The study of Prevalence of Antigen HBs Positive and High-risk Behaviors in Pregnant Women Referring to Urban Health Centers of Isfahan Province in 2009.

BACKGROUND: Around 5% of the world populations are the carriers of the hepatitis B virus. Prevalence of carriers in many different areas of the world is various. Iran, including the rate of 2 to 3%, is among countries, which has the average prevalence. The aim of this study was to determine the prevalence of antigen HBs positive and associated factors in pregnant women who had referred to urban health centers of Isfahan Province in 2009.
METHODS: A descriptive study conducted on 1078 pregnant women who had referred to the urban health centers of Isfahan, Barkhovar, Meymeh, Khomeini Shahr, Lenjan and Najaf Abad in 2009 in order to register their physical condition and conducting pregnancy care. Random sampling method by quota was systematic. First, a questionnaire completed including demographic characteristics and records of high-risk behaviors in mothers and wives. Then, 4 cc of their blood drawn and evaluated the antigen surface in serum. Finally, the data were analyzed using SPSS15 software, Chi-square, Fisher and Logistic Regression tests.
RESULTS: According to the findings, serum of 0.5% of pregnant women under the study was HBsAg-positive. The average age of subjects was 26.1 (4.9) years old and the average pregnancy number was 1.79 (1.0). Using Fisher's test as well as logistic regression test and based on the previous records of high-risk sexual behaviors and tattooing, a significant difference was observed in positive-HBsAg group in comparison with negative-HBsAg group (p ≤ 0.05).
CONCLUSIONS: Instructing target groups and giving awareness in large-scale, close monitoring in high-risk centers such as beauty shops, tattooing centers and etc, and also staff training in how to use disposable and sterilized equipments have to be accomplished at the right time.

Neonatal period care is of high priority in providing community health.1 Today, in advanced countries, one of the most prevalent painful procedures in infants is vaccination which requires continuous intramuscular injection during the first year of life.2 Studying the painful experiences of infants has significantly increased during the past two decades.3 Recently, it was believed that young infants and newborns were not able to feel the pain due to lack of evolution in the central nervous system.4–7 But, nowadays, it is recognized that physiological, anatomical and nervous-chemical structures which lead the pain, have been well evolved several weeks before the birth.5–9

Although vaccine injection creates a short period of pain, studies show that this short-term pain distresses the infants, parents and vaccinators during the injection.210 In addition to the mentioned immediate effects, pain had short-term and long-term effects on infants.711–15 Short-term effects included decline in oxygenation, hemodynamic instability and increase in intracranial pressure.13 In spite of the fact that long-term effects of pain and stress were not known yet, some obtained studied evidences from animals showed that uncontrolled pain and stress experienced by infants caused some changes in the central nervous system.16 These changes included a permanent impairment in the cognitive development of learning, memory,14 IQ11 and behavior. They also caused an increase in physical impairment,14 anxiety, emotional complications, hyperactivity and disturbed attention in the childhood period.13

Considering the short and long term negative effects of uncontrolled pain and undeniable necessity of vaccination, an effective and secure pain controlling method seems necessary.17 Non pharmacological methods included sweet solutions such as oral sucrose and glucose,5121318–21 pacifiers, skin contact18 and breastfeeding.171822 Sucrose is an available and non-sedative substance with short-term effects. The findings of Hatfield et al indicated that oral sucrose administration was an effective and easy method with short-term effect during the routine immunization process.14 The results of Irani et al in Gonabad also showed the effectiveness of oral sucrose on pain reduction during Hepatitis B vaccination.23 On the contrary, the results of NikRooz et al in Yasuj showed that oral glucose had no pain relieving effects.24 Some studies also suggested that more investigations and studies are needed in order to conclude about the pain relieving effects of sweet solutions.1925 The implemented studies about the impact of breastfeeding on pain relief in infants indicated that this was a physiological, accessible, practical and safe method which could easily be accepted by the parents and health care providers.26 Osianaike et al observed that breastfeeding had an analgesic effect on neonates during the venipuncture prick.27 But, in another study made by Bilgen et al breastfeeding had no impact on the duration of crying after receiving the heel lance.28 Regarding the acute pain resulting from blood sampling in term neonates, Malekan Rad et al concluded that while breast feeding had no impact on their pain, glucose and lidocaine cream reduced the pain and crying time.11

