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KNOWLEDGE AND PERCEPTION TOWARDS

EBOLA VIRUS DISEASE AMONG NURSING


STUDENTS IN UNIVERSITY OF NURSING,
YANGON

MIN HTIKE AUNG


B.N.Sc

MASTER OF PUBLIC HEALTH


UNIVERSITY OF PUBLIC HEALTH
YANGON
2014

KNOWLEDGE AND PERCEPTION TOWARDS


EBOLA VIRUS DISEASE AMONG NURSING
STUDENTS IN UNIVERSITY OF NURSING,
YANGON

A thesis submitted to
The Postgraduate Academic Board of Studies
University of Public Health, Yangon
for the partial fulfillment of the requirements
for the Degree of Master of Public Health (MPH)

MIN HTIKE AUNG


B.N.Sc
2014

KNOWLEDGE AND PERCEPTION TOWARDS


EBOLA VIRUS DISEASE AMONG NURSING
STUDENTS IN UNIVERSITY OF NURSING,
YANGON

MIN HTIKE AUNG

Thesis submitted for the partial fulfillment of the requirements


for the Degree of Master of Public Health (MPH)
University of Public Health, Yangon
2014

This thesis has been approved and passed by the Board of Examiners.

Chief Examiner
-------------------------------

External Examiner

Co-Examiner

--------------------------------

-----------------------------

ACKNOWLEDGEMENTS

Firstly, I would like to express my special and deepest gratitude to my


admirable and honorable Rector, Professor Nay Soe Maung, chairman of Board of
studies of University of Public Health for giving me opportunity to conduct this study.
Secondly, I would like to expand my appreciation and great thanks to my
respectful and admirable Professor Win Myint Oo for his excellent suggestion and
precious guidance in improving my thematic paper. He also provided his vigorous
technical assistance for remarkable checking of my data analysis especially by sharing
his time and patience for me.
Moreover, I would like to express my gratefulness and best regards to my
supervisor Dr. Kay Khaing Lynn, Lecturer of Department of Nutrition and Food
Safety for her valuable guidance, informative technical support and warm
encouragement. She also gave her inspiration, constructive comments, intellectual
stimulation and other moral and academic supports not only throughout the whole
process of this study paper but also for the whole academic period at University of
Public Health, Yangon. And, I am very grateful to our MPH students coordinator
Dr. Khay Mar Mya, Associate Professor of Department of Epidemiology, for her
helpful expert opinions, facilitating and thoughtful suggestions during the post
graduate course to accomplish my paper.
Then, my sincerely appreciation goes to Professor Myat Thandar, Rector of
University of Nursing, Yangon for her authorized permission to collect data in
University of Nursing, Yangon. Continuously, I am very grateful to Daw Naw Clara,
Lecturer and Head of Department of Community Health Nursing, Yangon and all
teachers for supervising and participating with me to collect data at their university.
Furthermore, I gratefully acknowledge with my thankfulness and sincere
regards to academic staffs and supportive staffs of MPH program, seniors and all of
my classmates for their moral, friendliness, encouragement, kindness, technical and
enthusiastic supports, academic supports and sharing their respective experience and
knowledge during my study period. My heartfelt thanks go to all students who

participated in my study for giving me their valuable information and voluntary


consent.
Finally, but not least, I am indebted and wanted to express my heartfelt and
deepest gratitude to my parents, my elder sisters and my younger brother, all of my
beloved relatives and my friends for their affection, patience, understanding, support
and encouragement throughout my study time and my life.

ABSTRACT

A cross-sectional study of knowledge and perception towards Ebola disease among


nursing students was conducted in University of Nursing, Yangon in October 2014. A
total of 170, first year and second year (Bridge) course students from University of
Nursing, Yangon were sampled by simple random sampling method and surveyed by
using self-administered questionnaire with the general objectives of studying of the
knowledge and perception towards Ebola disease among the study population.
Exactly 170 of the students are 2 male and 168 female students respectively. The
respondents have been working as nurses in various levels of hospitals and health
centers before their university students life. 92.4% (95% CI: 88-96%) of them had
been present another degree (Diploma in ICU, ENT) or graduation (B.A or B.Sc). In
this study, the minimum service years in government employee life of the respondent
were 3 years and the maximum was 26 years. 0 to 5 service years are 35.9% and > 5
service years are 64.1%. Most of the respondents had been working clinical
(hospitals) sites (92.9%) and then 10.6% (95% CI: 6-15%) among respondents have
been experienced about infection control training regarding emerging disease like
Ebola. In this study, they all knew the general information about Ebola disease and
got via TV, radio, internet news and friends. Regarding questionnaires about
knowledge scores were assessed and described, minimum knowledge scores are 7
while maximum one is 40 upon 42 given marks, 54.7% respondents had good
knowledge about Ebola disease and poor knowledge was found in 45.3% of the
respondents. Regarding perception scores, minimum perception scores are 32 while
maximum one is 48 upon 48 given marks, 55.3% had good perception and 44.7% had
poor perception towards Ebola disease. Quantitative data was analyzed by using SPSS
version 22.0 to perform Chi-square test, independent sample t test and ANOVA for
analysis of bivariates. The level of knowledge and perception were not associated
with the students' age group and current posting. The academic year was associated
with the knowledge level (p < 0.001) and then was also associated with perception
level (p =0.033). Then, the total years of services were associated with knowledge
level of Ebola disease (p =0.040) and the knowledge level was associated with
perception level (p =0.019) OR=2.082 (95%CI = 1.125 to 3.855). It was concluded
that the respondents had good knowledge and perception if they were high education
level. Although, the respondents had had good experience on infection control
training and another degree or graduation, the perception gap was still present among
them. According to this study, most of the respondents were needed to be adequate
knowledge and perceptions regarding epidemiology of Ebola disease, understanding
disease threats and safe fulfillment in disease control activities about Ebola disease.

TABLE OF CONTENTS

Page
ACKNOWLEDGEMENT

ABSTRACT

iii

TABLE OF CONTENTS

iv

LIST OF ABBREVIATIONS

vi

LIST OF TABLES

viii

LIST OF FIGURES

CHAPTER 1 INTRODUCTION
1.1

Background information

1.2

Problem statement

1.3

Justification

CHAPTER 2 LITERATURE REVIEW

12

CHAPTER 3 OBJECTIVES
3.1

General objective

28

3.2

Specific objectives

28

3.3

Research hypothesis

28

3.4

Conceptual framework

29

CHAPTER 4 RESEARCH METHODOLOGY


4.1

Study design

30

4.2

Study area

30

4.3

Study period

30

4.4

Study population

30

4.5

Sample size determination

31

4.6

Sampling method

31

4.7

Sampling procedure

31

4.8

Data collection methods and tools

32

4.9

Data management and analysis

33

4.10 Ethical consideration

34

CHAPTER 5 FINDINGS

35

CHAPTER 6 DISCUSSION

67

CHAPTER 7 CONCLUSION

83

CHAPTER 8 RECOMMENDATION

85

REFERENCES
ANNEXES
Annex (1)

Variables and operational definitions

Annex (2)

Informed consent form (English and Myanmar)

Annex (3)

Questionnaire form (English and Myanmar)

Annex (4)

Scoring system

Annex (5)

Gantt chart

Annex (6)

Curriculum Vitae

LISTS OF ABBREVIATIONS

MOH

- Ministry of Health

WHO

- World Health Organization

CDC

- Centers for Disease Control and Prevention

AFRO

- WHO Regional Office for Africa

EMRO

-WHO Regional Office for the Eastern Mediterranean

DRC

-Democratic Republic of Congo

ROC

-Republic of Congo

OHS

-Occupation Health Staff

EVD

- Ebola virus disease

EBOV

-Ebola virus

EHF

-Ebola Hemorrhagic Fever

MVD

-Marburg virus disease

VHF

-Viral Hemorrhagic Fever

BDBV

-Bundibugyo Ebola virus

EBOV

- Zaire Ebola virus

RESTV

- Reston Ebola virus

SUDV

- Sudan Ebola virus

TAFV

- Tai` Forest Ebola virus

GAR

- Global Alert and Response

LISTS OF ABBREVIATIONS

IHR

-International Health Regulations

PPE

- Personal Protective Equipment

HCWs

- Health care workers

HCPs

-Health Care Professionals

NFPs

-National Focal Points

NHP

-Non-human primates

PHEIC

-Public Health Emergency of International Concern

SARS

-Sever Acute Respiratory Syndrome

SOP

-Standard Operation Procedure

NHL

-National Health Laboratory

ELISA

-Enzyme-linked Immunosorbent Assay

PCR

-Polymerase Chain Reaction

AST

-Aspartate Aminotransferase

ALT

-Alanine Aminotransferase

PT

-Prothrombin

PTT

-Partial Thromboplastin Times

DIC

-Disseminated Intravascular Coagulation

95%CI

-95% Confidence Interval

ANOVA

-Analysis of Variance

10

LIST OF TABLES

Table

Page

Age group of the respondents (n=170)

37

Sources of information about Ebola disease (n=170)

44

Knowledge of the respondents on causal agent about Ebola (n=170)

45

Knowledge of the respondents on mode of transmission about Ebola


(n=170)

46

Knowledge of the respondents on signs and symptoms and


complications about Ebola (n=170)

Knowledge of the respondents on 90 % fatal syndrome and incubation period


about Ebola (n=170)

48

Knowledge of the respondents on diagnostic measures about Ebola


(n=170)

48

Knowledge of the respondents on high risk persons about Ebola


(n=170)

49

Knowledge of the respondents on preventive measures about Ebola


(n=170)

10

49

Knowledge of the respondents on infection control measures about


Ebola (n=170)

11

50

Knowledge of the respondents on waste management about Ebola


(n=170)

12

47

50

Knowledge of the respondents on reporting within 3 days about


Ebola (n=170)

51

13

Total knowledge about Ebola disease (n=170)

51

14

Respondents' positive perception towards Ebola disease (n=170)

52

15

Respondents' negative perception towards Ebola disease (n=170)

54

16

Total perception towards Ebola disease (n=170)

55

17

Association between education status and knowledge on Ebola disease

56

18

Association between gender and knowledge towards Ebola disease

57

19

Association between age group and knowledge on Ebola disease

57

20

Association between marital status and knowledge on Ebola disease

58

11

21

Association between total years of service and knowledge on Ebola disease

58

22

Association between other qualification and knowledge on Ebola disease

59

23

Association between current posting and knowledge on Ebola disease

59

24

Association between current posting and knowledge on Ebola disease

60

25

Association between infection control training and knowledge on Ebola


disease

61

26

Association between education status and perception towards Ebola disease

62

27

Association between gender and perception towards Ebola disease

62

28

Association between age group and perception towards Ebola disease

63

29

Association between marital status and perception towards Ebola disease

63

30

Association between total years of service and perception towards Ebola


disease

31

64

Association between other qualification and perception towards Ebola


disease

64

32

Association between current posting and perception towards Ebola disease

65

33

Association between current posting and perception towards Ebola disease

65

34

Association between infection control training and perception towards

35

Ebola disease

66

Association between knowledge and perception towards Ebola disease

66

12

LIST OF FIGURES

Figure

Page

Conceptual framework of the study

29

Sampling procedure of the study

31

Gender of the respondents (n=170)

36

Academic year of the respondents (n=170)

37

Race of the respondents (n=170)

38

Religion of the respondents (n=170)

38

Marital status of the respondents (n=170)

39

Total years of service of the respondents (n=170)

40

Other qualifications of the respondents (n=170)

41

10

Current posting of the respondents (n=170)

42

11

Infection control and emergency training of the respondents (n=170)

43

13

CHAPTER 1

INTRODUCTION

1.1 Background Information


Ebola virus disease (formerly known as Ebola hemorrhagic fever) is a severe,
often fatal illness, with a death rate of up to 90%. Ebola first appeared in 1976 in 2
simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of
Congo. The latter was in a village situated near the Ebola River, from which the
disease takes its name. Since then sporadic cases and small scale outbreaks have
occurred in central African countries.
There are five strains of Ebola virus but the Zaire strain is the most severe,
with a case-fatality rate up to 90%. Genus Ebola virus is 1 of 3 members of the
Filoviridae family (filovirus), along with genus Marburgvirus and genus Cuevavirus.
Genus Ebola virus comprises 5 distinct species: (1) Bundibugyo Ebola virus (BDBV),
(2) Zaire Ebola virus (EBOV), (3) Reston Ebola virus (RESTV),(4) Sudan Ebola virus
(SUDV) and (5) Ta Forest Ebola virus (TAFV).BDBV, EBOV, and SUDV have
been associated with large EVD (Ebola Virus Disease) outbreaks in Africa, whereas
RESTV and TAFV have not. The RESTV species, found in Philippines and the
Peoples Republic of China, can infect humans, but no illness or death in humans
from this species has been reported to date (WHO, 2014).
The unprecedented scale of the current outbreak of EVD in Sierra Leone,
Guinea, Liberia and Nigeria, led to the declaring an international public health
emergency on August 8th 2014. The outbreak has since spread to Senegal, and a
reportedly unrelated outbreak has since occurred in the Democratic Republic of
Congo (WHO, 2014). Fruit bats of the family Pteropodidae are thought to be the
natural reservoir and humans are thought to acquire the disease through direct contact
with non-human primates (NHP) (Leroy et al., 2005).

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As of 22nd August 2014, the West African outbreak has resulted in 2615 cases
and 1427 deaths and is unprecedented because it has continued for more than double
the length of time of the largest previous outbreak in Uganda in 2000 (3 months vs. 8
months), has resulted in more than six times as many cases (425 cases vs. 2615 cases),
and has for first time occurred in more than one country simultaneously and in capital
cities (Okware et al., 2002, WHO, 2014). Among the total cases, 1251 have been
laboratory confirmed, and genetic sequencing has showed that the similarity of the
virus to the Zaire EV is 97% (Baize et al., 2014).
Unlike past outbreaks, the current outbreak of EVD has not been contained
and has resulted in social unrest, breakdown in law and order, shortages of personal
protective equipment (PPE) and depletion of the healthcare workforce, with over 240
health care workers (HCWs) becoming infected and 120 HCW deaths as of 25th
August 2014 (WHO, 2014). The inability to contain this outbreak has been blamed
variously on lapses in infection control, shortages of PPE and other supplies, myths
and misconceptions about EVD, and the fact that it is occurring in large cities rather
than small villages.
The risks persons are people exposed to and handling wild animals; people
depending on wild animals such as bats as a food source; mortuary attendants; health
workers caring for EVD patients; health workers in hospital settings with poor basic
hygiene and sanitation practices; family members of an infected patient; people that
go to hospitals with poor hygiene and sanitation practices; (1) avoid contact with the
blood/secretions of Ebola infected animals and humans or dead bodies by: maintain
good hygiene and sanitation practices in hospitals; isolate Ebola infected patients;
dispose of dead bodies of Ebola patients properly in a safe manner and avoid local
traditional burial rituals such as embalming for Ebola patients; (2) health workers and
visitors caring for Ebola patients should:(i) wear proper personal protective equipment
such as disposable face mask, gloves, goggles,(ii) and gown always;(iii) use
disposable needles;(iv) avoid reuse of needles or use of inadequately sterilized
needles; and (v) avoid embalming of a deceased Ebola patient (WHO, 2014).
The current Ebola epidemic among health care workers has presented
challenges both medical and ethical. Although we have known epidemics of
untreatable diseases in the past, this particular one may be unique in the intensity and

15

rapidity of its spread, as well as ethical challenges that it has created, exacerbated by
its geographic location (Donovan, 2014).Therefore, everybody especially all health
care personnel must have essential knowledge on transmission and prevention of
Ebola virus and involve in highlights prevention and control activities to fight against
Ebola outbreak.
1.2 Problem Statement
2014 outbreak in West Africa, by far the largest outbreak of Ebola virus
disease ever recorded is currently occurring in West Africa with the Zaire species of
the virus. Although most previous Ebola outbreaks occurred in Central Africa, this
outbreak started in the West African nation of Guinea in late 2013 and was confirmed
by WHO in March 2014. The outbreak subsequently spread to Liberia, Sierra Leone,
Nigeria, and Senegal. Sequence analysis of viruses isolated from patients in Sierra
Leone indicates that the epidemic has resulted from sustained person-to-person
transmission, without additional introductions from animal reservoirs (WHO, 2014).
On August 8 2014, the World Health Organization (WHO) Director-General
Margaret Chan declared the West Africa Ebola crisis a public health emergency of
international concern,1 st triggering powers under the 2005 International Health
Regulations (IHR). The IHR requires countries to develop national preparedness
capacities, including the duty to report internationally significant events, conduct
surveillance, and exercise public health powers, while balancing human rights and
international trade (Lawrence, 2014 & WHO, 2014).
Years of civil unrest and weak development have left West Africa with fragile
health systems as it faces a crisis. Although the director general urged international
solidarity, global governance once again was weakened from a lack of capacity in
developing countries. A sustainable solution to EVD, and other emerging threats,
requires binding commitments for funding and technical assistance to build national
preparedness capabilities, including surveillance, laboratories, health systems, and
rapid response (Lawrence, 2014).
The Ebola outbreak that is ravaging parts of West Africa is the largest, most
severe and most complex in the nearly four-decade history of this disease, Margaret
Chan, World Health Organizations director general, told that by The number of new

16

cases is moving far faster than the capacity to treat them. In Geneva, after declaring
the Ebola outbreak in West Africa a global health emergency, the WHO warned on
18th September, 2014 that the disease is still outpacing the international response to
contain.
A total of 18603 confirmed, probable and suspected cases of EVD have been
reported in six affected countries (Guinea, Liberia, Mali, Sierra Leone, Spain and the
United States of America) and two previously affected (Nigeria, Senegal) up to the
end of 17 December 2014 and there have been total mortality 6915 cases. The World
Health Organization (WHO) has estimated the mortality of the current outbreak of
EVD in West Africa to be approximately 55%, but appears to be as high as 75% in
Guinea (CDC, 2014). Over 70% of patients with EVD in Guinea are isolated, while
over 80% of required safe and dignified burial teams are in place, Liberia and Sierra
Leone report that fewer than 70% of patients are isolated, though local variations
mean capacity is still insufficient to stop transmission in some areas. Case incidence is
increasing in Guinea, stable or declining in Liberia, but may still be increasing in
Sierra Leone (WHO, 2014).
1.2.1 Global Situation
With a fast spreading Ebola and threatening all over countries, more can be
done to combat the disease. The Ebola virus has evolved since its first outbreak in
Central Africa. While transmission used to be limited to forested, remote and rural
areas in West Africa, the latest outbreaks are now seen in urban areas. The reported
rapid rate of infection has been caused by the weak and often substandard health
systems in these countries. Since Ebola has similar symptoms to malaria, typhoid
fever and meningitis, effective diagnosis has proven to be a tough challenge. There is
growing concern in Sub-Saharan Africa about the spread of the Ebola virus disease
(EVD), formerly known as Ebola hemorrhagic fever, and the public health burden that
it ensues. Since 1976, there have been 885,343 suspected and laboratory confirmed
cases of EVD and the disease has claimed 2,512 cases and 932 fatalities in West
Africa. There are certain requirements that must be met when responding to EVD
outbreaks and this process could incur certain challenges (Tambo et al., 2014).
The deadly Ebola virus has already killed about 4,000 people in West Africa
since its outbreak earlier this 2014 year. With the alarming rate of infection, despite

