BELITUNG NURSING JOURNAL Volume 4 Issue 3: May-June 2018 Belitung Nursing Journal (BNJ) is a bi-monthly, International, peer reviewed journal published by Belitung Raya Foundation, in collaboration with the Academy of Nursing of Belitung and Indonesian National Nurses Association, Belitung Indonesia. BNJ contributes to the advancement of evidence-based nursing, midwifery and healthcare by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. BNJ welcomes submissions of evidence-based clinical application papers, original research, systematic review, case studies, perspectives, commentaries, letter to editor and guest editorial on a variety of clinical and professional topics. The Official Publication of Belitung Nursing Journal – Belitung Raya Publisher- Belitung Raya Foundation ISSN: 2477-4073 (Online) | ISSN: 2528-181x (Print) Belitung Nursing Journal is indexed by DOAJ, Google Scholar, ISJD, WorldCat, Journal TOCs, and ROAD
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BELITUNGNURSING
JOURNALVolume 4 Issue 3: May-June 2018
Belitung Nursing Journal (BNJ) is a bi-monthly, International, peer reviewed journal published by Belitung Raya Foundation, in collaboration with the Academy of Nursing of Belitung and Indonesian National Nurses Association, Belitung Indonesia.
BNJ contributes to the advancement of evidence-based nursing, midwifery and healthcare by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. BNJ welcomes submissions of evidence-based clinical application papers, original research, systematic review, case studies, perspectives, commentaries, letter to editor and guest editorial on a variety of clinical and professional topics.
The Official Publication of Belitung Nursing Journal – Belitung Raya Publisher-
P-ISSN 2528-181x Copyright 2018, by Belitung Nursing Journal - Belitung Raya Publisher – Belitung Raya Foundation. All rights reserved. This book is protected by copyright. No part of it maybe reproduced, stored in retrieval system, or transmitted, in any form or by any means-electronic, mechanical. Photocopy, recording, or otherwise-without the prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher.
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EDITORIAL TEAM Editor-in-Chief Assoc. Prof. Yupin Aungsuroch, PhD, RN, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand Advisory International Editorial Board Asst. Prof. Rapin Poolsok, PhD, RN, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand
Jed Ray Montayre, PhD, RN, Department of Nursing, Auckland University of Technology, Auckland, New
Zealand
Pakamas Keawnantawat, PhD, RN, Ramathibodi School of Nursing Faculty of Medicine Ramathibodi
Hospital Mahidol university, Thailand, Thailand
Virya Koy, RN, SNA, MNSc, MHPEd, PhD, President of Nursing Council of Cambodia and Vice Rector of
Chenla University.
Hasanuddin Nuru, S.Kep, Ners, M.Kes, PhD, Faculty of Health Science, University of Islam Makassar,
Indonesia.
Abdulkareem Suhel Iblasi, MSN, Nurse Manager - Wound Care. King Saud Medical City, Ministry of
Health, Saudi Arabia, Saudi Arabia
Associate Editors Sqn.Ldr. La-Ongdao Wannarit, RN, MNS, The Royal Thai Air Force Nursing College, Thailand
Su-ari Lamtraktul, RN, MNS, Department of Pediatric Nursing, The Royal Thai Army Nursing College
Thi Thanh Huong Nguyen, MNS, Namdinh University of Nursing, 257 Han Thuyen, Namdinh, Vietnam,
Viet Nam
Agianto, S.Kep.,Ns., MNS, School of Nursing, Lambung Mangkurat University. Jl. A. Yani KM 36
Banjarbaru, South Kalimantan, Indonesia., Indonesia
Rian Adi Pamungkas, BNS, MNS, School of Health Science of Mega Rezky Makassar, Indonesia
Fauzan Saputra, S.Kep, Ns, MNS, Bumi Persada Nursing College and Public Health Office of
Lhokseumawe, Aceh, Indonesia
Melyza Perdana, S.Kep, Ns.,MNS, School of Nursing, Faculty of medicine Universitas Gadjah Mada,
Indonesia., Indonesia
Ety Hastuti, S.Kep, Ners, M.Kep, Director of Inpatient Services of the General Hospital of dr.H.Marsidi
Judono, Belitung, Indonesia
Nazliansyah S.Kep.Ns.MNS, Academy of Nursing of Belitung, Indonesia
Kusuma Wijaya Ridi Putra, S.Kep, Ners, MNS, Kerta Cendekia Nursing Academy, Sidoarjo, Indonesia
Journal Manager Joko Gunawan, BNS, PhD (c), Faculty of Nursing, Chulalongkorn University, Bangkok Thailand
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Table of Contents BREASTFEEDING EXPERIENCES OF WORKING MOTHERS IN VIETNAM Nguyen Thi Truong Xuan, Nhan Thi Nguyen
PDF 279-286
CORONARY HEART DISEASE PATIENTS' LEARNING NEEDS Aan Nuraeni, Ristina Mirwanti, Anastasia Anna
PDF 287-294
BURDEN AMONG FAMILY CAREGIVERS OF ADVANCED-CANCER PATIENTS IN INDONESIA Ike Wuri Winahyu Sari, Sri Warsini, Christantie Effendy
PDF 295-303
EFFECT OF EDUCATIONAL INTERVENTION ON FAMILY SUPPORT FOR PREGNANT WOMEN IN PREVENTING ANEMIA Mira Triharini, Ni Ketut Alit Armini, Aria Aulia Nastiti
PDF 304-311
THE DESCRIPTION OF RESILIENCE IN POST-ACUTE ATTACK PATIENT WITH CORONARY ARTERY DISEASE Eva Puspawatie, Ayu Prawesti, Titin Sutini
PDF 312-322
THE EFFECT OF KELAKAI (STECHNOLAENA PALUSTRIS) CONSUMPTIONS ON HEMOGLOBIN LEVELS AMONG MIDWIFERY STUDENTS Gracea Petricka, SN Nurul Makiyah, Retno Mawarti
PDF 323-328
THE APPLICATION OF ART THERAPY TO REDUCE THE LEVEL OF DEPRESSION IN PATIENTS WITH HEMODIALYSIS Atikah Fatmawati, M. Rachmat Soelaeman, Imas Rafiyah
PDF 329-335
THE EFFECT OF ANEMIA ON THE INCIDENCE OF PREMATURE RUPTURE OF MEMBRANE (PROM) IN KERTHA USADA HOSPITAL, SINGARAJA, BALI Putu Irma Pratiwi, Ova Emilia, Farida Kartini
PDF 336-342
INCREASING FOOT CIRCULATION WITH ELECTRICAL STIMULATION IN PATIENTS WITH DIABETES MELLITUS Iskandar Iskandar, Ridha Dharmajaya, Yesi Ariani
PDF 343-349
VALIDITY AND RELIABILITY OF INSTRUMENT TO MEASURE CLINICAL INDICATOR OF NURSING DIAGNOSIS: FATIGUE ON PATIENT UNDERTAKING HAEMODIALYSIS Atika Dwi Astuti, Intansari Nurjannah, Sri Mulyani
1Vice Head of Educational Testing Office, Binh Duong Medical College, Binh Duong province, Vietnam. 2Department of Midwifery, Faculty of Nursing and Medical Technology, University of Medicine and Pharmacy in Ho Chi
Minh City, Vietnam. *Correspondence: Nguyen Thi Nhan Department of Midwifery, Faculty of Nursing and Medical Technology, University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam Email: [email protected] Abstract Background: World Health Organization recommends mothers all over the world should continue breastfeeding up to the age of two years or beyond to achieve optimal health, growth and development for their infants. However, the breastfeeding practices among working mothers have been decreased by the time passed. Objective: to describe the breastfeeding experiences of mothers who returned to work after childbirth. Methods: This study was utilized a qualitative design. Purposive sampling was used to recruit the participant who met the inclusion criteria. Data were collected from 10 semi-structured in-depth interviews. All interviews were audio-recorded and transcribed verbatim. The interview transcriptions were analyzed by using the qualitative content analysis approach. Results: The breastfeeding period of 10 working mothers ranging from 7 to 15 months. Five categories emerged from the data were: 1) Attitude towards breastfeeding, 2) Breastfeeding support during working, 3) Strategic plan for breastfeeding, 4) Psychological distress, and 5) A need for support facilities and resources for breastfeeding during working. Conclusion: This research provided a better understanding of breastfeeding experiences of working mothers in Vietnam. The findings can help nurses and other healthcare professionals in providing anticipatory guidance to mothers who plan to continue breastfeeding after returning to work. Keywords: breastfeeding experience, working women, Vietnam
INTRODUCTION Breast-milk is a good source of macronutrients, micronutrients, bioactive components, growth factors, and especially immunological factors which protect against inflammation and infection for children (Ballard & Morrow, 2013). Additionally, breastfeeding also demonstrates many advantages to mothers such as protective effects against breast cancer in women, faster postpartum involution of the uterus in early postpartum period, delayed return of menstrual
periods, and also known as contraceptive method (Babita, Singh, Malik, & Kalhan, 2014; Kramer & Kakuma, 2012; Victora et al., 2016). Furthermore, breastfeeding enhances the mother-child interaction, which, in turn, positively affects both short-term and long-term health (Dieterich, Felice, O’Sullivan, & Rasmussen, 2013; Liu, Leung, & Yang, 2013). The evidence supported that breastfeeding as an effective intervention to advance mother–child health. Especially the timely initiation of
breastfeeding within the first hour after birth is very important, as well as breastfeeding exclusively during the first 6 months, and continued breastfeeding for the child until he/she is at least 2 years old (Chien & Tai, 2007). Despite the well-documented importance of breastfeeding, the prevalence of breastfeeding is still very low in Vietnam (Chung, Kim, Choi, & Bae, 2013). Because of the low rate of breastfeeding internationally including Vietnam, numerous studies have been conducted around the world to investigate factors influencing breastfeeding practices. It is well recognized that working mothers were less likely to give breastfeeding to their children compared to unemployed mothers (Asfaw, Argaw, & Kefene, 2015; Jessri, Farmer, & Olson, 2013; Jones, Kogan, Singh, Dee, & Grummer-Strawn, 2011; Maonga, Mahande, Damian, & Msuya, 2016; Saffari, Pakpour, & Chen, 2017). The breastfeeding practices among working mothers have been decreased by the time passed. For example, among 100 working mothers who continued breastfeeding while working outside the home, 30 mothers continued breastfeeding for 1 to 3 months, 25 mothers continued breastfeeding for 4 to 6 months, 25 mothers continued breastfeeding for 7 to 12 months, and 20 mothers continued breastfeeding for more than a year (Alhabas, 2016). Vietnam has the target to increase the rate of exclusive breastfeeding into 50% by the year 2020 and increased the rate of breastfeeding after six months. Currently, the prevalence of the working women in Vietnam is 72% (Dan, 2018) and among them, they are married women and have children. The decision to return to work after childbirth may be the results of financial constraints or women’s lifestyles change; but this decision presents a unique challenge for women who desire to continue breastfeeding when returned to work. In Vietnam, there is no study was conducted to describe the breastfeeding experiences of working mother when they returning to work. Therefore, the need of exploration about the breastfeeding experience of working mothers
is important. The aim of this study is to explore the breastfeeding experiences of mothers who returned to work after childbirth. METHODS Design A qualitative descriptive study design was used to address the research objective. Breastfeeding experiences were collected from participant’s stories. Setting and sample Participants were recruited by using a purposive sampling technique from Binh Duong province between March and April 2018. The inclusion criteria were working mothers either government officer or private officer, having breastfeeding experiences after return to work, having non-complicated normal vaginal delivery, and delivered a healthy baby without any medical conditions. Exclusion criteria were working mothers who have chronic diseases which breastfeeding is not allowed by a doctor such as HIV/AIDS or severe heart disease. In accordance with qualitative descriptive approach, the criterion of saturation was used to determine the number of sample size. The data saturation in this study was achieved by 10th interview. Therefore, the sample size for this study was 10 interviewees. Data collection Data were collected by using the semi-structured open-ended questionnaires. The interview was conducted in individual. The questionnaires were derived from literature review and from the researcher’s insight on breastfeeding experiences. The interview guide was presented in the table 1. The first author is the lecturer in Medical College at Binh Duong province and had the experience to work with working mothers for more than 10 years while the second author is the midwife lecturer with 8 years of working experiences in maternity units. All interviews were started with the question “Could you please tell me about your breastfeeding experiences?” and the
participants were asked by following prompting question such as “Any challenge with breastfeeding?” Other issues raised by participants during the interviews were used as cues for additional prompting questions. Interview were conducted in the participants’ preferred place in which 8 interview were conducted at homes and 2 at the offices. In Vietnam, the maternity leave is 6 months with full paid salary; therefore, all interviews were conducted after 6 months postpartum period so that the participant can share about their breastfeeding experiences while working. Ethical consideration Ethical approval was obtained from Binh Duong Medical College human research ethics
committees. Informed consent was obtained from the participants prior to commencement of interviews. The participants were informed about the objective of the study and informed about the right of participants. The participants can refuse to participate in the study at any time. Data analysis All recorded data from the interviews were fully transcribed verbatim; the qualitative content analysis approach was used to summarize the informational contents of the data. Themes and categories were formed after the first three interviews. Three procedures were used including coding data, categorizing text units, and refining the emerging themes (Miles & Huberman, 1994).
Table 1 Interview guideline
Hello,…….My name is……Thank you for your time for this interview. In this interview, I would like to know more about your breastfeeding experiences when you returned to work, is that possible? Could you please tell me about your breastfeeding experiences? How long did you breastfeed for your child? As a working mother, how did you think about breastfeeding? Before returning to work, how did you prepare for continuing breastfeeding during your working? When returning to work, how could you maintain breastfeeding? Did you follow exactly what you had planned about breastfeeding? Do you think it was the challenge for you to keep breastfeeding during your working? What were the challenges that you faced during your breastfeeding? How could you deal with the challenges? What kinds of support that you received during breastfeeding period? To make working mothers be able to give breastfeeding for their children until 2 years as the recommendation of WHO, do you think what we should provide? Are there any more things that you want to share with me? To more clarify: Could you explain more, please? To more reflect: What did it mean to you? It is very nice for me to learn from your experiences. Thank you very much for giving me time for this interview. Wishing you will have a good health and successful life. RESULTS Five themes were emerged from the data: 1) Attitude towards breastfeeding, 2) Breastfeeding support during working, 3) Strategic plan for breastfeeding, 4) Psychological distress, and 5) A need for support facilities and resources for breastfeeding during working. Attitude towards breastfeeding The emerging theme of attitudes towards breastfeeding by working mothers is explored
through the codes of two interview and the categories including plan for breastfeeding during working, dedication, commitment, assertiveness, and values the benefits of breastfeeding. Most of mothers perceive about the benefits of breastfeeding and have the intention to continue breastfeeding while they were working. The second participant seemed to have strong commitment on breastfeeding with the evidence that she can give the exclusive breastfeeding.
….Breastfeeding is a good nutrition for my baby. It contains the immune factors to help my baby
against the infection disease during the first two year, such as diarrhea, respiratory infection, and so on. I will try to continue to breastfeed for my baby for at least 18 months…I do understand about the benefits of breastfeeding for the baby, the baby was fed by breast milk, they could be healthier… it also help to create the good relationship between the baby and the mother…make the schedule for myself to feed my baby.
One participant appeared a little insecure about breastfeeding and acknowledged that it really requires a lot of effort for one to breastfeed successfully particularly while working away from home.
…I also think that it is a little bit difficult for me to breastfeed my child when I get back to work because of the time … it requires a lot of effort to give breastfeeding for my baby after I returned to work.
Breastfeeding support during working The theme is explored from the perception of participant about the support that they experienced from working environment, living conditions, family member, husband, government policies, and breastfeeding community. Even though the same working status but the perceptions about the breastfeeding support of participants are quite different. One mother spoke about the negative attitude and lack of support from colleagues and employers in an institution regarding breastfeeding. The lacking of support from co-workers and employers was highlighted as follows: …The employer not really support while the
women in breastfeeding period. I could not receive any support from my office…at that moment I had to go to the toilet and take out the breast milk. I use the toilet to be the place where I can take out the milk. Of course, when I used the toilet to take out the milk…because…it is…it is the common place for everybody…so…somebody they would not happy when I used the toilet.
In contrast, other mother stated that she received the good support from workplace:
In case, if I cannot deal with the working time, I can request the day off work. My colleagues helped me to resolve the emergency problem.
All working mothers acknowledged that they received the great support from their husbands and family members.
…I didn’t do housework, I didn’t cook, my mother and my husband cooked for me and brought the food to me for breakfast, for lunch, for dinner… I didn’t do anything at home. I spend a lot of time for my baby when I was at home… I felt so thankful for the support…the support from my husband…that the only one who was beside me at that time…he supported me a lot…he tried to do other stuffs to help me to have more time to rest…he encouraged me to eat healthy food…I think he supported me even in mental issues…yes…he made me feel so happy…that feeling is really good for mother.
Strategic plan for breastfeeding This theme reflected an organized plan that women needed to develop to combine breastfeeding and working. The participants described the strategic plan in terms of plan ahead, organize, process of maintaining milk supply, time management, and maintenance of physical health. In order to continue breastfeeding while working, mothers need to have a plan, become organized, and have the process to maintain breast milk for breastfeeding successfully. The participants tried to keep their health behavior during the time they were working and breastfeeding in order to produce the sufficient level of breast milk for their babies. One mother said:
…I try to eat the food ah…which can …improve the amount of breast milk. I drink milk…I drink the hot milk before feeding my baby. I keep relaxing…I keep relaxing in my mind, my body. For that way, I think it can maintain my breast milk…and… another way I exercise…yeah…I exercise at home every day.
Mother also showed time management for breastfeeding by keeping balance between working and breastfeeding.
…I tried to keep balance between working time and time for feeding my baby…I set the priority for my work. I did meditation when I have free time to relax myself.
Psychological distress Stress or pressures from the working environment were a major obstacle to continue breastfeeding. This psychological distress
included feeling overwhelmed, stress, under pressures, and having to make sacrifices. Participant indicated that they could not breastfeed as the desired time because they were working. It is too much work. They thought they were too pressures with working and it caused the insufficient lactation for baby; as a result, they needed to stop giving breastfeeding for their babies.
…I think it comes from my working pressure, I get pressure… I act as Vice Dean in the faculty, so…you know…sometimes I have to solve a lot of work at the same time…Someday, I spend a lot of time with my colleagues at my office…I decreased the time at my home and the time for my baby…it made me think a lot and I think it caused to reduce the amount of breast milk at that time…it is really difficult to continue with breastfeeding while we are working women.
All working mothers concerned about lack of time when they returning to work. The second participant mentioned that she has no time to rest, to eat.
…Someday I skip the breakfast…I don’t have enough time to enjoy a good meal…I do not have time to sleep.
That is the main reason why she stopped breastfeed to her child when her child was 13 months. In addition, most of participants were worried about the insufficient lactation while working.
I never have leaking since the first child…um…I think that it maybe because of my work…I knew that…that symptom (leaking and engorgement) could lead to the absence of breast milk late…so I was so worried but I could not receive any support from my office…at that moment I had to go to the toilet and take out the breast milk by hands to solve the problem.
Besides that, in order to breastfeed when returning to work, the mothers seemed that she needed to make sacrifices for breastfeeding during working.
…when I was at home with my baby I separate… um…meals…one day I may take five to six meals within a day with different kinds of food…um…but when I back to work…even there was some days I did not take my breakfast… I don’t have time to sleep…but I
tried to give time for my Mom to sleep…I mean my mother-in-law.
A need for support facilities and resources for breastfeeding during working Working mothers indicated their concern about lack of facilities for breastfeeding at work such as the private room for pumping the breast milk, the refrigerator to store the expressed breast milk. They thought that they really need the support and the understanding from their workplaces for their breastfeeding situation. They strongly felt that breastfeeding facilities could be improved in the workplaces or institutions if people identify the need of providing breastfeeding for children because its significance to increasing productivity for the society.
The refrigerator there…but it is not safe for keep the milk…because for keeping the milk we need a really clean suitable temperature referent…and we also need a private room even with the machine…the milk taking machine which is ready for use.
Or another mother said:
In my opinion, I think they should provide the private place for mother in the workplace for pumping the breast milk…Besides private room which is very important…the other thing is the perception of the society…because all the support will begin with the understanding of the employer…even the room or the machine, the hour to leave the office…all come from the perception and understanding… I think when the employers have knowledge…and when they have a suitable understanding they will know what they should do…that is all.
DISCUSSION The analysis presented in this paper is based on the group of working mothers who delivered healthy full-term babies and had continued breastfeeding while returning to work. Similar to the results of previous studies, working mothers in this study showed their attitudes towards breastfeeding and perceived the support from family member and husband. Support from family was helpful in enabling the working mother to continue the breastfeeding. Similar findings were reported
in previous studies whereby social support enabled the mothers to continue to breastfeed despite initial challenges (Hjälmhult & Lomborg, 2012; Jessri et al., 2013). Additionally, McInnes and Chambers conducted a qualitative synthesis in 2008 and the finding found that mothers may consider the support from their partners, mothers or from friends to be more important than the support from health professional. However, social support included support from husbands, mothers or friends may have a negative influence if there is a lack of knowledge or experiences of breastfeeding among the member of the social group (McInnes & Chambers, 2008). Interestingly, the Vietnamese mothers perceived that they have the insufficient lactation. It is the main reason that made them stopped to provide breastfeeding for their babies. Even though they have enough breast milk, they still add formula milk or water to their infants in the first six months. As already mentioned and discussed in many previous studies, perceived inadequate milk supply issues could be due to lack of knowledge on the physiological process of lactation (Carvalhaes, Parada, & Costa, 2007; Phillips, 2011; Sarasua, Clausen, & Frunchak, 2009). Working mothers in our study narrated similar perceptions of inadequate milk supply, especially when they returned to work. Education of working mothers during the antenatal period could help to address this concern. The antenatal education could emphasize on recognizing of the cues of infant’s hunger, the physiology of breast milk production, the ways to monitor if the baby is getting enough nourishment, and ways to boost breast milk production (Imdad, Yakoob, & Bhutta, 2011). Working mothers in this study showed their experiences differently about their emotions and states of mind during breastfeeding and working. In order to be able to breastfeed, they dedicated a lot such as extended maternity leave without any payment, or preparation to breastfeed during work. It was associated with
positive loving feelings of bonding or attachment with the baby. On the other hand, they also felt uncertain about their abilities to breastfeed and resented changes to their lifestyle because of the commitment to breastfeed. This result was similar to previous studies, in which a combination of positive and negative feelings was reported. In a study of Rojjanasrirat (2004), the results indicated that working mothers experienced of stress and they reported feeling stress from their workplace, their work schedules which strongly inhibit their ability to express their breast milk (Rojjanasrirat, 2004). Furthermore, the finding from this investigation showed that the working mothers prepared themselves to continue breastfeeding when returned to work. They have the plan to continue breastfeeding before returning to work. The finding is similar to previous study of Rojjanasrirat in which the working mothers stated the importance of maintaining the good physical health to keep the sufficient level of breast milk. In addition, the working mothers showed their time management to breastfeed successfully (Rojjanasrirat, 2004). Obviously, in order to make the working mother be able to continue breastfeed during working, workplace support is crucial for working mothers who are still breastfeeding. Therefore, strategies to promote breastfeeding in the workplace need to be implemented. For example, in the USA, the US Federal Patient Protection and Affordable Care Act (2010) ensures that companies give breastfeeding mothers of children under the age of 1-year reasonable time to express milk in a clean and private lactation room (United States Breastfeeding Committee, 2013). This is also the main recommendation for the government policy from working mothers in this study to make them can continue breastfeed until their children were two years old. In addition, companies should practice flexibility such as providing working mothers with lactation breaks and the physical space to express milk or breastfeed (Marinelli, Moren, Taylor, & The Academy of Breastfeeding
Medicine, 2013). Even though, the Vietnamese government has implemented many strategies to promote breastfeeding such as extension the maternity leave from 4 months to 6 months, organized the week of breastfeeding in August annually (UNICEF, 2017), the need of understanding about importance of breastfeeding from the workplace should be emphasized to make all the working mothers receiving the support from their institution. ACKNOWLEDGEMENT I would like to express my thankfulness to all participants who were the study population in my research for their cooperation. REFERENCES Alhabas, M. S. (2016). Breastfeeding among working
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Cite this article as: Xuan, N.T.T., Nhan, N.T. (2018). Breastfeeding experiences of working mothers in Vietnam. Belitung Nursing Journal,4(3),279-286.
