A Study to Assess the Effectiveness of Structured Teaching Programme on Emergency Contraception

ANNEXURE – I

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSSERTATION

Miss. P. SOLOMON NAYOMY NAME OF THE CANDIDATE I YEAR M. Sc. NURSING 1. AND ADDRESS (IN BLOCK AL-KAREEM COLLEGE OF LETTER) NURSING, GULBARGA.

AL-KAREEM COLLEGE OF NURSING, BAREY HILLS, 2. NAME OF THE INSTITUTION NEAR ADARSH NAGAR, GULBARGA-585 105.

M. Sc. NURSING COURSE OF STUDY AND 3. COMMUNITY HEALTH SUBJECT NURSING

4. DATE OF ADMISSION 02-06-2009

5. TITLE OF THE TOPIC

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON EMERGENCY CONTRACEPTION AMONG HEALTH CARE PROVIDERS IN SELECTED PHC’s, GULBARGA. INTRODUCTION

Contraception is the intentional prevention of fertilization of an ovum, as by special devices, drugs etc.1 Emergency contraception (EC) is an important post – coital contraceptive method for the prevention of unintended pregnancies after unprotected sexual intercourse or in the case of a planned method failure. Emergency contraceptive pills are more effective. When taken as soon as possible after unprotected intercourse. Obtaining medication can be delayed if the provider is unfamiliar with the patients medical records, unable to provide appropriate counseling for the condition or uncertain about ECP prescriptions/ dosages.2 Emergency post-coital contraception via mechanical or pharmacological means inhibits fertilization and/or implantation from unprotected sexual intercourse.3

Extremely high numbers of unintended pregnancies not only in United States but also world wide indicates that emergency contraception remains an important but under used method of pregnancy prevention.4 Levonorgestrol & ethinyl estradiol is given and repeated in 12 Hrs after unprotected sex, this method is called as Yuzpe method. This method should not be used more than 72 hrs of unprotected sexual intercourse. Patient should be advised of 1.6% failure rate. Post- coital Intra Uterine device insertion within 5 days of unprotected sexual intercourse also acts as emergency contraception.5

Emergency contraception decreases the costs & emotional and physical risks to women who had unprotected intercourse. Emergency contraception also increases the latitude women have to make reproductive decisions by offering an alternative to abortion and child bearing.4 Inspite of efficacy & safety of this method, it’s rate of use is low. Major obstacle of regular use of this method is insufficient information of health care providers, which in turn causes low prescription of this method and consequently insatiable practice.6

The heart of the problem with emergency contraception is not the failure rate or side effects of specific methods but the fact that so few women & adolescents who have had unprotected intercourse know the option exists and their providers may be reluctant to prescribe the method.4 6. BRIEF RESUME OF THE STUDY

6.1 Need for the Study

The term emergency contraception includes all measures designed to prevent pregnancy due to the unplanned coital act. Unprotected intercourse, condom rupture, missed pill, sexual assault or rape and first time intercourse, as known to be always unplanned. Risk of pregnancy following a single act of unprotected coitus around the time of ovulation is 8% .7

In India there is a growing evidence of early onset of sexual activity among young people in India. Studies in different cities showed that fewer than 10% of young women and 10-30% of young men indulged in premarital sex.8

A study of health care providers in Northern India reported that many providers (85% of Gynecologists 41% of general practitioners, 64% of medical students and 5% of paramedical workers) were vaguely familiar with the concept of emergency contraception, but very few know accurately the time and dosage.8

According to the report published in the journal of Health for missions, contraceptive use in rural India is 53.0% and Karnataka stands a better state in contraceptive use of 65.4%.12

A study was conducted in Karachi. Majority (71%) of the Physicians were familiar with the emergency contraception, at deficiencies in knowledge in accuracies were identified. Barriers to its use were identified as it will promote promiscuity (31%), religious/ethical reasons (27%), liability (40%), teratogenicity (44%) and inexperience (40%). Overall attitudes regarding emergency contraception were positive.11

