a multicenter cohort study from 68 Intensive Care Units in the United States found that 14.0% (701/5019) of patients had an in-hospital cardiac arrest, 57.1% (400/701) received CPR, and 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status [21]. According to data from 136 patients in China, about 113 (83.1%) of them required CPR, and ROSC occurred in 18 (13.2%) of the patients, 4 (2.9%) survived for at least 30 days, and one patient had a favorable neurological outcome at 30 days [22]. COVID-19 pandemic has clearly had a significant impact on the epidemiology and outcome of cardiac arrest in both out-of-hospital and in-hospital settings.

 

    3. Nursing Decision-Making

Nursing is patient-centered care. A nursing profession requires to follow an ethical code, which allowed to provide great nursing care. Therefore, the nursing profession intends to maintain and improve health care in society. The key point is that a lower survival rate in CPR was reported at the start of the COVID-19 pandemic compared to previous years. All intervention decisions must involve informed and involved patients and/or families, according to national and institutional policy [23]. However, patient and/or family preferences, as a factor associated with Do-Not-Resuscitate (DNR). Provision of further information regarding CPR to patients and/or families for consideration, including the advantages and disadvantages of CPR, before making a final decision regarding the administration of CPR.
It is critical for determine personal goals and preferences regarding a resuscitation attempt. The mortality rate for COVID-19 patients who seemed to be critically ill was significant and increased with age, comorbidities, and symptom severity. The AHA recommends taking these considerations into account when weighing the risk versus the benefit of initiating resuscitation. Furthermore, many different institutions have strongly advised patients with poor prognoses to consider DNR. When considering DNR, COVID-19 positivity by itself cannot be a factor except when it is accompanied by irreversible multi-organ dysfunction [16,24]. All potential COVID-19 patients should be offered the advantage of CPR by attempting to revive them after taking all required safety precautions, and the patient should only be confirmed dead after CPR has been performed. The statement emphasized the need for all professionals to consider every cardiac arrest victim who presents to the emergency room as a possible COVID-19 suspect during the pandemic and to wear the proper PPE. The CPR method should be performed with the fewest number of essential medical professionals present, ideally in a single-person room with the door closed.
It is noteworthy that CPR, in some cases, has been initiated by nurses, but the decision-making process for non-resuscitation is made by the physician and based on the discussion between the all-team members, considers not being useful the CPR maneuvers for some cases. It depends on the nurse, among other actions, the functionality of the stop cart, with availability of materials necessary for this type of assistance, technical procedures for venipuncture, preparation and administration of medications, supervision of the technical professionals of the nursing team and possible relay in resuscitation maneuvers.

 

    4. Ethical Approaches and DNR

The reality requires reflection with a professional ethical focus on the duty of updating professionals, as provided for in the Code of Ethics for Nursing Professionals, and which determines that the patient has the right to get preserve of correct information, to be heard in their needs, and to get preserve of resolute humanized care. These conclusions are based on bioethical reflection and acknowledgement that not all nurses working in palliative care for COVID-19 patients with DNR are able to provide communication that supports this choice, either by acting in accordance with protocol or by providing nursing care without considering or updating the practice of euthanasia. In this situation, struggling to take into consideration the knowledge of those involved or neglecting to listen to the patient and family interferes with their ability to communicate effectively and their autonomy, leading to conflicts and challenges in the management of nursing care.
According to qualitative research, in Maryland there are 31 nurses who worked for COVID-19 patients in the acute care units, in depth-interview the nurse mentioned that “They really push that DNR and that’s like a part of my distress, because I know I’m very patient-family centered in my thinking…because it’s futile they tell the family this person should be DNR. They’re over 70, we’re not going to escalate care…The family has to believe whatever we tell them…so hopefully they’re right, because they don’t have a choice, the family or the patient.[25]” Knowing the DNR order causes the nurse to experience moral distress. Rather than enhancing services, prepare for end-of-life care is something that is very difficult. Of course, as a nurse, you want to do the best for patients and their families, but not in the event of a DNR, because It is the patient and family's authority. Besides, disagreement about the proper use of end-of-life care is one of the triggers of moral distress when providers encourage families to do DNR.
According to qualitative research, in Philippines there are 12 nurses who worked in COVID-19 ward of several hospitals, the nurse mentioned that “Occasionally, family members decide against intubation because they do not wish to witness their family member suffer further and add to the agony of the patient [26].” Severe symptoms of COVID-19 prompt families to put their loved ones out of the misery and sign DNR forms. In this case, nurses support symptom-free death and suffering reduction through assisting patients and families.
According to qualitative research, in United States there are 7 ICU nurses, in interview session the nurse mentioned that "Patient was a DNR or DNI maxed out on BiPAP (bilevel positive airway pressure support) and developed respiratory arrest. I, the nurse, and the intensivist thoroughly explained the situation to the family and encouraged transition to comfort care, yet the family refused. The patient suffered for another day and a half before she died. I was furious at the family and heartbroken for the patient, she deserved a more dignified death than she received [27].” The nurse was not explicit use term “moral distress” but describe about condition when they experienced moral-constraint distress because they perceived the life-sustaining treatments provided were contrary to the patient’s wishes and contributing to the patient’s suffering because they were constrained by a DNR order. Surrogate decision-making are not reflect the fully patient’s wishes.
Evidence has emerged illustrating ethical dilemmas in conducting DNR discussions during the COVID-19 pandemic [28]. Based on some of the qualitative research findings in several countries, it shows that DNR status causes moral distress due to opposition, and disagreement about DNR. Moreover, nurses have to support symptom-free death and suffering reduction for patients and their families. Additionally, nurses believe that the DNR is not in line with the patient's intentions and that the surrogate decision-making certainly does not properly represent the patient's preferences. Some of the responses given by nurses depend on the assessment of the ethics held. This can be considered valid or correct if it is based on strong evidence.

 

CONCLUSIONS

Even when cardiopulmonary resuscitation is administered, cardiac arrest is common in critically ill COVID-19 patients and is associated with poor survival. COVID-19 patients with a poor prognosis might benefit from Do-Not-Resuscitate (DNR) if the patient and/or family who are accountable provide their approval and everything is in order. In fact, CPR efforts are still possible if there is a chance of surviving the patient. Although the survival rate for COVID-19 patients is poor, it is anticipated that CPR attempts will still be performed during the COVID-19 pandemic by following several guidelines in order to help people COVID-19 patients to survive using the American Heart Association (AHA), European Resuscitation Council (ERC), International Liaison Committee on Resuscitation (ILCOR), and other resuscitation associations modification guidelines or recommendations for the COVID-19 pandemic. However, patient and/or family preferences, as a factor associated with Do-Not-Resuscitate (DNR) in several cardiac arrest conditions. Nursing profession have to reflection and uphold ethical as provided for in the Code of Ethics for Nursing Professionals. DNR status causes moral distress due to opposition, and disagreement. Surrogate decision-making certainly does not properly represent the patient's preferences. As nurse, we have to support symptom-free death and suffering reduction for patients and their families, and respect the decisions that patients or families make because it is their right and their authority.

 

CONFLICT OF INTERESTS DISCLOSURE

The author declares that there is no conflict of interests

 

ETHICAL APPROVAL

Not applicable

 

FUNDING

Not applicable

 

 

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by OPI Napoli

THE EFFECTIVENESS OF AUDIO HYPNOTHERAPY IN REDUCING POSTPARTUM DEPRESSION DURING NEW NORMAL

Rosyati Pastuty1*, Elita Vasra1, Gustiana2

 

 

1Department of Midwifery, Health Polytechnic of Palembang, Indonesia

2Department of Midwifery, Health Polytechnic of Aceh, Indonesia

 

 

 

* Corresponding author:

Rosyati Pastuty, Jl. Inspektur Yazid, Sekip Jaya, Kec. Kemuning, Kota Palembang, Sumatera Selatan 30114, Indonesia, Orcid: https://orcid.org/0000-0003-0804-2291

Email: rrosyatipastuty@gmail.com

                                 

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ABSTRACT

Background: Postpartum depression is a life-threatening mental health disorder and occurs in 10-15% of women. “Globally, the incidence of postpartum depression reaches 10-15%. There are few reports in countries such as Malta, Malaysia, Austria, Denmark and Singapore. While in other countries such as Brazil, South Africa, Taiwan, Korea, Italy, and Costa Rica, symptoms of postpartum depression are reported to be quite high”. “Based the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and the Edinburgh Postnatal Depression Scale (EPDS). Audio hypnotherapy, which is the provision of positive suggestions delivered through MP3, is a method to reduce the level of postpartum depression. This study aims to determine the effectiveness of audio hypnotherapy in reducing postpartum depression during the new normal.

Materials and Methods: This quasi-experimental study used a pretest-posttest design involving 60 postpartum mothers with a history of normal delivery at 2 Midwife's clinics in Palembang City and 1 Midwife's clinic in Aceh. Postpartum depression levels were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Data analysis used Paired Samples Test to determine differences in postpartum depression levels before and after listening to Hypnotherapy audio.

Results: There was a decrease in postpartum mothers' depression level after listening to hypnotherapy audio for ± 2 weeks. Depression incidence before giving audio hypnotherapy has a mean value = 11.15, while after giving audio hypnotherapy, it increases to 8.90, with P-value <0.05.

Conclusion: Audio hypnotherapy therapy has proven to be effective in reducing the incidence of depression in postpartum mothers.