17

complaints of a belated global response; the WHO declared Ebola to be a Public


Health Emergency of International Concern (PHEIC) only in August, 2014: several
countries have now come forward to provide the much needed financial assistance to
affected countries in Africa. While financial assistance is no less critical, West
African leaders and humanitarian workers on the ground have also urgently called for
more qualified and trained health workers to be deployed in the affected areas to stem
further infections. The Ebola outbreak has also seen an alarming feature of health
workers at high risk of infection.
The discrepancy in fatality rates is a natural occurrence, because healthcare
workers are the ones who are dealing with patients infected with Ebola. Healthcare
professionals (HCPs) in particular have been affected. According to estimates from
the WHO, the fatality rate is 57% among HCPs, whereas it is 47% in the general
population (WHO, 2014). Among the thousands of cases are 443 health care workers,
244 of whom have died (CDC, 2014). Researchers hope to establish whether the
vaccine, which contains genetic material from the Ebola virus, can trigger the immune
system to produce enough antibodies to fight off the disease, which has a mortality
rate of over 50 percent. The WHO has said the vaccine could be available from
November 2014 if it proves safe, although researchers are more cautious and say it
would be by the end of the year (WHO, 2014).
However, that fatalistic notion is only part of the story. A number of factors
have contributed to the high case and fatality rates among HCPs. For example, viral
loads of the Zaire virus, which is responsible for the current outbreak, are higher than
those seen in strains in previous epidemics. Transmission of the virus occurs if
broken skin or mucous membranes come into contact with the blood, bodily fluids, or
secretions of an infected person, or with contaminated clothing, bed linen, or used
needles. With an incubation period of up to 21 days, and patients remaining infectious
as long as their blood and bodily fluids contain the virus, the risk for transmission to
HCPs is high and ongoing.
In response, the international community launched a US$100 million plan on
August 1, 2014 to scale up efforts to stem the Ebola outbreak the largest in history. It
calls for the deployment of hundreds of additional doctors, nurses, and social
mobilizes. At the same time, West African leaders have intensified their own efforts

18

to control the outbreak by closing borders and quarantining some of the worstaffected areas (Green, 2014).Therefore, Ebola disease is still threatening globally and
needed to prepare and alarm to control current outbreak.
1.2.2 Situation in South-East Asia Region
Malaysia, the Philippines and Thailand are the most vulnerable because of
their large migrant population working in the Middle East, only a short plane ride
from West Africa. Moreover, seven of the worlds 10 busiest air routes and air
passengers are in the Asia-Pacific region, accounting for almost 30 per cent of global
air traffic. Because of this, the fear of infection has spread around the world much
faster than the virus itself, according to South East Asia region is in a better position
now to respond to any outbreak, stressing that communication is the first line of
defense. To make a long story short, irrational fear drives health epidemics like severe
acute respiratory syndrome (SARS) and Ebola. That makes communication really the
first line of defense against epidemics like Ebola. Studies tell us that SARS spreads
faster than Ebola because SARS is a flu virus that is spread through the air by
coughing, while the Ebola virus is spread through contact with bodily fluids such as
blood, urine, and saliva and mucous. In short, Ebola does not spread as easily as
SARS and other airborne viruses, and people should not succumb to irrational fears.
The WHO says it has round-the-clock monitoring of the regional and global situation,
and is supporting each country to develop plans to contain the Ebola virus (Anthony
& Amul 2014).
Even Asian countries that have no direct flights to West Africa, and have
limited ties to the region, are wary of being caught off guard. The only thing to fear is
fear itself. This can be overcome with effective communication, which experts call by
a more technical term: risk communication, defined as communicating threats to
society like terrorism and epidemics. Risk communication involves identifying the
risks, how the public processes the risks, involves the community in disseminating
preparedness messages, and provides specific response strategies(SciDev.Net, 2014).
As Ebola continues to play global hopscotch, Asian countries are seeking to make
good on the advanced notice that the deadly Ebola virus could turn up anywhere,
anytime.

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Asian nations also have an edge in that they have been through epidemics
before: SARS tore through the West Pacific in 2003, killing almost 800 people
worldwide, mostly in Hong Kong and mainland China. Avian flu also pummeled this
area around the same time, and outbreaks of virulent influenza strains perennially
menace the region. Still, Asia has some advantages as it readies itself for Ebola. Flight
patterns suggest that the influx of travelers from Ebola-stricken West African
countries to the Asian continent is far less than it is to Africa, Europe or North
America (Barber, 2014). Governments in South-east Asia are increasingly on the alert
as Ebola spreads beyond West Africa, though the consensus is that the region is at
"low-risk" of catching the virus.
East and Central Africa and South and Southeast Asia focus on: (i) viral
detection-identification of viruses in wildlife, livestock, and human populations that
may be public health threats;(ii) risk determination-characterization of the potential
risk and method of transmission for specific viruses of animal origin;
institutionalization of a one health approach-integration of a multi-sector approach
to public health (including animal health and environment);(iii) outbreak response
capacity-support for sustainable, country-level response to include preparedness and
coordination; and (iv) risk reduction-promotion of actions that minimize or eliminate
the potential for the emergence and spread of new viral threats (Salaam-Blyther,
2014).
1.2.3 Situation in Myanmar
In Myanmar, a 22-year-old local man was taken to hospital in Yangon after
arriving home from Africa via Bangkok on the night of August 19, 2014. Myanmar
Centre for Disease Control (CDC) and Prevention said in a statement on its official
media. It said he is believed to have returned from Guinea, having also travelled to
Liberia. He was transported from Yangon International Airport to Waibargi Hospital
in North Okkalapa Township and placed in isolation. He had spent the previous 13
months working in Guinea and Liberia, two countries hit hardest by the ongoing
Ebola outbreak. He arrived at the airport with a fever and had lost consciousness
while he was travelling (Pandey, 2014).
Ministry of Health, Myanmar (MOH) confirmed that no Ebola virus was
found in the patient after a series of blood tests at Yangons Waibagi Hospital were

20

sent to a World Health Organization (WHO) recognized laboratory. Blood samples


added that four people who accompanied the man to hospital were also being kept
under observation although they have not shown signs of illness were also forwarded
to a virology laboratory in Hamburg, Germany, where the absence of Ebola was
confirmed (Myanmar Times, 2014).According to CDC Myanmar, he has shown
dramatic improvement since being admitted and is receiving treatment for malaria.
MOH added it will clean the plane which the passengers arrived in, as well as the
airport terminal, as preventative measures and also monitor the airport staff.
Ministry of Health (MOH), Myanmar, according to international health
regulation (IHR) guidelines has been implemented many health care activities such as
health promotion, education and knowledge and awareness dissemination rather than
disease controlling and rehabilitation activities about emerging disease like Ebola.
MOH has placed digital thermometers at Yangon international airport, as well as
seaports and 14 land border crossings, to scan travelers who display signs of fever,
one of the main symptoms of Ebola. If suspected of being infected, a traveler would
be sent to receive appropriate treatment at a designated hospital in Myanmar. The
hospitals include the Yangon General Hospital, Thingangyun Hospital and the
Infectious Diseases Hospital of North Okkalapa in Yangon. Hospitals in the border
cities of Myawaddy and Tamu are also equipped with special prevention methods. In
the past, Myanmar has taken similar prevention measures against infectious diseases
including SARS, H5N1 and H5N9 to prevent them from entering the country. The
preventive screening of travelers is expected to continue as long as the rates of Ebola
infection remain high elsewhere in the world. For now, there are going to carry out
these preventive measures nonstop (The Irrawaddy, 2014).
During the 2014 Ebola outbreak, MOH, Myanmar was done a number of
Ebola prevention and control activities. They included arrangement of isolation ward
in designated hospitals; job training; media conference on risk communication on
Ebola Virus Disease; emergency coordination meeting at Yangon International
Airport to discuss the future coordinated activities on development of standard
operation procedures (SOP) for Ebola suspected travelers and other activities;
advocacy meetings on EVD; and coordination meetings with the director of national
health laboratory (NHL) for laboratory preparedness on Ebola Virus Disease.

21

Myanmar, which began emerging from harsh junta rule in 2011, has one of the
worlds worst funded and poorly equipped healthcare systems, with many people cut
off from even basic medical help (The Sunday times, 2014). Many people there do not
even have access to basic medical care. Ebola is spread through direct contact with
the bodily fluids of sick patients, making doctors and nurses especially vulnerable to
contracting the virus that has no vaccine or approved treatment. During the outbreak,
the highest risks persons are health workers. Therefore, this study was conducted and
assessed the knowledge and perceptions towards Ebola disease among health care
workers especially nurses in Myanmar.
1.3 Justification
Ebola, global public health problem is an infectious and generally fatal
disease; fatality rates are between 50% and 100% (Adrian et al., 2011). The 2014
Ebola outbreak is one of the largest Ebola outbreaks in history and the first in West
Africa. Health care workers (HCWs), many of whom are nurses, are on the frontline
of the response, and their occupational health and safety is critical to control of the
outbreak and maintenance of the health workforce during a crisis. Nowadays, healthcare workers have frequently been infected while treating patients with suspected or
confirmed Ebola virus disease. This has occurred through close contact with patients
when infection control precautions are not strictly practiced, making doctors and
nurses especially vulnerable to contracting the virus that has no licensed vaccine or
approved treatment. WHO guidance with standard healthcare precautions, HCWs
should apply infection control measures to minimize exposure to infected fluids.
Therefore, the highest risk persons are HCWs who may face to fight Ebola threats by
treating and provision of care of patients.
Nurses were fearful for their own lives, their families lives; they lacked
protective gear, had few resources, families and colleagues shunned them but they
remained committed to their profession. As they had some biomedical training and
knowledge, which made them feel somewhat less vulnerable, they wanted to use this
knowledge to try to stop a rapid killing disease. Nurses expressed the importance of
knowledge because with knowledge, stigmatization decreased and cooperation
increased. Knowledge enabled them and other national and international health care

22

workers to feel secure and provide assistance in spite of being surrounded by their
own and others fears (Hewlett, 2005).
Moreover, health care system in affected countries have been suffered scarce
resources such as health personnel and health facilities that it has been still burden and
can not be used efficiently and effectively to control outbreak. Not only West Africa
but also Western countries, these conditions are threatening South East Asia countries
in the world including Myanmar where one suspected case of Ebola was detected in
this period of time. In fact, it still needed to combat Ebola outbreak so everybody
especially health care workers must have essential knowledge, perception and practice
to combat Ebola outbreak. There is currently a gap to assess the essential knowledge
and perceptions to highlights on how to prevent and control Ebola among general
population as well as health personnel. Health care workers are more prone to highly
fatal and seriously infectious than general population. So, they should have adequate
knowledge and perception towards Ebola disease to fight against Ebola disease. Up to
date, there are not enough previous studies and relevant researches and literatures
about Ebola disease and then few literature reviews in other countries were conducted
and assessed about it.
In Myanmar, but amount of scientific researches and studies are still needed to
combat Ebola disease efficiently following International Health Regulation guidelines
as Ebola disease is threatening in there. So this study will support and benefit to the
plans of emerging and remerging disease and prevention and control program in near
future. On the other hand, this study will also support reliable and scientifically sound
data for next studies. And then there is an opportunity is provided within which to
learn valuable information in how to deal more effectively with disease control.
Furthermore, this study was done in nurses, who should also have been
essential knowledge and perception towards Ebola outbreak. Those nurses or nursing
students (Bridge Course) at University of Nursing, Yangon, who have backgrounds
clinical or public health experiences before university students life. Moreover all of
them had got nursing diploma as they are government employee. Besides that, they
came from various stages of hospitals and health centers all over Myanmar in fact that
this study have been highlighted and usefully contributed to information gathering
and disseminating to other health care workers and people in Myanmar about the

23

knowledge and perception level towards Ebola disease. Therefore, better


understanding knowledge and perception of Ebola disease among health care workers
especially nurses in that study may help to describe their basic knowledge and
perceptions about Ebola disease leading to their willingness, interests, alertness,
preparedness and involvement to combat 2014 Ebola epidemic outbreak as a global
public health emergency.

24

CHAPTER 2

LITERATURE REVIEW

Ebola virus (EV) is a filovirus which causes viral haemorrhagic fever (VHF)
in humans (WHO, 2014). Ebola virus disease (EVD) is a severe, often fatal disease
that was first detected near the Ebola River in the Democratic Republic of the Congo
(DRC) in 1976. Originating in animals, EVD is spread to and among humans through
contact with the blood, secretions, organs, or other bodily fluids of those infected. It is
not transmitted through the air. The Ebola virus that is circulating in West Africa is
not new, but the current Ebola outbreak has infected and killed more people than all
previous Ebola outbreaks combined. Since then, outbreaks have appeared sporadically
in several African countries. The Filo virus family includes three genera: Ebola virus,
Marburg virus, and Cueva virus (newly discovered in Spanish bats). There are five
strains of Ebola virus but the Zaire strain is the most severe, with a case-fatality rate
up to 90%. The Ebola virus genus includes 5 species: Reston virus (RESTV), Sudan
virus (SUDV), Ebola virus (EBOV; formerly Zaire virus), Tai Forest virus (TAFV;
formerly CotedIvoire virus), and Bundibugyo virus (BDBV) (WHO, 2014).
Mortality rates of up to 80% were recorded and more recent outbreaks in
Democratic Republic of Congo (DRC, formerly Zaire) and Gabon in 19951996.
Epidemiologic data from recent outbreaks indicate that close contact is necessary for
efficient transmission of Ebola virus from one individual to another. Little genetic
difference has been detected between Ebola-Zaire viruses isolated 20 years apart and
from locations over 1,000 km from one another, suggesting that ecological rather than
genetic factors may play the dominant role in initiation of Ebola hemorrhagic fever
outbreaks (Nicho, 1998).
Ebola hemorrhagic fever (EHF) is an acute viral syndrome that presents with
fever and an ensuing bleeding diathesis that is marked by high mortality in human and

25

nonhuman primates. Fatality rates are between 50% and 100%. Due to its lethal
nature, this Filo virus is classified as a biological class 4 pathogen. Since there is no
specific treatment outside of supportive management and palliative care, containment
of this potentially lethal virus is paramount. In almost all outbreaks of EHF, the
fatality rate among health care workers with documented infections was higher than
that of nonhealth care workers (Adrian et al., 2011).
2.1 Mode of Transmission
Ebola is introduced into the human population through close contact with the
blood, secretions, organs or other bodily fluids of infected animals. In Africa,
infection has been documented through the handling of infected chimpanzees,
gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the
rainforest. Health-care workers have frequently been infected while treating patients
with suspected or confirmed EVD (WHO, 2014).
Ebola virus disease could be spread through the following: direct contact with
an infected animal or human; direct contact with the blood and or secretions of an
infected person especially within families; contact with contaminated medical
equipment such as needles; reuse of unsterilized needles in hospital; eating or
handling of the carcass of infected animals; inhalation of contaminated air in hospital
environment; use of infected non human primate/bats as food source; and non
implementation of universal precautions. Burial ceremonies in which mourners have
direct contact with the body of the deceased person can also play a role in the
transmission of Ebola. Men who have recovered from the disease can still transmit the
virus through their semen for up to 7 weeks after recovery from illness (CDC, 2014).
Job-specific attack rates estimated for Kikwit General Hospital, the epicenter
of the EHF epidemic, were 31% for physicians, 11% for technicians/room attendants,
10% for nurses, and 4% for other workers. Among 402 workers who did not meet the
EHF case definition, 12 had borderline positive antibody test results; subsequent
specimens from 4 of these tested negative. Although an old infection with persistent
Ebola antibody production or a recent atypical or asymptomatic infection cannot be
ruled out, if they occur at all, they appear to be rare. This survey demonstrated that
opportunities for transmission of Ebola virus to personnel in health facilities existed in

26

Kikwit because blood and body fluid precautions were not being universally followed
(Oyewale, 1995 & Tomori et al., 1999).
A retrospective descriptive survey of hospital records for hospitalized children
and adolescents under 18 years on the isolation wards in Gulu, Northern Uganda was
conducted. Analysis revealed that 90 out of the 218 national laboratory confirmed
Ebola cases were children and adolescents with a case fatality of 40%. The mean age
was 8.2 years SD 5.6 with a range of 16.99 years. All (100%) Ebola positive
children and adolescents were febrile while only 16% had hemorrhagic
manifestations. Similar to previous Ebola outbreaks, a relative sparing of children in
this outbreak was observed. The under fives were at an increased risk of contact with
the sick and dying. Strategies to shield children from exposure to dying and sick
Ebola relatives are recommended in the event of future Ebola outbreaks. Health
education to children and adolescents to avoid contact with sick and their body fluids
should be emphasized (Mupere et al., 2001).
2.2 Clinical Presentation and Clinical Course
Patients with EVD generally have abrupt onset of typically 8-10 days after
exposure (mean 4-10 days in previous outbreaks, range 2-21 days). Initial signs and
symptoms are nonspecific and may include fever, skin rashes, chills, myalgias, and
malaise. Fever, anorexia, asthenia/weakness are the most common signs and
symptoms. Patients may develop a diffuse erythematous maculopapular rash by day 5
to 7 (usually involving the face, neck, trunk, and arms) that can desquamate (Casillas
et al., 2003 & CDC, 2014).
Due to these nonspecific symptoms particularly early in the course, EVD can
often be confused with other more common infectious diseases such as malaria,
typhoid fever, meningococcemia, and other bacterial infections (e.g., pneumonia).
Patients can progress from the initial non-specific symptoms after about 5 days to
develop gastrointestinal symptoms such as severe watery diarrhea, nausea, vomiting
and abdominal pain. Other symptoms such as chest pain, shortness of breath,
headache or confusion, may also develop. Patients often have conjunctival injection.
Hiccups have been reported. Seizures may occur, and cerebral edema has been
reported. Bleeding is not universally present but can manifest later in the course as

27

petechiae, ecchymosis/bruising, or oozing from venipuncture sites and mucosal


hemorrhage. Frank hemorrhage is less common. Pregnant women may experience
spontaneous miscarriages (CDC, 2014).
Patients with fatal disease usually develop more severe clinical signs early
during infection and die typically between days 6 and 16 of complications including
multi-organ failure such as liver and renal failure and septic shock. In non-fatal cases,
patients may have fever for several days and improve, typically around day 6-11.
Patients that survive can have a prolonged convalescence. The World Health
Organization has estimated the mortality of the current outbreak of EVD in West
Africa to be approximately 55%, but appears to be as high as 75% in Guinea (CDC,
2014).
2.3 Pathogenesis
Ebola virus enters the patient through mucous membranes, breaks in the skin,
or parenterally and infects many cell types, including monocytes, macrophages,
dendritic cells, endothelial cells, fibroblasts, hepatocytes, adrenal cortical cells and
epithelial cells. The incubation period may be related to the infection route (i.e., 6
days for injection versus 10 days for contact). Ebola virus migrates from the initial
infection site to regional lymph nodes and subsequently to the liver, spleen and
adrenal gland. Although not infected by Ebola virus, lymphocytes undergo apoptosis
resulting in decreased lymphocyte counts. Hepatocellular necrosis occurs and is
associated with dysregulation of clotting factors and subsequent coagulopathy.
Adrenocortical necrosis also can be found and is associated with hypotension and
impaired steroid synthesis. Ebola virus appears to trigger a release of proinflammatory cytokines with subsequent vascular leak and impairment of clotting
ultimately resulting in multi-organ failure and shock (CDC, 2010).
2.4 Diagnosis and Laboratory Findings
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM
ELISA, polymerase chain reaction (PCR), and virus isolation can be used to diagnose
a case of Ebola HF within a few days of the onset of symptoms. Persons tested later in
the course of the disease or after recovery can be tested for IgM and IgG antibodies;

