KNOWLEDGE AND ATTITUDES BETWEEN NURSES, MIDWIVES AND STUDENTS ABOUT VOLUNTARY TERMINATION OF PREGNANCY: A SCOPING REVIEW OF THE LITERATURE

Sofia Di Mario¹, Andrea Minciullo² & Lucia Filomeno³*

1. RN, MSN, PhD Student; Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
2. RN, MSN, Gastroenterology and Digestive Endoscopy Unit, Campus Bio-Medico, 00128, Rome, Italy,
3. RN, MSN, PhD Student; AOU Policlinico Umberto I – Department of Neurosciences and Mental Health, Viale dell’Università, 30, 00185, Rome, Italy.

* Corresponding author: Lucia Filomeno, Department of Neurosciences and Mental Health, AOU Policlinico Umberto I, Rome. E-mail: lucia.filomeno@uniroma1.it

 

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ABSTRACT

Background: Voluntary termination of pregnancy (VTP) is influenced by ethical convictions, religious orientations and knowledge of the law. The latter is essential for students to be improved in University curricula, in order to develop attitudes among future nurses and midwives with the objective to reduce stigma and reluctance in providing VTP. Previous research has shown that nursing and midwifery students' attitudes and knowledge can be improved.

Aim: The aim of this study is to describe literature regarding knowledge and perception about abortion and voluntary termination of pregnancy in several countries of the world among nurses, midwives and university students.

Methods: This is a scoping review of the literature conducted by following the recommendations of the PRISMA-ScR Statement. The authors selected studies in MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC, published in English and Italian in the last decade. Quality assessment was performed using the Jadad scale.

Results: Initially, 434 studies were selected. A total of 11 articles met the inclusion criteria. The articles included in the scoping review deal with the issue of abortion from different perspectives. From the analysis it emerged that the barriers for VTP are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the procedure.

Conclusions: Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. Therefore, it is recommended to implement university curricula on the topic.

Keywords: knowledge, attitudes, voluntary termination of pregnancy, nurses, midwives, students.

 

 

INTRODUCTION

Abortion, originated as birth control, is the termination of pregnancy before 20 weeks of gestation or with the foetus weight less than 500 gr at birth [1,2]. It can happen when at least three events occur: spontaneous or habitual abortion (also called Voluntary Termination of Pregnancy - VTP), criminal or illegal abortion, and therapeutic or legal abortion [3]. In the last decades of the 20th century, many countries all over the world legalised this practice. The World Health Organization (WHO) states that 3 out of 10 (29%) of all pregnancies, and 6 out of 10 (61%) of all unintended pregnancies, ended in an induced abortion [4]. In many societies, a deep conflict about the legality and morality of abortions manifests itself in restrictive laws and strong antiabortion attitudes. Women, including adolescents, with unwanted pregnancies often resort to unsafe abortion when they cannot access a safe one. Barriers to accessing safe VTP include: restrictive laws, poor availability of services, high cost, stigma, conscientious objection of health-care providers and unnecessary requirements, such as mandatory waiting periods, mandatory counselling, provision of misleading information, third-party authorization, and medically unnecessary tests that delay care [5,6]. Kumar et al. [7], defined abortion stigma as “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to the ideals of womanhood”. According to this definition, women who experience VTP challenge social norms regarding female sexuality and maternity, and their doing so elicits stigmatising responses from the community. Where opposition to abortion is widespread, abortion-related stigma is likely to negatively influence women’s abortion experience.

Increased knowledge and improved attitudes among health care providers and university students have the potential to reduce stigma and reluctance to provide abortion [6]. In a recent study conducted by O'Shaughnessy et al. [8], it was reported that “low levels of knowledge among staff suggests that training is required to ensure the provision of a safe and effective VTP service”. Midwifery and Nursing schools do not provide termination of pregnancy education or, if they do, it is inadequate and so, most staff were left to navigate this procedure without support or prior practice.

Termination is only possible in the rarest of cases: when the pregnancy poses a serious risk to the woman’s life or in the event of foetal malformations [7]. In Italy, as in many countries, it is set at 12 weeks’ gestation according to the law No. 194 enacted on May 22nd, 1978. Before that date, VTP was considered illegal by the criminal code [9]. The law regulates VTP with the aim of guaranteeing the bio-psycho-social integrity and well-being of women. A woman can have an abortion within the first 90 days, or within the fourth and fifth months only for therapeutic reasons [9]. Conscientious objection status does not exempt the professional from assisting the woman before and after the procedure, but from carrying out only those procedures directed towards and aimed at the termination [10-13]. The nurse can raise a conscientious objection to assisting the VTP with a declaration that can be withdrawn at any time [9]. Termination is a woman’s right, and the staff involved must act in accordance with the law and the woman’s right to free choice. A better understanding of factors influencing perceptions may be useful in determining the curricula of university programs and in giving nurses and midwives the tools to cope with their own beliefs towards late abortions [14-16]. Thus, this review seeks to contribute to research on abortion stigma by exploring literature regarding attitude, knowledge and perception differences toward abortion among nursing, midwifery and students, assessing the scientific evidence available to date and thereby delineating directions for future research.

 

METHODS

Identification of Relevant Studies

A scoping review was chosen as the research methodology [17]. This supports what is referred to as a systematic approach to the synthesis of evidence, helping to identify gaps for future studies. In this case, the goal is to determine the strength of the evidence using a consistent best practice approach. The search of the international literature was conducted in accordance with the PRISMA-ScR Statement (PRISMA extension for Scoping Reviews)[18] and was conducted within some main databases of biomedical interest: MEDLINE, Scopus, CINAHL, PsycINFO, Academic Search Index, Science Citation Index and ERIC. The review was carried out from October 2021 to February 2022. The keywords used were “knowledge; attitude; perception; nurse; student; abortion; midwife and questionnaire”. The latter were useful in formulating the research question according to the PCC (Population, Concept and Context) methodology (Table 1).

 

Table 1. Clinical research question identified through the PCC methodology

 

Study Selection and Eligibility Criteria

Research question: “What are the differences in knowledge and attitudes between nursing and midwifery staff and the corresponding university students?”. The search string was created using the Boolean operators (AND and OR), the terms MeshTerms and the truncation function, to ensure maximum search sensitivity and specificity:

 

(Knowledge OR Attitude OR Perception) AND (Abortion) AND (Nurse OR Midwife OR Student) AND (Questionnaire OR Assessment)

The study population were nurses, midwives and nursing and midwifery students. The primary studies concerning the assessment of attitudes, perceptions and knowledge about abortion between the two groups and the efficacy and validity of these arguments within the degree programs were considered eligible. The studies included experimental or quasi-experimental studies and observational studies. Since grey literature (i.e., unpublished conference proceedings or theses or dissertations) was not considered, other potentially relevant studies were not included in this review.

The selection criteria listed below were met to identify suitable studies for the purpose of this review.

 

Inclusion criteria

• Literature from the last 10 years.
• Italian or English language.
• Experimental and observational studies: RCT (Randomised Controlled Trial), quasi-experimental research designs, pretest-posttest, cross-sectional.
• Nurses, midwives and corresponding university students.

 

Exclusion criteria

• Other healthcare professionals, physicians, medical students or students of other healthcare professionals.
• Grey
• Qualitative and mixed-methods studies.

 

Data Extraction

In the first phase, the results obtained from the research were imported into a software for the management of bibliographic references and duplicates were eliminated. In the second phase, each article uploaded to the database was carefully and independently examined. Initially, they were analysed by reading their title and abstract and, according to the previously established eligibility criteria, the irrelevant ones were excluded, while those relevant for full-text reading were selected. Thanks to the in-depth reading, it was possible to exclude the articles that did not answer the research questions. Two reviewers worked independently. The following data was collected for each article: study title, first author, year of publication, study sample and study design, objective, assessment and a summary of the results. The approach used to group the articles was thematic: the main objective of the thematic analysis is to identify similar concepts in the collected dataset, exploring their relationships of meaning. These reports can be used to further develop and corroborate the interpretation of theories that seek to investigate the phenomena studied [19].

 

Quality Assessment

The quality of the studies was assessed usingthe Jadad Scale [20], focusing on methods for random allocation, double blinding, and withdrawals and dropouts. Total scores ranged from 0 to 5 points, where studies with 0-2 points were considered poor quality and those with 3-5 points represented high-quality evidence [20].

 

RESULTS

Initially, 434 articles were selected with duplicates removed (Figure1). Of these, 11 met the inclusion criteria and underwent the review process. The main information of the relevant articles was organised in a data extraction table (Table 2). Studies were conducted in 11 different countries: Belgium, Ghana, Iran, Brazil, Israel, Spain, Ethiopia, Finland, Canada, Pakistan and South Korea. This demonstrates a notable absence of literature in Italy. The studies included a sample ranging from a minimum of 74 to a maximum of 647 participants. The most recent one dates to 2020, while the oldest one dates to 2010. From the analysis it emerged that the barriers for abortion treatment are the lack or inadequate knowledge of the legislation and of the practical / technical phases of the intervention [21-24]. The possession of skills is often not enough as in the study by Romina et al. [22] where it emerged that there was no significant relationship between the knowledge of the law and the care performance of health professionals while a statistically significant relationship was observed between their opinion of abortion and their active collaboration[22].

Figure 1. - PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.

Personal and religious beliefs have been considered to have a profound influence on opinion and behaviour, in some cases resulting in the inability to take care of the patient for fear of remorse [21; 25-27]. The presence of moral and / or religious values in health workers was significantly correlated with the occurrence of the request for conscientious objection (CO) [21-26].

Table 2. Data Extraction Table.

In South Korea, where about half of the population declared themselves irreligious, Chung Mee Ko et al. [26] assessed the opinions of 167 nurses regarding CO; the majority replied that patients’ rights to health care should take priority over nurses’ right to refuse health care, concluding that the nursing profession should seriously consider whether it is necessary to insist on nurses’ right to CO and should be actively involved in the determination process of new abortion laws and related policies [26]. Nieminen et al. [6] studied CO among Finnish nursing students and practitioners. Most of them seemed to consider the continuation of adequate services to patients in the event of the introduction of CO as crucial, while emphasising the surgical act over patient support. Despite their views and beliefs, health workers sometimes faced a conflict with their commitment to care; in the work of Ben Natan et al. [15], they stated that bioethical dilemmas, as well as the reasons for abortion, influenced their ability to actively collaborate during the termination of pregnancy [15]. Nurses attitude and ability to actively participate in late abortions were found to be strongly conditioned by the level of religious observance [21-22]. The study by Roets et al. [28] found that in several neonatal intensive care units in Belgium, healthcare workers practicing late abortion had a high degree of tolerance towards late termination of pregnancy, regardless of the patient’s socio-demographic factors, so much so that they asked the institutions to provide for a change in legislation [28].

Ben Natan et al. [15], however, found that nursing students had more prejudices towards late abortions than experienced nurses, evidence in line with the study conducted by Assefa et al. [24] where it turned out that a predictor of a positive attitude towards VTP was seniority [24]. The role of health workers is very important, especially on a psychological level, even more so when they must help women to deal with a negative event such as a miscarriage. To this end, Engel et al. [27] suggested that health workers should receive specific training to be able to support women and their families [27]. Previous research has shown that university education programs do not provide the tools necessary to achieve the objectivity required in preparation for abortion and that this may have contributed to anti-abortion attitudes and misconceptions about legal regulations that are common among students¹⁰. Same results emerged from the work of Baig et al. [29] who studied the knowledge, attitudes and practices of midwives in post-abortion care services [29]. The work highlighted the need to provide comprehensive training and mentoring to midwives and students, building strong networks to enable the development of broader initiatives to reduce the stigma of abortion.

 

DISCUSSION

Although the total number of studies investigating abortion stigma among undergraduate students and nurses and midwives such as nurses and midwives is low, results indicate that knowledge, personal and religious beliefs significantly affect attitudes about VTP. This is in line with the findings by Madziyire et al. [10] where incomplete comprehension of abortion laws highlights the urgent need for providers education as a key step in reducing stigma and mortality associated with unsafe abortion [10]. Additionally, the lack of expertise evidenced by most of the studies, suggest that even nurses and midwives who have good intentions may unwittingly disseminate misinformation. One study underlined the fact that type of profession and seniority were important in providers’ knowledge about abortion. Also, being male and having high knowledge significantly influenced providers’ attitude. The same findings were highlighted by Hammarstedt et al. [30] who stated that gynaecologists and midwives were less restrictive towards legal abortion the more experience they had, being especially influenced by recently obtained experience within the last year [30]. Claims of conscientious objection must be ethically justified, and not become a strategy to hide prejudices or fear of lawsuits and moral accusations. Such an instrument cannot be an obstacle for women to have access to abortion [31]. Humanized care in the abortion process is part of the reproductive and sexual rights of women, and ensuring it is a duty of all health professionals.

Abortion laws and practice differ between cultures, religions and countries. The Finnish healthcare system is relatively liberal regarding the right for induced abortion until the 12° gestational week. Despite lively discussion, there is no legislation in this country on the possibility of CO [32]. Post-abortion care is important especially in countries like Pakistan, where half of pregnancies are unintended. Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement [33]. This has been reported in other surveys in other countries. In Ghana, for example, only 45% of surveyed physicians said that they would perform abortions, whereas another 36% said that they would provide counselling prior to abortion but not the procedure itself [33]. Women deserve a well-prepared, informed personnel and similarly, students deserve a thoughtfully inclusive curriculum that accurately addresses ethical topics, as most programs do not require sexual health courses as a part of their curriculum [34-35].

 

CONCLUSION

The role of the health professional assisting the woman who decides to undergo a voluntary termination of pregnancy is very important, especially in the phases before and after the intervention. Assistance must always be provided with respect for the woman’s dignity, confidentiality and freedom of choice. Nurses need to provide a source of support for the woman by establishing a relationship based on trust. Health professionals and students have different perspectives and attitudes toward VTP. Nurses and midwives have inadequate knowledge of procedures and legislation. It is important that the health professional realises the crucial importance of their role in the woman’s grieving process to ensure good care.

 

Limitations of the study

Our study has some limitations that should be mentioned. In our analysis, only research articles published in English and Italian were included, which may have produced a language bias regarding the conclusion, as some scientific papers were published in other languages. Additionally, only studies published in peer-reviewed journals were included; this criterion was meant to ensure reporting quality but may mean that relevant grey literature was missed.

 

Practical implication

Nurse sneed to have adequate training in the bereavement context: they should know what interventions implement and what to avoid. The aim of the scoping review was to analyze the international panorama regarding abortion as a point of departure on which to develop an Italian study to compare legislation knowledge, attitudes and perspective differences among students and nurses and midwives. Therefore, it is recommended to implement university curricula on the topic.

 

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

The authors declared no conflict of interest.

 

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by OPI Napoli

NUTRITION EDUCATION MODELS IN PREGNANCY TO INCREASE KNOWLEDGE AND DIETARY PATTERNS: A SYSTEMATIC REVIEW

Suryani*¹, Muhammad Rusdi¹, Asni Johari¹, Solha Elrifda¹

1. Post-Graduate Program of Mathematic and Natural Science Education College, Jambi University, Indonesia
   

Correspondence: Suryani, Address : Dr. Tazar Street, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36361, Indonesia, Email : suryanipoltekkes3@gmail.com, Orcid : 0000-0001-6540-2607

 

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ABSTRACT

Background. The misconception of nutritional principles causes dietary oversight, resulting in an excess or deficit of energy and specific nutrients essential for the proper course of pregnancy and a child's healthy growth. This review aims to evaluate the effectiveness of nutrition education in improving knowledge and dietary change conducted in pregnant women.

Methods. This review study complies with the 2009 PRISMA guidelines. The studies included in this review are mainly studies with experimental designs. Databases used in searching relevant literatures such as PubMed, ScienceDirect, Willey online Library, Web of Science, Cochrane, and Proquest that were published from 2010 to 2021, full text, English version, experimental studies. Two review authors conducted studies screening based on the eligibility criteria, and extracted important points in the studies included. Quality of the studies included were assessed using EPHPP.

Results. A total of 10 studies were identified in this review. Six studies in the high quality, and four studies in moderate quality. Overall outcomes of the studies included are Knowledge, Attitude, practice, dietary practice, awareness, hemoglobin blood level, and Gestational Weight Gain (GWG).

Conclusion. Nutrition education in many methods has a power to improve knowledge, and dietary change of pregnant women. It implies the need for future large high quality trials using a standardized approach to measuring and reporting similar findings across studies.

 

Keywords : Pregnancy, Pregnant women, Education, Nutrition

INTRODUCTION

Pregnancy is one of the most notable moments in a person's life, and at that time, diet is essential [1]. So far, maternal malnutrition or failure to meet nutritional needs has caused specific health problems for both mothers and newborns [2]. Due to insufficient and unbalanced nutrition, problems such as anemia, osteomalacia, and pregnancy toxemia often arise, and the chances of stillbirth in newborns, premature delivery, congenital abnormalities, and mental retardation increase [3,4]. Furthermore, poor maternal nutritional quality causes developmental maladaptation in the fetus [5]. This results in long-term structural, physiological and metabolic changes and an increased risk of cardiovascular, metabolic, and endocrine diseases in adults [6].

Poor eating habits are a leading contributor to the development of overweight and obesity across the world [7,8]. The frequency of home-cooked meals has decreased over the last five decades, while consumption of foods produced outside the house (i.e., fast food and restaurant food), often higher in calories, fat, and salt, has grown [9,10]. Consumption of home-cooked meals regularly is linked to better diet quality over the lifespan [11,12]. As a result, increasing the frequency of home-prepared meal intake is a significant health habit to target for preventing overweight and obesity in adults and children, and it has been the topic of extensive research over the last two decades [13,14].

International authorities define pregnancy as a moment of highly nutritional needs to promote mother and fetal growth [15]. Nutritional support needed in pregnancy includes carbohydrates, fiber, protein, and micronutrients, such as vitamin A, vitamin B complex folate, and iron [16]. However, a study in Canada found that people have insufficient micronutrients through food, such as high levels of iron (97 percent), vitamin D (96 percent), and folate (70 percent) intake [17]. Therefore, stakeholders intended to present food and nutrition education to encourage a balanced diet based on food culture's valorization [18]. Food and nutrition education is an essential strategy for upgrading health because it encourages people to identify and tolerate their cultural discrepancies and empowers them to complete decisions concerning their health care [19]. Antenatal nutrition education is related to better eating patterns and a healthier pregnancy [20]. Healthy fetal growth and development, cognitive capacity, and immunological function are promoted by optimal nutrition throughout pregnancy  [21]. Pregnant women's adherence to dietary guidelines decreases due to a lack of nutrition expertise and insufficient information from health providers [22]. Before and during pregnancy, the mother's behavior becomes a determining factor for both the mother and her child  [23,24]. Many dietary mistakes can be caused by a lack of understanding of nutritional principles, resulting in an excess or deficit of energy and specific nutrients essential for the proper course of pregnancy and a child's healthy growth [25,26]. Adequate diet, in combination with sufficient physical activity and the avoidance of harmful habits, enhances the chances of a healthy pregnancy [27,28]. One of the previous systematic reviews on pregnant women's compliance in following dietary guidelines during pregnancy stated that knowledge was an essential predictor concerning adherence to the given nutritional guidelines [29].

It is essential to assess how successful nutrition educations are in improving the nutritional status of pregnant women especially their knowledge and dietary.

This systematic review aimed to assess the efficacy of nutrition education in knowledge and dietary change during pregnancy and their implications for future research. Therefore, the question for this review is, "what kind of nutritional education model is good for increasing knowledge and changes in the diet of pregnant women?".

 

METHODS

Design

When reporting this systematic review, the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed [30].

 

Eligibility Criteria

The participants, intervention, comparator, outcome, and study design (PICOS) criteria outlined in Table 1 were used to select studies for inclusion in this review.

Table 1. Studies Criteria based on PICOS

 

Type of Studies

The studies included in this review use experimental designs such as Randomized Controlled trials (RCT) and Quasi-experimental. Participants in the study should be pregnant women in any trimester of pregnancy.

Search Strategy

The following databases (platforms) were searched: PubMed, ScienceDirect, Willey online Library, Web of Science, Cochrane, and Proquest in the time frame between 2010 to 2021. We also searched the gray literature database for additional information such as Google Scholar, conference proceedings, and BASE. The keywords used are based on the Medical Subject Headings (MeSH) standard. Using Boolean operators and a combination of keywords used, namely: ((("pregnancy nutrition"[Title/Abstract]) OR ("pregnancy nutrition knowledge"[Title/Abstract])) AND ((("health education"[Title/Abstract]) OR ("nutritional education"[Title/Abstract])) OR ("health promotion"[Title/Abstract]))) AND (((("knowledge"[Title/Abstract]) OR ("attitude"[Title/Abstract])) OR ("practice"[Title/Abstract])) OR ("awareness"[Title/Abstract])).

 

Study selection

Two review authors independently assessed the titles and abstracts of the retrieved studies to see if they met the eligibility criteria (RUS and ASJ). The full-text publications for the remaining studies were obtained and evaluated for eligibility which obtained and read full texts of the studies that potentially met the inclusion criteria. The first ineligibility criterion from the following list determines why a publication was excluded: study design, population, intervention, and results. The first authors decided disagreements from review authors regarding the feasibility of the study (SUR and SOE), and this procedure was followed throughout the review.

 

Data Extraction and Quality Assessment

Two authors (SUR and SOE) independently extracted data in duplicate from studies that met the

inclusion criteria to avoid any chance of misinterpretation of conceptualizations in each study.

Data were synthesized in two ways: (1) research design and intervention strategies were presented. (2) the findings of each study were analyzed qualitatively by collecting the main findings with the design and intervention applied. Furthermore, data extraction was carried out to provide a brief description of the articles' substance, such as the characteristics of the respondents and the characteristics of the study. Data extracted included author, year, country, participant, study design, Intervention, outcome, and main findings. The researchers then examined each extraction and any discrepancies were discussed until consensus was reached.

The quality of the articles included was measured using an assessment tool for the Effective Public Healthcare Panacea Project (EPHPP) [31] which allows experts to apply this tool to articles on any public health topics. This tool uses STRONG, MODERATE, and WEAK categorizations based on the assessment results on eight components, namely Selection Bias, Study Design, Confounders, Blinding, Data Collection Methods, Withdrawals, and Drop-outs, Intervention Integrity, and Analyzes. Articles in the STRONG category are the article reached four strong from the EPHPP component without any of the components being considered weak, the MODERATE category if four components reach strong. One component is rated "weak," and for the WEAK category, it is given if two or more components reach a "weak" value.

