Knowledge about occupational latex allergy amongst Thai nurses and student nurses

doi:10.4236/health.2011.35054

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Vol.3, No.5, 312-318 (2011)

doi:10.4236/health.2011.35054

Health

Knowledge about occupational latex allergy amongst

Thai nurses and student nurses*

Chompunuch Supapvanich, Andrew Povey, Frank de Vocht#

Centre for Occupational and Environmental Health, School of Community Based Medicine, The University of Manchester, Man-

chester, UK; #Corresponding Author: frank.devocht@manchester.ac.uk

Received 22 January 2011; revised 24 April 2011; accepted 28 April 2011.

ABSTRACT

Glove usage, particularly powdered latex glove

is a cause of latex allergy in hospital workers;

therefore those workers must have latex allergy

knowledge to protect themselves and patients

from serious health problems. This study aimed

to examine knowledge about latex allergy among

nurses and compare their performance with

student nurses in Thailand. A knowledge ques-

tionnaire was administered to a random sample

of 30 nurses and 30 student nurses who worked

in hospitals where powdered latex gloves were

used. Overall, nurses and student nurses gave

correct responses to 27% and 28% of the ques-

tions, respectively. There was no statistically

significant difference in knowledge between

nurses and student nurses. Both nurses and

student nurses in Thailand have insufficient

knowledge about latex allergy and its risk fac-

tors. Additional continuing education should be

provided to reduce the probability of adverse

reactions in sensitized staff and patients in Thai

hospitals.

Keywords: Latex Allergy; Education; Nurses;

Student Nurses; Hospitals

1. INTRODUCTION

Natural rubber latex (NRL) can cause allergic symp-

toms in health care workers who use products containing

these allergens in their daily work and it has been shown

that the incidence of latex allergy in health care workers

can usually be associated with exposure to latex aller-

gens encountered at the workplace [1]. The prevalence

of latex allergy in health care workers ranges from 2% to

18% [2,3], whilst in the general population, the preva-

lence of latex allergy ranges between 0.4% - 2.3% [4].

Exposure to natural rubber latex can result not only in

skin problems such as irritant, allergic contact dermatitis,

angioedema, and itchy skin [2,5], but also respiratory

problems such as rhinitis, sneezing, wheezing [3,6].

Furthermore, it can also cause serious adverse health

effects such as asthma and anaphylaxis [7]. Whilst the

replacement of latex gloves with non-latex or non-

powder gloves has been shown to reduce the incidence

of latex allergy [8], such measures may not be suitable in

some developing countries due to their cost. For exam-

ple, in Thailand, powdered latex gloves are still widely

used [9]. In such situations, it has been argued that con-

tinuing education about latex allergy is essential to sup-

port the effectiveness of latex allergy prevention and

control policies in hospitals [10]. Health effects of latex

allergy can occur not only in health care workers but

also in sensitised patients for whom they take care [11].

Thus providing latex allergy education is of importance

not only for health care workers themselves but also for

the health of their patients. To the best of our knowledge

no study has yet reported on the levels of knowledge

about latex allergy among health care workers in Thai-

land. The purpose of this study was to evaluate the use

of a dedicated latex-knowledge questionnaire in health

care workers in Thailand and subsequently to provide an

indication about the level of knowledge about latex al-

lergy-related issues among Thai nurses and student

nurses.

2. METHODS

In this cross-sectional study, 30 nurses were randomly

selected from 11 community hospitals and 30 3rd-year

student nurses from a University in Thailand were also

randomly invited to participate. The study was collected

in June - July 2008. All enrolled nurses were currently

*Funding: This work is part of a PhD project sponsored by the Royal

Thai Government.

Competing Interests: None

thical approval for this study was obtained from the University o

Manchester’s Committee on the Ethics of Research on Human Beings

(ref TPCS/ethics/08117).

C. Supapvanich et al. / Health 3 (2011) 312-3 18

313313

employed in one of the hospitals, while student nurses

had just finished their nursing internships in hospitals

where powdered latex gloves were routinely used. All

participants were asked to complete a questionnaire that

evaluated their knowledge on latex allergy.