28

the disease can also be diagnosed retrospectively in deceased patients by using


immunohistochemistry testing, virus isolation, or PCR (Casillas et al., 2003).
Laboratory findings at admission may include leukopenia frequently with
lymphopenia followed later by elevated neutrophils and a left shift. Platelet counts are
often decreased in the 50,000 to 100,000 range. Amylase may be elevated, reflecting
pancreatic involvement (inflammation/infection). Hepatic transaminases are elevated
with aspartate aminotransferase (AST) exceeding alanine aminotransferase (ALT).
Proteinuria may be present. Prothrombin (PT) and partial thromboplastin times (PTT)
are prolonged and fibrin degradation products are elevated, consistent with
disseminated intravascular coagulation (DIC).
An outbreak of Ebola in nature is described in 1994, 25% of 43 members of a
wild chimpanzee community disappeared or were found dead in the TaF National
Park, Co te dIvoire. A retrospective cohort study was done on the chimpanzee
community. Laboratory procedures included histology, immunohistochemistry,
bacteriology, and serology. Ebola-specific immunohistochemical staining was
positive for autopsy tissue sections from 1 chimpanzee. Demographic, epidemiologic,
and ecologic investigations were compatible with a point-source epidemic. Contact
activities associated with a case (e.g., touching dead bodies or grooming) did not
constitute significant risk factors, whereas consumption of meat did. The relative risk
of meat consumption was 5.2 (95% confidence interval, 1.321.1). A similar outbreak
occurred in November 1992 among the same community. A high mortality rate
among apes tends to indicate that they are not the reservoir for the disease causing the
illness. These points will have to be investigated by additional studies (Formenty et
al., 1999).
The control of Filovirus outbreaks can be greatly enhanced by timely
laboratory confirmation of infection or the identification of alternative disease
processes. In addition, the role of field-based laboratory support and its limitations
and capabilities in an outbreak response setting, especially in regards to real-time
PCR and immunofiltration assays, is presented (Grolla et al., 2005). During the 1995
outbreak of Ebola (EHF) hemorrhagic fever in Kikwit, Democratic Republic of
Congo, two surveys using a new ELISA for EBO (subtype Zaire) virus antigen were
conducted to assess the prevalence of EBO IgG antibodies among residents of Kikwit

29

and the surrounding area. The difference in the overall prevalence of EHF antibodies
may indicate that villagers have a greater chance of exposure to EHF virus compared
with those living in and in close proximity to cities (Kristina et al., 1995).
2.5 Preventive Measures
Health-care workers caring for patients with suspected or confirmed Ebola
virus should apply, in addition to standard precautions and other infection control
measures. When in close contact (within 1 meter) of patients with EBV, health-care
workers should wear face protection (a face shield or a medical mask and goggles), a
clean, non-sterile long sleeved gown, and gloves (sterile gloves for some procedures)
and should frequently perform hand hygiene before and after patient contact, contact
with potentially infectious material, and before putting on and after removing PPE,
including gloves. Laboratory workers are also at risk. Samples taken from suspected
human and animal Ebola cases for diagnosis should be handled by trained staff and
processed in suitably equipped laboratories. Additionally, certain job responsibilities
and tasks, such as attending to dead bodies, may also require different personal
protective equipments (PPE) than what is used when providing care for infected
patients in a hospital. A person infected with Ebola is not contagious until symptoms
appear (WHO, 2014).
In studies, facemasks have been recommended for HCWs by CDC and WHO
because of the assumption that EV is not transmitted via the airborne route. However,
there is uncertainty about transmission, the consequences of EVD infection are
severe, and there is no proven treatment, vaccine or post-exposure prophylaxis.
Recommending a surgical mask for EVD has much more serious implications than for
influenza, which has a far lower case-fatality rate and for which there are easily
accessible vaccines and antiviral therapy. Further, numerous HCWs have succumbed
to EVD during this epidemic, including senior physicians experienced in treating
EVD and presumably less likely to have suffered lapses in infection control (WHO,
2014).
Moreover, a clear description of risk should be provided to HCWs (Jackson et
al., 2014). Given the predominant mode of transmission, every HCW death from
Ebola is a potentially preventable death. It is highly concerning that a recent
commentary suggests HCWs do not need a mask at all to speak with conscious

30

patients, as long as a distance of 12 meters is maintained (Martin-Moreno et al.,


2014). This fails to consider the changeability and unpredictability of the clinical
environment and disregards the rights of the HCW. It is also unrealistic to believe a
HCW can constantly keep track of their distance from a patient in the hectic acute
care setting. Besides the emotional losses, the death of so many skilled and
experienced healthcare workers will severely impair health care and research in
affected regions, which can only be restored through dedicated, long-term programs
(Bausch et al., 2014).
Arguments about comfort and duration of tolerance of PPE were raised that
are secondary to the risk of death for HCWs. Many HCWs have contracted Ebola
despite wearing PPE, which in itself supports the case for conservative
recommendations. Whilst there is some increase in discomfort with use of a N95
respirator compared to a mask, comfort should not be the primary consideration in
making recommendations for a disease with such a high case-fatality rate (MacIntyre
et al., 2011, 2013).
Describing the experiences of health care workers during rapid killing
epidemics has focused in this study. In this article, the views and experiences of
nurses during three outbreaks of EHF in Central Africa in Kikwit, Democratic
Republic of Congo (DRC, 1995); Gulu, Uganda (2000-2001); and Republic of Congo
(ROC, 2003). Open ended and semistructured interviews with individuals and small
groups were conducted during the outbreaks in Uganda and ROC; data from DRC are
extracted from published sources. Three key themes emerged from the interviews: (a)
lack of protective gear, basic equipment, and other resources necessary to provide
care, especially during the early phases of the outbreaks; (b) stigmatization by family,
coworkers, and community; and (c) exceptional commitment to the nursing profession
in a context where the lives of the health care workers were in jeopardy (Hewlett,
2005).
Staff contacts of two HCWs infected with Ebola in 1996, whose were treated
in South Africa, took universal precautions, with respirators used for high-risk
procedures, and no further cases occurred in 300 potential contacts. This occurred
despite no obvious lapse in infection control. In contrast, once EBV had been
diagnosed in the HCW, respirators, impermeable one-piece suits and visors were used

31

(according to South African guidelines), and no further infections occurred despite


procedures such as intubation, mechanical ventilation, dialysis, central line placement
and the insertion of a Swan Ganz catheter (Richards et al., 2000).
In a past study, a passive immunization strategy for treating Ebola virus
infections was conducted that pretreatment of monkeys delayed onset of viremia and
delayed death several additional days. Interferon-a2b (2 1 107 IU/kg/day) had a
similar effect in monkeys, delaying viremia and death by only several days. Effective
treatment of Ebola infections may require a combination of drugs that inhibit viral
replication in monocyte/macrophage-like cells while reversing the pathologic effects
(e.g., coagulopathy) consequent to this replication (Busico et al., 1999 & Jahrling et
al., 1999).Response to the current Ebola virus outbreak based on traditional control
measures has so far been insufficient to prevent the virus from spreading rapidly. This
has led to urgent discussions on the use of experimental therapies and vaccines
untested in humans and existing in limited quantities, raising political, strategic,
technical and ethical questions (Feldmann & Geisbert, 2014).
In July 2014, two U.S. citizen health workers contracted Ebola in Liberia and
were first provided medication that had shown promise in animal studies but that had
not yet been tested in humans and had responded early and effectively enough to
contain the virus; the appropriate use of experimental drugs that had not yet been
tested for human safety and effectiveness, including how to choose recipients of
scarce and sometimes costly drug supplies and how to arrange dispensing to allow
analysis of safety and effectiveness; and feasible approaches to accelerating drug and
vaccine development and the scale-up of manufacturing capacity for investigational
products (U.S., 2014).
ZMapp, being developed by Mapp Biopharmaceutical Inc., is an experimental
treatment, for use with individuals infected with Ebola virus. It has not yet been tested
in humans for safety or effectiveness. The product is a combination of three different
monoclonal antibodies that bind to the protein of the Ebola virus. It is too early to
know whether ZMapp is effective. However, the best way to know if treatment with
the product is efficacious is to conduct a randomized controlled clinical trial in people
to compare outcomes of patients who receive the treatment to untreated patients. No
such studies have been conducted. It's important to note that the standard treatment for

32

Ebola remains supportive therapy. This includes the following measures: balancing
the patients' fluids and electrolytes; maintaining their oxygen status and blood
pressure; and treating them for any complicating infections. The manufacturer of this
experimental treatment continues to research and evaluate the products safety and
effectiveness and much more study is needed (CDC, 2014).
Information is presented that is needed to educate patients and to protect
oneself, staff, and other patients in the event a patient with suspected Ebola presents
for medical care. A screening tool is provided, as well as a concise method to
eliminate differential diagnoses related to this dreaded disease. Diagnostic testing and
initial treatment requirements are outlined. In the event a patient presents to primary
care, guidance is given for initial steps and precautions necessary to contain and
manage a patient with Ebola (Jarrett, 2014).
2.6 Infection Control Measures
Ebola viruses can survive in liquid or dried material for a number of days.
However, Ebola virus can be inactivated by UV radiation, gamma irradiation, heating
for 60 minutes at 60 C or boiling for five minutes. The virus is susceptible to sodium
hypochlorite and disinfectants. Freezing or refrigeration will not inactivate Ebola
virus. Ebola virus is easily killed by soap, bleach, sunlight, or drying. Machine
washing clothes that have been contaminated with fluids will destroy Ebola virus.
Ebola virus survives only a short time on surfaces that are in the sun or have dried
(CDC, 2014).
In addition, the availability of pre- and post-exposure prophylaxis or treatment
must be considered. The immune status and co-morbidities in HCWs should also be
considered, as some HCWs may be innately more vulnerable to infection. As the
ageing of the nursing workforce occurs in developed countries, there is likely to be a
high proportion of HCWs with chronic conditions. In this case, facemasks have been
recommended for HCWs by Center of disease control and prevention (CDC) and
WHO because of the assumption that Ebola virus disease (EVD) is not transmitted via
the airborne route. However, there is uncertainty about transmission, the
consequences of EVD infection are severe, and there is no proven treatment, vaccine
or post-exposure prophylaxis.

33

Standard precautions are recommended in the care and treatment of all


patients regardless of their perceived or confirmed infectious status. They include the
basic level of infection control-hand hygiene, use of personal protective equipment to
avoid direct contact with blood and body fluids, prevention of needle stick and
injuries from other sharp instruments, and a set of environmental controls (CDC,
2007). In anticipation of EVD introduction, public health authorities need to:

Sensitize staff working at points of entry, in healthcare settings or involved


in first response (emergency departments, ambulance services, GP offices, fire
department, civil defense, airport operators, aircraft operators, port health
authority) for early and advanced symptoms of viral hemorrhagic fever.

Emphasize systematic recording in health clinics of travel history of those


with relevant symptoms.

Establish a standard diagnostic procedure for EVD and for common


differential diagnoses at an early stage (e.g. malaria, dengue, typhoid fever,
shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever,
meningitis, hepatitis, yellow fever and other viral hemorrhagic fevers).

Establish a protocol for notification to the competent public health authorities


at an early stage if an EVD case is suspected.

Identify and establish laboratory procedures and operational channels to


perform Ebola virus diagnostic testing in the country or refer to the closest
WHO Collaborating Centre or reference laboratories able to perform viral
hemorrhagic fever diagnostics if cases are suspected.

Ensure basic training of health care workers on principles of provisional


barrier and use of personal protective equipment.

Emphasize to personnel working in the travel sector the importance of


infection control methods.

Keep the regulatory authorities (e.g. national civil aviation authority) informed
and involved in decision-making.

2.7 Ethical Issues


On August 11, 2014, the World Health Organization convened a panel to
discuss the ethical issues among health care workers. Their response was widely
reported: It is ethical to offer unproven interventions with as yet unknown efficacy

34

and adverse effects, as potential treatment or prevention. What received less


attention were their qualifiers: the statement applied to the particular circumstances
of this outbreak, and emphasized the ethical criteria; including transparency,
informed consent, freedom of choice, confidentiality, respect for autonomy and
involvement of the community which must guide the provision of such interventions.
Moreover, if and when they are used to treat patients, there is a moral obligation to
collect and share all data generated and there was unanimous agreement that there
is a moral duty to also evaluate these interventions in the best possible clinical trials
under the circumstances in order to definitively prove their safety and efficacy or
provide evidence to stop their utilization. This has been the constant position, and it
remains so (Donovan, 2014).
There is a practical reason to consider treating healthcare workers first. It
serves the interests of the majority of patients to keep medical workers and caretakers
alive and in the field. It also increases the likelihood that others may be willing to
come and help them, if they dont believe they would be sent to the back of the line or
stranded should they succumb to infection. And, finally, healthcare workers might be
the ones most likely to accept enrollment in trials of these medications, and
understand the requirements of informed consent in the treatment, study, given the
widespread misinformation and mistrust regarding Western clinical trials by a large
number of Africans (Donovan, 2014).
The high case-fatality rate warrants the use of better protection such as a
respirator and full body suit with face shield, where it can be provided. Aside from
these factors, it is also important to consider the perspectives of the staff member. In
this highly stressful situation, staff members will want to be reassured that they are
using the highest level of protection and are not putting themselves and their
families/colleagues at risk. This is especially important if the outbreak escalates and
additional staff members are required to assist. Staff may refuse to treat patients
unless they feel adequately protected.
Sub-Saharan Africa about the spread of the EVD, five points have been
identified: (i) the deficiency in the development and implementation of surveillance
response systems against Ebola and others infectious disease outbreaks in Africa; (ii)
the lack of education and knowledge resulting in an EVD outbreak triggering panic,

35

anxiety, psychosocial trauma, isolation and dignity impounding, stigmatisation,


community ostracism and resistance to associated socio-ecological and public health
consequences; (iii) limited financial resources, human technical capacity and weak
community and national health system operational plans for prevention and control
responses, practices and management; (iv) inadequate leadership and coordination;
and (v) the lack of development of new strategies, tools and approaches, such as
improved diagnostics and novel therapies including vaccines which can assist in
preventing, controlling and containing Ebola outbreaks as well as the spread of the
disease. Hence, there is an urgent need to develop and implement an active early
warning alert and surveillance response system for outbreak response and control of
emerging infectious diseases (Tambo et al., 2014).
In particular, the epidemic is unfolding in regions characterized by limited
public health infrastructure including: (1) a lack of essential supplies to implement
infection control measures in health care settings; (2) scarcity of health care workers
and staff to manage a growing case burden and carry out essential contact tracing
activities to find new cases quickly so that these can be effectively isolated (CDC,
2014); and (3) the absence of epidemiological surveillance for the timely
identification of case clusters (Okeke, 2011 & Del et al., 2014) . Containing the
ongoing epidemic poses an unprecedented challenge as the virus has moved from
Guinea to reach urban areas after crossing the unprotected borders of neighboring
Liberia and Sierra Leone. A major coordinated operation on the ground is needed to
limit the geographic extension of the epidemic.
2.8 Travel Guidelines
Template message for travelers and EVD are; Ebola Virus Disease is rare.
Infection is by contact with blood or body fluids of an infected person or an animal
infected or by contact with contaminated objects. Symptoms include fever, weakness,
muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash,
and in some cases, bleeding. Cases of Ebola have recently been confirmed in XXX
and YYY. Persons who come into direct contact with body fluids of an infected
person or animal are at risk. There is no licensed vaccine and motivate to practice
careful hygiene. Avoid all contact with blood and body fluids of infected people or
animals. Do not handle items that may have come in contact with an infected persons

36

blood or body fluids. If you stayed in the areas where Ebola cases have been recently
reported seek medical attention if you feel sick (fever, headache, achiness, sore throat,
diarrhea, vomiting, stomach pain, rash, or red eyes) (Africa, 2014).
If you are in or traveling to an area affected by the Ebola outbreak, protect
yourself by doing the following: wash hands frequently, avoid contact with blood and
body fluids of any person, particularly someone who is sick, do not handle items that
may have come in contact with an infected persons blood or body fluids, do not
touch the body of someone who has died from Ebola, do not touch bats and
nonhuman primates or their blood and fluids and do not touch or eat raw meat
prepared from these animals, avoid hospitals where Ebola patients are being treated,
seek medical care immediately if you develop fever (temperature of 101.5 F/ 38.6 C)
and any of the other following symptoms: headache, muscle pain, diarrhea, vomiting,
stomach pain, or unexplained bruising or bleeding and limit your contact with other
people until and when you go to the doctor. Do not travel anywhere else besides a
healthcare facility (WHO, 2014).
Any hospital that is following CDCs infection control recommendations and
can isolate a patient in their own room with a private bathroom is capable of safely
managing a patient with Ebola. These patients need intensive supportive care; any
hospital that has this capability can safely manage these patients. Standard, contact,
and droplet precautions are recommended. CDC is providing information to partners,
such as Customs and Border Protection and airlines, on signs and symptoms to look
for in travelers arriving from Ebola outbreak-affected countries that should be
reported to CDC quarantine station staff. Advance notice will help your doctor care
for you and protect other people who may be in the office (CDC, 2014).
WHO provides technical advice to countries and communities to prepare for
and respond to Ebola outbreak. WHO actions include: disease surveillance and
information-sharing across regions to watch for outbreaks; technical assistance to
investigate and contain health threats when they occur such as on-site help to identify
sick people and track disease patterns; advice on prevention and treatment options;
deployments of experts and the distribution of health supplies (such as personal
protection gear for health workers) when they are requested by the country;
communications to raise awareness of the nature of the disease and protective health

37

measures to control transmission of the virus; and activation of regional and global
networks of experts to provide assistance, if requested, and mitigate potential
international health effects and disruptions of travel and trade (WHO, 2014).
During an Ebola outbreak, the affected countrys public health authority
reports its disease case numbers and deaths daily. Case numbers reflect both
suspected cases and laboratory-confirmed cases of Ebola. Sometimes numbers of
suspected and confirmed cases are reported together. Sometimes they are reported
separately. Thus, numbers can shift between suspected and confirmed cases.
Analyzing case data trends, over time, and with additional information, is generally
more helpful to assess the public health situation and determine the appropriate
response. During outbreak, WHO reviewed the public health situation regularly and
recommended to any travel or trade restrictions if necessary.
The risk of infection for travelers is very low since person-to-person
transmission results from direct contact with the body fluids or secretions of an
infected patient. WHOs general travel advice -travelers should avoid all contact with
infected patients, health workers traveling to affected areas should strictly follow
WHO-recommended infection control guidance, anyone who has stayed in areas
where cases were recently reported should be aware of the symptoms of infection and
seek medical attention at the first sign of illness, and clinicians caring for travelers
returning from affected areas with compatible symptoms are advised to consider the
possibility of Ebola virus disease (WHO, 2014).
2.9 Global Outbreak Management
Ebola or Marburg virus disease outbreaks constitute a major public health
issue in Sub-Saharan Africa. Of the 2 870 Marburg and Ebola cases documented
between June 1967 and June 2011, 270 (9%) were health-care workers. In order to
provide health-care workers in risk areas with a working tool to combat Ebola Virus
Disease (EVD) or Marburg Virus Disease (MVD) effectively, the WHO Regional
Office for Africa (AFRO), the WHO Regional Office for the Eastern Mediterranean
(EMRO), WHO Headquarters and their partners have produced this document: Ebola
and Marburg virus disease epidemics: preparedness, alert, control and evaluation. The
main target audience of this document are district-level health-care workers (doctors,
nurses, and paramedics), as well as intermediate- and central-level health-care