 

Keywords: Audio Hypnotherapy, depression, Post-partum mother

 

 

INTRODUCTION

Antepartum Depression (APD) and Postpartum Depression (PPD), are disorders characterized by mood swings during pregnancy and after childbirth, which have a negative impact on the physical and mental health of mothers and children [1,2]. Melville et al [3] in their study reported that prevalence rates ranged from 4.8% to 18.4% for mild depression, and from 5.1% to 12.7% for severe depression.
Globally, the incidence of postpartum depression reaches 10-15%. There are few reports in countries such as Malta, Malaysia, Austria, Denmark and Singapore. While in other countries such as Brazil, South Africa, Taiwan, Korea, Italy, and Costa Rica, symptoms of postpartum depression are reported to be quite high. A study in India, involving 359 primiparous mothers, reported an 11% incidence of postpartum depression [4,5].
Approximately 70% of new mothers have mild depressive symptoms which generally peak in the 2 to 5 days after delivery. These symptoms usually begin to subside spontaneously within 2 weeks, but if not detected immediately and treatment is delayed, it can develop into postpartum depression [6].
Most pregnant women who face the birth process experience feelings of anxiety, even depression. Factors causing postpartum depression consist of biological factors, characteristics and background of the mother. Levels of the hormones estrogen (estradiol and estriol), progesterone, prolactin, cortisol which increase and decrease too quickly or too slowly are biological factors that cause postpartum depression [7]. The greater the decrease in estrogen and progesterone levels after childbirth, the greater the tendency for a woman to experience depression in the first 10 days after giving birth [8]. The estrogen and progesterone exert a suppressive effect on the activity of the monoamine oxidase enzyme. This enzyme can inactivate both noradrenaline and serotonin, which play a role in mood and depression. Estradiol and estriol are the active forms of estrogen formed by the placenta. Estradiol functions to strengthen the function of neurotransmitters by increasing the synthesis and reducing the breakdown of serotonin. Therefore, theoretically the decrease in estradiol levels due to childbirth plays a role in causing postpartum depression [2,6,9,10]. Biological causative factors are difficult and rarely measured in terms of maternal depressive symptoms [11]. Other factors that influence maternal depressive symptoms described in several studies include interpersonal variables (neural disorders, poor life experiences), social variables (marital dissatisfaction, lack of social support), and clinical variables related to pregnancy (risk in current pregnancy, problems with previous pregnancy) [12].
Antepartum Depression (APD) and Postpartum Depression (PPD) together are called perinatal depression. Various diagnostic criteria with major depression occur during pregnancy or within 4 weeks after delivery [13]. Based on previous research, women with a history of high levels of stress may be at increased risk for perinatal depression [14,15].
Based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) [16] and the Edinburgh Postnatal Depression Scale (EPDS) [17], mothers with symptoms of postpartum depression are defined by several major symptoms, including a depressed mood or decreased pleasure. These symptoms include impaired appetite, physical agitation or psychomotor slowing, weakness, decreased concentration, and suicidal ideation. Mothers also often feel insomnia even though the baby has fallen asleep. These symptoms must be present throughout the day and last for at least two weeks [3,9].
Women who experienced depression during pregnancy had seven times the risk of developing postpartum depression than women who did not have symptoms of antenatal depression. An observational study of 78 depressed women in the first trimester of pregnancy found that postpartum depression did not occur in all women who received treatment, both psychotherapy and pharmacotherapy, compared with 92% of women who were depressed and did not receive treatment. Supportive and psychological interventions are more effective when performed after delivery than when they are initiated during pregnancy [18].
Mothers with postpartum depression need extensive treatment with both pharmacological and non-pharmacological therapies. Through non-pharmacological therapy, such as psychological therapy, mothers can find the right way to deal with the symptoms of depression, deal with disorders that arise, or think positively when the situation is stressful [19,20].
There are several non-pharmacological techniques to relieve anxiety such as pregnancy exercise, distraction, biofed back, yoga, acupressure, aroma therapy, steam therapy and hypnosis. Hypnosis is a natural method used to relieve fear, panic, tension, and other pressures. Hypnosis is done by making direct contact with the subconscious, by giving suggestions in order to build various positive emotional conditions [21,22].
Khoirunnisa et al., [21] used a narrative review method to explore types of interventions for postpartum depression and found that several interventions such as music therapy [22], postpartum exercise [23], aerobic exercise [24], laughter therapy [25], cognitive behavior Therapy [26], Effleurage Massage Therapy [27], Acupressure Therapy [28], are effective in reducing postpartum depression.
Based on some of these studies provides an illustration that not many hypnotherapy interventions have been thoroughly scrutinized considering the impact of depression on postpartum mothers; we are therefore interested in analyzing the effectiveness of Audio Hypnotherapy in reducing postpartum depression, especially in the new normal period in 2021.

 

MATERIALS AND METHODS

Study design

This type of research is a quasi-experimental design using a pretest - posttest design.

 

Study Population

This research was conducted in January–December 2021 at the Teti Herawati Midwife clinic, Meli Rosita Palembang City and the Mariana Aceh Besar Indonesia, midwife clinic involving 60 participants who were randomly selected and had met the sample inclusion requirements such as being healthy after giving birth, having never received hypnotherapy audio, mentally healthy, and has a cell phone.  Demographic characteristics of postpartum women collected in this study were age, education, occupation and parity.

 

Sample size

The number of samples involved was 60 participants who were randomly selected from the population. Calculating the number of samples is determined using the Slovin formula [29], where from 71 people in the population, d = 0.05, the number of samples is 60.

 

Instruments

The incidence of postpartum depression will be measured using a standardized questionnaire developed by Cox et al., the Edinburgh Postnatal Depression Scale (EPDS). This questionnaire consists of 10 questions; each has four responses with a Likert scale from 0 – 3. The maximum value is 30, and the lowest is 0. It is called experiencing depression if the score is ≥ 10. EPDS has a sensitivity of 80% and a specificity of 84.4 % [23]. Meanwhile, EPDS in Indonesian has a sensitivity of 86% and a specificity of 78% [24].
The scale shows how the mother felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. This scale is not used to detect mothers with anxiety neuroses, phobias or personality disorders [25].

 

Interventions

Audio hypnotherapy is giving positive suggestions or orders to the subconscious mind to change thoughts, feelings, and behaviors for the better through MP3 voice recordings sent via WhatsApp groups. In this study, hypnotherapy was carried out by selfhypnosis using standardized hypnotherapy audio recording media. The selfhypnosis method with standard hypnotherapy audio recording media for 30 minutes in stages; pre-induction (introduction, explaining goals, and building trust), filling in the informed consent sheet, explaining the use of tools, induction (the relaxation process brings the patient to the subconscious mind with Hanung techniques), deepening (trance), suggestion (giving messages with the aim of certain), and termination (slowly awakening the patient).
Before the intervention, all respondents filled out the EPDS questionnaire to determine the risk of postpartum depression. Then, respondents listened to Hypnotherapy audio for ± 30 minutes every night before going to bed for 2 weeks. After undergoing an audio Hypnotherapy intervention for 2 weeks, all respondents filled out the EPDS questionnaire to determine the risk of postpartum depression.

 

Ethical Consideration

Before the respondents filled out the questionnaire, the researchers first explained their informed consent about the scope of the research. Then after the prospective respondent agreed, the respondent signed an agreement to become a respondent. All data about respondents will be kept confidential and only used for research purposes.No economic incentives were offered or provided for participation in this study. The study protocol matched the Declaration of Helsinki ethical guidelines for clinical studies.  This research has been approved by the Health Research Ethics Commission of the Health Polytechnic of the Palembang Ministry of Health with the number 1250/KEPK/Adm2/VIII/2021.

 

Statistical analysis

The statistical analysis was performed by SPSS software version 16. 0. Data are presented as number and percentage for categorical variables, and continuous data expressed as the mean ± standard deviation (SD) unless otherwise specified. The first statistical test, the McNemar test, aims to analyze differences in depression status before and after the intervention using categorical data. Before conducting the different tests, first, we tested the normality of the data using the Kolmogorov Smirnov and found the data was not normally distributed. The research data were analyzed using the Wilcoxon test. This test was performed on same data sample in two different periods where the data were not normally distributed. It is considered significant if the research variable has a P-value <0.05.

 

RESULTS

The characteristics of respondents in this study include age, education, employment status and parity. The following is the frequency distribution of the respondents' characteristics in this study:

 

Table 1. Frequency Distribution of Respondents Characteristics

 

Table 1 shows that most of the mothers aged 24-30 years were 22 mothers (36.6%). The respondents' education is mostly High school as many as 28 respondents (46.7%). Most respondents did not work as many as 41 (68.3%), and multipara as many as 40 respondents (66.7%).

The results of statistical tests and the distribution of depression status before and after the intervention are presented in table 2.

 

Table 2. Distribution of depression incidence before and after interventions

 

Table 2 shows that before the intervention there were 26 depressed respondents then after the intervention there were 12 respondents. Based on the McNemar test, a p-value <0.05 was obtained, meaning that there were differences in depression status before and after the intervention.

        



Table 3. Normality Test Results of depression incidence pretest and posttest audio hypnotherapy

 

Table 3 shows that the results of the Kolmogorov Smirnov statistical test obtained a P-value <0.05, so the normality is rejected. The depression incidence data at the pre-post test audio hypnotherapy not normally distributed. Therefore, the statistical difference test was tested using Wilcoxon.

The results of the audio hypnotherapy pre-post test statistics and the mean depression incidence values ​​are presented in table 4.

 

Table 4. Average Depression Incidence Pretest and Posttest Audio Hipnoterapy

 

Table 4 shows that depression incidence before giving audio hypnotherapy has a mean value = 11.15, while after giving audio hypnotherapy, it decreases to 8.90, with P-value <0.05.

 