This questionnaire was developed specifically for this

study and was divided in four distinct domains: 1) pre-

vention of latex allergy, 2) potential adverse effects on

health, 3) potential risk factors for latex allergy and 4)

diagnosis of latex allergy. Questions were derived by the

authors based on literature reviews [5,12] and on the

latex allergy guidelines from the National Institute for

Occupational Safety and Health (NIOSH) and Health

and Safety Executive (HSE) [13,14]. The questionnaire

was designed so that positive and negative statements

were randomly distributed in all four domains. The final

version was peer reviewed by experts in the field of im-

munology and epidemiology. Subsequently, it was

translated from English to Thai and back-translated from

Thai into English by a second bilingual researcher to

check for consistency and clarity of translation. Re-

spondents were required to reply to each question on a

five-point Likert scale ranging from “strongly disagree”

to “strongly agree” [15]. Five-point Likert scale answers

were then scored between +2 to –2 depending on

whether the answer was correct or incorrect, respectively

(either strongly agree (+2), agree (+1) or disagree (–1) or

strongly disagree (–2), depending on the question), with

the response of ‘uncertain’ scored as zero score. Scores

from each nurse or student nurse were subsequently

added up per question as well as per domain to compare

group-differences in knowledge between nurses and

student nurses. This implies that a participant who gave

the correct answer to all questions (answering strongly

agree/disagree) would have a score of 50, while some-

one who was incorrect at all questions (answering

strongly agree/disagree) would have –50. A Cronbach’s

alpha (reliability) of 0.755 was found indicating internal

consistency in this knowledge questionnaire instrument.

Statistical analyses were conducted using SPSS 15.0

software for window (SPSS Inc.UK). Descriptive data

analysis was used to assess the distribution of variables.

Independent t-tests were used to compare the difference

of knowledge scores between nurses and student nurses.

A p-value of 5% was considered to indicate statistical

significance. Bonferroni corrections were used to ac-

count for issues of multiple-comparisons [16].

3. RESULTS

56 of 60 respondents completed and returned the

questionnaires giving a response rate of 93%. There was

no difference in the response rate between nurses and

student nurses. The general characteristics of the re-

spondents are described in Table 1. About 91% of re-

spondents were female, which is comparable to the Thai

nursing population [17]. The age of respondents ranged

from 20 to 50 years with a mean age (SD) of 27.2 (7.8)

years. Students were on average 7 years younger than

nurses (27 vs. 34, respectively). 24 of 28 nurses (86%)

graduated with a bachelor degree in nursing, with the

remaining 4 (14%) graduating with a diploma in nursing.

On average, nurses had been working as nurses for 6

years, ranging from 3 months to 26 years. 90.4% of re-

spondents wore powdered latex gloves in their work

shifts (80% and 100% for nurses and students, respec-

tively), using on average 5.5 (SD = 3.7) pairs per day.

Group knowledge scores were normally distributed.

The mean knowledge assessment scores of all respon-

dents was –0.04 (SD = 0.16) (Table 2). A comparison of

mean scores between both groups of nurses and student

nurses showed that there were no significant difference

in latex allergy knowledge (p = 0.71). None of the mean

knowledge scores for domains D1 to D4 differed sig-

nificantly from zero, and were –0.09, –0.05, 0.20, and

–0.65 for domains D1 to D4, respectively. The partici-

pants knew the least about issues related to the diagnosis

of latex allergy (D4) with only 1.8% and 5.4% of ques-

tions answered correctly by the nurses and student

nurses (Table 3), respectively. The highest number of

correct answers was found for questions addressing po-

tential risk factors for latex allergy (D3) (34.5% in

nurses and 37% in student nurses, respectively).

No Statistically significant differences were found

between nurses and student nurses in any of the do-

mains.

Overall, 28% of answers were correcting answer, but

the majority of questions (41%) were answered as “Do

not know” (Table 3). Over 50% of all respondents gave

a correct answer on “Screening can assist to identify

latex allergy” (question 1), “Atopic individual have risk

to develop latex allergy” (question 9), and “Instruments

such as syringes, air ways, endotracheal tubes and oxy-

gen tubing contain latex allergens” (question 24).

However, knowledge was low, with less than 25% of

respondents giving a correct answer, on the following

questions;

Q3. The room must be clean and the air allowed to

settle for at least 6 hours before latex allergy patients are

admitted.

Q11. Skin irritation to latex gloves is a result from an

immune response.

Q13. Latex allergy can be diagnosed by clinical symp-

toms only.

Q14. The patch test is a common investigation method

in latex allergy (immediate hypersensitivity).

Q16. Diagnosis of immediate hypersensitivity to latex

C. Supapvanich et al. / Health 3 (2011) 312-3 18

314

can be confirmed by skin prick test, blood test, wear test

of a patch test.

Q23. Chemicals in latex gloves can induce respiratory

symptoms in health care workers.

