INTRODUCTION:

Background and Significance of study:

The blood-borne diseases include a broad spectrum of infectious conditions that reach their target tissue through the circulation of blood. Health care workers, emergency response and public safety personnel, barbers and other workers can be exposed to blood through needle stick and other sharps injuries, mucous membrane, and skin exposures¹.

AIDS has inflicted immense suffering on countries and communities throughout the world. More than 65 million people have been infected with HIV. UNAIDS in 2011 estimated that there were 2.4 million people living with HIV in India. Globally 4 billion people are infected with Hepatitis B Virus, of which 45 million people are from India. An estimated 200 million persons are chronically infected with hepatitis C Virus of which 20 million people are from India².

Mangalore city, being the head quarters of Dakshina Kannada district is the largest urban coastal centre and the fourth largest city of Karnataka state with a total population of 20, 00,000. Once a sleepy town in the eighties and nineties, Mangalore has now emerged as a bustling educational commercial, industrial and residential centre, but the status of HIV/AIDS in Mangalore is getting worse day by day. Over 1% of the population is HIV positive. What is more alarming is that over 150 cases are reported every month in Dakshina Kannada and majority of the victims are below 30 years. Dakshina Kannada leads the list of districts in Karnataka for the prevalence of HIV/AIDS³.

The most common routes of transmission of blood borne disease are through sexual route, blood transfusion, mother to child transmission. More than 90% of bloods borne disease transmission occur through the combination of these three routes. Other routes of transmission of blood borne disease includes sharing of non sterile sharp instruments such as those used for barbering, circumcision, facial scarification, incision, tattooing, ear perforation, bloodletting injections and acupuncture. Prevention is the only viable way to control the spread of blood borne diseases⁴.

Barbers are cosmetic workers who undertake skin piercing practices involving reusable sharp instruments which present risk for transmission of blood borne pathogens. Though barbers do not carry out procedures that deliberately penetrate the skin, the procedures can inadvertently damage the skin through abrasions and minor accidental cuts. The virus can survive on the surface of barbering instruments for a period long enough for transition to occur⁵.

Barbers are from low educational background and are not formerly trained in health related fields. They often come in contact with clients during their course of work. They also have less favourable and a discriminatory attitudes towards blood borne disease patients and also lack safety job practices to prevent blood borne infection transmission through occupational exposure. This is the main cause which makes them to stand in the front line of risk groups⁶.

The investigator personally experienced the incidences of accidental cuts on scalps and poor hygiene practices including low disinfection rates of reusable instruments. The responsibility to keep the instruments free of infective agent’s lies on the barbers. So the investigator found the need to assess the knowledge and practice of barbers regarding occupational risk of blood borne diseases and educate the barbers about it and its consequence.

REVIEW OF LITERATURE:

A descriptive study was conducted to determine the personnel at risk for occupational blood exposure in a university hospital in West Algeria. Personal and professional data, immunization status, circumstances of OBE incidents, preventive measures, workers' behaviour post-exposure, and serology surveillance were collected. 108 exposures were reported by 70 women and 38 men. In total, 44 accidents were reported in 2005, and 64 in 2006. Needle stick injuries represented 81% of cases. Source patient serology was unknown in most of the cases, negative in 9% of cases and positive in 10% of cases. 62% of exposed health workers received immediate serology, follow up and screening as of the first day of exposure, 12% after 3 months and 36% after 6 months. Thus, 41.66% of injuries could be avoided if objects were thrown away correctly in specific containers. It is urgent to raise awareness of health care personnel and strengthen adherence to standard precautions as well as to provide suitable containers for the collection and disposal of needles and sharp objects⁷.

A cross-sectional survey of barbers in Hyderabad city, Pakistan was conducted to establish their knowledge and attitudes to the risk of HBV and HCV transmission and their working patterns. Observations showed that 96.2% washed razors with antiseptic after each client and 95.7% used a new blade with new clients. However, knowledge about the diseases and modes of transmission were poor and only 36.6% knew that hepatitis can be transmitted via shaving instruments. Only 3.2% of 186 barbers were vaccinated against HBV. Strategies are needed for raising awareness and regulations of barbers' practices⁸.

