Health Education and Health Promotion

Effectiveness of an Educational Program on Nannies' Practice Regarding Cholera Infection in the Nurseries

Document Type : Original Research

Authors

A.O. Azeez 1
A.H.M. Hussain 2
A.H. Shawq 3

1 Dhari al-Fayad Hospital, Ministry of Health and Environment, Baghdad, Iraq

2 Department of Basic Science, College of Nursing, University of Baghdad, Baghdad, Iraq

3 Department of Pediatric Nursing, College of Nursing, University of Baghdad, Baghdad, Iraq

https://doi.org/10.58209/hehp.11.3.349
Abstract
Aims: In nurseries, hygiene measures are considered as an effective practice to prevent infection. By implementing appropriate hygiene techniques and effective prevention measures, the transmission of infectious diseases such as cholera among children and youth can be limited. The present study aimed to assess the effectiveness of an educational program on nannies' practice regarding cholera infection and explore any relationship between their practice and demographic characteristics.

Materials & Methods: This quasi-experimental study was conducted with a pre-test and post-test design with a control group in public nurseries in different cities of Baghdad province. Sixty nannies were randomly selected and divided into two equal intervention and control groups. The intervention group received the cholera education program, and the control group did not receive any intervention. Data were collected using a researcher-made checklist to evaluate nannies' practice and analyzed by SPSS 26 software.

Findings: Both groups had inadequate practice regarding cholera infection (0.96±0.31 and 1.00±0.15, respectively). After the implementation of the program, the practice of the intervention group improved significantly (1.59±0.13), while the practice of the control group remained inadequate (1.00±0.12). There was no significant difference in the mean scores of nannie’s practice based on their demographic characteristics (p>0.05), except for the level of education (p=0.0001).

Conclusion: The practice of nannies in public nurseries in Baghdad against cholera is limited, and the educational program of this study has a positive effect on the practice of nannies. The educational qualification of nannies plays a significant role in responding to the program.

