African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) Supplement 1:1 (September), 2014, pp

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1 African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) Supplement 1:1 (September), 2014, pp Knowledge, practices and attitudes of professional nurses on prevention of mother to child transmission of HIV at a government hospital in Mabopane, Pretoria, South Africa P.I. MOGANO, N. SCHELLACK AND A.G.S. GOUS University of Limpopo, Medunsa Campus and Odi district hospital, Odi. South Africa. natalie.schellack@ul.ac.za Abstract In Sub-Saharan Africa, where there is a critical shortage of health workers, nurses remain the core of the health workforce. Nurses or midwives knowledge on Human Immunodeficiency Virus (HIV) is important because it is the basis on which positive changes in behaviour occur as it brings awareness, which in turn leads to action. The purpose of the study was to explore Prevention of Mother To Child Transmission (PMTCT)-related knowledge, attitudes, practices and if there were any barriers in terms of professional nurses at learning these latest PMTCT guidelines. The quantitative study was conducted at Odi District Hospital, in Mabopane, Pretoria amongst professional nurses. A cross-sectional design using a quantitative approach was used. The study sample consisted of 36 professional nurses drawn from Antenatal clinic (ANC), labour ward, postnatal and neonatal ICU (Intensive Care Unit), paediatric ward, and paediatric Out Patient Department (OPD). A response rate of 81% (29) was obtained. Data collection took place over a period of three weeks. Majority of the participants (93%) were female. Out of the 29 participants, 76% (22) have had training in HIV/AIDS management, and the mean score was 45.7% in terms of the knowledge about HIV and paediatric HIV statistics. The mean score on the knowledge on PMTCT was above average (69%). Most of the participants were not familiar with the latest national PMTCT guidelines. Keywords: Knowledge, practices, attitudes, professional nurses, PMTCT. How to cite this article: Mogano, P.I., Schellack, N. & Gous, A.G.S. (2014). Knowledge, practices and attitudes of professional nurses on prevention of mother to child transmission of HIV at a government hospital in Mabopane, Pretoria, South Africa. African Journal for Physical, Health Education, Recreation and Dance, September (Supplement 1:1), Introduction Today, HIV-related conditions are a major contributor to childhood morbidity and mortality in South Africa (Chaparanganda, 2012). Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge efforts in resource-limited settings (Johri1& Ako-Arrey, 2011). Mother to Child Transmission (MTCT) of HIV represents a major threat to the gains in child health, achieved during the last decades and represents a huge health problem in HIV-affected populations (Leshabari, Blystad, de Paoli & Moland, 2007). Vertical transmission remains the main mode of acquisition of

2 184 Mogano, Schellack and Gous HIV infection in children, as delivery involves exposure of blood and body fluids (Ndikom & Onibokun, 2007). As the number of children infected during the HIV epidemic increases, the nurse/midwife has a vital role to play in the achievement of the millennium goals of reduction of child mortality, improving maternal health and combating HIV/AIDS (Ndikom & Onibokun, 2007). While care has been described as the essence of nursing, it is generally agreed that care is a complex phenomenon that remains elusive (Vaga, Moland, Evjen-Olsen, Leshabari & Blystad, 2012). Nurses or midwives knowledge on HIV is important because it is the basis on which positive changes in behaviour occur as it brings awareness, which in turn leads to action (Ndikom & Onibokun, 2007). South Africa (SA) has the highest number of pregnant women infected with HIV, which results in more than infected babies being born each year (Mbombo & Bimerew, 2012). Virtually all (90%) HIV-infected children acquire the infection through MTCT, which can occur during pregnancy (5 10%), labour and delivery (10 20%), or through breastfeeding (10 15%) (USAID, 2010). AIDS is the major contributor to maternal and child morbidities and mortalities in the country (McKerrowi & Mulaudziii, 2010). For PMTCT to be successful, women need to be empowered with knowledge regarding HIV infection and the risk of transmission thereof to the baby, and appropriate services should be available to reduce the risk of transmission (Atwiine, Rukundo & Mutibwa, 2012). Therefore knowledge, training and experience in every aspect of PMTCT are vital, especially with regards to the latest South African PMTCT guidelines (NDoH, 2013). The study aimed to assess the knowledge of nurses on PMTCT against the national guidelines on PMTCT (2013), to determine the attitude of nurses towards the PMTCT programme and to establish if learning barriers existed in acquiring knowledge on PMTCT at Odi Hospital in Mabopane, Pretoria. Methodology Design This was a descriptive quantitative study, which utilized a cross-sectional design to elicit information on knowledge, practices and attitudes of professional nurses on PMTCT. Data collection Data were collected from the professional nurses by means of a self-administered questionnaire developed by the researcher from reviewed literature and the latest