A interventional study was conducted in Karachi, Pakistan to evaluate the effectiveness of educational intervention on Knowledge and Practices regarding hepatitis B and hepatitis C among barbers. After completion of baseline interviews of 70 barbers, a 30-min educational session was conducted. The same sessions were repeated twice for all barbers at an interval of 1 month each for reinforcement. Post-intervention interviews were conducted after 1 month of the last session. Before intervention, only 11.4% of the study participants had scored “good” about the knowledge of HBV, which improved to 74.3% after intervention (p < 0.001). Similarly, for HCV, significant improvement was observed after intervention. Regarding the safe practices to prevent HBV and HCV infections, <2% had scored to the level of “good” at baseline, which improved to 48.6% after intervention (p < 0.001). Educational interventions to prevent cancer-induced viruses are highly effective even in illiterate/low-educated people⁹.

MATERIAL AND METHODS:

Research design:

The research design selected for the study was pre experimental i.e. one group pre-test- post-test design because this study was intended to ascertain the gain in knowledge and practice of barbers who were subjected to the planned teaching programme.

I. Population:

In this study, the population consisted of barbers who are barbering in selected barbershop at Mangalore.

II. Sample Size and Sampling Technique:

In this study, sample comprised of 30 barbers in the selected barbershops at Mangalore who fulfilled the sampling criteria. Purposive sampling technique was used to select the sample to assess the knowledge and practice of barbers on blood borne diseases.

Tool of research:

Based on the objectives of the study, a demographic proforma, structured knowledge questionnaire and practice observation checklist were prepared and administered to the barbers who barber in selected barbershops at Mangalore.

Selection and Development of Instrument:

A structured knowledge questionnaire and practice observation checklist were prepared to assess the knowledge and practice of the barbers. The tools were selected based on the research problem, review of the related literature and with suggestions and guidance of experts in the field of community health nursing, Statistician, English language expert, and Social worker.

The tools were prepared on the basis of objectives of the study. The final tools were prepared with guidance and suggestion of the guide.

Data collection process:

Written permission was obtained from the president of barbers association. The main study was conducted from 1/09/2011-30/09/2011 in barbershops at Mangalore. 30 barbers from 12 barbershops had participated in the study. Purposive sampling technique was used to select the subjects. Prior to the data collection, the investigator familiarized himself with the barbers and explained the purpose of the study to them. Investigator requested participant’s full cooperation and assured them of the confidentiality of their responses. The informed consent was taken from the subjects.

Pre-test was conducted by administering knowledge questionnaire and the job practices were observed using the practice observation checklist. The average time taken for completing knowledge questionnaire was 20minutes. Three days were taken to complete knowledge related data. From 30 barbers the pre-test practice data was collected with job practice observational checklist. Time taken to observe the job practice was 5 days. The planned teaching programme was administered next day after the pre-test data collection was done. The time taken for the planned teaching programme was 1 hr.

The post-test was done after the seven days of the planned teaching programme with the same tool. The average time taken for completing knowledge questionnaire was 15minutes. Two days were taken to complete knowledge related data. From 30 barbers the post-test practice data was collected with the same job practice observational checklist. Time taken to observe the job practice was 5 days.

Plan of data analysis:

Descriptive statistics (frequencies, percentage, range, mean, median and standard deviation) and inferential statistics (t test, Karl Pearson’s correlation coefficient) would be used for the analysis of the data.

Data was planned to be analysed on the basis of objectives and hypothesis:

· Demographic data would be analysed using frequency and percentage.

· The knowledge and practice of barbers on blood borne diseases, before and after PTP would be analysed in terms of frequency, percentage, mean, median, standard deviation and would be presented in the forms of tables and diagrams.

· The significant difference between mean pre-test and post-test knowledge and practice score would be determined by paired t test.

· The relationship between post-test knowledge and practice of barbers on blood borne diseases would be determined by Karl Pearson Correlation coefficient.

RESULTS:

Analysis and interpretation of data:

This deals with the analysis and interpretation of results of the data collected from 30 barbers regarding their knowledge and practice on blood borne disease and determine the effectiveness of planned teaching programme on blood borne disease, keeping in mind the objectives of the study.

Organisation of findings:

The data collected were organised and presented under the following headings.

Section A: Description of the demographic variables of the sample.

Section B: Knowledge of barbers regarding blood borne diseases and its management.

Section C: Practice level of barbers on blood borne diseases.

Section D: Effectiveness of planned teaching programme on blood borne disease.

Section E: Relationship between post-test knowledge scores and practice scores of barbers.

Section A: Description of the demographic variables of the sample.

