IOSR Journal of Nursing and Health Science (IOSR-JNHS)

IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 01-04
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Staff Nurses (Nicu) Knowledge Regarding Care Of Low Birth
Weight Baby
Ms.Rajwinder Kaur*
Guide: Ms. Lalita Kumari Professor cum Principal S.G.L. Nursing College Jalandhar, Punjab
Abstract: Low birth weight babies are immature, they need special nursing care. Nurses are front line care
providers they are key persons involved with the care of the low birth weight neonates round the clock. A preexperimental study was conducted to assess the effectiveness of structured teaching programme on knowledge
regarding care of low birth weight baby among (NICU) staff nurses. The study was conducted in 6 pediatrics
hospitals at district Jalandhar, Punjab. Total 60 staff nurses those who met the inclusion and exclusion criteria
were selected by convenience sampling technique. A pre-test was taken by using structured questionnaire
followed by structured teaching programme. After 7 days post-test was taken. The overall mean score of pre-test
was 15.60 with the S.D.5.98. Whereas in post-test the overall mean score of 22.68 with S.D. of 4.55 the t-test
value was 14.46* which is statistically significant at p<0.005 level of significance. The study finding implied
that the education had a vital role in improving the knowledge of staff nurses regarding care of low birth weight
baby.
I.
Introduction
“We need to make a world in which fewer children are born, and in which we take better care of
them.’’
- Max Born
Birth weight is the single most important factor determining the survival chances of the newborn. Many of the
newborn die during their first year of life. The infant mortality rate is higher for all low birth weight babies than
other babies. The lower the birth weight, the lower is the survival chance of the newborn.
There were1.8 million infant deaths in the world in 2003. Most of them occurred in developing countries and
approximately one half took place during their neonatal period.
Low birth weight babies can be managed at the time of Antenatal period. Many mothers go on to enjoy
near normal life if their babies were properly managed. Early intervention is important, especially for the
management of feeding, handling, cleanliness, prevention from the infection. Mother’s knowledge about care of
baby reflects the health and nutritional status of the baby. Nurses play the significant role in empowering the
mother of LBW with reliable method of management. Structure teaching and counseling of mothers of LBW
babies by nurses may help the mother to get relieved of their worries and to join hands with the nurses in care of
low birth weight babies.
II.
Need Of The Study:
The prevalence of low birth weight exists universally in all population. Low birth weight with high
mortality and morbidity continuous to be a major public health problem in India. LBW is one of the most
serious challenges in maternal and child health in both developed and developing countries. Low birth weight
newborn forms a pediatric priority because they have less chance of survival than babies weighing 2500 gm.
Half of the prenatal and one third of infant mortality are due to the low birth weight. Low birth weight may lead
to serious physical and mental handicap in those who survive. 18
In India over 30% of the infants are born with low birth weight. Nearly 75% of the neonatal deaths and
50% of infant deaths occur among low birth weight baby. In India low birth weight was 30% in year 2008, and
only in Punjab state 21.3% low birth weight babies were born in year 2008.
Further, the investigator during the clinical experience found more number of low birth weight babies
born and admitted in neonatal intensive care unit. LBW newborn faces problems like hypothermia, unable to
suckle at the breast and hypoglycemia. Due to lack of immunity and LBW newborn are at high risk of having
problem with increased chance to acquire infection which later on can lead to death. Low birth weight babies are
immature, they need special nursing care. Nurses are front line care providers they are key persons involved
with the care of the low birth weight neonates round the clock. An assessment of nurse’s knowledge is felt to be
essential for improvement in the nursing care of low birth weight baby. So here comes the role of the nurses to
assess the low birth weight babies and to protect them from various complications. Hence it is important to
educate the NICU nurses about the problems and how to manage the newborn with such problems .
Ms. Rajwinder Kaur, Lecturer Child Health ( Paediatric) Nursing,
N.R.I. college of Nursing, Amritsar Punjab
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Staff Nurses (Nicu) Knowledge Regarding Care Of Low Birth Weight Baby
Nursing trends are changing with the scientific and technological growth. Nurses must acquaint
themselves with the changing trends. Hence it is felt that a study on the nurse’s knowledge regarding care of the
low birth weight baby is a safety ladder to ensure skilled services. Thus, it is felt that the assessment of nurse’s
knowledge regarding care of low birth weight baby will help in ensuring skilled neonatal care which will help in
decreasing the mortality rate of low birth weight baby.
Statement Of Problem:
A pre-experimental study on the effectiveness of structured teaching programme on the knowledge
regarding care of low birth weight baby among Staff nurses working in Neonatal Intensive Care Units (NICU)
in selected hospitals, at district Jalandhar, Punjab, 2012.
Objectives:
1. To assess the pre test knowledge of NICU staff nurses regarding care of low birth weight baby.
2. To plan and implement structured teaching programme regarding care of low birth weight baby among
NICU staff nurses.
3. To assess post test knowledge of NICU staff nurses regarding care of low birth weight baby.
4. To compare pre test and post test knowledge of NICU staff nurses regarding care of low birth weight baby.
5. To find out association between knowledge of NICU staff nurses regarding care of low birth weight baby
with selected socio-demographic variables
Hypothesis:
H1- The mean post test knowledge score of the group after structured teaching programme on knowledge
regarding care of low birth weight baby among staff nurses working in NICU will be significant.
H0- The mean post test knowledge score of the group after structured teaching programme on knowledge
regarding care of low birth weight baby among staff nurses working in NICU will be non significant.
Conceptual Framework:
Conceptual frame work selected for this study was based on the general system theory as postulated by
Von Ludwig Bertanlanfly (Marcia Stanhope, 1995).
III.
Materials And Methods
The research design used in this study was pre experimental in nature. The study was conducted at
NICU in six hospitals at district Jalandhar,Civil Hospital, Jalandhar( Punjab),Chawla Children Hospital,
Jalandhar( Punjab),Sigma Hospital, Jalandhar( Punjab),Doaba Hospital, Jalandhar( Punjab),Ankur Kids Superspecialty Hospital, Jalandhar(Punjab) and Malhotra Hospital, Jalandhar (Punjab) . The sample included 60
NICU staff nuses on the basis of inclusion and exclusion criteria were selected. Non probability convenience
sampling technique was used for this study. The tool used for the study was the structured knowledge
questionnaire consisting of section I (Socio- demographic varriables such as age, gender, professional
qualification, clinical experience(years), experience in NICU (years), In-service education programme) and
section II (consisting of 30 items related to knowledge regarding care of low birth weight baby). The content
validity of structured questionnaire was ensured by submitting the tool to the experts in the field of paediatrics
for content validation. Pilot study was conducted on 10 subjects (who were not included in the study) at S.G.L.
Charitable hospital Jalandhar, Punjab. The reliability of tool was computed by applying split half technique and
was calculated by Karl Pearson’s coefficient of correlation formula, which was found 0.76.
A. Results And Findings
B. Related to socio demographic Varriables of the subjects
 Study results had shown that maximum of staff nurses 28 (47%) were in the age group 21-25 years.

In this study 54 (90%) sample were female and 06(10%) were male.
 Majority of sample 41 (68%) had professional qualification GNM and 07 (12%) had B.Sc. nursing and 12
(20%) had Post Basic B.Sc. nursing.
 Maximum number of sample 40 (66%) had 0-5 years of clinical experience and minimum number of
sample 07 (12%) had 11 years and above experience and 13 (22%) had 6-10 years of experience.
 Maximum number of 34(57%) staff nurses had 0-2 years experience in NICU and minimum 06 (10%) staff
nurses had both 4-6 years and 6 and above years of experience followed by 14 (23%) had 2-4 years
experience in NICU.
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Staff Nurses (Nicu) Knowledge Regarding Care Of Low Birth Weight Baby

40
30
20
10
0
Poor
Below average
Average
Good
Excellent
Excellent
KNOWLEDGE
SCORE
Maximum number of sample 24 (40%) were those who did not attend any in-service education programme
related to care of baby and minimum 07(12%) had attended conference, 16(26%) sample were those who
attended workshop and 13 (22%) sample had attended seminar.
A. Related to the pre test and post test knowledge scores of (NICU) staff nurses regarding care of low
birth weight baby.
Good
Average
Below average
Poor
KNOWLEDGE LEVEL
Figure 1. Pre test knowledge score of (NICU) staff nurses.
50
40
30
20
10
0
Excellent
Poor
Below…
Average
Good
Good
Excellent
KNOWLEDGE
SCORE
Figure 1 depict that in pre test majority of sample 38.3% nurses had average level knowledge, 26.7% had
below average of knowledge, 18.3% nurses had good knowledge, 13.3% had poor knowledge and only 03.3%
had excellent level of knowledge regarding care of low birth weight baby.
Average
Below average
Poor
KNOWLEDGE LEVEL
MEAN SCORE
Figure 2. Post test knowledge score of (NICU) staff nurses
Table 2 Shows that in post test it was observed that 45.5% sample had good level of knowledge, 38.30% had
excellent level of knowledge , 11.70% had average level of knowledge, 05.00% had below average level of
knowledge and no one had poor level of knowledge after administration of STP
25
20
15
Pre-test
10
Post test
5
0
Pre-test
Post test
Figure 3.Comparison of pre test and post test knowledge score
Figure 3 shows that in the mean pre test knowledge score was (15.60) and post test mean knowledge score was
(22.68) and. The difference between mean pre test and post test knowledge score was-7.08* significant at p<
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Staff Nurses (Nicu) Knowledge Regarding Care Of Low Birth Weight Baby
0.05 level of significance hence there was an impact of structured teaching programme on knowledge regarding
Care of low birth weight baby.
B. Related to the impact of Socio-demographic variables on the knowledge scores.
All the Socio-demographic variable such as age, gender, professional qualification, clinical
experience(years), experience in NICU (years), In-service education programme) had non significant
association.
IV.
Nursing Implication
Nursing education
 This structured teaching programme can be utilized by the students to develop skills in creating the
awareness among the nurses in selected hospitals.
 In-service education can be planned for nurses & the other health care professionals at various levels to
enable them to improve their knowledge and to gain the skills in the care of LBW baby.
 Nurses should educate the family members or care takers about monitoring of height and weight of baby at
home.
Nursing practice
 The structured teaching can be utilized to create awareness among the staff nurses who doing work in
neonatal intensive care units.
 Nurses are the key persons who spend maximum time with baby in NICU and provide quality care to low
birth weight baby.
 Nurses should take the responsibility to teach mothers admitted in wards regarding breast feeding, warmth,
personal hygiene, infection control and the general care vaccination which enables mothers to acquire insight
into the care of LBW baby.
Nursing administration
 Nurse administrator may use the study findings to improve the quality of care in the community. The concept
of the extended role of nurse offers many opportunities for a nurse administrator to improve the quality of
life of the public and health care professionals.
 The nurse administrator in the higher level of the authority must hold discussions and meetings on the
prevailing health status of the health care personnel. Based on that, the knowledge of the staff nurses can be
accessed and related programme can be planned and implemented.
 Administrator should organize in-service education programmes, refresher courses and workshops for health
care personnel and encourage them to participate in these activities.
Nursing research

The findings of the study shows that the majority of the staff nurses in NICU had moderately adequate
knowledge regarding the care of LBW baby. The study will motivate new researchers to conduct the same study
with the different variables on a large scale.
Recommendations
 The study can be repeated on the large scale sample to validate and for better generalization of the findings.
 The study can be conducted on the large scale where equal sample are taken from each hospital.
 Comparative study can be done in different hospitals on the same topic.
V.
Conclusions
The study findings implied that the education has a vital role in improving the knowledge of (NICU)
staff nurses regarding care of low birth weight baby. Health related education is an integral part of hospital’s
services, structure teaching programme can play an important role in health educational programme, making the
nurses an important channel for disseminating the health information to the mother’s and the communities.
References
[1].
[2].
[3].
[4].
[5].
Gurav BR, Kartikeyan S, Jape RM. Low birth weight babies. Journal of pediatric.2003; 45(3): 413-415.
Ghai.O.P. Essential pediatrics.6 th edition. New Delhi: CBS Publishers, 2004.
A. Parthasaraty. IAP Textbook of Pediatrics. jaypee brothers, medical publishers(P)ltd., New Delhi.2003 pp-60-62
Parthsarthi. Text book of Paediatric. 2 nd edition, Jay Pee :61-63.
United Nations Children’s Fund and the World Health Organization, Low birth weight: Country, regional and global estimates,
UNICEF and WHO, New York and Geneva, 2004,pp.2-3.
[6]. United Nations Children’s Fund and the World Health Organization, Low birth weight: Country, regional and global estimates,
UNICEF and WHO, New York and Geneva, 2004,pp. 9.
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 05-08
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School Children Knowledge Regarding Dental Hygiene.
Ms. Manveer Kaur*
Children are our most valuable natural resources”
Guide: Ms. Lalita Kumari (Principal cum Professor S.G.L. Nursing College, Jalandhar Punjab)
Abstract: School health education services are an economical and powerful means of raising standard of
community health, especially for the future generations. School is considered as a best setting for the positive
health and prevention of diseases, awakening health consciousness in which the child grows and develops. A
pre-experimental study was conducted to assess the effectiveness of structured teaching programme on
knowledge regarding dental hygiene among middle schoolchildren. The study was conducted in government
schools of Jalandhar district, Punjab. Totally 60 students those who met the inclusion and exclusion criteria
were selected by convenience sampling technique. A pre-test was taken by using structured questionnaire
followed by structured teaching programme. After 7 days post-test was taken. The result of the post-test score
revealed that the structured teaching programme had its impact on improving the level of knowledge regarding
dental hygiene among middle school children. The overall mean score of pre-test was 14.91 with the S.D. 3.84,
whereas in post-test the overall mean score of
23.01 with S.D. of 3.72. The t-test value was -8.1* which is
statistically significant at p<0.005 level of significance. After structured teaching programme 68% students had
average and 32% had good level of knowledge and no one had poor level of knowledge regarding dental
hygiene. The study finding implied that the education had a vital role in improving the knowledge of school
children regarding dental hygiene.
I.
Introduction
A child is a precious gift which has lots of potential within, which can be the best resource for nation if
raised and moulded in good manner. Healthy children can become healthy citizen constituting a healthy nation.
Healthy children are also successful learners. School age children represent about 25% of total population, so it
indicates that health care of the school children can contribute to the overall health status of the country. Dental
caries is the leading dental problem of children, 90% of all children have some tooth decay by 12 years of age.
95% of all cavities are caused by specific eating sugar habits like candies, ice-cream, canned juice which usually
develop during early childhood as a result of changing life style. Dental diseases affecting the child are not same
as affecting that adult. The target organs are the same like, teeth, gingival, but the etiopathogenesis are different
because, primary dentition is morphologically different, food habits are different from that of adult and poor
control over maintance of oral hygiene leads to common dental problems that include dental plaque, dental
caries, malocclusion, gingivitis etc. Hence the importance of preventing dental caries is at the school age level is
very essential.
Need of the study
School health is an important branch of community health. According to Elias M.J.et al. (1994), the
school years are a time of increasing risk for negative health related outcomes. Hence, these groups develop
cognitive, affective and behavioural changes which in turn can promote children’s health and prevent health
problems. Thus, the school remains a natural channel through which the health of the community can be
improved with the children as the natural agent to change.
Today the child health is viewed as a holistic and positive component for the total development and
health is essential for high quality of life for children. A healthful school environment therefore is necessary for
the best emotional, social and personal health of the pupils. The ultimate aim of structured teaching programme
is to bring a significant change in the knowledge and health behaviour of children and family.
According to WHO, aim of “ Health for All by the year 2000” the global status for children, should be
that 50% of children between the ages of 5 and 6 years will be caries free and at 12 years of age they should
have 3 or fewer decayed, missing or filled teeth. In India caries is the commonest disease in school age,
affecting 50-75% of them. Children are suffering more from dental disease which is continuously increasing at a
high rate due to lack of appropriate care and inadequate knowledge regarding Dental hygiene. Dental health is
recognized as one of the vital need of the children. The school environment is more conducive to learning,
hence dental health education and motivation shall be more effective.
Ms. Manveer Kaur, Lecturer Child Health ( Paediatric) Nursing,
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School Children Knowledge Regaringdental Hygiene.
Anand college of Nursing, Amritsar Punjab
Statement of problem
A pre-experimental study on the effectiveness of structured teaching programme on knowledge
regarding Dental hygiene among middle school children in selected schools of Jalandhar district, Punjab, 2012.
Objectives
1. To assess the pre test knowledge of middle school children regarding Dental hygiene.
2. To plan and implement structured teaching programme regarding Dental hygiene among middle school
children.
3. To assess post test knowledge of middle school children regarding Dental hygiene.
4. To compare pre test and post test knowledge of middle school children regarding Dental hygiene.
5. To find out the association between knowledge of middle school children regarding Dental hygiene with
selected socio-demographic variables.
Hypothesis
H1: There will be significant difference in the pre test and post test knowledge score of middle school
children regarding Dental hygiene.
H0: There will be significant difference in the pre test and post test knowledge score of middle school
children regarding Dental hygiene.
Conceptual frame work
The frame work of the present study was based on the on Daniel L, Stufflebeam’s Context, Input,
Process and Product Evaluation (CIPP) Model.
II.
Materials and Methods
The research design used in this study was pre experimental in nature. The study was conducted at
Government Middle School Salempur, district Jalandhar and Government Senior Secondary School Talhan,
district Jalandhar, Punjab. The simple included 60 middle school children on the basis of inclusion and
exclusion criteria were selected. Non probability convenience sampling technique was used for this study. The
tool used for the study was the structured knowledge questionnaire consisting of section I (Socio- demographic
varriables such as age of student (years), class standard of student, gender, type of family, monthly income of
family, educational status of mother and educational status of father) and section II (consisting of 30 items
related to knowledge regarding dental hygiene). The content validity of structured questionnaire was ensured by
submitting the tool to the experts in the field of paediatrics for content validation. Pilot study was conducted on
10 subjects (who were not included in the study) at government school Dhanowali, Jalandhar, Punjab. The
reliability of tool was computed by applying split half technique and was calculated by Karl Pearson’s
coefficient of correlation formula, which was found 0.78.
III.
Results And Findings
A. Related to socio demographic varriables of the subjects
 Maximum of middle school children 26(43.34%) were in the age group above 13 years.
 20(33.33%) middle school children were studying in 6th standard, 20(33.33%) were in 7th standard and
20(33.33%) were in 8th standard.
 30(50%) sample were female and 30(50%) were male.
 Majority of sample 38(63.34%) were belonging to nuclear family.
 Maximum number of sample 41(68.34%) belonging to those family who had <5000 monthly family
income.
 Maximum number of mothers 23(38.33%) of middle school children were illiterate.
 Maximum number of fathers 23(38.34%) of middle school children had educational status primary.
B. Related to the pre test and post test knowledge scores of middle schoolchildren regarding dental
hygiene.
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School Children Knowledge Regaringdental Hygiene.
Figure 1 shows that in pre test majority of sample 47(78.3%) had average level of knowledge, 09(15%) poor
level of knowledge and only 04(06.6%) had good level of knowledge regarding Dental hygiene.
Y
68%
Percentage
80%
60%
Poor
32%
40%
20%
Average
0%
Good
0%
Poor
Average
Good
Level of Knowledge
X
Mean Knowledge Score
Figure 2. Post test knowledge score of middle school children
Figure 2 Shows that in post test it was observed that 41(68%) sample had average level of knowledge, 19 (32%)
had good level of knowledge and no one had poor level of knowledge after administration of STP.
23.01
Y
25
20
14.91
15
Pre test
10
5
0
Post test
Pre test
Post test
X
Figure 3.Comparison of pre test and post test knowledge score
Figure 3 shows that in the mean pre test knowledge score was (14.91) and post test mean knowledge score was
(23.01) and. The difference between mean pre test and post test knowledge score was-8.1* significant at p< 0.05
level of significance hence there was an impact of structured teaching programme on knowledge regarding
Dental hygiene.
C. Related to the impact of Socio-demographic variables on the knowledge scores.
The variable gender had significant association with knowledge regarding Dental hygiene among
middle school children at 0.05 level of significance. But variables age of student, class standard of student, type
of family, monthly income of family, educational status of mother and father had non significant association.
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School Children Knowledge Regaringdental Hygiene.
IV.
Nursing implication
Nursing practice
 Nurses working in Paediatric ward should have enough knowledge about Dental hygiene of children; they
should be a keen observer since the children cannot speak out their needs.
 Posters can be displayed on the importance of the correct technique of brushing and flossing in the rural
areas to increase the knowledge of the community.
 Not only nurses but all the health care providers such as auxiliary nurses and midwives, village health
guides, nurses working in community centre should provide in-service education regarding Dental hygiene.
Nursing education
 Nursing curriculum can be modified with increased emphasis on child health nursing.
 Students can be also trained to work in paediatric care under proper guidance.
Nursing administration
 Administrator can organise educational programmes in schools and community areas to provide knowledge
regarding importance of Dental hygiene.
 The nurse administrator in the higher level of the authority must hold discussions and meetings on the
prevailing Dental problems. Based on that, the knowledge of the school children can be assessed and
prevention programmes can be planned and implemented in schools at various levels.
Nursing research
 The findings of the study had shown that the majority of the middle school children had inadequate level of
knowledge regarding Dental hygiene. The study will motivate the beginning researchers to conduct the
same study with the different variables on a large scale.