Keywords

Cholera
Pediatric Nurse
nurseries
Training Programs
Preschool children
Subjects
Introduction
Cholera is an acute, potentially life-threatening diarrheal disease caused by intestinal infection with Vibrio cholerae serogroups O1 or O139 [1, 2]. Profuse watery diarrhea and vomiting can lead to dehydration and shock. Without treatment, death can occur within hours. Oral and intravenous rehydration therapy has markedly decreased case fatality rates [3]. Vibrio cholerae can be found in food or water, so people can get infected after oral ingestion. When Vibrio cholerae is ingested, it produces enterotoxins (toxins that act in the gastrointestinal tract) whose actions on the mucosal epithelium are responsible for the characteristic symptoms of cholera, namely, acute watery diarrhoea and vomiting [4].
Cholera is a major public health threat in many parts of the world [5], particularly in areas facing complex emergencies [6]. Cholera outbreaks generally occur when Water, Sanitation and Hygiene (WASH) services are inadequate or compromised [7-9].
Cholera remains a dreaded illness because of its rapid onset, severity, and potential to cause outbreaks that easily overwhelm public health systems in impoverished settings. Seasonal disease occurs in many less developed countries that cannot afford to establish or to maintain essential infrastructure for safe water supply and sanitation. Outbreaks may arise during natural disasters and complex emergencies [10].
Cholera is a disease that reflects social protection levels, availability of clean water, sanitation, and hygiene, as well as population density [11, 12].
In many underdeveloped and low-income countries, cholera, as an ancient disease, continues to be a global health challenge [11]. Cholera infections affect both children and adults who consume water and food contaminated with the bacterium Vibrio cholerae [12]. Annually, over 2.8 million people are affected by cholera, resulting in more than 94,000 deaths globally [13]. This burden is disproportionately borne by the young, with children under five having the highest incidence of cholera and contributing almost half of the mortality [1]. This disease may occur as sudden progressive outbreak after a natural disaster, such as a cyclone, flood, and an earthquake. The disruption of the water distribution system and an inadequate hygiene situation or inadequate sanitation system after a natural disaster may cause cholera outbreaks [14].
Diarrhoeal diseases such as cholera are transmitted through the faecal-oral route. Infection with V. cholerae can originate from a susceptible person ingesting the bacteria from environmental point sources (e.g., contaminated water in lakes and rivers or a faecal-contaminated environment) [15], which is known as the environment-to-human transmission pathway [16, 17].
Infection with V. cholerae can also occur between infected and susceptible individuals [11, 18] from consuming contaminated food [19-21] or water at the Point of Use (POU) [22, 23] that has been contaminated by a cholera case or through caring for existing cholera cases, particularly among household contacts of a case [18], this is known as the human-to-human transmission pathway.
During outbreaks, recurrent environment-to-human reinfection of the population may also occur through ingestion of V. cholerae through contaminated environmental point sources due to sustained contamination of the environment by symptomatic and asymptomatic cholera cases [15]. Both transmission pathways occur through the faecal-oral routes of diarrhoeal disease transmission, commonly known as the F-diagram [24].
It seems that inadequate knowledge of parents to make adequate provision for clean water, clean environment, and decent toilets contributed to its high prevalence among children. Moses et al. [25] observed that many of the victims face a lot health challenges, such as extreme diarrhea, nausea, vomiting, and dehydration. The infected children may lose as much as liter of fluid an hour, nausea and vomiting may last for several hours at a time, and dehydration causes electrolyte imbalance, which can lead to muscle spasms and shock. Hence, victims suffer a life-long disability, reduction in life expectancy, and majority of affected individuals hardly survive to adulthood [25].
Cholera has occurred twice in Iraq in the last ten years. The first outbreak was in 2015, resulting in 1,500 cases, while the second outbreak took place in June 2022, with 13 cases reported in Al-Sulaymaniyah City. During 2022, cholera cases were reported in the majority of governorates. However, the highest impact was observed in Kirkuk, Baghdad, and Thi-Qar, with a significant number of confirmed cases [26, 27]. The persistence of the disease can be attributed to low public awareness of cholera transmission and inadequate infection control measures. To curb the pandemic, it is essential to provide adequate health education about cholera and implement effective preventive measures [28].
When young children contract cholera, they are at risk of severe dehydration, which can be life-threatening due to excessive diarrhea. Additionally, cholera in children can lead to serious complications such as electrolyte imbalance that adversely affects the functioning of vital organs. Due to factors like their young age, level of maturity, and ongoing development, children are less likely to follow recommended behavioral and hygienic practices, such as regular hand washing, which help prevent or reduce the risk of infection. Furthermore, their immune system is still developing and are therefore less able to provide adequate protection [11, 29].
Effective control of transmission relies on educating individuals about infection prevention. This entails providing comprehensive instruction on infection control principles and increasing awareness of the risks and modes of transmission for common pathogens [30].
Nurses play an important role in stopping the spread of infections by educating the community, with a special focus on protecting children. Key aspects of this education include promoting good hygiene practices and cultivating healthy habits, which have been very effective in preventing a variety of infectious diseases. Additionally, nurses are responsible for emphasizing essential measures like regular hand washing and ensuring proper immunization [31]. Therefore, we must prepare a program to prevent the spread of infectious diseases, including cholera, among kindergarten children and to find out the effectiveness of this program. Hence, the present study aimed to assess the effectiveness of an educational program on nannies' practice regarding cholera infection and explore any relationship between their practice and demographic characteristics.

