The knowledge of care givers regarding prevention of complication of circumcision among children.

Mr. Richie Chacko

Lecturer, Department of Paediatric Nursing, College of Medical & Health Sciences, Wollega University, Nekemte, P.O. Box 395 Ethiopia

*Corresponding Author’s Email: richiecccare4u@yahoo.co.in

ABSTRACT:

Circumcision is the surgical removal of the foreskin. It is thought to be one of the oldest medical procedures in human history. Worldwide figures suggested that 30% of males have been circumcised¹. Most healthcare professionals now agree that the risks associated with routine circumcision are haemorrhage, redness, swelling, urinary retention, etc.. Children under 5 years of age are the major victims of the complications and a majority of the complications after a routine circumcision can be prevented by timely implementation of appropriate cost effective public health interventions. This study’s core aim was to assess the effectiveness of planned teaching programme on knowledge of care givers regarding prevention of complication of circumcision among children in selected hospitals of Udupi district, Karnataka. Objectives: Objectives of the study are to assess the pre-test knowledge score of the caregivers regarding prevention of complication of circumcision among children, to evaluate the effectiveness of planned teaching programme on prevention of complication of circumcision among children and to find out the association of pre-test knowledge score of caregivers regarding prevention of complication of circumcision among children with selected demographic variables. Design: A pre experimental evaluatory study was conducted using one group pre -test - post-test research design. Data Source: The samples were care givers of children of selected Hospitals by using purposive sampling technique. Review Method: Data was collected using structured knowledge questionnaire. Results: The collected data was analyzed and interpreted using descriptive and inferential statistics. The pre-test knowledge score ranged between 6-18 with the mean 10.56, whereas the post- test score ranged between 11-25 with the mean of 20.4. The result showed significant difference suggesting that planned teaching programme was effective in increasing the knowledge of caregivers (t29=30.40) regarding prevention of selected communicable diseases among under five children. Interpretation and conclusion: The study findings revealed that planned teaching programme is effective in increasing knowledge of care givers regarding prevention of complication of circumcision among children in selected hospitals of Udupi district, Karnataka. There was one significant association between pre-test levels of knowledge with selected demographic variable, i.e. occupation. After the administration of planned teaching programme to caregivers regarding prevention of complication of circumcision among children, the caregivers gained adequate knowledge about prevention of complication of circumcision among children and gained awareness regarding introduction, definition, aetiology, signs and symptoms, diagnosis, management, prevention and complications of circumcision and the caregivers can apply this knowledge in day-to-day life.

KEYWORDS: Effectiveness; planned teaching programme; knowledge; circumcision; caregivers..

INTRODUCTION:

Circumcision is an operation of great antiquity. With almost universal coverage, an estimated one in three males worldwide is circumcised². Circumcision is often performed on healthy babies within the first few days after birth; itis considered a very safe procedure for both newborns and older children³. Circumcision confers a lifetime of medical and health benefits. At least 1 in 3 uncircumcised males will, over their lifetime, develop a condition requiring medical attention. In contrast, circumcision can prevent or greatly reduce the risk of most of these medical conditions, but irrespective of the advantages, there are surgical risks and complications associated with circumcision, thereby enhancing the quality of information to caregivers regarding the prevention of complications of circumcision in male children is considered crucial by the investigator. This motivated the investigator to conduct a study to impart knowledge of caregivers regarding the prevention of complications of circumcision in children and the need to educate the caregivers on hygienic healthy practices.

STATEMENT OF THE PROBLEM:

“A pre-experimental study to assess the effectiveness of planned teaching programme on knowledge of caregivers regarding the prevention of complications of circumcision among children in selected hospitals of Udupi district, Karnataka”.

OBJECTIVES OF THE STUDY:

1. To assess the pre-test knowledge score of the caregivers regarding the prevention of complications of circumcision among children in selected hospitals of Udupi district.

2. To evaluate the effectiveness of planned teaching programme on prevention of complications of circumcision among children in selected hospitals of Udupi district.

3. To find out the association of pre-test knowledge score of caregivers regarding the prevention of complications of circumcision among children with selected demographic variables.

MATERIAL AND METHOD:

Research Approach: An evaluative research approach was adopted.