V.
Recommendations
The study can be repeated on the large scale sample to validate and for better generalization of the findings.
Descriptive study can be conducted to assess knowledge, attitude and practice of school children regarding
Dental hygiene.
Comparative study may be conducted to find out the similarities or differences between the knowledge and
practices of urban and rural school children.
Regular Dental check-up may be conducted for school children.
School syllabus may include topic related to Dental hygiene.
Education can be given to school teachers on Dental hygiene who are the sources of knowledge for
children.
VI.
Conclusions
The study findings implied that the education has a vital role in improving the knowledge of the
students regarding dental hygiene. Since school education is an integral part of medical and dental services,
nurses can play an important role in health educational programme, making the children an important channel
for disseminating the health information to the families and the communities. Today’s students are tomorrow’s
leaders. The student community needs to be strengthened with the treasure of knowledge especially with health
related issues.
References
Peter S. Essentials of Preventive and Community Dentistry. 1 st ed. New Delhi: Arya Medical, 1999. p102.
Nair MCK, Menon PS, Parathasorthay A. IAP Textbook of Pediatrics. 2nd ed, India: Jaypee, 2000.p.910-11.
Chandra satish. Textbook of community dentistry. 1 st ed. New Delhi: Jaypee, 2004. p.159-60, 72.
Jurgensen N, Peterson PE. Oral health and impact of socio behavioral factors in a cross section survey of 12 year old school children
in Laos. BMC oral health. Nov 2009; 9: 29
[5]. Amin TT, AL Abad BM. Oral hygiene practice, knowledge, dietary habits and their relation to caries among male primary school
children in Al Hassa. Indian Journal of dentistry.Nov2008; 6(4):361-70.
[6]. Polit F. Denise Hungler. Essentials of Nursing Research. 2 nd ed. JB Lippincott Company, p-117-167.
[7]. Kalawole K, Oziegde E, Bamise C. Oral hygiene measures and the periodontal status of school children in Ile-Ife. Indian Journal of
dental hygiene. March 2011; 10.1601,5037.
[1].
[2].
[3].
[4].
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 09-13
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Effectiveness of acupressure on nausea and vomiting among
cancer patients receiving chemotherapy in a selected hospital,
Coimbatore.
Jagon.J.Babu
(Lecturer, School of Nursing, / Galgotias University, Greater Noida, Utter Pradesh, India)
Abstract: Chemotherapy induces nausea and vomiting. In this context; bio-field therapy like acupressure has
its own significance, thus enhancing the scope of nursing. The main objective of the study was to evaluate the
effectiveness of acupressure (p6) on nausea and vomiting among cancer patients receiving chemotherapy. A
quantitative approach using Experimental design with pretest posttest was carefully utilized. For this 60 cancer
patients receiving chemotherapy was selected using stratified random sampling in G.K.N.M Hospital. The
intervention p6 acupressure was given by the researcher thrice a day for three days. Data collected using
Standardized Rhodes index of nausea and vomiting to assess the level of nausea and vomiting by interview
method was analyzed using independent ‘t’ test and paired ‘t’ test that found significant values 15.12 and 9.14
respectively at p<0.001. Thus, the study finding point out the effectiveness of p6 acupressure on nausea and
vomiting among cancer patients receiving chemotherapy.
Keywords– Acupressure, Cancer, Chemotherapy, Nausea and Vomiting.
I.
INTRODUCTION
Cancer is a class of disease in which group of cells display uncontrolled growth, invasions and
sometime metastasis. Chemotherapeutic agents are the drug of choice generally cyto-toxic in nature, which can
destroy cancer cells. Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and
divide quickly. It is noted that among chemotherapy side effects, the most distressful events are nausea and
vomiting [1]. Even though drug therapies are widely practiced for nausea and vomiting control, it is found, not
100% effective [2]. In such cases, alternative therapy like p6 acupressure plays a vital role. Acupressure is non
invasive pressure applied by the thumbs, fingers, and hands on the surface of the skin at key points (active
acupressure). Mechanism of acupressure is based on a theory that body has a system of meridians through which
energy (Qi) flows (Cohen and Doner 1996) [3]. The greatest advantage of Acupressure is that it can be
administered by health care providers, family members, or patient’s themselves and does not involve puncture
of the skin.
II.
METHODOLOGY
Methodology deals with the research approach, research design, setting of the study, population, criteria
for selection of sample, sample size, sampling technique, description of the tool, scoring procedure, data
collection procedure, data analysis and protection of human rights [4] . According to Polit and Hungler, (2004)
research methodology refers to the researcher ways of obtaining, organizing and analyzing data [5].
A Basic true experimental study was selected for the study with pre-test and post test design. The study
samples were recruited as per Stratified random sampling technique. Here the population was divided into two
stratum based on gender and then the researcher allocated the population, 50% proportionately in experimental
and control group respectively who met the inclusion and exclusion criteria. The tool designed for the study
comprised demographical variables (Age, Gender, Diagnosis, Cycle of chemotherapy, Antiemetic drug
receiving status). Meanwhile, the level of nausea and vomiting was assessed by Rhodes Index of Nausea and
Vomiting scale. This consisted of 8 sub questions assessing subjective experience of nausea and vomiting.
Domains of factors included frequency, amount, duration, severity and distress of each symptom. Among 8 sub
questions, 5 questions were related to occurrence and 3 related to distress. The maximum score for occurrence
was ‘4’ and minimum score for occurrence was ‘0’ with the total maximum score possible of ‘32’ and the
minimum possible of ‘0’.
The data collection procedure was done for a stipulated period of 6 weeks among total of 60 samples
with 30 each in experimental and control group respectively in oncology wards of G.K.N.M Hospital at
Coimbatore after obtaining content validity from experts and doing a pilot study for the feasibility of the tool.
During the main study, samples were also informed by the researcher about the nature and purpose of the study.
The written consent was also obtained as per rule. The standardized, Rhodes Index of Nausea and Vomiting
interview questionnaire was administered to assess pre-test score of nausea and vomiting on day 2 that was
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Effectiveness of acupressure on nausea and vomiting among cancer patients receiving chemotherapy
followed by the acupressure on 2nd, 3rd and 4th day at p6 region. Post test was done on the 5th day, i.e. at 120hrs.
As per protocol the acupressure at p6 was given 6hrs apart on each day with duration of each session lasting 5
minutes. On the 5th day the same standardized, Rhodes Index of Nausea and Vomiting interview questionnaire
was administered to assess the post test score of nausea and vomiting to experimental and control group.
III.
ANALYSIS AND INTERPRETATIONS
Table 1: Frequency and percentage distribution of cancer patients receiving chemotherapy according to their
selected demographic variables.
N=60
Experimental
Control
Total
Group
Group
S.No.
Demographic Variables
n
%
n
%
N
%
1
Age (in Years)
a)
18-40
6
20
5
16.7
11
18.4
b)
41-60
11
36.7
13
43.3
24
40
c)
61-80
12
40
10
33.3
22
36.6
d)
81 and above
1
33.3
2
6.7
3
5
2
3
Cycle of chemotherapy
a)
1st Cycle
b)
2nd Cycle
c)
3rd Cycle
d)
4th Cycle
17
9
4
0
56.7
30
13
0
16
8
4
2
53.3
26.7
13.3
6.7
33
17
8
2
55
28.3
13.3
3.4
Anti-emetic drug receiving
30
100
30
100
60
100
It was inferred that, with regard to age, majority of the cancer patients receiving chemotherapy
24(40%) belonged to age group of 41-81 years and 33(55%) belonged to 1st cycle of chemotherapy. Meanwhile,
majority of the cancer patients 20(33.3%) receiving chemotherapy were diagnosed with respiratory tract cancer
and all 60(100%) received anti-emetic drugs.
Table 2: Mean, Standard deviation, Mean difference and ‘t’ value of pre-test, post-test score of nausea and
vomiting among cancer patients receiving chemotherapy in experimental and control Group.
N=60
S. No.
Variables
1
Experimental group
Pre test
Post test
Control group
Pre test
Post test
2
Mean
SD
MD
‘t’ value
18.5
7.23
5.50
2.56
11.27
15.12***
18.03
16.44
5.3
1.59
2.90NS
4.87
***Significant at p<0.001 level, NS - Not Significant
Above table reveals that among experimental group, the mean pretest score 18.5 with standard deviation 5.50
was more than the mean post test score 7.23 with standard deviation 2.56. The calculated mean difference was
11.27. The obtained‘t’ value 15.12 was highly significant at p<0.001 level. On the other hand, among control
group, the mean pretest score 18.03 with standard deviation 5.3 was more than the mean post test score 16.44
with standard deviation 4.87. The calculated mean difference was 1.59 with the obtained‘t’ value 2.90 that was
not significant.
Hence, it is identified that acupressure is effective in reducing chemotherapy induced nausea and
vomiting among cancer patients.
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Effectiveness of acupressure on nausea and vomiting among cancer patients receiving chemotherapy
Table 3: Mean, Standard Deviation, Mean Difference and ‘t’ value of post-test score of nausea and vomiting
among cancer patients receiving chemotherapy in experimental and control group
N=60
S. No
Variables
Mean
SD
MD
‘t’ value
1
Experimental group
Post test
7.23
2.56
9.21
9.14***
2
Control group
Post test
16.44
4.87
***Significant at p<0.001 level
The above table reveals that the mean experimental group post test score 7.23 with standard deviation
2.56 was less than the control group mean post test score, 16.44 with a standard deviation 4.57. The calculated
mean deviation was 9.21. The obtained‘t’ value 9.14 was significant at p<0.001. Thus there was a significant
difference between the experimental group post test score and control group post test score.
Fig 1: Bar diagram depicting the post test mean scores after acupressure among experimental and control
group.
Thus it was inferred that acupressure is effective in reducing nausea and vomiting among cancer patients
receiving chemotherapy.
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Effectiveness of acupressure on nausea and vomiting among cancer patients receiving chemotherapy
Table 4: Frequency, percentage and Chi square- distribution of level of nausea and vomiting among cancer
patients receiving chemotherapy with their selected demographic variables.
N=60
S.
No
1
2
3
4
Level of Nausea and Vomiting
Demographic Variables
n
Mild
%
Age (in years)
a)
18-40
b)
41-60
c)
61-80
d)
80 and above
0
2
0
0
Sex
a)
b)
Female
Male
Diagnosis
a)
Respiratory
system
b)
Hematological
system
c)
Gastro
intestinal
system
d)
Reproductive
system
e)
Urinary system
Cycle of chemotherapy
a)
1st Cycle
b)
2nd Cycle
c)
3rd Cycle
d)
4th Cycle and
above
Moderate
n
%
n
Severe
%
0
3.4
0
0
11
5
0
3
18.3
8.3
0
5.0
0
17
20
0
1
1
1.6
1.7
15
4
25
6.6
1
1.7
4
0
0
0
0
2
Value
n
Worst
%
0
28.3
33.3
0
0
0
2
0
0
0
3.4
0
45*
df=9
14
23
23.3
38.4
0
2
0
3.4
10.54*
df=3
6.6
14
23.4
1
1.7
4
6.7
10
16.6
1
1.7
3
5
7
11.6
0
0
9.7NS
df=12
1
1.7
4
6.7
4
6.6
0
0
0
0
4
6.6
2
3.4
0
0
0
0
1
1
0
0
1.7
1.7
12
6
0
1
20
10
0
1.7
20
10
7
0
33.3
16.6
11.6
0
1
1
0
0
1.7
1.7
0
0
23.83*
df=9
* - Significant p<0.05 level, NS – Not Significant
From the above table thus it is understood that that their was a significant association between the age, sex and
cycle of chemotherapy among cancer patients receiving chemotherapy with their selected demographic variables
hence the research hypotheses stated was supported.
IV.
CONCLUSION
The main conclusions drawn from this present study was that most of the cancer patients receiving
chemotherapy had significant level of nausea and vomiting. After acupressure session, it is found that there had
been a significant level of reduction in nausea and vomiting. Samples become familiar and found themselves
comfortable and also expressed satisfaction. After the completion of the study, subjects in control group were
demonstrated acupressure technique. It is thus concluded that, acupressure as an effective and simple strategy to
reduce nausea and vomiting cancer patients receiving chemotherapy.
Implication in Nursing practice and education:

Learn accurate assessment of nausea and vomiting using Rhodes index of nausea and vomiting.

Understand the importance of acupressure as adjunct to the conventional anti-emetics.

Encourage the importance of acupressure as a complimentary therapy.

Learn accurate assessment of chemotherapy induced nausea and vomiting among cancer patients.

Fresh hand training can be given to nurses to encourage patient practice of this simple technique.
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Effectiveness of acupressure on nausea and vomiting among cancer patients receiving chemotherapy

Understand and bring to practice acupressure intervention.
Implication in nursing administration:

In-service education programme can be organized for the nurses on this complimentary technique.

The nurse can make cost effectiveness on the nursing care by reducing the usage of anti-emetics of cancer
patients receiving chemotherapy.
Limitation:

The study couldn’t be done among patients with head and neck cancer.

