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Effectiveness of health education on prevention and management of constipation in terms of knowledge among geriatric people in a Selected Old Age Home Kolkata.

INTRODUCTION: Aging is an universal, inevitable and irreversible phenomenon common to all communities and nations. (1) Constipation is an abnormal infrequency or irregular of defecation, abnormal hardening of stools that makes the passage difficulty and sometime painful, decrease stool volume and sense of incomplete evacuation after defecation. (2) One or more health related problem among elderly aged 65 and above is reported 86.1%. Constipation is the main problem/complication of the elderly. (3) Constipation is developed five time older people than the younger people. (4) Constipation negatively affects patient social and professional lives and places great economic burden on both patients and nations. (5) Approach and treatment of chronic constipation is nonpharmacological and pharmacological for elderly people. With the absence of secondary causes and medication induced causes life style changes i.e. intake of eight glass of water, eating high fiber diet like fruit, vegetable, optimal time of bowel movement preferable morning and soon after meal (6). Constipation of geriatric of geriatric people is managed by i) prevention of constipation focusing on the people who have in the risk of suffering of constipation ii) changing lifestyle and behaviour iii) pharmacological treatment iv) maintenance and prevention of recurrence. (7)

According to WHO, "health education is the development of individual, group, institutional, community and systematic strategy to improve health knowledge, attitude, skills and behavior. (8)

Health education is an important aspect of health care for elderly people to minimize the problem. It was helpful to adopt and inculcate the behavioral patterns through constant practice to prevent the occurrence of disease or reduce the effects of illnesses. (9) In the "Era of Population Aging century, (10) presently there are estimated 600 million persons aged 60 years all over the world. This may double by 2025 and two billion by 2050. According to estimation by 2021, India's elderly population will cross 137 million. Presently India has the second largest aged population in the world. (11)

The old age population is increasing proportionately in West Bengal. (12) Old age people residing old age homes to fulfill their need and care. Old age home population is increasing in India. Most of the elder people have poor health as they have a lifelong exposure to health risks, deprivation, and lack of knowledge and resources for health promotion and poor access of health services. (10) Kolkata has also joined in the WHO Global Network of age-friendly Cities and communities. (13) Effective intervention and programs are the significant cost saving health related behaviors to reduce risk and morbidity and mortality. (14) This study was to evaluate the effectiveness of develop health education program on prevention and management of constipation in terms of knowledge among geriatric people in old age home.

OBJECTIVE:

1. To assess the knowledge level on prevention and management of constipation among geriatric people before and after exposure to health education on prevention and management of constipation.

2. To determine the effectiveness of health education in terms of change in knowledge of prevention and management of constipation among geriatric people.

3. To find the association between pre-test knowledge score and selected variables, post-test knowledge score and selected variables.

HYPOTHESIS: H1: After exposure to health education program on prevention and management of constipation, the mean post-test knowledge score is higher than the mean pre-test knowledge score of the geriatric people at 0.05 level of significant. H2: There is association between pre-test knowledge score and selected variables at 0.05 level of significance. H3: There's association between posttest knowledge score and selected variables at 0.05 level of significance.

Conceptual Framework: The General System theory by Ludwig Von Bertalanffy is an appropriate and useful framework to provide interrelated concepts for systemic explanation of knowledge enhancement of geriatric people of the old age home through effective health education program on prevention and management of constipation.

MATERIALS AND METHOD: Pre-experiment research approach and one group pre-test post-test research design was adopted in this study. The study was conducted at Navanir Home for the aged, Shyam Bose Road, Chetla, Kolkata-27. Geriatric people with the confirmed age of 60 and above in the old age home was the population. Thirty geriatric people from the old age home was selected by nonprobability purposive sampling technique. An inclusion criterion of sample was geriatric people between the ages of 60 years and above who could see, move and hear effectively. Background information of geriatric people was collected by interview technique using semi structured interview schedule. Content validity and language validity was obtained of this tool.

Reliability of the tool was obtained by 100% agreement of inter-rater method. Knowledge on prevention and management of constipation of geriatric people was assessed by interview technique using structured knowledge interview schedule in two parts. Part A: all possible correct responses and part B: multiple choice questions. Content validity and language validity of the tool was obtained.