Research Design: A Pre-experimental, i.e., one group pre-test – post-test design was adopted for the study. This study intended to ascertain gain in knowledge by the caregivers who were subjected to planned teaching programme.

Setting of the Study: The study was conducted in selected hospitals, namely, Sri Devi Hospital and Chinmayi Hosptal of Udupi district ,Karnataka.

Population: In this study, population consisted of caregivers whose child will undergo or has already undergone circumcision in the selected hospitals at Udupi district, Karnataka.

Sample: Caregivers of children in the selected hospitals of Udupi district.

Sampling technique: Purposive sampling technique was be used to select the sample.

Sample size: In this study the sample size will be 30 caregivers.

Criteria for sample selection

Inclusion criteria: Caregivers whose children are planned to undergo or who have already undergone circumcision, Caregivers who are willing to participate in the study and Caregivers who are present at the time of data collection.

Exclusion criteria: Caregivers who are already exposed to teaching programme on prevention of complications of circumcision among children.

Data collection instruments: In this study, the data collection instruments are.

Part I Demographic proforma of caregivers in selected hospitals of Udupi district.

Part II Structured knowledge questionnaire on prevention of complications of circumcision .

Pilot study

Pilot study was conducted on ten caregivers to assess the feasibility of the study. It was done at Shri Devi Hospital, Kundapura, after obtaining administrative permission. The collected data was analysed using descriptive and inferential statistics. The significance of difference in the pre-test and post-test was found using paired ‘t’ test. The mean post-test knowledge score (20.7±20.5) was higher than mean pre-test knowledge score (10.9±10.5). The calculated ‘t’ value (12.48, P<0.05) was greater than table value (t₉=2.262) at 0.05 level of significance. Hence the null hypothesis was rejected and the research hypothesis was accepted. Thus it can be inferred that the planned teaching programme was effective in increasing the knowledge of the caregivers.

Method of data collection

Data collection is the process of selecting subjects and gathering data from those subjects. Prior to the data collection permission was obtained from the concerned authority of the hospitals or conducting the study. The sample was selected according to the selection criteria of the study. In order to obtain free and true responses, self-introduction was made and the purpose of the data collection was explained to the sample. Informed consent was taken from the sample. On the first day, pre-test data was obtained using a self-administered structured knowledge questionnaire. On the same day, planned teaching programme was administered to the caregivers. On the seventh day, post-test was conducted using the same knowledge questionnaire to assess the knowledge on prevention of complications of circumcision among children.

RESULT:

Organisation of findings

The data obtained were entered into a master data sheet for tabulation and statistical processing. The data is analysed and interpreted by using descriptive and inferential statistics. The analysis of the data is organised and presented under the following sections:

Section A

Description of the demographic characteristics of the samples

Section B

Knowledge of caregivers regarding the prevention of complications of circumcision among children.

a. Frequency and percentage distribution of sample according to level of knowledge.

b. Frequency percentage and cumulative frequency distribution of pre-test and post-test knowledge scores of caregivers

c. Area-wise mean and standard deviation of pre-test and post-test knowledge scores.

d. Area-wise mean percentage and mean gain of pre-test and post-test knowledge scores.

Section C

Effectiveness of planned teaching programme on knowledge of caregivers regarding the prevention of complications of circumcision among children.

Section D

Association between pre-test knowledge scores and selected demographic variables.

Section A: Description of demographic variables of the sample

This section deals with the description of demographic characteristics of caregivers.

Table 1: Frequency and percentage distribution of samples according to demographic variables of caregivers N=30

Sl. No.	Variables	Frequency (f)	Percentage (%)
1.	Age (in years)
	18-23	8	27
	24-29	14	46
	30-35	6	20
	36-41	2	7
	Above 42	-	-
2.	Gender
	Male	3	10
	Female	27	90
3.	Religion
	Hindu	3	10
	Muslim	27	90
	Christian	-	-
	Others	-	-
4.	Educational status
	Illiterate	-	-
	Primary Education	18	60
	High school education	10	33
	PUC and above	2	7
5.	Occupation
	Home Maker	23	77
	Coolie/ unskilled	-	-
	Skilled	4	13
	Semiskilled	3	10
	Others	-	-
6.	Number of children
	1	10	33
	2-4	19	64
	≥4	1	3
7.	Family income per month
	Below Rs. 3000	-	-
	Rs. 3001-Rs5000	-	-
	Rs. 5001-Rs.7000	5	17
	Rs. 7001- Rs.9000	14	46
	Rs. 9001 and above	11	37
8	Do you have any past experience in managing wound infection among children?
	Yes	19	64
	No	11	36
9.	Previous source of information regarding the prevention of wound infection among children
	No information	5	17
	Experience of managing previous case	7	23
	Mass Media	12	40
	Health Personnel	6	20
	Others	-	-

