Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

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I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : August | Volume : 6 | Issue : 6 | Page : 1041 - 1046

The Skin Preparation Knowledge, Attitudes and Practices among the Healthcare Professionals in Compliance with the World Health Organization (WHO) Guidelines

Muhammad Qamar, Syed Wasif Gillani, Syed Azhar Syed Sulaiman

1. MPharm Candidate, School of Pharmaceutical Sciences, Universiti Sains Malaysia. 2. Lecturer, School of Pharmaceutical Sciences, Universiti Sains Malaysia. 3. Professor of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia.

Correspondence Address :
Syed Wasif Gillani
Lecturer/Researcher, School of Pharmaceutical Sciences
University Sains Malaysia (USM), Penang 11800, Malaysia.
Phone: +60174203027,
Facsimile: +60164886908
E-mail: wasifgillani@gmail.com

Abstract

Objective: To evaluate the knowledge, attitudes and the practices of healthcare professionals towards the skin preparation before giving injections.

Methods: Cross sectional study. A pre-tested, pre-designed, well-structured questionnaire which was written in English was administered to the volunteer doctors, pharmacists and the nurses at Penang General Hospital during 20th March 2011 to 20th April 2011. A total of 136 anonymously completed questionnaires were returned to the investigator. The data was analyzed by using SPSS-16 and the results were expressed as counts and percentages.

Results: Most of the respondents derived their knowledge from healthcare personnel (70.5%, n = 136) and medical books (44.1%, n = 136). Most of the healthcare professionals knew that an alcohol swab would not minimize the pain either during (70%-85%) or after (55%-80%) an injection and that it would not minimize the risk of bleeding (50%-82%) after an injection. Almost all the respondents (93.7%) were of the view that not using a swab was not time saving and economical. However, more than 95% thought that skin preparations would minimize the risk of an infection; therefore, they would not administer an injection without using an alcohol swab.

Conclusion: The knowledge on the use of an alcohol swab before giving intra-dermal, subcutaneous and intra-muscular injections was poor. The healthcare professionals believed that skin preparations would minimize the risk of an infection and that an injection could not be given after cleaning the site with soap and water.

Keywords

Skin preparations, Clinical practices, Injections, Healthcare, Knowledge survey

How to cite this article :

Muhammad Qamar, Syed Wasif Gillani, Syed Azhar Syed Sulaiman. THE SKIN PREPARATION KNOWLEDGE, ATTITUDES AND PRACTICES AMONG THE HEALTHCARE PROFESSIONALS IN COMPLIANCE WITH THE WORLD HEALTH ORGANIZATION (WHO) GUIDELINES. Journal of Clinical and Diagnostic Research [serial online] 2012 August [cited: 2018 Oct 22 ]; 6:1041-1046. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2012&month=August&volume=6&issue=6&page=1041-1046&id=2321

INTRODUCTION
Injections are among the most common procedures which are used by healthcare professionals throughout the world. There is a general reluctance among people to accept injections without the site being cleaned with an alcohol swab (1),(2). According to the World Health Organization, there is no need to routinely use a 60%-70% alcohol swab for skin preparations before giving subcutaneous, intra-dermal and intra-muscular injections (3). For the purpose of this survey, the term ‘injection’ refers to intradermal, intra-muscular and subcutaneous injections and to assess the knowledge awareness about the latest World Health Organization Guidelines 2010. In the medical care, an injection is the introduction of a drug, contraceptive, vaccine or another therapeutic agent into the body by using a needle and syringe. Injections are among the most common healthcare procedures which are used throughout the world. According to the World Health Organization (4), among the best infection control practices, eliminating unnecessary injections is the highest priority in preventing injection-associated infections and when the injections are medically indicated, they should be administered safely to protect the patients, providers and the communities.

