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VIDEO-BASED INTERVENTION ON THE KNOWLEDGE OF BREAST-MILK SUPPORT GROUP IN SEMBUBUK VILLAGE, MUARO JAMBI REGENCY: A PRE-EXPERIMENT STUDY

Yuli Suryanti¹*, Damris Muhammad², M. Naswir³, Guspianto²

 

¹Department of Midwifery, Health Polytechnic of Jambi, Indonesia

²Department of Environmental Engineering, Jambi University, Indonesia

³Department of Chemistry, Jambi University, Indonesia

⁴Department of Public Health, Jambi University, Indonesia

* Corresponding author: Yuli Suryanti, Department of Midwifery, Health Polytechnic of Jambi, Indonesia, Jalan Prof DR GA Siwabessy No.42. Buluran Kenali, Kec. Telanaipura, Kota Jambi,.36122, Phone : +62 813-6635-9359, E-mail: suryantiyuli03@gmail.com

 

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Abstract

Introduction: Breast milk is the best food for babies because it contains nutrients to support growth and development. The achievement rate of exclusive breastfeeding in ASIA countries has not yet reached the expected target. The coverage of exclusive breastfeeding in Jambi Province in 2018 was 59.36%. The success of exclusive breastfeeding is not only influenced by the mother's physical and mental readiness to breastfeed. Still, it is also influenced by support from health workers and the family. The study aimed to determine the effect of counseling using breastfeeding video on grandmothers' knowledge as breastfeeding support in Sembubuk Village, Muaro Jambi Regency.

Methods: This type of pre-experimental research using the One Group Pretest-Posttest design, which saw 40 grandmothers of the Breast Milk Support Group members, was carried out from June 2020 to July 2021. Respondents answer the questionnaires to complete the data collection. The intervention carried out in this study was the provision of counseling using video media about breastfeeding. Data were analyzed through univariate and bivariate using the Wilcoxon test.

Results: The results showed the p-value = 0.0001, which means that breastfeeding video affects grandmothers' knowledge in breastfeeding support groups in Sembubuk village, Muaro Jambi District.

Conslusion: The results of this study are expected to increase public knowledge and insight regarding the importance of breastfeeding for infant health so that positive behavior is formed in breastfeeding, providing additional appropriate information to advance understanding of breastfeeding support groups about breastfeeding.

Keywords: Exclusive breastfeeding, health education, Knowledge, Video-based

 

 

 

Introduction

Breast milk has been an optimal food source for babies due to its rich nutrients for growth and development [1–3]. The benefits of breast milk will be optimal if it is given regularly from birth with the correct breastfeeding position, breastfeeding at the baby's desire (on demand), and offered exclusively [4–6]. In Indonesia, exclusive breastfeeding for 6 (six) months has been stipulated in the Decree of the Minister of Health No. 450/Menkes/SK/IV/20042 [7].

The achievement target of exclusive breastfeeding in Indonesia is 75% [8], while globally, it is 70% [9]. Exclusive breastfeeding in ASIA countries is far from the achievement target [10]. Exclusive breastfeeding coverage for infants under 6 months is 15% in Thailand, 40% in China, Indonesia 42%, India 46%, Mongolia 66% [11]. Based on this percentage, Indonesia has the third position of lowest breastfeeding coverage compared to other ASIA countries [12]. The issue is related to the number of mothers who do not like exclusive breastfeeding, where almost 9 out of 10 mothers have breastfed [13]. Still, only 49.8% gave exclusive breastfeeding for six months [14,15]. The low coverage of exclusive breastfeeding impacts the quality of life of the next generation and the national economy [16–18]. The number of mothers who have breastfed in Indonesia is already high at 90%, but those who give exclusively for six months are still low (20%) [19,20]. The coverage of exclusive breastfeeding in 2018 in Jambi Province was 59.36%, while the target for the province was 61%. Merangin Regency is the only district with the highest achievement of exclusive breastfeeding with 88.75%. In comparison, the lowest is Tanjung Jabung Barat Regency at 30.91%, and Muaro Jambi Regency with the 3rd rank of 64.54% [21]. Penyengat Olak, one of the sub-districts in Muaro Jambi Regency, consists of 8 villages. Sembubuk village is the only village with the lowest breastfeeding coverage; based on the survey results, the number of infants aged 0-2 years old in Sembubuk was 71 people, and the number of infants 0-6 months was 40 people. The Penyengat Olak Health Center targets exclusive breastfeeding of 65% [22].

Infants, who get insufficient breastfed until the first six months of life, are at risk of developing diarrhea [23,24]. Meanwhile, complementary foods such as formula milk also increase the risk of diarrhea, resulting in malnutrition because the nutritional content in formula milk is not sufficient to meet baby needs. Lack of breastfeeding causes babies to be malnourished [25,26]. Malnutrition will decrease the quality of human resources, such as failure of physical growth, mental and intellectual development, lowering productivity, increasing morbidity and mortality. Breast milk benefits both mother and fetus, and it also appears to reduce the chances of getting leukemia, lymphoma, diabetes, and asthma as the child grows older [27].

The success of exclusive breastfeeding is not only influenced by the mother's physical and mental readiness but is also influenced by support factors from both health workers and family [28]. Research by Nankuda et al. [29], in rural areas in Uganda proves that peer support in the form of visits and providing support can be more readily accepted in the breastfeeding mother community. Mothers feel happy to have a peer counselor who can help them with various problems during breastfeeding [30]. To improve and support the process of exclusive breastfeeding for mothers, forming a breastfeeding support group can be an option [31]. The Breast Milk Support Group is a forum for breastfeeding mothers to give and receive technical, moral, and emotional support by exchanging experiences and discussing maternal and child health, especially breastfeeding and nutrition [32]. Those are facilitated or guided by breast milk motivators. It is considered to cause behavioral changes in society. One of these behavioral changes can be seen in the mother's breastfeeding belief [33]. Bekti and colleagues [7], in their study on the Effectiveness of Exclusive Breastfeeding Support Groups (EBSG) toward Exclusive Breastfeeding Behavior, found that the majority of the groups with exclusive EBSG support (86.4%) gave exclusive breastfeeding. In comparison, there is only a tiny part (31.8%) of exclusively breastfed in the leaflet group. The formation of breastfeeding support groups affects entire breastfeeding behavior (p-value 0.001).

The involvement of grandmothers who support breastfeeding is essential because grandmothers play a vital role in the family. Grandmothers can influence decisions in the family, whether the mother should breastfeed a newborn baby or not. This condition is almost evenly spread throughout Indonesia [34,35]. Other research in the Ayeyarwaddy Region in Myanmar found that one of the primary barriers to exclusive breastfeeding was that mothers, husbands, and grandmothers believed exclusive breastfeeding was insufficient for babies and solid foods and water were necessary [36]. Supporting EBSG activities, a counseling program is needed to increase grandmother's knowledge about the importance of exclusive breastfeeding. Counseling is effective using a variety of media. It depends on the learning component, such as the use of media. Engaging media will provide confidence to accelerate affective and psychomotor cognitive changes [37]. One of the media in counseling is video. Video is a modern interactive medium by times (advancement of science and technology) because it can be seen and heard. Messages delivered are more efficient because moving images can communicate messages quickly and naturally [38].

Video media has advantages in providing good visualization to facilitate absorbing knowledge. Video is included in audio-visual media because it involves the sense of hearing and the importance of sight [38].

This study aims to determine the effect of video media on breastfeeding knowledge of breastfeeding support groups in Sembubuk Village, Muaro Jambi Regency.

 

Methods

Trial design

This study establishes a pre-experiment with the One Group Pretest-Posttest approach, aiming to determine the Effect of Video Media on Breastfeeding on Knowledge of Breastfeeding Supporting Grandmothers Group in Sembubuk Village, Muaro Jambi Regency.

Participants

The population in this study were EBSG members totaling 40 people, selected randomly and consecutively according to our inclusion criteria. This study was conducted in June 2021.

 

Inclusion and Exclusion Criteria

Grandmothers who live with nursing mothers, while grandmothers who do not understand Indonesian are excluded

Intervention

The data was collected by filling out a questionnaire by the respondents. The intervention that will be carried out in this study is the provision of counseling using video media about breastfeeding. The research team made Breastfeeding videos are made. This video is 15 minutes long which contains the understanding of breastfeeding, the benefits of breastfeeding, the correct way to breastfeed, the recommended breastfeeding time, the duration of breastfeeding. video screening was held at the conference hall in Sembubuk Village, Muaro Jambi Regency

The knowledge questionnaire consists of 15 questions about breastfeeding. If the mother who supports breastfeeding is correct, she is given a score of 1, while if the answer is wrong, she is given a 0. The objective criteria for the variable are good and imperfect knowledge. Cut-off criteria are good and less, using a median value of 8. Good criteria, if the total answer score is 8-15, while the criteria are less if the total answer score is 1-7.

This questionnaire contains the definition of breastfeeding, benefits for mothers and babies; baby satisfied signs, the content of breast milk, the age of breastfeeding, breastfeeding manner, the actions after breastfed, when the baby is breastfed for the first time, the meaning of colostrum, the age of giving. Complementary feeding, grandmother's understanding of breastfeeding, frequency of breastfeeding in a day. The questionnaire used has been validated and declared valid and reliable. Determine the validity of the questions by using the product-moment test. If the coefficient between each item and the total item is equal to or above 0.3, the item is declared valid. Still, if the correlation value is below 0.3, the item is declared invalid. While the correlation is 0.7, the item provides a sufficient level of reliability; otherwise, if the correlation value is below 0.7, the item is said to be less reliable—determination of reliable items using Spearman Rho test [39]. The instrument test was carried out on ten breastfeeding mothers with the results. From the 15 questions asked, two questions had a validity index value of <0.3, so they had to be corrected, and two questions correlated 0.7, so they had to be updated again.

Questionnaires were distributed to grandmothers in Sembubuk village, Muaro Jambi district, Indonesia. After the researcher carried out data collection, the researcher then compiled the data, processed and analyzed the data. Female researcher aged 35-50 years with qualified health research experience.

Outcomes

The research outcome is in the form of information about the influence of video media on the knowledge of breastfeeding mothers

 

Sample size

This study involved 40 participants, namely grandmothers who support breastfeeding, where these grandmothers will be given education in the form of breastfeeding videos and then evaluate the knowledge of the grandmothers.

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 Commission of the Ministry of Health, Jambi, and registration number: LB.03.02./3.5/140/2021.

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data were expressed as mean ± standard deviation (SD) or median with Interquartile Range (IQR). Then proceed with bivariate analysis using the Wilcoxon test. The Wilcoxon test was used to determine the effect of counseling using breastfeeding video on the knowledge of breast milk supportive groups. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.

Results

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

Table 1. Frequency Distribution of Respondents Characteristics

 

In Table 1 it is known that most of the respondents with an age range of 46-55 years are 18 respondents (45%), and there are no respondents aged <25 years. most of the respondents with elementary education are 15 respondents (37.5%). Most types of work are housewives as many as 18 respondents (45.0). Knowledge of breastfeeding support groups before and after being given an intervention using video media about breastfeeding underwent univariate analysis.

Table 2. Distribution of Knowledge Frequency of Breastfeeding Support Groups Before and after Video Media About Breastfeeding

 

Table 2 shows that of the 40 respondents who knew the breastfeeding grandmother group before being given video media about breastfeeding, 19 respondents (47.5%) had good knowledge, and 21 respondents (52.5%) had poor knowledge. Then it changed after counseling using video media, namely 40 respondents (100%) had good knowledge.

The effect of breastfeeding counseling using video media on the knowledge of the grandmothers of the support group can be seen in the following table:

Table 3. The Effect of Video Breastfeeding on Knowledge of Breastfeeding Supporting Group

 

Table 3 shows an increase between before and after being given video media about breastfeeding with statistical test results obtained p-value = 0.0001 <0.05. This statistical test indicates an effect of video media on breastfeeding on the knowledge of the breastfeeding support grandmother group in Sembubuk village, Muaro Jambi District.

 

 

Discussion

The description of the knowledge of the breastfeeding grandmother group before (pre-test) the video-based intervention was rated at a minimum of 5, and the maximum value of the ability of the breastfeeding support grandmother group before being given video-based intervention was 15. The average value of the knowledge value of the breastfeeding support grandmother group before being given an intervention using media the video is 11.25.

The current study revealed respondents knowledge which appears inadequate regarding breastfeeding. Respondents indicated some of their ignorance about the economic benefits of breastfeeding for mother and baby, baby signs of enough breast milk, the nutrients in breast milk, exclusive breastfeeding time, breastfeeding manner, activities after breastfeeding, the right time to provide breast milk, breast milk for the first time, Breastfeeding in infants, the role of colostrum, timing of additional food and drink, sources of information, and frequency of breastfeeding in a day.

The description of support groups' breastfeeding knowledge in Sembubuk Village after (post-test) intervention reaches a minimum score of 13, a maximum value of 15 and a median value of 14.00. After being given a video-based intervention, nearly all of the questions can be answered by respondents. It shows an increase in the knowledge of the breastfeeding support grandmother group. The questionnaire correctly answers statements about the nutritional contained in breast milk, such as carbohydrates, proteins, fats, minerals and vitamins. The following information is regarding the correct way of breastfeeding. Washing hands, cleaning the mother's breasts, removing a little milk and then smearing it on the nipple and the surrounding areola, inserting the nipple and making sure the baby sucks the entire dark area of ​​the breast and not just the nipple. The following statement is about when a baby should be given his first breast milk immediately after birth or a maximum of 1 hour after birth. The results are in line with the previous study [7] regarding the Effectiveness of Exclusive Breastfeeding Support Groups on Exclusive Breastfeeding Behavior, where the group with exclusive Breast Milk Support mainly (86.4%) gave exclusive breastfeeding, while the group with leaflet intervention only a tiny proportion (31.8%) of exclusively breastfeeding. The formation of breastfeeding support groups affects exclusive-breastfeeding behavior (p-value 0.001).

Another study by Fatiyani & Ani [40] regarding the Formation and Implementation of Breastfeeding Support Groups in the Work Area of ​​the Rejosari Health Center, Tenayan Raya Pekanbaru, in 2019 found the formation of a Breastfeeding Support Group (BSG) "Bintang with Sirih Adat." Increase knowledge of Exclusive Breastfeeding Support Groups mothers on Early Breastfeeding Initiation (IMD) material from an average of 60 to 80. Knowledge of Exclusive Breastfeeding Support Groups mothers on breastfeeding material from an average of 70 to 90.4. The provision of Exclusive Breastfeeding Support Groups mothers' skills in providing IEC was 83.75.

The BSG in Penyengat Olak is the Breastfeeding Supporting Grandmother Group (BSGG), an association or community whose members consist of grandmothers who work in breastfeeding support groups. This group of grandmothers who support breastfeeding is followed by prospective grandmothers/grandmothers aged 34-65 years, established in 2019. The activity was carried out at the Penyengat Olak Health Center with several briefings and providing materials using leaflet media by a team of health workers about the importance of exclusive breastfeeding during breastfeeding. Six months, and continued breastfeeding for up to 2 years.

BSGG can assist in counseling activities and increase the coverage of exclusive breastfeeding in Sembubuk village, Muaro Jambi District. The reason for choosing grandmothers as a supporter of breastfeeding is related to the role of parents. Both in-laws and grandmothers significantly influence exclusive breastfeeding, such as the recommendation to give complementary foods (MPASI) too early, usually because the baby is fussy even though he has been given breast milk or formula milk. In addition, a grandmother is a person who is more experienced in taking care of babies because grandmothers already have this experience so that they can be an example or role model for young mothers. Although mothers know that giving MP-ASI too early can interfere with the baby's health, they think that parents, whether in-laws or grandmothers, are considered to learn better ways to take care of children because they are deemed to have experience and understand better in taking care of children [41].

 

Conclusion

There is an increase in BSGG knowledge after being given video-based counselling, with statistical test results obtained p-value = 0.0001, which means that video media's effect on breastfeeding on BSG knowledge in Sembubuk village Muaro Jambi District.

This intervention can be used as an effort to improve the quality of health services and health promotion as well as add information and insight for health workers at the Penyengat Olak Health Center, especially in Sembubuk Village, where breastfeeding coverage is the lowest in the work area of ​​the Penyengat Olak Health Center of 7 other villages. 

Limitations of Study

The limitations of this study include the very limited number of samples and the research only involves one province in Indonesia.

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

THE EFFECT OF EMOTIONAL DEMONSTRATION METHODS AND VIDEO LEARNING ON HAND WASHING ON KNOWLEDGE AND SKILLS OF HOUSEWIVES

Winda Triana¹*, Ervon Verza ¹, Pahrur Razi ¹

 

1. Department Of Health Promotion, Health Polytechnic of Jambi, Indonesia

 

* Corresponding author: Winda Triana, Jl. Prof DR GA Siwabessy No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, Jambi 36122 Department of Midwifery, Health Polytechnic of Jambi, Indonesia. Orcid : https://orcid.org/0000-0003-0574-7915. Email: trianawinda146@gmail.com

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Abstract

Introduction: Efforts to prevent the transmission of infectious diseases through hands can be prevented by washing hands. It is especially emphasized on mothers with toddlers. However, many mothers do not know how to wash their hands using soap correctly and adequately. This study aims to analyze the effect of the emotional demonstration method and video media on how to wash hands on the knowledge and skills of homemakers.

Materials and Methods: This research is a quasi-experimental method, with a two-group design pretest-posttest approach involving 40 participants, conducted in September-October 2020 in Penyengat Olak Village. The research sample was divided into two groups, 20 participants received the emo demo method, and 20 other participants received videos.

Results: The results showed an increase in mothers' knowledge and skills after receiving an education using the emotional demonstration method and video media and statistically showed significant results (<0.05).

Conclusion: Therefore, this educational media is highly recommended as a method of educating the public about good and correct hand washing

Keyword: Wash-hands, Education media, Emotional demonstration, video learning, knowledge, skill

 

Introduction

The hand is the easiest part of the body as an intermediary for entering germs in the body [1,2]. Therefore, hand hygiene can reduce morbidity and mortality due to infections spread by the fecal-oral route and person-to-person contacts, such as diarrhea and upper respiratory tract infections. Information about this is widely known, but the habit of washing hands with soap is still not optimal [3,4]. Most people already know the importance of washing hands with soap, but there are still few (only 5%) washing hands properly in practice. Most people think that washing hands with water is enough to prevent disease. This perception is undoubtedly wrong because water cannot kill germs/bacteria on hands [5]. Handwashing with proper soap reduces the risk of developing diseases such as diarrhea and can reduce the risk of diarrhea among children five years and under by up to 45% [6].

The lack of public awareness, especially mothers who have pre-school children, in implementing washing hands with soap is the effect of lack of understanding. Therefore, the form of intervention that can improve community compliance, especially homemakers, can be done by giving examples to mothers through demonstrations or showing videos [7]. Emotional Demonstration (Emo Demo) is one of the public education methods developed by the Global Alliance for Improved Nutrition (GAIN) through a new approach that refers to the Behavior Centered Design (BCD) theory [8]. BCD was initiated by the Environmental Health Group of the London School of Hygiene and Tropical Medicine (LSHTM) [9]. BCD was developed based on evolutionary principles and environmental psychology and a way to plan and test imaginative and provocative behavior change interventions. BCD theory holds that behavior can only change in response to something new, challenging, surprising, or interesting. This Emo Demo method uses imaginative and provocative ways to achieve behavior change in public health  [10]. 

Emo Demo is a communication strategy in behavior change that incorporates Behavior Communication Change (BCC), an interactive process between individuals, groups, or communities to develop communication strategies to achieve positive behavior change. Behavior Communication Definition (BCD) is a communication process that utilizes individual psychological constructions involving feelings, needs, and thoughts. It is one of the methods that is being widespread and gaining attention [11].  The success and effectiveness of using Emo Demo have been proven in implementation in several areas. These results encourage the need for the introduction of this method in other areas of health education. The Emo Demo method, in addition to providing health information, also uploads the subject's emotions so that the subject will be encouraged to make behavioral changes [12,13].

Another method that can be used is learning videos on how to wash hands properly and correctly. Video media has become an integral part of both desktop and laptop computers. The latest development of video media as a digital device is its ability to display images and sound simultaneously with a high level of clarity. It is known as picture and sound in high definition format. The rapid development of video technology, both software, and hardware, has given this media its advantages to be used as a learning medium [14].

The learning video program differs from other video programs regarding the objectives to be achieved  [15,16]. The instructional video program has more specific objectives when compared to the objectives to be achieved in the entertainment video program. This program is usually proposed to support learning activities for specific audience groups to achieve specific competencies [17,18].

Lack of proper handwashing practice causes bacteria to enter the body quickly because hands are a medium for rapid transfer/exchange. Therefore, this study aims to analyze the effect of the Emotional Demonstration Method and video media on How to Wash Hands on the knowledge and skills of homemakers in Penyengat Olak Village. 

Methods

Trial design

This research is a quasi-experimental study using two groups of pretest-posttest design

Participants

This study involved 40 participants who were divided into 2 groups and was carried out in September-October 2020 in Penyengat Olak Village. The study involved housewives who were randomly selected with the inclusion criteria of mothers who had never participated in a study with the same theme, mothers who were under or equal to 35 years of age, while mothers who had hand skin disease were not included.

Intervention

The study sample was divided into two groups, 20 participants received the emo demo method, and another 20 participants received videos. a video on how to wash hands with soap made by the researcher himself, as well as a demonstration on how to wash hands by the researcher.

The research variable is the mother's knowledge and skills. Before the intervention was given, the researcher first measured the level of knowledge and skills of the mother/participant (pre-test), then after the intervention was given the researcher again measured the level of knowledge and skills of the mother. /participant (post-test). The knowledge and skills questionnaires each consist of 15 questions with correct and incorrect answer choices. If the mother answered correctly, she was given a score of 1 and if the answer was wrong, she was given a score of 0. Both of these questionnaires used the Guttman scale.

Researchers have done a lot of research in the health sector and have compiled a lot of questionnaires so that the questionnaires in this study have been prepared by the researchers themselves. Before the research was conducted, the questionnaire was tested on 10 mothers and the results showed that there were 2 questions that had to be replaced because they were invalid.

Outcomes

This study compares the knowledge and skills of mothers in washing hands using soap after being given an intervention in the form of emo demos and videos

 

Sample size

This study involved 40 participants who were divided into 2 groups

 

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 Commission of the Ministry of Health, Jambi, and registration number: LB.02.06/2/151/2020.

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data were expressed as mean ± standard deviation (SD) or median with Interquartile Range (IQR). Then proceed with bivariate analysis using the Wilcoxon test. The Wilcoxon test was used to determine the effect of the emo demo and video intervention on knowledge and skills. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.

Results

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

Table 1. Frequency Distribution of Respondents Characteristics

In Table 1 it is known that all participants in the study were women, most of the respondents with an age range of 26-30 years were 19 respondents (47.5%). most of the respondents have high school education as many as 17 respondents (42.5%). Most types of work are housewives as many as 21 respondents (52.5%).

Participants' knowledge before and after being given emo demos and videos can be presented in the following table,

Table 2. Frequency Distribution Knowledge about hand washing with soap Before and After intervention

Table 2 shows that participants' level of knowledge before giving the intervention using the emo demo method or video media was higher in the less category. However, after being given the material, participants' level of knowledge increased higher in the "good" category than in the "poor" category.

Participants' skills before and after being given emo demos and videos presented in the following table:

Table 3. Frequency Distribution Skills about hand washing with soap Before and After intervention

 

Table 3 shows that participants' skills before giving the intervention using the emo demo method or video media were higher in the poor category, but after the intervention, the participants' skills increased higher in the good category than the poor category.

The effects of emo demo and video media interventions on participants' knowledge and skills are presented in the following table:

Table 4. Effects of emo demo and video media interventions on participants' knowledge and skills

Table 4 shows the effect of providing emo demo and video media interventions on participants' knowledge and skills with a p-value < 0.05.

Discussion

Based on the study results, it was known that before the intervention, their level of knowledge and skills on how to wash their hands correctly and adequately was very low. It may be influenced by the low level of education and low access of homemakers to the media; the subordinate role of health workers also influences it in providing information and education to the public.

In line with previous research by Padila [19] at Aisyiyah 1 Kindergarten, Bengkulu City, it was found that before the intervention was given, most of them received the first-star category as many as 27 people (90%), while the number of respondents after the intervention was mostly increased in ability and received the fourth-star category. totaled 23 people (76.7 %). Likewise, Nidiyah's research [20] at RA Raisul Anwar Kedung Rejoso, Kota Anyar District, Probolinggo Regency, found a change in knowledge after obtaining material through demonstration media (emo demo) how to wash hands in 7 steps.

The results of this study reject the null hypothesis regarding the effect of the emotional demonstration method and video media on how to wash hands on the knowledge and skills of homemakers. The result is in line with Nidiyah's research [20] which states that the emo demo method increases children's knowledge, behavior, and habits to wash their hands properly and well. Fermi Avissa [21] also found that the demonstration method was more effective in increasing the knowledge and skills of handwashing in preschool children at Flamboyan Platuk Kindergarten Surabaya. Indah Lastari's research [22] found differences in health education skills through demonstrations and learning videos of the washing skill with the hand-soap method in PAUD. The way of learning through a demonstration method is suitableto be applied on preschool children because this demonstration method makes students receive a clear   perception from direct observation. Students obtain practical experiences to develop their proficiency and skill.

Through the demonstration method of hand washing, mothers can directly practice the appropriate intervention that has been given. Skills that are trained with repeated practice will become habitual or automatic [23]. A suitable respondent's knowledge then impacts the actions taken by respondents with good criteria as well. Health education interventions with demonstration and video methods cause homemakers to be skilled in washing their hands to prevent various diseases related to hand hygiene, especially when feeding children when eating [24].

This research is very important to be carried out, especially during the COVID-19 pandemic, where everyone is required to practice hand washing before and after contact with other people, and according to the researcher, washing hands in 7 steps is very effective in preventing transmission of the COVID-19 virus [25–27].