Section B: Knowledge of caregivers regarding the prevention of complications of circumcision among children

Knowledge of 30 caregivers was assessed using a structured knowledge questionnaire and analysed using descriptive statistics.

Table 2: Frequency and percentage distribution of caregivers according to level of knowledge N=30

Level of knowledge	Pre-test		Post-test
Level of knowledge	Frequency (f)	Percentage (%)	Frequency (f)	Percentage (%)
Inadequate	12	40	-	-
Moderate	18	60	7	23
Adequate	-	-	23	77
Total	30	100	30	100

The data in Table 2 shows that in the pre-test, majority (60%) of caregivers had moderate level of knowledge whereas in the post-test only (7%) of them had moderate level of knowledge. In the pre-test higher percentage (40%) of caregivers had inadequate level of knowledge but in the post-test none had inadequate level of knowledge. In the pre-test none had adequate knowledge whereas in the post-test majority (77%) of them had adequate level of knowledge.

Table 3: Range of scores, mean, median and standard deviation of pre-test and post-test knowledge level of caregivers N=30

	Range of score	Mean	Median	SD
Pre-test	6-18	10.56	10	9.04
Post-test	11-25	20.4	20	3.12

The data presented in Table:3 shows that post-test knowledge score was in the range of 11-25 which was higher than pre-test (6-18). The data also reveals that post-test knowledge score mean (20.4±3.12) is significantly higher than mean pre-test knowledge score(10.56±9.04).

Table: 4 Frequency and percentage and cumulative frequency distribution of pre-test and post-test knowledge score of care prevention of complications of circumcision among children N=30

Range	Pre –test				Post-test
Range	f	%	Cf	Cf%	f	%	Cf	Cf%
0 -3	-	-	-	-	-	-	-	-
4-6	2	6.66	2	6.66	-	-	-	-
7 -9	10	33.33	12	40.00	-	-	-	-
10-12	12	40.00	24	80.00	1	3.33	1	3.33
13-15	3	10.00	27	90.00	1	3.33	2	6.66
16-18	3	10.00	30	100.00	5	16.66	7	23.33
19-21	-	-	-	-	13	43.33	20	66.66
22-24	-	-	-	-	7	23.33	27	90.00
25-26	-	-	-	-	3	100.00	30	100.00

Table 5: Area-wise mean, standard deviation of pre-test and post–test knowledge scores of caregivers regarding the prevention of complications of circumcision among children N=30

Area	Max. score	Pre-test		Post-test
Area	Max. score	Mean	SD	Mean	SD
Introduction	5	2.03	1.16	3.80	0.97
Definition	3	1.80	0.47	2.50	0.50
Aetiology	2	0.26	0.51	1.43	0.55
Signs and Symptoms	2	1.53	0.49	1.90	0.30
Prevention	8	3.06	1.31	6.70	1.15
Management	5	1.53	1.02	3.30	1.59
Complication	1	0.16	0.36	0.73	0.43

Table 6: Area–wise mean percentage and mean gain of pre-test and post-test knowledge score of caregivers regarding the prevention of complications of circumcision among children N=30

Areas of knowledge	Mean% knowledge score		Mean possible gain (A)	Mean actual gain (B)	% of modified gain score
Areas of knowledge	Pre-test	Post-test	Mean possible gain (A)	Mean actual gain (B)	% of modified gain score
Introduction	41	76	59	35	60
Definition	60	83	40	23	58
Aetiology	13	72	87	59	67
Signs and Symptoms	77	95	23	19	79
Prevention	38	84	62	45	73
Management	31	66	69	35	51
Complication	16	73	84	57	68

Section C: Effectiveness of planned teaching programme on knowledge of caregivers regarding the prevention of complications of circumcision among children

H₀: The mean post-test knowledge score of caregivers regarding the prevention of complications of circumcision among children will be significantly higher than their mean pre-test knowledge score at 0.05 level of significance.