A study was conducted in London, only 1/3 of the general practitioners had information about the post-coital contraception available in their practices. Family planning doctors and nurses had the most accurate knowledge of the method but many health professionals appeared to lack sufficient knowledge to ensure appropriate prescribing and publicizing of this method to their women patients. It is concluded that if the high rate of abortion in the district is to be reduced, health professionals as well as their women patients must be further educated as part o0f a post-coital contraception publicity campaign.14 A study in Jamaica, nearly all respondents had heard of emergency contraceptive pills and large majorities of health care providers had dispensed the method. However, about half had ever refused to dispense it; frequently cited reasons were medical contraindications to use, method unavailability, safety concerns and being uncomfortable prescribing it. Only one in five providers knew that the method could be safely used as often as needed, and few knew that it was effective if taken within 120 hours unprotected sexual intercourse.16

A cross-sectional survey was conducted on induced abortions amongst under graduate students of university of Port Harcourt. The incidence of induced abortion amongst the respondents was 47.2%. About 40% had never used an effective form of contraception in the part and 13% were unaware of contraception.9

A study conducted in New Delhi, all the women in the sample were married and multi-parous. The husband’s unwillingness for contraception and the improper use of condoms was responsible for one third of all unwanted pregnancies. Lactation was believed to be a protection against pregnancy by 11.3% of women while 6.3% were unaware of any contraceptive method.13

The National Family Health Survey and several micro-studies have given a grim picture about the use of contraceptives among married adolescents only 13% had ever used contraception and 8% were currently using any contraception at the time of survey.15

This opportunity has the potential to lead to the development of effective educational programme for providers as one of the means of pregnancy prevention strategies. This programme is consistent with healthy people 2010 goals to decrease the unintended pregnancy rate to 30% and increase the family planning agencies that offer emergency contraception to 90% .2

As the incidence of morbidity and mortality rates are very high in number it created interest in the investigator to conduct the study to assess the knowledge on emergency contraception among health care providers because if health care providers prescribe & encourage for emergency contraception, induced abortions, and unwanted pregnancies can be reduced by providing in depth knowledge through structured teaching programme. 6.2 Review of Literature

The review of literature is defined as a broad, comprehensive in depth, systematic and crucial review of scholarly publications, unpublished scholarly print materials, audio visual materials and personal communications.22

A cross- sectional study was conducted among health workers in Manisa. The aim of the study is to determine knowledge level of the health workers and practice of emergency contraception. The study was conducted on nurses and midwives. The results of the study was almost one in 10 was unfamiliar with the term ‘emergency contraception’, only few health-care providers knew how to use and the dose of emergency contraceptive pills. Many of the providers thought that young people should not know about emergency contraception.17

A cross- sectional survey was conducted among resident doctors, clinic nurses in Ann Arbor. The aim of the study is to assess family physicians and nurses providers knowledge and belief about emergency contraception. The majority of providers reported that they were familiar with indications (96%) and protocols (78%) for prescribing emergency contraception, yet knowledge inaccuracies were identified.18

A study was conducted in North India on health care providers. Practically none of the clients were familiar with the concept of emergency contraception. Many providers (84.8% Gynecologists, 41.0% general practitioners, 2.7% paramedical workers, and 64.4% medical students) were vaguely familiar with the concept of emergency contraception, very few know accurately timing and dosages.20

A study was conducted in Nagpur, all the participants (98%) had heard of emergency contraception, but many lacked specific knowledge about methods available, doses, timings for administration. The investigator, concludes that, if providers are well informed about emergency contraception, they can provide information and educate the public.19

A study was conducted in New Delhi. It was found that while all specialists were aware of emergency contraception, the awareness amongst general practitioners was only 40%. Doctors familiar with various emergency contraceptive regimens lacked knowledge of dosage schedule, efficacy, side-effects in both groups and 80% doctors in group I and 71.2% doctors in group II had never prescribed an EC pill. The Yuzpe regimen was correctly known to 35% doctors in group I and 42% doctors in group II. The correct use of copper IUD as an emergency contraception was known to 45% and 48% doctors in group I and II respectively.19 A study was conducted in Turkey on health care providers. Two hundred participants completed the questionnaire, of respondents 26.0% said that they did not know anything about emergency contraception, while the remaining 74.0% said that they knew about at least one of the methods of emergency contraception. But among these, the knowledge of 38.5% of the participants about emergency contraception was accurate and that of 61.5% was inaccurate.21 6.3 Statement of the Problem

A study to assess the effectiveness of structured teaching programme on Emergency Contraception among health care providers in selected PHC’s Gulbarga.