In the current pandemic, the best way to prevent infection is to avoid exposure to the virus that causes it. Prevention of transmission can be done in daily life practices, such as washing hands using soap and running water, the behavior of people who have not practiced clean and healthy lifestyles, especially washing hands with soap can increase the risk of contracting COVID-19. For the community, it is very important to carry out clean and healthy living behavior in the form of washing hands to prevent COVID-19 in the current pandemic era even though COVID-19 can be prevented as recommended by the government to reduce the increase in COVID-19 cases, especially in Indonesia [10].

In general, the results of the study found that the knowledge and skills of respondents increased after the intervention, although there were some respondents that did not change after being given education through emo demo media and video media, this was probably due to their poor memory.

 

Conclusion

Health education using the demonstration method has been proven to increase knowledge and skills in washing hands, especially for homemakers, so it is highly recommended that health workers provide education on how to wash hands to apply the emo demo and video methods.

 

Limitations of Study

The limitations of this study include the very limited number of samples, and this study only involves one country, namely Indonesia, so the results may be different when comparing the effects of emo demo and video interventions on mothers in European countries.

 

Acknowledgement

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

 

Funding statement

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

 

Competing interests statement

There are no competing interests for this study.

References

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9. Tidwell JB, Chipungu J, Bosomprah S, Aunger R, Curtis V, Chilengi R. Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial. The Lancet Planetary Health. 2019;3(4):e187–96.
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11. Wilbur J, Bright T, Mahon T, Hameed S, Torondel B, Mulwafu W, et al. Developing behaviour change interventions for improving access to health and hygiene for people with disabilities: two case studies from Nepal and Malawi. International journal of environmental research and public health. 2018;15(12):2746.
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by OPI Napoli

THE EFFECTIVENESS OF THE DEMONSTRATION METHOD AND AUDIO-VISUAL METHOD ON ADOLESCENT KNOWLEDGE ABOUT BREAST SELF-EXAMINATION

Titik Hindriati*, Nurmisih, Diniyati, Rosmaria

Department of Midwifery, Health Polytechnic of Jambi, Indonesia

* Corresponding author: Titik Hindriati, Department of Midwifery, Health Polytechnic of Jambi, Indonesia, Jalan Prof DR GA Siwabessy No.42. Buluran Kenali, Kec. Telanaipura, Kota Jambi, 36122, Phone : +62 852-6970-1226, E-mail: titikpoltekkes@gmail.com

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Abstract

Introduction: Breast cancer is the most frequent type of cancer in women, and it is one of the major causes of mortality. Efforts should be made to prevent breast cancer by using the breast self-examination (BSE) method of early diagnosis. This study aims to determine the effectiveness of the demonstration and audio visual methods on adolescent knowledge about breast self-examination at SMA Pertiwi 1 Jambi City, Indonesia.

Methods. This study is a quasi-experimental study using a two-group pretest-posttest design at the private high school Pertiwi 1 Jambi City, involving 122 participants divided into two groups. Group 1 consisted of 61 participants given BSE material by demonstration, while group 2 consisted of 61 participants given material using audio-visual media. Data processing in this study used univariate and bivariate analysis, and the statistical test used was the Wilcoxon test.

Results. The results showed that there was an increase in students' knowledge about BSE after the demonstration with p-value < 0.0001, and displayed audio-visually with p-value < 0.0001.

Conslusion: demonstration and audiovisual methods proved effective in increasing adolescent knowledge about breast self-examination at at SMA Pertiwi 1 Jambi City, Indonesia.

 

Keywords: breast self-examination, knowledge, cancer, demonstration, audio visual

Introduction

The breast is one of the crucial organs for women because apart from being a tool for breastfeeding, it is also a symbol of beauty [1–3]. Because its vital existence makes a woman feel worried if the breast is abnormal; the most feared abnormality is malignancy or cancer [4]. Breast cancer is a condition in which cells have lost their usual control and mechanism, resulting in irregular, fast and uncontrolled growth in breast tissue [5,6].

According to the Breast Cancer Management Organization and the World Health Organization, by 2030, cancer in the world will increase 300%, and the majority occur in developing countries, including Indonesia [7].

Breast cancer is second cancer with the highest prevalence compared to other cancer in Indonesia in 2013, namely breast cancer, by 0.5% or around 61,682 patients in Indonesia. The prevalence of breast cancer incidence in Jambi Province was approximately 0.6% or about 977 cases in 2013 [8].

Based on data from the Jambi Provincial Health Office, in 2014, the number of patients who have breast cancer reached 38 (55%) people, and in 2015 the number of cases of breast cancer patients was 15 (22%) people. The age group in patients who have breast cancer starts from 14 years to 64 years. The data shows that the age at which breast cancer is susceptible is from the age of 24 years to the age of 64 years, and it occurs mainly in women. In 2016 it was found that breast cancer patients were only 14 years old; this could make it possible that all women can suffer breast cancer, both married and unmarried [9].

Only a tiny proportion of women perform the breast self-examination (BSE) [10]. It is estimated that only 25% to 30% of women perform regular monthly breast self-exams. Whereas, the level of sensitivity to detect breast cancer is about 20-30%. Almost 85% of lumps are found by sufferers independently through proper examination [11]. Breast self-examination is the first step. If breast cancer can be detected early and treated appropriately, the cure rate will be higher (80-90%). 85% of sufferers detect breast abnormalities [8]. If this examination becomes a routine and regular habit, it can detect more breast cancer early. Although this method is cheap, safe, repeatable and straightforward, only about 15-30% of women use it [12–14].

Breast exam (BSE) can be applied to young women who experience change physical and secondary sexual development that is, puberty breast enlargement occurs between the ages of 12-13 years [15]. Benefits of breast examination alone on teenage girls for early detection of tumors or lump in the breast [16–18].

Better breast self-examination carried out during menstruation, i.e 7-10 days from the first day of menstruation with consideration at that time the influence of the hormones estrogen and Progesterone is very low and at the same time it’s deep breast gland tissue no edema or not swell so much easier feel for tumors or abnormalities [19,20].

The results of the interviews in the initial survey at the Pertiwi 1 Private High School in Jambi City to 8 students stated that they did not know about BSE. Allegedly due to lack of information on reproductive health, especially BSE. One method of providing information is by delivering a demonstration using audio-visual.

This study aims to determine the effectiveness of the demonstration and audio visual methods on adolescent knowledge about BSE at SMA Pertiwi 1 Jambi City, Indonesia.

Methods

Design

This study is a quasi-experimental study using a two-group pretest-posttest design

 

Participants

The study was conducted at Pertiwi 1 Private High School Jambi City involving 122 female students with inclusion criteria ranging from 16-19 years of age, while adolescents under 16 years of age and not present at the time of the study were not included in the study.

 

Intervention

51 years old researcher, works as a lecturer at one of the universities in Indonesia, actively conducts research and writes a special book on midwifery. Group 1 consisted of 61 female participants (F) with an age range of 16-19 years, who were given BSE material by means of a demonstration, while group 2 consisted of 61 participants who were given material using audio-visual media. Before the BSE material, students’ knowledge was first measured using a questionnaire, then after the material was given, it was continued with an evaluation of the students’ level of knowledge about BSE (post-test).

The knowledge questionnaire consisted of 20 questions containing students’ knowledge about breast self-examination. If students answer correctly, they are given a score of 1, while if students answer incorrectly, they are given a score of 0. The objective criteria for the knowledge variable are good and bad. Good, if the total score of student answers is 11-20, while the criteria is less, if the total score of student answers is 1-10. The questionnaire used has been validated and declared valid and reliable. Determine the validity of the questions using the product moment test. If the coefficient between the items and the total items is equal to or above 0.3 then the item is declared valid, but if the correlation value is below 0.3 then the item is declared invalid. While the correlation is 0.7, it is said that the item provides a sufficient level of reliability, on the contrary, if the correlation value is below 0.7, it is said that the item is less reliable. Determining reliable question items using the Spearman Rho test [21]. The instrument test was carried out on 15 adolescents with the results, of the 20 submitted there were 4 questions that had a validity index value <0.3 so they had to be corrected and 3 questions had a correlation below 0.7 so they had to be corrected again.

Questionnaires were distributed to students at Pertiwi 1 Private High School Jambi City, Indonesia. After the data collection was carried out by the researcher, the researcher then compiled the data, processing and analyzing the data.

 

Outcomes

To determine the effectiveness of learning using demonstration and audio visual methods

 

Sample size

This study involved 122 participants who were divided into two groups defined in random way, and namely group 1 and group 2 both composed of 61 female participants.

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 Commission of the Ministry of Health, Jambi, and registration number: LB.03.02./3.5/130/2021.

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data were expressed as mean ± standard deviation (SD) or median with Inter Quartile Range (IQR). Then proceed with bivariate analysis using the Wilcoxon test. The Wilcoxon test was used to determine the effect of counselling using breastfeeding video on the knowledge of breast milk supporting group. All tests with p-value (p)<0.05 were considered significant. Statistical analysis was performed using the SPSS version 16.0 application.

Results

As for the characteristics of the respondents can be presented in the following table :

Table 1. Characteristics of research respondents in high school

The highest respondent's age characteristic is the range of 16-17 years as much as 60.7%, then the most students occupy class 12

Students' knowledge about breast self-examination before and after giving the material using demonstration and audio-visual methods is presented in the following table:

Table 2. Frequency distribution of students' knowledge about BSE

Table 2, shows that students' knowledge about breast self-examination before giving the demonstration group was higher in the poor than in the excellent category. After the demonstration, students' learning was higher in the superb class than in the fewer categories. Meanwhile, students' knowledge before audio-visual material was higher in the lower category than the excellent category. After giving the material, the same changes occurred for both classes.

The effect of giving the method using demonstration and audio-visual techniques on students' knowledge about breast self-examination is presented in the following table:

Table 3. The effect of giving material using demonstration and audio-visual methods on students' knowledge

Table 3 shows the increase in students' knowledge about breast self-examination after demonstration with p-value < 0.0001. as well as shown audio visually with a p-value < 0.0001.

 

Discussion

Prior to the application of the demonstration method and the audio-visual group, data was obtained that a small number of respondents had good knowledge of BSE. Meanwhile, more than half of the respondents have poor knowledge. This is because students have never received information about breast cancer and BSE examinations at school.

After giving the material using the demonstration method, there was an increase in students' knowledge about BSE. Most of the respondents had good knowledge about understanding, examination, standard nipple colour and the purpose of BSE, and only a small number of respondents had less knowledge about BSE.

After giving the material using audio-visual media, there was an increase in respondents' knowledge after the audio-visual about BSE; that is, most of the respondents had good knowledge. Using video media has a more significant impact on health education; it relies on hearing and vision from the target; it is interesting; the messages are delivered quickly and efficiently and can develop the mind and develop the imagination of young women. The video can clarify the pictures and the steps of the importance of the BSE examination. In the process of giving it, the respondent not only hears the sound, but the respondent will see directly and the steps of the breast self-examination.

Based on the results of research by [22], the demonstration method through demonstration activities has proven to be more effective in increasing young women's knowledge to perform BSE techniques. It is also supported by research by [23] that there is a relationship between knowledge, attitudes and BSE actions through demonstrations to detect breast cancer early in female students at the Faculty of Public Health. This result is also supported by the research of [13], which suggests that the demonstration method is proven to be more effective in increasing knowledge through learning media on BSE skills. A similar thing was reported by [13], who researched SMA 1 Sumber, Indonesia students who found an increase in student's knowledge after being given information using demonstrations and media in the form of videos.

The counselling was carried out to increase the respondent's knowledge about BSE. There was material about BSE in the counselling, which was packaged in an attractive video format and demonstrated by conducting a demonstration to obtain information directly. In addition, in the counselling process, answers are also held so that respondents who do not understand the material about BSE can now ask questions, and the respondents can understand the information [18,24,25].

The current research is to improve health education about reproductive health, especially breast health of a young woman in the research location. Knowledge of breast self-examination (BSE) is essential to be known and understood by a young woman [26].

 

Conclusion

The use of demonstration methods and audio-visual media in learning is considered adequate to increase students' knowledge about breast self-examination for students of SMAN Pertiwi 1 Jambi city. It is hoped that the high school will provide information about BSE in adolescent girls to detect early symptoms of breast cancer.

Limitations of Study

The limitations of this study include, in addition to the relatively small number of participants, the type of quasi-experimental research does not do randomization

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

THE EFFECT OF ACUPRESSUR THERAPY IN REDUCING NAUSEA AND VOMITING PREGNANT WOMEN TRIMESTER I : QUASI-EXPERIMENTAL STUDY

 Suryani, Ika Murtiyarini*, Yuli Suryanti, Misnanda

Department of Midwifery, Health Polytechnic of Jambi, Indonesia

* Corresponding author: Ika Murtiyarini, Department of Midwifery, Health Polytechnic of Jambi, Indonesia, Jalan Prof DR GA Siwabessy No.42. Buluran Kenali, Kec. Telanaipura, Kota Jambi, .36122. E-mail: ikamurtiyarini.poltekkes@gmail.com

 

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Abstract

Introduction. Nausea and vomiting are the most common symptoms experienced by pregnant women in the first trimester, and these symptoms are experienced by 70-85% of women. Nausea and vomiting are often experienced by pregnant women, especially in the first trimester, affecting about 50-80% of pregnant women. Management of nausea and vomiting in pregnancy consists of pharmacological and non-pharmacological. This study aims to analyze the effect of acupressure therapy on nausea and vomiting.

Methods. This type of research is a quasi-experimental design using a two-group pre-post design involving 30 first trimester pregnant women who experience nausea and vomiting selected by purposive sampling. The criteria for the participants were gestational age at 10-16 weeks and maternal age at 20-35 years (productive age), while mothers taking nausea and vomiting drugs were excluded from this study. Data analysis used the Wilcoxon test and Mann-Withney test.

Results. a significant decrease group with p-value <0.05. Based on the Mann Whitney test, it was found that the p-value for the pre in the frequency of moderat nausea and vomiting scores before and after acupressure in the intervention -test (<0.0001), and the post-test was 0.55, post test scores showed no difference between the two study groups.

Conslusion. The study shows encouraging signs about reducing the frequency of nausea and vomiting in first-trimester pregnant women, so this therapy can be used as an alternative intervention for pregnant women who experience nausea and vomiting.

Keywords: Acupressure, Nausea Vomiting, Pregnant Women, Non-pharmacological Therapy

Introduction

Pregnancy is fertilization or joining of spermatozoa and ovum, so nidation or implantation occurs [1]. According to the international calendar, from the time of fertilization until the birth of the baby, pregnancy will generally last 40 weeks or ten months [2,3]. The signs and symptoms of pregnancy include nausea without vomiting, micturition disorders, and fatigue [4]. Nausea occurs due to increased hormone estrogen and chorionic gonadotropin hormone (HCG) in the serum [5]. The physiological changes of this hormone increase are not yet apparent, perhaps due to stimulation of the central nervous system or gastric emptying that is not optimal [6]. A study in Indonesia revealed that pregnant women with nausea and vomiting reached 14.8% of all pregnancies. Complaints of nausea and vomiting occur in 60-80% of primigravida and 40-60% of multiple pregnancies [7]. The coverage of First Prenatal Visits in Jambi Province reached 10-15% of the 73,096 pregnant women in 2018 [8]. According to the Jambi City Health Office data, the number of pregnant women who had a First Prenatal Visit in Jambi City was 76,681 (74.9%) [8]. If nausea and vomiting in pregnancy do not treat immediately, it will impair fetal growth, fetal death and congenital abnormalities. The consequences for the mother are dehydration, acid-base balance disorders, and potassium deficiency [9]. Management of nausea and vomiting in pregnancy consists of pharmacological and non-pharmacological. Diet settings, emotional support and acupressure are options in non-pharmacological therapy which effective as an intervention to treat nausea [10]. Acupressure is a healing technique by pressing and massaging certain body parts to re-activate the energy balance in the mother's body due to adaptation to changes during pregnancy. Acupressure, especially at the pericardial point, can achieve balance in the mother's body [11]. In treating nausea and vomiting in pregnancy, acupressure carries out three fingers above the middle of the inner wrist and four fingers below the kneecap on the outer edge of the shinbone [12]. Acupressure is found to be effective in reducing nausea and vomiting through the mechanism of increasing beta endorphins. This substance is one of the natural anti-emetics that can reduce the vomiting stimulus in the CTZ (Chemoreceptor Trigger Zone) and the vomiting center which in turn can reduce nausea and vomiting [12].

A meta-analysis of acupuncture in pediatric tonsillectomy revealed that the number of patients with Postoperative Nausea and Vomiting was significantly reduced with acupuncture compared to the control group, with a risk ratio of 0.77 (95% confidence interval: 0.63–0.94, p < 0.05) [13]. A study in the Maternity and Child Hospital in Istanbul reported that acupressure would appear to be effective in symptom control, and alleviation and placebo effects in reducing the symptoms of nausea and vomiting during pregnancy [14]. Previous studies have not mapped the characteristics of nausea and vomiting severity in pregnant women. Therefore, in this study, we analyzed the effect of acupressure therapy in reducing moderate nausea and vomiting in the working area of ​​the Talang Banjar Health Center, Jambi City.

Methods

Design

This study uses a two group with pretest-posttest design where the design provides a pretest before being treated and a posttest after being treated in each group [15]. This quasy-experimental study used two group with pretest-posttest design.

Participants

The criteria for the participants were gestational age at 10-16 weeks and maternal age at 20-35 years (productive age), while mothers taking nausea and vomiting drugs were excluded from this study.

Intervention

Acupressure therapy performs for three days for each pregnant woman. First, measurements of maternal nausea and vomiting provide, then acupressure therapy was performed. Massage performed on three fingers above the wrist in a circular motion and on four fingers below the kneecap on the outer edge of the shin, given emphasis as much as 30 times. This therapy conducts for 5 minutes every morning. At the end of the 4th-day therapy session, maternal nausea and vomiting measured. The interpretation of the results of the PUQE measurement is severe, if the score is ≥13, moderate if the score is 7-12, and mild if the score is ≤6. The measurement of nausea and vomiting used Pregnancy Unique Quantification of Emesis and Nausea (PUQE). The Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring system instrument is a research instrument developed by Koren et al. [16] and validated by Koren et al. [17].

Outcomes

The outcome of the study is that pregnant women are expected to show a decrease in the frequency of nausea and vomiting

Sample size

Involving 30 first trimester pregnant women who were divided into 2 groups, 15 pregnant women experienced moderate nausea and vomiting (score 7-10) and 15 pregnant women experienced moderate nausea and vomiting (score 10-12).

Randomisation (Sequence generation, Allocation etc)

The selection of research samples was carried out at simple random

Blinding

The included samples were selected blindly

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 Commission of the Ministry of Health, Jambi, and registration number: LB.02.06/2/54/2020.

Statistical analysis

There are 2 data analyses used, namely univariate analysis to describe the characteristics of pregnant women (age, education level, and occupation of pregnant women) and a description of the frequency of nausea and vomiting before and after the intervention. Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). Then proceed with bivariate analysis using the Wilcoxon test and the Mann Whitney test. The Wilcoxon test was used to determine the effect of acupressure therapy on reducing nausea and vomiting in each study group, while the Mann Whitney test was used to determine differences in nausea and vomiting between the two study groups. All tests with p-value (p)<0.05 were considered significant. Statistical analysis performed using the SPSS app version 16.0.

Results

The characteristics of respondents in this study include age, education level, occupation, gestational age, and parity.

The following is a table of the frequency distribution of the characteristics of the respondents in this study:

 

Table 1. Frequency Distribution of Respondents' Characteristics

 

Table 1 shows that most of the respondents in Group 2 aged 20-30 years were 14 people (93.3%), and respondents aged 30-40 years were 1 (6.7%) people. The majority of respondents in group 1, as many as 13 (86.7%), have high education, namely high school graduates or more (college), and as many as two people (13.3%) have low education (< high school). At work, most of the respondents in Group 1 are housewives; 9 (60%) and 1 (6.7%) respondents were traders and entrepreneurs. At gestational age, most of the respondents in group 1 had a gestational age of 9-12 weeks, namely 9 (60%), and as many as 6 (40%) respondents had a gestational age of 5-8 weeks. In the parity aspect, some respondents in group 2 had parity > 1, namely 12 (80%) respondents and 3 (20%) had parity 1.

The results of measuring nausea and vomiting in the Group 1 and Group 2 prior to acupressure therapy using the PUQE scale can be seen in the following table:

Table 2. Results of the PUQE Scale for Respondents in the Group 1 and Group 2 Before and After Acupressure in First Trimester Pregnant Women

Table 2 shows, Group 1, as many as 6 (40%) respondents with a score of 9, 4 (26.7%) respondents had a score of 10, 3 (20%) respondents had a score of 7, and 2 (13.3%) respondents had score 8. After acupressure therapy, the nausea and vomiting score scale decreased to 13 (86.7%) in the last 24 hours experiencing nausea and vomiting with a score of 6 (mild nausea and vomiting), and as many as 2 (13.3%) respondents in The last 24 hours experienced vomiting with a score of 5 (mild nausea and vomiting). Group 2, 9 (60%) respondents experienced nausea and vomiting with a score of 10 in the last 24 hours, 5 (33.3%) respondents experienced nausea and vomiting in the previous 24 hours with a score of 11, and 1 (6.7%) respondents experienced nausea with a score of 12 in the last 24 hours. After doing acupressure therapy, 14 (93.3%) respondents got a PUQE score of 6 and 1 (6.7%) respondents got a score of 5.

The condition of nausea and vomiting before and after the acupressure technique in group 1 and Group 2 can be seen in the table below:

Table 3. Frequency distribution of Group 1 and Group 2 before and after acupressure therapies

Table 3 shows a significant decrease in the frequency of nausea and vomiting scores in both groups before and after acupressure in the intervention group with p-value <0.05. Based on the Mann Whitney test, it was found that the p-value for the pre-test (<0.0001), and the post-test was 0.55, the post-test value showed no difference between the two research groups.

Discussion

The result of study showed that patients in the treatment group, who were given acupressure therapy after day 3, had less severity of nausea, frequency of vomiting and the level of intensity of discomfort felt from nausea, when compared to the condition of nausea and vomiting on the first day before treatment. Previous research conducted by O’Brien B [18], Werntoft E [19], and Tara F [20] showed that have reported a reduction in the intensity of nausea and vomiting discomfort during the first trimester of pregnancy.

In group 1, before giving acupressure therapy, the average value of nausea and vomiting was 8.73 and it decreased very significantly after giving acupressure therapy to 5.87, meaning that there was a decrease of 2.86 points. The same thing was shown by group 2 after acupressure therapy experienced a significant decrease of 4.57 points. The results of this study indicate that acupressure therapy is very effective in reducing nausea and vomiting, especially for pregnant women in the 1st trimester.

The results of the current study have shown the ability of acupressure to significantly reduce acute nausea and vomiting scores in respondents who experience acute nausea and vomiting, so it can be concluded that acupressure is an effective intervention in reducing nausea in pregnant women. This finding is in accordance with previous findings which stated that acupressure is one of the appropriate measures in the management of nausea and vomiting due to pregnancy [11].

In a study conducted in Turkey by Gürkan ÖC [14], it was shown that in subjects undergoing at Neiguan (PC6) acupoint acupressure between days 4–6, there was less severity of nausea, frequency of vomiting, and feeling of discomfort after nausea. Another study by Markose MT [21] showed that the frequency of vomiting, nausea, and retching, as well as the discomfort caused by nausea and vomiting were significantly lower in the at Neiguan (PC6) acupoint pressure treatment group than in the control group under drug therapy. In line with the research of Mojgan Naeimi Rad et al [22] involving 80 first trimester pregnant women concluded that acupressure on KID21 point is more effective than sham acupressure in reduction of nausea and vomiting in pregnancy.

15 respondents experienced nausea and vomiting at a score of 10-12 and after being given acupressure, the score decreased to 5-6, from 15 respondents experienced nausea and vomiting a score of 7-10, after receiving acupressure therapy, the score for nausea and vomiting decreased to a score of 5-6. In group 1, the decrease was lower than in group 2. The cause could be due to stress factors, so that even though acupressure therapy has been given, the frequency of nausea and vomiting can increase again [23]. Psychological factors are factors that are triggered from the surrounding environment such as work or family problems that make pregnant women stressed, because stress can interfere with the hormonal system of the gastric organs in controlling gastric acid secretion so that stomach acid can increase and cause nausea and vomiting [24,25].

In line with the research of Pirimoglu ZM, et al [26] that pregnant women suffering from hyperemesis gravidarum were identified as 80% afraid of losing their jobs, afraid of getting pregnant again in the future, experiencing psychiatric symptoms such as depression and anxiety. Based on this research, that acupressure therapy is ideally applied to mothers who suffer from emesis or nausea and vomiting on a mild or moderate scale, and as an alternative therapy in reducing nausea and vomiting, especially pregnant women who have a fear of the side effects of medical treatment therapy, such as doubts of the effect of the drug on fetal defects in the womb.

The results of data analysis using the Mann Whitney test to determine differences in nausea and vomiting before (pre) acupressure therapy in the two study groups and differences in nausea and vomiting after (post) acupressure therapy in the two study groups showed that the pre-test of the two study groups had a p-value of 0.0001, which means that there is a difference in the point of nausea and vomiting of the two study groups before acupressure therapy, but after acupressure therapy there is no difference in the scale of nausea and vomiting in the two study groups (p-value = 0.55). there was no significant difference based on the results of statistical data analysis in the two groups after acupressure therapy was most likely strongly influenced by the same type of intervention given to both study groups. 

The main limitation of this study is the absence of controlling for other factors that can affect the frequency of nausea and vomiting such as stress, and the type of food consumed by pregnant women, so it is very likely that the variable data measured are less accurate.

 

Conclusion

Acupressure therapy is the choice of pregnant women and is more enjoyable than medical treatment because in addition to being easy and cheap, it is also effective in reducing the frequency of nausea and vomiting in first trimester pregnant women.