Materials and Methods
This quasi-experimental study was conducted with a pre-test and post-test design with a control group from September 14, 2022 to June 15, 2023 in public nurseries in different cities of Baghdad province, including Haifa Street, Baeaa, Amriya, Kadhimiya, Salihiea, Al-Sulaikh Center, Al Washash, Rahmaniyah, Mahmudiyah, Jadriya, Habibia, and Al Talibia.
Sixty nannies were randomly selected and divided into two equal intervention and control groups. The intervention group received the cholera education program, and the control group did not receive any intervention. Before starting the study, written consent was obtained from each participant.
The program was designed to provide information and training regarding the prevention of cholera infection and consisted of three lectures for three days. Each lecture was about 45 minutes that took place at classroom in the nursery. The first lecture included general information about cholera, methods of transmission, and its risk factors. The second lecture was prepared for awareness of signs and symptoms, complications and diagnosis, as well as the principles of treatment. The last lecture included training on ways to prevent cholera and practices that nannies follow to prevent the disease from occurring.
After obtaining the validity and reliability, the data was collected by an observation checklist to evaluate the nannies' performance. This checklist was made by researchers to evaluate the performance of nannies regarding cholera infection and included 18 items that were scored on a 3-point Likert scale: never = 1, sometimes = 2, always = 3.
A panel of 11 experts, each with at least 10 years of experience in their respective fields, assessed the validity of the questionnaire. The reliability of the tools was determined by conducting a pilot study using Cronbach's alpha. The level of practice was scored as inadequate, fair, and adequate
The collected data were analyzed using independent t-test and one-way analysis of variance. Data analysis was done by SPSS 26 software.

Findings
The age of the participants ranged from 26 to 54 years. The mean age for the intervention group was 38.43±7.65 years, and for the control group was 36.9±7.12 years.
More than three-quarters of the nannies were married (86.7% for the intervention group and 80% for the control group), while the rest were either widowed or divorced, and a small percentage of them were single. Also, a high percentage of them had children (96.7% for the intervention group and 90.0% for the control group).
Regarding the level of education, 36.6% of the intervention group had an intermediate degree, 23.3% of them had a primary school degree, while 13.0% and 23.4% had a baccalaureate and bachelor's degree, respectively, and 3.3% had a Master's degree. On the other hand, the highest percentage (56.7%) of the control group had an intermediate degree, followed by 20%, 13.3%, and 10% with a primary, bachelor's, and high school degrees, respectively.
In the intervention group, the majority (46.6%) of nannies had experience between 5 and 11 years, followed by 30.0% between 11 and less than 16 years, 16.7% more than 16 years, and 6.7% less than 5 years. In the control group, 46.7% of nurses had 11 to less than 16 years of experience, followed by 36.6%, 10.0%, and 6.7% with 5 to less than 11 years, more than 16 years, and less than 5 years of experience, respectively. All participants had previous experience in childcare and the majority (46.7% in both groups) had gained their experience outside of a nursery setting.
Both intervention and control groups had inadequate practice regarding cholera infection, with mean scores of 0.96±0.31 and 1.00±0.15, respectively. After the implementation of the program, the practice of the intervention group improved significantly, with a mean score of 1.59±0.13, while the practice of the control group remained inadequate, with a mean score of 1.00±0.12 (Table 1).

Table 1) Evaluation of nannies' practice regarding cholera for both intervention and control groups during the study period




At the beginning of the study, there was no significant difference between both groups (p=0.307). After the implementation of the program, in the intervention group, there was a significant difference between the mean score of nannies' practice compared to the pre-test (p=0.0001). However, no significant difference was observed in the control group (p=0.423; Table 2).

Table 2) Comparing the mean scores of nannies' practice in both groups before and after the intervention


There was no significant difference in the mean scores of nannie’s practice based on their demographic characteristics (p>0.05), except for the level of education (p=0.0001; Table 3).

Table 3) Comparing the mean scores of nannie’s practice based on their demographic characteristics