6.4 Objectives of the Study

1. To assess the level of knowledge regarding emergency contraception among health care providers by pre-test knowledge scores. 2. To administer a structure teaching program on emergency contraception among health care providers. 3. To determine the effectiveness of structure teaching programme on emergency contraception among health care providers by pre-test and post-test knowledge scores. 4. To find out the association between pre-test knowledge scores with selected demographic variable.

6.5 Operational Definitions

Assessment In this study assessment refers the act or an instance of assessing to estimate or determine the significance, importance, or value of knowledge on emergency contraception by a structured questionnaire among health care providers.

Effectiveness In this study effectiveness refers to determine the extent to which the structure teaching program has achieved the desired effect in terms of gain in knowledge scores obtained on a structured questionnaire among health care providers.

Structured Teaching Programme In the study structured teaching programme refers to the systematic planned teaching on emergency contraception by verbal interaction and by using various teaching aids.

Knowledge In the study knowledge refers to the awareness and familiarity about emergency contraception among health care providers.

Health Care Providers In this study it refers to the persons who are trained to take care of sick, injured or infirm people Ex: Staff nurses / Nurse Midwives/ ANM working in selected PHC’s. Emergency Contraception In the study emergency contraception refers to selected mechanical or pharmacological means that inhibits fertilization and/or implantation from unprotected sexual intercourse.

6.6 Assumptions 1. Health care providers possess some knowledge regarding emergency contraception. 2. Structured teaching program is an accepted strategy to improve the knowledge level. 3. Health care providers have an attitude to acquire information regarding emergency contraception. 4. Acquiring knowledge on emergency contraception is essential for health care providers.

6.7 Projected Outcome (Hypotheses)

All hypotheses will be tested at 0.05 level of significance.

H1: The mean of post-test knowledge scores of health care providers will be higher than the mean pre-test knowledge scores.

6.8 De Limitations

1. Health care providers who are working in selected PHC’s Gulbarga. 2. Health care providers who are willing to participate in the study. 3. Health care providers who are present at the time of study. 4. Health care providers who are able to conversate in Kannada & English.

7. MATERIAL & METHODS 7.1. Source of Data

Data will be collected from health care providers working in a selected PHC’s Gulbarga.

7.1.1 Research Design

One group pre-test – post-test design with pre experimental design.

PRE-TEST INTERVENTION POST-TEST

O1 X O2 O1 - Pre-test to assess the knowledge on emergency contraception by structured questionnaire.

X - Structure teaching program on emergency contraception.

O2 - Post - test to re-assess the knowledge on emergency contraception by structured questionnaire.

7.1.2 Setting

The Study will be conducted in selected PHC’s Gulbarga. 7.1.3 Population

In this study it refers to health care providers who are working in selected PHC’s Gulbarga.

7. 2 Method of data collection

The data will be collected by using structured knowledge questionnaire.

7.2.1 Sampling Procedure

Non-Probability convenient sampling technique is used to conduct the study.

7.2.2 Sample Size

Based on the objective of the study (35) samples will be selected. Who are working in selected PHC’s Gulbarga.

7.2.3 Inclusion Criteria for sampling

1. Health care providers who are working in selected PHC’s. 2. Health care providers who are willing to participate in the study. 3. Health care providers who are able to conversate in Kannada & English. 4. Health care providers who are present at the time of study.

7.2.4 Exclusion Criteria for Sampling

1. Health care providers who are not able to conversate in Kannada & English. 2. Health care providers who are not willing to participate in the study. 3. Health care providers who are not present at the time of study. 4. Who do not belong to selected PHC’s.

7.2.5 Instruments Intended to be used A structured knowledge questionnaire will be developed to assess the knowledge of health care providers regarding the emergency contraception, after reviewing the relevant literature & consulting with subject experts.