Table 7: Mean ,Mean difference ,SD and t value of pre-test and post-test knowledge score of caregivers regarding the prevention of complications of circumcision among children N=30

Parameters	Mean	SD	Mean difference	‘t’ value
Pre-test	10.56	9.04	9.84	30.40*
Post-test	20.4	3.12	9.84	30.40*

t₂₉=2.05 P<0.05 * Significant

The data presented in Table 7 shows that the mean post-test knowledge score (20.4±3.12) was higher than the mean pre-test knowledge score (10.56±9.04). The calculated ‘t’ value (30.05) p was greater than the table value (t₂₉=2.05) at 0.05 level of significance. Hence the null hypothesis is rejected and research hypothesis was accepted.

H₀₂: There is no significant difference between mean pre-test and post-test knowledge scores of caregivers in various areas regarding the prevention of complications of circumcision among children at 0.05 level of significance.

Table 8: Comparison of area-wise pre-test and post-test knowledge scores of caregivers on regarding the prevention of complications of circumcision among children N=30

Area	Pre-test		post-test		Mean difference	‘t’ value
Area	Mean	SD	Mean	SD	Mean difference	‘t’ value
Introduction	2.03	1.16	3.80	0.97	1.77	50.9*
Definition	1.80	0.47	2.50	0.50	0.70	127.6*
Aetiology	0.26	0.51	1.43	0.55	1.17	159.9*
Signs and symptoms	1.53	0.49	1.90	0.30	0.37	10.6*
Prevention	3.06	1.31	6.70	1.15	3.64	124.4*
Management	1.53	1.02	3.30	1.59	1.80	17.2*
Complication	0.16	0.36	0.73	0.43	0.57	44.5*

t₂₉= 2.05, P<0.05 * Significant

Table 9 shows that c² value of demographic variables like age (0.806), educational status (0.424), and source of information (0.823), are higher than 0.05 therefore they have no significant association with pre-test knowledge scores at 0.05 level of significance. The table also shows that c² value of demographic variable Occupation (0.042) is lesser than 0.05 therefore occupation have significant association with per-test knowledge at 0.05 level of significance.

DISCUSSION:

This chapter presents the major findings of the study and discusses them in relation to similar studies conducted by other researcher. A well developed discussion section “makes sense” of the research results. This is the most important section of research report.

Knowledge of caregivers regarding the prevention of complications of circumcision among children

The investigator found that in the pre-test majority (60%) of the samples had moderate knowledge whereas in post-test 23 (77%) samples gained adequate knowledge regarding the prevention of complications of circumcision among children. Overall mean pre-test knowledge score of samples was 10.56 with a standard deviation of 9.044. This indicates that the samples had inadequate knowledge on prevention of complications of circumcision among children. But in the post-test, knowledge score of the caregivers was 20.4 with a standard deviation of 3.125. This indicates that knowledge level of caregivers on prevention of complications of circumcision among children had increased after the administration of planned teaching programme.

An area-wise mean percentage was computed for both pre-test and post-test. In the pre-test the mean percentage was highest (77%) for the “signs and symptoms of complications of circumcision” whereas in the post-test the highest 95% gained in “signs and symptoms of complications of circumcision.” The mean percentage for other areas like ‘introduction’, ‘definition’, ‘aetiology’, ‘signs and ‘symptoms’, ‘prevention’, ‘management’, and ‘complication’ in the pre-test were 41%, 60%, 13%, 77%, 38%, 31%, and 16%, respectively whereas in the post-test in all these areas increased to 76%, 83%, 72%, 95%, 84%, 66%, and 73%, respectively. Thus the findings suggest that planned teaching programme was effective in terms of gain in knowledge score.