Restriction of sample size of 60.
ACKNOWLEDGEMENT
I would like to acknowledge all the samples who has made my effort fruitified and accepting the new
intervention in Indian clinical settings that is not been widely been practiced.
REFERENCES
[1]
[2]
[3]
[4]
[5]
Chemotherpy/reducing sideeffects/chemo,:// www.pubmed . pmid: 8943569 Dated on 23.9.2008.
Gilda’s club worldwide: www.gildasclub.org Dated on 17.12.2005.
National institute of health. http://www.nim.nih.gov/medline plus/cancer.html Dated on 23.7.2006.
F. Polit, Nursing research principles and methods (Philadelphia: Lippincott Williams and Wilkins, 2004).
F. Polit, and D. Hungler Nursing research principles and methods (Philadelphia: J.B. Lippincott, 2001).
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 14-19
www.iosrjournals.org
Comparative Analysis of Health Institutions on the Attitude and
Practice af Midwives Towards Pregnant Women During Child
Delivery In Ogbomoso, Oyo State, Nigeria.
Dr. Florence O ADEYEMO
Dept. of Nursing, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso, Nigeria.
Abstract: The aim of this study was to compare the attitude and practice of midwives in a mission and
government health institutions in Ogbomoso, town in south west Nigeria towards pregnant women during
delivery. Five hundred and seventy nine pregnant mothers from antenatal clinic, labour and postpartum ward,
were enrolled for this study. Primips were excluded from the study. Four hypotheses were tested.
The study showed that the attitude and practice of mid-wives have great influence on the pregnant women
perception about them. There is a mutual relationship between the mid-wife and the pregnant women and this
may result to successful child(ren) delivery. The study also revealed that the attitude of mid-wives from Mission
hospital is significantly different from the attitude of mid-wives from general hospital. Similarly, the Value for
practice of mid-wives from Mission hospital is significantly higher than that of the mid-wives from general
hospital. Lastly, the perception of pregnant women toward choice of health institutions shows great significant
difference.
The present study suggests the need for strict supervision of midwives to ensure quality care and
positive attitude towards women in labour and Stakeholders including Nursing and Midwifery Council should
intensify action on continuous education on human relations.
Keywords: Attitude, Child Delivery, Health Institutions, Midwives, Practice, Pregnant Women.
I.
Introduction
STATEMENT OF PROBLEM.
Women need to be encouraged during delivery. It is believed that with the introduction of modern techniques of
practice and the introduction of servicom by the federal government, the midwives’ attitude and practice will be
better hence, this study.
SIGNIFICANCE OF STUDY.
There are many studies on the attitude, practice and knowledge of midwives towards pregnant women
during delivery, but none has given information to show if the midwives current attitude and practice is still the
same or there is a better progress modification.
1. Introduction
Child birth is a normal phenomenon among human beings but most stressful experience in women.
Child delivery is usually accompanied by labour pain which mothers experienced irrespective of their
educational, ethnic, social or financial background. This pain is associated with the physiological termination of
pregnancy at term to bring about motherhood. This pain is also referred to as labour pain due to its severity and
the vigorous task the mother must perform to accomplish result. Response to pain by women will depend on
cultural background, individual and physical state [1]. During this period, pregnant women exhibit lots of
anxiety. These women need care and support of the health professionals during labour. The health professionals
such as doctors and midwives play an important role in the care of pregnant mothers during prenatal, antenatal,
delivery and post natal period.
The midwives seem to be closest health professional to pregnant mothers. A midwife is a person who
went through the school of midwifery for a period of three years or eighteen months and certified by the Nursing
and Midwifery Council of Nigeria. Wikipedia [2] defined Midwifery as a health care profession in which
providers offer care to childbearing women during pregnancy, labour and birth, and during the postpartum
period. They also help care for the newborn and assist the mother with breastfeeding. Midwives work with
women and their families in many different settings. Midwives generally support and encourage natural
childbirth in all practice settings. The midwife must be able to give the necessary supervision, care and advice to
women during pregnancy, labour and the post-partum period, to conduct deliveries on her own responsibility,
and to care for the newborn and the infant [3]. Nurses including midwives are at the forefront of caring for all
patients and inadequate care will not only affect the patient, but it has the capacity to adversely affect the
nursing profession [4]. Midwives are expected to display a positive caring attitude towards pregnant women
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Comparative Analysis Of Health Institutions On The Attitude And Practice Of Midwives Towards
during delivery and also use their knowledge on pain management to reduce or relief pain. Mahlako [5] believed
that the midwives attitude can be influenced by culture, religion, personal experience and professional
background. It is also believed that midwives have the ability to relief anxiety because some of these mothers
threshold to pain is very low. The relationship between the women in labour and the midwife is important as the
midwife ensures that the birth experience is fulfilling and gratifying [6]. Women in labour tend to overestimate
their ability to cope with pain, therefore midwives are expected to be courteous, patient and attend to client’s
need immediately in the practice of safe delivery [7].
Many women lose their lives in the process of childbirth every year. About half a million of women die in sub
Saharan Africa from pregnancy related causes and maternal mortality rate (MMR) is between 166 to 1.549 per
100,000 live birth[8]. Nwosu, Odubanjo and Osinusi [9] explained that ‘an estimated 500,000 women die each
year throughout the world from complications of pregnancy and childbirth and about 55,000 of these deaths
occur in Nigeria. Factors that contribute to the high maternal mortality rates in Nigeria include lack of antenatal
care, a low proportion of women attended to by skilled birth attendants, and delays in the treatment of
complications of pregnancy. Poor utilization of quality health services contribute to maternal mortality rate
which may be attributed to the attitude and practice of the skilled workers especially the nurses and midwives.
Statistics from different sources have revealed that children and women are the most vulnerable to the threats of
poverty and untimely death and a recent World Health Organisation report stated that, more than 600,000
women have died in recent time due to childbirth or pregnancy-related complications while Nigeria accounts for
close to 10 per cent of this figure [10]. The death of a woman during pregnancy, labor or pueperium is a tragedy
and it carries a huge burden of grief, pain, and is a major public health problem in developing countries because
women have an enormous impact on their families’ welfare [11]. Potani[12] stated that Callister Mutherica, the
first lady of Malawi was persuading the pregnant women to deliver in public health facilities at a National
Nurses and Midwives Advocacy Campaign meeting in Lilongwe. She also pleaded with nurses and midwives in
Malawi to practice professionally, ethically and with empathy towards pregnant women. It is believed that some
nurses are scarring the pregnant women by their attitude and practice. Only one third of births in Nigeria are
attended to by doctors, nurses and midwives and the relationship between the health workers and pregnant
women during delivery can reduce maternal deaths including related complications but the attitude of many
nurses and midwives to women during labour is poor[13]. In contrast, findings on ‘Evaluation of satisfaction
with midwifery care’ revealed that women in the midwife group reported significantly greater satisfaction and a
more positive attitude toward their childbirth experience than women in the doctor group (p < 0.001) in Arbour
Birth Center, Calgary, Alberta, Canada[14].
Lanre-Abass [15] examines poverty as a major cause of maternal deaths in Nigeria along with the practice of
medicine in Nigeria which is different from that of modern medicine because of the uncaring attitude of many
health care providers in the context of maternal care. He suggested that in order to reduce maternal deaths in
Nigeria, there is need for ethical orientation emphasizing the need to show care to vulnerable patients (for
example, pregnant women) irrespective of their socio-economic status. This will enhance quality care and foster
good relationships between health-care providers and their patients. At the safe motherhood Initiative
conference 1987 in Kenya, participating countries agreed to decrease MMR by 50% yet this remains high in
Nigeria.
The attitude and practice in each hospital defers thus contributing to different experiences of pregnant mothers
in developing countries. Some of the experiences the women in Bayelsa state in Nigeria shared were positive,
others described serious abuse and neglect by midwives, they were rude, refused to offer assistance, and in some
cases threatened women in labour.[16] This attitude may influence pregnant women in labour on the decisions
about where to give birth in Ghana [17], thus this study will study is comparing the attitude and practice of
midwives in two health institutions in Ogbomoso.{Mission and State hospitals}The result of this study will
reveal the current attitude and practice of midwives and further assist the health care facilities to plan new
strategies on how to improve services rendered not only by midwives but all health workers.
II.
Methodology
2.1 MATERIALS AND METHODS
2.1.1Study Design: Descriptive survey
2.1.2 Research Settings: Mission Hospital and government hospital in Ogbomoso
The Mission hospital is a 182 bedded hospital founded 1907. The total numbers of nurses working in
this hospital are ninety seven. It has facilities such as medical, surgical, paediatric and maternity wards, eye
clinic, dental clinic, intensive care unit, outpatient department, theatre, accident and emergency unit etc.
Laboratory services such as X- ray, ultra-sonography, medical microbiology laboratories etc. are also available.
IT serves Ogbomoso, Oyo, Igbetti, Iwo and its environment.
Goverment hospital is a 60 bedded hospital founded in 1957 by the then Premier of Western region.
The number of nurses working in this hospital is fifty five. It has facilities such as medical, surgical, paediatric
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Comparative Analysis Of Health Institutions On The Attitude And Practice Of Midwives Towards
and maternity wards, theatre, ophthalmic, dental, outpatient department physiotherapy dept., Laboratory services
such as X- ray, medical microbiology lab, etc. It serves Ogbomoso, and its environment.
Target Population under Study: Pregnant Clients attending antenatal clinic admitted to labour and postpartum
ward.
Sampling Technique: A simple random sampling technique was used to select 579 from both health institutions
Instrument: The instrument for collecting the data required for this study is a standardised instrument – Caring
Behaviour Inventory (CBI). The content of the questionnaire are divided into four sections namely:
demographic data, attitude, practice and perception. Twenty statement items was used to measure attitude,
eleven to measure practice and seven to measure perception. For each statement, respondents are asked to state
their experience on the attitude and practice and perception of midwives using a four point Likert scale rating,
ranging from 1 strongly disagreed to 4 strongly agree.
Validity test: The questionnaire was given to experts for review.
Reliability of the research instrument was done through test-retest method which gave 0.84 reliability coefficient
Procedure for data collection: On the receipt of approval from the hospital ethical committees of Mission
Hospital and government hospital in Ogbomoso, a descriptive survey questionnaire were be distributed to all
interested participants. A consent form and a cover letter were attached to each questionnaire. The questionnaire
was first prepared in English and also translated into the Yoruba language. Participants who gave their consents
to participate in the study received elaborated explanation on the purpose of the study and the type of questions
and how to answer by trained facilitators. Furthermore, to enhance honest and frank responses privacy ensured.
Participants were being instructed to complete the questionnaire through the help of the research assistances.
The study was conducted within a period of six months.
The returned questionnaire was coded and a statistical package for social sciences (SPSS) was used to analyse
the coded response.
The data collected were analyzed using independent t- test and Regression co-efficient.
Ethical Considerations: The right of the subjects’ privacy will be maintained. This includes the issues on
restriction and anonymity, also confidentiality.
III.
Results
Table 1
Regression coefficient of relative contribution of influence attitude and practice of midwives towards pregnant
women during delivery
Model
Unstandardized coefficient Standardized coefficient T
Sig
Beta
(Constant
Attitude of midwives
Practice of mid-wives
B
Std. Error
.559
.026
.015
.156
.005
.007
.234
.099
3.588
4.866
2.080
.000
.000
.038
Table 1 reveals the relative contribution of two predictor variables (attitude of mid-wives and practice of midwives) toward pregnant women in south west Nigeria as it is given by beta weight. The β value indicates the
contribution of each of the two predictor variables to the criterion variable (perception of pregnant women
toward mid-wives). The higher the β value, the greater the contribution of the predictor variable. This implies
that attitude of mid-wives and practices of mid-wives when used alone are important factors to predict pregnant
women perception towards mid-wives. This means that the attitude and practice of mid-wives goes along way to
influence pregnant women perception about them and promote mutual relationship between the mid-wife and
the pregnant women and this may result to successful child(ren) delivery.
Hypothesis two
Health institutions do not significantly influence attitude of midwives towards pregnant women during delivery.
Independent t-test was used to test this hypothesis at 0.05 level of significance
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Comparative Analysis Of Health Institutions On The Attitude And Practice Of Midwives Towards
Table 2
Result of Independent t–test of difference of Health institutions and influence of attitude of midwives
towards pregnant women during delivery
Variable
N
M
SD
t-value
Attitude of midwives: Government. Hosp.
212
26.08 4.40
7.200
Mission Hosp.
367
28.68 4.07
Significant at 0.05 level, critical t = 1.96, df = 577
The result presented in table 2 shows a mean value of 26.08 for attitude of mid-wives in government
hospital and a mean of 28.689 attitude of mid-wives mission hospital. The two groups yielded a t–value of
57.200 which is higher than the critical t-value of 1.96 at 0.05 level of significance with 577 degree of freedom.
With this result, the null hypothesis which states that, Health institutions does not significantly influence attitude
of midwives towards pregnant women during delivery is rejected.
This implies that there is significant difference in attitude of mid-wives from the different health
institution. The mean value indicate that the attitude of mid-wives from Mission teaching hospital (M 28.689) is
significantly higher than the value for attitude of mid-wives from government hospital (M 26.080).
Hypothesis three
Health institutions do not significantly influence practice of midwives towards pregnant women during delivery.
Independent t-test was used to test this hypothesis at 0.05 level of significance.
Table 3
Result of Independent t–test of difference of Health institutions and practice of midwives towards
pregnant women during delivery
Variable
N
M
SD
t-value
Practice of midwives: Government Hosp.
212 23.01 4.2`
1
8.32
Mission Teaching Hospital. 367 26.66 3.02
Significant at 0.05 level, critical t = 1.96, df = 577
The result presented in table 7 shows a mean value of 26.66 for practice of mid-wives in Govrnment
Hospital and a mean of 23.01 for practice of mid-wives in Mission hospital. The two groups yielded a t–value of
8.32 which is higher than the critical t-value of 1.96 at 0.05 level of significance with 577 degree of freedom.
With this result, the null hypothesis which states that, Health institutions does not significantly influence
practice of midwives towards pregnant women during delivery is rejected.
This implies that there is significant difference of practice of mid-wives from different health
institution. The mean value indicate that the practice of mid-wives from Mission teaching hospital (M 26.66) is
significantly higher than the value for practice of mid-wives from general hospital (M 23.01)
Hypothesis four
Health institutions do not significantly influence perception of pregnant women delivery. Independent t-test was
used to test this hypothesis at 0.05 level of significance.
Table 4
Result of Independent t–test of difference of Health institutions and perception of pregnant women
Variable
N
M
SD
t-value
Perception of pregnant women: Govt. Hosp.
212 23.05 3.48
5.616
Mission Hosp.
367 24.53 2.77
Significant at 0.05 level, critical t = 1.96, df = 577
The result presented in table 6 shows a mean value of 23.05 for perception of pregnant women in
General Hospital and a mean of 24.53 perceptions of pregnant women in Mission hospital. The two groups
yielded a t–value of 5.616 which is greater than the critical t-value of 1.96 at 0.05 level of significance with 577
degree of freedom. With this result, the null hypothesis which states that, Health institutions do not significantly
influence perception of pregnant women during delivery is rejected.
This implies that there is significant difference in perception of pregnant women toward choice of health
institutions. The mean value indicate that the perception of pregnant women who attain Mission hospital (M
24.53) is significantly higher than the value for perception of pregnant women who are attended to in general
hospital (M 23.05).
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Comparative Analysis Of Health Institutions On The Attitude And Practice Of Midwives Towards
IV.
Discussion
The present study is on the attitude and practice of mid-wives towards pregnant women perception in labour
in mission and government hospitals in Ogbomoso, Oyo state, Nigeria. The study revealed that There is a
mutual relationship between the mid-wives and the pregnant women and this may result to successful child(ren)
delivery as Bluff and Holloway [6] explained that the provision of a client centered service is important where
women can express their opinion. WHO/UNICEF(1996)[18] explained that the presence of skilled attendant
during child birth can lead to reduced maternal morbidity and mortality rate which is one of the indicators to
assess millennium development goal of improving maternal health. Centre for maternal and children enquires
(CEMACH) on 27th May 2005 mentioned that poor quality care provided by health workers contributed to the
increase in maternal mortality and morbidity rates in Nigeria. Brink [19] asserted that quality care is a major
public health concern and it has the potentials of improving the health of the mother and child.
The attitudes of mid-wives from the mission and government hospitals are significantly different in this
study. The attitude of mid-wives from Mission hospital (M 28.689) during labour is significantly higher than the
value for attitude of mid-wives from government hospital (M 26.080). This implies that the midwives in
Mission hospital show better positive caring attitude towards their clients than the midwives in government
hospital. It therefore explained the reason why mission hospital receive better patronage from pregnant mothers
because Mitchell [4] stated that inadequate care will not only affect the patient utilization of hospital facilities,
but it has the capacity to adversely affect the nursing profession, thus supporting Omoruyi(2008) report that the
relationship between the health workers and pregnant women during delivery can reduce maternal deaths
including related complications
Similarly, this study showed that there is a significant difference in the practice of mid-wives from both
Mission and government health institutions because the mean value indicate that the practice of mid-wives
from mission hospital (M 26.66) is significantly higher than the value for practice of mid-wives from
government hospital (M 23.01). This may be as a result of discipline instilled on the midwives in mission
hospital because all midwives in both hospitals were duly trained. There are policies that are strictly adhered to
in the mission hospital.
Lastly, there is significant difference in the perception of pregnant women toward choice of health
institutions because the mean value indicate that pregnant women who attended mission hospital (M 24.53) is
significantly higher than that of pregnant women who attended government hospital (M 23.05) due to positive
caring attitude and adequate skills in the practice of midwifery. Studies in Ghana revealed that the attitude of the
health workers towards pregnant women has a major influence on of the choice about where to give birth [17]
which is in line with this present study.
V.
Conclusion
Despite the increasing activities of the nurses and midwives to improve the quality of care, it was
observed that mothers still complain of midwives’ attitude and practice. It seems the midwives do not take the
views of the mothers for effective care. This study revealed that there is a mutual relationship between the midwives and the pregnant women. The attitude and practice of mid-wives from the mission and government
hospitals are significantly different.
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1994.
S. Harvey, D. Rach, M.C. Stainton, J. Jarrell, R. Brant, Evaluation of satisfaction with midwifery care, PubMed Journal, 18(4),
2002, 260-267.
K.M. Mahlako, The perception of selected groups of Midwives towards women experience in labour, masters diss., University of
South Africa, South Africa, 2008.
R. Bluff and I. Holloway, They know best: Women’s perceptions of midwifery care during labour and childbirth, PubMed, 10 (3),
1994, 157-164.
L.O. Ogunjimi, Rosemary Thomas, Ibe and M.M. Ikorok, Curbing maternal and child mortality: The Nigerian experience,
International Journal of Nursing and Midwifery, 4(3), 2012, 33-39.
C.I. Iyaniwura and Q. Yusuf, Utilization of Antenatal care and delivery services in Shagamu, South Western Nigeria, African
Journal of Reproductive Health, 13(3), 2009, 110-123.
Nwosu Joanna, M. Oladoyin Odubanjo and Osinusi O. Bandele, Overview of Maternal and Infant deaths in Nigeria: Reducing
Maternal and Infant Mortality in Nigeria, The Nigerian Academy of Science forum on evidence-based health policy making
workshop summary, 2009, 1-8.
Bakare Biliqis, Tackling maternal and child mortality in Nigeria: Advocacy for maternal and infant deaths in Nigeria, 2011.
Available on: http://www.punchng.com/Articl.aspx?theartic=Art201108030434517
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birth: The Canadian survey of maternity care providers’ attitude towards labour and Birth, Canadian Journal of Midwifery Research
and Practice, 2(10), 2011, 1-11.
Lanre-Abass .A. Bolatito, Poverty and maternal mortality in Nigeria: towards a more viable ethics of modern medical practice,
International Journal for Equity in Health, 7(11), 2008, PMC2390565.
Onasoga, A. Olayinka, Opiah, Margaret Mombel and Osaji Teresa Achi, Perceived effects of midwives attitude towards women in
labour in Bayelsa State Nigeria, Archives of Applied Science Research, 4 (2), 2012, 960-964.
D’Ambruoso, Lucia Abbey and Mercy, Midwives’ attitudes to women in Labour in Ghana, BMC Public Health, 5(140), 2008, 1-2.
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19 | Page
IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 20-24
www.iosrjournals.org
Factors Contributing to Miss Appointments among 1-4 Years Old
Toddlers for Routine Health Care in Government Health Clinics
in Peninsular Malaysia
Noor Hafizan M S1, Rusnah S1 , Khalib L1
1
Department of Community Health, University Kebangsaan Malaysia Medical Centre, Cheras, Malaysia
Abstract: Scheduled routine health care follow up visits among 1-4 years old toddlers to government health
clinics are not fully utilized and factors contributing to missed appointments are not well studied. Continuous
health care among children under 5 years of age is one of the important factors to reduce morbidity and
mortality. Therefore, this study aimed to identify the factors contributing to missed appointments among 1-4
years old toddlers for health care. Unmatched case control study among 570 mothers (285 cases and 285
controls) in five government health clinics in Tumpat district, Kelantan, Malaysia that serving a routine child
health care was conducted using guided questionnaire. Analysis involved was binary logistic regression. Results
showed that working mothers (adjusted OR:1.59, 95% CI :1.10-2.30, p:<0.05), knowledge of the mothers about
child health services in government health clinic (adjusted OR: 8.45, 95% CI: 4.40-16.24, p:<0.001), mother’s
perception towards health facilities and services in government health clinic (adjusted OR: 1.59, 95% CI: 1.102.30, p:<0.05 and mother’s social support from people surrounding (adjusted OR : 4.89, 95% CI: 2.40-9.98,
p:<0.001) were the factors contributing to missed appointments. The research findings indicate that special
efforts should be made to help working mother, to promote child health care services in government health
clinic and to increase social support to mother in child health care in improving their routine health care follow
up visits to government health clinic.
Keywords Factors, government health clinic, miss appointment, toddler
I.
Introduction
Regular health care among children in health facilities is very important for improvements of theirs
health and become one of health intervention to reduce child mortality. The reported under five mortality rate
(U5MR) has declined from 57 per 1,000 live births in 1970 via 16.6 in 1990 to 8.1 in 2005 (1). However,
worldwide data in 2010 showed about 29,000 children under the age of five die every day, mainly from
preventable causes (2). In order to make the mortality rate continuously reduced, the health of our children
needs to observe closely by regular attendance to health facilities. In Malaysia, as part of the overall package of
maternal and child health services in government health facilities, all children are needed to continue their
regular attendance as scheduled for health care services (3). The availability of child health services in all
government health facilities in Malaysia through the country’s primary health care system has contributed to
better health care for children and reduces children morbidity and mortality.
One of the challenges of this programme is a failure of continuous attendance at the recommended time
or in easier term, misses appointments. Low rates of attendance among children especially 1-4 years old toddlers
to government health clinic leave our young children at risk for undetectable medical problems (3). Many
factors influencing the attendance of children for health care to health clinic. The factors include
sosiodemografic factors like family size, household’s income monthly, availability of transport, mother’s
education, mother’s married status and age, children’s age and sex, number of children, order of children, lack
of knowledge or negative perception on child health services and facilities in health clinic include waiting time,
attitude of service providers and limited accessibility to health care due to poor support (4 - 8). However, no
research has been carried out to identify the factors that contributing to missed appointments among 1-4 years
old toddlers to government health clinic in Malaysia, including in Kelantan where the rate of attendance is low.
Hence, this study was conducted to identify the factors contributing to missed appointments among 1-4 years
old toddlers for routine health care in government health clinics in Kelantan, Peninsular Malaysia.
II.
Materials And Methods
Unmatched case control study was carried out over a period of four months (November 2011 to
February 2012) in all 5 government health clinics in Tumpat district, Kelantan. Tumpat district is a coastal area
in the North-eastern state of Kelantan, Peninsular Malaysia and is among the poorest district in the country. The
study population was all children age from 1 to 4 years who registered in the government health clinics in
Tumpat district for their regular health care services. Case group were mothers of 1-4 years old toddlers who
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Factors Contributing to Miss Appointments among 1-4 Years Old Toddlers for Routine Health Care
missed follow up for 2 times and above. Control group were defined as mothers of 1-4 years olds toddler who
never miss their follow up more than once. We reviewed the attendance status of the toddler using their clinic
record from birth to their stated age.
The sample size was calculated based on two proportions comparison. It was determined using Fleiss
(1981) formula with requirement for significance level (α) of 0.05 and 80% power (9). The ratio of cases and
control were 1:1. The calculated sample size was 285 for each group. Therefore the total sample size was 570
(285 cases and 285 controls). The sampling was conducted using purposive sampling method. We collected the
data through an interview with the mothers (respondents) of the 1-4 years old toddlers in health clinics, their
house and also via telephone using a set of guided questionnaire. The questionnaire consisted of five parts that
covered sociodemographic, knowledge, perception, practice and social support factors that related to health care
of 1-4 years old toddlers in government health clinic in Malaysia. Prior to data collection, the questionnaire was
pre-tested on 30 sample of similar population. The validation revealed good reliability with internal consistency
of Cronbach’s alpha 0.8 and good construct validity using factor analysis.
The collected data were entered into computer and analyzed using Statistical Package for Social
Sciences (SPSS) for Windows Version 20.0 statistical software. The data was cleaned for inconsistencies and
missing values. Descriptive, bivariate analysis and multivariate analysis were done. Simple frequency tables of
maternal and child characteristics were made. The confidence level was set at 95%. Factors that were found to
be significant at p < 0.05 from the bivariate analysis were entered into a multiple logistic regression model. This
study was approved by the National Medical Research Register (NMRR) and the ethical approval was obtained
from National University of Malaysia Medical Research Ethical Committee, Cheras, Kuala Lumpur, Malaysia
III.
Results And Discussion
3.1 Respondent’s demographic information
A total of 570 respondents (285 cases and 285 controls group) responded to the survey. Table 1 shows
the characteristics of the respondents. For the children’s characteristics, no difference for age’s group in case
and control group. There were minimal differences for sex, number of sibling and order of the children in family
for both groups. For the mother’s characteristics, majority of them were married, attained primary/ secondary
education level and aged 35 and above in both group. However, there were differences in working status in case
and control group. Most of mothers were working (54.4%) in case group compared to control group (43.9%).
There were more respondents with low monthly family income, having car and others transport and family size
more than 5 persons in both group.
Table 1 Sociodemografic characteristics of the case and control group
Sociodemografic factors
Case
n (%)
Gender of children:
Girl
133 (46.7)
Boy
152 (53.3)
Age of children:
<2 years old
83 (29.1)
≥2 years old
202 (70.9)
Number of siblings:
< 5 person
≥ 5 person
Birth order:
First
Others
Status of mother:
Widow
Married
Age of mother:
< 35 years old
≥ 35 years old
Employment status of mother:
Employed
Unemployed
Education level of mother:
Low (Primary/secondary level)
Control
n (%)
123 (43.2)
162 (56.8)
83 (29.1)
202 (70.9)
202 (70.9)
83 (29.1)
211 (74.0)
74 (26.0)
68 (23.9)
217 (76.1)
82 (28.8)
203 (71.2)
17 (6.0)
268 (94.0)
10 (3.5)
275 (96.5)
93 (32.6)
192 (67.4)
101 (35.4)
184 (64.6)
155 (54.4)
130 (45.6)
125 (43.9)
160 (56.1)
224 (78.6)
226 (79.3)
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Factors Contributing to Miss Appointments among 1-4 Years Old Toddlers for Routine Health Care
High (Tertiary level and above)
Transport:
Motorcycle only
Car and others
Household income:
Low ( < RM1320)
High ( ≥ RM1320)
Family size:
≤ 5 person
> 5 person
61 (21.4)
59 (20.7)
108 (37.9)
177 (62.1)
110 (38.6)
175 (61.4)
162 (56.8)
123 (43.2)
166 (58.2)
119 (41.8)
92 (32.3)
193 (67.7)
86 (30.2)
199 (69.8)
3.2 Statistical Analysis
Table 2 shows simple binary logistic regression and multiple binary logistic regressions. In bivariate
analysis (simple binary logistic regression), only employment status of the mother in sosiodemographic factors
was found to be associated with missed appointments (p= 0.012). The other independent variables like
knowledge of mothers about child health care services in government health clinic (p< 0.001), perception of
mothers toward facilities and services in government health clinic (p< 0.001) and social support to mother from
people surrounding (p< 0.001) had significant association with missed appointments. All these independent
variables were categorized by scoring it into 2 categories before bivariate analysis.
Multivariate analysis (multiple binary logistic regressions) was conducted to find the important
determinants while adjusting for other factors. It was found; all the factors that significant in bivariate analysis