 

Data synthesis

Data from the included studies could not be pooled for meta-analysis because to the substantial diversity in the methodological design of the investigations. Consequently, the narrative synthesis of the included study findings was provided using the Synthesis without Meta-analysis in Systematic Reviews: Reporting Guideline [32].

RESULTS

Search Results

The process of searching for articles up to the determination of articles that meet the inclusion requirements can be illustrated in Figure 1.

Figure 1. PRISMA Flowchart for Literature Search

Search results from five databases yielded 486 articles according to the keywords applied, and then 159 articles were eliminated because they were duplicates, leaving 327 articles. Furthermore, the screening stage was carried out on the remaining articles; as many as 295 articles were excluded because they did not discuss the nutrition status in pregnancy. At the end of the screening, ten articles met the inclusion criteria (Table 2). Those were included in the moderate and robust categories based on the EPHPP assessment tool for article quality assessment.

Table 2. Extraction of Literature Included

Description of studies included

The articles reviewed in this study are located in several countries such as Iran [37], Ethiopia [34], USA [41], Brazil [33], Palestine [36], and Somalia [39]. Study design including Randomized Controlled Trial (RCT) [33–35,38,39,42], and Quasy experimental [36],[37,40,41].

 

Characteristics of participants

All reviewed studies included pregnant women with variations in gestational age including below 36 weeks (Oliveira et al., 2018), below 16 weeks [34,35] below 20 weeks [41,42], 14-16 weeks [36], 6-10 weeks [38], 18 – 24 weeks [40], 14-20 [41]. Two studies were not applied the gestational age [37,39].

Description of interventions

Some studies provided booklet regarding Healthy Diet during Pregnancy [33], Counseling regarding dietary practice [34], Nutrition education (theoretical session, poster, brochures, flipchart, and whiteboard) [35,37,40], theoretical and practical [36], the nutrition‑education intervention based on Pender’s HPM [38], video health information [39], exercise, self-monitoring, facebook private group [41], web-based health information [42].

A booklet entitled “Healthy Diet during Pregnancy with Regional Foods (Alimentação Saudável na Gravidez com os Alimentos Regionais)” was used as the main intervention which contains the concept of healthy nutrition, allowed and avoided foods during pregnancy, the benefits of healthy dietary habits for mothers and babies, food hygiene, and recipes with regional foods. The intervention group participated in the individual intervention in a private room, in a single session, with an average duration of 20 minutes. During the meeting, the booklet was introduced, read, and the patients kept a copy to take home [33].

The counseling model has also been used in a study in Ethiopia. The intervention package was community-based guided counseling using the HBM and the TPB. The core content of counseling guide including meal frequency, portion size with increasing gestational age and taking diversified meals, consumption of iron/folic acid supplementation, iodized salt use, reducing of a heavy workload, taking day rest, use of impregnated bed nets, and health services. Counseling was given monthly using a counseling guide and leaflets with core contents. Individual Nutrition counseling was given through a home visit on non-working days. Each counseling session lasted for 40 to 60 minutes. Participants attended four counseling sessions during pregnancy. The first counseling was given before 16 weeks of gestation, the second and third counseling sessions were given during the second trimester of pregnancy, the fourth counseling was given during the early third trimester of pregnancy. The control group received nutrition education given by the health system [34].

Nutrition education intervention recorded in three studies was given to pregnant women between 1 and 4 months at baseline. The education was given every 15 days for 5 consecutive months. For intervention group, education intervention was given based on Health Belief Model theory: (1) susceptibility of the pregnant women and fetus to malnutrition due to inappropriate dietary practices nutrient deficiency or over nutrient intake; (2) severity of malnutrition such as wasting/thinness and overweight/obesity and high risk of fetus to intrauterine growth retardation, brain development, and cognitive function due to macro- and micronutrient deficiency; (3) benefits of right eating or dietary practices on women nutritional status and fetus health, (4) barriers to practice appropriate good dietary practices; and (5) self-confidence/efficacy to follow right dietary practices. The education was provided using theoretical session, poster, brochures, flipchart, and whiteboard. For the control group, nutrition education was given by trained community health volunteers based on the general usual nutrition education which is currently provided by health extension workers [35]. Fallah et al [37] conducted face-to-face nutritional education which contains two to four lessons based on a nutrition package by Iranian ministry of health. Another study by Shakeri [40] nutrition education conducted in groups of 12 people, held in 8 sessions each planned for three sections taking 90 minutes. An educational CD, educational booklet, tract, and pamphlet about the advantages of good nutrition for mothers and embryo, appropriate  ways  of  doing  activities  during  pregnancy, and false beliefs were given to the participants.  Furthermore,  lecture,  question  and  answer,  group discussion,  and  film screening  methods  were  used  to educate the patients. Paticipants in control group received the routine prenatal instructions [40].

The complementary nutritional intervention (CNI) program proposed by Al-Tell and colleague, it was developed based on the educational principles using the principles of health belief model that aimed to behavior change. The program composed of two parts that were presented within 16 hours and through 8 grouped sessions, in addition to another 2 individualized/ follow-up session for each woman. The content of the theoretical part consisted of 60% of program hours, and the practical part consisted of 40% of program hours. The study also used educational booklet for additional materials. It included information regard iron deficiency anemia in term of causes, complication, treatment inhibitors and promoters of iron absorption and examples of prepared meals rich of iron [36].

Khoigani and colleague conducted nutritional education based on the Pender’s HPM for intervention group, included three 45 – 60 minutes training        sessions in 6 – 10, 18, and 26 weeks of pregnancy. Each participant had a meeting with the study nutritionist      at the time of enrollment for nutritional assessment. In the first session,           the dietary pattern, including the average daily servings     of five food groups, was explained to the participants. In the second session, practical steps (goal‑setting      techniques) to increase self‑efficacy [38].

Destephano et al evaluated the use of DVD to spread information about caesarean birth, episiotomy, nutrition and exercise, the father’s role, preparation and prevention, and pregnancy myths and facts. Each video topic ranged from 3 to 4 min in length, incorporated

traditional songs and poetry, and had English subtitles [39].

Baruth et al used the social cognitive theory to develop SELF intervention (Supporting hEaLthy Futures: Creating a Healthy Family by Investing in YourSELF). The intervention included four key components: Exercise is Medicine™, self-monitoring, opportunities for support, and walking groups (optional). In self monitoring, Participants were given a FitBit Charge to monitor their physical activity (daily) and an Eat Smart Precision digital scale (model ESBS-01) to monitor their weight. Participants were instructed to weigh themselves once a week using the scale provided, and enter their weight into their FitBit account [41].

Participants (control and intervention groups) in Olson et al [42] trials given access to the intervention website and to the placebo control website. The self-directed, integrated online and mobile phone behavioral intervention was designed using the Integrative Model of Behavior Prediction and the Behavior Model for Persuasive Design based on a non-electronic pregnancy lifestyle intervention. Participants in intervention group received access to three behavior change tools including a weight gain tracker, a diet and a physical activity goal-setting and self-monitoring tool, as well as, health information including tips, articles, frequently asked questions; a description of pregnancy and parenting-related resources available in the local community; a blogging tool; and an event and appointment reminder [42].

 

Quality Assessment

Assessment of the methodological quality of studies resulted in 6 studies with a high quality score [33–35,38,41,42] and 4 studies with a moderate quality score [36,37,39,40].

 

Description of Outcomes

Outcome measures reported in the included studies were Knowledge, attitude, practice [33–35,37,39,40], Dietary practices [34,35,38], Gestational Weight Gain (GWG) [41,43], behavior change [42], Hemoglobin blood level [36]. One study collected the result of outcomes measurement immediately after the intervention [39], Three studies conducted the evaluation in two times for 6 weeks [40], 5 months [36], and 8 months [42]. The rest of the studies evaluated the outcomes in the range of one to five months [33–35,37,38,41].

As mentioned in Oliveira et al study, the knowledge was considered adequate when used to prepare varied meals and/or juices, knew three or more types of regional foods, and mentioned at least two types of meals prepared with regional foods. The attitude was considered adequate when pregnant women prefer to use regional foods and know the advantages. The practice was considered adequate when pregnant women referred to use regional foods at least twice a day [33]. In Diddana study, knowledge measurement is based on the Health Belief Model consists of 15 nutrition question [35]. In Fallah study, Knowledge as a primary outcome was measured before the intervention and two posttests within three weeks interval [37]. Another study in Iran with knowledge and attitude as primary outcome completed the evaluation immediately and 6 weeks after the educational intervention for the samples of experimental and control groups [40].

For dietary practice outcome, assessment used a food frequency questionnaire (FFQ) collected between 36 to 37 weeks of gestation. Women who didn’t attend all counseling sessions were considered non-adherent to the guideline. But, women who withdraw from participating in the study were labeled as lost to follow up [34]. In Diddana study, dietary practice variable was collected by using 17 dietary habit questions [35].

 

DISCUSSION

Overview study included

This review provides evidence that interventions with a health education on pregnancy issue can improve pregnant women knowledge, attitude, practice, dietary pattern, awareness, hemoglobin level, and weight gain outcomes. There is somewhat more persuasive evidence that health education interventions are favorably linked with healthy living change during pregnancy of pregnant women as participants due to the number of RCTs that revealed significant findings. Because of the high variability of research designs and methodology utilized in the included papers, meta-analysis cannot be conducted. Furthermore, the goal of this evaluation was to serve as a first step in identifying evidence-based treatments that would help transfer prenatal nutrition research and guidelines into practice. Although the evidence highlighting the importance of nutritional status during pregnancy has been documented, and numerous practice guidelines, including the recently consolidated inter-professional practice guidelines, have existed for some time, there is still a significant gap in translating this evidence to pregnant women through health promotion efforts. Overall, there are few dietary promotion treatments during pregnancy, and only 10 interventions have been assessed on specified health outcomes, according to this analysis.

Overall, the studies comprised a wide range of pregnant women from six different nations, resulting in some findings. Furthermore, all of the research was done in a communal context. A previous evaluation noted that complete prenatal care treatments should be available in remote regions or with less infrastructure and that their duties and those of trained CHWs should be harmonized across nations to assure basic levels of care [44]. Pregnant women who did not take advantage of offered interventions, so missing out on the possibility of a better pregnancy outcome, exemplified the lack of access to services in remote regions [45].

We recommend that maternal and family health service managers at the national, state, and local levels devote resources to adapting and testing existing culinary nutrition programs or, as appropriate, developing new culinary nutrition programs tailored to these life stages, as a result of the potential benefits of culinary nutrition interventions during pregnancy and postpartum identified in this review. Culinary nutrition programs for pregnant or postpartum women might be incorporated into existing health education programs or offered separately. A workforce with culinary nutrition expertise in maternity and family health care would be required to support such initiatives.

Nutrition Education

For this group is included in the demographic group prone to nutrition and health concerns, nutrition education is crucial during pregnancy [46]. According to cross-sectional research, pregnant women's understanding of nutrition during pregnancy went from 53.9 percent to 97 percent after receiving nutrition education, while their pregnancy-specific dietary practices increased from 46.8 percent to 83.7 percent [47].

Besides knowledge, GWG is also an important issue to be discussed In both the short and long term, excessive GWG is linked to unfavorable health outcomes for mother and child health [48]. Excess GWG is linked to an increased risk of hypertensive disorders [49], glucose intolerance [50] and and poor delivery outcomes during pregnancy [51]. It also predicts more significant baby morbidity and fetal development, such as birth weight, big for gestational age, and macrosomia, among other things [52].

Olson et al., [42] In their experiment, a self-directed, integrated online and mobile phone behavior modification intervention failed to show a beneficial effect on the proportion of the sample with excessive total GWG when compared to an information-only placebo control condition (which is included in this review). It was most likely discovered because the intervention was self-directed. That may have been a wrong decision. Structured, personalized treatments were more likely to be successful in promoting dietary change, according to a recent assessment of the research on e-behavioral nutrition interventions [42].

One research included in this review, which focuses on the hemoglobin blood level as an outcome, was done in Palestine. Compared to the control group, the study found a substantial beneficial link between dietary behaviors and improved hemoglobin levels. Compared to the control group, there was also a good connection between maternal hemoglobin levels in the third trimester and tiredness levels in the study group [36]. According to review research, nutrition education such as counseling, web-based, and text messages may enhance pregnant women's adherence to iron supplements. The research also stressed the significance of a more extended trial period to assess the intervention's effectiveness correctly [53].

According to the World Health Organization, pregnant women who reside in areas with high nutritional deficits should get some primary nutritional treatment. Nutrition counseling on a healthy diet, energy and protein dietary supplements, iron and folic acid supplementation (all settings), calcium supplementation to reduce the risk of pre-eclampsia in settings where dietary calcium intake is low. Zinc supplementation is only recommended for pregnant women in the context of rigorous research, and multiple micronutrient supplementation is all recommended in settings where 20% or more of women are underweight. Nonetheless, in areas where nutritional shortages are common, several micronutrient supplements include iron and folic acid, may be recommended for maternal health [54].

 

CONCLUSION

Nutrition education in many methods has a power to improve knowledge, and dietary change of pregnant women. However, there is a need for future large high quality trials using a standardized approach to measuring and reporting similar findings across studies. A future study might use a double-blind RCT approach with larger sample size and a variety of nutritional outcomes. Longer duration in implementing the trials will improve the outcomes of the study as expected.

 

Limitation

Our study has several flaws, including a lack of access to the most often recommended databases for searching relevant literature and, ultimately, trial trials. Some research relied on self-reported outcome measures, which might be vulnerable to various biases (e.g., recall bias and response bias). Because some of the studies are of intermediate quality, their conclusions should be read with care. We should also consider that non-English paper were not considered and included in this review, with a potential bias to not identify as many eligible studies as possible.

 

Conflict of interest statement

The author(s) declares no conflict of interest.

 

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Acknowledgements

We express our gratitude to the director of Jambi University for its support for the implementation of this research and President of Jambi University, Indonesia

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by OPI Napoli

The influence of mobile app in Glycemic Control and Prevention of Hypoglycemics in Diabetic management: A Systematic Review

Netha Damayantie^1* Muhammad Rusdi², Syamsurizal², Ummi Kalsum³

¹ Student of Doctoral Programme faculty of Mathematic and and science, Jambi University

² Chemical Education Study Program, Teacher Training and Education Faculty, Jambi University

³Public Health Study Program, Medicine and Health Sciences Faculty, Jambi University

 

* Corresponding author: Netha Damayantie, Jl. Jambi - Muara Bulian No.KM. 15, Mendalo Darat, Kec. Jambi Luar Kota, Kabupaten Muaro Jambi, 36129, Indonesia, Orcid : https://orcid.org/0000-0002-5628-2700. Email: netha.dam.57@gmail.com

 

Cita questo articolo

Abstract

Background. The use of technology in the treatment of diabetes can facilitate the medium of communication between nurses and clients in data collection to create a comfortable life for patients. The use of mobile health technology in diabetic education is an innovative learning method that can engage patients and influence positive health behaviors.

Aim. This study aims to find out the influence of mobile-based education applications in the Haemoglobin A1c control and prevention of hypoglycemia in patients with type 2 diabetes mellitus.

Methods. Database search for article are from four databases such as Pubmed, Sciencedirect, Proquest, and Cochrane is limited to the publication of the last ten years from 2010 to 2021 and full text article in English. Authors individually screened the titles and abstracts, then full articles in order to obtain papers that met inclusion criteria

Results. a total of 664 references were found. After duplicates were removed, 391 potentially relevant references remained from the database searches. Eight articles were finally designated as articles to be reviewed and use RCT design. Most studies put a Haemoglobin A1c (HbA1c) as a primary outcomes, and hypoglycemia as a secondary outcomes. Through the use of mobile app, there are reductions in HbA1c which affect the hypoglycemia events in Type 2 DM patients.   

Conclusion. Mobile application can enhance HbA1c and hypoglycemia control among T2DM patients. Because providing patient education face to face is time-consuming, the use of mobile application may be an effective complement or alternative for healthcare professionals to manage the rapidly increasing number of diabetes patients.

 

Keywords: Mobile app, Type 2 DM, Glycemic control, Hypoglicemia prevention

 

Introduction

Diabetes mellitus, particularly type 2, is a global health issue in the worldwide. The International Diabetes Federation (IDF) estimated an escalation of diabetes prevalence from 424.9 million in 2017 to about 628.6 million by 2045 [1]. More than 10,3 million people had diabetes mellitus in Indonesia [2]. Ninety percent (90%) of diabetes cases is type 2 diabetes mellitus with characteristics of insulin sensitivity disorders and/or impaired insulin secretion [3]. The prevalence of diabetes mellitus in Indonesia based on doctor's diagnosis in the population aged ≥15 years has increased from 1.5% in 2013 to 2.0% in 2018 [4,5]. Administration of insulin therapy causes the main side effect of hypoglycemia. Another side effect is the immune response to insulin which can lead to insulin allergies or insulin resistance [3]. Hypoglycemia is a condition in which glucose levels in the blood decrease below the value of 70 mg / dl or less [6,7].The prevalence of hypoglycemia with type II diabetes mellitus patients can reach 70-80%, which has a serious impact on morbidity, mortality, and quality of life [8]. Severe occurrence of hypoglycemia in type 2 diabetes mellitus patients reaches 3-73 episodes per 100 patients annually [6]. A common phenomenon in the clinical practice is that many patients argue that mild hypoglycemia as a consequence of hypoglycemic control [9]. In addition, many patients misunderstand the symptoms of hypoglycemia as a symptom of ketoacidosis, because they need to reduce or delay insulin administration [10]. Patients attempted to lower blood sugar levels without knowing the effects of using the drug where patients may experience severe hypoglycemia as the result. One of the reasons for the lack of patient knowledge about hypoglycemia is the lack of information provided by healthcare professionals [11]. Shreds of evidence have shown that the potential use of smartphone-based technology has helped people with diabetes in self-care management by staying connected with health care providers. Futuristic features are provided with all the ease to understand and use [12,13]. A well-suited App could transform a mobile phone into a medical device helping ease the burden of diabetes, preventing complications, and improving a patient’s quality of life. However, an overwhelming number of products and services are available to patients with diabetes. Patients and providers must recognize the characteristics of these products and services to capitalize on the advantages while avoiding harmful deficiencies [14]. The use of technology in the treatment of diabetes can facilitate the medium of communication between nurses and clients in data collection to create a comfortable life for patients. An important goal of treatment with electronic media is to enable patients the opportunity to maintain effective they education without interruption [12]. Interest in mobile health apps in supporting self-management of health arises because it is easily accessible, portable, low cost, convenient for users, and has a widespread. Furthermore, 50% of smartphone users will have at least one mobile health app [13]. The use of mobile health technology in diabetic education is an innovative learning method that can engage patients and influence positive health behaviors [14].

This review aims to collate and provide evidence related to mobile application for Glycemic Control, and prevention of hypoglycemia of Diabetes Melitus patients.

 

Methods

Design

This study is a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). PRISMA is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. PRISMA focuses on the reporting of reviews evaluating randomized trials, but can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions. Authors must use PRISMA as a guideline and theory underlying aims to help authors improve the reporting of systematic reviews and meta-analyses (PRISMA Statement, 2015).

 

Eligibility

Inclusion criteria for this systematic review are (1) adult-elderly patients (18-85 years), (2) uncomplicated or non co morbid diabetes mellitus patients, and (3) patients who are conscious and cooperative (4) study design that include in this review is randomized control trials (RCT). Exclusion criteria in this systematic review are (1) patients experiencing complications (stroke, heart, kidney), and (2) patients who have dementia and aphasia.

 

Search Methods

Database search for article are from four databases such as Pubmed, Sciencedirect, Proquest, and Cochrane is limited to the publication of the last ten years from 2010 to 2021 and full text article in English. Keywords used in the article search of all databases are combination of "diabetes mellitus" OR “Type 2 DM” AND "glycemic control” OR “Hypoglicemia prevention” OR “HbA1c” AND "health education" AND “m-health" OR “Mobile app”. The next step after the articles that meet the criteria are collected is to analyze and form the articles according to the specified inclusion   and   exclusion criteria. The article search process was carried out in August 2021. The article search uses keywords that have been determined by the researchers and limits the inclusion and exclusion criteria. The data obtained are then selected one by one by the researchers to determine the suitability of the articles desired by the researchers and delete the same articles or those that do not fit the criteria. After getting the articles according to the researchers, the articles are analyzed one by one and grouped to get the results. The next step is to discuss based on the points obtained from the selection results.

 

Critical appraisal

The included quantitative studies were appraised using the McMaster Critical Review Form for quantitative studies [18]. The critical appraisal process was undertaken independently by the two authors. Discrepancies in scoring were then resolved through discussions until consensus was achieved.

There are 13 question items that can be answered with yes, no, and not addressed options. Scores are given as a percentage, and one point for each question item if available. 90% were categorized as high quality, 70% medium, and low quality for the rest.

 

Data Abstraction

Two authors independently reviewed the abstracts of studies retrieved from the database Search and read the full-text of potentially relevant articles. For studies that met the inclusion criteria, data extraction was independently conducted by two investigators using our data extraction tool adapted from existing guidelines and other review articles of mobile application for DM [19,20]. Using this tool we extracted the general and mobile app features of the papers including the outcome, study design, characteristics of the intervention, evaluation method and main findings. Disagreements in data extraction were solved by a third investigator.

 

Data Analysis/ Synthesis

Data of the studies included were synthesized thematically in order to understand the effectiveness of mobile application. Thematic analysis involves discovering, interpreting and reporting patterns and clusters of meaning within the data. Using this frame-work and by reading the included articles several times, themes were identified. Subsequently, these themes were further examined for their similarities, differences and contradictions. The subject matter of the findings from the quantitative studies was examined, and the resulting information was placed under the qualitative themes. This integration of quantitative findings to the qualitative themes was completed by the first author. The second author reviewed the matched themes and quantitative studies. Any disagreement was resolved through mutual discussion. Due to the heterogeneity and insufficient number of the studies included, we could not conduct meta-analyses.

 

Results

Search Results

Combining the output of the searches in the various databases, a total of 664 references were found. After duplicates were removed, 391 potentially relevant references remained from the database searches. 283 articles removed by reasons of irrelevant, review/report, not full text, book chapter. Eight articles were finally designated as articles to be reviewed. PRISMA flowchart for Study selection can be presented in Figure 1.

