RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

BANGALORE, KARNATAKA

PERFORMA FOR SUBMISSION OF SUBJECT FOR DISSERTATION

MS. SARIGA PRASANNAN

M Sc. NURSING FIRST YEAR

PEDIATRIC NURSING

2012-2014

INDIAN ACADEMY COLLEGE OF NURSING

HENNUR CROSS, HENNUR MAIN ROAD,

KALYAN NAGAR

BANGALORE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : MS. SARIGA PRASANNAN

2. NAME OF THE INSTITUTION : INDIAN ACADEMY COLLEGE OF NURSING,

HENNUR CROSS, HENNUR MAIN ROAD,

KALYAN NAGAR,

BAGALORE-560043

3. COURSE OF STUDY & : 1ST YEAR M Sc. NURSING,

SUBJECT PEDIATRIC NURSING

4. DATE OF ADMISSION : 11.06.2012

COURSE

5. TITLE OF THE TOPIC : A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE AND ATTITUDE REGARDING TOILET TRAINING PROGRAM OF TODDLERS AMONG PRIMIPARA MOTHERS AT SELECTED HOSPITALS IN BANGALORE

6. BRIEF RESUME OF INTENDED WORK

6.1. INTRODUCTION.

“The child is not like an artesian well, where we put a funnel and water will gush out. How is like a bank, where something must be put before we expect to draw out”

-Mahatma Gandhi.

Toilet training is a developmental task that impacts families with small children. All healthy children are toilet trained and most complete the task without medical intervention. Many parents are unsure about when and what is the best way to start toilet training or potty training. Not all kids are ready at the same age, so it is important to watch the child for signs of readiness, such as stopping an activity for a few seconds or clutching his or her diaper1.

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 life2.

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 control3.

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 case4.

The American Academic of Paediatric (AAP) guidelines strongly suggest a child-oriented approach to toilet training and that parents do not pursue toilet training until the child is behaviorally, developmentally, and emotionally ready to begin. The guidelines recommend that parents and pediatricians discuss toilet training methods and expectations at the child's 12- to 18-month visits. At the 2-year visit, the pediatrician is able to assess the readiness of the child and parents5.

Different cultures have different methods of toilet training and distinct expectations about when bladder and bowel control should be achieved. Successful toilet training is good for parents and for children. The majority of parents, even those who are better informed, have inappropriate expectations with relation to the age at which toilet training should be completed.6

Parents or care giver play a key role in normal behavioral pattern on toilet training. The way in which the parents on care giver approach the process of toilet training are more important than the actual procedure itself. Their relaxed and positive attitude and behavior can influence the way child feel about themselves and others. 6 The correct knowledge and awareness among parents or caregiver is very essential for the success of the child. Sometimes they may have either inadequate or inappropriate knowledge regarding initiation, readiness process and hazards of toilet training. For the total success in each child parents should be aware of proper guidelines. To avoid hazards and to learn normal behavioral pattern, at primary level health professionals especially nurses can provide the perspective needed to help children, parent and care givers, so as to build healthier life and personality7

Toilet training is a developmental milestone and is a challenge to parents and children. It is one of the first steps that children take to become self-sufficient. All children will manage to acquire the necessary control eventually, but the difficulty involved is a major concern for parents and causes conflicts within the family8

6.2 NEED FOR THE STUDY

Parents have an important role in the toilet training of the children. Toilet training is mainly the work of parents. They have many responsibilities in toilet training their child such as identifies the readiness of the toddler, provision of potty, establishing a regular pattern of toilet training, reacting in a calm and quiet way if the child has an accident and finally should be knowledgeable about different steps of toilet training. Fathers and mothers are the primary care givers of the children. So they have an important role in toilet training. But studies reveal that they have only a little knowledge about the toilet training aspects of their children.9

Need in India

A child learns to use toilet is one of the pivotal milestone of development, it is necessary to adapt to the social and cultural values of the environment. A healthy bladder and bowel movement habit are important for healthy functioning of the body. Late toilet training may lead to dysfunctional elimination. Toilet training should start only after the child must be both physically and emotionally ready for toilet training. According to psychosexual theory by Sigmund Freud the correct time to start toilet training is toddler period especially 18-24 months. Toilet training usually becomes a long and frustrating process if we try to start it before the child is ready.10

A descriptive study on ‘the knowledge and practices regarding the toilet training among mothers of preschool children in selected urban community at Bangalore city’ was conducted at Bangalore. The samples were 60 mothers having preschool children at Mahalakshmipuram, Bangalore. The data was collected using a structured questionnaire. The results shows that only 59.7% of mothers are knowledgeable about toilet training and among them only 52.2% mothers are giving toilet training to their children. The researcher summarizes that there exists inadequate knowledge and practice among Mothers11.