Discussion
The practice of the nannies about Cholera before the educational program mostly were fair in both groups (intervened and control groups). The researchers suggest that this level of practice is inadequate for prevention and control infectious diseases among children in the nurseries. This inadequate practice can be attributed to many factors; Firstly, the absence of continuing and consistent training programs aimed at educating and enhancing their abilities to carry out their duties; Secondly, no special practical guideline for nannies about children care and how can deal with infectious diseases to prevent spread and complication; Thirdly, the educational qualifications of the nursery staff play a crucial role, as childcare necessitates a considerable level of competence and expertise. Insufficient adherence to proper childcare practices by nannies in nurseries can contribute to a swift transmission of infections among children [32]. Consequently, it is imperative for nannies to possess effective practices aimed at minimizing the spread of infections and safeguarding the health of young children. In fact, every field in child healthcare needs special training, even among healthcare providers [33].
To the best of our knowledge, no studies have been found on the practice of nannies in our society regarding infection control in general, and cholera in particular, and even in other pediatric healthcare contexts. On the other hand, few studies have been done in this field in other societies. In general, there are gaps in knowledge, as well as in practice and management in various aspects of healthcare among nannies [34, 35]. Indeed, public people have little idea how to deal with cholera [36].
After implementing our program, significant improvements have been made in four critical domains of the practical observation checklist: 1) hand hygiene, 2) diaper changing, 3) food safety, and 4) sterilization and disinfection. The observed improvements in nannies' performance are vital for nursery settings, as they directly affect their important role in caring for young children. These improvements encompass several aspects, such as maintaining cleanliness and sterilization of children's tools, ensuring safe use of water, and good management of designated diaper changing areas. By acquiring these advances, nannies help reduce the risk of infection and prevent their transmission in nursery settings.
Educational programs as knowledge or training have a positive role and impact on recipients in various occupational sectors, especially in health, education, etc. Also, educational programs for the general public, housewives, mothers and even patients in health centers have been successful and important in the development and education of society in various fields of life. For example, a study conducted to determine the effectiveness of a training program on the practice of healthcare workers showed that most participants performed well after the program intervention [37]. Other interventions also improved the practiceof nurses and midwives [38, 39]. In addition, the effectiveness of a health education program targeting mothers' child care practices showed that there was a positive statistical significance between pre-test and post-test outcomes [40]. Meanwhile, programs were held for patients with the aim of improving the knowledge and practice of patients, which showed that they improved in practice and self-care after applying the program [41]. In addition, the motivational interviewing program played a role in empowering and motivating dialysis-dependent patients to adhere to treatment, which led to an improvement in their health status [42].
Also, the results of the present study showed that there is no statistically significant difference in the practice of nannies based on their demographic characteristics except their education level. It means that as people increase their level of education, their knowledge and information about different practices will naturally enhance. Conversely, a lower level of education indicates a diminished level of knowledge. The level of education is very important in acquiring accurate knowledge and adopting appropriate practices. For instance, a nanny with a higher educational background will have a greater awareness of knowledge, and this will be evident in the caring practices she employs when caring for young children. These results are consistent with the results of Mohammed & Ali's study, which showed a significant correlation between mothers' practice and their socio-demographic characteristics, especially with their educational background [43]. Also, Ahmed & Hattab, in a study, showed a statistically significant association between the education level of nurses and their practice improvement [44]. In addition, another study showed that there is a significant correlation between the education level of patients and the effectiveness of the educational program [45].
It is suggested that the educational program used in this study be presented to a committee in the Ministry of Health for evaluation and revision, with the aim of implementing it in all nurseries throughout Iraq.

Conclusion
The practice of nannies in public nurseries in Baghdad against cholera is limited, and the educational program of this study has a positive effect on the practice of nannies. The educational qualification of nannies plays a significant role in responding to the program. In addition, continuing education is important to improve the care of children in nurseries.