Figure 1. PRISMA flowchart for Study selection

The main focus of this systematic literature review is the effects of mobile app on hypoglycemia prevention. However, to optimize the interpretation of these effects, we will first clarify the methodological quality and characteristics of the studies, as well as the characteristics of the mobile app under review. The authors developed tables for data analysis with the type of diabetes addressed in the review article, the types of technology used for the intervention along with outcomes measured. The most common health outcome measure was hemoglobin A1c (A1c), and hypoglycemia may present in secondary outcome. This shared data element allowed comparison between the varying interventions addressed in these reviews.

In Table 1 we reported the articles included in our study.

Table 1. Data extraction of studies included

 

The result of Critical review

The results of the critical appraisal of the studies are presented in Table 2, respectively. The data that contributed to the generation of these themes are presented narratively in the following results subsection, with the appropriate source references identified.

Table 2. Critical review for Quantitative studies included

Critical appraisal of quantitative research studies: As outlined in Table 2, all of the studies had a clear purpose and relevant literature reviews. All of the studies reported appropriate conclusions, given their study purpose.

Table 2 shows the value of Cohen's kappa coefficient in each article with a range of 0.41 to 0.806 with a moderate to strong category. This coefficient is the result of two reviewers who evaluate each article separately.

 

Study Characteristics

Most of the selected reviews used research from locations around the globe. Articles that meet the inclusion criteria come from several countries including China [21–23], USA [24,25], Norway [26], Japan [27], and France [28]. The mean age range reported was from 38 to 68 years old. Duration of the intervention was 3 months [27], 6 months [21,22,26], 9 months [23], and 12 months [24,25,28]. The number of participants involved in the study was in the range of 54 to 665 patients divided into intervention and control groups.

 

Outcomes Measured, Primary Focus

Primary outcomes

Change in HbA1c level after 1 year was chosen as the primary outcome because it is the main target measure when treating diabetes and is frequently used when evaluating interventions. HbA1c data were collected through the GPs and were assessed primarily with the Siemens DCA Vantage Analyzer a maximum of 2 weeks before or after the follow-up to reduce measurement bias [26].

In the study of Waki and colleague, HbA1c as a primary outcome was measured from baseline to 3-month follow-up for each patient with an intention-to-treat analysis in intervention and control groups [27].

The primary outcome of Quinn [25] study was change in glycated hemoglobin comparing control usual care (UC) and maximal treatment (Coach primary care providers portal with decision support (CPDS) at baseline versus 12 months. Medical chart reviews were used to ascertain patient data. For patients without a glycated hemoglobin within 4 months of the desired measurement, a glycated hemoglobin test was offered at no charge at baseline to determine eligibility and at 12 months. At baseline, glycated hemoglobin was measured using one device, the Bayer DCA 2000, by trained staff  blinded to patient group assignment. At follow-up, if glycated hemoglobin was not ascertained within 14 days of the 12-month time point, reminders were provided to patients and physicians to complete the test. Glycated hemoglobin level at intermediate time points (3, 6, and 9 months) was collected from patients’ medical charts [24,25].

Franc et al. determined the primary outcomes of their study was the mean change in HbA1c from baseline to 12 months (primary endpoint), and the occurrence of hypoglycemia. An independent ‘‘Hypoglycemia Adjudication Committee’’ validated the classification of all declared hypoglycaemic episodes. A severe hypoglycemic episode means that the patient required the indispensable assistance of a third person. A symptomatic hypoglycemic episode refers to those symptoms of hypoglycemia associated with rapid recovery after self-administration of sugar [28].

The primary outcome in Xu et al study [22] was diabetic symptom scores. It was assessed by the diabetes symptom grading and quantitative scale according to the Guidelines for the Clinical Research of Chinese Medicine New Drugs. Secondary outcome was blood glucose level including fasting blood glucose, 2-h postprandial blood glucose (2 hPG), and glycated hemoglobin (HbA1c) at baseline and 6 months after intervention. Serum HbA1c level reflects a patient’s blood glucose concentration during the previous 2–3 months, so it was taken into consideration as an essential indicator [22].

The primary outcome in Zhang et al. study [29] was glucose control, including the changes (from baseline to months 3 and 6) in the HbA1c level. The major adverse event was hypoglycemia. Hypoglycemia was defined as BG ≤3.9 mmol/L [21].

In the Sun study, there were intervention and control groups. Primary outcome was self-administered blood glucose level. HbA1c level was measured at 3 and 6 months [23].

The primary outcome of Quinn study [24] was the change in HbA1c (% of total hemoglobin) in the control group versus in the intervention group, at baseline versus at 12 months. HbA1c levels were recorded at baseline and at 3, 6, 9, and 12 months. Patient data were retrieved from medical charts [24].

 

Intervention Features

We will describe a mobile application intervention based on each of the studies that we included in this review. Holmen et al., [26]: To increase self-management comprised of 3 intervention groups:  the Few Touch Application (FTA) intervention group, the FTA with health counseling (FTA-HC) intervention group, and the control group. The FTA-HC group received health counseling for the first 4 months of the project period. The health counseling was based on the transtheoretical model of stages of change and a problem-solving model, and used motivational interviewing as a counseling technique. The health counseling in the present study was part of the mHealth intervention.

Waki et al., [27]. DialBetics is composed of 4 modules. First is the data transmission module: patients’ data—blood glucose, blood pressure, body weight, and pedometer counts. Second is the evaluation module: data are automatically evaluated following the Japan Diabetes Society (JDS) guideline’s targeted values. Third is the communication module: about meals, and advice on lifestyle modification. Fourth is dietary evaluation: patients’ photos of meals are sent to the server.

Quinn et al., [25]. The mobile software allowed patients to enter diabetes self-care data (blood glucose values, carbohydrate intake, medications, other diabetes management information) on a mobile phone and receive automated, real-time educational, behavioral, and motivational messaging specific to the entered data. The patient web portal augmented the mobile software application and consisted of a secure messaging center (for patient-provider communication), personal health record with additional diabetes information (e.g., laboratory values, eye examinations, foot screenings), learning library, and logbook to review historical data.

Franc et al., [28]. A reference nurse initiates the patient to the use of the DIABEO app on his smartphone. The patient enters relevant data (glycemia, physical activity, and ingested carbohydrates) and DIABEO calculates the insulin dose (an eventual dose adaptations). These data are sent every 2 h to a platform that is continuously visible by the reference nurse and the investigator.

Xu et al., [22]. The smartphone app for diabetes management was composed of 4 modules: syndrome differentiation, body differentiation and health preservation, thesaurus, and interactive follow-up. A reminder message would be received if the patients forget to complete that in time. The diabetes educators can track the data from the app and provide specific guidance and suggestions for the clients.

Zhang et al., [21]. Welltang app mainly comprises 4 parts: education, self-management (including records of SMBG, diet, exercise, medication, body weight, and other diabetes data), patient community, and communication between patients and clinicians. For clinicians, Welltang mainly provided the real-time uploading of data from patients.

Quinn et al., [24]. Mobile diabetes management software application (MDMA) allowed patients to enter diabetes self-care data (blood glucose values, carbohydrate intake, medications, and other diabetes management information) on a mobile phone and receive automated, real-time messages that were educational, behavioral, motivational, and specific to the entered data.

Sun et al., [23]. Patients uploaded the glucometer data to the mHealth management app which was then automatically transmitted to the medical server (glucometer was connected to the mobile phone via Bluetooth). The medical teams sent medical advice and reminders to patients to monitor their glucose levels via the personal messaging app or telephonically every 2 weeks.

 

Discussion

This systematic review provides an overview of studies on mobile applications in improving HbA1c and hypoglycemic control among T2DM patients. The highest decrease in HbA1c was 1.9% which is relatively high compared to several previous studies, which found a decrease in HbA1c of 0.49% [30] and 0.51% [31]. There was no subgroup analysis in studies involving patients in different age groups. In general, it can be concluded that mobile application interventions can provide the same benefits for younger (<55 years) or older (≥55 years) T2DM patients. It is inconsistent with findings from a previous systematic review [30], which suggested that ST interventions were more effective for younger T2DM patients than older patients. The mobile applications in the included studies are complex and generally include more than one component. Almost all studies evaluate mobile applications related to lifestyle modification and self-monitoring of blood glucose. Therefore, it is logical to conclude that a decrease in HbA1c is associated with improving the patient's lifestyle. Although quality improvement programs are usually multi-component, they are more oriented towards targeting changes in health care provider behavior or service delivery models [32]. Interventions using mobile applications have a stronger focus on empowering patient behavior change. A systematic review Barreira et al., [33] showed that exercise effectively reduced HbA1c. Of the four included studies, which have included a component of exercise adherence monitoring [23,26,27], this suggests that a mobile application may be an effective adjunct to controlling HbA1c, or It is more common to enhance lifestyle modification efforts among type 2 DM patients. These studies also suggest considering the mobile application as a complementary intervention that can be used in diabetes self-care strategies more effectively through lifestyle modification and self-monitoring blood glucose. In the included studies, self-monitoring of blood glucose was also included as part of a mobile application intervention, while its effectiveness in controlling DM was uncertain.

A previous systematic review study Xu et al., [34] concluded that SMBG only contributed to a 0.46% decrease in HbA1c. Available evidence suggests that SMBG can promote self-management, increase medication adherence rates, and improve the patient's ability to detect hypoglycemia [35]. However, the UK National Institute for Health and Care Excellence guidelines state that SMBG is not recommended as part of routine DM management but should be considered in subgroups of patients, such as those receiving insulin therapy and patients prone to hypoglycemia [36]. Current clinical practice guidelines recommend close monitoring of HbA1c and titration of drug therapy instead [37]. It was difficult for us to find relevant literature on mobile applications to reduce the risk of hypoglycemia in both type 1 and type 2 DM patients. Several studies that we included in this review made hypoglycemia a secondary outcome. The results obtained from the two studies stated that there was no significant difference between the intervention group and the control group. Reports of signs and symptoms of hypoglycemia occurred only once or twice in 1 year of follow-up [25,28]. However, post hoc analyses of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial indicated an increased hypoglycemia risk in type 2 diabetic participants with poorer glycemic control than subjects with more desirable HbA1c levels, irrespective of assigned treatment group [38]. Based on this statement, it can be concluded that from all studies included in this review, the mobile application can provide an effect on controlling hypoglycemia levels in Type 2 DM patients, although it is not clearly stated how the mechanism is. Little is known about the relationship between glycemic control and hypoglycemia in the usual care setting, where clinical decision-making about treatment intensity occurs and is modified throughout a patient's life [39].

Based on the two studies included in this review, it appears that there is no significant effect of the use of mobile phone applications on the quality of life of people with diabetes. The possible cause of no significant change in the quality of life before and after using the application is the age of the participants, most of which are in the elderly who feel less interested in using technology, especially smartphone-based [26]. The elderly need more intensive guidance regarding the use of technology applications, usually the elderly ask to be accompanied by family members or people who care for them. For the elderly who feel the exhaustion of their illness, they often hand over the responsibility to the people who take care of them [40,41].

 

Conclusion

In conclusion, mobile application can enhance HbA1c and hypoglycemia among T2DM patients. Because providing patient education face to face is time-consuming, the use of mobile application may be an effective complement or alternative for healthcare professionals to manage the rapidly increasing number of diabetes patients.  Because providing patient education face to face is time-consuming, the use of mobile application as an educational media may be an effective complement or alternative for healthcare professionals to manage the rapidly increasing number of diabetes patients. The evidence suggests that organizations, diabetes educators, policy makers, and payers should consider these solutions in the design of diabetes self-management education and support services for population health and value-based care models. With the widespread adoption of mobile phones, digital health solutions that incorporate evidence-based, behaviorally designed interventions can improve the reach of and access to diabetes self-management education and ongoing support.

 

Limitation

We have identified several limitations in this study, including limited access to several good-quality databases, which are expected to provide broader search results. In addition, studies that matched our inclusion criteria were also very limited with regard to hypoglycemic control. We also considered potential bias related to different intervention/app, duration of intervention, and the limited numbers of RCTs included. Also, in the search strategy, some important databases are missing.

 

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.

 

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by OPI Napoli

Nurses' experiences and emotions in the face of changes caused by the COVID-19 pandemic: a phenomenological study

Sara Muzzicato¹, Lorenza Garrino², Vincenzo Alastra², Valeria Miazzo¹

1. Opera San Camillo Foundation, Turin
2. Master Executive Narrative Practices in Care Professions, COREP, Turin

*Corresponding author: Sara Muzzicato, Department of Rehabilitation, Recovery and Functional Rehabilitation Level 2, Fondazione Opera San Camillo, Turin. Email: sara.muzzicato@gmail.com

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ABSTRACT

Introduction: Following the Covid-19 pandemic, healthcare personnel had to face a very difficult period linked to the healthcare emergency, with important repercussions from a professional and personal point of view. These aspects have been explored by numerous researches on an international level, but only a small number of articles have investigated the phenomenon in the Italian context. The aim of this research is to describe the experience of healthcare workers in a Covid ward, exploring their emotional responses.

Materials and Methods: The study consists of a qualitative research with a phenomenological approach according to Giorgi. Narrative interviews were used with healthcare workers who worked in a Covid ward at the San Camillo health centre in Turin, a hospital specialising in second level functional recovery and re-education.

Results: Through the field research, 12 interviews were collected, involving 9 nurses and 3 social-health workers, working in a ward dedicated to the care of Covid-19 patients. The common themes that emerged concerned: the beginning of the Covid operator's "journey", characterised by a profound change in professional life since the beginning of the pandemic; the whirlwind of emotions and feelings experienced (fear, feeling blocked, annulled, powerless, depersonalised by suits and masks, anguish due to both physical and psychological isolation, etc.); relations with family members and friends; the relationship with the patient's family; relations with the operators' families; the risk of contagion and the fear of infecting oneself and one's loved ones; the group as a handhold for not giving up, as a point of strength, union and trust; the awareness of change with the desire to take one's own life back into one's own hands, taking advantage of the good things this time can give.

Conclusions: The research highlights the ability of the operators to identify positive aspects in the experiences lived, the union and trust in the group and the support of the family despite the strong fear of contagion. There are also important suggestions to reinforce strategies for dealing with such health emergencies and the importance for each individual in feeling accompanied throughout the process, in the difficult challenges they face.

Keywords: Covid-19, Experiences, Nursing, Narrative, Phenomenological approach.

 

 

INTRODUCTION

On 31 December 2019, Chinese Health Authorities reported to the World Health Organisation a cluster of cases of pneumonia of unknown aetiology in the city of Wuhan, in China's Hubei province. On 9 January 2020, the Centre for Disease Control and Prevention of China reported that a new coronavirus (SARS-CoV-2)^[1] was identified as the causative agent of the respiratory disease later named Covid-19. China made public the genome sequence that enabled a diagnostic test and on 30 January 2020, the World Health Organisation (WHO)^[2] declared the Coronavirus outbreak in China to be an "International Public Health Emergency" ^[3,4]. From then on, the word 'COVID-19' has indicated the disease associated with the SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2), characterised by mild symptoms (fever, sore throat, fatigue, muscle pain, loss of taste and smell) or more severe symptoms (pneumonia, respiratory failure)^[5]. Such symptoms have often led to the need for intensive care^[6,7], thus causing high pressure on hospitals struggling to cope with too many patients to care for ^[8]. In this catastrophic scenario linked to the epidemic, Italy was one of the countries most affected^[9]. Between the beginning of February and 30 November 2020, 1,651,229 positive Covid-19 cases were diagnosed by Regional Reference Laboratories and reported to the Italian National Institute of Health (NIH) - Italian National Integrated Surveillance System by 20 December 2020^[10].

The pandemic has had different intensities and lethality in Italy compared to the rest of Europe. Differences in lethality rates are explained by: demographics, as mortality tends to be higher in older populations with co-morbidities; characteristics of the healthcare system, where there are organisational shortcomings, initial delays in understanding the severity of the emergency, deficits in infection tracking systems, hospitals overwhelmed by admissions, etc.; differences in the number of people tested; and different levels of virus aggressiveness^[11].

Italy faced an unprecedented health crisis, with serious shortages of health professionals and difficulties in procuring personal protective equipment. New organisational models had to be implemented and hospital inpatient facilities had to be rapidly transformed into units suitable for the care of pandemic patients^[12].

The NIH weekly bulletin of 28 April 2020 stated that 47.4% of the cases of infection among healthcare personnel were nurses^[13].

In Italy^[14] according to the provincial records, 40 nurses died, 32 of whom with the Covid-19 disease (positive swab), 4 with Covid-related illness (for whom the viral pathology was a favourable factor) and 4 (positive in any manner) for whom the mode of death was suicide^[15]. A different view of the same phenomenon is reported by the monitoring as of 15 June 2020 conducted by INAIL (Italian National Institute for Insurance against Accidents at Work). INAIL, considering the accident reports referring only to insured workers, certified that there were a total of 236 deaths from Covid-19, of which 40% were healthcare professionals and 61% were nurses. In this complex epidemiological and healthcare framework, healthcare personnel reported the consequences of significant psychophysical stress with experiences and emotions still largely to be explored. Arasli et al. (2020)^[16] explored experiences during the Covid-19 pandemic through testimonies written by nurses on social media through qualitative research. The study showed a high level of stress among healthcare professionals related to the risk and fear of becoming infected. Labrague et al. (2020)^[17], through a quantitative study conducted in a region of the Philippines, highlighted high dysfunctional levels of anxiety in frontline nurses, while recording an increase in their resilience. On the Italian scene, Catania et al. (2020)^[18] carried out qualitative research involving nurses from all regions of the peninsula. This study highlighted the enormous impact of COVID-19 on nurses, the need to identify new working practices, and highlighted the high-risk nature of nursing, exacerbated by the difficulty in Personal Protective Equipment (PPE) availability. In addition to reporting the high levels of stress experienced by the interviewees, the element of narratives also highlighted the resilience of the nursing community. Qualitative research was conducted by De Vito et al.^[19], through the narratives of paediatric doctors and nurses in the paediatric emergency room of the Regina Margherita hospital. The authors emphasise how much the number of admissions in the paediatric sector had fallen, reflecting profoundly on changes in care, but also on the relationship itself with and between patients.

The results of the study show how the act of describing helped participants to process and understand their experience. Storytelling provided a cathartic means for participants to reformulate the events they experienced, rationalising them and making sense of them. In the Turin landscape, the experiences of nursing students were investigated. Garrino et al. (2021)^[20], through a qualitative study, emphasised the changes induced by Covid-19 in nursing education. The need to use distance learning and the impossibility of doing internships during the pandemic period created many difficulties in training students. The narrative approach^[21] and reflective thinking^[22] aim to capture the latent aspects and hidden meanings of the complex pandemic reality^[23,24].

The aim of the research is to describe the experience of health workers on a Covid ward, exploring their experiences and emotions.

 

MATERIALS AND METHODS

Study design

In this study, a qualitative methodology was used to investigate subjective phenomena, based on the assumption that fundamental truths about reality are rooted in people's lived experiences. This method allows for exploration of experiences by the person who has them, attempting to describe the meanings that the individual creates and gives to that experience, understanding the structure, nature and form, as perceived by the individual^[25]. This survey aims to understand the experience of nurses and social workers during the first wave in a ward caring for Covid-19 patients, and who are now called upon again to provide the same type of care, in order to find out how the workers in question have responded to a pandemic emergency which, in addition to involving the work aspect, has invaded the personal sphere.

 

Background

The San Camillo hospital, as a hospital specialising in second-level functional recovery and rehabilitation, provides intensive rehabilitation treatment in the post-acute phase of the illness. The hospital has five departments that fulfil this function.

In November 2020, during the second wave of the pandemic, two wards were dedicated to the care of Covid patients. The health workers of these two wards, defined as 'COVID staff', had to cope with this new situation with various difficulties that have also characterised many healthcare facilities in Italy, but in this second phase they were able to use sufficient and appropriate PPE. The COVID wards of the facility were designed for a maximum capacity of 20 beds and intended for the care of patients coming from the intensive care units of other hospitals and in the sub-acute phase. Other patients in the early stages of the disease came directly from the emergency rooms of local hospitals, which could not cope with all the demand at that time. During admission, the intention was to stabilise the clinical condition and ventilatory support consisted of a Venturi mask or nasal cannulae, not having the tools provided in intensive care, such as assisted ventilation or intubation of the patient. The hospitalisation continued until the swab was negative, although the symptoms had already receded. Few of these patients died in the facility. The research was conducted in only one of the two Covid departments (with the participation of three respondents who worked in the second department, but who had worked sporadic shifts in the Covid department under consideration).

 

Participants

In this study, nurses and social workers (OSS) working in the Covid ward of the San Camillo hospital in Turin agreed to participate. Participants include the researcher (MS), in the role of observer-participant.

 

Mode of data collection

The study was based on a collection of semi-structured interviews consisting of 11 open-ended questions (Box 1) and proposed directly to the persons involved by email^[26,27]. Respondents participated on a voluntary basis. Non-probabilistic, purposive sampling continued until data saturation, collected between 15 December 2020 and 15 January 2021. The questions for the semi-structured interviews were elaborated with the narrative interview method^[28] and were chosen through the "SIFA" method, in order to try to explore each sphere of interest regarding Feelings, Ideas, Functions/Activities of the client, Expectations^[29].

 

Methods of data analysis

For data analysis, the phenomenological method according to Giorgi (2008)^[30] was used (Box 2). The interviews were read over and over again, seeking personal assessments through a suspension of judgement. Subsequently, an attempt was made to find common areas of meaning describing the most important themes reported by the interviewees^[31,32]. The analysis was conducted independently by researchers S.M., L.G., V.A. and V.M. They then compared their work using the triangulation method^[33]. During the analysis, the researchers reflected on their own values and suspended judgements, knowledge and ideas about the phenomenon under study^[34].

 

Ethical consideration

The persons involved voluntarily agreed to answer the interview and signed an informed consent on the use and processing of the data. The research was authorised by the Health Directorate and the General Directorate of the San Camillo Hospital.

 

RESULTS

Through field research, 12 interviews were collected. Table 1 shows the socio-demographic data of the participants.