3 Knowledge, practices and attitudes of professional nurses 185 (2013) South African PMTCT guidelines. Information sought included participants demographic characteristics, knowledge on HIV and paediatric HIV statistics, knowledge about and attitudes towards PMTCT, as well as the barriers in acquiring knowledge on PMTCT. Each participant was given an information leaflet about the study, available in English and Setswana, after which they were given an opportunity to ask questions. Upon agreement to participate in the study, each participant signed a consent form, which was available in English and Setswana. Participants completed the questionnaire themselves, with assistance from the researcher where necessary. Study setting and sample The study was conducted at Odi District Hospital, in Mabopane, located 36 kilometres from Pretoria. The hospital was chosen as there is a high prevalence of paediatric HIV. Almost all pregnant women are initially seen by professional nurses and/or midwives. Sampling in this study was generally purposive; all professional nurses working in the antenatal ward, labour ward, neonatal ICU, post-natal ward and paediatric outpatient department (OPD) were included. A response rate of 81% was obtained; that is 29 out of the 36 professional nurses that worked in the departments of interest, consented to participate in the study. Data analysis The data obtained from the questionnaire were analysed using Microsoft Excel spreadsheet. All statistical procedures were performed on Statistical Analysis Software (SAS). Frequency distribution tables and figures were used to present the analysis of each variable. Descriptive statistics were presented as graphs and tables to show frequency distribution of scores as well as their percentages. Basic knowledge questions were assessed using the participant s correct responses. Practice questions utilized a scale; always, often, sometimes and never. These were assessed using participant s positive responses. Attitude questions were assessed using participants positive responses. The five questions had a total of five marks, with each positive response scoring one mark and unfavourable response scoring zero. The overall data were analysed using scale categories; 50% being below average, 50% being average, 50% 75% being above average and 75% very much above average. The chi-square test was used to measure the association between variables (knowledge, attitudes and practices); a p-value of 0.05 was considered to be statistically significant.

4 186 Mogano, Schellack and Gous Ethics Ethical clearance was obtained from the University of Limpopo, Medunsa Campus Research Ethics Committee (MREC) prior to the commencement of the study (MREC/H/113/2013: PG). Permission to conduct the study at the different wards was obtained from the clinical manager of Odi Hospital. Informed consent was obtained from all research participants. Voluntary participation, anonymity and confidentiality were maintained throughout the study. Participants were allowed to withdraw from the study at any stage, without any consequences to them. Results Participants demographics There were 36 professional nurses working in the departments of interest, of whom 29 (81%) participated in the study. The majority of the participants (93%; n=29) were female. Most of the participants (69%) had a college diploma, and 31% had a tertiary degree. Nineteen participants (65.5%) were between the ages of 41 and 60 years, 9 (29%) were between 21 and 40 years, and only one person (3.5%) was above 60 years of age. The demographic characteristics are summarised in Table 1. Table 1: Demographic characteristics of the participants (n = 29) Gender Frequency (n = 29) Percentage Female Male 2 7 Total Highest educational qualification: Diploma Degree 9 31 Departments: Antenatal ward/ Paediatric OPD Labour ward Post-natal ward Neonatal ward Paediatric ward Knowledge on HIV and paediatric statistics Most participants (93%;27; n = 29) knew the name of the virus that causes AIDS, 86% were not aware or did not know the paediatric statistics of HIV in Africa and 69% of the participants were aware that artificial rupture of membranes increased the risk of HIV contraction during delivery. Only 31% (9; n = 29) and 34% (10; n = 29) of nurses knew that vaginal delivery and perineal trauma increased the risk of transmission, respectively (Table 2).