A comparison of the proportion of correct answers for

each question between nurses and student nurses sug-

gested statistically significant differences for questions 1

and 19 (p < 0.05). As a group, student nurses seemed to

better than nurses in identifying that screening can assist

in identification of latex allergic patients (question 1) (p

< 0.01), while more nurses gave a correct answer re-

garding adverse symptoms to latex allergens (question

19) (p < 0.05). However, adjusting for multiple com-

parisons none of these remained statistically significant.

Table 1. Personal status between response nurses and student nurses in thailand (n = 56).

Variable Total Number (%)Nurses (%) Student Nurses (%)

Study Population (% Response Rate) 56 (93.3) 28 (93.3) 28 (93.3)

Gender

Female 51 (91.1) 28 (100) 23 (82.1)

Male 5 (8.9) 0 5 (17.9)

Age (Mean ± SD) 27.2 ± 7.8 33.5 ± 6.4 20.9 ± 0.5

20 - 29 Years 32 (57.1) 4 (14.3) 28 (100.0)

30 - 39 Years 18 (5.3) 18 (64.3) 0

≥ 40 Years 6 (28.6) 6 (21.4)) 0

Ethnic

Thai 40 (71.4) 12 (42.9) 28 (100.0)

Thai-Malaysian 16 (28.6) 16 (57.1) 0

Education

Bachelor 52 (92.9) 24 (85.7) 28 (100.0)

Diploma 4 (7.1) 4 (14.3) 0

Work/Internship Experience (Mean ± SD) 6.1 ± 7.3 6.02 ± 7.46 0.49 ± 1.07

≤ 10 Years 35 (62.5) 7 (25) 28(100)

≥ 10 Years 21 (37.5) 21 (75) 0

Use of Powdered Latex Gloves (n = 52)

No 5 (9.6) 5 (20.8) 0

Yes 47 (90.4) 19 (79.2) 28 (100)

Number of Powdered Gloves (n = 47) (Mean ± SD) 5.5 ± 3.7 6.1 ± 4.6 5.3 ± 2.9

1 - 5 Pairs per Day 29 (61.7) 10 (52.6) 19 (67.9)

> 5 Pairs per Day 18 (38.3) 9 (47.4) 9 (32.1)

Table 2. Comparison of mean scores (two-sample t-test) on latex allergy knowledge between nurses and stu-

dent nurses.

Mean Score (± SD)

Knowledge Domain Total Nurses Student Nurses

95%CI

Overall –0.04 (± 0.16) –0.04 (± 0.15)–0.05 (± 0.17) –0.10 to 0.07

D1. Prevention of Latex Allergy –0.09 (± 0.27) –0.11 (± 0.25)–0.06 (± 0.28) –0.10 to 0.18

D2. Potential Adverse Effects on Health –0.05 (± 0.38) –0.02 (± 0.32)–0.08 (± 0.44) –0.26 to 0.14

D3. Potential Risk Factors for Latex Allergy 0.20 (± 0.29) 0.21 (± 0.25) 0.19 (± 0.33) –0.17 to 0.14

D4. Diagnosis of Latex Allergy –0.65 (± 0.55) –0.63 (± 0.46)–0.68 (± 0.65) –0.35 to 0.25

C. Supapvanich et al. / Health 3 (2011) 312-3 18

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Table 3. Percentages of correct, incorrect and unknown answers and “knowledge scores” for each question in the questionnaire,

stratified for nurses (n = 28) and student nurses (n = 28).

Correct (%) Wrong (%) Don’t Know (%) Mean Score

Items Total nursesStudent

nurses TotalNurses Student

nurses Totalnurses Student

nurses Nurses Student

nurses

Two-sample

t-test

P – value

< 0.051

Overall 28.0 27.628.4 33.132.134.1 39.040.437.6

D1: Prevention of Latex Allergy 23.3 23.023.5 29.827.532.1 46.749.044.4 –0.04 –0.05

1. Screening can assist health care workers to

identify an allergic patient. 82.1 67.996.4 5.410.70 12.5 21.43.6 0.71 1.43 **

2. A latex sensitized patient should be first on

the operation list. 25.0 14.335.7 26.832.121.4 48.2 53.642.9 –0.29 0.14

3. The room must be clean and the air al-

lowed settle for at least 6 hours before pa-

tients with latex allergy are admitted.*

16.1 28.63.6 53.657.150.0 30.4 14.346.4 –0.32 –0.68

5. “Hypoallergenic gloves” can reduce latex

allergy in health care workers.* 3.6 7.1 0 44.625.064.3 5064.335.7 –0.64 –0.75

8. Nitrile gloves can induce latex sensitisa-

tion in health care workers.* 5.4 3.6 7.1 21.417.925.0 73.278.667.9 –0.14 –0.18

18. The use of powder free glove is a way o

reducing latex allergy in health care workers. 30.4 39.321.4 16.17.1 25.0 53.6 53.653.6 0.32 0