Acknowledgements: Hereby, we express our deepest gratitude to Prof. Dr. Wissam Jabbar Qasim, Dean of College of the Nursing, University of Baghdad.
Ethical Permission: Official permissions were obtained from the relevant authorities before collecting the study data through a series of administrative procedures. The approval was obtained from the Council of college of Nursing, University of Baghdad.
Conflict of Interests: There is no conflict of interests.
Authors’ Contribution: Azeez AO (First Author), Introduction Writer/Methodologist/Main Researcher/Statistical Analyst/Discussion Writer (65%); Hussain AHM (Second Author), Introduction Writer/Methodologist/Statistical Analyst/Discussion Writer (17%); Shawq AH (Third Author), Introduction Writer/Methodologist/Statistical Analyst/Discussion Writer (18%)
Funding: The source of funding is personal.
  1. Ali M, Lopez AL, You YA, Kim YE, Sah B, Maskery B, et al. The global burden of cholera. Bull World Health Organ. 2012;90(3):209-18 . [Link] [DOI:10.2471/BLT.11.093427]
  2. Sack DA, Sack B, Nair GB, Siddique AK. Cholera. Lancet. 2004;363(9404):223-33. [Link] [DOI:10.1016/S0140-6736(03)15328-7]
  3. Carpenter CC. The treatment of cholera: clinical science at the bedside. J Infect Dis. 1992;166(1):2-14. [Link] [DOI:10.1093/infdis/166.1.2]
  4. LoBiondo-Wood G, Haber J. Nursing research: methods and critical appraisal for evidence-based practice. 9th Edition. St. Louis: Mosby; 2017. [Link]
  5. Legros D, Partners of the Global Task Force on Cholera Control. Global cholera epidemiology: opportunities to reduce the burden of cholera by 2030. J Infect Dis. 2018;218(suppl_3):S137-40. [Link] [DOI:10.1093/infdis/jiy486]
  6. Shannon K, Hast M, Azman AS, Legros D, McKay H, Lessler J. Cholera prevention and control in refugee settings: Successes and continued challenges. PLoS Negl Trop Dis. 2019;13(6):e0007347. [Link] [DOI:10.1371/journal.pntd.0007347]
  7. Spiegel PB, Checchi F, Colombo S, Paik E. Health-care needs of people affected by conflict: future trends and changing frameworks. Lancet. 2010;375(9711):341-5. [Link] [DOI:10.1016/S0140-6736(09)61873-0]
  8. Shikanga OT, Mutonga D, Abade M, Amwayi S, Ope M, Limo H, et al. High mortality in a cholera outbreak in western Kenya after post-election violence in 2008. Am J Trop Med Hyg. 2009;81(6):1085-90. [Link] [DOI:10.4269/ajtmh.2009.09-0400]
  9. Gayer M, Legros D, Formenty P, Connolly MA. Conflict and emerging infectious diseases. Emerg Infect Dis. 2007;13(11):1625-31. [Link] [DOI:10.3201/eid1311.061093]
  10. Deen JL, von Seidlein L, Sur D, Agtini M, Lucas MES, Lopez AL, et al. The high burden of cholera in children: comparison of incidence from endemic areas in Asia and Africa. PLoS Negl Trop Dis. 2008;2(2):e173. [Link] [DOI:10.1371/journal.pntd.0000173]
  11. Deen J, Mengel MA, Clemens JD. Epidemiology of cholera. Vaccine. 2020;38(suppl 1):A31-40. [Link] [DOI:10.1016/j.vaccine.2019.07.078]
  12. Witbooi PJ, Muller GE, Ongansie MB, Ahmed IHI, Okosun KO. A stochastic population model of cholera disease. Discret Contin Dyn Syst. 2022;15(2):441-56. [Link] [DOI:10.3934/dcdss.2021116]
  13. Mayry J, Mac R, Huynh M, Mitra S. Development of a low-cost lateral flow assay for rapid detection of Vibrio Cholerae. Electrochem Soc. 2022;54:2190. [Link] [DOI:10.1149/MA2022-01532190mtgabs]
  14. Watson JT, Gayer M, Connolly MA. Epidemics after natural disasters. Emerg Infect Dis. 2007;13(1):1-5. [Link] [DOI:10.3201/eid1301.060779]
