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KNOWLEDGE AND BARRIERS OF HEALTH SEEKING

BEHAVIOUR ON UTERINE PROLAPSE

AMONG MARRIED WOMEN

AKHILA.P

College of Nursing,

Academy of Medical Sciences, Pariyaram, Kannur.

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SCIENCE IN NURSING

KERALA UNIVERSITY OF HEALTH SCIENCES

2015

i
KNOWLEDGE AND BARRIERS OF HEALTH SEEKING BEHAVIOUR ON

UTERINE PROLAPSE AMONG MARRIED WOMEN

By

AKHILA.P

Dissertation submitted to the

Kerala university of Health Sciences

Thrissur

In partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE IN NURSING

In

Obstetrics and Gynaecological Nursing

Under the guidance of

Prof.(Mrs). SREEJA G PILLAI

Department of Obstetrics and Gynaecological Nursing

And

Mrs. ASHALATHA P.K

Department of Mental Health Nursing,

College of Nursing, ACME, Pariyaram

2015

ii
DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “ Knowledge and

barriers of health seeking behaviour on uterine prolapse among married

women” is a bonafide and genuine research work carried out by me under the

guidance of Mrs.Sreeja G. Pillai, Professor and Mrs.Ashalatha P.K, Senior

Lecturer, College of Nursing, ACME, Pariyaram, Kannur.

Date:
Place: Pariyaram AKHILA.P

iii
CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “ Knoweldge and barriers of

health seeking behaviour on uterine prolapse among married women’’ is a

bonafide research work done by Akhila.P in partial fulfillment of the requirement for

the degree of Master of Science in Nursing (Obstetrics and Gynaecological Nursing).

Date Prof.(Mrs).SREEJA G PILLAI,

Place : Pariyaram Department Of Obstetrics and

Gynaecological Nursing,

College of Nursing,

ACME, Pariyaram, Kannur.

Date Mrs. ASHALATHA P.K,


Place : Pariyaram Senior Lecturer,

Department of Mental Health Nursing

College of Nursing,

ACME, Pariyaram, Kannur.

iv
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled “ knowledge and barriers of

health seeking behaviour on uterine prolapse among married women” is a

bonafide and genuine work carried out by Akhila.P in partial fulfillment of the

requirements for the degree of Master of Science in Nursing (Obstetrics and

Gynaecological Nursing).

Signature of the HOD Signature of the Principal

Prof.(Mrs.) SREEJA G. PILLAI Prof.(Mrs.) PREETHA M .K

Date: Date:

Place: Pariyaram Place: Pariyaram

v
COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Kerala University of Health Sciences, Kerala shall

have the rights to preserve, use and disseminate this dissertation/thesis in print or

electronic format for academic/research purpose.

Date:
Place : Pariyaram AKHILA.P

© Kerala University of Heal th Sciences, Thrissur

vi
ACKNOWLEDGMENT

Though only my name appears on the cover of this dissertation, a great many

people have contributed to its production. I owe my gratitude to all those people who

have made this dissertation possible and because of whom my post graduate

experience has been one that I will cherish forever.

The investigator expresses her sincere gratitude to Prof. (Mrs) Preetha M K,

Principal, College of Nursing, Academy of Medical Sciences, Pariyaram for her

generous support, valuable suggestions and guidance throughout the study.

The investigator acknowledges her heartfelt gratitude and indebtness to

Prof(Mrs).Sreeja G Pillai, Professor, College of Nursing, Academy of Medical

Sciences, Pariyaram for her critical guidance and valuable suggestions.

The investigator is immensely obliged to her co guide Mrs.Ashaltha P.K,

Senior Lecturer, College of Nursing, Academy of Medical Sciences, Pariyaram for her

scholarly suggestions and guidance during the study.

Sincere gratitude is expressed to Mrs.Mollykutty Joyichan, Assistant

Professor, Mrs. Celine Thomas VT, Mrs.Soumya George and Mrs. Mini Mol Joseph,

Senior Lecturer, College of Nursing, Academy of Medical Sciences, Pariyaram for

their constant support, encouragement and priceless suggestions.

The investigator extends her special thanks to all faculty members of College

of Nursing, Academy of Medical Sciences, Pariyaram for their motivation and support

throughout the venture.

The investigator is thankful to all the members of institutional ethics and

research committee for giving permission to conduct the study.

The investigator recalls Mrs. Sucharitha Suresh for her valuable guidance and

help rendered in statistical analysis.

vii
The investigator extends her heartfelt gratitude to the Panchayat President of

Chittariparamba and Mangattidam Panchayat for granting permission and providing

facilities for the smooth conduct of the study.

Sincere gratitude is expressed to JPHN,ASHA workers and anganwadi

teachers for their help and co-operation throughout data collection.

It gives the investigator great pleasure to extend her heartful gratefulness to

all the study subjects for their willingness to participate and the co-operation rendered

during the study.

The investigator wishes to place on record her sincere gratitude to Mrs.Leena

Sooraj, Senior Lecturer, College of Nursing, Academy of Medical Sciences,

Pariyaram for editing the manuscript.

Heartfelt gratitude to the Library staff of College of Nursing, Academy of

Medical Sciences, Pariyaram for their sincere help and wholehearted cooperation.

A word of appreciation to the chief librarian and library staff of Govt. College

of nursing Kozhikode, Govt. Medical college library, learning resource centre for their

timely help in providing the reference facilities.

The investigator expresses her heartful thanks to all the non teaching staff of

College of Nursing, Academy of Medical Sciences, Pariyaram for their support, help

and co-operation.

A word of sincere thanks to the staff of Rajendra Printers, Payyannur for their

help in formatting and setting of this work into its present elegant form.

The investigator is highly indebted to her family members, friends and

colleagues for their constant encouragement, untiring support and prayers which

helped her to fulfil this endeavour successfully.

viii
Above all, she is indebted to God almighty for the gracious blessing that

accounted for the successful completion of this dissertation.

Date :

Place: Pariyaram AKHILA.P

ix
ABSTRACT

The most common and hidden, Gynaecological morbidity which affect

millions of women worldwide is uterine prolapse and uterine prolapse impairs the

health related quality of life of individuals. The present study is intended to assess the

knowledge and barriers of health seeking behaviour on uterine prolapse among

married women in the selected rural areas of Kannur district .The objectives of the

study are to assess the knowledge regarding uterine prolapse among married women,

identify the barriers of health seeking behaviour on uterine prolapse among married

women, find the correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women, find the association between

knowledge regarding uterine prolapse and selected socio-personal variables, find the

association between barriers of health seeking behaviour on uterine prolapse and

selected socio-personal variables and prepare an information booklet on uterine

prolapse and its prevention. The conceptual framework adopted was based on

Rosenstock and Becker’s Health Belief Model. A quantitative non-experimental

approach and descriptive survey design was used for the study. The tool used were an

interview schedule and five point rating scale to assess the knowledge and barriers of

health seeking behaviour on uterine prolapse. The sample consisted of 371 married

women between 30-60yrs of age in rural areas of chittariparamba panchayat of

Kannur district. Data collection period was from 31.01.15 to 18.03.15. The

information booklet was distributed to all subjects. The data were analysed using

descriptive and inferential statistics. The results revealed that the subjects have

moderate knowledge (54.99%) and mild barriers of health seeking behaviour

(40.33%)on uterine prolapse. There is significant moderate negative correlation

between knowledge and barriers of health seeking behaviour on uterine prolapse

x
among married women. (r = -0.325 p<0.001). A significant association between

knowledge score regarding uterine prolapse and selected socio personal variables such

as education, occupation, type of family, monthly income of family, exposure to

source of information on uterine prolapse. A significant association between barriers

of health seeking behaviour and selected socio personal variables such as education,

occupation, types of family, monthly income of family, number of children and

exposure to source of information on uterine prolapse. The study concludes that

giving proper and timely health education, can transform an individual/family’s health

beliefs, attitudes and concepts. Hence effort to address the problem of uterine prolapse

is very important for its prevention and to overcome barriers in early treatment

seeking behaviour.

Keywords: Knowledge; Barriers; Health seeking behaviour; Uterine prolapse;

Women.

xi
TABLE OF CONTENTS

List of tables

List of figures/ graphics

List of appendices

Chapters No Title Page No.

1 INTRODUCTION 2-24

2 REVIEW OF LITERATURE 26-48

3 METHODOLOGY 50-64

4 ANALYSIS AND INTERPRETATION 66-88

5 RESULTS 90-95

6 DISCUSSION, SUMMARY AND CONCLUSION 97-113

REFERENCES 115-120

APPENDICES 123-178

xii
LIST OF TABLES

Sl No. Title Page No.

1 Interpretation of knowledge score. 56

2 Interpretation of barrier rating 58

3 Distribution of sample according to age, religion, 68

education and occupation

4 Assessment of knowledge score regarding uterine 76

prolapse among married women

5 Mean, SD, and mean percentage of knowledge score 77

regarding uterine prolapse among married women

6 Assessment of barrier of health seeking behaviour 78

score on uterine prolapse among married women

7 Area wise mean, SD, mean percentage of barriers of 79

health seeking behaviour on uterine prolapse among

married women.

8 Correlation between knowledge and barriers of health 82

seeking behaviour on uterine prolapse among married

women.

9 Significance of Association between knowledge on 84

uterine prolapse among married women and selected

socio personal variables.

10 Significance of Association between barriers of health 87

seeking behaviour on uterine prolapse among married

women and selected socio personal variables

xiii
LIST OF FIGURES
Sl No. Figures Page No.

1 Conceptual framework based on Rosen stock and 24

Becker’s Health Belief Model

2 Schematic representation of the study 52

3 Distribution of samples according to marital status 69

4 Distribution of samples based on type of family 70

5 Distribution of samples according to monthly income 71

of family

6 Distribution of samples according to number of 72

children

7 Distribution of samples according to exposure to 73

source of Information on uterine prolapse

8 Distribution of sample based on source of information 74

regarding uterine prolapse

9 Distribution of sample based on family history of 75

uterine prolapse.

10 Distribution of sample based on history of uterine 75

prolapse and family member affected with uterine

prolapse

xiv
LIST OF APPENDICES
Sl No. Appendices Page No.
Section A- English
A List of Abbreviations 123
B List of experts for content validity of the tool 124
C Approval letter of ethics committee 125
D Letter seeking permission to conduct pilot study 126
E Letter seeking permission to conduct actual study 127
F Letter seeking expert guidance for content validation of the 128
tool
G Acceptance form for validation of tool 129
H Criteria checklist for validation of the tool 130
I Informed consent 134
J Tool I - Structured interview schedule to assess the knowledge 135
on uterine prolapse among married women
K Answer Key 142
L Blue print of Tool I 143
M Tool II-Rating scale to assess the barriers of health seeking 144
behaviour on uterine prolapse among married women.
N Scoring and rating. 148
Section B- Malayalam
O Informed consent 149
P Tool I-Structured interview schedule to assess the knowledge
150
on uterine prolapse among married women
Q Tool II-Rating scale to assess the barriers of health seeking
159
behaviour on uterine prolapse among married women.
R Information booklet on prevention and management of uterine
163
prolapse.

xv
1

CHAPTER 1

INTRODUCTION

· Background of the problem

· Need and significance of the study

· Statement of the problem

· Objectives

· Operational definitions

· Assumptions

· Hypotheses

· Conceptual/theoretical framework
2

CHAPTER 1

INTRODUCTION

Health in the broad sense of the world does not merely mean the absence of

the disease or provision of diagnostic, curative and preventive services. The state of

positive health implies the notion of perfect functioning of the body and mind.

Reproductive health has been defined by the WHO as the state of complete physical,

mental and social wellbeing and not merely the absence of disease or infirmity in all
1
matters relating to the reproductive system and to its functions and processes.

A healthy reproductive life is an essential component of the general health and


2
well-being of a woman . Reproductive health is a crucial part of general health and a
3
central feature of human development.

A woman’s ability to access reproductive health and rights is the cornerstone


2
of her empowerment. Reproductive health is a universal concern, but is of special
3
importance for women particularly during the reproductive years. A women

contribute to the health and productivity of whole family, community and for next
3
generation.
3
A healthy reproductive system makes the miracle of life possible.

Reproductive health problems constitute the leading cause of ill health in

women of reproductive age group worldwide especially to those in developing

countries. It accounts for 21.9% of the disability-adjusted life years lost by women
4
aged 15–45 years .

Gynaecological morbidities constitute an important health problem among


4
women of reproductive age in India. The community based prevalence of

gynaecological morbidities varies between 43 and 92 % among women of all age


3

groups combined. They are influenced by socio-cultural, demographic, and

5
behavioural factors.

One of the most common, but often hidden, gynaecological morbidities is

uterine prolapse. Uterine prolapse is a reproductive health condition in which uterus

protrudes or slips out from its normal position on the pelvic floor. Commonly women

are keeping this condition secret because of the shame, as it is affecting a sensitive
6
part. So it is considered as a “hidden tragedy for women”.

According to the reports of Women’s Right Reproductive Program [WRRP],

uterine prolapse is a significant health problem among women and has affected
6
woman all over, in the mountains, hills, plains and the villages.