5 Knowledge, practices and attitudes of professional nurses 187 Table 2: HIV and paediatric statistics knowledge (n=29) Questions 1. What is the name of the virus that causes AIDS? 93 % (27) 2. African Statistics of children living with HIV/AIDS? 14% (4) 3. The risk of MTCT increases when? a. Artificial rupture of membrane 69% (20) b. Perineal trauma 34% (10) c. Through vaginal delivery 31% (9) Knowledge Percentage The study revealed that 52% of the participants first source of information about HIV/AIDS was acquired from literature, 28% from pre-qualification or undergraduate training, and 21% from post-qualification training (Table 3). Twentytwo participants (76%) received training in HIV/AIDS management, of which most were in the form of workshops and in-service training. Table 3: First source of information on HIV/AIDS First source of information on Frequency (n=29) Percentage HIV/AIDS Literature Pre-qualification training 8 28 Post-qualification training 6 21 Internet 0 0 Knowledge on PMTCT The majority of participants (97%) were aware that there are guidelines for PMTCT, on the other hand less than a third (28%) knew when they were last updated (Table 4). Just more than half (59%) of the participants actually had training on PMTCT in the form of workshops. The study revealed that most of the participants had an above average knowledge on PMTCT, with the mean score of 69% and the standard deviation of Table 4: Knowledge on the PMTCT (n=29) Item Correctly answered (%) 1. The national guidelines on PMTCT exists 28 (97) 2. The year that the guidelines were last updated 8 (28) 3. Have you had training on PMTCT? 17 (59) 4. CD4 count at which HIV positive women start HAART 23 (79) 5. The PMTCT related services that are not offered at ANC 20 (69) 6. The stage when ART prophylaxis is initiated for pregnant HIV positive 24 (83) women 7. The stage when the single dose nevirapine is used as prophylaxis for 22 (76) PMTCT in HIV positive women 8. PCR is done for the infant born to HIV positive mother at this age 26 (90)

6 188 Mogano, Schellack and Gous Practices on MTCT strategies Most participants appeared to have adequate knowledge regarding PMTCT, with a mean score of 63.5%, which is above average. Protective clothing during delivery is/was worn by 66% of the participants. This number may be skewed as only 34.5% indicated that they worked in the labour department at the time of the study. Participants practices involved in MTCT prevention strategies are illustrated in Table 5. Table 5: Participants practices involved in MTCT prevention strategies Item Frequency (%) Educating women on HIV/AIDS 25 (86) Offering of HIV counselling and testing to pregnant women 20 (69) Obtaining consent before testing 25 (86) Pregnant women counselled with their husbands/partners 1 (3.5) Educating women on safe infant feeding 25 (86) Aprons, gloves and masks used during delivery 19 (66) Encouraging mothers living with HIV to feed their infants exclusively with formula Attitude or behaviour towards HIV and MTCT 13 (45) Nearly all of the participants (93%) thought that it was not advisable for HIV positive mothers to mix-feed their babies; breastfeeding and bottle-feeding. They were aware of the risk of mix-feeding, and believed that mothers needed counselling in order to make an informed decision when it comes to feeding their babies. Nine (9) participants (31%) supported exclusive breast-feeding as the better option. Nearly three quarters of the participants (72%) thought that healthcare workers were worried about HIV/AIDS when caring for pregnant women with HIV. Hypotheses tested The first hypothesis revealed no significant correlation between the level of knowledge on HIV (p = 0.271) / PMTCT (p = 0.096), of those that had experience managing pregnant women with HIV (Table 6). Hypothesis two also showed no significant correlation between the level of knowledge on HIV (p = 0.383) / PMTCT (p = 0.598) of those that had previous training on HIV / PMTCT, as illustrated in Table 7. Hypothesis three showed no significant correlation (p = 0.627) between the knowledge on PMTCT and practices involved in MTCT prevention strategies (Table 8). Hypothesis four showed no significant correlation (p = 0.87) between attitude towards HIV and MTCT (Table 9). No significant correlation (p = 0.242) existed between the attitude towards HIV/MTCT in those that felt there were barriers to learning the PMTCT guidelines (34.5%).

7 Knowledge, practices and attitudes of professional nurses 189 Table 6: Hypothesis 1. Knowledge and experience of managing pregnant women living with HIV 95% confidence interval of the difference Ever N Mean SD Lower Upper p 0.05 Remark managed a pregnant woman Knowledge Yes not No significant Table 7: Hypothesis 2. Knowledge and training on HIV/AIDS 95% confidence interval of the difference Training N Mean SD Lower Upper p 0.05 Knowledge Yes p = No Remark not significant Table 8: Hypothesis 3. Knowledge and practices involved in MTCT prevention strategies Variables N Mean p 0.05 Remark Knowledge not Practice significant Table 9: Hypothesis 4. Knowledge and attitude towards HIV and MTCT Variables N Mean p 0.05 Remark Knowledge not Practice significant Discussion The majority of the participants (93%) were female, which reflects the national statistics, with more female nurses ( ) as compared to males (9 890) (Republic of South Africa, 2005). More participants (69%) had a college diploma, as compared to 31% with a tertiary degree. This correlates well to literature which indicates that there is a higher diploma output (1866) than university output (398) (Republic of South Africa, 2005). No significant correlation existed between knowledge of HIV/PMTCT in those that had experience in managing pregnant women living with HIV (p = 0.271)/PMTCT (p = 0.096) and managing experience of pregnant women with HIV. The majority of the participants, 76% underwent training in HIV/AIDS management. Most of which were in the form of workshops, undergraduate and in-service training. HIV/AIDS knowledge was just below average, with the mean score of 45.7%, indicating gaps in the knowledge on paediatric HIV statistics, MTCT risk factors such as perineal trauma and vaginal delivery. The possible