Therefore, considering the short and long-term effect of uncontrolled pain on the infant's health, and thr fact the relieving the pain of the patients is the nursing mission, and in order to clarify the mentioned diversities and contradictions in the results of different studies, more studies are needed to find out the most effective and safest non pharmacological pain controlling method. Also, no study has been done yet to conduct the impact of breastfeeding and oral sucrose on pain management of the neonates. The aim of the present study was to compare the pain relieving effects of non pharmacological methods (breastfeeding or oral sucrose) and their combination on the first time vaccination of the infants.

Methods

This was a quasi-experimental study with two-group (pre-test & post-test) blind design conducted in Shahidan Ebrahimi and Eram health centers in Tabriz, year 2009. According to previous studies a sample size of 120 infants was selected. All the infants were in similar circumstances and were randomly divided into four groups: 1) breast fed infants 2) fed with 25% oral sucrose 3) simultaneous combination of breast feeding and 25% oral sucrose 4) control group (no intervention). The samples were selected from the accessible infants referred to the mentioned health centers for receiving their first vaccine. All these infants were eligible for the diphteria, tetanous and pertosis vaccines (DTP), they were term infants with less than 3 months of age, had no specific disease and were not born from a diabetic mother. Participants were assigned in different groups via random closed envelope method i.e. at the beginning, the first of four subjects randomly picked one of the envelopes and entered a group, then, the next subjects followed the procedure and entered another one of the four groups. In the first group (oral sucrose), 0.6 cc of 25% oral sucrose (per/kg) was administered via a 5 cc syringe. In the 2nd group (breastfed group), mothers were asked to be in a comfort position and take their infants in their arms and feed them with their milk. In the 3rd group (combination group), breastfeeding was done earlier and 0.6 cc of 25% oral sucrose (per/kg) was administered after that. The duration of the breastfeeding in both 2nd and 3rd groups was based on the infant's appetite. No interventions were conducted before the vaccine injection in the control group. DTP and hepatitis vaccination was performed two minutes after the above interventions. The intensity of the pain was accomplished by the partner of the researcher who was blind about the groups. The vaccinator also was blind about the subjects’ classification. Both vaccines had been prepared before the injection time by the vaccinator and been injected consecutively. Immediately after the injection, the pain intensity and crying time was measured at the beginning of the procedure by the Neonatal Infant Pain Scale (NIPS) and a stopwatch. The pulse rate was also measured by a pulse oximeter. The severity of the pain and pulse rate was assessed 5 and 10 minutes after the vaccination by the researcher's partner. It should be noted that if the pain score was zero, 5 minutes after injection, pain intensity was not assessed anymore. Finally, the controlled items were recorded in the relevant checklist.

The data collection tools in this study included two parts. The first part was related to the demographic, social and health history of the infants. The second part included the NIPS device for the pain intensity assessment which included the figure parameters (0-1), the crying state (0-2), respiratory patterns (0-1), the arms state (0-1), the legs (0-1) and infant arousal condition (0-1) which were graded from 0-7 scores. This tool was first designed and used by Lawrence in 1993.8 In order to obtain valid scientific data, content validity method was used, thus for the content validity, a questionnaire was given to 11 faculty members of Tabriz University of Medical Sciences. Kappa coefficient method was used to check the reliability coefficient i.e. the pain management was done on 10 infants by two trained neonatal nurses. The data were analyzed by SPSS software and Pearson's coefficient 0.91 was obtained.

The collected and encrypted data was entered in SPSS11 and analyzed using descriptive and inferential statistics, chi square, ANOVA, Kruskal Wallis and the Friedman tests.

Results

According to table 1, using chi square test and ANOVA, no significant difference was observed between the studied groups in terms of demographic data.