The stigma attached to some of gynaecological problems like Reproductive

Tract Infections, uterine prolapse, the myths, misconceptions and various cultural

beliefs associated with these problems, prove to be major hurdles in seeking health

care. This could aggravate the existing gynaecological conditions and force women to
7
suffer silently in misery.

Increased life expectancy and an expanding elderly population mean the

prolapse remains an important condition especially, since the majority of women may
8
now spend third of their life in the postmenopausal state.

In order to promote a healthy life, free of gynaecological problems, there is an

urgent need to increase the knowledge about various gynaecological problems like

reproductive tract infections, uterine prolapse among the women in the reproductive

age group. The women self-help groups, mahila mandals and basic health workers are

to be empowered to create awareness about the facilities available for seeking


9
treatment of gynaecological problems.
4

Background of the problem

Uterine prolapse is a significant global reproductive health condition that

affects women all over the world and this has not received sufficient attention despite
9
its high prevalence.

Uterine prolapse has been proven to seriously affect the quality of life of the

women with prolapse, costing them not only their physical health, but also sexual

dysfunction and their skill to work ultimately affecting their living. Being a hidden

condition, women did not feel comfortable discussing about it openly and only
6
preferred to discuss with people whom they had confidence.

The word prolapse is derived from Latin word procedure, which means “ to

fall”. It is defined as the downward displacement o r protrusion of pelvic structures in

the vaginal canal due to weakening or damage to pelvic support structures. Female

genital prolapse or sometimes also called pelvic organ prolapse is a condition of

slipping down of the genital organs like the uterus, urinary bladder and rectum from

their normal anatomical position and either protrude into the vagina or press against
8
the vaginal wall.

Uterine Prolapse means uterus descended from its normal position in the
9
pelvis further down the vagina along with other pelvic organ can also descend.

Uterine prolapse has been prevalent since ages and it is proven by the fact that

it was mentioned in the writing of Hippocrates and Galen. Its many fragments were

6
discovered by Flinder Petrie in 1889. Medical records indicating diagnosis and

treatment dating back over 4000 years to the Kahun Papyrus in 1835 BC. A

transcription of the Kahun Papyrus states, “Of a wo man whose posterior belly and

branching of her thighs are painful, say thou it is the falling of the womb” (Griffiths
10
translation).
5 Documentation exists of multiple treatments Hippocrates utilized for Pelvic Organ

Prolapse (POP) such as inserting a pomegranate into the vagina to hold the

uterus in position or suspending women upside down from a ladder with legs tied

together and shaking for 3 to 5 minutes to “encoura ge” the uterus to return to its
.10
normal position

An Egyptian medical text around 2000 BC also mentioned “falling womb”

and its treatment. In 98 BC Soranus of Rome first described the removal of the
10
prolapsed uterus when it became black.

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and

weaken, providing inadequate support for the uterus. Loss of normal vaginal support
2
can be seen, to some degree or another, in as many as 43% to 76% of women.

There are three degrees of uterovaginal prolapse.

First-degree prolapse, descend of the uterus to any point in the vagina above

the hymen.

Second degree prolapse, descend of the uterus till the hymen and
11
Third-degree prolapse, descend of the uterus halfway past the hymen.

The condition where the entire uterus may protrudes outside the vulva,
12
bringing with it both the vaginal walls, is called procidentia or complete eversion

In 1996, the International Continence Society (ICS) Standardisation

Committee introduced a standard system of terminology for description of Pelvic

Organ Prolapse (POP). The system is called the Pelvic Organ Prolapse Quantification

System (POP-Q). The descent of the anterior, posterior wall and the apex of the

vagina (cervix/vaginal cuff) are measured using the hymen as the point of reference

13
while the patient is straining.
6 Causes and risk factors for uterine prolapse are complex and deeply embedded in

the cultural, economic, and social conditions of women. They range from early

marriage and childbirth to malnutrition, work overload, and lack of rest in the pre and

postnatal period multiparty, having child at very young age and having children at less

interval. Other conditions which can cause uterine prolapse are constipation, obesity

and chronic cough, loss of the tone of vagina, prolong labour giving birth to large

baby, difficult labour, working immediately after child birth. Furthermore, there is a
2
lack of knowledge and access to antenatal medical care.

Next to the obvious physical consequences (difficulties when doing daily

work, infections, and pain), uterine prolapse can also trigger psycho-social problems.

Emotional isolation, risk of violence and discrimination, and facing social stigma are
2
only some such problems.

A woman with prolapse may complain of a lump in the vagina or a feeling of

“something is coming down”, back-ache and a bearing down sensation, abdominal

pain, vaginal discharge, disturbances of micturition, frequency and dysuria, stress

incontinence, difficulty in defecation, profuse periods, irregular bleeding and bleeding

due to the protruding prolapse becoming ulcerated. The psycho-social problems faced

by women with uterine prolapse include stress, emotional isolations, abandonment by

husband or divorce, ridicule and shame, inability to work, lack of economic support,
.2
risk of violence and abuse and more notably discrimination

Uterine prolapse leads to severe degrees of physical disability, including

inability to work, difficulties walking or standing up, sitting, difficulties urinating or


2
defecating, painful intercourse, increased social stigma, and economic deprivation.

Pelvic organ prolapse is a highly prevalent condition in the female population,

which impairs the health-related quality of life of affected individuals. Despite the
7

lack of robust evidence, selective modification of obstetric events or other risk factors

2
could play a central role in the prevention of prolapse.

While the value of pelvic floor muscle training as a preventive treatment

remains uncertain, it has an essential role in the conservative management of prolapse.

And also include rest during postpartum period, not doing heavy work during

pregnancy and postpartum period, marrying at appropriate age, having nutritious

food, care during antenatal, intrapartum and postpartum period, women should go

hospital for treatment when she suffers from uterovaginal prolapse. Pessary also

included in the conservative management of uterine prolapse. Pessaries can be made

from a great variety of materials and have been used since ancient time, modern

pessary, usually made of silicone, in a range of shapes and sizes. It also considered to

be a relatively safe method of managing pelvic organ prolapse without serious side
13
effects .

Once the prolapse is established it is much more difficult to control with only

medication or exercise or pessaries. Surgical trends are currently changing due to the

controversial issues surrounding the use of mesh and the increasing demand for

uterine preservation. The evolution of laparoscopic and robotic surgery has increased
2
the use of these techniques in pelvic floor surgery. Ultimately surgical restoration of
6
the vagina or the hysterectomy is required.

Uterine prolapse can be prevented and is treatable but majority of the women
6
do not have knowledge about it which makes the situation even more heartbreaking.

About 80% of the Indian women are residing in rural areas and these problems

are most commonly seen among them. Prevention of the risk factors play a vital role.

Prolapse can be prevented by having increased knowledge on preventive measures like

taking adequate rest during puerperium, performing Kegel exercise, maintaining a


8

healthy weight through diet, avoiding constipation and smoking. Conditions that increase the

intra abdominal pressure such as constipation, obesity and chronic cough

6
should be treated for the primary or secondary prevention of the prolapse.

Early identification of risk factors and knowledge about preventive measures


2
may help to prevent complications of the disease.

Women must be provided with counselling for prevention of uterine prolapse.

Efforts are needed at the grass root and addressing uterine prolapse at the community
6
level can have a positive impact on the women’s lives

The public health programmes should provide information on reproductive

health care and also provide people friendly services, preventive and curative care,

1
free or at genuinely nominal cost.

Need and significance of the study

Maternal health is getting special attention globally as it is highlighted in

many international declarations. The 1994 International Conference on Population

and Development (ICPD) in Cairo discussed reproductive health and women’s health

in a holistic way. ICPD delegates reached a consensus that the equality and

empowerment of women is a global priority. A women’s ability to access


2
reproductive health and right is the key to sustainable development.

Millennium Development Goal (MDG)-5 has also highlighted maternal health

throughout the world. The goals are to improve maternal health, reduce the maternal
2
mortality ratio by three quarters by the year 2015.

Maternal death is only the tip of the iceberg, pregnancy related complications

that do not lead to death but women suffer from severe lifelong disabilities are much

more prevalent than maternal death. For every maternal death there are up to 30
9

women with complications that will affect them for rest of their lives (World Bank,

2
1999.

The World Health Organization estimates that approximately 33 % of the total

global burden of disease is related to reproductive health. Poor reproductive health


6
among women has been a major public health problem in developing countries.

The health of women are also affected by problems that are not related to

pregnancy or child birth. Hence focusing more on mortality indicators may ignore

many treatable gynaecological condition that cause significant distress in women’s


5
lives.

One such chronic gynaecological health conditions that remains shrouded in

secrecy and millions of women in every country around the world suffer in silence is
.10
Pelvic Organ Prolapse (POP)

Pelvic organ prolapse is a global women’s health concern and is the leading
10
cause of gynaecological morbidity among married women in India.

Women with UP often suffer in silence for decades; stigma impacts their

personal, family, and socio dynamic aspects on physical, emotional, and intimate

levels. Despite a lot of attention, the exact scenario of uterine prolapse is still hidden

and expanding as these issues are not openly shared due to shyness, stigma and
2
discrimination.

Uterine prolapse is a health concern affecting millions of women world


14 .4
wide. The global prevalence of genital prolapse is 2 to 20 % under age 45 years. %

The incidence of uterine prolapse in U.S.A is 11.4%, Egypt 56%, Italy 5.5%, Iran

53.6%, California 1.9%, and Pakistan 19.1%. It is found that in India one in every five

women visiting private clinics in Bengal, Delhi, Punjab and Uttar Pradesh are
10

suffering from uterine prolapse. The incidence of uterine prolapse is 7.6% in Northern
15
India, 20% in Eastern India, 3.4% in Karnataka and 0.7% in Tamilnadu.

It is estimated that about half of the parous women lose their pelvic floor

support and this results in some degree of prolapse and among them only 10-20 %
10
seek medical treatment for the problem .

Study conducted in rural areas of Pondicherry to assess gynaecological

morbidity among postmenopausal women aged 50 years. The results shows that the

prevalence of gynaecological morbidity was 44.4%, whereas the prevalence was only

25.9% of at least one gynaecological symptom. Genital prolapse was the most
.5
common morbidity which was present in 18.8 % of women

WHO reported that nearly one third of all healthy life lost among adult

woman, because of reproductive health problems. Gynaecological disorders have a

substantial impact on female reproductive ability, mental health ability to work and to
1
perform routine physical activities.

The causative factor for pelvic organ prolapse is globally universal and
6
multiple. Every causal factor the women experience increases the risk of uterine
16
prolapse as well as its degree of severity.

Many studies done regarding cause and risk factors of uterine prolapse, show

that the main risk factors are immediate heavy work after delivery, heavy work load

during pregnancy, child birth injury, multiple birth, multiparity, lack of care during

antenatal, intranatal, postnatal, chronic cough and obesity.

Shah P.conducted a study regarding uterine prolapse and maternal morbidity in

Nepal among women suffering from the problem of uterus prolapse. The result shows

that causes of uterine prolapse include excessive physical labour during and

immediately after pregnancy, a lack of skilled attendants during delivery, frequent and
11

numerous pregnancies, early childbirth, and/or a lack of nutritious food during maternity.

Pelvic floor damage can occur where there is “overstretching of the perineum, obstructed

labour, delivery of a large infant, delay in episiotomy, and/or


17
imperfect repair of perineal injuries.”

Uterine prolapse presents with multiple symptoms, the degree of severity and

types of activity mean women’s symptoms have aspects of uniqueness and aspects of
2
similarity with variables day today and women to women.

The symptoms experienced by women have a significant impact on the quality


2
of life as it has physical, emotional, social, and sexual impact on women.

However, uterine prolapse directly affect other aspects of life as well. In fact it

severely affects the quality of life of women, causing physical, social, psychological,
2
occupational, domestic and sexual limitations on their lifestyle.

A qualitative study on Uterine prolapse and quality of life among women with

uterine prolapse at Nepal shows that physical effects of prolapse are listed as pain,

discharge and itching, ulceration and bleeding, difficulty in sitting, walking and

lifting, urination and defecation problems, and reduced food intake. Psychological

effects of prolapse are grouped as anxiety, depressive feelings and guilt, fear of death,

cancer and surgery. Social aspects are expressed as responses of husband, family and

friends, and implications on sexual, economic and social activities. Barriers and

facilitators to accessing health care, quality of care received, and the success and

failure of treatment done represent the women’s experiences regarding treatment


2
process.

Women who suffer from pelvic floor disorders like uterine prolapse (UP)

endure symptoms that decrease their quality of life, but rarely result in morbidity or
12

mortality. The symptoms are not only socially embarrassing but also disabling to the
2
women.

The aim of the intervention should be improvement in subjective symptoms


16
with minimal complications. Treatment options are exercise, pessary use, or surgery.

Preventing uterine prolapse requires raising awareness and behaviour changes


2
at the individual, family, and community levels.
5
Improving quality of life should be the main aim of the treatment.