Dann (5), in his six years of study, gave 5000 injections to unselected patients by all routes, from the intra-dermal to the intravenous routes, without using any form of skin preparation, without a single case of infection, either local or systemic. He suggested that a routine skin preparation may have unpleasant side effects. Yoshika Kazuaki (6) and colleagues compared distillate water cotton with an alcohol swab as a skin preparation before a vaccination, and found no infection in both the groups. The side effects of using swabs were more frequent among the alcohol swab users. Sutton, White, Edwards and Lewis (7), in their study, found only two cases of local infection at the venepuncture site. Both the patients were disinfected with Isopropyl Alcohol (IPA) and, interestingly, both the patients were on steroid therapy for chronic obstructive airways disease. Pus swabs subsequently grew Staphylococcus aureus in both the cases. The IPA skin disinfection did not prevent a local infection in either case, thus suggesting that IPA is an ineffective agent.According to the recommendation of the World Health Organization (WHO), swabbing of the clean skin before giving an injection is unnecessary. The WHO further states that wash the skin that is visibly soiled or dirty? If swabbing with an antiseptic is being tried, then a clean, single-use swab should be used and a product-specificrecommended contact time should be maintained. Cotton balls which are stored wet in a multi-use container should not be used. The recommendation for an alcohol swab is to wipe the swab for 30 seconds over the site of the injection and to allow drying for a further 30 seconds to ensure that the bacteria are rendered inactive (otherwise, there may be some increased injection pain (1),(3).

At present, according to the policy guidelines in Penang General Hospital, the use of an alcohol swab before giving an injection is necessary. Thus, this survey was conducted to assess the theoretical knowledge of the heathcare professionals on the use of alcohol swabs, to let them have some awareness of this issue and to bring them a step ahead towards the WHO guidelines.

Material and Methods

A cross-sectional survey was employed as a method of data collection by using a previously validated, structured questionnaire, among the healthcare professionals of Penang General Hospital, during March 2011 to May 2011. For this survey, the universal sampling method was used for both male and female doctors, pharmacists and nurses. The questions of this survey were adapted from a previous study and they were modified to suit the local subjects. The questionnaire was pilottested at Penang General Hospital in December 2010. The questionnaire was administered to 30 healthcare professionals from different departments. The covering letter of the questionnaire outlined the title and the purpose of the study and the identity of the researcher. The participants were informed about the importance of the study and they were encouraged to participate in the study.

The questionnaire consisted of 2 sections with 14 items: (1) Demographic and (2) Knowledge. In the first section, the participants were asked about their demographic data. The skin preparation knowledge among the healthcare professionals was in compliance with the WHO best injection practice guidelines. Thus, the demographic data which were collected were gender, age, ethnicity, country of origin, initial medical education, profession, and the number of years in the medical practice. The second section consisted of 8 questions which determined the level of the knowledge and the source of the knowledge of the participants regarding the use of a skin preparation before the parenteral practice. The respondents were asked to answer as “yes”, “no” and “don’t know”. The scoring range of the questionnaire was +5 (maximum) to -5 (minimum). A cut of level of +5 to +3 was considered as good knowledge, that of +2 to 0 was considered as moderate knowledge, and that of -1 to -5 was considered as poor knowledge about a skin preparation. The knowledge scores for the individual respondents were calculated and they were summed up to give the total knowledge score.

Out of 150, 136 anonymously completed questionnaires were returned to the investigator.

Statistical analysis:
The statistical analysis was performed by using the Statistical Package for Social Sciences (SPSS), version 16 software. Descriptive statistics such as percentages and means were used to describe the samples on the various variables. The results were expressed as counts and percentages.

Results

Out of 160 distributed questionnaires, 136 (85%) completed questionnaires were returned. Among the 136 respondents, a majority were females 118 (86.8%) and Malays. There were 90(66.2%) Malays, 28 (20.6%) Chinese, and 18(13.2%) Indians. The ages of the respondents ranged from 23 to 56 years, with a mean age of 27.54 + 3.604 years. Most of the participants were nurses 76 (55.9%), followed by house officers 23 (16.9%), medical officers 16 (11.8%), pharmacists 12 (8.8%), specialists 5 (3.7%) and consultants [4 (2.9%)]. Among the healthcare professionals, 17 (12.5%) answered “yes”, which meant that they had a copy of the WHO best practices for injections and related procedures toolkit guidelines 2010, while 119 (87.5%) said that “we don’t have” (Table/Fig 1). Among the respondents, the length of the years of practice was between 1 to 19 years, with a mean length of service of 3.29 + 3.14 years. The consultants had a higher mean age (37.25 + 7.136 years), followed by the specialists (34.00 + 3.240 years), pharmacists (28.67 + 2.605 years), medical officers (28.06 + 1.982 years), nurses (26.82 + 3.041 years) and the house officers (25.87 + 1.014 years). Regarding the years of practice, the consultants were found to have more experience (mean years 14.00 + 3.742), followed by the specialists [8.60 + 2.966 years], pharmacists (3.25 + 2.261 years), nurses (3.11 + 2.404 years), medical officers (2.97 + 1.848 years), and the house officers (1.10 + 0.302 years). A summary of the demographic information of the healthcare professionals has been presented in (Table/Fig 2).