  15. Islam MS, Zaman MH, Islam MS, Ahmed N, Clemens JD. Environmental reservoirs of Vibrio cholerae. Vaccine. 2020;38 Suppl 1:A52-62. [Link] [DOI:10.1016/j.vaccine.2019.06.033]
  16. Tien JH, Earn DJ. Multiple transmission pathways and disease dynamics in a waterborne pathogen model. Bull Math Biol. 2010;72(6):1506-33. [Link] [DOI:10.1007/s11538-010-9507-6]
  17. Fung ICH. Cholera transmission dynamic models for public health practitioners. Emerg Themes Epidemiol. 2014;11(1):1. [Link] [DOI:10.1186/1742-7622-11-1]
  18. Richterman A, Sainvilien DR, Eberly L, Ivers LC. Individual and household risk factors for symptomatic cholera infection: a systematic review and meta-analysis. J Infect Dis. 2018;218(suppl_3):S154-64. [Link] [DOI:10.1093/infdis/jiy444]
  19. Nguyen VD, Sreenivasan N, Lam E, Ayers T, Kargbo D, Dafae F, et al. Cholera epidemic associated with consumption of unsafe drinking water and street-vended water-Eastern Freetown, Sierra Leone, 2012. Am J Trop Med Hyg. 2014;90(3):518-23. [Link] [DOI:10.4269/ajtmh.13-0567]
  20. Moradi G, Rasouli MA, Mohammadi P, Elahi E, Barati H. A cholera outbreak in Alborz Province, Iran: a matched case-control study. Epidemiol Health. 2016;38:e2016018. [Link] [DOI:10.4178/epih.e2016018]
  21. Burrowes V, Perin J, Monira S, Sack D, Rashid MU, Mahamud T, et al. Risk factors for household transmission of Vibrio cholerae in Dhaka, Bangladesh (CHoBI7 Trial). Am J Trop Med Hyg. 2017;96(6):1382-7. [Link] [DOI:10.4269/ajtmh.16-0871]
  22. Fredrick T, Ponnaiah M, Murhekar MV, Jayaraman Y, David JK, Vadivoo S, et al. Cholera outbreak linked with lack of safe water supply following a tropical cyclone in Pondicherry, India, 2012. J Health Popul Nutr. 2015;33(1):31-8. [Link]
  23. Rashid MU, Rahman Z, Burrowes V, Perin J, Mustafiz M, Monira S, et al. Rapid dipstick detection of Vibrio cholerae in household stored and municipal water in Dhaka, Bangladesh: CHoBI7 trial. Trop Med Int Health. 2017;22(2):205-9. [Link] [DOI:10.1111/tmi.12797]
  24. Wagner EG, Lanoix JN. Excreta disposal for rural areas and small communities. Monogr Ser World Health Organ. 1958;39:1-182. . [Link]
  25. Moses FO, Iluku-Ayoola O, Adeola OB. Prevalence and causes of Cholera among children in Ekiti State, Nigeria. J Health Med Nurs. 2020;76:56-62. [Link]
  26. Qamar K, Malik UU, Yousuf J, Essar MY, Muzzamil M, Hashim HT, et al. Rise of cholera in Iraq: a rising concern. Ann Med Surg. 2022;81:104355. [Link] [DOI:10.1016/j.amsu.2022.104355]
  27. Sidiq K. A flashback to cholera outbreaks in Kurdistan region-Iraq. Passer J Basic Appl Sci. 2022;5(1):7-12. [Link] [DOI:10.24271/psr.2022.367483.1177]
  28. Gallandat K, Huang A, Rayner J, String G, Lantagne DS. Household spraying in cholera outbreaks: Insights from three exploratory, mixed-methods field effectiveness evaluations. PLoS Negl Trop Dis. 2020;14(8):e0008661. [Link] [DOI:10.1371/journal.pntd.0008661]
  29. Harris JB, LaRocque RC, Chowdhury F, Khan AI, Logvinenko T, Faruque ASG, et al. Susceptibility to Vibrio cholera infection in a cohort of household contacts of patients with cholera in Bangladesh. PLoS Negl Trop Dis. 2008;2(4):e221. [Link] [DOI:10.1371/journal.pntd.0000221]
  30. World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level [Internet]. Geneva: World Health Organization; 2016 [cited 2023 Apr 15]. Available from: https://apps.who.int/iris/handle/10665/251730. [Link]
