Impact of Universal Precautions Training on Nurse Midwives Knowledge,Attitude

and Practices toward Prevention of HIV Transmission in Khartoum State Teaching

Hospitals, 2006-2009
By:
Dr/Faiza Ali Nasor Taha
Faculty of Nursing Sciences
University of Khartoum
Human immunodeficiency virus (HIV) is the retrovirus that causes acquired
immunodeficiency syndrome (AIDS).
HIV Infections can include opportunistic infections, growth problems, and developmental
regression, (Collie .et al ,1999).
HIV has been isolated from blood, vaginal and cervical discharge; wound secretion,
breast milk, amniotic and other body fluids, (CDC, 1998).
CDC asserts that HIV positivity with low CD4 lymphocyte count (<200x10000000/L) is
sufficient for diagnosis of AIDS.
This test detects antibodies against HIV. It does not detect the HIV itself. An antibody
against the HIV takes 1 3 months to develop after initial infection (window period).
Back Ground
The first cases were reported in the United States in 1981 and in the immediate
subsequent years cases were reported from around the world.
In 1983 the virus that caused AIDS was discovered by scientists in France and the routes
of transmission were identified ( CDC, 1998).
Clinical manifestations:
The CDC states that HIV infection is a chronic progressive, terminal illness that can be
divided in to four stages:
Stage I : An acute , flue-like syndrome .
Stage II: An asymptomatic, HIV-positive carrier state
Stage III: Persistent fever, involuntary weight loss
Stage IV: The development of AIDS as manifested by neurological disease and dementia.
Opportunistic infections (CDC,1995).
The spread of HIV/AIDS is very quick worldwide and in the Sudan 1.4% of adult
acquired it (SNAP,2009)and 1%of pregnant woman(SNAP,2003).
Till now neither remedy nor vaccination exists, Prevention is the mainstay and
cornerstone of the response to HIV/AIDS.
Universal precaution (UPs) is now a common concept and guidelines have been
developed to enable all health-care workers to reduce their risk of occupational exposure
to HIV and other blood and body fluids infections; and to safe their clients and reduce
risk of mother to child transition of HIV during process of normal labor.
Universal Precautions components
1- Hand washing before and after all procedures.
2- Proper reprocessing of instruments and other contaminated equipment
3- Use of protective barriers such as gloves, gowns, aprons, mask, goggles when direct or
indirect contact with blood and other fluids.
4- Careful handling and disposal of "sharps"
5- Proper handling of soiled linen or other materials.

6 - Safe disposal of waste contaminated with blood or body fluids (WHO,2003).

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

Research design- intervention

Research Question
What is the impact
of Training UPS

Pre-intervention

Post-intervention

Out-come

The Study design

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

n= (zpq/d) 2 .
THEN n= (1.96) (1.96) (0.40) (0.60)/ (0.10) (0.10) =92
Sample size was then multiplied 2 =184 (to decrease design effect when
using cluster sample).
Sample design:
Given the study objectives and structure of the population outlined above, the
appropriate sample design chosen was stratified cluster sampling.
Selection procedures of the study subject:
Khartoum state is divided in to seven localities .These localities were considered as a
stratum but one of these localities did not fulfill the criteria of selection. Teaching
Hospitals in Khartoum state were considered as clusters. One cluster from each locality
was withdrawn and studied.
Then equal numbers of midwives from each selected cluster were taken, by division of
sample size/six giving number 30.(Total number 180 nurse/midwives).
Data collection technique and tools:
Data collection technique:
Observation
Administration of a written questionnaire.
Data collection tools:

observation check list, (two-path) .

An structured interview questionnaire .
Pre intervention phase comprised the following:
Preparatory phase:
In this phase the following was done:
Permission was taken from ministry of health Khartoum state, directors of the hospitals,
head departments of obstetric and labor rooms authorities.
Tools were designed.
Data collectors were trained and participated in the pilot study.
The pilot study was carried out to insure validity of the tools and to test the work of the
data collector short term training and to assist in determining sample size
Curriculum for theoretical and practical aspects of UPs was developed
Instructors were chosen.
Base line survey was conducted by the data collectors and check list to assess application
of UPs
Intervention phase:
A course of 2 days was offered which included
Two lectures for three hours
Demonstrations
Role play were used in the practical station for 3 hours in which application of steps of
UP and protocol of the safe labor was applied
Eight courses were offered
A total of 176 nurse midwives were trained

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

Processing soiled instruments and Other Items:

Decontamination:
Principles:

- Inactivates HBV and HIV.

- Makes items safer to handle.
- Must be done before cleaning.
Practices:

- Place instruments in 0.5% chlorine solution after use.