retained it significant. Employed mothers were 2 times more likely to miss their 1-4 years old toddlers
appointments for health care in government health clinic than unemployed mothers, [adjusted OR = 1.59, (95%
CI:1.10-2.30)].
Mothers who had poor knowledge about child care services in government health clinic were 8 times
more likely to miss their 1-4 years toddlers old appointments for health care in government health clinic than
mothers who had good knowledge, [adjusted OR = 8.45, (95% CI: 4.40,16.24)]. Similarly, mothers who had
negative perception towards facilities and services in government health clinic were 2 times more likely to miss
their 1-4 years toddlers appointments for health care in government health clinic than mothers with positive
perception, adjusted OR = 1.59, (95% CI:(1.10,2.30)]. Mothers who had poor social support were 5 times more
likely to miss their 1-4 years toddlers appointments for health care in government health clinic than mother who
had good social support, [adjusted OR = 4.89, (95% CI: 2.40,9.97)].
Table 2Factors associated with missed appointments among 1-4 years old toddlers for child health care in
government health clinic
Variables
Mother’s
employment
status:
Employed
Crude OR
(95% CI)
X2(df)*
p
value*
125
(43.9)
160
(56.1)
1.53 (1.092.12)
6.33
(1)
0.012
273
(95.8)
195
(68.4)
12 (4.2)
273
(95.8)
10.5 (5.5919.71)
42.02
(1)
164
(57.5)
121
(42.5)
119
(41.8)
166
(58.2)
1.89 (1.362.64)
14.27
(1)
Case
n (%)
155
(54.4)
130
(45.6)
Control
n (%)
X2
(df)**
p
value**
1.59 (1.102.30)
5.99
(1)
< 0.05
<
0.001
8.45 (4.4016.24)
55.73
(1)
< 0.001
<
0.001
1.59 (1.102.30)
6.04
(1)
< 0.05
Adjusted
OR
(95%CI)
Unemployed
Mother’s
knowledge:
Poor
Good
Mother’s
perception:
Negative
Positive
Social
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Factors Contributing to Miss Appointments among 1-4 Years Old Toddlers for Routine Health Care
support:
Poor
Good
60 (21.1)
225
(78.9)
11 (3.9)
274
(96.1)
6.64 (3.4112.94)
42.02
(1)
<
0.001
4.89 (2.409.97)
22.80
(1)
< 0.001
*Simple binary logistic regression, **multiple binary logistic regression
3.3 Discussion
Study has found employment status had significant association with missed appointments. Similar
findings noted by Shamsul Azhar et al. (2012) (10). On the other hand, other sosiodemographic factors were not
the factors that associated with missed appointments in this study, unlike reported by other studies (4, 7-8).
Among the community in Tumpat district, transportation is not one of the barriers to go to government health
clinic since it is situated near or in the community itself. Household income also was not contributing factors to
missed appointments. This was in contrast with the findings of other studies (7-8). Possible reason for the
insignificant finding may be due to services provided in government health clinic is free of charge. Other
explanation to marital status of the mother is a cultural itself, whereby most of women in Kelantan state are
active in outside business and may explain why to be a single mother is not a big problem to bring their children
to clinic.
We found that education level of mother was not contributing to missed appointments. Possible
reasons for the insignificant findings in this study might be due to the high number of respondents included in
both groups were mother with education level up to secondary school that categorized in low education level
may explain why the differences were not statistically significant. However study done by Shamsul Azhar et al.
(2012) in Malaysia regarding missed appointments to government health clinic for immunization among
children noted there was also no significant association between mother education level and missed
appointments (10). Similar finding also noted by Shamsul Azhar et al. (2012) for age of the mother was not
contributing to missed appointments (10).
Children characteristics like sex, gender, age, order in the family and number of siblings were not
statistically significant factors for missed appointments in this study. These were in accordance with findings of
Minty and Anderson (2004) and Getahun et al. (2010) (11, 12). However, Minty and Anderson (2004) revealed
statistically significant association between number of siblings and attendance to health facilities (11). Possible
reasons for the insignificant findings in this study might be due to the use of different research methodology
(sample selection, data gathering and others).
Similar to previous studies, our findings indicate that poor knowledge among mother about child care
services in government health clinic had significant association with missed appointments (5, 6, 8, 13).
Odusanya et al. (2008) found mothers' knowledge of immunization and vaccination were significantly correlated
with the rate of full immunization. Negative perception of mothers toward facilities and services in government
health clinic had significant association with missed appointments. Similar finding was obtained from Tadesse
et al. (2008) study which revealed mothers who had negative perception towards health institution were more
likely to have defaulter children than mothers with positive perception. Poor social support to mother from
people surrounding had significant association with missed appointments. Some other studies also found similar
findings (8, 14).
IV.
Conclusion
On the basis of the findings of this research, we suggest that specific efforts are needed to target
working women to assist them to adhere to government health clinics follow up as recommended. Poor
knowledge on child health care services in government health clinic among mother was associated with missed
appointments for child care to government health clinic. In recommending the above, we have to increase
mother’s knowledge on related knowledge of child health care via media, campaign and continuous health
education in clinic or elsewhere. There are also barriers that may inhibit their use of the services due to poor
social support to mother. The strengthening of social support networks for mother might be achieved through
community group development and implementation of community systems that can provide them with the
support they need when seeking health care. The conclusion of this study should have taken into consideration
limiting factors such as the definition of case group which was limited to 1-4 years old toddlers who missed
appointments for 2 times continuously due to difficulty in tracing the sample. These factors may have an
influence on this study outcome. A limitation is that these data were from a purposive sample of 1-4 years old
toddlers that registered for child health care in government health clinics in Tumpat district. Therefore, the
findings pertain to the population of Tumpat district. We consider that the possible information bias was
minimal, as parents were informed regarding the confidential of all information given. This finding also
provides basic information for future research and the development of interventions to promote 1-4 years old
toddlers adherence to government health clinic.
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Factors Contributing to Miss Appointments among 1-4 Years Old Toddlers for Routine Health Care
Acknowledgements
We wish to thank Universiti Kebangsaan Malaysia for funding this study (project code: FF-331-2011).
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H. Tahirovic and A. Toromanovic. Glycemic control in diabetic children: role of mother’s knowledge and socioeconomic status.
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E. Borras, A. Dominguez, M. Fuentes, J. Batalla, N. Cardenosa and A. Plasencia. Parental knowledge of paediatric vaccination.
BMC Public Health, 9, 2009.154.
A. Ruhul, M. Nirali and S. Becker. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural
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H. Tadesse, A. Deribew and M. Woldie. Predictors of defaulting from completion of child immunization in south Ethiopia, May 2008
– A case control study. BMC Public Health, 9, 2009, 150.
J. L. Fleiss, Statistical methods for rates and proportions (New York: John Wiley, 1981).
S. Shamsul Azhar, K. Nirmal, S. Nazarudin, H. Rohaizat, A. Azimatun Noor and H. Rozita. Factors Influencing Childhood
Immunization Defaulters in Sabah, Malaysia. The International Medical Journal Malaysia, 11(1), 2012.
B. Minty and C. Anderson. Non-Attendance at Initial Out-Patient Appointments at a Hospital-Based Child Psychiatric Clinic. Clin
Child Psychol Psychiatry, 9, 2004, 403.
A. Getahun, K. Deribe and A. Deribew. Determinants of delay in malaria treatment-seeking behaviour for under-five children in
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O.O. Odusanya, E. F. Alufohai, F. P. Meurice and V. I. Ahonkhai. Determinants of vaccination coverage in rural Nigeria. BMC
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M.E. Rutherford, J.D. Dockerty, M. Jasseh, S.R.C. Howie, P. Herbison, D. J. Jeffries, M. Leach, W. Stevens, K. Mulholland, R.A.
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 25-30
www.iosrjournals.org
Characterization of malignant solid thyroid nodules by
Ultrasound and Doppler
Dr. Hamad Elniel Hassan Eltyib , Dr Ibrahim Abass Awad and
Dr. Naglaa Mostafa Mohammad Elsayed.
Department of dignostic Radiology Faculty of Applied Medical Sciences King Abdulaziz University.
Abstract: This is a prospective, consecutive study of thyroid patients referred for ultrasound for the period of
2012 to 2014 m at King Abdulaziz University hospital.
Problem of the study lies in the interest or inadequate research that have been made about the role of
ultrasound imaging in monitoring and predicted differentiate benign from malignant thyroid nodule and lack of
diagnosis to see which should be subjected to histopathological examination and any of them need to medical
follow up only.
Importance of the study is to take advantage of the use of ultrasound system plasticity in description
Thyroid disease monitoring predicted characteristics that indicate the presence of slag between thyroids
nodules among patients in the study sample and comparing the results of science high aspiration needle cells
and results of histology.
Study aimed to take advantage of the characteristics of the ultrasound description Thyroid disease and
take advantage of the elastography ultrasound to distinguish and identify and evaluate thyroid nodule.
The study monitored a sample of 100 patients. Out of 100 nodules in100 patient examined by B-mode
Ultrasound and color flow doppler (CFD), 29 (29%) presented inadequate cytological specimens and were
excluded from the study (table 17).The remaining 71(71%) , histology diagnosed 11(15%) as malignant (MN)
and 60(85%) as benign nodules (BN). On Ultrasound, 7 nodules were diagnosed as malignant (MN) and 74 as
benign nodules (BN), with sensitivity of 55%, specificity of 98%, a positive predictive value of 85%, a negative
predictive value of 92% and the accuracy of 91%.
50 patients from the total 100 patients were also examined by ultrasound elastography. Final
diagnoses were obtained from fine needle aspiration. Out of 50patients 28 patients were excluded due to
insufficient diagnosis in histology .From the remaining 22 nodule elastography showed four malignant nodules
and 18 were benign. Sensitivity and specificity of the Ultrasound elastography for thyroid cancer diagnosis
were 80% (4/5) and 100% (17/17), respectively. The positive and negative predictive values were 100% (4/4)
and 94% (17/18), respectively. The accuracy of the technique was 95%.
I.
Introduction
Ultrasonography (US) has become the imaging modality of choice for diagnosing different thyroid
diseases. One of the commonest thyroid problems is thyroid nodules. They are found in 4%–8% of adults by
palpation, in 10%–41% by US examination [1, 2] and in 50% by histo-pathologic examination at autopsy [3, 4,
5]. It is known that the prevalence of thyroid nodules increases with age [5]. Although thyroid nodules are
commonly encountered problem in medicine, however, most of them are benign and the incidence of
malignancy is low, about 3-7% [6, 7]. The continuous advancement of high resolution US machines has resulted
in discovery of a large number of obscured, non palpable, tiny thyroid nodules [8]. Fine needle aspiration biopsy
(FNAB) is frequently requested for suspicious thyroid nodules to exclude underling malignancy. Diagnostic
accuracy of FNAB increases when guided by US. This ensures that the sample is obtained from the specific
nodule in question and allows direction of the needle into the solid portions of partially cystic nodules to avoid
inefficient sample, which will improve the diagnostic accuracy [9, 10]. Since the late 1990s, several studies have
been conducted to investigate the relation between certain US features of thyroid nodules and malignancy [5,
11, 12]. These studies show persistent limitation of specificity and sensitivity of certain ultrasound features in
the prediction of malignancy [13]. Some authors [14, 15] support a changed approach of recognition of specific
patterns rather than individual US features in characterizing benign and malignant nodules that warrants biopsy.
Many studies have been published in which the US ability to predict whether a thyroid nodule is benign or
malignant was assessed [16, 17, 8, 18, 19, 20, 21, 22, 23, 24, 25] There are certain criteria in the US
differentiation of benign and malignant thyroid nodules, however, there is also some overlap in their
appearances[ 5 ]. For that reason, FNAB and cytopathologic evaluation of a thyroid nodule are usually asked for
before a patient undergoes surgical resection for a suspicious thyroid malignancy [5 ].unexpectedly, the large
size of the nodule is not in favour of malignancy. The possibility of a thyroid nodule to be malignant has been
shown to be the same whether it is large or small on US basis [ 17.8, 19, 22]. Several US features have been
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Characterization of malignant solid thyroid nodules by Ultrasound and Doppler
found to be associated with an increased risk of thyroid malignancy ,including completely or premoninantly
solid consistency, hypoechoic texture, irregular and ill defined margins, absent halo sign, presence of
calcifications, and intranodule abnormal vascularity. However, no US feature has both a high sensitivity and a
high positive predictive value for thyroid cancer. The sensitivities, specificities, and negative and positive
predictive values for these criteria are extremely variable from study to study [ 5] Color Doppler US has also
been studied as a diagnostic tool for prediction of thyroid malignancy. Although color Doppler US finding of
abnormal central blood flow within the nodule appears to increase the chance that a nodule is malignant,
however, it cannot be used to prove or exclude malignancy with a high degree of confidence [ 5 ]. Solid or
predominantly solid nodules have a higher risk of malignancy than do mixed or predominantly cystic nodules.
cystic nodules have a very low possibility of being malignant. Nodules with mixed composition have an average
risk of malignancy. US greatly help localizing the solid component of mixed nodules during FNAB [5].
The relative ease and safety of FNAB compared with surgery and the increased frequency and quality
of imaging studies has resulted in more detection of thyroid nodules which is referred to as an epidemic of
thyroid nodules by some authors [ 6, 26]. For many reasons, it is not practicable to biopsy every thyroid nodule
discovered with ultrasound. Reasons for limiting thyroid biopsy include the small percentage of expected
malignant nodules, the small number of cases of thyroid cancer in which early diagnosis may actually have an
effect, the economic and community costs, , the patient anxiety for the possibility of having thyroid malignancy
and the load on radiology machines and staff. so, reliable guidelines for selecting nodules that need and that
don’t need biopsy have become essential [13].
The aim of this study is to evaluate the sensitivity and specificity of US and Doppler in predicting
malignancy of solid thyroid nodules that warrants biopsy.
II.
Patients and methods
Patients:
Prospective hospital-based study was done after obtaining ethical approval from the medical research
ethical committee. The study included 100 patients with thyroid nodules referred to the Ultrasound unit at the
diagnostic radiology department, at a university hospital between February, 2012 and October, 2012. The
patients were 87females and 13 males ranging in age from 19 - 80 years with the mean age is 49.5 years. The
exclusion criteria included; diffuse thyroid diseases and purely cystic nodules.
Ultrasound technique:
After obtaining verbal consent from patients,Ultrasound examination was done by an expert
sonographer and radiologist using high-frequency linear array transducer (5 to 12 MHz) with spatial digital iU22
Philips compounded B-mode, color and power Doppler US.
Images of each lobe were obtained in transverse and longitudinal planes. The size of the thyroid gland was
measured. Thyroid nodules were evaluated regarding their location, size, echogenicity, margin, halo sign and the
presence of calcification. Doppler application was done to detect any abnormal peripheral or central blood flow
within the thyroid nodules.
Image interpretation:
Thyroid nodules were classified into benign or malignant based on US and Doppler criteria by an
expert radiologist.
Fine Needle Aspiration biopsy:
FNA biopsy could be done for only 71 cases of suspicious thyroid nodules by expert radiologists at the
Diagnostic Radiology department. Written consent was obtained from the patient prior to biopsy. “Fine” or
“thin” (22- to 27-gauge) needles; most commonly 25-gauge needle were used under strict aseptic conditions.
Aspirate was sent for histopathology study at the main laboratory of the hospital. Results of FNAB were
correlated with those of US & Doppler. Twenty-nine patients were either missed for biopsy, refused biopsy or
the sample of biopsy was insufficient for histopathologic analysis.
Data analysis :
Demographic patients data including their age and sex associated with detailed US & Doppler criteria
of the thyroid nodules were collected and correlated with histopathologic results of cases subjected to FNAB.
All these data were statistically analyzed using SPSS 16 program. Data results in number and percentage were
described. The sensitivity, specificity, positive predictive value, and negative predictive value were defined for
each individual sonographic feature of benign or malignant nodules. The P value was considered to be
significant if it was <0.05.
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Characterization of malignant solid thyroid nodules by Ultrasound and Doppler
III.
Results :
Ultrasound criteria of benignity or malignancy included, internal nodule echogenicity, halo sign,
microcalcification within the nodule, nodule shape (taller than wide), margin and peripheral or intranodular
vascularity relative to the rest of the thyroid gland.
Our results showed the superior detection of thyroid nodules in females more than in males
(87% and 13% respectively).
Figure 1showed the age group distribution of thyroid nodules, where the highest percentage was in the age of
45-55 years (38%).
Figure 1: Distribution of thyroid nodules among different ages of the study population
Results of 71 patients subjected to FNAB were correlated with those of US characterization of thyroid nodules.
Significant individual US criteria for detection of malignancy (with the p value < 0.05) included;
hypoechogenicity (figure 2) with the sensitivity and specificity of hypoechogenicity to malignancy was 56%
and 94% respectively, absent halo sign (sensitivity and specificity were 0% and 94% respectively), presence of
intranodularmicrocalcification (figure 3) (sensitivity and specificity were 13% and 98% respectively), height to
width ratio > 1 (sensitivity 63% and specificity 65% respectively), presence of intranodular abnormal blood
flow (figure 4) showed 57% sensitivity and 95% specificity, blurred margin showed 9% sensitivity and 100%
specificity for malignancy. The highest positive predictive value was for hypoechogenicity and nodular shape
(94% and 90% respectively). Table 1 showed the details of US features for benign and malignant lesions.
Figure 2: axial US of the thyroid gland shows a well definedhypoechoic nodule of the left lobe (star).FNAB
revealedfollicular carcinoma.
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Characterization of malignant solid thyroid nodules by Ultrasound and Doppler
Figure 3: US of the thyroid gland shows lobulated nodule with foci of microcalcification (Papillary
carcinoma).
Figure 4: Doppler US of the thyroid gland shows a large solid mass with intranodular abnormal
vascularity. FNAB proved follicular carcinoma.
Table 1: US criteria of benign and malignant thyroid nodules in correlation with FNAB
Feature
Benign,
Malignan Sensitivity
Specificity
PPV
NPV
n
t n (n = %
%
%
%
(n = 84)
16)
Hypoechogenici
ty
5
11
56
94
64
94
Halo Sign
5
0
0
94
0
85
microcalcificatio
ns
1
3
13
98
67
86
Intranodular
blood flow
9
11
57
95
64
89
*H/T ≥1
10
55
63
65
27
90
Blurred margins
0
1
9
100
100
85
P
0.000
0.000
0.015
0.000
0.007
0.021
Comparing the overall criteria of US for detection of malignancy gathered together to FNAB showed increased
its sensitivity and specificity to 55% of 98% respectively with a negative predictive value of 92% and positive
predictive value of 85% as shown in table 2
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Characterization of malignant solid thyroid nodules by Ultrasound and Doppler
F.N.A Result
U.S.
Result
Total
M
B
M
6
1
B
5
11
59
60
Sensitivity%
Specificity%
PPV NPV%
%
P
55
98
85
0.000
92
Table 2: correlation of US and FNAB findings for malignant and benign lesions.
IV.
Discussion:
There are many US criteria for differentiating benign from malignant thyroid nodules. Such
differentiation is important for selecting patients for further FNAB in cases with suspicious of malignancy, or to
avoid unnecessary biopsy for those with benign criteria. It has been found in literature that no single criteria is
sure of malignancy, and combination of the known criteria of malignancy gives higher sensitivity and specificity
than depending on single individual one [13,5,27]. There are multiple US features that are highly suggestive of
malignancy in a thyroid nodule including presence of calcifications, hypoechogenicity, irregular margins,
absence of a halo sign , predominantly solid composition, and intranodule abnormal vascularity. However, the
sensitivities, specificities, and negative and positive predictive values for these criteria are extremely variable
from study to study, and no US feature has both a high sensitivity and a high positive predictive value for
thyroid malignancy [5]. It has been shown that the possibility of cancer in a thyroid nodule has been shown to be
the same regardless of the size of the nodule [17, 8, 19,22].The nodule size and multiplicity have not been
shown to affect the likelihood of malignancy [8, 17, 12, 28]. In the current study, the sensitivity and specificity
of hypoechogenicity to malignancy was 56% and 94% respectively. Out of the 16 cases with hypoechoic
nodules,11 of them proved to be malignant by FNAB. These results are matching with the results of some
authors [8, 17, 12, 29], where they found that marked hypoechogenicity has been a characteristic that is
suggestive of malignancy. Studying the margin of a nodule is an important part of the examination. A
hypoechoic or anechoic rim encircling a nodule, known as the halo sign is highly predictive of benignity [8, 17,
12, 29]. However, this sign may be absent in more than 50% of benign nodules and present in up to 20% of
malignant nodules [11].In our study, all nodules that show halo sign on US are proved to be benign on FNAB.
Halo sign is not a criteria of any malignant nodule in our study population. Blurred margin is an indicator to
malignant lesions that invade the surrounding tissues. In the current study, blurred margin is a strong indicator
of malignancy with 100% specificity. The presence of calcification within the nodule raises the probability of
malignancy. Microcalcifications and macrocalifications in a solid nodule are associated with an approximately
threefold and twofold increase in cancer risk respectively, as compared with predominantly solid nodules
without calcifications [19].
The sensitivity and specificity of microclcification detected by US as a predictor to malignancy is 13%
and 98% respectively. Out of the four nodules that show microcalcification by US, three were proved to be
malignant and the remaining one is benign on FNAB. Supporting our results are those of [8], where the
specificity of microcalcification to papillary carcinoma is 95% with a relatively low sensitivity 29%. in another
study of[ 19] ,although microcalcifications carry low sensitivity 26.1%–59.1%, they show the highest positive
predictive value (41.8%–94.2%) for malignancy. A shape that is taller than wide is highly suggestive of
malignancy [8, 17, 12, 29]. In the current study, The ratio of the nodular height to width of > 1 is found in 55
malignant and only 10 benign nodules. Color Doppler US has also been evaluated as a diagnostic tool for
Predicting thyroid malignancy, where peripheral nodular flow is suggestive of a benign nodule, while
flow predominantly in the central portion of the nodule is suggestive of malignancy. The results of these studies
are controversial, with some reporting that Doppler US is helpful in differentiating benign from malignant
lesions [8, 20] and others reporting that it did not improve diagnostic accuracy of thyroid nodules [21, 25]. In
one study[ 29] central flow was seen in a higher percentage of malignant nodules than benign nodules (42% vs
14%). However, like other US features, color Doppler US cannot be used to diagnose or exclude malignancy
with a high degree of confidence; rather, the color Doppler US finding of predominantly internal or central
blood flow appears to increase the chance that a nodule is malignant[ 5].out of the 20 cases showing
intranodular abnormal vasculature, 11 are malignant and 9 are benign on FNAB. intranodular abnormal blood
vessels carry a 57% sensitivity and 95% specificity for malignancy.Putting the whole previous criteria together
increases the likelihood of malignancy with confidence. Combining the hypoechogenicity, absent halo sign,
intranodularmicrocalcification, increased height than width and presence of intranodule vascularity increase the
sensitivity and specificity of US for malignant lesions to 55% and 98% respectively. As mentioned by some
authors[ 8, 18] , the combination of features improves the positive predictive value of US to some extent. In
particular, a predominantly solid nodule (<25% cystic) with microcalcifications has a 31.6% likelihood of being
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Characterization of malignant solid thyroid nodules by Ultrasound and Doppler
cancer, as compared with a predominantly cystic nodule (>75% cystic) with no calcification, which has a 1.0%
likelihood of being cancer [19].
In conclusion, US is the modality of choice in evaluation of thyroid nodules. No single criteria is sure of
malignancy, however, combination of some criteria- in particular- hypoechogenicity, microclcification and
intranodular vascularity increases the likelihood of malignancy that warrants biopsy.
Acknowledgement
This project was funded by the Deanship of Scientific Research (D S R), King AbdulazizUniversity,
Jeddah, under grant no. (371 /142 /1432 /1432). The authors, therefore, acknowledge with thanks DSR technical
and financial support.
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 31-43
www.iosrjournals.org
Male Circumcision within the context of HIV prevention in India:
a qualitative study conducted among young men in Chandigarh,
India
Dr. Sanchit Kharwal1, Prof. Shalini Bharat2
1
(Public Health in Social Epidemiology, Tata Institute of social sciences, Mumbai, India)
(Centre for Health and social sciences, Tata institute of social sciences, Mumbai, India)
2
Abstract: Male circumcision has been advocated as an additional HIV prevention strategy but in India, it is
not yet a part of the comprehensive HIV prevention package. In the Indian context male circumcision is strongly
associated with specific religions and little is known about the socio-cultural and religious dimensions of this
practice at the community level, the sensitivities attached to this practice, and its acceptance as a potential
method of HIV infection prevention. The objectives of the study were to assess the level of knowledge and
understanding of male circumcision among male youth of sexually active age group and to explore the practice
of traditional male circumcision in a north Indian city. Data was collected by conducting 25 in-depth
interviews, 5 key informant interviews and 2 focus group discussions. These interviews were tape recorded,
transcribed, coded and analyzed using a qualitative software package. Results show that a majority of the
respondents belonging to the non circumcising communities had limited understanding on male circumcision.
Respondents from the circumcising community listed several benefits of doing male circumcision such as, better
hygiene, prevention of infections, and enhancement of pleasure during sexual intercourse. The non circumcising
community respondents considered male circumcision as a social stigma and carried the belief that
approaching a traditional circumciser („nai‟ or „hajjam‟) to undergo circumcision will or may convert them to
the religion of Islam. The acceptance of circumcision as a practice to improve health and prevent infections
such as, HIV, looked seemingly negative among respondents from the non circumcising communities. Due to its
strong association as an identifier of a particular religion, there are fears in adopting it and being
discriminated or targeted as being a member of the minority community.
Keywords – Male circumcision, HIV, religion, social stigma, acceptance
I.
INTRODUCTION
Having claimed millions of lives over the past several decades, Human Immunodeficiency Virus (HIV)
is still a major public health burden across the globe [1]. As HIV epidemic persists and poses challenges to public
health goals, countries need dedicated policies and actions to further strengthen the HIV prevention efforts.
Thus, for national programs the prime focus should remain on identifying and promoting interventions that can
effectively prevent new infections and thereby control the HIV epidemic. In the three Randomized Controlled
Trials (RCT) conducted in the African region, Male Circumcision (MC) was seen to reduce chances of
contracting HIV through vaginal intercourse by 60% in South Africa [2], 53% in Kenya [3] and by 51% in
Uganda [4]. Evidence also suggests that MC reduces the risk of acquiring sexually transmitted diseases (STDs)
particularly ulcerative STI‟s like chancroid and syphilis [5]. Male circumcision is a surgical procedure of
removing foreskin from the penis and is one of the oldest known surgical procedures that carry „religious
connotations‟ [6]. Based on the compelling evidence that MC offers up to 60% protection from HIV, World
Health Organization (WHO) and Joint United Nations Program on HIV/AIDS (UNAIDS) recommended that
MC should be recognized as an additional HIV prevention strategy to reduce the risk of heterosexually acquired
HIV infections in countries with high rates of heterosexual transmission of HIV infection and low rates of MC
[7]
. Currently in India male circumcision is not a part of the comprehensive HIV prevention package as
advocated by government run National AIDS Control Program (NACP).
In the Indian context MC is traditionally and commonly practiced in certain minority communities such
as Jewish and Islamic. Since it is not a practice followed by the Hindus who are in majority in the country, a
majority of Indian men are non-circumcised. The association of MC with a key religious group that has a history
of conflicts with the majority religion makes the topic of MC a sensitive one in India. However, regardless of
religious affiliations circumcision is suggested and widely accepted as a medical intervention for children and
even adults who suffer from disorders of prepuce such as phimosis, paraphimosis, and balanoposthistis [8]. There
are limited studies assessing the community level perceptions about MC in the Indian context. The preliminary
findings of the Indian Council of Medical Research (ICMR) task force study on community perspective of MC
conducted by National AIDS Research Institute (NARI) had revealed that “male circumcision is a religious rite
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Male circumcision within the context of HIV prevention in India: a qualitative study
of circumcising communities; this belief is a common perception in the general population and religious
sentiments are evident” [9].
Religious beliefs and cultural systems will have a greater significance in determining attitudes
towards MC. In particular, in the background of cultural and religious sensitivities, the topic of MC needs to be
treated carefully so that barriers can be addressed to overcome resistance while promoting communal harmony.
The main objectives of the study were to assess the knowledge, attitude, beliefs and practice of MC among
traditionally circumcising and non–circumcising communities; and to explore the socio-cultural and religious
beliefs associated with MC and the difference in its practice among traditionally circumcising and non
circumcising communities of Chandigarh. The findings from this study are expected to contribute to a better
understanding of the socio-cultural and religious underpinnings and sentiments around MC in the country in the
context of the HIV epidemic.
II.
METHODOLOGY
An exploratory research design using qualitative approach was used in this study as it helps to elicit the
feelings, perceptions and opinions of the people in their own words and expressions allowing for gaining deeper
insights into the phenomenon [10]. This study was conducted in Chandigarh - the Union Territory of the states of
Punjab and Haryana.
2.1 Sampling frame
The study was carried out among male youth from two communities: the Muslim community in which
MC is part of a religious practice (hereafter called the „circumcising community‟) and non-Muslim communities
(Hindu/Sikhs) in which MC is not practiced as a religious ceremony (hereafter called „non-circumcising
communities‟). The sample for the research study comprised of male youth aged 19- 40 years, of which half of
them belonged to the circumcising community and the other half were chosen from non circumcising