*Correspondence: Aan Nur’aeni Faculty of Nursing Universitas Padjadjaran Email: [email protected] Abstract Background: Patients with coronary heart disease (CHD) should have good self-management capabilities. This is determined by the effective of health education which is based on the assessment of patients’ learning needs and consideration of health personel. On the other hand the study of perceptions of CHD patients’ learning needs in Indonesia is little known. Objective: This study aimed to identify the CHD patients’ learning needs. Methods: This study was a descriptive quantitative with cross-sectional approach. Population was CHD patients in one of the referral hospital in West Java Indonesia. Samples were recruited using consecutive sampling technique for a 2-month period (n=106). Data were collected using TR-CPLNI instrument and analyzed using descriptive quantitative and kruskall wallis test. Results: The order of learning needs based on the highest to the lowest mean was anatomy and physiology of heart (4.42); medication information (4.33); cardiopulmonary information (4.32); life style (4.28); dietary information (4.19); symptom management (4.08); psychology (4.07); and physical activity (3.64). The significant differences (p<0.05) based on ward categories were learning needs of dietary information (p=0.002); physical activity (p=0.009) and symptom management (p=0.037), with the highest needs respectively were in High Care Unit (HCU); HCU; and non-intensive care unit. Conclusions: These eight learning needs were important for CHD patients. However, the priority of the patients’ learning needs were seen by category of ward or recovery phase and illness duration different from each other. Therefore this can be a consideration in providing education to CHD patients. Keywords: Coronary Heart Disease, Learning need, Patient
INTRODUCTION The prevalence of Coronary Heart Disease (CHD) is increase every year, and so is its death rate. This condition leads CHD to be a health problem currently. In 2012 heart disease was one of the most health cases in Indonesia (MOH, 2014). Moreover the recurrences reached 40% of the total CHD cases (Indrawati, 2014). These conditions need to be overcome by health personnel through preventive and rehabilitative efforts. CHD is an acute illness that requires continuous prevention effort from its patients.
The management after acute attack should be done systematically and continuously in order to restore optimal body condition and prevents recurrence. It can be done through cardiac rehabilitation program and life style management. But in the other hand, the adherence for undertaking cardiac rehabilitation in CHD patients is low. It can be seen from data on cardiac rehabilitation attendance in one of the referral hospital in West Java in 2016, based on the data, cardiac rehabilitation only performed by 134 out of a total 910 outpatients. Other than that, the
obedience at life style management in CHD patients in terms of activity and diet was still being a problem (Harun, Ibrahim, & Rafiyah, 2016). Previous studies had shown various problems occurred in CHD patients after acute attack. According to previous study that physical limitations made up by 42% of CHD patients, frequent angina and low patients satisfaction in medication respectively accounted for 56% and 58% (Nuraeni, Mirwanti, Anna, & Prawesti, 2016). Other study showed the low spiritual well-being of a fifth CHD patients (15%) (Nuraeni, Mirwanti, & Anna, 2018). Furthermore anxiety and depression in outpatient CHD patients was high, and generally, their quality of life as much as 58% was also low (Nuraeni et al., 2016). Those problems might occur caused by poor management of CHD. This indicates the low adherence of CHD patients to management after acute attack. As stated by Indrawati that the predictor of CHD recurrences because of failure in preventing risk factors after acute attacks (Indrawati, 2014). According to Miller and DiMatteo, disobedience to disease management caused by lack of health information, poor health behaviors, side effects of treatment, financial problems and depression (Miller & DiMatteo, 2016). Latimer AE, Katulak NA, and Mowad L stated that information has an important role to shape health behavior and help in determining actions in health management (Latimer, Katulak, Mowad, & Salovey, 2005). Furthermore previous study had indicated that there was a significant relationship between knowledge with the ability to perform secondary prevention in CHD patients (Indrawati, 2014). A good of health education, should be given based on the individual needs and patients’ characteristic. Assessment based on data from or about individuals related to health problems is important to determine, in order to give appropriate information or strategy in addressing individual learning needs (Rimer & Kreuter, 2006). Moreover Timmins explained, health education would be more
effective if based on perception of patients’ learning needs. One of the problems of health education program consist of the lack of patients’ learning needs assessment, thus it was given only based on health personnel perception (Timmins & Kaliszer, 2003). This study was conducted to analyze the learning needs of CHD patients based on patient perception, as a recommendation for subsequent education especially educational programs for CHD patients in western Java Indonesia. METHODS Study design This study was a descriptive quantitative with cross sectional approach. The aimed was to analyze CHD patients’ learning needs based on patients’ perceptions. The population was CHD patients who underwent care after acute attack in high care unit (HCU); non intensive care ward; outpatient unit; and cardiac rehabilitation unit at one of referral hospital in West Java Indonesia. The sample selected using consecutive technique sampling in a-2 months period with the respondents’ criteria were patients had diagnosed CHD (UAP, STEMI and NSTEMI); patients had passed acute phase or had no chest pain at least in 24 hour. Instruments The data collected using A Turkish Version of the Cardiac Patients’ Learning Needs Inventory; Patient Questionnaire (TR-CPLNI) (Uysal & Enç, 2012). This instrument had passed the validity and reliability test with the value of content validity index was 0.96, and alpha cronbach’s was at the interval 0.65 and 0.85 (p<0.01) for all of subscales. The Instrument had been translated into Indonesian through back translation method. Data analysis The respondents characteristics and the patients’ cardiac learning needs were analyzed using univariate analysis, consists of mean and distribution frequency. The patients’ learning needs was analyzed using mean
which the value is in the range of 1 – 5, the higher the mean score (close to 5) then the learning needs of CHD patients is higher (important). While comparison of learning needs was analyzed using nonparametric test with kruskall wallis. This test compared the difference of learning needs among patients who underwent care in different wards category. Its difference significant when p<0.05. Ethical consideration Ethical clearance for data collection had been obtained from the Research Ethics Committee of the General Hospital of Dr. Hasan Sadikin No. LB.04.01/A05/EC/206/VII/2017. All respondents had informed consent and agreed to participate in the research. RESULTS The study carried out on 106 respondents. Data about respondents’ characteristic
involved age, sex, level of education, and duration of illness. The respondents age was 57.86 year in average, and a very large majority was male (76.4%) and more than two-third (68.9%) respondents had been ill for more than 6 months. The level of education vary among respondents, but mostly respondents were primary school graduates (43.4%), and more than just a quarter were high school or university graduates (25.5%), respondents whose level of education were middle school was 31.1%. Other than that, the respondents who underwent care in HCU; non intensive care ward; outpatient unit; and cardiac rehabilitation unit respectively was 9.4%; 28.3%; 38.7%; and 23.6%. Furthermore the result of CHD patients’ learning needs was shown in tables 1 and 2. A mean score close to 5 indicates an increasingly important learning need according to the respondent's perception.
Table 1 CHD patients’ learning needs
Learning needs Min Max Mean Standard
deviation Anatomy and physiology of heart (the working of heart) 1.00 5.00 4.42 0.59 Medication information 2.00 5.00 4.33 0.70 Life style 2.00 5.00 4.28 0.68 Dietary information 1.40 5.00 4.19 0.69 Symptom management 1.33 5.00 4.08 0.75 Psychology 2.00 5.00 4.07 0.64 Miscellaneous 2.00 5.00 4.00 0.72 Physical activity 1.50 5.00 3.64 0.79
Table 2 CHD patients’ learning needs on miscellaneous needs
Other CHD patients’ Learning Needs (Miscellaneous)
Min Max Mean Standard deviation
Support services after leaving the hospital 1.00 5.00 3.81 0.88 Support for family 1.00 5.00 3.89 0.90 The test will be done after been discharge from hospital 1.00 5.00 4.00 0.88 Information about CPR for family 1.00 5.00 4.32 0.84 The CHD patients’ learning needs was also seen based on the duration of illness. According to the study, the most important learning needs perceived by patients who had
been diagnosed for less or more than 6 month was anatomy and physiology of heart. It is shown in chart 1.
Chart 1 CHD patients’ learning needs based on duration of illness
Chart 2 gives information about CHD patients’ learning needs viewed based on ward categories. The most highest score of patients’ learning needs in the HCU; non intensive care ward; outpatient unit; and
cardiac rehabilitation unit respectively were anatomy and physiology of heart; information about life styles; anatomy and physiology of heart; medication information and anatomy and physiology of heart.
Chart 2 CHD patients’ learning needs based on Ward Categories
Table 3 shows the significant CHD patients’ learning needs difference based on ward categories and duration of illness. Patients’ learning needs in the dietary information and physical activity different significantly at p<0.01 in the different ward category and also
significantly different at p<0.05 for information needs of symptom management. Furthermore the significant different is also shown for life styles information (p<0.05) in the duration of illness category.
Table 3 Comparison of patients’ learning needs based on ward categories and duration of illness
*p < 0.05; **p < 0.01
DISCUSSION Health education gives benefit for increasing a good self-management particularly for chronically ill patients (Peterson et al., 2014). CHD is one of the chronic illness which require a good self-management to prevent recurrences. Self-management in CHD patients according to Indrawati is related with the knowledges about secondary prevention. Indrawati stated that the higher the knowledge about the secondary prevention of CHD, the higher the ability of the patient in doing the prevention. It is confirmed the importance of health education for CHD patients (Indrawati, 2014). Health education can be effective if it is given based on the assessment of patients’ learning needs and its characteristic (Rimer & Kreuter, 2006). It was strengthen the Timmins’ statement in his previous study that the education program which was developed based on the health personnel’s learning needs perceptions had the lower effectiveness than the education which was given based on patients’ learning needs perceptions (Timmins & Kaliszer, 2003). Therefore it is important for the educator to look for the patients’ learning needs before giving health education, thus the aims of effective education can be fulfilled. The cardiac patients’ learning needs based on this study, described all the needs which consists of anatomy and physiology of heart; medication information; life style; dietary information; symptom management;
psychology; physical activity; and miscellaneous were important. Perception of the importance of all these learning needs by the respondents can be correlated with the common-sense theory. Based on the common-sense theory, representation of threats or illness or treatment procedures that should be performed by patients can influence patients’ perceptions to their illnesses (Leventhal, Diefenbach, & Leventhal, 1992). The more severe the threat of a disease will reinforce the patient's perception of the importance of treatment. CHD can be a very threatening disease for the sufferers, death threats are very close to patients with the disease, so that it will encourage the patients to do all treatment their need. This condition can be related with the patients’ perception about the importance of all learning needs. The patients’ learning needs about the anatomy and physiology of heart was the highest learning needs based on patients’ perception in this study. It can be explained using the common-sense theory. CHD cause severe pain to the patients, even often the patients feel his death is imminent when they are experiencing an acute attack. When he can pass through the acute phase, the patients curious to know why it happened, what is the cause, how hearts working and etc. Chest pain is the most obvious and often perceived as CHD representation by its patients. This symptom often reported by the patients as an experience which difficult to forget because they felt death was very close (Monahan, Sands, Neighbors, Green-nigro, & Marek, 2006). This condition will affect the patients
emotionally, so they consider CHD as a very high threat disease. It will increase the patient's curiosity about his heart condition, and place the learning needs of anatomy and physiology as the most important learning needs. The systematic review conducted by Scott and Thompson mentioned that, from 14 studies on the learning needs of CHD patients, none of these studies put the anatomy and physiology of the heart as the highest learning requirements (Scott & Thompson, 2003). The same result was given by Timmins, based on his study the most prioritized learning needs based on patients perception was symptom management, and anatomy and physiology need was the most prioritized by nurses’ perception (Timmins & Kaliszer, 2003). The different results occurred based on this study. The difference result in anatomy and physiology learning need with the previous studies may occur due to differences in patients’ characteristics and health services. Based on the results of interviews and observations on the education program in the research setting, discovered that education provided for patients include the PCI treatment and medication, whereas anatomy and physiology education was rarely given. The information of anatomy and physiology information on cardiac anatomy and physiology was limited to the underlying causes and risk factors of CHD. These conditions may cause patient dissatisfaction with the given information. The respondents especially for patients treated at HCU, they had just passed the acute period of CHD, so the sense of curiosity about the condition that occurred to the heart became very important to know. Based on the study has been known that nearly three quarter respondents (74.5%) had the education background at the primary and middle school, this can be related with their literacy level, Hadisiwi and Suminar stated that the literature and literacy awareness of the people in Indonesia is not as good as the people in developed countries, it is also related to the low level of education (Hadisiwi, 2016). Many CHD patients doesn’t know how CHD
happened, this may be one of the reasons why information about the anatomy and physiology of the heart became the highest learning need in this study, it was illustrated by many patients questions correlated with how chest pain occurs. Experience during an acute attack, often felt difficult to forget. Severe chest pain which is sometimes accompanied by shortness of breath and information about the high risk of death in CHD patients, increase the patient's curiosity about CPR. It was showed by the high of mean score in cardiac patients’ learning need on CPR information for family. The mean was 4.32 which imply this information was very needed by respondents. Another fourth cardiac patients’ learning needs which also important according to the patients’ perceptions from the highest to the lowest respectively were medicine information; life styles; dietary information; and symptoms management. In the rehabilitative period following the acute attack, patients will choose the information which can be used to assist them of how they be able to survive (Timmins & Kaliszer, 2003). It generated these four learning needs were important after the need of physiological and anatomy information. The results of this study are in line with previous studies mentioned that the need for drug information and symptom management was a requirement with the highest mean score compared to other needs (Timmins & Kaliszer, 2003). The lowest learning need which found from this research was information about physical activity. The representation of CHD to the patients’ physical activity is obvious but not perceived as a higher learning need than any other learning needs by the respondents. The same result was explained by Uysal on his study (Uysal & Enç, 2012). The other findings were differences in priority needs of patient learning in each ward category. This findings strengthen prior studies, which explained that the patients' learning needs at each stage of recovery have
different priorities, meaning that learning needs change over time (Mirka, 1994; Scott & Thompson, 2003). Based on ward categories the significant differences on patients’ learning needs emerge on the need of dietary information and physical activity (p<0.01), these needs were highest needed by patients who underwent treatment in HCU. In general, patients undergoing ICU treatment had a higher mean score of learning requirement than patients in other wards for all cardiac patients’ learning need aspects. This can be due to they had just experienced of an acute attacks, this can lead to increase of perceptions about the importance of those learning needs. So as with the illness duration categories, the higher learning need on life style information found on CHD patients whose diagnosed less than 6 months, it is indicated that in early period after a heart attack patients still need adjustments to their health conditions, and in the process of adjustment, they need a lot of precise information regarding the healthy lifestyle to prevent recurrences. It is imply that the best time to provide health education to CHD patients is in the early period after an acute attack. In that period patients have more awareness to learn about disease and its treatment as Timmins conveyed that the education would be effective when patient realized that they need it (Timmins & Kaliszer, 2003). The cardiac patients’ learning needs which consists of anatomy and physiology of heart (the working of heart); medication information; life style; dietary information; symptom management; psychology; miscellaneous (particularly CPR information); and physical activity were perceived important by CHD patients. The higher of learning needs was perceived by patients who were in the early period after the acute attack and the priority emphasis of the learning needs in each recovery phase is different and change over time. To achieve goals of health education effectively, nurses or health personnel must provide education based on the results of the learning assessment, and the education
program should be held at the beginning of the period after a heart attack. REFERENCES Hadisiwi, P. S., J. R. . (2016). Literasi Kesehatan
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Cite this article as: Nur’aeni, A., Mirwanti, R., Anna, A. (2018). Coronary heart disease patients' learning needs. Belitung Nursing Journal,4(3),287-294.
Ike Wuri Winahyu Sari1*, Sri Warsini2, Christantie Effendy 3
1Department of Medical Surgical Nursing, Faculty of Health Science, Universitas Jenderal Achmad Yani Yogyakarta, Yogyakarta, Indonesia
2Department of Community and Mental Health Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
3Department of Medical Surgical Nursing, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia *Correspondence: Ike Wuri Winahyu Sari School of Nursing, Faculty of Health Science, Universitas Jenderal Achmad Yani Yogyakarta, Yogyakarta, Indonesia Jalan Brawijaya, Ring Road Barat, Ambarketawang, Gamping, Sleman, Yogyakarta, 55294; Phone: +62-274-4342000 E-mail: [email protected] Abstract Background: There have been various studies into the family caregivers’ experiences in taking care of advanced-cancer patients. But, a study exploring the burden among family caregivers has not yet been conducted in Indonesia, a country which has strong family bonds among family members. Objective: This present study aimed to identify the burden among family caregivers of advanced cancer patients. Methods: This study was a cross-sectional study conducted from December 2016 to February 2017 on 178 consenting family caregivers and advanced cancer patients, selected using a purposive sampling technique. The Caregiver Reaction Assessment (CRA) was used to measure their burden. Data were analyzed using descriptive analyzes and bivariate analyzes. Results: The burden among family caregivers was 2.38 ± 0.38 (mean range 1-5). The highest burden was in the disrupted schedule domain. Conclusion: Our findings identified that the burden among family caregivers was at the medium level. The length of care per day and family support are potential targets for preventative intervention strategies to reduce the burden among the family caregivers. Keywords: burden, cancer, family caregivers, Indonesia, palliative care
INTRODUCTION The World Health Organization (WHO) predicts that by 2020, more than 15 million people worldwide will suffer from cancer, and the mortality rate will increase by approximately 70% in the low- and middle- income countries (WHO, 2016). Cancer is one of the chronic diseases that has become a major health problem in Indonesia, one of the developing countries. The highest prevalence of cancer in Indonesia is found in Yogyakarta, and is recorded at 4.1% per 1,000 population for all ages (Riskesdas, 2013).
Cancer is a group of diseases characterized by uncontrolled cell growth and abnormal cell spreading (ACS, 2016). It can metastasize to other organs and can be incurable, i.e. advanced-cancer (ACS, 2016; National Cancer Institute, 2016). Advanced-cancer patients can experience multiple suffering from the disease itself, and also from the side effects of treatment, i.e. physical, psychosocial, and spiritual problems (Effendy et al., 2015).
The patient’s immediate family members, commonly known as family caregivers, are the people who are most responsible for the care of cancer patients (Rha, Park, Song, Lee, & Lee, 2015). Family caregivers experience a change in their lives, since they are responsible for taking care of cancer patients. Subsequently, the family caregiver, for the most part, assumes that such change is a pressure resulting in a burden for them (B. A. Given, Given, & Kozachik, 2001). The burden felt by family caregivers may have various underlying factors. It may come from the family caregiver, their environment, and/or the cancer patient undergoing treatment (Chou, 2000; Goldstein, Concato, Fried, & Kasl, 2004; Papastavrou, Charalambous, & Tsangari, 2009, 2012; Rafiyah, 2011). There have been various studies into the family caregivers’ experiences in taking care of advanced-cancer patients conducted in Asia and America (Effendy et al., 2015; Goldstein et al., 2004; Rha et al., 2015). Indonesia, like other Asian countries, has strong family bonds among family members (Effendy et al., 2015). But, a study exploring the burden among family caregivers has not yet been conducted in Indonesia. This can provide new findings from Indonesia. The aim of the present study is to identify the burden among family caregivers of advanced-cancer patients. METHODS Setting and population A cross-sectional design was used in this study. Data were collected from general hospitals in Yogyakarta and Purwokerto, Indonesia from December 2016 to February 2017. The eligibility criteria for the family caregivers were as follows: (a) Adults (older than 17 years); (b) taking care of advanced-cancer patient (stage III or IV) regardless of the type of cancer, or whether the cancer was newly diagnosed or recurrent, or treated with chemotherapy or radiotherapy; (c) being confirmed as the main caregiver by the patient (d) having accompanied the patient during hospitalization for at least 3 days, (e) taking care of the patient’s daily needs, (f) being able
to communicate; and (g) willing to consent to participate in the study. The eligibility criteria for the patients were as follows: (a) Adults (older than 17 years); (b) advanced-cancer patient (stage III or IV) regardless of the type of cancer, or whether the cancer was newly diagnosed or recurrent, or treated with chemotherapy or radiotherapy; and (c) willing to consent to participate in the study. A total of 191 family caregivers with their patients met the inclusion criteria, but only 178 consenting family caregivers with their patients formed our final sample (9 family caregivers did not stay in the room with the patient, and 4 patients did not agree to participate). Measure Demographic variables The first section of the survey instrument were the characteristics of the family caregivers, including their demographic characteristics’ questions such as age, gender, ethnic type, marital status, relationship with the patient, education level, income, and health status; the characteristics of the family caregivers included caring characteristics’ questions such as the lenght of care provided per day, previous caring experience, health education experience, time spent travelling from their home to the hospital; and patients’ characteristics such as their age, gender, and performance status. Family caregivers’ burden The Caregiver Reaction Assessment (CRA), developed by Given et al. (C. W. Given et al., 1992) was used in the present study. It has 24 items that contain five dimensions for the family caregivers’ situation: Self-esteem (7 items), lack of family support (5 items), impact on finances (3 items), impact on daily schedule (5 items), and impact on health (4 items). The perceived impact is rated on a 5-point Likert scale, with the format: 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), 5 (strongly agree). Each domain was added to a sum score, which was divided by the number of items, reflecting the unweighted mean-item score, with a mean range from 1 to 5. This kind of scoring was modified by Grov et al. (Grov, Fosså,
Tønnessen, & Dahl, 2006). In order to calculate the sum score, the self-esteem dimension was recoded. The CRA’s total score, as the sum score of the 24 items overall, reflects the caregiver’s situation. The higher scores reflect a higher burden. The CRA was translated into Indonesian, and then back-translated, following the appropriate processes. Cronbach’s alpha for the CRA was 0.761 at the baseline. Two items about the caregivers’ esteem (numbers 1 and 12) were not valid (Pearson correlation (r) < 0.199) but it was decided to still use them in this study. Family support The family’s Adaptability, Partnership, Growth, Affection, and Resolve (APGAR), developed by Smilkstein, Asworth, & Montano (Smilkstein, 1978), was used in the present study. It has five items to assess a family caregivers’ perception of the functioning of the family by examining their satisfaction with the family’s support. The response options were designed to describe the frequency of feeling satisfied with each parameter on a Likert scale ranging from 0 (hardly ever) to 2 (almost always). The scale was scored by summing the values for the five items for a total score, ranging from 0 to 10. A higher score indicated a greater degree of satisfaction with the family’s functioning. The family APGAR was also translated into Indonesian and then back-translated following the appropriate processes. Cronbach’s alpha for the family APGAR was 0.896 at the baseline. All items were valid because it has a Pearson correlation (r) > 0.182. Patients’ performance status The Palliative Performance Scale (PPS) is a tool to measure the performance status of palliative care, developed by Anderson, Downing, & Hill (Anderson, Downing, Hill, Casorso, & Lerch, 1996). The PPS is divided into 11 categories that are measured at 10% decreasing stages (100% to 0%). The lower the PPS level, the higher is the need for help from professionals or family caregivers. There are five observable parameters included in the functional assessment, such as the degree of ambulation, the ability to carry out activities,
the ability to do self-care, the intake, and level of consciousness. The PPS was translated into Indonesian and back-translated following appropriate processes. Cronbach’s alpha for the PPS was 0.982 at the baseline; Cohen’s Kappa was 0.814; and the average measure of the Interclass Correlation Coefficient (ICC) was 0.982. Statistical analyzes The Statistical Package for the Social Sciences (SPSS) (version 16, SPSS, Inc., Chicago, IL, USA) software package was used for entry data and analyzes. The descriptive normality test was used to describe the normality of the numerical data. Mean values and Standard Deviation (SD) were used when symmetrical. Median values and Inter-quartile Ranges (IQR) were used when skewed. The independent t-test was used in order to compare the difference in the mean of the burden, according to the family caregivers’ and patients’ characteristics. The Pearson correlation and the Spearman Rho coefficient were used in order to correlate the burden with the family caregivers’ and patients’ characteristics. A p-value of < 0,05 was considered statistically significant. Ethical Consideration The Institutional Review Board of the Faculty of Medicine at Universitas Gadjah Mada, Yogyakarta, Indonesia, approved all the materials and protocols used in this study (Number: KE/FK/1318/EC/2016). All the family caregivers and patients gave their written informed consent to participate in this study. RESULTS General characteristics of family caregivers and patients The characteristics of the respondents are summarized in Table 1. One-hundred and seventy eight consenting family caregivers and patients were included in the final analysis. The mean age of the family caregivers and patients was 44.03 ± 12.69 years old and 51.64 ± 10.84 years old, respectively. Most of the
family caregivers were married (83.1%), almost half of them (47.2%) were spouses, and 60.7% of them had a low income (< 1,338,000 IDR). Most of the family caregivers have no
previous experience of caring, or health education about cancer (59%; 67.4%, respectively).