Comparison of pre-test and post-test knowledge score caregivers regarding the prevention of complications of circumcision among children

The data illustrates that the mean post-test knowledge scores 20.7 is higher than mean pre-test knowledge scores 10.56. The computed ‘t’ value 30.40 (p <0.05) showed that there was highly significant difference between the pre-test and post-test mean knowledge scores (9.84) at 0.05 level of significance. These results had proved that the PTP has helped the subjects to improve their knowledge score caregivers regarding the prevention of complications of circumcision among children.

Association between pre-test knowledge score caregivers regarding the prevention of complications of circumcision among children and their selected demographic variables

An association of selected demographic variables in relation to their knowledge was studied using Chi-square test. The Chi-square values for the demographic variables like age (0.806), educational status (0.424), source of information (0.823), are higher than the table value at 0.05 level of significance. The table also shows that c² value of demographic variable occupation (0.042) was lesser than 0.05. Therefore occupation had significant association with per-test knowledge at 0.05 level of significance.

DISCUSSION OF THE FINDINGS WITH OTHER STUDIES:

OBJECTIVE 1. To assess the pre-test knowledge score of the caregivers regarding the prevention of complications of circumcision among children in selected hospitals of Udupi district, Karnataka

PRESENT FINDINGS

SUPPORTIVE STUDY

The investigator found that in the pre-test majority (40%) of the samples had inadequate knowledge whereas in the post-test (78%) samples gained adequate knowledge on prevention of complications of circumcision among children. Overall mean pre-test knowledge score of samples was 10.56 with a standard deviation of 9.04. In the post-test, knowledge score of the caregivers was 20.4 with a standard deviation of 3.12.

A cross-sectional survey was conducted to assess the knowledge, attitudes, and practices (KAP) of mothers regarding care of the umbilical cord. The study interviewed a total of 307 mothers with infants less than 3 months old and 64 .The results revealed that 91% of mothers knew the need for hygiene while cutting and tying the cord, respectively. As to postnatal cord care, 79% of mothers were afraid of handling an unhealed cord. Based on the findings, it was recommended that good health and cord care practices be taught at all levels of contact with mothers⁴.

OBJECTIVE 2. To evaluate the effectiveness of planned teaching programme on knowledge of caregivers regarding the prevention of complications of circumcision among children of Udupi district, Karnataka.

PRESENT FINDINGS

SUPPORTIVE STUDY

A study which conducted in Udupi District, Karnataka, to determine the knowledge of mothers on immunisation of children and 70 to the effectiveness of planned teaching programme (PTP) in selected paediatric wards. One group pre-test post-test design was used. Data were collected from 50 samples using a knowledge questionnaire and PTP was administered. Data were showed that post-test mean knowledge score (29.74%) was significantly higher than the pre-test mean score (16.16%) (t49=27.77, p<0.01). This indicated that the PTP was effective in improving the knowledge level of mothers regarding immunisation. Majority of the mothers (87.7%) strongly agreed that PTP was highly effective to a great extent⁵.

OBJECTIVE 3. To find the Association between pre-test knowledge score of caregivers regarding the prevention of complications of circumcision among children and their selected demographic variables.

PRESENT FINDINGS

SUPPORTIVE STUDY

Demographic variables like age (0.806), educational status (0.424), and source of information (0.823), are higher than 0.05 therefore they have no significant association with pre-test knowledge scores at 0.05 level of significance. The result also shows that demographic variable Occupation (0.042) is lesser than 0.05 therefore occupation have significant association with per-test knowledge at 0.05 level of significance.

An evaluatory study was conducted to determine the effectiveness of planned teaching programme (PTP) about home care of patients with chronic renal failure and their attendants in KMC Manipal. One group pre-test post-test design was used to collect the data from 30 caregivers of CRF patients. Convenience sampling technique was used to select the sample. The findings showed that the pre-test mean percentage knowledge regarding home care of patient with CRF was found to be less than 50%; whereas in the post-test mean percentage score was more than 78% which indicated that the teaching programme was effective⁶.

CONCLUSION:

The study concluded that the planned teaching programme was effective in increasing the knowledge of caregivers regarding the prevention of complications of circumcision among children.

NURSING IMPLICATIONS:

The present study was conducted to evaluate the effectiveness of planned teaching programme in increasing the knowledge of caregivers regarding the prevention of complications of circumcision among children.