communities. The sample also included key informants namely, Islamic Scholar (locally referred as Mufti - an
Islamic Scholar who has the authority to issue legal opinions known as Fatwa), Muslim teachers at an Islamic
school (locally referred as Madarsa), traditional circumcisers (locally referred as „Nai‟ or „Salamani Nai‟ –
Barbers who practice circumcision), and, medical doctor from a hospital in Chandigarh. The purpose of
conducting key informant interviews was to understand the issue from a wider range of perspective and also to
triangulate the findings in order to increase the quality of the data.
2.2 Recruitment
The non-probability purposive sampling was carried out at different sites within Chandigarh city
keeping in mind the objective to select male youth from the two target communities. In order to facilitate entry
into the Muslim community, officials at the two local mosques were first approached and after explaining the
purpose of the study, they extended all support and assistance in conducting the interviews. The data was
collected in the months of May and June, 2012, using three main qualitative research methods: in-depth
individual interviews, key informant interviews (KIIs), and focus group discussions (FGDs). Separate guidelines
were drafted for the method of data collection by KIIs, FGDs, and in-depth individual interviews. Themes
included in the guidelines were based on a comprehensive review of existing literature on the subject [11, 9]. This
research study complied with ethical principles at all stages, respecting the dignity and rights of participants by
ensuring confidentiality and anonymity, voluntary participation and providing informed consent.
2.3 Data Analysis
The data collected in the form of field notes and audio recordings of face to face interviews was first
translated and transcribed from local languages of Hindi and Punjabi to English by the researchers. In enabling
exploration and understanding the qualitative data, grounded theory approach given by Glaser and Strauss
(1967) was used. Using the open coding method a selected random set of interviews were read and meaningful
idea units were identified as „codes‟. Subsequently an extensive code list was prepared. Convergence among the
codes with similar thematic content helped to identify „themes‟. ATLAS.ti (version 5) software was employed to
manage the rich textual data. The prepared code list was used to code all the transcripts that were entered for
analysis in the software. Careful analysis of the qualitative data highlighted a number of „core themes‟. A few
additional sub-themes were also identified in this process. By employing the method of compare and contrast
themes were grouped together and analyzed for similarities and differences between responses from men
belonging to traditionally circumcising and non circumcising communities.
III.
RESULTS
In total 25 respondents have participated in the In-depth interviews in addition to 5 key informants, and
a total of 18 respondents who participated in 2 FGDs (Table 1, 2 and 3); adding to the total sample of 48. This
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Male circumcision within the context of HIV prevention in India: a qualitative study
section is organized as follows: The first section presents the socio-demographic profile of the respondents that
includes background information on age, religion, education, marital status, and occupation and circumcision
status of respondents. The second section presents the free listing data analysis and the last section presents the
main findings under “core themes” and sub-themes that emerged from the data using the grounded theory
analysis.
3.1 Socio-demographic profile of respondents
Table 1: Socio-demographic characteristics of study respondents who participated in In-depth interviews:
Characteristic
Categories
Frequency Percentage
(%)
19-25
11
44%
1. Age in completed
26-34
8
32%
years
35-40
6
24%
25
100%
Total
Hindu
10
40%
Muslim
13
52%
2. Religion
Sikh
2
8%
25
100%
Total
Primary
7
28%
Secondary
3
12%
Higher
8
32%
3. Education
secondary
Graduate
5
20%
Post
2
8%
graduate
25
100%
Total
Unmarried
14
56%
4. Marital status
Married
11
44%
25
100%
Total
Student
5
20%
Unemployed 2
8%
Self
8
32%
5. Occupation
employed
Service
10
40%
25
100%
Total
Circumcised 14
56%
6.Circumcision
Non11
44%
Status
circumcised
25
100%
Total
Informant
ID
KI-1
KI-2
KI-3
KI-4
KI-5
Table 2. Socio-demographic characteristics of key informants:
Marital
Age
Education Religion
Occupation
status
72
Primary
Muslim Married
Barber / Traditional
circumciser
25
Primary
Muslim Married
Barber / Traditional
circumciser
30
Doctorate Muslim Married
Religious scholar
(Mufti)
38
Post
Muslim Married
Religious teacher in
graduate
a local mosque
30
Post
Sikh
Unmarried
Allopathic doctor
graduate
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Male circumcision within the context of HIV prevention in India: a qualitative study
Table 3. Socio-demographic characteristics of FGD participants:
Community
Characteristic
Categories
Frequency
20-25
5
1. Age in
completed years
26-30
3
Hindu
6
2. Religion
Sikh
2
Secondary
2
Non
Higher
3. Education
2
circumcising
secondary
Graduate
4
Unmarried
6
4. Marital status
Married
2
Student
1
5. Occupation
Self employed
7
25-30
6
1. Age in
31-35
3
completed years
36-40
1
Muslims
10
2. Religion
Primary
2
Secondary
2
3. Education
Circumcising
Higher
2
secondary
Graduate
4
Unmarried
2
4. Marital status
Married
8
Service
4
5. Occupation
Self employed
6
3.2 Free listing (FL) data analysis
FL was carried out with the objective of identifying the local religious and cultural terminologies used
for MC and for the tools used in doing MC. In addition, local phrases and expressions used during the
interviews were noted and linked with items and concepts related with circumcision. Analysis was done by
reading the transcripts and identifying and counting the number of times an expression was used by a respondent
to refer to a specific item. (See Table 4)
Table 4. Local terminologies used by Muslim respondents in the context of MC derived after FL analysis:
Frequency
Translated items
Local Terminologies
of usage
Sunnat,
32
Male Circumcision
Traditional
circumcisers
Remaining Pure
Khatna
25
Sunnat ka tareeka
6
Musalmaani
4
Bithana
1
Nai
15
Hajjam
6
Khatna karne wala nai
5
Khatna
Hakeem
Jarrah
1
karne
wala
1
Nazu
1
Paak saaf rehna
15
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Male circumcision within the context of HIV prevention in India: a qualitative study
Impure
Inventor of
circumcision
Napaak
10
Nabi ki sunnat hai
4
God‟s Messenger Nabi
Aaz-ul-khanaaz
Cutting of the
foreskin
Logistics for Traditional Circumcision :
Ustra
Razor
5
1
6
3
Ash of the earthen Chule ki raakh
oven
Jandri
3
Foreskin holder
Sunn ka teeka
2
Anaesthetic
Injection
Baans ka sua
2
Bamboo needle
All the above listed local terminologies were mainly used by respondents from traditionally circumcising
communities (Muslim) except from the two terms viz. „sunnat‟ and „khatna‟ that were used and understood by
few respondents from traditionally non-circumcising communities.
3.3 Main findings listed under core themes and sub themes
a) Knowledge, beliefs and perceptions about MC: Under this theme five different subthemes emerged from
the data. Findings are presented according to each subtheme.
i) MC as a religious practice: Almost all the respondents had heard of MC and a majority referred to it as
„sunnat‟ or „khatna‟. In the non-circumcising communities the usage was restricted to these two terms and some
even used the term „male circumcision‟ while respondents from circumcising community also referred to it as
„Mussalmani‟. When asked to elaborate, a majority were able to define it in their own way mainly as the,
“cutting of the foreskin of the penis”. All respondents identified it as a religious practice that is followed among
Muslims. Some of the respondents (5 of 12) from non circumcising communities were not aware of the specific
terminologies used for MC, however once the procedure was described to them, they were able to recognize and
link it with a specific religion i.e. Islam. Only two respondents both from non circumcising community were
able to link MC with other circumcising communities as well such as, Jewish and Orthodox Christians. The
majority (10 of 12) of the respondents from non circumcising communities had a limited understanding on MC.
This was reflected in their responses when they were further asked to provide more details and elaborate the
procedure, to which they replied with phrases such as “I only know this much…don‟t know more” (21 years old
Hindu) or “I don‟t know the reasons for this” (30 years old Hindu). One Hindu respondent lacked
understanding on the subject of MC and confused it with castration; his verbatim response is as stated below
“I think they (Muslims) do this so that somebody can‟t do rape. What I have seen on internet
is that a Muslim boy raped a girl and for that he was punished by cutting his penis” (22 years
old Hindu)
On the other hand respondents from the circumcising community displayed adequate understanding of MC
and revealed substantial information on the role of faith in performing MC. For them it is not just a religious
ritual but has a deep rooted meaning in their religion and utmost importance is given to this practice. MC is
known to them as “Sunnat” or “Khatna” and majority of them consider it as part of the religious ordainment.
“It is performed in Muslims not merely for benefit instead it is a way or a method which Jews,
Christians and Muslims much respected messenger of God Hazrat-e-ibrahim has started.
Than Hazrat-Mohammad-PBUH also ordered for this, so in reality the Muslims do
circumcision for the reason that ALLAH and his messengers have given this order to us.
Actually, because this is a religious practice, it is an order from God…” (30 years old Islamic
scholar)
ii) MC as a symbol of being a Muslim: Among the non circumcising communities, MC is essentially seen as a
religious practice which is only followed by Muslims. There is limited knowledge about the reasons for which it
is practiced among circumcising communities. They feel that religion and culture is the primary reason for doing
MC. Majority of the respondents replied that they do not possess sufficient knowledge on this subject and stated
that “it‟s a value or custom among Muslims”. Some respondents believe that MC is an identifier of Muslim
religion and because of which it cannot be followed by other religions. Their responses are documented below:
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“No it can‟t be practiced by others except Muslims as it is specific to their culture. I think that
by doing this we can come to know about their religion. If everybody started doing this than
how will we come to know that who is a Muslim and who is Hindu?”(22 years old Hindu)
As per the responses received from a medical doctor and one of the non circumcising respondents, MC is still
being seen as a mode of religious discrimination and a common point noted from both was that people from non
circumcising communities who have undergone circumcision will tend to hesitate in disclosing their
circumcision status as it is perceived to be a part of a Muslim identity. They said:
“Yes they might hesitate in disclosing their circumcision status mainly in those parts of the
country where religious discrimination is still prevalent as I have already mentioned if a man
is circumcised then it is assumed that he belong to Muslim community” (30 years old Sikh,
Medical doctor)
However according to respondents from circumcising communities, MC does not only make oneself a
Muslim and in order to become a true Muslim one has to accept the preaching‟s of Islam as well. According to
one of the religious scholar as he states:
“Actually Islam is not just a word that one should do „khatna‟ (circumcision) and becomes a
Muslim. There are certain rules which one has to necessarily accept, there are views which
had to be accepted from the heart like if you see all Christians are getting circumcised but
still they are Christians, if only because one does „khatna‟ and he is said to become Muslim
then the entire world would have done „khatna‟ and everyone would have become Muslim. It
is a medical necessity also” (30 years old Islamic scholar)
iii) Beliefs about MC: The individual beliefs on male circumcision amongst the Muslim community
respondents were associated strongly with religious ritual and practices. All of them considered circumcision as
a religious obligation. The respondents from circumcising community emphasized that being uncircumcised
makes them „napaak‟ or impure and this sense of “purity” is linked to the belief that presence of foreskin helps
to hold urine drops making them „napaak‟ or impure. This belief of remaining „paak‟ or Pure underlies the
practice of MC as a ritual. According to the key informants, most of whom were religious scholars, in Islam,
circumcision is synonymous with being “Pure” which is also about self respect and a part of the Muslim
identity. A Muslim respondent says:
“The main reason to do this is because it brings purity… in Islam this is a part of our self
respect (imaan)… in case if we are not pure then we will not remain a Muslim, so to become a
true Muslim it is very important…. As we urinate so because of the foreskin some urine drops
are left in the foreskin and we will not remain pure, so this is basically linked with purity
(paak) - (39 years old Muslim)
iv) MC and its association with health and hygiene: Nearly all respondents from traditionally circumcising
community associated MC with not just the religion and religious practice but with health and hygiene also. A
few of the quotes that convey the importance of MC for hygiene and good health are documented below:
“Sunnat is a part of our „Aaz -ul – khanaz‟ (cutting of the foreskin). In this the extra skin
(Aaz) on the penis is cut and the same is shined, so that no dirt particle accumulates under the
skin and the same leads in hygiene (safaai)” (30 years old Muslim)
In addition to associating MC with the notion of „paak‟ or purity, some also cited its importance for disease
prevention. MC was considered the reason for a low prevalence of HIV among Muslims.
“This is the message of „Nabi‟ and we have to follow this, secondly it has health benefits, if
you are not circumcised there will be dirt accumulation and rottenness due to which body is
prone to many diseases, prevention from AIDS illness and other illnesses during intercourse
(sambhog) when two bodies will mate” (38 years old Muslim).
v) MC is beneficial in various ways: Perceptions on sexual benefits: The understanding on sexual benefits of
MC among the majority of the respondents from both traditionally circumcising and non circumcising
communities was based on the perception that MC increases sexual pleasure and confidence during penetrative
sexual intercourse. The presence of tight foreskin, it was pointed out makes penetrative sex difficult. Some of
the respondents from non circumcising communities were not aware of the health benefits but acknowledged
that MC offers benefits in one‟s sexual life. The participants from traditionally non circumcising communities
expressed their views thus,
“No I haven‟t heard about the health benefits due to circumcision but yes I have heard that if
someone had problem in penetration while intercourse then they can undergo this” (28 years
old Hindu).
“Because of the absence of foreskin people enjoy sex life more because there is no sensation
as compared to people who are not circumcised” (27 years old Sikh)
A respondent from traditionally non circumcising community who had undergone MC for treatment of
phimosis expressed his views as:
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“I have undergone it myself. In case if someone has any problem of foreskin like infection,
tight foreskin, tearing of foreskin during sex, and some also advise it for better hygiene. The
health benefits are better hygiene, protection against HIV and STDs. It could result in
sensitivity and dryness in the operated area during the initial days but no such harmful
effects. I came to know about this through internet and after undergoing the procedure I
personally felt that it results in erection for a longer period of time” (29 years old Hindu)
One of the respondents from traditionally non-circumcising community held a different perception on MC
and its sexual benefit. According to him MC is a way to detect or prove the virginity of female sex partners. His
viewpoint was not shared by any other respondent and possibly is part of the commonly held misbelieves about
the religion and its practices. His response is documented below:
“In this religion, if you see it has a very deep reason which is that they don‟t trust ladies very
much. Means after marriage they think that a girl should be a virgin….means… after
marriage during intercourse the girl should bleed. Because at times if foreskin is not cut in
boys then during intercourse the foreskin may rupture and it may bleed. So when I interacted
with them and asked about this they said that if we do this then they can come to know
whether a girl is virgin or not” (29 years old Hindu)
Among the circumcising men the perception was that circumcision offers sexual benefits in many different
ways. It was considered particularly useful for enhancing sexual power and pleasure for the partner. The quote
below illustrates this view.
“Yes, it has sexual benefit, Firstly in sex, pleasure (josh) increases; because of circumcision
there is lot of tension (tanaav) inside the men and secondly your partner with whom sex is
done enjoys very much, feels completely satisfied” (26 years old Muslim)
vi) MC and HIV related perceptions: It became evident from the data that for some, knowledge of HIV is
fairly good but most of the respondents were not able to distinguish between HIV and AIDS. Many of them
perceived AIDS as a dreaded and incurable illness and some have used metaphors like “lailaaj bimari” and
“khatarnaak”.
It was also observed that there is limited knowledge about the modes of HIV transmission and its prevention
methods. Majority of the respondents from both traditionally circumcising and non circumcising communities
had expressed its strong association with sex and some have emphasized on the immoral behavior on the part of
the partner (bedmate). The association was also made with „strangers‟ as partners.
“That‟s what I just told you that when we have impermissible relations (najayaz sambandh)
with somebody. When our bedmate (humbistar) is wrong or is somebody who is not known to
us (gair logon k sath), from them it spreads” (40 years old Muslim)
With regard to the HIV prevention methods, majority of the respondents have heard about barrier methods
and mentioned about the use of condom as an HIV prevention method. Importantly some of them maintained
one should exercise „self control‟.
“Firstly one should have control on themselves, which is possible when one will not indulge
in immoral behavior (galat sobat), should be committed to one partner and not give into
sexual pleasures (sharirik sambhandh). Government has also introduced condoms for
protecting oneself from AIDS” (40 years old Muslim)
Almost all of the respondents from both the communities lacked understanding on the role of MC in HIV
prevention. Some of the respondents from circumcising community perceived that the role of MC in HIV
prevention is linked to the collection of semen in the foreskin after having the sexual intercourse that further
leads to germ accumulation.
“Yes it plays a vital role in protection of HIV, since when one has intercourse (sharirik
sambandh), the fluid that comes out (Mani) gets collected under the foreskin which has germs
and if the same is not cleaned than these germs remain inside the foreskin (khaal), it might
cause infection, thus leading to increased chances of contracting HIV / AIDS” (30 years old
Muslim)
b. Sources of Information on MC: While most respondents had heard of MC from different sources, the
majority had not received comprehensive information on MC from a reliable source. Circumcision was
described as an identifier for the Muslim community that is, it is symbolic of their membership to the religion,
but it was also referred in a more casual way among peers of non-circumcising community respondents and used
to label membership in the religion. The peer talk was also recognized as a source of misbelieves such as
Muslims do MC in order to test the virginity of female partner and some loose talk. The data also revealed that
male circumcision is often a subject which is laughed about as one of the respondents on being asked about the
information source on MC reported that „Usually this happens by ways of jokes about the other community
(Muslims). I studied in a school which has lots of Muslims and during my childhood many of the Muslim
students were teased by saying that “ye to katwa hai”‟ (29 years old Hindu).
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For non-circumcising men the sources of information on MC primarily included either mass media such as
TV and internet, or very importantly the presence of a Muslim friend in their social network or living in a
Muslim neighborhood or studying in a school with Muslim students. For traditionally circumcising community,
different information sources on MC included conversations with parents and discussions among family and
friends during gatherings, religious scholars who preach about the religion and Holy books such as Quran
Sharif. Male circumcision, it was revealed is a common topic of discussion within Muslim families signifying
its relevance and importance for average community members.
c. Attitude and sentiments around MC in the context of HIV: The role of MC was explored with the
respondents for its health benefits and more specifically in relation to HIV. Most of the informants from
traditionally non circumcising communities expressed their worries by emphasizing on fears and cultural
sentiments associated with MC. This also reflected their attitude towards MC and its acceptance as an HIV
prevention strategy. They related this worry to the perception that circumcision is often a topic of laughter
among them and that it is seen as a symbol of Islam, due to which they may suffer religious reparations.
Therefore, undergoing circumcision may not be a desirable option in the context of any health issue such as,
HIV. Three different kinds of fears were identified in the present study:
i) Fear of Rejection from one’s own community: some of the informants sensed that circumcised men from
the non circumcising communities might be neglected and disrespected in their own community. One of the
respondents shared his view regarding MC by non circumcising communities as:
“One may have „Fear of rejection‟ if you are from non-circumcising community, people
without proper knowledge may not think that it has been done for some complication but may
link you with being Muslim” (29 years old circumcised Hindu)
ii) Fear of being converted / identified as belonging to Muslim community: Some of the respondents
mentioned incidents where traditionally non circumcising men approached traditional circumcisers to get
circumcised but because of cultural implications and a fear of being labeled as a Muslim, refused to get it done
from them and had undergone the procedure in a hospital. One such incident is mentioned below:
“…and the lady went home and she was told by her family that if you get your child‟s
circumcision done by a Muslim „nai‟ then he will also become a Muslim and so you will not
get it done from him…” (35 years old Muslim)
iii) Fear of being mocked at: MC is often a subject that is joked about. Some respondents have expressed their
views by reporting incidents where men from traditionally non circumcising communities who have undergone
MC for some medical problem were teased and as a result those individuals will have a hesitation and fear to
disclose their circumcision status to their own community members. One such incident is documented below:
“I have seen it in my childhood as well, we had a Rajput family in our neighborhood who
followed Hinduism, even they had done it, I could not believe it back then, people used to
tease them as well, that being a Hindu what have you done, what I mean is that circumcision
was associated with Muslims, the people in the village used to tell him that he is now
converted to a Muslim, he was our classmate, but here is where I have now seen the sure
benefits of it, we used to read about it in the magazines, but people used to still relate it to
religion, in spite of its benefit people never voluntarily came forward to accept it” (39 years
old Muslim)
d. Acceptance of MC as an HIV prevention Strategy: Post the interview, a brief introduction was provided to
the respondent on circumcision as a method to prevent HIV, and respondents were asked about its chances of
acceptance by the community. Participants‟ expressed a mixed feeling on its acceptance as an HIV preventive
strategy. While the respondents belonging to the non circumcising community expressed a seemingly negative
acceptance to this attribute, on the other hand respondents from the circumcising community already had a
predefined positive outlook because of the religious values associated. The uncertainty with regards to the
acceptance of circumcision amongst the non circumcising communitoes, are clearly noted in the below quotes:
“No, they (non circumcising communities) will not accept it because if everybody started
doing it then what is the difference left in being a Muslim or Hindu. But incase if it the only
method of prevention of HIV then I think it should be done by all” (22 years old Hindu)
“Everybody will not accept it may be 50% people might accept but 50% may not because in
India religion is always given prime importance and circumcision is only practiced by
Muslims so others may not accept this. Only those who will consider these benefits to be
important particularly those who are educated can accept it” (19 years old Hindu).
A few respondents have expressed doctors as an important medium of communication and for promoting its
benefit. Few of the responses were:
“If it prevents from HIV then firstly we will contact a doctor about this…if the doctor says
that circumcision has benefits and no harm than we can undergo but if a doctor says no than
nobody will undergo circumcision”(26 years old Hindu)
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Some respondents have expressed a low risk perception as a cause for not accepting MC as an HIV
preventive strategy as they said:
“Even if we promote this in a country like India, it will not be accepted. Because in India it
has a strong link with religion and your study shows only 60% protection, 40 % is not sure,
even if you remove the foreskin your semen still carries the virus, so there is no protection in
that…the new generation can accept this, but the old people cannot accept this…it is difficult
to change the mentality of people and it will take some time and education can help in
bringing this change” (28 years old Hindu)
Those who have expressed a positive attitude towards MC stated:
“If this has been proved scientifically in any survey, or anyhow, then this is possible, this can
be given as an option that you can get circumcised just like in market you have condoms or it
is advised to avoid multiple partners…then this can be advised. Yes definitely they will do
accept it… there can be religious barrier, every place has different thoughts and for
addressing these religious barriers you can go to them and make them understand that it
prevents from HIV. In any community, there is nothing like you can‟t get circumcised, it‟s not
written anywhere…circumcision is only done by Muslims if you think like this then it‟s not
possible”(21 years old Hindu)
“Yes it will be acceptable provided the awareness is created in a proper manner. It can start
with educated people who can understand its role in protection of HIV and the health and
sexual benefits it offers. I feel it should be encouraged during male child birth itself” (29
years old Hindu)
e) The Practice of traditional male circumcision: In this section the results are presented based on several
themes- some that were predetermined at the time of designing the interview guide and some new sub-themes
were identified after reviewing and coding the interview transcripts. These include:
i) General information on traditional MC: Traditional MC is a method of doing circumcision using traditional
tools, following certain religious rituals and is done by a religious or traditional circumciser. None of the
respondents from traditionally non-circumcising communities were aware of the details about traditional MC,
instead all of them were identified to have held a common misconception that traditional MC is done by
religious priests (Maulwi) or a person from Mosque who read the Holy prayer (Namaaz), and the procedure is
usually done in Mosques. The rest of the information presented in this section is based on the interviews with
participants from circumcising community and key informants. Traditional MC was recognized as one of the
oldest practices and an integral part of the Islamic culture. This practice being considered as an important
occasion in the life of a Muslim, it was reported that some people celebrate it by organizing a small feast;
however some respondents argued otherwise and stated that it is not a compulsion to conclude this event with a
celebration. This was evident from the responses documented below:
“Normally when the kid is 2 to 3 days old “Khatna” is done, but there are many people who
do it in a traditional way, call people, give them food, it is done like a function, but others
don‟t make this a big function” (40 years old Muslim)
Traditional circumcisers: On enquiring about information on traditional circumcisers it was identified that in
the earlier times usually in a village there used to be one family that belonged to caste of “Nai” and male
members of these families used to do hair cutting, shaving and perform MC as an important responsibility. This
profession is being continued in the family over the years and inherited from father to son and so on. On being
asked about the evolution of this profession an informant replied:
“…. It can‟t be said from where this practice started but in actual this work was done by
“Jarrah”, these jarrah were meant to apply traditional medication (marham) on wounds
(jhakham) or boils and blisters (phoda-phunsi) and these people (Nai) started helping them
by giving hand in their work, so this real work used to be done by jarrah. They are a kind of
Hakeem (faith healers) and they only, used to do this work…you can call them Hakeem but
they don‟t do hazaamat (cutting and shaving). Because Nai‟s also started doing this job, they
also started being called as with the same name otherwise hakeem, hazaam and jarrah are
similar…” (38 years old Muslim, Religious teacher)
On being further enquired about information on traditional circumcisers a respondent said:
“They (traditional circumcisers) do not have a fixed place or a venue, where they can put up
their business. They are normally a part of the hair cutting saloon. They also keep all their
equipments at their home, one can go to their homes and get this done, but most of the people
prefer calling these people in their homes to conduct the ritual” (22 years old Muslim)
Seasonal Trend of MC: In the study area researchers were able to locate and interview two traditional
circumcisers who were practicing traditional MC in the area for more than seven years and fifty years
respectively. During the interview with the traditional circumcisers it was identified that, the demand for
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circumcision normally increases during vacations, that is, at the beginning of summer season. This they said was
irrespective of age constraint.
“Yes, we see it has to be some auspicious day. It should be a warm and easy day (naram
garam). It should not be too hot neither too cold. From the term „naram garam‟ I mean it
should not be the monsoon season. Because during monsoon there is a fear of „hausne‟
(possible infection), and during the rains the urine is hazardous and because of that we see a
day when it is not too cold neither too hot” (40 years old Muslim).
However the other traditional circumciser stated that this practice was followed in the past, currently parents
prefer to conclude this activity as soon as the child is born, keeping in mind the healing capacity and that the
child at that age is not prone to the understanding of pain and other such feelings.
“Yes it was so earlier, but now as soon as the child was born he gets circumcised within few
weeks, whether he is born during monsoon or in winter” (72 years old Muslim Traditional
circumciser)
ii) Significance of traditional MC: In order to understand the significance of traditional MC and explore the
reasons for circumcising by traditional ways respondents were asked on their ideologies associated with
traditional MC. Some of the respondents also expressed a strong conviction that this practice of MC should be
followed with prayers and reading verses from religious books. However some of the respondents argued, that
this practice might be important but not a religious compulsion to perform MC. While interacting with one
religious scholar it was noted that while Islam emphasizes on the benefits of MC, it is a secondary practice and
does not compel a male born in a Muslim family to undergo MC, in order for one to be called a Muslim, he
needs to comply with the principles of Islam and accept the preaching‟s of Allah / prophets from his heart, one
cannot be termed as a pure Muslim only if he undergoes circumcision. Thus, although circumcision is generally
associated with being Muslim, according to the religious scholars this practice does not make one a Muslim. Just
the mere activity being undertaken is not enough to make one a Muslim. The verbatim is presented below:
“Practically speaking „Khatna‟ in our religion (Islam) is important but it is not like very
important. Instead it should be first accepted from Heart that God is one. Than who told
about this thing is Hazrat Muhammad Sal-Allaho Alai he wassalam. On the day of justice the
good and the bad will be known…all HIS angels will descend and it will be important to
imbibe their teachings...have faith on them, all the messengers who have come up till now..;
these are the actual fundamental things…it‟s ok that other practical identifying things are
there, that is do khatna, but before this if these things are there (i.e faith on Angels and HIS