8 190 Mogano, Schellack and Gous reason for this low percentage might be that only 34.5% of the participants have worked in the labour department. This is consistent with Ndikom and Onibokun (2007) who also reported that participants answered approximately 50% of the items correctly on a HIV questionnaire where knowledge was acquired as an input from the environment, through lectures, workshops, seminars and experience. Labhardt et al. (2009) also found that nurses displayed inadequate knowledge on HIV diagnosis (66%) (Labhardt et al., 2009). PMTCT knowledge was above average (mean score is 69%), and almost all of participants (97%) were aware that there are guidelines for PMTCT, on the downside only a few (28%) knew when they were last updated. A possible reason for this low response is that there are no copies of the recent guideline in any of the wards. Participants indicated that shortage of staff and high workload was amongst others, the reasons that prevented them from attending workshops or seminars. The hypothesis on knowledge and training in HIV/AIDS revealed no significant correlation (p = 0.383) between those that had previous exposure through workshop and pre-qualification training and those who did not. The overall knowledge on PMTCT was above average (69%), but on the downside most participants did not know when the PMTCT guidelines were last updated. The findings were supported by Mobisson and Neale, which revealed that most nurses agreed on the importance of screening pregnant women for HIV and majority of participants appeared to have adequate knowledge regarding PMTCT (Mobisson & Neale, 2006). Palmer, Anderson-Allen and Billings (2004) also emphasised that nursing intervention is a vital part of a PMTCT programme, however on-going education and training needs to be continued in order to strengthen the programme (Palmer et al., 2004). No significant correlation existed between knowledge and practice involved in MTCT prevention strategies (p = 0.627). The overall practice on MTCT prevention strategies was favourable, even though there were gaps in knowledge. Majority of the participants (86%) regularly obtained consent before testing pregnant women, provided education on HIV and safe infant feeding. HIV counselling and testing was regularly offered to pregnant women by 69% of the participants, and 66% of the participants always wore protective clothing during delivery. No significant correlation existed between knowledge and attitude towards HIV and MTCT (p = 0.87). The overall attitude was positive. Nearly all of the participants (93%) thought that it was not advisable for HIV positive mothers to mix-feed. They were aware off the risk of mix-feeding, and most believed that mothers needed counselling in order to make informed decision when it comes to feeding their babies. Most of the participants supported exclusive breast-feeding

9 Knowledge, practices and attitudes of professional nurses 191 as the better option. Participants also indicated that all the patients deserved to be treated the same, whether HIV positive or not. Contrary to the study conducted in Vietnam, where nurses indicated reasons for the unsatisfying performance as inadequate knowledge and skills due to lack of training (Nguyen et al., 2009), 24% (7; n = 29) of the participants in the current study had never received training in HIV/AIDS management due to staff shortage but had a positive attitude. Leshabari, Blystad, de Paoli and Moland (2007) also found that nursecounsellors expressed a lack of confidence in their own knowledge of HIV and infant feeding, as well as their own skills in assessing a woman s possibility of adhering to a particular method of feeding. The findings of the study also showed that participants reasons for the unsatisfying performance were inadequate knowledge and skills due to lack of training, and these were due to staff shortage. No significant correlation (p = 0.242) existed between the attitude towards HIV/MTCT in those that felt there were barriers to learning the PMTCT guidelines (34.5%). The overall attitude was positive towards learning the PMTCT guidelines. Mnyani and McIntyre (2013) also found that there was no significant difference between the mean score of those who were satisfied with their knowledge of the guidelines and those who were not (p=0.157). Limitations The sample was too small as compared to the ones from the literature reviewed. One participant represented 3.5% of the total participants. Most of the professional nurses had never been exposed to most of the departments of interest. Even with theoretical training, practical training or experience is necessary to enforce knowledge. The recent or latest national PMTCT guidelines (2013) were not readily available in the ward. Conclusion Despite improvements in Prevention of Mother to Child Transmission (PMTCT) services over the years, MTCT of HIV infections are high especially in Sub- Saharan Africa. It is imperative to ensure that PMTCT continuous training for all nurses, irrespective of the department they work in. Most of the participants were not familiar with the 2013 national PMTCT guidelines, mainly because of unavailability of the latest (2013) guidelines at the hospital or in the wards.