Many studies shows that the treatment options to support a prolapse include

physiotherapy, pessaries and surgery but that simple lifestyle changes, such as losing

weight, smoking cessation, treatment for a chronic cough, treatment for constipation

and avoiding heavy physical activities can reduce symptoms of pelvic organ prolapse

and reduce the chances of a prolapse returning after surgery, Eat estrogen rich food
7
plenty of high-fiber foods such as whole grains, fruits, and vegetables every day.

Studies on nonsurgical and surgical management options performed for

patients considering uterine preservation revealed that nonsurgical management of

prolapse remains the first line treatment as it provides benefit to the patient and has a

favourable safety profile. For patients seeking treatment for pelvic organ prolapse

who do not desire surgical management, two options are available. Pelvic floor

physical therapy and pessary provide nonsurgical options that have distinct
18
advantages. Both treatments are non-invasive and can be discontinued at any time.

Studies revealed that of 100 consecutive women with symptomatic pelvic

organ prolapse fitted with a pessary, 73 women retained the pessary two weeks later.

After two months, 92% of these women were satisfied with the pessary; virtually all

symptoms of prolapse and 50% of urinary symptoms had resolved, although occult
19
stress incontinence was unmasked in 21% of the women.
13 Health seeking behaviour or treatment seeking behaviour depends upon the

perception of individual and when they think it is normal or non-serious they do not

2
take treatment.

Woman carries a disproportionate and growing share of economic and

domestic responsibility for the family. Despite this fact, they do not have the decision

making power to determine when they are to start a family and at what time intervals
6
they will have children.

In India, married woman are reluctant to seek medical advice because of lack

of privacy, lack of female doctor at the health facility, the cost of treatment and the

social status of their sub ordinates. Many women considered most reproductive
9
morbidities to be normal and may not seek treatment.

Despite the fact that uterine prolapse is a matter of discomfort for women

which affect many aspects of daily living, they hesitate to seek medical assistance due
10
to the social positioning and conditioning.

Stigma prevents women from disclosing Pelvic Organ Prolapse (POP); the

universal impact of stigma to women’s lives has kept pelvic organ prolapse shrouded

despite documentation dating back multiple millennium. While women in developed

countries remain silent about Pelvic Organ Prolapse (POP) because of embarrassment

of symptoms, fear of stigma permeates women’s lives where disclosure of Uterine

Prolapse (UP) may result in a woman being ostracized from her husband, family, or
10
community.

Deep rooted socio-cultural perceptions prevent women from capturing full

value of programs that have been initiated till date. There is a need to address this

cryptic women’s health concern from screening standpoint in all countries.10


14

Women with prolapse can often recall the exact scenario they first felt their
10
prolapse occur, but fear of stigma keeps them from revealing it to anyone.

Cultural norms related to societal expectations of covering private parts under

all circumstances make it difficult for women to discuss this extremely private,
2
personal, condition with healthcare facilitators when access to health camps occurs.

Many studies shows that women believe or are made to believe that

reproductive health problems are part of women’s fate and that the falling of uterus is

just part of being a woman. Women often won’t admit to uterine prolapse because

they will be ill-treated by their husbands. Women’s discomfort regarding being

screened for uterine prolapse by a man must be considered; female assistants should

be in screening rooms during pelvic examination many did not report the condition to
3
their doctor due to being ashamed.

Due to less data and surveillance, the prolapsed uterus has become a scourge

that is everywhere. The enormous physical and psychological burden it represents

goes practically unnoticed in the public health debate raised in the country. For

women, uterovaginal prolapse is a matter of utmost discomfort, that affects many

aspects of daily living, but social conditioning often deters women from seeking
4
medical assistance even if it is available.

Uterine prolapse is the leading cause of morbidity among the women.

Attention need to be paid more in the intensive planning of educational programme on


9
deficient areas of awareness of parous women for preventing uterine prolapse.

Approaches such as Geriatric- friendly camps and opportunistic screening

among women with chronic co-morbidities can be considered complementary


6
approaches to uncover the hidden gynaecological morbidities.
15 Health treatment and education, awareness, stigma, income generation, and gender

disparity must be addressed in order to achieve success in long term initiative to deal

with uterine prolapse. A program that integrates multiple factors and dissects and

evaluates the outcome of each aspect is pivotal to achieve long term reproductive

health ballast for women. There is considerably less value in humanitarian aid than a

well balanced program which provides healthcare while educating and empowering

2
women to help themselves and their families.

Education always enlightens the mind of people and helps them to think freely

and take decisions, and enable them to avoid becoming victim of this hidden
1
morbidity uterine prolapse.

By giving proper and timely health education, we are bringing real

transformation of family’s health beliefs, attitudes and concepts. Gradually we can

wash out the stains of misconceptions and barriers. The need of the hour is setting up

health education campaigns, screening and counselling services to educate the

women, identify the barriers of health seeking behaviour and try to reduce the
1
barriers.

Nurse must be sensitive while assessing the female patient so that their care needs

can be intervened and quality of life improved. There is need to educate women on

different symptoms of reproductive infection and need for treatment so that women

1
can themselves identify the symptoms and seek timely treatment.

Many women are silent victims of uterine prolapse. Despite of lots of focus, still

hidden and expanding is the exact scenario of uterine prolapse as these issues are not

openly shared due to shyness, stigma and discrimination . Hence effort to address the

problem of uterine prolapse is very important for its prevention and to overcome
10
barriers in early treatment seeking behaviour.
16 Investigator during her clinical experience also found that the majority of

uterine prolapse cases admitted in hospital are of third degree prolapse. Even though

the symptoms appeared in early stages, they are not seeking hospital care due to

shyness, embarrassment, hesitant to discuss it with others and due to fear of

examination. As per monthly Operation Theatre statistics of Pariyaram Medical

College Hospital, an average number of 20 cases of uterine prolapse are undergoing

vaginal hysterectomy. Based on the degree of prolapse and pelvic organ involvement

Pelvic Floor Repair is also done with vaginal hysterectomy.

Based on the reviews and facts, the investigator felt the need to assess the

knowledge and barriers of health seeking behaviour on uterine prolapse among

women in selected rural areas of Kannur district and to prepare an information

booklet on uterine prolapse and its management in order to aware of the symptoms, to

increase service utilization at early stages of uterine prolapse and thereby might

contribute both primary and secondary prevention of uterine prolapse.

Statement of the problem

A study to assess the knowledge and barriers of health seeking behaviour on

uterine prolapse among married women in selected rural areas in Kannur District.

Objectives

· Assess the knowledge regarding uterine prolapse among married women.

· Identify the barriers of health seeking behaviour on uterine prolapse among

married women.

· Find the correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women.

· Find the association between knowledge regarding uterine prolapse among

married women and selected socio-personal variables.


17

· Find the association between barriers of health seeking behaviour on

uterine prolapse among married women and selected socio-personal

variables.

· Prepare an information booklet on uterine prolapse and its management.

Operational definition

Knowledge: Refers to the awareness regarding causes, clinical manifestations,

management and prevention of uterine prolapse among married women as measured

by structured interview schedule.

Uterine Prolapse: Refers to descent or herniation of uterus into or beyond the


12
vagina.

Health seeking behaviour: Refers to a state in which a women in stable health, is

actively seeking ways such as regular check up, avoidance of risk factors of uterine

prolapse, life style changes and utilization of health care services in order to move

towards a higher level in health.

Barriers: Refers to the factors that hinder the health seeking behaviour on uterine

prolapse among married women as measured by a five point rating scale.

Married Women: Refer to married females within 30-60yrs of age residing in

selected rural areas of Kannur district

Selected socio personal variables : Refers to age, education, occupation, type of

family, number of the children, monthly income of family, exposure to source of

information, history of uterine prolapse among sample and family members.

Information booklet: A small bound book having organized instructions regarding

causes, symptoms, management and prevention of uterine prolapse.


18

Assumptions

· Women have some knowledge regarding uterine prolapse

· Women have barriers in health seeking behaviour on uterine prolapse.

· Health education promote early health seeking behaviour

Hypotheses

Following hypothesis are tested at 0.05 level of significance

H1: There is a significant correlation between knowledge and barriers of health

seeking behaviour on uterine prolapse among married women as measured by

structured interview schedule and five point rating scale.

H2: There is significant association between knowledge on uterine prolapse among

married women and selected socio-personal variables.

H3: There is significant association between barriers of health seeking behaviour on

uterine prolapse among married women and selected socio-personal variables.

Conceptual framework

The conceptual framework is developed by the investigator herself based on

health belief model and this model is based on motivational theory. Health belief

model is a health behaviour change and psychological model for studying and

promoting the uptake of health services.

Health belief model is the most commonly used theory in health education and

promotion. In the 1950s Rosenstock (1974) proposed a Health Belief Model (HBM)

intended to predict which individual would or would not use such preventive

measures. They address the relationship between a person’s beliefs and behaviours. It

provides a way of understanding and predicting how clients will behave in relation to

their health and how they will comply with the health care therapies. Becker (1974)
19

modified the health belief model to include these components: individual perceptions,

modifying factors, and variables likely hood of action.20

The following four perceptions serve as the main constructs of the model;

perceived seriousness, perceived susceptibility, perceived benefits, and perceived

barriers. Each of these perceptions, individually or in combination, can be used to

explain health behaviour. More recently, other constructs have been added to the

HBM; thus, the model has been expanded to include cues to action, motivating

factors, and self-efficacy. Rosenstock assumed that good health is an objective


21
common to ill people. Becker added “positive health motivation" as a consideration.

Individual perceptions

Individual perception include the following

Perceived susceptibility: "Perceived susceptibility refers to a person's view o f the

likelihood o f experiencing a potentially harmful condition". This is a subjective

perception of the risk of contracting a particular condition. It is one of the more

22
powerful perceptions in promoting people to adopt healthier behvaviour. Awareness of

personal high risk lifestyle behaviours also increases perceived susceptibility. A family

history of a certain disorder diabetes or heart disease may make the individual
20
feel at high risk.

In the present study, perceived susceptibility refers to risk factors of uterine

prolapse which include multiparity, child birth trauma, big baby, lack of rest in

postpartum,obesity,chronic cough and family history of uterine prolapse.

Perceived seriousness: Perceived severity is concerned with how threatening a

condition is to the individual. An individual’s assessment of the seriousness of the

condition, and its potential consequences. This includes individual’s evaluation of


20
physical, emotional, and social consequences.
20

In the present study, perceived seriousness is the health consequences to

women due to uterine prolapse. They are

· Physical consequences: include pain, vaginal bleeding, discharge, urination

problem difficulty in walking and standing, lifting and dyspareunia.

· Emotional consequences: include anxiety, guilt, fear of surgery.

· Social consequences: include stress, effect on family, inability to work,

abandonment by husband and divorce, shame, and lack of economic support.

Perceived threat: perceived susceptibility and perceived seriousness combine to


21
determine the perceived threat of an illness to a specific individual.

In the present study perceived threat include lack of knowledge on uterine

prolapse, risk factors of prolapse, physical, emotional and social consequences of

uterine prolapse.

Modifying factor

The four major constructs of perception are modified by other variables, such

as culture, education level, past experiences, skill and motivation, to name a few.
20
These are individual characteristics that influence personal perceptions. Factors that

modify a person’s perceptions include the following

·
Demographic variables:- Demographic variables include age, sex, race,
20
ethnicity etc.

In the present study the socio personal variables such as age, religion,

education, occupation marital status, type of family, monthly income, number of

children,

· Socio psychological variables:- Socio psychological variables such as low

socioeconomic class, cultural factors and peer group pressure can encourage
21

health behaviours even when individual motivation is low also shows any risk
20
taking behaviour.

In the present study socio psychological variables include low socioeconomic

class, cultural factors and peer group pressure.

·
Structural variables:- Knowledge about the target disease and prior contact

with it are structural variables that are perceived to influence preventive

20
behaviour.

In the present study, knowledge regarding uterine prolapse, source of information

regarding uterine prolapse, history of uterine prolapse among sample and family

members, are structural variables.

Cues to action:- Cues can be either internal or external. Internal cues include

feelings or fatigue, uncomfortable symptoms or doubts about the condition of

an ill person who is close. External cues are mass media, advice from others,

reminder post card from the health team member, illness of family members or
21
friends, newspapers or magazine article .

In the present study, cues to action include mass media, medical camp, health

personnel, health education, family members or relatives or known person affected

with prolapse, information booklet on uterine prolapse and its management.

Likelihood of action

According to the theory, likelihood of persons taking recommended preventive

health actions depends on the perceived benefits of its action minus the perceived

barriers of the action.

Perceived benefits of action:- An individual’s assessment of positive


21
consequences of adopting the behaviour.
22 In the present study the perceived benefits of action is adopting healthy life style

intervention, routine pelvic examination, pelvic floor exercises, genital health

protection and measures, developing knowledge on uterine prolapse and its

prevention.

Perceived barriers to action:- Individuals assessment of the influences that facilitate

or discourage adoption of the promoted behaviour. Examples include cost,


21
inconvenience, unpleasantness, and lifestyle changes.

In this study, the barriers may include lack of knowledge and awareness on

uterine prolapse, embarrassment and fear related to screening, negative attitudes and

beliefs, lack of support and peer pressure, lack of time and cost, cultural factors and

inaccessibility to health care facilities.