38

workers responsible for epidemic control, and International Health Regulations (IHR)
National Focal Points (NFPs). The objective of this document is to describe
preparedness, prevention, and control measures that have been implemented
successfully during previous epidemics. These measures must be implemented during
the following four phases: pre-epidemic preparedness, alert (identify, investigate,
evaluate risks), outbreak response and containment operations and post-epidemic
evaluation (WHO, 2014).
The first meeting of the Emergency Committee convened by the DirectorGeneral under the International Health Regulations (2005) [IHR (2005)] regarding the
2014 Ebola Virus Disease (EVD) outbreak in West Africa was held by teleconference
that emphasized the importance of continued support by WHO and other national and
international partners towards the effective implementation and monitoring of these
recommendations. There should be no general ban on international travel or trade;
restrictions outlined in these recommendations regarding the travel of EVD cases and
contacts should be implemented. States should provide travelers to Ebola affected and
at-risk areas with relevant information on risks, measures to minimize those risks, and
advice for managing a potential exposure. States should be prepared to detect,
investigate, and manage Ebola cases; this should include assured access to a qualified
diagnostic laboratory for EVD and, where appropriate, the capacity to manage
travelers originating from known Ebola-infected areas that arrive at international
airports or major land is crossing points with unexplained febrile illness. The general
public should be provided with accurate and relevant information on the Ebola
outbreak and measures to reduce the risk of exposure. States should be prepared to
facilitate the evacuation and repatriation of nationals (e.g. health workers) who have
been exposed to Ebola (WHO, 2014).
Understanding the unending risks of transmission dynamics and resurgence is
essential in implementing rapid effective response interventions tailored to specific
local settings and contexts. Therefore, the following actions are recommended: (i)
national and regional inter-sectorial and trans-disciplinary surveillance response
systems that include early warnings, as well as critical human resources development,
must be quickly adopted by allied ministries and organizations in African countries in
epidemic and pandemic responses; (ii) harnessing all stakeholders commitment and

39

advocacy in sustained funding, collaboration, communication and networking


including community participation to enhance a coordinated responses, as well as
tracking and prompt case management to combat challenges; (iii) more research and
development in new drug discovery and vaccines; and (iv) understanding the
involvement of global health to promote the establishment of public health
surveillance response systems with functions of early warning, as well as monitoring
and evaluation in upholding research-action programmes and innovative interventions
(Tambo et al.,2014).
The World Health Organization has said it will earmark $100 million to fight
the outbreak. Other commitments include $200 million from the World Bank, $181
million from the European Union, $75 million from the United States and $50 million
from the gates foundation (WHO, 2014). The impact Ebola is having on other health
problems, such as maternal and child mortality, and to respond rapidly to unforeseen
events, like the Ebola outbreak, in light of budgetary constraints and spending
directives. Therefore, Ebola outbreak in 2014 has been still more and more terrific
and life threatening public health problem that needs to control and manage
effectively with over great attention all over the world.

40

CHAPTER 3

OBJECTIVES

3.1 General objective


To study the knowledge and perceptions towards Ebola disease among nursing
students in University of Nursing, Yangon

3.2 Specific objectives


(1) To assess the socio-demographic characteristics of nursing students
(2) To identify the sources of information about Ebola disease
(3) To describe the knowledge on Ebola disease among nursing students
(4) To describe perception towards Ebola disease among nursing students
(5) To determine the relationship between the demographic characteristics of nursing
students and knowledge on Ebola disease
(6) To determine the relationship between the demographic characteristics of nursing
students and perception towards Ebola disease

3.3 Research Hypotheses


3.3.1 There is an association between socio-demographic characteristics and
knowledge
of the respondents.
3.3.2 There is an association between socio-demographic characteristics and
perception
of the respondents.
3.3.3 There is an association between the knowledge and perception of the
respondents.

41

3.4 Conceptual Framework


Socio demographic characteristics
Age / gender
Race / Religion
Academic year
Marital status
Total years of service in government
Other qualification
Current posting (Hospital / public
health)

Knowledge about Ebola

Perception towards Ebola

disease

disease

Causal agent
Mode of transmission
Signs and symptoms
Complications
Diagnostic measures
High risks personnel
Prevention measures
Infection control measures
Waste control measures
Reporting

Perceived about knowledge


Perceived about information
Perceived about fever screening
Perceived about PPE training
Perceived about infection
control and waste management
Perceived about health talks
Perceived about involvement
Perceived about national
surveillance

Information
Media (TV, Radio, Newspaper,
Pamphlets and posters)
Social networking
Health education program
Training
Infection control training
Personal protective equipment
training
Figure 1. Conceptual framework of the study
42

Public health plan or


measures on Ebola
epidemic
Preparedness
Alertness
Outbreak Response
Epidemic Control
Evaluation

CHAPTER 4

RESEARCH METHODOLOGY

5.1 Study design


An analytical cross-sectional study design was used.

5.2 Study area


The study was conducted in University of Nursing, Yangon.

5.3 Study period


The study was taken place four months starting from September to December
2014.

5.4 Study population


The study population was all nursing students (Bridge Course) from
University of Nursing, Yangon. There were total 260 nursing students (Bridge
Course) studying in 2013-2014 academic year.
The inclusion criteria was included (1) who were attending to first year and
second year (Bridge Course), (2) who were present on the day of data collection and
(3) who were willing to participate voluntarily to this study.
The exclusion criteria was included (1) who were not attending to first year
and second year (Bridge Course), (2) who were absent on the day of data collection
and (3) who were unwilling to participate voluntarily to this study.

43

5.5 Sample size determination


The sample size determination was done by using Epi-info 7 sample size
calculation software that was calculated from base of the study population, and
proportion for favorable knowledge and perception towards Ebola disease 50% (p 50%), absolute precision on either side of the proportion 10% (d-10%) and reliability
coefficient (95% CI limit) was assumed each in calculation sample was resulted 155
total sample population. For attrition rate 15 (10%) was added, therefore, the sample
size was 170.
5.6 Sampling method
Simple random sampling method was used.
5.7 Sampling procedure
At University of Nursing (Yangon), there were 2 classes of B.N.Sc (Bridge
Course); it had been 157 first year students and 103 second year students respectively.
Firstly, the list of students was taken from school registers. Then, by proportionate for
two classes was done 60% of students from first year (102 first year students) and
another 40% of students from second year (68 second year students) was selected by
using simple random sampling method with lottery selection. Thus, in this study, total
sample size 170 nursing students was collected and conducted absolutely.

University of Nursing (Yangon)

2 (Bridge) Classes

First Year (157) Students

Second Year (103) Students

68 Second Year Students (40%)

102 First Year Students (60%)

Figure 2. Sampling procedure (Simple Random Sampling Method)

44

5.8 Data collection method and tools


Data collection was started after ethical clearance had been requested and
approved from ethical committee of faculty of public health at University of Public
Health, Yangon. Before data collection, the researcher self-introduced and explained
the purpose of the study, the duration of interviewing, inform consent form to every
respondents to make sure the understanding about the study and then mutual
agreement with respondents were done by making signature on the inform consent
forms. The respondents were freely allowed to withdraw anytime from the study
according to inform consent agreement if they did not wish to participate or response
the questionnaires. The confidentiality was also kept for their information. The
required data was collected by using a pre-tested with self-administered structured
questionnaire, after taking informed consent from the respondents. The questionnaires
are categorized by four types;
(A) Socio-demographic characteristics
(B) Sources of information about Ebola disease
(C) Questions regarding knowledge on Ebola disease
(D) Questions regarding the perception towards Ebola disease
Before data collection, a small scale pilot study was done with 20 nurses from
Yangon General Hospital (YGH) to test the clarity, feasibility and reliability of
research instrument. The main purpose of the test was to know the problems regarding
on the structure of the questionnaires, components, wording or terms that would be
clearly understood by respondents and to assess the reliability of the questionnaires.
Then, the reliability of the questionnaires was tested by using SPSS 22.0 version
software for Cronbachs alpha coefficient of the questionnaires. The reliability test
was 0.758 for 42 knowledge questionnaires, 0.802 for 12 perception questionnaires.
The overall result of reliability test was 0.803. A reliability coefficient of 0.70 or
higher is Acceptable for social and health sciences and so the result of reliability
was also acceptable level for this study. Attention was paid to choice of wording and
meaningfulness of questionnaire. After that some questions were edited and revised.
The questionnaire was included four sections : (A) socio-demographic
characteristics of nursing students such as gender, educational level, age, race,
religion, marital status, total years of service in government, other qualification,

45

current posting and infection control training (B) sources of information about Ebola
disease (C) questions regarding knowledge on Ebola disease which encompassed 42
items including 26 positive statements and 16 negative statements (True/False/Dont
know questions) and (D) questions regarding the perception towards Ebola disease
which involved 12 items including 5 positive perceptions and 7 negative perceptions
(four-point Likert type scale). The questionnaire was distributed to the participants
and requested them to answer all the questions frankly and honestly. The duration of
responding to the questionnaire was taken place 30 to 40 minutes. Then, the
completed questionnaires were compiled in back by the researcher.

5.9 Data management and analysis


After data collection, data checking was done daily for its completeness and
consistency. Then, coding and scoring was done. For the knowledge questions, the
correct answer was given one mark and the incorrect or dont know answer was given
zero mark. The total possible score was ranged from 0 to 42. The higher the score
means the respondent has more knowledge on Ebola disease. The knowledge score
was grouped into two categories: poor knowledge (below mean score) and good
knowledge (mean score and above).
With regard to perception questions, four marks for strongly agree, three
marks for agree, two marks for disagree and one mark for strongly disagree was given
for positive statements. Then, the scoring was reversed for negative statements. The
possible summed score was ranged from 12 to 48. The higher the score refers to the
respondent has demonstrated more positive perception towards Ebola disease. The
perception score was also grouped into two categories poor perception (below mean
score) and good perception (mean score and above).
The data entry and analysis was done by using SPSS software version 22.0.
Descriptive statistics such as mean, median, mode, range, standard deviation,
frequency and percentage was used appropriately to describe the demographic data
and respondents knowledge and perception towards Ebola disease. Chi-square,
independent samples t test and ANOVA statistics was used appropriately to determine
the relationship between knowledge and perception towards Ebola disease and the

46

demographic characteristics of nursing students. Data summarization was done by


using appropriate figures and cross tabulations.

5.10 Ethical consideration


Before conducting the research, the approval from the ethical committee of
University of Public Health was obtained. The research study was conducted from the
permission of authorized person; rector at University of Nursing (Yangon) to be done
data collection. Informed consent was provided with full information of the study to
all respondents of the study. Each respondent was also explained the objective of the
study and asked for informed consent form before starting the interview. The
participation in this study was voluntary absolutely. In the process of interview, the
respondents had the right to refuse or withdraw from their participation in this study if
they did not enjoy or feel bad to answer the questions. No name was recorded and the
information was kept in confidentiality. Anonymity and confidentiality of the
respondents information was strictly maintained. The completed questionnaires were
kept in secret by the researcher.

47

CHAPTER 5

FINDINGS

This analytical cross-sectional study aimed to find out the association between
knowledge and perceptions towards Ebola virus disease among nursing students in
University of Nursing, Yangon. The ages of the respondents were between 26 and 49
years old and total 170 students who met the inclusion criteria were recruited from
nursing students in University of Nursing, Yangon by simple random sampling
method and answered by self-administered structured questionnaires.
For this study, descriptive statistics were used to describe the results of
different variables by reporting frequency, percentage, mean, median, mode, range
and standard deviation. To describe the associations between dependent and
independent variables, chi square test, independent samples t test and ANOVA
statistics were used. The significance level used in hypothesis tests was set at 95%.
The results of this study were divided into 4 parts and presented as follow;
(1) Socio-demographic characteristics - independent variables (gender, academic year,
age group, race, religion, marital status, total years of service in government, other
qualification, current posting and infection control training)
(2) Source of information about Ebola disease (Television, radio, internet news,
posters and pamphlets and friends)
(3) Knowledge about Ebola disease - dependent variables (causal agent, mode of
transmission, signs and symptoms and complications, diagnostic and preventive
measures, incubation period, high risk persons, infection control and waste control
measures and reporting)
(4) Perceptions towards Ebola disease - dependent variables (positive perceptions and
negative perceptions)
(5) Associations between independent variables and knowledge about Ebola disease

48

(6) Associations between independent variables and perception towards Ebola disease
(7) Associations between knowledge and perception towards Ebola disease
5.1 Socio-demographic Characteristics
5.1.1 Gender of the respondents (n=170)
Gender
Male

Female
1.2%

98.8%

Figure 3. Gender of the respondents (n=170)


In this study, female occupied most (98.8%) of respondents and 168 in
numbers. There are only participated 2 male students (1.2%) in this study.

49

5.1.2 Academic year of the respondents (n=170)


Academic year
First year

Second year

40%

60%

Figure 4. Academic year of the respondents (n=170)


In this study, 102 first year students (60%) and 68 second year students (40%)
were participated in the study.

5.1.3 Age group the respondents (n=170)


Table (1) Age group of the respondents (n=170)
Age group

Frequency

Percent

21 to 30 years

67

39.4

31 to 40 years

93

54.7

41 to 50 years

10

5.9

Total

170

100

MeanSD = 32.464.259; Min=26; Max= 49


In this study, age was purposively categorized as three groups of 21 to 30
years, 31 to 40 years and 41 to 50 years to do data analysis among respondents in
study area. The youngest age of the respondent was 26 and the oldest was 49 with
average age of 32.46 years and standard deviation 4.259. Among these three age
group, 21 to 30 years are 67 members (39.4%), 31 to 40 years are 93 members
(54.7%) and 41 to 50 are 10 members (5.9%).

50

5.1.4 Race of the respondents (n=170)


Race Groups
Bamar

Ethnic groups
1.2%

Others

27%

71.8%

Figure 5. Race of the respondents (n=170)


In this study where majority of the respondents are Bamar 122 (71.8%), ethnic
groups 46 (27.0%) and others 2 (1.2%) included Hindu and Indian. Ethnic groups
included Kayin and Rakhine are most frequent than others.

5.1.5 Religion of the respondents (n=170)


Religion
Buddhist

Christian Hinduism
0.6% 0.6%
9.4%

Islam

89.4%

Figure 6. Religion of the respondents (n=170)


Majorities were Buddhist 152 (89.4%) and others were Christian 16 (9.4%),
Hinduism 1 (0.6%) and Islam 1 (0.6%) respectively.

51

5.1.6 Marital status of the respondents (n=170)


Marital status
Single

Married

23%

77%

Figure 7. Marital status of the respondents (n=170)


Most of the respondents were single 131(77.0%) and other respondents were
married 39 (23.0 %).

52

5.1.7 Total years of services of the respondents (n=170)

Number of respondents

120

109

100
80
61
60
40
20
0
0 to 5 years

> 5 years

Total years of service

Figure 8. Total years of services of the respondents (n=170)


MeanSD = 7.644.370; Min=3; Max= 26
In this study, total years of service of the respondents were purposively
categorized by two groups that showed 0 to 5 years and > 5 years respectively. The
minimum years of service of the respondent were 3 and the maximum was 26 with
average service of 7.64 years with standard deviation 4.370. By two groups, 0 to 5
service years are 61(35.9%) and > 5 service years are 109(64.1%).

53

5.1.8 Other qualifications of the respondents (n=170)


Other degree or qualification
Present

Absent

7.6%

92.4%

Figure 9. Other qualifications of the respondents (n=170)


In this study, 92.4% (95% CI = 88 to 96%) of the respondents have other
degree or graduation and 7.6% of the respondents have not other degree or
graduation. 157 members of degree or graduations of the respondents were contained
51 B.Sc graduated; (Physics, Mathematic, Zoology, Chemistry and Botany), 98 B.A
graduated; (History, English, Myanmar, Economic, Psychology, Geography and
Philosophy) and 4 L.L.B (Law) and 2 Diploma in intensive care unit (ICU) and 2
Diploma in ear, nose and throat (ENT).

54

5.1.9 Current posting of the respondents (n=170)

Number of respondents

80

69

70
60
50

47

42

40
30
20

12

10
0

Current Posting

Figure 10. Current posting of the respondents (n=170)


In this study, current posting of the respondents were categorized four groups
that township/station hospitals 47 respondents (27.6%), district hospitals 42
respondents (24.7%), regional/state hospitals 69 respondents (40.6%) and health
centers 12 respondents (7.1%) respectively. Then, the current posting of respondents
were purposively categorized two groups; clinical posting and public health posting.
The clinical posting of the respondents were included township/station hospitals,
district hospitals and regional/state hospitals and the public health posting of the
respondents were included health centers only. So, most of the respondents have been
working in hospital based clinical sites 158 respondents (92.9%) and community
based public health sites are only 12 respondents (7.1%) in this study.

55

5.1.10 Infection control and emergency training of the respondents (n=170)


Infection Control Training

10.6%

Absent
Present

89.4%

Figure 11. Infection control and emergency training of the respondents (n=170)
In this study, 10.6% (95% CI = 6 to 15%) of the respondents have got
infection control and emergency training and 89.4% havent got about training.

56

5.2 Sources of information about Ebola of the respondents (n=170)


Table (2) Sources of information of the respondents (n=170)
Information sources

Frequency

Percent

TV

87

51.2

Radio

63

37.1

Journals and newspaper

87

51.2

Internet news

144

84.7

Posters and pamphlets

14

8.2

Peer groups

77

45.3

In this study, ways for information was got about Ebola disease of the
respondents that 144 frequency (84.7%) via internet news accessed information about
Ebola, 87 frequency (51.2%) via television, 87 frequency (51.2%) via journals and
newspapers, 77 frequency (45.3%) from peer groups, 63 frequency (37.1%) via radio
and 14 frequency (8.2%) via posters and pamphlets. Most respondents had got
information access about Ebola disease from internet news.

57

5.3 Knowledge about Ebola


5.3.1 Knowledge about Ebola causal agent
Table (3) Knowledge of the respondents on causal agent about Ebola (n=170)
Knowledge about causal agent

Correct answer
Freq.

155

Influenza virus*
Humans species*

Incorrect answer
Freq.

91.2

15

8.8

36

21.2

134

78.8

116

68.2

54

31.8

Monkeys and chimpanzees

93

54.7

77

45.3

Pigs and bats

80

47.1

90

52.9

118

69.4

52

30.6

Survive in freezers

47

27.6

123

72.4

Die in heating

39

22.6

131

77.1

Ebola virus

Vector animals*

* Negative statement (Data analysis statement about this study was showed that this
point (*) of the data distributions was displayed to negative question statement.)
Regarding causal agent 155 (91.2%) respondents answered correctly that
Ebola disease is caused by Ebola virus, 116 (68.2%) respondents answered correctly
that Ebola disease started from humans and 118 (69.4%) respondents answered
correctly that vector animals can cause Ebola disease, 93 (54.7%) respondents
answered correctly that Ebola virus was found in monkeys and chimpanzees and 80
(47.1%) respondents answered correctly that Ebola disease was found in pigs and fruit
bats. 134 (78.8%) respondents answered incorrectly that Ebola is one of the influenza
species, 123 (72.4%) respondents answered incorrectly that Ebola virus can survive in
freezers and refrigerators and 131 (77.1%) respondents answered incorrectly that
Ebola virus can die in heating 60 C in 60 minutes.