Limitations

The limitations of this study include a very small sample and the pattern or type of food of pregnant women that was not controlled during the study

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

THE EFFECT OF YOGA ON STRESS LEVEL OF PREGNANT WOMEN IN TRIMESTER III IN PRIVATE MIDWIVES IN JAMBI CITY

Ika Murtiyarini, Imelda*, Yuli Suryanti, Rosmaria

Department of Midwifery, Health Polytechnic of Jambi, Indonesia

 

* Corresponding author: Imelda, Department of Midwifery, Health Polytechnic of Jambi, Indonesia, Email: imelda.poltekkesjambi@gmail.com

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ABSTRACT

Introduction: Prenatal stress is often encountered but is rarely recognized and is considered not to affect pregnancy. Pregnancy has the potential to cause morbidity during pregnancy. In a study in Indonesia, 64.4% of pregnant women experienced severe stress and were at risk of causing preterm labour. One of the preventive measures during pregnancy to improve the health condition of the mother and baby is yoga. Prenatal yoga can prepare pregnant women physically, mentally, and spiritually to play a role in the delivery process.

Materials and Methods: The current study is a quantitative study with a pre-experimental design with one group pretest-posttest without control to determine the effect of prenatal yoga on stress levels of pregnant women in the private midwives of Jambi City in 2020. The study population was 86 pregnant women; by purposive sampling, 30 pregnant women were taken. The time of the study was from March to November 2020. The data analysis used was univariate analysis and bivariate analysis with the Wilcoxon test.

Results: In the initial assessment, most pregnant women experienced moderate stress levels; after prenatal yoga, most pregnant women experienced mild and average stress levels. Wilcoxon test results show that prenatal yoga has an effect on stress levels of pregnant women with a p-value of 0.0001 (<0.05). 

Conclusion: Prenatal yoga is effective for reducing stress in third-trimester pregnant women.  

Keywords: Stress, pregnant women, Prenatal yoga, Depression Anxiety and Stress Scale (DASS)

INTRODUCTION

Pregnancy is a process that starts from the meeting of sperm and ovum in a woman's uterus or by another name, namely fertilization or conception, to form a zygote which then implants into the uterus and develops into a baby [1–3]. Sometimes, pregnancy has a stressful impact on pregnant women. Prenatal stress is almost expected in all pregnant women, especially in primigravida [4]. This stress can be caused by external factors (external stressors) or from within (internal stressors) pregnant women. Stress is an uncomfortable condition (dysphoric) defined as an imbalance of pregnant women to feel able or resist various changes in the adaptation process of their pregnancy [5,6].

Psychosocial studies of stress during pregnancy conducted on Asian, African, and white races found that 6% of pregnant women experienced mild stress, 78% experienced severe stress, and 16% did not experience stress at all [7]. Pregnancy stress is significantly caused by economic hardship, household problems, physical violence, medical problems, busyness, work, and a pregnancy history with complications [8].

Prenatal stress is often but is rarely recognized and is thought not to affect pregnancy [9]. A Canadian study showed that pregnant women experienced low levels of psychosocial stress and 6% of high levels of stress. Pregnant women in Spain, 30% have a lower chance of experiencing stress, while in Indonesia, 64.4% of pregnant women experience severe stress and can give birth prematurely [10].

Stress in pregnancy has the potential to cause morbidity during pregnancy [11].  Complications arise from prenatal stress, such as preterm delivery caused by the placenta, increased corticotrophin-releasing hormone (CRH), and progesterone in stressful conditions [12]. In addition, in early pregnancy, stress and a decrease in progesterone can cause abortion, progesterone which is calming and slows gastric motility as a trigger for hyper emesis gravidarum to Low Birth Weight (LBW). This impact proves that the mother's mental state can affect the mother's health during pregnancy and the baby's growth and development in the next period of life [13,14].

DASS-42 is an assessment of stress scale that can be used in the stress assessment of pregnant women [15]. DASS-42 has been used to identify stress in Hispanic, American, British, Australian and Indonesian populations. Assessment items in DASS-42 include emotional states, communication barriers and physical disturbances felt by pregnant women. Measurement of stress levels using the DASS-42 score can reflect the state of prenatal stress as a predisposing factor for pregnancy complications [16,17].

Maintaining the health of the mother and fetus during pregnancy can be done by exercising in the morning, static cycling, aerobics, water exercise, dancing, and yoga. Some pregnancy exercise methods that can be an option include yoga, pilates, Kegels, hypnotherapy [18]. Prenatal yoga is effective for pregnant women to achieve comfort during pregnancy even until the delivery process. Prenatal yoga is a skill to cultivate the mind in a comprehensive personality development technique that includes physical, psychological and spiritual. This prenatal yoga includes various relaxations, adjusting breathing postures and meditation done by pregnant women every day [19].

Several studies have shown that yoga positively affects pregnant women, significantly reducing stress levels and back pain [20,21]. Another study conducted by Rahma [22] showed an increase in sleep quality in pregnant women after prenatal yoga. Another study conducted by Mediarti et al. [23] showed differences in the complaints of pregnant women before and after prenatal yoga, including back pain, insomnia, leg cramps and anxiety.

Based on the results of several studies that have been carried out showing the benefits of implementing prenatal yoga in reducing stress during pregnancy, but no research focuses on primigravida pregnant women; therefore, we tried to conduct this research on third-trimester pregnant women in the independent practice of midwives in Jambi City, Indonesia.

MATERIALS AND METHODS

This pre-experimental study consisted of a pre-test and post-test without a control group design involving 30 third trimester primiparous pregnant women in independent practice of midwives (PMB) Jambi City, Indonesia, which was carried out from March to November 2020. The implementation of  intervention was carried out in PMB Jambi City, carried out by researchers assisted by midwives et PMB and enumerators, after asking participants' consent and participants agreed by signing a certificate. The criteria for participants who were included in the study were primiparous mothers and third trimester, while mothers who were not healthy at the time of the study were not included in the study. The sample has been selected using purposive sampling, namely the technique of selecting samples based on the researcher's considerations.

The prenatal yoga intervention was given by a certified midwife as a prenatal yoga instructor, with the first procedure (1) the mother doing warm-up movements, (2) doing the Uttkatasana movement, (3) doing the Vrkasasana movement, (4) doing the Adhatasana movement, (5) perform the Virabadhanasana movement, (6) perform the Utitatrikonasana movement, (7) perform the Anjeneyasana movement, (8) perform the Utkatakonasana movement, (9) perform the Malasana movement, (10) perform the Supta Baddha Konasana movement, (11) perform the Savasana movement, and Finally, take a deep breath from the nose 5-8 times.

Treatment is carried out once a week for two weeks with duration of 1-2 hours per session. The implementation of treatment complies with health protocols during the covid-19 pandemic, including washing hands, disinfecting mats, and not doing yoga in groups. The assessment of stress levels both pre and post prenatal yoga was carried out at PMB Jambi City, Indonesia by researchers assisted by enumerators.

This stress level was measured using the Depression Anxiety Stress Scale 42 (DASS 42) (Lovibond, 1995) both before and after the implementation of prenatal yoga. Psychometric anxiety stress scale of the Depression Anxiety stress scale 42 (DASS 42) consists of 42 question items, which include 3 subvariables including 1) physical 2) emotional/psychological 3) behavior. According to Lovibond (1995) cited by Crawford & Henry (2003) in their journal entitled "DASS: Normative data & latent structure in large non-clinical sample". DASS has a discrimant validity level and has a reliability of 0.91 which is processed based on Cronbach's Alpha assessment, so that the stress questionnaire is not tested for reliability because the questionnaire has been applied internationally. The stress level on the DASS 42 instrument (lovibond, 1995) is classified into five levels, namely Normal, score: 0 – 7; Mild, score: 8-9; Medium, 10-14; Severe, score: 15-19; Very severe, score: ≥ 20.

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. Ethical eligibility was obtained from the Health Research Ethics Commission of the Ministry of Health, Jambi, No. LB.02.06/2/140/2020.

Statistical Analysis

Data were analyzed using univariate analysis to obtain a frequency distribution based on each variable studied and bivariate analysis to determine the effect of prenatal yoga on stress levels of pregnant women. Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). Wilcoxon’s test was used to evaluating repeated measurements of the same objects using them as their own control. The test was carried out on 2 groups of related samples, the measurement scale was ordinal data. All tests with p-value (p)<0.05 were considered significant. Statistical analysis performed using the SPSS app version 16.0.

RESULTS

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

Table 1. Frequency Distribution of Respondents' Characteristics

 

Table 1 shows that most respondents in group aged 20-30 years amounted to 13 people (43.3%), and respondents aged 30-40 years amounted to 17 (56.7%) people. Majority of respondents' education level is low education as much as 86.7%, and the dominant occupation of respondents is housewives as much as 63.3%.

Table 2. Distribution of stress levels of pregnant women before and after prenatal yoga

 

Table 2 show that 11 (36.7%) respondents experienced medium stress during pregnancy, 10 (33.3%) respondents experienced mild stress levels and did not experience stress after prenatal yoga.

This analysis aims to determine the effect on variables using the Wilcoxon test, which can be seen in Table 3 below:

 

Table 3. The effect of prenatal yoga on the stress level of pregnant women in private midwives in Jambi City.

 

The analysis of the influence of prenatal yoga on the stress level of pregnant women in private midwives obtained a p-value = 0.0001 (p <0.05). These test results show that prenatal yoga affects the stress level of pregnant women in private midwives in Jambi City.

DISCUSSION

Anxiety in maternity mothers is related to the length of labour which results in complications in childbirth. One of the causes of prolonged labour is the stress response, and this ranks at the top among other causes [24].

Based on the study results, it is known that there are three categories of stress levels experienced by pregnant women during pregnancy. Stress is the body's reaction to situations that cause pressure, change, emotional tension, and others. Stress is universal; that is, all people can feel it, but the way it is expressed is different. According to individual characteristics, the response is different for each person. Stress in pregnant women harms themselves and their babies. Moreover, if the stress is ongoing and chronic, it can have implications for recurring anxiety, frustration, or fear that has been suffered for a long time and can have adverse health effects.

Before prenatal yoga, most pregnant women experienced moderate stress. Many things can affect this incident, for example, worrying about the baby, not deciding where to give birth, doubting the family's economic capacity. Prenatal stress often occurs only rarely recognized and considered not very important during pregnancy. Based on the study results, it is known that 64.4% of pregnant women in Indonesia experience severe stress.

Prenatal yoga is one way that can be done to relax pregnant women so that it can reduce stress levels in pregnant women. Based on the study results, it is known that there is a decrease in stress levels after prenatal yoga. Most of the stress levels of pregnant women drop to mild stress and even become routine. 

Yoga affects the hypothalamus to suppress the secretion of CRH, which will affect the anterior lobe of the pituitary gland to suppress the release of the hormone ACTH so that the production of adrenal hormones and cortisol decreases and orders the anterior lobe of the pituitary gland to secrete endorphins. Yoga will inhibit the increase in sympathetic nerves so that the number of hormones that cause body deregulation can be reduced. The parasympathetic nervous system signals to influence catecholamine release. As a result, there is a decrease in heart rate, breathing rhythm, blood pressure, muscle tension, metabolic rate, and the production of hormones that cause anxiety or stress [25].

Based on the respondents' stress levels before and after prenatal yoga, there was a significant decrease  with the median pre-test stress value decreasing from 10 to 8 after the post-test, p=0.0001. The results of this test indicate the influence of prenatal yoga on the stress levels of pregnant women. Several previous studies showed that yoga had a positive effect on pregnant women, namely reducing stress levels and back pain [20]. Another study conducted by Rahma [22] showed an increase in sleep quality in pregnant women after prenatal yoga.

The application of prenatal yoga, which is one way to ensure the condition of the mother and fetus in a healthy and comfortable condition during pregnancy, is appropriate [26,27]. Yoga is a combination of stretching, breathing, postures, and meditation that promotes health and spiritual growth in the practitioner. This prenatal yoga includes various relaxations, adjusting breathing postures and meditation done by pregnant women every day [28].

One experimental study at a prenatal clinic in Taipei found that prenatal yoga significantly reduced pregnant women's stress and improved their immune function. Attractive value from this study is the finding of higher immunoglobulin A (p < 0.001) in the intervention group than in the control group [29].

 

CONCLUSIONS

Prenatal yoga is effective for reducing stress in pregnant women in the third trimester. The variable for reducing stress levels is strongly influenced by the ability of pregnant women to control their thoughts so that the decrease in stress as a result of prenatal yoga varies in pregnant women

Study Limitations

The lack of control in this study is a limitation, so it cannot compare the intervention group who was given yoga practice and not yoga. In addition, other limitations of this study are No multicenter study, limited geographical area, small sample size.

 

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

DIFFERENCES IN THE QUALITY OF VACCINES STORED IN COOLER BOXES COMPARED TO HOUSEHOLD REFRIGERATORS

Herinawati¹*, Atikah Fadhilah Danaz Nasution¹, Lia Artika Sari¹, Iksaruddin²

¹Midwifery Department, Health Polytechnic of the Ministry of Health, 36128 Jambi, Indonesia

²Department of Health Promotion, Health Polytechnic of Jambi, 36128, Indonesia

Corresponding Author: Herinawati, herinawati.poltekkes@gmail.com, Jl. Prof DR GA Siwabessy No.42, Buluran Kenali, Kec. Telanaipura, Kota Jambi, 36122

 

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ABSTRACT

Background: The inappropriate temperature of vaccine storage may cause vaccine damage leading to degrading or even dispelling the vaccine’s quality. This research aims to reveal the difference of vaccine’s quality stored in the cooler box compared to the household refrigerator with vaccine only and the difference of vaccine’s quality stored in the cooler box compared to the household refrigerator with vaccine stored along with food and beverage

Methods: The research design uses an experimental study with a post-test-only control group design. The research was conducted at two independent practice midwives in Antapani Sub-district and the  Faculty of Mechanical and Aerospace Engineering Bandung Institute of Technology from November to December 2015. The research object used eight types of vaccine (Hepatitis B, BCG, DPT-HB-Hib, Polio, Measles, DT, Td, and TT) with 72 vaccine vials divided into 3 vaccine storage units. The data analysis uses the chi-square test.

Results: The results of the research show that there are statistically significant differences between the vaccine’s quality stored using a cooler box compared to a household refrigerator with vaccine only and the vaccine’s quality stored using a cooler box compared to a household refrigerator with vaccine stored along with food and beverage with the value of p<0,05.

Conclusion: It is concluded that there are differences of the vaccine’s quality stored using cooler box compared to a household refrigerator with vaccine only and also different vaccine’s quality stored using cooler box compared to a household refrigerator with vaccine stored along with food and beverage

Keywords: Cooler box, household refrigerator, vaccine quality

 

INTRODUCTION

Vaccines are biological preparations to increase immunity against several diseases[1]. Immunization will be effective if the vaccine is distributed evenly with well-maintained quality. The quality of the vaccine is influenced by the time of distribution because the life of the vaccine is very limited and requires special treatment. For this reason, the cold chain must be adequate as a guarantee of vaccine quality [2]. The vaccine cold chain system is a series of storage and transportation processes using various equipment accordingly to ensure the quality of the vaccine from the factory to the patient [3].

The Minister of Health Regulation Number 12 of 2017 concerning the Implementation of Immunization has standardized a vaccine storage temperature of 2 to 8ºC for freeze sensitive vaccines (not frozen), and at a temperature of -15 to -25 C for heat sensitive vaccines. Currently, only polio vaccine still requires storage at temperatures below 0°C. A number of vaccines, such as Hepatitis B, DPT-HB-Hib, IPV, DT, Td will potentially be damaged if exposed to freezing temperatures. Meanwhile, the Polio, BCG, and Measles vaccines will potentially be damaged if exposed to hot temperatures. However, in general, vaccines will spoil if exposed to direct sunlight. In general, the cold chain consists of refrigerators and freezers to store vaccines, and thermos (vaccine carriers) to bring vaccines to immunization services, especially for activities outside the building/field [4]. Annually, more than 1.4 million children in the world die from various diseases, which should be avoided by immunization. Several infectious diseases that are included in the Disease Preventable by Immunization include: diphtheria, tetanus, hepatitis B, meningitis, pneumonia, polio, pertussis, and measles. Children who have been immunized will be protected from these dangerous diseases, which can cause disability or death[5,6]. Immunization for infants is called basic immunization, while immunization for primary school-age children and women of childbearing age is called advanced immunization. Vaccines for routine immunization in infants include: hepatitis B, BCG, polio, DPT, and measles. At school age: Diphtheria Tetanus (DT), Diphtheria Tetanus (Td). Immunization of women of childbearing age is given tetanus toxoid[7]. Incompatibility of the vaccine storage temperature with the standard, resulting in damage to the vaccine which means lowering the quality of the vaccine [8].Vaccine quality cannot be improved even if it is stored again at the right temperature. Defective vaccines must be destroyed, because it cannot induce immunity in the body through immunization, in fact itmayaffect Post Immunization Adverse Events (AEFI) to the target. Household refrigerators are designed to store food and drink, it is not recommended to store vaccines. At the district and immunization service units, most household refrigerators are used to store vaccines. Research conducted in Tunisia on 10 household refrigerators found that many household refrigerators found problems with freezing and high temperatures, making it a risk for vaccine storage[9]. Cooler box, a new tool made by ITB students, is an innovation in the medical field that utilizes technology to store vaccines, uses electricity and has a stable temperature (+4.63^oC)[10]. Cooler Box’s ability to store vaccines is measured through a vaccine vial monitor (VVM). All vaccines in the immunization program are equipped with VVM, which is an indicator attached to each vaccine vial to monitor vaccines during transit and storage. The combined effects of time and temperature provide information about heat exposure and potency.

In Indonesia, there are still a number of deaths from Immunization Preventable Diseases (PD3I), including tuberculosis (TB) and measles [11]. In 2013 West Java Province achieved the highest measles immunization coverage in Indonesia at 95.8%, with the incidence of measles at 1,910 cases, occurring in the immunized group as many as 562 cases (34%). Measles Extraordinary Events (KLB) occurred in West Java as many as 18 outbreaks with 205 cases [11]. Another disease that is included in PD3I, and is still high in West Java is tuberculosis with a total of 61,721 people (306 patients aged <12 years)[11]. The city of Bandung is the center of the province of West Java and has 73 health centers (30 UPTs and 34 networks). In 2013 UPT Griya Antapani had 31 cases of measles and increased in 2014 to 33 cases of measles. Other diseases that are included in PD3I are at UPT Griya Antapani, namely tuberculosis [11].

The success of the immunization program cannot be determined only by the high coverage rate, but also by the reduction in cases and outbreaks of PD3I as an indicator of increasing service quality. [12]. Several studies have revealed that outbreaks can be caused by low immunization coverage or due to low vaccine quality caused by poor vaccine cold chain management [13,14].

Based on the existing problems, we tested a tool that had been developed by ITB students and was an innovation for storing vaccines. Trials by storing vaccines for 4 weeks in cooler boxes, household refrigerators filled with vaccines, and household refrigerators filled with vaccines with food and drinks. Furthermore, a vaccine vial monitor (VVM) was assessed to determine the quality of the vaccine.

 

METHODS

This experiment uses the Post test only control group design approach. The research group consisted of two groups including vaccines stored in household refrigerators and vaccines stored in cooler boxes. The study was conducted at 2 independent midwife clinics in Antapani sub-district and the FTMD ITB laboratory from November to December 2015. The object of the study used 8 types of vaccines (Hepatitis B, BCG, DPT-HB-Hib, polio, measles, DT, Td and TT) with a total sample of 72 vaccine vials which were divided into 3 vaccine storage devices: cooler box, refrigerator filled only with vaccines and household refrigerator filled with food and drinks.

Collecting research data by recording the temperature of household refrigerators and refrigerators, researchers make visits to the midwife's clinic 2 times a day, in the morning at 09.00-11.00 and in the afternoon at 17.00-19.00. Recording the cooler box temperature in the FTMD ITB laboratory, in the morning at 8.00-10.00 and in the afternoon at 15.00-17.00 after one month of vaccine quality assessment (VVM). The temperature of the cooler box and refrigerator is set (+2⁰C)-(+8^oC).

The limits for the condition indicators of the vial monitor vaccine (VVM) are detailed in the following Table 1.

Table 1. Various vaccine vial monitor (VVM) conditions

The study was performed in accordance with the ethical considerations of the Helsinki Declaration. The Health Research Ethics Commission of the Faculty of Medicine, Padjadjaran University has given clearance approval with certificate number 694/UN6.C1.3.2/KEPK/PN2015. The ethical aspects of this study consider in detail the place of research to be used.

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). In the case of categorical variables, the chi-square test is performed to test the difference between the two independent samples. All tests with p-value (p) <0.05 were considered significant. Statistical analysis was performed using SPSS app version 16.0.

 

RESULTS

The 8 types of vaccines used include Hepatitis B, BCG, polio, DPT-HB-Hib, measles, TT, DT and Td. Vaccines are stored for one month using three vaccine storage devices which are placed in different places, including a cooler box in the FTMD ITB laboratory, a household refrigerator and a refrigerator containing only vaccines at the midwife's clinic. The results showed a statistically significant difference in vaccine quality (VVM) using a cooler box compared to a household refrigerator containing vaccines, food, and beverages (p<0.05) (Table 2).

Table 2. Differences in the Quality of Vaccines stored in Cooler Boxes Compared to Household Refrigerators

The results also showed a statistically significant difference in the quality of the vaccine (VVM) stored in a cooler box compared to a refrigerator containing only vaccine (p<0.05) (Table 3).

Table 3. Differences in the Quality of Vaccines Stored in Cooler Boxes Compared to Home Refrigerators containing Vaccines

The temperature fluctuations in the cooler box during the morning and afternoon inspections can be seen in Figure 1. Descriptively there is a difference in the temperature of the cooler box, where in the afternoon it is higher than in the morning. up to 7.3⁰C.

Figure 1. Vaccine Temperature Chart Stored in Cooler Box

The temperature fluctuations in the household refrigerator during the morning and afternoon inspection can be seen in Figure 2. Descriptively there is a difference in the temperature of the household refrigerator, which is higher in the afternoon than in the morning. The highest household refrigerator temperature in the morning is 11.7^oC and in the afternoon it reaches 18.1^oC.

Figure 2. Graph of Vaccine Temperature Stored in Household Refrigerators

Temperature fluctuations in the refrigerator containing only vaccines in the morning and afternoon examinations can be seen in Figure 3, where descriptively there is a difference in temperature in the refrigerator containing only vaccines, which is higher in the afternoon than in the morning. The temperature of the refrigerator containing the vaccine only in the morning is 7.1^oC and in the afternoon it reaches 13.1^oC.

Figure 3. Vaccine Temperature Chart Stored in the Refrigerator Only Contains Vaccine

 

DISCUSSIONS

Vaccines have certain characteristics and require a special cold chain since they are produced in the factory until they are used in health care units. Deviations from the storage of vaccines from existing provisions can result in damage to the vaccine so that it reduces or even eliminates the quality of the vaccine, resulting in no immunity. Monitoring of vaccine storage temperatures is crucial in establishing vaccine viability. Vaccine is a biological product that is sensitive to temperature, exposure to heat will shorten the shelf life of the vaccine. Vaccine quality depends on the cold chain, with a defined temperature range from (+2^oC)-(+8^oC) during transport and storage [7]. Vaccine vial monitors (VVM) are used to assess whether the vaccine has ever been exposed to temperatures above the allowable limits, it is said to be VVM A or VVM B conditions. must be used immediately. The condition of VVM C or VVM D if the color of the rectangular box is the same or darker than the circle and its surroundings, then the vaccine has been exposed to temperatures above the permissible limit, the vaccine should not be used.

The results of this study revealed a significant difference in the quality of vaccines (VVM) stored in cooler boxes compared to household refrigerators (p=0.001). WHO and the Indonesian Ministry of Health do not recommend household refrigerators for vaccine storage because they are not designed to maintain a temperature (+2^oC)-(+8^oC) as the temperature range used to store vaccines, this is due to the rapid changes in warm temperatures when fridge door opened [15].

In accordance with the recommendations of WHO and the Indonesian Ministry of Health, it is not allowed to store food, drinks, medicines, or other objects in the vaccine refrigerator, it will disrupt temperature stability because it is often opened Any refrigerator or freezer used for vaccine storage should be dedicated only to vaccine storage without any food and drink mixes. The results of trials conducted by WHO, showed that a refrigerator or freezer for storing vaccines that is often opened can cause the refrigerator temperature to be unstable because warm air flows into the refrigerator every time the refrigerator door is opened and results in food and beverage spills and contamination [6,16]. WHO and the Indonesian Ministry of Health have recommended monitoring the temperature of the vaccine storage area twice a day, in the morning and evening before taking the vaccine. The refrigerator door should not be opened for more than one minute at a time when the vaccine is taken (avoid opening the refrigerator door too often as possible). Research conducted by WHO shows that frequently opening the refrigerator door can cause temperature instability and excessive exposure to light [15]. Several studies have found poor knowledge and practice in administering immunization vaccines in primary care centers, also found a lack of attitudes and behavior of midwives in administering vaccines according to established standards. The behavior of midwives in vaccine management is strongly influenced by the level of knowledge of the midwife about vaccines and their management. The quality of immunization is closely related to how the vaccine is handled and treated, and the maintenance of the cold chain. Vaccine management is part of the quality of service. Indicators of good vaccine management quality are indicated by maintained vaccine temperature (+2)-(+8)^oC, no vaccine found with VVM C or VVM D[17]. Research in Bandung City showed that midwives had low knowledge of vaccine storage, some midwives showed a negative attitude towards vaccine storage and most respondents did not practice vaccine storage according to standards. Research in the city of Bogor found that most of the vaccines stored in the midwife clinic at the same time as placing food such as fruits, cakes, eggs, meat and vegetables, and beverages, and it was found that most of the vaccines were in VVM C and VVM D[18]. The current study found that the vaccine quality in the cooler box was better than the household refrigerator containing only vaccine (p<0.05) where there was a significant difference, this was related to the temperature in the cooler box where the vaccine was stored according to the standard (+2^oC)-(+8^oC) while the household refrigerator filled with vaccines did not meet the standard, the temperature (> 8^oC) was found in the afternoon recording. These results are consistent with several previous studies, such as in Kelantan Malaysia found 73.5% of household refrigerators found that the temperature was more than 8^oC.17 Studies in Thailand and Cameroon also showed high warm temperatures in vaccine storage using household refrigerators[19,20], and a study in Semarang City found that 52.2% of household refrigerator temperatures had a temperature > 8^oC [21]. Thus, the results of the current study are in line with previous studies where the results of household refrigerator temperatures are more than 8^oC. Several things related to higher refrigerator temperatures or unstable refrigerator temperatures, including the refrigerator door not closing tightly, this usually occurs because the rubber door on the refrigerator door is uneven or torn so that the cold air inside the refrigerator exchanges with air outside the refrigerator. As a result, low temperatures in the refrigerator are difficult to achieve or there is a refrigerant or freon leak in the refrigerant system which results in disruption of the cooling process because there is no refrigerant as a medium for heat transfer from inside the refrigerator to outside the refrigerator [16]. These results indicate that the polio vaccine stored in the cooler box is in VVM B (the vaccine is immediately used) while in the household refrigerator the contents of the vaccine are in VVM C [22]. Polio vaccine is stable for 6 months if stored at (+2^oC)-(+8^oC), and stable for 2 years if stored at (-15^oC)-(-25^oC). The polio vaccine does not contain preservatives, stabilizers, and adjuvants. Preservatives are used to prevent bacterial and/or fungal contamination (contamination) of bacteria and/or fungi into vaccines. Stabilizers are added in vaccine production to ensure vaccines are subject to extreme conditions or changing environmental conditions, such as heat, light, humidity, and acidity. Adjuvant are substances used to enhance the immune response of a vaccine, optimize immune system-stimulating cells, reduce the number of antigens used in a vaccine and reduce the frequency of administration [23].