Table 1 - Social and personal data of participants

The average age of those involved is 30, with a minimum age of 23 and a maximum age of 47. All operators were professionally trained in Italy. None have postgraduate or Master's degrees. Several main and recurring themes emerged from the analysis of the interviews. These macro-categories bring us back to the experience of the participants. Terminology as presented and written by the interviewees themselves is reported, outlining the importance of the meanings expressed by them. The following themes emerged: the beginning of the Covid worker's 'journey' and the whirlwind of emotions and feelings that accompanied that (fear, feeling stuck, helpless, powerless, concerns for one's family in relation to the risk of contagion and the fear of infecting oneself and loved ones), the group as a foothold to keep going, a point of strength, union and provider of trust, the awareness of change, the cognition of time and the constructive vision of the experience (table 2).

Table 2 – Main themes emerging from the analysis

 

The start of the Covid worker's 'journey'

The interviews reveal the profound change that occurred in the participants' professional lives at the beginning of the pandemic. Most of them talk about the impossibility of choosing whether to work in a Covid department or not, often indicating it as a decision linked to a sense of duty fulfilment.

[...] "It wasn't really a personal choice to join the Covid team... I happened to be there, and I was probably OK with that." [...] (interview 1)

[...] "I didn't really have a choice in deciding whether I could work closely with Covid-positive patients... So compared to my start in a Covid department, I can't even explain how it came about." [...] (interview 3)

Participants underline the initial impact they had following the news, accompanied by a set of feelings that were difficult to deal with at the time and to talk about later. They describe thoughts, emotions and sensations and there are often conflicting feelings, accompanied by fear, anxiety and stress.

[...] "Literally thrown into the deep end... My thoughts were questions. Why? Why? Why? So many questions that had no answers." [...] (interview 8)

[...] "I'm still trying to figure it out... on the front line in a Covid ward... I wasn't chosen, I found myself there almost by accident." [...] (interview 7)

In the interviews, the theme of travel emerges significantly, as a symbol of uncertainty and restlessness in trying to know and explore unknown places; as well as the theme of battle, almost as if they had to fulfil a destiny already written in their professional profile.

[...] "I didn't feel chosen, I felt enlisted in an impromptu army for an impromptu battle... I was there, so I had to fight... I had the fear and adrenaline of those who leave without knowing the destination and the consequences of their journey." [...] (interview 4)

 

A whirlwind of emotions and feelings: fear, feeling stuck, helpless, powerless

Concerning the emotions felt during this long experience by the health workers, many of them found themselves facing different difficulties, multiple fears and feelings, one of the main ones being isolation, not only physical but also psychological.

[...] "I avoided even the contact allowed by the Decrees, I isolated myself completely, more than was necessary... All you can do is wake up in the morning and wonder when it will end... I would have liked to live fully, not at the mercy of anxiety and worry. [...] (interview 1)

[...] "I would arrive home drained, feeling nothing but tiredness that muffled all the outside world." [...] (interview 2)

[...] "I see myself as someone who put aside feelings and sensations to face a big battle, so today I don't even remember what I was feeling... We have lost all consciousness, we no longer saw well, we no longer heard well, we no longer spoke much..." [...] (interview 3)

Respondents write that they feel alone in this battle, misunderstood, stuck and aimless, depersonalised, helpless due to the suits and masks, powerless before an invisible enemy so difficult to defeat.

[...] "When I finish a shift, I feel like I have finished a test under stress... as though I had passed a test... many times I felt like I hadn't made it, as though the ground was sinking from under my feet, other times I felt empty, as though under that suit there was almost nothing left... as if I had failed, as if I hadn't done enough." [...] (interview 4)

[...] "I remember the fear... and the tiredness because I had been alone in facing that new beginning so physically and psychologically intense... The whole condition of isolation puts a lot of pressure on you psychologically... I felt powerless, a nobody before something so big... I felt like a wrapper, a container whose contents had been disposed of along with the protective suit." [...] (interview 5)

 

The family and the risk of contagion: the fear of infecting oneself and one's loved ones

A topic that is repeated in almost every narrative is the importance of family affection. This theme is often addressed in the interviews, emphasising the importance that health workers attached to the support given by their loved ones, but at the same time linked to the constant fear of infecting themselves and consequently their families.

 [...] "If I get infected will I be sick? And at home? If mum and dad get ill? Who will take care of Granny if we are sick? What if Granny gets sick?" [...] (interview 1)

 [...] "I was afraid though, afraid of not being up to it and afraid of infecting myself and my loved ones." [...] (interview 2)

[...] "The biggest fear I had was that I would get worse and that I could infect my partner... that last idea drove me mad." [...] (interview 5)

There was a high level of stress among the interviewees, which, despite everything, also contributed to an increase in attention and precautions regarding safety regulations, the correct use of personal protective equipment and the correct way of disposing of it.

[...] "At the onset, I didn't have tumultuous emotions, it was the people next to me who were really very worried and I honestly experienced their emotion... The first thing I think about when I start my shift is that I must not get sick, so I must do everything I can to avoid infection." [...] (interview 3)

[...] "I try to be focused because you can let your guard down due to tiredness and then risk getting infected." [...] (interview 12)

 

Conflict with PPE: distancing, anonymity and protection

The interviews reveal the perceptions of nurses and social workers obliged to wear "all those layers of latex", exploring their experiences in relation to the care provided to their patients on the Covid ward. Nurses and social workers talk of overalls, double gloves, double masks, footwear, goggles and face shields which, while vital for working on Covid wards, have raised barriers between staff and patients.

[...] "A person covered from head to toe without knowing what he looks like or not remembering his name, as if he wasn't human... and all I know of this person are his brown eyes surrounded by a mask and a big suit." [...] (interview 1)

[...]“"Halfway between astronauts and aliens!" [...] (interview 2)

[...]“I never imagined that I would keep my physical and moral distance from a patient in such a way that I could become one of the many operators, just any operator, someone easily replaceable... I didn't use to feel naked unless wearing a gown, visor and mask, whereas now I do." [...] (interview 3)

[...]“"So many little white men, completely covered by overalls, gowns, masks, gloves and visor, almost clumsy in their movements and practically indistinguishable from each other... What I miss most is being able to show my smile to the patients, free from masks, and to shake their hands, free from those multiple layers of gloves." [...] (interview 5)

[...]“Living diving suits... it's as though there were a thousand barriers, a thousand layers separating us...a gentle caress with double latex gloves is not the same..."[...] (interview 6)

 

The group as a foothold for not giving up: strength, unity and trust

From the interviews, it emerges that the group has been a strong point, an important support for the health workers to go on and not give up.

[...] "I have never believed in the motto 'unity is strength' as I do now... in April there were so many brave little soldiers, in November we were one giant soldier...I don't feel alone, never; I feel escorted, I feel that someone is looking out for me as I am looking out for someone else... the working group has become a family... I would get through this as long as I had this team to rely on." [...] (interview 4)

[...] "I am grateful to her for that moment, for understanding me and giving me strength when she was probably also on her last legs. We hugged each other when we left the hospital, amidst tears. I don't think I could have done it without her that day." (Interview 6)

[...] "We have been able to overcome some difficult moments only thanks to our unity. (Interview 7)

According to the interviewees, coping with such a complex period with one's team helped to increase cohesion, strengthen group dynamics and was often the driving force needed to cope with stressful situations.

[...] "The wonderful team I have the honour of sharing this experience with has become very cohesive. We all worked together for the same goal on the same road, holding hands, hugging ideally, supporting each other, experiencing the same feelings, falling down and helping each other up." [...] (interview 3)

[...]“"I believe that the greatest strength came from the working group, which I have never before felt close to me, or rather part of me... in the group set up for the Covid emergency, I really found a rock to rely on. We work with common principles, side by side to achieve the same goals. What I perceive between us is harmony, respect and sharing"[...] (interview 5)

 

Awareness of change: time, self-work, constructive view of the experience

What emerges from the interviews is the strength and the desire to take charge of one's own life again, the desire to make it through this pandemic, trying to find a positive side, not to throw everything away, to seize what good can come from this experience. From the words of those interviewed, one can see a devastating past and present, which has affected people greatly, but also a future full of hope.

[...] "I hope to be myself with some more awareness, especially about what was taken for granted before Covid... I'm happy to still feel like myself, to not want to give in to the suffering that Covid forced us to face every day." [...] (interview 2)

[...]“"I worked on myself like we all did...The nurse I loved to be is here somewhere, she is not gone... My job will go back to that wonderful normality I loved, with some more experience, some scars that won't go away, some indelible memories..."[...] (interview 4)

[...]“"I hope to still be the same, with more experience on my shoulders. Of course, the pandemic has changed everything and everyone, but life goes on and you have to think about facing the next enemy."[...] (interview 8)

[...]“"I hope to see myself proud of what I have done, I hope to have left a good memory in the people I have met and I will be able to say this one is gone too." [...] (interview 12)

 

DISCUSSION

The aim of this study was to describe the experience of healthcare workers in a Covid ward, exploring their emotional experiences and attempting to capture the meanings that the individual creates and gives to that experience, understanding the structure, nature and form, as perceived by the individual. This survey collected the experiences of nurses and social and health workers who worked in a ward for the treatment of patients affected by Covid-19, in order to know how they responded to an emergency situation that not only involved the work aspect but also invaded the personal sphere. From the data collected, it emerges that the pandemic is immediately experienced by health workers as insidious, bringing uncertainties and anxiety, emotions and feelings that can be traced back to a scenario reminiscent of a battle. You feel overwhelmed by a storm, you prepare for the arrival of a real 'enemy' ^[19]_, you find yourself united by the same feelings, but at the same time alone and ill-prepared, forced to take the to the field with the few weapons available. This describes the whirlwind of emotions, fears, worries, feelings of helplessness, a mixture of negative feelings in which there is rarely any slight hope for the future. In the interviews, all subjects tell of their fears: of becoming sick and infected, of being isolated, of not being ready to face the big changes in the work structure. This issue is dealt with extensively by Catania et al.^[18] and by De Vito et al.^[19], highlighting how the narratives of the nurses, also working in different wards, underline the common theme of the physical and psychological impact that the change in work organisation had on the same individual workers and on team work. In the study by Arasli et al^[16], 'fear' and 'risk' were two of the most frequently used words by nurses in social media during the pandemic. Among the feelings experienced there is certainly no lack of anxiety, which is expressed several times in the narratives considered in this study and is also widely described in the article by Labrague et al.^[17]. From the data collected it emerges how the entire pandemic situation forces nurses and social and health workers to create a different way of being workers, a situation that almost imposes a different way of directing the therapeutic relationship no longer mediated by touch, words, reciprocal dialogue and the security of familiar clothing, but hindered by the trappings of a distancing "dress" and by the impossibility of speech that bring out a problematic core of objectification of care. This aspect emphasises how to deal with health emergencies, without at the same time renouncing the humanity of the therapeutic relationship that characterises this profession. All the images described in the interviews are of 'detachment' from one's own body which, within the innumerable protective layers within which it is forced, finds itself taking on a form unknown to the eyes of the subjects themselves. These people are the same as those who performed acts of care, but in doing so they all felt equal and experienced a human closeness made up only of glances. From the narratives of this research, a strong spirit of adaptation and resilience emerges in nurses, aspects also described by Catania et al.^[18] and Labrague et al.^[17]. This theme was widely taken up in the interviews, allowing us to outline through these nurses "made of suits and personal protective equipment", an image in which latex and nitrile are transformed into a material capable of absorbing a shock without breaking, to face and overcome a traumatic and extreme event, to give hope in the future. Wu Y. et al. ^[35] show that doctors and nurses working in Covid wards experienced lower levels of anxiety, depression and burnout than those working in their usual wards, with a response to the pandemic characterised by a high level of adaptation and resilience. The participants of our study emphasised that the team proved to be the most important strength in overcoming daily difficulties within the Covid department. The objectives for which the group meets and works together and the dynamics of consolidation of the process that forms the working group, from interaction to integration^[35], are essentially described in both processes and activities: the group intervenes whenever someone is in difficulty; a hand is always extended towards the other when one finds oneself lost in what should be a known world but has become an unexplored labyrinth. The feeling of belonging to the group is found to be a decisive positive factor also among the students of the article by Garrino et al.^[20], which underlines how the comparison between peers and the support provided by peers are a decisive element to deal positively with the practical traineeship experience.

Another important theme that emerged from the interviews was time. A time that sometimes expands, sometimes shrinks, but which must be lived anyway^[19]. In fact, the impact of the pandemic marked a deep rift between what was before and what would be after. This perception had different effects. On the one hand, it made them feel stuck and unable to imagine the future from such an uncertain present; on the other hand, it allowed them to discover new physical spaces and adopt new or renewed daily habits which helped them to imagine a possible future. The perspectives described are linked to fear, but also to the hope that normality will be re-established, both on the horizon of care and in daily life. These reflections represent an added value that contributes to a greater understanding of oneself and the role that one's experiences played during the emergency. Narratives have been a useful tool for making sense and meaning of the experiences associated with the pandemic experience^[19].

 

CONCLUSIONS

The research explored the lived experiences of a small group of health workers working in a Covid ward during the pandemic in November 2020. Telling stories was a chance to give shape to the situations experienced, continuing to plan oneself, giving new meaning and significance to one's existence. Narrative and mutual listening practices were recognised as very useful and effective in capturing and understanding meanings, emotions and representations about one's professional role and wider existential issues. This research provides evidence to improve the strategies to deal with a health emergency by listening to personal experiences and thoughts, by accepting the emotions and feelings felt by the care professionals, experiences and representations that, many times, in these situations the caregiver may struggle to express or, even, prefers to keep hidden under his uniform. It can be concluded that narrative medicine used in care environments, in situations where there is no space and time for the individual, offers the possibility to improve and increase the communication and cooperation skills of all; to develop new knowledge of each operator to improve the relationship with others; to give meaning and value to the experience of care of health workers and help them to process and alleviate, as far as possible, the emotional stress that accompanies them in the difficult path of care.

 

LIMITATIONS

Data were collected by sending an interview outline via email. This method was chosen due to the lack of opportunities to conduct the interview due to the national lock-down and to allow the interviewees to express themselves freely and openly without time constraints. this deprived the research of elements concerning the conducting and interaction aspects that usually characterise face-to-face interviews.

 

CONFLICTS OF INTEREST AND FUNDING SOURCES

No funding sources were used to support the project. There is no conflict of interest.

 

DECLARATIONS

No formal approval by the Local Ethics Committee was required for this study.

 

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29. Hogan-Quigley B., Palm M.L., Bickley L.B. Valutazione per l'assistenza infermieristica. Rozzano: Casa Editrice Ambrosiana. 2017.
30. Giorgi A.P., Giorgi B. Phenomenological psychology: The Sage handbook of qualitative research in psychology. 2016. doi: 3402/qhw.v11.30682
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32. Mortari L., Zannini L. La ricerca qualitativa in ambito sanitario. Roma: Carocci Editore. 2017.
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35. Wu Y., Wang J., Luo C., Hu S., Lin X., Anderson A.E., et al. A Comparison of Burnout Frequency Among Oncology Physicians and Nurses Working on the Frontline and Usual Wards During the COVID-19 Epidemic in Wuhan, China. Journal of Pain and Symptom Management.2020;60.
36. Quaglino G.P., Casagrande S., Castellano A.M. Gruppo di lavoro, lavoro di gruppo. Milano: Raffaello Cortina Editore. 1992.

 

Box 1 – Interview outline

1. Could you tell me how your adventure in the Covid ward started?

2. What was the first thought that came into your mind when you were chosen as Covid-19 worker?

3. How do you think your way of working has changed compared to before?

4. If you saw yourself through the eyes of a patient, how would you describe yourself?

5. How do you feel and what do you think when you finish your shift and leave the hospital?

6. And what do you think and feel when you have to start a shift?

7. has anything changed in the working group compared to previous months? If so, what?

8. Can you tell me an episode that made you think you could deal with all this with your team?

 

Box 2 – Giorgi's method (2008)

A. Read the whole description of the experience with the aim of making sense of it all

B. Rereading the descriptions to discover the essences of the experience. Observe every time a transaction takes place in meaning. Make these meaning units or themes abstract

C. Examine units of meaning for redundancy, clarification or elaboration. Relate units of meaning to each other and to the meaning of the whole

D. Reflect on the units of meaning and extrapolating the essence of the experience for each participant. Transform each unit of meaning into scientific language

 

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

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by OPI Napoli

How to Trust your Intuition when You're Making a Decision

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by pietro

Everyday inspired by the Beauty of the Mountains

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by pietro

How to Appreciate the Little Things in Life and be Happy

Just the other day I happened to wake up early. That is unusual for an engineering student. After a long time I could witness the sunrise. I could feel the sun rays falling on my body. Usual morning is followed by hustle to make it to college on time. This morning was just another morning yet seemed different.

Witnessing calm and quiet atmosphere, clear and fresh air seemed like a miracle to me. I wanted this time to last longer since I was not sure if I would be able to witness it again, knowing my habit of succumbing to schedule. There was this unusual serenity that comforted my mind. It dawned on me, how distant I had been from nature. Standing near the compound’s gate, feeling the moistness that the air carried, I thought about my life so far.

Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma – which is living with the results of other people's thinking.
Steve Jobs

I was good at academics, so decisions of my life had been pretty simple and straight. Being pretty confident I would make it to the best junior college of my town in the first round itself, never made me consider any other option. I loved psychology since childhood, but engineering was the safest option. Being born in a middle class family, thinking of risking your career to make it to medical field was not sane. I grew up hearing ‘Only doctor’s children can afford that field’ and finally ended up believing it. No one around me believed in taking risks. Everyone worshiped security. I grew up doing the same.

‘Being in the top will only grant you a good life’ has been the mantra of my life. But at times, I wish I was an average student. I wish decisions would have not been so straightforward. Maybe I would have played cricket- the only thing I feel passionate about. Or maybe I would have studied literature (literature drives me crazy). Isn’t that disappointing- me wishing to be bad at academics. It’s like at times I hate myself for the stuff I am good at.

When you step out of these four walls on a peaceful morning, you realize how much nature has to offer to you. Its boundless. Your thoughts, worries, deadlines won’t resonate here. Everything will flow away along with the wind. And you will realize every answer you had been looking for, was always known to you. It would mean a lot to me if you recommend this article and help me improve.

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by pietro

Assessing the outcome of admissions: Pilot study in a High Intensity Psychiatric Residential Facility

Pierluigi Ricchiuto¹, Stefania Impicci², Martina Schiano³

   1.Nurse at the Department of Emergency and Acceptance, Emergency Department - OBI, Asl Napoli 2 Nord, Santa Maria delle Grazie Hospital, Pozzuoli.
   2.Nurse at "Casa Rossa" Residential Rehabilitation Centre. Area Vasta 2 - Ancona.
   3.Nurse at UOS Clinical Risk, AORN - Ospedale dei Colli, Monaldi Hospital, Naples.

*Corresponding Author: Pierluigi Ricchiuto, Department of Emergency and Acceptance, Emergency Department - OBI, Asl Napoli 2 Nord, Santa Maria delle Grazie Hospital, Pozzuoli.

Email: pierluigi.ricchiuto@aslnapoli2nord.it

 

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ABSTRACT

Background: The Italian health system related to mental disorders is currently experiencing a period of radical reforms. This process began in 1978 with the adoption of the law 180 which produced a radical reform in mental health care. The problems of the continuous confrontation with increasing levels of expenditure are reflected in the search for models to improve both the efficiency and effectiveness of the health care system. Among these, the value creation model proposes to optimize the relationship between effectiveness, quality, and appropriateness of care on the one hand, and efficiency, cost and how resources are used on the other. The intervention involves redesigning services on the principles of recovery; implementing treatments supported by scientific evidence; encouraging processes of social inclusion. The proposed rehabilitation interventions are recovery oriented that place the person at the center of his rehabilitation path, motivating him in assuming responsibility for the treatment proposed during hospitalization.

Objective: Evaluate the impact of the organisational reorganisation of the DSM S.R.R Regional Health Service of Ancona Area Vasta 2 by introducing evidence-based and recovery-oriented practices through the evaluation of clinical outcomes and psychosocial functioning.

Methods: Longitudinal descriptive observational study with evaluation of a cohort of 13 patients, hospitalized in residential and semi-residential care at SRP1 “Casa Rossa” Area Vasta 2 of Ancona, by administration of a questionnaire (HoNOS) at the time of recruitment (February 2019), at 6 months (August 2019) and at 12 months (February 2020). The 12 items of the questionnaire were grouped into four subsets: behavioural problems (items 1-3), deficits and disabilities (items 4-5), psychopathological symptoms (items 6-8) and relational/environmental problems (items 9-12).

Results: Survey results show a reduction in mean scores at 6 and 12 months compared to baseline in all subscales.

Conclusions: Intensive mental health residential facilities need to put more effort into evaluating effectiveness in practice, using appropriate tools for outcome assessment and analysis of results. It is possible, in daily clinical practice, to evaluate the outcome of admissions in order to satisfactorily describe the changes induced during the period of hospitalization.

Keywords: outcome of care, mental health, psychiatric facility, biopsychosocial.