21. Nitrile gloves and vinyl gloves contain

latex allergens.* 0 0 0 41.142.939.3 58.957.160.7 –0.43 –0.50

D2: Potential adverse effects on health 33.6 34.532.7 32.733.332.1 33.331.535.1 –0.02 –0.08

4. Latex allergic reactions cannot develop to

be potential life–threatening.* 50.0 42.957.1 16.125.07.1 33.932.135.7 0.25 0.61

11. Skin irritation to latex gloves is a reac-

tion that results from an immune response. * 3.6 3.6 3.6 83.982.185.7 12.514.310.7 –0.86 –1.11

17. Allergic symptoms to latex usually occu

within six hours.* 16.1 17.914.3 39.339.339.3 44.6 42.946.4 –0.25 –0.32

19. Bronchospasm, hypotension and cardiac

arrest can occur in latex sensitised individu-

als.

58.9 75.039.3 12.53.6 21.4 30.421.439.3 0.89 0.29 **

22. Delayed hypersensitivity is caused by

exposure to chemicals used in latex gloves. 42.9 42.939.3 7.13.6 10.7 5050.050.0 0.43 0.36

25. Latex allergic reactions can occur in latex

sensitive workers if they work with col-

leagues who wear latex gloves.

33.9 25.042.9 37.546.428.6 28.6 28.628.6 –0.21 0.11

D3: Potential risk factors for latex allergy 35.7 34.536.9 20.415.925.0 43.849.638.1 0.21 0.19

6. Latex proteins are a main cause of latex

sensitisation. 37.5 35.739.3 5.40 10.7 57.1 64.350.0 0.36 0.36

7. Individuals with an allergy to soy milk o

cow milk can develop an allergic cross reac-

tion to latex products.*

16.1 7.1 25.0 12.514.310.7 71.478.664.3 –0.07 0.14

9. Atopic individuals have a high risk o

developing latex allergy. 71.4 78.664.3 12.53.6 21.4 16.117.914.3 0.79 0.64

10. Spina bifida patients have a high risk o

developing latex allergy. 35.7 32.139.3 10.77.1 14.3 53.660.746.4 0.25 0.46

12. Grass pollen allergy is associated with

latex sensitisation. 28.6 32.125.0 28.617.939.3 42.9 50.035.7 0.18 –0.04

15. Individuals who are allergic to fruits such

as banana, mango, or papaya have an in-

creased risk of developing latex allergy.

33.9 39.328.6 19.617.921.4 46.442.950.0 0.25 0.14

C. Supapvanich et al. / Health 3 (2011) 312-3 18

316

20. Multiple operations increase the risk o

latex allergy in the patient. 25.0 21.428.6 26.814.339.3 48.2 64.332.1 0.11 –0.07

23. Chemicals in latex gloves can induce

respiratory symptoms in health care work-

ers.*

5.4 3.6 7.1 55.457.153.6 39.339.339.3 –0.57 –0.64

24. Instruments such as syringes, air ways,

endotracheal tubes and oxygen tubing con-

tain latex allergens.

67.9 60.775.0 12.510.714.3 19.628.610.7 0.61 0.75

D4: Diagnosis of late x a lle rgy 3.6 1.8 5.4 71.472.671.4 33.721.423.2 –0.63 –0.68

13. Latex allergy can be diagnosed by clini-

cal symptoms only.* 5.4 0 10.7 78.682.175.0 9 17.914.3 –0.89 –0.89

14. The patch test is a common investigation

method in latex allergy (immediate hyper-

sensitivity).*

1.8 3.6 0 69.671.467.9 28.625.032.1 –0.75 –0.82

16. Diagnosis of immediate hypersensitivity

to latex can be confirmed by skin prick test,

blood test, wear test or a patch test.*

3.6 3.6 3.6 66.164.367.9 30.432.128.6 –0.64 –0.75

*Negative question. P-value of difference between nurses and student nurse based on summary scores (Table 2), ** statistics significant level < 0.05 (P-value

adjustment (Bonferroni correction) = 0.002).

These data further suggest some remarkable gaps in

knowledge regarding risk factors for latex allergy. Most

notably, none of the participants knew that nitrile gloves

and vinyl gloves do not contain latex allergens (question

21). Also, none of the students (and only 7% of nurses)

were familiar with “hypoallergenic gloves” (question 5),

while all nurses (and only 11% of students) thought that

latex allergy could be diagnosed based on clinical

symptoms only (question 13).

