of student nurses about Post. Exposure Prophylaxis(PEP)in HIV and. AIDS prevention. T. J. Katsinde. Department of Social Sciences. Bindura University. And.
Knowledge, attitudes and practices of student nurses about Post Exposure Prophylaxis(PEP)in HIV and AIDS prevention T. J. Katsinde Department of Social Sciences Bindura University
And D. Katsande Bindura School of Nursing
Introduction
• • • •
Efforts to prevent HIV infection have mainly focused on pre-infection and hence the use of methods such as: abstinence, condoms, The methods aim to prevent HIV infection. There is a method which is used to prevent infection after exposure.
Introduction cont. •The method is Post-exposure prophylaxis (PEP). •In Zimbabwe it was introduced in 2006. •In other countries it started to be used in the 1990s.
Introduction Cont. • The method was introduced mainly for health workers who are exposed to possible HIV infection at their work places. • PEP originally meant for occupational protection but extended to non-occupational situations such as sexual assault, drug users or consensual sexual exposure.
Definitions • Exposure- has been unprotected to HIV infection • Prophylaxis- a form of treatment or medication • So PEP is a form of treatment or medication that is given to those who have already been exposed to HIV which must been taken within a prescribed time after exposure.
Definitions cont. • SAFAIDS cited by Sachiti (2010) defines PEP as a short term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or sexual exposure. • Thus in this case the exposure is occupation or work related as student nurses work with patients in the wards who may be infected.
Definitions cont. • World Health Organisation(WHO) (2007) defines PEP as a medical response given to prevent transmission of blood-borne pathogens following a potential exposure to HIV. • It should be noted that it is not only health workers who are exposed at work but also rescue workers, waste-disposal, law-enforcement or fire fighters as they may come into contact with blood as they work.
Definitions cont. • Knowledge- refers to what students know about PEP. In this case we wanted to find to find whether they know transmission sources, components of PEP, work-related risks. • Attitudes- student nurses’ feelings about PEP • Practices- find out whether student nurses actually implement PEP.
PEP Guidelines • Wash exposed area thoroughly with soap under running water. • Report the injury to a senior member of staff or supervisor immediately. • Start ARV drugs for HIV PEP as recommended within one hour, if possible, or latest within 72 hours of exposure. • Ascertain the HIV status of the client and injured health worker following counseling of both individuals.
PEP Guidelines cont. • HIV test results determine whether the exposed health worker should continue with PEP drugs. Only those exposed who are found to be HIV negative on baseline and the source positive should continue with ARVS for PEP for 28 days. • Individuals have a right to defer or refuse HIV testing. • If it is rape and it is not possible to get perpetrator’s HIV status consider it positive and follow as above.
Importance of the study • Studies in Zimbabwe, done so far, about PEP have focused on all health workers but this study is specific on student nurses who do most of the work in the wards that exposes them to infection. • For example student nurses conduct procedures such as infusion care, injection administrations, changing soiled linen or dressing patients. • Sometimes they do these procedures without due care or without adequate protection.
Importance cont. • There has been a decline in the number of student nurses who requested for PEP at the provincial hospital: • 2006: 3.7%; 2007: 2.4% and 2008: 1.2%. • The question was why this decline? • For the government of Zimbabwe the study is important so that it knows whether its policy on PEP for health workers is being implemented.
Related literature • Not many studies in Zimbabwe on PEP. Studies by WHO(2006) and MOHCW(2007) showed that health workers had poor knowledge about PEP and how to access it. • The studies also show health workers underreported needle stick injuries because of lack of confidentiality, they felt PEP was ineffective and fear of knowing their HIV status.
Related literature cont. • In other countries a study by Fan, Conner and Villareal (1994) showed that the majority of health workers were able to narrate first aid steps following needle stick injury. • Pratt(2003) showed that health workers practised universal precaution at work using protective clothing. • Muralidhar and others (2010) found out that 40% of health workers at a hospital knew about PEP.
Literature cont. • On how effective PEP is to prevent HIV, WHO(2007) says studies are limited but some evidence supports that a short course of antiretroviral effectively reduces HIV transmission rates following needle stick exposure. • But failures have also been recorded, so not 100 % effective.