Table 1 General characteristics of family caregivers and patients (n = 178)
Characteristic Family caregivers (n/%) Patients (n/%)
Age (years) (Mean±SD) 44.03±12.69 51.64±10.84 Gender
Male 73 (41.0) 63 (35.4) Female 105 (59.0) 115 (64.6)
Education level Illiterate to senior high school 146 (82.1) College 32 (17.9)
Family incomea < Minimum income level 108 (60.7) ≥ Minimum income level 70 (39.3)
Time spent from home to the hospital (hours) (Median;IQR) 1.5(1.00-2.00) Lenght of care per day (hours) (Median; IQR) 24.00(17.5-24.00) Previous caring experience
Yes 73 (41.0) No 105 (59.0)
Health education experience about cancer Yes 58 (32.6) No 120 (67.4)
Health status Good 145 (81.5) Have symptom of disease 33 (18.5)
Family support (Median; IQR) 10.00(5.00-10.00) Performance status (Mean±SD) 68.76±16.04
aThe minimum income level in Yogyakarta and Purwokerto, Indonesia: 1,338,000 IDR; SD. Standard Deviation; IQR. Inter-quartile Range
Family caregiver burden As seen in Table 2, the mean overall burden score was 2.38 ± 0.38. The highest burden was the impact on the daily schedule’s dimension
and the lowest burden was on the caregiver’s self-esteem dimension (mean 3.26 ± 0.80; 1.65 ± 0.33 respectively).
Table 2 Family caregiver burden (n = 178)
Domains (items) Mean range Mean±SD Caregiver self-esteem (7 items) 1.00-5.00 1.65±0.33 Lack of family support (5 items) 1.00-5.00 2.62±0.78 Financial problem (3 items) 1.00-5.00 2.47±0.71 Disrupted schedule (5 items) 1.00-5.00 3.26±0.80 Health problem (4 items) 1.00-5.00 2.20±0.61 CRA total score (24 items) 1.00-5.00 2.38±0.38
CRA. Caregiver Reaction Assessment; SD. Standard Deviation Bivariate analyzes
As seen in Table 3, we found that the family caregivers’ age (p = 0.008), marital status (p = 0.009), relationship with the patient (p < 0.001), education level (p = 0.001), family income (p < 0.001), lenght of care per day (p <
0.001), health status (p = 0.042), family support (p < 0.001), and the patients’ gender (p = 0.001) were statistically significant with the burden (CRA) of family caregivers.
Table 3 Correlation/comparison between family caregiver and patient characteristics with burden (n=178)
Family caregivers age (years) - 0.200 0.008** Family caregivers gender - 0.457
Male 2.36±0.38 Female 2.40±0.39
Family caregivers ethnic - 0.671 Javanese 2.39±0.39 Non-Javanese 2.33±0.24
Family caregivers marital status - 0.009** Married 2.42±0.37 Non-married 2.22±0.43
Relationship with patient - <0.001** Spouse 2.50±0.34 Non-spouse 2.28±0.39
Education level - 0.001** Illiterate to senior high school 2.43±0.38 College 2.19±0.32
Family income - <0.001** < Minimum income level 2.50±0.36 ≥ Minimum income level 2.21±0.35
Lenght of care per day 0.372 <0.001** Previous caring experience - 0.290
Yes 2.35±0.41 No 2.41±0.37
Health education experience about cancer - 0.323 Yes 2.34±0.39 No 2.40±0.38
Family caregivers health status - 0.042* Good 2.36±0.37 Have symptom of disease 2.51±0.44
Family support - -0.287 <0.001** Time spent from home to the hospital (hours) - 0.026 0.728 Patients age (years) - -0.027 0.722 Patients gender - 0.001**
Male 2.51±0.37 Female 2.32±0.38
Patient performance status - -0.077 0.309 aIndependent t-test; bPearson correlation or Spearman Rho; **p < 0.01 indicate significance; *p < 0.05 indicate significance; SD. Standard Deviation
DISCUSSION Main findings In the present study, the mean of the family caregiver’s burden was 2.38, with a mean range of 1-5 (Table 2). This finding corroborates a previous study (Rha et al., 2015), although using different instruments to measure the burden. Korean family caregivers
experience a moderate burden when taking care of cancer patients (Korean version-Zarit Burden Interview (K-ZBI) = 36.45 range 10-74). A study in Taiwan (Lee, Yiin, & Chao, 2016) also showed that the mean of the family caregiver’s burden in taking care of cancer patients in the terminal stage was 62.2-64.3, range 24-120 using a CRA instrument (the score was not divided by the total number of
items). This similarity is because these two countries are located in the same area of Asia. Asian cultures hold strong bonds among family members (Effendy et al., 2015; Rha et al., 2015; Yoon, Kim, Jung, Kim, & Kim, 2014). They also have the belief that taking care of family members is an obligation (Effendy et al., 2015; Yoon et al., 2014). The difficulties experienced by family caregivers, in terms of the lack of family support and disruptions to their daily schedule were secondary to their desire to care for their loved ones (Yoon et al., 2014). In contrast with this present study, a study on family caregivers taking care of advanced-cancer patients conducted in the South of England showed different results (Higginson & Gao, 2008). That study found that the family caregivers’ burden was low (ZBI score 18.55 range 10-74) (Higginson & Gao, 2008). In taking care of advanced-cancer patients, England applies a home-based palliative care service, the implementation of which is carried out in a participative manner by actively involving the patient and the family caregiver. Beside that, England is one of a number of European countries which value independence (Effendy et al., 2015; Vernooij-Dassen, Osse, Schadé, & Grol, 2005). Therefore, the family caregivers’ burden was low. Family caregivers who take care of male patients experience a greater burden compared to family caregivers who look after female patients. This is in line with a study conducted in Greece (Govina et al., 2015). That study specified that female patients will be more independent in addressing their own daily needs (Govina et al., 2015). In terms of social status, the male is the head of the family. If he is sick or unable to provide for his family, surely this will be a burden for his family caregiver. Based on this present study, the older the family caregiver is, the greater is the burden on the family caregiver. This is in line with a study conducted in Iran which stated that the age of a family caregiver is related to the burden they face, although the average age of
the family caregivers in Indonesia and Iran is different (Vahidi et al., 2016). The greater burden experienced by the more elderly caregivers is mainly due to the social status, physical, and psychological factors of the caregiver (Harding et al., 2015). The social status changes in middle and late adulthood, commonly this is caused by unemployment; while, in terms of the physical issues, the aging process plays a significant role. Whereas in terms of their psychology, family caregivers face the fear of losing someone they love due to aging (Harding et al., 2015). That result was in contrast with an American study which found that younger family caregivers felt more of a burden than older ones (Goldstein et al., 2004). The younger family caregivers felt a greater burden because they had to take care of their own family, as well as their patients, so that they had multiple roles to fill (Goldstein et al., 2004). In this study, the greater the family’s support is, the lesser the burden is on the family caregiver. This result is supported by the greater average rate of family caregivers’ burdens, in terms of the lack of family support. It is in line with the previous study conducted in Korea and two studies in America (Burton et al., 2012; Francis, Worthington, Kypriotakis, & Rose, 2010; Yoon et al., 2014). These three studies concluded that a lack of family support and visits will make the uncomfortable situation of taking care of a patient, in an advanced stage of cancer, much worse (Burton et al., 2012; Francis et al., 2010; Yoon et al., 2014). Family caregivers with low incomes carry a very heavy burden, compared to a family caregiver with a large income. Economic issues, evidently, are one of the main findings in developing countries (Ratnawati & Loebis, 2014; Vahidi et al., 2016). The two biggest concerns for family caregivers are insurance and treatment costs (Vahidi et al., 2016). Family caregivers are under pressure, not only due to their income, but they also have to pay for their patients’ required treatments, as well as their own and their family’s needs (Ratnawati & Loebis, 2014).
In this present study, the longer the family caregiver spends taking care of an advanced-cancer patient, the greater will be the family caregiver’s burden. This is in line with the studies conducted in Korea and Greece which signified that the lenght of care per day serves as the significant factor in terms of the greater burden borne by the family caregiver, particularly because of its impact on their schedule (Govina et al., 2015; Yoon et al., 2014). The longer they spend each day caring for their patient, the less time they have for their hobbies, social life, and meeting their own basic needs (Yoon et al., 2014). The longer the family caregiver spends with the patient will result in the greater dependency of the attended family member on the caregiver to meet the attended family member’s needs (Govina et al., 2015). Surprisingly, this factor had the strongest effect on the family caregivers’ burden. Lenght of care per day was not the strongest factor in two previous studies (Govina et al., 2015; Yoon et al., 2014). This could be due to the difference in the duration of care per day between Korea, Greece, and Indonesia. Family members in Indonesia accompany the patient almost 24 hours a day (Effendy et al., 2015). This may have positively impacted on the family caregivers’ burden. In this present study, family caregivers with a lower education level have a greater burden compared to a family caregiver with a higher education level. A person having a higher education level will employ issue-focused coping when facing difficulties, instead of emotional coping (Papastavrou et al., 2009). The level of education is closely related to a person’s socioeconomic status (Govina et al., 2015). A person with lower education levels will struggle to find a high-paying job, and they will end up in a low-paying job (Govina et al., 2015; Ratnawati & Loebis, 2014). This subsequently will trigger the burden. The results of this study showed that the married family caregivers have a greater burden compared to the single ones. Family caregivers having a spousal relationship
(husband/wife) with the advanced-cancer patient bear a greater burden compared to the family caregiver with a non-spousal relationship. The results of this study are supported by research conducted in Greece (Govina et al., 2015). Although the family caregiver is not always the spouse of the patient, when the family caregiver’s marital status is married, he/she must also take care of his/her own family members, in addition to attending to the needs of the cancer patient (Govina et al., 2015). This will increase the burden of the family caregiver. A study conducted in Canada affirmed that the spouse holds the greatest burden when attending an advanced-cancer patient (Braun, Mikulincer, Rydall, Walsh, & Rodin, 2007). A spouse is the person at the highest risk of experiencing the burden when taking care of an advanced-cancer patient (Braun et al., 2007). In this study, a family caregiver suffering from symptoms of the illness bears a greater burden compared to a healthy one. This is in line with research conducted in Iran (Vahidi et al., 2016). Family caregivers who are in good health are physically stronger and more capable of providing for their family member with advanced- cancer, and therefore feel less of the burden (Vahidi et al., 2016). This study was the first study about the family caregivers’ burden for advanced-cancer patients in Indonesia, a developing country with a huge population, with a diversity of cultures and many people who still have a low socioeconomic status. Because this study has not been explored previously, it provides a better understanding of the family caregivers’ burden and helps identify family caregivers who are at higher risk of being overburdened. This study has several limitations that must be improved by the next research. Firstly, it is difficult to generalize our result, because there were only two hospitals included in this study, in only two provinces in Indonesia. Secondly, there were two items on the CRA instrument (number 1 and 12) that were not valid, but were still used. It was due to the importance of these items that we measured the caregivers’
esteem on the family caregivers’ burden. The exploration of the CRA instrument must be done on the other populations. Using our results, preventative interventions could be possible in the early days of admission, to reduce the family caregiver’s burden. Since the nurses are in close contact with the family caregivers, we recommend that they pay more attention to the family caregivers' needs. They can also make an assessment of the family caregiver with the highest risk of burden. The long duration of care can create possible moments for the nurses to conduct a health education or basic skills training program for family caregivers so they are not bored. CONCLUSION The burden was higher for family caregivers who spend a greater amount of time per day caring for their patient, suffer from a lack of family support, and have symptoms of the disease. These three characteristics were identified as modifiable factors that could be potential targets for preventative intervention strategies to reduce the burden. Developing and applying interventions, such as giving an education program about cancer care, or involving family caregivers in advanced care planning, may be important to reduce the burden among family caregivers in caring for a family member suffering from advanced cancer. Acknowledments We also thank the research assistants (Yulia, Cindy, Dyah) who assisted with the data collection. Conflict of Interest The authors declare that there is no conflict of interest. References ACS. (2016). If Treatment for Cervical Cancer Stops
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Cite this article as: Sari, I.W.W., Warsini, S., Effendy, C. (2018). Burden among family caregivers of advanced-cancer patients in Indonesia. Belitung Nursing Journal,4(3),295-303.
Mira Triharini1,2*, Ni Ketut Alit Armini2, Aria Aulia Nastiti2
1Doctoral Student’s Health Science of Public Health Faculty, Universitas Airlangga, Surabaya, Indonesia 2Department of Maternity and Pediatric Nursing, Nursing Faculty, Universitas Airlangga, Surabaya, Indonesia
*Correspondence: Mira Triharini Department of Maternity and pediatric nursing, Nursing Faculty, Universitas Airlangga Kampus C, Jl. Mulyorejo, Mulyorejo, Surabaya, Kota SBY, Jawa Timur, Indonesia 60115 Email: [email protected] Abstract Background: Anemia during pregnancy is a major nutritional problem that can cause health problems for mothers and their fetus. Prevention of anemia has been done but many obstacles are perceived by pregnant women. Families need to provide support to improve the prevention behavior of anemia. Objective: This research aims to explore the effect of educational intervention on family support for pregnant women in preventing anemia. Methods: A quasi-experimental design was carried out on 60 pregnant women who had done pregnancy check ups at Community Health Centre and had received iron supplement, in which 30 women were in the experimental group and the rests were in the control group. This study was conducted from December 2016 to January 2017. Family support was measured using questionnaires before and after educational intervention. Results: After educational intervention, there was a significant change from the pretest score to the posttest score in the experimental group (p<0.05). There was an increase in the average score in the experimental group, 14.47 ± 2.89 becomes 16.83 ± 2.32. Conclusion: Educational interventions can increase family support for maternal behavior in preventing pregnancy anemia such as improving adherence to taking iron supplements and high intake of food containing iron. Keywords: Anemia, Family Support, Pregnancy, Iron Supplement.
INTRODUCTION Iron deficiency anemia in pregnant women is still a major nutritional issue. Appropriate data of Riskesdas showed that there were 37.1 pregnant women with anemia (Riskesdas, 2013). While the incidence of anemia in East Java was 25.3% (Rizki, Widodo, & Wulandari, 2016). Anemia in pregnant women has an impact on her and their fetus. Preterm delivery and low birth weight are associated with anemia for pregnant women in the third trimester (Kumar, Asha, Murthy, Sujatha, & Manjunath, 2013). Anemia can also adversely effect on mothers such as the occurrence of
infection and postpartum hemorrhage in the postpartum period (Van Bogaert, 2006). Anemia in pregnancy is a condition in women with hemoglobin levels below 11 gr/dl in the first and third trimester or the hemoglobin level <10.5 gr/dl in the second trimester (Varney, Kriebs, & Gegor, 2007). Anemia prevention efforts can be done by increasing the intake of iron through food and reducing the consumption of foods that can inhibit the absorption of iron such as fitat, phosphate, and tannin (Wiknjosastro, 2005).
The fulfilment of iron needs in pregnant women (Riskesdas, 2013). During pregnancy, there is an increase in the needs of iron. The amount of iron that can be absorbed through food has not been able to fulfil the needs of iron in pregnant women. Iron supplements are essential to prevent iron deficiency (Bothwell, 2000). Various obstacles can be felt by the pregnant women in taking iron supplements. The presence of fear of side effects that may harm the health of infants will affect adherence (Taye, Abeje, & Mekonen, 2015). Iron supplements taken also may cause gastrointestinal discomfort that mothers feel as nausea after taking that further makes them lazy to take the supplements regularly (Tolkien, Stecher, Mander, Pereira, & Powell, 2015). Iron supplements are given in addition since the food cannot fulfil the iron needs. Foods containing iron, protein, and vitamin C are excellent for preventing anemia. Iron in the diet can be found in meat, fish, chicken, liver, eggs, green vegetables, and beans. Vitamin C is widely found in spinach, broccoli, guava, papaya, and tomatoes (Nadesul, 2000). Family support can be provided in the form of informative, emotional, instrumental and assessment support (Setiadi, 2008). Family support for pregnant women provides benefits for both mother and fetus. Family support provided will make mothers feel strong and able to overcome the perceived obstacles. Research results in India showed that emotional support is more needed by pregnant women than other types of support. There are no complications in pregnant women and neonatal (Haobijam, Sharma, & David, 2010). Other researches support the importance of family support for pregnant women. Mothers with a supportive partner were 63% less likely to experience low birth weight and nearly 2 times less likely to have pregnancy loss compared to those with no partner support (Shah, Gee, & Theall, 2014). To be able to provide good support for pregnant women in the prevention of anemia, it is necessary to increase knowledge on the family about the importance of support pregnant women. This research aims to determine the effects of educational intervention on family support for
pregnant women in preventing anemia in Surabaya. METHODS Study design The research used a quasi-experimental design with two groups, pretest and posttest was conducted from December 2016 to January 2017. The population was pregnant women receiving antenatal care at Community Health Centers of Sidotopo Wetan and Tanah Kali Kedinding Surabaya, East Java, Indonesia. Research subjects This study used the Consecutive sampling method. Selection of sample by selecting subjects that met the criteria of research until a certain period until the fulfillment of the required number of samples (Sastroasmoro & Ismael, 2002). The sample which met the inclusion criteria were 60 mothers. 30 of them were in the experimental group and the rests were in the control group. Inclusion criteria were the pregnant women who got iron supplements from Community Health Center and gestational age of 13-33 weeks. Exclusion criteria were the pregnant women with health problems that occur during pregnancy and require medical treatment such as gestational diabetes, preeclampsia, hyperemesis gravidarum, and infection. Intervention Educational interventions were given to pregnant women and their families for two meetings. The first meeting discussed anemia and family support on prevention of pregnancy anemia. At the end of the first meeting, the pregnant women were given a monitoring card of the consumption of iron tablets at home. Families have a duty to remind pregnant women to take tablets appropriately. The monitoring cards will be reassembled during the second meeting in the following week. At the second meeting, an evaluation of the compliance of iron tablet consumption was based on monitoring cards that had been filled at home. At the second meeting, the family support that had been given so far and the
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obstacles felt by pregnant women were discussed in each meeting and held for 2 hours through lectures and discussion methods. This research was conducted at two Community Health Centers. The experimental group at Community Health Centers of Tanah kali kedinding and the control group at Community Health Centers of Sidotopo Wetan. In this study the control group was only given leaflet about prevention of anemia from researchers and did not get educational intervention such as the experimental group. After the researchers obtained posttest data in the control group, the researchers conducted educational interventions in the control group. Instrument Data collection tools were sociodemographic characteristic questionnaires about family support. The sosiodemographic characteristics questionnaire consisted of questions about age, parity, education and income. The questionnaire was developed by researchers with items according to concept of family support in the Health Promotion Model, the theory of anemia pregnancy, and forms of family support (Pender, 2011; Setiadi, 2008; Sharma & Shankar, 2010). In the preparation of the contents of the questionnaire, researchers assisted by two experienced nurses in the field of maternity nursing. Translation processes by qualified translator and proofreader from Indonesia. Before being used in data collection, questionnaires that have been compiled were tested for validity and reliability on 17 pregnant women who attending antenatal care at Community Health Center of Tanah Kali Kedinding Surabaya. The initial questionnaire composed consists of 8 questionnaires. The results of the validity test show Corrected Item-Total Correlation between 0.294-0.776 (df = 15; r = 0.482). Cronbach's alpha shows 0.791. By issuing an invalid question item, the questionnaire validity test results obtained 5 items questionnaire question with Corrected Item-Total Correlation between 0.453-0.728, Cronbach's alpha: 0.762. The family support questionnaire consisted of questions about giving advice for any complaints due to taking iron,giving compliment for taking iron tablets
regularly, understanding and helping house work, and supporting pregnancy checkup regularly. The questionnaire consisted of 5 questions with Likert scale items with options of always, often, sometimes, rarely, and never. Score range was 0-20, in which the lower score indicated lower levels of family support. Family support in this study is the perception of pregnant women to the support provided by the husband in the prevention of anemia. Ethical consideration Sampling began after obtaining ethical approval from the Ethics Committee of Faculty of Nursing of Universitas Airlangga Surabaya, Indonesia (Ethics code:242-KEPK). Written informed consent was obtained from all individuals who agreed to participate in the research, while information collected was used only for the intended purposes in which the confidentiality was ensured. Data analysis The Wilcoxon test was used to examine the differences between the pretest and posttest scores for both the experimental group and control group. Descriptive statistics including frequency, percentage, mean, and standard deviation were used to describe sosiodemographic characteristics and family support. In all statistical analyses, a p-value of < 0.05 was considered significant. All data were analyzed using SPSS software. RESULTS Sociodemographic characteristics Table 1 showed that the majority of respondents were aged 25-35 years both in the experimental group (66.67%) and the control group (63.33%). The majority of respondents had a 1 parity both in the experimental group (36.7%) and the control group (43.3%). More than half of experimenta lgroup (66.7%) and control groups (53.3%) had secondary education levels. More than half of experimental group (63.3%) and the control group (66.67%) had income of < 3 million rupiahs.
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Table 2 presented the distribution of participants in the experimental group before and after the intervention. There was an increasing number of participants who gave the answer ‘always’ to all statements in the questionnaire. In posttest, there was as much as 33.33% women that stated “Family gives advice for any complaints due to taking iron tablets”, 60.00% women that stated “Family gives compliment for taking iron tablets regularly”, 60.00% women that stated “Family understands and helps doing housework”,
76.67% women that stated “Family provides budget for nutritional food”, and 93.3% women that stated “Family supports pregnancy check up regularly’. There was a decrease in the number of participants who gave answer ‘always’ to the statement “Family gives advice for any complaints due to takingiron tablets” from 26.67% to 23.33%, “Family understands and helps doing housework” from 73.33% to 60.00%,“Family provides budget for nutritional food” from 90% to 86.67%.
