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

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 r_count 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 Pailaha^1*

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

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

REFERENCES

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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

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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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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

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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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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

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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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

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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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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

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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