Research questions The study aimed to answer the following questions: • How do student nurses learn about PEP in HIV and AIDS prevention? • What is the attitude of student nurses towards PEP? • What are the practices of student nurses about PEP in HIV and AIDS prevention if exposed?
Research methodology Study type and location • This was a descriptive study carried out at a provincial hospital which trains state registered nurses. • The hospital is situated about ninety km from Harare and is referral hospital for other health institutions in the province.
Methodology cont. Population and sample • The target population were student nurses who were in their second and third years who had been to the clinical area. • The first years were excluded because they had not been to the clinical area. • The number of students were 41, made up of 24 second year and 17 third year students. • A sample of 30 respondents (73%) was randomly chosen, made up 18 second year students and 12 third year students. • The sample was made up of 26 female and 4 male students.
Population and sample cont. • Most of the respondents (93.3%) were in the age range of between 21 and 32. • Sixty percent (60%) of them were single, while 33.3% were married.
Methodology cont. Instruments • A questionnaire was the main instrument used to collect data. • The questionnaire was made up of 4 sections: bio-data, knowledge, attitudes and practices. • Data was also collected from a focus group discussion. The group was made up of 2 male and 3 female students who discussed attitudes and practices on PEP. • Three senior nurses were individually interviewed to find out whether student nurses actually implemented PEP.
RESULTS Knowledge about Transmission Sources •The majority of student nurses knew the main sources of HIV transmission at the workplace. Transmission sources
%C. R
% Inc. R
Blood
100
0
amniotic fluid
86.7
13.3
urine
86.7
13.3
Semen
90
10
sweat
93.3
6.7
Tears
86.7
13.3
Saliva
76.7
23.3
Faeces
76.7
23.3
Gloves
93.3
6.7
Eye shield
100
0
Masks
100
0
Sodium Hypochlorite
96.7
3.3
Sterile Equipment
93.3
6.7
15%
85%
Correct responses Incorrect responses
Knowledge about Components of PEP (No.=30) •Most of them also knew components of PEP. Components of PEP in HIV Prevention
% C. R
% Inc. R
It is treatment of HIV to a person accidentally exposed.
80
20
Services that are manage specific exposure.
90
provided aspects
to of
90 80 70
10
60 50
100
0
It involves first aid.
40
60
It includes counseling
96.7
3.3
30
It is exposure to HIV
66.7
33.3
20
It is treatment for AIDS
93.3
6.7
It involves prescription of a 28 day course of ARVS.
73.3
26.7
It is a vaccine against HIV.
83.3
%
It is a cure for HIV and AIDS.
40
10 0
16.7
Correct responses Incorrect responses
Knowledge about workplace risks (No.=30) •Most of them knew work-related risks in health that may require PEP. Risks to HIV that require PEP
% C. R
% Inc. R
Needle Stick Injury
93.3
6.7
Sharp Object Injury
96.7
3.3
Sharing food
100
0
Exposure to blood
93.3
6.7
Exposure to amniotic fluid
66.7
33.3
Broken skin exposed to blood
100
0
Shaking hands
100
0
Sexual assault
100
0
Correct responses
Chatting
96.7
3.3
Incorrect responses
6%
94%
Results cont. Attitudes • Student nurses generally had positive attitude about PEP but had some reservations about certain aspects of PEP. • However what students said in focus group discussion differs with how they responded to the questionnaire.
Attitudes towards PEP (No.=30)
Variables on attitudes
% Agree
% Disagree
Wise to use PEP
100
0
PEP is useful to prevent HIV
93.3
6.7
PEP is recognized internationally
86.7
13.3
I am exposed workplace
at
26.7
73.3
Requested for PEP after exposure
62.5
37.5
I would request for PEP 53.3 if exposed
46.7
PEP is easily accessible
6.7
Agree Disagree
93.3
Attitude cont. • “I would hesitate to be involved with PEP because friends and relatives may stigmatise and discriminate me. The whole day when it happens you become talk of the day.” • “Some counsellors and supervisors may divulge the information. The process goes through many hands- the supervisor, matron, medical superintendent , the pharmacist, laboratory technician. It is difficult for so many people to be confidential.”
Attitudes cont. • “ The ARVs have side effects and one’s health may deteriorate after taking them. For example a former student was negatively affected after taking the drugs.”