58

5.3.2 Knowledge about mode of transmission


Table (4) Knowledge of the respondents on mode of transmission about Ebola
(n=170)
Knowledge about mode of
transmission
Air borne*

Correct answer
Freq.

Incorrect answer
Freq.

87

51.2

83

48.8

Food and water borne*

104

61.2

66

38.8

Contact infected persons

162

95.3

4.7

Contaminated objects

143

84.1

27

15.9

Blood and bodily secretions

159

93.5

11

6.5

* Negative statement
Regarding mode of transmission that the respondents answered correctly were
87 (51.2%) by air borne, 104 (61.2%) by foods and water borne, 162 (95.3%) by
contact infected persons, 143 (84.1%) by contaminated objects and 159 (93.5%) by
blood and bodily secretions.

59

5.3.3 Knowledge about signs and symptoms and complications


Table (5) Knowledge of the respondents on signs and symptoms and
complications about Ebola (n=170)
Knowledge about signs and
symptoms and complications

Correct answer

Incorrect answer

Freq.

Low grade fever*

131

77.1

39

22.9

Headache and sore throat

149

87.6

21

12.4

Muscle and joint pain

146

85.9

24

14.1

97

57.1

73

42.9

Intense weakness

146

85.9

24

14.1

Bloody vomiting and diarrhea

115

67.6

55

32.4

Impaired kidneys and liver

119

70.0

51

30.0

Internal and external bleeding

141

82.9

29

17.1

50

29.4

120

70.6

Constipation*

Fits*

Freq.

* Negative statement
Regarding signs and symptoms and complications that the respondents
answered correctly were 131 (77.1%) low grade fever, 149 (87.6%) headache and
sore throat, 146 (85.9%) muscle and joint pain, 97 (57.1%) constipation, 146 (85.9%)
intense weakness, 115 (67.6%) bloody vomiting and diarrhea, 119 (70.0%) impaired
kidneys and liver, 141 (82.9%) internal and external bleeding and 50 (29.4%) fits.

60

5.3.4 Knowledge about 90 % fatal syndromes and incubation period about Ebola
Table (6) Knowledge of the respondents on 90 % fatal syndrome and incubation
period about Ebola (n=170)
Correct answer
Knowledge about Ebola

Incorrect answer

Freq.

Freq.

90% fatal syndrome

167

98.2

1.8

Incubation period

118

69.4

52

30.6

Questionnaires about Ebola disease is 90 % fatal syndrome was answered 167


correctly (98.2%) and 3 incorrectly (1.8%). Questionnaires about incubation period of
Ebola disease was answered 118 correctly (69.4%) and 52 incorrectly (30.6%).
5.3.5 Knowledge about diagnostic measures
Table (7) Knowledge of the respondents on diagnostic measures about Ebola
(n=170)
Knowledge about diagnostic
measures

Correct answer

Incorrect answer

Freq.

Detected by blood

144

84.7

26

15.3

Detected by urine*

62

36.5

108

63.5

Detected by tissues

51

30.0

119

70.0

112

65.9

58

34.1

X ray and Ultrasound*

Freq.

* Negative statement
Questionnaires about diagnostic measures that the respondents answered
correctly were 144 (84.7%) about Ebola detected by blood, 62 (36.5%) about Ebola
detected by urine, 51 (30.0%) about Ebola detected by tissues, and 112 (65.9%) about
Ebola detected by X ray and ultrasound.

61

5.3.6 Knowledge about high risk persons


Table (8) Knowledge of the respondents on high risk persons about Ebola
(n=170)
Correct answer
High risk persons

Incorrect answer

Freq.

Freq.

Health personnel

164

98.2

1.8

Mortuary attendants

140

82.4

30

17.6

Questionnaires about high risk persons were answered 164 correctly (98.2%)
about health personnel and 140 correctly (82.4%) about mortuary attendants.
5.3.7 Knowledge about preventive measures
Table (9) Knowledge of the respondents on preventive measures about Ebola
(n=170)
Knowledge about preventive
measures

Correct answer

Incorrect answer

Freq.

Freq.

Hand washing

126

74.1

44

25.9

Personal protective equipments

161

94.7

5.3

Vaccination*

129

75.9

41

24.1

Effective medications*

127

74.7

43

25.3

* Negative statement
Questionnaires about preventive measures that the respondents answered
correctly were 126 (84.7%) by hand washing, 161 (94.7%) by personal protective
equipments, 129 (75.9%) by vaccination, and 127 (74.7%) by effective medications.

62

5.3.8 Knowledge about infection control measures


Table (10) Knowledge of the respondents on infection control measures about
Ebola (n=170)
Knowledge about infection
control measures
Washed by soap

Correct answer
Freq.

Incorrect answer
Freq.

87

51.2

83

48.8

Bleaching powders

110

64.7

60

35.3

Care in normal inpatient units*

167

98.2

1.8

Care in isolation unit

167

98.2

1.8

19

11.2

151

88.8

Quarantine for 5 days*


* Negative statement

Questionnaires about infection control measures that the respondents answered


correctly were 87 (51.2%) about washed by soap, 110 (64.7%) by using bleaching
powders, 167 (98.2%) about care in normal inpatient units, and 167 (98.2%) about
care in isolation unit and 19 (11.2%) about quarantine for 5 days.
5.3.9 Knowledge about waste management
Table (11) Knowledge of the respondents on waste management about Ebola
(n=170)
Waste management

Correct answer

Incorrect answer

Freq.

Freq.

Buried as normal dead bodies*

150

88.2

20

11.8

Burning all waste materials

156

91.8

14

8.2

* Negative statement
Questionnaires about waste management were answered 150 correctly
(88.2%) about Ebola patients can be buried as normal dead bodies and answered 156
correctly (91.8%) about burning all waste materials.

63

5.3.10 Knowledge about reporting


Table (12) Knowledge of the respondents on reporting within 3 days about Ebola
(n=170)
Reporting within 3 days

Frequency

Percentage

Correct answer

46

27.1

Incorrect answer

124

72.9

Total

170

100

Questionnaires about Ebola suspected patient can be reported within 3 days


answered 46 correctly (27.1%) and 124 incorrectly (72.9%).
5.3.11 Total knowledge about Ebola disease
Table (13) Total knowledge about Ebola disease (n=170)
Knowledge about Ebola

Frequency

Percentage

Good (above mean score)

93

54.7

Poor (below mean score)

77

45.3

Total
MeanSD = 28.515.144

170

100

Median=29.00

Mode=29.00

Min=7; Max= 40
Skewness= - 0.572

Kurtosis=0.944

Regarding knowledge scores, minimum knowledge scores are 7 while


maximum one is 40 upon 42 given marks. Mean knowledge scores is 28.51 and
median is 29.00 and the standard deviation was 5.144. As skewness is - 0.572
(negatively skewed) and kurtosis is 0.944, mean was chosen as line of demarcation to
avoid affecting by extreme value. And two categories of knowledge scores were got
as shown in table (13).The distribution of the level of knowledge was that 93 (54.7%)
respondents had good knowledge about Ebola disease and the poor knowledge was
found in 77 (45.3%) of the respondents.

64

5.4 Perception towards Ebola disease


5.4.1 Perception questions towards Ebola disease
Table (14) Respondents' positive perception towards Ebola disease (n=170)

Positive Perception
Everybody should aware the
life threatening about Ebola
disease.
Nurses should have a
systematic PPE (personal
protective equipments)
training.
Infection control and
systematic waste management
is important method to control
Ebola disease.
In continuing nursing
education program, the
selection topic towards
emerging disease like Ebola
should be presented and
discussed.
It would share and distribute to
family, friends and colleagues
about information on Ebola
disease.

Strongly
Agree
Freq. (%)

Agree
Freq.(%)

Disagree
Freq.(%)

Strongly
disagree
Freq.(%)

143(84.1%) 27(15.9%)
-

137(80.6%) 32(18.8%)

1(0.6%)

113(66.5%) 55(32.4%)

1(0.6%)

122(71.8%) 45(26.5%)

115(67.6%) 53(31.2%)

1(0.6%)

1(0.6%)

3(1.8%)

1(0.6%)

Table (14) expressed about the positive perception towards Ebola disease.
This study showed that more than 50% of the respondents described on strongly
agreed point regarding positive perception questionnaires. 84.1 % of the students
strongly agreed that everybody should aware the life threatening about Ebola disease,
80.6 % of them strongly agreed that nurses should have a systematic PPE (personal
protective equipments) training, 66.5 % of them strongly agreed that infection control
and systematic waste management is important method to control Ebola disease,
71.8 % of them strongly agreed that in continuing nursing education program, the
selection topic towards emerging disease like Ebola should be presented and

65

discussed and 67.6 % of them strongly agreed that It would share and distribute to
family, friends and colleagues about information on Ebola disease. In this study, the
positive perception statements about Ebola disease were described more strongly
agreed point than others in 4 levels Likert scale.

66

Table (15) Respondents' negative perception towards Ebola disease (n=170)

Negative Perception
All health personnel are not
important whose access
updated information about
Ebola disease.
Fever screening is done into
external travelers is not
important to control Ebola
disease.
It is not important that health
personnel have adequate
knowledge, experiences and
practices about emerging
disease like Ebola.
If have no desire to involve in
Ebola combating activities.
If do not induce to co-workers
for involvement in Ebola
combating activities.
If do not interest about Ebola
disease that has currently
caused in Myanmar.
Ebola that cannot reach in
Myanmar is recognized a
national surveillance disease.

Strongly
Agree
Freq.(%)
-

5(2.9%)

Freq.(%)

Strongly
disagree
Freq.(%)

1(0.6%)

29(17.1%)

140(82.4%)

7(4.1%)

52(30.6%)

106(62.4%)

29(17.1%)

140(82.4%)

Agree
Freq.(%)

Disagree

1(0.6%)
4(2.4%)

6(3.5%)

76(44.7%)

84(49.4%)

5(2.9%)

81(47.6%)

84(49.4%)

2(1.2%)

3(1.8%)

82(48.2%)

83(48.8%)

2(1.2%)

4(2.4%)

50(29.4%)

114(67.1%)

Table (15) expressed about the negative perception towards Ebola disease.
This study showed that about 50% of the respondents described on strongly disagreed
regarding negative perception questionnaires. 82.4 % of the students strongly
disagreed that all health personnel are

not important whose access updated

information about Ebola disease, 62.4 % of them strongly disagreed that fever
screening is done into external travelers is not important to control Ebola disease, 82.4
% of them strongly disagreed that it is not important that health personnel have
adequate knowledge, experiences and practices about emerging disease like Ebola,
49.4 % of them strongly disagreed that If have no desire to involve in Ebola
combating activities, 49.4 % of them strongly disagreed that If do not induce to co-

67

workers for involvement in Ebola combating activities, 48.8 % of them strongly


disagreed that If do not interest about Ebola disease that has currently caused in
Myanmar and 67.1 % of them strongly disagreed that Ebola that cannot reach in
Myanmar is recognized a national surveillance disease. In this study, the negative
perception statements about Ebola disease was described more strongly disagreed
point than others in 4 levels Likert scale.
5.4.2 Perception towards Ebola disease
Table (16) Perception towards Ebola disease
Perception towards Ebola

Frequency

Percentage

Good (above mean score)

94

55.3

Poor (below mean score)

76

44.7

Total
MeanSD = 43.733.645

170

100

Median=44.00

Mode=48.00

Min=32; Max= 48
Skewness= - 0.588

Kurtosis= - 0.403

Regarding perception scores, minimum perception scores are 32 while


maximum one is 48 upon 48 given marks. Mean perception scores is 43.73 and
median is 44.00 and the standard deviation was 3.645. As skewness is - 0.588
(negatively skewed) and kurtosis is 0.403, mean was chosen as line of demarcation
to avoid affecting by extreme value. And two categories of perception scores were got
as shown in table (16). The distribution of level of perception among respondents was
94 persons (55.3%) had good perception and 76 persons (44.7%) had poor perception
towards Ebola disease.

68

5.5 Relationship among knowledge and perception towards Ebola disease


The levels of knowledge were categorized into two categories by grouping of
good and poor knowledge about Ebola disease. The levels of perception were also
categorized into good and poor perceptions. Then, the association among levels of
knowledge and perception towards Ebola disease were calculated by chi-square test
with p value assumptions results or Fisher Exact test results, independent sample t test
and ANOVA statistics.

5.5.1 Relationship between socio-demographic data and knowledge on Ebola


disease
Table (17) Association between academic year of the respondents and knowledge
on Ebola disease (by independent sample t test)
N

Mean
knowledge
score

t value

p value

First Year

102

26.91

-5.335

<0.001

Second Year

68

30.90

Academic year

Association between academic year and knowledge on Ebola disease is


described in Table (17). The mean knowledge scores indicate that second year
students were more (MeanSD = 30.904.963) than first year (MeanSD
=26.914.640). There was statistically significant association between academic year
and knowledge on Ebola disease t (df=168) = -5.335, p <0.001.

69

Table (18) Association between gender and knowledge on Ebola disease


Knowledge on Ebola disease
Good

Poor

Gender

Percent

Percent

Total

Male

100.0

0.0

Female

91

54.2

77

45.8

168

p value = 0.298 (Fishers Exact Test)


There was no statistically significant association between gender and
knowledge on Ebola disease p =0.298.

Table (19) Association between age group and knowledge on Ebola disease
(by one way ANOVA)
Age Group

Mean
knowledge
score

F value

p value

21 to 30

67

28.18

0.269

0.764

31 to 40

93

28.67

41 to 50

10

29.20

Total

170

28.51

Association between age group and knowledge on Ebola disease is described


in Table (19). The mean knowledge scores for age group indicate that as the
knowledge level among age group were increased from 21 to 30 years age group
(MeanSD = 28.18 5.051), to 31 to 40 years age group (MeanSD = 28.67 5.370),
to 41 to 50 years age group (MeanSD = 29.20 3.676). There was no statistically
significant association between age groups and knowledge on Ebola disease F (df
=2,167) = 0.269, p =0.764.

70

Table (20) Association between marital status and knowledge on Ebola disease
Knowledge on Ebola disease
Good

Poor

Marital Status

Percent

Percent

Total

Single

74

56.5

57

43.5

131

Married

19

48.7

20

51.3

39

X2 = 0.734, p value = 0.693


There was no statistically significant association between marital status and
knowledge on Ebola disease p =0.693.

Table (21) Association between total years of service and knowledge on Ebola
disease (by independent sample t test)
N

Mean
knowledge
score

t value

p value

0-5 years

61

27.43

-2.067

0.040

> 5 years

109

29.11

Total years of
service

Association between total years of service and knowledge on Ebola disease is


described in Table (21). The mean knowledge scores indicate that > 5 years of service
were more (MeanSD = 29.11 4.806) than 0 to 5 years of service (MeanSD=27.43
5.578). There was statistically significant association between total years of services
and knowledge on Ebola disease t (df=168) = -2.067, p = 0.040.

71

Table (22) Association between other qualification and knowledge on Ebola


disease (by independent sample t test)
Other
qualification

Mean
knowledge
score

t value

p value

Absent

13

26.92

-1.156

0.250

Present

157

28.64

Association between other qualification and knowledge on Ebola disease is


described in Table (22). The mean knowledge scores indicate that the presence of
other qualifications among respondents were more (MeanSD = 28.64 5.223) than
the absent (MeanSD=26.92 3.883). There was no statistically significant
association between other qualification and knowledge on Ebola disease t (df=168)
= -1.156, p =0.250.

Table (23) Association between current posting and knowledge on Ebola disease
Knowledge on Ebola disease
Good

Poor

Current posting

Percent

Percent

Total

Clinical (Hospitals)

85

53.8

73

46.2

158

Public Health

66.7

33.3

12

p value = 0.290 (Fishers Exact Test), OR=0.582 (95%CI= 0.168 to 2.012)


There was no statistically significant association between current posting and
knowledge level towards Ebola disease p =0.290.

72

Table (24) Association between current posting and knowledge on Ebola disease
(by one way ANOVA)
Current posting

Mean
knowledge
score

F value

p value

Township/Station
hospital

47

28.57

0.177

0.912

District hospital

42

28.33

Regional/State
hospital

69

28.39

Health center

12

29.50

Total

170

28.51

Association between current posting and knowledge on Ebola disease is


described in Table (24). The mean knowledge scores for current posting indicate that
as the knowledge level in various posting of respondents were district hospital posting
(MeanSD = 28.33 4.421), regional/state hospital posting (MeanSD = 28.39
4.631), township/station hospital posting (MeanSD = 28.57 5.995) and health
centers posting (MeanSD = 29.50 7.039). There was no statistically significant
association between current posting and knowledge on Ebola disease F (df =3,166)
= 0.177, p =0.912.

73

Table (25) Association between infection control training and knowledge on


Ebola disease (by independent sample t test)
N

Mean
knowledge
score

t value

p value

Absent

152

28.42

- 0.624

0.534

Present

18

29.22

Infection
control training

Association between infection control training and knowledge on Ebola


disease is described in Table (25). The mean knowledge scores indicate that the
presence of infection control training among respondents were more (MeanSD
= 29.22 5.036) than the absent (MeanSD=28.42 5.167). There was no statistically
significant association between infection control training and knowledge on Ebola
disease t (df=168) = - 0.624, p =0.534.

74

5.5.2 Relationship between socio-demographic data and perceptions towards


Ebola disease
Table (26) Association between academic year and perception towards Ebola
disease (by independent sample t test)
N

Mean
perception
score

t value

p value

First year

102

43.25

-.2.144

0.033

Second year

68

44.46

Academic year

Association between academic year and perception towards Ebola disease is


described in Table (26). The mean perception scores indicate that second year
students

were

more

(MeanSD

44.463.483)

than

first

year

(MeanSD=43.253.687). There was statistically significant association between


academic year and perception towards Ebola disease t (df=168) = -.2.144, p = 0.033.

Table (27) Association between gender and perception towards Ebola disease
Perception towards Ebola disease
Good

Poor

Gender

Percent

Percent

Male

50.0

50.0

Female

93

55.4

75

44.6

168

p value = 0.696 (Fishers Exact Test)


There was no statistically significant association between gender and
perception level towards Ebola disease p =0.696.

75

Total

Table (28) Association between age group and perception towards Ebola disease
(by one way ANOVA)
Age Group

Mean
perception
score

F value

p value

21 to 30

67

43.76

0.039

0.962

31 to 40

93

43.68

41 to 50

10

44.00

Total

170

43.73

Association between age group and perception towards Ebola disease is


described in Table (28). The mean perception scores for age group indicate that as the
perception level among age group were 21 to 30 years age group (MeanSD = 43.76
3.693), 31 to 40 years age group (MeanSD = 43.68 3.672 and 41 to 50 years age
group (MeanSD = 44.00 3.399). There was no statistically significant association
between age group and perception towards Ebola disease F (df =2,167) = 0.039,
p =0.962.