A total of 119 healthcare professionals (87.5%) claimed that, “we don’t have the copy of the WHO best practices for injections and related procedures toolkit guidelines 2010”. Only 17 claimed (12.5%) that, “we have the copy of WHO guidelines” (Table/Fig 1).

The Survey Participant’s Source of Knowledge Multi-source and multi-response information was obtained from the respondents, so percentage > 100. Most of the participants derived their knowledge about the cleansing site of the injection before giving subcutaneous, intra-dermal, and intra-muscular injections from other healthcare professionals. Approximately 96 (70.5%) respondents obtained the knowledge from healthcare professionals, 60 (44.1%) obtained it from medical books and 16 (11.8%) obtained it from medical journals. Other identified sources were the internet, medical books, medical journals, mass media and friends (Table/Fig 3).

The respondent’s knowledge about swabbing the site before giving intra-dermal, subcutaneous and intra-muscular vaccines was poor. More than 90% participating groups wrongly answered and said that “A routine skin preparation by using an alcohol swab before giving intra-dermal, subcutaneous and intra-muscular vaccine injections will prevent infections” (Table/Fig 4). Most of the healthcare professionals knew correctly that swabbing the site before giving subcutaneous, intra-dermal, intra-muscular vaccines, therapeutics and venous access injections would not minimize the pain before or after an injection (Table/Fig 4). Some of the doctors (20.8%) and nurses (40.8%) had a wrong belief and they mentioned that, “An alcohol swab will minimize bleeding after a venous access,” whereas a majority of them correctly replied this question (Table/Fig 4). More than 90% of the healthcare professionals believed that intradermal, subcutaneous and intra-muscular vaccine injections could not be given after just cleaning the site with soap and water (Table/Fig 4).

Almost all the healthcare professionals answered correctly that, “if swabbing is selected for use, wipe the swab for 30 seconds over the site of the injection and allow drying for a further 30 seconds before giving an injection.” Only few doctors (6.2%) and nurses (10.5%) answered wrongly, “while the skin wet with alcohol” (Table/Fig 4). Only 21% of the participants answered correctly that an alcohol swab could affect the contents of the injected medication and that it could affect the mode of action of the injection also [Table/ Fig-4]. The knowledge was assessed by giving 1 for a correct answer and -1 for a wrong answer. A “don’t know” response was also taken as 0. The scale measured the knowledge from a maximum of +5 to a minimum of -5. The scores which ranged between +5 to +3 were taken as good, those which ranged from +2 to 0 were taken as moderate and those which ranged from -1 to -5 were considered as a poor knowledge on the skin preparation.

The mean knowledge score regarding the skin preparation among the intra-dermal, subcutaneous, intra-muscular and the venous access injections for the doctors were 2.7, for the pharmacists, it was 3 and for the nurses, it was were -3.4. In general, the doctors had a moderate level of knowledge on the skin preparation, the pharmacists had good knowledge and the nurses had poor knowledge on the skin preparation before injections. The mean knowledge score regarding the skin preparation among the intra-dermal, subcutaneous and the intra-muscular injections for question 1 and question 5 was poor. For question 1, the doctors scored -4, the pharmacists scored -3.5 and the nurses scored -3.8. Similarly, for question 5, the doctors scored -3.5, the pharmacists scored -2.8 and the nurses scored -3.15.