  31. Elliot L, Bertrand SL. Guidance note: Protection of children during infectious disease outbreaks [Internet]. The Alliance for Child Protection in Humanitarian Action; 2021 [cited 2023 Apr 15]. Available from: https://alliancecpha.org/en/child-protection-online-library/guidance-note-protection-children-during-infectious-disease. [Link]
  32. Ibfelt T, Engelund EH, Schultz AC, Andersen LP. Effect of cleaning and disinfection of toys on infectious diseases and micro-organisms in daycare nurseries. J Hosp Infect. 2015;89(2):109-15. [Link] [DOI:10.1016/j.jhin.2014.10.007]
  33. Kadhim NS. Assessment of nurses practice regarding poisoning children. Iraqi Nation J Nurs Special. 2022;35(2):60-7. [Link] [DOI:10.58897/injns.v35i2.612]
  34. Alkhubaizi Q, Moule A, Al-Sane M, Sorkin JD. Oral health practices and knowledge among parents and hired caregivers. Eur Arch Paediatr Dent. 2018;19(6):403-10. [Link] [DOI:10.1007/s40368-018-0372-6]
  35. Greiwe JC, Pazheri F, Schroer B. Nannies' knowledge, attitude, and management of food allergies of children: an online survey. J Allergy Clin Immunol Pract. 2015;3(1):63-7. [Link] [DOI:10.1016/j.jaip.2014.07.017]
  36. Ali EM, Mohamed MB, Tawhari M. Knowledge, attitude, and practice study regarding cholera among the people in Jazan city, KSA. J Family Med Prim Care. 2021;10(2):712-7. [Link] [DOI:10.4103/jfmpc.jfmpc_965_20]
  37. Shabib H, Khalifa M. Effectiveness of Education program on health care workers' practices toward waste management in primary health care centers. Iraqi Nation J Nurs Special. 2016;29(2):75-93. [Link] [DOI:10.58897/injns.v29i2.257]
  38. Oleiwi S, Abbas I. Effectiveness of an education program concerningcardiotocography on nurses-midwives practice in maternity hospitals at Baghdad City. Iraqi Nation J Nurs Special. 2018;31(1):24-34. [Link] [DOI:10.58897/injns.v31i1.289]
  39. Ridha BA, Ahmed SA. Effectiveness of an educational program on nurses'/midwifes' knowledge and practices about managements of breastfeeding disorders among women during lactation at hospital in Holy Karbala City. Resmilitaris. 2022;12(2):6908-15. [Link]
  40. Mahday ZAA, Khudhair SHK. Effectiveness of health educational program on mothers practices toward care of children with squint of eyes at Ibn Al- Haitham Teaching Eye Hospital in Baghdad City. Int J Psychosoc Rehabil. 2020;24(1):7213-21. [Link]
  41. Al-Kinani MRD, Ahmed SA. Effectiveness of an instructional program on patients ‎knowledge and practices toward insulin injection technique used by patients with diabetes ‎at specialized centers for endocrinology and diabetes in Baghdad City. Int ‎J Psychosoc Rehabil. 2020;24(9):3321-9. [Link]
  42. Mankih RA, Mirza Hussain AH. The role of motivational interviewing in improving health state of patients undergoing hemodialysis. Pakistan J Med Health Sci. 2022;16(6):642. [Link] [DOI:10.53350/pjmhs22166642]
  43. Mohammed AAA, Ali E. Practices of early childhood's mothers regarding toilet training at primary health care centers in Al-Rusafa District in Baghdad City. Iraqi Nation J Nurs Special. 2021;34(1):30-7. [Link] [DOI:10.58897/injns.v34i1.457]
  44. Ahmed AQ, Hattab KM. Effectiveness of an intervention program on nurses' practices toward neonatal intubation suctioning procedure at neonatal intensive care unit. Pakistan J Med Health Sci. 2022;16(5):650. [Link] [DOI:10.53350/pjmhs22165650]
  45. AL Hamad HAAA. Instruction program for patient with peptic ulcer about nutritional habits: case-control study. Iraqi Nation J Nurs Special. 2023;36(1):35-48. [Link] [DOI:10.58897/injns.v36i1.637]
Health Education and Health Promotion
Volume 11, Issue 3
Autumn 2023
Pages 349-356