The BCG vaccine is derived from live attenuated bacteria and the measles vaccine is derived from a live attenuated virus. Storage of BCG vaccine at a temperature (-15^oC)-(-25^oC)or at a temperature (+2^oC)-(+8^oC) there is no difference, BCG vaccine is stable for 1 year. Measles vaccine is derived from live attenuated virus, measles vaccine is stored at (-15^oC)-(-25^oC)or at (+2^oC)-(+8^oC) temperature there is no difference, measles vaccine is stable for 2 years[6].

Similar to polio vaccine, BCG vaccine and measles vaccine do not contain preservatives, stabilizers and adjuvants. Preservatives are used to prevent bacterial and/or fungal contamination (contamination) of vaccines. Stabilizers are added in vaccine production to ensure vaccines are subjected to extreme conditions or changing environmental conditions, such as heat, light, humidity, and acidity[24]. Adjuvants are substances used to enhance the immune response of a vaccine, optimize immune system-stimulating cells, reduce the number of antigens used in a vaccine and reduce the frequency of administration[25]. In addition, the vaccine is also light sensitive and the tinted glass vial has been shown to minimize potency loss[26].

The current study revealed that high temperatures (>8^oC) in vaccine storage using household refrigerators containing only vaccines can cause changes in VVM in polio, BCG, and measles vaccines. The polio vaccine was obtained with VVM C while the BCG and measles vaccines with VVM B this was related to the use of VVM 2 in the polio vaccine (low stability) while the BCG vaccine and measles vaccine used VVM 14 (medium stability)[5].

In this study, it was found that there was no difference between the quality of the vaccine stored in the cooler box and the home refrigerator containing the vaccine because the quality of the vaccine was safe and maintained in the refrigerator. The reason is that the home refrigerator containing the vaccine is not opened often, and this is what distinguishes the vaccine from being stored in a refrigerator containing food ingredients, because it is often opened so that the temperature in the refrigerator becomes high or more than 8^oC.

Based on research at the National Institute of Standards and Technology (NIST) Gaithersburg Thermal Studies Laboratory found a way to maintain cold temperatures in household refrigerators that lose cold temperatures due to frequent openings or as a result of lights, namely inserting ice bottles in household refrigerators which has an impact on prolonging  time cold in the fridge. Thermal ballast usage is a practical and effective strategy for mitigating the negative impact of power outage events[27].

 

CONCLUSIONS

There is a difference in the quality of vaccines stored in cooler boxes compared to household refrigerators. There is a difference in quality that is stored in a cooler box compared to a refrigerator containing only vaccines. Finally, the correct cold chain for the good conservation of vaccines must always be maintained according to the indications of the manufacturers

 

LIMITATION OF STUDY

The limitation of this study is the small sample size

 

CONFLICT OF INTEREST

The authors have no conflict of interest.

 

FUNDING STATEMENT

The author(s) received no financial support for the research, authorship, and/or publication of this article.

REFERENCES

1. Pollard AJ, Bijker EM. A guide to vaccinology: from basic principles to new developments. Nature Reviews Immunology [Internet]. 2021;21(2):83–100. Available from: https://doi.org/10.1038/s41577-020-00479-7
2. Yuniar Y, Syaripuddin M, Sasanti R, Susyanty AL. Sistem Manajemen dan Persediaan Vaksin di Dua Provinsi Indonesia. Indonesian Bulletin of Health Research. 2014;42(2):108–21.
3. Centres for Diseases Control and Prevention. Vaccine Storage and Handling Tollkit. the U.S. Department of Health and Human Services (DHHS). the U.S. Department of Health and Human Services (DHHS); 2021. 493–493 p.
4. Kemkes. Peraturan menteri kesehatan republik indonesia Nomor 12 tahun 2017 Tentang Penyelenggaraan imunisasi. Jakarta; 2017.
5. WHO. Cold chain, vaccines and safe-injection equipment management. In: Department of Immunization VaB. Geneva: Department of Immunization, Vaccines and Biologicals; 2008.
6. UNICEF. Handbook for Vaccine & Cold Chain. Department of Health & Family Welfare. India: Ministry of Health and Family Welfare; 2010.
7. WHO. Temperature sensitivity of vaccines ed: Immunization. Vaccines and Biologicals; 2006.
8. Chojnacky M, Miller W, Ripple D, Strouse G. Thermal Analysis of Refrigeration Systems Used for Vaccine Storage. America: Department of Commerce Gary Locke, Secretary; 2009.
9. WHO. PATH. Domestic Refrigerators for Vaccine Storage in Tunisia Conclusion and Recommendations. USA: Vaccines and Biologicals; 2012.
10. Anggita Y. Perancangan, Pembuatan, dan Pengujian Pengembangan Berpendingin Termoelektrik. Bandung: ITB; 2015.
11. Dinkes. Profil Kesehatan Provinsi Jawa Barat Tahun 2013. Bandung: Dinas Kesehatan Kota Bandung; 2013.
12. Kemenkes RI. Riset Kesehatan dasar Tahun 2013. Jakarta: Kementerian Kesehatan Republik Indonesia; 2013.
13. Mishra A, Mishra S, Lahariya C, Jain P, Bhadoriya R, Shrivastav D. Practical observations from an epidemiological investigation of a measles outbreak in a district of India. Indian J Community Med. 2009;34(2):117–21.
14. Thakur J, Ratho R, Bhatia S, Grover R, Issaivanan M, Ahmed B. Measles outbreak in a Periurban area of Chandigarh: need for improving vaccine coverage and strengthening surveillance. Indian J Pediatr. 2002;69(1):33–7.
15. WHO. Annual Cold Chain Management Guide and Record. New Zealand: Ministry of Health; 2012.
16. Wilsdon C. How Do Refrigerators Work? New York: ience in the Real World; 2010.
17. Nurjanti S. Hubungan Tingkat Pengetahuan Bidan Tentang Imunisasi Dengan Perilaku Pengelolaan Vaksin Di Bidan Praktek Swasta Se-Wilayah Ranting Tengah Bantul Yogyakarta. Jurnal Kesehatan. 2010;1(1).
18. Astuti M. Pengaruh Pengetahuan dan Kelengkapan Peralatan Rantai Dingin Terhadap Kualitas Pengelolaan vaksin Oleh Bidan Praktik Mandiri di Kota Bogor. Universitas Padjadjaran; 2013.
19. Techathawat S, Varinsathien P, Rasdjarmrearnsook A, Tharmaphornpilas P. Exposure to heat and freezing in the vaccine cold chain in Thailand. Vaccine. 2007;25(7):1328–33.
20. Yakum M, Ateudjieu J, Walter E, Watcho P. accine storage and cold chain monitoring in the North West region of Cameroon: a cross sectional study. BMC Res Notes. 2015;8(1):145.
21. Kristini TD, Purwanti A, Udiyono. Faktor-Faktor Risiko Kualitas Pengelolaan Vaksin Yang Buruk Di Unit Pelayanan Swasta (Studi Kasus di Kota Semarang). Jurnal Kesehatan Masyarakat. 2008;3(2).
22. WHO. Making use of Vaccine Vial Monitors. Geneva: Biologicals DoVa; 2000.
23. Rahuh G, Suyitno H, Hadinegoro S, Kartasasmita C, Ismoedijanto, Soedjatmiko. Pedoman Imunisasi Di Indonesia. Jakarta: Badan Penerbit Ikatan Dokter Indonesia; 2014.
24. Gomez PL, Robinson JM, Rogalewicz JA. Vaccine manufacturing. Vaccines. 2013;44.
25. Mohan T, Verma P, Rao DN. Novel adjuvants & delivery vehicles for vaccines development: a road ahead. The Indian journal of medical research. 2013;138(5):779.
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27. Chojnacky M, Rodriguez AL. Effect of thermal ballast loading on temperature stability of domestic refrigerators used for vaccine storage. PloS one. 2020;15(7):e0235777.

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by OPI Napoli

THE CHILDBIRTH UTILIZATION IN HEALTH FACILITIES IN THE WORKING AREA OF SUNGAI LOKAN PHC TANJUNG JABUNG TIMUR REGENCY: A CROSS SECTIONAL STUDY

Lia Artika Sari¹*, Yuli Suryanti¹, Enny Susilawati¹

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

 

* Corresponding author: Lia Artika Sari, Department of Midwifery, Health Polytechnic of Jambi, Indonesia, liaartikasari57@gmail.com        

 

                     

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ABSTRACT

Introduction: The low number of deliveries assisted by midwives or health workers is an indicator of the low utilization of health facilities by mothers in labor. This study analyzes the factors related to the utilization of childbirth in health facilities in the Sungai Lokan Community Health Center Work Area, Tanjung Jabung Timur Regency.

Materials and Methods: This research is an analytic observational using a cross-sectional approach involving 74 participants. The research was conducted from January to July 2019 in the Sungai Lokan Health Center Work Area, Tanjung Jabung Timur Regency.

Results: The results showed that the factor of the utilization of childbirth in health facilities was related to family culture (p = 0.0001) and family support (p = 0.003), while the service access factor was not related (p = 0.364).

Conclusion: The role of health workers in socializing the importance of utilizing health facilities as a place of delivery is significant in reducing maternal mortality

Keywords: Health Facilities, Family Culture, Family Support, Access To Services

 

INTRODUCTION

Maternal Mortality Rate (MMR) is one indicator of success in maternal health programs. MMR is a recapitulation of maternal deaths during pregnancy, childbirth, and the puerperium due to pregnancy, delivery, and postpartum problems or their management per 100,000 live births. Reducing maternal mortality due to complications of pregnancy and childbirth is one of the eight targets of the Millennium Development Goals (MDGs) [1]. Family planning, especially for postpartum mothers and unmet need groups, integrated reproductive health services; strengthened village midwives' function, strengthened the referral system, and reduced financial barriers [2,3].

The achievement of the Millennium Development Goals (MDGs) health workforce target needs to receive support from service providers who are health service providers who have a major role in achieving health development goals [4]. Health workers are also providers of health services to patients in accordance with their professional authority to make optimal health efforts. Midwife is one of the non-medical health workers in accordance with their competence and authority to provide midwifery services which are an integral part of health services [5,6]. Every day, some 7,000 babies die in the first month of life. In 2019, an estimated 2.4 million newborns died worldwide. High Maternal Mortality Rate (MMR) and Infant mortality (IMR) is caused by complications in pregnancy and labor [7]. More in the MDG's target on MMR, as stated in the Roadmap to Accelerate Achievement of the Millennium Development Goals in Indonesia, is to reduce from 228 per 100,000 live births in 2007 to 102 per 100,000 live births in 2015. Coverage of deliveries by health workers in health care facilities in Indonesia based on data from the Profile Indonesian Health in 2017 amounted to 5,078,636 with deliveries assisted by health workers totaling 4,222,506 (83.14%). In 2019, 90.95% of deliveries were assisted by health workers. Meanwhile, pregnant women who underwent childbirth assisted by health workers in health care facilities were 88.75% [1]. Thus, around 2.2% of deliveries are assisted by health workers but are not carried out in health care facilities. The coverage of deliveries in Jambi Province based on Indonesia's health profile data in 2017 was 69,774, with deliveries assisted by health workers at health facilities totaling 25,387 (76.37%) [8]. The government targets 85% of deliveries to be carried out in health care facilities. For this reason, the government seeks to improve the quality of quality health care facilities. It is a matter of being available and affordable [9]. The current condition, Puskesmas, as a primary health service facility owned by the government, already exists in every sub-district; it is just that it is still not evenly distributed so that it is less accessible to the public [10]. As a state administrator, the government is obliged to ensure equity and quality of health services for the community. Physically, equitable distribution of health services can be interpreted as affordability in topographical, demographic, and geographical aspects. Physical topographical affordability is the proximity of the population settlements to health service facilities. Affordability in the demographic aspect means that the Puskesmas can accommodate and serve the health needs of the entire population in the work area [9,11,12]. Another critical factor is the public's misconception about the competence of traditional birth attendants that they are birth attendants that are safe, inexpensive, and able to provide services that health workers cannot provide. It is exacerbated by the absence of family support, especially mothers or mothers-in-law to take advantage of health facilities as a place to give birth.

Several previous studies found that delivery coverage at health facilities was influenced by accessibility factors [13], family support [14,15], mothers knowledge [16]. The results of the study [17] show that one of the causes of neonatal death, in addition to the distance of access to health facilities, is also influenced by birth attendants, namely giving birth to a traditional birth attendant with a risk of causing neonatal death by 12.4 times compared to not giving birth to a traditional birth attendant.

Tanjung Jabung Timur Regency, Indonesia has 17 Health centers, with the number of deliveries in 2018 totaling 4,069, with deliveries assisted by health workers in health facilities totaling 1,512 (37.16%). Specifically, Sungai Lokan Village has one main health center and one secondary Health center with total deliveries in 2018 of 29.58%, namely out of 71 deliveries, health workers assisted only 21 deliveries in health facilities [18]. The low number of deliveries assisted by midwives or health workers is an indicator of the low utilization of health facilities by mothers in labor.

Based on the existing phenomena, we tried to examine the factors related to the utilization of childbirth in health facilities in the Sungai Lokan Community Health Center Work Area, Tanjung Jabung Timur Regency”.

MATERIALS AND METHODS

The research design is a cross-sectional survey. Data collection was carried out by the research team assisted by two midwives from January to July 2019 in the Sungai Lokan Health Center Work Area, Tanjung Jabung Timur Regency. The research population was all mothers who gave birth in the Sungai Lokan Public Health Center, Tanjung Jabung Timur Regency, with a sample of 74 mothers who gave birth and at the same time as respondents who were selected by total sampling with inclusion criteria, namely the mother's place of residence is accessible, the mother is in good health, the mother who lives at home with her in-laws while the mother who does not live at home with her in-laws was excluded from the study. Before the research was carried out, the researcher first asked the mother's consent as a prospective respondent, after the mother signed the consent letter to become a respondent, then the researcher conducted interviews using a questionnaire. The research questionnaire consisted of a questionnaire on Utilization of childbirth in health care facilities consisting of 10 questions, a family culture questionnaire consisting of 10 questions, family support consisting of 10 questions, and an Access to the service questionnaire consisting of 10 questions. when the questionnaire was distributed, the mother was accompanied by a member of the researcher until the questionnaire was completed by the mother.

The study was performed in accordance with the ethical considerations of the Helsinki Declaration. No economic incentives were offered or provided for participation in this study. Ethical eligibility is obtained from the Health Research Ethics Commission of the Health Polytechnic, Jambi Ministry of Health with the number: LB.02.06 / 2/110/2019.

 

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). The chi-square test and Fishers exact test were performed to evaluate significant differences of proportions or percentages between two independent groups. Particularly Fishers exact test was used where the chi-square test was not appropriate. The variables measured were adequate delivery facilities as the dependent variable and family culture, family support, and access to services as independent variables. All tests with p-value (p) < 0.05 were considered significant. Statistical analysis was performed using SPSS app version 16.0.

 

RESULTS

The research results are then presented in the form of distribution tables and cross-tabulations and then narrated. The following will present research data on research variables, as follows:

Table 1. Frequency distribution of research variables in the working area of ​​Sungai Lokan Public Health Center, Tanjung Jabung Timur Regency.

 

Table 1 shows that of the 74 respondents, most (71.6%) of respondents will not use health facilities, most (62.2%) of respondents with unsupportive culture, most (58.1%) of respondents do not. Most of them received support from their families (77.0%) were close to the place of service.

Table 2. Results of the analysis of the relationship between the utilization of childbirth in health care facilities with a family culture, family support, and access to services in the working area of ​​

the Sungai Lokan Community Health Center, Tanjung Jabung Timur Regency

In Table 2, it can be seen from 46 respondents with a culture that does not support there are 40 people (87.0%) respondents who will not use health facilities. Meanwhile, out of 28 respondents with a supportive culture, 15 people (53.6%) will use health facilities. The results of statistical tests using the chi-square test obtained a value of p = 0.0001 (p <0.05), meaning that there is a socio-cultural relationship with the use of delivery services in health facilities. Respondents who do not receive family support have 39 people (90.7%) respondents who will not use health facilities. Meanwhile, of the 31 respondents who received family support, 17 (54.8%) respondents would use health facilities. The results of statistical tests using the chi-square test obtained a value of p = 0.003 (p <0.05), meaning that there is a relationship between family support and delivery services in health facilities. Of the 17 respondents with long distances to the four health facilities, 14 (82.4%) respondents would not use the health facilities. Meanwhile, out of 57 respondents with proximity to health facilities, 39 (68.4%) respondents would not use health facilities. The statistical test results using the Fisher Exact test obtained a value of p = 0.364 (p> 0.05), meaning that there is no relationship between distance to the place of service and the utilization of delivery services in health facilities.

DISCUSSION

The question components in family culture variables include the habits of family members to give birth still choose a traditional birth attendant as a birth attendant. In this study it was found that the role of traditional birth attendants was very central and became the family's choice as birth attendants. family habits in giving birth to traditional birth attendants that have been carried out for generations. This has become a culture not only for the respondent's family but also for most of the people in the study area and Indonesia in general. Cultural factors have a very big influence in the selection of birth attendants. Moreover, in rural areas, the position of traditional birth attendants is more respectable, their position is higher than that of midwives, so that from examinations, delivery assistance to postpartum care, many ask for help from traditional birth attendants.

Based on the research results on the socio-cultural community in the working area of ​​the Sungai Lokan Public Health Centre, when approaching delivery, they choose to give birth at home, in addition to being hereditary, because they feel comfortable giving birth at their own home. Some dukuns accompany mothers during childbirth, and some even choose to give birth to be assisted by shamans alone. They also think that their previous children born with the help of a dukun are no different from those who are now being helped by a midwife, apart from feeling comfortable giving birth at their own home because they feel ashamed and reluctant to give birth in a health facility.

The limited use of the national language is also one of the difficulties for the community to communicate with health workers, most of who are not from the local area. So that communication difficulties also make people more comfortable giving birth at their own home and choosing a shaman to help the delivery process.  It is in line with Yeni Aryani's research [19], which found that statistical tests showed a relationship between culture and the choice of place of delivery (p = 0.028). The results of the OR (Odds Ratio) of 3.162 indicate that mothers who receive support from culture have a 3.162 times greater chance of choosing a place of delivery in a health facility compared to mothers who do not receive support from culture. In line with research in Rural Uganda which states that for both men and women in the village, the cultural behaviour patterns of the community have the most substantial impact on birth choices [20]. A woman's relationship with her partner and family is also a factor in whether the mother will use health facilities for the birth process or not. In the family role variable, one component of the question in the questionnaire is the husband's role in determining the choice of place to give birth. The husband's role is very dominant in this study determining the place of delivery for the mother. The husband is the head of the household in a family, so the rules in the household should have deliberation with the husband. Therefore, how important is the role of the husband and family in making decisions for choosing the place of delivery. Based on this and previous studies, husband/family support can influence respondents to use health facilities as a place of delivery. It is due to the husband's/family's lack of knowledge about the importance of using health facilities, especially for childbirth due to lack of knowledge of Husband/family regarding the importance of health utilization and the advantages of giving birth in health facilities. Based on the research results from 74 respondents, most of the respondents did not receive support from their families in the working area of ​​Sungai Lokan Public Health Centre, Tanjung Jabung Timur Regency, with a p-value <0.05. In line with previous research at Puskesmas XIII Koto Kampar, obtained p-value (0.010 < 0.05), this means that there is a socio-cultural influence with the selection of birth attendants [21].

The results of this study are also in line with previous research in the working area of ​​the Muara Ancalong Health Centre, Kutai Timur Regency, which found that family support affected the choice of place of delivery with a p-value of 0.019, namely husband and parents, this indicates that the influence of the closest family is considerable on respondents' decision making in choosing a place to give birth [21]. Another study in Kenya showed that family support in the form of funds was associated with the utilization of childbirth in health facilities [22]. The distance from a mother's house to a health facility is closely related to transportation costs and the time it takes to reach it. The closer the distance of a mother's house to a health facility is, the cheaper the costs. Accessibility based on geographical dimensions is related to time and space, which is believed to shape access to health services significantly. If these obstacles are overcome, someone will still think to decide whether the distance is an obstacle. A study states that the low utilization of health services is due to the existence of barriers for the community in accessing preventive, curative, and promotive health services [13].

Based on the study results, from 74 respondents, most of the respondents were close to the place of service in the working area of ​​Sungai Lokan Public Health Center, Tanjung Jabung Timur Regency. It will undoubtedly increase pregnant women's access to give birth to health facilities, but in reality, this condition is very contrary to the respondent's decision not to use health facilities as a place to give birth.

This study indicates that there is no significant relationship between a mother's access to health facilities and the choice of place of delivery. According to the researcher's assumptions, this occurs because people travel long distances by using transportation to get to the garden. Affordability is based on the perception of distance and the presence or absence of private or public vehicles to reach the nearest health facility. Respondents who choose delivery assistance by traditional birth attendants are generally people whose homes are closer to the traditional birth attendant, while respondents who choose birth assistance by midwives need more time to get services because of the longer distance.

Unlike previous research in the work area of ​​the Kawangu Health Centre, the utilization of childbirth in health facilities was influenced by the ability to access health services (p < 0.001) [16]. In this study, transportation limitations with high costs and poor road structures caused pregnant women to prefer to give birth. The difference in the results of this study is that the ability to access services in our study is already high because the distance from pregnant women's homes to the PHC is very close and does not cost a lot, even though the dominant mother decides to be more comfortable giving birth at home.

Conclusions

Most of the respondents did not use health facilities in the working area of ​​Sungai Lokan Health Centre, Tanjung Jabung Timur Regency. Utilization of delivery services in health facilities in the working area of ​​Sungai Lokan Public Health Center, Tanjung Jabung Timur Regency, is related to family culture and family support, while access to services is not related.

Limitation

In this study, there are limitations such as the presence of some areas that cannot be reached by the research team so they cannot participate in the study. Then in this study using a cross-sectional design so that the information obtained by researchers is only limited to data when the research is conducted.

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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2. Paul VK, Sachdev HS, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, et al. Reproductive health, and child health and nutrition in India: meeting the challenge. The Lancet. 2011;377(9762):332–49.
3. Lule E, Ramana GN V, Ooman N, Epp J, Huntington D, Rosen JE. Achieving the millennium development goal of improving maternal health: determinants, interventions and challenges. 2005;
4. Tangcharoensathien V, Mills A, Palu T. Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals. BMC medicine. 2015;13(1):1–5.
5. Mansoor GF, Hashemy P, Gohar F, Wood ME, Ayoubi SF, Todd CS. Midwifery retention and coverage and impact on service utilisation in Afghanistan. Midwifery. 2013;29(10):1088–94.
6. ten Hoope-Bender P, de Bernis L, Campbell J, Downe S, Fauveau V, Fogstad H, et al. Improvement of maternal and newborn health through midwifery. The Lancet. 2014;384(9949):1226–35.
7. Unicef. Newborn and maternal mortality snapshot [Internet]. 2019. Available from: https://www.unicef.org/health/maternal-and-newborn-health
8. Dinkes Kota Jambi. Profil Kesehatan Kota Jambi. Jambi; 2018.
9. Laksono AD, Mubasyiroh R, Laksmiarti R, Suharmiati EN, Sukoco NE. Aksesibilitas Pelayanan Kesehatan di Indonesia. Yogyakarta: PT Kanisius. 2016.
10. Izati ARM. Trend Cakupan Kunjungan Ibu Hamil (K4) Dan Pertolongan Persalinan Oleh tenaga Kesehatan Di Propinsi Jawa Timur. Jurnal Ilmiah Kesehatan Media Husada. 2018;7(1):1–10.
11. Senewe FP, Elsi E. Descriptive Analysis to environment health in less development, borderlands, archipelagoes and remote areas (DTPK-T). Media Litbangkes. 2014;24(3):153–60.
12. Agustina R, Dartanto T, Sitompul R, Susiloretni KA, Achadi EL, Taher A, et al. Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet. 2019;393(10166):75–102.
13. Laksono AD, Sandra C. Analisis Ekologi Persalinan di Fasilitas Pelayanan Kesehatan di Indonesia. Buletin Penelitian Sistem Kesehatan. 2020;23(1):1–9.
14. Suci CM. Hubungan Pengetahuan Ibu Dan Dukungan Keluarga Dengan Pemilihan Penolong Persalinan di Wilayah Kerja Puskesmas Pintu Padang Kabupaten Pasaman. Universitas Andalas; 2019.
15. Fahriani M, Sitorus E. Hubungan Sikap Ibu Bersalin Dan Dukungan Keluarga Dengan Pemilihan Penolong Persalinan di Wilayah Kerja Puskesmas Nibung Kabupaten Musi Rawas Utara. An-Nadaa: Jurnal Kesehatan Masyarakat. 2020;6(1).
16. Adriana N, Wulandari LPL, Duarsa DP, Adriana N, Wulandari LPL, Duarsa DP. Akses pelayanan kesehatan berhubungan dengan pemanfaatan fasilitas persalinan yang memadai di Puskesmas Kawangu. Public Health and Preventive Medicine Archive. 2014;2(2):175–80.
17. Kusnan A, Rangki L. Faktor determinan proksi kejadian kematian neonatus di wilayah kerja Dinas Kesehatan Kabupaten Buton Utara. Berita Kedokteran Masyarakat. 2019;35(4):131–8.
18. Lokan PDS. Profil Kesehatan Desa Sungai Lokan. 2018.
19. Aryani Y, Islaeni I. Hubungan Dukungan Suami dan Budaya Dengan Pemilihan Tempat Persalinan. SEAJOM: The Southeast Asia Journal of Midwifery. 2018;4(1):8–14.
20. Dantas JAR, Singh D, Lample M. Factors affecting utilization of health facilities for labour and childbirth: a case study from rural Uganda. BMC Pregnancy and Childbirth [Internet]. 2020;20(1):39. Available from: https://doi.org/10.1186/s12884-019-2674-z
21. Nurhapipa N, Seprina Z. Factors Affecting in Choosing the Birth Mother in Health Care Delivery XIII Koto Kampar I. Jurnal Kesehatan Komunitas. 2015;2(6):283–8.
22. Kawakatsu Y, Sugishita T, Oruenjo K, Wakhule S, Kibosia K, Were E, et al. Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study. BMC pregnancy and childbirth. 2014;14(1):1–10.