(Table/Fig 4) shows the healthcare professionals’ attitude and their practices towards the skin preparation. Almost more than 90% of the healthcare professionals believed that intra-dermal and subcutaneous injections could not be administered after cleaning the site with soap and water. Similarly, the HCPs did not agree with the method of giving intra-muscular vaccines without alcohol swabbing (70% alcohol). There was a negative attitude in these two statements. While they had a positive attitude about the swabbing before injections, it was not found to be time saving and economical. While for the practice statements, 97% of the healthcare professionals stated that alcohol swabbing of a clean skin was notan unnecessary practice, while they are also did not agree with the method of administering IM vaccine injections after cleaning the site with soap and water. On the practice regarding the reuse of an alcohol swab after dipping it into 70% alcohol, only 71.3% disagreed and stated that it could not be used, while 17% agreed to its reuse (Table/Fig 5).

Discussion

The survey was conducted in one of the government hospitals in Penang. The purpose of this survey was to focus on the specific education, training and awareness programs for healthcare professionals with respect to the implementation of the WHO guidelines for giving safe injections. Among the healthcare professionals, 17(12.5%) claimed that they had a copy of the WHO best practices for injections and related procedures toolkit guidelines 2010, while 119 (87.5%) said they did not have it, as shown in (Table/Fig 1). It shows that a majority of the healthcare professionals lacked awareness and knowledge about the availability of the WHO practice guidelines for giving safe injections. A study showed that among the 78% of the guidelines, more than 10% of physicians are not aware of their existence. The lack of awareness was contributed as a major factor of non adherence to the guidelines (2). During the discussion which was held with the healthcare professionals, they said that they did not have an idea about the presence of any guidelines for safe injection practices. No evidence-based guidelines were available to guide the injection providers through the steps that they had to follow, to prevent injection-associated infections. Thus, the WHO developed the best practices for the use of the safe injections guidelines (4).

Most of the participants derived their knowledge from various sources. This study found that 70.5% of the healthcare professionals got the knowledge from other healthcare personnel. 44.1% got their knowledge from medical books (Table/Fig 2). In contrast to the findings of the study which was done by Rajab Ali (1), 85% of the healthcare professionals were found to have got their knowledge from other health personnel and 45% had got it from medical books in our study. These similar findings showed that a majority of the healthcare professionals got their knowledge from other healthcare personnel during their practice. Regarding the knowledge of the healthcare professionals, this study showed that the respondent’s knowledge about swabbing before giving an injection and the injection related infections were poor in the case of intra-dermal, subcutaneous and intra-muscular vaccines, and therapeutics, which showed that our findingswere similar to those of the study which was done by Rajab Ali Khawaja (1). More than 95% of all the participating groups wrongly answered and said that “Routine skin preparations with the use of an alcohol swab before giving intra-dermal, subcutaneous and intra-muscular vaccine injections will prevent infections”. In case of the intravenous injections, 94.8% of the respondents answered the questions correctly (Table/Fig 4).

Barbara Workman (8), in her study, reported that swabbing before giving subcutaneous insulin injections predisposed the skin to be hardened by the alcohol. Previous studies have suggested that the lack of a skin preparation did not result in an infection ((Dann 1969; Koivisto and Felig 1978) (9),(10). Veikko A Koivisto and Philip Felig, in their study subjects (10), omitted the skin preparation before giving insulin injections every other week. More than 1700 insulin injections were given without a skin preparation. No signs of local or systemic infections were observed. These results indicated that giving insulin injections without a skin preparation did not prevent infections at the injection site.

The success in reducing the rate of unnecessary skin preparations with the use of an alcohol swab before giving subcutaneous, intradermal, and intra-muscular injections as per the WHO guidelines could only occur if the current theoretical knowledge, attitude and practice of the healthcare professionals were known. This would help in tailoring the training and the awareness programs for the healthcare professionals. When asked whether the intra-dermal, subcutaneous and the intra-muscular vaccine injections could be given just after cleaning the site with soap and water (Table/Fig 4), more than 90% of the healthcare professionals replied in the negative, and the main reason for the refusal was that they believed that just cleaning the site with water and soap could cause an infection. Other studies suggested that there was no increased risk of infection when the injections were given in the absence of a skin preparation (5), (9), (10), (11), (12), (13).

With respect to the knowledge about the correct time of giving the skin preparation, previous studies which were done in Saudia found that 59.4% of the doctors and nurses responded with a correct answer (1), while in the present study, 93.8% doctors, 100% pharmacists and 85.5% nurses responded with the correct answer (Table/Fig 6). This showed that a high percentage of doctors, pharmacists and nurses had good knowledge about the correct time of giving injections in Malaysia.