The findings of the study have implications in the following areas:

· Nursing education

· Nursing practice

· Nursing administration

· Nursing research

Nursing education

One of the leading functions of nursing is imparting education. With newer knowledge the scope of education too increases. Nurse educators should get the benefit of studies to incorporate them in their classroom teachings to enhance the knowledge of students. They may make use of the planned teaching programme, which is prepared for to use as a teaching tool. The students should be motivated to give health teachings using the teaching materials available. There is a need to plan the planned teaching programme according to the level of understanding of the beneficiaries, their practices and the needed improvement in knowledge to prevent complications of circumcision among children. The studies of this nature will help the nurse educators in planning the awareness in clinical teaching as well as in the hospitals.

Nursing practice

Nursing profession has been developing faster in a unique way. The major changes that has occurred in the profession is expansion in the role of nurses. Educating caregivers regarding the prevention of complications of circumcision among children is very important role of community nurses as well as paediatric nurses while taking care of children.

Majority of caregivers are not able to take care of the child with complicated circumcision wound because of lack of knowledge. Every nurse practitioner must possess a prepared planned teaching programme to teach the regarding the prevention of complications of circumcision among children in the hospital or in the community. Nurse should conduct training programme and plan health education to promote the wellbeing of child.

Nursing administration

The nurse administrators should see that the aspect of health promotion while providing nursing care. The nurse administrator can take the initiative in imparting health information by individual and group teaching in the hospital, and other community settings. Nurse administrators in the hospital shall make arrangements for organising and conducting education programme for patients. They should explore their potentials and encourage innovative ideas in the preparation of appropriate instructional material and if needed must train the personnel in preparing the material. Therefore, the nurse administrators should teach her subordinates regarding the prevention of complications of circumcision among children and can suggest their subordinates to teach the community regarding preventive measures by using different AV aids planned teaching programme.

Nursing research

Extensive research studies can be undertaken in different fields to quantify the magnitude of deficiency of knowledge on prevention of complications of circumcision among children and the needful can be done. This study revealed that there was deficiency of knowledge among caregivers which needs further research to explore it. The findings of the present study can form a basis for the future research. More research on these areas is more helpful in expanding our body of knowledge. This study helps the nurse to plan, implement, and evaluate the planned teaching programme and orientation programme through research.

RECOMMENDATIONS:

Keeping in view the findings of the present study the following recommendations are made. Since this study was carried out a small sample, the result can be used only as a guide for further studies.

1. Further prospective studies to monitor the risks following circumcision are needed to document the complications using standardized definitions, and to compare the risks associated with different methods, age at circumcision, and to evaluate the impact of specific and ongoing training of care providers.

2. A similar study could be done by using control group.

3. Design a training programme for the training of traditional care providers about safe circumcision practices.

4. The community health nurses should create opportunities to educate traditional circumcisers of children and adolescents on basic hygiene requirements to be met before, during, and after circumcision.

5. The study can be conducted on a larger sample.

6. Creating a formal structure to monitor and regulate the conduct of circumcision.

7. A descriptive study can be carried out to evaluate the knowledge and practice of caregivers regarding the prevention of complications of circumcision among children.

REFERENCES:

1. Saihaye VU, Goswami AK, Sharma SK. Skin bridge - a complication of paediatric circumcision. Br J Urol 1990;66:214.

2. WHO/UNAIDS. Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva: World Health Organisation; 2008.

3. Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal survey. Soc Sci Med 1981;15E:315-25.

4. Obimbo E, Musoke RN, Were F. Knowledge, attitudes and practice of mothers and knowledge of health care workers regarding care of the newborn umbilical cord. East Afr Med J 1999 Aug;76(8):425-9.

5. Linkins RW, Salmon DA, Omer SB, Pan WK, Stoklev S, To determine the knowledge of mothers on immunisation of children. BMC Public Health 2006 Sep 226;236.

6. Kothari CR. Research Methodology. 2nd ed. New Delhi: New International Publishers; 2005.

Sl. No	Variables	c²value	df	Table value	P value	Inference
1.	Age	0.060	1	3.84	0.806	NS
2.	Educational status	0.639	1	3.84	0.424	NS
3.	Occupation	4.100	1	3.84	0.042	S
4.	Source of information	0.050	1	3.84	0.823	NS