messengers) and then alongside there is khatna also then it is like an identifier that he is a
Muslim, Anyways it is compulsory but not such a big compulsion that an individual who…in
straight and simple terms we say that he does not have faith on Allah and His teachings, but
does khatna, then just by doing khatna he does not become a Muslim. Both the things are
important” (30 years old Islamic scholar)
The significance of traditional MC is also evident from the fact that some members of the Muslim
community, in the study area, irrespective of their educational background, prefer to conclude this practice
through a traditional circumciser but in the presence of a doctor. This in turn reflects the importance of
traditional circumcisers in the practice of MC. The traditional circumciser mentions an instance as quoted below
“Those who are knowledgeable in actual sense get it done by us (traditional circumcisers)
only, because it is a sunnat in our religion, and it is the only method of „sunnat‟, the way in
which we do it, and others who believe in science and consider themselves more learned will
say that anesthetic injection should be used and it would have been better if it was done in
hospital, and there are some who are very educated like for instance there is a principal, a
professor in XYZ who told me that he wants to get his son circumcised in presence of doctor
but would like to get the „sunnat‟ done by me only” (72 years old Muslim, Traditional
circumciser).
iii) Procedure of traditional MC: Post interviewing a few traditional circumcisers; it became evident that the
practice of circumcision is being followed in a specific pattern from one generation to another. The instruments
used vary from the practice and skill of each circumciser. The views on importance given to factors such as
hygiene, safety, sterilization and techniques that were mentioned by some respondents differed in each
interview. The procedure of circumcision as described by one traditional circumciser below:
“We hold the foreskin with fingertips and then insert a „salai‟ (needle made of Bamboo)
inside that and then apply “jandri”. We only use the sharp edge of the Ustra and not use any
blade…instead we don‟t keep a blade and make a cut using our skilled hand …very fine cut
and do it…after being done on one kid we clean the „ustra‟ with dettol and remove the blood
stain from there and if other one is required to be done we use other ustra…we keep 3
ustra….and in a week or within 2 days I boil them in water by adding dettol to it. After doing
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it we apply a medicine known as „mercury kohroon‟: a laal dawaai followed by tying ash of
the earthen oven on the operated area, there is one laal dawaai, one nilli dawaai and there is
one pilli dawaai so basically this is mercury which are available in medical store.
Instruments we use are Ustra, Gel (Xylocaine), jandri which is made of bamboo and needles
made of bamboo that are used to hold the foreskin in correct manner”(72 years old Muslim,
Traditional circumciser)
iv) Changes in traditional MC over time: Traditional MC has been practiced for decades in the study area.
The demand for traditional MC increased over the years with an increase in the number of Muslim population,
and also as a result of immigration. Traditional circumcisers were considered an important source of service
providers because of cultural implications. These traditional circumcisers were found to be providing services
not only limited to the study area but also in the neighboring states. However they are not formally trained and
have acquired the knowledge of cutting practices from their fathers and forefathers. From the information
collected on traditional MC from different sources, it became evident that over the years the practice has
changed in a number of aspects as shown below but not limited to these alone.
Age at circumcision: Most of the respondents (9 of 12) from traditionally non circumcising communities have
limited knowledge on age at which MC is carried out among circumcising communities. Compared to common
understanding, it was identified that unlike Judaism, there is no fixed age for circumcision in Islam and majority
of the children were circumcised before reaching the puberty.
“Islam does not have a fix age for this, this can even be done when they become an adult, but
till such time they will remain impure, there is no upper age limit for this, just that it should
be done as early as possible, within a week of birth is ideal, otherwise some people do it at
the age of 2 , 3 or even 5” (38 years old Muslim)
Majority of the respondents from circumcising community showed a preference for circumcising their
children as early as possible and within a month of child‟s birth, the only exception to this is that if the child is
weak only then it should be delayed and performed later. Several reasons for performing MC at an early age
were cited by some of the Muslim respondents because of which they prefer their children to get circumcised
during infancy. Respondents had said:
“It is said that the early you do it the better it is. Because in children they do not understand
the pain sensation, they do not move their hands and legs… and because there is no
movement it becomes easy to do and also it heals faster” (39 years old Muslim)
“…it‟s better to do it in childhood, so that the child doesn‟t feel much pain and doesn‟t even
come to know and circumcision is seen as a symbol of Islam and for this reason it must be
done in childhood so that the child also feels as a part of Islamic Culture” (30 years old
Islamic scholar)
While interviewing a traditional circumciser, it was found that there exist certain differences in terms of the
practice in rural and urban areas and some age restrictions. Whereas the children in urban areas are circumcised
within a month of their birth but in some rural part, they get circumcised till the age of 10 years. Also another
finding was made that these traditional circumcisers now refer the older aged children to get circumcised in
hospitals because of the fear of encountering complications.
Use of Modern medicines in the traditional MC procedure: With modernization and advent of over the
counter pharmaceutical products, traditional circumcisers tend to incorporate modern medical techniques while
performing MC. They are aware of the use of local anesthetics, injections and also instruct the people who
approach them for circumcision to visit a medical doctor and get the ointments and tetanus injections after the
procedure. However, as evident from their responses the scientific role of maintaining sterilization and aseptic
conditions seems unknown to them.
“earlier we used to get only cocaine, which we used to mix in the cream, which is used to cool
the wound and when we perform circumcision the person feel nothing” (72 years old Muslim,
Traditional circumciser)
“To make the skin Numb (sunn) I use a “pressure wali dawai” (possibly a lignocaine spray).
I don‟t know its name and also I use a pin” (25 years old Muslim, Traditional circumciser)
“Once we do it for one kid, we clean the ustra (razor) with Dettol, clear the stains, and then if
there is another one to perform, we use another ustra (razor), there are 3 ustra‟s (razors)
lying, and twice in a week we even boil them in water adding dettol (antiseptic) to it”(72
years old Muslim, Traditional circumciser)
Preference for medical MC: On being asked about medical MC, almost all of the respondents (11 of 13) from
traditionally circumcising communities know about medical MC and are aware of the fact that MC also happens
in hospitals as a treatment for illnesses of the foreskin and also some Muslims prefer to get it done in hospitals
by doctors as a part of their religious rite of MC. However among traditionally non-circumcising communities
few respondents (4 of 12) were aware of medical MC and about the reasons for which it is carried out.
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Male circumcision within the context of HIV prevention in India: a qualitative study
“Nowadays most of the people are getting this done in the hospital, but the older people …
like the barber (nai) they used to do it earlier, there are few people also doing it” (35 years
old Muslim)
“Yes it is done in hospitals also. Doctors only do this.. in our family all kids got circumcised
by a doctor he was a BAMS doctor. Nowadays people are aware and use precaution to avoid
any infection and even if they get it done by a traditional circumciser then after the procedure
they take the child to a doctor to get the medicines” (39 years old Muslim)
While interviewing religious scholar it was noted that though they promote Islamic preaching‟s and are the
face of Islam for their followers, they have themselves expressed a preference for getting MC done in hospitals
and linked this change with modernization. According to him:
“Actually circumcision, till the time when there was no urbanization and it was not so
developed and there was not much mobilization in between nations, there used to be one
person or one family in the village who used to do this and who is called Nai. The only
knowledge or qualification they have is the knowledge and training given by his father and
forefathers they don‟t have any formal certification but there is nothing like it is done by
Priests (maulwi)..Now a day‟s culture has developed so much that it happens in hospitals.
Doctors are doing this…surgeons are doing this. Here also in our family, our children got
circumcised by surgeons” (30 years old Islamic scholar)
This preference for medical MC was also mentioned in another interview with an allopathic doctor. His
response is as below:
“Yes with increase in literacy rate and awareness, people have started preferring medical
circumcision over traditional circumcision as it is a bloody and surgical procedure and I
think it is not done in aseptic conditions by traditional circumcisers”30 years old Sikh,
Medical doctor)
iv) Safety concerns about traditional MC: In some of the interviews Muslim respondents have expressed the
safety concerns in doing MC in traditional ways and this raises their concerns about the safety of the child and
influences them to get the child circumcised in hospitals. One of the Muslim respondent admitted that in villages
it is done by untrained traditional circumcisers and they do it in aseptic conditions that expressed this as a reason
to prefer medical MC.
“This is handled by untrained people in the village like a barber, they don‟t sterilize the
razor. So some people catch infection, and it takes a little long time to heal. Otherwise people
today are aware and they prefer doing it through some doctor, but still majority of the people
in the villages get it done through traditional circumcisers, they have a razor to cut, wooden
needles, which is a very old (desi) system, ash of the earthen oven etc .. it can be unsafe to
apply, but today even after getting it done from them, people still visit doctors for medicines
and other ointments, and many people bring their own blade” (39 years old Muslim)
“there are ill effects if an inexperienced person (Kam tajurbekar) does khatna for someone
and if the foreskin is not properly cut or less cut or cut wrongly (tircha cut) the person can
suffer from urine problems like, the urine (dhaar) might split, it can also damage the penis”
(30 years old Muslim)
On probing about any challenges or errors encountered during their experience as traditional circumcisers,
some of them notified a few instances, but declined to acknowledge the responsibility for the mistake; rather
they attributed it to the carelessness of the person being circumcised.
IV.
DISCUSSION
The study investigated the knowledge, perceptions and beliefs about MC among young men from
traditionally circumcising and non- circumcising communities in Chandigarh, and explored the practice of
traditional MC in the circumcising community. The study also explored respondents‟ views about accepting MC
as a potential method of HIV infection prevention and identified the socio-cultural and religious underpinnings
and sentiments around MC which may act as facilitators or barriers in introducing MC as an HIV prevention
method if it was ever considered any time in future in India. A majority of the respondents belonging to the non
circumcising communities had limited understanding on MC but most of them knew circumcision as a symbol
that differentiates Muslims from non-Muslims implying that practicing it carried the risk of being identified as
belonging to that religious community. Misconceptions about MC among them were mainly due to lack of
authentic sources of information on MC for general public. Due to religious implications the custom of
“Sunnat” has to be performed by a traditional circumciser in order for it to be concluded in a religious manner.
But many respondents from circumcising community did not necessarily link circumcision to be done by
traditional circumcisers. Rather they were more open to approaching doctors. Another change in the practice of
traditional MC is that although traditional circumcisers try to incorporate modern medical practices in their
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Male circumcision within the context of HIV prevention in India: a qualitative study
procedure of doing circumcision, however they are not formally trained and lack knowledge on sterilization and
maintaining aseptic conditions while doing MC. But they are receptive about need for safety in procedure and
are able to assess risks. The acceptance of circumcision among other communities, as a practice to improve
health and prevent infections such as, HIV, looked seemingly negative amongst respondents from the non
circumcising community. Due to its strong association as an identifier of a particular religion, there are fears in
adopting it and being discriminated or targeted as being a member of the minority community. Those who
expressed a positive outlook towards the acceptance of male circumcision feel that this could be best absorbed
by those who are educated, and those who understand and prioritize on the benefits that male circumcision has
to offer.
4.1 Study limitations:
Firstly, the focus of the study is only limited to men‟s perception about MC and women were not a
part of this research study. This limits its validity as women‟s perception is crucial too in relation to sexual
relationships and prevention of STIs. Secondly, the study was conducted in a specific region of India and
included three different religions amongst which MC is only traditionally followed in one religion. The beliefs
about and attitude towards MC from this study may be limited to a specific region and religions and may differ
from the areas with a history of communal tensions.
V.
CONCLUSION AND RECOMMENDATIONS
Beliefs and the deep rooted perceptions about male circumcision amongst men from non circumcising
communities may pose a challenge for implementing a public health program on male circumcision as an HIV
prevention measure.
5.1 Recommendations:
There is need for educating all communities about the correct meaning, practice and procedures of MC
in order to remove the misperceptions and give correct knowledge about MC. As evident from the research
study that traditional MC has certain drawbacks and might result in complications, it is therefore extremely
important to identify and address the issue by providing the traditional circumcisers with necessary training and
facilities as they are able to assess the risks and are receptive about the need for safety in the procedure. They
can be partnered as stakeholders and trained for safer procedures or for promoting safety in MC. Future research
using the quantitative methods and in other parts of the country is warranted to explore the acceptance about
MC which may help in identifying the facilitators and barriers to strengthen the evidence on provision of safe
MC services as an additional HIV prevention method.
Acknowledgements
Authors would like to thank all participants for sharing insights on this issue
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43 | Page
IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 44-51
www.iosrjournals.org
Condition of Child Health and Child Morbidity in Bangladesh
Md. Shahidul Islam1 , Muhammad Alamgir Islam 2
1
Department of Mathematics & Statistics, Bangladesh University of Business & Technology
Dhaka – 1216, Bangladesh.
2
Department of Mathematics & Statistics, Bangladesh University of Business & Technology
Dhaka – 1216, Bangladesh.
Abstract: The main aim of the study is to find the child health and child morbidity under five years for the
cause of various diseases such as acute respiratory infection (ARI) and diarrhea. Therefore ARE and diarrhea
are considered as the dependent variable and all other possible characteristics that may influence the child
morbidity considered as independent variables. Many statistical techniques are used to analysis the data
whenever warranted. To explore bi-variants relationship, series of cross tabulations have run. In some cases
the extend of relationship discerned from the analysis has been evaluated by some usual measures of
association such as chi square and odd ratio statistics. The statistical technique employed here include
multivariate coefficient regression
Keywords: Health, Morbidity, Children, acute respiratory infection, diarrhea, Bangladesh.
I.
Background of the study
One of the most burning problems of world today is that of controlling the population explosion.
Bangladesh is one of the most densely populated countries of the world. The area of Bangladesh is only 56,977
sq. miles or 1, 47,570 sq. kilometer (Census 2011). It lies in the north-eastern part of south Asia between 2034
and 2638 north latitude and 8801 and 9241 east longitude. The country is bounded by India on the west, the
north and the north -east and Burma on the south-east and the Bay of Bengal on the south. Bangladesh enjoys
generally a sub-tropical monsoon climate.
The population of Bangladesh stood at 146.888 millions; Density is 1,015 /km2 or 2,676.8/sq miles
(Census 2011). The population of the country is growing at approximately the rate of 1.37 percent per annum
(Census 2011). The percentage of urban residing population is 28.1 while that of rural is 71.9.
As in many developing region of the world the core health problem in Bangladesh are related to high fertility
malnutrition and communicable disease about 1030000 children less than 5 year of age die every year. The
infant mortality at birth in Bangladesh is the second highest in the world. Three illnesses that are major
contributors to childhood mortality in Bangladesh are discussed in this section: acute respiratory infection
(ARE) and diarrhea.
The battle with diarrhea in Bangladesh goes back a long time before the Independent of the country.
Diarrhea, over the years, has killed millions of people and continues to be a major threat. It occurs throughout
the year because of geographic, climate and poor socio-economic conditions, which hinder efforts to control the
disease. Each year three million people in the world die of diarrhea. Despite the fact that diarrhea cases have
started to decrease. It is still a critical health problem in Bangladesh. One way to address this issues us to
stabilize the rapid population growth (RPG) of Bangladesh. Diarrhea is a symptom of a verity of clinical
diseases and is not a disease itself .It is caused by bacterial and viral infections and parasites.
The second leading cause of child deaths after acute respiratory infections in the world, but in
Bangladesh it is the leading cause. In Bangladesh, the people who are most affected by diarrhea are the urban
crash dwellers and the people that live in rural areas (mainly children) because they are the ones who are most
likely to get the disease and least likely to receive treatment (Paudyal, 1993). They lack knowledge about the
causes and treatments, and they have limited access to health care. The sanitation in the areas where they live is
also very poor. Child Mortality Data from the 2007 BDHS show that under-five mortality (88 deaths per 1000
live births) has continued to decline thanks primarily to the substantial decline (20 percent) in child mortality
(age 1-4 years) over the past five years. However, this still means that for the most recent five-year period, one
in every Bangladesh children dies before reaching the first birthday (65 death per 1000 live birth) A majority of
infant deaths occur during the first month of life (neonatal mortality). Overall for all children under five, the two
most important causes of death were: possible serious infections (31 percent) including possible ARI and
diarrhea and ARI (21 percent). Which particularly affect children age 1-11 months.
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Condition of Child Health and Child Morbidity in Bangladesh
Objective of the Study
The main aim of the study is to find the child morbidity for the cause of various disease such as acute respiratory
infection (ARI) and diarrhea. Also analysis the levels and patterns of the child illnesses in Bangladesh. The
specific objectives of this study are as follows:
1. To investigate the levels of illnesses of children under five years
2. To examine the associations between children illnesses and available background
characteristics.
3. To examine the effect of different explanatory variables on child illnesses.
II.
Data collection and Methodology
The study uses a secondary data of which the source in Bangladesh demographic and health survey
(BDHS), 2007. The survey was conducted under the authority of the National Institute of Population Research
and Training (NIPORT) of the ministry of health and family welfare. Mitra and associates a private research
firm implemented the survey. A total of 6150 children aged under five years were included in the analysis.
Administratively, Bangladesh is divided into six divisions. In turn, each division is divided into zilas, and in turn
each zilas into upazilas. Each urban area in the upzilas is divided into wards, and into mahallas within the wards;
each rural area in the upzilas is divided into union parishads (UP) and into mouzas within the UP’s. These
divisions allow the country base a whole to the easily separated into rural and urban areas. The present study
makes use of a number of statistical techniques to analysis the data whenever warranted. To explore bi-variants
relationship, series of cross tabulations have run. In some cases the extend of relationship discerned from the
analysis has been evaluated by some usual measures of association such as chi square and odd ratio statistics
some advanced statistical techniques were employed with selected variable in order to access to contribution of
each independent on the dependent variable controlling for the others.
Frequency and Percentage distribution of the Variables:
Table of Frequency distribution of
socioeconomic characteristics:
Variable
1.Mother’s education
Illiterate
Primary education
Secondary & Above
Total
2.Father’s education
Illiterate
Primary
Secondary
Higher & Above
Table of Frequency distribution
Demographic characteristics:-
Frequency
Percentage
2129
1927
2094
27.3
31.3
41.4
6150
100.0
2094
1748
1570
758
34.0
28.4
25.5
12.0
Variable
1.Total children ever born
Standard
Not standard
Total
2.Birth order--1st
2nd
3rd
4th
Total
Total
6150
100.0
3.Mother age at birth
12 through 16
All others
Total
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of
Frequency
Percentage
1543
4607
6150
25.1
74.9
100.0
2039
1596
1027
1488
33.2
26.0
16.7
24.2
6150
100.0
2193
3957
6150
35.7
64.3
100.0
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Condition of Child Health and Child Morbidity in Bangladesh
3.No of family member
Standard
Not standard
Total
4.Respondent’s
occupation
Not working
Working
Business
Total
5.Husband’s occupation
Not working
Working
Business
Total
6.Source of drinking water
Hygienic
Unhygienic
Total
7.Type of toilet
Hygienic
Unhygienic
Total
8.Economic status--Poor
Middle
Rich
Total
2871
3279
46.7
53.3
6150
100.0
Table of Frequency distribution of
Psychological characteristics:Variable
4532
1536
82
6150
73.7
25.0
1.3
100.0
76
4726
1348
1.2
76.8
21.9
6150
100.0
5313
837
86.4
13.6
6150
100.0
2527
3623
41.1
58.9
6150
100.0
2504
1153
2493
6150
40.7
18.7
40.5
100
1.Sex of child
Male
Female
Total
2.Access to mass mediaNo access
Limited access
Access
Total
3.Belong to organization
No
Yes
Total
Frequency
Percentage
2107
4043
6150
34.3
65.7
100.0
791
1275
1285
714
967
118
6150
12.9
20.7
20.9
11.6
15.7
18.2
100.0
5609
541
6150
91.2
8.8
100.0
Percentag
e
3118
3032
50.7
49.3
6150
100.0
2355
2544
1251
38.3
41.4
20.3
6150
100.0
3920
2230
63.7
36.2
6150
100.0
Table of Frequency distribution of
Dependent characteristics:Dependent variable
Frequency
Percenta
ge
No
Yes
3669
2481
59.7
40.3
Total
Diarrhoea
No
Yes
6150
100.0
5203
947
84.6
15.4
Total
6150
100.0
ARI
Table of Frequency distribution of
Community characteristics:Variable
1.Type place of
residence
Urban
Rural
Total
2.Division(Religion)
Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Sylhet
Total
3.Religion--Islam
Others
Total
Frequency
Statistical Analysis & Comments:
A chi-square test is a statistical test commonly used for testing independence and goodness of fit.
Testing independence determines whether two or more observations across two populations are dependent on
each other. In both cases the equation to calculate the chi-square statistic is
Where, Oi =the observed frequency and Ei = the expected frequency and n= the number of cells.
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Condition of Child Health and Child Morbidity in Bangladesh
Bvariate effect of ARI into different independent variables:
Acute Respiratory Infection
Background
characteristics
Type of place of
Residence
Sex of child
Division
(Region)
Father’s education
Mother’s education
Age of mother at birth
Access to mass media
Economic status
Source of drinking
water
Type of toilet facility
Level
No
Yes
Total
Urban
1314(62.4%)
793(37.6%)
2107
Rural
2355(58.2%)
1688(41.8%)
4043
Chi-squire=9.74
d.f.=1
P value=.002
6150
Male
1851(59.4%)
1267(40.6%)
3114
Female
1818(60.0%)
1214(40.0%)
3032
Chi-squire=.226
d.f.=1
P value=.034
6150
Barisal
453(57.3%)
338(42.7%)
791
Chittagong
730(57.3%)
545(42.7%)
1275
Dhaka
801(62.3%)
484(37.7%)
1285
714
Khulna
501(70.2%)
213(29.8%)
Rajshahi
582(60.2%)
385(39.8%)
967
Sylhet
602(53.8%)
516(46.2%)
1118
Chi-squire=57.33
Illiterate
d.f.=5
1224(58.6%)
P value=.000
866(41.4%)
6150
2094
Primary
978(55.9%)
770(44.1%)
1748
Secondary
962(61.3%)
608(38.7%)
1570
Higher & Above
501(67.9%)
237(32.1%)
738
Chi-squire=33.35
d.f.=3
P value=.000
6150
Illiterate
964(57.7%)
712(42.5%)
1676
Primary
1120(58.1%)
807(41.9%)
1927
Secondary & Above
1583(62.2%)
961(37.8%)
2547
Chi-squire=12.04
d.f.=2
P value=.002
6150
12 through 16
1283(58.5%)
910(41.5%)
2193
16+year
Chi-squire=1.89
No access
Limited access
Access
Chi-squire=7.91
Poor
Middle
Rich
Chi-squire=28.24
Hygienic
Unhygienic
Chi-squire=.979
Hygienic
Unhygienic
Chi-squire=9.205
2386(60.3%)
d.f.=1
1354(57.5%)
1542(60.6%)
773(61.8%)
d.f.=2
1408(56.2%)
677(58.7%)
1584(63.5%)
d.f.=2
3170(59.7%)
499(59.6%)
d.f.=1
1565(61.9%)
2104(58.1%)
d.f.=1
1571(39.7%)
P value=.170
1001(42.5%)
1002(39.4%)
478(38.2%)
P value=.019
1096(43.8%)
476(41.3%)
909(36.5%)
P value=.000
2143(40.3%)
338(40.4%)
P value=.001
962(38.1%)
1519(41.9%)
P value=.002
3957
6150
2355
2544
1251
6150
2504
1153
2493
6150
5313
837
6150
2527
3625
6150
III.
Comments:
According to the table the highest prevalence of ARI is found in Sylhet (46.2 percent) and the lowest is
at Khulna (29.8 percent). ARI is more common in rural areas than urban areas while there is statistically
significant association between prevalence of ARI and place of residence. The prevalence of ARI varies
according to the place of residence where their mother was born. 41.8 percent of children whose mother have
rural childhood background are repeated to have had symptoms of respecter illness and it is 37.6 percent of the
children of mother who was born in urban areas. Mother’s educations have statistical significance effect on
prevalence of ARI. ARI prevalence is found to be highest among children of mothers who have primary level
education and lowest for children of mothers who have above primary education. The prevalence of ARI also
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Condition of Child Health and Child Morbidity in Bangladesh
varies with respect to father’s characteristic. According to table it is revealed that the higher education levels of
father, the lower the prevalence of ARI. ARI prevalence is the lowest for children of father whose occupation is
service. ARI is less common for children of mother’s who are related to any media. The ARI prevalence is less
common among the children of working respondent. Also from table we see that the higher wealth index of
respondent, the lower the prevalence of ARI found among their children. The percentage of children with ARI is
36.9 percent found among rich women compared to 43.6 percent found among poor women.
Source of drinking water have effect on the prevalence of ARI among children under five year. The
percentage of acute respiratory infected children whose households use unsafe water is higher than that of
children whose household use safe water by 40.3 percent. The prevalence of ARI varies by the type of toilet
facility. 38.1 percent children whose household use modern toilet are reported to have had symptoms of
repertory illness and the household who use pit on open toilet have 41.9 percent of children with ARI. ARI is
less common among female children and among children over 24 months old. ARI is also lower among children
whose mother gives their first child at 20 years and above.
Bivariate effect of Diarrhoea into different independent variables:
Background
characteristics
Type of place of
Residence
Division
(Region)
Father’s education
Mother’s education
Sex of child
Age of mother at birth
Access to mass media
Economic status
Source of drinking water
Type of toilet facility
Diarrhoea
Level
Total
Urban
Rural
Chi squire=1.002
Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Sylhet
Chi-squire=20.79
Illiterate
Primary
Secondary
Higher & Above
Chi-squire=35.09
Illiterate
Primary
Secondary and Above
Chi-squire=18.12
No
1796(85.2%)
3407(84.3%)
d.f.=1
678(85.7%)
1061(83.2%)
1091(84.9%)
621(87.0%)
844(87.3%)
908(81.2%)
d.f.=5
1738(83.0%)
1453(83.1%)
1336(85.1%)
676(91.6%)
d.f.=3
1385(82.6%)
1604(83.2%)
2211(86.9%)
d.f.=2
Yes
311(14.8%)
636(15.7%)
P value=.317
113(14.8%)
214(16.8%)
194(15.1%)
93(13.0%)
123(12.7%)
210(18.8%)
P value=.001
356(17.0%)
295(16.9%)
234(14.9%)
62(8.4%)
P value=.000
291(17.4%)
323(16.8%)
333(13.1%)
P value=.000
2107
4043
6150
791
1275
1285
714
967
1118
6150
2094
1748
1570
738
6150
1676
1927
2544
6150
Male
Female
Chi-squire=5.08
2606(83.6%)
2597(85.7%)
d.f.=1
512(16.4%)
4135(14.3%)
P value=.024
3118
3032
6150
12 through 16
16+year
Chi-squire=2.96
No access
Limited access
Access
Chi-squire=3.41
Poor
Middle
Rich
Chi-squire=11.27
Hygienic
Unhygienic
Chi-squire=.253
Hygienic
Unhygienic
Chi-squire=1.692
1832(83.5%)
3371(85.2%)
d.f.=1
1967(83.5%)
2168(85.2%)
1068(85.4%)
d.f.=2
2097(83.7%)
952(82.6%)
2154(86.4%)
d.f.=2
4490(84.5%)
713(85.2%)
d.f.=1
2156(85.3%)
3047(84.1%)
d.f.=1
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361(16.5%)
586(14.8%)
P value=.086
388(16.5%)
376(14.8%)
183(14.6%)
P value=.181
407(16.7%)
201(17.4%)
339(13.6%)
P value=.004
823(15.5%)
124(14.8%)
P value=.001
371(14.7%)
5761(15.9%)
P value=.193
2193
3957
6150
2355
2544
1251
6150
2504
1153
2493
6150
5313
837
6150
2527
3623
6150
48 | Page
Condition of Child Health and Child Morbidity in Bangladesh
Comments: According to the response of the respondent the children of Sylhet division are more affected by
diarrhea than all other divisions. And it is followed by Chittagong, Khulna, Rajshahi, Sylhet and Dhaka. The
prevalence of diarrhea decreases with the increases of mother’s education. Economic status of the respondent is
found to have negative association with their child illness due to diarrhea. Diarrheas are reported on 42.4%
found among poor respondent which gradually decreases to 37.0% found among rich respondent. Diarrhea is
more common among male children than female children and also among children aged below 25 months. There
exist little variations in the percentage of children who had diarrhea with respect to age of mother at first birth.
Diarrhea prevalence is more common among children of respondent who have became mother in the teenage
and among children of respondent whose households use open latrine. There exist statistically significant
relation association between father’s education and prevalence of diarrhea among their children who have had
diarrhea. The percentage of children whose father has no education is higher by 17.0% than that of children of
father having above primary education. It is seen that father’s education is more effective variable than mother’s
education in this case.
Diarrhea prevalence is less common among children of father who works in service occupation. UrbanRural comparison reveals that diarrhea is more common in rural areas than that of urban areas. But on the basis
of childhood place of respondent we get the opposite result. The respondents who are accessed to any mass
media can safe their children from effect of diarrhea compared to the others. And also those who use safe water
and modern toilet facility can safe their children from the illness of diarrhea compared to other respective
counterparts.
Logistic Regression Analysis:
Logistic regression model is useful to find the best fitting and most parsimonious, yet biologically
reasonable model to describe the relationship between an outcome (dependent or response variable) and a set of
independent (predictor or explanatory) variables.
For a single variable, the logistic regression model is of the form
Prop (event) =
1
1 e
 (  0  1 x )
Where  0 and  1 are the regression co-efficient estimated from the data, x is the independent variable and
the base of natural logarithm.
For more than one independent variable, the model assumes the form
e
1
1  ez
Where z =  0  1 X 1   2 X 2  ............   P X P
Prop (event) =
The model is to be written in terms of the log odds of event occurring. This is called logit;
 prob(event ) 
 =  0  1 X 1  ...........   P X P
 prob(noevent ) 
ln 
Here we consider, the absence of diarrhea among children is coded as 0 and the presence of diarrhea is coded
as1
Regression co-efficient (  ) and odds ratios (Exp (  )) of ARI by background variables
Background variables
Type of place of residence
Urban
Rural(RC)
Division
Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Sylhet
Father’s education
Illiterate
Primary
Secondary
Higher