Results cont. Practices • The majority of student nurses were aware of most practices involved in PEP, but were not comfortable to actually put them into practice as shown by the following statements that emerged during group discussions:
Awareness of practices of PEP C. R
Inc. R
90
Wash with water
90
10
80
Scream for help
80
20
70
Leave client alone
100
0
60
Report exposure to supervisor
100
0
50
Start ARVs for PEP immediately within 72 hours
100
0
Wait for HIV results
26,7
73,3
Ascertain HIV status for both patient and health worker.
100
0
HIV results determine Health Worker PEP 86,7 continuation
%
Practices involved in pep
40
30 20 10
13,3
0 Correct responses
Incorrect responses
Practices cont. • “PEP is not 100% effective so being involved in the procedure does not mean I will be spared of the infection.” • “It is not easy as it affects psychologically because there is no enough time to prepare to take up the HIV test.” Such views were also supported in interviews with senior nurses who said, • “ No student nurse has been accidentally exposed in the ward I manage so no one has asked for PEP.”
Practices cont. “ Many health workers know about PEP but avoid implementing it even when they know they have been dangerously exposed. The process is tedious and scary as its success is not guaranteed.” “I just heard of one nurse who asked for PEP here but I was not involved so I do not know much about what happened.”
Discussion • The study was carried out to evaluate knowledge, attitudes and practices of student nurses about PEP. • The study revealed that the majority of student nurses had adequate knowledge about PEP in relation to transmission sources, components of PEP and workplace risks. • These results differ with earlier studies carried out by MOHCW and WHO in Zimbabwe who found out health workers had poor knowledge about PEP. • The difference may be due to the fact that student nurses have to know about PEP not only for their protection but also to pass tests.
Discussion cont. • Secondly earlier studies were carried out soon after the introduction of the policy on PEP in 2006 and 2007 so not all health workers might have been familiar with what was involved. • The difference may also be due to the different methods used. WHO and MOHCW used survey hence sampled more health workers than the ones we sampled in our study .
Discussion cont. • The study has also revealed that student nurses had some positive beliefs about PEP but their attitude towards actually practicing it was negative. • The respondents alluded to lack of confidentiality and privacy, stigmatisation and the possible negative side effects of drugs for not being keen to implement PEP even when exposed.
Discussion cont. • Previous research , for example by WHO(2007), also indicate negative attitude of practice when health workers underreported exposure to needle stick injuries because they felt PEP was ineffective, lack of confidentiality and fear of being tested. • There are three possible explanations for these results which show negative attitude towards implementing PEP by student nurses. • First explanation is to do with the theory of stigmatisation. A stigma, according to Giddens(2001) is any characteristic that sets an individual or group apart from the majority of the population with the result that the individual or group is treated with suspicion or hostility.
Discussion cont. • Student nurses, although aware of benefits of PEP , fear that if it is known that they have been exposed to HIV and had used PEP, workmates or relatives may stigmatise them. • The second explanation is to do with Sunderland’s theory of differential association (Schaefer, 2004). • The theory states that learning proper or improper behaviour is a result of types groups to which a person belongs and kinds of friendships one has. • Thus student nurses, when they go to the clinical area, may be copying from their seniors who may not be practising PEP.
Discussion cont. • The third explanation relates to the theory of Health Belief Model suggested by Rosenstock in 1966 and developed by others over the years to help study and promote the uptake of health services by individuals. • In short it says personal beliefs influence health behaviour. • The personal beliefs depend on a number of perceptions: seriousness, risk, benefits, barriers, cues to action, motivating factors and self-efficacy. Therefore student nurses may have a number
Discussion cont. personal perceptions which influences their behaviour towards PEP.
Conclusion • The majority of student nurses at a school of nursing have adequate knowledge about PEP. • They have some positive attitude towards certain aspects of PEP but most of them are not comfortable to practice PEP when they have been exposed. • They fear stigmatisation, lack of confidentiality and negative effects of drugs used for PEP. • The MOHCW is urged to address these concerns so that student nurses benefit from the intended benefits of PEP. A survey study in schools of nursing in Zimbabwe be carried out on the same topic.
ACKNOWLEDGEMENTS
• The student nurses and other members of staff who took part in this research. • The Organizers of this Expo.