DISCUSSION

Most pregnant women who face the birth process experience feelings of anxiety, even depression. Factors causing postpartum depression consist of biological factors, characteristics and background of the mother. Levels of the hormones estrogen (estradiol and estriol), progesterone, prolactin, cortisol which increase and decrease too quickly or too slowly are biological factors that cause postpartum depression [7]. The greater the decrease in estrogen and progesterone levels after childbirth, the greater the tendency for a woman to experience depression in the first 10 days after giving birth [8].
The estrogen and progesterone exert a suppressive effect on the activity of the monoamine oxidase enzyme. This enzyme can inactivate both noradrenaline and serotonin, which play a role in mood and depression. Estradiol and estriol are the active forms of estrogen formed by the placenta. Estradiol functions to strengthen the function of neurotransmitters by increasing the synthesis and reducing the breakdown of serotonin. Therefore, theoretically the decrease in estradiol levels due to childbirth plays a role in causing postpartum depression [9,10]. Biological causative factors are difficult and rarely measured in terms of maternal depressive symptoms [11]. Other factors that influence maternal depressive symptoms described in several studies include interpersonal variables (neural disorders, poor life experiences), social variables (marital dissatisfaction, lack of social support), and clinical variables related to pregnancy (risk in current pregnancy, problems with previous pregnancy) [12].
The results of the current study showed a decrease in the level of postpartum depression before and after listening to audio hypnotherapy. This means that listening to audio hypnotherapy can reduce the level of postpartum depression, where postpartum mothers feel comfortable, calm and relaxed after listening to audio hypnotherapy, although not every night or every day. Audio hypnotherapy is a hypnosis therapy, where respondents get positive suggestions through MP3 audio sent via cellphone. Hypnotherapy or clinical hypnosis is an integrative mind-body technique using hypnotic suggestions for specific therapeutic purposes that are identified jointly by the hypnotherapist and client [26].
The results of the Paired Samples Test analysis showed a difference in the average level of depression before and after listening to audio hypnotherapy with a significance value of P-value 0.001. For this reason, it can be concluded that audio hypnotherapy can reduce the level of depression in pregnant women, especially during the Covid-19 pandemic. The average decrease in anxiety levels of pregnant women before and after listening to audio hypnotherapy is 2.6.
Hypnotherapy has long been believed to reduce postnatal pain by giving suggestions in the form of positive commands [27]. Through the process of hypnosis, the patient is brought into a relaxed state in order to calm the autonomic nervous system and induce positive emotions that affect the patient's coping mechanisms for pain perception [28]. It stimulates positive emotions for more norepinephrine production, reduces ROS production, increases tryptophan levels, and stimulates the ventricular nucleus which functions to secrete oxytocin in the dopamine system, and subsequently plays a role in pain modulation [6,29]. A deeper hypnotic state (trance) can help activate the endorphins and encephalin system that can inhibit the production of substance P, a pain sensitizing agent in the dorsal horn of the spinal cord [30].
Some respondents experienced persistent depression despite the intervention. This condition was caused by the respondent's disobedience in carrying out audio hypnotherapy. Most of the respondents underwent audio hypnotherapy at night before going to bed. Some respondents listen when they feel uncomfortable or when they have free time. Some respondents do not run audio hypnotherapy every night.
In the future, audio hypnotherapy in order to reduce the level of depression in postpartum mothers can be an important alternative therapy besides the provision of medical drugs.

 

CONCLUSION

Before the intervention, there were 26 depressed respondents. Then after the intervention, there were 12 respondents. Audio hypnotherapy has been proven effective in reducing depression in postpartum mothers.

 

LIMITATIONS

The assessment of the level of depression in the current study is still subjective. Future research can use more real/objective measurements or combine subjective and objective scales. Furthermore, the research location only involves 3 places, therefore it cannot compare the results of similar studies in different populations.
The future research must be carried out involving several regions. This study also showed the possibility that socio-demographic factors' influence could not be controlled because the respondent's character was not matched.

 

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.

 

AUTHORS’ CONTRIBUTION 

All authors equally contributed to preparing this article.

                                                                                                                                     

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by OPI Napoli

THE EFFECT OF PARENTAL HOLDING ON PAIN LEVELS INFANT DURING MEASLES IMMUNIZATION: QUASI-EXPERIMENTAL STUDY

 

Nesi Novita1*, Ratnaningsih Dewi Astuti2, Yeni Elviani3, Emi Latifah Sukasna4

 

1,4Department of Midwifery, Health Polytechnic of Palembang, Indonesia

2Department of Pharmacy, Health Polytechnic of Palembang, Indonesia

3Department of Nursing, Health Polytechnic of Palembang, Indonesia

* Corresponding author: Nesi Novita: Jl. InspekturYazid, Sekip Jaya, Kec. Kemuning, Kota Palembang, Sumatera Selatan 30114, Department of Midwifery, Health Polytechnic of Palembang, Indonesia, Orcid : https://orcid.org/0000-0002-1572-5448, Email: nesinovita51@gmail.com

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ABSTRACT

 

Background: Immunization is the most effective and efficient public health effort in preventing various dangerous diseases, one of which is measles immunization. In practice, it is very closely related to needles that can cause anxiety, pain, avoidance, and even suffering in children when visiting health services to get vaccines. Parental care is a form of non-pharmacological intervention to treat pain. The purpose of this study was to determine the effect of parental maintenance on infant pain levels during measles immunization.

Methods: Quasi-experimental research method with pretest posttest control group design. The number of samples was 42 respondents who were divided into an intervention group and a control group in the working area of ​​the Taman Bacaan Health Center Jambi city, Indonesia. This research was carried out in May-July 2021. The instrument used is the Face, Legs, Activity, Cry and Consolability (FLACC) scale and parental holding Standard Operating Procedures (SOP). Research statistical test with paired t test and independen t test.

Results: The results obtained p-value < 0.0001 with the level of pain in infants during measles immunization in the intervention group with an average of 5.52 and a standard deviation of 0.928, while the level of pain in infants during measles immunization in the control group with an average of 8.24 and standard deviation 1.044.

Conclusion: The parental grip in the position of holding the baby facing the chest with the parents affects the baby's level of pain during measles immunization. It is hoped that parental holding can be used as an alternative during immunization so that babies are more comfortable and can reduce pain.

Keywords: Parental Holding, Pain Management, Complementary Therapy, Measles Immunization

 

 

INTRODUCTION

Immunization is a public health effort that is most effective and efficient in preventing various dangerous diseases [1,2]. The magnitude of the role of immunization has been recorded in history to save the world community from illness and even death from diseases such as smallpox, polio, tuberculosis, hepatitis B, diphtheria, including measles [3–5]. Immunization is an effort to actively generate or increase a person's immunity to disease and if exposed to the disease, he or she will not get sick or experience mild illness [6].
Immunization is a critical agenda in children’s health. The World Health Organization (WHO) has set a goal that all countries should reach 90% coverage of all vaccines by 2020. The coverage rate considerably varies among countries. Today there are still 19.4 million unvaccinated children globally. Among those children, 60% come from 10 countries, and Indonesia is on that list [7,8].
In the Indonesian Health profile, the number of diseases that can be prevented by immunization for tetanus neonatorum increased in 2019, accompanied by suspected measles which also increased from 8,429 cases in the previous year, to 8,819 suspected cases of measles. Complete basic immunization coverage for infants from the 2019 target is expected to be 95% where in 2017 it reached 80% but in 2018 it decreased to 68.75% in districts/cities [7].
Immunization, which is mostly given in the form of injections, will create new problems. Pain and trauma due to immunization injections are effects that need attention in addition to other unexpected side effects. These side effects can be one of the causes of the lack of immunization coverage [8,9]. Parents assume that repeated immunizations can make children feel pain, which in turn contributes greatly to refusal, non-adherence to schedules, and delays in immunization [10]. Anxiety and pain due to injection are complaints that are often conveyed by both parents and children due to immunization. This condition makes parents reluctant to come to health services afterwards [8,11]. More than 90% of children experience severe stress during immunization which results in parents not complying with the existing schedule. The results of studies in America show that 24% of parents and 63% of children are afraid of needles when immunizations affect 7-8% of children with incomplete immunization status [8]. Needle phobia is estimated to reach 10-20% of the population [11].
One type of non-pharmacological intervention that has been developed to treat this pain is parental holding with hug therapy. Parental holding involves close contact between parent and baby, with the baby in the parent's arms, facing each other and parallel, and there is eye contact between the two. Parental grip may reduce the response to procedures that are painful for the baby, such as exercise [9]. Parents can get the attention and attention of their babies, this is in line with the recommendations from WHO to give special attention to babies during technique. According to Sari [9] hugs from parents to their children will help the pituitary gland secrete endorphins which function to improve the immune system, improve the ability to reduce pain, besides that the baby will avoid fear, anxiety and stress. In addition, the comfortable feeling that arises due to the mother's embrace is able to make the baby's body to secrete endorphins. Endorphins can improve mood, reduce anxiety, causing muscles to relax, and calm. So that the level of pain experienced by the baby will decrease [10,11].
According to Modanloo et al. [12] vaccination for early childhood is one of the most important public health interventions therefore clinical practice guidelines recommend the use of pain management strategies for infants during vaccination. Immunization is closely related to needles that can cause anxiety, avoidance, and even distress in children during visits to health services to get vaccines [13]. Medical procedures performed using needles such as immunizations are a source of pain for children. In addition, children will also feel anxiety and fear that become trauma which will continue into adulthood [14].
Pain is a protective mechanism that alerts the body that there will be tissue damage in the body that can affect survival [15]. This procedure is a painful procedure for children especially when immunized without adopting pain management [16]. Young children have difficulty understanding pain and procedures performed by health workers. Toddlers have difficulty interpreting the pain experienced, usually the toddler responds to pain with crying or facial expressions and simple words for toddlers who are able to speak [17].
Wahyuni & Suryani [18] resulted in an average pain scale before being given parental holding was 7.8 with a standard deviation of 1.4 and a minimum - maximum value range 5.0-10.0, and the average pain scale after parental holding was given was 3.6 with a standard deviation of 1.6 and a minimum-maximum value range of 1.0-7.0. With the result that 12 respondents who received parental holding intervention experienced a decrease in pain scale by a difference of 4, and the results of the sample t test were obtained  p <0.05, meaning that there is a difference in pain scale before and before being given parental holding.
Research Sri Rahyanti et al [19] in Jakarta using a randomized clinical trial method and involving 34 respondents aged 1 to 4 years who were included in the intervention group and the control group, it was found that parental holding and upright position results in significant differences in pain scores in children were compared with the group that was not given parental holding and upright position with a p-value <  0.0001.
The results of the preliminary study at the time of giving technique midwives will perform a distraction technique (guided imagery) on the baby by saying there is something interesting on the other side, hidden the syringe used and giving breast milk after the exercise.
The problem in this study was pain management in infants during immunization is still not optimal and has an impact on ongoing trauma into adulthood. Is there any effect of parental holding on the baby's pain level during measles immunization?
The purpose of the study was to carry out parental holding it would affect the level of infant assistance during measles in the work area of ​​the Taman Bacaan Health Center Palembang. The benefits are in order to provide comfort for babies during immunization and to make standard operating procedures (SOPs) with parental holding techniques that can be applied by health workers.

 

METHODS

Study design

This study used quantitative research methods with a quasi-experimental design and a pre-test post-test control group design.

 

Study Population

The population and sample are all infants under the age of 1 year given measles immunization in the working area of ​​Taman Bacaan Health Center conducted on May-July 2021.
Inclusion criteria consisted of infants aged 9-12 months, The baby's parents agree that their child is a respondent, and the baby's parents agree to provide parental holding. And the exclusion criteria include babies who are not directly accompanied by their parents, babies who are not directly accompanied by their parents crying and not being soothed before the injection, sick or contraindication of immunization, and parents who refuse to be respondents.