Table 1

Demographic profile of the participants in different groups

In order to compare the pain scores in each group, Friedman nonparametric test was used based on non-normal distribution of pain. As it can be seen in table 2, there were significant differences in the number of measurements in terms of pain. Statistical nonparametric Kruskal-Wallis test was used for the comparison of the pain intensity between the groups of the study. The findings of this study showed that there were some significant differences only after the injection in terms of pain score between different groups of the study. Based on the tukey post hoc test, significant difference was found only between breastfeed and control groups (p = 0.007). No significant relationship was observed between the groups in terms of pain score before, at 5 and 10 minutes after the injection of the vaccine. The maximum crying time was in control group with 126.26 (46.15) seconds and the minimum crying time was in breast feed group with 66.60 (32.62) seconds. Using statistical nonparametric Kruskal Wallis test a significant difference was observed between the groups of the study in terms of crying time (p < 0.001). The findings of the tukey post hoc test showed that there was a significant difference between each one of intervention groups and the control group. Mixed ANOVA test was used to compare (multiple assessments) the pulse frequency in different number of measurements. As in table 3, results showed that pulse changes in different number of measurements were significant in all the groups. The comparison of pulse frequency in different numbers of measurements showed no significant difference between the groups of the study.

Table 2

Mean pain score before, at 0, at 5 and 10 minutes after the vaccine injection in each group of the study

Table 3

Mean pulse frequency before, at 0, at 5 and 10 minutes after vaccination in each group of the study

Discussion

The results of this study showed that breastfeeding significantly reduces vaccination pain comparing with the control group. However, oral sucrose and combination of sucrose and breastfeeding did not have any significant pain reduction intensity in comparison with the control group. Also, breastfeeding significantly reduced crying time in comparison with the control group but had no effect on preventing the following tachycardia after the procedure. The findings of this study were in accordance with the findings of Efe & Savasar in which crying time was shorter in oral sucrose group and breastfeeding group in comparison with the control group. And the pain scores of the mentioned groups were lower in comparison with the control groups, but no significant difference was observed in sedative effects of breastfeeding and sucrose.5 Carbajal et al also showed that breastfeeding and oral glucose significant reduced the pain intensity of the neonates during heel lance in comparison with the control group, but no significant difference was observed between the pain intensity of breastfeeding and oral glucose groups.22 Golestan et al showed that the crying time was shorter in oral glucose group in comparison with water and not implementing any intervention but there was no significant difference between the groups of that study in terms of changes in pulse frequency.13 Regardless of methods of the studies, the findings of the present study were in accordance with Golestan's study. The findings of Bauer et al showed that oral glucose significantly decreased the pain and crying time after vein puncture in comparison with the control group. But, it did not prevent pulse rate increase following the painful procedure.29 Regardless of different sweet solutions, the difference of the above studies might be due to method of prescription of the oral glucose; in Bauer's study it was given through the pacifier (non-nutritive sucking), however the pain relieving effects of sucking should also be considered. The results of Gray et al showed that breastfeeding effectively caused a reduction in pain intensity and crying time after receiving heel lance in comparison with the control group; it also prevented tachycardia following the procedure.30 The findings of Gray's study were in accordance with this study in terms of effectiveness of breastfeeding in pain reduction and crying time. But, there was a difference between two above studies in terms of breastfeeding efficacy in preventing from tachycardia following the procedure. The reason could be due to different methods; for example, in the study conducted by Gray et al breastfeeding lasted during the heel lance. The difference in types of tachycardia procedures also could be the difference between these two studies. The study findings of Malekan Rad et al showed that crying time during vein puncture was significantly shorter in the group in which 33%oral glucose solution was administered, in comparison with the control group. But breastfeeding did not bring about a significant decrease in crying time and pain score.11 There was a difference between the findings of two studies; it might be due to the difference in breastfeeding process.

Finally, the findings of this study showed that breastfeeding caused reduction in pain and crying time in neonates immediately after the vaccine injection. According to the findings of this study and considering the fact that breastfeeding was a safe and free method accepted by mothers and health center staff, it can be advised for painful procedures in order to reduce infant's pain. It can also encourage mothers for breastfeeding and facilitate maternal and childhood links. Besides, breastfeeding can provide psychological benefits for mothers due to their participation in infant's care without incurring any additional cost to the health care system. Moreover, since hospitalized neonates are particularly premature infants who need to be hospitalized for a long time and may suffer painful procedures, similar studies are recommended about the effectiveness of breastfeeding and oral sucrose on hospitalized premature infants.

The authors declare no conflict of interest in this study.