Mr. Mallappa Arabhavi

MR. MALLAPPA ARABHAVI

1ST YEAR M.Sc. NURSING

CHILD HEALTH NURSING

2010-11

SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE,

B.H. ROADTUMKUR- 572102

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKABANGALORE

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / MR. MALLAPPA ARABHAVI
I YEAR M.SC NURSING
SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, TUMKUR-572 102.
2. / NAME OF THE INSTITUTION / SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, TUMKUR.-572 102.
3. / COURSE OF STUDY AND SUBJECT / MASTER OF SCIENCE IN NURSING
CHILD HEALTH NURSING
4. / DATE OF ADMISSION TO THE COURSE / 10TH JUNE 2010.
5 / STATEMENT OF THE PROBLEM / “ A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE AND PRACTICE REGARDING TOILET TRAINING AMONG THE MOTHERS OF EARLY CHILDHOOD CHILDREN (17 TO 30 MONTHS) IN SELECTED RURAL AREA AT TUMKUR DISTRICT’’.

6.0 BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION:

All the stages in human life are exposed to challenges, difficulties and success as a gain. One such stage is the toddler period. It is the magical time of childhood. It is a different exciting and interesting period of life. [1]

Achieving control of the body function of defecation and urination is one of the major tasks of the toddler period. Relative importance of this achievement depend on the culture and the socioeconomic status of the child family Toilet control over defecation and urination are two personal phases of toddler learning closely revealed to their sensory and motor control.[2]

Fundamental learning process develop in the child as the child begins to seek autonomy explores the world. It learns how things mostly begin to tolerate, express desires and develop relationships. [3]

Toilet training is often taken for granted because it appears to occur so readily in such a large majority of children. It would be easy to hypothesize some internal mechanism which, if triggered at the right point in time, results in the initiation of a preprogrammed process that terminates with the child being trained. Variations across cultures regarding the age at which children are trained, the multitude of training procedures used by parents, and the variety of problems encountered during toilet training suggest that such is not the case.[3]

There is a window of learning open from birth until about 4-5 months. During this sensitive period, babies are very aware of elimination. They attempt to communicate, but mothers watch and listen since they have not taught them how to do so. The basics of infant toilet training involve learning your infant's elimination body language, timing and patterns, and/or instinctively knowing when your baby needs to go. [2]

In India many mother starts toileting their babies around 1 month old and finish before their babies walk. At that time, babies still need some assistance since they can't dress or walk, but mothers there don't consider these things to be a big deal. Staying clean and dry, giving signals, and responding to cues is what it is all about. Once babies can crawl, they typically head for the bathroom door when they need to go, and mothers are delighted to help with the rest. [2]

There are, of course, many different ways a baby can communicate the need to go, including body language, vocalizations, imploring looks, pointing and eventually sign language and verbalizations. Some babies may give obvious signals for one kind of elimination but not the other. In situations where your infant's signals are not clear, you may need to rely on timing, elimination patterns, body language, intuition or a combination of these. [2]

Toilet training has not been the focus of extensive systematic research as incontinence appears to impose no immediate or uncompromising physical threat to the child. The apparent insensitivity to the emotional and psychological discomfort is perhaps highlighted by cavalier attitude regarding the necessity of treating the younger (6 to 10 year old) child. Enuresis takes on added significance to the extent that it seems to be the symptom of some underlying neurologic or urologic abnormality. Once the enuresis is determined to be functional in nature, one can be satisfied with allowing the children and family to deal with the matter on their own and to return if the problem persists into adolescence. If treatment is begun at an early age, it seems to have a greater chance of success with fewer complications. It need not be particularly time-consuming once an adequate assessment has been carried out. Nurses, paraprofessionals, mental health technicians, and so forth, can be trained.

6.2 NEED FOR STUDY:

Toilet training is an essential issue in child education, and its completion represents a developmental milestone. The last 40 years the Western medical community has recommended to start toilet training after 18 months of age. As currently practiced, assisted child toilet training emphasizes child-caregiver communication for the gradual acquisition of bowel and bladder control. Signals emitted by the child lead the caregiver during elimination assistance.

The process of toilet training children has received surprisingly little attention in the medical research literature, and many parents may welcome guidance from their physician on how best to carry out this important parental duty. Theory and prescription for toilet training in the United States since 1900 has traced a pendulum's path between the polar opposites of passive permissiveness and systematic control. Since midcentury, the trend in the United States has been toward delayed toilet-training, typically between the child's second and third year. Like all trends, however, this one may reverse. Given children's developmental differences, a new trend toward early toilet training, if it emerges, may be accompanied by an increase in toilet-training problems. If so, physicians who advise parents and treat pediatric populations may wish to become more familiar with data-based behavioral management of toilet training and the implications of this approach for early toilet training and the treatment of toileting-refusal behavior. [4]