Table (29) Association between marital status and perception towards Ebola
disease
Perception towards Ebola disease
Good

Poor

Marital Status

Percent

Percent

Total

Single

73

55.7

58

44.3

131

Married

21

53.8

18

46.2

39

X2 = 0.056, p value = 0.973


There was no statistically significant association between marital status and
perception level towards Ebola disease p =0.973.

76

Table (30) Association between total years of service and perception towards
Ebola disease (by independent sample t test)
Total years of
service

Mean
perception
score

t value

p value

0-5 years

61

43.20

-1.430

0.155

> 5 years

109

44.03

Association between total years of service and perception towards Ebola


disease is described in Table (30). The mean perception scores indicate that

>5

years of service were more (MeanSD = 44.03 3.513) than 0 to 5 years of service
(MeanSD=43.20 3.842). There was no statistically significant association between
total years of service and perception towards Ebola disease t (df=168)

= -1.430,

p = 0.155.

Table (31) Association between other qualification and perception towards Ebola
disease (by independent sample t test)
Other
qualification

Mean
perception
score

t value

p value

Absent

13

44.54

0.832

0.407

Present

157

43.66

Association between other qualification and perception towards Ebola disease


is described in Table (31). The mean perception scores indicate that the presence of
other qualifications among respondents were less (MeanSD =43.663.675) than the
absent (MeanSD=44.54 3.282). There was no statistically significant association
between other qualification and perception towards Ebola disease t (df=168) = 0.832,
p =0.407.

77

Table (32) Association between current posting and perception towards Ebola
disease
Perception towards Ebola disease
Good

Poor

Current posting

Percent

Percent

Total

Clinical (Hospitals)

88

55.7

70

44.3

158

Public Health

50.0

50.0

12

X2 = 0.15, p value = 0.702, OR=1.257 (95%CI = 0.388 to 4.068)


There was no statistically significant association between current posting and
perception level towards Ebola disease p =0.702.

Table (33) Association between current posting and perception towards Ebola
disease (by one way ANOVA)
Current posting

Mean
perception
score

Township/Station
hospital

47

43.21

District hospital

42

44.10

Regional/State
hospital

69

43.91

Health center

12

43.42

Total

170

43.73

F value

p value

0.539

0.656

Association between current posting and perception towards Ebola disease is


described in Table (33). The mean perception scores for current posting indicate that
as the perception level in various posting of respondents were township/station
hospital posting (MeanSD = 43.21 3.787), district hospital posting (MeanSD =
44.10 3.427), regional/state hospital posting (MeanSD = 43.91 3.625) and health
centers posting (MeanSD = 43.42 4.144). There was no statistically significant
association between current posting and perception towards Ebola disease F (df
=3,166) = 0.539, p =0.656.

78

Table (34) Association between infection control training and perception towards
Ebola disease (by independent sample t test)
N

Mean
perception
score

t value

p value

Absent

152

43.83

1.035

0.302

Present

18

42.89

Infection
control training

Association between infection control training and perception towards Ebola


disease is described in Table (34). The mean perception scores indicate that the
presence of infection control training among respondents were less (MeanSD =
42.893.676) than the absent (MeanSD=43.83 3.641). There was no statistically
significant association between infection control training and perception towards
Ebola disease t (df=168) = 1.035, p =0.302.

Table (35) Association between knowledge and perception towards Ebola disease
Perception towards Ebola disease
Good

Poor

Knowledge level

Percent

Percent

Total

Good

59

63.5

34

36.5

93

Poor

35

45.5

42

54.5

77

X2 = 5.513, p value = 0.019, OR=2.082 (95%CI = 1.125 to 3.855)


Association between knowledge level and perception level towards Ebola
disease is described in Table (5.35). This study found out that good knowledge and
good perception is 63.5% and good knowledge and poor perception is 36.5%. Poor
knowledge and good perception is 45.5% and poor knowledge and poor perception is
54.5%.Odd ratio is 2.082 and 95% confidence level is 1.125 to 3.855 by data analysis.
There was statistically significant association between knowledge and perception
towards Ebola disease p =0.019.

79

CHAPTER 6

DISCUSSION

In this study, total 170 comprising 2 male and 168 female students from
nursing (Bridge) course students in University of Nursing, Yangon were chosen to
identify their knowledge and perception level about Ebola disease. Regarding to this
discussion, this study did not access and get the previous literature and studies
regarding knowledge and perception towards Ebola disease among health care
workers so the general discussion point only come from the reliable data collection
and analysis in this study population. The main objective of this study was to
determine the relationship between knowledge and perception towards Ebola disease
and the demographic characteristics of nursing students in University of Nursing,
Yangon, Myanmar. The hypotheses of this study were assumed that there were
associations between socio-demographic characteristics, knowledge level and
perceptions level toward Ebola disease of the study area. There were 4 discussion
parts in this chapter as follows;
1) Socio-demographic characteristics
2) Sources of information getting about Ebola disease
3) Knowledge level about Ebola disease
4) Perceptions level towards Ebola disease

6.1 Socio-Demographic Characteristics


The

socio-demographic

factors

are

the

personal

information

and

characteristics of the respondents that based on each respondent belong. These factors
can also associate with or relate to knowledge and perceptions levels toward Ebola
disease among respondents. With regards to the socio-demographic factors;

80

independent variables (gender, academic year, age, race and religion, marital status,
and total years of service in government servants, other qualification, current posting
and infection control training) were associated with dependent variables (knowledge
and perception levels towards Ebola disease). According to data analysis, knowledge
level was significantly association with academic year, total years of service and
perception level.
Gender - In this study, 2 male students (1.2%) and 168 female students
(98.8%) were participated in the study. Nursing students in Myanmar especially as
University of Nursing, Yangon was 1 male/10 female proportional recruitment and
enrollment so male students are usually fewer than female students. In this study, total
study population was 260 followed by 157 first year students as included one male
student and 103 second year students as included only one male student so the
participants were selected by simple random sampling method that 2 male participants
were included with lottery selection by chance. Two male participants are 1 from 1st
year and 1 from 2nd year Bridge course student in each and 101 female students from
1st year and 67 female students from 2 nd year Bridge course respectively. On female
dominated nursing profession in Myanmar, this study found out the relationship
between gender and knowledge level and perceptions level towards Ebola disease.
There was no statistically significant association between gender and knowledge level
p value = 0.298 and gender and perception level towards Ebola disease p value =
0.696. In this study, gender display was unequal; the knowledge and perception level
of the respondents cannot distinguish high and low level about Ebola disease.
Academic year - In this study, 102 first year students (60%) and 68 second
year students (40%) were participated in the study. This study found that there was
statistically significant association between academic year and knowledge level
towards Ebola disease p value <0.001. Data analysis showed when education level
was more and more; the knowledge level of the respondents was high level about
Ebola disease (Mean score=30.90). And then, there was statistically significant
association between academic year and perception level towards Ebola disease p
value =0.033. So, data analysis showed that education level was high, the perception
level of the respondents was increased about Ebola disease (Mean score=44.46).So,
the education level of the respondents is important and needed to be adequate

81

knowledge access during outbreak control and through it also needed to try and
promote absolutely for career preference as personal development regarding formal or
informal educational accessibility.
Age - In this study, age was purposively categorized as three groups of 21 to
30, 31 to 40 and 41 to 50 years to do data analysis among respondents in study area.
The youngest age of the respondent was 26 and the oldest was 49. Mean knowledge
scores among age group were increased from 21 to 30 years age group (Mean
= 28.18), to 31 to 40 years age group (Mean = 28.67), to 41 to 50 years age group
(Mean = 29.20). There was no statistically significant association between age groups
and knowledge level towards Ebola disease p value=0.764. Regarding the perception
score, mean perception score among age group were 21 to 30 years age group (Mean
= 43.76), 31 to 40 years age group (Mean = 43.68) and 41 to 50 years age group
(Mean = 44.00). There was no statistically significant association between age group
and perception level towards Ebola disease p value =0.962. However, this study found
out that the elder respondents were higher knowledge and perception score as they
have been longer service duration and longer life experiences than the younger one.
So, the younger age groups are needed to improve knowledge in various ways for
information access and increase perception level by their voluntary involvement,
participation and motivations during epidemic outbreak.
Race and religion In this study where majority of the respondents are
Bamar 122 (71.8%), ethnic groups 46 (27.0%) and others 2 (1.2%) included Hindu
and Indian. Ethnic groups included Kayin and Rakhine are most frequent than others.
Majorities were Buddhist 152 (89.4%) and others were Christian 16 (9.4%), Hinduism
1 (0.6%) and Islam 1 (0.6%) respectively. Most respondents were major identity in
Bamar race and Buddhist religion. This study did not find out the association between
race and religion and knowledge and perception level of the respondents because most
of the Bamar race and Buddhist religion were influencing prominently on others.
Marital status - Most of the respondents were single 131(77.0%) and other
respondents were married 39(23.0%). In this study, the marital status of the
respondents were unmarried 56 members in 21 to 30 years of age group,70 members
in 31 to 40 years of age group and 5 members in 41 to 50 years of age group so
nursing profession in Myanmar, nurses are prominently unmarried people in their

82

human life. However, there was no statistically significant association between


marital status and knowledge level towards Ebola disease p value = 0.693 and there
was no statistically significant association between marital status and perception level
towards Ebola disease p value = 0.973. In this study, most of the respondents are
single so it was not much different between high and low levels of knowledge and
perception about Ebola disease.
Total years of service - In this study, total years of service of the respondents
were purposively categorized by two groups that showed 0 to 5 years and > 5 years
respectively. The shortest years of service of the respondent were 3 and the longest
was 26. The mean knowledge scores indicate that > 5 years of service were more
(Mean = 29.11) than 0 to 5 years of service (Mean =27.43). There was statistically
significant association between total years of services and knowledge level towards
Ebola disease p = 0.040. Regarding the mean perception scores indicate that

>5

years of service were more (Mean = 44.03) than 0 to 5 years of service (Mean
=43.20). There was no statistically significant association between total years of
service and perception level towards Ebola disease p = 0.155. The respondents with
> 5 years of service were longer duration of services as they may have enthusiastic
and relevant life experiences in infection control and epidemic outbreak control like
H1N1, Avian Influenza that this study was described the association between total
years of service and knowledge level. In this study, the longer duration of service of
the respondents have the higher knowledge and higher perception level according to
their willingness and life experiences.
Other qualifications - In this study, other qualification of the respondents
whose were present of another degree or graduations 92.4% (95% CI = 88 to 96%)
and 7.6% absent of another of degree respectively. 157 members of degree or
graduations of the respondents were contained 51 B.Sc graduated, 98 B.A graduated
and 4 L.L.B (Law) and 4 Diploma in ICU and ENT. The mean knowledge scores
indicate that the presence of other qualifications among respondents were more (Mean
= 28.64) than the absent (Mean =26.92). There was no statistically significant
association between other qualification and knowledge level towards Ebola disease p
=0.250. The mean perception scores indicate that the presence of other qualifications
among respondents were less (Mean =43.66) than the absent (Mean =44.54). There

83

was no statistically significant association between other qualification and perception


level towards Ebola disease p =0.407. According to the data analysis, these studies
were described 90% and above of the respondents were the background degree and
graduation so their knowledge level was remarkable higher than the absent one. In
this study, although the presence of other degree or qualification among respondents
have the higher knowledge level but have lower perception level about Ebola disease
because they may have proper knowledge access about Ebola outbreak that have
known the disease process such as seriousness, fatality and infectious of Ebola disease
to be lower perception level that showed to their unwillingness involvement in disease
control activities. So, this study showed that the health care workers especially nurses
are needed to encourage and motivate for involvement in disease controlling
activities.
Current posting - In this study, current posting of the respondents were
categorized two groups that showed clinical (hospitals) and public heath (health
centers). The clinical posting of the respondents showed (92.9%) followed by 158 and
the public health posting of the respondents showed (7.1%) followed by 12
respectively. In clinical posting of the respondents were categorized three groups that
had township/station hospital (47 persons, 27.6%), district hospital (42 persons,
24.7%), regional/state hospital (69 persons, 40.6%) respectively. Most of the
respondents had been working more hospital based clinical sites than community
based public health site. In a relation with current posting and knowledge level, mean
knowledge score in various posting of respondents were district hospital posting
(Mean = 28.33), regional/state hospital posting (Mean = 28.39), township/station
hospital posting (Mean = 28.57) and health centers posting (Mean = 29.50). There
was no statistically significant association between current posting and knowledge
level towards Ebola disease p =0.912.

Regarding relationship between current

posting and perception level, mean perception score in various posting of respondents
were township/station hospital posting (Mean = 43.21), district hospital posting
(Mean = 44.10), regional/state hospital posting (Mean = 43.91) and health centers
posting (Mean = 43.42). There was no statistically significant association between
current posting and perception level towards Ebola disease p =0.656. In this study,
although the health centers especially public health posting among respondents have

84

the slightly higher knowledge level than clinical posting sites as they have known the
disease process such as seriousness, fatality and infectious about Ebola disease that
leads to be lower perception level and showed their unwillingness involvement in
disease controlling activities. And then, other clinical posting sites were not much
different between high and low levels of knowledge and perception about Ebola
disease.
Infection control and emergency training - In this study, 10.6% (95% CI =
6 to 15%) of the respondents have got infection control and emergency training and
89.4% havent got about training. Thus, most of the respondents had not been about
infection control and emergency training towards epidemic outbreak control like
Ebola disease. Only 18 respondents had got about infection control and emergency
training; they are 7 respondents in regional/ state hospitals, 5 respondents in
township/station hospitals, 3 respondents in district hospitals and 3 respondents in
public health site. The mean knowledge scores indicate that the presence of infection
control training among respondents were more (Mean = 29.22) than the absent (Mean
=28.42). There was no statistically significant association between infection control
training and knowledge level towards Ebola disease p =0.534. Regarding mean
perception scores indicate that the presence of infection control training among
respondents were less (Mean = 42.89) than the absent (Mean =43.83). There was no
statistically significant association between infection control training and perception
level towards Ebola disease p =0.302. In this study, although the presence of infection
control training among respondents have the remarkable knowledge score as they
have known the disease process such as seriousness, fatality and infectious regarding
higher knowledge level about Ebola disease that leads to be lower perception level
and showed their unwillingness involvement in disease controlling activities. By data
analysis, only 18 members of the respondents had got the infection control and
emergency training as well as personal protective equipments training so the
respondents in respective posting sites are needed to get and access about those
trainings efficiently and relevantly. Therefore, these studies found out that the
presence of infection control training among the respondents have ethical issues for
involvement in Ebola combating activities.

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6.2 Sources of information getting about Ebola disease


In this study, sources of information were got about Ebola disease of the
respondents that accessed information about Ebola via television, via radio, via
journals and newspapers, via internet news, from posters and pamphlets and from peer
groups. They all have got information about Ebola disease as one of the public health
emergency was announced from World Health Organization (WHO) and then
Myanmar media channels, TV channels, radio, internets websites, journals and
newspapers and center of disease control and prevention, Myanmar (CDC, Myanmar)
whether was done information dissemination about etiology, morbidity and mortality
and disease process about Ebola disease into Myanmar public. In fact, nursing
students like the respondents have already known about it that this study was assessed
and conducted their knowledge and perceptions level about Ebola disease. Most
respondents had got 84.7% via internet news accessed information about Ebola
disease than other media channels. However, Myanmar, one of the developing
countries, there is so many remote areas that people in there only can access to health
information dissemination from television and radio channels so policy makers in
Myanmar are needed to extend and upgrade to TV and radio channels timely and
effectively.
6.3 Knowledge level about Ebola disease
The operational definition of knowledge is the way of facts knowing about
something, general understanding, and familiarity with Ebola disease. The knowledge
is a fundamental unit of a person that it has the psychological result of perception,
learning and reasoning about Ebola disease. In this study, knowledge questionnaires
about Ebola disease was included; causal agent, mode of transmission, signs and
symptoms and complications, incubation period, high risk persons, diagnostic and
preventive measures, infection control and waste control measures and reporting. In
42 knowledge questionnaires were included 26 positive question statements and 16
negative question statements that specified 1 score in correct items and 0 score in
incorrect items.

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Ebola virus disease (formerly known as Ebola hemorrhagic fever) is a severe,


often fatal illness, with a death rate of up to 90% (WHO, 2014). Transmission of the
virus has been documented through the handling of infected chimpanzees, gorillas,
fruit bats, monkeys, forest antelope, and porcupines found ill or dead or in the
rainforest (Jarrett, 2014). Ebola viruses can survive in liquid or dried material for a
number of days. However, Ebola virus can be inactivated by UV radiation, gamma
irradiation, heating for 60 minutes at 60 C or boiling for five minutes. The virus is
susceptible to sodium hypochlorite and disinfectants. Freezing or refrigeration will
not inactivate Ebola virus (CDC, 2014).
This study was assessed knowledge questionnaires regarding causal agent
about Ebola disease that 91.2 percent respondents answered correctly about Ebola
disease is caused by Ebola virus, 68.2 percent answered correctly about Ebola disease
started from humans and 69.4 percent answered correctly about vector animals can
caused Ebola disease, 54.7 percent answered correctly about Ebola virus is found in
monkeys and chimpanzees and 47.1 percent answered correctly about Ebola disease
was caused in pigs and fruit bats. 78.8 percent answered incorrectly about Ebola is
one of the influenza species, 72.4 percent answered incorrectly about Ebola virus can
survive in freezers and refrigerators and 77.1 percent answered incorrectly about
Ebola virus can die in heating 60 C in 60 minutes. This study showed that the
knowledge level of the respondents about causal agent was described slightly
favorable so it is needed to improve their knowledge regarding etiology of Ebola
disease.
The Ebola virus is spread through direct contact (through broken skin or
mucous membranes) with blood and body fluids (urine, feces, saliva, vomit, and
semen) of a person who is sick with Ebola, or with objects (like needles) that have
been contaminated with the virus. Ebola is not spread through the air or by water or,
in general, by food; however, in Africa, Ebola may be spread as a result of handling
bush meat (wild animals hunted for food) and contact with infected bats. Ebola
viruses can survive in liquid or dried material for a number of days (CDC, 2014).
According to the literature reviews, mode of transmission about Ebola disease
regarding questionnaires that the respondents answered correctly were 51.2 percent by
air borne, 61.2 percent by foods and water borne, 95.3 percent by contact infected

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persons, 84.1 percent by contaminated objects and 93.5 percent by blood and bodily
secretions. This study showed that the knowledge level of the respondents about mode
of transmission was described favorable level indicated correctly answered up to 50%.
Initial signs and symptoms about Ebola are nonspecific and may include fever,
chills, myalgias, and malaise. Fever, anorexia, asthenia/weakness are the most
common signs and symptoms. Patients may develop a diffuse erythematous
maculopapular rash by day 5 to 7 (usually involving the face, neck, trunk, and arms)
that can desquamate (Casillas et al., 2003 & CDC, 2014). Other symptoms such as
chest pain, shortness of breath, headache or confusion, may also develop. Patients
often have conjunctival injection. Hiccups have been reported. Seizures may occur,
and cerebral edema has been reported. Bleeding is not universally present but can
manifest later in the course as petechiae, ecchymosis/bruising, or oozing from
venipuncture sites and mucosal hemorrhage. Frank hemorrhage is less common.
Pregnant women may experience spontaneous miscarriages. Patients with fatal
disease usually develop more severe clinical signs early during infection and die
typically between days 6 and 16 of complications including multi-organ failure and
septic shock (CDC, 2014).
Questionnaires were assessed on signs and symptoms and complications about
Ebola disease that the respondents answered correctly were 77.1 percent about low
grade fever, 87.6 percent about headache and sore throat, 85.9 percent about muscle
and joint pain, 57.1 percent about constipation, 85.9 percent about intense weakness,
67.6 percent about hematemesis and bloody diarrhea, 70.0 percent about impaired
kidneys and liver, 82.9 percent about internal and external bleeding and 29.4 percent
about fits. This study showed that the knowledge level of the respondents about signs
and symptoms and complications was described favorable level.
Ebola virus disease (EVD) is a severe, often fatal illness, with a death rate of
up to 90% (WHO, 2014). Questionnaires about Ebola disease is 90 percent fatal
syndrome was answered 98.2 percent correctly and 1.8 percent incorrectly. The
incubation period is 2 to 21 days (WHO, 2014). Questionnaires about incubation
period of Ebola disease was answered 69.4 percent correctly and 30.6 percent
incorrectly. This study showed that the knowledge level of the respondents about it
was described higher level indicated correctly answered nearly 70% and above.