The belief in one’s own ability to do something is self efficacy. Positive self

efficacy means married women’s belief in her ability to adopt a new healthy

behaviour. Then only she can overcome perceived barriers. Hence self efficacy refers

to women’s ability to adopt healthy life style changes including well balanced diet,

adequate hydration, pelvic floor exercises and adoption of measures which promote

genital health in order to prevent the occurrence of uterine prolapse and thus to
21
achieve optimal reproductive and sexual health.

Knowing what aspect of the Health Belief Model, patients accept or reject can

help in designing appropriate interventions. If a patient is unaware of his or her risk

factors for diseases, we can direct teaching toward informing the patient about

personal risk factors. If the patient is aware of the risk, but feels that the behaviour

change is overwhelming or unachievable, we can focus our teaching efforts on


21
helping the patient overcome the perceived barriers.
23 Information booklet regarding uterine prolapse, its causes, symptoms,

management and prevention helps the women to overcome the perceived barriers and

achieve perceived benefits to develop actions which lead them to take good health

decisions in order to achieve optimum reproductive and sexual health.

The conceptual frame work based on Rosen stock and Becker’s Health

Belief Model is depicted in figure 1.


24

INDIVIDUAL PERCEPTION MODIFYING FACTORS LIKELY HOOD OF ACTION

Socio-personal variables Perceived benefit of action (Adopting


Age, education, occupation, number of healthy lifestyle intervention, routine
Perceived susceptibility children ,marital status, monthly income pelvic examination, pelvic floor
to uterine prolapse Socio psycho variables
exercises, genital health protection
Low socio economic status, cultural
factors, pressure or influences from peer or measures)
· Multiparity
self help group(kudumbasree workers) Positive self efficacy
· Child birth trauma
Structural variables Overweighs
· Lack of rest in Perceived barriers (lack of knowledge
Knowledge regarding uterine prolapse,
postpartum
exposure to source of information, history of and awareness, embarrassment and fear,
· Obesity uterine prolapse among sample and family negative attitudes and beliefs, lack of
· Chronic cough members on uterine prolapse support and peer pressure, lack of time
· Family history of
and cost, cultural factors and
uterine prolapse
inaccessibility to health care facilities.).
Perceived seriousness
associated with uterine Perceived threat associated
prolapse with uterine prolapse
Likely hood of action
Physical, emotional, social Lack of knowledge on uterine -Developing knowledge
prolapse, risk factors of regarding uterine prolapse.
consequences of uterine
prolapse, physical, emotional -Identify barriers of health seeking
prolapse
and social consequences behaviour on uterine prolapse.
-Educate family and friends regarding
Provide uterine prolapse and its management
Information
booklet
Cues to action regarding
Not included in the study Mass media, medical camp, health personnel, peer uterine Insignificant gain Significant gain
group, health education, family member or relatives or prolapse in knowledge and in knowledge and
known person affected with prolapse, information
booklet on uterine prolapse and its management. strong barriers no barriers

Optimum

24
Figure 1: Conceptual frame work based on Rosen stock Rep
and Becker’s Health Belief Model rodu
ctiv
e
and
Se
xu
al
H
ea
lth
25

CHAPTER 2
REVIEW OF LITERATURE

Knowledge and barriers of health seeking behaviour on uterine prolapse

Incidence, prevalence and causes of uterine prolapse

Symptoms, management and prevention of uterine prolapse

Barriers of health seeking behaviour on uterine prolapse.


26

CHAPTER 2

REVIEW OF LITERATURE

Review of literature in a research report is the summary of current knowledge

about a particular practice problem and includes what is known and not known about

the problem on a topic of interest, often prepared to put a research problem in context
23
or as the basis for an implementation project.

This chapter deals with selected studies which are related to the objectives of

the proposed study. A review of literature relevant to the study was undertaken, which

helped the investigator to develop a deeper insight into the problem and gain

information on what has been done in the past.

Review of literature for the present study has been organized and presented

under three sections.

Section I: Literature related to incidence, prevalence and causes of uterine

prolapse.

Section II: Literature related to symptoms, management and prevention of

uterine prolapse.

Section III: Literature related to barriers of health seeking behaviour on uterine

prolapse.
27

Section I: Literature related to incidence, prevalence and causes of uterine

prolapse.

Karki S, Neraula A conducted a descriptive study to assess the awareness

regarding uterovaginal prolapse among 118 parous women in Bhaktapur Municipality

in Bhaktapur, Nepal using Systematic random sampling technique and by using semi-

structured interview schedule. The result shows that the majority of the respondents

were <40 years (69.6%), were literate (65.3%), all respondents were Newar, and

Hindu religion. Major occupation of the mothers was house work (63.6%) and 15.3%

were engaged in agriculture. In knowledge related to uterovaginal prolapse this study

showed that the causes of uterovaginal prolapse ( UVP) by carrying heavy loads

during postnatal periods (72.2%), by multiparty (63.9%), having child at very young

age (60.8%), having children at less interval (<5yrs) (57.7%), other condition like

constipation, obesity and chronic cough (55.7%), by loss of the tone of vagina

(53.6%), by prolonged labour (52.8 %) and by giving birth to large baby (39.2%) It

state that uterovaginal prolapse is because of child bearing at an early age (43%),

carrying heavy loads during pregnancy (43%), working immediately after child birth

(37%), lack of care during postnatal period (32%), pressure on lower abdomen during

child birth (28%), and multiple birth

14
(9%).

Eleje GU, Udegbunam OI, Ofojebe CJ, Adichie CV conducted a five year

cross-sectional study to determine the incidence, risk factors and management

modalities of pelvic organ prolapse with retrospective data collection in women who

attended the gynaecologic clinic , and were also diagnosed with pelvic organ prolapse

in Nnamdi Azikiwe University Teaching Hospital, Nnewi, south-east Nigeria. The

results show that there were 199 cases of pelvic organ prolapse, out of a total
28

gynecologic clinic attendance of 3082, thus giving an incidence of 6.5%. The mean

age was 55.5 (15.9) years with a significant association between prolapse and

advanced age (P < 0.001). The age range was 22-80 years. The leading determinants

were menopause, advanced age, multiparity, chronic increase in intra-abdominal

pressure (IAP) and prolonged labour. Out of the 147 patients with uterine prolapse,

majority, 60.5% (89/147) had third degree prolapse. Vaginal hysterectomy with pelvic

floor repair was the most common surgery performed. The average duration of

hospital stay following surgery was 6.8 (2.9) days and the most common complication

was urinary tract infection, 13.5% (27/199). The recurrence rate was 13.5% (27/199).

Most of the patients who presented initially with pelvic organ prolapse were lost to
24
follow-up.

Shrestha B, Devkota B, Khadka B B, Choulagai B, Pahari D P, Onta S et al

conducted a cross-sectional study to assess knowledge on uterine prolapse among

4,693 married women aged 15–49 years at 25 district s representing all five

administrative regions, three ecological zones, and urban and rural settings in Nepal

using structured questionnaire .The result shows that mean age of participants was 30

years, 67.5% were educated, 48% belonged to the advantaged Brahmin and Chhetri

groups, and 22.2% were Janajati from the hill and terai zones. Fifty-three percent

(53%) had never heard about uterine prolapse (UP). Among women who had heard

about uterine prolapse (UP), 37.5% had satisfactory knowledge. Knowledge about

uterine prolapse(UP) was associated with both urban and rural settings, age group,
25
and education level.

Sharma A, Zhang J P conducted a study to explore the risk factors and

symptoms of uterine prolapse experienced by Nepali women. The results shows that

the prevalence of uterine prolapse was found to be in the range of 10-40%. The grass
29

root causes are poverty, illiteracy, male dominated social structure, gender based

discrimination, inaccessibility to health services, poor nutrition, early marriage, early

pregnancy, multi parity in the need of son, work load during pregnancy and postnatal

period, domestic violence, home deliveries, lack of awareness about uterine prolapse,

shyness to explain about reproductive health related problems which in turn leads to
2
uterine prolapse.

Vidhyalatha conducted a descriptive study to assess the knowledge and risk

factors of uterine vaginal prolapse among 300 married women aged 30-60 year in

selected villages of Udupi district, Karnataka. Villages for this study selected by

simple random sampling and subjects by purposive sampling and tool was knowledge

questionnaire. The result shows that majority (59%) of the married women had

moderate knowledge on uterovaginal prolapse ,6% had good knowledge and 35% had

poor knowledge. The risk factors identified were(77%) had at least one vaginal

delivery,50(16.7%) of women delivered first child at less than 20 years of age,107

(35.7%) had 3 and more than 3 children 30(10%) of the women delivered a baby

weighing more than 3.5kg, 86(28.7%) women delivered at home ,147 (49%) of the

women had 1-2 years gap between pregnancies 6(2%).Women took less than two

weeks of rest in postnatal period 16(5%) of them had constipation, no one had chronic

cough,10(3.3%) women BMI was more than 30kg/m2. There was significant
26
association between knowledge with education and monthly income.

Paneru DP conducted a community based cross sectional study to estimate the

prevalence of uterus prolapse and its associated factors among the 360 women in Doti

district of Nepal using three stage probability sampling technique by using structured

interview schedule. Result revealed that nearly half of the respondents were over age

35 years with one in every five belonging to age group 21-25 years; and 33.3% were
30

dalits/schedule castes. Majorities (75%) of the respondents were illiterate and

housewives. Nearly 96% of the respondents were married before 20 years of age. Literacy

status, caste, age of respondents, age at marriage, parity and time to resume work after

delivery were independently and significantly associated with Uterus prolapse (p<0.05)

where strongest variation was observed due to parity. Moreover, the type of delivery at

first, second, third and fourth child birth, age at marriage, numbers of children, parity, age

at first child births were observed to be strongly associated

27
factors; that explained 40 percent variations of uterus prolapse.

Tamrakar A conducted a community based descriptive cross sectional study

regarding prevalence of uterine prolapse and its associated factors among 300 women

of the Kaski district of Nepal who have experienced at least one time pregnancy

during her life using multistage sampling technique, by using face to face interview

and semi structured interview schedule. The results show that the prevalence of

uterine prolapse was reported to be 11.7%, the mean age of the respondents was 38.83

years ,majority of the respondents (30.7%)were of age between 21 to 30 years and

only 3.3% were below 20 years .Majority Of the respondents were Brahmin having 39

% of the total respondents followed by Dalits with 21.7%.large numbers of the

respondents were literate (74.7%).Maximum respondents educational level was

primary level (49%) and least with bachelor degree. Half of the respondents were

indulging in agriculture and a quarter of them were housewives. The major source of

more than half (51%) of the respondents was agriculture and 52.3% were living in
28
joint families.

Ravindran TK, Savitri R, Bhavani A conducted a qualitative study to assess

perceptions of causes of uterine prolapse among 37 women experiences of utero-

vaginal prolapse in Tamil Nadu, India .The result revealed that clinical examination
31

confirmed a diagnosis of uterine prolapse in 32 women. All the women worked as

wage labourers in agriculture. The mean age at which the women had developed

symptoms of the condition was 26.2yrs, and roughly 40 per cent of the women

reported to be suffering from uterine prolapse after their very first or second

deliveries. The finding show that strenuous manual work after delivery was an

important factor associated with uterine prolapse, alongside factors such as frequent

childbearing, or trauma to the pelvic floor following surgery. Uterine prolapse

seriously compromises the quality of life of the women affected. There were a series

of barriers to medical help for uterine prolapse, ranging from women’s reluctance to

seek treatment and lack of familial support, to ineffective treatment and high
29
monetary and opportunity costs.

Puri R conducted a cross sectional study to measure the prevalence of uterine

prolapse (UP), the associated risk factors and documentation of the traditional

remedies used among 368 women for the treatment of uterine prolapse in a mid

western hilly part of Nepal Manma by using designed questionnaires and simple

random sampling technique . Result revealed that the prevalence of uterine prolapse

(UP) was 22.6 %. The risk factors for uterine prolapse (p value < 0.05) were

illiteracy, multi parity, poverty, home delivery, early age at marriage, less rest time

period after delivery and smoking. Results also showed that the majority of women

(63.9%) believe in Traditional Medicine for the treatment of Uterine Prolapse.

Commonly used herbs reported were Cedrus deodara, Butea monosperma, Oxalis
13
latifolia, and Canabis sativa.

Baruwal A, Somronthong R, Pradhan S conducted s a cross sectional

analytical community based study to assess knowledge, attitude and preventive

measures of uterine prolapse among 267married women of reproductive age in the


32

mid western region of eight village development committees (VDCs) of Surkhet

district of Nepal using systematic random sampling .The results show that majority of

the respondents were in the age group 30-34(20.6%), lacked formal education

(47.2%) and more than three fourths (74.2%) were involved in farming. The

prevalence of the uterine prolapse, based on self report as well as diagnostic cases,

was found to be 24.7%. Diagnostic here means women who have had own self

diagnosed by the staff at the health center. Of this, nearly 50% had undergone
30
treatment for uterine prolapse.