Age: Majority of the barbers (80%) were in the age group of 21-30yrs and only 20% were in the age group of 31-40yrs

Educational status: Majority of the barbers (50%) had high school education and 30% of them had primary education and only 20% of them had education up to PUC

Job experience: Majority of the barbers (53.3%) are having more than 10 yrs of experience and 26.7% of them had job experience of 6-9 yrs and rest of them had less than 5 years of job experience.

Monthly income: Majority of the barbers (40%) earned around Rs 4,000-6,000 /month and 33.3% of them earned around Rs 2,000-4,000/month and rest of them earned above Rs 6000 /month

Residence: Majority of the barbers (43.3%) reside in urban area and 30% of them reside in semi urban and rest of them (26.7%) reside in rural area.

Religion: All barbers (100%) belonged to Hindu religion.

Previous knowledge on blood borne diseases:

Majority (70%) of the barbers had no previous knowledge regarding blood borne diseases and 30% of them had some previous knowledge on blood borne diseases.

Source of information:

Most of the barbers (43%) got information on blood borne diseases through news papers and radio.

Section B: Knowledge of barbers regarding blood borne disease and its management

Data presented in the table1 shows that in the pre-test majority of the barbers (83.3%) had average knowledge. Only few (13.3%) had good knowledge, and 3.3% of them had poor knowledge on blood borne diseases. Where as in the post-test it is seen that 83.3% of barbers had excellent knowledge and 16.7% had good knowledge. None of them had average or poor knowledge on blood borne diseases

Table 2: Range, Mean, Median. Standard deviation and Mean Percentage of pre-test and post-test knowledge score of barbers

	Range	Mean	Median	SD	Mean %
Pre-Test	6-20	11.6	11	3.1	41.4
Post-test	20-27	23.8	23.5	1.97	91.5

Table 3: Area wise Mean and SD of pre-test and post-test knowledge scores of barbers regarding blood borne diseases

Areas of knowledge	Maximum score	Pre-test			Post-test
Areas of knowledge	Maximum score	Mean	S.D	Mean%	mean	S.D	Mean%
General aspects and meaning of blood borne diseases.	6	1.8	0.8	30.5	4.5	0.8	75
Causes ,risk factors and modes of transmission	8	3.3	1.6	41.6	7.3	0.8	91.6
Signs and symptoms, diagnosis and treatment	2	1.3	0.7	65	1.8	0.4	91.5
Prevention and control in barbershop	12	5.1	1.6	42.8	10.1	10	84.4

Section C: Practice level of barbers on blood borne diseases

Table 4: Frequency and percentage distribution of barbers based on practice level

Practice level	Range of score	Pre-test		Post-test
Practice level	Range of score	Frequency	Percentage	Frequency	Percentage
Highly safe practice	10-14	-	-	30	100
Moderately safe practice	6-9	20	66.7	-	-
Unsafe practice	<5	10	33.3	-	-

Table 5: Range, Mean, Median, Standard deviation and Mean Percentage of pre-test and post-test practice score of barbers

	Range	Mean	Median	S.D	Mean %
Pre-Test	4-9	6	6	1.3	43.3
Post-test	10-13	12	12	0.8	85.9

Table 6: Area wise Mean and SD of pre-test and post-test practice scores of barbers

Areas of knowledge	Maximum score	Pre-test			Post-test
Areas of knowledge	Maximum score	Mean	S.D	Mean%	mean	S.D	Mean%
Use of personal protective devices	3	1.9	0.4	63.3	2.4	0.5	80
Hand washing and cleanliness	3	0.1	0.4	4.3	1.8	0.7	60
Safe handling and disposal of wastes	8	4	1.3	50.5	7.8	0.4	97.9

Data in the Table 10 shows that the mean post-test practice score in all areas was higher than the mean pre-test practice score. The calculated‘t’ value in all areas was significantly higher than the table value (t₂₉=2.045) at 0.05 level of significance. So null hypothesis H₀₄was rejected and research hypothesis was accepted. This suggests that planned teaching programme was effective in improving the practice of barbers.