The reliability of Part A tool was computed by test-retest method and correlation coefficient obtained 0.96 by Pearson Product Moment Method. The reliability of part B tool was computed by split half method and reliability coefficient was obtained 0.83 by Spearman's Brown correlation coefficient. Health education program was developed after obtain content validity from expert.

Ethical clearance obtained from ethical committee. After obtaining permission from secretary and obtaining informed consent from all participants' demographic data and pre-test knowledge data on prevention and management of constipation was collected. Followed by pre-test, health education on prevention and management of constipation was administered. On seventh day post-test knowledge data was collected. Knowledge score interpretation: <50%-poor knowledge, 51-59%-average knowledge, >60%-good knowledge.

RESULTS: Demographic Characteristics of Geriatric People: Major participants (33%) are in the age group 65-69years, only 17% of the participants are 60-64years. The major participants (40%) are graduates and 7% are educated up to the primary level. Previous occupation of major participants (47%) was service, only 10% are businessman. The major participants (53.33%) are widows and only 10% are married. Major participants (33.33%) are cigarette addicted and only 20% are not addicted. Maximum (60%) participants are non-vegetarian and only 40% participants are vegetarian major participants (30%) are suffer from hypertension and only 30% are suffer from arthritis. Maximum participants (67%) are taking medicine and only 33% participant are not taking medicine. Among them, major (35%) participants take anti-hypertensive and 3% take diuretics.

Assess the Pre-Test and Post-Test Knowledge Score after Exposure to Health Education: In pre-test, 70% participants had poor knowledge or knowledge deficit and only 30% geriatric people had knowledge on an average to perform preventive action of constipation. 83, 33% participants had gained good knowledge and only 16.67% had average knowledge in posttest. All participants appreciable gained knowledge to perform preventive action of constipation. Maximum (70.83%) mean knowledge gained in the aspect of 'prevention of constipation and management of constipation'.

Effectiveness of health education in term of change of participant's knowledge score from pre-test to post-test. N=30

The maximum knowledge gain was occurred in 'prevention of constipation' aspect as evidence by modified gain (0.5) as well as actual mean gain (28.95) in percentage and minimum knowledge gain occurred in 'development process of constipation ' aspect as per modified gain (0.13) as well as actual mean gain (7.78) in percentage.'

N=30

The pre-test knowledge score ranges from 16 to 29 with the mean 22.87 and median 23, mode 23 and standard deviation 3.43. The post-test knowledge score ranges from 26 to 37 with the mean 32.27 and median 32.5 mode 33 and standard deviation 2.77. Lowest knowledge score of pretest was 16 to 18 where as in post-test it ranged between 28 to 30. Maximum knowledge score of geriatric people was 22 to 24 in pre-test whereas 32-34 in post-test. The standard deviation of posttest knowledge score of geriatric people (2.77) seemed to be less distributed than the pre-test knowledge score indicating less homogeneity in the respondents compared to pretest knowledge score (3.43). Figures 1 depicts that the mean pretest knowledge score lies to the left side of the median, so distribution is positively skewed and skew ness =3(mean-median)/S is -0.11 which is negligible indicting the scores are normally distributed. The mean posttest knowledge score lies to the left side of the median, so distribution is positively skewed and skew ness is -0.24 which is negligible indicting the scores are normally distributed. N=30

FIG. 2: Cumulative frequency polygon for the comparison of participants' pre-test and post-test knowledge score after exposure to health education on prevention management of constipation.

The post-test o give lies to the right of the pre-test o give over the entire range. It indicates that the post-test scores are consistently higher than the pre-test scores. The distance separated the two curves at various levels showing the gain in knowledge after exposure to health education. A comparison between certain percentile points can also show the gain in knowledge. The 25th percentiles of pre-test and posttest are 21 and 31.67, 50th percentiles are 23.25 and 32.88, 75th percentiles are 25.8 and 34.71 respectively. So the 25th percentile of post-test knowledge scores (31.71) falls beyond the 75th percentile of pre-test (25.8), which indicates on appreciable rise in knowledge among the participants after exposure of health education. In order to find the significance of the difference between the two means of pre-test and post-test knowledge score the 't' value computed as the pre-test and post-test knowledge score was normally distributed. In order to see the effectiveness of health educational program, the following research hypothesis was stated.