Table 2 Distributions of participants based on family support in experimental grup and in control group
Statement Pretest Posttest
always often sometimes rarely never always often sometimes rarely never n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Experimental grup Family gives advice for any complaints due to taking iron tablets
6 (20.00)
6 (20.00)
7 (23.33)
2 (6.67)
9 (30.00)
10 (33.33)
11 (36.67)
5 (16.67)
1 (3.33)
3 (10.00)
Family gives compliment fortaking iron tablets regularly
14 (46.67)
6 (20.00) 5 (16.67) 0
(0.00) 5
(16.67) 18
(60.00) 7 (23.33) 5 (16.67) 0 (0.00)
0 (0.00)
Family understands and helps doing housework
9 (30.00)
12 (40.00) 7 (23.33) 1
(3.33) 1
(3.33) 18
(60.00) 5 (16.67) 6 (20.00) 1 (3.33)
0 (0.00)
Family provides budget for nutritional food
19 (63.33)
5 (16.67) 1 (3.33) 0
(0.00) 5
(16.67) 23
(76.67) 2 (6.67) 1 (3.33) 0 (0.00)
4 (13.33)
Family supports pregnancy checkup regularly
23 (76.67)
6 (20.00) 1 (3.33) 0
(0.00) 0
(0.00) 28
(93.33) 2 (6.67) 0 (0.00) 0 (0.00)
0 (0.00)
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Table 3 presented the analysis of the mean and standard deviation score item of family support in both the experimental and control group, before and after the intervention. Of the 5 family support statements in the posttest
experimental group ‘Family supports pregnancy checkup regularly” had the highest scores (3.93 ± 0.25) and ‘Family gives advice if mother has any complaints due to taking irontablets" had the lowest score (2.80 ± 1.24).
Table 3 Items analysis of family support in experimental and control group
Table 4 Comparison of family support scores between the experimental and control group
Scale Family support score (a) Pretest
E group (n=30) 14.47 ± 2.89 C group (n=30) 16.20 ± 3.18 (b) Posttest E group (n=30) 16.83 ± 2.32 C group (n=30) 16.37 ± 3.00 (b) Posttest- (a) Pretest E group (n=30) 2.36 ± 2.48 P value wilcoxon test 0.000 C group (n=30) 0.17 ± 2.35 P value wilcoxon test 0.835
E group = experimental group C group = control group
Table 4 presented result from Wilcoxon test used to examine the differences between the
pretest and posttest scores for both the experimental group and control group. After
Control group
Family gives advice for any complaints due to taking iron tablets
8 (26.67)
6 (20.00) 8 (26.67) 0
(0.00) 8
(26.67) 7
(23.33) 10
(33.33) 3 (10.00) 0 (0.00)
10 (33.33)
Family gives compliment for taking iron tablets regularly
13 (43.33)
4 (13.33) 8 (26.67) 3
(10.00) 2
(6.67) 18
(60.00) 4 (13.33) 4 (13.33) 3 (10.00)
1 (3.33)
Family understands and helps doing housework
22 (73.33)
2 (6.67) 4 (13.33) 0
(0.00) 2
(6.67) 18
(60.00) 7 (23.33) 3 (10.00) 0 (0.00)
2 (6.67)
Family provides budget for nutritional food
27 (90.00)
3 (10.00) 0 (0.00) 0
(0.00) 0
(0.00) 26
(86.67) 3 (10.00) 1 (3.33) 0 (0.00)
0 (0.00)
Family supports pregnancy checkup regularly
28 (93.33)
2 (6.67) 0 (0.00) 0
(0.00) 0
(0.00) 28
(93.33) 2 (6.67) 0 (0.00) 0 (0.00)
0 (0.00)
308
Triharini, M., Armini, N.K.A., Nastiti, A.A. (2018)
educational intervention, statistically significant changes from the pretest to the posttest were found in the experimental group (p < 0.05). No significant increases occurred in the control group’s score (p = 0.835). Comparison of increased mean scores showed that the experimental group had a significant increase in score (2.36) compared with the control group (0.17). DISCUSSION Mothers, during pregnancy, experience physical and psychological changes that make them stressful. Support from their husband or family is very important thatit gives many benefits such as happiness and anxiety decrease that will also afironct the condition of the fetus. The support provided may be both emotional and physical support. Emotional support, such as giving encouragement, compliment, and advice, was given if pregnant women had problems. While physical support was such as helping doing housework, providing budget for fulfilling their needs, accompanying them during pregnancy checkup, and providing them relaxation therapy (WebMD, 2018). Maternal anxiety will increase pregnancy problems, so family support will be more necessary. Anxiety is influenced by low levels of education and income (Gourounti, Anagnostopoulos, & Sandall, 2014). Emotional support given by family also had a significant relationship with outcome during pregnancy (Haobijam et al., 2010). Family support can be provided in the form of informative, emotional, instrumental, and assessment support (Setiadi, 2008). Informative support can be done by reminding the mothers to taketablets regularly in the right way and reminding them to have nutritious food every day. Emotional support can be done by listening to their complaints and providing time to talk about problems experienced. Instrumental help can be done by providing them nutritious food. Fulfilling iron needs through food can also be a problem if family has no knowledge of the importance of
nutritious food for pregnancy. This causes the family to provide less budget for the provision of nutritious food for the pregnant women. Assessment assistance can be done by helping pregnant women in solving their problems, providing motivation and giving them compliment. Family support for pregnant women is influenced by several factors from the family. The lack of knowledge of the husband about the cause of anemia and how to overcome it will lead to decreased support from husbands to pregnant women (da Costa Fernandes, 2017). Culture and perception in society greatly affect the action of pregnancy care. The culture of society often set about food that may and should not be eaten by the pregnant women. Culture are difficult to change through the provision of health education in a short time (Kavle et al., 2014). Family patterns, such as the status of husband and members of the husband's family as a culture in Qatar, can also affect the health care to pregnant women, so that sensitive health education is culturally needed to increase family knowledge and able to provide support to pregnant women (Kridli, Ilori, & Verriest, 2012). Education for family is needed to increase knowledge and provide support for pregnant women appropriately. The educational interventions provided for pregnant women and family contain materials on the understanding of anemia, the danger of anemia to mothers and infants, precautions, forms of family support, as well as the perceived benefits to pregnant women who will get support from the family. Several pregnant women who were respondents in the experimental group, after the education intervention, claimed to have received no support from their family in preventing anemia in the statement of "Family gives advice for any complaints due to taking iron tablets" and "Family provides budget for nutritional food". Family support in advice is related to family’s education and culture, where it is difficult to change through the educational interventions that have been done.
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Material support on the a budget provision for nutritious food is related to family income levels. The demographic data showed that the majority of pregnant women’ family income was <3 million rupiahs. Although families understood the benefits of nutrition for pregnancy health, the limited income made them prioritize other needs. The increase of the mean posttest score compared to of the pretest in the experimental group showed that the educational intervention provided had a positive effect to the family in providing support to pregnant women to prevent anemia. Educational interventions that have been given to families had explained the various barriers that might be felt by pregnant women when taking iron supplements. Researchers also emphasized the anemic hazards that could occur during pregnancy and childbirth, which will increase the understanding of the family that mothers need to continue to take iron supplements appropriately. The complications that can arise from anemia are: miscarriage (abortion), premature birth, prolonged labor due to uterine muscle fatigue in contraction (uterine inertia), postpartum hemorrhage due to absence of uterine muscle contraction (uterine atony), shock, infection both during labor and postpartum, as well as severe anemia (<4 g%) may cause cardiac decompensation. Hypoxia due to anemia can cause shock and maternal death in labor (Winkjosastro, 2008). Educational interventions that had been given also explained that family support had great benefits to pregnant women, so it could increase the motivation of families in providing support. CONCLUSION After intervention education given, statistically significant changes from the pretest to the posttest were found in the experimental group. No significant increases occurred in the score of control group. Health education given by healthcare providers on prevention of anemia was not only directed to pregnant women but
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Cite this article as: Triharini, M., Armini, N.K.A., Nastiti, A.A. (2018). Effect of educational intervention on family support for pregnant women in preventing anemia. Belitung Nursing Journal,4(3),304-311.
THE DESCRIPTION OF RESILIENCE IN POST-ACUTE ATTACK
PATIENT WITH CORONARY ARTERY DISEASE
Eva Puspawatie1*, Ayu Prawesti2, Titin Sutini3
1Faculty of Nursing, Universitas Padjadjaran 2Critical care and emergency Department, Faculty of Nursing, Universitas Padjadjaran
3Department of mental health nursing, Faculty of Nursing, Universitas Padjadjaran
*Correspondence: Eva Puspawatie Faculty of Nursing, Universitas Padjadjaran Email: [email protected] Abstract Background: Coronary heart disease patients shall experience physical, psychological and social changes that will affect life. The psychological condition of outpatients that has been investigated include anxiety, depression and quality of life, all of these problems can be attributed to resilience. Objective: The purpose of this study was to determine the image of resilience of coronary heart disease patient following up the acute attack in outpatient ward. Methods: The research method used quantitative descriptive using CD-RISC instrument 25. Instrument had validity value r = 0.83, P <.0001 and reliability value of Cronbach’s α 0.89. The selection of sample with consecutive sampling and got sample number 50 people for 2 weeks. Data were analyzed based on the value of each respondent categorized using tertile to see the overall resilience picture, while for the five sub-variables measured using the mean and standard deviation. Result: The results showed that almost half of respondents had 70-75 resilience. The mean value of sub-variables if sorted from the lowest to the highest is trust and reinforcement (2.71±0.58); competence and resilience (2.88±0.53); relationships with others (2.92±0.48); self-control (3.04±0.62) and spiritual influence (3.33±0.45). These results are influenced by lack of self-efficacy, optimism and family support. Conclusion: The conclusions of the research resilience of patients are in the medium category, for the lowest sub-variable value is trust and strengthening, while the highest is the spiritual influence. So, it is advisable to provide education to improve management skills post-acute attacks and increase social support in the care of patients at home. Keywords: resilience, coronary heart disease, post-acute attacks
INTRODUCTION Coronary heart disease (CHD) will affect patients both acute and post-acute. The symptoms experienced by patients with acute post-acute CHD differ from acute conditions. Research on post-heart attack patients concluded some of the most frequent symptoms in the post-acute phase such as fatigue, shortness of breath, weakness, headache (Kim, Kim, & Hwang, 2015), sleep disturbance, daytime sleepiness, decreased
physical activity and difficult to lose weight (Le Grande, Jackson, Murphy, & Thomason, 2016) and sexual disorders (Rosidawati, 2015). Coronary heart patients with a good prognosis will still have a risk of new coronary obstruction that causes impaired left ventricular function and heart failure that will have an impact on the risk of death (Kawecka-Jaszcz, Klocek, Tobiasz-Adamczyk, & Bulpitt, 2012).
The healing process of CHD patients following acute attacks is set in post-attack management and will be affected by psychological problems. Post-acute management includes the provision of secondary prevention therapy, lifestyle change suggestions and rehabilitation referrals (Redfern et al., 2014), but optimal secondary prevention measures in stable heart disease patients will still increase the risk of death from psychosocial problems (Hagström et al., 2018). According to Sararoudi, Motmaen, Maracy, Pishghadam, & Kheirabadi, the life of patients following an acute heart attack will be affected by physical decline and psychological problems such as depression and anxiety (Sararoudi, Motmaen, Maracy, Pishghadam, & Kheirabadi, 2016). Anxiety of coronary heart patients who have passed the acute period showed high levels of anxiety in the face of death (Nisa, Nur’aeni, & Widianti, 2016). While patients with coronary heart disease who have signs of depression will affect lifestyle risk factors, decreased physical activity, medication adherence and sleep quality (Sin, Kumar, Gehi, & Whooley, 2016). CHD patients will be revascularized either PCI (Percutaneous Coronary Intervention), fibrinolytic or CABG (Coronary Artery Bypass Graft). Post-revascularize patients have a risk of complications after recovery. The risk of complications will be exacerbated by psychological problems. Psychological problems of persistent and untreated patients will be stressors that will affect the mental status and coping of patients in decision making. According to Skinner & Zimmer-Gembeck, the process of adaptation or coping is the ability of individuals to initiate, organize and manage behavior, emotions, cognition, motivation and attention in stressful situations (Xanthopoulos & Daniel, 2012). Coping plays an important role in the adaptation of chronic patients, unlike external and biological factors, coping can be modified through effective nursing interventions (Lee, Kim, & Choi, 2014). The process of coping, anxiety, depression, anger and aggression can be mediated by
resilience according to Rutter and Atkinson's theories (Ng, Ang, & Ho, 2012). Resilience is defined as a dynamic and multilevel process of adaptive ability to a great event such as a chronic illness or stress-inducing situation (Cal, Sá, Glustak, & Santiago, 2015) while maintaining normal psychological and physical functioning (Elisei, Sciarma, Verdolini, & Anastasi, 2013). Resilience can change with time as a function of individual development and interaction with the environment (Southwick, Bonanno, Masten, Panter-Brick, & Yehuda, 2014). Strong resilience is associated with improved psychological function and adjustment to disease (Toukhsati et al., 2017). Psychological problems are still often found in patients who do not have good resilience. The value of resilience will be contrary to the anxiety and incidence of depression, high resilience will protect from the development of psychiatric illness where the prevalence of psychiatric illness is high in individuals with chronic disease (Cal et al., 2015). Resilience has been shown to have a good impact in coping and recovery that will improve the quality of life of patients with heart disease (Subban et al., 2014). In general, individual coping outcomes have two effects: negative effects (depression and anxiety) and positive effects (life satisfaction, hope, quality of life and positive mood) (Xanthopoulos & Daniel, 2012), while quality of life will affect the level of individual health (Cepeda-Valery, Cheong, Lee, & Yan, 2011). Research on the quality of life of patients with heart disease previously showed depression is the most influential factor compared with anxiety and revascularization (Nuraeni, Mirwanti, Anna, & Prawesti, 2016). Depression affects catecholamine release, inflammatory marker factors and impaired serotonin function thus increasing the need for cardiac oxygen and worsening the incidence of thrombosis in patients with coronary heart disease. Quality of life can be enhanced by health education, resilience (White et al., 2012), age
and income (MALIK & AFZAL, 2015) and some cannot be modified by health personnel. Resilience is a factor that can be modified by nurses with effective nursing interventions. Nurses interact with patients and families at different stages of development, the concept of resilience can be used by nurses when caring for patients facing both physical and psychosocial changes (Scoloveno, 2016). It is important for nurses to be able to recognize the relationship between physical and psychological that can cause stress due to differences in the level of psychological problems and impact on the patient. This research is expected to know the resilience of CHD patient after the Acute Attack. METHODS Study design The research was designed using descriptive quantitative with cross sectional approach. This study was conducted in a cardiac outpatient unit at Dr. Hasan Sadikin Hospital. The data had been collected in February 2018, using consecutive sampling techniques with inclusion criteria were: 1) patients who have been at least one month after acute heart attack, 2) patients with acute coronary syndrome (unstable angina pectoris, NSTEMI, STEMI). The exclusion criteria were patients with acute heart attacks. Setting Resilience was measured using Connor-Davidson Resilience Scale (CD-RISC) 25 which consists of 25 questions (Kathryn M Connor & Jonathan RT Davidson, 2003). The questionnaire includes five sub-variables: 1) personal competence, high standards and resilience; 2) trust in one's instincts, tolerance of negative impacts and strengthening to face the effects of stress; 3) positive acceptance of change and strong relationships with others; 4) self-control; and 5) spiritual influences. CD-RISC 25 had a validity value of r = 0.83, P <.0001 and the reliability value of Cronbach’s α 0.89.
Research subject Population used in this research were those who went to outpatient clinic at Heart Polyclinic Room at one of public hospital in Bandung City. The sample was taken by using consecutive sampling technique to get the number of respondents as much as 50 people for two weeks. Ethical consideration Ethical clearance for data collection in this research had been obtained from the Research Ethics Committee of the General Hospital of Dr. Hasan Sadikin No. LB.04.01/A05/EC/005/I/2018 on 5 January 2018. All respondents had obtained appropriate informed consent in the research. Data analysis Data were analyzed based on the value of each respondent categorized using tertile to see the overall resilience picture, with one tertile restricting the low value (0-69), the tertile two limiting the medium value (70-75), and the third tertile limiting the high value (76-100); whereas for the five sub-variables measured using the mean scores and standard deviations. RESULTS The majority of respondents had medium resilience as can be seen in Table 1 below:
Table 1 The level of Resilience (n=50)
Resilience Frequency (f)
Percentage (%)
Low 16 32 Medium 20 40 High 14 28
Based on the table 2, it can be seen that respondents with medium resilience are (50%), uneducated 1 person (50%), primary education 4 people (44.4%), 12 (50%) and monthly victims > from Rp. 5,000,000 as many as 5 people (45.55%).
Table 2 Characteristic distribution of resilience based on demography
Characteristic Low Medium High f % f % f %
Age 36-45 years (late adult) 46-55 years (early elderly) 56-65 years (late elderly) > 65 years (elderly)
0 9 6 1
0.0
47.4 30.0 16.7
0 6
12 2
0.0
31.6 60.0 33.3
5 4 2 3
100.0 21.1 10.0 50.0
Gender Male Female
15 1
32.6 25.0
18 2
39.1 50.0
13 1
28.3 25.0
Marriage status Married Not married Widow
13 1 2
31.7 50.0 28.6
16 1 3
39.0 50.0 42.9
12 0 2
29.3 0.0
28.6 Last education
Elementary Middle High
1
12 3
11.1 48.0 18.8
4 9 7
44.4 36.0 43.8
4 4 6
44.4 16.0 37.5
Occupation unemployment employment
7 9
29.2 34.6
12 8
50.0 30.8
5 9
20.8 34.6
Salary (Rp.) < 2.8 million 2.8 -5 million > 5 million
10 4 2
35.7 36.4 18.2
12 3 5
42.9 27.3 45.5
6 4 4
21.4 36.4 36.4
While based on table 3, respondents with medium resilience were respondents with Unstable Angina and 3 VD (Vessel Disease); were diagnosed with coronary heart disease over 6 months, had a comorbid illness, had a medication history, had angina frequency more than once per day, and not the respondents who routinely perform cardiac rehabilitation. The mean and deviation values of each sub-variable of resilience of CHD patients following acute attacks are listed in Table 4. The first sub-variables of personal competence, high standards and resilience had the highest aspect of the statement of confidence reaching for the objectives although there were obstacles with mean value 2.98; whereas the aspect with the lowest mean value in the statement likes a challenge with a value of 2.20. The second sub-variable of belief in instinct had the highest aspect of the statement overcoming a painful or unpleasant feeling with a mean of 2.96; and the aspect
with the lowest mean on the statement sometimes followed a hunch in decision making 2.30. The third sub-variable of positive acceptance of change and a strong relationship with others had the highest aspect of the tendency to rise after the condition of sickness, injury or other suffering with mean 3.18; whereas the aspect with the lowest value in the statement had a close and secure relationship that helps in the event of stress with mean 2.64. The fourth sub-variable of self-control had the highest aspect of a statement of belief in purpose of life with mean 3.18; and the aspect with the lowest value in the statement knows what to do to seek help when there was a stress / crisis with mean 2.94. The final sub-variable of spiritual influence had the highest aspect of the statement of belief or belief in God sometimes can be helpful when there was no clear problem solving with mean 3.50; while the lowest aspect is in the assertion that everything that happens most had a particular reason with a mean of 3.50.