Section E: Relationship between post-test knowledge and practice scores of barbers on blood borne diseases

Table 11: Correlation between post-test knowledge and practice of barbers on blood borne diseases N=30

Variable	Inference
Post-test knowledge and practice	0.4* significant

r₂₉=0.3494 p<0.05

Data presented in the Table 11 indicates that there was a significant positive correlation (0.4) existing between post-test knowledge and practice of barbers on blood borne diseases. Hence null hypothesis H₀₅was rejected and research hypothesis was accepted

DISCUSSION:

The findings are discussed under five headings:

Part. I: Discussion about the demographic variables under study.

Part II: Discussion on knowledge scores of barbers

Part III: Discussion on practice scores of barbers

Part. IV: Discussion on effectiveness of planned teaching programme on knowledge and practice of barbers regarding blood borne diseases in selected barbershops at Mangalore.

Part. V: Discussion on relationship between knowledge scores and practice scores of barbers regarding blood borne transmission of disease

Part I: Discussion about the demographic variables under study:

Majority of the barbers (80%) were in the age group of 21-30yrs. Similar findings regarding age group ranging from 20 -35 years were noted in a study conducted to evaluate the effectiveness of educational intervention on knowledge and practices regarding hepatitis B and hepatitis C among barbers.⁹This indicates that barbers those who are barbering in barbershops are very young adults and thus there is a need to create awareness among them on blood borne diseases.

Majority of the barbers (50%) had high school education and 30% of them had primary education and only 20% of them had education up to PUC. This finding of the present study is supported by a similar study conducted in Ibadan, Southwest Nigeria, which reveals that majority of the barbers (60%) are with low educational background ¹⁰

Majority of the barbers (53.33%) are having more than 10 yrs of experience and 26.66% of them had job experience of 6-9 yrs and rest of them had less than 5 years of job experience. Similar findings regarding job experience ranging from 10-12 yrs were noted in a study conducted to assess the occupational health risks of barbers¹¹.

Part II: Discussion on knowledge scores of barbers:

The pre-test scores showed that the highest percentage (83.3%) of the barbers had average knowledge and none of them had very good knowledge.

The level of knowledge about modes of transmission was low among the majority of the barbers (65%) for most questions. Knowledge about the existence of protective drugs and vaccines was low; about 10% knew about the presence of an HBV vaccine and around one-quarter claimed to know about a protective vaccine for HCV.

The above study findings was supported by a descriptive study to assess the knowledge regarding HIV transmission of 375 barbers selected randomly from three different categories of saloons. A significantly large proportion of road side barbers (67%) were ignorant about modes of transmission of HIV particularly through the infected blades.¹²

Part III: Discussion of practice scores of barbers:

The pre-test scores showed that the highest percentage (66.7%) of the barbers had moderately safe practice and none of them had highly safe practice.

On observing barber’s shops and their practice during shaving it was found that, in general, the majority of shops were not well-equipped. Barbers appeared to have job-related risk of acquiring blood borne infections. This may be due to the relatively poor knowledge among barbers about modes of transmission and also due to poor practices by the majority of the studied barbers.

The above study findings were supported by a descriptive study to assess the practices of barbers regarding transmission risk of HBV and HCV viruses. During the actual observation of 192 clients razors were cleaned with antiseptic solution for 22 shaves and reused for 88(46%) shaves. The study revealed that level of awareness among barbers about Hepatitis and risk of transmission is very low and their practice of razor reuse that may spread Hepatitis is very common.⁵

Part IV: Discussion on effectiveness of planned teaching programme on knowledge and practice of barbers regarding blood borne diseases in selected barbershops at Mangalore:

In the present study the difference between the pre-test and post-test knowledge and practice score of barbers was analyzed using student ‘t’ test. The difference was found to be highly significant. A significant increase was observed in the knowledge and practice score of barbers following administration of planned teaching programme regarding blood borne diseases.

These findings are similar to an interventional study conducted in Karachi, Pakistan to evaluate the effectiveness of educational intervention on knowledge and practices regarding hepatitis B and hepatitis C among barbers. After completion of baseline interviews of 70 barbers, a 30-min educational session was conducted. Before intervention, only 11.4% of the study participants had scored “good” about the knowledge of HBV, which improved to 74.3% after intervention (p< 0.001). Similarly, for HCV, significant improvement was observed after intervention. Regarding the safe practices to prevent HBV and HCV infections, <2% had scored to the level of “good” at baseline, which improved to 48.6% after intervention (p<0.001).⁹

Part V: Discussion on relationship between knowledge and practice of barbers regarding blood borne transmission of disease

Findings of this study showed a significant positive relationship between knowledge and practice of barbers on blood borne diseases(r =0.4, p<0.05).