Toilet training is a developmental task that impacts families with small children. All healthy children are eventually toilet trained, and most complete the task without medical intervention. Most research on toilet training is descriptive, although some is evidence based. In the United States, the average age at which training begins has increased over the past four decades from earlier than 18 months of age to between 21 and 36 months of age. Newer studies suggest no benefit of intensive training before 18 months of age. Mastery of the developmental skills required for toilet training occurs after 24 months of age. Girls usually complete training earlier than boys. Numerous toilet-training methods are available. The Brazelton child-oriented approach uses physiologic maturity, ability to understand and respond to external feedback, and internal motivation to assess readiness. Dr. Spock's toilet-training approach is another popular one. [5]

The study was conducted on the prevalence and associations of enuresis and encopresis in children in Kerala, The parents of 1403 randomly selected 8-12-year-old children were interviewed. The prevalence of enuresis and encopresis was ascertained using Rutter's A2 scale. Subsamples of children underwent psychiatric, physical and psychometric evaluations.Of the children, 18.6% had an episode of enuresis in the past year and 4.3% in the past week. Four per cent had an episode of encopresis in the past year.[6]

The American Academy of Pediatrics incorporates components of the child-oriented approach into its guidelines for toilet training. "Toilet training in a day," a method by Azrin and Foxx, emphasizes operant conditioning and teaches specific toileting components. Because each family and child are unique, recommendations about the ideal time or optimal method must be customized. Family physicians should provide guidance about toilet-training methods and identify children who have difficulty reaching developmental milestones.[7]

A study was conducted to determine if later toilet training is associated with urge incontinence in children.The Investigators used a case-controlstudy design to yield level 2 evidence. Initiation of toilet trainingafter 32 months of age was associated with urge incontinence (P=0.02).Further study suggests that for children who display signs of toilet-training readiness, trainingshould be initiated prior to 32 months of age to reduce the risk for urgeincontinence.[8]

A cross-sectional study was conducted to examine racial and socioeconomic differences in parental beliefs about the appropriate age at which to initiate toilet training. Total 779 parents visiting child health providers in 3 clinical sites in Washington, DC and the surrounding metropolitan were included. Using multiple linear regressions, differences in beliefs were assessed in relation to race, family income, parental education, parental age, and age of the oldest and youngest children. Results found that among respondents, parents felt that the average age at which toilet training should be initiated was 20.6 months (+/-7.6 months), with a range of 6 to 48 months. Caucasian parents believed that toilet training should be initiated at a significantly later age (25.4 months) compared with both African-American parents (18.2 months) and parents of other races (19.4 months). Conclusions were, race and income were independent predictors of belief in age at which to initiate toilet training. More research is needed to determine what factors contribute to toilet training practices in populations.[9]

The above studies reflects that there are many factors associated with child toilet training, and delaying of toilet training over 2 years may interfere with acquisition of bladder control and increase frequency of day time wetting.

The investigator’s personal experience during his BSc community posting, many mothers did not know at what age and how to initiate toilet training to their children, so these all factors made investigator curious to evaluate the mothers knowledge and practices on toilet training their children.

6.3REVIEW OF LITERATURE.

Review of literature is a key step in the research process. It refers to an extensive, exhaustive and systematic examination of publications relevant to research. A literature review helps to lay the foundation for a study and can also inspire new research ideas. It can help with orientation to what is known and not known about an area of inquiry, to ascertain what research can best make a contribution to the existing base of evidence.

According to PolitHungler (1999) review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in context or to identify gaps and weakness on previous studies to justify a new investigation.[10]

A randomized controlled study was conducted to evaluate, the use of a daytime wetting alarm in a day-care center during three consecutive weeks in healthy children. Thirty-nine healthy young children, between 18 and 30 months old, were selected at random for a wetting alarm diaper training (n = 27) or control wearing a placebo alarm (n = 12). Toilet behavior was observed during a period of 10 hr by independent observers before, at the end of, and 2 weeks after training. Children in the wetting alarm diaper training group achieved independent bladder control in 51.9% and did significantly better than in the control group (8.3%) (P = 0.013). The results were sustained during the following 14 days (P = 0.013).The wetting alarm diaper training is an effective option for toilet training young healthy children in a day-care center.[11]

A study was conducted to determine the prevalence of diurnal enuresis and its association with background variables among children aged 5-15 years living in Sivas and Kahramanmaraş, Turkey. The parents of 1,760 children voluntarily completed a questionnaire consisting of 42 items under supervision of a researcher. Smoking during pregnancy, delayed initiation and dealing with the child by punishment in toilet training, urination frequency, urgency, soiling, arousal difficulty, urinary infection history, lower school performance, poor social adaptation, wetting history in the family, were all significantly prevalent among diurnal enuretics (p < 0.05).[12]