 

Sample size

The numbers of samples involved were 42 participants who were chosen randomly or randomly from the population. The sample was divided into an intervention group of 21 respondents in (given parental holding by hugging) and 21 respondents in the control group (held and on the lap by his mother). Calculation of the number of samples was determined using the Slovin formula [20], where from a population of 47 people, d = 0.05, the total sample was 42 people. The research population, also known as the target population in this study, was the number of toddlers aged <1 year who visited the Taman Bacaan Health Center in Jambi City, Indonesia, conducted on May-July 2021, totaling 47 people.

 

Instruments

The independent variable is parental holding, and the dependent variable is the level of pain in infants during measles immunization. Pain variables were measured using the FLACC Pain Assessment Tools instrument. The FLACC Behavioral Pain Scale is a pain assessment tool for children less than three years of age or with cognitive impairment. FLACC is an acronym for Face, Legs, Activity, Cray, and Consolability (face, legs, activity, crying, and controllability). The five components are totaled, and the severity of pain is determined from a score of 0-10.
The assessment consisted of facial expressions (0-2), leg movements (0-2), activity (0-2), crying (0-2), ability to be entertained (0-2). The results of the behavioral scores are: 0: No Pain, 1-3: mild pain/mild discomfort, 4-6: moderate pain and 7-10: severe pain/severe discomfort. Measurement of the pain level variable was carried out before the intervention (pre-test) and 15 minutes after the intervention (post-test).
The type of intervention in this study was parental holding by hugging (Intervention group), and held and on the lap by the mother (control group). Both of these interventions were only carried out once when the child was given measles immunization.

 

Ethical Consideration

Prior to the implementation of measles immunization, the researcher first asked the mother's willingness to provide informed consent. After the consent became the research sample, the baby's mother signed the informed consent. No economic incentives were offered or provided for participation in this study. The study protocol matched the Declaration of Helsinki ethical guidelines for clinical studies.  This research has been approved by the Health Research Ethics Commission of the Health Polytechnic of the Jambi Ministry of Health with the number LB.02.06/2/51/2021.

 

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). To see the distribution of research data, the Kolmogorov Smirnov test was used. The research data is normally distributed. Then proceed with bivariate analysis using the Paired t test. The Paired t test was used to determine the effect of Parental holding on infant pain level during measles immunization. Then to analyze the differences between the intervention and control groups, using the Independent t test. All tests with p-value <0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.

 

RESULTS

The research respondents were 42 respondents, which were divided into 21 respondents in the intervention group and 21 respondents in the control group. The general description of the frequency distribution by gender and age can be seen in the following table:

 

Table 1. Frequency distribution of general characteristics of the sample

 

Based on table 1, it is known that in the intervention group most of them were female, namely 66.7%, and in the control group most were female, namely 61.9%. While the age variable in the intervention group was mostly 10 months old, namely 47.6%, and in the control group most were 11 months old, namely 47.6%.
To find out the distribution of research data, a normality test of the data was carried out, presented in table 2.

 

Table 2. Data normality test

 

Based on table 2, the research data obtained were normally distributed with p-value > 0.05.
Bivariate analysis aims to explain or describe the dependent variable, namely the level of infant pain during measles immunization in the intervention group and the control group.

 

Table 3. Analysis of the effect of parental holding on infant pain levels

 

Based on table 3, it is known that the results of paired t test have the effect of parental holding on the baby's pain level during measles immunization with a p-value < 0.0001 . The mean value of the two groups (intervention and control) is 6.88. The result of independent t test is a p-value <0.05, it means that there is a difference in the effect of the two interventions on the pain level of infant during measles immunization.

 

DISCUSSION

The purpose of the study was to carry out parental holding it would affect the level of infant assistance during measles in the work area of ​​the Taman Bacaan Health Center Palembang. In this study, the age of the respondents was between 9-11 months; based on Minister of Health regulations no. 42 of 2013 the first measles immunization was given to infants aged 9 months. Measles immunization is given in 2 doses, namely when the baby is 9 months old (as basic immunization), and when the baby is 9 months old (as basic immunization). when the child is 2 years old (as a follow-up immunization) [21]. According to Perry et al. [17] young children have difficulty understanding pain and procedures performed by health workers. Toddlers have difficulty interpreting the pain experienced, usually the toddler responds to pain with crying or facial expressions and simple words for toddlers who are able to speak. Babies have not been able to express pain with words; therefore the level of pain in infants is measured using the FLACC scale which is seen through the baby's responses in the form of behaviour, facial expressions, crying, and movements.
In this study, the observed of level pain was in infants aged 9-12 months, babies could not show the pain response, it was necessary to have skills of health workers to assess the baby’s pain level based on the FLACC scale, besides that most mothers said they were afraid to accompany the baby directly during immunization. In this study, it was stated that there was a significant decrease in the infant's pain level during measles immunization with a p-value < 0.0001 and the minimum and maximum pain values ​​obtained from the control group (who were not given parental holding) of 7.00 and 10.00. to the minimum - maximum values ​​in the intervention group (given parental holding) of 4.00 and 7.00.
This study is in line with research Modanloo et al. [12] which states that pain management strategies during vaccination can be carried out by holding. While in this study, parental holding is done by hugging or hugging. According to Sari [9] hugs from parents to their children will help the pituitary gland secrete endorphins which function to increase the immune system, increase the ability to reduce feelings of anxiety. In addition, the baby will avoid fear, anxiety and stress. Increased endorphins can affect mood, reduce anxiety, cause muscles to relax, and calm down, therefore, the level of pain experienced by the baby will decrease. Endorphins are natural substances produced by the body whose job is to inhibit the passage of pain sensations from the traumatized body part to the brain. Everyone's endorphin levels are different, this causes different responses to the same type of pain [22]. Besides being useful for inhibiting pain, endorphins also have other benefits, namely to regulate hormone production, reduce persistent aches and pains, and control stress [23,24]. In line with research Qiu et al. [25] which states that endorphins are endogenous opioids that are released in response to pain and increase pain inhibition when an organism is exposed to stress or painful stimuli (acute pain). In this study, painful stimuli in the form of measles immunization injections can affect the release of endorphins.
This study is in line with research Dewi et al. [26] which states that babies who given parental holding will feel a sense of love and comfort from their parents, so that the fear and anxiety they experience will be reduced because of their parents holding them. Parental hugs provide a sense of comfort and reduce pain levels in children.
In this study, the difference in the level of infant pain in the intervention group and the control group can be seen from the pain response felt by the baby, as evidenced by changes in facial expressions, grimacing, body squirming, crying, body rigidity, restlessness, to an increase in stress hormones. Parental holding involves close contact between parents and babies, with the baby in the parent's arms, facing each other and parallel, and there is eye contact between the two. Parental holding may reduce the response to procedures that are painful for the baby, such as immunizations. Parents can distract and calm their babies, this is in line with the recommendations from WHO to pay special attention to babies during immunization. When babies are immunized using injections, parental holding by hugging other forms of touch that can minimize pain, make babies feel more comfortable and good, so that it has an impact on the baby's quality of life by getting a direct touch of love from the parents [18].
Parental holding comfort to the baby and mother at the time of immunization with the injection technique, so that immunization does not have an impact on causing trauma to babies until they are adults for fear of being injected. In addition, it can be used as an alternative effort for health workers when giving immunizations to minimize level pain in infants.
Researchers would like to convey that these two interventions have been proven to reduce immunization pain in children. although in the independent t test the two interventions had differences in reducing the pain scale in immunized children. This means that the way the mother holds or hugs the child during immunization has a calming effect on the child.
The strength of this study compared to previous studies lies in the comparison of the effects of 2 different interventions on the pain scale during measles immunization in children which was not carried out in the previous study, which only used 1 intervention in the form of parental holding.

 

CONCLUSION

Parental holding has an effect on reducing pain in infants when given measles immunization by providing a sense of comfort, and reducing distress in infants. So that health workers can use this method as an alternative in reducing pain levels in infants when immunized. Parental holding can be used as a basis in formulating policies or standard operating procedures (SOPs) for the management of measles immunization, namely the provision of parental holding as one of the procedures in reducing pain levels in infants during immunization. With this policy, it is hoped that health workers will apply techniques to reduce pain in infants when immunized against measles.

 

LIMITATION OF STUDY

One of the limitations of this study is the very small sample size (a pilot study). The research location only involves one region, therefore  it cannot compare the results of similar studies in different populations. In addition to these two things, the environmental conditions where the vaccination is carried out must be designed not to have little effect on the research results. Likewise, the clothing of health workers must be adapted because usually, children are treated at hospitals or trauma clinics in white clothes.

 

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 Midwifery and Pharmacy, Palembang Health Polytechnic for supporting this research

 

AUTHORS’ CONTRIBUTION 

All authors equally contributed to preparing this article.

 

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8. Hardhantyo M, Chuang Y-C. Urban-rural differences in factors associated with incomplete basic immunization among children in Indonesia: A nationwide multilevel study. Pediatrics & Neonatology. 2021;62(1):80–9.

9. Indah. Pengaruh parental holding terhadap distress anak selama prosedur insertion intravena (IV) di ruang rawat inap anak RSUD Adnan WD Payakumbuh tahun 2019. stikes perintis padang; 2019.

10. Nurlaila N, Baniyah N, Iswati N. Terapi Dekapan dapat Menurunkan Kecemasan Anak saat Pemberian Terapi Intravena. Jurnal Berita Ilmu Keperawatan. 2022;15(1):27–33.

11. Utario Y, Rustina Y, Efendi D. Family Centered Care Intervention Effectively Reduces Parental Anxiety in Perinatology Ward. Dunia Keperawatan: Jurnal Keperawatan dan Kesehatan. 2021;9(1):143–51.

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by OPI Napoli

THE EFFECT OF VIRTUAL EDUCATION ON THE KNOWLEDGE OF POSTPARTUM MOTHERS ABOUT BREASTFEEDING DURING THE COVID-19 PANDEMIC: QUASI-EXPERIMENTAL DESIGN

 

Imelda, Atika Fadhilah Danaz Nasution*, Ika Murtiarini, Rosmaria, Diniaty

 

 

Department of Midwifery, Health Polytechnic of Jambi, Indonesia

 

Corresponding author: Atika Fadhilah Danaz Nasution, Jl. Prof DR GA Siwabessy No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36122, Indonesia.