 

INTRODUCTION

The Department of Mental Health (DSM in Italian) is the set of facilities and services whose task is to take charge of the demand for care, assistance and protection of mental health; it is the body which governs, coordinates and manages Community Psychiatry, guaranteeing the unity and integration of psychiatric services within the area of competence defined by ASUR Marche [1]. Moreover, the DSM's task is to promote mental health and quality of life in the target population; to guarantee primary and secondary prevention of mental disorders with the early detection of situations of distress and tertiary prevention with the reconstruction of the affective, relational, social and work fabric [2]. The typology of psychiatric residential facilities is distinguished both by the level of therapeutic-rehabilitative intervention, related to the level of impairment of the patient's functions and abilities (and its treatability), and by the level of care intensity offered, related to the overall degree of autonomy. Psychiatric residential facilities for intensive therapeutic rehabilitation treatment (SRP1) are facilities for patients with severely impaired personal and social functioning. These structures play a transitional role, aimed at reintegrating the patient into his/her usual living environment (generally family) [3,4]. The intervention areas of SPR1 concern the clinical psychiatric, psychological, rehabilitation, resocialisation and coordination areas. The new organisation of the Psychiatric Residential Facilities (SRP in Italian) of the Area Vasta 2 DSM is part of the new organisation suggested by the Unified Conference Agreement of 17 October 2013 [5] and subsequently accepted at regional level by D.G.R.M. 1331/14 [6], where the concept of residency is declined in a different way of managing psychological distress. The user is no longer placed in a purely medical dimension, but an individual project is built in agreement with other professionals. Therefore, the care pathway must be configured as a project characterised by: unity, continuity, multidisciplinarity, high organisational complexity, relevant professional specificity and ability to manage sociomedical integration [7]. It is based on the integration of specific activities such as: clinical and rehabilitation activities, care activities, family and social mediation, networking and coordination. The realisation of this pathway implies a strong investment in team work, understood as a multi-professional group able to develop an accurate reading of the patient's biopsychosocial dimension, to integrate the observation data and to modulate a coherently articulated therapeutic planning. Thus, the 'biopsychosocial' model systematically employs biological, psychological and social factors, including their complex interactions, in the understanding of psychophysical health and the choice of therapeutic intervention [8]. Consequently, by focusing on the unitary and global approach to the person, the biopsychosocial model is the one most conducive to an interdisciplinary approach between the various professions, such as doctors, psychologists, social workers and educators. For patients with severe mental illnesses, controlling symptoms, regaining a positive sense of self, dealing with stigma and discrimination, and trying to lead a productive and satisfying life is increasingly referred to as an ongoing process of recovery [9]. Equally important is to enhance personal attitudes and skills such as communication skills, enthusiasm and willingness to learn, cultural background and to develop the practice of outcome assessment among practitioners. Patient care in residential psychiatric facilities is therefore linked to a practice oriented towards therapeutic continuity and is implemented through individual projects [10]. In past years, at national and regional level, activity data have shown a progressive lengthening of hospital stays, with a consequent reduction in patient turnover. In this sense, psychiatric residency has often taken on the function of a 'housing solution' rather than being functional to the 'individual treatment project', generating the danger that SRPs are used for forms of new institutionalisation. All SRPs should therefore provide for light residential care with assistance, which facilitates the transition from the structure to the territory [3].

There is a need for evidence-based assessment and rehabilitation activities in order to provide residents with the possibility of being involved in social interactions outside of the facilities, and possibly with opportunities for sheltered work and social integration. Indeed, work, social relationships and independence are aspects of quality of life recognised as important by both patients and their treating physicians [11]. Well-designed rehabilitation plans, adapted to the needs of each patient, are mandatory to foster the development of independence, increase the likelihood of discharge and ultimately improve quality of life [12]. The development of the clinical pathways model requires addressing fundamental clinical and organisational aspects [13]:

• organising a reception/assessment function for demand and requests from psychiatric services;
• the centrality of the sending Mental Health Centre (CSM in Italian);
• the centrality of family;
• the involvement of the GP to be implemented from the earliest stages of the patient's contact with the structure;
• the definition and organisation of individualised therapeutic-rehabilitation paths;
• facilitating access procedures for all DSM operators;
• defining criteria for a maximum length of stay consistent with the level of rehabilitation intensity (18/24 months for rehabilitation facilities, 36 months for care facilities).

The result of the change process was to orientate the whole Structure to adopt principles, develop policies and implement actions, in order to help people with mental disabilities to remain in their life context, trying to achieve the best possible biopsychosocial functioning compatible with functional deficits, persistent psychopathology and relapses.

 

MATERIALS AND METHODS

Study design

Longitudinal descriptive observational study by administering the HoNOS questionnaire after the reorganisation of the psychiatric residential facilities of the Department of Mental Health of the Ancona Vasta 2 Area.

 

Population and settings

The pilot study was conducted at SRP1 "Casa Rossa" Area Vasta 2 of Ancona and involved 13 patients admitted to SRP1 Casa Rossa - AN ASUR Marche.

 

Inclusion criteria

Residential and semi-residential patients.

 

Ethical consideration

After explaining the purpose, the study was authorised by the Director of the DSM.

The study protocol was developed in accordance with the guidelines of the Declaration of Helsinki. Participation in the study was voluntary: patients were provided with a consent form for data processing and an information and consent form for the study. Only after obtaining consent and ensuring that the patient understood the purpose of the study was the paper-based HONOS questionnaire administered.

Data were collected after obtaining informed consent from each patient. The confidentiality of the data collected was guaranteed by ensuring the anonymity of all participants and avoiding the use of any personal identifiers.

The surveys, carried out in a homogeneous way by the Coordinator of the Operating Unit with over thirty years of working experience (twenty years of experience in the mental health area) took place in a protected environment, with a standardised method: a room specifically dedicated to surveys and data collection, no outside involvement and respect for the patient’s privacy.

 

Survey instrument

The validated Italian version of the Health of the Nation Outcome Scales [14] was used. The HoNOS scale is a multidimensional outcome and severity assessment tool developed specifically for routine use in mental health services, suitable for the assessment of clinical and psychosocial problems [15,16]. It consists of 12 items that the therapist assesses according to the severity of the problems. Each item represents a clinical problem area and is rated on a 5-point Likert scale. Relevant items include:

   1.Hyperactive, aggressive, destructive or agitated behaviour;
   2.Deliberately self-harming behaviour;
   3.Problems related to drug or alcohol use;
   4.Cognitive problems;
   5.Problems of somatic illness or physical disability;
   6.Problems of somatic illness or physical disability;
   7.Problems related to depressed mood;
   8.Other mental and behavioural problems;
   9.Relational problems;
   10.Problems in activities of daily living;
   11.Problems in living conditions;
   12.Problems in the availability of resources for work or leisure activities.

Each of the twelve items in the questionnaire is given a score from 0 to 4, where:

• a score of 0 indicates that no problem has been found;
• a score of 1 indicates that the problem is present, but because of its reduced severity no intervention is needed;
• a score of 2 indicates that a problem of mild severity is present, for which intervention (rehabilitation, care or therapy) is required;
• score 3 indicates the presence of a problem of moderate severity;
• a score of 4 indicates that a serious or very serious problem is present.

Unknown information was given a score of 9. The twelve scores can be added together to obtain an estimate of total severity or evaluated individually.

 

Study procedures and data collection

The reconversion project of SRP1 "Casa Rossa" took place in accordance with the principle of gradualness and with the participation of all operators through weekly meetings specifically planned by the nursing coordinator. Subsequently, patients were assessed three times over a one-year period by administration of the HoNOS questionnaire, at recruitment (February 2019), at 6 months (August 2019) and at 12 months (February 2020). Patients excluded from care were not included in the study. After data collection, the 12 items of the HoNOS scale were grouped into four subscales:

   1.behavioural problems (items 1-3),
   2.deficits and disabilities (items 4-5),
   3.psychopathological symptoms (items 6-8)
   4.relational/environmental problems (items 9-12).

 

Statistical analyses

Data was expressed as mean and standard deviation (SD) or median and interquartile range (IQR) in the case of numerical variables, while in the case of qualitative variables, it was expressed as absolute numbers or percentages.

The normality of the data was checked with the Shapiro-Wilk test, where with a p-value > 0.05 there is evidence of normally distributed data.

The difference between the averages of the total score and the scores of the four subscales, at the three follow-up points, was statistically evaluated with an analysis of variance model for repeated measures, in the case of normally distributed residuals; in the case of non-normally distributed data, the non-parametric Friedman test was applied.

For the scales with statistically significant differences in scores, multiple comparisons were made retrospectively between the groups (baseline, 6 months, 12 months) maintaining the 5% significance level with Bonferroni correction. Statistical analyses were carried out using the software R-CRAN v.3.6.2 for Windows.

 

RESULTS

Table 1 shows the demographic and clinical characteristics of the cohort of patients examined in the study.

Table 1. Descriptive statistics for demographic and clinical variables.

The mean with the standard deviation and the median with the interquartile range of the total score and the scores of the items of the 4 sub-scales, at baseline and in the two surveys at follow-up, are shown in table 2 and figure 1.

Table 2. Mean, standard deviation, median and interquartile range of Total Scale and 4 Subscales scores at baseline, 6 months and 12 months.

Figure 1. Average total score and average score of the 4 sub-scales.

The residuals of the analysis of variance model are distributed in accordance with the Normal random variable for the subscales of "deficit and disability" and "psychopathological symptoms" (p-value>0.05); the scale HoNOS Total, that of behavioural problems and of relational/environmental problems do not present normally distributed residuals (table 3).

Table 3. P-value Shapiro-Wilk normality test

The statistical significance (p-value) of the differences between the averages of the total score and the scores of the four subscales at the three follow-up points are given in Table 4; the results show a statistically significant difference between the averages at the 95% confidence level.

Table 4. Statistical significance of ANOVA and Friedman's Test.

Table 5 shows the p-values of multiple retrospective comparisons between the groups (baseline, 6 months, 12 months) while maintaining the 5% significance level with the Bonferroni correction.

*P-value <0.05 Statistically significant difference

Table 5. P-value of pairwise retrospective comparisons of scores on the HoNOS Total scale and the 4 subscales at baseline, 6 months and 12 months.

 

DISCUSSION

The study performed predates the SARS-CoV2 pandemic and involved a cohort of 13 patients admitted to SRP1 Casa Rossa in Ancona. The mean age at recruitment and at disease onset was 46 and 19 years respectively, 69% of patients were male, 46% had a caregiver and 38.5% had undertaken other rehabilitation pathways. The results of the study show a reduction in the average HoNOS scale scores at 6 and 12 months compared to baseline in the four subscales considered. Considering the HoNOS scale in its entirety, there was a considerable decrease in the score from an overall mean of 2.1 at baseline to 1.3 at the end of the 12-month study period (Table 2). In all subscales considered, this decrease is statistically significant. The analysis of the data showed that the adjustment of the organisational set-up produces greater improvements especially in the initial phase (after 6 months) with a very significant decrease in average scores. After 6 months from the start of the study there is a stabilisation of the average HoNOS Total and subscale scores. Table 5 shows the p-values of the multiple comparisons between the groups; the scores of the groups compared were statistically significant with the exception of the scores taken at 6 and 12 months for the subscales of "behavioural problems", "deficits and disabilities" and "relational/environmental problems" and the scores taken at 6 months and at baseline for "psychopathological symptoms". 

Similarly to a study by Buratti et al. [17], it is important to underline that, in the face of a clear prevalence of pharmacological treatments, the items that undergo a clear improvement are precisely those on which the drug has a direct effect (e.g. items concerning behavioural problems, deficits and disabilities and psychopathological symptoms), while the items concerning problems that would also require the use of other types of treatments (e.g. relational, environmental items) show a smaller decrease in average scores. Other data in the literature demonstrate the importance of using the HoNOS scale for assessing outcomes in patients with mental illness. A first longitudinal study in 3 times (14 months) was carried out in the Mental Health Services of the A.O. Ospedale Niguarda Ca' Granda in order to contribute to the validation of the Italian version of the HoNOS scale and to make operators aware of the importance of a standardised assessment of outcomes. With regard to the results on improvement (clinically significant criterion of 7 points), improved patients correspond to 45.3% of the sample after 14 months from the start of the study [16]. Two other longitudinal studies [18,19] in three stages and with a two-year follow-up, were implemented in a Mental Health Centre in Rome where the following were analysed: the relationship between the severity detected by HoNOS and the ICD-9-CM diagnosis; the convergence between the two instruments; the relationship between HoNOS severity and the types of interventions used by the Mental Health Centre (psychiatric interview, psychological interview, psychotherapy, pharmacotherapy, home visits, rehabilitation, insertion in residential facilities) in order to assess the distribution of resources and finally the improvement of patients in one year. The results found convergence between HoNOS and ICD-9, appropriate use of interventions in relation to the specificity and severity of the diagnosis, and an improvement in patients with a significant decrease in mean scores.

Further studies have involved the Mental Health Departments of the A.O. Ospedale Niguarda Ca' Granda as part of the introduction of a tool to formalize the Individual Treatment Plan (I.T.P.) in which the HoNOS scale is used for assessment and final evaluation of the chosen treatment [19,20]. In this research several aspects were evaluated: the type of intervention foreseen (counselling, intake, treatment), the treatments carried out (pharmacotherapy, psychotherapy, work placement, family involvement, etc.), the outcome of the intervention (re-evaluation at 6 months in case of intake and treatment), drop-out, costs, the role of the case manager and the impact on the work of the operators. The results showed a statistically and clinically significant improvement in severity scores even though there was a medical/nursing imbalance in the treatments provided. The number of psychological, social and rehabilitation treatments is still too low. In psychiatric services, the professional figure and services of psychiatrists predominate, to the detriment of the scarce presence of psychologists/psychotherapists, despite the fact that psychotherapy has been shown to bring about greater and more constant changes over time than the use of medication alone [19]. For this reason, one of the innovative elements in the study was to go beyond the medical-centric model in favour of interdisciplinary teamwork. In community psychiatry, all professionals must be united by a single aim: to provide patients with opportunities to use the skills learned in rehabilitation programmes in natural environments and to increase the quality of their lives. In order to ensure such integration, it is necessary to establish and implement an interdisciplinary and multidisciplinary team, whose operation is ensured by individual and collective tasks, well-defined performance standards, supervision and continuous on-the-job training [21]. It becomes a moral duty to assess whether in one's own reality, with one's own patients, colleagues, organisational difficulties and shortcomings, one can achieve the same results as in experimental effectiveness studies. It is possible, in everyday clinical practice, to routinely assess the outcome of hospitalisation using a scale such as the HoNOS, because not only is it simple and quick to fill in, but above all because it satisfactorily describes the changes induced by the period of hospitalisation.

 

CONCLUSIONS

In recent decades, mental health care has seen a shift from symptom management to the promotion of quality of life within psychiatric facilities: both patients and their relatives consider quality of life as one of the main goals of mental health care [22]. Rehabilitation facilities should be aimed at social integration; provide for a maximum length of stay of 24 months, with a 24-hour presence of health and psycho-socio-educational staff; provide for areas of involvement of patients and relatives [5]. The results of this pilot study show how an organisational reorganisation aimed at adopting principles, developing policies and implementing actions to help people with mental disabilities can improve the quality of hospitalisation and consequently the quality of life of patients with mental disorders. Achieving the best possible biopsychosocial functioning compatible with functional deficits, persistent psychopathology and relapses, involving the family and the general practitioner from the earliest stages of the patient's contact with the facility are fundamental aspects of a care pathway for patients with mental disorders. At the end of a residential treatment programme, there should be a continuation of rehabilitation and care treatment by the mental health centres (CSM) in the region, where there is support and home visits through a single and integrated socio-health pathway with re-evaluation over time of patients under treatment for mental disorders. The evaluative approach should not be seen by practitioners as an inquisitorial control, but as an opportunity geared towards improving care, the severity of patients and the outcome of their treatment. The use of HoNOS in Psychiatric Facilities should not be considered as a goal, but as a starting point for a journey towards a more adequate clinical practice for the management of patients with mental disorders, which favours the effectiveness of treatments and the self-reflection of professionals [16].

 

LIMITATIONS OF THE STUDY

Despite the supervision of the nursing coordinator and the medical director of the facility, a potential information bias due to the detector effect (degree of subjective evaluation of information) is present and cannot be eliminated. The main limitation is the small sample size, which does not allow confounding factors such as diagnosis, age at onset, etc. to be taken into account in the statistical analysis. Although the results show a reduction in mean scores at 6 and 12 months compared to baseline, a longer observation period would be desirable to allow further evaluations of the effectiveness of the biopsychosocial intervention.

 

POSSIBLE FUNDING

This research has not received any form of funding.

 

CONFLICTS OF INTEREST

The authors declare that they received no funding for the following study and have no financial interest in the subject matter or the results obtained.

 

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22. Salvi G., Leese M., Slade M. (2005). Routine use of mental health outcome assessments: choosing the measure. British Journal of Psychiatry, 182(2), 146-152

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by OPI Napoli

The Effect of Spirotive Relaxation Techniques in Reducing the Level of Osteoarthritic Pain in the Elderly: Quasi Experiment Design

Abbasiah¹*, Monalisa¹, Yunike¹, Mohd Syukri¹, Dewi Masyitah¹

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

 

* Corresponding author: Abbasiah, H. Department of Nursing, Health Polytechnic of Jambi, Indonesia; Agus Salim Street, Kota baru Jambi, 36129 Indonesia. Orcid: https://orcid.org/0000-0001-7692-7337. Email: ummiabbasiah35@gmail.com

 

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Abstract

Introduction: Pain is a common issue in the elderly. Osteoarthritis is often encountered in the elderly and contributes significantly to pain. Pain complaints involve multifactorial and often face many hindrances in the management.

Objective: This study aims to determine the effect of spirotive relaxation techniques in reducing osteoarthritis pain scale in the elderly.

Methods: This quasi-experimental study used the Pre-Post Test Control Group Design, conducted in the Penyengat Olak and Sungai Duren Community Health Center, Jambi Province, Indonesia, from September to November 2021. Sixty-four elderly participants in this study were divided into Spirotive relaxation exercise and dhikr as the intervention group and the control group given Spirotive relaxation exercise only. Data analysis used t-test and independent t-test at a significant level of 95%.

Results: There are differences in pain levels of the intervention group before and after Spirotive relaxation exercise and dhikr. Before the intervention, pain levels were moderate to severe, and pain levels were mild to moderate after the intervention. Similar results were also obtained in the control group given Spirotive relaxation exercise only with a significant reduction in pain. The independent test results showed a p-value = 0.207, indicating no difference in osteoarthritis pain in the intervention and control groups.

Conclusion: Spiritual relaxation exercises have been shown to reduce pain levels in the elderly with osteoarthritis. There are also differences in the level of joint pain scale in the intervention and control groups. It suggests that public health centers provide non-pharmacological inspirational interventions as an additional therapy for the elderly.

Keyword: Osteoarthritic, Pain, Spirotive, Elderly

 

Introduction

Various health problems will arise along the ageing process and rising age. It is mainly a physical inconveniences problem, such as ailments of musculoskeletal function [1]. Pain in the joints frequently becomes an obstacle for the elderly to carry out daily activities [2,3]. Osteoarthritis is the most common joint disease, which increases in age. The ageing process exerts a shrinking effect on human muscle fibres. Muscle strength will undoubtedly decrease due to the shrinkage of muscle mass impacting the weakness in activity or movement, thereby reducing the quality of life. In addition, it also affects bone mass diminishes. The elderly with regular exercise do not encounter the same loss as the sedentary elderly [4].

Approximately 20% of the world's population obtains joint pain at 55 years old. The current increase in the elderly population goes hand in hand with an increase in the number of cases of joint pain [5,6]. Accordingly, the prevalence of joint disease in Indonesia is 7.3%, of which 45.58% arises in the 56-65 age group, 82.54% is discovered in the female group, and 53.26% complains of knee pain [7].

Knee Osteoarthritis (OA) is a common progressive multifactorial joint disease characterized by chronic pain and functional disability [4]. Knee OA accounts for almost four-fifths of the burden of OA worldwide and increases with obesity and age [6]. Knee arthroplasty is considered an effective treatment at an advanced stage of the disease. However, which is responsible for substantial health costs [5]. Many researchers have shifted their focus to the prevention and treatment in the early stage of the disease [2]. Accordingly, it is essential to understand the prevalence, incidence, and modifiable risk factors of knee OA to provide efficacious preventive strategies [3,8].

Non-pharmacological management of osteoarthritis pain in the elderly include Spirotive Relaxation Exercise (SRE) and dhikr [9]. Spirotive relaxation is a combination and modification of progressive muscle relaxation and spiritual relaxation (dhikr) interventions. Relaxation begins with dhikr, then relaxes muscle tension. Those activities are expected to obtain His grace in the form of peace, tranquillity, happiness, health and physical fitness. [10].

Spiritual Relaxation (Dhikr) involves praising, remembering, and submitting supplications to God in resignation [11]. Medically, it has been proven that dhikr will automatically stimulate the secretion of endorphins to feel happiness and comfort [12]. Yusuf et al. [11] found changes in psychological well-being in the treatment group before and after the dhikr intervention.

The Spirotive Relaxation Exercise (SRE) is based on the Comfort theory of Kolcaba [13]. Comfort is the main goal in nursing because it is closely related to healing [14–16]. According to Yusuf, et al [11] Spiritual Relaxation intervention can provide comfort by doing SRE and spiritual relaxation (dhikr). Sound waves during dhikr will stimulate auditory receptors. Furthermore, the stimulus will be forwarded to the temporal lobe to catch the point of God (circuit of God). The prefrontal cortex will respond to stimuli at the point of God for the process of forming positive perceptions, both emotionally and spiritually. The amygdala will respond to the prefrontal cortex to the hippocampus as feedback. In addition, the amygdala also stimulates the hypothalamus through the hypothalamic-pituitary-adrenal (HPA) axis to secrete corticotrophin-releasing factor (CRF).

SRE induces muscle contraction of the skeletal fibers, leading to muscle tension [17,18]. In this case, the central nervous system (CNS) involves the sympathetic nervous system and the parasympathetic nervous system [19]. Several organs are affected by these two nervous systems [20]. Sympathetic and parasympathetic nerves work reciprocally. Activation of the parasympathetic nervous system, also called Trophotropic, provides a desire to rest and physical improvement of the body [20,21]. The feeling of comfort and relaxation may reduce even eliminate pain [18,22–24].

Gonçalves, et al [25] stated that dhikr could reduce joint pain in the elderly with knee osteoarthritis. Another study stated that being more active may reduce pain and the risk of functional impairment or disability [26].

Joint pain is a subjective experience that impacts the quality of life and impaired functional activities of the elderly. Therefore, adequate treatment is needed. Non-pharmacological intervention SRE has the potential to reduce the intensity of osteoarthritis pain. To the best of our knowledge, this has never been studied. Therefore, this study aims to determine the effectiveness of Spirotive Relaxation Exercises to reduce osteoarthritis pain in the elderly.

Methods

Research design

The research design used in this study was Experimental with a Quasi Experiment Design in Pre-Post Test Control Group approach. This study revealed a causal relationship by involving the control group and the experimental group.

Research Time and Place

The study was conducted in the working area of ​​the Penyengat Olak and Sungai Duren Community Health Center, Jambi Province, Indonesia, from September to November 2021.

 

Participants   

The participants in this study were all the elderly in the Penyengat Olak Health Center (n=32 people) and the elderly at the Sungai Duren Health Center (n=32 people).

Intervention

SRE is administered independently for 45 minutes twice a week for four weeks. SRE measurement used SOP, While the pain level was measured using the WOMAC Questionnaire. In this index, 24 parameters consisting of pain, stiffness, physical and social function were evaluated using WOMAC. The higher value obtained indicates the magnitude of the patient's functional limitations. The higher the value obtained indicates the magnitude of the patient's functional limitations.