.030
----
Sig.
Exp(  )
.625
.----
.970
1.00
-.167
-.106
-.328
-.668
-.250
----
.083
.206
.000
.000
.006
----
.846
.899
.720
.513
.779
1.00
.223
.375
.219
----
.045
.000
.026
----
1.250
1.455
1.245
1.00
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Condition of Child Health and Child Morbidity in Bangladesh
Mother’s education
Illiterate
Primary
Secondary and Higher
Access to mass media
No access
Limited access
Access
Type of toilet facility
Hygienic
Unhygienic
Economic status
Poor
Middle
Rich
-.020
-.002
-----
.804
.979
-----
.980
.998
1.00
-.036
.021
----
.661
.774
----
1.265
1.021
1.00
-.028
----
.641
----
.972
1.00
.225
.131
----
.006
.112
----
1.252
1.140
1.00
RC = Reference Category
*Significance at the p-value of 0.01
**Significance at the p-value of 0.05
Comments: From the results, it appears that the region has influence on the prevalence of ARI. Children in
Barisal and Chittagong are 84.6 percent and 89.9 percent higher ill with ARI than children in Sylhet. These
analyses reveal that the children whose fathers are illiterate are 1.25times more likely to have had ARI than
whose fathers have higher education. Among the children of father who have primary and secondary education
are 1.455 and 1.245 times more likely to have ARI than whose fathers have higher education. The respondents
who use hygienic toilet, the prevalence of ARI is .028 times less than the respondents who use unhygienic toilet
and The respondents who have no Access to mass media, the prevalence of ARI is 1.265 times more than the
respondents who have Access to mass media. Economic status is an important variable which determine the
child illness with ARI. From the logistic regression it is clear that there exists a negative association between
economic status and ARI. The prevalence of ARI in poor children is 1.252 times more likely than rich children.
Regression co-efficient (  ) and odds ratios (Exp (  )) of diarrhea by background variables:
Background variables