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by OPI Napoli

DETERMINANTS OF BREASTFEEDING EXCLUSIVE IN THE WORKING AREA OF RUMBIA HEALTH CENTER, BOMBANA REGENCY: A CROSS SECTIONAL STUDY

Asnidawati¹, Wa Ode Salma²*, Adius Kusnan³

1. Public Health of Faculty, Haluoleo University, Kendari, Indonesia
2. Nutrition department, Public Health of Faculty, Haluoleo University, Kendari, Indonesia
3. Nursing department, Medical of Faculty, Haluoleo University, Kendari, Indonesia

* Corresponding Author: Wa Ode Salma, waode.salma@uho.ac.id, Nutrition department, Public Health of Faculty, Haluoleo University, Kendari, Indonesia

 

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ABSTRACT

Background: Breast’s milk is an excellent food for the growth and development of infants. The United Nations Children's Funds (UNICEF) and the World Health Organization (WHO) recommend that children only be exclusively breastfed for six months and continued until two years. This study analyzes the effect of family support, health workers, and socio-culture on exclusive breastfeeding in the working area of the Rumbia Health Center, Rumbia District, Bombana Regency.

Methods: This study involved 86 mothers who had babies aged 0-6 months who were registered and domiciled in the working area of the Rumbia Health Center spread over 4 Kelurahan and 1 Village, which were selected by purposive sampling using a cross-sectional design from February to April 2021. Data analysis using odds ratio (OR) and logistic regression at significance level < 0.05.

Results: The largest age group in the range of 20-35 years, as many as 68 people (79.1%), undergraduate as many as 32 people (37.2%), and income above Rp. 2.552.014, - / month as many as 60 people (69.8%). The results showed an effect of family support on exclusive breastfeeding (p = 0.002<0.05). There is no influence of socio-cultural factors on exclusive breastfeeding (p = 0.282>0.05) and the results of multivariate analysis of the most dominant variables associated with exclusive breastfeeding in the working area of Rumbia Health Center District Rumbia Bombana Regency is supported by health workers with an OR = 9.199 (p-value = 0.039<0.05).

Conclusions: This study concludes that the support of health workers plays a very important role in exclusive breastfeeding to infants aged six months, which can impact improving the health of toddlers.

 

Keywords: Determinant, breastfeeding exclusive, toddler, mother

 

INTRODUCTION

Breast milk is an ideal food for infant growth and development [1,2]. The United Nations Children's Funds (UNICEF) and the World Health Organization (WHO) recommend that children be breastfed exclusively for six months and continued until two years. Global research reports in 2018 showed that the rate of exclusive breastfeeding was quite low, only 41 percent [3]. Meanwhile, in Indonesia, data from the Basic Health Research (RISKESDAS) in 2018 showed that the rate of exclusive breastfeeding was only 37 percent [4]. It is known that the rate of exclusive breastfeeding is still low globally, and it is possible that in Indonesia, the coverage rate of exclusive breastfeeding is below 37% due to the consequences of the Covid-19 pandemic [5].

The study results in 19 developing countries show that socio-cultural factors such as maternal beliefs and other people are significantly strong barriers to exclusive breastfeeding [6–8]. Another study reported that in general, mothers know about breastfeeding, and the majority of respondents (97.3%) had breastfed their babies, 56.5% of them started within one hour after delivery, and 74.1% only gave exclusive breastfeeding until a mean age of 4 months and 30.7% had bottle-fed [9].

The importance of appropriate breastfeeding practices for the healthy growth and development of infants and children has been presented in various policy documents, and guidelines have been set on how to practice exclusive breastfeeding [10]. Social support is widely recognized as influencing the practice of breastfeeding exclusively for six months and continuing to breastfeed for at least two years [11,12]. In addition, health care worker supporting interventions have been shown to increase the rate of exclusive breastfeeding in many developing countries [13,14].

The coverage of achieving exclusive breastfeeding in 2017 in Southeast Sulawesi province for infants 0-6 months was 55.56%, and the coverage of achieving exclusive breastfeeding in 2018 increased by 72%. Although it increased from the previous year, it was not significant and still far from the national target (80%) and the target for Southeast Sulawesi Province (85%). Fluctuating achievements indicate that the exclusive breastfeeding improvement program is not standardized by related technical programs [15]. The working area of the Rumbia Health Center is 40.74%. It is still far from the target set, 50% [16].

The coverage of exclusive breastfeeding in the working area of ​​the Rumbia Health Center has continued to decline over the last three years. It is known that the results of data observations at the Rumbia Health Center showed that data related to mothers who brought their babies to come to the Posyandu in March 2020 recorded only 63 babies and 14 babies who received exclusive breastfeeding while 49 babies were not exclusive. Still far from the expected target of 108 infants (aged 0-6 months). It means that only about 22% of babies get exclusive breastfeeding, and 78% of babies do not get exclusive breastfeeding.

The outbreak of the covid-19 virus has greatly impacted health services, especially Posyandu services in the working area of ​​the Bombana district office, since it was announced that there were residents in Bombana Regency who were confirmed on Covid-19. Overall, Posyandu services at the Rumbia Health Center and other health centers in Bombana Regency are no longer organize the Integrated health service from April to May 2020; therefore, services, data collection, and counseling related to exclusive breastfeeding are not well controlled.

Based on the available scientific data and evidence, this research was conducted to find out how to the influence of family support, health workers, and socio-culture on exclusive breastfeeding in the working area of ​​the Bombana District Health Office, especially at the Rumbia Health Center.

 

METHODS

Study design

This type of research is analytic observational using a cross sectional design with a purposive sampling technique, so that each participant in this study was selected based on the researcher's considerations.

 

Participants Sampling

This study involved 86 mothers who had babies aged 0-6 months who were registered and domiciled in the working area of ​​the Rumbia Health Center spread over 4 Kelurahan and 1 Village

 

Procedure Inclusion and exclusion criteria

To control the quality of research data, the researchers conducted an initial screening by setting sample criteria. The sample inclusion criteria were mothers who had babies aged 0-6 months, mothers who did not experience psychosomatic disorders, while babies who were sick during the study and were born with low birth weight were excluded from the study.

 

Instruments

In this study involved 3 variables, namely family support, Healthcare worker support and Social-Culture. All variables in this study were measured using a questionnaire which was prepared by the researcher himself by taking into account relevant reference sources [17–19] and had been tested and declared valid and reliable.

 

Statistical Analysis

Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). Data analysis in this study used the Odds Ratio (OR) test to determine the factors associated with breastfeeding exclusivity and multivariate analysis used logistic regression to determine the determinants of breastfeeding exclusivity. The results of the p-value will be the basis for the independent variables to be included in the logistic regression test if p < 0.30, while the dependent variable in the study was the provision of Breastfeeding Exclusive, which was measured using a questionnaire. All tests with p-value (p) < 0.05 were considered significant. Statistical analysis was performed using SPSS app version 16.0.

 

Ethical consideration

All participants in this study have signed a letter of willingness to participate in the study. 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 research has been approved by the Haluoleo University Health Research Ethics Commission numbered: 21/KEPK-IAKMI/III/2021.

 

RESULTS

In the results of this study, the characteristics of the mother, distribution of research variables, results of bivariate and multivariate analysis are presented. The distribution of respondents' characteristics can be seen in the following Table 1:

Table 1. Distribution of Respondents’ characteristics

Table 1 informs the largest age group in the range of 20-35 years, as many as 48 people (82.8%), high school as many as 23 people (39.7%), and income above Rp. 2.552.014, - / month as many as 40 people (69.0%).

Table 2 shows the distribution of the dominant study variables consisting of 50 people (58.1%) receiving family support, 67 mothers who received support from health workers (77.9%), and 79 mothers with good socio-culture. (91.9%). There is an effect of family support (p=0.002) and Healthcare worker support (p=0.004) on exclusive breast-feed. There is no influence of socio-cultural factors on the exclusive breastfeeding (p = 0.282).

Table 2. Distribution of Study variable

Table 3 shows that after all independent variables were analyzed multivariate with logistic regression, the results obtained that the support of health workers had the greatest OR, namely 4.350 at 95% Cl with a lower limit value of 1.114 and an upper limit value of 75.974 because the confidence interval range was not. Including a value of 1 means that health workers support exclusive breastfeeding in the Work Area of ​​the Rumbia Health Center, Rumbia District, Bombana Regency.

Table 3. Multivariate Analysis

DISCUSSION

1. The Effect of Family Support on Exclusive Breastfeeding

The study results found that there was an effect of family support on exclusive breastfeeding in the working area of ​​the Rumbia Health Center, Rumbia District, Bombana Regency. The results of this study are supported by several previous studies that state that exclusive breastfeeding success is closely related to family support, especially husbands and grandmothers of toddlers [20–22].

A mother needs support from the family in providing exclusive breastfeeding; support from the family will affect the mother's decision to give exclusive breastfeeding [23]. The success in providing exclusive breastfeeding by mothers is very dependent on the environment, one of which is the husband or family. If mothers get support from the surrounding environment, mothers can comfortably provide exclusive breastfeeding and take care of their children while working at home. Support or support from other people or closest people, both family support and support from health workers, is very important in the success or failure of breastfeeding [24]. The greater support to continue breastfeeding, it makes the greater the ability to continue breastfeeding. Husband and family support is very influential; a mother who lacks her husband, mother, sister, or even being scared, is influenced to switch to formula milk [25].

The success factor of exclusive breastfeeding, in addition to knowledge, to be cleared, is accompanied by the mother's own will. The role of health workers is very influential on the mother in the process of exclusive breastfeeding. The success of exclusive breastfeeding cannot be separated from family support because the family is the closest person who can encourage mothers to continue giving exclusive breastfeeding and the surrounding culture that encourages exclusive breastfeeding [26].

Family, apart from being a supporting factor, is also as retarder factor. The mother's desire to give exclusive breastfeeding should have been discussed with the family, especially people who will live with the mother when the baby is born, for example, husband, mother, mother-in-law long before the baby is born or at least during the pregnancy phase [27]. In still to families regarding the importance of breastfeeding, how to give exclusive breastfeeding and what support they can provide. It is important, because in some cases, a mother's failure to provide exclusive breastfeeding is precisely because of a misunderstanding from the family, for example, being given water, so the baby does not turn yellow, or adding a baby with formula milk because the baby cries and thinks the baby is still hungry and hungry. At that time, the baby's mother had difficulty refusing or resisting because the one who gave it was the mother-in-law and her biological mother. This event will be minimized when the mother and family have good breastfeeding knowledge and a strong agreement and commitment to supporting mothers in exclusive breastfeeding.

2. The Effect of Health Worker Support on Exclusive Breastfeeding

The study results found that there was an effect of the support of health workers on exclusive breastfeeding in the working area of ​​the Rumbia Health Center, Rumbia District, Bombana Regency. Furthermore, the results of the multivariate analysis of this study found that the most dominant variable influencing exclusive breastfeeding in the working area of ​​the Rumbia Health Center, Rumbia District, Bombana Regency, was the support of health workers with an OR value of 9.633.

According to the theory, the support of officers is very helpful, where the support of officers has a big influence on exclusive breastfeeding [22]. A health worker is responsible for health workers who provide health services to individuals, families, and communities. If health workers actively socialize with the community, they can change traditions or habits that can slowly harm health, such as providing complementary foods to infants before six months [28]. Thus, the public will know and understand more about traditional practices that can be detrimental to health so that they will change their behavior and mindset towards what they know from the health worker [29]. The encouragement of health workers can influence respondents to have a high intention of giving exclusive breastfeeding to their babies. The success of breastfeeding mothers requires health workers, especially perinatal service workers such as midwives who are trained and understand the ins and outs of the breastfeeding process. They are the first to help mothers give birth to give breast milk to babies. The role of health workers is the beginning of the mother's success or failure in exclusive breastfeeding. Knowledge, attitudes, and actions of health workers such as midwives are the determinants of the readiness of officers in managing breastfeeding mothers with lactation management (lactation management) so that the implementation of exclusive breastfeeding increases.

This study is in line with previous studies concluding that there is a relationship between the support of health workers and exclusive breastfeeding (p-value = 0.0001) with a PR of 2.48, meaning that mothers who receive support from midwives have a 2.48 times greater chance of breastfeeding independently—exclusively compared to mothers who received less support from the midwife [28]. Furthermore, in line with other research in South Tomohon, it shows a relationship between the support of health workers in exclusive breastfeeding for six months in the Pangolombian Community Health Center, South Tomohon District, p-value = 0.008 [30].

3. The Influence of Socio-Cultural Factors on Exclusive Breastfeeding

The results showed no influence of socio-cultural factors on exclusive breastfeeding in the working area of ​​the Rumbia Health Center, Rumbia District, Bombana Regency. Breastfeeding cannot be separated from the cultural order. Every breastfeeding from mother to child will be related to the social culture that exists in the community. Behavior is formed by habits that are colored by social culture. Everyone is always exposed and touched by environmental habits and is influenced by the community, either directly or indirectly. Behavior that habits and beliefs have shaped about exclusive breastfeeding will impact the mother's desire to give exclusive breastfeeding to children. This socio-cultural will affect the success of exclusive breastfeeding; respondents who have good socio-cultural categories will show success in exclusive breastfeeding. The good social culture indicates it in providing exclusive breastfeeding, as many as 27 people (34.2%) and those who do not give exclusive breastfeeding, as many as 52 people (65.8%) while out of 7 respondents with poor socio-culture giving exclusive breastfeeding, one person (14.3%) and who did not give exclusive breastfeeding were six people (85.7%). The beliefs and traditions that exist in the community lead to the community's mindset on the actions taken to respond to something. Beliefs that exist in society are very important in shaping a person's behavior.

A study conducted [31] in Athens, Greece, found that the breastfeeding process is often not determined by biological factors but is mainly based on habits, traditions, and behaviors in society. Tradition is a social behavior where the behavior is passed down from generation to generation by going through socialization. A tradition determines the values ​​and morals of society because tradition contains rules according to the community about what should be done.

Habits are carried out from generation to generation and carried out by the community, the judge, and assumes that it is the most correct and good thing [32]. The mother's beliefs and desires to imitate the mother's intention to breastfeed her baby. The respondent's intention to do exclusive breastfeeding is influenced by the mother's own beliefs and beliefs [33]. Logically, the existence of a tradition in Rumbia District regarding breastfeeding is closely related to the mother's intentions and expectations regarding exclusive breastfeeding success. Traditions and beliefs develop a pattern to lead people's behavior to do things under the traditions and beliefs that exist in their environment, such as colostrum contained in breast milk are not good and dangerous for babies, special teas or liquids are needed by babies before breastfeeding, and babies will experience a lack of nutrients for growth if only given breast milk [34].

Unfulfilled breast milk needs will cause malnutrition in children—some dietary restrictions at certain times and certain types of food that should not be eaten while breastfeeding. The lack of knowledge of mothers about nutrition and their beliefs causes nutritional problems for their children and impacts the body's defense against infection and delays in growth and development [35]. Interventions promoting behavior change should focus on dispelling less than optimal beliefs and practices into beliefs to build positive breastfeeding practices, involving family support (partners and other family members) as they are an important source of information about breastfeeding [36,37]. Changing people's habits and beliefs is not an easy task, so the role of health workers is very much needed to carry out activities to increase exclusive breastfeeding programs. Guidelines for increasing exclusive breastfeeding programs cannot be separated from the reproductive process of mothers after giving birth, which is expected to change the behavior of people who initially do not believe in the benefits and benefits of breastfeeding to believe and slowly leave the culture and tradition of giving additional food to infants aged 0-6 months. which can interfere with health [38].

The development of community and religious leaders is an important strategy for the health workforce because people tend to obey the directions of trusted people around their environment than people outside their environment. Community empowerment about the importance of exclusive breastfeeding for babies is known by all levels of society, which is expected to provide support and motivation for breastfeeding mothers and can automatically improve reproductive health.

 

CONCLUSIONS

The success of the Breastfeeding exclusive program is strongly influenced by various factors such as family support such as husbands and grandmothers of toddlers, as well as support from health workers through promotional programs when mothers of toddlers visit health care facilities, as well as socio-cultural factors that are believed by the family such as the existence of dietary restrictions for babies of a certain age, babies born must be given sweet food immediately, at a certain age babies must be given food in traditional events.

This study suggests the importance of the role of health workers in providing a good understanding to families about the benefits of exclusive breastfeeding until the baby is 6 months old.

 

Limitations study's

In this study, there are limitations such as the presence of some areas that cannot be reached by the research team so they cannot participate in the study. Then in this study using a cross-sectional design so that the information obtained by researchers is only limited to data when the research is conducted.

Clinical implications of research

The results of this study can be the basis for health workers in maximizing the role of the family in supporting mothers to provide exclusive breastfeeding to infants and paying attention to the socio-cultural background of the family, especially mothers in providing interventions in the field, especially regarding exclusive breastfeeding.

 

ACKNOWLEDGEMENT

We would like to express our gratitude to several parties who have provided support for our research. To the chief of the Poltekkes Jambi in her support in providing suggestions and input for the development of this research, and to mothers who have actively participated as respondents in this research.

 

FUNDING STATEMENT

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

 

CONFLICT OF INTEREST

The author(s) declares no conflict of interest.

 

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by OPI Napoli

Occupational Health and Safety for Nurses: Literature Review

Antonio Brusini.¹

1. Nurse in Sports Medicine, AUSL Modena, Alma Mater Studiorum university tutor, Bologna

Corresponding author: Brusini A., nurse in Sports Medicine at AUSL Modena, master's degree in "Management of Sport and Motor Activities". Email: antoniobrusini87@outlook.it

 

Cita questo articolo

 

ABSTRACT

Introduction: The prevention of occupational accidents in the sphere of occupational health and safety is an important issue in the Italian work setting; health workers, and especially nurses, are continually exposed to the risk of work-related accidents, which can affect the quality of care provided.

Aim: The aim of this review is to investigate the nurse's perceived level of preparedness with regard to occupational safety.

Methods: A narrative review of the literature was conducted using some of the main databases such as PubMed, CINAHL and Cochrane.

Results: The studies analysed show that Italian nurses have little knowledge about occupational health and safety legislation.

Conclusions: Establishing specific postgraduate training events and identifying specific legislation for healthcare personnel could represent essential steps towards implementing this specific knowledge.

 

Keywords: Prevention; Training; Nurses; Healthcare workers

 

 

Introduction

Occupational safety has always been a central issue in the Italian working environment [1]: in 2019, 641,638 accidents at work were reported by December 2019 (640,723 in 2018), 100,905 of these took place on the journey between home and workplace (98,446 in 2018) and 540,733 in the workplace (542,277 in 2018), with 1089 fatal accidents at work (1133 in 2018) [2].

A key area for safeguarding workers, including nurses, is training, which is a useful tool for working safely [3]. Indeed, the risk of injury has increased during the COVID-19 pandemic period (131,090 reports of injuries due to COVID-19 infection in the workplace in 2020 [4]). Fewer accidents would lead to reduced expenditure, related to the cost of treatment, lost working days and replacement of the injured worker. In the UK, for example, in the 2011–12 season, there was a quantifiable loss of 10.4 million working days and a consequent reduction in productivity linked to work-related stress injuries.

The specific high-risk topics to be covered during the course include accident risks; general mechanical risks; general electrical risks; machinery; equipment; falls from height; explosion risks; chemical risks; mists, oils, fumes, vapours, dusts; labelling; carcinogenic risks; biological risks; physical risks; noise; vibration; radiation; microclimate and lighting; display screens; PPE; work organisation; working environments; work-related stress; manual handling of loads; handling of goods (lifting equipment, means of transport); signposting; emergencies; safety procedures with reference to the specific risk profile (high in this case); escape and fire procedures; organisational procedures for first aid; accidents and near misses; other risks. Any further training is at the discretion of the employer, who may decide to give his or her staff additional training [6,7].

 

Objective

The aim of this study is to investigate, through a narrative review of the literature, nurses' knowledge of occupational safety.

 

Methods

PubMed, CINAHL and Cochrane databases were used as a search medium, and all databases were searched on 28/02/2021 for the set of keywords: 'occupational', 'health', 'safety', 'nurse', without Boolean operators between them. No time limit was given to the research, and only English-language sources were taken into account.

This search yielded 422 results on the Cochrane database (using the 'all text' filter); the same search yielded 2418 results on the Pubmed database and 631 results on CINAHL; of these, 3 articles could not be traced (2 on PubMed and 1 on CINAHL). Only studies that discussed the topic of occupational health and safety training and that had carried out a survey in the form of a questionnaire or other methods on training or nurses' perceptions of training in their workplaces were included. Studies involving an education or training programme for nurses who had carried out a survey of subject knowledge prior to the intervention then performed in the study were also taken into account. The selected studies were carried out on a nursing population or included nurses among other professions in the sample. The outcomes to be studied were the survey responses of the studies on the level of preparedness in the field of occupational safety and, if not reported in quantitative terms, the authors' considerations.

 

Results

Articles concerning the figure of the 'Occupational Health Nurse/Nursing' were excluded (Table 1), as it is a figure that specifically deals with occupational health and safety but is not present in Italy, as were repeat sources. After reading the title, 22 sources on Cochrane, 515 on PubMed and 80 on CINAHL were retained.

All articles other than primary studies were excluded. After reading the abstract and the article, 10 articles were selected (1 on Cochrane and Pubmed, 5 on Pubmed and CINAHL, 4 on Pubmed only). Duplicate results were skimmed after the results selection. 2 results concern nurses together with other health professionals, 1 result involves nurses and nursing managers.

Table 1: Databases consulted, sources found and selected

The detailed procedure used in the selection of articles is presented as a flow chart in Figure 1.

Figure 1. Diagram showing the stages of the review and article selection

Table 2 shows the studies classified by author, year, health personnel involved in the study, method, number of participants and results.

Table 2: Citations on training for nurses and healthcare professionals in the literature found, in alphabetical order by the author. OHSA 'Occupational Health and Safety Act', MAPO Movimentazione Assistita Pazienti Ospedalieri (Assisted Handling of Hospital Patients)

Ghasemi [8] conducted a study surveying 211 nurses by asking questions on various topics related to teamwork safety (nurse relationships, accumulated fatigue, communication with physiatrists, supervisor attitude, nursing unit conditions, error reporting, and nursing training), finding that 20% of respondents considered health and safety training to be poor, and only 36.5% participated in occupational safety training programmes. Lee [9] surveyed knowledge of the law that came out in California in 2012 on patient handling, one year (2013) and three years (2016) later, finding 56.4% of nurses in 2013 and 74.3% of nurses in 2016 were familiar with the current law, with those figures changing to 66.5% and 73.3% respectively for nurses who had received training in patient handling within the past year. Foromo [10] administered an evaluation questionnaire to 75 nurses and 52 'nursing managers' asking whether health and safety regulations were implemented in the workplace and found that 93.3% were not implementing the correct instructions. Vendittelli [11] administered an online questionnaire with scales of 1 to 5 (and the optional possibility to write comments) to 104 nurses who graduated between 2011 and 2014 (offered to 435 in total, with only 104 participating), marking demographics, training (and incidence) in occupational safety, including in mobility procedures, and general nursing training, with only 38.2% stating that they had received adequate training specific to their operating unit, and only 25.3% stating that they had adequate time for training in patient handling. He [12] administered a comparative questionnaire between two groups, before and after a training programme on the topic of HIV/AIDS, and the awareness of HIV/AIDS-related knowledge improved significantly after the training (correct answers increased from 67.9% to 82.34%, on risk perception from 54.4% to 66.6%).

Faller [13] conducted a qualitative study with various healthcare professionals using instruments such as interviews and focus group discussions on some focal points (experience of accidents at work, implementations, barriers and strategies to improve safety), and eight groups with semi-structured interviews, and indicated the genuine need for further training and investigation of staff competences in the field of safety. Markannen [14] worked mainly on prevention in infusion practice, presenting possible working situations in focus groups, with pre- and post-intervention evaluation questionnaires, and agreeing on the need to implement training in home care. Morishima [15] administered a questionnaire to two groups of health professionals, one in 2008 and one in 2010, on the subject of radiation: whether there are different types (24.5% responded positively in 2008 and 40.3% in 2010), about the external protection procedure (17.6% and 26.7% positive responses respectively), the correct distance to the machine (31.5% and 41.5%) and the correct position of the dosimeter (60.8% and 55.1%). Rogers [16] conducted an investigation into the ergonomic risks of the nursing profession through focus groups, interviews and workplace observations of 42 registered nurses in five hospitals in North Carolina, finding training to be one of the main tools in preventing ergonomic risks. Finally, Srikrajang [17] conducted a study on a group of 24 emergency and laboratory health workers (including a control group of 12), demonstrating improvements with the use of training tools in preventing needlestick injuries.

