Impact of Universal Precautions Training on Nurse Midwives Knowledge,Attitude and Practices toward Prevention of HIV Transmission in Khartoum State Teaching

Hospitals, 2006-2009 By:

Dr/Faiza Ali Nasor Taha Faculty of Nursing Sciences

University of Khartoum

Human immunodeficiency virus (HIV) is the retrovirus that causes acquired immunodeficiency syndrome (AIDS). HIV Infections can include opportunistic infections, growth problems, and developmental regression, (Collie .et al ,1999). HIV has been isolated from blood, vaginal and cervical discharge; wound secretion, breast milk, amniotic and other body fluids, (CDC, 1998). CDC asserts that HIV positivity with low CD4 lymphocyte count (<200x10000000/L) is sufficient for diagnosis of AIDS. This test detects antibodies against HIV. It does not detect the HIV itself. An antibody against the HIV takes 1 – 3 months to develop after initial infection (window period). Back Ground The first cases were reported in the United States in 1981 and in the immediate subsequent years cases were reported from around the world. In 1983 the virus that caused AIDS was discovered by scientists in France and the routes of transmission were identified ( CDC, 1998). Clinical manifestations: The CDC states that HIV infection is a chronic progressive, terminal illness that can be divided in to four stages: Stage I : An acute , flue-like syndrome . Stage II: An asymptomatic, HIV-positive carrier state Stage III: Persistent fever, involuntary weight loss… Stage IV: The development of AIDS as manifested by neurological disease and dementia. Opportunistic infections (CDC,1995). The spread of HIV/AIDS is very quick worldwide and in the Sudan 1.4% of adult acquired it (SNAP,2009)and 1%of pregnant woman(SNAP,2003). Till now neither remedy nor vaccination exists, Prevention is the mainstay and cornerstone of the response to HIV/AIDS. Universal precaution (UPs) is now a common concept and guidelines have been developed to enable all health-care workers to reduce their risk of occupational exposure to HIV and other blood and body fluids infections; and to safe their clients and reduce risk of mother to child transition of HIV during process of normal labor. Universal Precautions components 1- Hand washing before and after all procedures. 2- Proper reprocessing of instruments and other contaminated equipment 3- Use of protective barriers such as gloves, gowns, aprons, mask, goggles when direct or indirect contact with blood and other fluids. 4- Careful handling and disposal of "sharps" 5- Proper handling of soiled linen or other materials.

6 - Safe disposal of waste contaminated with blood or body fluids (WHO,2003). Rational No information exists regarding the impact of universal precautions training programs on nurse midwives′ skill and practices Midwives were not trained on universal precautions, (universal precaution with standard structure had been engaged in the midwifery curriculum in 2006) (Reproductive Health,2006) so they may be unable to participate actively in decreasing the spread of HIV infections. Application of the universal precaution during the process of labor decreases spread of HIV infections on its all dimension (WHO,2003). Midwives are the most important birth attendants internationally as well as nationally as they deliver the babies and take care of the mothers, so this intervention study is going to improve the skills of midwives when performing the process of delivery regarding universal precautions. General objective: To evaluate the effect of training program on nurse midwives practice to prevent HIV infections during the process of labor in Khartoum state teaching hospitals 2006 -2009. Specific objectives: To determine knowledge, attitude and practices of the nurse /midwives to wards prevention of HIV infections during the process of labor. To implement guidelines of universal precaution by in-service training infection control methods. To measure the effect of the training on the practice of the midwives to prevent HIV infections. Methodology

Research design- intervention

Post-interventionPre-intervention

Out-come

Research Question What is the impact of Training UPS

The Study design This was an interventional hospital based study. Pre and post intervention design was conducted to evaluate the effect of training program of universal precautions on the nurse midwives performance towards prevention of HIV transmission during the process of labor Study variables such as social status, educational level, experience, application of universal precaution, knowledge, practices and attitude were assessed or/and estimated Study area Khartoum state Study setting: Labor rooms in six civil public teaching hospitals were selected Study population The study population included all nurse/midwives who complete basic nursing education and had experience of at least two years and then studied midwifery program for one year The total number of these nurse/midwives in the units was 240(25 labor rooms in Khartoum state 2006) Inclusion criteria: All nurse midwives who are regularly working in labor rooms in Khartoum state Exclusion criteria: Those that refused to participate in the study or other types of midwives (sister midwives, village midwives and traditional midwives) Sampling: Sample size: For calculation of the sample size a pilot study was carried out (n=30). Then we used the following formula where sample size: n= (z²pq/d²) ×2 .