[H.sub.1]: After exposure to health education on prevention and management of constipation, the mean post-test knowledge score is higher than the mean pre-test knowledge score of geriatric people at 0.05 level of significance. To test the research hypothesis the following null hypothesis is stated.

[H.sub.01]: After exposure to health education on prevention and management of constipation, there is no difference between the mean post-test and the mean pre-test knowledge score of geriatric people on prevention and management of constipation score at 0.05 level of significance.

The mean posttest knowledge score of geriatric people (32.27) is significantly higher than the mean pre-test knowledge score (22.87) after exposure to health education on prevention and management of constipation with a mean difference of 9.67. The obtained difference between the mean post-test knowledge score and the mean pre-test knowledge score of geriatric people is found to be statistically significant as evident from 't' value of 12.57 for degree of freedom 29 at 0.001 level of significance. Therefore the obtained mean difference between pre-test and post-test knowledge score of geriatric people is a true difference and not by chance. Hence the null hypothesis H01 is rejected and research hypothesis Hi is accepted because calculated 't' value is higher than table value.

Association between the participant's pre-test knowledge score and selected variables e. g., education, marital status, previous occupation and food habit.

In order to see the effectiveness of the health educational program, the following research hypothesis was stated 2: There is association between pretest knowledge score and selected variables at 0.05 level of significance. To test the research hypothesis, the following null hypothesis is stated. H 02: There is no association between pretest knowledge score and selected variables at 0.05 level of significance.

Calculated [chi square] value between participants' pre-test knowledge score and education and food habit is higher than table value which indicates that the null hypothesis is rejected, research hypothesis is accepted. So Pretest knowledge score is significantly associated with education and food habit of participants at 0.05 level.

Association between the participant's post-test knowledge score and selected variables e. g., education, marital status, previous occupation and food habit.

In order to see the effectiveness of the health educational program, the following research hypothesis are stated. H3: There is association between posttest knowledge score and selected variables at 0.05 level of significance. To test the research hypothesis, the following null hypothesis is stated. H03: There is no association between posttest knowledge score and selected variables at 0.05 level of significance.

Calculated [chi square] value between participants' post-test knowledge score and education, marital status, previous occupation, and food habit is lower than table value indicating that the null hypothesis is accepted, research hypothesis rejected. So Post-test knowledge score is not significantly associated with education, marital status, previous occupation and food habit of participants at 0.05 levels,

DISCUSSION: Maximum participants are within age-group 65-69 years (33%), graduates(40%), previously in service (47%), widows (53.33%), cigarette addicted (33.33%), non-vegetarian (60%), suffering from hypertension (30%), and among them taken antihypertensive medicine (67%). Maximum knowledge gained in terms of mean percentage (28.95%) and modified gain (0.5) in the aspect of 'prevention of constipation'. Standard deviation of pre-test and post-test knowledge score is 3.43 and 2.77 respectively. Mean pre-test and post-test knowledge score is 22.87 and 32.67 respectively with a mean difference is 9.67.

The 't' value for knowledge score is 12.57 at 0.001 level of significance. Mean pre-test and post-test knowledge score is 22.87 and 32.67 respectively with a mean difference is 9.67. The 't' value for knowledge score is 12.57 at 0.001 level of significance. There is association between pretest knowledge score and selected variables for example education at 0.001 level of significance and food habit at 0.05 level of significance. But there is no association between posttest knowledge score and selected variables at 0.05 level of significance.

CONCLUSION: Geriatric people have poor knowledge (70%) before administration of health educational program but knowledge (83.33%) is increased consistently after exposure to health education, to perform the preventive health behavior. Pre-test knowledge score is significantly associated with education and food habit but post-test knowledge score is not significantly associated with education and food habit The major knowledge gain (28.95%) of geriatric people in respect of 'prevention of constipation" indicates that health education program is more effective for prevention of constipation among geriatric people. The heath educational program is an effective measure to increase the knowledge of geriatric people on prevention and management of constipation. So it is effective intervention for reduce the recurrence and reduces or relieves the discomfort of constipation of the old aged people in the old age home.