 

Discussion

The literature review identified few sources, most agreeing that participants in the various studies show structural deficiencies in occupational health and safety training, calling for thorough training interventions. The results show that a significant number of nurses are not familiar with their state's occupational health and safety legislation, and there are many nurses who are not familiar with risk factors and how to work as safely as possible. In fact, the pandemic period, as pointed out by Giorgi [18], highlighted a particular situation for care staff with consequent stress due both to the working conditions resulting from a higher-than-normal workload due to the emergency both in terms of working hours and in terms of working conditions (overload of patients and the continuous use of personal protective equipment (PPE) to which they were not accustomed, except in very few departments, greater emotional involvement) and to the condition that in some settings was already present before the pandemic. Moreover, there is continuous exposure to biological risk due to possible contagion between patient and operator and between operators, no longer represented almost exclusively by contact with biological liquids, although as shown by Maida [19], there is still a need for training also in this type of risk. The COVID-19 pandemic, therefore, exaggerated the possibility of an accident at work, without any clear preparation for the event. The lack of training on the correct handling of the equipment, and the impossibility of training during the lockdown period, led to a substantial change in the training offer in the field of occupational health and safety, with an increase in online portals. The example of FadinMed (https://www.fadinmed.it/) was necessary, as it offered courses, together with the Ministry's portals, useful for training on the use of PPE during a pandemic.

A possible improvement in an Italian perspective for nurses would be the conferral of the management of training topics on occupational health and safety by the professional order (for each health category, it is compulsory to be registered; nurses must be registered with the Professional Order of Nurses, FNOPI): in the case of nurses, it could also give indications based on the work task (therefore, after a risk assessment per department and per health figure). To give a practical example, a nurse who has a higher rate of patient handling (with a high MAPO index, a rating scale for patient handling risk, above 1.51), must be trained to do so as safely as possible, and not at the discretion of the employer, but as a matter of obligation (although indications with MAPO indexes above 1.51 and especially 5 strongly recommend further training) [20].

It must also be said that the FNOPI already has a programme of courses (including in occupational health and safety training under COVID-19). However, if the use of CME has been made compulsory (the training credits for post-basic training, a quota of 150 for the three-year period, and at least 25 per year), the topics and courses to be followed still remain the choice of the professional. Therefore, a differentiation of the type of courses to be carried out in addition to the statutory ones would be necessary according to the task and location of work (Kim [21] in his study investigated 1672 nurses of childbearing age on the subject of radiation risks and found that 50.3% had not received training, and only 25.1% had received it regularly), to be included in the category of CME, and more control in the private sector. In addition, it would be appropriate to standardise the subjects of biohazard and clinical risk (and the use of PPE), given the current pandemic situation, and to organise refresher training more frequently. Also, at university level, well before the career stage, there should be a greater emphasis worldwide on occupational safety [22,23], following the American example as shown by Whitaker [24], where occupational safety and health courses are taught in more than 80% of American universities and nursing schools.

Finally, it is also necessary to run courses that encourage healthcare personnel to implement healthy lifestyles and proper management of work-related stress: sport and a positive approach to leisure time, which can be combined with family life, can help to properly manage work-related stress and reduce the risk of burnout [25]. This article explores an important open question, that of the safety of the worker (in this case, the nurse), his or her level of preparedness, and how we can work to improve it. This is an issue that is not given much consideration in Italy, and in the future, it is hoped that more studies will be carried out in this regard.

 

Conclusions

It is necessary to evaluate the occupational health and safety system for nurses and in universities, in order to have better-prepared professionals in the world of work in the health sector, by implementing training systems and creating a continuous survey of nurses' knowledge, by frequently administering tools such as questionnaires and other evaluation systems, thereby inviting nurses to continue studying the topic after their basic training. In addition, the training system must also be consolidated at the university level, which is the true starting point of a nurse's career. It is extremely important to consider that, along with training, work should also be undertaken on non-individual measures to reduce accidents (continuous research into collective protection systems and a continuous supply of increasingly high-quality PPE are examples of this), and more responsibility should be given to Prevention and Protection Service Managers, supervisors and nursing coordinators, for example, and greater collaboration with universities, with an annual update of the Nursing Guidelines and Procedures, and to work on an individual level on considerations that improve the quality of work and life outside the healthcare working environment, inviting companies to take an interest in the personal situation of employees and to help them to fulfil the concept of health as defined by the WHO in 1948 ("a state of complete physical, mental and social well-being"). In addition, there is a need for improved mechanisms in university curricula and postgraduate training (in terms of frequency and content).

 

Limitations of the Study

The limitations of the study are represented by the selection of considerably diverse samples: the possibility of researching any studies of a national nature, which are not currently present in the international literature, would have focused the research by giving a more precise overview of our country, together with the use of other databases and with the aid of grey literature. The data may be subject to bias as it does not include feedback from institutional channels, and is based on data in databases from doctors and health professionals in different countries. ISTAT data may be out of date and obsolete, in addition to the difficulty in distinguishing between accidents in the different health sectors.

 

Funding statement

This research did not receive any form of funding.

 

Conflicts of Interest

The author declares that he/she has no conflicts of interest associated with this study.

 

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• Permanent Conference for relations between the State, the Regions and the Autonomous Provinces of Trento and Bolzano, 21 December 2011, Agreement between the Minister of Labour and Social Policy, the Minister of Health, the Regions and the Autonomous Provinces of Trento and Bolzano for worker training, pursuant to Article 37, paragraph 2, of Legislative Decree 9 April 2008, no. 81 (published in the Official Gazette General Series no. 8 of 11/02/2012)
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by OPI Napoli

THE EFFECT OF BABY MASSAGE ON THE SLEEP QUALITY OF 3-12 MONTHS BABIES IN PRIVATE MIDWIVE JAMBI CITY

Atika Fadhilah Danaz Nasution, *Nuraidah, Imelda

Department of Midwifery, Health Polytechnic of Jambi, Indonesia

* Corresponding Author: Nuraidah, Department of Midwifery, Health Polytechnic of Jambi, Indonesia. E-mail: nuraidah.poltekkes869@gmail.com

    

                             

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ABSTRACT

Introduction: Sleep needs in infants 3-12 months are not only in terms of quantity but also quality. Good quality sleep provides benefits to the fulfilment of physical and psychological needs. One method of meeting these needs is baby massage. A common reason for mothers to give baby massages is the child's habit of fussing at night and often waking up, and they say that after the massage, their child becomes calm at night. This study aims to analyze the effect of baby massage on the sleep quality of infants aged 3-12 months at private midwife Muji Kenali Asam in Jambi City.

Material and Methods: This pre-experimental study consisted of a one-group pretest-posttest design for a group of 68 infants aged 3-12 months. The questionnaire was compiled into a google form, and the link was distributed to each mother. Data processing consists of editing, coding, tabulating and statistical tests (Wilcoxon test) at the limit of significance value of 0.05.

Results: The study results that can be described are that most of the sleep quality of infants aged 3-12 months before the intervention was sufficient at 45.6%, and for poor quality, it was 27.9%. After the intervention, most infants aged 3-12 months were good in sleep quality by 45.5% and sufficient sleep quality by 52.9%. The results of the Wilcoxon test revealed the effect of infant massage on infant sleep quality with a significance value of p-value = 0.001.

Conclusion: Baby massage tends to improve the baby's sleep quality. Therefore Midwifery students need to acquire baby massage skills and promote the method to mothers, particularly those with babies 3-12 months.

Keywords: Baby Massage, Sleep Quality, Pre Experimental, Infants Aged 3-12 Months

 

INTRODUCTION

Infancy is a golden period for maximum growth and development of children and needs special attention [1]. Sleep is one of the factors that affect the growth and development of babies because, during sleep, the baby's brain growth reaches its peak and produces three times more growth hormone than when the baby wakes up [2].

As published by the World Health Organization (WHO) in 2012, about 33% of babies have sleep problems. In Melbourne, Australia, found that 32% of mothers reported repeated occurrences of sleep problems in infants [3]. In 2016, Sekartini reported that 80 children aged less than three years, 51.3% of them had sleep disorders [4]. Another study of 385 respondents in Jakarta, Bandung, Medan, Palembang and Batam reported that 44.2% of the night sleep hours were less than 9 hours, waking up more than three times and staying awake at night for more than one hour [5].

Sleep quality is influenced by several factors, namely appropriate rest needs, environment, physical exercise, nutrition and disease. Remember the importance of sleep time for babies, then the need for sleep must really be so as not to adversely affect its development. Quality sleep is determined by the presence of sleep disturbances, the baby is said to have sleep disturbances if the baby is awake at night for more than one hour [6].

Sleep has a significant effect on mental, emotional and physical health and the immune system [7]. The development of infant sleep is related to age and brain maturity, so the total amount of sleep needed is reduced, followed by a decrease in the proportion of Rapid Eyes Movement (REM) and non-REM. Sleep needs are not only seen from the aspect of quantity but also quality [8]. With good sleep quality, the baby's growth and development can be achieved optimally [9].

Sleep problems in children have various impacts, which have not been fully detailed, including growth disorders, cardiovascular disorders, cognitive function and daily behavior [10]. Several studies have stated that disruptive behaviour disorders, such as attention-deficit/hyperactivity disorder (ADHD), are sometimes caused by an undiagnosed sleep disorder [11]. Academic abilities at various age levels can also be affected by undetected sleep disturbances [12].

For the importance of sleep time for the development of the baby, then this need must be met entirely to avoid adverse effects on its development [13]. One of the efforts that can be done to improve the quality and quantity of baby sleep is massaging [14]. Baby massage is very beneficial for the health and development of babies. Regular baby massage will help reduce levels of stress hormones (catecholamines) and increase levels of immune substances in infants (immunoglobulins) while also stimulating digestive and excretory functions and increasing the baby's weight [15]. Massage can stimulate the release of endorphins that can reduce pain, so the baby becomes calm and reduces the frequency of crying. This massage also improves the quality and quantity of the baby's sleep [16].

An increase in the quantity of infant sleep after the massage is associated with increased levels of serotonin secretion [14]. Serotonin is the primary transmitter substance that triggers sleep by suppressing the activity of the reticular activating system and other brain activities [17].

Research conducted at the Touch Research Institute of America on 20 children massaged for 2x15 minutes within five weeks experienced 50% changes in brain waves compared to before the massage. These brain wave changes occur by decreasing alpha waves and increasing beta waves so that babies can sleep more soundly [18]. Based on research from the Warwick Medical School and the Institute of Education from the University of Warwick, examining nine kinds of baby massage movements performed on 598 babies under six months of age, the results showed that baby massage could make sleep patterns more regular because it is influenced by the sleep hormone melatonin which is influenced by baby massage performed [19].

The Muji Private Midwife is located in Kenali Asam, Jambi city, which provides baby massage services. An average of 25 babies is massaged per month. The results of interview with the baby's mother who came for baby massage, because babies like to wake up in the middle of the night, and the next day they like to cry and like to fuss. Based on this phenomenon, we are interested in examining the effect of infant massage on the sleep quality of infants aged 3-12 months in the Muji Private Midwife in Jambi City.

METHODS

The research method used in this study was a pre-experimental study with a pretest and posttest one group design conducted on infants at PMB Muji Kenali Asam Jambi City with 68 babies aged 3-12 months. Infants in the study who met the inclusion criteria set by the researcher, including infants aged 3-12 months, parents of babies willing to be respondents, babies who were breastfed and babies who were massaged three times during the study. The procedure for implementing baby steps in this study is guided by the baby massage procedure that has been used in previous studies [6,15,19] as follows:  first, the researcher prepared baby oil, then a towel or blanket as a tool. The next step was to massage the legs, abdomen, and chest, massage the hands, face and finally massage the back. This procedure was carried out three days in a row, where every day, five babies received the intervention. Researchers measured sleep quality before implementing infant massage using a standardized questionnaire that has been tested for validity and reliability referring to Morrell's Infant Sleep Questionnaire (MISQ) [20] and A Brief Screening Problems (BSP) [21], and after three massages, the quality of sleep was measured again using the same questionnaire. 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 research has obtained ethical feasibility from the Health Research Ethics Commission of the Health Polytechnic of the Ministry of Health Jambi with LB.02.06/2/130/2020.

 

Statistical analysis

Data are presented as numbers and percentages for categorical variables. Continuous data are expressed as the mean ± standard deviation (SD), or median with Interquartile Range (IQR). The Wilcoxon test was performed to evaluate significant differences between two dependent groups. All tests with p-value (p) < 0.05 were considered significant. Statistical analysis was performed using SPSS app version 16.0

RESULTS

Research results are presented in the form of frequency distribution tables and inferential analysis tables. The characteristics of the baby are presented in the following table:

 

Table 1 Distribution of Babies by Gender, and Age

Based on the table above, the gender of the respondents is almost the same, with the difference between women being less than men, mostly aged 3 – 5 months 44.1% and both aged 6 – 8 months 26.5%. This data shows that the babies who come to PMB Muji are mostly babies aged three months to 8 months.

Distribution of baby's sleep quality before and after a baby massage can be seen in the following table:

 

Table 2. Distribution of Respondents Based on Sleep Quality of Babies Age 3-12 Months before Massage

 

Table 2 shows that the sleep quality of babies aged 3-12 months before baby massage was mostly of adequate quality, namely 31 respondents (45.6%). After stepping on the baby, most of the baby's sleep quality was adequate, namely 52.9%, there was an increase in good quality to 45.6%, only one had poor sleep quality.

The results of the inferential test using the Wilxocon test obtained the mean and standard deviation values ​​as well as the p-value as presented in the following table:

 

 

Table 3. The effect of massage on the sleep quality of infants aged 3-12 months

Before the intervention, the mean score is 4.3235, and after the intervention, the mean score found is 5.3382. The mean difference between before and after the intervention is 1.0182. It can be seen that there has been an increase in the quality of sleep for babies 3-12 months after massaged which is 1. 0182. The results of the p-value showed that there was an effect of the baby's grip on the baby's sleep quality with sig. 0.001.

DISCUSSION

The sleep quality of infants aged 3-12 months before the massage mainly was adequate (45.6%) and less (27.9%). It is because many babies are fussy when they go to sleep (37%), babies look weak and cry when they wake up in the morning (73.5%), and babies always look fussy, cry and find it difficult to fall back asleep when they wake up (70.6%). The above situation occurs because the baby lacks sleep.

Inadequate sleep and poor sleep quality can lead to physiological and psychological balance disorders. Physiological impacts include decreased daily activities, fatigue, weakness, poor neuromuscular coordination, slow healing process and decreased immune system. At the same time, the psychological impact includes more unstable emotions, anxiety, and lack of concentration, lower cognitive abilities and combined experiences [22,23].

Many infants 3-12 months experienced less sleep. According to data obtained, 44.1% sleep less than 9 hours at night. Many factors may cause a baby to lack sleep, such as health status where an unhealthy baby will interfere with sleep, an uncomfortable environment such as too noisy, too hot, too cold, lighting that makes the baby sleepless and restless, psychological factors such as an anxious baby, there are scary sounds that make the baby feel scared which has an impact on sleeping often wakes up. The last is the dietary factor that also determines the baby's comfortable sleep or not. Babies who do not eat/are hungry or consume foods that contain gas cause bloating or drink too much at night, so they often wake up to urinate. In line with Wahyuni ​​[24], babies who sleep enough without waking up frequently at night will be fitter and less fussy. Babies are said to have sleep disorders if they sleep less than 9 hours at night, wake up more than three times and wake up more than 1 hour.

Based on the results of data analysis after the baby was massaged, the sleep quality of infants aged 3 -12 months mainly was of sufficient quality (52.9%) and good quality (45.6%). Only 1.5% of infants experienced poor sleep quality. According to respondents, most of the babies who had been massaged (94.1%) looked cheerful and fit when they woke up and most stated that the babies did not look weak and cried when they woke up in the morning (95.6%). The quality and quantity of baby sleep affect physical development and emotional development [4]. Babies who get enough sleep without waking up are fitter and less fussy the next day. Not only has that, but lack of sleep also had an impact on the baby's thinking ability. If the body is tired, the quality of thinking becomes low. As a result, the baby cannot respond well. Babies who are sleep deprived become fussier, whiny and have trouble sleeping. For this solution, the baby needs to be massaged.

The baby is fast asleep after the massage because through the massage and the brain waves can change. This change occurs by decreasing alpha waves and increasing beta and theta waves proven by EEG (Electroencephalography) [17]. As for one baby after being given a baby foothold but did not show good sleep quality, according to research studies, it may be caused by several factors such as the habit of drinking milk before bed will also affect the quantity and quality of baby sleep. Meanwhile, the baby's bed environment is not comfortable, and the crowd in the family.

The effect of the baby's sleep quality is seen from the difference in mean values ​​before and after massage. The mean value of the baby's sleep quality before massage was 4.3235 and after massage the mean was 5.3382 with a mean difference of 1.0182, this means that the baby after massage experienced an increase in sleep quality by 1.0182 points. p-value shows the effect of baby massage on baby's sleep quality with sig. 0.001. Another study on the relationship of massage infants with pattern and sleep in infants concluded that the touches given during infant massage were associated with increased infant sleep quality as indicated by an increase in the number of infant sleep duration and a reduction in infant sleep disturbances [25]. In contrast to this study, a study in Yogyakarta found that there was no effect between Infant Massage on weight gain and infant sleep quality [26].

 

CONCLUSIONS

Infant massage affects the sleep quality of infants aged 3-12 months before and after the intervention with a mean difference of 1.0182, which means that massage can improve the quality of infant sleep by 1.0182 points with a p-value of 0.001 (p <0.05).

LIMITATION

The limitation of this study is that it does not control other factors that can affect the quality of baby sleep, and than this intervention was only carried out in one place, namely at PMB Muji Kenali Asam Jambi City.

ACKNOWLEDGEMENT

We would like to express our gratitude to several parties who have provided support for our research. To the chief of the Poltekkes Jambi in her support in providing suggestions and input for the development of this research, and to mothers who have actively participated as respondents in this research.

CONFLICT OF INTEREST

The author(s) declares no conflict of interest.

FUNDING STATEMENT

The author(s) received no financial support for the research, authorship, and/or publication of this article.

 

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18. Afriyanti D. Effects of Baby Massage Using Lavender Aromatherapy In Fulfillment Of Sleep Need Among Baby Age 6-12 Months In The Working Area Nilam Sari Health Center Bukittinggi In 2017. Journal of Midwifery. 2018;3(1):13–24.
19. Haryanti RS. Pengaruh loving tauch baby massage terhadap pola tidur batita. Profesi (Profesional Islam): Media Publikasi Penelitian. 2019;17(1):61–8.
20. Morrell JMB. The infant sleep questionnaire: a new tool to assess infant sleep problems for clinical and research purposes. Child Psychology and Psychiatry Review. 1999;4(1):20–6.
21. Sadeh A. A brief screening questionnaire for infant sleep problems: validation and findings for an Internet sample. Pediatrics. 2004 Jun;113(6):e570-7.
22. Eliza S. Hubungan Pijat Bayi dengan Lamanya Tidur Bayi Usia 0-12 Bulan. Java Health Jounal. 2014;1(1).
23. Akib H, Merina ND. The Influence of Baby Massage on Baby Sleep Quantity in Bedadung Village, Sumbersari Subdistrict Jember District. Jurnal Kesehatan dr Soebandi. 2018;6(1).
24. Afrina DN, Rahayu UB, Wahyuni Ss. Pengaruh Baby Solus Per Aqua (Spa) Terhadap Kuantitas Tidur Bayi Usia 6-9 Bulan. Universitas Muhammadiyah Surakarta; 2012.
25. Roth DE. The Relationship Massage Infant With Pattern And Sleep In Infants. journal of pediatric. 2010;
26. Fauziah A, Wijayanti HN. Pengaruh Pijat Bayi terhadap Kenaikan Berat Badan dan Kualitas Tidur Bayi di Puskesmas Jetis Yogyakarta. PLACENTUM: Jurnal Ilmiah Kesehatan dan Aplikasinya. 2018;6(2):14–9.

 

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by OPI Napoli

THE ROLE OF HYPERBARIC OXYGEN THERAPY IN FOURNIER'S GANGRENE: LITERATURE REVIEW

Vincenza Giordano ^{1 *}, Luca Cardillo ²

1. Nurse with Master's Degree in Nursing and Midwifery Sciences, AORN Antonio Cardarelli
2. Nurse and Business Trainer at A.S.L Napoli 2 NORD (Hospital Santa Maria delle Grazie)

*Corresponding Author: Dr. Vincenza Giordano, Nurse with Master's Degree in Nursing and Midwifery Sciences, AORN Antonio Cardarelli

E-mail: enza-giordano@hotmail.it               

 

             

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ABSTRACT

Introduction: Fournier's Gangrene is a severe necrotising infection that can be fatal if not recognised and treated immediately. Treatment consists of a combination of conventional therapy with a multidisciplinary approach (early diagnosis,  surgical debridement, antibiotic therapy, intensive care and reconstructive surgery) and adjuvant therapy with hyperbaric oxygen therapy sessions.

Objective: To identify the role and evaluate the efficacy of hyperbaric oxygen therapy in Fournier's gangrene.

Method: To conduct the following narrative review a research question was outlined using the PIO methodology. Subsequently, a literature review was conducted using the PubMed, Scopus and CINAHL Complete databases from December 2020 to February 2021.

Results: Eight studies emerged from the literature review showing that the use of adjuvant Hyperbaric oxygen therapy (HBOT) in combination with classical treatment has beneficial effects and enhances the efficacy of hyperbaric oxygen therapy, resulting in lower mortality rates, in contrast to the average number of hospital days spent in intensive care, which do not undergo any significant change. But in contrast to mortality, the average number of days spent in intensive care differed significantly in favour of the standard treatment group.

Conclusion: The combined effect of hyperbaric oxygen therapy with conventional therapy offers a significant advantage in the management of FG; furthermore, HBOT is associated with a significant survival advantage.

 

Keywords: Fournier's gangrene, Fournier's disease, Hyperbaric oxygen therapy and HBOT

 

INTRODUCTION

Necrotising fasciitis, better known as "Fournier's Gangrene" (FG), is a polymicrobial infection caused by aerobic and anaerobic microorganisms acting synergistically to cause severe soft tissue infection (NSTI), targeting the genital, perineal and perianal region [1,2]. The term, coined by the scholar Wilson, first appeared in the scientific world in 1952 [3]. FG is now considered a rare disease [4-6], predominantly affecting males (10 to 1 ratio) with a mean age of 50 years [4,7], with an incidence rate ranging from 0.3 to 15.5 cases per 100000 inhabitants [8,9]. It is associated with high morbidity and mortality between 3% and 67% [4]. FG has a subtle and rapid pathogenesis, so much so that some authors have divided the disease into 4 phases[5]: (i) the initial phase occurs within 24-48 hours and is associated with non-specific symptoms, such as itching, oedema, erythema and partial hardening of the affected tissues; (ii) the second phase is brief and invasive with the presence of local inflammatory manifestations; (iii) the third phase is the necrotic phase in which there is a rapid deterioration, which may evolve into septic shock, with the risk of spreading necrosis to the anterior abdominal wall and thighs; (iv) the fourth phase is one of spontaneous repair which occurs after a few months, during which epithelial regeneration and healing take place [5].  From an aetiological point of view, the bacteria responsible for this infection include group A Streptococcus as the most common monomicrobial culprit [10,11], while Escherichia coli, Bacteroides, Staphylococcus, Proteus, Streptococcus, Pseudomonas and Enterococcus are among the polymicrobial culprits [12,13]. Microorganisms have been found in the urogenital tract and in the digestive tract: the causes of bacterial presence in the urogenital tract are urethral stenosis, scrotal abscesses, orchitis, epididymitis, renal abscess, ureteral trauma, renal calculosis, bladder and penile cancer, prostate biopsy and catheterization [14,15], while the presence of bacteria in the digestive tract is found in outbreaks originating from perianal abscesses, colorectal tumours, appendicitis, acute diverticulitis, Crohn's disease, incarcerated hernias and perforation of the rectum, particularly caused by a foreign body [16,17]. Without treatment, the process may not only rapidly spread to the abdominal wall, dorsal region, upper limbs and retroperitoneum, but also lead to sepsis, multi-organ failure and death [1,18,19]. Systemic diseases listed as risk factors for the development of FG include: diabetes mellitus, alcoholism, hypertension, obesity, smoking, immune suppressive conditions such as HIV infection, radiotherapy and chemotherapy [4,7,20-23]. In terms of semeiotics, the most frequent manifestations include pain, erythema, oedema and necrosis of the scrotum or the perianal and perineal region, often associated with fever and chills [24-26]. Other symptoms are mostly localised and include the presence of blisters, crackles, cyanosis and malodorous discharge; however, it should be emphasised that the skin manifestations are the 'tip of the iceberg', while the infection spreads rapidly and aggressively along deep fascial planes [27,28]. The FGSI (Fournier's Gangrene Severity Index) scale is used to estimate the severity of Fournier's gangrene. It uses 9 parameters: temperature, pulse, respiratory rate, sodium, potassium and creatinine levels, haematocrit, leukocytosis and bicarbonate levels. Each parameter is assigned a score from 0 to 4. A high FGSI score denotes a worse prognosis [29]. Treatment of FG includes management of sepsis according to guidelines (early diagnosis,  surgical debridement, antibiotic therapy, intensive care and reconstructive surgery) [30] and hyperbaric oxygen therapy (HBOT) is highly recommended whenever possible [31].

Hyperbaric oxygen therapy is a therapeutic approach that involves the use of 100% pressurised oxygen, which is delivered in an airtight chamber. HBOT has a bactericidal action on anaerobes and reduces the activity of endotoxins in the presence of high oxygen levels. This treatment has provided benefits such as improved neutrophil phagocytic action, fibroblast proliferation and angiogenesis, reduced oedema, absence of free radicals and increased intracellular transport of antibiotics [32,33]. Adverse effects associated with this treatment approach are relatively rare, but there are not enough studies that have investigated the role of HBOT in FG [34,35]. Among the few studies presented in literature, adverse events include barotrauma of the tympanic membrane and paranasal sinuses, the possibility of sudden onset of epileptic seizures and pulmonary and central nervous system toxicity caused by oxygen[36]. However, the use of hyperbaric oxygen therapy in the management of FG is widely discussed, sometimes even controversially, because clinical evidence regarding HBOT in these infections is scarce and of generally low quality and, moreover, the use of hyperbaric oxygen therapy is not standard of care in many centres, so much so that some authors recommend HBOT as an adjuvant treatment [37], while others do not recommend it as routine use in the management of FG [38]. This literature review aims to investigate the role that HBOT plays in Fournier's gangrene, its effectiveness and influence on some variables. Some studies show that HBOT reduces the extent of necrosis, mortality, morbidity rates [39,40] and the need for further surgery [41]. The strength of this review is to highlight that, although oxygen therapy is a second-line treatment, in all the studies reported in this review, it still plays a decisive role in the treatment of Fournier's gangrene, as it allows restitutio ad integrum.