Orcid: https://orcid.org/0000-0002-4181-8621; Email: atikapoltekkes@gmail.com

 

 

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Abstract

Introduction: Postpartum mothers and newborns are a group that is vulnerable to COVID-19. Due to the COVID-19 pandemic, access to essential services such as breastfeeding counseling in hospitals, health clinics, and home visits has been disrupted. Postpartum mothers will immediately breastfeed. Therefore there is a need for knowledge, appropriate information, and support to provide breast milk, especially during the COVID-19 pandemic. This study aims to analyze the effect of virtual counseling on the knowledge of postpartum mothers during the COVID-19 pandemic at the Delima Midwife Clinic in Jambi City.

Materials and Methods: The current study utilized a quasi-experimental design with one group design pretest-posttest approach. This research was conducted in January-October 2021 and involved 75 postpartum mothers. This study using the zoom app. and questionnaire. Data analysis using Wilcoxon statistical test.

Results: The results showed an increase in knowledge where before being given virtual education, most of the respondents' knowledge was in the Poor category, as much as 80% (mean 6.18). After the intervention, the knowledge of most respondents in the Good category was 46.7% (mean 12.15) with P-value <0.05.

Conclusion: The study concludes that virtual counseling significantly affects the knowledge of postpartum mothers about breastfeeding during the COVID-19 pandemic.

 

Keywords: Postpartum Mothers, Breastfeeding, COVID-19 pandemic, Counseling, Virtual.

 

INTRODUCTION

Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). SARS-CoV-2 is a new type of coronavirus that has never been previously identified in humans [1,2]. There are at least two types of coronaviruses known to cause diseases that can cause severe symptoms, such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) [3]. The average incubation period is 5-6 days, with the most prolonged incubation period being 14 days. In severe cases of COVID-19, it can cause pneumonia, acute respiratory syndrome, kidney failure, and even death [4,5].
The spread of COVID-19 has reached almost all provinces in Indonesia, with the number of cases and deaths increasing. This condition impacts the political, economic, social, cultural, defense and security aspects, as well as the welfare of the people in Indonesia [6]. Indonesia reported its first case of COVID-19 on March 2, 2020, and the number continues to grow until now. The data on confirmed cases of COVID-19 in Indonesia as of October 21, 2021, were 4.237.834 people, 143.120 people died, and patients who had recovered were 4.079.120 people [7]. Meanwhile, in Jambi Province, COVID-19 cases increased sharply. As of October 3, 2021, the Jambi Provincial Government recorded 29.616 positive confirmed cases of COVID-19, 768 people died, and 28.476 people recovered [8].
Postpartum mothers and newborns are a group that is vulnerable to the COVID-19 virus [9,10]. During the COVID-19 pandemic, access to essential services such as breastfeeding counseling in hospitals, health clinics, and home visits has been disrupted [11,12]. The amount of inaccurate information and news circulating about the safety of breastfeeding has reduced the number of breastfeeding mothers because mothers are afraid of transmitting diseases to their babies even though this is the most appropriate moment to provide the best intake for babies through breastfeeding. After all, breast milk contains immune substances which protect children from infections and chronic diseases and reduces the chances of suffering from health problems later in life. The Covid-19 virus has never been found in breast milk [13,14].
Social restrictions during the COVID-19 pandemic require staying at home so that continuous care cannot be carried out, both health workers to make visits and mothers and babies to check their health status at the nearest health service. The impact of this situation can cause stress and worry for postpartum mothers who are still adapting to breastfeeding activities. Breastfeeding mothers need to continue to get support in the form of assistance to overcome problems during the breastfeeding process [2,15].
The current state of the COVID-19 pandemic has made it difficult for postpartum mothers to get information and consult face-to-face due to the strict rules of physical distancing. This condition resulted in a decrease in the number of visits by postpartum mothers to health workers. The limitations of accessing information on exclusive breastfeeding from health workers can be overcome by providing health promotions delivered via Telemedia, where postpartum mothers can communicate virtually and see some presentation materials and videos of good and correct breastfeeding techniques [16,17].
Health promotion through Telemedia/online is expected to increase the knowledge of postpartum mothers about exclusive breastfeeding and sound and correct breastfeeding techniques. This online learning for postpartum mothers is expected to help postpartum mothers to obtain information and consult during the COVID-19 pandemic.
This study aims to examine the effect of Virtual Counseling on Postpartum Mother's Knowledge of Breastfeeding during the Covid-19 Pandemic at the Delima Midwife Clinic in Jambi City.

 

Method

Trial design

The current study utilized quasi-experimental design with one group design pretest-posttest approach.

 

Participants

This research was conducted in January-October 2021 and involved 75 postpartum mothers who were randomly selected and met the sample inclusion requirements, such as breastfeeding mothers, mothers who have never participated in counseling activities about breastfeeding, and who have the Zoom app.

 

Intervention

The research variable is the knowledge of postpartum mothers. Before the intervention was given, the researcher first measured the level of knowledge of postpartum mothers (pre-test). After being given the intervention, the researcher again measured the level of knowledge of postpartum mothers (post-test). In this study, the intervention model provided was virtual education about breastfeeding, which was carried out once for 1 hour, i.e., 45 minutes of material delivery and 15 minutes of discussion). In this study, researchers explain the principles of breastfeeding, including the correct way of breastfeeding. The researcher presented the material with a poster or picture of the correct breastfeeding technique.
The knowledge questionnaire consists of 33 questions with correct and incorrect answer choices. If the postpartum mother answered correctly, she was given a score of 1; if the answer was wrong, she was given a score of 0. The range of scores obtained was between 0-33. The questionnaire used the Guttman scale. The contents of the postpartum mother's knowledge questionnaire included the benefits of breastfeeding, breastfeeding techniques, breastfeeding positions, correct breastfeeding steps, duration and frequency of breastfeeding, milk release, milk storage, breast care, nutrition during breastfeeding, and problems in breastfeeding.
The Guttman scale has an important feature where it is a cumulative scale and only measures one dimension of a multidimensional variable; therefore, this scale is dimensionless. The data obtained are interval data or dichotomous ratios (two alternatives) [18].
Researchers did not try out the knowledge questionnaire because this questionnaire was adopted from Nalsalisa's study [19]. The results of the validity test obtained a p-value <0.05 on 33 questions. For the reliability test, this questionnaire is reliable because the value of r count> r table is reliable. 
The researcher has worked as a lecturer and researcher for 10-15 years and has Master and Doctoral degrees. The researcher has done much research in the health sector and has compiled many questionnaires, so the researcher prepared a questionnaire for this study. Before the research was conducted, the questionnaire was tested on ten postpartum mothers, and the results indicated that two questions had to be replaced because they were invalid.

 

Outcomes

This study has produced a description of the knowledge of postpartum mothers before and after virtual educational interventions and the effect of virtual education interventions on postpartum mothers' knowledge.

 

Sample size

75 postpartum mothers who have been calculated using the Slovin formula at a precision (d) = 0.1, the total population is 307 people. The study population, also known as the target population in this study, is the number of postpartum mothers who visited the Delima Midwife Clinic, Jambi City, Indonesia, in 2020, totaling 307 people.

 

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.02.06/2/161/2021.

 

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). To see the distribution of research data, the Kolmogorov Smirnov test was used. Then proceed with bivariate analysis using 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.

 

RESULTS

The characteristics of respondents in this study include age, education, employment status and parity. The following is the frequency distribution of the respondents' characteristics in this study:

 

Table 1. Frequency Distribution of Respondents Characteristics

 

The majority of respondents are in the age range of 32-38, have high school education, do not work and have multiparous status.

 

Table 2. Distribution of knowledge before and after interventions

 

Most of the respondents' knowledge before the intervention was in the Poor category, as much as 80%. After the intervention, the knowledge of postpartum mothers was mainly in the Good category, as much as 46.7%.
Table 3 shows that the Kolmogorov Smirnov statistical test results obtained a significant value of knowledge at the pretest and posttest virtual education, each less than 0.05.

 

Table 3. Normality Test Results of Knowledge pretest and posttest virtual education

 

The knowledge data at the pretest and posttest virtual education not normally distributed. Therefore, the statistical difference test was tested using Wilcoxon (Table 4)

 

Table 4.  Average Knowledge Pretest and Posttest Virtual Education

 

Table 4 shows that knowledge before giving virtual education has a mean value = 6.18, while after giving virtual education, it increases to 12.15, with P-value <0.05.

 

DISCUSSION

Postpartum conditions cause a partial decrease in immunity due to physiological changes during pregnancy, making postpartum women more susceptible to viral infections. Therefore, the COVID-19 pandemic will likely cause severe consequences for postpartum mothers. Social distancing measures are effective in reducing disease transmission. It also applies to postpartum mothers to limit themselves to not being exposed to the outside environment, let alone traveling to pandemic areas [20,21]. The risk of postpartum mothers being infected with COVID-19 is one of them when visiting a postnatal check-up at a midwifery clinic or hospital, so mothers must increase their vigilance by continuing to be disciplined in the use of PPE [21,22]. Postpartum mothers can limit visits to obstetric clinics or hospitals by conducting online consultations, actively self-checking for signs and dangers during pregnancy, and only making visits when things are worrying. This study aims to analyze the effect of virtual education on postpartum mothers' knowledge about breastfeeding [13,23]. Based on the univariate analysis, it is known that most of the respondents have less knowledge (80%), and a small portion (5.7%) have good knowledge. Health promotion cannot be separated from activities or efforts to convey health messages to communities, groups, or individuals.
There are still many mothers who say that mothers who are confirmed positive for COVID-19 cannot breastfeed their babies directly. The world Health organization still recommends that mothers continue breastfeeding their babies but must follow hygiene procedures. SARS-CoV-2 has not been detected in mothers with suspected or confirmed COVID-19, and there is no evidence that the virus is transmitted through breast milk [22,24].
Postpartum mothers who have good knowledge increased to 42% after counseling. The mean value of knowledge before counseling was done was 6.18, then after virtual counseling, there was an increase in the mean value of postpartum mothers' knowledge about breastfeeding to 12.15.
There is an increase in knowledge of breastfeeding mothers about breastfeeding during the COVID-19 pandemic. It is hoped that changes in behavior will occur, such as giving exclusive breastfeeding to their babies because concerns about transmission of COVID-19 through breast milk have been answered, namely that it is not proven to transmit COVID-19, and breastfeeding mothers can also provide breast milk exclusively with due observance of health protocols. Thus, even though the baby is in a pandemic, the baby's needs are still met with the mother giving exclusive breastfeeding even though the mother is still working and can still provide exclusive breastfeeding [25].
The statistical test results obtained a P value < 0.05, so it can be concluded that virtual counseling affects postpartum mothers' knowledge about breastfeeding during the COVID-19 pandemic. Silalahi's research (2012) reported differences in the level of knowledge of postpartum mothers after being given counseling. There was an effect of counseling on exclusive breastfeeding on mothers' knowledge about exclusive breastfeeding.
This finding strengthens the previous finding that reported that knowledge for the intervention group obtained a mean value of 58.89. In contrast, the control group obtained a mean value of 45.47, with P-value = 0.012, meaning that counseling affects the knowledge of postpartum mothers in the Timbusseng Village Work Area, Pattallassang District, Kab. Gowa [26].
Extension activities can be carried out with two-way communication where the communicator (extension) provides the communicant opportunity to provide feedback on the material. This interactive discussion on two-way communication is expected to trigger the desired behavior change. This health education's success is determined by the material presented and the interpersonal relationships between communicators and communicants [16,27]. An indicator of the success of extension that can be measured quickly is the similarity of meaning or understanding of what is conveyed by the communicator and accepted by the communicant [24,28].
Virtual counseling media is an alternative for health workers to consult postpartum mothers during the COVID-19 pandemic to reduce the risk of spreading COVID-19 disease, which can endanger pregnant women and neonates. The Good knowledge of the mother determines the correct breastfeeding technique. Good knowledge about the importance of breastfeeding and ways to breastfeed will form a positive attitude, and then correct breastfeeding behavior will occur [24,29].