In comparison, the lower value indicates improved functional ability. WOMAC parameters include (1) the presence of pain, which aspects are assessed when walking, climbing stairs, doing activities at night, at rest and when supporting (2) the presence of stiffness in the morning and stiffness throughout the day (3) the state of physical function Patients have difficulty going downstairs, difficulty going upstairs, difficulty from sitting to standing, difficulty standing, difficulty sitting on the floor, difficulty walking on a flat surface, difficulty getting in and out of a vehicle, difficulty shopping, difficulty wearing socks, difficulty lying in bed, difficulty taking off socks, difficulty sitting, difficulty doing heavy tasks and difficulty doing light tasks. WOMAC produces an algorithmic value obtained from a questionnaire to measure pain and disability in patients' knees. In the questionnaire, the answers were given a 0 - 4. Each score represents the patient's perceived state. Details of the WOMAC questionnaire can be seen in the table. Furthermore, the scores of the 24 questions are added up divided by 96 and multiplied by 100% to find out the total score and categorized as Mild (0-40%), moderate (40%-70%), and severe (70%-100%). The greater the score, the more severe the pain and disability of the knee [27,28].

The Assessment of pain is based on stiffness and physical function with mild, moderate, and severe categories. The intervention group was given SRE and reciting dhikr, while the control group only received SRE.

 

Outcomes

The output of this study was to determine the level of pain and the differences in pain levels before and after giving spirotive relaxation exercises.

Sample size

The sample in the current study was 64 participants divided into two groups, 32 participants as group intervention and 32 participants as group control. The minimum sample size was determined using the GPower software version 3.1.9.4, where the effect size d = 0.63, alpha = 0.05, at power 0.80 with a sample ratio of 1:1. The sample size for group 1 was 32 and group 2 was 32 for a total of 64. The sample was randomly selected. The sample size in the study initially involved 124 potential participants, whereas 60 people did not meet the criteria. The inclusion criteria for the sample were 45-80 years old, a minimum education level of Elementary School (SD), and no cognitive impairment (MMSE score >23). At the same time, the elderly with limited range of motion and bed rest were excluded.

Randomisation

Participants were selected from the total population using a simple random technique. Sample selection includes determining prospective participants, selecting participants, and reporting participants to researchers. Enumerators received a briefing on applying the sample selection mechanism for the provision of SRE and dhikr.

Blinding

The included samples were selected blindly. The enumerator who had been assigned by the researcher did not previously know the potential participants.

Ethical Consideration

No economic incentives were offered or provided for participation in this study. The study was performed under the ethical considerations of the Helsinki Declaration by the Health Research Ethics Commission of the Ministry of Health, Jambi, and registration number: LB.02.06/2/59/2021.

Statistical analysis

Description of participant characteristics (age, gender, education level, and occupation) and osteoarthritis pain before and after the intervention is based on univariate analysis results. 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). The normality test used the Kolmogorov-Smirnov test with Lilliefors significance correction.

In bivariate analysis, a t-test was used to assess the effect of spiritual healing and dhikr in the intervention and control groups. In contrast, an independent t-test was used to determine differences in osteoarthritis pain intensity between the two study groups. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using SPSS version 16.0.

Results

The characteristics of respondents are presented in table 1 below :

Table 1. Characteristics of Respondents

Characteristics of respondents from the two groups are based on gender, primarily female, 62.5% from the intervention group, and 68.7% from the control group. The characteristics of respondents based on age were mainly in the elderly group (60-74) years, 56.3% in the intervention group, and 53.1% in the control group. Based on education level, most respondents were junior high school, as much as 53% in the intervention group and 50% in the control group. Characteristics of respondents based on the type of work show that most respondents did not work, as much as 87.5% in the intervention group and 90.7% in the control group.

The description of osteoarthritis pain in the intervention group before and after the intervention presented in table 2 below:

Table 2. Description of pain scale before and after spirotive intervention in the intervention group

Table 2 shows that the scale of osteoarthritis pain before the SRE was mild pain (6.3%), moderate pain (46.9%), and severe pain (46.9%). The osteoarthritis pain scale felt by respondents after the SRE was mild pain (37.5%), moderate pain (56.3%), and severe pain (6.3%).

The description of osteoarthritis pain in the control group before and after the intervention presented in table 3 below:

Table 3. Description of pain scale before and after spirotive intervention in the control group

Table 3 shows that the scale of osteoarthritis pain before SRE was 15.6% in mild pain, 65.6% in moderate pain, and 18.8% in severe pain. After the intervention, it was found that participants felt mild pain (59.4%), moderate pain (37.5%), and severe pain (3.1%).

Furthermore, the data normality test was carried out using the Kolmogorov-Smirnov test to determine the distribution of research data. The results of the data normality test are presented in table 4 below:

Table 4. Data Normality Test

Table 4 shows that the p-value of the intervention group > 0.05, as well as the p-value of the control group > 0.05, so it can be concluded that the data is normally distributed.

The condition of painful scale before and after the intervention in Group 1 and Group 2 can be seen in the table 5 below:

Table 5. Frequency distribution of Group Intervention and Group Control before and after interventions

Table 5 shows a significant decrease in pain level in both groups before and after the intervention with a p-value <0.05. Based on the t independent test, it was found that the p-value for the pre-test (<0.005) and the post-test was 0.207. The post-test value showed no difference between the two research groups.

Discussions

The t-test result of pre-post intervention revealed a decrease in pain. In both the intervention and control groups, the p-value was <0.05. The independent t-test showed differences in the two groups before the intervention with a p-value <0.05, but after the intervention (post-test), the p-value was >0.05. It indicates that SRE and dhikr therapy may reduce knee OA pain in the elderly.

Older people with osteoarthritis often run into joint pain [29,30]. These complaints are often found in geriatric care in the community and clinic. This study provides an SRE intervention with a combination of spiritual techniques: dhikr (spirotive) to reduce joint pain in the elderly with osteoarthritis [24]. Joint disease is a degenerative process and causes pain in the elderly [31]. Pain itself can be caused by several conditions, including rheumatoid arthritis, gout (uric acid), and osteoarthritis [32]. SRE is a technique for reducing muscle tension by a simple and systematic process of stretching a group of muscles and then relaxing back [33].

SRE focuses on maintaining a deep form of relaxation, applying contraction and relaxation of various muscle groups from the feet up or from the head down. This method will realise where the muscles are located and increase awareness of the body's muscle response [34,35]. SRE may reduce pain, anxiety, depression, improve sleep quality, and reduce fatigue [36].

Religious relaxation (dhikr) is a technique that includes a belief factor. In this study, we used the element of Islamic belief with the repeated praise of God's name submissively [11]. Religious relaxation: dhikr is one of the efforts to meet the psychological needs of the elderly through the fulfillment of spiritual needs. It is also a practice of prayer to God by continuously remembering God name submissively. The essence of dhikr is praying for forgiveness, praising and glorifying God, being grateful, takbir to humble before God. Finally, eliminate ourselves and our ego against God's ego in all the activities we do [37].

Dhikr relaxes the body and produces impulses sent through afferent nerve fibers. Physiologically, spiritual therapy by dhikr or remembering God's name causes the brain to work. When the brain gets external stimulation, it will produce neuropeptides chemicals to provide comfort. The substances will be involved and absorbed in the body, providing feedback in comfort. Psychologically dhikr will balance serotonin and norepinephrine levels in the body. This phenomenon is natural morphine that works in the brain and will cause the heart and mind to feel calm compared to before dhikr [37].

The results of this study must be interpreted cautious because the limitations of this study are: the patient was not directly supervised by the researcher in doing dhikr. It is difficult to determine the quality of dhikr performed by a person, and there are no clear parameters to determine it. Supposedly, the acceptable quality of dhikr will give a calming effect. It could result in no difference in pain levels between the two groups after the intervention. In future studies, supervision should be conducted strictly when the intervention ensues.  The strength of this study lies in its RCT design, using an intervention that has never been done before in patients with osteoarthritis pain.

Conclusion

SRE has been proven to reduce joint pain scale in the elderly with osteoarthritis, and there are also differences in joint pain scale levels in the intervention and control groups.

It is suggested that the community health centers may use SRE as an additional therapy for the elderly. Increasing the capacity of elderly health assistance needs to be carried out by the community health centers to increase the knowledge and behavior of the elderly in overcoming problems related to their degenerative conditions.

The limitations

The limitations of this study include a small sample and only involving respondents in one country, namely Indonesia, so it cannot compare the intervention responses in each different ethnic group.

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.

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by OPI Napoli

COVID-19 Vaccines Side Effects Among Iraqi people In Kurdistan Region: A cross-sectional study

Rebar Yahya Abdullah^1*, Arazoo Issa Tahir², Dlkhosh Shamal Ramadhan³, Zuhair Rushdi Mustafa^4, Kawther Mohammed Galary⁵

 

¹ MSc. ⁽Maternity and Community Health Nursing Department, College of Nursing, University of Duhok,Kurdistan,Iraq).

² MSc ⁽Nursing Department, Bardarash Technical Institute, Duhok Polytechnic University, Kurdistan,Iraq).

³ MSc ⁽Maternity and Community health nursing Department, College of Nursing, University of Duhok, Kurdistan, Iraq)

⁴PhD  ⁽Adult Nursing Department, College of Nursing, University of Duhok, Kurdistan, Iraq).

⁵ MSc (Maternity and Community Health Nursing Department, College of Nursing, University of Duhok, Kurdistan, Iraq).

*Corresponding Author: Rebar Yahya Abdullah, Maternity and Community Health Nursing Department, College of Nursing, University of Duhok, Kurdistan, Iraq.

E-mail: rebar.abdullah@uod.ac

 

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ABSTRACT                                                                                                                   

Background: Communities around the world have expressed concern about the safety and side effects of SARS-CoV-2 vaccines. The adverse effects of the Covid-19 vaccines played a critical role in public trust in the vaccines. The current study aimed to provide evidence on the side effects of the BNT163b2 mRNA COVID-19 vaccine (Pfizer-BioNTech®); ChAdOx1 nCoV-19 vaccine (AstraZeneca®); BBIBP-CorVvaccine (Sinopharm®) COVID-19 vaccines. 

Material and Methods: A cross-sectional study design was performed from April 26th, 2021, to June 3rd, 2021. Convenience sampling was used to select respondents; face validity was performed to the mandatory multiple-choice items questionnaire to cover the respondent’s demographic characteristics, coronavirus-19 related anamneses, and the side effect duration of coronavirus-19 vaccines, the data were analyzed by using descriptive statistics.

Results: The 588 participants enrolled in the current study. ChAdOx1 nCoV-19 vaccine received 49.7%, followed by BNT163b2 mRNA COVID-19 vaccine and BBIBP-CorV (39.5% and 10.9%). The most common complaint was headache (61.2%), followed by vaccine injection site discomfort (58.8%), fatigue (49.7%), fever (48.3%), muscle discomfort (42.9%), and approximately (10.5% and 10.2%) had injection site swelling and nausea, respectively. Most of those surveyed had post-vaccine symptoms for one to two days (25.2%), (41%), and only a small percentage (3.7%) experienced them for over one month. ChAdOx1 nCoV-19 vaccine handled 53% of the side effects, followed by BNT163b2 mRNA COVID-19 vaccine (42%) and BBIBP-CorV vaccines (5%).

Conclusion: Prevalence of various local and systemic vaccines side effects, such as headache, fever, and pain at the injection site, was observed. Almost all participants had mild symptoms and were well-tolerated .AstraZeneca® vaccine has the most side effects, followed by the Pfizer® vaccine, and the Sinopharm® vaccine has the least. More independent studies on vaccination safety and public awareness are critical to improving public trust in vaccines.

Keywords: COVID-19; Vaccines; Side effects; Prevalence; Cross-sectional design.

 

INTRODUCTION

Millions of people around the world were infected by the Coronavirus Disease-2019 (COVID-19) within three months, until World Health Organization declared it as a pandemic on March 11, 2020 [1]. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a coronavirus that belongs to the Coronaviridae family's Sarbecovirus subgenus, and a non-segmented positive-sense Ribonucleic acid (RNA) virus encompasses it [2]. Older individuals are at an increased risk of being infected with the SARS-CoV-2 [3]. Most vaccine options target the spike (S) protein. It is the principal target of neutralizing antibodies. It helps to neutralize antibodies to prevent the Angiotensin Converting Enzyme-2 (ACE2) receptor binding motif (RBM) from engaging with the host cell [4, 5]. The vaccine development for COVID-19 prevention has grown into a struggle between viruses and humans, which has made it more complicated, along with the discovery of other related strains. Many platforms are attempting to grow, with Deoxyribonucleic acid (DNA) and RNA-based platform showing the most promise [6]. Several countries have entered the vaccine development battle, hastening the clinical trial phase and attempting to produce an efficient and safe vaccine against COVID-19 [7]. The COVID-19 vaccines have been studied in large, randomized-controlled studies with people of all ages, genders, nationalities, and individuals with known medical disorders. Across all demographics, the vaccines have shown a high level of effectiveness and are safe and efficacious in patients with various underlying diseases [8]. According to a recent national study [9], the side effects of the COVID-19 vaccine were the most common reason for vaccine hesitancy among the population in the United Kingdom (U.K.). This finding was confirmed in the context of COVID-19 vaccinations, as fear of side effects has been cited as the primary reason for healthcare workers and students in Poland refusing to accept the Covid-19 vaccine [10, 11]. Vaccines are not completely free of side effects or complications [26], headache, nausea, pain, redness, and swelling are early adverse effects of vaccines that must be expected when taking vaccines [27]. Furthermore, conditions like blood clotting were suggested to be caused by the administration of COVID-19 vaccines from Pfizer, Moderna, and AstraZeneca. [28,29].The present study aimed to determine the prevalence of side effects of the COVID-19 vaccine among vaccinated people in the Kurdistan Region, Iraq.

 

MATERIALS AND METHODS

Study design

The study was conducted using a cross-sectional design from April 26th to June 3rd, 2021, in the Kurdistan region, Iraq.

 

Samples and sampling 

An Internet-based study in the Kurdistan region of Iraq recruited to enroll a sample size of 588 people from people who had been vaccinated with one of the following vaccines: BBIBP-CorV, ChAdOx1 nCoV-19 vaccine, and BNT163b2 mRNA COVID-19 vaccines. However, illiterate and old age individuals were interviewed directly by authors to increase the sample representation. The individuals were invited by using invitation links in Viber™, Facebook™, and WhatsApp™ groups by using a non-random convenience sampling method. A Google™ form document was utilized to host and deliver the questions to responders. The inclusion criteria were participants who received one of the three mentioned COVID-19 vaccines and either received the first or second dose of the vaccine.

 

Instruments of the study 

The self-administered questionnaire of the present study, composed of nine mandatory multiple-choice items, has been adapted from previous studies and World Health Organization data [12, 13]. The questionnaire was divided into four parts: the first part included demographic data, including gender, age, and profession; the second part dealt with COVID-19 history, including COVID-19 previous infection, type and dose of COVID-9 vaccines, and medical history like having any chronic disease; the third part included the side effects and side effect duration of COVID-19 vaccines.

Statistical analysis

The descriptive statistics were performed to determine the study variables; age, gender, occupation, and the data that related to the COVID-19 vaccine. The current study used SPSS version 23 for the descriptive statistics.

 

RESULTS

588 participants in the study. Nearly two-thirds of participants were males (64.3%); their mean age was 41.5 years and ranged between 18 and 65 years. Most of the participants were healthcare workers (31.3%), government employees (25.2%), jobless (19), students (18), and self-employed (6.5%), as shown in Table 1.

Table 1. Demographic Characteristics of study participants

According to some questions stated in Table 2, nearly half (46.3%) of the participants did not infect before taking the vaccine. About (40.8%) reported that they were infected with COVID-19 previously. Compared with a tiny percentage (12.9%) having the vaccine without knowing whether they were infected with the COVID-19 virus or not.

Table 2. COVID-19 vaccines related anamnesis

Regarding chronic diseases among the participants who had the COVID-19 vaccine, over three-quarters (77.9%) had no chronic diseases. The most common types of vaccines received by the participants were ChAdOx1 nCoV-19 vaccine (49.7%), followed by BNT163b2 mRNA COVID-19 vaccine and BBIBP-CorV (39.5% and 10.9%). Regarding the number of vaccine doses gained, over three-quarters (79.3%) of participants had a single dose of vaccine at the time of the study.

Regarding the response of the participants toward COVID-19 side effects, they reported having at least one side effect after the COVID-19 vaccine job. The most common side effects among the study population (61.2%) were headaches, followed by vaccine injection site pain (58.8%), fatigue (49.7%), fever (48.3%), muscle pain (42.9%), and nearly the same percentage (10.5% and 10.2%) complained of injection site swelling and nausea, respectively. Rarely (0.3% and 0.7%) reported mouth ulcers and tonsillitis, side effects of the vaccine, as noted in Table 3.

Table 3. Prevalence of COVID-19 vaccine side effects among study participants

Table 4 shows that, for the duration of the occurrence of side effects, the vast majority (41.5%) of the participants had post-vaccination side effects for about two days, while 25.2% had them for one day, and 10.9% of the individuals complained about side effects for three days. 3.7% of them had a longer duration of side effects for over one month.

Table 4. The duration of side effects of COVID-19 vaccines

Regarding side effect prevalence with different age groups, symptoms were more common among the younger age groups ranging from 18 to 57 years old. Symptoms were much less severe in older age groups (58–64), with no noticeable side effects observed in participants older than 60 years old. Headache was more common in the age group 34-41 years old (14.2%); injection site pain was more common in the age group 26-33 years old (16.6%); fatigue was more common in the age group 34-41 years old (13.2%) as in Table 5.

Concerning the occurrence of side effects among BNT163b2 mRNA COVID-19 vaccine, ChAdOx1 nCoV-19 vaccine, and BBIBP-CorV vaccines, the vast majority (53%) of the side effects were because of ChAdOx1 nCoV-19 vaccine, followed by BNT163b2 mRNA COVID-19 vaccine (42%), BBIBP-CorV vaccines (5%) were safer than BNT163b2 mRNA COVID-19 vaccine and ChAdOx1 nCoV-19 vaccine vaccines in that almost all side effects occurred among vaccinated individuals.

Table 5. Prevalence of the side effects of COVID-19 vaccines among age groups

Some side effects such as nausea, epigastric pain, chills, injection site swelling, backaches, tonsillitis, and mouth ulcers have not occurred at all. Only a few participants (43.7%, 28.1%, 21.9%, and 18.7%, respectively) experienced injection site pain, fatigue, headache, and fever after receiving the BBIBP-CorV vaccine.

Most of the symptoms were observable in those who received the ChAdOx1 nCoV-19 vaccine and BNT163b2 mRNA COVID-19 vaccine vaccines, although symptoms were more common in individuals vaccinated with ChAdOx1 nCoV-19 vaccine. Common side effects between BNT163b2 mRNA COVID-19 vaccine and ChAdOx1 nCoV-19 vaccine were headache (69 % versus 63.7 %), injection site pain (56.8 % versus 63.6 %), fever (42.2 % versus 59.5 %), fatigue (56.8 % versus 48.6%), and muscle pain (44.8 versus 47.9 %) as shown in Table 6.

Table 6. Occurrence of side effects between vaccines

 

DISCUSSION

During the pandemic of COVID-19, the World Health Organization recommended that all nations strive to maintain population immunization. Although legislation and policies in this region are different, they still emphasize people at risk of coronavirus disease, such as healthcare workers, the elderly, and patients with chronic conditions [14]. Thus, the results of the current study showed that most of the participants (31.3%) were healthcare workers (males 64.3%), and most of them (46.3%) did not affect COVID-19. A similar study was conducted in India, which stated that, according to government regulations, the vaccine was initially administered to healthcare personnel in both government and private hospitals throughout India [15]. Correspondingly, in the US, priority is given mainly to all healthcare workers, then individuals who have an underlying condition, and after that to all essential service workers and older adults [16].

Because of the speed of COVID-19 vaccine manufacturing, concerns among the public have emerged about the safety of these new vaccines. No serious safety problems were reported [17]. Overall, COVID-19 vaccines are safe and will protect the community from developing severe COVID-19 disease and dying from COVID-19. BNT163b2 mRNA COVID-19 vaccine is an mRNA-based vaccine, ChAdOx1 nCoV-19 vaccine is an Adenovirus vaccine, and BBIBP-CorV is a vaccine [18]. According to the research, COVID-19 vaccination adverse effects are characterized as either local or systemic reactions, with severity ranging from mild to moderate [19]. The mRNA-based vaccines such as BNT163b2 mRNA COVID-19 vaccine have the highest level of side effects reported, except for diarrhea and arthralgia [20]. Since some of the vaccinated individuals in the current study received the mRNA-based vaccines, they were not free from side effects. No serious events associated with the COVID-19 vaccines, such as vaccine-induced immune thrombotic thrombocytopenia reported. However, most of the side effects were common and non-life-threatening. The side effects were systematic and local. The systemic reactions were headache (61.2%), fatigue (49.7%), fever (48.3%), muscle pain (42.9%), joint pain (26.2%), backache (18.4%), chills (16.7%), nausea (10.2%), epigastric pain (7.1%), and rash (1.7%), whereas the local reactions were injection site pain and injection site swelling (50.8%) and (10.5%), respectively. The rarest side effects were tonsillitis (0.7%) and mouth ulcers (0.3%). These findings are in line with those reported in the literature and reported by the Food and Drug Administration (FDA), which are: injection site pain, fatigue, headache, fever, chills, muscle pain, and joint pain are common side effects of COVID-19 vaccines [21, 15]. Similar findings were observed in the Czech Republic where the most common side effects among vaccinated individuals were injection site pain, fatigue, headache, muscle pain, and feeling unwell [12]. Also, a retrospective cross-sectional study was conducted among Saudi residents to study the side effects of the BNT163b2 mRNA COVID-19 vaccine. The study found that the most common symptoms were injection site pain, fever, headaches, flu-like symptoms, and tiredness. Less common side effects were tachycardia, generalized body aches, shortness of breath, joint pain, chills, and drowsiness. Rare side effects were tenderness, lymph node swelling, and Bell’s palsy [22]. In contrast to our study, in a systematic review study, the most common side effects were arthralgia (20). Mild to moderate side effects are experienced by vaccinated individuals. They are signs that the immune system of the body is responding to the vaccine and building protection against the COVID-19 virus (23/24). Also, in the present study, we found that the duration of post-vaccination side effects varied among participants. The majority (41.5%) were complaining about the side effects for two days, whereas 25.2% had side effects for one day, and 10% for three days. Only 3.7% had long-duration side effects for over one month. These findings follow the current studies which state that most of the side effects occur within the next 3 days after vaccination [15]. Also, similar findings were reported by Riad et al., [12]. They found that the duration of general side effects following the vaccine was mainly one day (45.1%) or three days (35.8%), and only 1.4% of them had lasted over a month.