THEN n= (1.96) (1.96) (0.40) (0.60)/ (0.10) (0.10) =92

Sample size was then multiplied ×2 =184 (to decrease design effect when using cluster sample). Sample design: Given the study objectives and structure of the population outlined above, the appropriate sample design chosen was stratified cluster sampling. Selection procedures of the study subject: Khartoum state is divided in to seven localities .These localities were considered as a stratum but one of these localities did not fulfill the criteria of selection. Teaching Hospitals in Khartoum state were considered as clusters. One cluster from each locality was withdrawn and studied. Then equal numbers of midwives from each selected cluster were taken, by division of sample size/six giving number 30.(Total number 180 nurse/midwives). Data collection technique and tools: Data collection technique: Observation Administration of a written questionnaire. Data collection tools:

observation check list, (two-path) . An structured interview questionnaire . Pre intervention phase comprised the following: Preparatory phase: In this phase the following was done: Permission was taken from ministry of health Khartoum state, directors of the hospitals, head departments of obstetric and labor room’s authorities. Tools were designed. Data collectors were trained and participated in the pilot study. The pilot study was carried out to insure validity of the tools and to test the work of the data collector short term training and to assist in determining sample size Curriculum for theoretical and practical aspects of UPs was developed Instructors were chosen. Base line survey was conducted by the data collectors and check list to assess application of UPs Intervention phase: A course of 2 days was offered which included Two lectures for three hours Demonstrations

Role play were used in the practical station for 3 hours in which application of steps of UP and protocol of the safe labor was applied

Eight courses were offered A total of 176 nurse midwives were trained

Training Package

Teaching universal precautions (UPS) Best Practices or protocol of Safe labor: to be applied during delivery

Processing soiled instruments and Other Items:

Decontamination:

Principles:

- Inactivates HBV and HIV. - Makes items safer to handle. - Must be done before cleaning.

Practices:

- Place instruments in 0.5% chlorine solution after use. - Soak for 10 minutes and rinse immediately.

Instructions for Preparing

Dilute Chlorine Solutions

To make a 0.5% chlorine solution from 5% bleach

Mix 1 part bleach to 9 parts water

eConcentrat %

Dilute % =Total parts

(TP) (H2O) -1 Total parts (TP)

(H2O) =

eConcentrat .5%

Dilute .5% -1=9 (H2O.

Decontamination of soiled instruments:

Practical stations application of steps of UPs and protocol of the safe labor was applied

post intervention monitoring Monitoring and supervision was carried out monthly for six months(memory gap) to assess application of UPs two midwives monthly observed from each selected hospital the first two months observed in the morning shift the second two months were observed in the after noon night shift and the last two months were observed again in the morning shift Post intervention data was collected. (Using check list) after six months to assess application of UPs by the same data collector. Data analysis: The statistical package for social sciences (SPSS) was used and epo info, for frequency distribution, intra group cross tabulation and inter group comparison The results were displayed in figures &tables Ethics:Permission was obtained from health authorities and from hospitals directors Consents were taken verbally from participants Validity and Reliability of instruments The instruments were pre-tested in the pilot study (n= 30) before final data collection For reliability, the test-retest at a three week interval period yielded a Pearson correlation coefficient of 0.6713

This result confirmed that the instrument was suitable for the study. Results

Socio demographic data of the respondents (n,180).