Sig.
Exp(  )
-.307
-.107
-.262
-.384
-.413
----
.020
.329
.021
.006
.001
-----
.736
.898
.769
.681
.662
1.00
.608
.655
.575
----
.000
.000
.000
-----
1.836
1.925
1.778
1.00
.045
.060
-----
.680
.535
-----
1.046
1.062
1.00
.164
---
.022
----
1.178
1.00
.781
.888
-----
.069
.040
-----
2.183
2.430
1.00
Division
Barisal
Chittagong
Dhaka
Khulna
Rajshahi
Sylhet
Father’s education
Illiterate
Primary
Secondary
Higher
Mother’s education
Illiterate
Primary
Secondary and Higher
Sex of child
Male
Female
Respondent’s occupation
Not working
Working
Business
Comments: From the results, it appears that region has influence on the prevalence of Diarrhea. Children in
Barisal and Chittagong are 73.6 percent and 89.8 percent higher ill with Diarrhea than children in Sylhet. The
analysis reveals that the children whose father is illiterate are 1.836 times more likely to have diarrhea than the
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Condition of Child Health and Child Morbidity in Bangladesh
children whose fathers have secondary and higher education. Among the children of father who have primary
education, the risk of having been diarrhea in 92.5 percent higher than reference category (RC).
The children whose mother was illiterate are 1.046 times more likely to have diarrhea then children whose
mother has secondary and higher education. The analysis shows that respondent’s occupation is one of the
strongest determinants of diarrhea. For respondent occupation it is 2.183 time higher for not working and 2.430
for working than business. The risk of occurring diarrhea is 17.8 percent higher among the male children than
the female children.
References
[1].
[2].
[3].
[4].
[5].
[6].
[7].
[8].
[9].
[10].
[11].
Population
And
Housing
Census
2011
Preliminary
Result
Bbs.gov.bd
www.bbs.gov.bd/.../userfiles/.../PHC2011Preliminary%20Result.pdf
Al-Kabir, Ahmes (1984). ٬ Effect of community factors on infant and child mortality in rural Bangladesh, Scientific Report , No-56.
Voorburg, WFS, London.’
Amir, Ruhul(1988). ٬Infant and child mortality in Bangladesh.’ Journal of Biosocial Science, 20(1),pp.59-95.
Huda, K.S.(1980). Differentials in child mortality in Bangladesh: An analysis of individual and community factors, Ph.D.thesis,
University Microfilms International, Ann Arbox, Michigan.
Caldwell JC(1979). Education as a factor in mortality decline: an examination of Nigeria data, population studies , 33(3): 395-413.
Mazumder K.A. Khuda, Kane and Hill(1992). Determinants of Infant and child mortality in rural Bangladesh. Reproductive health in
Rural, pp490-504.
Kabir M and Amin R(1993). Factors influencing child mortality in Bangladesh and their implications for the National Health
Programme. Journal of Asian-Pasific Population.Vol.8.No.3.pp.31-46.
Islam S.M.S. Alam M.F.(1996). Factor affecting child mortality in Bangladesh, the Journal of Family Welfare, and Vol.42 No.3 pp 1318.
Majumder A.k. Islam S.M.(1993). Socioeconomic and Environmental Determinants of Child Survival in Bangladesh, J. of Biosocial
Science, Vol.25 No. 3.pp.311-318.
Ahmed, B. "Differential Fertility in Bangladesh (unpublished Masters Thesis, Australian National University, Canberra, 1979).
Bongaarts, J “Does Family Planning Reduce Infant Mortality Rates?” Population and Development Review. Voi.3.No.2pp. 323-334
www.iosrjournals.org
51 | Page
IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 52-54
www.iosrjournals.org
Noble Ganga Tears-Sweat Bomb Theory
Thiyagarajan Babu*
Abstract: Tears and perspiration are the regular secretions of eye organ for any human being owing to
emotional issues. There were numerous literatures available on the products associated with the tears, why
tears were created but the how part was not solved till date. Huge volume of literatures projecting tears were
secreted by the lachrymal glands involving complex body mechanism was available. Similarly the roles of sweat
glands were attributed for perspiration in the skin of mammals. My simple two instruments namely pH meter
and ORP (Oxidation Reduction Potential) meter unopened this mystery that tears and perspiration were formed
with an outside molecule. Lachrymal glands and Sweat glands secreted vital compounds carried by the cellular
fluid in order to protect eyes and skin respectively from harmful organisms or agents.
I.
Introduction
(I)TEAR FILM
Human beings consume water and lachrymal gland secretion adheres to the tear film (Wu K, Galina
VJ, 2006). The normal water was converted as cellular water in order to reduce the surface tension of the water
to lubricate the cornea and conjunctiva, to provide anti-bacterial activity, to keep the cornea moist, to serve as a
conduit for the entry of polymorphonuclear leucocytes into the cornea to remove toxic substances from the
ocular surface for different protection of the eyes. They were not tears as the surface tension of cellular water
and the tears were varied.
(ii)HYDROGEN- THE WONDER MOLECULE
Hydrogen is the lightest element and its monoatomic form (H1) is the most abundant chemical
substance (75 per cent of the Universe's baryonic mass (Finkel T, Holbrook 2000). H2+ is composed of two
positively charged protons and one negatively charged electron and lack electron–electron repulsion. Being the
lightest gas Hydrogen diffuses in the cells as rapidly as possible. Notice that the hydrogen bond is somewhat
longer than the covalent O—H bond. This means that it is considerably weaker; it is so weak, in fact, that a
given hydrogen bond cannot survive for more than a tiny fraction of a second. This build up more and more
Hydrogen molecules pressure in the cell in addition to Hydrogen’s released due to internal and external
pressures.
About two-thirds of this water is located within cells, while the remaining third consists of extracellular water,
mostly in the blood plasma and in the interstitial fluid that bathes the cells. The water molecules are made up of
tiny combination of three nuclei and eight electrons and have unique properties. This would ordinarily result in
a tetrahedral geometry in which the angle between electron pairs (and therefore the H-O-H bond angle) is
109.5°. However, because the two non-bonding pairs remain closer to the oxygen atom, these exert a stronger
repulsion against the two covalent bonding pairs, effectively pushing the two hydrogen atoms closer together.
The result is a distorted tetrahedral arrangement in which the H—O—H angle is 104.5° (Lide, David R, 2003).
In the human system the biological activity of proteins (of which enzymes are an important subset) is
critically dependent not only on their composition but also on the way these huge molecules are folded; this
folding involves hydrogen-bonded interactions with water, and also between different parts of the molecule
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Noble Ganga Tears-Sweat Bomb Theory
itself. Anything that disrupts these intra-molecular hydrogen bonds will denature the protein and destroy its
biological activity (Source: Water Structure and Properties).
It is worth mentioning that the source of Hydrogen molecules were not only the hydrogen-bonding always
involved with water; plus the two parts of the DNA double helix are held together by H—N—H hydrogen bonds
(Greenwood, Norman N.; Earnshaw, 1997).
Hence, there is a huge source of Hydrogen molecules exist in the human system.
The present thinking, influenced greatly by molecular modeling simulations beginning in the 1980s, is that on a
very short time scale (less than a picoseconds), water is more like a "gel" consisting of a single, huge hydrogenbonded cluster. On a 10-12-10-9 sec time scale, rotations and other thermal motions cause individual hydrogen
bonds to break and re-form in new configurations, inducing ever-changing local discontinuities whose extent
and
influence
depends
on
the
temperature
and
pressure
(Source:
www.imimphd.edu.pl/contents/Lectures/Electrochemistry). Hence, the Hydrogen molecules were prone for diffusion when
there were pressures in the cells besides their weak property due to its lightest nature unlike other stable
molecules like Oxygen. Those millions of Hydrogen molecules diffuse through the tissues like bullets in search
of an exit in the human system.
II.
Thousands Years of Cry on Cry
Molecules have quantized energy levels that can be analyzed by detecting the molecule's energy
exchange through absorbance or emission (Nic, M.; Jirat, J.; Kosata, B., 2006). Whenever there was a pressure
of any kind internal or external, the billions of human cells were pressurized and this led to many molecule's
energy exchange through absorbance or emission or and human physio-chemical alterations.
(i) Eyes and Tear Mechanism
Eyes were prone for all kinds of pressures both internally and environmentally. Once there was a
pressure that had to be released which was a natural law. Strain in eye region inevitably pressurizes the tissues
around and that triggers the release of millions of Hydrogen molecules. The lightest Hydrogen molecules were
fired like bullets from different tissues and march like a battalions in search of an exit. The exit being the eyes
inner layer they make a cloud of Hydrogen molecules being positively charged. Why does Hydrogen released
like bullets? ―Hydrogen Bomb‖ was created by uniting the two Hydrogen molecule nucleuses. If such things
happen in human cell then cells would bulge and tear away. Hence the powerful neurotransmitters signal the
brain instantly to rush the hydrogen molecules out of cells as fast as possible in order to avoid any collision of
two hydrogen molecules. Released Hydrogen molecules due to various pressure, "stick" to the surface of the tear
film moving through it. This layer of Hydrogen molecules forms the ―Hydrogen cloud‖ at the the innere layer of
eyes. At the surface of the eyes, it is essentially static due to the friction of the surface. The Hydrogen
molecules, with its boundary layer were in fact the new shape of the eyes that the rest of the molecules form the
new water molecules with the atmospheric Oxygen. This boundary layer could separate from the surface of the
eyes’ inner layer, essentially creating a new surface and completely changing the flow path of tears. In general,
the liquids drift to the bottom upon mixing hence the cellular water and the tears which were formed outside the
tear film mix together. And this was the reason many scientists reported tears with innumerable products.
They get the contact of atmospheric stable Oxygen which was electromagnetic negatively charged
molecules. The first tear molecule was formed with a plucking feeling in the human eyes. This led to further
bonding of positively charged Hydrogen molecules with negatively charged Oxygen molecules. The chain
reaction continues and the tears start shedding due to gravitational pull. As the drops get bigger, their weight
deforms them into the typical tear shape.
Oxygen as a compound is present in the atmosphere in trace quantities in the form of carbon
dioxide (CO2). Due to its electro-negativity, oxygen forms chemical bonds with almost all other elements at
elevated temperatures to give corresponding oxides.
I just compare this process with the process of rain drop lets formation in the sky. There was no sac like
lachrymal gland in the sky in order to secrete huge water molecules in order to rain. The atmospheric Hydrogen
and Oxygen molecules get associated in the sky forming rain causing clouds and temperature and atmospheric
pressure ignite the clouds to drizzle and rain due to gravity. The same process happens in human eyes.
I put forth once again strongly that the lachrymal gland secrets only the vital compounds carried by the cellular
water to protect the eyes and forms the tear film.
(ii) Nasal Fluid
In this context it was worth clearing another myth behind nasal watering. Nasal is the part where plenty
of Oxygen is always available as human being breath through nasal pipe. When Hydrogen molecules were
released through nasal tissues around the nasal pipe, those molecules obviously bond with the Oxygen
molecules and nose drains with watery fluid. Tears sometimes passes through a small opening on the inner side
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Noble Ganga Tears-Sweat Bomb Theory
of the eyelid into the nose. But the rate of Hydrogen molecules pumping must be far less when compared to
tissues surrounding the eye region. It is important to mention nasal fluid does not include filtration, as does the
formation of urine by the glomerular kidney (source: http://www.aquaticape.org/tears.html).
(iii) Perspiration Mechanism
I further clearly substantiate with another process called ―Perspiration‖ (Mosher, H.H., 1933). Due to
lack of stable Oxygen molecules in the blood human tissues receive the at most pressure and this led to release
of Hydrogen molecules through skin pores in a line. Chemical bonding that arises from the mutual attraction of
oppositely charged Hydrogen and Oxygen molecules. Therefore, Oxygen molecules did not usually exist on
own, but will bind with ions of opposite charge to form a water molecule from the atmosphere. Each drop
coalesces with adjoining sweat drop leading to increase in drop size and the volume of sweating.
III.
Conclusion
This theory is going to disprove hundreds of years old biochemical tears theories and sweat theories
(William H. Frey II, 1985; Benjamin Milder, M.D. 1987) and ought to cease the thousands years of cry on cry.
The scientists would realize their wrong projections since long years and realize now that tears were not secreted
by lachrymal glands and perspiration was not due to sweat glands. Tears obviously contain some of the products
along with cellular water as tear droplets were associated with tear film. Darwin reported in his book
―Expression of the Emotions in Man and Animals‖ (Darwin, C., 1872) where observations of recently captured
elephants showed no tearing and "the native hunters asserted they had never observed elephants weeping.‖ I am
to contradict his views as release of the Hydrogen molecules create the tears and any animal like Elephant,
Whales, Monkeys etc., could develop tears.
I can add many more findings associated with my discovery like closing of eyes stops the contact with
atmospheric Oxygen and tear formation gradually reduces. The fire lit before the crying baby limits the
availability of atmospheric Oxygen and the baby stops crying. The dead bodies were advised to burn for the
reason it would limit the atmospheric Oxygen availability stopping the sobering kin and kith at grave yard. My
list is pretty long and I would mention in my next paper.
* Scientist (Ministry of Textiles)
Literatures:[1]. Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000; 408:239–47.
[2]. Nic, M.; Jirat, J.; Kosata, B., eds., "spectroscopy". IUPAC Compendium of Chemical Terminology (Online ed.). 2006;
doi:10.1351/goldbook.{file}. ISBN 0-9678550-9-8).
[3]. William H. Frey II, Ph.D, , The Mystery of Tears Muriel Langseth. Minneapolis: 1985; Winston Press.
[4]. Darwin, C. (1872). The Expression of Emotions in Man and Animals. 1979; London: Julian Friedman Publishers.
[5]. Greenwood, Norman N.; Earnshaw, Alan Chemistry of the Elements (2nd ed.).Butterworth–Heinemann, 1997; ISBN 0080379419.,p.
28.
[6]. Lide, David R. "Section 4, Properties of the Elements and Inorganic Compounds; Melting, boiling, and critical temperatures of the
elements". CRC Handbook of Chemistry and Physics (84th ed.). Boca Raton, Florida: CRC Press. 2003; ISBN 0-8493-0595-0.
[7]. Mosher HH (1933). "Simultaneous Study of Constituents of Urine and Perspiration". The Journal of Biological Chemistry 99 (3): 781–
790.
[8]. Wu K, Galina VJ, da Costa SR, Sou E, Schechter JE, HammAlvarez SF. Molecular mechanisms of lacrimal acinar secretory vesicle
exocytosis. Exp Eye Res 2006 83 84-96.
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IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 1, Issue 3 (Mar – Apr 2013), PP 55-62
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A Statistical study Regarding Knowledge and Risk Factors of
Hepatitis B and C in Muzaffarabad Azad Jammu & Kashmir
Atif Abbasi1, Azhar Saleem1, Samarah Aqeel Butt1, Nazneen Habib2 ,Wafa
Hussain2, Sheeba Arooj2
1
(Department of Statistics, University of Azad Jammu & Kashmir Muzaffarabad)
2(Department of Sociology and Rural Development, University of Azad Jammu & Kashmir Muzaffarabad)
Abstract: Background:. Hepatitis B and C is considered to be a significant threat to the mankind around the
globe. Hepatitis is one of the major viral disease affecting significant proportion of population not only in
developing countries but also in developed countries. This threat is most alarming in developing countries
where poverty, illiteracy may contribute to the high risk for causes of Hepatitis B and C Pakistan is highly
endemic for Hepatitis B and C. Objective: The objective of the present study were to investigate the risk factor
of hepatitis among the people of Muzaffarabad Azad Jammu & Kashmir and also to check the prevalence of
hepatitis B and C in the presence of different risk factors. And to investigate the relationship between education,
area and gender with hepatitis. Methods: a cross-sectional descriptive study was conducted over a sample of
400 respondents based on multistage sampling technique. The chi-square test was used to assess the statistical
significance to different risk factors with blood transfusion. The multiple logistic regression, Mann-Whitney U
test and Kruskal-Wallis H test were also used to get the most significant risk factors of hepatitis B and C.
Results: the study shows that the most dominant risk factors of the hepatitis B and c that were age group 15-20
(OR=2.621), 21-26 (OR=1.344) 27-31 (OR=1.005) with 95% CI. Marital status that is married (OR= 0.438)
Un-married (OR= 0.850), education at different level that is Primary (OR=0.728), Secondary (OR=0.973),
graduate (OR=0.688), knowledge about hepatitis B and C, yes (OR=1.412), No (OR=1.547), history of ear
piercing (OR=1.401), Re-use of syringes (OR=1.250, 2.498), sexual relation with affected person (OR=3.943,
1.877). Mann-Whitney U test with gender and area of the respondents with values (15759.500, p-value=.005)
and (18907.00, p-value=.266).It was found that there is difference between male and female opinion regarding
knowledge about hepatitis B and C there was same knowledge about risk factor of hepatitis B and C among the
people of rural and urban areas. The study shows that the educated people have more awareness and
knowledge regarding hepatitis B and C.
Key Words: Chi-Square; Hepatitis B and C; Logistic Regression; Mann-Whitney U test; Odd
Ratio,Muzaffarabad
I.
Introduction
Human beings are at risk due to infinite number of disease. From these infinite numbers of diseases
some are identified and some are still unidentified. Hepatitis B virus and hepatitis C virus infection is one of
them.
A viral hepatitis caused by the hepatitis B virus is known as HBV also called serum hepatitis. The virus
is transmitted by transfusion of contaminated/infected blood or blood products, by sexual contact with an
infected person, by using contaminated needles and instruments. It can cause acute and chronic hepatitis. Severe
infection may cause prolonged illness, destruction of liver cells, cirrhosis, increased risk of liver cancer, or
death. Vaccination against HBV is recommended for infants, teenagers, and adults at risk for exposure.
Treatment may involve transplantation.
A viral disease caused by the hepatitis C virus is known as HCV, commonly occurring after transfusion
or parenteral drug abuse; it frequently progresses to a chronic form that is usually asymptomatic but that may
involve cirrhosis.
Chronic and acute viral hepatitis is global health problem and common public health problems in
Pakistan [1]. The word hepatitis means the inflammation of the liver. Pakistan carries one of the world's highest
burdens of chronic hepatitis and mortality due to liver failure and hepatocellular carcinomas. Despite efforts at
different levels, incidence is increasing day by day. Hepatitis B virus (HBV) and hepatitis C virus (HCV)
infections account for a substantial proportion of liver diseases worldwide. These viruses are responsible for
liver damages ranging from minor disorders to liver cirrhosis and hepatocellular carcinoma (HCC).
Approximately 2 billion people in the world have been infected by HBV, and more than 350 million are chronic
carriers of the virus. Hepatitis C virus (HCV) infection affects approximately 180 million people worldwide.
HBV infection accounts annually for 1 million deaths worldwide from cirrhosis, liver failure, and hepatic
cellular carcinoma. The prevalence rate is about 10% for HBV and 4-7% for HCV in Pakistan [2].
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
Combined HBV and HCV infection is possible because of common modes of viral transmission [3]. The
two most common Ways through which chronic and acute hepatitis spread in Pakistan are by injection and
blood transfusion. Other causes, incidence and risk factors such as unchecked blood transfusion in thalasema or
peoples on haemodialysis, regular contact with blood at work, IDUs, receiving blood and its products, Received
a tattoo, ear piercing, surgery etc with contaminated instruments, sharing of personal items such as tooth brush,
razors with infected person or involved in sexual abuse are at increased risk of developing these infections [5].
During birth, a mother with hepatitis B or C can pass hepatitis B or C on her infant. Study to decide the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and the possible risk factors
among blood donors in Nyala, South Dar Fur State of western Sudan, which has never been consider before. A
total of 400 male blood Donors were tested for the exposure of HBsAg (Hepatitis B Surface Antigen) and antiHCV antibodies, (6.25%) were establish Immediate for HBsAg and (0.65%) were immediate for anti-HCV
antibodies. The study accomplished that the sero-prevalence of HBV and HCV was in middle and low rates
respectively and insecure sexual activities was the major risk factor for infection in the population studied[7].
Therefore the present study was conducted to have an idea about the knowledge regarding different risk
factors of hepatitis B and C in the people of Azad Jammu and Kashmir Muzaffarabad.In our knowledge this is a
first study about that serious issue mentioned above.
.Although there are many ways of passing, the virus actually is not very easily transmitted. There is no
need to worry that casual contact, such as shaking hands, will expose one to hepatitis B or C. There is no reason
not to share a workplace or even a restroom with an infected person. The some major symptoms that can occur
in hepatitis is usually abdominal pain, dark urine, fatigue, jaundice, itching, vomiting, colored stool and nausea.
Both HBV and HCV are the blood born viruses. Both HCV and HBV can be detected by rapid assay
test, ELISA (Enzyme Link Immune Sorbent Assay) and PCR (Polymerase Chain Reaction). Prevention is the
only way to cope with the epidemic of viral hepatitis and screening provides an opportunity to detect the virus in
its asymptomatic and helps early diagnosis and management. Screening programs are now widely used to detect
the virus in peoples with prior infection of hepatitis B and C and helps to prevents in complications [5].
In the past, there was no treatment available for hepatitis B and C. But developments have been made
in recent years on drugs that suppress the virus and its symptoms. The prevention/treatment of hepatitis B is (a)
Active Immunization and (b) Passive Immunization (Hep. B Immunoglobulin) where as in hepatitis C, the alpha
interferon therapy is given for treatment but it is effective only in 30% of the peoples.
The best way to prevent any form of viral hepatitis is to avoid contact with blood and other body fluids
of infected individuals. The use of condoms during sex also is advisable. Babies born of a mother with HBV
should receive the vaccine within 24 hours. An effective and safe vaccine is available that reliably prevents
hepatitis B. Vaccination is suggested for most infants and for children aged 10 and younger whose parents are
from a place where hepatitis B is common. Teenagers not vaccinated as children and all adults at risk of
exposure also should be vaccinated against hepatitis. Three doses are recommended [6].
II.
Methodology
The objective of the study were to investigate the risk factors of hepatitis among the people of
Muzaffarabad Azad Jammu & Kashmir and also check the prevalence of hepatitis B and C in the presence of
different risk factors. A cross sectional descriptive study was conducted in district Muzaffarabad. A sample of
400 respondents was taken who visited the hospitals in Abbas Institute of Medical Sciences Muzaffarabad and
Sheikh Khalifa Bin Zaid al nahyan Hospital Muzaffarabad based on multistage sampling technique. A
structured close ended questionnaire was used to collect the information from the respondents. Questionnaire
were distributed randomly to well trained staff nurses who collected the information from the respondents
visited in hospitals. Data was analyzed using SPSS version 13.
III.
Results and Discussion
As discussed earlier that sample size of 400 respondents were selected for the current study.
Table 1. Feedback of the respondents about the knowledge about hepatitis B and C.
Age
Gender
15-20
21-26
27-31
>31
Total
male
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Frequency
61
140
123
76
400
257
Percentage
15.3
35.0
30.8
19.0
100.0
64.3
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
Area
Marital Status
Education
Knowledge about Hepatitis B and C
How to screen hepatitis B and C
History of liver disease?
History of ear piercing
History of tattoo
History of surgery
History of dental treatment
Do you have blood transfusion ever?
Can hepatitis B and C spread through reusing of syringes?
Can hepatitis B and C spread through
affected mother to child?
Can hepatitis B and C spread through prick
of ear and nose?
Can hepatitis B and C spread through sexual
relation with affected person?
female
Total
urban
rural
Total
Married
Unmarried
Divorced
Total
Primary
Secondary
Graduate
post graduate
Total
Yes
No
don’t know
Total
blood test
sputum test
Total
yes
no
Total
yes
no
Total
yes
no
Total
yes
no
Total
yes
no
Total
yes
no
Total
Yes
No
don’t know
Total
Yes
No
don’t know
Total
Yes
No
don’t know
Total
Yes
No
don’t know
Total
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143
400
202
198
400
214
162
24
400
105
161
100
34
400
258
82
60
400
349
51
400
148
252
400
148
252
400
89
311
400
165
235
400
211
189
400
127
273
400
208
87
105
400
183
91
126
400
192
91
117
400
181
95
124
400
35.8
100.0
50.5
49.6
100.0
53.5
40.5
6.1
100.0
26.3
40.3
25.0
8.5
100.0
64.5
20.5
15.0
100.0
87.3
12.8
100.0
37.0
63.0
100.0
37.0
63.0
100.0
22.3
77.8
100.0
41.3
58.8
100.0
52.8
47.3
100.0
31.8
68.3
100.0
52.0
21.8
26.3
100.0
45.8
22.8
31.5
100.0
48.0
22.8
29.3
100.0
45.3
23.8
31.0
100.0
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
Have you ever suffered from Hepatitis B
and C?
No
yes
Total
Yes
No
don’t know
Total
Yes
No
don’t know
Total
Is it possible to save from hepatitis B and C?
Is there any treatment available for hepatitis
B and C?
207
193
400
221
63
116
400
142
80
178
400
51.8
48.3
100.0
55.3
15.8
29.0
100.0
35.5
20.1
44.5
100.1
The above table 1 shows that out of 400 respondents 61 were in the age group 15-20 years,while others
140 were in the age group 21-26 years,123 were in the age group 27-31 years, and 76 were in the age group >31
years. 15.3 % were in 15-20 age group, 35.0% were in 21-26 age group, 30.8% were in 27-31 age group and
19.0% >31 age group. Majority of respondents were in the age group 21-26 years. In this study, 64.3%
respondents were male and 35.8% were female. 50.5% of the respondents were from rural area and rest of the
respondents were from urban A study by Ahmad et al. [7] revealed the frequency of HBV and HCV amongst
urban and rural population was 45% and 55%, respectively. Out of 400 respondents, 214 (53.5%) respondents
were married, majority of the respondents (40.3%) were having secondary education, 26.3% were primary
educated, 25.0% were graduate and rest of the respondents were post-graduate (8.5%). Majority of respondents
258 (64.5%) had knowledge about Hepatitis B and C and 87.3% knew that hepatitis B and C is detected by
blood test. Out of 400 respondents, 63.0% had no family history about hepatitis and majority of (43.3%)
respondents get shave at their home and 28.5% get shave from barbers. History of piercing (63.0%) and tattoo
(77.8%) was not found in majority of the respondents while history of surgery was found in 41.3% of the
respondents and 58.8% have no history of surgery. On the other hand, 52.8% get dental treatment and 47.3% did
not have dental treatment ever. Majority of respondents 68.3% were in favor that hepatitis can be transmit
through blood transfusion while 52.2% were in favor that hepatitis can be transmit through re-using of syringes.
45.5% respondents knew that hepatitis can be transmitting through effected mother to child while 31.5% have
no idea about that. Similarly, 45.3% were in favor that hepatitis can be transmit through having sex with
effected person while 31.0% have no idea about this risk factor. 55.3% of the respondents were agreed that it is
possible to save from hepatitis by adopting precautionary measures and treatment. 35.5% knew that there is
treatment available for hepatitis (see table 1).
Table 2. Prevalence of Hepatitis B and C in the presence of different risk factors
Variables
Age
d.f
Odds ratio
2.621
1.344
1.005
1
0.856
1
.751
1
0.438
0.850
1
0.728
0.973
0.688
1
p-value
0.055
0.028
0.011
95% C-I
lower
0.978
0.647
0.491
Upper
7.024
2.793
2.054
0.019
0.312
2.346
0.041
0.441
1.278
0.001
0.049
0.139
0.260
1.379
2.776
0.001
0.000
0.021
0.253
0.371
0.263
2.093
2.553
1.805
15-20
21-26
27-31
>31(r)
Male
Female(r)
Urban
Rural (r)
Married
Unmarried
Divorced(r)
Primary
Secondary
Graduate
Post graduate(r)
1
1
1
Knowledge about hepatitis B
and C
Yes
No
Don’t know(r)
1
1
1.412
1.547
1
0.000
0.007
0.639
0.664
3.122
3.603
History of ear piercing
Yes
No(r)
1
1.401
1
0.011
0.747
2.626
Sex
Area
Marital status
Education
1
1
1
1
1
1
1
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
Re-use of syringes
Yes
No
Don’t know(r)
1
1
1.250
2.498
0.012
0.030
0.650
1.170
2.401
5.333
Affected mother to child
Yes
No
Don’t know(r)
1
1
1.126
0.611
1
0.012
0.030
0.650
1.170
2.401
5.333
Prick of ear and nose
Yes
No
Don’t know(r)
1
1
1.718
0.928
1
0.016
0.041
0.562
0.297
2.255
1.258
Sexual relation with affected
person
Yes
No
Don’t know(r)
1
1
3.943
1.877
1
0.015
0.023
0.884
0.451
3.339
1.911
Affected blood
Yes
No
Don’t know(r)
1
1
1.384
1.449
1
0.032
0.040
1.990
0.917
7.812
3.840
Table 2 shows the results of multiple logistic regression model with odd ratios and their 95%
confidence interval. The logistic regression model was used to check the significant risk factors of hepatitis B
and C. In which we considered have you ever suffer in hepatitis Band C as binary response variable (yes or no)
and the remaining variable such as age, sex, area, marital status, education, knowledge about hepatitis, history of
ear piercing, re-use of syringes, affected mother to child, prick of ear and nose, sexual relation with affected
person and affected blood were considered as independent variables.
It was observed that the peoples in the age group 15-20 years were 2.621 times more likely to have
hepatitis B and C than the peoples whose age group was >31 years, similarly the people whose age group 21-26
years were 1.344 times more likely to have hepatitis B and C than the people whose age group was >31 years.
Similarly the peoples whose age group 27-31 years were 1.005 times more likely to have hepatitis B and C than
the people whose age group was >31 years and the 95% confidence interval for the odds ratio of the age group
15-20 years,21-26 years and 27-31 years was also calculated and the limits for the age group 15-20 years were
0.978 to 7.024 and its p-value was 0.055 and limits for age group 21-26 years were 0.647 to 2.793 and its pvalue was 0.028 similarly for age group 27-31 years were 0.491 to 2.054.and its p-value was 0.011.it is
observed that male were 0.856 times fewer chances to have hepatitis B and C than the female and the 95%
confidence interval for the odds ratios were 0.312 to 2.346. its p-value was 0.019 p-value is less than level of
significance 0.05, it shows significant results. The prevalence of hepatitis B surface antigen and anti-HCV
antibody was high in patients below 50 years of age [10]. results of the study conducted by Abel the prevalence of
HBV was highest, 16/26 (61%) in the age group of 28–37 years but none (0%) in age groups above 68 years.
More urban dwellers, 34 (28.3%) were HBsAg positive than rural dwellers, 9 (7.5%). Married patients had
prevalence of 23 (19.2%), single were 15 (12.5%) and widows, 3 (1.7%).
It is observed that married peoples had 0.438 times less chances to have a hepatitis B and C as
compared to divorced people, similarly unmarried people had 0.850 times less chances to have hepatitis B and C
as compared to divorced peoples and 95% confidence interval for married people was 0.139 to 1.379 and its pvalue was 0.011 and for unmarried people was 0.260 to 2.776 and its p-value was 0.049 the p-value is less than
level of significance it shows significant results.
It was also observed that people who live in urban area have 0.751 times less chance to have hepatitis B
and C as compared to the people who live in rural area.95% confidence interval for odds ratios of urban area
was 0.441 to 1.278.and its p-value was 0.041. Hepatitis infection in urban population may be due to the nature
of living in which urban areas are densely populated as compared to rural areas and this might expose urban
dwellers for different risk factors. The sociodemographic characteristics have not been significantly associated
with acquisition of infection except history of dental extraction at health facility in HCV infection [10].
It was also observed that people having primary education were 0.728 times less chances to have
hepatitis B and C as compared to post graduate peoples, similarly the peoples who have secondary education
were 0.973 times less chances to have hepatitis B and C as compared to post graduate and the respondents who
have graduate education were 0.688 times less chances to have hepatitis B and C.95% confidence interval for
primary educated people were 0.253 to 2.093 and its p-value was 0.001 ,for secondary educated peoples were
0.371 to 2.553 and its p-value was 0.000 and for graduated people were 0.263 to 1.805.and its p-value was
0.021.
It was also observed that people who said yes that they aware about hepatitis have 1.412 times more
knowledge about hepatitis as compared to the people who don’t know about knowledge of hepatitis, similarly
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
the people have 1.547 times more likely to have knowledge about hepatitis as compared to the people who don’t
know about the hepatitis.95% confidence interval for those have knowledge about hepatitis were 0.639 to 3.122
and its p-value was 0.000 and for those have no knowledge about hepatitis were 0.664 to 3.603.and its p-value
was 0.007. The respondents having history of ear piercing were 1.401 times more likely to have hepatitis as
compared to those having no history of ear piercing and 95% confidence interval for those have history of ear
piercing was 0.747 to 2.626 and its p-value was 0.011 and p-value is less than level of significance it shows
significant results.
It was observed that hepatitis B and C spread 1.250 and 2.498 times more likely through re-use of
syringes as compared to those who don’t know whether it is spread through re-use of syringes, and 95%
confidence interval was 0.650 to 2.401 and 1.170 to 5.33 respectively.
The risk of Hepatitis B and C spread 1.126 times more likely through affected mother to child as
compared to those who don’t know whether it is spread through affected mother to child, and 95% confidence
interval was 0.562 to 2.255 and its p-value was 0.016 and for those who say it is not spread through affected
mother to child were 0.297 to 1.258.and its p-value was 0.041. Hepatitis B and C spread 1.718 times more likely
through prick of ear and nose as compared to those who don’t know about whether it is spread through prick of
ear and nose and 95% confidence interval was 0.884 to 3.339 and its p-value was 0.015and for those who say it
is not spread through prick of ear and nose was 0.451 to 1.911and its p-value was 0.023.
It was also observed that hepatitis Hepatitis B and C spread 3.943 and 1.877 times more through
sexual relation with affected person as compared to those who don’t know whether it is spread through sexual
relation with affected person and 95% confidence limits were 1.990 to 7.812 and 0.917 to 3.840 respectively.
The risk of hepatitis spread 1.384 and1.449 times more likely through affected blood as compared to
those who don’t know whether it is spread through affected blood and 95% confidence interval was 0.714 to
2.680 and 0.711 to 2.954 respectively.
Table 3. Results of Chi-square test for association of blood transfusion with different variables.
Variables
Blood Transfusion* Is hepatitis B and C spread through re-use of
syringes
Blood Transfusion*any family member have liver disease
Blood Transfusion* History of ear piercing
Blood Transfusion* history of tattoo
Blood Transfusion*history of surgery
Blood Transfusion*history of dental treatment
Blood Transfusion*effected mother to child
Blood Transfusion*prick of ear and nose
Blood Transfusion*sexual relation with affected person
Blood Transfusion*through affected blood
Chi-square value
21.330
9.999
1.210
10.392
10.640
1.163
7.471
5.736
10.34
10.37
p-value
0.000
0.007
.546
0.006
.031
.884
0.113
.220
0.010
0.012
To check the association of blood transfusion with different variables the chi-square test was applied.
Results showed that high risk variables are strongly associated with blood transfusion such as hepatitis spread
through re-use of syringes, any family member have liver disease, tattoo making, sexual relationship with
affected person and through affected blood with p value <0.05 the level of significance (see table 3).
Table 4. Results of Mann-Whitney U test with gender and area of the respondents.
Knowledge about
Hepatitis B and C
Knowledge about
Hepatitis B and C
Male
Female
Rural
Urban
No
Mean Rank
257
143
202
198
190.32
218.79
195.10
206.01
Sum
of
Rank
48912.50
31287.50
39410.00
40790.00
Value Mann-Whitney
U Test
15759.500
p-value
18907.00
.266
.005
Mann-Whitney U test was also applied (see table 4) to investigate the knowledge about Hapatitis B and
C among male and female of the rural and urban area. It was concluded that there is difference between male
and female regarding knowledge about hepatitis B and C with value of u is 15759.500 and p-value is 0.005
which is less than level of significance. On the other hand, value of u is 18907.000 and p-value is 0.266 which is
greater than level of significance and we conclude that there is no difference between rural and urban areas
regarding to knowledge about hepatitis B and C.
Kruskal-Wallis H test was also applied to investigate the knowledge of hepatitis B and C among
education level of the people (see table 5). It has been observed that the knowledge about hepatitis among the
highly educated is more then the respondents having primary and secondary education with p-value 0.000 which
is less then level of significance.
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
Table 5. Result of Kruskal-Wallis H test with education of the respondents.
Knowledge about
Hepatitis B and C
Education
Primary
Secondary
Graduate
Post Graduate
No
105
161
100
24
Mean Rank
233.69
211.36
160.68
163.68
p-value
0.000
IV.
Summary and Conclusions
The objective of the present study were to investigate the risk factor of hepatitis among the people of
Azad Jammu & Kashmir Muzaffarabad and also to check the prevalence of hepatitis B and C in the presence of
different risk factors. Respondents from rural and urban area almost have same knowledge about hepatitis B and
C. There was difference between male and female respondents about knowledge and awareness about hepatitis
B and C. It is concluded from the study that educated people have more knowledge about hepatitis B and C as
compared to uneducated people . It was also observed that Tattoo making, un-safe sex or sex with affected
person, re-use of syringes and un screened blood transfusion are the major risk factor of hepatitis B and C.
Proper sterilization of dental and surgical instruments must be carried out. To prevent the spread of
HBV and HCV, people must be educated about these infections and modes of transmission [10]. Mass media
campaigns should be started to raise the awareness among people about hepatitis B and C. Government should
start the awareness programs and project to combat this major threat. Clinicians particularly gastroenterologist,
hepatologists and other medical and practitioners should be made aware of the danger of twin infection [12].
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
Muhammad Arif Mahmood, Shireen Khawar, Abdul Hameed Anjum, Siraj Munir Ahmed, Shahid Rafiq, Imran Nazir, Muhammad
Usman. “Prevalence of Hepatitis B, C and HIV infection in blood donors of Multan region”. Ann King Edward Med Coll. Oct - Dec
2004; 10 (4): 459-61.
Malik IA, Kaleem SA, Tariq WUZ. “Hepatitis C infection. Where do we stand?” (Editorial) J College of Physcians and Surgeons
Pakistan 1999; 9 (4): 234-37.
Z. Liu and J. Hou, “Hepatitis B virus (HBV) and hepatitis C virus (HCV) dual infection,” International Journal of Medical Sciences,
vol. 3, no. 2, pp. 57–62, 2006.
Khuwaja AK, Qureshi R. “Knowledge and Attitude about Hepatitis B and C among patients attending Family Medicine Clinics in
Karachi”. Eastern Mediterranean Health J 2002; 8(6): 1-6.
Kumar A, L. Saima. “Screening of B and C among People Visiting General Practice Clinics in Rural Dist. Of Sindh, Pakistan”. J
Ayub Med Coll Abbotabad 2010; 22(4).
"Hepatitis B Vaccine Loses Effectiveness in Older Adults." Vaccine Weekly January 29, 2003: 23.
I. Ahmad, S. B. Khan, Rahman, H. u, M. H. Khan, and S. Anwar, “Frequency of hepatitis B and hepatitis C among cataract
patients,” Gomal Journal of Medical Sciences, vol. 4, pp. 61–64, 2006.
Abou,M.A, A.,Eltahir, Y.M. & Ali,A.S. (2009). “Seroprevalence of hepatitis B and C virus among blood donors in Nayla, South
Dar Fur,Sudan”,Virology Journal,6,146.
E. R. Charles, R. Fanjansoa, R. Maherisoa, R. Vaomalala, R. Richter, R. Rindara, et al.,“Seroprevalence of hepatitis C and
associated risk factors in urban areas of Antananarivo, Madagascar,” BMC Infectious Diseases, vol. 8, article 25, 2008.
Ayele G.A; “Prevalence and Risk Factors of Hepatitis B and Hepatitis C Virus Infections among Patients with Chronic Liver
Diseases in Public Hospitals in Addis Ababa Ethiopia” ISRN Tropical Medicine 2013.
P. Pasquini, L. Bisanti, L. Soldo et al., “Hepatitis B infections in the Arsi region of Ethiopia,” European Journal of Epidemiol ogy,
vol. 4, no. 3, pp. 310–313, 1988
Khan A U, “True Prevalence of twin HDV-HBV Infection in Pakistan: A Molecular Approach” Virology gournal 2011, 8:420.
Appendix
Questionnaire
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Age
a. 15-20
b. 21-26c. 27-31 d. >31
Sex
a. Male
b. Female
Area
a. Rural
b. Urban
Marital Status
a. Married
b. Unmarried
c. Divorced
Education
a. Primary
b. Secondary
c. Graduate d. Post graduate
Knowledge about Hepatitis B and C
a. Yes
b. No
How to screen the Hepatitis B and C?
a. Blood Test
b. Sputum
History of liver disease?
a. Yes
b. No
History of ear Piercing?
a. Yes
b. No
History of tattoo?
a. Yes
b. No
History of surgery?
a. Yes
b. No
History of dental treatment?
a. Yes
b. No
Do you have any blood transfusion ever?
a. Yes
b. No c. Don’t know
Can hepatitis B and C spread through re-using of syringes?
a. Yes
b. No c. Don’t know
Can hepatitis B and C spread through affected mother to a. Yes
b. No c. Don’t know
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A Statistical study Regarding Knowledge and Risk Factors of Hepatitis B and C in Muzaffarabad
child?
16. Can hepatitis B and C spread through prick of ear and nose?
17. Can hepatitis B and C spread through sexual relation with
affected person?
18. Have you ever suffered from Hepatitis B and C?
19. Is it possible to save from hepatitis B and C?
20. Is there any treatment available for hepatitis B and C?
www.iosrjournals.org
a.
a.
Yes
Yes
b. No
b. No
c. Don’t know
c. Don’t know
a.
a.
a.
Yes
Yes
Yes
b. No
b. No
b. No
c. Don’t know
c. Don’t know
62 | Page
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