Table 3 Characteristic distribution of resilience based on history of the disease
Characteristic Low Medium High f % f % f %
Diagnose (CAD) UAP NSTEMI STEMI 1 VD 2 VD 3 VD
1 1 2 2 3 7
25.0 50.0 50.0 50.0 27.3 28.0
3 0 1 0 4
12
75.0 0.0
25.0 0.0
36.4 48.0
0 1 1 2 4 6
0.0
50.0 25.0 50.0 36.4 24.0
Length of being diagnosed 0-6 month > 6 months
9 7
42.9 24.1
6
14
28.6 48.3
6 8
28.6 27.6
Comorbidity 1 Comorbid > 1 Comorbid None
6 1 9
30.0 50.0 32.1
10 1 9
50.0 50.0 32.1
4 0
10
20.0 0.0
35.7
Medication history Medication Angiography and or Revascularization
2
16
25.0 38.1
3
15
37.5 35.7
3
11
37.5 26.2
Angina frequency
Never >1x/week >1x/ day
6
10 0
30.0 41.7 0.0
8 7 5
40.0
29.2 83.3
6 7 1
30.0 29.2 16.7
Participation of Heart Rehabilitation Never Routine Not a Routine
9 8 1
45.0 32.0 20.0
9 6 3
45.0 24.0 60.0
2
11 1
10.0 44.0 20.0
Table 4 The level of resilience per sub-variables
Resilience Mean ± SD Trust in One's Instincts, Tolerance of Negative Impacts and Strengthening to Face the Effects of Stress
2.71 .58
Personal Competence, High Standards and Resilience 2.88 .53 Positive Acceptance of Change and Strong Relationships with Others 2.92 .48 Self-Control 3.04 .62 Spiritual Influences 3.33 .45
DISCUSSION The results showed the resilience value of CHD patients after acute attacks had medium value. The study showed a fairly high mean result when compared to the study using the same instrument (Nouri-Saeed, Salari, Nouri-Saeed, Rouhi-Balasi, & Moaddab, 2015) with mean value of CHD patients in Iran (65.5). The results of this study may be influenced by protective factors and risk factors such as coping mechanisms used by patients with heart disease. This study was conducted in cardiac outpatient ward, and based on research conducted by Rakhman, Widianti, & Nur’aeni
in cardiac outpatients ward showed that most coronary heart patients used coping strategies that focused on the problem, so it is most likely that coping strategies were used in the respondents heart disease patients are coping strategies that focus on the problem so as to have sufficient resilience (Rakhman, Widianti, & Nur’aeni, 2016). This statement is in accordance with the research of Doustdartousi & Shafiabadi using the same instrument in patients with coronary heart disease, which says the increasing resilience is more widely used coping is the problem-focused coping style (Doustdartousi
& Shafiabadi, 2014). Patients who use problem-focused coping will use fear as a guide to assess threats, have high optimism, perceive themselves capable, have strong support from family and friends and ultimately cognitively restructure the problem. The protective factor is self-regulation with participation in cardiac rehabilitation, where patients who do not routinely follow cardiac rehabilitation have moderate scores. Cardiac rehabilitation has been known to improve the lives of coronary heart patients, according to the results of high scores in patients undergoing rehabilitation. Patients who get and understand education about the disease will better understand the benefits of cardiac rehabilitation, especially knowing the chronic condition of diseases that require attention. Understanding conditions will help in the improvement of self-care and lifestyle changes over the long term including medication adherence as well as other health care programs such as cardiac rehabilitation. In a cardiac rehabilitation program, the patient can train physical appearance with scheduled and monitored exercises so that patients can benefit such as decreased cholesterol levels, increased six-minute road results, decreased stress incidence, anxiety and depression. This is in line with research from Jaszcz et al. who said that by following a month of physical training can improve the quality of life of coronary heart disease patients (Kawecka-Jaszcz et al., 2012). However, the category of never following cardiac rehabilitation in this study found patient statements that have not been suggested for cardiac rehabilitation. Patients who suggest this are primarily post-angiographic patients or stent-mounting measures. Education on rehabilitation programs has been provided since initial patients are hospitalized, and outpatients are given during routine visits, so this statement can result from differences in perceptions of patients and health personnel. A protective factor that may be affected is income. This study showed a fairly equitable value score in working patients and moderate
value in patients with more than five million rupiahs. The patient's pain condition will affect the stability of the family's financial condition. Lifestyle changes made to direct the patient to control and some checks, requiring financial and family support. However, according to Nouri-Saeed et al., work status is the only factor that is enough to affect resilience. Working demands will affect the patient's psychology, and coronary heart disease patients are known to have limitations in their eventual decline in work ability will have an impact on job stability (Nouri-Saeed et al., 2015). Patients working in this study were not divided by either permanent or temporary employment, but on the basis of resilience the results showed a fairly clear difference, where the higher the income the better the resilience value. This is consistent with a study (Helgeson & Zajdel, 2017) says that the resulting income will influence protectively, but the work does not fall into the factors that can affect resilience. In addition to protective factors, risk factors will also negatively affect. Risk factors belonging to biological factors that may affect the results of this study are the age of respondents. Cognitive patients cannot be separated from the level of development that serves as another protective factor. The prevalence of moderate amounts in the elderly is influenced by the patient's positive acceptance of the condition of the disease, as the age increases, the patient begins to adapt positively to disease conditions and lifestyle changes. This is in accordance with the research (Kong, Liu, Liu, & Yu, 2018) that age differences and income differences will affect the resilience and self-efficacy of coronary heart patients. The second biological factor that is at risk of affecting resilience results is also possible because most of the respondents in this study were male. Men are often associated with strong and non-complaining, in contrast to women, and women in this study have low scores. This result is supported by research (MALIK & AFZAL, 2015) that men are more
resilience than women because men have power, power, autonomy and interests. A third biological factor that may affect the results of this study is medical diagnosis. Respondents with Unstable Angina Pectoris (UAP) diagnoses and three coronary artery blockages (3 VD) had medium resilience values. Patients who have a UAP have not performed an angiographic action, so the patient has not known the certainty of a blockage in the coronary arteries and the patient may have been given an explanation of the plan of action. While in patients with three coronary artery blockages in this study was not divided based on complete or incomplete revascularization so that the limitations of the study. This can be attributed to the patient's psychological acceptance of the way in which the news is conveyed concerning the condition of their coronary arteries, the choice of revascularization action plan, how many blockages they have and the actions they can take or cannot make in the best settlement and decisions taken by the respondent and family. The choice of revascularization action in accordance with the medical diagnosis that is able to overcome the problems in the patient, will give a perception of improvement of physical condition, thus increasing the psychological and more able to empower themselves. This is in accordance with research (Chaudhury & Srivastava, 2013) said successful revolutionary coronary revascularization actions will reduce anxiety, depression, physical limitations and increased perceptions of disease and health status. Therefore, the method of revascularization action is an important concern to maximize positive effects for patients and families. Psychological factors that include resilience risk factors such as depression, stress or anxiety to the disease, where respondents who have one or more of the comorbidities have a moderate level of resilience. Patients who have more than one concomitant disease will have more constraints in adjusting to lifestyle changes. However, low scores were found in more respondents who did not have comorbidities. This result may be due to the
comorbidities listed in the medical records, not all of which include depression or anxiety that the patient possesses because of the need for a special recitation, in which case both may affect the level of resilience. This is in accordance with the results of research that says that multiple stressors do not reduce the level of resilience (Morin, Galatzer-Levy, Maccallum, & Bonanno, 2017). That way with the presence or absence of physical accompanying disease does not affect resilience, other than the more affect is the depression or anxiety. In accordance with the study that resilience is more related to psychological variables than disease severity (Carvalho et al., 2016). A second psychological factor that can affect risk resilience is perception of disease. The value of resilience is being found in considerable numbers on the characteristics of experiencing angina more than once per day, but low resilience values are found to be considerable in patients without angina. This result can be influenced by the patient's perception of his illness, when the patient, even without the angina, perceives itself to be in a fragile state, then all that happens will be felt unable to deal with. In accordance with the research said the perception of fragility to stress will affect the value of resilience. Increased understanding of the impact of disease, empowerment and changes in patient perceptions of disease will increase resilience that will indirectly improve quality of life (K. M. Connor & J. R. Davidson, 2003). This is in line with the research of Sararoudi et al. which says the perception of disease will affect a person in the conduct of coping and self-management related to the disease (Sararoudi et al., 2016). Risk factors in environmental factors that can affect the resilience value of this research include the last education. The majority of respondents with resilience are having a basic education level. Increased levels of education will improve one's perception of health and be able to apply coping more adaptively. Risk factors in the second environmental factors that affect resilience is a marriage where in the
results of this study married respondents have a medium value. The quality of good family relationships, mutually supportive, loving and demanding family members with firm, rational and consistent will provide cognitive stimulation and improve adherence. Support gained will result in openness, but if there is no openness in the relationship of marriage it will lower the trust including trust in self-ability. This is in line with DeYoung study, that men are higher in intellectual level than openness / intellect personality, but marriage will bring down both openness and intellectuality to both men and women (Deyoung, 2014). This will be detrimental to the loss of support that may be obtained, the choice of plans, and the feeling of having people who understand the condition, other than that chronic diseases that its development will last for a long time will make men become less resilience. The last risk factor is a negative life experience, where resilience values are being found in respondents who know the disease for more than six months. This may occur due to learning from previous attack experiences, whereas after an acute attack the patient analyzes his or her abilities during an attack and the action that should be done when an attack occurs. This is in line with research from Baldacchino (Baldacchino, 2011)which says time can improve the search for meaning in life and adaptation of patients with their illness. The time after the patient has experienced an attack is an important experience to restore the patient's life goals, hopes and presence, and to maximize the patient should know the positive potential in himself such as optimism, post-acute management skills or social support. Nurses and healthcare workers can improve communication with patients and families to provide support and assistance so that it is possible for patients to share with what they feel about the disease and related to the impact of disease in social life. This can reduce the pressure and help patients understand themselves better without getting stuck with labels that strong men do not complain and as
a result the psychological problems that can worsen the disease can be suppressed by increasing resilience. The existence of perceptual gaps can be influenced by time conformity, availability of logistics, satisfaction of health services and functional status of patients (Stevani, Nur’aeni, & Afrima, 2017). Quality services will be the goal of the service provider so that the patient will be satisfied and follow the directions given by the health worker so that it is necessary to study the patient's expectation on the health program offered and communicate the benefits of the rehabilitation program so that the perception gap can be minimized. Resilience based on sub-variables Resilience based on sub-variables, on the sub-variable of personal competence, high standards and resilience indicates the second lowest mean. This result can be affected by the lowest mean value in the statement that likes challenges and perceives oneself as being strong when faced with challenges, so this statement indicates low self-efficacy. Patients faced with a change and perceiving themselves as someone who does not like challenges will then perceive the change as a formidable challenge and unconsciously affect the space of attention to a problem. Narrowing attention will affect the patient's standards and competencies, this is stated by the patient's statement that there is no reason for him to be proud of self-achievement because of the illness suffered which ultimately limits the possibility of choice of effort in achieving the goal. Sub-variables of instinct trust, tolerance of negative impacts and strengthening facing stress impacts show the lowest mean of the five sub-variables. Respondents have some constraints in making good decisions if the decisions taken are not liked by the nearest person or difficult to follow the premonition when they do not know the reason for the decision. This is related to risk factors perceptions of patient psychological vulnerability. Logical decision making is often used for considering outcomes, and decision-making based on instinct is more likely to have
uncertain outcomes. This is in line with the study of illness cognition in coronary heart patients (Delima, Sriati, & Nur’aeni, 2018), which states patients feel helplessness so that patients feel useless. Patients who experience helplessness will find it difficult to make decisions for themselves, decision-making is not expected to add worsening conditions, and also must face judgment from others on the impact of decision-making. Therefore, it also decreases the mean of the revelation that the patient will advance and lead the problem-solving effort rather than allowing others to make decisions for themselves. The sub-variables used are strong relationships with others indicating averages in third order. Patient statement that they can solve the problem with a high average value on success items. Mean value means lower than the numbers used and what happens in life. This can be changed by psychologically becoming a risk factor incorporated in a closed situation, a different understanding and cannot be a burden to the family. This will worsen the psychological condition and post-attack healing process. In line with research from Rakhman et al. who say that low social co-existence will have a direct impact on the increase and depression that will lead to worsening conditions and mortality (Rakhman et al., 2016). Environmental factors at risk exist in strong relationships with someone giving their inner beliefs. This is in line with research (Edward, 2013), which states that one's endurance type consists of optimism, active coping style or social interaction. This can lead to patients who do not use the services they use. The sub-variables are mean self-control means the second highest. This is supported by an average meaning that patients have confidence in life, but in others who believe they are not able to develop, so the ability becomes ineffective. The lowest means available to find out what to do to rediscover stress and there are four respondents who say do not know what to do. This happens because the lack of optimal factors that drive a person can happen because of the patient he or she can be the one
who can do with the hope and the problem of life after the illness. In line with the words of patients with coronary disease in Canada (Rodrigues, Jongbloed, Li, & Dean, 2014) that indicate the existence of a disease they are experiencing is not, uncontrollable, and there is already an illness. and health responsibilities that ultimately lower their self-efficacy. The sub variable set the spiritual show the highest average, it can be assumed the patient has enough strong belief to live and believe that whatever happened is God's will. Spiritual Influence as a protective factor that protects from decreasing endurance. True meaning value to a statement of trust or belief in God's direction can sometimes help no obvious problem. Belief in God can be used in life, that their God will not change the bad things that happen to them and will therefore give strength to the patient. This is in accordance with research (Mirwanti & Nuraeni, 2016), which states a high spiritual will be inversely proportional to the level of risk of coronary disease. CONCLUSION The results showed that the resilience of CHD patients after an acute attack in one of the heart polyclinics of Bandung general hospital had a moderate value. However, this value did not cover half of all respondents. This was supported by the lack of self-efficacy, optimism and family support. The study was limited to a sample of only 50 people, and the study's respondents also had only 4 female respondents so there was a possibility of bias in generalizing gender with resilience. Respondents with low resilience values were patients who had performed revascularization angiography either stent insertion, in the preparation of cardiac surgery and postoperative heart, but this study cannot describe patients who received comprehensive blockage treatment, in the process of continuous action and possible prognosis of the action.
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CONSUMPTIONS ON HEMOGLOBIN LEVELS AMONG MIDWIFERY STUDENTS
Gracea Petricka1*, SN Nurul Makiyah2, Retno Mawarti1
1Aisyiyah University of Yogyakarta
2Muhammadiyah University of Yogyakarta *Correspondence: Gracea Petricka Aisyiyah University of Yogyakarta Jalan Ringroad Barat No.63, Mlangi Nogotirto, Gamping, Nogotirto, Gamping, Kabupaten Sleman Daerah Istimewa Yogyakarta 55592 Email: [email protected] Abstract Background: It is estimated that 49.2% of Indonesian adolescents (10-19 years) have iron deficiency of anemia. Green vegetables can be used as an alternative consumption to meet the body's need for iron. Kelakai (Stenochlaena palustris) containing 291.32 mg-100 g of Fe has been consumed by Dayak ethnic society to prevent anemia. Objective: The aim of this study was to determine the effect of Kelakai (Stenochlaena palustris) consumptions to increase hemoglobin levels among late adolescents (17-19 years). Methods: It was a quasy-experiment with pre-test and post-test study on anemic Midwifery students (8-11 g / dl) of Betang Asi Midwifery Academy of Palangka Raya in September 2017. In which Kelakai was given as dietary supplements of the subject line and ferrous fumarate tablet as a control. There were 66 participants recruited by purposive sampling, divided into 33 subjects for each group. Kelakai (Stenochlaena palustris) (250 mg) and ferrous fumarate tablet (60 mg) were administrated daily for a week. Hemoglobin levels were measured before and after intervention using the hemoglobin testing system quick-check tool. Data were analyzed using paired and independent t-test. Result: The result showed of significant increases on hemoglobin levels (3.24 g / dl) after consuming Kelakai (Stenochlaena palustris) for a week (p≤0.05). The hemoglobin levels after intervention in the control group were 0.03 g / dl higher than Kelakai group, but based on the analysis, there was no significant difference on both groups (p≥0.05). Conclusion: Kelakai is proven to increase hemoglobin levels. Thus, Kelakai (Stenochlaena palustris) is recommended a food supplementation to prevent iron deficiency of anemia. Keywords: kelakai, stechnolaena palustris, iron deficiency of anemia, adolescent, adolescence INTRODUCTION Adolescents (10-19 years) have higher risk for iron-deficiency of anemia due to increased iron requirement, inadequate nutrition intake, worm infections and severe infections that affect the reserves of iron in the body (WHO, 2011). WHO estimates that 22% of women of reproductive age (15-49 years) and 49.2% of young women (10-19 years) in Indonesia have
iron deficiency of anemia (Dick & Ferguson, 2015; WHO, 2011). The study of 87 adolescent girls in India on non-hematological effects arisen from iron deficiency was the growth and developmental barriers, decreased immunity, decreased physical activity performance and cognitive function (More, Shivkumar, Gangane, & Shende, 2013).
The target to realize the goal of "ending all forms of malnutrition’ of Nutrition Global Targets for 2025 by the Sustainable Development Goals program is to reduce 50% incidence of anemia among women of reproductive age (IFPRI, 2016). The Indonesian government's efforts to handle the incidence of deficiency anemia are through the Program Penanggulangan Anemia Gizi Zat Besi with supplementation of ferrous tablets for adolescents, women of childbearing age, pregnant women and postpartum women (MOH, 2015). Alternatives to meet iron needs include food-based approaches, the fortification and diversification of foods containing iron (WHO, 2011). Green vegetables can be a source of iron that can be consumed daily (Hurrell & Egli, 2010). Kelakai (Stenochlaena palustris) is a typical ferns of Central Kalimantan commonly found in swamps, roadsides, agricultural areas, open lands and a former area of land burned grown without the use of pesticides and fertilizers (Wijaya, Widiputri, & Rahmawati, 2017). Dayak tribes hereditary consume Kelakai (Stechnolaena palustris) to treat anemia (Purwandari). The people of the Dayak tribes of Central Kalimantan consume Kelakai (Stenochlaena palustris) as vegetable preparations by means of pan-fried, boiled, made into plain vegetables or eaten raw (Irawan et al., 2006). Kelakai contains Fe (4153 mg / 100 g), vitamin C (41 mg / 100 g), protein (2.36%), beta carotene (6.69 mg/100 g) and folic acid (1.13 mg/100 g) (Wijaya et al., 2017). Consuming Kelakai (Stenochlaena palustris) for 22 days shows to significantly increase maternal hemoglobin concentration (p-value ≤0.05) and proves to be as effective as taking ferrous fumarate tablets to increase Hemoglobin levels (Mahyuni, Riyanto, & Muhhalimah, 2016). A study on the effect of giving Kelakai (Stechnolaena palutris) extract for 1 week on a white rat showed that hemoglobin levels was improved two times higher than the control group (p-value ≤0.05) (Negara, 2017).
METHODS Study design This study was quasy-experiment with pretest-posttest control group design. Setting The study was conducted at the Midwifery Academy of Betang Asi Raya Palangka Raya in Central Kalimantan province on September 2017. Research subject There were 66 participants recruited by purposive sampling, with 33 randomly assigned to the experiment and control group. Inclusion criteria of this study were female students aged 17-19 years, who had regular menstrual cycles (21-35 days) and mild-moderate anemia status (8-11.9 g/dL). The exclusion criteria in this study were female students aged 17-19 years, who had a history of severe disease affecting hemoglobin levels (kidney failure, lung disease, lymphatic disorders, cancer and malaria) and experienced menstrual disorders including metroragia, hipermenorrhoe, polimenorrhoe, oligomenorrhoe and amenorrhoe. Instrument Hemoglobin levels were measured before and after intervention using the hemoglobin testing system quick-check tool. An observation sheets was used to record the possible side effects of Kelakai (Stechnolaena palustris) and ferrous fumarate tablet consumption. Intervention The experiment group was given 250 gr of sauteed Kelakai (Stechnolaena palustris), which was consumed at dinner for seven days. While the control group was consumed ferrous fumarate tablet (60 mg) at the same time. Based on the results of biochemistry laboratory tests in the Medical Faculty of Universitas Lambung Mangkurat, Banjarbaru, South Kalimantan province, the sauteed Kelakai (Stechnolaena palustris) in this study contains 0,48 µg/250 gr. All female students was given the same food 3 times a day and
snacks in the afternoon, which is prepared by researcher and a nutritionist. Ethical consideration This study has been approved by the ethical feasibility (Ethical Clearance) from the Ethics Commission of the 'Aisyiyah University of Yogyakarta. All of the subject research has already signed study approval sheets. Data analysis Univariate analysis was conducted to see the distribution of age and hemoglobin level of participants. The Shapiro-Wilk test was conducted to see the normality of the data. The increase levels of hemoglobin in the
intervention group were analyzed using paired t-test, whereas the control group of hemoglobin levels were analyzed using the Mann Whitney. The differences in hemoglobin levels between intervention and control groups were analyzed using independent t-test (CI 95%; α = 5%). RESULTS Table 1 shows the majority of all participant aged 18 years old, had normal BMI, had mild anemia before the intervention and after being given intervention for 7 days the majority of subjects were no longer anemic.
Table 1 Characteristic of participant (n=66)
Variable Mean Median SD Min Max
Age (year) 18 18 0.72 17 19 Body Mass Index (BMI) 21.04 20.15 4.45 15.38 35.19 Hemoglobin Level (g/dl)
Table 2 shows the mean of hemoglobin levels in the experiment group before given Kelakai (Stechnolaena palustris) was 11.06 gr/dl and increases by 1.04 gr/dl after a week. While in the control group the mean of hemoglobin levels before intervention is 11.14 gr/dl and
increases by 0.94 g/dl after a week of consuming ferrous fumarate tablets. Comparing both groups, it can be seen that the experiment group increased hemoglobin level of 0.02 g/dl higher than the control group.
Table 2 Distribution hemoglobin level before and after given intervention
Table 3 shows a significant increase (p-value ≤0.05) in hemoglobin level of 3 g/dl after consuming Kelakai (Stechnolaena palustris) for a week. The comparison
between the two groups shows the control group increased hemoglobin level of 0.04 g/dl higher than the experiment group.
Hemoglobin level (gr/dl) Mean Median SD Min Max All participants
Table 3 Mean different of hemoglobin levels in the experiment and control group
Characteristics Mean t-calculate//Z-calculate P-value Fe Tabletδ
Before After
- -
-5.007 -
0.000 Kelakai ʃ
Before After
9.38
12.62 3.91 -
0.005 Intervention ǂ
Ferrous fumarat tablet Kelakai
11.62 11.58
- -0.44-0.47
- 0.938
Source: The results of the data analysis changes in Hb levels Ket: δ = Mann Whitney, ʃ = Paired t-test, ǂ= Independent t-test, CI = Value of confidence interval, P-value (CI = 95%, α = 5%)
DISCUSSION The finding of present study showed there was a significant effect of (Stechnolaena palustris) on increased hemoglobin levels. Kelakai (Stechnolaena palustris) was given 250 g/day for seven days can improve hemoglobin levels of 3 g/dl, as previous study proved that Kelakai (Stechnolaena palustris) extract (624.2 mg) for a week can improve hemoglobin levels for three times (p-value ≤0.05) (Negara et al.,2017). Study Mahyuni et al. (2015) also proved that the consumption of Kelakai (Stechnolaena palustris) for 22 days can increase maternal hemoglobin level of 1.86 g/dl (p-value ≤0.05). The increase of hemoglobin levels due to the non-heme iron content in the Kelakai (Stechnolaena palustris) (Chai, 2015). Each 100 g of Kelakai (Stechnolaena palustris) contain 4.153-33.64 mg of Fe (Purwandari). Iron contained in Kelakai (Stechnolaena palustris) is a non-heme iron which the absorption depends on the enhancer and inhibitor factors (Hurrell & Egli, 2010). Another previous study revealed that the vitamin C increases non-heme iron absorption three times higher group control (da Silva Rocha et al., 2011). The results of this study reinforce the empirical evidence regarding the potential
Kelakai (Stechnolaena palustris) to prevent anemia that is believed by Dayak tribes (Negara, 2017). Based on the result of this study, Kelakai (Stechnolaena palustris) is an alternative choice in order to increase hemoglobin levels naturally (Zannah, 2015). The results independent t-test of analysis stated that the ferrous fumarate tablets is able to increase the hemoglobin levels of 0.04 g/dl higher than the Kelakai (Stechnolaena palustris), however was not clinical significance (p-value ≥0.05). The increase of Hb levels due to the consumption of ferrous fumarate tablet is 0.1 g/dl per day (Arisman, 2004; Dewoolkar, Patel, & Dodich, 2014). Mahyuni et al. also proved that there is no significant difference in increase of hemoglobin level between experiment group and control group (p-value ≥0.05) (Mahyuni et al., 2016). In present study Kelakai (Stechnolaena palustris) was consumed as dishes served through heating. Kelakai (Stechnolaena palustris) which has been through a heating process (stir-fried, boiled) will decreased by 9-43% Fe (Chai, Panirchellvum, Ong, & Wong, 2012). The consumption of Kelakai (Stechnolaena palustris) extract on white rats (Rattus norvegicus) proved to increase hemoglobin levels four times higher than
the control group (Negara, 2017). Therefore, the Kelakai (Stechnolaena palustris) processing affect to the increase of hemoglobin levels. Other data collected from this study are the side effects of both types of provided intervention. The reasons supporting data collection regarding the side effects of iron consumption is based on theory and previous study (Friedman et al., 2015; Tolkien, Stecher, Mander, Pereira, & Powell, 2015; Yakoob & Bhutta, 2011), which stated that the chances of the side effect emergence on the digestive system after ingestion of ferrous sulfate tablets are 20-40% of nausea, bloating, abdominal pain, diarrhea, constipation, and dark feces. In the group consuming ferrous fumarate tablets, 81.8% of the study complained of feeling dizzy, nauseous and discoloration of feces from the first day of consumption. Complaints of dizziness and nausea are also experienced by 15.2% of the study who consumed Kelakai (Stechnolaena palustris). Side effects arising from the consumption of ferrous fumarate tablet are five times higher than the side effects of Kelakai (Stechnolaena palustris) consumption. CONCLUSION This study provided the evidence that Kelakai (Stechnolaena palustris) is effective to increase hemoglobin levels. Kelakai (Stechnolaena palustris) can be recommended as food supplements that cost efficiencies, effectiveness and minimal side effects to prevent iron deficiency anemia. Future study is expected to perform an analysis of the substances of these compounds in Kelakai (Stechnolaena palustris) that have potential inhibitors and
enhancers of iron. In addition to required more study to formulate Kelakai (Stechnolaena palustris) in the dosage form in which iron content is better. REFERENCES Arisman, M. B. (2004). Gizi dalam daur kehidupan.
C. (2012). Phenolic contents and antioxidant properties of Stenochlaena palustris, an edible medicinal fern. Botanical Studies, 53(4), 439-446.
da Silva Rocha, D., Capanema, F. D., Netto, M. P., de Almeida, C. A. N., Franceschini, S. d. C. C., & Lamounier, J. A. (2011). Effectiveness of fortification of drinking water with iron and vitamin C in the reduction of anemia and improvement of nutritional status in children attending day-care centers in Belo Horizonte, Brazil. Food and Nutrition Bulletin, 32(4), 340-346.
Dewoolkar, A., Patel, N. D., & Dodich, C. (2014). Iron deficiency and iron deficiency anemia in adolescent athletes: A systematic review. International Journal of Child Health and Human Development, 7(1), 11.
Dick, B., & Ferguson, B. J. (2015). Health for the world's adolescents: a second chance in the second decade. Journal of Adolescent Health, 56(1), 3-6.
Friedman, A. J., Shander, A., Martin, S. R., Calabrese, R. K., Ashton, M. E., Lew, I., . . . Goodnough, L. T. (2015). Iron deficiency anemia in women: a practical guide to detection, diagnosis, and treatment. Obstetrical and Gynecological Survey, 70(5), 342-353.
Hurrell, R., & Egli, I. (2010). Iron bioavailability and dietary reference values–. The American journal of clinical nutrition, 91(5), 1461S-1467S.
IFPRI. (2016). Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, D.C: International Food Policy Research Institute.