 

CONCLUSION

Virtual counseling has a significant effect on the knowledge of postpartum mothers about breastfeeding during the COVID-19 pandemic.

 

STUDY LIMITATIONS

There are limitations to the number of research samples, and samples only come from one location; therefore, the results of this study cannot be differentiated from samples or participants with different characters in other locations. Future research must involve many samples, and research locations must also be heterogeneous.

 

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.

 

AUTHORS’ CONTRIBUTION 

All authors equally contributed to preparing this article.

 

ACKNOWLEDGEMENT

We would like to thank the director of the Department of Midwifery, Health Polytechnic of Jambi, Indonesia for supporting this research.

 

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14. Theurich MA, McCool-Myers M, Koletzko B. Supporting breastfeeding of small, sick and preterm neonates. In: Seminars in Perinatology. Elsevier; 2021. p. 151387.
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16. Haider R, Ashworth A, Kabir I, Huttly SRA. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. The lancet. 2000;356(9242):1643–7.
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by OPI Napoli

The Effectiveness of Electric Toothbrushes and Conventional Toothbrushes in Reducing Plaque Scores on School-Aged Children with Mental Impairment: Pilot Study

 

Rusmiati*, Rosmawati, Sri Febrianti, Andriani

 

 

Department of Dental Health, Health Polytechnic Ministry of Health Jambi, Indonesia

 

Corresponding author: dr. Rusmiati, Tazar Street, BuluranKenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Orcid :https://orcid.org/0000-0003-0913-4219, Phone: +62 823-0615-7373, Email: rusmiati.dentalpoltekkes@gmail.com

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ABSTRACT

Introduction: Improving the quality of life of children is one of the goals of the health development program. The growth of children's health is not discriminated against in this scenario. All children with special needs or impairments are covered by child health services, whether at Special Schools (SS), other institutions, or in the community. This study aimed to evaluated the effectiveness of using an electric toothbrushes, compared to conventional toothbrushes, in the reduction of dental plaque score.

Methods: This study was designed as a quasi-experimental study with a pretest-posttest design. All school-aged children with mental impairment in SS Jambi City, Indonesia were included in this study. Overall, 20 children were assigned to the intervention group (n=10) and to the control group (n=10). The Personal Hygiene Performance-Modified (PHP-M) was used to examine plaque index for the assessment of dental and oral hygiene.

Results: In the pretest-posttest, mean difference values in plaque scores were statistically significant in both the intervention (19.50±3.89, p<0.009) and control (17.90±1.61, p<0.001) groups. A statistically significant reductions was showed in mean post-test plaque index (p<0.001) in the intervention group compared to the control group (14.50 ±7.83; 32.80± 13.14, respectively).

Conclusion: When compared to conventional toothbrushes, electric toothbrushes are more effective in reducing plaque scores in mentally retarded children at SS Jambi City.

 

Keywords: Conventional toothbrush, Electric toothbrush, Plaque score, Children, Mental impairment

 

 

INTRODUCTION

Overall health, well-being, and quality of life are all influenced by dental and oral health[1,2]. Oral health is a state of a person who is free of chronic oral diseases, facial pain, mouth and throat cancer, infections and sores, gum disease, tooth decay, tooth loss, and other diseases that impair the ability to bite, chew, smile, and talk[3].
Dental and oral health care are crucial components of comprehensive health care[4–6]. Dental and oral health indicators represent the Global Goals for Oral Health 2020. One of the technical activities of the WHO Global Oral Health Program (GOHP) is to offer advice to nations on how to build policies for preventing and promoting dental and oral illnesses[7].
Improving the quality of life of children is one of the goals of the health development program. In this situation, the development of children's health is not discriminatory, and child health services are available to all children with special needs or disabilities, regardless of whether they are in special schools (SS), other institutions, or the community[8–10].
According to the 2012 Susenas (National socio-economic survey for Indonesia), 2.45 per cent of Indonesia's population has impairments [11]. Mental retardation is one group of people with disabilities. Individuals with mental impairment are referred to as having mental retardation (mental retardation). Mental retardation, according to the American Association of Mental Deficiency (AAMD), is defined as a significant divergence from general intellectual functioning that coexists with adaptive behaviour impairments and manifests during the formative period [12].
Indahwati, et al [13] compared the dental and oral hygiene of mentally disabled and deaf students in SS-B and SS-C Tomohon City. According to the findings, mentally disabled kids had lower oral and dental hygiene than deaf students. According to Martens L et al. [14], mentally impaired children's motor abilities at the age of 12 are lower than that of normal children, and mentally disabled children have difficulties holding and using a toothbrush. Rosmawati's [15] study demonstrates that children with special needs have poor dental and oral health with an average Decay Missing Filled-Teeth (DMF-T) score of three.
Because mentally retarded children endure physical and mental development delays, such as disruptions in sensorimotor coordination, children with special needs require particular health services, one of which is children with special needs for mental retardation [16–19]. According to an interview with the principal of the State Extraordinary School 2 in Jambi City, the students at the school have a joint tooth brushing program after recess directed by the teacher and use a conventional toothbrush. However, the prevalence of dental caries remains high [20].
Brushing the teeth prevents dental caries, and the toothbrush most usually used to remove plaque is a standard toothbrush. Traditional toothbrushes need motor coordination from users, but sensorimotor skills are limited in mentally disabled youngsters.
According to some authors, manual toothbrushing entails the application of much higher pressure than the use of power brushes. Powered toothbrushes appear to be helpful in improving the oral health of physically or mentally handicapped individuals because these devices require minimal hand motion and coordination skills. Some models are designed with each bristle rotating individually and are effective plaque removers [21,22].
Considering the benefits of an electric toothbrush, it can make it easier for mentally handicapped children to clean their teeth and mentally disabled children in SS Jambi City have never used an electric toothbrush, it is vital to investigate the usefulness of conventional and electric toothbrushes in them. This study aims to evaluate the effectiveness of using an electric toothbrushes, compared to conventional toothbrushes, in the reduction of dental plaque score.

 

METHODS

Study design

A monocentric pilot study, with pretest-posttest design, was carried out from February to July 2022 at State Special School 2 in Jambi City, Indonesia.

 

Sample size

The minimum sample size required for this study was calculated using the G*Power program, considering effect size of 0.82, α-value of 0.05, power of 0.80, and sample group ratio of 1 [23]. In public health research, the value of sample size strength is at least 80%, therefore, we choose an effect size of 82% (lowest).

 

Participants

Eligible subject were selected according to the following inclusion criteria: all children in SS Jambi, diagnosed with mild mental retardation [24], aged 10-16 years, Dental caries index ≥ 6.6, unkempt teeth, Dental plaque score 1, bracesless. Children with moderate and severe mental retardation who were unwilling and under ten years old, Dental caries index < 6.6, Dental plaque score > 1, kempt teeth, braces and were excluded. Overall, 20 children participated in the study and were split into Intervention (n=10) and Control groups (n=10) which were randomly defined.

 

Intervention

After enrollment, participants were randomly assigned into a control group (n=10), in which they used a conventional toothbrush, and in the intervention group (n=10), in which they used an electric toothbrush. In both groups, the dental plaque score was evaluated at baseline (T0) and after seven days (T1). On the day 7th (T1), all participants were advised to brush their teeth and not eat food for 30 minutes before the oral health examination was conducted. All participants were instructed to brush their teeth in the morning after getting up, lunch, and dinner using the same toothpaste for both study groups. The DMF-T index is an index to assess dental and oral health status in terms of permanent dental caries [25,26]. The DMF-T index is an assessment of the total number of teeth or surfaces that are Decayed/Carious (D), Missing (M), and Filling (F) for everyone. The severity of dental caries at the age of 12 years or older is categorized into five categories, including very low severity with a DMF-T value of 0.0 – 1.0. Then the low severity level with a DMF-T value of 1.2 -2.6. Moderate severity with a DMF-T value of 2.7 – 4.4. And a high severity level with a DMF-T value of 4.5 – 6.5, and a very high severity level with a DMF-T value of ≥ 6.6

 

Outcomes

Disclosing solution was used to carry out the procedure for measuring plaque scores. It works by putting a disclosing solution on the subject’s tooth surface and recording the findings. Dental and oral hygiene was assessed using PHP-M (Personal Hygiene Performance-Modified). The assessment begins by making imaginary lines on the teeth to form 5 imaginary lines. The lingual and labial surfaces of the teeth were examined. If a plaque was observed in one area, it was given a score of 1. Otherwise, a score of 0 or a sign was provided (-). Plaque assessment findings were calculated by summing each plaque on each tooth surface, resulting in a plaque score for each tooth ranging from 0-to 10. Plaque scores for all teeth can range from 0 to 60, with 0-20 indicating good criteria, 21-40 indicating moderate criteria, and 41-60 indicating poor criteria.

 

Ethical Consideration

In this study, parents of the children had given their consent to the 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, with number: LB.02.06/2/04/2022.