- Soak for 10 minutes and rinse immediately.
Instructions for Preparing
Dilute Chlorine Solutions
To make a 0.5% chlorine solution from 5% bleach
Mix 1 part bleach to 9 parts water
% Dilute
% Concentrate =Total parts

(TP) (H2O) -1

Total parts (TP)

(H2O) =

.5% Dilute
-1=9 (H2O.
.5% Concentrate

Decontamination of soiled instruments:

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

post intervention monitoring

Monitoring and supervision was carried out monthly for six months(memory gap) to
assess application of UPs
two midwives monthly observed from each selected hospital
the first two months observed in the morning shift the second two months were observed
in the after noon night shift and the last two months were observed again in the morning
shift
Post intervention data was collected. (Using check list) after six months to assess
application of UPs by the same data collector.
Data analysis:
The statistical package for social sciences (SPSS) was used and epo info, for frequency
distribution, intra group cross tabulation and inter group comparison
The results were displayed in figures &tables
Ethics:Permission was obtained from health authorities and from hospitals directors
Consents were taken verbally from participants
Validity and Reliability of instruments

The instruments were pre-tested in the pilot study (n= 30) before final data collection
For reliability, the test-retest at a three week interval period yielded a Pearson correlation
coefficient of 0.6713

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

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

NO quest

Socio demographic

Frequency %

1- Marital status

Married

148 ( 82.2)

Single

12

( 6.7 )

Divorced

12

( 6.7)

Widowed

( 4.4)

Total

180

( 100)

Primary school

26

( 14.4)

Intermediate

103

( 57.2)

Secondary

51

(28.3)

Total

180

( 100)

Less than 5 years

16

( 8.9)

5years and more

164

( 91.1 )

Yes

140

(77.8)

No

40

2- Education level

3- Years in current occupation

4- Previous courses on HIV/AIDS

( 22.2)

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

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

Figure (2) Application of UPs by NM in the memory gap(monitoring in the memory

gap 1-6 months).

60
50
40
30
20
10
0
Series1

applica

first

secon

third

forth

fifth

six

51.5

48.6

44.4

38.7

45.5

44.9

1,2.5and 6 months monitoring in the morning

shift 3rd and 4rth months monitoring in the
after noon night shift

Figure (3) Detailed Results of Application of Universal Precautions by The Nurse

Midwives Pre intervention (n,180)
Compared With Pos Intervention (n,169)

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

Discussion
Education is a very crucial element for nurse midwives, particularly in
countries where there is lack of formal and well-organized infection
control programs. Despite limited resources, developing countries,
such as Sudan, still have to deal with complex issues related to
enforcement of standard precautions. In this context, exposure to risk
is increased, because of the inadequate supply of personal protective
equipments, improper disposal of medical waste, and lack of effective
sharp instrument disposal systems. In this study, despite these
conditions, Universal precautions application scores increased

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

supported by (Diekema, 2002) who mentions that Universal
precautions

knowledge

scores

increased

significantly

after

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

"Effects of Training Programme on HIV/AIDS Prevention Among
Primary Health Care Workers in Oyo State, Nigeria" , showed that: at
pre-test, only 30.8 per cent of trainees could list at least four signs
and symptoms of AIDS compared with 70.9 per cent who could do so
after the training. . (Charles, 2001) in his study: Impact on Knowledge,
Attitudes and Compliance with Universal Precautions, revealed that
a number of positive changes occurred over the period of the study.
(Goldman and Glei .2003) argued that training midwives had little
effect on the quality of midwife care.
The study revealed that: Performance of the midwives in the first month
immediately following intervention was very high compared with the
following months in the memory gap and there were marked reduction of
UPs application in the months monitored in the afternoon night shift as
shown in (figure 2) and this may be due to lack of supervision and decreased
number of the staff or supplies. Similar to this is finding mentioned by
(Elkadi, 2007) in the Province of North Sumatera, knowledge and skill of
midwives were significantly increased after given health promotion, but
there was significant decrease of knowledge in the coming period and after 1
month after promotion and (S.Lund, etal, 1994) mentioned that during each
of the three shifts, 88% of all high-level contacts to blood and body fluids
were limited to the hands; 47% of these contacts occurred during the night
shift.