Also, it is important to highlight that the prevalence of side effects was higher among younger individuals (> 49 years old) and almost no noticeable side effects occurred among older participants (60 years old). These findings are consistent with those published by the FDA, which found that injection site pain, weariness, headache, and muscle soreness were more common in the 55-year-old group than in the > 55-year-old group [21, 15]. Also, the same findings reported among the Czech Republic and Saudi residents, respectively [12], reported that younger adults 43 years old were more frequently affected by side effects, and [22] concluded that the frequency of side effects was higher in individuals younger than 60 years of age, except for injection site pain, which was more frequent among those 60 years old.

Concerning the comparison of the occurrence of side effects between BNT163b2 mRNA COVID-19 vaccine, ChAdOx1 nCoV-19 vaccine, and BBIBP-CorV vaccines, the findings of the present study revealed that there were substantial variations between these vaccines in the presence of side effects. The majority (53%) of side effects were because of ChAdOx1 nCoV-19 vaccine, followed by BNT163b2 mRNA COVID-19 vaccine (42%) except for headache, nausea, epigastric pain, fatigue, and tonsillitis which were more sever in BNT163b2 mRNA COVID-19 vaccine than ChAdOx1 nCoV-19 vaccine. The current study found BBIBP-CorV vaccine was safer than BNT163b2 mRNA COVID-19 vaccine and ChAdOx1 nCoV-19 vaccine vaccines in all side effects that occurred among vaccinated individuals. This finding is supported by a systematic review and meta-analysis of randomized control trials (RCTs), which revealed that those who received mRNA-based vaccines had higher rates of side effects in reactogenicity [20]. The same findings were documented in Jordan. 2213 individuals received BBIBP-CorV, ChAdOx1 nCoV-19 vaccine, BNT163b2 mRNA COVID-19 vaccine, and other vaccines. They found that those who received the ChAdOx1 nCoV-19 vaccine reported the most abundant post-vaccination symptoms, while most of those who received the BBIBP-CorV vaccine were free from symptoms [23]. Another study was conducted to assess the symptoms following the COVID-19 vaccine among residents in India. 5396 people responded to the survey. The findings revealed that the frequency of experiencing symptoms following the BBIBP-CorV vaccine was less (24.4%) compared to BNT163b2 mRNA COVID-19 vaccine 70.7% [25]. As seen, the BBIBP-CorV vaccine has few side effects compared to other vaccines.

CONCLUSIONS

The most common side effect of the BNT163b2 mRNA COVID-19 vaccine, ChAdOx1 nCoV-19 vaccine, and BBIBP-CorV among the vaccinated population of the current study was headaches, injection site pain, injecting site swelling, fatigue, fever, muscle pain, joint pain, backache, chills, nausea, epigastric pain, and rash. These side effects were consistent with the data reported in the literature. Most of these side effects were mild, and no serious incidents were documented. Symptoms were more common in younger people. Although data reported in the literature showed that mRNA-based vaccines such as BNT163b2 mRNA COVID-19 vaccine had higher side effects, However, the current study found that the ChAdOx1 nCoV-19 vaccine, which is an adenovirus-based vaccine, had more side effects than other vaccines, and the BBIBP-CorV vaccine had the lowest side effects compared to the ChAdOx1 nCoV-19 vaccine and BNT163b2 mRNA COVID-19 vaccine vaccines.

 

Limitations

The limitation of the current study is that it was difficult to measure the severity of the side effects because the study is a survey-based technique. Thus some side effects needed to be measured by using instruments or tools, for instance, measuring body temperature by the thermometer to know the severity of fever, and using a pain scale to measure headache, joint pain, and muscle pain. Also it is prone to selective bias as it is internet based study, not everyone has equal chance to be included in the study. Further studies needs to be done with more representative samples concerning COVID-19 intention.

 

Conflict of interest

The authors have no conflict of interest to declare.

 

Funding

The current study was not funded by any financial resources.

 

Ethics

The present study was carried out in accordance with the Helsinki Declaration”. Study approval was obtained by written authorization of the Ethics Committee of the College of Nursing at Duhok University. The approval is without a serial number and verbal informed consent has been obtained from each participant before participation in the current study.

Acknowledgments

We would like to extend our appreciation to all respondents who took part in this online survey. We highly appreciated their time and effort. 

REFERENCES

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2. Zhuo Zhou , Lili Ren , Li Zhang , Jiaxin Zhong , Yan Xiao , Zhilong Jia et alHeightened innate immune responses in the respiratory tract of COVID-19 patients. Cell Host Microbe .2020; 27, 883-890.e2.
3. Centers for Disease Control and Prevention. COVID-19 information page (https://www.cdc.gov/coronavirus/2019 -ncov/index.html).
4. Addetia A, Crawford KHD, Dingens A, Zhu H, Roychoudhury P, Huang ML, Jerome KR, Bloom JD, Greninger AL. Neutralizing Antibodies Correlate with Protection from SARS-CoV-2 in Humans during a Fishery Vessel Outbreak with a High Attack Rate. J Clin Microbiol. 2020 Oct 21;58(11):e02107-20. doi: 10.1128/JCM.02107-20. PMID: 32826322; PMCID: PMC7587101.
5. Thompson, C. P., Grayson, N. E., Paton, R. S., Bolton, J. S., Lourenço, J., Penman, B. S., Lee, L. N., Odon, V., Mongkolsapaya, J., Chinnakannan, S., Dejnirattisai, W., Edmans, M., Fyfe, A., Imlach, C., Kooblall, K., Lim, N., Liu, C., López-Camacho, C., McInally, C., ... Girvan, M.. Detection of neutralising antibodies to SARS-CoV-2 to determine population exposure in Scottish blood donors between March and May 2020. Eurosurveillance, 25(42). https://doi.org/10.2807/1560-7917.ES.2020.25.42.2000685
6. Lurie N, Saville M, Hatchett R, Halton J. Developing Covid-19 vaccines at pandemic speed. New England Journal of Medicine..2020; 21;382(21):1969-73.
7. Caddy S. Developing a vaccine for covid-19. BMJ 2020;369:m1790 doi: 10.1136/bmj.m1790
8. World Health Organization. . Safety of covid-19 vaccines. https://www.who.int/news-room/feature-stories/detail/safety-of-covid-19-vaccines.2020.
9. Luyten, J.; Bruyneel, L.; van Hoek, A.J. Assessing vaccine hesitancy in the UK population using a generalized vaccine hesitancy survey instrument. 2019;37, 2494–2501. [CrossRef] [PubMed] .
10. Szmyd, B.; Bartoszek, A.; Karuga, F.F.; Staniecka, K.; Błaszczyk, M.; Radek, M. Medical Students and SARS-CoV-2 Vaccination: Attitude and Behaviors. 2021; 9, 128. [CrossRef].
11. Szmyd, B.; Karuga, F.F.; Bartoszek, A.; Staniecka, K.; Siwecka, N.; Bartoszek, A.; Błaszczyk, M.; Radek, M. Attitude and Behaviors towards SARS-CoV-2 Vaccination among Healthcare Workers: A Cross-Sectional Study from Poland. Vaccines 2021, 9, 218. https://doi.org/10.3390/vaccines9030218
12. Riad, A.; Pokorná, A.; Attia, S.; Klugarová, J.; Košˇcík, M.; Klugar, M.Prevalence of COVID-19 Vaccine Side Effects among HealthcareWorkers in the Czech Republic. Clin. Med., 10, 1428. https://doi.org/ .2021;10.3390/jcm10071428.
13. World Health Organization. . Side Effects of COVID-19 Vaccines. https://www.who.int/news-room/feature-stories/detail/side-effects-of-covid-19-vaccines.2021
14. World Health Organization. Guidance on routine immunization services during COVID-19 pandemic in the WHO European region: World Health Organization. Regional Office for Europe.2020.
15. Das, L., Meghana, A., Paul, P., & Ghosh, S. Are We Ready For Covid–19 Vaccines?–A General Side Effects Overview. Journal of Current Medical Research and Opinion.2021; 4(02).
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22. El-Shitany, N. A., Harakeh, S., Badr-Eldin, S. M., Bagher, A. M., Eid, B., Almukadi, H., Sindi, N. Minor to Moderate Side Effects of Pfizer-BioNTech COVID-19 Vaccine Among Saudi Residents: A Retrospective Cross-Sectional Study. International journal of general medicine.2021;14, 1389.
23. Hatmal MM, Al-Hatamleh MAI, Olaimat AN, Hatmal M, Alhaj-Qasem DM, Olaimat TM, Mohamud R. Side Effects and Perceptions Following COVID-19 Vaccination in Jordan: A Randomized, Cross-Sectional Study Implementing Machine Learning for Predicting Severity of Side Effects. 2021; 9(6):556. https://doi.org/10.3390/vaccines9060556
24. World Health Organization. Side Effects of COVID-19 Vaccines. Retrieved 4 June, 2021, from https://who.int/news-room/feature-stories/detail/side-effects-of-covid-19-vaccines.2021
25. Jayadevan, R., Shenoy, R. S., & Anithadevi, T. Survey of symptoms following COVID-19 vaccination in India. medRxiv.2021.
26. Kimmel SR. Vaccine adverse events: separating myth from reality. Am Fam Physician. 2002;66(11):2113–20.
27. Center for Disease Control and Prevention. Reactions and adverse events of the pfizer-BioNTech COVID-19 vaccine | CDC [Internet]. Centers Dis Control Prev. 2020 [accessed 2021 May 30]. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfi zer/reactogenicity.html
28. Lee E, Cines DB, Gernsheimer T, Kessler C, Michel M, Tarantino MD, Semple JW, Arnold DM, Godeau B, Lambert MP, et al. Thrombocytopenia following Pfizer and moderna SARS-CoV-2 vaccination. Am J Hematol. [Internet]. 2021 [accessed. 2021 Aug 31];96:534–37. /pmc/articles/PMC8014568/ .
29. European Medicines Agency. AstraZeneca’s COVID-19 vaccine: EMA finds possible link to very rare cases of unusual blood clots with low blood platelets [Internet]; 2020 [accessed 2021 May 30]. 

The questionnaire

         (COVID-19 Vaccines Side Effects Among Iraqi people In Kurdistan Region)

Dears the aim of this survey is to determine the (Prevalence of Covid-19 Vaccines side effects). We are grateful for filling in this survey from you and your family who got vaccinated. I would like to assure you that your answers will remain confidential and your personal details are not required. Also, your answers will be on online systems only.

1. Age

18_25

26_33

34_41

42_49

50_57

57_64

65 and more

 

2. Gender

Male

Female

3. Occupation

Health care workers

Employee Government

Student

Own Job

Jobless

4. Do you have any chronic disease?

Yes

No

5. Did you infected with Covid-19 before?

Yes

No

I don't know 

6. Which Covid-19 Vaccine you took it?

Sinopharm

Astrazenea

Pfizer

7. How many Doses you got it?

1 dose

2 doses

8. Select the vaccine side effects that occurred with you

Headache

Vaccine injection site pain

Fever

Nausea

Epigastric pain

Chills

Joint pain

Muscles pain

Fatigue

Injection site swelling

Allergy

Backache

Tonalities

Mouth Ulcers

No one 

 

9. Duration of side effects of Covid-19 Vaccines

1 day

2 days

3 days

4 days

5 days

6 days

1 week

More than 1 week

More than 1 month

No duration

 

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

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by OPI Napoli

Analysis of Determinants of Factors Related to the Performance of Non-Communicable Diseases Development Post Cadres in Kendari City: Cross Sectional Study

Saida, Rahmawati*, Wa Ode Syahrani Hajri

 

Department of Nursing, Medical of Faculty, Halu Oleo of University, Kendari, Indonesia

 

* Corresponding author: Rahmawati, Kampus Hijau Bumi Tridharma, Anduonohu, Kec. Kambu, Kota Kendari, Sulawesi Tenggara 93232, Indonesia, Orcid : https://orcid.org/0000-0002-6826-5393. Email: saida@uho.ac.id

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Abstract

Introduction: Non-communicable diseases (NCDs) are diseases that are not caused by bacterial infection and are the main cause of death in the world. The increase in NCDs cases also occurred in Southeast Sulawesi Province (Indonesia), including Kendari City. The purpose of this study was to analyze the determinants of proxies related to the performance of Integrated Non-Communicable Diseases Development Post (INCDDP) cadres in Kendari City, Indonesia.

Materials and Methods: A cross-sectional study carried out in Kendari City, Southeast Sulawesi Province (Indonesia), with a population of all INCDDP cadres in the working area of PHC Abeli, Lepo-Lepo, and Perumnas. The sample consisted of 56 responders. Data were analyzed univariate and bivariate statistics, using the chi-square test. Multivariate using logistic regression.

Results: The results of the research on the performance of INCDDP cadres were awards (p = 0.079), cadre training history (p = 0.031), infrastructure (p = 1.0) and knowledge (p = 0.007). The factor most related to the performance of INCDDP cadres was cadre knowledge (p = 0.019) with the coefficient of determination (R²) = 27.4%.

Conclusion: Cadre performance is related to awards, cadre training history, infrastructure and cadre knowledge. The most related factor to INCDDP cadre performance is cadre knowledge.

Keywords: Health-Cadres, Non-Commnicable Diseases, Performance, Health Services

Introduction

Non-communicable diseases (NCDs) have become an enormous public health problem, especially in Indonesia [1]. It is marked by a shift in disease patterns which is often referred to as an epidemiological transition characterized by increased mortality and morbidity due to NCDs such as stroke, heart disease and diabetes mellitus [2].

NCDs account for 41 million deaths each year, equivalent to 71% of all deaths globally [3]. The 2018 Basic Health Research (BHR) results show an increase in the prevalence of NCDs compared to the 2013 BHR results [4]. NCDs cases in Southeast Sulawesi in 2018 were still relatively high [4,5]. In 2019, the number of hypertension sufferers in Kendari city was 13,807 cases, and DM patients were 2876 cases [6].

The high number of NCDs cases in Kendari City requires severe treatment by increasing the Public Health Center (PHC) role through the Integrated Non-Communicable Diseases Development Post (INCDDP), significantly expanding the part of cadres in the context of preventing and controlling NCDs. INCDDP is a form of community participation in activities for early detection, monitoring, and early follow-up of NCDs risk factors independently [7], routinely, integrated, and continuously [8]. The high number of PTM cases in Kendari City (Indonesia) requires serious handling by increasing the role of the Puskesmas through the Integrated Non-Communicable Disease Development Post (INCDDP), significantly expanding the role of cadres in the context of preventing and controlling PTM. INCDDP is a form of community participation in activities for early detection, monitoring, and early follow-up of PTM risk factors independently [7], routinely, integrated, and continuously [8].

In improving the skills of cadres, it is necessary to support the development of health workers, especially community nurses [9]. One of the intervention strategies that can be applied as community nurses as educators or educators is to provide health education to high-risk community groups and health cadres and change public health behavior. Following this research, nurses are expected to be able to empower cadres by increasing the knowledge and skills of cadres as mover in the community. One of the ways to increase knowledge and skills is through community-based education programs. This is intended to improve the quality of cadres in providing counseling and management to patients and families of NCDs patients, as well as the community [10–12].

The role of INCDDP cadres is as an implementer of NCDs risk factor control for the surrounding community. The functions of cadres are as coordinator of INCDDP implementation, community mobilizer to participate in INCDDP, monitoring of measurement of NCDs risk factors, counsellor for INCDDP participants, recorder of results of INCDDP activities [13].

There are still many problems in service at INCDDP related to the capacity of cadres. In theory, three factors affect a person's performance: individual elements consisting of abilities and expertise, background, and demographics. The second is psychological factors consisting of perceptions, attitudes, learning and motivation. The last is organizational factors, namely resources, leadership, rewards, structure and job design. These three factors can be classified into intrinsic factors, while extrinsic factors include political, economic and social factors [14].

The results of previous studies stated a relationship between cadre performance with attitudes, motivation, rewards, job design, and there was no relationship between HR and the role of stakeholders [15]. It is in line with other research states that the support of health cadres and family support by using INCDDP in the Ballaparang working area of ​​Makassar City [16]. Kendari City has 15 PHCs, 13 of which have INCDDP. INCDDP cadres have a very big role in the prevention and early detection of risk factors for NCDs in the community [6].

The purpose of this study was to analyze the factors related to the performance of INCDDP cadres in Kendari City (Indonesia).

 

Materials and Methods

Trial design

This type of research is an observational analytic with a cross-sectional design to analyze the determinants of the proxy factors related to the performance of INCDDP cadres in Kendari City (Indonesia).

 

Participants

This research was carried out in October 2021 at 3 (three) Puskesmas in Kendari City (Indonesia) consisting of Abeli, Lepo-Lepo, and Perumnas Health Centers involving 56 INCDDP cadres with criteria including cadres who were present at the time of the study, cadres with active status participating in Integrated Non-Communicable Diseases Development Post (INCDDP) activities, while the inactive Cadres are expelled.

 

Intervention

The dependent variable in this study is the performance of cadres with the objective criteria of "good" and "bad". While the independent variables are cadre training, infrastructure, knowledge, awards with "good" and "less" objective criteria. Collecting data on cadre performance variables using a questionnaire, and cadre training variables, infrastructure, knowledge, awards, also using questionnaires. on each variable, consisting of 10 questions with an alternative scoring as follows: if the respondent answers yes then it is given a score of 1 and if the respondent answers no it is given a score of zero. All questionnaires in this study used previous research questionnaires that had been tested for validity and reliability. The questionnaire received an award from the Kiting PR research. et al, [15], questionnaire of knowledge, training and infrastructure adoption from Handayani RO. et al, research [17].

 

Outcomes

Knowing the performance of cadres, training history, rewards, infrastructure, and knowledge.

 

Sample size

The number of participants in this study was 56 people. The age of the sample in this study was between 26-67 years, all of whom were female because all Integrated Non-Communicable Diseases Development Post (INCDDP) cadres were female. The sampling method in this study was total sampling because the number of Integrated Non-Communicable Diseases Development Post (INCDDP) candidates was very small.

 

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). The bivariate analysis uses the chi-square test, and multivariate uses logistic regression. Logistic regression test is used because the data scale used is categorical or binomial. in the multivariate test, there is R² or R square also referred to as the coefficient of determination which explains how far the dependent data can be explained by independent data. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.

 

Ethical Consideration

No economic incentives were offered or provided for participation in this 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 Committee of the College of Medicine, Halu Oleo University, number: 183/UN29.17.1.3/ETIK/2021.

 

Result

The distribution of the characteristics of the results of this study is showed in Table 1:

Table 1. Frequency Distribution Based on Characteristics of Respondents

Table 1 shows the frequency distribution of 56 respondents based on age characteristics, primarily aged 36-45 years as many as 24 (42.9%), the highest length of being a cadre is 2-3 years, and > 5 years each is 20 (35.7%), the highest level of education is high school graduates as many as 34 (60.7%). The most elevated employment status is as a housewife as much as 34 (60.7%).

The distribution of research variables is presented in table 2. Table 2 shows the frequency, distribution by knowledge, perception of vulnerability, and compliance, there were 29 cadres (52.8%) who performed well, 26 cadres (46.4%) had attended training, 45 cadres (80.4%) stated that they had received awards, there were 48 cadres (85.7%) who indicated that infrastructure facilities were not available. Meet the minimum requirements, and 36 cadres (64.3%) have good knowledge.

Table 2. Frequency Distribution by Knowledge, perception of vulnerability, and compliance

The distribution of the relationship between research variables can be presented in the following table 3:

Table 3. Relationship between variables

Table 3 shows that of the 26 respondents who have a good training history, there are 15 cadres (57.7%) who perform well and 11 cadres (42.3%) who perform poorly, then from 30 respondents who have a history of lack of training, there are 16 cadres (53.3%). Underperforming and 14 cadres (46.7%) performed well. The chi-square test showed a p = 0.579, indicating no significant relationship between training history and the performance of INCDDP cadres.

Forty-five respondents assessed the availability of the award, as many as 27 cadres (60.0%) with good performance and 18 cadres (40.0%) with less performance. Then from 11 respondents who assessed that the award did not exist, nine cadres (81.8%) with poor performance and two cadres (18.2%) performed well. The chi-square test shows the p = 0.031, indicating a significant relationship between rewards and the implementation of INCDDP cadres.

Eight respondents assessed the minimum requirements of infrastructure, four cadres (50.0%) with good performance and four cadres (50.0%) with poor performance. Of the 48 respondents who assessed that the infrastructure did not meet the minimum requirements, 23 cadres (47.9%) underperforming and 25 cadres (52.1%) performed well. The chi-square test shows that the p = 1.0 indicates no significant relationship between infrastructure and the performance of INCDDP cadres.

Of the 36 respondents who have good knowledge, there are 24 cadres (66.7%) with good performance and 24 cadres (33.3%) with poor performance; then from 20 respondents who have less knowledge, there are 15 cadres (75.0%) with poor performance and five cadres (25.0 %) perform well. The chi-square test showed a p = 0.007, indicating a significant relationship between knowledge and performance of INCDDP cadres.

Multivariate data analysis using logistic regression test is presented in table 4.

The results of the multivariate analysis showed that the Wald value of the knowledge variable was the largest with a significant value (p = 0.090).

Table 4. Multivariate Analysis of INCDDP Cadre Performance

The value of R² = 27.4% indicates that this model can explain the effect variable (INCDDP cadre performance) of 27.4%, while 72.6% is influenced by other variables not examined.