 

Statistical methods

For categorical variables, data were presented as numbers or percentages. The mean, standard deviation (SD), or median with Interquartile Range are used to express continuous data (IQR). Before the statistical test was carried out, the data normality test was first carried out using Shapiro Wilk test.
The non-parametric test used was Wilxocon to assess pre vs post conventional groups, while the Mann Whitney test was used to assess pre vs pre both study groups. The non-parametric tests were used for non normal data. The Paired T-Test was employed in data analysis to see if there was a difference in mean plaque scores before and after using a traditional toothbrush versus an electric toothbrush. The difference in plaque scores before and after treatment between the conventional toothbrush group and the electric toothbrush group was investigated using the independent T-Test. All tests with a p-value (p) of less than 0.05 were deemed significant. The SPSS version 16.0 application was used for statistical analysis.

 

RESULTS

Participants characteristics

The general characteristics of children, as shown in Table 1:

 

Table 1. Characteristics of childrens

 

The results of research on childrens with mental retardation SS Jambi City, as shown in Table 2:

 

Table 2. Frequency Distribution of Plaque Score Criteria Based on PHP-M Index

 

Table 2 shows that before brushing their teeth, the criteria for plaque scores of children were one child (10%) with moderate criteria and nine children (90%) with poor criteria. After brushing their teeth, the criteria for plaque scores of children were two children (20%) with good criteria, three children (30%) with moderate criteria, and five children (50%) with poor criteria.
Before brushing their teeth with an electric toothbrush, the plaque score of children was eight children (80%) with moderate criteria, one child (10%) with good criteria, and one child (10%) with poor criteria. After brushing their teeth, the plaque score of nine children (90%) with good criteria and one child (10%) with moderate criteria.

 

Figure 1. Plaque score criteria for control                       Figure 2. Plaque score criteria for intervention

group children                                                                   group children

 

Because the sample size was less than 50 children, the Shapiro Wilk test was employed to determine the normality of the data. The sample size in this study was 20 children, as shown in Table 3:

 

Table 3. Normality Test Results of Plaque Score Data for Children with Mental Requirements in SS Jambi City

 

The non-parametric test will be continued since the pre-test results in the conventional toothbrush group had an aberrant distribution of 0.014<0.05, and the post-test data were typically distributed at 0.261 > 0.05, as shown in table 3. In the meantime, the results in the electric toothbrush group were normally distributed, with a pre-test of 0.123 > 0.05 and a post-test of 0.122 > 0.05, respectively, followed by a parametric test.

Table 4. Test of the Effectiveness of Using Conventional Toothbrushes and Electric Toothbrush on Decreasing Plaque Scores in SS Jambi City

 

Table 4 shows that the mean score of plaque before brushing teeth is 52.30, whereas the mean score of children's plaque drops to 32.80 after brushing, indicating a 19.50 decrease in the mean value. The p-value for the paired data effectiveness test is < 0.009, indicating that using a conventional toothbrush to reduce plaque scores in mentally disabled children at SLBN 2 Jambi City is thriving. The mean score of plaque before cleaning teeth is 32.40, that the mean score of children's plaque falls to 14.50 after brushing, and that the mean value decreases by 17.90. The findings of the paired data effectiveness test show that the p-value is < 0.001, indicating that using an electric toothbrush to reduce plaque scores in mentally disabled children in SS Jambi City is beneficial.
The mean post-test value for the conventional toothbrush group is 32.80, while the electric toothbrush group is 14.50, with a P-Value of < 0.001. It indicates the difference in plaque score reduction effectiveness between conventional and electric toothbrushes in mentally disabled children.
The use of electric toothbrushes is more effective in reducing plaque scores in mentally retarded children at SS Jambi City, based on this description.

 

DISCUSSION

The current study is based on the theoretical basis of the physical condition of children with mental retardation. It has been known that children with mental disorders have mobility limitations, specifically in their extremities. This situation raises question marks about their ability to brush their teeth. Some studies have proven that mentally impaired children's motor abilities are lower than normal children, and mentally disabled children have difficulties holding and using a toothbrush. Children with special needs have poor dental and oral health with an average Decay Missing Filled-Teeth (DMF-T). So in this study, we evaluated the effectiveness of using an electric toothbrushes, compared to conventional toothbrushes, in the reduction of dental plaque score.
We reported that the use of conventional toothbrushes helped lower plaque scores in children with mental retardation in SS Jambi. These findings are in line with research conducted by Sitepu et al. [27] that using soft toothbrushes reduces plaque scores in mentally disabled children and a study conducted by Basith et al. [28] on 40 kids with Down syndrome in India. They observed manual or conventional toothbrushes to eliminate plaque and reduce gingivitis in children with Down syndrome for two months in each group.
In this study, it was also found that electric toothbrushes reduced the number of plaque scores in mentally disabled children in SS Jambi. Electric toothbrushes are effective in reducing OHI-S rates in children with Down syndrome, according to research conducted by Az Zahra et al. [29] and research conducted by Vandana et al. [30] on 30 people with mental problems who were observed for 45 days showed that brushing teeth with an electric toothbrush can reduce the number of mycobacteria in the oral cavity of mentally disabled children.
Plaque removal is the most critical activity for maintaining good teeth and oral health. The most popular tool for eliminating supra-gingival plaque is a toothbrush. However, most people do not clean their teeth correctly, and there is still a lot of plaque on the surface of their teeth [31].
Although electric toothbrushes are more expensive, because of the numerous designs and colors, they are thought to be more effective in raising the interest of mentally challenged youngsters in brushing their teeth. Electric toothbrushes are also good teeth cleaning equipment for preventing biofilm or plaque from forming on the surface of the teeth [32].
After brushing their teeth with an electronic toothbrush, the growing criteria for plaque scores in youngsters improve. This is due to the fact that the movement utilized in electric toothbrushes is better and more successful in reaching all parts of the mouth, as it is a systematic movement [33].
Mentally retarded children usually have difficulty in imitating the way of brushing their teeth that has been shown because their fine motor development is worse than normal children in general. Furthermore, mentally retarded children's eye and hand coordination is severely impaired. As a result, the child will have difficulties with fine motor movements, which will prevent the youngster from executing actions that demand concentration and complex hand movements [34]. Electric toothbrushes are more effective for intellectually impaired youngsters because of this. Because electric toothbrushes move automatically and children can feel the proper vibration to massage the gum and gingival area, they are a good choice for youngsters. As a result, using an electric toothbrush is more efficient and effective [29].
Although the results of this study have reported that electric toothbrushes are very suitable for use by children with mental retardation, the role of parents is highly expected. Parents or companions are required to take a more active role in encouraging mentally challenged youngsters to clean their teeth twice a day, in the morning after breakfast and at night before bed. We really hope that in the future the production of electric toothbrushes will be further improved at a price that can be affordable by all circles of society.
Based on the results of this study, we strongly recommend the use of an electric toothbrush, especially for students with mental retardation.

 

CONCLUSION

When compared to electric toothbrushes, electric toothbrushes are more effective in reducing plaque scores in mentally retarded children at SS Jambi City.

 

Study Limitations

One of the limitations of this study is the very small sample size (a pilot study), we collected data at only one center in Indonesia, which may limit the generalizability of our results to the larger population, so that in the future it is necessary to conduct similar studies in a larger population. Another limitation of the study was that the genders were not matched in the second group, which may have influenced the study results.

 

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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by OPI Napoli

EFFECTIVENESS OF E-BOOK APPLICATION MODEL UTERINE ATONY MANAGEMENT GUIDE AND POCKETBOOK IN IMPROVING MIDWIFE KNOWLEDGE AND SKILLS IN BASIC CARE: PRE-POST STUDY

Titik Hindriati1*, Nuraidah1, Rosmaria1, Diniyati1

 

1. Department of Midwifery, Health Polytechnic of Jambi, Indonesia

 

* Corresponding author: Titik Hindriati, Jl. Prof DR GA Siwabessy No.42, BuluranKenali, Kec. Telanaipura, Kota Jambi, Jambi 36122 Department of Midwifery, Health Polytechnic of Jambi, Indonesia. Orcid :https://orcid.org/0000-0001-7604-8068. Email: titikpoltekkes@gmail.com

 

 

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Abstract

Background: Midwives are one of the main health workers at the frontline of health development to accelerate the decline in Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). Therefore, competent and skilled midwives are needed in carrying out clinical procedures, especially in handling emergency cases of postpartum hemorrhage, with critical analysis skills. This study aims to determine the effectiveness of e-book application model uterine hypotonia management guide and pocket book in improving midwife knowledge and skills in basic care.

Method: The research design used was pre-post study, which was carried out in February-April 2021. The population and sample in this study were all midwives who provided delivery assistance at the Jambi City Health Center, totaling 64 respondents. Data analysis used the Wilcoxon and Mann-Whitney tests.

Results: In each intervention group, all variables, including knowledge and skills, are increased in both groups defined. The results showed that the educational media application of guidelines and pocketbooks on postnatal emergency management increased knowledge and skills.

Conclusion: The two study groups had a significant effect on increasing the knowledge and skills of midwives in handling postnatal emergencies due to uterine atony.