DOI: 10.14260/jemds/2015/1615

REFERENCES:

(1.) Dawale Ajay K, Mudey Abhay, Lanjewar Ashok, Vasant V Wagh. Study of Morbidity Pattern in Inmates of Old Age Homes in Urban Area of Central India. Journal of the Indian Academy of Geriatrics, 2010; 6: 23-27.

(2.) Smeltzics Suzanne C, Brenda G. Barc, Brunner & Suddarth's. Text Book of Medical Surgical Nursing, 11th edition, New Delhi, Published by Wolters Kluwer (India) Pvt. Ltd. 2008.page 1068-1070.

(3.) Sharma Shalika, Thakur Manjula and Kaur Sukhpal. Health Problems and Treatment Seeking Behavior among Elderly: [online] Help Age India-Research & Development Journal, Vol. 18, No. 2, May 2012. Available at http: //www.helpageindia.org/helpageprd/index.php. Accessed on January 2013.

(4.) World Gastroenterology Organization Practice Guidelines: Constipation. World Gastroenterology Organisation, 2007. Available at http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/05_constipatio n.pdf accessed on 20.01.13

(5.) Spinzi G, Amato A, Imperiali G, Lenoci N, Mandelli G, Paggi S et al. Constipation in the elderly: management strategies. Drugs Aging. 2009; 26(6): 469-74. Available at http://www.ncbi.nlm.nih.gov/pubmed/19591521 accessed on 21.01.13

(6.) Vasanwala Dr Farhad Fakhrudin. Management of chronic constipation in elderly. The Singapore Family Physician; Vol 35 No 3 Jul-Sep 2009: 84 SFP2009; 35(3): 84-92.

(7.) A Guide to the Management of Constipation and Fecal Impaction in the Older Person Impact bowel care in older patient (2010), Australia available at

(8.) http://www.movicol.com.au/files/Support_Material/IMPACT. accessed on January 2012.

(9.) Health education: theretical concepts, effective strategies and core competencies. World Health Organization 2012. Available at www.emro.who.int/dsaf/EMRPUB_2012_EN_1362.pdf

(10.) S. Siva Raju. Health of the Elderly in India, available at. helpageindia.org/helpageprd/download.php accessed on January 2013.

(11.) Bharati Kanchan. Old Age Homes: New Face of Old Age Care in India, Help age India-research & development journal. Vol. 15, no. 2 MAY 2009. Available at http://www.helpageindia.org/helpageprd/index.php accessed on January 2013.

(12.) International Day of Older Persons 2012. Available at http://www.gits4u.com/renew/snrctz8.htm accessed on January 2012.

(13.) Maulik Sanghamitra, Dasgupta Aparajita. Depression and its determinants in the rural elderly of West Bengal. Int J Biol Med Res. 2012; 3(1): 1299-1302.

(14.) Megacity Kolkata Joins WHO Global Network of Age-friendly cities and communities (Note for the media). World Health organization online. avvialable at, http://www.who.int/mediacentre/news/notes/2012/day_older_persons_20121001/en/accessed on January 2013.

(15.) Catherine Swann, Chris Carmona, Mary Ryan, Michael Raynor, Enis Bari$, Sarah Dunsdon, Jane Huntley and Michael P. Kelly, Health systems and health-related behaviour change. 2008 available at, http://www.nice.org.uk/media/0E6/62/SpecialReportHealthSystemsAndHealthRelatedBehavi ourChange.pdf.

Subrata Dalal [1]

AUTHORS:

[1.] Subrata Dalal

PARTICULARS OF CONTRIBUTORS:

[1.] Sister Tutor, Department of Health & Family Welfare, School of Nursing, S.S.K.M Hospital, Kolkata.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Subrata Dalal, E/5, Banophool Abasan RHE, Lake Town, Kolkata.