Irawan, D., Wijaya, C. H., Limin, S. H., Hashidoko, Y., Osaki, M., & Kulu, I. P. (2006). Ethnobotanical study and nutrient potency of local traditional vegetables in Central Kalimantan. Tropics, 15(4), 441-448.
Mahyuni, A., Riyanto, S., & Muhhalimah, M. (2016). Perbandingan Pemberian Tablet Fe dan Mengkonsumsi Sayuran Kalakai (Stenochlaena palustris) Pada Ibu Hamil Terhadap Kenaikan Kadar Hb Di Puskesmas Gambut. Jurnal Kesehatan Indonesia, 6(1).
MOH. (2015). Situasi Kesehatan Reproduksi Remaja. Retrieved from
More, S., Shivkumar, V., Gangane, N., & Shende, S. (2013). Effects of iron deficiency on cognitive function in school going adolescent females in rural area of central India. Anemia, 2013.
Negara, C. K. (2017). PENGARUH EKSTRAK KELAKAI (Stenochlaena palustris) TERHADAP KADAR HEMOGLOBIN PADA TIKUS PUTIH (Rattus norvegicus). Borneo Journal of Pharmascientech, 1(1).
Purwandari, S. E. KALAKAI SEBAGAI SAYURAN ORGANIK KALIMANTAN TENGAH.
Tolkien, Z., Stecher, L., Mander, A. P., Pereira, D. I., & Powell, J. J. (2015). Ferrous sulfate supplementation causes significant gastrointestinal side-effects in adults: a systematic review and meta-analysis. PLoS ONE, 10(2), e0117383.
WHO. (2011). Prevention of iron deficiency anaemia in adolescents. Retrieved from
Wijaya, E., Widiputri, D. I., & Rahmawati, D. (2017). Optimizing the antioxidant activity of Kelakai (Stenochlaena palustris) through multiplestage extraction process. Paper presented at the AIP Conference Proceedings.
Yakoob, M. Y., & Bhutta, Z. A. (2011). Effect of routine iron supplementation with or without folic acid on anemia during pregnancy. BMC Public Health, 11(3), S21.
Zannah, F., Amin, M., Suwono, H., Lukiati, B. . (2015). Ethnobotany Study of Kelakai (Stecnolaena palutris Bedd) as an Endemic Fern at Central of Kalimantan. Paper presented at the International Conference on Global Resource Conservation (ICGRG).
Cite this article as: Petricka, G., Makiyah, SN. N., Mawarti, R. (2018). The effect of kelakai (stechnolaena palustris) consumptions on hemoglobin levels among midwifery students. Belitung Nursing Journal,4(3),323-328.
THE APPLICATION OF ART THERAPY TO REDUCE THE LEVEL OF
DEPRESSION IN PATIENTS WITH HEMODIALYSIS
Atikah Fatmawati1*, M. Rachmat Soelaeman2, Imas Rafiyah3
1Medical Surgical Nursing, STIKES Majapahit, Mojokerto 2SMF Ilmu Penyakit Dalam, Rumah Sakit Hasan Sadikin, Bandung
3Mental Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung
*Correspondence: Atikah Fatmawati Medical Surgical Nursing STIKES Majapahit, Mojokerto Jl. Raya Jabon KM.2, Tambak Rejo, Gayaman, Mojoanyar, Mojokerto, Jawa Timur 61364 Email: [email protected] Abstract Background: Depression can occur in patients with chronic kidney disease undergoing hemodialysis and can lead to decreased quality of life, and will have a two-fold risk for the occurrence of death and hospitalization. Objective: The purpose of this study was to identify the effects of art therapy on the level of depression patients with hemodialysis. Methods: This study used a quasi-experimental method with pretest posttest with control group design. Collecting data using questionnaires of Beck Depression Inventory (BDI-II) versions of Indonesia, which was done twice, before and after art therapy intervention. Data were analyzed using paired t-test and unpaired t-test. Results: The results showed that after given intervention of art therapy there were differences in the average scores of depression in the intervention group (t = 0.764; p-value = 0.000). Art therapy is a medium to expose and express the feelings, fears or perceived problem, so it can be used as an adaptive coping method in patients with chronic kidney disease undergoing hemodialysis. Conclusion: It is concluded that art therapy could reduce depression in patients with chronic kidney disease undergoing hemodialysis. Nurses can act as a facilitator to provide art-based therapy in order to improve the ability of psychological adaptation in patients with chronic kidney disease undergoing hemodialysis. Keywords: art therapy, chronic kidney disease, depression, hemodialysis
INTRODUCTION Current disease trends shift from initially infectious diseases to degenerative diseases, one of which is kidney disease that will eventually develop into Chronic Kidney Disease (CKD). CKD is defined as an abnormality of renal structure and function for more than 3 months, which has health implications (Levin et al., 2013; Mariotti & Rocha de Carvalho, 2011). Based on data from the Centers for Disease Control and Prevention in 2007 mentioned that the incidence of CKD
increased dramatically over a decade, from 261.3 events per one million inhabitants in 1994, increasing to 348.6 events per one million population in 2004 (Kring & Crane, 2009). Management of CKD is one of them is hemodialysis and will be lived in a long time, so patients must have high awareness and coping mechanisms appropriate to deal with changes in psychological conditions that can
arise (Lii, Tsay, & Wang, 2007). This may be due to patients who are reluctant to discuss or discuss the illness-related feelings experienced by health personnel, loss of privacy, changes in body image, decline or loss of self-esteem, and feelings of helplessness (Kring & Crane, 2009). Tsay, Lee & Lee (2005) mentioned that patients undergoing hemodialysis are confronted with complicated routines, including food and fluid restrictions, fears about changes in body appearance, and feelings of uncertainty about the future or job disruption. All of these conditions can cause depression in hemodialysis patients (Tsay, Lee, & Lee, 2005). Depression often accompanies chronic disease conditions and is the most common psychological problem in patients with PGK undergoing hemodialysis (Battistella, 2012; Bautovich, Katz, Smith, Loo, & Harvey, 2014; Tavallaii, Ebrahimnia, Shamspour, & Assari, 2009). Depression is a condition that can affect the body, mind, and feelings and can affect the diet, sleep, and mood of the individual. Depression can be a risk factor to inhibit the treatment process. Patients with depression will be three times as likely to not adhere to planned treatment as compared to non-depressed patients (Yunitri, 2012). The integration between pharmacological and non-pharmacologic interventions is needed to meet the psychological needs of patients with CKD undergoing hemodialysis (Kring & Crane, 2009). Innovative and holistic therapy using a complementary approach can be used to improve the psychological adaptability of CKD patients, and the expected end is to improve the overall quality of life (Kring & Crane, 2009). One therapy that can be applied to reduce depression is art therapy. Through art therapy, nurses can facilitate the patient in order to express feelings related to the condition of the illness experienced, in a way that is considered not scary and even can be regarded as a game. One indication of this art therapy is in adolescents and adults who
cannot afford and do not want to talk about his thoughts and feelings (Setyoadi, 2011). Previous research has shown that the application of art therapy interventions has a positive impact on the psychological condition and quality of life of patients. The study was conducted in patients with cancer in Japan involving only 7 respondents and did not use the control group. Art therapy interventions are given as much as 2 sessions with 1 hour for each individual in each session. The results showed that there was a decrease in depression and fatigue in the respondents as measured using Profile of Mood Scale (POMS). However, there are some patients who want the number of intervention sessions to be added (Ando, Imamura, Kira, & Nagasaka, 2013). Another study was conducted by Vella & Budd, which involved 28 female patients with stage I and II breast cancer in the United States. The intervention of art therapy is given as much as 3 sessions, i.e. on the first day, the seventh day, and after 6 weeks later. The results showed that there were decreases in 3 domains, namely depression, anxiety, and somatic stress measured by using Brief Symptom Inventory (BSI) (Vella & Budd, 2011). Of the two studies that have been done, it was found that art therapy could reduce depression in breast cancer patients. Will therapy gauge used is not specific to measure depression. In addition, there is a difference in the number of sessions given, although in one literature it is stated that there is no specific reference on the number of art therapy implementation sessions. Another thing to note is the existence of differences in cultural context between the two studies, which allegedly can also affect the results of research. Individuals in Japan and the United States may already be accustomed to using the image media as a method to express the feelings or problems it faces. However, in Indonesian culture, it is rare for individuals to use the media to express feelings.
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Based on the above background, it becomes important to do further research related to the influence of art therapy on the depression level of CKD patients undergoing routine hemodialysis. This is supported by the absence of special research on art therapy in CKD patients undergoing hemodialysis, which also has many problems with their psychological status. METHODS Study design This study used a quasi-experimental method with pretest posttest with control group design. Setting The study was conducted for 4 weeks (from December 2014 to January 2015) in the Hemodialysis Unit of Jombang General Hospital. Research subject The population in this study were all patients with a diagnosis of chronic kidney disease who outpatient hemodialysis at RSUD Jombang. While the number of samples used in this study was 26 samples for each group. This study used purposive sampling. The inclusion criteria in this study were 18 years old, had routine hemodialysis schedule twice a week, had hemodialysis at least 6 months, had mild to moderate depressive condition, had stable hemodynamic condition, conscious compos mentis consciousness, and could read and write. The exclusion criteria in this study were respondents who did not follow the intervention sessions until the end and the patients who had to undergo hospitalization in the middle of the intervention sessions. Intervention The intervention of art therapy was done separately between the intervention group and the control group to respect the ethics of research that is the aspect of justice. In the intervention group, respondents were given one blank sheet of paper and were given the freedom to choose the color instrument to be used (colored pencils, markers, or crayons).
Respondents were released to draw in accordance with what was felt at the time. Art therapy intervention was administered for 4 sessions (2 sessions per week) according to the respondent's hemodialysis schedule. Interventions are provided in accordance with the SOP that have been prepared and there are 4 phases in each of the intervention sessions, that is unfreezing phase, doing phase, dialoguing phase, and ending and integrating phase. Instrument The instrument used in this research is BDI (Beck Depression Inventory). It consists of 21 statement items, which include cognitive domains (8 items), emotional/affective (8 items), and somatic/vegetative (5 items). Each item is rated on a scale of 0 - 3. BDI-II has a significant positive correlation to DS14 (D-Personality Scale) and BAI (Beck Anxiety Inventory) with r = 0.52 and p = 0.01. The reliability test shows Cronbach's alpha coefficients are at a value of 0.90 for all items in the Indonesian version of BDI-II and values for each domain, i.e. 0.80 (cognitive), 0.81 (somatic), and 0.74 (affective). This indicates that this instrument has a high internal consistency. This instrument has been translated in accordance with the International Test Commission Guidelines for Test Adaptation. Original English questionnaire translated into Indonesian by qualified translators in their field. Then the Indonesian version is translated back into English by a native English translator. The translator did not understand the purpose of this instrument (Ginting, Näring, van der Veld, Srisayekti, & Becker, 2013). Ethical consideration This research has been through ethical test from The Health Research Ethics Committee Faculty of Medicine Universitas Padjadjaran with a code number of ethics: No.725/UN6.C2.1.2/KEPK/PN/2014 Data analysis Independent t-test and paired t-test were performed in this study.
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Prior to statistical tests to see the difference in average scores in each group, test homogeneity to determine whether there are differences in characteristics between the two groups. Based on the result of the different test of respondent characteristic presented in Table 1, the available result there is no difference, which depends on the characteristic of the respondent in control group and intervention group. Based on Table 2, it was seen that there was no significant difference in mean depression score before giving intervention in the form of art therapy between the intervention group and the control group (p = 0.251). While after intervention it was seen that there was a
significant difference in mean depression score between intervention group and control group (p = 0.000). In each group, there was no significant difference in mean depression score before and after intervention in the control group (p = 0.226). While in the intervention group, the results showed that there was a significant difference in mean depression score before and after intervention (p = 0.000). Based on Table 3, it can be seen that in the cognitive and emotional/affective domains there are differences between before and after intervention in the control and intervention groups (p = 0.037 and p = 0.001). While in the somatic/vegetative domain there is no difference (p = 0.346).
Table 1 Frequency Distribution of Respondent Characteristics
Characteristics
Group
x p-value Control Intervention F Percentage
(%) F Percentage
(%) Age 18-25
26-30 31-50 51-60 >60
0 0
15 8 3
0 0
57.7 30.8 11.5
0 0
19 5 2
0 0
73.1 19.2 7.7
1.515 0.224a
Mean (SD) 50.4 (4.24) 49.1 (4.94) Gender Men
Woman 13 13
50 50
17 9
65.38 34.61 1.231 0.267b
Marital Status No Married
0 26
0 100
0 26
0 100
Education No SD SMP SMA College
0 16 5 2 3
0 61.53 19.23 7.69
11.53
0 15 10 0 1
0 57.69 38.46
0 3.84
0.178 0.859c
Job No Working
18 8
69.23 30.76
19 7
73.07 26.92 0.303 0.762c
Duration of hemodialysis
<6 months >6 months
0 26
0 100
0 26
0 100
Table 2 Different Tests of Mean Depression Score Before and After Intervention
Group Mean (SD) t p-value Pre Intervention Post Intervention Control Group (n=26) 17.42 (2.759) 18.00 (2.383) -1.241 0.226a
Intervention Group (n=26) 18.23 (2.383) 15.04 (2.144) 11.506 0.000a
t -1.160 0.764 p-value 0.251b 0.000b
Note: a : paired t-test b : independent t-test
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Table 3 The Difference of Mean in BDI-II Instrument Domain
Domain Group t p-value Control (n=26) Intervention (n=26) Cognitive Pre Intervention Post Intervention
5.50 (1.364) 5.54 (1.334)
5.96 (1.341) 4.85 (0.967)
-1.230 2.143
0.224 0.037
Emotional/Affective Pre Intervention Post Intervention
5.12 (2.321) 5.54 (1.944)
5.38 (2.282) 3.65 (1.958)
-0.422 3.483
0.675 0.001
Somatic/Vegetative Pre Intervention Post Intervention
6.81 (1.524) 6.92 (1.495)
6.88 (1.681) 6.54 (1.421)
-0.173 0.951
0.863 0.346
Note: independent t-test DISCUSSION The different test result of mean depression score showed that there was no significant difference in mean depression score before giving art therapy intervention between intervention group and control group with significance value 0.251 (p> 0.05). So it can be concluded that the condition of depression between the two groups is the same. According to the researchers, this is probably due to the characteristics of respondents who tend to be the same, both from age (p = 0.224), gender (p = 0.267), education (p = 0.859), and job (p = 0.762). The result of the analysis showed that the absence of average difference of depression score before giving intervention in control group and intervention was due to the homogeneity of respondent characteristics in this study. From the test results of the difference of the average depression score in each group, there are significant differences in both groups. In the control group, the p value was 0.226, which means that there was no difference in mean of depression score before and after giving art therapy intervention in control group (p> 0.05). While in the intervention group obtained p-value of 0.000, which means there is the difference in mean score of depression before and after giving intervention art therapy in the intervention group (p <0.05). Art therapy offers a nonverbal way for individuals to be seen and heard and provides an alternative form of communication for those with psychological disorders. It is suitable for
CKD patients undergoing hemodialysis and is often reluctant to discuss the problem with the family or the professionals (Mok & Tam, 2001). The method is simple enough, that the patient is given the opportunity to express his feelings through art activities, such as drawing, painting, sculpture, or sculpting. The results of creativity are not assessed aesthetically (good or not) but viewed from the way the patient to express feelings. Art therapy has several benefits, including communication and revisiting life. In terms of communication, art therapy offers a nonverbal way for individuals to be seen and heard and provides an alternative form of communication for those with psychological disorders. One descriptive study was conducted to identify the coping method commonly used by 50 patients undergoing hemodialysis in Hong Kong. The results show that the patient's tendency to discuss the problem, either to the family or friends and to the professionals is at a low rate (each mean scores 1.2 and 0.98) (Mok & Tam, 2001). As a result, these problems will be personally stored by the patient and the end result is not infrequently the condition of depression, which also appears in patients with chronic disease. One way that can be used to express one's feelings is through the art. Art is a mode or way of a sensory system that will naturally express when there is touch, olfactory, and other senses gained from previous experience. Drawing and other art activities mobilize expressions of sensory memories that cannot be done through interviews and verbal
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interventions (Malchiodi, 2011). In this study, respondents were given 4 therapy art therapy interventions, each session was conducted for approximately 30 - 45 minutes. In one study, two-session art therapy interventions reduced depression in 7 respondents (Ando et al., 2013). Each session of the study was conducted for 1 hour. From the results of the study, respondents wanted the intervention-giving sessions to be added. However, when viewed from the number of respondents, the study still involves a small number, i.e. only 7 respondents and do not use the control group. When viewed from the decrease in the average score of depression, it can be seen from the average score is indeed a decrease in the intervention group, which is 3.19, and in the control group increased, namely 0.58. However, when viewed from the category level depressing, no change in the level. That means the condition of depression is at the same level before and after the intervention of art therapy. This can be due to the unpopularity of respondents in the way offered by researchers, namely drawing therapy. In the control group who were not given art therapy intervention, there was an increase, indicating that the current therapy given is not effective enough to overcome the psychological disorders that occur in CKD patients undergoing routine hemodialysis. Nurses as a comprehensive nursing care nurse can play a role in improving the psychological well being of patients. Nurses in dealing with the psychological condition of CKD patients undergoing hemodialysis should be in accordance with the conditions and needs of patients. This can be started by not excluding the study of the psychological condition in the patient so that it not only focuses on the physical condition alone. As has been explained that one of the interventions that can be done in depressed patients is to improve therapeutic relationships. Given the routine assessment of the patient's psychological condition, it is expected to improve the therapeutic relationship between patient and nurse.
It can be seen also from the results of this study that there is a difference in the cognitive domain after giving art therapy intervention (t = 2.143; p-value = 0.037). This result is supported by findings from Pike (2013), which states that giving art therapy intervention gives a positive effect on the cognitive ability of the respondents (Pike, 2013). As it is known that cognitive can be defined as the thinking ability of a person. The ability to think is inseparable from brain function. The brain structure provides an alternative pathway that can be used to access and process information that is visual, motor, and memorable. Art therapy has unique properties because it is a medium that can facilitate alternative pathways that exist in the brain and activate it through the use of media art in therapy (Lusebrink, 2004), so as to improve the ability of a person's cognition as a result of the ease in processing existing information. The results also showed that there were differences in the emotional/affective domain between before and after art therapy intervention (t = 3.483; p-value = 0.001). In terms of managing emotions, participation in creating art provides a mechanism for emotional representation and resolution. The multi-sensory experience of making art creations is a creative process that can strengthen, stimulate memory, free emotions, and increase the level of activity. Making art has a calming effect on anxious patients (Johnson, Johnson, & Zhang, 2005). In the somatic/vegetative domain, the results of this study showed that there was no difference between before and after art therapy intervention (t = 0.951; p-value = 0.346). This result is different from some studies that have been done before. The result of the study was that after art therapy intervention there was an improvement in physical/somatic condition (Ando et al., 2013; Thyme et al., 2009). All three studies were similarly used female respondents with breast cancer. However, no mention of how long the respondent has suffered from cancer. In this study, the researchers used respondents who were suffering from CKD patients who have been in
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the final stage and undergo hemodialysis at least 6 months, with frequency 2 times a week. When viewed from the tendency of physical condition, there is a difference between findings of this study with previous research. Respondents in this study were largely unemployed as before they suffered CKD and underwent hemodialysis. CONCLUSION Art therapy interventions are expected to serve as a consideration of modal-based nursing therapy interventions in an effort to improve the psychological health of chronic disease patients, especially patients with Chronic Kidney Disease undergoing hemodialysis, looking at situations and time spent at least 4 hours for each hemodialysis process. Knowledge and understanding related to art therapy that can be used to overcome psychological disorders, especially in patients with Chronic Kidney Disease undergoing hemodialysis, need to be owned and improved by nurses. This can be done by holding discussions, seminars, and training on art therapy. REFERENCES Ando, M., Imamura, Y., Kira, H., & Nagasaka, T.
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Cite this article as: Fatmawati, A., Soelaeman, M.R., Rafiyah, I. (2018). The application of art therapy to reduce the level of depression in patients with hemodialysis. Belitung Nursing Journal,4(3),329-335.
THE EFFECT OF ANEMIA ON THE INCIDENCE OF PREMATURE
RUPTURE OF MEMBRANE (PROM) IN KERTHA USADA HOSPITAL, SINGARAJA, BALI
Putu Irma Pratiwi1*, Ova Emilia2, Farida Kartini3
1Sekolah Tinggi Ilmu Kesehatan Buleleng
2Universitas Gadjah Mada 3Aisyiyah University of Yogyakarta
*Correspondence: Putu Irma Pratiwi Sekolah Tinggi Ilmu Kesehatan Buleleng Email: [email protected]
Abstract Background: Premature Rupture of Membranes (PROM) causes morbidity and mortality complications in both maternal and perinatal. Pregnancy with anemia where low hemoglobin level which is less than 11.1 g / dL can be the cause of PROM through biological mechanisms and mechanisms of disease. Objective: This study aims to compare the risk of PROM between anemic maternal mothers and non-anemic maternal mothers. Methods: A case-control study was conducted on the maternal mothers at KerthaUsadaSingaraja Bali Hospital, with 106 cases and 106 controls, using maternity medical records data in January-December 2016. The cases and controls were adjusted to the parity. The data were collected using questionnaires consisting of 2 parts: the first part was about the demographic characteristics, and the second part was about the time of membrane rupture and hemoglobin level at the delivery. The obtained data were analysed using descriptive and analytic statistics on the computer program. Result: On univariable analysis, the prevalence of PROM equalled to 28,3% in maternal anemia group. In bivariableanalysis, the risk factors of were anemia status, maternal activity, and maternal age (p <0.05). A multivariable analysis of conditional logistic regression analysis, controlling the possibility of confounding factors, showed that pregnant women with anemia would be at risk of PROM 3.59 times greater than non-anemic mothers (OR = 3.59, 95% CI = 1.82-7, 09). Conclusion: The risk of PROM is higher in anemic maternal mothers than in non-anemic mothers, after homogenising with parity variables. Keywords: Premature Rupture of Membranes, Anemia, Hb Level
INTRODUCTION Premature rupture of membranes is an obstetric condition in which an amnionic leak occurs at least one hour before the onset of labour, complicating 5-10% of all deliveries (Caughey, Robinson, & Norwitz, 2008). For pregnant women, premature rupture of membranes may increase the incidence of maternal morbidity and mortality, including
chorioamnionitis, endomyometritis, post-partum hemorrhage, pelvic abscess, and an increased chance of cesarean delivery (Rouse et al., 2004). Low hemoglobin levels which were less than 11.1 gr/dl during pregnancy issuspected as theprimary cause of the infectionthat can result inpremature rupture of membranes (Ferguson, Smith, Salenieks,
Windrim, & Walker, 2002). Anemia may affectthe strength of body response to infections and immune function that can lead to the decrease of natural cell capability (Oppenheimer, 2001). In Singaraja, there is a tendency of increasing premature rupture of membranes cases and anemiaduring partum process for the last three years (Dinkes, 2016). The cause of premature rupture of membranes is most likely multi-factorial. The effects of anemia are not only on the mother but also on the fetus in pregnancy as well as pregnancy outcomes such as early rupture of membranes, the researcher compared postpartum women with premature rupture of membranes and those who did not suffer from premature rupture of membranes to see the occurrences of anemia. METHODS Study design The study applied a retrospective cohort study with a hospital-based control case design (1:1). Settings The study was conducted from 25 September to 25 October 2017 at Kertha Usada Singaraja Bali Hospital. Kertha Usada Hospital Singaraja Bali is a referral hospital in Buleleng district. Kertha Usada Hospital equipped with medical facilities and equipment with a total capacity of 300 beds. Human resources Kertha Usada Hospital consist of 313 people, 29 specialist doctors, 15 general practitioners, two pharmacists, 174 nursing paramedics and 106 non-medical personnel. Kertha Usada Hospital facilities, include Emergency Unit, Laboratory, Pharmacy, Nutrition Installation, Hemodialysis, Operating Room, Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), Intermediate Care Room, delivery room, radiology (X-ray and CT-Scan), and three units of theambulance. Referrals received at Kertha Usada Hospital includes maternal and child health such as delivery. Birth referrals received by the KerthaUsada hospital in 2016 were majority due to premature rupture of membranes. Premature rupture of membranes casesin 2016 at Kertha Usada
hospital reached 256 out of total 803 births. Normal deliveries were 366 incidences, and delivery with cesarean section was 419. The causes of childbirth with cesarean section were due to fetus position abnormalities, prolonged labour and premature rupture of membranes. Research subjects The study was conducted using medical records data of maternity from January to December 2016 to identify anemia effects on premature rupture of membranes occurrences. A total of 106 maternity mothers of premature rupture of membranes used as case group and 106 maternity mothers without premature rupture of membranes as control group included in this research. In case of a group, premature rupture of membranes is diagnosed by medical professionals like midwives or doctors at Kertha Usada Hospital Singaraja Bali. The control group consisted of the maternal mother without premature rupture of membranes. Case and control groups were matched (1: 1) based on parity. Those 212 maternal mothers were between nullipara and gran multiparaparity during the study conducted. Both cases and control groups used the same questionnaire for data collection. The inclusion criteria in this study were pregnant women who gave birth with gestational age (37-42 weeks), and single fetus alive. The gestational age was determined by the first day of the first menstrual period. The exclusion criteria in this study were pregnant women with multiple pregnancies, infants with acongenital anomaly, intrauterine fetus death, maternity mothers who hadthe chronic illness (diabetes mellitus, hypertension, asthma, heart attack). Instrument Data collection was conducted by self-administered questionnaires using secondary data from Maternity Medical Record at KerthaUsada Hospital Singaraja Bali from January to December 2016. The data were collected using a questionnaire comprising two parts: the first part was about demographic characteristics, and second partconsisted ofanemia and hemoglobin levels during labor.