In addition, these analyses further suggest that several

questions (questions 6, 7, 8, 18, 21) were very difficult

for nurses or student nurses to answer with the majority

(> 50%) of the nurses and student nurses answering

“Don’t know” to these questions. Overall, the results in

this study suggest that 62% of study population (33% of

respondents giving wrong answers and 39% of respon-

dents giving “do not know” answers) had insufficient

knowledge about latex allergy.

4. DISCUSSION

Results from this study suggest that both nurses and

student nurses had insufficient knowledge about latex

allergy and that no statistically significant differences

were observed between knowledge levels of nurses and

student nurses. This finding is similar to that found in

other countries [18-20]. Nurses who were allergic to

latex on average have been shown to have less knowl-

edge about latex allergy knowledge than nurses who

were not allergic [18]. This association might also be

presented in this study, but allergic status was not deter-

mined in this study. However, it is possible that inade-

quate knowledge about latex allergy and risk factors may

lead to the development of serious adverse symptoms in

sensitized nurse, a suggestion made previously [18].

Although most of the students in this population (75%)

knew that instruments such as syringes, air ways, en-

dotracheal tubes and oxygen tubing contain latex aller-

gens, surprisingly, only 21% knew that the use of pow-

der free gloves can reduce latex allergy in health care

workers, while none of the nurses or students knew that

nitrile gloves and vinyl gloves did not contain any latex

proteins at all. Opposite results were found in a study in

Turkey [20] which showed that whereas all Turkish

medical students knew that gloves may contain latex

allergens, as many as 82% were not aware that medical

instruments such as catheters, surgical materials, intra-

venous lines, and syringes could also contain latex al-

lergens. We speculate that these differences are either

caused by differences in education in both countries or

by methodological differences in the way the questions

were asked, although which of these hypotheses is valid

cannot be proven.

Also, although over 80% of students in our study

knew that NRL can cause allergy, less than 8% were

familiar with the fact that the NRL can cause both im-

mediate hypersensitivity (type I) and delayed hypersen-

sitivity (type IV). This is comparable to the data from

Turkey, where 84.8% of medical students knew that

avoidance of exposure to NRL products is a protection

method and 15.8% knew that wearing vinyl gloves be-

fore wearing latex gloves can prevent the direct contact

with latex proteins [20].

This study provides data specifically for the health

care industry in Thailand and, in agreement with data

from other countries discussed above, suggests that ad-

ditional and continuing training should be provided to

student nurses as well as to nurses to reduce the risk of

C. Supapvanich et al. / Health 3 (2011) 312-3 18

317317

personnel and patients for becoming sensitised or de-

velop latex allergy. This is in agreement with recom-

mendations from NIOSH who recommended that work-

ers should receive education programs and training ma-

terials about latex allergy [13]. Furthermore, HSE also

recommended that employers and healthcare providers

should be education on NRL allergy and risk factors [14].

A study in Sweden reported an improvement in knowl-

edge about latex allergy-related topics in nurses who

received a special training program, although after this

one-off program the score remained inadequate provid-

ing additional argumentation for continuing education

[19].

It has been suggested that additional training should

be focussed on three groups. Firstly, sensitised individu-

als should be educated on conditions and latex allergy

avoidance and prevention. Secondly, workers, particu-

larly health care workers, who are at risk of latex allergy,

should be educated about latex allergy and prevention of

latex allergy as well as about latex-free alternative in-

struments. Finally, latex allergy education, particularly

latex allergy prevention policies and latex safety in

workplaces for latex sensitised individuals, should be

provided to employers [21].

5. CONCLUSIONS

In conclusion, the finding of this study indicate that

nurses working in community-based hospitals in Thai-

land as well as Thai student nurses have a similar educa-

tion level regarding latex allergy in the workplace and its

risk factors, and that this level at present is insufficient

in both groups. Additional latex allergy education and

training should be provided to student nurses during

their degrees and this should be continued during their

professional lives. Education training programs should

not be limited to general information about latex allergy

but should also focus on reducing latex allergens in the

workplace environment.

6. ACKNOWLEDGEMENTS

The authors would like to thank all nurses and student nurses par-

ticipated in this study. Furthermore, we would like to thank Miss Ka-

nokporn Boripat from Saiburi Hospital and Mrs. Supaluk Toulamoon,

from the Naresuan University for their help.

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