NURSES' KNOWLEDGE, ATTITUDES AND PRACTICES REGARDING HEPATITIS B: AN INTEGRATIVE REVIEWABSTRACT
Objective: to analyze, in the literature, the nurses' knowledge, attitudes and practices regarding Hepatitis B.
Method: an integrative review, with search and selection conducted independently by peers, after electronic queries in the CINAHL, MEDLINE, SCOPUS, Web of Science, LILACS, BDENF and IBECS databases in January 2021. The sample consisted in 15 primary studies published with no time or language restrictions. Analysis and synthesis of the results were carried out in a descriptive manner.
Results: limitations in knowledge, inconsistent attitudes and commonly neglected assistance-related practices were identified, related to prevention, immunization and biosafety measures, to risk management and to monitoring of symptoms and complications, which contributed to greater occupational exposure. Among the associated factors, low participation in permanent education activities, training level, working conditions, limitations in the availability of immunization tests (anti-HBs) and underreporting of health problems stood out.
Conclusion: the knowledge, attitudes and practices developed by nurses in relation to Hepatitis B proved to be limited and inconsistent, which may result in greater occupational exposure, as well as exert a direct impact on vaccination coverage and occurrence of incidents.
DESCRIPTORS: Nurses; Knowledge; Attitude of the health personnel; Pieces of knowledge; Attitudes and practice in health; Hepatitis B
RESUMEN
Objetivo: analizar, en la literatura, los conocimientos, las actitudes y las prácticas de los enfermeros en relación a la Hepatitis B.
Método: revisión integradora, en la cual la búsqueda y la selección fueron realizadas por pares y de manera independiente, luego de consultas electrónicas en las siguientes bases de datos: CINAHL, MEDLINE, SCOPUS, Web of Science, LILACS, BDENF e IBECS en enero de 2021. La muestra estuvo compuesta por 15 estudios primarios publicados sin restricciones de tiempo o de idioma. El análisis y la síntesis de los resultados se realizaron en forma descriptiva.
Resultados: se identificaron limitaciones en el conocimiento, actitudes inconsistentes y prácticas asistenciales comúnmente desatendidas, relacionadas con las medidas de prevención, inmunización y bioseguridad, y con la administración del riesgo y el monitoreo de síntomas y complicaciones, que contribuyeron a una mayor exposición ocupacional. Entre los factores asociados, se destacaron los siguientes: escasa participación en actividades de educación permanente, el nivel de formación, las condiciones laborales, las limitaciones en la disponibilidad de pruebas de inmunización (anti-HBs) y la subnotificación de problemas de salud.
Conclusión: los conocimientos, las actitudes y las prácticas desarrolladas por los enfermeros, en relación con la Hepatitis B, demostraron ser limitados e inconsistentes, con la posibilidad de derivar en una mayor exposición ocupacional, al igual que de afectar directamente la cobertura de las vacunas y la frecuencia de incidentes.
DESCRIPTORES: Enfermeras y enfermeros; Conocimiento; Actitud del personal de salud; Conocimientos; Actitudes y práctica en salud; Hepatitis B
RESUMO
Objetivo: analisar, na literatura, o conhecimento, as atitudes e as práticas de enfermeiros sobre hepatite B.
Método: revisão integrativa, com busca e seleção realizadas por pares e de forma independente, após consulta eletrônica às bases de dados CINAHL, MEDLINE, SCOPUS, Web of Science, LILACS, BDENF e IBECS em janeiro de 2021. A amostra foi constituída por 15 estudos primários publicados sem restrição temporal ou de idioma. A análise e a síntese dos resultados ocorreram de forma descritiva.
Resultados: foram identificadas limitações no conhecimento, atitudes inconsistentes e práticas assistenciais comumente negligenciadas, relacionadas às medidas de prevenção, imunização e biossegurança, ao gerenciamento de risco e monitoramento de sintomas e complicações, que contribuíram para uma maior exposição ocupacional. Dentre os fatores associados, destacaram-se a baixa participação em atividades de educação permanente, o nível de formação, as condições laborais, as limitações na disponibilização de testes de imunização (anti-HBs) e a subnotificação de agravos.
Conclusão: o conhecimento, as atitudes e as práticas desenvolvidos por enfermeiros, relacionados à hepatite B, mostraram-se limitados e inconsistentes, podendo resultar na maior exposição ocupacional, assim como impactar diretamente a cobertura vacinal e a ocorrência de incidentes.