Objective of the study

Identify the role and evaluate the effectiveness of hyperbaric oxygen therapy in Fournier's gangrene.

 

MATERIALS AND METHODS

Study design

A narrative review of the literature was conducted using an evidence method. To conduct the review, a research question was outlined using the Population, Intervention, Outcome (PIO) methodology. The PIO specifies the population to be studied, the intervention to be implemented and the outcomes (Table 1).

Table 1. Question according to the PIO method. FG= Fournier's gangrene

Research strategy

The research of the articles was carried out through the following databases PubMed, Scopus and CINAHL Complete in the time period from December 2020 to February 2021.

The following keywords were used:

 

"Fournier’s Gangrene", "Fournier’s Disease", "Gangrena de Fournier", "Hyperbaric Oxygen Therapy", "hbot", "hyperbaric oxygen" and "oxygen therapy".

For each MeSH term, the respective synonyms have been identified in each database. Next, advanced search terms were set up, using the Boolean operators 'OR' and 'AND' to cross terms in different combinations and make the search more specific. The only limit included is the date of publication: only articles published within the last 10 years were taken into account.

The formulation of the keywords and MeSH terms was carried out jointly by the two authors in order to comply with validity criteria and reduce search bias . Similarly, the authors also collaborated in the retrieval of articles and full-texts and their respective evaluations, to identify reports relevant to the research topic. The search terms are shown in Table 2.

Table 2. Search terms

 

Inclusion and exclusion criteria

The following criteria were set for the search. We included (a) primary studies; (b) studies carried out on the adult population of both sexes; (c) studies published in the past 10 years. We excluded: (A) secondary studies; (b) editor's reviews and / or letters to the editor; (c) studies with subjects under the age of 18; (d) studies in which the role of hyperbaric oxygen therapy was not fully exposed. The detailed procedure used in the selection of articles is presented below in the form of a flow chart shown in Figure 1.

Figure 1. PRISMA Flow Diagram of the literature review

Our search strategy yielded a total of 150 preliminary stage articles (27 on Pubmed ,107 on Scopus and 16 on CINAHL Complete). 9 duplicate articles were excluded. The remaining 141 were assessed by title and abstract, 121 were discarded because they were not relevant to the objective or inconsistent with the inclusion criteria. Of the 20 remaining articles, after reading the full-text, 12 records were discarded as they were secondary studies or not relevant to the research question. 8 articles were included in the review after a full evaluation of the text. The two authors independently conducted the literature review and no discrepancies emerged between the evaluators.

 

RESULTS

Eight studies relevant to our question emerged and Table 3 summarises their characteristics and results. Fournier's Gangrene is a severe necrotising infection that can be fatal if not detected and treated immediately. Treatment consists of a combination of conventional therapy with a multidisciplinary approach (early diagnosis,  surgical debridement, antibiotic therapy, intensive care and reconstructive surgery) and adjuvant therapy with hyperbaric oxygen therapy sessions. This is confirmed in the articles that follow. A retrospective study [42] has shown that the use of adjuvant HBOT, in combination with classic treatment is associated with reduced mortality: this percentage was lower in the group treated with HBOT than in the control group treated with the standard approach ( 3.7% vs 28.8%). This finding is further confirmed in other studies [43,44]: in the retrospective, multicentre observational study by Anheusera et al. [44], mortality in patients treated with HBOT was 0% vs. 4.4% mortality for patients not receiving adjuvant treatment. In the latter study, as opposed to mortality, a variable on which it is important to pay attention was the average days spent in intensive care, which differed significantly in favour of the standard treatment group. In fact, the frequency of wound debridement and hospital stay were significantly higher in the hyperbaric oxygen therapy group (13 vs 5 debridements and 40 vs 22 days). However, the latter contrasts with a retrospective, multicentre study present in the literature [45], in which the variables of length of hospital stay, direct costs of hospital stay, complications and mortality in the three FG classes (minor, moderate and major), regardless of treatment, were not significantly different. In contrast, subjects receiving adjuvant therapy with HBOT had a lower rate of complications (45% vs. 66%) and deaths (4% vs. 23). In a retrospective analysis of 60 patients, first treated with broad-spectrum antibiotics and then undergoing surgery within 24 hours of admission, it was observed that fasciotomy alone was an insufficient treatment and that in many patients debridement was necessary   (average of 3.1 debridements), combined with early diagnosis, intensive care and in some cases colostomy, with the addition of hyperbaric oxygen therapy sessions, which demonstrated an increase in survival [46]. In this study, 12 patients were treated with HBOT, with a survival rate of 100% (12/12 patients), compared to 66.7% (32/48) of patients who did not undergo HBOT. In addition, hyperbaric oxygen therapy, as shown in Chao et al's case-control study [29] of 28 subjects, reduces infection rates and improves prognosis, although the most effective method for FG remains surgical treatment. However, due to the depth of the retroperitoneal space, the presence of large cavities and soft tissue, the lesions are diffuse and it is often difficult to completely debride the necrotic tissue during surgery. Therefore in such conditions, hyperbaric oxygen therapy used as an adjunct to standard therapy can reduce debridement sessions and times, shorten the length of drainage tube use, reduce healing time and improve the prognosis process of FG. In this study, as in previous studies, the experimental group had a lower mortality rate than the non-HBOT control group (12.5% vs. 33.3%). These findings are supported by two studies: a retrospective and descriptive study conducted by accessing the medical records of 34 FG patients who underwent HBOT from 1989 to 2014 [47] and a single-center, case-control study involving 341 subjects, which described the potential benefits of HBOT in FG from a pathophysiological perspective (inflammation, modulation of reperfusion injury and facilitation of wound healing), with respective reduction in mortality [48].

Table 3. Analysis of the studies included within the review.

 

DISCUSSION

The aim of the review was to identify the role and assess the effectiveness of hyperbaric oxygen therapy in Fournier's Gangrene.  From the studies analysed, it is clear that the primary treatment of Fournier's Gangrene uses a multidisciplinary approach based on conventional therapy (early diagnosis, surgical debridement , antibiotic therapy, intensive care and reconstructive surgery). In recent years, hyperbaric oxygen therapy has shown to have an adjuvant role in the treatment of FG, but at the same time a decisive one, as it has allowed a return ad integrum with or without surgery. In fact, due to the depth of the retroperitoneal space, the large cavities and non-linear tissue, and the diffuse lesions, it is often difficult to define and carry out a complete debridement of the necrotic tissue during surgery, so that tissue hypoxia and infection factors interact and in the post-operative period, poor drainage or the onset of other factors favour the spread of the disease. Therefore it becomes necessary in such conditions, to find an adjuvant therapy that can reduce the infection rates and improve the prognosis. HBOT acts as a bactericide and/or bacteriostatic against anaerobic bacteria by increasing the formation of oxygen free radicals and restores the bactericidal capacity of leukocytes in hypoxic wounds by increasing tissue oxygen tension; in addition, HBOT interacts synergistically with several antibiotics to enhance their effect and thus reduce complications that may occur. Oxygen therapy is commonly started as soon as patients are stabilised (after initial debridement) and continued until the wound is completely healed. HBOT as an adjunctive therapy may reduce debridement sessions and drainage tube time in situ; but the efficacy of hyperbaric oxygen therapy is demonstrated by the exponential decrease in mortality rates reported in all studies, even in those patients where FG is associated with critical situations such as septic shock. It is not possible, however, to conclude that HBOT has a real positive influence on the reduction of average days of hospitalisation and treatment in intensive care units and consequently on health care expenditure, as the studies in the literature are conflicting. In fact, although HBOT has potential in FG therapy, not all hospitals have or can allow the patient rapid access to hyperbaric chambers and the degree of critical illness accompanying gangrene often precludes access to oxygen therapy. Moreover, there is no established treatment protocol for HBOT and given the rarity of FG cases, it is often very difficult to carry out studies, which is why the role of hyperbaric oxygen therapy is much discussed and, at the same time, a matter of controversy. It must be said that there has not been enough studies carried out in the literature to introduce this type of therapy as a first-line treatment in the clinical routine, but only as a second-line treatment, supporting standard therapy (early diagnosis, surgical debridement, antibiotic therapy, intensive care and reconstructive surgery).

 

CONCLUSION

The results in the literature review suggest that the combined effect of hyperbaric oxygen therapy with conventional therapy offers a significant advantage in the management of FG and that HBOT is associated with a significant survival benefit. Multicentre studies with a larger sample size are needed to confirm these observations, but are difficult to conduct due to the rarity of FG and the limited availability of HBOT in some centres. With a better understanding of the disease and treatment experience, the management of FG could see significant developments in the future.

ABBREVIATIONS

FG (Fournier's gangrene)

FGSI (Fournier's Gangrene Severity Index)

HBOT (Hyperbaric oxygen therapy)

ICU (Intensive Care Unit)

PIO (Population, Intervention, Outcome)

Conflicts of interest

The authors state that they have no conflicts of interest associated with this literature review.

Funding

The authors declare that they have not received any form of funding and that the study has no financial sponsor.

 

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by OPI Napoli

La paura nell’anziano: una ricerca intervento basata sull’osservazione partecipe

Giulia Bindi¹ and Gabriele Giacomelli*²

1. Dipartimento di infermieristica ospedaliera, A. O. U. Careggi, Firenze
2. Dipartimento di infermieristica territoriale, USL Toscana Centro

* Corresponding Author: Gabriele Giacomelli, Assistenza Infermieristica Territoriale USL Toscana Centro & Scuola di Scienze della Salute, Facoltà di Medicina e Chirurgia, Corso di Laurea in Infermieristica, Università Firenze (Italia). E-mail: gabriele@relazioniesalute.it

 

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ABSTRACT

Introduzione: La fragilità dell’anziano è fisica e psichica e su di entrambe vi è influenza degli eventi stressanti della vita. Le paure che insorgono possono essere determinate da stereotipi che spesso egli tende ad accettare e che lo portano a ritenersi incapace fino ad un lento declino intellettuale. Questa ricerca ha l'obiettivo di approfondire le conoscenze sulle paure dell’anziano ricoverato e sperimentare la “presenza dell’infermiere” come possibile intervento.

Materiali e Metodi: All'interno di un Reparto “Cure Intermedie” è stata svolta una ricerca qualitativa con osservazione partecipante (studio osservazionale descrittivo tipo “serie di casi”). I dati raccolti sono stati analizzati attraverso il metodo l’analisi del contenuto.

Risultati: Dalle osservazioni di 13 pazienti (9 donne e 4 uomini; età media 71 anni), sono emersi principalmente contenuti positivi come “Gioia (47)”, “Attesa (35)” e “Offerta-ricordo (33)”. Il contenuto "Paura (16)” diversamente dalla bibliografia consultata è risultato presente ma non preponderante.

Discussione: Dall’analisi approfondita del materiale pare emergere che gli aspetti negativi comprendenti la “Paura” sono tra loro molto collegati ma il grosso nucleo di sofferenza viene destabilizzato dagli aspetti affettivi (speranza, aspettativa, amore) che arriva ad una prospettiva positiva (gioia, piacere, gratitudine). “Ascolto” e “disponibilità” sono stati i principali interventi attuati durante l’osservazione e coerentemente a quanto descritto in letteratura hanno permesso di registrare un impatto positivo sui pazienti. Un approfondimento è stato dedicato al concetto di “Offrire-dono” inteso come atto di riconoscimento attivo da parte del paziente verso l’operatore, con le sue implicazioni simboliche e psicologiche. Nell’analisi del materiale sono anche stati presi in considerazione aspetti legati alla psicologia positiva e allo “human caring”, come l’importanza e l’effetto del sorriso, della presenza fisica, dell’empatia nella condivisione e i risvolti nell’ambito di cura.

In base agli indicatori della Diagnosi Infermieristica di Paura di Lynda Juall Carpenito-Moyet, la valutazione iniziale durante la fase di accertamento degli stati di paura del paziente, permette un'assistenza basata anche sulla pratica dell'ascolto, competenza fondamentale dell'infermiere. Nei pazienti valutati si è assistito ad una riduzione dello stato di paura nelle osservazioni successive e nelle stesse, ipotizzando un effetto efficace della “presenza”.

 

Parole Chiave: anziano; paura; presenza; gratitudine; human caring.

 

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Fear in the Elderly

ABSTRACT

Introduction: Frailty in elderly is physical and psychological conditions which could negatively influence their life events. The fears that arise can be determined by stereotypes that the elderly often tend to accept and that lead them to consider themselves unable up to a slow intellectual decline. This research aims to deepen the description of the manifestations of fear in the elderly and “the presence of nurses” as a possible intervention.

Materials and Methods: A qualitative research with participant observation (descriptive study with case series) was carried out within an “Intermediate Care” Department. Data collected was analyzed using the content analysis method.

Results: From content analysis of the collected material, during the participatory observation of the 13 patients enrolled in this research (9 women and 4 men; mean age 71 years), mainly positive contents emerged: "Joy (47)", "Waiting (35)" and "Offer-memory (33)". The content "Fear (16)", unlike the bibliography consulted, was present but not preponderant.

Discussion: From the in-depth analysis of the material it seems to emerge that negative aspects including "Fear" are very closely linked but the large core of suffering is destabilized by the affective aspects (hope, expectation, love) that reaches a positive perspective (joy, pleasure, gratitude). "Listening" and "availability" were main interventions implemented during observation and consistently with what is described in the literature, they made it possible to record a positive impact on patients. An in-depth study was dedicated to the concept of "Offering-gift" understood as an act of active recognition by the patient towards the operator, with its symbolic and psychological implications. In the analysis of the material, aspects related to positive psychology and "human caring" were also taken into consideration, such as the importance and effect of smiling, physical presence, empathy in sharing and the implications in the area of care.

Based on the indicators of Lynda Juall Carpenito-Moyet's Nursing Diagnosis of Fear, the initial assessment during the assessment phase of the patient's states of fear, allows assistance based also on the practice of listening, a fundamental nursing competence. In the patients evaluated there was a reduction in the fear, in the subsequent observations and in the same, hypothesizing an effective effect of "presence".

Keywords: elderly; fear; presence; gratitude; human caring.

 

 

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INTRODUZIONE

“Uscendo dalla stanza ripenso alla sua risposta, al fatto di aver dichiarato di aver avuto paura e di averlo negato in un secondo momento quando gli è stato chiesto in maniera diretta.” (Paziente 3, osservazione 1)

“Saluto S. e lo ringrazio per le sue parole. Mi sento piccola davanti a tanta sofferenza che ha provato S. e che continua a provare. Credo che dovremmo amare la vita ed ogni singolo giorno perché purtroppo c’è chi ha avuto la sfortuna di avere meno di noi e che soffre in silenzio. Questa chiacchierata con S. mi ha lasciato un mix di emozioni, inizialmente un po' di distacco davanti ad una persona molto espansiva ed io molto più chiusa, poi interesse nelle sue parole, dispiacere, gioia allo stesso tempo nel vedere tanta vita in una persona che soffre così tanto. Incontrare persone con un grande bagaglio così, ci fa sentire tanto piccoli.” (Paziente 4, osservazione 1)

 

La dichiarazione e poi la negazione della paura da parte del paziente fanno pensare ad una sopraffazione della realtà. Molte volte avvertendo un sentimento forte, come la paura, è l’imbarazzo del proprio giudizio che può portare alla negazione.

Gli eventi negativi nella vita dell’anziano, come la presenza di malattie, morte del partner o dei familiari, povertà, rappresentano un peso sul piano dell’esperienza affettiva e sono inevitabili solitudine, dolore e paura della morte [1–3]. Le conseguenze a livello psicologico delle patologie che possono affliggere la persona anziana, diventano evidenti durante il ricovero nell’ambiente estraneo – ospedaliero [4]. Le capacità intellettuali subiscono dei cambiamenti nell’età senile le quali possono impedire di adattarsi velocemente a situazioni nuove [5]. Molte situazioni provocano sentimenti di paura e spesso tali sentimenti causano conseguenze negli esiti della cura delle patologie con le quali interagiscono [6], il sentimento di sicurezza è un aspetto che necessita di essere curato nell’assistenza [7,8].

Le persone anziane si avvicinano al concetto della paura di morire, data anche dalla presenza di patologie che tendono ad aumentare questo sentimento e spesso rimane difficile per loro affrontare questo argomento [9]. La paura è amplificata anche dall’ambiente ospedaliero, diverso rispetto a quello nel quale la persona solitamente vive, poiché nel nuovo ambiente mancano gli oggetti personali, tutti possono entrare senza bussare ed essa si sente privata della sua libertà. “Il trasferimento di abitazione è considerato un evento stressante a tutte le età e lo è a maggior ragione per i soggetti anziani” [1,4,10]. La comparsa della paura può influire sul benessere psicologico dell'intera persona. Molte volte l'anziano teme di essere inadeguato al contesto e l'operatore che lo percepisce, tende ad allontanarsi creando un distacco o sviluppando ostacoli per una buona relazione. Così facendo si creano degli ostacoli nella relazione che possono incidere sulla qualità dell'assistenza erogata [6].

 

Obiettivo dello studio

Lo scopo di questa ricerca è stato dunque di approfondire alcuni aspetti della paura nell’anziano e verificare se la “presenza” dell’infermiere è un intervento efficace a ridurre la sensazione di paura.

 

MATERIALI E METODI

Procedure

Lo studio è iniziato a fine settembre 2017 ed è durato un mese con una cadenza di due/tre sessioni di osservazioni a settimana. Le osservazioni sono state svolte da una studente di infermieristica dopo una preparazione di base alle relazioni di cura infermieristica [11] e sotto la supervisione di due infermieri esperti. Nella Figura 1 è riportata la successione cronologica delle fasi della ricerca. Su richiesta del personale sono state inserite nel campione di studio anche tre persone con età inferiore a 65 anni, identificati come portatori di “problemi relazionali”. I pazienti che hanno manifestato rifiuto alla partecipazione nello studio o alla firma del consenso dati sono stati esclusi dallo studio. Prima di iniziare la ricerca è stato richiesto e ottenuto il parere favorevole della “S.O.S. Etica e cura” della Azienda USL Toscana Centro (rilasciato in data 14.09.2017) e tutti i dati sono stati resi anonimi per garantire la privacy.

 

Nella seconda fase sono stati svolti due o tre incontri di osservazione partecipante dei pazienti: sono stati riportati su un diario anche gli indicatori relativi alla diagnosi di paura in collaborazione col personale di reparto. Ad ogni incontro l’osservatore entrava nella stanza dei pazienti selezionati, accompagnato da un operatore del reparto (oss / infermiere) o in modo autonomo; dopo la presentazione veniva spiegato il motivo della ricerca e chiesto la firma per il consenso. Successivamente l’osservatore si tratteneva nella stanza del paziente per compiere le osservazioni che venivano riportate su un diario per un periodo di osservazione di circa 30 minuti: in tale situazione di osservazione partecipe l’osservatore se interrogato o coinvolto dava il suo contributo per evitare una situazione asettica di osservazione. Nel limite del possibile sono state riportate frasi o parole che in seguito sono state sottoposte al processo di analisi; nei casi in cui la redazione delle osservazioni avrebbe compromesso la serenità del setting la trascrizione è avvenuto dopo il periodo di osservazione.

Nella terza fase è stata svolta l’analisi dei dati raccolti assegnando dei codici ad ogni frase o gesto espresso e/o manifestato dai pazienti. Dopo una razionalizzazione dei codici emersi, l’analisi è proseguita attraverso un raggruppamento dei codici tramite “categorie” e lo studio di tabelle e grafici [12].

 

Popolazione di studio

Lo studio condotto è stato rivolto alla popolazione anziana, ricoverata in strutture sanitarie. La ricerca è stata svolta su un campione di pazienti anziani (età media 71 anni) provenienti da reparti di medicina e ricoverati in una unità di “Cure intermedie”. L’inclusione dei pazienti nello studio è stata svolta da parte del personale infermieristico del reparto, sulla base di una diagnosi infermieristica di “Paura” [13] secondo una modalità di comodo compatibile con le attività istituzionali della struttura ospitante. Nella ricerca sono stati inclusi 13 pazienti, 9 donne e 4 uomini con età superiore o uguale ai 65 anni, con l’eccezione di 3 pazienti che hanno costituito un nucleo di confronto sui dati rilevati (considerando il gruppo di confronto, il gruppo di ricerca ha avuto un’età media di 75 anni). Tutti i pazienti che sono inclusi in questo studio avevano letto, capito e firmato il consenso informato, per coloro che non erano in grado è stato fatto riferimento ai rispettivi caregiver; tutti i dati sono stati resi anonimi; per la partecipazione allo studio non sono stati distribuiti incentivi.

 

Criteri di inclusione

• età uguale o superiore ai 65 anni;
• Comprensione e firma del consenso informato.
• Un eventuale stato di confusione è stato considerato inseparabile dalla situazione complessa correlata alla paura (per le persone in stato di confusione è stato richiesto il consenso ai propri caregiver).

 

Criteri di esclusione

• Volontà a non voler partecipare allo studio.
• Impossibilità di far comprendere all’assistito o ai familiari i motivi dello studio.

 

Strumenti

Per esplorare gli aspetti legati alla paura è stata ideata una ricerca-intervento [14], basata su osservazione partecipante. La rilevazione dei dati è avvenuta attraverso un diario nel quale sono stati descritti gli incontri con frasi dette dai pazienti, dall’osservatore, dai familiari, dagli operatori, anche decifrando le espressioni sul volto dei pazienti stessi. Il report delle osservazioni e interazioni ha costituito il testo base su cui sono state svolte le analisi.

Per la valutazione del livello di paura invece è stata effettuata attraverso le caratteristiche definenti la diagnosi infermieristica di “Paura” [13] e l’attribuzione di un punteggio (0-nessuna, 1-lieve, 2-moderata o 3-elevata). Con la collaborazione del personale di reparto è stato riportato lo stato del paziente rispetto al primo incontro (vedere Tabella 1).

La modalità di osservazione, che prevedeva una disponibilità al colloquio durante i momenti di osservazione sul campo ha reso sicuramente meno obiettiva l’osservazione ma è stata scelta per rendere l’ambiente maggiormente confidenziale e garantire l’agiatezza ai partecipanti.

 

Analisi qualitativa

La prospettiva teoria considerata alla base dell’analisi svolta si ispira al modello di “grounded theory” [15]; l’analisi sul testo prodotto attraverso i diari delle osservazioni è stata una analisi del contenuto quantitativa [12]. Per l’analisi qualitativa è stata utilizzata una Analisi Qualitativa Computer Assistita (CAQDAS - computer assisted qualitative data analysis software) tramite “R” (16) ed in particolare il modulo “RQDA” [17]. I dati sono presentati tramite una condensazione in tabella e una rappresentazione tramite diagramma network (basato sulla teoria dei grafi). L’analisi qualitativa non si è posta l’obiettivo della completa saturazione dei dati a favore di una maggiore realizzabilità in tempi relativamente brevi della ricerca, comprendendo che una semplificazione del genere non orienta verso dati certi ma almeno la dichiarazione di dati fondati, sui quali confrontare alcuni aspetti dell’assistenza (in particolare l’effetto della presenza).

 

RISULTATI

Nella tabella 1 sono riportate le caratteristiche del campione analizzato: 9 partecipanti di sesso femminile e 4 di sesso maschile; l’età media del campione è stata 71 anni. Sono state svolte 3 sessioni di osservazione per 2 partecipanti, 2 sessioni per 5 partecipanti e una unica sessione per i rimanenti 6 partecipanti. Nella stessa tabella è riportata la riduzione dello stato di paura avvenuto in 6 casi, ovvero il suo mantenimento in altri 6 casi (di cui 2 risultavano già al grado minimo quando è stata svolta l’osservazione) e l’unico caso in cui si è assistito ad una comparsa dove era assente. 

Nella Tabella 2 e nella Figura 2 sono riportati codici e frequenze. “Gioia-felicità” è il codice che appare più volte rispetto a tutti gli altri (47 volte). Seguono: “Attesa” (35 volte), “Offerta-ricordo” (33 volte), “Preoccupazione” (29 volte), “Gratitudine” (23 volte). Il codice “Paura” compare solo 16 volte.

 

Nella Figura 3 può essere osservato il diagramma network risultato dall’analisi del materiale raccolto. In minuscolo vengono riportati i codici attribuiti durante l’analisi, in maiuscolo le “categorie”, costruzioni dotate di maggiore astrazione.

Figura 3. Diagramma network. Relazioni tra codici e categorie (riportate in maiuscolo).

La parte centrale del grafico riporta i codici con molte interazioni quindi più coinvolti nell’oggetto di studio; possono essere notati codici quali: “Offerta-ricordo”, “Fragilità(indifeso)”, “Supporto”, “Attesa”, “Desiderio”, “Cambiamento”, “Patologia”, “Salute”, “Consapevolezza”.

Il grafico è una chiara illustrazione del conflitto paura-stati-correlati versus speranza-amore-piacere, i costrutti sui quali agisce sono in rapporto maggiormente con “Patologia – salute”, “Igiene”, “procedure”, “Fragilità(indifeso)”, “offerta ricordo”, “Comunicazione”, “desideri” e “Affetto”.

 

Ulteriori temi emersi

Oltre a quelli riportati nella descrizione del diagramma, alcuni temi hanno richiamato una particolare attenzione e sono stati particolarmente stimolanti durante l’analisi del materiale.

 

Dono e Gratitudine

Questo tema ha messo in luce che pensare la cura come qualcosa che dal sanitario va verso il paziente ha un carattere limitato.

«Vuoi un budino?» Colpisce la semplicità del gesto: dovremmo essere noi a “dare” assistenza al paziente e invece è lei ad “offrire” qualcosa. (Paziente 06, osservazione 1)

«Sì, ho letto altre pagine, poco per volta. Poi te lo passo e lo leggi anche te!» (Paziente 09, osservazione 2)

Nella parte centrale del Grafico Network (Figura 3), emerge come centrale il codice “Offerta-ricordo”. Durante le sessioni di osservazione in quasi tutti i pazienti è emersa l’azione di offrire qualcosa: budini, caramelle, poesie, ricordi.