Human excreta are source of infection and it is an important cause of environmental pollution. The health hazards of improper excreta disposal are soil pollution, water pollution contamination of foods and propagation of this that leads to diseases like paratyphoid, and typhoid fever, dysentery, diarrhea, cholera, hook worm disease, ascariasis, viral hepatitis and similar other intestinal infections and parasitic infections. So prevention of this hazards required proper training for the excreta disposal from childhood itself that is, toilet training at the appropriate time.12

Need in world wide

Children learn to care for themselves initially by attempting to imitate the action of their parents and siblings. Achieving control of the bodily functions of defecation and urination is one of the major tasks of the early childhood. The control of bladder and bowel functions involves a complex integration of neuromuscular pathways at the peripheral and central levels. The 50% of the girls and boys are toilet trained at 35 and 39 month respectively.13

World wide, the incidence of behavioral problem on toilet training like Enuresis and Encopresis (with some disease condition) is 15% and 12.6%. The incidence of female child is 60% and in male child 90% In India, there are about 65,600 creche are present and per year 24,900 children put in the crèche. The incidence of Enuresis and Encopresis is 18.6% and 4%. A positive family history of enuresis was in 28.57% children in Mumbai-2007. In Karnataka, there are 12,000 creche are present & per year 580 children have been put in the crèche, in Bangalore. The prevalence of Enuresis & Tempertantrum with Enuresis is 12% and 75.3% in Bangalore.14

A study on Enuresis is manifested as the repetitive and inappropriate passage of urine. The voiding may be voluntary or involuntary. A minimum chronological age of 3 years and minimum mental age of 4 are regarded. There is sharply decreasing prevalence up to age 4 and gradually declines there after 82% of 2 years old, 49% of 3 years old, 20% of 4 years old, 7% of 5 years old, 3% of 10 years old and 11% of 19 years old are enumerate. Most children are toilet trained by age of 30 months, although 2% to 10% of children are not toilet trained by age of 4 years. Problems of toilet training have become a common behavioral concern for parents of school going children. 15

A study on bowel control is estimated to be more than 95% of children by fourth birthday & 99% of children by fifty birthday frequently decrease to virtual absence by age sixteen. At age four the functional encopresis at all ages is 3 – 4 times as common in boys as in girls by age 7 to 8, frequency is 2.3% in boys and a 7% in girls by age 10 – 12, once in a month soiling occurs in 1.3% of boys and in 0.3% in girls.16

These studies and observation of practice of parents makes the investigator understands the fact that it is important to check the parents knowledge and give them health education for proper toilet training of the toddlers. Keeping these aspects in mind, the investigator felt the need to assess the knowledge on toilet training. Education will help to improve their knowledge. So the investigator planned to conduct a pre-experimental study.

6.3 REVIEW 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 Polit Hungler (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.17

Investigator organised review of literature under following headings

SECTION –I Literature related to toilet training

SECTION –II Literature related to toilet training problems

SECTION-III Literature related to toilet training method

SECTION –IV Literature related to knowledge and attitude of mothers in toilet training

SECTION –I LITERATURE RELATED TO TOILET TRAINING

A longitudinal study was conducted by Mota M Denise, Barros J.D , Aluiseo in 2008 on ‘Toilet training situation at two years of age in a birth cohort’ at Japan .The samples were 3281 children’s mothers at 24 months of age. The data was collected using questionnaire which contained questions about socio demographic data and characteristics of their children’s urinary & intestinal evacuation habit with special attention to ‘Toilet Training’. The result shows that 85.5% of children show four or more abilities needed for toilet training at 24 months of age .Among the mothers42% of successfully completed toilet training of their children at 24 months of age. Only 10.2% of them received medical advice.58% of cases were unsuccessful. The researchers reaches the conclusion that child is ready to be trained and should be instructed by their parents, who should in turn guided by trained professionals18.

A descriptive study on ‘Sequential acquisition of toilet-training skills: gender and age differences in normal children’ was conducted by Schum TR, Kolb TM, Mc Auliffe TL, Simms MD, Underhill RL, Lewis M on march 2008 at London .The samples for the study was 121 boys & 146 girls of 12 to 16 months & their parents. The data was collected using a longitudinal survey. Result shows that in this study population, girls achieve nearly all toilet-training skills earlier than boys, including successful completion of toilet training. That is 95% girls show an interest in using potty at 24 months, &indicating need to go to bathroom at 26 months Majority (68%) of boys showing an interest in using the potty at 26 months& indicating a need to go to the bathroom, at 29 months.19

A cohort study was conducted by Bakker etal., US, (2009) analyzed the effects of early and late toilet training of 378 children, found that toilet training was completed at a mean of 36.8 (range 22 to 54 months). Late toilet training (at least 42 months of age) was associated with a later mean age of initiating toilet training, lower language score at 18 months, stool toileting refusal, increased constipation, and hiding during toilet training. He concluded that training children at a younger age, that is, between the ages of 18 and 26 months, resulted in a longer training duration; however, there were no adverse events (constipation, stool toileting refusal, stool withholding, or hiding during training) associated with early training.20