Vol.3, No.5, 312-318 (2011)
doi:10.4236/health.2011.35054
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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
E
thical approval for this study was obtained from the University o
f
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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
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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
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315315
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
f
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
r
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
r
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
f
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
f
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
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316
20. Multiple operations increase the risk o
f
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
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Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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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