Dr.Shrestha A D, Dr Lakhey B, Sharma J , Singh M, Shrestha B, Singh S,et al


conducted a case study to determine the prevalence and incidence of Uterine Prolapse
and its Socio‐Cultural determinants among 3616 women who visited Gynaecology
OPD in Tribhuvan University Teaching Hospital in Nepal during the three month
period from November 2008 to February 2010. The data was generated from primary
and secondary resources. Secondary information was taken from published reports
and documents on uterine prolapse, the primary data was generated using four tools

screening questionnaire, structured in‐depth interview questionnaire, and focus group

discussion. The study reveals that uterine prolapse is a major public health issue in

Nepal with little attention given to the problem. It is clear that women lack knowledge

about uterine prolapse. Uterine prolapse is prevalent among women from across the

country irrespective of their geographical locations. Teenage pregnancy and too many

pregnancies contributed to the occurrences of uterine prolapse. Another reason was

that most of the women delivered their babies at home assisted by untrained persons,

and most of the parturient mothers or delivering women resumed work soon after
31
delivery and had very poor nutrition.
33

Baruwal A conducted a cross sectional study to determine the prevalence of

knowledge, attitude and preventive measures of uterine prolapse among 267 married

women of reproductive age in the eight village development committees (VDCS)

Surkhet district of Nepal by using systematic random sampling by using survey

questionnaire and focused group interview. The results show that the prevalence of

uterine prolapse was 24.7%. Women had a moderate level of knowledge regarding

uterine prolapse (51.9%). The results show that knowledge in about the preventive

measures is less as compared risk factors, signs and symptoms therefore showing that

more awareness programs are needed in the area. Focus group revealed that though

women had knowledge about uterine prolapse, they could not practice it due to lack of
2
help from family members including her husband.

Bodner-Adler B, Shrivastava C, Bodner K conducted a case analytical study to

find out the risk factors of uterine prolapse among women in Nepal. The results reveal

that during three months, 96 women were diagnosed and treated with uterine prolapse

and the risk factors for prolapse was age 50 yrs, smoking, postmenopausal 35%,

hypertension 16%, diabetic mellitus 5%, COPD 16%, heavy working during

pregnancy and puerperium, maternal weight, and majority of women were of Newari

origin 84%. The disbursement of extensive information, preventive programs and

early management of uterine prolapse should be the first steps to reduce this
32
significant, social and public health problem .
34

Section II: Literature related to symptoms, management and prevention of

uterine prolapse.

Karki S, Neraula A conducted a descriptive study to assess the awareness

regarding uterovaginal prolapse among 118 parous women in Bhaktapur Municipality

in Bhaktapur, Nepal using Systematic random sampling technique by using semi-

structured interview schedule. The result shows that majority of the respondents

(68%) reported that foul vaginal discharge and 64.9% reported feeling of something

coming out per vagina and backache/abdominal pain, 63.9% reported difficulty in

voiding or urinary incontinence, 62.9% and 56.7% reported difficulty in walking and

feeling of pelvic heaviness. However more than half of the respondents were unaware

of the sign and symptoms of uterovaginal prolapse such as constipation and less desire

for intercourse. Majority of the respondents (84.5%) who responded that uterovaginal

prolapse can be prevented by avoiding heavy loads during postpartum periods

followed by 83.5% who reported that medical attention should be sought as soon as

problem is noticed, 81.4% replied that nutritional diet, regular exercise and hygiene

should be maintained in the antenatal period and 79.4% replied delivery should be

done by trained health personnel. In same way 74.2% reported problem such as

constipation, obesity and chronic cough should be cured in time followed by 72.2% of

the respondents who reported that food rich in fibre and intake of plenty of water can

prevent uterovaginal prolapse, 56.7% of respondent were aware about keeping tight

pessary in vagina and more than 50% were not aware that regular exercise of pelvic

organ can prevent uterovaginal prolapsed. Thirty nine percentage (39%) reported

having rest during postpartum period, not doing heavy work during pregnancy and

postpartum period (36%), marrying at appropriate age (31%), having nutritious food,

care during antenatal and postpartum period (22%) women should go


35

hospital for treatment when she suffers from uterovaginal prolapse. And 62.9%

reported that drugs alone cannot cure the uterovaginal prolapse. Most of the

respondents (63.9%) responded that cystocele is the complication of uterovaginal

prolapse, 58.8% reported hemorrhoids, 55.1% reported secondary infection and


14
36.1% reported rectocele as complication of uterovaginal prolapse

Wiegersma M,R Panman C M C,Kollen BJ,Berge M Y,Leeuwen Y L V,Dekker

JH et al conducted a randomized control trial to compare the effects of pelvic floor

muscle training and watchful waiting (no treatment and no recommendation)on pelvic

floor symptoms among 287 women age of 55 years or over with symptomatic mild

prolapse in Dutch primary care The participants,145 women was allocated to pelvic

floor muscle training and 142 to watchful waiting..The result shows that of 287

women who were randomized to pelvic floor muscle training (n=145) or watchful

waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention

group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) than did

participants in the watchful waiting group (P=0.005). Of women in the pelvic floor

muscle training group, 57% (82/145) reported an improvement in overall symptoms

from the start of the study compared with 13% (18/142) in the watchful waiting group

(P<0.001). Other secondary outcomes showed no significant difference between the

groups. Women with mild prolapse who received pelvic floor muscle training showed

greater improvement in symptoms than those who belong to watchful


33
waiting.

Sharma A, Zhang J P conducted a study to explore the risk factors and

symptoms of uterine prolapse experience by Nepali women. The results shows that

the women suffering from uterine prolapse presented with a variety of physical

symptoms like backache, difficulty in standing, sitting and walking, difficulty in


36

lifting, vaginal foul smelling discharge/itching, sore or ulcer in protrusion of tissue,

painful intercourse, burning micturition, urinary incontinence, and difficulty in

passing stool. The study also shows that psychological dimensions of life is also

affected by uterine prolapse. The psycho-social problems faced by women include

stress, emotional isolations, abandonment by husband or divorce, ridicule and shame,

inability to work, lack of economic support, risk of violence and abuse and more
2
notably discrimination.

Chhabra S, Ramteke M, Mehta S, Bhole N, Yadav Y conducted a meta

analysis to investigate the trends of vaginal hysterectomy for genital prolapse in

Maharashtra (India), in the year 2013, by analyzing the case records of affected

women for the last 20 years. During the analysis period, 4831 women underwent

hysterectomy. Of these, 911 (21.6%), had vaginal hysterectomy for genital prolapse

(study subjects). Eighty percent (80%)women who had vaginal hysterectomy for

genital prolapse were over 40 years of age. Only 4 (0.4%) women had not given birth,

874 (96%) women had had two or more births, and 383 (42%) had 5 or more births.

Having given birth was the major factor responsible for genital prolapse. In all, 94.2%

of women presented with something coming out of the vagina.” Some women

presented with abnormal vaginal bleeding or pain in abdomen as the chief


34
complaints.

Shrestha B, Onta S, Choulagai B, Poudya A, Pahari D P,Uprety A, et al

conducted a study to explore women’s experiences of uterine prolapse and its effect

on daily life, its perceived causes, and health care-seeking practices in a hill district of

Nepal among women of aged 23-82years by using semi-structured, in-depth

interviews and convenience sampling. The results shows that twenty-four percent

were literate, 47.2% had experienced a teenage pregnancy, and 29% had autonomy to
37

make healthcare decisions. Most participants (>85%) described the major physical

discomforts of uterine prolapse as difficulty in walking, standing, working, sitting,

and lifting. They also reported urinary incontinence (68%) bowel symptoms (42%),

and difficulty in sexual activity (73.9%). Due to inability to perform household chores

or fulfil their husband’s sexual desires, participants endured humiliation, harassment,

and torture by their husbands and other family members, causing severe emotional

stress. Following disclosure of uterine prolapse, 24% of spouses remarried and 6%

separated from the marital relationship. The study concluded that uterine prolapse

adversely affects daily life and negatively influences their physical, mental, social
35
wellbeing.

Frawley H, Galea M P ,Janet Logan, DonaldA M C ,Pherson G M , Moore K

H, et al conducted a randomized control study to establish the effectiveness of one-to-

one individualized pelvic floor muscle training for reducing prolapse symptoms

among 824 women at 23 centers in the UK .The eligible patients (447) were

randomized to the intervention group (n=225) or the control group (n=222). Three

seventy seven( 377), (84%) participants completed follow-up for questionnaires at 6

months and 295 (66%) for questionnaires at 12 months. The results show that the

women in the intervention group reported fewer prolapse symptoms (ie, a

significantly greater reduction in the Pelvic Organ Prolapse Symptom Score [POP-

SS]) at 12 months than those in the control group (mean reduction in POP-SS from

baseline 3·77 [SD 5·62] vs 2·09 [5·39] . Eight adverse events (six vaginal symptoms,

one case of back pain, and one case of abdominal pain) and one unexpected serious

adverse event, all in women from the intervention group, were regarded as unrelated
36
to the intervention or to participation in the study.
38

Good MM, Korbly N, Kassis NC, Richardson ML, Book NM, Yip S, et al

conducted a cross-sectional study to describe the basic knowledge about prolapse and

attitudes regarding the uterus among 213 women seeking care for prolapse symptoms

in University of Texas South western Medical Center by using self-administered

questionnaire. The result revealed that the overall mean knowledge score was 2.2 ±

1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly

responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises

(34.3%) prolapse treatment options for prolapse. Prior evaluation by a female pelvic

medicine and reconstructive surgery specialist and higher education was associated

with a higher mean knowledge score. For attitude items, the overall mean score was

15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is

important for sex. The majority disagreed with the statement that the uterus is

important for a sense of self (60.1%); that hysterectomy would make me feel less

feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%).

Previous consultation with a female pelvic medicine and reconstructive surgery


37
specialist was associated with a higher mean benefit of uterus score.

Radl CM, Rajwar R, Aro A R conducted a qualitative study on primary and

secondary prevention of uterine prolapse among 71 women in Eastern Nepal using

convenience sampling technique and group discussions and interview. The result

revealed that patriarchy, gender discrimination, and cultural traditions such as early

marriage and pregnancy make it difficult for people to discontinue risk behaviour of

uterine prolapse risk behaviours. Women are aware of risk factors, prevention, and

treatment, but are powerless to change their situations. Health professionals and

women are fond of surgery as treatment, but opinions on the use of ring pessaries and

38
pelvic floor muscle training are split.
39

Hagen S, Stark D, Maher C, Adams E conducted a randomised and quasi-

randomised trials study in women with pelvic organ prolapse to determine the effects

of conservative management (physical interventions and lifestyle interventions) for

women with pelvic organ prolapse in comparison with no treatment or other treatment

options (such as mechanical devices or surgery). Two reviewers assessed all trials to

inclusion or exclusion and methodological quality. Data were extracted by the lead

reviewer onto a standard form and cross checked by another. Disagreements were

resolved by discussion. Data were processed as described in the Cochrane Handbook

for Systematic Reviews of Interventions. Three trials of relevance to this review were

identified. The largest of these, of pelvic floor muscle training in preventing anterior

prolapse from worsening, had significant limitations which affect the generalisability

and rigor of the findings. A small feasibility study (which is to be followed up with a

larger trial) randomised 47 women to pelvic floor muscle training or control and

found suggestions of better outcomes (better self-reported improvement, decreased

severity) in the intervention group. The third trial evaluated peri-operative

physiotherapy for women undergoing surgery for prolapse and/or incontinence. The

authors report that urinary symptoms, pelvic floor muscle function and quality of life

were improved more in the treatment group than the control group, but data were not

provided to allow this to be assessed.39

Meyer S, Hohlfeld P, Achtari C, De Grandi P conducted a study among 107

women, at Switzerland which stated that 51 women (47.66%) were educated about

pelvic floor exercises and 56 women (52.33%) were not imparted knowledge

regarding pelvic floor exercises. The women who had the knowledge of pelvic floor

exercises experience significant reduction in the incidence of symptoms of


40

uterovaginal prolapse compared with women who did not have knowledge of
40
uterovaginal prolapse.

Powers K, Lazarou G, Wang A, LaCombe J, Bensinger G, Greston WM,et al

conducted a comparative study to review the experience with pessary use for

advanced pelvic organ prolapse at Albert Einstein College of Medicine, Bronx, USA

using Charts of patients treated for Stage III and IV prolapse. Comparisons were made

between patients who tried or refused pessary use. Thirty-two patients tried a pessary;

45 refused. Patients who refused a pessary were younger, had lesser degree of

prolapse, and more often had urinary incontinence. Most patients (62.5%) continued

pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery

included four patients (33%) with unwillingness to maintain, three patients (25%)

with inability to retain and two patients (17%) with vaginal erosion and/or discharge.

The findings suggest that pessary use is an acceptable first-line option for
41
treatment of advanced pelvic organ prolapse.