The value of chi square = 12,900 with sig. 0.012 in Degree of Feedom 4 the value of chi square table = 9.49. it can be seen that the p value < 0.05, so it can be ascertained that the addition of the independent variable has a real effect on the model, in other words other models are declared FIT

 

Discussion

      1.Reward

The purpose of this study was to analyze the factors related to the performance of INCDDP cadres in Kendari City (Indonesia). The existence of cadres should receive fair and sincere recognition and appreciation [18]. Recognition of the existence of cadres from cadre coaches in the sub-district needs to be realized by prioritizing free health services and the presence of cadre uniforms [19]. The hierarchy of human needs starts from primary needs (physiological needs and safety needs) to be dominant until these needs are felt to be sufficiently fulfilled [20].

Appreciation for the work done is a desire from selfish needs, manifested in praise, gifts (in the form of money or not), announced to his co-workers [21]. Therefore, giving awards for cadre loyalty will be very helpful to maintain the activeness of Posbindu cadres; giving tasks that are not boring with praise, completing attributes while on duty will increase cadre performance [22].

In this study, it was found that of the overall respondents, more than half had received awards from the government through the Puskesmas or the Kendari city health office. Indeed, this greatly influenced the motivation of Posbindu cadres in working. It is statistically proven that cadres who have a history of receiving awards tend to perform well and vice versa.

It is stated that usually, a person will feel mistreated if the treatment is seen as a dangerous thing. In working life, this perception is associated with various things, namely incentives and the number of hours worked [23]. The provision of incentives is a basic payment to motivate employees to be more advanced in work with more excellent skills and responsibilities [24]. Incentives are one type of award that is associated with work performance [25].

The award should be given to human resources, in this case, Posbindu PTM cadres who perform well to increase the spirit of work. Other cadres will see and will encourage other cadres to work better so that performance improves. Therefore, the performance of PTM Posbindu cadres will significantly increase if awards are given to their human resources.

In line with the findings of Renate Pah Kiting [15] stated that there is a relationship between rewards and performance (p=0.013 OR=10.400). Furthermore, Renate et al. said that cadres who received awards ten times would have the opportunity to have better performance compared to cadres who did not accept awards.

 

      2.Training

The commitment of cadres to the responsibilities and functions of the INCDDP program in the Anambas Islands is quite good. It is evidenced by the continued implementation of the INCDDP program even though it is still constrained by several problems such as limited tools and materials and has never received special training. Therefore, support and commitment from cadres are very vital in the implementation of the INCDDP program. In the results of his research, it is stated by [26] that INCDDP cadres who always consistently run INCDDP with or without training will motivate other cadres to take an active role and try to help active cadres with what has been exemplified.

In this study, only a few respondents had ever been sent to receive training, although some of the cadres who had attended the training section stated that they were not under the assignment field at INCDDP. This condition will undoubtedly affect cadres' performance where when doing work. They do not look professional due to their lack of knowledge.

There is a difference in the proportion of cadres who received training and whose performance was considered "good" compared to cadres whose performance was "good" but did not receive training. The result shows that the more often cadres attend training, the better their performance [27]. Cadre training is carried out to increase the knowledge and skills of cadres. It will be achieved if the training section is carried out correctly. Puspasari A stated that the quality of cadre training is a factor causing cadres' low knowledge and skills level in carrying out their roles and duties. Therefore, training activities should be carried out regularly with a distance that is not too long.

The training should always start with the importance of an INCDDP cadre's goals so that interest and strong desire to make decisions and take action in implementing PTM Posbindu activities arise. It is expected that cadres will work with higher motivation and feel satisfied with their work so that it has a direct impact on increasing performance [28].

 

     3.Infrastructure

Not all of the INCDDP in the working area of ​​the PHC have complete kits; it requires them to use alternate tools at implementation. The Posbindu kit contains tools for checking blood sugar, cholesterol, uric acid, measuring height and then a body fat analyzer. Digital devices have never been calibrated, and this, of course, has fatal consequences in calculating the inspection results. Based on the inspection, the digital sphygmomanometer is broken, which give abnormal results in measurement.

Regarding the damaged digital INCDDP equipment, it is also following the research of Astuti et al. [29] that the number of NCDs INCDDP equipment is damaged/error. These tools include; body fat scale analyzer, measuring blood sugar and measuring total cholesterol. Likewise, research by Pranandari et al. [30] concluded that the infrastructure for the NCDs Posbindu in Banguntapan District, Bantul Regency for examining NCDs risk factors in the form of examination strips was not sufficient. Nova Silviyani's research [31] states that the statistical results obtained a p of 0.05 = (0.05), so it can be noted that there is no significant relationship between infrastructure and Posbindu performance.

In motivating the work, it should provide suitable facilities and infrastructure to carry out tasks. However, as complained by the cadre coach at the Kendari City District level, inadequate facilities and infrastructure such as tables, chairs, scales, stationery and especially the Posbindu place will hinder the performance of Posbindu cadres [32].

Posbindu activities will not be able to run correctly if adequate facilities do not support them. The provision of work facilities is that the work facilities provided must be sufficient and follow the duties and functions. Moreover, it must be implemented and available at the right time and place. Therefore, Posbindu facilities are everything that can support the implementation of Posbindu activities such as a fixed place or location, routine funds for giving additional food (PMT), the necessary tools, for example, kitchenware, KMS, tables, chairs, register books and others [33].

 

     4.Knowledge

Knowledge of health cadres is an essential factor in supporting the ability of cadres to provide services. This study shows that several cadres have a low level of knowledge. There needs to be an effort to increase the knowledge of cadres, where one of the steps that can be taken is to provide health education and training to health cadres [34],[35].

Cadre knowledge is the extent to which cadres understand their duties and roles in INCDDP activities, including preparation before implementation, during implementation and after the implementation of INCDDP for the elderly. Knowledge of health cadres about INCDDP services is obtained from the information they obtain both from official sources, meaning from the health office that fosters them, from informal sources, and activities aimed at increasing cadre knowledge such as training, seminars and so on [36].

It is evident from the results of statistical tests that there is a relationship between knowledge and the performance of Posbindu cadres in the working area of ​​the Puskesmas in Kendari City. Hence, there is a tendency for cadres who have an excellent ability to do their jobs well.

It is in line with research [37] which examines the relationship between knowledge and length of work with the skills of cadres in assessing the growth curve of toddlers at the Posyandu, Tegalsari Village, Candisari District, Semarang City. This study shows that the level of knowledge of cadres about the growth curve of toddlers is primarily adequate, where one of the factors related to this knowledge is the level of education of cadres, most of whom are in high school.

We assume the level of education of cadres varies from elementary school to high school level. This level of schooling dramatically affects the attitude and ability of cadres in capturing information conveyed by officers both when training and visits to INCDDP.

 

     5.Multivariate test results

In Table 4, there is a significant positive correlation between the Performance and Knowledge of INCDDP Cadres (OR=4.987; p=0.019). it can be explained that after going through a simultaneous test between the performance of cadres and all independent variables (knowledge, training, infrastructure, and awards) it was found that only the knowledge of cadres was significant while the other 3 variables were not significant. Knowledge of cadres dominates the motivation of cadres to improve their performance, so even though infrastructure is available, if cadres do not have knowledge of what to do, then cadres' performance tends to be poor.

Implications of research results for nursing and clinical practice is to be valuable information for health service providers, especially community health centers to maximize the performance of nurses in assisting cadres when providing services to the community.

 

Conclusion

Cadre performance is related to awards, cadre training history, infrastructure and cadre knowledge. The most related factor to INCDDP cadre performance is cadre knowledge.

There is a need to increase advocacy to the legislative body regarding the importance of getting more budget for PHC and the need to improve health funds budgeted through the Regional Revenue and Expenditure Budget (APBD) to support the implementation of services and the need to formulate regulatory policies to tackle financing for cadres immediately. It is necessary to carry out periodic training for cadres, and it is hoped that INCDDP cadres will continue to explore knowledge and experience to improve performance in the implementation of INCDDP activities and always be positive in every action carried out at INCDDP and need to improve and improve facilities and infrastructure to meet basic service needs.

 

Limitations of Study

The limitations of this study include the very limited number of subjects, and this research only involves one region or 1 region so the results may be different when compared to other regions or regions in Indonesia.

 

Acknowledgement

We would like to thank the Chairperson of the research institute and community service who have 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.

 

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Appendix A

QUESTIONNAIRE

Instruction :

1. Fill in the blanks with honest answers
2. Put a tick (X) on the multiple choice answer
3. Put a tick (√ ) on the available answer choices

A. Cadre performance

B. INCDDP Cadre Training
           Have you ever received training for INCDDP cadres?
      a. Yes
      b. No

C. Awards
   1. Have you ever received an award in the form of a charter or award while being a INCDDP cadre?
        a. Yes
        b. No
   2. Have you ever received an award in the form of funds while being a INCDDP cadre?
        a. Yes
        b. No
  3. Do you get a uniform to carry out INCDDP activities?
        a. Yes
        b. No
  4. Do you always receive an award if you are active in INCDDP activities?
        a. Yes
        b. No

D. Facilities and infrastructure

E. Knowledge

 

 

---

by OPI Napoli

PROBLEM BASED LEARNING MODEL IN VIRTUAL ENVIRONMENT CLASS IN HEALTH: A SISTEMATIC REVIEW

Rosmaria¹, Rayandra Ashar², Muhaimin³, Herlambang⁴

 

¹Department of Midwifery, Health Polytechnic of Jambi, Indonesia

²Chemistry Education Study Program, Faculty of Teacher Training and Education, Jambi University, Indonesia

³Study Programs In Chemistry Education, Faculty of Teacher Training and Education, Jambi University, Indonesia

⁴Medical Study Program, Faculty of Medicine, Jambi University, Indonesia

 

* Corresponding author: Rosmaria, Department of Midwifery, Health Polytechnic of Jambi, Indonesia. , E-mail: rosmaria.poltekkes@gmail.com

Cita questo articolo

Abstract

Background. PBL is a student-centred learning method where students determine their own learning goals from clinical-based problems. Many studies have been conducted regarding the effectiveness of PBL based on virtual classes or online classes in various fields of science. This systematic study aims to evaluate the implementation of PBL in various online learning contexts.

Methods. This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We include intervention studies, training, or educational strategies using PBL method focusing on any health student class, and published between 2010 to 2021. Three authors (RA, MH, HR) performed data extraction. Differences that arise are resolved by consensus, in consultation with other investigators (RS).

Results. The search returned 1,678 articles; after removing the duplicated articles, 731 articles remained, of which 721 articles were removed after screening titles and abstracts. The remaining ten articles were reviewed and checked for eligibility, so three articles were excluded. The final results were collected as many as seven articles that met the inclusion criteria.

Conclusion. Online PBL is perceived to be an effective educational strategy by lecturer. Overall, the results for PBL in online/virtual class include Positively impact the learning experience, Increase knowledge and skills, improve the learning process, Increased self-learning capacity, motivation, self-monitoring, and interpersonal communication, Improve student understanding and application of theoretical knowledge in a large classroom setting, Increased availability and acceptance, reduced interactivity.

 

Keywords: Problem-Based learning, Virtual, Online Class, Students

 

 

 

INTRODUCTION

As a modern pedagogical philosophy, Problem-Based Learning (PBL) is increasingly recognized as a critical research area in student learning and pedagogical innovation in health science education [1,2]. In contrast to teaching and learning approaches dominated by conventional lectures, inquiry-based approaches such as PBL encourage students to be actively involved in knowledge construction and develop competencies in various contexts [3]. This review focuses on PBL rather than other inquiry-based pedagogical approaches, such as discovery learning, experiential learning, and project-based learning. Given the high level of technological involvement of 21st-century learners, a new area of ​​research is examining the emerging role of educational technology in PBL [4–6]. Therefore, this study aims to review the application of PBL in the concept of problem-based online classes. What is interesting from this review are studies investigating the effectiveness of online classes in achieving PBL-related student learning outcomes of flexible knowledge, practical problem-solving skills, independent study skills, collaborative teamwork skills, and intrinsic motivation [7,8].

The studies included in this review are studies where educational technology has been adopted to support PBL for undergraduate and postgraduate program learning. Traditional pedagogy, which is teacher-centred, class-oriented, and pressure on exams, places students passively “acceptance” state [9]. PBL is a student-centred learning method where students determine their own learning goals from clinical-based problems [10,11]. As an established approach, PBL has been reported to be suitable for use in graduate medical schools [12]. Recently, PBL has become a subject of considerable interest in postgraduate education. PBL can cultivate postgraduate leadership, teamwork, communication, and problem-solving skills, which are helpful for lifelong learning and facilitate postgraduates to take responsibility for their learning.

The online PBL format has been piloted with varying degrees of success, and although the PBL approach is beneficial for students in various disciplines, the results associated with this strategy are inconclusive in nursing education [13]. One such study compared conventional classroom-based strategies with problem-based asynchronous learning for part-time public health students. The development of web-based technology has resulted in new ways to implement PBL in large classrooms [14]. New teaching methods facilitated by web-based technologies have been applied in nursing education using web-based PBL methods with promising effects. Web-based PBL also enables better communication between teachers and students. When used with conventional PBL teaching methods, web-based PBL facilitates the development and promotion of more significant self-directed learning and innovation in nursing and other professional education systems.

Many studies have been conducted regarding the effectiveness of PBL based on virtual classes or online classes in various fields of science. It has prompted the author's interest to conduct a systematic study of this review on PBL implementation based on online classes or virtual classes. For this reason, the current study aims to evaluate the implementation of PBL in various online learning contexts.

METHODS

Review Protocol

This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [15]. The current study tries to evaluate the application of the problem-based learning method in virtual or online learning situations from articles that have been published in the period 2010 to 2021.

 

Searching strategy

Relevant articles were searched and collected using Sciencedirect, Google Scholar, Proquest, Pubmed, and the Wiley Online Library, with a publication time between 2010 and 2021. The search keywords were adjusted according to the Mesh terms for health research. The keywords used vary, depending on the search engine used. In general, the keywords focus on 'Effectiveness' OR 'Effect' OR 'Evaluation' AND 'Problem-Based Learning' OR 'PBL' AND 'Online class' OR 'Virtual class' OR 'virtual meeting' AND 'web-based' OR 'social-media OR 'Online group discussion'.

 

Eligibility

Inclusion criteria consist of intervention studies, training, or educational strategies using PBL method focusing on any health student class in certain subjects for example Physiology, anatomy, nursing care, community health, etc. Study outcomes such as increased knowledge, attitude, skills, and/or student satisfaction. We choose only articles published in English, and in the time range 2010 to 2021. We excluded or not reviewed books, disertation, letter to editor, and systematic review study.

Study Quality

Overall articles were assessed using the NIH (National Institutes of Health) quality assessment of controlled intervention studies, for Observational Cohort and Cross-Sectional Studies, and Quality Assessment of Case-Control Studies [16].

A scoring sheet was developed to assess the research methodology and adherence to the scoring criteria for each article that met the inclusion criteria of this study. Articles with scores <30% of the criteria were classified as "poor", scores between 30 and 70% were classified as "moderate", and scores >70% were classified as "good" study quality. The articles taken are classified as moderate and "good".

 

Extraction and Analysis

Three authors (RA, MH, HR) performed data extraction. Differences that arise are resolved by consensus, in consultation with other investigators (RS) if an agreement is not reached. Main items extracted included: lead author/year, country, purpose of the study, method (Quasi-experimental, Randomized Controlled Trial), evaluation strategies, and results.

Titles and abstracts are screened on each database. Screening for duplicate articles is carried out using the Mendeley application. Substantive information is extracted from each article into a Microsoft Word table.

The author determined the selection of articles after being reviewed from 7 full-text articles adjusted to the inclusion and exclusion criteria. Data extraction was carried out with care. The interpretations are presented in the table by taking the critical parts of the article.

 

RESULTS

The search returned 1,678 articles; after removing the duplicated articles, 731 articles remained, of which 721 were removed after screening titles and abstracts. The remaining ten articles were reviewed and checked for eligibility, so three articles were excluded. The final results were collected as many as seven articles that met the inclusion criteria.

 

Article Characteristics

Most of the literature included is in the quantitative type with a Quasy experimental research design of five articles [13,17,18,21,22] and one each for the Randomized Controlled Trial [20], and Research & Development [19]. A total of 654 students were involved in all the studies included in this study. Included articles were published from 2010 to 2021 and conducted in five different countries, including China (n = 3) and one study in Hong Kong, Turkey, Korea, and the USA.

Areas of knowledge for the implementation of Problem-Based Learning (PBL) in online classes include Hematology [17], Dentistry [13], Nursing management [22], problem-solving skills, and communication skills [18], Division of Speech and Hearing Sciences [19], Oncology Nurses [20], bio-pharmaceutics [21].

The educational levels of participants in several articles included in this review consist of clerkship students [13], Post-graduate students [15], undergraduate students, and working nurses [18].

 

Figure 1. PRISMA Flowchart literature search

 

Table1. Critical data extraction from included articles

Online settings

The online class system used is varied, such as We-chat social media used in three studies conducted in China with results showing that this strategy provides an increase in the learning experience, increases student knowledge, and interpersonal communication [13,17,22]. Two studies conducted in the same year, namely 2014 in Hong Kong and Korea, used a web-based interface to form Adobe Connect and the e-PBL program. In carrying out the study, authors combined several other internet-based communication channels such as e-mail, and social media as a forum to discuss the assigned tasks where it improvises the learning process and can increase students' knowledge [19,20]. Meanwhile, a study in the USA used the Google Hangout application to discuss the tasks of the Problem-Based Learning program; this is considered the most accessible medium to use where this application is available on every gadget or smart phone. Through those media may increased availability and acceptance, but unfortunately reduced interactivity [21]. The application that is currently most often used is "Zoom" Aslan conducted a study that tried to investigate the effect of using this application in the PBL model on the problem-solving skills, communication skills, and interactions of 45 students involved in his studies. Zoom PBL improves student understanding and application of theoretical knowledge in a large classroom setting [18].

The entire study was conducted to assess the effect of implementing the PBL method in online classes. Some studies even compare with conventional methods or face-to-face [21]; [20]. Meanwhile, the study conducted by [18] tried to compare the online class with the PBL approach with the online class teacher-based methods. Three studies using We-chat applications in China aimed to assess the effectiveness of online class-based PBL using We-chat, but each has a different field of knowledge for its application [13,17,22].

 

DISCUSSION

The articles reviewed in this systematic review generally show the implementation of PBL methods in online classes. In some cases, this method can reduce cognitive load and allow students to learn in complex domains [18,20].

The We Chat-based PBL mode conducted by [17] is designed to support postgraduate students' abilities in haematology courses, including those related to clinical reasoning, team skills, and meta-cognition. This online PBL model has succeeded in eliminating the physical and temporal limitations of traditional PBL, as has been implemented so far [17]. Similar results were also obtained in another study that used We-Chat as a medium in the implementation of PBL, where this method succeeded in removing the physical and temporal limitations of traditional PBL in dental registrars. We-chat is very common and familiar in China, so this application is the primary choice for people to socialize in cyberspace. This method also ensures the time required and quality of PBL, expands the means of acquiring knowledge, and increases efficiency in problem-solving. As a modern pedagogical philosophy, the importance of PBL is increasingly recognized in student learning and innovation in medical education [1]. Many educators have tried to improve traditional PBL by modifying instruction. Therefore, other PBL modes such as tutors PBL, 3C3R Modified PBL, and Hybrid PBL have emerged in PBL teaching [13,23,24]. However, compared to traditional PBL, WeChat-PBL has several advantages that take PBL to a higher level [13,22].

M.L. Ng and colleagues used Adobe Connect to implement online tutorials to embody the Problem-Based Learning model for students. Users, namely students, can open any web browser to connect to Adobe Connect. All PBL sessions ran smoothly, without significant delays in audio or serious interruptions in video transmission. Students stated that Adobe Connect was smooth, easy to install and worked well with their home internet connection. The students agreed that the system met the requirements for online tutorials. The study also concludes that the pedagogical effectiveness associated with online PBL does not differ from traditional PBL for students in later years with the curriculum well integrated into the PBL process. Through online PBL, students enjoy PBL more and save a lot of travel time [19]. Thus, online PBL appears to be the way forward when time and place requirements cannot be met or when weather or other conditions do not allow for regular meetings or the current situation, namely the Covid-19 pandemic.

The e-PBL program that is trying to be developed in Korea shows that this program is very useful, especially for Oncology nurses. Online learning allows participants to interact with each other regardless of time and place restrictions and presents complex data in an accessible way that is fun and easy to learn. This program is highly expected to be integrated into continuing education for nurses. when PBL is delivered in online groups, students can play an active role in solving problems through the use of case studies and online discussions. Tutors participate in online discussions by contributing questions and comments, and provide timely feedback to encourage collaboration and topic-focused discussion [20].

The challenges of online education include technological capabilities, student acceptance of technology, and the ability of lecturers to adapt to new roles and to acquire new instructional skills [25]. The survey results in research in the USA show that technology is not a barrier for students. However, almost half of the students in the class indicated that they preferred discussion in class to online. Many students get lower online discussion learning scores than in class meetings [5]. PBL discussion meetings may be held online due to the increased availability and acceptance of technology but may lead to reduced interaction and participation. This suggests that online discussions require facilitators to encourage and stimulate student participation and active student-student interaction which may differ from the approach used for face-to-face class discussions [5].

The current reviews corresponds to the findings from other reviews focusing on the effectiveness of DPBL (Digital Problem Based Learning) in improving health professionals’ knowledge, skills, attitudes, and satisfaction [1],[26]. These reviews explores more the differentiation between DPBL and traditional PBL [26]. In current review, we found few evidence that show the effectiveness of PBL in virtual environment similar with traditional PBL. Jin & Bridges reviews stated more on the hardware used in PBL, while our review mostly used software or application which commonly can be accessed using android technology in mobile phone.

CONCLUSION

This systematic review shows the implementation of various PBL-based online classroom technologies. Overall, the results for PBL in virtual class include Positively impact the learning experience, Increase knowledge and skills, improve the learning process, Increased self-learning capacity, motivation, self-monitoring, and interpersonal communication, Improve student understanding and application of theoretical knowledge in a large classroom setting, Increased availability and acceptance, reduced interactivity.

LIMITATION

The systematic preparation of this review cannot be separated from efforts to collect relevant articles completely and comprehensively discussing issues related to the theme of implementing the PBL model in online classes. The author does not collect enough relevant articles due to the accessibility of relevant articles in the database that the author cannot do, besides the language that the author limits to English articles only. In the end, we were unable to carry out further analysis (meta-analysis) because the number of articles included in this study did not meet the requirements (very few).

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.

 

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