Ethical consideration The research was conducted after obtaining the approval or letter of research ethics from ‘Aisyiyah University of Yogyakarta's Ethics Committee on August 16, 2017, with the number 01 / KEP-UNISA / Exe / VIII / 2017. The research was reviewed and approved by the director of Kertha Usada Hospital Singaraja Bali with number 507 / RSU-KU / IX / 2017 on September 19, 2017. Confidentiality well maintained during research by using anonymous techniques (respondents are identified by code number to ensure confidentiality). Data analysis The data were analysed using a computer program. For better understanding, the information was tabulated using univariable, bivariable and multivariable analysis. The result of the univariable analysis presented in frequency and percentage. The bivariable analysis was done to test the relationship between dependent variable and independent variables, such as premature rupture of membranes and anemia. The statistical test
used Mantel-Haenszel (x2MH) test, with significance level p <0.05 and confidence interval (95%). The strength of the relationship was seen from the odds ratio (OR) between anemia and premature rupture of membranes incidence. The multivariable analysis used conditional logistic regression with a significance level of p <0.05 and confidence interval (95%). Modeling in conditional logistic regression shows 95% confidence interval (CI) value, AIC (Akaike's Information Criterion) to see how far all variables in each model predict the risk of premature rupture of membranes (PROM). RESULTS Distribution frequency of research subjects characteristic The results of univariable analysis present respondent characteristics based on each variable analysed in the form of the frequency distribution (number and percentage), more completed data ware presented in Table 1.
Table 1 Distribution frequency of research subjects characteristic
Variables PROM Without PROM Total n=106 (%) n=106 (%) n=212 %
Anemia Status • Anemia 60 28.3 36 16.9 96 45.3 • Without Anemia 46 21.7 70 33.1 116 54.7
Source: characteristic data of research subjects Based on the data in Table 1, the status of anemia, the most dominant factor of maternal mothers who did not experience premature rupture of membranes did not suffer from anemia which had Hb ≥11 gr/dL of 33.1%. Based on the characteristics of the mother's occupation, the most commonly found in mothers who did not experience premature rupture of membranes were mostly unemployed (34.4%). According to the characteristics of maternal age, the most dominant was mothers who suffered
apremature rupture of membranes was the risky age that was in the age range of <20 and> 35 years (29.7%). The effect of anemia on the rate of premature rupture of membranes The bivariable analysis was conducted to examine the relationship between dependent variable and independent variable, i.e.premature rupture of membranes and anemia variables. The statistical test used Mantel-Haenszel (x2MH) test, with
significance level p <0.05 and confidence interval (95%). The strength of the relationship was seen from the odds ratio (OR) between anemia and the incidence of premature rupture
of membranes.Analysis of the effect of anemia on the rate of premature rupture of membranes presented in Table 2.
Table 2 Analysis ofMantel-Haenszel Parity equivalent to independent variable (anemia) and dependent variable (PROM)
Variable PROM
Without PROM
!!MH p ORMH (CI 95%)
Anemia status Anemia Withoutanemia
n (%) n (%) Anemia status • Anemia 30 28.3 30 28.3 10.97 0.0009 3.59
(1.82-7.09) • Without anemia 6 5.7 40 37.7 Information :!!MH = UjiMantel-Haenszel p<0,05. ORMH = (OR) Mantel-Haenszel (CI 95%) Source: result of data analysis about anemia impact to PROM occurrences
Based on the result of the analysis on table 2, it showed that anemia on maternal mothers had a significant correlation with PROM occurrences by looking at p-value= 0.0009 and OR = 3.59 (95% CI: 1.82-7.09). It can be interpreted that maternal mothers with anemia
would have three times higher risk of experiencing PROM compared to those who did not have anemia. The analysis of other variables to PROM occurrences was presented in Table 3.
Table 3 Analysis of Mantel-Haenszel Parity equivalent to other variables (occupation and age) with dependent variable
(premature rupture of membranes)
Variable PROM Without PROM
!!MH p ORMH (CI 95%) Occupation
Working Unemployment Occupation n (%) n (%) • Working 19 17.9 42 39.6 14.98 0.0001 2.93
(1.66-5.17) • Unemployment 14 13.2 31 29.3 Mother’s age (yrs) n (%) n (%) • <20 and >35 30 28.3 33 31.2 6.81 0.0091 2.09
(1.20-3.63) • 20-35 14 13.2 29 27.3 Information :!!MH = Mantel-Haenszeltest p<0.05. ORMH = (OR) Mantel-Haenszel (CI 95%) Source: the result of data analysis of anemia impact to PROM occurrences
From the analysis result of Table 3, it shows that the occupation of the mother had a significant relationship with the incidence of PROM, by looking at the value p = 0.0001 and OR = 2.93 (95% CI: 1.66-5.17). It can be interpreted that pregnant women who work will have a twice higher risk of experiencing PROM than those who do not work. Maternal age has a significant relationship with PROM incidents, by looking at the values p = 0.0091 and OR = 2.09 (95% CI: 1.20-3.63). It can be interpreted that mothers who have a risky age that is in the age range <20 and ≥35 years at the time of pregnancy will have a twice higher risk to experience PROM than those who are 20-35 years.
Multivariable Analysis Seeing whether occupation and age were confounding factors that changed the anemia effect on PROM incidence, conditional logistic regression analysis was performed with a significance level of p <0.05 and confidence interval (95%). Modeling in conditional logistic regression shows odds ratio (OR) value, confidential interval (CI) 95%, and AIC (Akaike's Information Criterion) to see how far all variables in each model predict the risk of premature rupture of membranes. The results of the multivariable analysis can be seen in Table 4.
Table 4 Analysis of Conditional Logistic Regression on Anemia impact to PROM occurrences
PROM
Variable Model 1 Model 2 Model 3 Model 4
OR (CI 95%)
OR (CI 95%)
OR (CI 95%)
OR (CI 95%)
Anemia Status • Anemia 3.59★★★
(1.82-7.09) 2.56★
(1.24-5.24) 3.55★★★
(1.78-7.08) 2.53★
(1.22-5.24) • Without Anemia 1 1 1 1
Occupation • Working 2.59★★
(1.37-4.92) 2.59★★
(1.35-4.96) • Not working 1 1
Mother’s age (yars) • <20 and >35 2.14★
(1.18-3.85) 2.12★
(1.16-3.87) • 20-35 1 1
N 212 212 212 212 AIC 259.5 252.7 255.0 248.5
Information: OR= oddsratio with CI= Confidential Interval (95%), AIC= Akaike’sInformationCriterion, 1 = reference. Sig ★ p<0.05,★★ p<0.01, ★★★ p<0.001 Source: The result of data analysis of anemia impact to PROM occurrences
The result of analysis model in Table 4 used conditional logistic regression. Model 3 was chosen as a parsimonious model that is the best model to predict the risk of premature rupture of membranes. Thus, model 3 does not change the value of OR and significance value. Prevent the occurrence of PROM then the age of the mother should be considered. DISCUSSION The results of this study presented that maternal anemia in women had a significant association with PROM occurrences. Pregnancy with anemia will have three times higher risk than those without anemia. Low hemoglobin levels (<11.1 g / dL) are associated with premature rupture of membranes, presumably low levels of hemoglobin are the initial symptoms which do not appear sothat can cause infection (Ferguson et al., 2002). Other studies say anemia that occurs early in pregnancy in which low blood hemoglobin levels is<11 g /dL may increase the risk of PROM compared to normal hemoglobin levels in preterm pregnancy (Zhang, Ananth, Li, & Smulian, 2009). Anemia of iron deficiency may increase
risk factors for maternal infection (Allen, 2001). Meanwhile, research conducted mentions that 59.6% of anemic mothers experience premature rupture of membranes, which in this study showed a significant relationship between anemia status and premature rupture of membranes, pregnant women with anemia had a 2.4 times greater risk compared with non-anemic pregnant women (Pusparini, 2013). An imbalance rate between the need and intake of iron during pregnancy will lead to deficiency resulting inanemia. In biological mechanisms, anemia is found to affect the pregnancy outcomes (Allen, 2001). The decrease in hemoglobin or anemia causes a decreased amount of oxygen transported to the tissues, potentially increasing the risk of premature rupture of membranes due to hypoxia in the tissues. Anemia can lead to hypoxia in the tissues, and anemia of iron deficiency may increase serum concentrations of norepinephrine, causing maternal and fetal stress. The incidence of anxiety in pregnancy will stimulate the synthesis of hormone Corticotrophin Releasing Hormone (CRH). The presence of elevated CRH concentrations can lead to premature birth, hypertension in
pregnancy, preeclampsia and PROM. The relationship between anemia and infection may be caused by increasing ability of phagocytes activity and rising bactericidal, resulting in a decrease in immune cells resulting in aproliferation of T and B cells that can cause infection (Lone, Qureshi, & Emmanuel, 2004). The results of this study state that the occupation of the mother has a significant relationship with the incidence of PROM. Pregnant women who work will have atwice higher risk of experiencing PROM than those who do not work. Mothers who work outside the home could increase the incidence of PROM, the more factors that can cause fatigue, the higher the risk of amother experiencing PROM (Newman et al., 2001). The results of other studies say that the pattern of pregnant women's work affects the energy needs; physical work performed too heavy and exceeded eight hours per day during pregnancy may cause fatigue. Fatigue in work causes weak corion amnion, which can cause premature rupture of membranes (Tahir, Seweng, & Abdullah, 2012). The results of this study indicate that maternal age has a significant relationship with the incidence of PROM. Mothers aged <20 and ≥35 years of age during pregnancy will have a twice higher risk for PROM than mothers aged 20-35 years (Tahir et al., 2012). Iron deficiency anemia is likely to cause reproductive disorders such as the risk of maternal infection. Lack of iron effect immune function. Anemia can alter the proliferation of T cells and B cells and reduce the cell's ability in do phagocytes activity, decrease cell activity and bactericidal. The presence of infection is a risk of preterm birth. The presence of bacteria or inflammation of cytokines in amniotic fluid or the chorioamniotic membrane has a strong association with PROM and premature birth incidences (Allen, 2001). The Kovavisarach study says that there is no difference in the risk of PROM in the risky age group and the age group whichis not at risk
(Kovavisarach & Sermsak, 2000). A pregnancy that occurs at <20 years old or too young often causes complications for the mother and fetus; this is due to immature reproduction organs. The small reproductive organ at <20 years of age produces the uterus to be unable to support the pregnancy adequate; the amniotic membranes are naive and susceptible to tears that may cause premature rupture of membranes (Prawirohardjo, 2008). As the age grows, it will decrease the ability of the reproductive organs to perform its functions. The decrease in service of the reproductive organs also affects the process of embryogenesis, the quality of the ovum also decreases, which is why pregnancy in old age is at risk for abnormal fetal development, congenital abnormalities as well as other conditions that interfere with pregnancy and childbirth such as labour with premature rupture of membrane. As a result, it makes easier to break prematurely (Cunningham, Leveno, Bloom, Spong, & Dashe, 2014). CONCLUSION The risk of premature rupture of membranes was higher in the maternal anemia than the mothers without anemia, after homogenised with the parity variable. The maternal age had a significant relationship with the incidence of early rupture of membranes. Mother’s agewas not a confounding factor of prematurerupture of membranes occurrences; it means that in the context of intervention to prevent the event of premature rupture of membranes, mother's age should be considered. REFERENCES Allen, L. H. (2001). Biological mechanisms that might
underlie iron’s effects on fetal growth and preterm birth. The Journal of nutrition, 131(2), 581S-589S.
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Oppenheimer, S. J. (2001). Iron and its relation to immunity and infectious disease. The Journal of nutrition, 131(2), 616S-635S.
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Rouse, D. J., Landon, M., Leveno, K. J., Leindecker, S., Varner, M. W., Caritis, S. N., . . . Miodovnik, M. (2004). The maternal-fetal medicine units cesarean registry: chorioamnionitis at term and its duration—relationship to outcomes. American Journal of Obstetrics and Gynecology, 191(1), 211-216.
Tahir, S., Seweng, A., & Abdullah, Z. (2012). Faktor Determinan Ketuban Pecah Dini di RSUD Syekh Yusuf Kabupaten Gowa. Makassar: Fakultas Kesehatan Masyarakat Universitas Hasanuddin.
Zhang, Q., Ananth, C. V., Li, Z., & Smulian, J. C. (2009). Maternal anaemia and preterm birth: a prospective cohort study. International Journal of Epidemiology, 38(5), 1380-1389.
Cite this article as: Pratiwi, P.I., Emilia, O., Kartini, F. (2018). The effect of anemia on the incidence of premature rupture of membrane (PROM) in Kertha Usada Hospital, Singaraja, Bali. Belitung Nursing Journal,4(3),336-342.
1Master student, Faculty of Nursing, University of Sumatera Utara, Medan 2Faculty of Medicine,University of Sumatera Utara, Medan
3Department of Medical Surgical Nursing, Faculty of Nursing,University of Sumatera Utara, Medan *Correspondence: Iskandar Master student, Faculty of Nursing, University of Sumatera Utara Jl. Prof. Maas No. 3 Kampus USU 29155 Medan, Indonesia Email: [email protected] Abstract Background: Peripheral arterial disorders in diabetes mellitus is a common complication that often occurs and can develop into diabetic foot ulcers. High blood sugar levels in people with diabetes mellitus can cause increased blood viscosity resulting in thickening of the capillary membrane, where erythrocytes, platelets and leucocytes are attached to the blood vessels. Electrical stimulation by placing electrodes in the calf muscle is one of the measures to increase foot blood flow that can reduce the poor foot circulation. Objective: This study aims to determine the effect of electrical stimulation in improving blood flow of patients with diabetes mellitus. Methods: The research use one-group pretest-posttest pre-experimental design. Sampling technique using pusposive sampling as many as 62 patients with diabetes mellitus. Electrical stimulation is done by attaching electrodes to left and right calf muscles for 20 minutes, frequency 3 times a week for 2 weeks. Before and after electrical stimulation performed foot circulation examination by ankle brachial index technique. Data analysis using Wilcoxon signed rank test. Results: The results showed that before the stimulation was obtained the mean ankle brakhial index 0.82 mmHg and after stimulation 0.95 mmHg (p = 0.000), meaning there is an effect of electrical stimulation in increasing foot blood flow. A calf muscle contraction during stimulation leads to increased leg blood flow through the addition of vascular endothelial growth factor and increased nitric oxide as a vasodilator of blood vessels. Electrical stimulation can be applied in increasing the blood flow of the foot, thus preventing the occurrence of diabetic foot ulcers. Conclusion: Stimulation is one therapy that can be done to prevent poor foot circulation of diabetes mellitus patients. Keywords: electrical stimulation, foot circulation, diabetes mellitus
INTRODUCTION Diabetes mellitus (DM) has a broad impact on the lives of patients, mainly due to the occurrence of prolonged complications. This disease is mentioned as one of the main causes of chronic disease and causes loss of limbs around the world (Hingorani et al., 2016). International Diabetes Federation (IDF) says that the prevalence of DM in the world in 2015 reached 7.3 billion people and is predicted to
increase again in 2040 to 9 billion people. Indonesia is currently the seventh largest DM patient in the world with a total of 10 million people and is predicted to rise in sixth place by 2040 with a total of 16.2 million people. Based on the results of Basic Health Research (Riskesdas, 2013), an increase in DM prevalence in Indonesia from 1.1% in 2007 to 2.1% in 2013.
High blood glucose levels in DM patients can cause increased blood viscosity resulting in thickening of the capillary membrane, where erythrocytes, platelets and leucocytes are attached to the blood vessels. Narrowing of blood vessels due to membrane thickening resulted in reduced blood flow, resulting in various complications in patients with DM (Association, 2017). Peripheral neuropathy is the most common complication of type 2 DM and occurs in the lower extremity of the limb which may affect the sensory, motor, and autonomic systems. The risk of peripheral neuropathy disorders 2 to 4 times higher in diabetics compared with non-diabetics, this disorder will increase with age and duration of diabetes (Beckman, Creager, & Libby, 2002). One of the symptoms that appear in diabetic neuropathy is a leg injury. This is due to the disruption of blood vessels in the peripheral arteries and is a factor that contributes to the development of wounds in diabetic feet up to 50% of cases. Recommended interventions to reduce the continued effects of peripheral blood flow disruption such as regular exercise routine (walking, leg exercising, joint movement range) (Francia et al., 2015). Prevention to reduce the bad feet circulation in patients with diabetes mellitus is often done today, among others, regular exercise such as gymnastics fitness, walking exercise, range of motion on the feet. Some DM patients are found not to have enough time to exercise regularly because they are busy with other activities. Electrical stimulation is one alternative therapy that can improve foot circulation to prevent potential foot injuries. Several studies have shown that commonly used electrical stimulation is to reduce pain, speed up wound healing and lower blood sugar levels. Research on electrical stimulation combined with walking for 50 minutes a day, 3 times a week for 4 weeks found an increase in foot circulation of DM patients compared to walking without electrical stimulation (Park,
Son, Kim, Kim, & Oh, 2011). Previous study on electrical stimulation for 60 minutes, 3 times a week for 4 weeks found the perfect wound healing in the diabetic foot (Asadi, Torkaman, Mohajeri-Tehrani, & Hedayati, 2015). Previous research about electrical stimulation for 40 minutes a day, 3 times a week for 2 weeks on quadriceps femoris muscle with 50 Hz frequency was obtained before the average electrical stimulation of blood sugar 197.30 mg/dl and after stimulation in the last session an average of 148.10 mg/dl (Sharma, Shenoy, & Singh, 2010). Foot circulation is assessed using the ankle brachial index (ABI) method, which compares the systolic ankle and brachial systolic values. The purpose of this study was to determine differences in foot circulation of patients with diabetes mellitus before and after electrical stimulation of the calf muscles. METHODS Study Design This study used one-group pretest-posttest pre-experimental design. The study was conducted at Public Health Center Muara Satu and Public Health Center Muara Dua of Kota Lhokseumawe from 5 July to 10 September 2017. Research Subject The sample size was 62 DM patients, using purposive sampling technique. The inclusion criteria established were (1) age over 40 years, (2) not diabetic foot ulcer, (3) blood sugar levels less than 500 mg/dl (4) did not suffer from respiratory diseases, (5) no cerebrovascular disorders. Exclusion criteria include DM patients with heart rhythm disturbances, experiencing respiratory complications (tachypnea/bradipnea). Intervention The electrical stimulation given in this study is using Veinoplus. Before the stimulation is done blood glucose examination and the measurement of ankle brachial index (ABI) as a pretest to determine foot circulation. Stimulate for 20 minutes by attaching
electrodes to both left and right calf muscles in the sleeping patient position.. Treatment is given 3 times a week for 2 weeks. In the last session the treatment performed again measurement of blood sugar and ABI. ABI is determined on the patient's supine position by inserting a sphygmomanometer cuff over the ankles (lateral malleolus), applying jelly to the artery tibial anterior, the vascular probe is placed in the artery tibial anterior of the until a pulse is heard, the cuff is then pumped until no pulse is heard. The cuff is released slowly to determine the ankle systolic. Similarly, to determine the brachial systolic in the patient's position to sleep on his back, then the cuff is mounted on the upper arm, the vascular probe is placed on the brachial artery. While blood glucose levels were assessed by taking blood samples on the patient's fingertips after being stabbed using a needle until blood came out about one drop, inserted into the Gluco-Dr. Instrument Instruments used include electrical stimulation with the brand VeinoPlus with battery type 9V (made in AD Rem Technology Paris, France). Vascular Doppler brand Bistos HI-dop (made in Model BT-200, 8 MHz ultrasound frequency, 1.5 V x 2 type battery (AA Type) (made in Bistos Co. Ltd., Seoul Korea).
Furthermore, to support the implementation of vascular doppler is also used Sphygmomanometer Aneroid Type Tensi 200 brand OneMed (permit Depkes RI AKL 20501906481) to measure the systolic ankle and brachial pressure. Examination of blood glucose levels using Gluco-Dr (made in Alimedicus, Indonesia). Ethical Consideration This study has obtained ethical approval from the Ethics Committee of the Faculty of Nursing, University of Sumatera Utara with number 1236/VII/SP/2017. The researcher also confirmed that each respondent has gained approval for research. Data Analysis Data were analyzed using wilcoxon signed rank test RESULTS Table 1 shows that the mean age of DM patients in this study was 57.15 years (standard deviation = 6.44). The most dominant age was found by the 56-65 years old (62.90%). Minimum age 42 years, and makasimal 72 years. While the majority gender is female (64.50%).
Table 1 Characteristics of respondents
No Characteristics f % Average Min-Max 1. Age (years) 57.15 42-72 36 – 45 years old 5 8.10 46 – 55years old 16 25.80 56 – 65years old 39 62.90 >65years old 2 3.20 2. Gender Female 40 64.50 Male 22 35.50 3. Body Mass Index (BMI) 21.93 15.11-28.65 <17 kg/m2 3 4.80 17 – 18.5 kg/m2) 3 4.80 18.6–25kg/m2) 48 77.40 25.1–27kg/m2) 6 9.70 > 27 kg/m2 2 3.20 4. During DM 9.63 2-22 <10year 41 66.10 > 10 year 21 33.90
Body mass index (BMI) averaged 21.98 kg/m2 (standard deviation 2.87). Minimum BMI value 15.11 kg/m2 and maximum 28.65 kg/m2. Viewed from the long suffering DM average 9.63 years (standard deviation 5.05 years). The majority of patients less than 10 years (66.10%). At least suffer DM 2 years and 22 years old.
Table 2 shows that before the patient's blood sugar levels were stimulated in mild and moderate range (38.70%) and ABI in the mix arterial-venous category (50%). Meanwhile, after the stimulation of blood sugar levels in the normal category (58.10%) and ABI increased or normal (82.30%).