NO quest Socio demographic Frequency %

1- Marital status

Married 148 ( 82.2)

Single 12 ( 6.7 )

Divorced 12 ( 6.7)

Widowed 8 ( 4.4)

Total 180 ( 100)

2- Education level

Primary school 26 ( 14.4)

Intermediate 103 ( 57.2)

Secondary 51 (28.3)

Total 180 ( 100)

3- Years in current occupation

Less than 5 years 16 ( 8.9)

5years and more 164 ( 91.1 ) 4- Previous courses on HIV/AIDS

Yes 140 (77.8)

No 40 ( 22.2)

Knowledge level of nurse midwives about HIV was more than 80% 80% of nurse/midwives prone to needle stick injury and few of them reported it (23%)

Figure (1) Base line application of UPs, pre-intervention (n, 180).

Figure (2) Application of UPs by NM in the memory gap(monitoring in the memory gap 1-6 months). %

0

10

20

30

40

50

60

1,2.5and 6 months monitoring in the morning shift 3rd and 4rth months monitoring in the

after noon night shift

Series1 51.5 48.6 44.4 38.7 45.5 44.9

applica first secon third forth fifth six

Figure (3) Detailed Results of Application of Universal Precautions by The Nurse Midwives Pre intervention (n,180) Compared With Pos Intervention (n,169)

Figure (4) Comparison 0f means of total application of UPs .Pre & post intervention

Discussion Education is a very crucial element for nurse midwives, particularly in

countries where there is lack of formal and well-organized infection

control programs. Despite limited resources, developing countries,

such as Sudan, still have to deal with complex issues related to

enforcement of standard precautions. In this context, exposure to risk

is increased, because of the inadequate supply of personal protective

equipments, improper disposal of medical waste, and lack of effective

sharp instrument disposal systems. In this study, despite these

conditions, Universal precautions application scores increased

significantly after training(P<0.000) as shown in Figure (3&4) this is

supported by (Diekema, 2002) who mentions that Universal

precautions knowledge scores increased significantly after

training(P<0.0001). Also(Ademola Ajuwon, etal ,2008) in the study

"Effects of Training Programme on HIV/AIDS Prevention Among

Primary Health Care Workers in Oyo State, Nigeria" , showed that: at

pre-test, only 30.8 per cent of trainees could list at least four signs

and symptoms of AIDS compared with 70.9 per cent who could do so

after the training. . (Charles, 2001) in his study: Impact on Knowledge,

Attitudes and Compliance with Universal Precautions˝, revealed that

a number of positive changes occurred over the period of the study.

(Goldman and Glei .2003) argued that training midwives had little

effect on the quality of midwife care.

The study revealed that: Performance of the midwives in the first month

immediately following intervention was very high compared with the

following months in the memory gap and there were marked reduction of

UPs application in the months monitored in the afternoon night shift as

shown in (figure 2) and this may be due to lack of supervision and decreased

number of the staff or supplies. Similar to this is finding mentioned by

(Elkadi, 2007) in the Province of North Sumatera, knowledge and skill of

midwives were significantly increased after given health promotion, but

there was significant decrease of knowledge in the coming period and after 1

month after promotion and (S.Lund, etal, 1994) mentioned that during each

of the three shifts, 88% of all high-level contacts to blood and body fluids

were limited to the hands; 47% of these contacts occurred during the night

shift.

The high level of knowledge shown in this study did not correspond with

nurse midwives performance and even post intervention .This was similar to

what was mentioned by(Grellier ,2000) in the South Thames Region of the

UK who concluded that : “Knowledge obtained within midwifery education

may be difficult to be translated into clinical practice˝.

The prevalence of needle stick injury, as shown by this study, was very high

among most of midwives who are all have needle stick injury while suturing

because of the fact that they didn’t use a needle holder this, is similar to

what was mentioned by(Ismail ,etal,2005) in Egypt, who found that

exposure to needle stick injuries were common among the HCWs (66.2%).