7.2.6 Data Collection Method

Data will be collected by the investigator herself after obtaining prior permission from concerned authority. Assess the knowledge by structured knowledge questionnaire of emergency contraception among health care providers.

7.2.7 Data Analysis plan

Data will be analyzed by using descriptive and inferential statistics. Analysis would be presented in the form of graphs, tables & diagrams. Association of knowledge of pre-test and post-test scores with selected demographic variable by Chi-square test.

7.3. Does the study require any investigations or interventions to be conducted on health care providers? If so, please describe briefly.

Yes, the investigator is giving teaching program on emergency contraception for health care providers.

7.4. Has ethical clearance has been obtained from your institution.

Yes, ethical clearance has been obtained from our college, that is Al-Kareem College of Nursing, Gulbarga and Medical Officer and DHO of Gulbarga District. 8. LIST OF REFERENCE

1. Webster’s, College, Dictionary, 4th Edition, Wiley India, New Delhi, 2006. 2. Http://www. blitz.com/news/2008/05/13 3. Pediatric Adolescent Gynecology, 1999 Feb: 12(1): 3-9 4. Chiou V.M, Shrier LA, EMans SJ, Emergency Post-Coital contraception, Pediatric Adolescent Gynecology, 1998 May: 11(2) : 61-72 5. Siddharth’s & Brunner, Text Book of Medical Surgical Nursing, 10th Edition, Lippincott/ Williams, 2004. 6. Jamali B. and Azimi H., Orimi, Knowledge attitude practice of practitioners, Mazandaran University of Medical Sciences, 17. 7. Dutta D.C., Text book of obstetrics, 6th Edition, New Central Book Agency, 2004. 8. International Institute for Population Sciences, and ORC Macro 2000. National Family Health Survey 1998-99 India 9. Oriji V K, Jermiah J. Kassot, Induced abortion Nigeria Journal of Medical, 2009 AprilJun; 18 (2): 199-202. 10. Unuigbe J A, Oronsaye Au Abortion related Morbidity. International Journal of Gynecology & Obstetrick, 1988 Jun: 26(3) 435-9 11. Abdulghani, Emergency Contraception, health population, Nutrition, 2009 Jun; 27(3): 339-44. 12. Health for Millions, Oct-Dec. 2007, Jan 2008 (33) 485. 13. Banerjee N. Sinha A, Factors determining unwanted pregnancies, National Medical Journal of India, 2001, Jul-Aug: 14 (4):211-4. 14. Burton R., knowledge on post-coital contraception, General Practioners, 1990 Aug; 40(337): 326-30. 15. Chaudri Leni, Human rights, Health Action, Nov-2007. 16. Yam EA, knowledge on health care providers, International family planning perspect, 2007 Dec; 33(4): 160-7. 17. Sevi U, A survey of Knowledge on emergency contraception, Medwifery, 2006 Mar; 22(1):66-77. 18. Wallace JL, WUJ, Weinsein J, Emergency Contraception, Family Medicine 2004 Jun; 36(6): 417-22. 19. http://www.aiims.edu/aiims/events/gynaewebsite/ec-site/report/1-6-7.htm. 20. Tripathi R, Emergency contraception, obstetrics, Gynecology research, 2003 ; 29(3) 142-6. 21. Zeteroglu S, Knowledge on contraception, Eur Journal of Contraception reproductive health care 2004 Jun; 9(2) : 102-6. 22. Polit Denise, Nursing research, 8th Edition, Wolters Kluwer, New Delhi, 2008. 23. Basavanthappa B.T., Nursing research, 3rd Edition, Jaypee, New Delhi, 2005. SIGNATURE OF THE 9. CANDIDATE

THIS STUDY IS FEASIBLE AND REMARK OF THE 10. I FORWARD IT FOR GUIDE ACCEPTANCE.

11. NAME AND DESIGNATION OF (IN BLOCK LETTERS)

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

THE TOPIC IS DISCUSSED WITH THE MEMBERS OF THE 12.1 REMARKS OF THE RESEARCH COMMITTEE AND 12. CHAIRMAN AND IS FINISHED. SHE IS PRINCIPAL PERMITTED TO CONDUCT THE STUDY.

12.2 SIGNATURE