DESCRITORES: Enfermeiras e enfermeiros; Conhecimento; Atitude do pessoal de saúde; Conhecimentos; Atitudes e prática em saúde; Hepatite B
INTRODUCTION
Despite the scientific, diagnostic and therapeutic advances and the preventive measures adopted through vaccination, infection by the Hepatitis B Virus (HBV) is still a global health problem that is difficult to control, capable of generating physical, mental and social repercussions, compromising quality of life and raising the hospital costs and the morbidity and mortality indicators.1-2
Estimates by the World Health Organization (WHO) indicate that one third of the world population presents serological evidence of previous contact with the virus and that 325 million people have become chronic carriers of the disease. In Brazil, prevalence is variable, as diagnosis frequency is still underestimated due to the asymptomatic cases and to underreporting.3
Hepatitis B is one of the most prevalent infections in human beings, being considered the tenth cause of death in the world, with a prolonged incubation period and primary transmission constantly associated with direct contact with bodily fluids.3 It is also an expressive occupational disease in different care contexts and levels due to the high professional exposure to chemical, physical, ergonomic, mechanical, psychosocial and biological risks, as well as failures in training and levels of knowledge, skills and competences that determine the behaviors, attitudes and practices adopted for biosafety and for proper management of the patients.4-5
The reduction in morbidity and mortality and complications related to HBV can result from investments in care restructuring, training and qualification for the expansion of knowledge, as well as for adherence to the adequate practices by the health professionals, especially nurses.6-7
In the professional Nursing practice, knowledge is an effective tool, which exerts positive effects on critical ability, attitude and professional practice capable of intervening in the most prevalent situations and health problems/diseases in the national epidemiological profile, thus contributing to early detection of the disease, proper treatment, health promotion and prevention of avoidable conditions.8
Assessment of the nurses' knowledge, attitudes and practices contributes to effective, safe and quality decision-making, favoring the consolidation of evidence-based practice. And, when inconsistencies are found, they must be considered as parameters for the development of activities aimed at qualifying care and reducing the direct and indirect impacts, whether financial, physical, psychological or social.9
Consequently, these attributes prove to be essential to promote evidence-based care. Thus, the research question was elaborated based on the domains of the PICo strategy, defining nurses as P (population), knowledge, attitudes and professional practices as I (phenomenon of interest), and the Hepatitis B viral infection as Co (context).10
Given the above, this review was guided by the following question: “which is the scientific evidence related to the nurses' knowledge, attitudes and practices regarding Hepatitis B?”. The objective was to analyze, in the literature, the nurses' knowledge, attitudes and practices regarding Hepatitis B.
METHOD
This is an integrative literature review based on the theoretical framework proposed by Whittemore and Knafl and delimited in six research stages: identification of the theme and elaboration of the research question; sampling and search in the literature; definition of the information to be extracted from the articles included; critical analysis of the results; synthesis of the knowledge and presentation of the review.11
Search and selection of the articles were conducted in January 2021 by means of queries in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL); Medical Literature Analysis and Retrieval System On-line (MEDLINE via PubMed); SCOPUS; Web of Science; Literatura Latino-Americana e do Caribe em Ciências da Saúde(LILACS); Banco de Dados em Enfermagem (BDENF) and Índice Bibliográfico Español en Ciencias de la Salud (IBECS) via Biblioteca Virtual em Saúde.
For operationalization of the search, controlled and uncontrolled descriptors (keywords) indexed in Descritores em Ciências da Saúde (DeCS), Medical Subject Headings (MeSH) and List of Headings of the CINAHL's Information Systems were used. The combinations were made by means of the Boolean operators OR and AND. Chart 1 presents the terms, as well as the strategy adopted in CINAHL, considered a priority for this study, which maintained the same search standardization for the other databases consulted.
For inclusion of the studies, the following criteria were considered: primary articles, indexed in the databases consulted and that evaluated the knowledge, attitudes and/or care practices adopted by nurses regarding the Hepatitis B viral infection, without time or language restrictions.
Exclusion was conditioned to editorials, theses, dissertations and reviews, as well as to productions that prioritized evaluation of the research outcome in professional categories or in other infectious conditions. Duplicate studies were considered only once, with registration maintained in the specific databases for Nursing followed by the multidisciplinary ones. To such end, the Endnote web software was used in order to assist in the selection, sorting and exclusion of duplicate records.
Access to the productions occurred through the Journals Portal of Coordenação de Aperfeiçoamento de Pessoal de Nível Superior in an area with Internet Protocol (IP) recognized at Universidade Federal do Piauí and the search, selection and inclusion were carried independently out by two reviewers. When in divergent situations, consensus was sought with the aid of a third reviewer, who issued an opinion to decide regarding inclusion.