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The risks persons are people exposed to and handling wild animals; people
depending on wild animals such as bats as a food source; mortuary attendants; health
workers caring for Ebola patients; health workers in hospital settings (WHO, 2014).
In almost all outbreaks of Ebola Hemorrhagic Fever (EHF), the fatality rate among
health care workers with documented infections was higher than that of nonhealth
care workers (Adrian et al., 2011). Questionnaires about high risk persons were
answered correctly 98.2 percent in health personnel and 82.4 percent correctly in
mortuary attendants. This study showed that the knowledge level of the respondents
about it was described higher level indicated correctly answered up to 80%.
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM
ELISA, polymerase chain reaction (PCR), and virus isolation can be used to diagnose
a case of Ebola disease within a few days of the onset of symptoms. Persons tested
later in the course of the disease or after recovery can be tested for IgM and IgG
antibodies; the disease can also be diagnosed retrospectively in deceased patients by
using immunohistochemistry testing, virus isolation, or PCR (Casillas et al., 2003).
Diagnostic measures were assessed questionnaires that the respondents answered
correctly 84.7 percent about Ebola detected by blood, 36.5 percent about Ebola
detected by urine, 30.0 percent about Ebola detected by tissues, and 65.9 percent
about Ebola detected by X ray and ultrasound. This study showed that the knowledge
level of the respondents about diagnostic measures was described unfavorable level
indicated correctly answered <50%.
The occupation health staff (OHS) of the health care workers (HCWs) is the
primary consideration and reason for recommending personal protective equipments
(PPE) in the first place. The choice of respiratory protection is one facet of an array of
PPE for ensuring the OHS of health workers, including gowns, gloves, goggles and
protective suits. Suggesting HCWs use lesser protection because they could work 3 h
instead of 40 min is illogical, when the risk of working longer in lesser PPE may be
death (CDC, 2014).
Many HCWs have contracted Ebola despite wearing PPE, which in itself
supports the case for conservative recommendations (MacIntyre et al., 2011& 2013).
Standard precautions are recommended in the care and treatment of all patients
regardless of their perceived or confirmed infectious status. They include the basic

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level of infection control-hand hygiene, use of personal protective equipment to avoid


direct contact with blood and body fluids, prevention of needle stick and injuries from
other sharp instruments, and a set of environmental controls (CDC, 2007). Close
physical contact with Ebola patients should be avoided. Gloves and appropriate
personal protective equipment should be worn when taking care of ill patients at
home. Regular hand washing is required after visiting patients in hospital, as well as
after taking care of patients at home (CDC, 2014).

Knowledge questionnaires

regarding preventive measures about Ebola disease were assessed that the respondents
answered correctly 84.7 percent prevention by proper hand washing, 94.7 percent
prevention by personal protective equipments, 75.9 percent prevention by vaccination,
and 74.7 percent prevention by effective medications. Response to the current Ebola
virus outbreak based on traditional control measures has so far been insufficient to
prevent the virus from spreading rapidly. This has led to urgent discussions on the use
of experimental therapies and vaccines untested in humans and existing in limited
quantities, raising political, strategic, technical and ethical questions(Feldmann,
2014). This study showed that the knowledge level of the respondents about
preventive measures was described higher level indicated correctly answered nearly
75% and above.
Ebola virus is easily killed by soap, bleach, sunlight, or drying. Machine
washing clothes that have been contaminated with fluids will destroy Ebola virus.
Ebola virus survives only a short time on surfaces that are in the sun or have dried
(CDC, 2014). By reviewing CDC notes, questionnaires were assessed infection
control measures about Ebola disease that the respondents answered correctly 51.2
percent about washed by soap, 64.7 percent by bleaching powders, 98.2 percent about
care in normal inpatient units, and 98.2 percent about care in isolation unit and 11.2
percent about quarantine for 5 days. This study showed that the knowledge level of
the respondents about infection control measures was described slightly favorable
level indicated correctly answered average about 50%.
Communities affected by Ebola should inform the population about the nature
of the disease and about outbreak containment measures, including burial of the dead.
People who have died from Ebola should be promptly and safely buried. Burial

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ceremonies in which mourners have direct contact with the body of the deceased
person can also play a role in the transmission of Ebola (CDC, 2014).
Waste management during outbreak was assessed by questionnaires that
answered 88.2 percent correctly about Ebola patients can be buried as normal dead
bodies and 91.8 percent correctly about burning all waste materials. This study
showed that the knowledge level of the respondents about waste management was
described higher level indicated correctly answered average nearly 90%.
Continuously, questionnaires was assessed about Ebola suspected patient can be
reported within 3 days that answered 27.1 percent correctly and 72.9 percent
incorrectly. This study showed that the knowledge level of the respondents about
reporting was described unfavorable level indicated correctly answered < 30%.
According to the knowledge questionnaires, total knowledge score about
Ebola disease given was 42 total scores that it was divided by good knowledge above
mean score and poor knowledge below mean score (mean score 28.51). The
distribution of the level of knowledge was that 93 respondents 54.7 percent had good
level of knowledge about Ebola disease and the poor level of knowledge was found in
77 respondents 45.3 percent. In this study, half and above of the respondents were
good knowledge level that described proper information access, relevant background
knowledge and life experiences to be interests, understanding

and alertness on

disease threats regarding current public health problem called Ebola disease.
However, above these finding results; most of the respondents needed to be adequate
knowledge regarding epidemiology of Ebola disease, understanding disease threats
and safe fulfillment in infection control activities about Ebola disease.
6.4 Perceptions level towards Ebola disease
The operation definitions of perceptions is the way of feeling or thinking so
the perceptions level towards Ebola disease do not the same feeling in each mind of
respondents. Questionnaires regarding perceptions level of the respondents about
Ebola disease were answered by four point Likert scale. This study showed that more
than 50% of the respondents described on strongly agreed point. Positive perceptions
questions were marked on strongly agreed point that showed 84.1 percent perceived
about life threatening Ebola disease, 67.6 percent perceived about information

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distributions, 80.6 percent perceived about personal protective equipments training,


66.5 percent perceived about infection control and 71.8 percent perceived about
health talks on continuous nursing education program.
Previous study has focused on describing the experiences of nurses during
rapid killing Ebola epidemics. Three key themes emerged from the interviews: (a)
lack of protective gear, basic equipment, and other resources necessary to provide
care, especially during the early phases of the outbreaks; (b) stigmatization by family,
coworkers, and community; and (c) exceptional commitment to the nursing profession
in a context where the lives of the health care workers were in jeopardy (Hewlett,
2005). Nurses demonstrated what it means to work with dedication and strength. They
manifested the resiliency of the human spirit about what it means to give care in the
face of death (Kabananukye, 2001).
Regarding negative perception questionnaires, this study showed that about
50% of the respondents described on strongly disagreed point. Negative perceptions
questions were marked on strongly disagreed point that showed 82.4 percent
perceived about updated information, 82.4 percent perceived about adequate
practices, 67.1 percent perceived about national surveillance, 62.4 percent perceived
about fever screening, 49.4 percent perceived about involvement, 49.4 percent
perceived about co-workers and 48.8 percent perceived about interests. In this study,
perception questionnaires about Ebola disease found out more than half of the
respondents on strongly agreed points in positive perceptions and nearly half of the
respondents on strongly disagreed points in negative perceptions in 4 levels Likert
scale so the respondents had had adequate perception level that have been showed
their willingness, interests, preparedness and alertness to combat Ebola disease.
According to the perception scores, minimum perception scores are 32 while
maximum one is 48 upon 48 given marks that it was divided by good perception
above mean score and poor perception below mean score (mean score 43.73). The
distribution of level of perception among respondents was 94 respondents 55.3
percent had good perception and 76 respondents 44.7 percent had poor perception
towards Ebola disease. Therefore, this study showed that the respondents or nurses
were described about their perceptions to be highlights on outbreak control measures
regarding preparedness, alertness, and response and control activities about Ebola

92

disease. Moreover, there is a practical reason to consider treating healthcare workers


first. It serves the interests of the majority of patients to keep medical workers and
caretakers alive and in the field. It also increases the likelihood that others may be
willing to come and help them, if they dont believe they would be sent to the back of
the line or stranded should they succumb to infection. And, finally, healthcare
workers might be the ones most likely to accept enrollment in trials of these
medications, and understand the requirements of informed consent in the treatment,
study, given the widespread misinformation and mistrust (Donovan, 2014).
The Ebola crisis has impacted some of the most vulnerable areas of the world,
and frontline health workers are struggling to keep pace with the outbreak. The
Training Health Workers for Ebola series consists, and aims to provide health
workers with the clear, reliable, and timely information they need to protect
themselves, detect the disease, and respond. Reducing the risk of Ebola infection in
people in the absence of effective treatment and a human vaccine, raising awareness
of the risk factors for Ebola infection and the protective measures individuals can take
is the only way to reduce human infection and death. In all countries, during EVD
outbreaks, educational public health messages for risk reduction should focus on
several factors: Reducing the risk of wildlife-to-human transmission from contact
with infected fruit bats or monkeys/apes and the consumption of their raw meat.
Animals should be handled with gloves and other appropriate protective clothing.
Animal products (blood and meat) should be thoroughly cooked before consumption
and reducing the risk of human-to-human transmission in the community arising from
direct or close contact with infected patients, particularly with their bodily fluids.
Therefore, the following actions are recommended: (i) national and regional
inter-sectoral and trans-disciplinary surveillance response systems that include early
warnings, as well as critical human resources development, must be quickly adopted
by allied ministries and organizations in all countries in epidemic and pandemic
responses; (ii) harnessing all stakeholders commitment and advocacy in sustained
funding, collaboration, communication and networking including community
participation to enhance a coordinated responses, as well as tracking and prompt case
management to combat challenges; (iii) more research and development in new drug
discovery and vaccines; and (iv) understanding the involvement of global health to

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promote the establishment of public health surveillance response systems with


functions of early warning, as well as monitoring and evaluation in upholding
research action programmes and innovative interventions(Tambo et al.,2014).
In this study, association between knowledge level and perception level
towards Ebola disease is described; good knowledge and good perception level is
63.5% and good knowledge and poor perception level is 36.5%. poor knowledge and
good perception level is 45.5% and poor knowledge and poor perception level is
54.5%.Odd ratio is 2.082 and 95% confidence level is 1.125 to 3.855 by data analysis.
There was statistically significant association between knowledge level and
perception level towards Ebola disease (p =0.019). So, this study showed that if the
respondents knowledge level was high, perception level would be high. According to
these findings, health care workers are needed to be higher knowledge levels that are
followed as higher perception levels by encouraging and motivating for involvement
in outbreak controlling activities. Moreover, as shown Ebola cases, where experts
perceive there to be a high risks, there can sometimes be insufficient social or political
concern, or attenuation. An understanding of what drives the perception of risk is
therefore sorely needed (CDC, 2014).
WHO Headquarters and their partners have produced this document: Ebola
and Marburg virus disease epidemics: preparedness, alert, control and evaluation. The
main target audience of this document are district-level health-care workers (doctors,
nurses, and paramedics), as well as intermediate- and central-level health-care
workers responsible for epidemic control, and International Health Regulations (IHR)
National Focal Points (NFPs). The objective of this document is to describe
preparedness, prevention, and control measures that have been implemented
successfully during previous epidemics. These measures must be implemented during
the following four phases: pre-epidemic preparedness, alert (identify, investigate,
evaluate risks), outbreak response and containment operations and post-epidemic
evaluation (WHO, 2014).
According to this study, the study population was nurses as current university
students that they have two level of education were compared. With regards education
level of the nurses and their knowledge and perception level were significant
association; higher education level was higher knowledge and perception level about

94

the research topic. Therefore, health education program should be done widely to get
adequate knowledge and to be awareness raising about Ebola disease among pubic in
disseminating preparedness messages and provides specific response strategies and
then capacity building program should be promoted such as infection control training
and personal protective equipments training and health talks, workshop, symposium
and seminar about emerging disease like Ebola among all health care workers.
Moreover, regarding the title of the study; Knowledge and perceptions
towards Ebola virus disease among nursing students in University of Nursing,
Yangon in the study population that was found out to their willingness, interests,
desires and conceptual knowledge and perception level leading to alertness,
preparedness, response, and control activities about Ebola disease. In Myanmar, there
are not previous studies and still needed to find out relevant research on current
outbreak Ebola virus disease. And then few literature reviews in other countries were
conducted and assessed about it. These findings will be useful and beneficial for
another study regarding Ebola virus disease and other outbreak control program and
health care and infectious disease control activities that will be relevant and reliable
data among nurses or health personnel about Ebola disease. Ministry of Health in
Myanmar has been many activities as health promotion, prevention and disease
control activities so this study was showed to emphasize and be absolutely highlights
and then effectively prepare and mange to 2014 epidemic Ebola outbreak as an
international public health emergency.

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CHAPTER 7

CONCLUSION

This study is an analytical cross sectional study conducted in University of


Nursing, Yangon Region, Myanmar to study knowledge and perception towards
Ebola virus disease among nursing students. Total 170 students were recruited by
using school registers with lottery method and selected by simple random sampling
methods. By self-administered questionnaires method, data were collected with
structured questionnaires during October, 2014. Frequencies, percentage, mean,
median, mode, range and standard deviation were used for descriptive analysis in this
study. Chi-square, independent samples t test and ANOVA method were used as
statistical test to find out the associations between independent and dependent
variables. The significant level used in hypothesis tests was set at 95%.
In this study, age was purposively categorized as three groups of 21 to 30
years, 31 to 40 years and 41 to 50 years to do data analysis among respondents in
study area. The majority were Buddhists and Bamar race. More than half of the
students 77.0% were single. Most of the respondents 92.4% (95% CI = 88 to 96%)
respondents have other degree or graduation such as diploma in ICU, ENT and
graduated in B.A or B.Sc. In this study, total years of service of the respondents were
purposively categorized by two groups that showed 0 to 5 years and > 5 years
respectively. 92.9% of the respondents have been working in hospital based in clinical
sites members and community based in public health sites are only 7.1% in this study.
10.6% (95% CI = 6 to 15%) of the respondents have got infection control and
emergency training and 89.4% have not got about training. In this study, elder age
groups had more knowledge level than younger age groups and it was also associated
with total years of service. Furthermore, the level of knowledge and perception was
high between the level of academic year and it was also associated with total years of

96

service. Moreover, level of knowledge was also high level that depended on longer
years of service, presence of other degree or graduation and infection control training.
Then, the knowledge level of the respondents was slightly higher in public health
posting site than clinical posting sites but also association was not found out.
In this study, regarding knowledge scores, more than half of the students
54.7% had good knowledge about Ebola disease and nearly half of the students 45.3%
had poor knowledge respectively. Minimum knowledge scores are 7 while maximum
one is 40 upon 42 given marks. In this study, regarding perception scores, more than
half of the students 55.3% had good perception and nearly half of the students 44.7%
had poor perception towards Ebola disease respectively. Minimum perception scores
are 32 while maximum one is 48 upon 48 given marks.
Through, most of the respondents heard information about Ebola disease from
social media and they mainly heard from television, radio, internet news, journals and
newspapers and friends. Most of the respondents heard more than one kind of social
media. It could conclude that health education program and media information
dissemination play an important role to achieve the better outcomes of disease
controlling and combating activities.
Study findings revealed that higher education level were significantly
associated with knowledge and perception level. Although respective with higher
education level has higher knowledge and higher perception level. This study also
found out that knowledge level was significantly associated with perception level.
In conclusion, the results of this study showed that knowledge level was
significantly associated with education level, total years of service, and perception
level after data analysis. It was concluded that although they had got life experience in
government employee life, their knowledge and perception levels were not much
different between high and low levels. There was some misconception on the
knowledge and perception towards Ebola disease. Therefore, health education about
emerging disease like Ebola should be provided not only in general population but
also in health care workers with correct and essential information to reduce incorrect
knowledge and encouraged the health care personnel to be good perception and
attitude in disease controlling activities with voluntary involvement.

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CHAPTER 8

RECOMMENDATIONS

In this study, that found out to the knowledge level of the respondents was
significantly associated with academic year, total years of service and perception level
of the respondents about Ebola disease these were the most important factors to
determine these study objectives. Based on the study finding, the following
recommendations are suggested for future outbreak control program.
8.1 Implementation
1) According to this study result, television and radio are proper channels and
effective means of information dissemination widely during disease outbreak. So,
health promotion and disease control programs especially for outbreak control are
recommended to disseminate health information through television and radio to
achieve the effective outcomes of disease control programs.
2) The academic year of the respondents was associated factor on knowledge and
perception towards Ebola disease. The findings from the respondents highlighted that
higher education level can access and understand current problems regarding health
knowledge, health care provision, outbreak and disease control activities. Beside that,
all health care workers such as nurses also need to be essential knowledge level that
based on the education level to combat epidemic outbreak. Also updating education
program and technical trainings and supervisory meetings between healthcare workers
and general population are recommended to do as a regular basis and more frequent.
3) The total years of service were also associated with good knowledge and good
perception in this study. Service years are one important fact to manage disease
control and epidemic outbreak so the health care workers with longer services
duration should be recruited and enrolled voluntary into outbreak control activities.

98

4) The support from elder age can increase the knowledge and perception level among
the respondents according to result of this study. The elder age among the respondents
is showed the higher knowledge level whose have been longer service duration and
life experiences about outbreak control so is recommended that elder age group than
younger age group should be emphasized to be recruitment and enrollment voluntary
with personalized consent into outbreak control activities like a crisis.
5) In this study, the support from presence of other degree or qualification can
increase the knowledge level among the respondents according to result of this study.
So, educational career preference among health care workers especially nurses is
recommended to expand, invite and be attended and learned by voluntary or
sequential enrollment that can get proper knowledge and awareness raising in
comprehensive health care services.
6) In this study area, the support from presence of infection control training can
increase the knowledge level among the respondents according to result of this study.
So this study is recommended that infection control training such as H1N1 or SARS
training should be trained to all health care workers alternatively and sequentially.
Therefore, a comprehensive outbreak control program which includes health
information and education sessions, and capacity building for service providers
(including health educators and health care workers) is recommended to design for
educational policy maker and advisors, government and international organizations.
Then, the continuous sessions for capacity building and trainings on Ebola disease are
recommended to conduct for both of nurses or healthcare workers and volunteer
workers. Consequently, the raising awareness and promoting knowledge and
motivating perception among health sectors will also support to be proper knowledge
and to change health workers attitude on outbreak control. Finally, successful disease
control programs among those study population like health care workers are needed to
encourage and engage with implementation and intervention by service providers,
focal persons and implementing organizations.