E-mail: k_subrata@rediffmail.com

Date of Submission: 13/07/2015. Date of Peer Review: 14/07/2015. Date of Acceptance: 04/08/2015. Date of Publishing: 08/08/2015.

Table 1: Mean percentages of participants' pre-test and post-test
score, maximum possible gain, actual gain in percentage and modified
gain of knowledge aspects on prevention and management of
constipation

                                        Mean (%) Score

                         Max score   Pre-test   Post-test

Concern about                5          40        56.67
constipation

Development process          3        42.22        50
of constipation

Risk of suffering from       8         47.5        65
constipation

Symptom                      6        51.11       62.22

Complication                 6        53.33       61.11

Treatment/                   6        47.22       66.66
management

Prevention                  16        41.88       70.83

                                 Mean % gain
                                                       Modified
                         Actual gain   Possible gain     gain

Concern about               16.67           60           0.28
constipation

Development process         7.78           57.78         0.13
of constipation

Risk of suffering from      17.5           52.5          0.33
constipation

Symptom                     11.11          48.89         0.23

Complication                7.78           46.67         0.17

Treatment/                  19.44          52.78         0.37
management

Prevention                  28.95          58.12         0.5

Table 2: Mean, Mean difference, standard deviation of difference,
standard error of mean difference and 't' value of mean pre-test and
mean post-test knowledge scores on prevention and management of
constipation of geriatric people. N=30

Knowledge test   Mean    MeanD   SDd    SEMd    't' value

Pre-test         22.87   9.67    4.21   0.769   12.57 ***
Post-test        32.27

t (29)=3.66, *** p < 0.001

Table 3: Chi-squires values of association between pretest knowledge
level and participants' educational level, previous occupation,
marital status and food habit. N = 30

                                                    Degree
                                                      of
Selected Variables            Knowledge Score       freedom

                                      [greater
                                    than or equal
                          <median    to] median
Education
  * [less than or           11            2            1
    equal to] Secondary
  * > Secondary              2           15
Marital Status
  * Married                  1            2            1
  * Single                  12           15
Previous occupation
  * Service                  2           12            3
  * Business                 2            1
  * Self employed            3            0
  * Housewife                6            4
Food habit
  * Vegetarian               1           11            1
  * Non-vegetarian          12            6

                                            p value
                                          at level of
Selected Variables          [X.sup.2]     significant

Education
  * [less than or           15.93 ***        10.83
    equal to] Secondary                     P<0.001
  * > Secondary
Marital Status
  * Married                  0.14 Y          7.82
  * Single                                  P<0.05
Previous occupation
  * Service               Value cannot       7.82
  * Business              be calculated     P<0.05
  * Self employed
  * Housewife
Food habit
  * Vegetarian              12.54 ***        10.83
  * Non-vegetarian                          P<0.001

Table 4: Chi-squires values of association between post-test
knowledge level and participants' educational, previous occupation,
marital status and food habit N = 30

Selected                                            Degree of
Factors                       Knowledge Score        Freedom

                                      [greater
                                    than or equal
                          <median    to] median

Education
  * [less than or equal      5            8             1
    to] Secondary
  * > Secondary             10            7
Marital Status
  * Married                  1            2             1
  * Single                  14           13
Previous occupation
  * Service                  6            8             3
  * Business                 1            2
  * Self employed            3            1
  * Housewife                5            4
Food habit
  * Vegetarian               8            5             1
  * Non vegetarian           7           10

                                      p value at
Selected                               level of
Factors                   [X.sup.2]   significant

Education
  * [less than or equal     1.38         3.84
    to] Secondary                       P<0.05
  * > Secondary
Marital Status
  * Married                  0 Y         7.82
  * Single                              P<0.05
Previous occupation
  * Service                 1.73         7.82
  * Business                             P<.05
  * Self employed
  * Housewife
Food habit
  * Vegetarian              1.38         3.84
  * Non vegetarian                      P<0.05
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Title Annotation:ORIGINAL ARTICLE; Kolkata, India
Author:Dalal, Subrata
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Aug 10, 2015
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