Crepin G, Cosson M, Lucot JP, Collinet P conducted a study about genital

prolapse among patients under 50 years of age with genital prolapse represent about

25% of candidates for surgical reconstruction in University of Tempere, Finland. Five

per cent of these women, all fewer than 35, have isolated hysterocele and a

hypertrophic uterine cervix. It focuses on the etiology, prevention and new surgical

treatments of genital prolapse in young women. Etiologies include late age at first

pregnancy, chronic lung disease, and perineal damage during delivery. New surgical

procedures include vaginal repair with synthetic mesh. Laparoscopic sacropexy is still

the gold standard. Prevention includes non-traumatic delivery (Caesarean section),


42
while pelvic floor exercises are mandatory after vaginal delivery
41

Ottesen M conducted a randomized study to determine the effects of pelvic

floor muscle training for women with symptoms or urodynamic diagnoses of stress,

urge and mixed incontinence, in comparison to no treatment or other treatment

options.. The study concludes that pelvic floor muscle training was better than no

treatment or placebo treatments for women with stress or mixed incontinence. Pelvic

floor muscle training appeared to be an effective treatment for adult women with

stress or mixed incontinence.43

Pratee S,Bansal R, Batra A, Minocha B conducted a retrospective study to

analyze the incidence, diagnosis, treatment and management given, morbidity and

mortality amongst the female patients aged 60 years and above admitted in one of

three units of the department of OBG Safdarjang Hospital New Delhi . Among the

1175 admitted patients ,78 were selected after diagnosis. Out of them 79.7% were

between 60-65 years, 16.66% were between 65-70 years of age and only 3.7% were

more than 70 years of age. Findings were 44.8% with genital tract malignancies,

34.2% with uterovaginal prolapse and 21 .2 % with other benign disorders. The study

results showed malignancy was the commonest problem followed by uterovaginal

prolapse and stated that cases of uterine prolapse can be markedly reduced by proper

obstetric care. Finally study concluded that health care personnel who interact with

women during menopause may play a great role by in corporating them into the

regular health care system, maintenance of continuity of care, appropriate referrals


44
when needed and supervision of cost effectiveness of care.

Piya-Anant M, Therasakvichya S, Phatandit LC, Techatrisak K conducted a

crosssectional study to determine the prevalence of uterine prolapse and the

effectiveness of pelvic floor exercise to prevent worsening of uterine prolapse among

682 multiparous women. in Siriraj hospital, Bangkok, Thailand. Of 682 women,324


42

subjects in the control group and 330 subjects in the experimental Group. The

experimental group received training in pelvic floor exercise and were asked to

perform the exercises 30 times after a meal, every day for 24 months. After 24 months

of pelvic floor exercises, the rate of worsening of uterine prolapse was 72.2% in the

control group and 27.3% in the experimental group. A 24 months pelvic floor excise

programme was effective to prevent worsening of uterine prolapse in the women who
45
had severe uterine prolapse.

Handa VL, Jones M conducted a study to describe the course of uterine

prolapse among women using a pessary among 56 consecutive women fitted with a

pessary for at least one year. Nineteen (19) continued its use under our care of at least

1 year. The researcher compared baseline and follow-up examination, using the

uterine prolapse quantification examination system. At baseline 16(84.2%) had stage

3 or 4 prolapse after one year observed a significant improvement in stage. No women

had worsening in stage of prolapse. These study suggest that there may be a
46
therapeutic effect associated with the use of a supportive pessary.

Oliveira D C, Lopes B A M ,Pereira L C L, Zugaib M conducted an

interventional study to evaluate the effect of pelvic floor muscle training among 46

nulliparous pregnant women in an exercise group and a control group. Functional

evaluation of the pelvic floor muscle was performed by digital vaginal palpation using

the strength scale described by Ortiz and by a perineometer . The results shows that

the functional evaluation of the pelvic floor muscles showed a significant increase in

pelvic floor muscle strength during pregnancy in both groups (P < .001). However, the

magnitude of the change was greater in the exercise group than in the control group

(47.4% vs. 17.3%, P < .001). The study also showed a significant positive correlation

(Spearman's test, r = 0.643; P < .001) between perineometry and digital


43

assessment in the strength of pelvic floor muscles .Pelvic floor muscle training

resulted in significant increase in pelvic floor muscle pressure and strength during
47
pregnancy.

Roets L conducted a qualitative study to describe the experiences of women

with a diagnosis of genital prolapse among women in the ages of 40 and 80years using

convenience sampling and in-depth interviews . The result shows that quality of life

and social behaviour may be negatively influenced. The self-image of a woman with

genital prolapse is affected and emotions that include anxiety, aggression, frustration

and despondency may be experienced. Urinary incontinence compelled some of the

respondents to wear sanitary pads, and often restricted their social lives. Urinary

incontinence is one of the most common symptoms of genital prolapse, but urinary

retention, urinary tract and vaginal infections, anal incontinence, constipation


48
and a spastic colon were also experienced by participants in this study.

Section III: Literature related to barriers of health seeking behaviour on uterine

prolapse

Subedi A conducted a cross sectional study to measure the barriers in seeking

treatment with uterine prolapse among 160women between age group of 26-86 years

in Bungmati, Chhampi, Khokana, Lubhu, Harisiddhi and Imadol village development

committee (VDCs) of Lalitpur district using purposive sampling technique by using

the pencil and paper based semi- structured questionnaire. The result shows that

barriers for access to treatment were individual like lack of knowledge and perception

about Uterine Prolapse as normal due to heavy work load, weakness, no pain, it would

go inside itself etcetera. They found more concern about the household autonomy and

much careless was about their health. Some of them were much scared of surgery.
44

Many of them did not know what it was. There is association between knowledge and
49
visiting Health Facility.

Shrestha B, Onta S , Choulagai B, Poudya A, Pahari D P,Uprety A. et al

conducted a study to explore women’s experiences of uterine prolapse and its effect

on daily life, its perceived causes, and health care-seeking practices in a hill district of

Nepal among women of age 23-82yrs by using semi-structured , in-depth interviews

and convenience sampling. The results show that the causes of uterine prolapse were

unsafe childbirth, heavy work during the postpartum period, and gender

discrimination. Prior to visiting these camps some women (42%) hid uterine prolapse

for more than 10 years. Almost half (48%) of participants sought no health care; 42%

ingested a herb and ate nutritious food. Perceived barriers to accessing health care

included shame (48%) and feeling that care was unnecessary (12.5%). Multiple

responses (29%) included shame, inability to share, and male service provider, fear of

stigma and discrimination, and perceiving uterine prolapse. as normal for childbearing

women. The study concluded that the effective development of uterine prolapse

awareness programme to increase service utilization at early stage of uterine prolapse

and thereby might contribute to both primary and secondary prevention of uterine

35
prolapse.

Kumari S, Walia I, Singh A conducted a study to estimate the prevalence of

self reported uterine prolapse and to determine the treatment-seeking behaviour

among 2,990 married women of Dadu Majra colony, Chandigarh, India. Result

revealed that among the 2,990 women surveyed, 227 (7.6%) reported symptoms of

uterine prolapse. Of the 227 women with self-reported uterine prolapse, 128 (57%)

had not taken any treatment, 28 went to a traditional birth attendant (TBA), and 47

(21%) consulted a doctor. Thirty-eight women were advised to have an operation, but
45

only eight complied. Other treatments used by small numbers of women included the

use of a ring pessary or alcohol-soaked swab and heel pressure technique. Reasons for

non-consultation included shyness (80; 63%), lack of cooperation by the husband,

lack of time (80; 63%) and lack of money (74; 58%). The prevalence of prolapse was

significantly higher in women with higher parity. More than 7% of the women
50
reported symptoms of uterine prolapse.

Kaur S, Jairus R, Samuel G conducted an exploratory study to assess

reproductive morbidities and treatment seeking behaviour among 200 married women,

in the age group of 15-44 years in Jamalpur Awana rural health center of Christian

Medical College and Hospital Ludhiana, Punjab by using convenience sampling and

interview schedule. The study explored that one fourth of the woman (24.5%) suffered

from excessive vaginal discharge, followed by 18% reporting pain during

menstruation, other reported morbidities were frequent micturition in 9% and frequent

menses in 9% of the population. The study also reported health seeking behaviour on

treatment seeking behaviour depend upon the perception of individual and when they

think it is normal or non serious they do not take treatment In India, married woman

are reluctant to seek medical advice because of lack of privacy, lack of female doctor

at the health facility, the cost of treatment and their subordinates social status .The

reason for not seeking treatment among 45% women was that they did consider these

symptoms as normal followed by 16.5% who can’t afford the


1
treatment.

Bhanderi M N conducted a community based cross sectional study to assess

the reproductive health of 1046 ever married women of reproductive age group (15-

49) at slums of Rajkot city ,Gujarat using a pre-tested, structured interview schedule

women using two stage cluster sampling. The result shows that cost and
46

societal barriers were the reasons for not seeking care, whereas poor provider‘s

attitude, poor quality of services and long waiting time were the reasons for not

utilizing public health facilities. Women from low socio economic status, minority

group and distance of health facility more than two km, had lesser access to

reproductive health services compare to their counterparts. There were also other

reasons mentioned by women related to cultural practices, norms and beliefs. Many
51
reported that there was no time to go hospital because they were not decided.

Summary

Literature review revealed that uterine prolapse is a significant reproductive

health condition that affects women all over the world and this has not received

sufficient attention despite its high prevalence. Uterine prolapse affects daily life and

negatively influences their physical, mental and social wellbeing of women.

From the literature review it is clear the causes and risk factors of uterine

prolapse include multiparty ,early age at marriage, carrying heavy work load during

pregnancy, giving birth to large babies, working immediately after child birth,

pressure on lower abdomen during child birth and also poverty, home delivery,

obesity and constipation . The studies also pointed out that sternous manual work

soon after delivery was an important factor associated with uterine prolapse.

From reviews the symptoms manifested by women include foul vaginal

discharge, feeling of something coming out per vagina, backache/abdominal pain,

difficult to void or urinary incontinence, difficult to walk and feeling of pelvic

heaviness. Studies shows that both physical and psychological symptoms have direct

impact on quality of life of the women.


47

Literature review also found that management of uterine prolapse include

surgery (vaginal hysterectomy with PFR), pessary, pelvic floor muscle training. The

pelvic floor muscle training cause a significant improvement in symptoms of uterine

prolapse and appears to be an effective treatment for women with stress or mixed

incontinence. There may be therapeutic effect associated with the use of supporting

pessary. Studies also revealed that uterovaginal prolapse can be prevented by having

rest during postpartum period, not doing heavy work during pregnancy and

postpartum, nutritious diet, regular exercise, care during antenatal intrapartum and

post partum period and seeking early treatment for prolapse.

Studies also shows that secondary infection, malignancy are the problem

followed by prolapse.

From the literature review it is evident that perceived barriers for seeking

treatment include shame, feeling that care was unnecessary, lack of family support,

inability to share, male service provider, fear of stigma and discrimination and cost of

treatment, their subordinate social status.

Studies recommended the exclusive information, preventive programme and

early management of uterine prolapse should be the first step to reduce this significant

social and health problem. The health care personnel who interact with women may

play a great role by entering them into regular health care system, maintenance of

continuity of care, appropriate referrals when needed and supervision of cost effective

care.

The literature reviewed under different headings enabled the investigator to

have in depth understanding and deep insight into the problem under study. It also

helped the researcher to establish need for the study, preparation of the tool, designing
48

the conceptual model and research design, planning for data analysis and for good

discussion. The investigator has made exclusive search for the literature related to the

study and it was found that there is a dearth of studies in this area of concern

especially those of Kerala and Indian origin.


49

CHAPTER 3

METHODOLOGY

· Research approach

· Research design

· Variables

· Schematic representation of the study

· Setting of the study

· Population

· Sample and sampling technique

Inclusion criteria

Exclusion criteria

· Tools/Instruments

Development/selection of the tool

Description of the tool

· Content validity

· Reliability of the tool

· Pilot study

· Data collection process

· Plan for data analysis


50

CHAPTER 3

METHODOLOGY

Research methodology is a way to systematically solve the research problem;

it indicates the general pattern for organizing the procedure for collecting valid and
23
reliable data for investigations.

This chapter deals with the methodology adopted for the present study. It

briefly explains the research approach, research design, and variables, setting of the

study, population, sample and sampling techniques, development /selection of the

tool, description of the tool, pilot study, data collection process and plan for data

analysis.

The present study was aimed to assess the knowledge and barriers of health

seeking behaviour on uterine prolapse among married women in selected rural areas

in Kannur District.

Research Approach

Research approach is the description of the plan to investigate the

phenomenon under study in a structured (quantitative), unstructured (qualitative) or a


52
combination of the two methods (quantitative qualitative integrated approach).

Quantitative approach involves the generation of data in quantitative form

which can be subjected to rigorous quantitative analysis in a formal and rigid


53
fashion.

In non experimental research studies the researcher collects data without


52
introducing an intervention.

In view of the nature of the problem under study and to accomplish the

objectives of the study, a quantitative non experimental approach was considered

most appropriate.
51

Research Design

Research design can be defined as an overall plan or blue print the researchers
54
select to carry out their study.

The design selected for the study is descriptive survey design.

A descriptive design can provide information about the naturally occurring


55
health status, behaviour, attitudes or other characteristics of a particular group.