 

Keywords: Midwive, Emergency handling, learning media, pocket books, applications

 

 

Introduction

The role of health workers will determine the success of development programs in the health sector [1–3]. Midwives are one of the main health workers spearheading health development to accelerate the decline in Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) [4]. For this reason, it is necessary to have midwives who have the ability and skills in clinical procedures, especially in proper management in handling emergency cases of postpartum mothers due to uterine atony with critical analytical skills [5,6].
According to the World Health Organization (WHO), the maternal mortality rate in the world in 2015 was 216 per 100,000 live births, with the highest number in developing countries, namely 239 per 100,000 live births, or 20 times higher than the maternal mortality rate in developed countries, which were only 12 per 100,000 live births [7]. Nearly 75% of all maternal deaths are caused by postpartum hemorrhage, infection (usually after delivery), high blood pressure during pregnancy (pre-eclampsia and eclampsia), and unsafe abortion [8].
Based on the 2012 Indonesian Demographic and Health Survey (IDHS), the maternal mortality rate in Indonesia is 359 per 100,000 live births. It shows a downward trend to 117 per 100,000 live births in 2017, while the Maternal Mortality Rate (MMR) target is according to the Sustainable Development Goals (SDGs) of 70 per 100,000 live births in 2030 [9]. The Maternal Mortality Rate (MMR) in Jambi city in 2018 was 18.86/100 live births, and in 2019 it increased to 46.15/100 live births, although this data is still below the national Maternal Mortality Rate (MMR). Medical factors that are direct causes of maternal death are bleeding by 42%, pregnancy poisoning (eclampsia) 13%, miscarriage (abortion) 11%, infection 10%, delayed labor / prolonged labor 9% and other causes 15% [10].
Obstetric emergencies are life-threatening health conditions that occur during pregnancy or during and after labor and birth [11,12]. The government's effort to reduce Maternal Mortality Rate (MMR)  and Infant Mortality Rate (IMR) is to provide quality basic maternal and neonatal health services, namely Basic Emergency Obstetrics and Neonatal Services (PONED) at the Puskesmas. However, the maternal and neonatal emergency case services at the PONED Health Center have not been running according to the targeted expectations [13].
The high maternal and infant mortality rate can be caused by the lack of skilled midwives as health service providers, starting from pregnancy to delivery. To improve the knowledge and skills of midwives as service providers, maximum innovation is needed, including the provision of a pocketbook for handling emergency midwifery. This guideline is compiled in the form of a pocketbook equipped with an algorithm to facilitate health workers in handling emergency obstetric cases quickly. The second option can be using an android application that contains an e-book of obstetric emergency case materials, especially in the treatment of uterine atony [14,15].
In Interactive Multimedia, the stimulus appears by presenting exercises related to the material so that the midwife can respond by typing or pressing a button and then facilitated by feedback [16–19]. The existence of an attractive program display can lead to motivation so that aspects of learning readiness will also appear [20–23]. Multimedia applications can assess midwifery/psychomotor skills in basic services to detect emergency cases. Midwives as spearheads for maternal and infant health are good in theory and practice, especially for handling emergency cases. A midwife must provide quality midwifery services to prevent complications and maternal death due to complications [15,24].
The current study aims to evaluate the effectiveness of e-book application model uterine atony management guide and pocket book in improving midwife knowledge and skills in basic care.

 

Methods

Design

The design used is development, where this method is used to produce certain products and test the effectiveness of these products. Product testing is done by using pre-post Study.

 

Participants

The research respondents were 64 midwives (divided into 32 people in group 1 and 32 people in group 2) at PutriAyu Health Center and PakuanBaru Health Center who were randomly selected with the inclusion criteria of midwives who provide delivery services and have a working period of more than one year.

 

Intervention

The variables of this study are the knowledge and skills of the midwife who will be measured before and after the educational intervention using the application of postpartum emergency guidance due to uterine atony and pocketbooks.
The knowledge questionnaire has objective criteria of good or low, uses a Guttman scale, and consists of 15 questions with a rating range of 0-15. The variable of midwifery skill in this study was defined as the ability of the midwife to practice the procedures for handling emergency obstetrics, in this case uterine atony.
The skill questionnaire has good or poor objective criteria, uses a Guttman scale, and consists of 15 question items with an assessment range of 0-15.
The Guttman scale was used in this study because the variables used were nominal scales. 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) [25].
The group 1 received an intervention providing education on using an emergency postpartum guide application due to uterine atony for seven days. The group 2 will receive an education pocketbook on handling emergency postpartum due to uterine atony for seven days. On the first day before giving the intervention, researchers measured the level of knowledge using a questionnaire in both study groups, as well as the skills of midwives were measured using a questionnaire consisting of the midwife's ability to prepare tools, prepare patients, perform actions according to procedures, evaluate patient responses to actions that have been taken. midwife, and the ability of the midwife to document the actions that have been taken.
The first stage is the research starting from determining the team, determining the development schedule, selecting and determining the scope, structure, and order of the material, determining multimedia specifications, and making storyboards. The second stage is the development stage consisting of expert validation, practitioner validation, and the implementation and evaluation stages. The third stage is the Effectiveness Test.

 

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. The enumerators involved in this study were final year students who were about to complete their midwifery diploma, and were tasked with helping researchers collect data in the field by distributing questionnaires, however, the assessment of participants' skills was assessed by the researcher.

 

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 and Mann Whitney 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.02.06/2/167/2021.

 

Results

The results of the univariate analysis, which aims to determine the frequency of each variable studied, can be seen in the following table:

 

Table 1. Demographic data of participants

 

Table 1 shows that the dominant respondents aged 21-32 year are 41 people (65.6%), have employment status as permanent employees as many as 44 people (68.8%), 52 people are married (81.2%), and have a working period of ≤5 years as many as 38 people (59.4%).
Based on the normality test, the statistical test used in this study is non-parametric, with the results as shown in the following table:

 

Table 2. Differences in mean values ​​and Wilcoxon test results

 

Table 2 shows that in each intervention group, group 1 vs group 2, all variables, both knowledge and skills, have increased. In group 1 (e-book emergency guidance application) the median value of knowledge before intervention was 10 with a mean value of 7.2 while in group 2 (pocket book) it had a median value of 8 with a mean value of 6.7. After the intervention, group 1 (e-book emergency guidance application) had a median value of knowledge of 12 with a mean value of 9.9, while group 2 (pocket book) had a median value of 10.5 with a mean value of 8.6.
On the skill variable, in group 1 (e-book emergency guidance application) the median value before intervention was 8.5 with a mean value of 6.9 while in group 2 (pocket book) it had a median value of 8.5 with a mean value of 6.75. After the intervention, group 1 (emergency guide application e-book) had a median skill score of 12.5 with a mean value of 9.7, while group 2 (pocket book) had a median value of 11 with a mean value of 8.8.
The differences in knowledge and skills between the two study groups are presented in table 3.

 

Table 3.  Result of Mann Whitney test

 

Table 3 shows that the results of the Mann Whitney test prove that there is no difference between the two study groups in improving the knowledge and skills of midwives, in the sense that both groups (group 1 and group 2) are equally effective in improving the knowledge and skills of midwives in handling emergency obstetric cases.

 

Discussion

The information obtained by previous respondents strongly influences a person's level of knowledge. When the pre-test was carried out, the results obtained showed that the midwife had less knowledge before being given an android application for handling postnatal emergencies and a pocketbook. After the intervention, the respondent's knowledge increased by 71% in the group that received Android educational media. In contrast, the group that received pocketbooks in the group 2  also increased even though it was only 57%.
The Mobile Application, Education for handling postnatal emergencies, provides menus of information on handling postnatal emergencies, especially animated videos so that participants pay more attention to and master the techniques of handling postnatal emergencies.
Educational media serves to mobilize as many senses as possible to an object to facilitate the perception of the recipient of information [26]. The media will help clarify the information conveyed because it can be more interesting and interactive and overcome the limitations of space, time, and human senses. So that the information conveyed can be clearer and easier to understand according to the purpose for which it will be used [27]. Educational materials can be packaged according to the characteristics of each media used [28]. Today's cellphones not only function as a means of telecommunications but have switched functions to become androids that can do many things [29]. Mobile phones with functions like this can be known as smartphones. Smartphones can assist in medical activities, such as establishing diagnosis and therapy. From various forms of information technology and telecommunications, mobile phones are considered a suitable medium for increasing knowledge in the current developing era. The use of this smartphone is more effective than the module without the application [30,31].
Wahyuni's research [32] on the effect of smartphone applications on a person's knowledge and skills in stimulating the growth and development of toddlers shows an increase in knowledge and skills. Therefore, providing education through interesting media based on Android will make it easier for someone to stimulate independently. In addition to these researchers, other researchers state an effect of using printed media in the form of pocketbooks on increasing the knowledge of postpartum mothers. The study states that print media is the most frequently used and easy-to-reach media, for example, pocketbooks [33]. Pocket books occupy an important position in providing education because they provide clear and practical messages that allow readers to read at any time without the need for the internet to access them and are equipped with images that match the material, making it easier to understand the material [34].
Studies among various healthcare professionals reported mixed results regarding the usefulness of the e-learning, mobile learning and technology-enhanced learning. A Cochrane systematic review conducted by Vaona et al in [35] compared traditional learning with e-learning and reported that e-learning may make little or no difference in health professionals’ behaviours, skills or knowledge. A study conducted by Subhash et al, [36] among medical students reported that smartphones can be effectively used for learning. A study conducted by Snashall et al, [15] among medical students reported that medical apps can be used as an adjunct in medical education, though the evidence remains limited. Furthermore, data analysis showed that the respondent's skills increased after being given an intervention using an application for handling postnatal emergencies 43%. After being given education through a pocketbook in the group 2, the increase was lower than 21.4%. The results of the Mann-Whitney test in this study showed that there was no difference in knowledge and skills between the two study groups regarding postnatal emergency management who received the android application and the group who received a pocketbook. It shows that any media used can improve knowledge and skills because the function of the media is to help facilitate learning for students, provide a more real experience, attract greater attention from respondents because it is not boring, and all senses of respondents can be activated, attract more attention and interest of respondents in learning [37]. The most plausible reason is that the skill of midwives is higher in the group that received application media education compared to pocketbooks because the application media can be studied anytime and anywhere and displays interesting features and videos of emergency obstetric emergencies, especially uterine atony, so that midwives able to understand and remember strongly the material seen and heard [38].

 

Conclusion

The application model of pocket books and e-books for the management of uterine atony has been proven to be effective in improving the knowledge and skills of midwives in primary care.

 

Study Limitations

The limitation of this study is that this research involves a small number of samples so that this type of research is a preliminary study, and only involves a certain location, namely 1 area, so it cannot compare the results of this study to the character of the community in different locations. In the future it is necessary to conduct research on a large regional scale and the number of samples in a very large size.

 

Acknowledgement

We would like to express our gratitude to the director of the Midwifery Department of Jambi health polytechnic who has supported 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.

 

Authors’ contribution

TH and NU were responsible for the study conception and design; RO performed the data collection; TH and DN performed the data analysis; NU, and RO were responsible for the drafting of the manuscript; TH and NU made critical revisions to the paper for important intellectual content.

 

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by OPI Napoli

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

 

 

Cita questo articolo

 

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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by OPI Napoli

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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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.
18. Fu VX, Oomens P, Klimek M, Verhofstad MHJ, Jeekel J. The Effect of Perioperative Music on Medication Requirement and Hospital Length of Stay: A Meta-analysis. Ann Surg. 2020 Dec;272(6):961-972.

 

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by OPI Napoli

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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by OPI Napoli

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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