The strategy allowed retrieving 961 articles. Of these, 307 were excluded due to duplicity, resulting in 654 for reading titles and abstracts. The sample consisted of 15 studies. Figure 1 presents the path corresponding to the identification, selection, eligibility, inclusion and composition of the sample, which followed the recommendations set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).12
Path corresponding to the selection, inclusion and composition of the sample. Teresina, PI, Brazil, 2021.
For data collection, a validated instrument was adapted,13 prioritizing variables related to the identification of the studies (main author, title, year and country), methodological aspects (design and level of evidence), the outcome evaluated, the main results and the conclusions.
The Level of Evidence (LE) was determined based on the recommendations proposed by the Oxford Centre for Evidence-based Medicine, which considers the following: 1A - systematic review of randomized controlled clinical trials; 1B - randomized controlled clinical trial with narrow confidence interval; 1C - therapeutic results of the “all or nothing” type; 2A - systematic review of cohort studies; 2B - cohort study (including lower quality randomized clinical trial); 2C - observation of therapeutic results or ecological studies; 3A - systematic review of case-control studies; 3B - case-control study; 4 - case reports (including lower quality cohort or case-control); and 5 - experts' opinion.14
The analysis was descriptive, employing calculation of relative and absolute frequencies, as well the characterization, synthesis and presentation of results in charts. For not involving human beings, this study was not submitted to appreciation by any Research Ethics Committee.
RESULTS
The descriptive analysis of the results showed the researchers' growing interest in evaluating the knowledge, attitudes and practices developed by nurses regarding the HBV infection, thus constituting an expressive research phenomenon in different contexts of the national and international literature, involving different countries such as Pakistan, Iran and Brazil, which stood out for concentrating the largest number of productions.
Most of the studies were published in the English language and from 2017 to 2019 (53.3%). As for the methodological design, there was predominance of the cross-sectional approach and level of evidence 2C (100%), with significant samples varying from ten to 518 nurses.
Chart 2 presents the characterization of the productions included (n=15) according to the main author, journal and year of publication, title, country where the study was developed, methodological design, sample and level of evidence.
In the analysis of different outcomes, such as behaviors, attitudes and professional practices, the knowledge assessment prevailed in the studied sample. Other contexts investigated involved the perception of threat and the professional courses of action adopted for biosafety, self-care and case management in the face of occupational exposure and the occurrence of percutaneous incidents (Chart 3).
Amid awareness raising of the risk and state of vulnerability to the infection, there were limitations in knowledge that involved the preventable nature of the disease, the transmission mechanisms and the prevention measures. In addition, it was evidenced that the care practices are commonly neglected and that the attitudes were materialized inconsistently, resulting in the sporadic use of Personal Protective Equipment (PPE), underreporting of the disease and work-related incidents, inadequate risk management and failures to monitor symptoms and complications and to refer patients for specialized evaluation.
Among the factors associated with the inconsistencies in professional knowledge, practices and attitudes, the following stood out: low offer and participation in permanent education activities, sporadic and inappropriate use of PPE, limitations in the availability of immunization tests (anti-HBs) and underreporting of occupational accidents. In addition, conditions related to age, training level and workload were determinant for greater vulnerability to the infection and for the development of risk behaviors.
Other conditions were evidenced, such as the absence of a complete vaccination schedule, the failures in adherence to protocols and preventive practices, and the high prevalence of injuries with sharps and of mucocutaneous exposure to body fluids.
DISCUSSION
The analysis of the knowledge, attitudes and professional practices developed by nurses towards HBV proves to be a necessary resource for the development of good Nursing care practices and for providing the basic action instruments based on evidence and on quality, effectiveness and safety elements.