A survey is designed to obtain information about the prevalence, distribution,


56
and interrelation of variables within a population.

The main objective of the study was to assess the knowledge and barriers of

health seeking behaviour on uterine prolapse among married women. The researcher

did not want to manipulate any variables. These made the researcher to select a

descriptive survey design.

Variables

Variables are attributes of a person or object that varies, that is takes on


55
different values.

In this study variables refer to

1. Knowledge and barriers of health seeking behaviour on uterine prolapse

among married women.

2. Extraneous variables refers to socio personal variables such as age, religion,

education, occupation, marital status, type of family, monthly income of

family, number of children, exposure to source of information on uterine

prolapse, source of information on uterine prolapse and history of uterine

prolapse among sample and family members.

Schematic representation of the study is presented in Figure 2


52

Setting Data collection Socio personal


-Assessment of knowledge regarding variables
Selected sub centers and areas of
uterine prolapse among married Age
Chittariparamba panchayat of
women using structured interview -Religion
Kannur district .
schedule. . -Education
· Manandheri
Subcenters -Assessment of barriers of health -Occupation
· Kannavam
seeking behaviour on uterine -Marital status
· Vattoli prolapse among married women - Type of family
 Chittariparamba Areas using five point rating scale. ‐ Monthly income of
· Poovathinkeezhil family
- Number of children
Population
‐ Exposure to source
Married women in the age group of information on
of 30-60 years uterine prolapse.
Sample Distribution of
- Source of information
information booklet
371 married women on uterine prolapse
regarding uterine
Sampling technique prolapse - its causes, -History of uterine
symptoms prolapse among
Convenience sampling management and sample and her family
preventive measures. members.

52
Figure 2 : Schematic representation of the study
53

Setting of the Study

Setting refers to the physical locations and conditions in which data collection
56
has taken place.

The present study was conducted in selected subcenters and areas of

Chittariparamba panchayat in Kuthuparamba block of Kannur district.

The investigator selected subcentres –Manandheri (ward 11,12 ),Kannavam

(ward 9 ). Areas –Vattoli (ward 2), Chittariparamba ( ward 8), and P oovathinkeezhil

(ward 9 ) of Chittariparamba panchayat.

Selection of panchayat were done on the basis of

· Feasibility of conducting the study

· Accessibility of the area

· Availability of sample

· Investigators familiarity with the area.

Population:

Population is the set of people or entities to which the results of a research are
52
to be generalized.

In the present study, population is referred to married women in the age group

of 30-60 years.

Sample

Sample is a subset of population elements, which are the most basic units
55
about which data are collected.

The sample size of present study was 371 married women residing in

Chittariparamba panchayat. They were selected as per inclusion criteria of the study

Sample estimation is calculated by using power analysis

N = Z 2 × (1-P) 2
54

Confidence interval (0.05)

Z :- (1.96)2 for 95% confidence

P :- estimated proportion

N :- Number of sample.

= 371.7

Inclusion Criteria

Women

· In the age group of 30-60 years.

· Who are able to read and write Malayalam.

· Who are willing to participate in the study.

Exclusion Criteria

Women:

· Who are unmarried.

· With major gynecological illness and who have undergone hysterectomy/

Bilateral salpingo oopherectomy.

· Who are differently abled.

Sampling Technique:

Sampling technique is concerned with the selection of a subset of individuals

from within a population to estimate characteristics of the whole population.54

In the present study, convenience sampling technique was used.

Tool/ instruments:
55
A technique is a procedure used to accomplish a specific activity or task.
56
An instrument is the device used to collect data.

The technique used for data collection was self report (interview). The

instrument/ tool used was structured interview schedule to assess the knowledge
55

regarding uterine prolapse and five point rating scale to assess barriers of health

seeking behaviour on uterine prolapse.

Development / selection of the Tool

The most appropriate tool was selected based on the utility with respect to the

research problem.

The following steps were taken for the development of items and preparation of

tool.

· Reviewed research and non-research literature related to uterine prolapse.

· Reviewed several tools related to knowledge and barriers of health seeking

behaviour on uterine prolapse and gynecological morbidity.

· Formal discussion were held with guide, co-guide, experts of Obstetrics and

Gynaecology, Obstetrics and Gynaecological nursing and Community

Medicine.

· Reviewing of text books.

· Discussion and consultation with statistician

· Investigators own clinical experience.

· Discussion with local public near areas of panchayat

· Translation of tool done with the help of experts.

· The final tool was prepared with guidance and suggestion of the guides.

Description of the tools

The following tool are developed for collecting data:

Tool I

Structured interview schedule to assess the knowledge regarding uterine

prolapse among married women in selected rural areas in Kannur.

Tool I consist of two sections.


56

Section A: Socio personal data

This section consists of age, religion, education, occupation, marital status ,type

of family, monthly income of family, number of children, exposure to source of

information on uterine prolapse, source of information on uterine prolapse, history of

uterine prolapse among sample and family members.

Section B: Knowledge regarding uterine prolapse among married women.

The section consists of 20 items related to knowledge regarding uterine

prolapse (anatomy of reproductive system, causes, symptoms ,management and

prevention of uterine prolapse.) among married women.

The maximum score for interview schedule is 20 and each right answer was

given one mark and wrong answer zero.

Development of criteria for knowledge score

In order to achieve the objectives of the study, opinion from statistician, guide,

and experts were taken to categorize the sample according to their knowledge. The

score was categorized on arbitrary basis as follows.

Table 1

Interpretation of knowledge score

Sl No Range of Score Percentage Level of knowledge

1 0-6 0-30% Inadequate

2 7 – 13 31 -65% Moderate

3 14 – 20 66 - 100% Adequate

As represented in the table 1, the knowledge scores of married women 0-30% was

considered as inadequate, 31-65% moderate, and 66-100% was considered adequate

knowledge regarding uterine prolapse.


57

Tool II

Rating scale to assess the barriers of health seeking behaviour on uterine

prolapse among married women.

It is a five point rating scale to assess the barriers of health seeking behaviour

on uterine prolapse among married women.

The rating scale consists of 24 statements arranged under seven areas

reflecting barriers of health seeking behaviour on uterine prolapse among married

women. The seven areas of barriers of health seeking behaviour on uterine prolapse

are:

Area 1: Three statements on knowledge and awareness

Area 2: Five statements on embarrassment and fear

Area 3: Four statements on attitude and beliefs

Area 4: Three statements on lack of support and peer pressure

Area 5: Three statements on time and cost

Area 6: Four statements on cultural factors

Area 7: Two statements on accessibility to health care facility.

The investigator rate the barrier statement according to the agreement on each

statement expressed by the respondents based on points, Strongly agree = 5;Agree= 4;

Uncertain = 3; Disagree = 2;strongly disagree = 1.All the statements carried a score of

five to one with a maximum total score scale is 120 and minimum score is 24.

Development of criteria for barrier score:-

In order to achieve the objectives of the study, opinion from statistician, guide,

and experts were taken to categorize the sample according to their barriers of health

seeking behaviour. The score was categorized on arbitrary basis as follows,


58

Table 2

Interpretation of barrier ratings

Sl No Range of Score Percentage Level of barrier

1 24-56 20-46% Mild

2 57-88 47-73% Moderate

3 89-120 74-100% Strong

As represented in the table 2, the barrier score 20-46% was considered as mild

barrier, 47-73% moderate barrier and 74-100% considered as strong barriers of health

seeking behaviour on uterine prolapse among married women.

Preparation of the Blue print:


A blue print on structured interview schedule was prepared consisting of 20

items. It depicted the distribution of items according to the content areas on three

domains as knowledge, comprehension and application.

A blue print on structured interview schedule items regarding uterine prolapse

was prepared which consists of causes, symptoms, management and preventive

aspects of uterine prolapse among married women. The knowledge domain had 9

items (45%), comprehension had 4 items (20%), and application domain had 7 items

(35%) covering all the aspects of uterine prolapse.

Development of criteria for checklist

A criteria checklist was developed to validate the tool regarding accuracy,

relevance, and appropriateness of the content. Criteria check list consisted of four

columns namely very relevant, somewhat relevant, and not relevant. Experts were
59

requested to give their valuable suggestions and opinions. Based on the suggestions

and recommendations from the experts, the tool was modified.

Content validity

Validity is the degree to which an instrument measures what it is supposed to


56
measure.

Content validity of the structured interview schedule and rating scale was

established in consultation with eight experts in the field of Obstetrics and

Gynaecological nursing, Obstetrics and Gynaecology, Community Medicine, and

Psychiatric Nursing .The experts were requested to judge the items for accuracy,

relevance, appropriateness of content and degree of agreement. The suggestions of the

experts were incorporated in to the tool and the tool was modified accordingly.

The final draft of the tool consisted of 20 items related to anatomy of female

reproductive system, causes, symptoms, management and prevention of uterine

prolapse and 24 statements under seven areas in five point rating scale to assess

barriers of health seeking behaviour on uterine prolapse among married women.

Ethical clearance:

Approval was obtained from the institutional ethics committee to conduct the

research study. Permission was also obtained from the panchayat president of

Chittariparamba panchayat to conduct the study. Individual consent was taken from

the sample before the data collection.

Reliability of the tool

Reliability of an instrument is the degree of consistency with which it


54
measures the attribute it is supposed to measures.

To establish reliability of tool, it was administered to 30 married women other

than study sample. Reliability coefficient of the interview schedule was established by
60

split half method using Spearman-Brown Prophecy formula and was found to be 0.65.

The reliable coefficient of rating scale was estimated using Cronbach’s alpha

correlation coefficient formula and was found to be 0.75.

Preparation of the final draft

The final draft of the tool was prepared incorporating the modifications

suggested by experts.

Translation of the tool

Tool I and II was translated to Malayalam and retranslated to English with the

help of language experts. It was found that the tool was valid regarding language and

was equally semantic in both language.

Pretesting of the tool

The trial administration of a newly developed instrument to identify flaws or


54
assess time requirements.

The pretesting of the validated tool was done among five married women at

ward 9 of Chittariparamba under Chittariparamba panchayat on 23-01-2015, to

determine the clarity of item, feasibility, ambiguity and time required to complete the

items. The researcher herself collected data using structured interview schedule and

five point rating scale. The language was clear and simple. The women were able to

understand and respond to items clearly. The average time taken for the interview was

20-30 minutes.

Pilot study

A pilot study is a small -scale version or a trial run done designed to test the
55
methods to be used in a larger, more rigorous in preparation of the complete study.

After obtaining administrative permission from the Panchayat President of

Mangattidam Panchayat and approval from the ethics committee, a pilot study was
61

conducted at ward 6 of Ayithara, a rural community area of Mangattidam Panchayath

of Kannur district on 25.01.15 and 26.01.15.

After explaining the purpose of the study and willingness to participate in the

study, 30 married women were interviewed using interview schedule and barrier

rating scale. The data collected were tabulated and analyzed using descriptive and

inferential statistics.

Pilot study revealed the appropriateness of the methodology selected, clarity

and comprehensiveness of the tool and information booklet. The collected data were

amenable to statistical analysis. Hence the study was found feasible.

Data collection process

Data collection is a process of gathering of information to address a research


52
problem.

The study was conducted after getting approval from the institutional ethics

committee and formal administrative permission from Chittariparamba panchayath

president. The investigator selected ward 11,12 and ward 9 of Manandheri and

Kannavam subcenters and ward 2,8,9 of Vattoli, Chittariparamba and

Poovathinkeezhil areas of Chittariparamba panchayat. Data collection period was

from 31.01.15 to 18.03.15.

Data was collected from 371 women residing in Chittariparamba panchayat by

using convenience sampling and descriptive survey approach. The rural areas were

acquainted with the help of Kudumbasree members and anganwadi workers of

particular areas.

Investigator visited each house, identified women based on inclusion criteria.

The purpose of the study was explained and confidentiality was ensured. After

obtaining written informed consent, data was collected using interview schedule and
62

rating scale. It took 20-30 minutes for conducting interview for each subject.

Investigator had interviewed 10-15 samples per day. The investigator took 5-13 days

for the interview in one area. After interview has completed, both individual and

group health education was given on the causes, symptoms, management and

prevention of uterine prolapse followed by the distribution of information booklets.

Group health education was given with the help of kudumbasree workers of the

concerned area on all Sundays. Kudumbasree workers of concerned area organised a

meeting where health education was given to all married women who have undergone

data collection. This pattern was followed during entire data collection period.

Initially, the investigator collected data from ward 11 and 12 of Manandheri

subcenters of Chittariparamba panchayat. Here the investigator spends 13 days for

interview and obtained data from 113 married women.

The second area was at ward 9 of Kannavam subcenter. Here investigator

conducted interview for five days and collected data from 70 subjects.

The next region was at ward number 8 and 9 of Poovathinkeezhil area of

Chittariparamba panchayat. Here the investigator spent 6 days for interview and

collected data from 100 subjects.

The investigator collected data from ward 2 of Vattoli, area of Chittariparamba

panchayat. Here the investigator spends 2 days for interview and obtained data from

20 subjects.