 

Paura

“Era la morte all’inizio la mia più grande paura...” (Paziente 13, osservazione 2)

Le emozioni sono strettamente correlate all’ambiente circostante o a quello che è interno alla persona. James dichiara che l’uomo non scappa perché ha paura, ma perché si accorge di averla ed ha già messo in atto il tentativo di fuga [1].

Alcune emozioni mostrano una connessione con paura (Figura 3): sfiducia per la paura dell’abbandono, rabbia per paura di non essere considerato, pregiudizio per paura del confronto, impotenza per la paura di fare, giudizio per paura dell’altro, senso di colpa per paura di aver sbagliato. Infelicità, tristezza e dolore richiamano emozioni negative che possono sovrapporsi con la paura. Tale vicinanza di concetti richiama anche il costrutto di “sindrome migratoria”, che si manifesta quando una persona si trova in un ambiente di vita estraneo [4]. Così potrebbe essere interpretata la sovrapposizione dei concetti negativi osservabile nel Diagramma Network (Figura 3). La paura di non essere amati risale alle cure parentali insieme alle quali veniva trasmesso l’amore. “Amore” è una categoria della parte positiva del Diagramma Network (si veda Figura 3).

 

Depersonalizzazione

“Ho durato fatica ad accettarlo, lì per lì ho sdrammatizzato con una delle mie solite battute, poi una volta da solo, ci ho riflettuto … non mi riconoscevo più all’inizio … è stata dura da digerire” (Paziente 4, osservazione 1).

La depersonalizzazione si caratterizza dal fatto che il paziente non si sente più la stessa persona che era prima del ricovero.

 

Contatto

In molte occasioni l’aspetto fisico è risultato centrale, una comunicazione oltre le parole.

“Le accarezzo la mano, mi sorride, le sorrido. Rimaniamo per un po' in silenzio” (Paziente 7, osservazione 2)

“Grazie tesoro, vieni qua, dammi la mano” è stato sufficiente stringere loro la mano, sorridendo in silenzio. Quella stretta ha permesso di comunicare oltre alle parole, l’emozione della “presenza”. (Paziente 14, osservazione 2)

 

Speranza

Dall’analisi dei dati emerge una categoria centrale nella parte positiva del Diagramma Network (Figura 3), la “Speranza”. Essa è correlata a ottimismo, in quanto si presenta come l’attesa di un esito gradito o al contrario come rimozione di un esito sgradito riguardo un evento futuro [5].

 

Emozioni Positive

“Mi ripete più volte che sta aspettando la nuora e non sa se avvertire il figlio che si è sentita male ma mi dice «non voglio dargli pensiero»” (Paziente 7, osservazione 1-Stato di paura: 3-elevato)

“Chiude nuovamente gli occhi e noto che respira a bocca aperta, le sue mani sono meno tese e la respirazione è meno accelerata rispetto a prima, forse inizia a rilassarsi un pò” (Paziente 7, osservazione 1-Stato di paura: 1-lieve) […] “Lei guarda davanti a sé in maniera fissa con la bocca leggermente aperta. E' tranquilla, ha una respirazione normale rispetto all'altro giorno” […] “Chiude gli occhi come se si stesse addormentando. Le braccia sempre distese lungo i fianchi, il respiro più profondo e lento. Dorme.”  (Paziente 7, osservazione 2-Stato paura: 1-lieve)

Il codice più frequente è stato Gioia-felicità (47 volte). Attesa (N=35), Offerta-ricordo (N=33), Preoccupazione (N=29) e Gratitudine (N=23) sono termini che si evidenziano con maggior frequenza (Tabella 2).

 

Identificazione ed Empatia

"Sono stata con lei più del previsto, un po' perché ho dato modo alla nipote di stare con lei, un po' perché era piacevole parlare della sua vita, dei suoi ricordi, decido di salutarla per dare spazio anche ad un altro paziente. Sono contenta di questo incontro, di essere entrata in sintonia con lei, il fatto che mi abbia chiamata con un soprannome, credo che ciò sia positivo.” (Paziente 1, osservazione 1)

“Sono stati 20 minuti passati molto velocemente e mi ha fatto piacere aver rivisto R., mi interessa ascoltarla e sono contenta dei progressi che ha fatto in questi giorni. R. ha tanto bisogno di avere qualcuno vicino col quale poter parlare.” (Paziente 1, osservazione 2)

“Sono contenta di aver passato tre giorni con R., di averla ascoltata, delle belle parole ricevute. Nonostante come da lei riferito, qui in reparto abbia trovato dei bravi operatori, lontani dalla famiglia avvertiamo sempre qualcosa che ci manca; sono contenta che R. ritorni a casa con la figlia.” (Paziente 1, osservazione 3)

Durante le interviste si sono manifestate nell’osservatore emozioni, soprattutto legate alla gioia, ma anche di tristezza e di nostalgia alle quali si è sentito il bisogno di rispondere con un sorriso. Il sorriso è risultato essere fondamentale per entrare in sintonia con l’altra persona, guardarla negli occhi per cercare di lasciare un ricordo piacevole. Al “sorriso” la paziente rispondeva con un ulteriore sorriso che ha alimentato una spirale positiva.

 

DISCUSSIONE

Il ricovero sembra effettivamente costituire un evento che mette a rischio l’equilibrio della persona anziana, costituisce quindi, di per sé, una causa di paura:

“Mi dice di continuo di non farcela più e piange” (Paziente 10, osservazione 1)

“Ho tanta paura … non ne posso più ...” (Paziente 12, osservazione 1)

 

Naturalmente la paura della morte è una delle più importanti anche se nel materiale raccolto non sembra essere l’unica; altre paure espresse riguardavano: perdere un arto, di sentirsi male e fare male ad altri, di essere a carico familiare, l’incertezza, di non essere più la solita persona, l'ambiente ospedaliero, gli operatori e le loro divise, le procedure di routine, di essere truffata. Tutte paure connesse con lo stato di fragilità.

Il modello espresso dal diagramma network (Figura 3), condensato del lavoro di ricerca svolto, mostra una struttura che vede da un lato la paura collegata ad altri concetti quasi del tutto sovrapponibili dal punto di vista delle connessioni (sconforto, dispiacere, vergogna, tristezza, rinuncia e agitazione) come a formare un costrutto che sembra richiamare la “sindrome migratoria” [4]; dall’altro lato le reazioni di speranza, aspettativa che arrivano fino ad amore e piacere. Le reazioni che hanno sorpreso maggiormente e attratto l’attenzione dei ricercatori sono state appunto quelle relative al piacere, uno stato d’animo sicuramente inatteso, soprattutto perché la selezione dei pazienti è avvenuta sulla base della diagnosi di paura. La sindrome migratoria accennata può facilmente trovare spiegazione nella situazione “estranea” rappresentata dall’ambiente ospedaliero, ma per la parte orientata alla salute (fino al piacere) sembra necessario il ricorso ad una teoria infermieristica che permetta di includere la crescita personale del paziente all’interno degli obiettivi di cura, intendendo l’assistenza infermieristica come strumento per lo sviluppo e il benessere [18,19] e non solo come mezzo assistenziale di supporto. La funzione della assistenza infermieristica in questo senso è quella di “contenere” sia le categorie collegate alla paura sia quelle collegate alla speranza tramite aspetti tipici della professione quali patologia-salute, igiene, procedure.

Partendo dalla rilevazione della maggiore frequenza riscontrata dai codici gioia-felicità, attesa e offerta-ricordo, che riflettono un clima sorprendentemente positivo, i contenuti riportati sotto il codice offerta-ricordo costringono, anche per la loro posizione di centralità nel modello, ad una riflessione. Una possibile spiegazione che è stata posta riguardo a tale risultato di emotività positiva è in relazione con lo “stile” utilizzato per la ricerca: l’intervistatore-osservatore ha svolto delle osservazioni utilizzando una modalità improntata alla gentilezza [19], all’ascolto non direttivo [20] e non in modo asettico (non interagire avrebbe introdotto una variabile “spersonalizzante”).

La diagnosi di “paura” si è ridotta in tutte le diagnosi di paura media / alta e rimasta stabile nei casi lievi / assente (Tabella 1). Solo in un caso è aumentata da assente a lieve durante l’osservazione. La sintesi è che nel campione osservato prevalgono sentimenti di gioia, attesa e la volontà di offrire qualcosa all’operatore, mentre paura compare solo al decimo posto in ordine di frequenza, almeno questo è accaduto nell’ambiente di osservazione attenta realizzato dal dispositivo della ricerca-intervento [14] attuata. Il tema del dono ha portato il coinvolgimento al centro dell’attenzione: accettare o rifiutare? Ovviamente accettare o rifiutare si estende dal dono al paziente e in questo ambito anche un gentile rifiuto costituisce comunque un rifiuto, ma accettare significa diventare “debitori” verso il paziente: il dono è un elemento fondamentale per la nascita dei rapporti sociali e delle comunità umane, in quanto esprime la volontà degli uomini di “creare relazioni”, le quali hanno come conseguenza l'obbligo della restituzione [21]: ad anche l’operatore che si ferma al letto di un paziente per ascoltarlo, gli “dona” il suo tempo e non lo fa in modo gratuito poiché in un certo senso spera di avere in cambio, come restituzione del suo ascolto, un appagamento personale per aver fatto confidare e liberare il paziente dalle preoccupazioni che lo turbavano [22]. Il ricevente si sente obbligato a restituire qualcosa che ha ricevuto.

“Mi ha fatto piacere conoscerti, ti ringrazio tanto tanto!” (Paziente 13, osservazione 2) la frase del paziente, in questo caso, ha trasmesso all’osservatore il senso di gratitudine per l’ascolto che le era stato dedicato.

Donando e ricevendo si innesca una spirale di riconoscenza e in effetti la maggior parte dei pazienti del presente studio ha manifestato la gratitudine.

«Grazie tesoro, vieni qua, dammi la mano!» (Paziente 14, osservazione 2)

«Grazie...», Mi prende la mano e la stringe portandola verso la sua guancia... (Paziente 13, osservazione 2)

In questa frase è possibile notare la manifestazione di emozioni controverse: gratitudine verso chi dona, ma anche imbarazzo poiché a questo punto la persona è debitrice nei suoi confronti, si crea dunque uno squilibrio, uno stato di debito, definito da Hochschild “economia della gratitudine” nella quale ogni ricevente è grato al donatore [9].

“Mi avvicino, l’abbraccio e piange” (Paziente 13, osservazione 2)

E’ proprio dalla gratitudine verso il dono ricevuto che può scaturire il pianto nel momento degli abbracci e dei saluti [23]. A proposito di “Gratitudine”, Esopo riteneva: “la gratitudine come segno di anime nobili”, mentre per Cicerone serviva per mantenere l’amicizia ed una giusta società, per Adam Smith rappresenta una delle emozioni di base nella società [22]. Secondo Klein la gratitudine nasce nell'infanzia [1,24], già nei primi scambi relazionali madre-bambino attraverso l’allattamento al seno. Se quest’ultimo viene sottoposto a frustrazioni, proietta sul seno della madre degli impulsi aggressivi e sarà più difficile provare gioia e gratitudine: frustrazione, gioia e gratitudine sono temi sicuramente presenti nei luoghi di degenza. Determinati atti di gratitudine sono in grado di trasmettere a chi li riceve la capacità di offrirne a sua volta, poiché la presenza di feedback positivi da parte di chi riceve, come un abbraccio, un sorriso, permette di rinforzare le motivazioni del donatore. Durante l’osservazione si è creata una spirale di “gentilezza amorevole” [19]: è possibile fare l’ipotesi che questa sia responsabile dei contenuti di gioia, molto frequenti, che sono stati rilevati.

Naturalmente le osservazioni di fenomeni ansiosi e di sofferenza non sono state poche: il codice preoccupazione al 4° posto, delusione-tristezza al 7°, stanchezza 8°, dolore al 9° e paura al 10° (Tabella 2) ne danno piena testimonianza.

La persona sofferente, tende a fuggire:

“Mi dice di continuo di non farcela più e piange” (Paziente 10, osservazione 1)

Ascoltare la persona che soffre, si è dimostrato un intervento utile ad alleviare il suo dolore.

“Dice di non sapere, poi si convince a parlare. Dal colloquio è emersa tutta la sua sofferenza, una sofferenza che, in un primo momento, era stata mascherata […] è bastato sedersi vicino, ed essa si è liberata di un peso che si portava dentro da molto tempo: una serie di lutti di persone a lei care, il marito, la figlia, si sente sola e trova difficoltà nel pensare al futuro, poiché ha dubbi sulla sua guarigione. «è dura […] sono sola»; mi dice di continuo di non farcela più e piange. Agli operatori si era presentata come la più sorridente del reparto (Paziente 10, osservazione 1. Scala paura iniziale = 3, post intervento = 2).

“I drammi più commoventi e più strani non si svolgono a teatro, ma nel cuore di uomini e donne comuni. Questi vivono senza attirare l’attenzione e non tradiscono minimamente i conflitti che imperversano nel loro animo” [25].

Secondo Nhat Hanh, lo scopo della pratica dell’ascolto compassionevole consiste nel permettere alla persona di esprimersi, senza interromperlo o correggerlo, diminuendo così il suo dolore [26].

 

“Ma, tornerò a casa?” (Paziente 10, osservazione 1)

Il dolore a volte accresce per paura dell’ignoto, ma l’uomo finge di stare bene perché non ama provare solitudine, rabbia o paura. Spesso sono i forti desideri che egli ha ad ostacolare la sua felicità, permettendo così alle emozioni negative di accumularsi. Quando una persona è malata, essa desidera che sia fatto qualcosa per lei e la sensazione di essere curata aumenta le aspettative di guarigione riducendo ansia e depressione connesse all’essere malati [27]. Molte volte viene applicato l’effetto placebo per diminuire uno stato di dolore, di ansia, ma anche la capacità di trasformare la sofferenza in emozioni positive è di grande aiuto.

La guarigione non è solo un placebo, essa condensa l’effetto dell’ambiente, della fiducia e della cura, gli “atti sacri infermieristici”, un contatto profondo dell’essere che avviene alla presenza di un infermiere, supporto e testimone [8,19].

Senza la sofferenza non ci sarebbe la felicità; se la persona è in grado di riconoscere il dolore, allora sarà in grado di riconoscere anche la gioia. La sofferenza del corpo è determinata dal dolore, dalla fame, dalla malattia e dalle lesioni fisiche, invece il tormento della mente è caratterizzato dalla presenza di ansia, gelosia, disperazione, paura e rabbia [26]. Possono coesistere entrambi i due tipi di sofferenza provocando tensione e stress ed è grazie alla consapevolezza che l’uomo è in grado di riconoscerla: «Appena apriamo la bocca per dire sofferenza, sappiamo che nello stesso momento è già presente anche l’opposto della sofferenza. Dove c’è sofferenza, c’è felicità» [28].

“Inspirando, so che la sofferenza è presente. Espirando, saluto la mia sofferenza” [26], un paziente agitato, per essere calmato, viene invitato a respirare lentamente e pian piano il suo turbamento, la sua sofferenza in quel momento si placa lentamente.

L’atteggiamento positivo è sempre benefico e per superare la paura è necessario informarsi sulla malattia, ottimismo e speranza inoltre possono essere trasmesse al paziente dalle persone che lo circondano. “L’ottimismo è la fede che porta al risultato. Senza speranza né fiducia, non si può fare niente.” (Helen Keller), fattori fondamentali per la guarigione e la sopravvivenza del paziente, che non possono essere misurati scientificamente, ma nemmeno ignorati [29], “l’ottimismo sembra avere effetti positivi sulla salute anche in situazioni particolarmente delicate” [30].

“Anche se nella stanza c’è il buio, tu mi porti la luce col tuo sorriso” (Paziente 1, osservazione 3)

“Proprio una bella persona, complimenti per il sorriso” (Paziente 4, osservazione 1)

In queste frasi comuni, troppo poco considerate, si manifestano le indicazioni per comportamenti che il paziente sente di accudimento.

 

Se la persona pensa di non essere amata abbastanza, è esposta maggiormente alla paura della mancanza di amore. “Il riso, è in alcuni casi, una risorsa vitale che cura, previene, riabilita, educa e libera dalla paura restituendoci una consapevolezza più ampia della nostra esistenza” [23] oltre ad avere documentati effetti terapeutici [31].

In ultimo, si vogliono riportare gli aspetti emotivi di coinvolgimento che seguendo le prospettive teoriche legate alla presenza autentica [19] rappresentano un importante fattore curativo:

 

“Anche se ripete le solite cose, mi fa piacere stare con lei, provo tanta tenerezza ad ascoltarla. Quei capelli grigi e bianchi sono il segno del tempo che passa, così come la sua memoria è segno del tempo che scorre.” (Paziente 9, osservazione 1)

La tristezza spesso sembra essere l’aspetto più intenso nella comunicazione del paziente, il perdere le cose importanti e dare importanza a cose inutili che spinge a riflettere sulle cose veramente importanti della vita: il grande tema del significato. Ascoltare, anche il silenzio, ha fatto emergere emozioni e riflessioni che potrebbero essere utili alla crescita di ogni operatore.

 

“Rimango commossa uscendo dalla stanza. È incredibile come un piccolo gesto, una piccola parola di conforto possa far sentire meno sola una persona. È brutto pensare a quanta solitudine e sofferenza possano esistere in una persona.” (Paziente 10, osservazione 1)

“Mi sono sentita in imbarazzo a sentire parlare così suo figlio...mi viene da pensare che quell’inizio di depressione, forse non sia dovuto soltanto alle patologie della signora N., ma anche ad un suo stato emotivo determinato dalle circostanze nelle quali si ritrova. Sono rimasta un po' turbata da questa scena...magari è soltanto un’impressione, ma sembra che N. dipenda molto dal figlio, non tanto per spostarsi dal letto alla sedia, bensì nelle parole.” (Paziente 13, osservazione 1)

Tenerezza, senso di protezione che diventa rabbia per la ridotta considerazione nel paziente hanno caratterizzato molti momenti dell’osservazione. La tenerezza, legata allo stato di fragilità ha anche sostenuto la gran parte degli interventi di ascolto e presenza-vicinanza che sono stati attuati durante l’osservazione.

 

Conclusioni

Le paure che insorgono nell'anziano possono essere determinate da stereotipi come ad esempio che esso diventi dipendente da un'altra persona. Questi pregiudizi possono portare la persona anziana a ritenersi inutile, malato, priva d’idee e di interessi. A volte gli anziani tendono ad accettare questi stereotipi negativi che li portano a ritenersi incapaci fino ad un lento declino intellettuale. Per invecchiare bene è necessario seguire una buona alimentazione ed esercizio fisico, ma è fondamentale anche mantenere delle relazioni sociali basate su amicizia ed amore per evitare la comparsa di solitudine.

La domanda di ricerca iniziale si proponeva di individuare se l’infermiere durante la fase di accertamento, individuando la paura nell’anziano, può aiutarlo a superarla appena si manifesta; se la “presenza” in particolare potesse essere un intervento efficace a garantire un buon percorso di assistenza. La “presenza” è un fattore di cura capace di produrre cambiamenti di per sé. Le categorie SPERANZA, AMORE, PIACERE, sono risultate l’antidoto.

Differentemente da quanto atteso, in questo studio, il codice paura non è risultato frequente quanto ipotizzato, ma è addirittura stato superato dal codice gioia-felicità. Sulla base dei dati raccolti e delle riflessioni presentate nel capitolo precedente è possibile ipotizzare che per una parte sia stata proprio la sua presenza dell’osservatore, come figura esterna al reparto nel quale si è presentato senza indossare la divisa, proprio per evitare un distacco col paziente dato dalla “paura del camice bianco” e che, per la parte partecipe, si è coinvolto emotivamente e deliberatamente nelle relazioni con i pazienti. Relativamente agli interventi, quelli codificati come modalità di osservazione partecipe, cioè ascolto attento, riformulazione, presenza emotiva espressa anche con gesti di contatto fisico, così come descritti dalla letteratura consultata, si sono dimostrati utili e coerenti con la riduzione della sensazione di paura o di preoccupazione. Come affiora dall’analisi dei dati nella popolazione osservata, sono presenti aspetti negativi quali paure e preoccupazioni, ma la relazione efficace di ascolto ha permesso ai pazienti di far emergere maggiormente le loro emozioni positive, poiché è stato permesso loro di esprimersi, senza interruzioni o correzioni, diminuendo così le loro ansie.

Rispetto agli indicatori forniti dalla diagnosi infermieristica di “paura”, l’osservazione partecipe, utilizzando le tecniche descritte è risultata efficace nella riduzione della paura in tutti i pazienti gli stati iniziali nei quali era presente anche una minima paura, quest’ultima è migliorata con , con diagnosi di paura media o alta, senza effetto nei casi di paura lieve o assente e solo in un caso ha registrato il passaggio da assente a lieve.

Anche l’atteggiamento ottimistico è stato preso in considerazione come strumento terapeutico: “Essere ottimisti non vuol dire essere rassegnati o negare che esistano le malattie, ma ricercare e inseguire il lato buono di tutte le situazioni convinti che esiste”, per affrontare meglio l’età senile, l’accettazione di quest’ultima, non deve arrestare la vita della persona, ma bensì indirizzarla verso nuove aspettative [32].

 

Tipi Di Paure

Benché non rientrasse negli scopi di questa ricerca l’esplorazione dei differenti tipi di paura manifestati dai partecipanti durante l’osservazione, le paure più frequentemente espresse riguardavano: la paura di perdere un arto, di sentirsi male e fare male ad altri, “di essere a carico familiare … di avere un futuro incerto, paura di non essere più la solita persona”, “dall’ambiente ospedaliero, dagli operatori e le loro divise, dalle procedure di routine”, di non trovare più lavoro, di morire, di essere stata truffata. L’alterazione del concetto di sé, l’ambiente ospedaliero, la perdita di autonomia, sembrano le diagnosi infermieristiche [4] che si correlano maggiormente con l’esperienza di paura dei pazienti osservati.

 

Human Caring E Relazione D’aiuto

Per la spiegazione degli effetti registrati di riduzione della paura, ma anche di sviluppo di un senso di piacere all’interno dell’esperienza di ricovero, è stato necessario ricorrere ad una teoria infermieristica che consideri la possibilità di facilitare ed attivare il processo di guarigione attraverso la “presenza”: «spostare l’attenzione dalla malattia, dalla diagnosi e dal trattamento al prendersi cura umano, alla guarigione e alla promozione della salute spirituale potenzia la salute stessa, la guarigione e la trascendenza (…). La relazione umana transpersonale ha una dimensione spirituale... che può sfociare nella guarigione». La presa in carico della persona rappresenta un momento delicato, fatto di amore e di una visione globale dell’esistenza umana. Infermiere e paziente determinano insieme la relazione scegliendo quale uso fare di quel momento nel tempo e nello spazio. Il modo in cui l’infermiere si relaziona avrà un impatto significativo sulle opportunità immediate e sui risultati finali [11,19,29]. SPERANZA, PRESENZA e GRATITUDINE sono i contenuti emersi in opposizione a PAURA, nelle sue varie forme.

 

LIMITI DELLO STUDIO

Questa ricerca qualitativa è basata sull’osservazione partecipante di un gruppo ristretto di pazienti, 13 in tutto, ricoverati nel Reparto Cure Intermedie, nei quali il metodo applicato è risultato efficace nella riduzione dell’intensità del livello di paura (Tabella 1), ma non vi è la certezza che esso sia applicabile a tutta la popolazione. Soprattutto non è stato possibile raggiungere la saturazione delle osservazioni, proseguendo l’attività di ricerca, le definizioni delle categorie in particolare avrebbero necessitato di ulteriori osservazioni per verificarne la saturazione. Un limite è dato dal fatto che non è stato possibile seguire tutti i pazienti più di una volta, poiché spesso la dimissione avveniva prima del tempo previsto. Un altro limite è dato dalla difficoltà di reperire l’argomento paura, nella produzione scientifica a fronte della facilità di reperimento nella bibliografia umanistica ed esistenziale: la maggior parte degli studi riporta la “paura di cadere”, la “paura di morire” o la “paura nel bambino”; minori quelli sugli aspetti esistenziali della paura o di un senso di paura diffuso nell’esperienza di ricovero dell’anziano.

Una limitazione non prevista è stata creata dal non aver misurato in modo preventivo tutte le emozioni ma solo l’intensità della paura perché non previsto dall’ipotesi iniziale: mentre la presenza e la prevalenza sugli altri costrutti è emersa dall’analisi del contenuto delle frasi raccolte, l’aumento di gioia-felicità è stato inferito sulla base dei resoconti del ricercatore.

 

Analisi riflessiva

Questa ricerca testimonia il valore della tecnica dell’osservazione partecipe, tramite l’ascolto attento, la riformulazione e la presenza emotiva per ridurre la sensazione di paura o di preoccupazione e tramite la relazione efficace di ascolto, per permettere ai pazienti di far emergere maggiormente le loro emozioni positive. Anche la variabile legata al colore delle divise potrebbe essere oggetto di sperimentazione per valutare se possa contribuire ad un miglioramento dell’umore anche nelle persone anziane [33]. Le competenze ontologiche, nella. Parte relazionale dell’assistenza, sono state il fondamento dell’approccio utilizzato con i pazienti [19].

Un approfondimento dello studio potrebbe essere svolto sull’effetto della divisa (o di una divisa colorata) sulla risposta emotiva che si otterrebbe dai pazienti. L’osservatore avrebbe inoltre cercato di accettare maggiormente ed approfondire gli “Offerta-dono” materiali dei pazienti.

“Apprensione, incertezza, attesa, aspettative, paura delle novità, fanno a un paziente più male di ogni fatica”. (Florence Nightingale)

 

EVENTUALI FINANZIAMENTI

Questa ricerca non ha ricevuto nessuna forma di finanziamento

 

CONFLITTI DI INTERESSE

Gli autori dichiarano che non hanno conflitti di interesse associati a questo studio

 

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by OPI Napoli