Also (Nsubuga and Jaakkola, 2006) in a study of needle stick injuries

among nurses in Sub-Saharan Africa showed that, 57% of the nurses and

midwives had experienced at least one needle stick injury a year. Only 18%

had not experienced any such injury in their entire career

Conclusions This program was effective in increasing nurse midwives application of universal precautions The study showed a high rate of needle stick injuries occurred among nurse midwives Also the study revealed that the nurse/midwives were highly knowledgeable, but their knowledge did not reflect on their performance Resources needed for safe practice should always be made available and the environment should be much more conducive for practice Recommendations Creation of a body to supervise application of universal infection control precautions to grantee the continuity of the program We call for effective training that should include safe system of work with availability of resources and reasonable number of staff Application of universal precautions should be carried by all health care workers (HCWS) during the process of labor There is a responsibility on managers to provide appropriate Protective measures to enable midwives to practice safely and thus, ensure safety of the women they care for References

1-A demola Ajuwon, Fawole Funmilayo, Oladimeji Oladepo, Kayode Osungbade, Michael Asuzu 2008 Effects of training programme on HIV/AIDS prevention among primary health care workers in Oyo State, Nigeria ,Health Education,Vol.108 ,no.6 ,pp, 463 – 474.viewed,4/1/2009,<http://www.emeraldinsight.com/10.1108/09654280810910872>. 2- Centers for Disease Control and Prevention ,1995, acquired immunodeficiency syndrome, MMWR,vol.44,pp.1–3 3-Centers for Disease Control and Prevention ,1998, Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for post exposure prophylaxis, MMWR, 47(RR-7)pp.1–29 4-Charles B.U. Uwakwe 2001,Systematized HIV/AIDS education for student nurses at the University of Ibadan, Nigeria: impact on knowledge, attitudes and compliance with universal precautions, Journal of Advanced Nursing,vol.32,no.2,pp.416-424.viewed 12/26/2008,<http://www.3intrtscience.wily .com/cgi-bin/fulltext/119185814/ HTMLSTART>.Infect Control Hosp Epidemiol 2007;28:241–244 5- Collie, J.A.B, Longmire, J.M and .Duncan,T.J ,1999).oxford hand book of clinical specialties ,fifth edn, Oxford university press Inc,UK, pp,98-99 and155. 6-Diekema D. J., Schuldt S. S., Albanese M. A. and Doebbeling B. N,2002, Universal Precautions Training of Preclinical Students: Impact on Knowledge, Attitudes, and Compliance,Preventive Medicine,vol.24,no.6,pp.580-585.viewed 6/8/2008< .http://www.sciencedirect.com/science journal/00917435.>. 6- Elkadi,2007, health promotion regarding universal precaution HIV/AIDS for midwife of Primary Health Care in Medan municipality , Jl. Farmako No. 1,viewed 8/8/2008.<http://www.digilib.litbang.depkes.go.d/index.php > 7-Goldman, N& Glei, D ,2003. Evaluation of midwifery care: results from a survey in rural Guatemala. Social Science & Medicine. 2003;56,pp.685-700.

8-Grellier R ,2000, 'Everyone is scared of it inside so they start being a bit irrational': HIV/AIDS education within midwifery, Midwifery vol.16,no.1,pp.56-67.viewed ,viewed 17/7/2008. 9-Ismail NA, Aboul Ftouh AM, El Shoubary WH, (2005) Safe injection practice among health care workers, Gharbiya, Egypt. Journal of the Egyptian Public Health Association , vol.80,no.1, pp.563-83. 10-Nsubuga, F. M and Jaakkola, M. S. (2006 ),Needle stick injuries among nurses in sub-Saharan Africa, Tropical Medicine and International Healthviewed 3/22/2009.http://www.cabi.org. 11-RH,2006 .workshop 13-15 June 2006. curriculum revision . 12-S. Lund, J. Jackson, J. Leggett, L. Hales, R. Dworkin and D. Gilbert (1994) Reality of glove use and handwashing in a community hospital, American Journal of Infection Control, Vol. 22, no. 6, pp. 352-357, viewed ,3 /3/2009 <http://www.science direct.com.scienceˀ_ob=atrtice ur&udi >. 13-SNAP,2003, surveillance report April – June 2003 . 14-SNAP,2008, June report 15-WHO,2003.Fact sheet 11 HIV& the workplace and universal precautions for nurses &midwives. viewed 2/8/2008 . <http://www3.who.int/whosis/factsheets_hiv_nurses/fact-sheet-11/index.html>. .