There is a growing interest in researchers in evaluating the professional knowledge, attitudes and practices, especially in the international scenario in recent years, through studies with cross-sectional designs, which, despite not establishing cause-and-effect relationships, consider relevant methods for the clinical Nursing practice for requiring less time and cost, being constantly used to indicate prognoses and to evaluate results of exposure to risks.15-29
The evaluation of the knowledge outcome was predominant in the studies included, constituting a basic instrument for clinical decision-making and for the implementation of prevention and biosafety measures. In general, knowledge was characterized by limitations and deficits that involved the preventable character of the disease, as well as the transmission and control mechanisms.15-20,22-29
Two studies considered that the professional's knowledge is determinant for the consolidation of the evidence-based practice, which should be a constant target of evaluations and, in the face of inconsistencies, a parameter for the development of continuing education activities, aiming to qualify care and reduce the direct and indirect costs, whether financial, physical, psychological or social.16-18
The main inconsistencies involved the transmission mechanisms, the sporadic use of PPE and the failures in the monitoring of symptoms and complications, as well as the referral of patients for specialized evaluation, resulting in diagnostic delays and in inadequate management of the clinical conditions.15,25-26,28-29
Added to this is underreporting of the disease and of occupational accidents, as well as low availability of tests for the detection of the anti-HBs marker, which indicates immunity through previous vaccination, and failures in case management, which were also significant, representing a potential risk for different population groups, given the absence of data that show the magnitude of the problem and allow for the proper implementation of prevention strategies.15,25
In addition to gaps in knowledge, underreporting of Hepatitis B can be associated with difficult access to diagnostic methods, thus making it impossible to estimate the real number of cases and evaluate the efficacy of the control measures.15
The evaluation of the care practices for the control of vertical transmission was also investigated, showing that the limitations in knowledge and the deficiencies in the provision of training or qualification can influence the potential for chronicity of the disease, configuring it as a public health problem in Brazil.24-25
Other outcomes evaluated involved the perception of threat, self-care and case management regarding occupational exposure and occurrence of percutaneous incidents, showing that professional training prioritizes the development of knowledge, strategies and action plans aimed at managing the patient's needs, with self-care being constantly neglected.20-21,26
In this context, the high occupational exposure to biological material stands out as a significant problem experienced by nurses working at different health care levels, characterizing the work environment as a predictor for the risk of contamination. In the midst of this, there is high exposure to bodily fluids and occurrence of injuries with sharps, which are of high magnitude in the face of failures in risk management, in the adoption of prophylactic measures and in the absence of a vaccination schedule.20,26
Despite the benefits and importance of the Hepatitis B vaccine, a number of studies have shown low vaccination coverage and seroconversion among professional nurses.16,28 Vaccination against HBV is considered the most effective prevention means, favoring a reduction of the risk of occupational exposure as it presents evidence of quality, safety and protection of up to 92% for immunocompetent adults.25-26
Amid this problem, a research study showed that different factors can exert a positive impact on greater acceptance and vaccination coverage among the nurses. Among them, free availability of the resource and broad disclosure of the benefits related to the practice stand out.27
In addition, a number of factors associated with the training level were determinant for greater vulnerability to the infection and adherence to the risk behaviors. It is noteworthy that the professionals with higher training levels are more aware and cautious regarding the assessment, prevention and treatment of the disease, showing even greater care during exposure to bodily fluids. Regarding the workload, relationships were evidenced between high hour load and exposure risk, incidents and adverse events.17,21,23
Thus, despite awareness of the risk and state of vulnerability to the infection, the care practices were commonly neglected and the attitudes were performed inconsistently, reflecting on the effective implementation of programs and public policies aimed at the prevention of Hepatitis B and on compliance with clinical protocols and recommendations.18
Therefore, it is considered that identifying the knowledge deficit and the inadequate Nursing practices is fundamental for the construction of institutional policies that prioritize the development of permanent education strategies and specific interventions aimed at the population's needs.30
As for the limitation, the predominance of the cross-sectional design is highlighted, which, in spite of involving significant samples and of the clinical relevance, does not allow establishing cause-and-effect relationships, revealing that the development of intervention studies in Nursing is still incipient and little promoted.
Studies of this nature can contribute to the improvement of Nursing care, given their potential for the development of assistance-related skills favorable to the early identification of the vulnerable groups, the effective implementation of prevention strategies, the reduction of occupational exposure and the morbidity and mortality indicators and to the improvement of the population's health status and quality of life.
CONCLUSION
The knowledge, attitudes and practices developed by nurses related to Hepatitis B for risk management, biosafety, vaccination indication and case monitoring, are still limited, being marked by the adoption of inconsistent behaviors and attitudes that can result in greater occupational exposure and in occurrence of incidents.
Among the factors associated with the knowledge, attitudes and professional practices, the training level, workload, d low offer and participation in permanent education activities stood out. In addition to that, few research studies conducted in Brazil were cross-sectional.
The need for new research studies aimed at evaluating the effectiveness and impact of interventions in improving knowledge is evidenced, as well as the adoption of behaviors, attitudes and Nursing practices based on evidence and on safety, quality and effectiveness elements
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» https://doi.org/10.1590/1980-265X-TCE-2019-0122
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Publication Dates
-
Publication in this collection
29 Apr 2022 -
Date of issue
2022
History
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Received
02 June 2021 -
Accepted
06 Sept 2021