Table 2 Frequency distribution Blood sugar levels and ankle brachial index values
Differences in blood sugar level and ABI values before and after the wilcoxon signed rank test were presented in table 3. The results showed that there was a significant difference
in the decrease in blood sugar levels (p = 0.000, p <0.05). The same is true of the patient's foot circulation before and after treatment (p = 0.000, p <0.05).
Table 3 Differences in blood sugar levels and brachial ankle value index between pre-test and post-test of electrical
stimulation
No Blood Sugar Level and Ankle Brachial Index Pre-test Post-test pvalue
1. Blood Sugar Level Mean 305.06 204.87
0.000 Standar deviasi 86.97 68.30 Min – Max 114 - 425 90 - 375 2. Ankle Brachial Index Mean 0.82 0.95
0.000 Standar deviasi 0.11 0.79 Min – Max 0.62 – 1.17 0.77 – 1.17
DISCUSSION Blood Sugar Level Pre-test and Post-Test Electrical Stimulation Increased blood sugar levels in DM patients due to pancreas do not produce enough insulin, or when the body cannot effectively use the insulin that has been produced (WHO, 2016). Hyperglycemia that occurs can cause increased blood viscosity so as to affect the blood flow is not good. Changes in blood
sugar levels are influenced by multifactors, including age, body mass index, long DM, physical activity and tobacco use (Pamungkas, Limansyah, Sudarman, & Siokal, 2016). Based on table 1 above can be seen there is a decrease in blood glucose levels before and after electrical stimulation. Mean pre-test blood sugar levels were 305.06 mg/dl and post-test 204.87 mg/dl (p = 0.000). Decreased blood sugar levels can occur due to muscle
contraction by vibration of electrical stimulation in the calf muscles. Cells take glucose in the blood to convert into energy within the mitochondria. Furthermore, such energy causes contraction in the smooth muscles in the calf. A significant reduction in the study was also influenced by patient compliance in regular blood sugar control and oral therapy to lower blood sugar. According to Asadi, Torkaman, Mohajeri-Tehrani, and Hedayati, explaining that the management of blood glucose levels of DM patients can be pursued by doing physical activity exercises so that glucose needs will increase compared to at rest. Regular electrical stimulation increases the absorption of glucose by the tissues during and after exercise, improves insulin sensitivity and improves the translocation of glucose transport. In addition to the stimulation provided, DM management also depends on lifestyle, pharmacological interventions with oral hypoglycemic or insulin preparations, blood glucose monitoring and early or continuous health education or counseling (Asadi et al., 2015). The absorption of glucose that is transferred by muscle contraction is responsible for the decrease in blood glucose levels. Electrical stimulation can activate the absorption of glucose in the calf muscles by transporting GLUT-4 to the cell surface. However, the decrease in blood glucose after 2 weeks of stimulation in this study may be due to the accumulation of insulin-dependent effects of increased insulin sensitivity. Differences in Foot Circulation Pre-test and Post-Test of Electrical Stimulation Increased age in DM patients can cause endothelial vascular disorders. This disorder occurs from the early age of the elderly, causing the shrinkage of skeletal muscle cells progressively causing the disorder of protein cynthesis. The adverse effects of circulation will damage the nerves. When interference on the autonomic nerves it will experience impaired function in the smooth muscles, glands and
visceral organs. Changes in muscle tone can cause blood flow abnormalities (Petrofsky, 2011). From the research results found the difference of foot circulation before and after electrical stimulation. The average ABI before the intervention was 0.82 (venous disorder) and the mean ABI after the intervention of 0.95, whereas after intervention there was an increase in the ABI value by an average of 0.13 or included in the normal ABI category. The result of test analysis of wilcoxon signed rank test to identify that 82.5% of respondents have increased circulation. The statistical results obtained p value = 0.000 means electrical stimulation has a significant effect on increasing the foot circulation of DM patients. These results are consistent with the findings of Asadi et al. stimulation there was a change in peripheral skin temperature caused by increased blood flow (Asadi et al., 2015). Aldayel, Jubeau, Mcguigan, dan Nosaka reported that skin temperature in healthy individuals increased significantly within 10 minutes after induction of electrical stimulation in the quadriceps femoris muscle compared with the control group (Aldayel, Jubeau, McGuigan, & Nosaka, 2010). While Sandberg, Sandberg, and Dahl, induction of electrical stimulation of trapezius muscle in healthy individuals for 15 minutes can improve blood circulation in muscles (Sandberg, Sandberg, & Dahl, 2007). Stimulation of the calf muscles causes increased blood flow in the leg area through the addition of endogenous blood vessel factors, which in turn will reduce the pain experienced by diabetic patients. Thakral et al. states that increased perfusion due to electrical stimulation is associated with increased vascular endothelial growth factor (VEGF) (Thakral et al., 2013). Where, VEGF is an angiogenic factor with selective endogenous cell mitogenic activity that plays an important role in vasculogenesis, the growth factor is highly specific to the function of vascular endothelial cells. The role of VEGF is very
dominant in the process of formation of new blood vessels called angiogenesis. In addition, VEGF also plays a role in the permeability of blood vessels that cause extravasion of several other molecules. VEGF determination after electrical stimulation occurs through RNA expression by oxygen exposure initiated by contraction of the smooth muscles that cause angiogenic formation of blood vessels. Angiogenic itself is a basic process in the formation of new blood vessels from the existing blood vessels. The angiogenic target here is arterial or venous capillaries in vascular endothelial cells and smooth muscle cells (Valiatti et al., 2011). Asadi et al. increased blood flow in the wound area was associated with a vasodilation process caused by electrical stimulation. By releasing nitric oxide (NO), as a coronary vasodilator, or inhibiting sympathetic vasoconstriction. NO is a small atom, relatively unstable, free radicals and lipophilic molecules. NO works as an intermediary or regulates endothelium-dependent vasorelaxation, blood pressure, macrophage cytotoxicity, platelet aggregation. In addition, the role of NO serves to dilate blood vessels, phagocytosis process and inhibit platelet adhesion (Asadi et al., 2015). The mechanism of improving blood circulation during electrical stimulation is due to the production of NO in vascular endothelial cells in response to electrical stimulation. Where, a calcium channel is called a transient receptor voltage vanilloid (TRPV) -4 that contains an open voltage to respond to electrical stimulation in the tissues. It further increases blood flow to the tissues through ENOS which is activated with calcium (Petrofsky, 2011). Ghosh, Sherpa, Bhutia, Pal, dan Dahal explains that increased superoxide concentration causes decreased endothelial nitric oxide synthase (eNOS) isoforms by triggering the final product of glycation and polymerization. NO is synthesized as a byproduct of the conversion of its L-arginine physiological precursor to L-citrulline. This reaction is catalyzed by an enzyme known as
NO synthesis (NOS) (Ghosh, Sherpa, Yazum Bhutia, & Dahal, 2011). Toda, Imamura, dan Okamura stated that NO is constitutively produced from endothelial cells and nerve fibers that contribute to the regulation of cardiovascular function (Toda & Morimoto, 2008). This substance is formed through endothelial NO synthesis that induces vasodilation, increased blood flow rate, thrombocyte aggregation and adhesion resistance, decreased smooth muscle proliferation and as other antioxidants. When a person has hypercholesterolemia, hyperglycemia and hypertension can cause endothelial cell disruption resulting in disruption of the NO release. In people who stimulated an electric current in a low-voltage category, it can cause NO release of vascular endothelial cells, which can lead to vasodilation associated with increased blood flow to tissues and the metabolism of glucose present in the blood. The results showed after electrical stimulation performed on the calf muscles for 20 minutes with frequency 3 times a week for 2 weeks, showed an increase in circulation to the foot area. Significant increases in ABI after electrical stimulation are important to suggest that the form of passive exercise therapy has a therapeutic effect on diabetes mellitus. Limitations of the study are no examination of nitric oxide levels to detect vascular endothelial changes that cause vasodilation of blood vessels, so there is no known good time sessions to increase the levels of NO. CONCLUSION The conclusion of the research is that there is an effect of electrical stimulation on the improvement of foot circulation of diabetes mellitus patients. Stimulation is one therapy that can be done to prevent bad foot circulation resulting from high levels of sugar in the blood so it can be used as management or prevention diabetic feet diabetic patients. Health workers, especially nurses, need to socialize the use of
electrical stimulation to improve foot circulation or reduce pain in diabetes REFERENCES Aldayel, A., Jubeau, M., McGuigan, M., & Nosaka, K.
(2010). Comparison between alternating and pulsed current electrical muscle stimulation for muscle and systemic acute responses. Journal of Applied Physiology, 109(3), 735-744.
Asadi, M., Torkaman, G., Mohajeri-Tehrani, M., & Hedayati, M. (2015). Effects of Electrical Stimulation on the Management of Ischemic Diabetic Foot Ulcers. Journal of Babol University Of Medical Sciences, 17(7), 7-14. doi:10.22088/jbums.17.7.7
Association, A. D. (2017). Standards of medical care in diabetes—2017 abridged for primary care providers. Clinical Diabetes, 35(1), 5-26.
Beckman, J. A., Creager, M. A., & Libby, P. (2002). Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA, 287(19), 2570-2581.
Francia, P., Anichini, R., De Bellis, A., Seghieri, G., Lazzeri, R., Paternostro, F., & Gulisano, M. (2015). Diabetic foot prevention: the role of exercise therapy in the treatment of limited joint mobility, muscle weakness and reduced gait speed. Italian Journal of Anatomy and Embryology, 120(1), 21-32.
Ghosh, A., Sherpa, M. L., Yazum Bhutia, R. P., & Dahal, S. (2011). Serum nitric oxide status in patients with type 2 diabetes mellitus in Sikkim. International Journal of Applied and Basic Medical Research, 1(1), 31.
Hingorani, A., LaMuraglia, G. M., Henke, P., Meissner, M. H., Loretz, L., Zinszer, K. M., . . . Marston, W. (2016). The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery, 63(2), 3S-21S.
Pamungkas, R. A., Limansyah, D., Sudarman, S., & Siokal, B. (2016). SELF MANAGEMENT PROGRAM AMONG TYPE 2 DIABETES MELLITUS PATIENTS: A LITERATURE REVIEW. Belitung Nursing Journal, 2(3).
Park, R. J., Son, H., Kim, K., Kim, S., & Oh, T. (2011). The effect of microcurrent electrical stimulation on the foot blood circulation and pain of diabetic neuropathy. Journal of physical therapy science, 23(3), 515-518.
Petrofsky, J. S. (2011). The effect of type-2-diabetes-related vascular endothelial dysfunction on skin physiology and activities of daily living: SAGE Publications.
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Sandberg, M. L., Sandberg, M. K., & Dahl, J. (2007). Blood flow changes in the trapezius muscle and overlying skin following transcutaneous electrical nerve stimulation. Physical Therapy, 87(8), 1047-1055.
Sharma, D., Shenoy, S., & Singh, J. (2010). Effect of electrical stimulation on blood glucose level and lipid profile of sedentary type 2 diabetic patients. International Journal of Diabetes in Developing Countries, 30(4), 194.
Thakral, G., LaFontaine, J., Najafi, B., Talal, T. K., Kim, P., & Lavery, L. A. (2013). Electrical stimulation to accelerate wound healing. Diabetic foot & ankle, 4(1), 22081.
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Valiatti, F. B., Crispim, D., Benfica, C., Valiatti, B. B., Kramer, C. K., & Canani, L. H. (2011). The role of vascular endothelial growth factor in angiogenesis and diabetic retinopathy. Arquivos Brasileiros de Endocrinologia & Metabologia, 55(2), 106-113.
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Cite this article as: Iskandar., Dharmajaya, R., Ariani, Y. (2018). Increasing foot circulation with electrical stimulation in patients with diabetes mellitus. Belitung Nursing Journal,4(3),343-349.
VALIDITY AND RELIABILITY OF INSTRUMENT TO MEASURE CLINICAL INDICATOR OF NURSING DIAGNOSIS: FATIGUE ON
PATIENT UNDERTAKING HAEMODIALYSIS
Atika Dwi Astuti1, Intansari Nurjannah2*, Sri Mulyani3
1Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada 2Department of Mental Health and Community Nursing, Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada 3Department of Mental Health and Community Nursing, Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
*Correspondence: Intansari Nurjannah, S.Kp., MN. Sc., Ph.D Department of Mental Health and Community Nursing, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada Email: [email protected] Abstract Background: Fatigue as nursing diagnosis is a common phenomenon in patient undertaking hemodialysis. There is, however, no clear instrument to measure the clinical indicators of this nursing diagnosis. Objectives: To measure the validity and reliability an instrument to measure clinical indicator in nursing diagnosis fatigue. Methods: Content Validity Index for Scale (S-CVI) and Point-Biserial Correlation were used to measure the validity of instrument. Cronbach Alpha Reliability was used for reliability of 72 patients undertaking haemodialysis. Results: S-CVI score was 1 on relevance, accuracy and clarity, 0.98 on simplicity and ambiguity. The Cronbach’s Alpha of the instrument was 0.675 which was considered reliable. Conclusion: The instrument to measure clinical indicators of nursing diagnoses fatigue has acceptable validity and reliability score in Indonesian, and it is recommended to be used in clinical setting. Keywords: Validity, reliability, fatigue, haemodialysis
INTRODUCTION Nursing diagnosis is part of nursing process which has to be established in nursing care (Doengoes & Moorhouse, 2013). This diagnosis establishment is considered an important element that can determine the next step for the treatment and evaluation of nursing care for patients (Carpenito, 2006). Diagnostic process is not a simple process. Nursing process can be effectively implemented if nurses have an ability to apply basic skill in nursing process (Doengoes & Moorhouse, 2013). Nurses need to collect
accurate and relevant data for hypothetically established nursing diagnosis (Herdman & Kamitsuru, 2014). In this case, it is important for nurses to recognize data or clinical indicators. In order to recognize data, nurses must have sufficient knowledge regarding specific nursing diagnosis, and they must recognize the symptoms of specific diagnosis (Herdman & Kamitsuru, 2014). There are several methods to collect important data to establish nursing diagnosis. Specific instrument is required for accurate nursing
diagnosis, for example: the use of Beck Depression Inventory (Beck, Guth, & Steer, 1997) to establish a diagnosis in those patients who suffer from depression. Instruments used to detect anxiety experienced by the patients are State-Trait Anxiety Inventory, Beck Anxiety Inventory, Hospital Anxiety, and Depression Scale-Anxiety (Julian, 2011). The instrument used to detect patients who experience sleep disturbance is the Pittsburgh Sleep Quality Index (Carpenter & Andrykoswki, 1998). Those instruments are however, not used in establishing nursing diagnosis. Thus, the question arises whether there is any instrument that facilitates the establishment of nursing diagnosis. Currently, nursing diagnosis is based on NANDA-I Taxonomy that has been developed only by stating what clinical indicators may be identified in “problem focused diagnosis” and what risk factors may be identified in “risk nursing diagnosis” (Herdman & Kamitsuru, 2014). Despite clinical indicators or risk factors in each specific nursing diagnosis, there is no clear information on how to weigh those clinical indicators and risk factors, which one is more important than other data. Moreover, there is no research which explores how to design an instrument for establishing nursing diagnoses based on their own clinical indicators or risk factors. The present study aims to develop an instrument based on clinical indicators for the nursing diagnosis of fatigue. In this development process, an instrument was developed and the validity and reliability of this instrument were assessed. METHODS Study design The research type are used quantitative with Cross Sectional design Setting Research was carried out at the haemodialysis unit, at one central hospital in Yogyakarta, Indonesia.
Research subject The study population comprised 72 patients undergoing haemodialysis (n = 72), and 3 experts were selected for analysing the validity of the instrument. Instrument Instrument for measuring the NANDA-I nursing diagnosis: fatigue (00093) is developed from 16 clinical indicators (item) of this diagnosis. In the process of development of this instrument, one item is divided into three questions. Thus, the total items in this instrument are 18 questions. Measurement by the instrument is based on the Guttman scale. Patient can answer yes (score 1) or no (score 0). This instrument was used to collect data for content validity from three experts and point-biserial correlation measured on 72 patients. The reliability was measured on 72 patients who were undergoing haemodialysis. Respondents were interviewed using Piper Fatigue Scale to find out the fatigue scale of each respondent. From a total of 97 respondents who experienced fatigue then researcher selected 72 respondents using simple random sampling technique. Those respondents were interviewed using instrument derived from clinical indicators from nursing diagnosis fatigue based on NANDA-I Taxonomy (Herdman & Kamitsuru, 2014). Ethical consideration The study was approved by the Ethics Committee of the Faculty of Medicine, Gadjah Mada University with approval number: KE/FK/1328/EC/2016. Data analysis I-CVI was used to analyze the instrument which measured content validity of clinical indicators of nursing diagnoses fatigue, while point-biserial correlation was used to measure validity of each items, whereas reliability was measured using Cronbach’s alpha. Cronbach’s alpha was used to measure internal consistency or reliability of this instrument with multipleitems, while using this scale (Dukes, 2005).
1 Listlessness Changes into ‘Apathy’ And developed into three items
Three questions 1a. Do you feel less energetic since undergoing haemodialysis? 1b. Do you find it difficult to devise a plan of action? 1.c Do you find it difficult to implement plans?
2 Alteration in concentration No modification
Do you experience alteration in concentration or paying attention?
3 Alteration in libido No modification
Do you experience sexual dysfunction since undertaking haemodialysis?
4 Introspection No modification Do you self-evaluate regarding haemodialysis you undertake?
5 Tiredness No modification Do you feel easily tired or less energetic since undertaking haemodialysis?
6 Insufficient energy No modification Do feel less energetic while performing an activity or at work?
7 Disinterest in surroundings No modification Do you feel lack of interest toward surroundings?
8 Lethargy No modification Do you feel tired or no enthusiasm while undergoing haemodialysis?
9 Drowsiness No modification Do you feel sleepy while undergoing haemodialysis?
10 Guilt about difficulty maintaining responsibility
No modification Do you feel guilty about difficulty in maintaining responsibility?
11 Increase in rest requirement No modification Do you feel you need more time for taking a rest since you undergoing haemodialysis?
12 Increase in physical symptoms
No modification Do you feel you complain more about your physical condition since undergoing haemodialysis
13 Ineffective role performance No modification Do you feel a decrease in your performance since undergoing haemodialysis?
No modification Do you feel sleep deprived and repeatedly awaken since undergoing haemodialysis?
15 Impaired ability to maintain usual physical activity
No modification Do you feel unable to maintain your usual physical activity?
16 Impaired ability to maintain usual routines
No modification
Do you feel unable to maintain your usual daily routine activity?
Reproduced/translated with kind permission of NANDA International
RESULTS Result shows that the mean of respondents’ age was 51.53 years old (SD ± 12.56). A majority of respondent were aged 46–59 years. The youngest was 25 years old and the oldest was 94 years old (Table 2). All the respondents were routinely undergoing
haemodialysis twice a week. And the result of content validity shows that, in the relevance component, all items has 1 value which means that this instrument was valid (Table 3). Based on Polit & Beck (2007), I-CVI value more than 0.78 measured by 3 experts or more is considered as having good content validity.
S-CVI value of this instrument was 1, which is considered as valid and acceptable. Polit & Beck (2007) stated that S-CVI value is accepted and valid if the S-CVI value is 0.8 or more. Relevance, accuracy and clarity have a value of 1 both in I-CVI and S-CVI. The score
of items on the simplicity and ambiguity, could not reach 1, because the item libido has a score of 0.67 in I-CVI. The result of point-biserial correlation to measure validity of each items on 72 patients shows that 3 out of 18 items were not valid (Table 4).
The result of analysis shows that Cronbach’s alpha was 0.675, meaning this instrument was reliable (Table 5)
Table 5 Reliability Statistics
Cronbach's Alpha
Cronbach's Alpha Based on
Standardized Items
N of Items
.675 .680 18 Researcher analyzed the data and found that if items that were not valid based on point-biserial correlation ( 4, 9, and 13) were deleted, then the reliability increased from 0.675 to 0.688. DISCUSSION Content validity is related to the power of the instrument’s items to measure a concept. Content validity process is started from concept analysis and instrument development. There are several methods for measuring content validity for example literature review,
personal reflection and analytical critique (Higgins & Straub, 2006). Content validity is an important factor in identifying the concept of measuring (Yaghmaie, 2003). By documenting the content validity of the instrument that has been used, the reader can understand the process of measuring content validity and then by measuring content validity, the interpretations of results are precise (Yaghmaie, 2003). The result of this study shows that content validity is considered as acceptable, even though there is one item which scored less than 1 in I-CVI ,which was ‘libido’,and in item content validity ‘simplicity’ and ‘ambiguity’, the S-CVI score was 0.98. Lyn states that if, 5 or less than five raters conduct measurement then I-CVI has to reach a score 1 and if the number of raters is 6 or more than I-CVI should not be less than 0.78 (Dukes, 2005). Based on Lyn’s statement, the instrument is considered as less acceptable, however, Polit et al. (Polit et al., 2007) suggests that items with an I-CVI of .78 or higher for three or more experts could be considered evidence of good content validity (Polit et al., 2007). Items with an I-CVI lower than .78 would be considered for revision, and those with very low values would be candidates for deletion. For scale to be judged as having excellent content validity, it should be composed of items that had I-CVIs of .78 or higher and a S-CVI/ I-CVI of .90 or higher (Polit et al., 2007). In this study, item ‘libido’ has got less score in ‘simplicity’ and ‘ambiguity’. This may be because sexual topic is considered as taboo in developing country. It also may be affected by Javanese culture in which sexual topic is rarely discussed openly. It is known that something that is taboo, is not as simple as it looks. Collecting data regarding sexual topic is not always easy. It may also be understood differently among people. These may the reasons of this item having a lower score for I-CVI in both item ‘simplicity’ and ‘ambiguity’. Point-biserial correlation is a type of correlation between a dichotomous variable (the multiple choice item score which is right
or wrong, 0 or 1) and a continuous variable (the total score on the test ranging from 0 to the maximum number of multiple choice items on the test) (Varma, 2006). In this study, point-biserial correlation find that item 4, 9, and 13 were not valid. Items that have low point-biserial values need further examination even if that item have good score in I-CVI values. Something in the wording, presentation, or content of such items may explain the low point-biserial correlation (Varma, 2006). Factors that may affected validity of the instrument is the reliability coefficients, that can affect validity coefficients, for examples the more heterogeneous the groups are, the higher the correlations between two measures will ultimately be (Thanasegaran, 2009). If the data range is limited, the scores become more homogenous and the resulting correlation coefficients derived are artificially inflated (Thanasegaran, 2009). Some factors may result in low validity values, because the items may not have a clear correct response and may represent a different content area than that measured by the rest of the test (also known as multidimensionality) (Varma, 2006). Result shows that this instrument has a good reliability. The range of reliability measures is rated as follows: less than 0.50, the reliability is low, between 0.50 and 0.80 the reliability is moderate and greater than 0.80, the reliability is high (Tan, 2009). In this study, as the patients were undertaking haemodialysis, researchers considered patient’s state of mind and wellbeing while collecting data. Interview to collect data was conducted in short time as instrument has also only 16 items (18 questions). This strategy was applied as test performance can be influenced by patient’s psychological and physical state (Polit et al., 2007).
CONCLUSION The instrument to measure clinical indicators of nursing diagnoses fatigue has acceptable validity and reliability score score in Indonesian language. This instrument can be used for measuring nursing diagnosis fatigue, in Indonesian setting. REFERENCES Beck, A., Guth, D., & Steer, R. (1997). Screening for
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Cite this article as: Astuti, A.D., Nurjannah, I., Mulyani, S. (2018). Validity and reliability of instrument to measure clinical indicator of nursing diagnosis: fatigue on patient undertaking haemodialysis. Belitung Nursing Journal,4(3),350-355.