Simmonds (14), in his study, stated that if it was necessary to use skin disinfection, the skin had to be cleaned with an alcohol swab for 30 seconds, and then allowed to dry for at least 30 seconds; otherwise it would be ineffective. Additionally, if the injection was given before the skin dried, not only would it increase pain for the patient, as the needle entry would make the site sting, but also the bacteria would not be rendered inactive and they could be inoculated into the injection site (6),(15),(16).

In this survey, only 31% of the respondents answered correctly that an alcohol swab could affect the contents of an injected medication and that it could affect the mode of action of the medication (Table/Fig 3), while in the Rajab Ali (1) survey, only 22% of the participants answered correctly that an alcohol swab could affect the contents of an injected medication and that it could affect the mode of action of the medication. Both these studies showed the lack of knowledge of the healthcare professionals. The World Health Organization guidelines for safe practice in injections 3 has mentioned that alcohol disinfection should not be used for the administration of an intra-muscular vaccine. Ramskogler K (17) reported in his study that, alcohol dehydrogenase (ADH), acetaldehydede hydrogenase (ALDH) and cytochrome P450 2E1 were the enzymes which were responsible for the metabolism of ethanol. These enzymes were also the sites of a direct pharmacological interaction between ethanol and other drugs. However, the altered effects of the medication could also be caused by ethanol, adding to or reducing the drug’s effect. Interactions have most frequently been described for analgesics, psycho pharmacologically active drugs, antihistamines, anticoagulants antihypertensive drugs, and antibiotics.

In this survey, the knowledge of the healthcare professionals regarding the routine preparation of the skin before giving an injection was poor. According to the findings of this survey, the important disadvantage which was observed among the healthcare professionals was that the absence of an alcohol swab before giving an injection could lead to the risk of an infection. This concept was not in agreement with the findings which were reported earlier, both from the developing and the developed countries (5), (9), (10), (12), (18), (19). Poor knowledge on these issues would most likely lead to a defective attitude and some misconceptions towards the use of a routine alcohol swab. A World Health Organisation (WHO) (4) bulletin which was published in 2003 stated that swabbing clean the skin prior to giving an injection was unnecessary. However, if cleaning was necessary, soap and water would be sufficient. There is very little evidence to support the need for the disinfection of theskin prior to giving any intra-dermal, subcutaneous and intramuscular injections. Many studies have reported that a routine skin preparation with the use of an alcohol swab before giving intra-dermal, intra-muscular and subcutaneous injections was unnecessary (5), (10),(11),(12), (19),(20). The results of this study clearly showed that the WHO guidelines had only to be implemented after providing sufficient knowledge and after changing the behaviour of health care providers by further training, and that of the patients by awareness programs.

Limitations of the study
The current study has three limitations. Firstly, it is limited by its cross sectional methodology. Secondly, the study population was small and the survey only focused on the healthcare professionals within the hospital. The healthcare professionals from health clinics were not included in this survey and thus the results cannot be generalized to all the healthcare professionals in Penang. In addition, the third limitation is that the study took place in only one hospital of Penang city. Finally, the data represents the professionals’ knowledge; attitude and practice up to a particular point in time and it does not necessarily reflect the future.

Conclusion

In general, the doctors had a moderate level of knowledge and the pharmacists were at a good level, while the nurses had poor knowledge about the skin preparation before giving an injection. Most of the respondents reported that healthcare professionals were the major sources of getting information about the use of a skin preparation before giving injections. Success of positive attitude and good practice is dependent upon the level of knowledge of the skin preparation which is carried out by healthcare professionals. It is believed that knowledge is one of the key factors in achieving a positive attitude and practice. It was observed that the healthcare professionals had a perception that swabbing before giving intra-dermal, subcutaneous and intramuscular injections would minimize the risk of infections and also that injections couldn’t be given after just cleaning the site with soap and water. Thus, the results provided a valuable insight into the healthcare professionals’ knowledge and attitude towards the routine preparation of the skin with the use of an alcohol swab before giving injections in Malaysia. Arranging seminars and awareness programs can play a major role in this regards and this can facilitate the education of the healthcare professionals about skin preparations.

Acknowledgement

The Authors wish to thank the healthcare professionals for participating in the study, and the hospital practice staff for their support.

References

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