The findings were consistent with findings of another similar study which was conducted in Rawalpindi and Islamabad to assess the knowledge and practice of barbers regarding transmission risk of HBV and HCV viruses. Barbers were queried about hepatitis, knowledge regarding hepatitis transmission through razor, vaccination, sterilization and the form of media they use for information and entertainment. Of 96 barbers approached, 12 knew that it is transmitted through parenteral route and could also be transmitted by razor. During the actual observation of 192 barbering procedure, 22 times razors were cleaned with antiseptic solution and reused for 88(46%) shaves. Study revealed that level of awareness among barbers about Hepatitis and risk of transmission is very low and their practice of razor reuse may spread Hepatitis is very common. It also shown that there was a positive correlation between knowledge and practice of barbers regarding blood borne diseases (r=0.721, p<0.05).⁵

ACKNOWLEDGEMENTS:

Author express thanks to all the experts for their valuable remarks, constructive criticism, recommendations and valuable suggestions while validating the tool, also to the president and members of Savitha Samaja, for granting me the permission to conduct the study. Authors would like to express thanks to all the barbers who participated in the study.

REFERENCES:

1 Biswas DR. Health care workers and risk of transmission of HIV/HBV/HCV. Int Conf AIDS 2002 Jul; 14:7-12

2. HIV/AIDS: A labour issue. [online]. 2011 Mar 25. Available from: URL:http/www.amre.org.nk/4702.htm

3. Bimal KN. Extent of HIV/AIDS interventions. Health Action 2008 Aug;21(8):17-21.

4. Park K. Park’s textbook of preventive and social medicine. 20^th ed. Jabalpur: M/s. Banarsidas Bhanot Publishers 2009; 187-94.

5. Januja NZ, Nizamy MA. Knowledge and practices of barbers about Hepatitis B and C transmission in Rawalpindi and Islamabad. Journal of Pakistan medical association 1998 Dec.

6. Centre for health and population research. Public health impact of health care waste. ICDDR, B: Centre for Health and Population Research; 2002

7. Beghdadli B, Ghomari O, Taleb M. Personnel at risk for occupational blood exposure in a university hospital in West Algeria. Sante Publique 2009 May-Jun; 21(3):253-61

8. Jokhio AH, Bhatti TA, Memon S. Knowledge, attitudes and practices of barbers about hepatitis B and C transmission in Hyderabad, Pakistan. East Mediterr Health J 2010 Oct; 16(10):1079-84

9. Mukesh KK, Waris Q. Educational Intervention among Barbers about Liver Cancer-Inducing Viruses: A Study from a Developing Country. Journal of Cancer Education 2010 Mar;11(3):70-5.

10. Arulogun OS, Adesoro MO. Potential risk of HIV transmission in barbering practice among professional barbers in Ibadan, Nigeria. Afr Health Sci 2009 Mar; 9(1):19-25.

11. Aliye M,Sukran K,Ayhan G. Occupational health risks of barbers and coiffeurs in Izmir. Med Lav 2007 Jan-Feb; 98(1):48-54.

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Received on 24.02.2015 Modified on 27.03.2015

Asian J. Nur. Edu. and Research 5(3): July- Sept.2015; Page 392-398

DOI: 10.5958/2349-2996.2015.00079.8

Level of knowledge	Range of score	Pre-test		Post-test
Level of knowledge	Range of score	Frequency (f)	Percentage (%)	Frequency (f)	Percentage (%)
Excellent	22-28	-	-	25	83.3
Good	15-21	4	13.3	5	16.7
Average	8-14	25	83.3	-	-
Poor	< 7	1	3.3	-	-

Parameter	Mean	SD	Mean difference	t value
Pre-test	11.6	3.00	12.2	21.4*
Post-test	23.8	1.97	12.2	21.4*

Area	Pre-test		Post-test		Mean difference	‘t’ value
Area	Mean	SD	Mean	SD	Mean difference	‘t’ value
General aspects and meaning of blood borne diseases	1.8	0.8	4.5	0.8	2.7	12.8*
Causes, risk factors and modes of transmission	3.3	1.6	7.3	0.8	4	12.2*
Signs and symptoms, diagnosis and treatment	1.3	0.7	1.8	0.4	0.5	4.6*
Prevention and control in barbershop	5.1	1.6	10.1	1	5	14.9*