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8.2 Limitations of this study


1) Target study group were only limited on nurses.
2) Time constraints and cross sectional analytic study was done.
3) Study population was conducted in 170 populations.
4) Study area was restricted only in University of Nursing, Yangon.
5) Associated factors were identified may be difficult to interpret.

8.3 Further research


1) A study should also be conducted to find out the factors and their perceptions and
health care practice towards emerging disease like Ebola disease among health care
workers.
2) This study is a quantitative study and future studies should be conducted to identify
the factors associated with outbreak control like Ebola disease and to explore more
constraints and barriers in health care workers by using both quantitative and
qualitative methods.
3) Another qualitative study should be conducted among healthcare providers about
emerging disease like Ebola disease by using in-depth interview and focus group
discussion to be helpful for health policy makers.

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106

ANNEXES
Annex (1) Variables and operational definitions
No.

Variable Names

Operational definitions

Measurement
scale

1.

Age

Age in completed years

Ratio

2.

Gender

Acquired identity for male or female

Nominal

3.

Race

Race of respondent

Nominal

4.

Academic year

5.

Marital status

6.

Level of student in his/her University


students life
The respondents whose have married or
unmarried condition

Total years of

The respondents whose have been

service in

functioned years in government service

government

life

Other qualification

8.

Current posting

9.

Training

10.

Information

Present/absence of other formal


education level of the respondents
It means the place of work site that has
been posted currently of the respondents
It means the present/ absence of Infection
Control Training or others
Sources of information getting about
Ebola disease
It means that the facts of knowing about

11.

Knowledge

Ordinal

Nominal

Ordinal

Nominal

Nominal

Nominal

Nominal
Ordinal

something, general understanding or


familiarity with Ebola disease

12.

Perception

The way of feeling or thinking towards


Ebola disease

107

Nominal

Annex (2) Informed consent form (English and Myanmar)


Informed Consent Form for the research about Knowledge and Perception
towards Ebola virus disease among nursing students in University of Nursing,
Yangon
This informed consent form is for involvement of the nurses (Nursing
University (Bridge) Students) in the present study and who are inviting to participate
in research, titled Knowledge and perception towards Ebola virus disease among
nursing students in University of Nursing, Yangon.
Name of Principal Investigator

- Min Htike Aung

Name of Organization

- University of Public Health, Yangon

Name of Proposal

-Knowledge and perception towards Ebola


virus disease among nursing students

in

University of Nursing, Yangon

PART I: Information Sheet


(1)

Introduction
I am Min Htike Aung, and studying at University of Public Health. I am doing

research on Knowledge and perception towards Ebola virus disease among nursing
students in University of Nursing, Yangon. I am going to give you information and
invite you to be part of this research. Before you decide, you can talk to anyone you
feel comfortable with about the research. This consent form may contain words that
you do not understand. Pleases ask me to stop as we go through the information and I
will take time to explain. If you have questions later, you can ask me or another
researcher.

(2)

Purpose of the research


In this study, we would like to gather Knowledge and perception towards

Ebola virus disease among nursing students in University of Nursing, Yangon. This
information might helpful in strengthening of the public health education program.

108

(3)

Type of research intervention


This research will involve your participation in self-administered questioning
and answering.

(4)

Participant selection
You are being invited to take part in this research because we feel that you had

knowledge and perception towards Ebola disease.

(5)

Voluntary participation
Your participation in this research is entirely voluntary. It is your choice

whether to participate or not. If you choose not to participate in the study and nothing
will change. You may change your mind later and stop participating even if you
agreed earlier.

(6)

Procedures
We are inviting you to take part in this research. If you accept, you will be

asked to answer self-administered questions. Some questions may be sensitive or


potentially cause embarrassment to you as the questions are concerned with
perception towards Ebola virus disease. If you do not wish to answer any of the
questions during the interview, you can move to the next question. The information
recorded is confidential, and no one else except [Min Htike Aung] will access to the
information documented during your interview.

(7)

Risk and discomforts


There is a risk that you may share some personal or confidential by chance, or

that you may feel uncomfortable talking about some of the topics. However, we do
not wish for this to happen. You do not have to answer any questions or take part in
the survey if you feel the question(s) are too personal or if talking about them makes
you uncomfortable.

109

(8)

Benefits
There will be no direct benefit to you, but your participation is likely to help

us find out more about how to provide appropriate public health information and
services in line with the needs of knowledge and perception towards Ebola virus
disease.
.
(9)

Incentives
You will not be provided any incentives to take part in the research.

(10)

Confidentiality
The research being done in the community may draw attention and if you

participate you may be asked questions by other people in the community. We will
not be sharing information about you to anyone outside the research team. The
information that we collect from this research will be kept private. Any information
about you will have a number on it instead of your name. Only the researcher will
know what your number is and we will keep the number safely.

(11)

Sharing the results


The knowledge that we get from this research will be shared with you and

local health staff before it is made widely available to the public. We will publish the
results so that other interested people may learn from the research.

(12)

Right to refuse or withdraw


You do not have to take part in this research if you do not wish to do so, and

choosing not to participate will not affect your rights and advantages in any way. You
may stop participating in the answering the questions at any time that you wish
without being affected.

110

(13)

Who to contact
If you have any questions, you can ask them now or later. If you wish to ask

questions later, you may contact Min Htike Aung (Phone no - 0943004426),
University of Public Health, Yangon.

PART II: Certificate of Consent


I have been invited to participate in research about Knowledge and
perception towards Ebola virus disease among nursing students in University of
Nursing, Yangon. I understand that I will participate in answering the survey
questionnaire. I have been informed that the risks are minimal and may include
feeling of embarrassment or discomfort. I am aware that there may be no benefit
(money or any other rewards) to me personally. I have been given with the name and
address of a researcher who can be easily contacted.
I have read foregoing information, or it has been read to me. I have had the
opportunity to ask questions about it and any questions I have been asked and have
been answered to my satisfaction. I consent voluntarily to be a participant in this
study and understand that I have the right to withdraw from the interview at any time
without in any way affecting my personal life.

Name of participant

-------------------------

Signature of participant

-------------------------

Date

-------------------------

I have been read this consent form for participation and known about their
desire questioning and answering. I confirm about participants consent freely getting
it.

Name of researcher

-------------------------

Signature of researcher

-------------------------

Date

-------------------------

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116

Annex (3) Questionnaire form (English and Myanmar)


Questionnaire on Knowledge and Perception towards Ebola Virus Disease
This questionnaire is only for research purpose. The results will not be linked to
individual respondent and will be kept confidential. Name of the respondent is not
needed to describe. It is requested to answer all questions. Thank you for your
participation.
Identification No.
(A) Socio-demographic characteristics
Please 'Circle' for your answers e.g.
1. Gender
(1) Male

for First Year (B I) student

(2) Female

2. Academic year
(1) First Year (B I)

(2) Second Year (B II)

3. Age (completed age in years)


4. Race (1) Bamar

------------- yrs

(2) Other ------------------------ (Specify)

5. Religion
(1) Buddhist

(2) Christian

(3) Hinduism

(4) Islam

(5) Others -------------------------- (Specify)

6. Marital Status
(1) Single
(4) Widow

(2) Married
(3) Divorced/Separated
(5) Others -------------------------- (Specify)

7. Total years of service in government

-------------------- yrs

8. Other degree or graduation


(1) Present ------------------------------------------- (Specify)
(2) Absent
9. Current place of posting/ department
(1) Station/Township Hospital (2) District Hospital
(3) Regional Hospital

(4) Health Center

10. Infection Control Training


(1) Present -------------------------------------------- (Specify)
(2) Absent

117

Office Use

(B) Sources of information about Ebola Disease


I have heard information about Ebola disease from the following sources
(a) Television

(1) Yes

(2) No

(b) Radio

(1) Yes

(2) No

(c) Journals/ Newspaper (1) Yes

(2) No

(d) Internet news

(1) Yes

(2) No

(e) Pamphlet/posters

(1) Yes

(2) No

(f) Health talks

(1) Yes

(2) No

(g) Peer groups

(1) Yes

(2) No

(h) Others (Specify) ---------------------------------------

(C) Knowledge about Ebola Disease


1. Ebola disease is caused by Ebola virus.
(1) True

(2) False

(3) Dont know

2. Ebola virus is one of the species of Influenza virus.


(1) True

(2) False

(3) Dont know

3. Ebola species were started from human.


(1) True

(2) False

(3) Dont know

4. Ebola virus is found in monkeys and chimpanzees.


(1) True

(2) False

(3) Dont know

5. Ebola disease was found in pigs and bats.


(1) True

(2) False

(3) Dont know

6. Ebola virus was also found in vector animals as mosquitoes and flies.
(1) True

(2) False

(3) Dont know

7. Ebola virus can survive in freezers and refrigerator.


(1) True

(2) False

(3) Dont know

118

Office Use

8. Ebola virus can die into heating 60 C in 60 minutes.


(1) True

(2) False

(3) Dont know

9. Ebola virus is transmitted by air borne.


(1) True

(2) False

(3) Dont know

10. Ebola virus is transmitted through food and water.


(1) True

(2) False

(3) Dont know

11. Ebola virus can be transmitted by direct contact with infected patients.
(1) True

(2) False

(3) Dont know

12. Ebola virus can be transmitted by touching contaminated objects.


(1) True

(2) False

(3) Dont know

13. Ebola virus can be transmitted by touching contaminated blood and


bodily fluids.
(1) True

(2) False

(3) Dont know

14. Low grade fever is a sign of Ebola disease.


(1) True

(2) False

(3) Dont know

15. Headache and sore throat are early signs of Ebola disease.
(1) True

(2) False

(3) Dont know

16. Signs of Ebola disease include muscle pain and joint pain.
(1) True

(2) False

(3) Dont know

17. Constipation is a signs of Ebola disease.


(1) True

(2) False

(3) Dont know

119

18. Intense weakness is a prominent sign of Ebola disease.


(1) True

(2) False

(3) Dont know

19. Hematemesis and bloody diarrhea are followed by Ebola symptoms.


(1) True

(2) False

(3) Dont know

20. Ebola disease may destroy kidney and liver.


(1) True

(2) False

(3) Dont know

21. Internal bleeding includes one of the complications of Ebola disease.


(1) True

(2) False

(3) Dont know

22. Fits are a sign of Ebola disease.


(1) True

(2) False

(3) Dont know

23. Ebola disease is a 90% fatal syndrome.


(1) True

(2) False

(3) Dont know

24. The incubation of Ebola disease is from 2 to 21 days.


(1) True

(2) False

(3) Dont know

25. Ebola virus can be detected by blood test.


(1) True

(2) False

(3) Dont know

26. Ebola virus can be detected by urine testing.


(1) True

(2) False

(3) Dont know

27. Ebola virus can be detected by tissues biopsy.


(1) True

(2) False

(3) Dont know

28. Ebola virus can be detected by X ray and ultrasound.


(1) True

(2) False

(3) Dont know

120

29. Health workers are high risks persons in Ebola disease.


(1) True

(2) False

(3) Dont know

30. Mortuary attendants include persons at risks in Ebola disease.


(1) True

(2) False

(3) Dont know

31. Regular hand washing is one method to prevent Ebola disease.


(1) True

(2) False

(3) Dont know

32. Ebola disease can be protected by using personal protective


equipments.
(1) True

(2) False

(3) Dont know

33. Ebola disease can be protected by vaccination.


(1) True

(2) False

(3) Dont know

34. Effective medication is available to control Ebola disease.


(1) True

(2) False

(3) Dont know

35. By using and rinsing soap to contaminated objects can prevent


Ebola transmission.
(1) True

(2) False

(3) Dont know

36. Using disinfectants such as bleaching powders can prevent


Ebola transmission.
(1) True

(2) False

(3) Dont know

37. Ebola suspected patients can treat in normal patient units.


(1) True

(2) False

(3) Dont know

38. Ebola suspected patients should be kept in isolation unit.


(1) True

(2) False

(3) Dont know

121

39. Ebola suspected patients should be kept quarantine for five days.
(1) True

(2) False

(3) Dont know

40. The person who died of Ebola disease can be done in


usual burial ceremonies.
(1) True

(2) False

(3) Dont know

41. All waste products touching with Ebola patients must be destroyed
by burning.
(1) True

(2) False

(3) Dont know

42. When Ebola suspected patient is detected, you should inform to


near health center respectively within 3 days.
(1) True

(2) False

(3) Dont know

122

(D) Perception towards Ebola disease

Office Use

1. Everybody should aware the life threatening about Ebola disease.


(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
2. All health personnel are not important not to access updated
information about Ebola disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
3. Fever screening is done into external travelers is not important to
control Ebola disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
4. Nurses should have a systematic PPE (personal protective
equipments) training.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
5. Infection control and systematic waste management is important
method to control Ebola disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree

123

6. It is not important that health personnel have adequate knowledge,


experiences and practices about emerging disease like Ebola.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
7. I have no desire to involve in Ebola combating activities.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
8. I do not induce to my co-workers for involvement in Ebola
combating activities.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
9. I do not interest about Ebola disease that has currently caused
in Myanmar.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
10. Ebola that cannot reach in Myanmar is recognized a national
surveillance disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree

124

Office Use

11. In continuing nursing education program, the selection topic towards Office Use
emerging disease like Ebola should be presented and discussed.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
12. I would share and distribute to my family, friends and colleagues
about information on Ebola disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree

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()

133




()
()
()
()

()
()
()
()


(Emerging diseases)
()
()
()
()


()
()
()
()

134

Annex (4) Scoring System


Scoring system of Knowledge and Perception towards Ebola Virus disease
1. Knowledge about Ebola disease
Score
No. Knowledge about Ebola disease

True

False Don't
know

1.

Ebola disease is caused by Ebola virus.

2.

Ebola virus is one of the species of Influenza virus.

3.

Ebola species started from human.

4.

Ebola virus is found in monkeys and chimpanzees.

5.

Ebola disease was caused in pigs and bats.

6.

Ebola virus is also found in vector animals as

mosquitoes and flies.


7.

Ebola virus can survive in freezers and refrigerator.

8.

Ebola virus can die into heating 60 C in 60 minutes.

9.

Ebola virus is transmitted by air borne.

10.

Ebola virus is transmitted through food and water.

11.

Ebola virus can be transmitted by direct contact with

infected patients.
12.

Ebola virus can be transmitted by touching


contaminated objects.

13.

Ebola

virus

can

be

transmitted

by

touching

contaminated blood and body secretions.


14.

Low grade fever is a sign of Ebola disease.

15.

Headache and sore throat are early signs of Ebola

disease.
16.

Signs of Ebola disease include muscle pain and joint


pain.

17.

Constipation is a signs of Ebola disease.

18.

Intense weakness is a prominent sign of Ebola disease.

135

1. Knowledge about Ebola disease


Score
No. Knowledge about Ebola disease
True
19.

Hematemesis and bloody diarrhea are followed by

False Don't
know

Ebola disease.
20.

Ebola disease may destroy kidney and liver.

21.

Internal bleeding includes one of the complications of

Ebola disease.
22.

Fits are a sign of Ebola disease.

23.

Ebola disease is a 90% fatal syndrome.

24.

The incubation of Ebola disease is from 2 to 21 days.

25.

Ebola virus can be detected by blood test.

26.

Ebola virus can be detected by urine testing.

27.

Ebola virus can be detected by tissues biopsy.

28.

Ebola virus can be detected by X ray and ultrasound.

29.

Health workers are high risks persons in Ebola disease.

30.

Mortuary attendants include persons at risks in Ebola

disease.
31.

Regular hand washing is one method to prevent Ebola


disease.

32.

Ebola disease can be protected by using personal


protective equipments.

33.

Ebola disease can be protected by vaccination.

34.

Effective medication is available to control Ebola

disease.
35.

By using and rinsing soap to contaminated objects can


prevent Ebola transmission.

136

1. Knowledge about Ebola disease


Score
No. Knowledge about Ebola disease
True
36.

Using disinfectants such as bleaching powders can

False Don't
know

prevent Ebola transmission.


37.

Ebola suspected patients can treat in normal patient


units.

38.

Ebola suspected patients should be kept in isolation


unit.

39.

Ebola suspected patients should be kept quarantine for


five days.

40.

The person who died of Ebola disease can be done in


usual burial ceremonies.

41.

All waste products touching with Ebola patients must


be destroyed by burning.

42.

When Ebola suspected patient is detected, you should


inform to near health center respectively within 3 days.

Good knowledge level (>67%)

29 - 42 scores (By mean score - 28.51)

Poor knowledge level ( 66%)

0 - 28 scores

137

2. Perception towards Ebola disease


No.
1.

4.

Positive statements

Score

Everybody should aware the life threatening about Ebola disease.


(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Nurses should have a systematic PPE (personal protective


equipments) training.

5.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Infection control and systematic waste management is important


method to control Ebola disease.

11.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

In continuing nursing education program, the selection topic towards


emerging disease like Ebola should be presented and discussed.
(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

138

No.

Positive statements

Score

12.

I would share and distribute to my family, friends and colleagues


to information about Ebola disease.

No.
2.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Negative statements

Score

All health personnel are not important not to access updated


information about Ebola disease.

3.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Fever screening is done into external travelers is not important to


control Ebola disease.

6.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

It is not important that health personnel have adequate knowledge,


experiences and practices about emerging disease like Ebola.
(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

139

No.
7.

8.

Negative statements

Score

I have no desire to involve in Ebola combating activities.


(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

I do not induce to my co-workers for involvement in Ebola


combating activities.

9.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

I do not interest about Ebola disease that has currently caused in


Myanmar.

10.

(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Ebola that cannot reach in Myanmar is recognized a national


surveillance disease.
(1) Strongly agree

(2) Agree

(3) Disagree

(4) Strongly disagree

Good perception

44 - 48 scores (By mean score - 43.73)

Poor perception

12 - 43 scores

140

Annex (5) Gantt Chart

Month
Days(From---to--)
Protocol
preparation
Protocol defense
Data collection
Data Entry and
Analysis
Thesis
preparation
Submission of
thesis(draft)
Distribution of
draft to readers
Thesis defense
Submission of
Thesis

September
1

19

22

October
24

25

10

13

November
31

21

24

28

December
4

12

15

19

22

31

Annex (6) Curriculum Vitae


1. Name

Min Htike Aung

2. Date of Birth

8-7-1986

3. Place of Birth

Chaungzon Township ,Mon State

4. Nationality

Mon/Bamar

5. Religion

Buddhist

6. Education

B.N.Sc
University of Nursing, Yangon

7. Year of Qualification

January, 2007

Tutor

8. Current function
1-12-2014 up to now

Community Health Nursing


Department,
University of Nursing, Yangon
9. Previous function
25-3-2009 to 31-3-2011

Trained Nurse
Yangon Children Hospital

1-4-2011 to 30-11-2014

Instructor
Community Health Nursing
Department,
University of Nursing, Yangon

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