A cross sectional survey was conducted to determine the patterns of toilet training and the factors that may be related to its timing and duration and the approaches of different sociocultural groups within a developing country. 745 children who live in three different sociocultural settlements were included in the survey. Mean initiation and completion ages were 22.05 +/- 6.73, 28.05 +/- 8.40 months respectively. The infants whose mothers had an education over 12 years, completion age was later than others and the earliest completion age was seen in families who used punishment method. Mean duration needed to complete toilet training was 6.84 +/- 7.16 months. The duration of training was longer in families living in rural and semi-urban settlements, mothers educated for less than 5 years, unoccupied mothers, and children living in houses which do not have a toilet inside, families who use washable diapers and when the initiation was before the child was 18 months old. Toilet training shows differences among cultures.[13]

A study was conducted to evaluate a randomized way the comprehensive use of a daytime wetting alarm at home for 5 days in healthy children and compared it with timed potty training. Thirty-nine children, between 20 and 36 months of age, were randomized to wetting alarm diaper training (WAD-T; n = 20) or timed potty training (TP-T; n = 19). Toilet behavior was observed by parents and independent observers before, at the end, and after 2 weeks of training. Late evaluation at 1 month was done by telephone. The WAD-T group did significantly better than the TP-T group at the end training (p = .041), at 14 days (p = .027), and 1 month after training (p = .027). Independent bladder control was achieved in 88.9% of the WAD-T group.[14]

The longitudinal, population based study was conducted to describes trajectories of daytime wetting and soiling in children 4.5 to 9.5 years old. Participants consisted of a cohort of nearly 11,000 children forming part of the United Kingdom population based cohort study known as ALSPAC (Avon Longitudinal Study of Parents and Children).. Developmental variation could be adequately described by 4 trajectories for each of daytime wetting and daytime soiling. Trajectory shapes could be interpreted as normative (daytime wetting 86.2%, daytime soiling 89.0%), delayed (6.9%, 4.1%), persistent (3.7%, 2.7%) and relapsing (3.2%, 4.1. Study suggested that identification of trajectories of daytime wetting and soiling in children is an essential starting point in understanding the development of bladder and bowel control. These findings can be used to examine risk factors for the different trajectory groupings identified in the study.[15]

A study was conducted to identify temperament and behavioral patterns in children with difficult toilet training and to compare those children with same-aged toilet-trained children. The Investigators compared 46 referred clinic patients who were difficult toilet trainers (DTT) with 62 comparison children (CC) using the Carey-McDevitt Behavioral Style Questionnaire, CC were more likely to have easy temperaments (odds ratio [OR]: 33.51). DTT were more likely to be less adaptable (OR: 3.12), and lower in approach (OR: 1.85). DTT were more likely than CC to be constipated (OR: 3.52), although 55% of CC were constipated. DTT were likely to hide to stool (74%) and to ask for pull-ups in which to leave stool (37%). Although the referral population may be inherently biased, these data suggest that difficult toilet training is associated with difficult temperamental traits and constipation in affected children.[16]

The study was conducted on toilet training in first children among Parents, total 266 parents of children were queried about the process they used to toilet train their first child. Results showed that they learned the training process mostfrequently from intuition, from their parents, and from friends with smallchildren. The largest numbers of children(42.6%) were 24 to 29 months old when training began and 30.5% were 18 to 23months old. The mean ages for completion of training were between 24 and 27months.[17]

A study was conductedto evaluate the effectiveness of an intervention targeting parental behavior on stool toileting refusal. In this study population comprised 406 childrenaged 17 through 19 months from a single suburban private practice. Children were randomly assigned to receive 1 of 2 written toilet-training instructions. Follow-up telephone calls were made every 2 to 3 months, and 381 children were followed up until they developed stool toileting refusal or completed daytime toilet training. Theresults of stool toileting refusal was 23% in the control group and 26% in the intervention group (P>.10).The mean +/- SD duration was 5.2 +/- 4.9 months in the intervention group vs7.6 +/- 4.9 in the control group (P =.04) the investigator concluded that intervention did not decrease the incidence of stool toileting refusal but did shorten its duration, leading to earlier completion of toilet training.[18]

A study was conducted to determine the “toilet habits and incontinence in children”. Sample of 1192 children was assessed on basis of toilet training and elimination status by an interview and questionnaire. Toilet training age ranged from 0.75 to 5 years, with a mean of 2.4 ± 0.6 years. There was a general linear relationship between age and reported age at toilet training. (r=-0.183; P<0.01). Voiding frequency was inversely related to age. Bowel movements per week ranged from 1 to 21 with a mean of 6.8 ± 2.5. This information is useful in evaluation and toilet training of children with voiding dysfunction or constipation.[19]

6.4STATEMENT OF THE PROBLEM

“A descriptive study to assess the knowledge and practice regarding toilet training among mothers of early childhood children(17 to 30 months) in selected rural area at Tumkur district.”

6.5 OBJECTIVES OF THE STUDY

1. To assess the knowledge regarding toilet training among mothers of early childhood children.
2. To assess the practice regarding toilet training among mothers of early childhood children.
3. To correlate level of knowledge and practice regarding toilet training among mothers of early childhood children.
4. To find an association between the knowledge with selected socio-demographic variables.
5. To find an association between the practice with selected socio-demographic variables.

6.6 OPERATIONAL DEFINITIONS