10 192 Mogano, Schellack and Gous Acknowledgements The authors would like to acknowledge Prof Herman Schoeman for the statistical analysis, Nikki Williamson for editorial assistance, the Department of Pharmacy, Medunsa Campus for financial and logistical support, and the participation of the staff at Odi Hospital. References Atwiine, B.R., Rukundo, A., Mutibwa, D., Sebikali J.M., Tumusiime, D., Turyamureeba, R, Birungi, L., Tibanyendera, B., Schlech, W. & Macdonald, N.E. (2012). Knowledge and practices of women regarding prevention of mother to child transmission of HIV (PMTCT) in rural southwest Uganda. International Journal of Infectious Diseases, 17(3), e Chaparanganda, I. (2012). Effectiveness of PMTCT Programme at Mogwase Health Centre, South Africa. Retrovirology, 9(Suppl 1), doi: / S1-P114. Falnes, E.F., Tyllerskar, T., de Paoli, M.M., Manongi, R. & Engebretsen, I.M.S. (2010). Mothers knowledge and utilization of prevention of mother to child transmission services in Northern Tanzania. Joint International AIDS Society, 13, 36, doi: / Johri, M. & Ako-Arrey, D. (2011). The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review. Cost Effectiveness and Resource Allocation, 9:3, doi: / Labhardt, N.D., Manga, E., Ndam, M., Balo, J.R., Bischoff, A. & Stoll, B. (2009). Early assessment of the implementation of a national programme for the prevention of mother-to-child transmission of HIV in Cameroon and the effects of staff training: a survey in 70 rural health care facilities. Tropical Medicine & International Health, 14(3), Leshabari, S.C., Blystad, M., de Paoli, M. & Moland, K.M. (2007). HIV and infant feeding counseling: challenges faced by nurse-counsellors in Northern Tanzania. Human Resource Health, 24(5), 18. Mbombo, N. & Bimerew, M. (2012). Integrating Prevention of Mother to child HIV Transmission competencies into nursing curriculum: Methodological lessons from a university based undergraduate programme. Curationis, 35(1), E1-E10. Mnyani, C.N. & McIntyre, J.A. (2013). Challenges to Delivering Quality Care in a Prevention of Mother-To-Child Transmission of HIV Programme in Soweto. Centre for Infectious Diseases Epidemiology and Research, University of Cape Town: doi: /SAJHIVMED.902 Mobisson, L.N. & Neale, D. (2006). Knowledge, attitude and practices of physicians and nurses towards antenatal HIV screening and the prevention of Mother to Child Transmission of HIV in Nigeria: AIDS XVI International AIDS Conference: Abstract no. CDB1266. McKerrowi, N. & Mulaudziii, M. (2010). Child Mortality in South Africa: Using Existing Data. Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex and Department of Paediatrics, University of KwaZulu-Natal and Kalafong Hospital and University of Pretoria.

11 Knowledge, practices and attitudes of professional nurses 193 National Department of Health (2013). The South African Antiretroviral Treatment Guidelines. Pretoria, South Africa: National Department of Health. Ndikom, C.M. & Onibokun, A. (2007). Knowledge and behavior of nurses/midwives in the prevention of vertical transmission of HIV in Owerri, Imo State, Nigeria: a cross-sectional study. BMC Nursing, 6:9, doi: / /6/9. Nguyen, T.A., Oostterhoff, P., Pham, Y.N., Hardon, A. & Wright, P. (2008). Health workers' views on quality of prevention of mother-to-child transmission and postnatal care for HIVinfected women and their children. University of Amsterdam, Amsterdam, the Netherlands. Human Resources for Health, 7, 39, doi: / Palmer, P.M., Anderson-Allen, M.M. & Billings, C.C. (2004). Nursing interventions in Kingston Paediatric and perinatal HIV/AIDS programme. Jamaica: West Indian Medical Journal, 53(5), Republic of South Africa (2005). Nursing Act (No 33). Pretoria, South Africa: Government Printer. Vaga, B.B., Moland, K.M., Evjen-Olsen, B., Leshabari, S.C. & Blystad, A. (2012). Rethinking nursing care: An ethnographic approach to nurse-patient interaction in the context of a HIV prevention programme in rural Tanzania. International journal for student nurses, 50(8),