The high level of knowledge shown in this study did not correspond with
nurse midwives performance and even post intervention .This was similar to
what was mentioned by(Grellier ,2000) in the South Thames Region of the
UK who concluded that : Knowledge obtained within midwifery education
may be difficult to be translated into clinical practice.
The prevalence of needle stick injury, as shown by this study, was very high
among most of midwives who are all have needle stick injury while suturing
because of the fact that they didnt use a needle holder this, is similar to
what was mentioned by(Ismail ,etal,2005) in Egypt, who

found that

exposure to needle stick injuries were common among the HCWs (66.2%).
Also (Nsubuga and Jaakkola, 2006) in a study of needle stick injuries
among nurses in Sub-Saharan Africa showed that, 57% of the nurses and
midwives had experienced at least one needle stick injury a year. Only 18%
had not experienced any such injury in their entire career
Conclusions
This program was effective in increasing nurse midwives application of universal
precautions
The study showed a high rate of needle stick injuries occurred among nurse midwives
Also the study revealed that the nurse/midwives were highly knowledgeable, but their
knowledge did not reflect on their performance
Resources needed for safe practice should always be made available and the environment
should be much more conducive for practice
Recommendations
Creation of a body to supervise application of universal infection control precautions to
grantee the continuity of the program

We call for effective training that should include safe system of work with availability of
resources and reasonable number of staff
Application of universal precautions should be carried by all health care workers
(HCWS) during the process of labor
There is a responsibility on managers to provide appropriate Protective measures to
enable midwives to practice safely and thus, ensure safety of the women they care for
References

1-A demola Ajuwon, Fawole Funmilayo, Oladimeji Oladepo, Kayode

Osungbade, Michael Asuzu 2008 Effects of training programme on
HIV/AIDS prevention among primary health care workers in Oyo State,
Nigeria ,Health Education,Vol.108 ,no.6 ,pp, 463
474.viewed,4/1/2009,<http://www.emeraldinsight.com/10.1108/0965428081
0910872>.
2- Centers for Disease Control and Prevention ,1995, acquired

immunodeficiency syndrome, MMWR,vol.44,pp.13

3-Centers for Disease Control and Prevention ,1998, Public Health Service
guidelines for the management of health-care worker exposures to HIV and
recommendations for post exposure prophylaxis, MMWR, 47(RR-7)pp.129
4-Charles B.U. Uwakwe 2001,Systematized HIV/AIDS education for
student nurses at the University of Ibadan, Nigeria: impact on knowledge,
attitudes and compliance with universal precautions, Journal of Advanced
Nursing,vol.32,no.2,pp.416-424.viewed
12/26/2008,<http://www.3intrtscience.wily .com/cgibin/fulltext/119185814/ HTMLSTART>.Infect Control Hosp Epidemiol
2007;28:241244
5- Collie, J.A.B, Longmire, J.M and .Duncan,T.J ,1999).oxford hand book of
clinical specialties ,fifth edn, Oxford university press Inc,UK, pp,98-99
and155.
6-Diekema D. J., Schuldt S. S., Albanese M. A. and Doebbeling B. N,2002,
Universal Precautions Training of Preclinical Students: Impact on
Knowledge, Attitudes, and Compliance,Preventive
Medicine,vol.24,no.6,pp.580-585.viewed 6/8/2008<
.http://www.sciencedirect.com/science journal/00917435.>.
6- Elkadi,2007, health promotion regarding universal precaution HIV/AIDS
for midwife of Primary Health Care in Medan municipality , Jl. Farmako
No. 1,viewed 8/8/2008.<http://www.digilib.litbang.depkes.go.d/index.php >
7-Goldman, N& Glei, D ,2003. Evaluation of midwifery care: results from a
survey in rural Guatemala. Social Science & Medicine. 2003;56,pp.685-700.

8-Grellier R ,2000, 'Everyone is scared of it inside so they start being a bit

irrational': HIV/AIDS education within midwifery, Midwifery
vol.16,no.1,pp.56-67.viewed ,viewed 17/7/2008.
9-Ismail NA, Aboul Ftouh AM, El Shoubary WH, (2005) Safe injection
practice among health care workers, Gharbiya, Egypt. Journal of the
Egyptian Public Health Association , vol.80,no.1, pp.563-83.
10-Nsubuga, F. M and Jaakkola, M. S. (2006 ),Needle stick injuries among
nurses in sub-Saharan Africa, Tropical Medicine and International
Healthviewed 3/22/2009.http://www.cabi.org.
11-RH,2006 .workshop 13-15 June 2006. curriculum revision .
12-S. Lund, J. Jackson, J. Leggett, L. Hales, R. Dworkin and D. Gilbert
(1994) Reality of glove use and handwashing in a community hospital,
American Journal of Infection Control, Vol. 22, no. 6, pp. 352-357, viewed
,3 /3/2009 <http://www.science direct.com.science_ob=atrtice ur&udi >.
13-SNAP,2003, surveillance report April June 2003 .
14-SNAP,2008, June report
15-WHO,2003.Fact sheet 11 HIV& the workplace and universal precautions
for nurses &midwives. viewed 2/8/2008 .
<http://www3.who.int/whosis/factsheets_hiv_nurses/fact-sheet11/index.html>.
.