The investigator took 10 days for interview and collected data from 68

subjects in ward 8 of Chittariparamba.

All the subjects were co-operative, they were able to understand and respond

to items clearly and clarified their doubts. Investigator was able to complete data
63

collection, and health education without much difficulty with the help of kudumbasree

and anganwadi workers.

Distribution of information booklet

The investigator developed an information booklet an educational material

which is easily understood and helps to improve awareness regarding uterine prolapse

and its causes, symptom, management and preventive aspects after reviewing various

books, journals, web and research studies. The content was validated by experts in

Obstetrics and Gynaecology and Obstetrics and Gynaecological Nursing and also by

the Proof editors. It was distributed to all the subjects after interview and health

education.

Plan for data analysis

Analysis is the process of organizing and synthesizing the data so as to answer


52
research questions and test hypothesis.

Data would be analyzed by using descriptive and inferential statistics.

Socio- personal variables would be analyzed in terms of frequencies and

percentage.

Analysis of knowledge score regarding uterine prolapse among married

women using mean and standard deviation

Analysis of barriers of health seeking behaviour on uterine prolapse among

married women using mean and standard deviation.

Correlation between knowledge and barriers of uterine prolapse among

married women would be analysed using Karl Pearson’s coefficient of

correlation.
64

Association between knowledge regarding uterine prolapse among married

women and selected socio personal variables would be analysed using chi-

square test.

Association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio personal variables

would be analysed using chi- square test.


65

CHAPTER 4

ANALYSIS AND INTERPRETATION


66

CHAPTER 4

ANALYSIS AND INTERPRETATION


Analysis is defined as the process of organizing and synthesizing data in such
56
a way that research questions can be answered and hypotheses tested.

Interpreting the findings is the most challenging and least structured step in
56
the findings which requires the investigator to be creative.

This chapter deals with the analysis and interpretation of data collected to

assess the knowledge and barriers of health seeking behaviour on uterine prolapse

among married women in selected rural areas in Kannur. The data collected from 371

women using a structured interview schedule and rating scale was organized,

tabulated, analyzed and interpreted using descriptive and inferential statistics.

The findings of the study have been presented under the following sections:-

Section I:- Socio personal characteristics of sample.

Section II:- Analysis of knowledge score regarding uterine prolapse among

married women.

A:- Assessment of knowledge score regarding uterine prolapse among married

women.

B:- Analysis of knowledge score regarding uterine prolapse among married

women in terms of mean ,SD and mean percentage.

Section III:- Analysis of barriers of health seeking behaviour score regarding

uterine prolapse among married women.

A:- Assessment of barriers of health seeking behaviour score on uterine

prolapse among married women.


67

B:-Area wise analysis of barrier of health seeking behaviour score on uterine

prolapse among married women in terms of mean, SD and mean

percentage.

Section IV: Testing of hypothesis.

A: Correlation between knowledge and barriers of health seeking behaviour

on uterine prolapse among married women

B : Association between knowledge regarding uterine prolapse among

married women and selected socio-personal variables

C : Association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio-personal variables

Section I : Socio personal characteristics .

This section deals with the distribution of subjects according to socio personal

characteristics such as age, religion, education, occupation, marital status, type of

family, monthly income of family, number of children, exposure to source of

information on uterine prolapse, source of information on uterine prolapse, family

history of uterine prolapse, history of uterine prolapse among sample and family

members affect with uterine prolapse. The data was analyzed using frequency and

percentage and summarized in the following tables and figures.


68

Table 3

Distribution of sample according to age, religion, education and occupation.


(n = 371)
Socio- personal characteristics Frequency Percentage

Age

a) 30-40 Years 168 45.3

b) 41-50 years 37 36.9

c) 51-60 Years 66 17.8

Religion

a) Hindu 309 83.3

b) Muslim 62 16.7

c) Christian - -

d) Others - -

Education

a) Primary Education 69 18.6

b) High School 156 42

c) Higher Secondary 63 17

d) College 70 18.9

e) Professional/ Technical 13 3.5

Occupation

a) Home maker 170 45.80

b) Manual labour 77 20.80

c) Private employee 36 9.70

d) Govt. Employee 88 23.70

Data presented in table 3shows that 45.3% of subjects are in the age group of

30-40years,36.9% belongs to the age group of 41-50 years and 17.8% are in the age
69

group of 51-60years. Majority of the sample (83.3%) belongs to the Hindu religion,

16.7 % of the sample are Muslims. Forty two percentage (42%) women had high

school education, 18.9% had college education, 18.6% had primary education, 17%

and 3.5% of the sample had higher secondary education and professional /technical

qualifications. Most of the sample (45.80%) are homemakers, 20.80% are manual

labour, 9.7% private employees and 23.70% are government employees.

a. Marital status

1.60%
8.60%

Married
Widow
Seperated /Divorced

89.90%

Figure 3: Distribution of sample according to marital status.

Data presented in figure 3 shows that majority of the sample (89.90%) are

married, 8.60% widows, 1.60% are to separated/divorced.


70

b. Type of family

4.30%

31.30%

Nuclear family
Joint family
Extended family

64.40%

Figure 4 : Distribution of sample based on type of family

Data presented in figure 4 shows that 64.40% of the sample belongs to nuclear

family, 31.30% belongs to joint family and 4.30% to extended family.


71

c. Monthly income of family

3.50%
11.10%

≤ 5000
5001-10,000
10001-20,000
>20001
26.40%

59.00%

Figure 5: Distribution of sample according to monthly income of family

Figure 5 depicts that most of the sample (59.0%) have monthly income

Rs≤5000, 26.40 % of the sample belongs to the income group of Rs. 5001 -10,000,

11.1% have and income of Rs 10001-20,000 and 3.50% have more than Rs 20,000 as

their monthly income.


72

d. Number of children
60 56.1%

50

40
Percentage

30

20
15.6% 16.2%

10 7.5%
4.6%

0
Nil One Two Three Four/more
Figure 6: Distribution of sample according to number of children

Figure 6 reveals that most of the samples (56.1%) have two children, 4.6%

have no children.
73

e. Exposure to source of information on uterine prolapse

47.20% yes
52.80% No

Figure 7: Distribution of sample according to exposure to source of information

on uterine prolapse

Figure 7 depicts that 52.80% do not have any exposure to source of

information on uterine prolapse and 47.2% have exposure to source of information on

uterine prolapse.
74

f. Source of information regarding uterine prolapse


50.00%
46.30%
45.00%
40.00% 35.40%
35.00%
30.00%
Percentage

25.00%
18.30%
20.00%
15.00%
10.00%
5.00%
0.00%
Hea lth personnel Friends /relatives Media /magazine
Figure 8: Distribution of sample based on source of information regarding

Uterine prolapse.

Data presented in figure 8 shows that 35.4% of sample responded as health

care personnel being their major source of information, 46.3% of sample received

information from frie nds / relatives and 18.3% considered maga zine and medias as

their source of inform ation.


75

g. History of uterine prolapse among sample and family members affected with

prolapse

3.50%

Yes
No

96.50%

Figure 9: Distribution of sample based on family history of uterine prolapse

Figure 9 shows that of 371 sample ,3.5% of the women have history of uterine

prolapse in their family.

Sample
23.10%
30.80% Sister
23.10% Mother
23.10% Mother in law

Figure 10: Distribution of sample based on history of uterine prolapse and family

member affected with uterine prolapse.

Figure 10shows that of 371 sample only 13 reported uterine prolapse and also

their family members affected with uterine prolapse. Of the 13 subjects, four (30.8%)

reported to be affected with uterine prolapse and having undergone surgery. Nine

(three sample each) reported that their sister (23.10%), mother (23.10%) and mother

in law (23.10%) are having uterine prolapse.


76

Section II:- Analysis of knowledge score regarding uterine prolapse among

married women.

A:- Assessment of knowledge score regarding uterine prolapse among married

women.

B:- Analysis of knowledge score regarding uterine prolapse among married

women in terms of mean ,SD and mean percentage.

A:- Assessment of knowledge score regarding uterine prolapse among married

women.

Table 4

Assessment of knowledge score regarding uterine prolapse among married

women ( n=371)

Range of score Percentage Level of Number of Percentage

Score Knowledge respondents

0-6 0-30 Inadequate 21 5.7

7-13 31-65 Moderate 285 76.8

14-20 66-100 Adequate 65 17.5

Data presented in table 4 shows that majority of the subjects (76.8%.) have

moderate knowledge, 17.5% of them have adequate knowledge and 5.7% have

inadequate knowledge regarding uterine prolapse.


77

B:- Analysis of knowledge score regarding uterine prolapse among married women

in terms of mean ,SD and mean percentage

Table 5

Mean ,SD and mean percentage of knowledge score regarding uterine prolapse

among married women

(n=371)

Variable Mean SD Median Mean %

Knowledge regarding 11.0 2.638 11.0 54.99

Uterine prolapse

From table 5 it is clear that the mean percentage of total knowledge score is

54.99% with mean± SD of 11.0±2.638. Hence it is evi dent that knowledge regarding

uterine prolapse is moderate among married women .

Section III:- Analysis of barriers of health seeking behaviour score on uterine

prolapse among married women.

A:-Assessment of barriers of health seeking behaviour score on uterine

prolapse among married women.

B:-Area wise analysis of barrier of health seeking behaviour score on uterine

prolapse among married women in terms of mean, SD, and mean

percentage.
78

A:- Assessment of barriers of health seeking behaviour score on uterine prolapse

among married women.

Table 6

Assessment of barriers of health seeking behaviour score on uterine prolapsed

among married women

( n=371)

Range of score Percentage Level of Number of Percentage

score(%) barrier respondents %

24-56 20-46 Mid 261 70.4

57-88 47-73 Moderate 98 26.4

89-120 74-100 Strong 12 3.2

From the table 6 it is evident that majority of sample (70.4%) have mild

barriers, 26.4% have moderate barriers and 3.2% of sample have strong barriers of

health seeking behaviour on uterine prolapse.


79

B:-Area wise analysis of barrier score of health seeking behaviour on uterine prolapse

among married women in terms of mean, SD, mean percentage.

Table 7

Area wise mean, SD, mean percentage of barrier of health seeking behaviour on

uterine prolapse among married women.

(n = 371)
Sl No Barrier area Mean SD Median Mean

Percentage

1 Knowledge & awareness 5.34 2.791 4.0 35.60

2 Embarrassment, fear 11.69 4.933 11.0 46.77

3 Attitude and benefits 7.72 3.440 8.0 38.58

4 Lack of support and peer 4.99 2.390 4.0 33.26

pressure

5 Time and cost 5.50 3.173 4.0 36.66

6 Cultural factors 8.65 3.908 8.0 43.27

7 Accessibility to health care 4.50 2.737 4.0 44.99

facility

Total 48.39 18.367 43 40.33

The data presented in the table 7 shows that the mean percentage of the total

score on barriers of health seeking behaviour on uterine prolapse among married

women is 40.33 with mean ± SD of 48.39 ±18.367. Are a wise mean percentage of

barriers of health seeking behaviour score is 35.60% with mean± SD of 5.34 ± 2.791

in the area of knowledge and awareness. In the area of embarrassment and fear, mean

percentage of barrier score is 46.77% with a mean ± SD of 11.69 ± 4.933. Mean

percentage of barrier score is 38.58% with a mean ± SD of 7.72± 3.440 in the area
80

related to attitude and beliefs .In the area related to lack of support and peer pressure,

the mean percentage of barrier score is 33.26% with a mean ± SD of 4.99±2.390. In

the area of time and cost, mean percentage of barrier score is 36.66% with a mean ±

SD of 5.50± 3.173. Mean percentage of barrier score is 43.27 % with a mean ± SD of

8.65±3.908 in the area of cultural factors. In area related to accessibility to health care

facility, mean percentage of barrier score is 44.99% with a mean ± SD of 4.50± 2.737.

From the above findings, it is evident that the married women in rural area

have mild barrier of health seeking behaviour on uterine prolapse (40.33%).The

findings also reveal that area wise analysis of seven areas of barriers of health seeking

behaviour on uterine prolapse reveal that mean percentage of barrier score is more in

the area of embarrassment, fear (46.77%) when compared to other areas. Hence it is

inferred that embarrassment and fear act as moderate barriers of health seeking

behaviour of uterine prolapse among rural women.

Section IV: Testing of hypotheses.

A: Correlation between knowledge and barriers of health seeking behaviour on

uterine prolapse among married women.

B : Association between knowledge regarding uterine prolapse among married

women and selected socio-personal variables.

C : Association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio-personal variables.


81

A: Correlation between knowledge and barriers of health seeking behaviour on

uterine prolapse among married women

To test the correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women, a null hypothesis and research

hypotheses are formulated. Following hypotheses are tested at 0.05 level of

significance.

H0:-There is no significant correlation between knowledge and barriers of health

seeking behaviour on uterine prolapse among married women as measured by

structured interview schedule and five point rating scale.

H1:- There is significant correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women as measured by structured

interview schedule and five point rating scale.

The Hypotheses are formulated and are tested using Karl Pearson’s correlation

coefficient test.

The value of r is calculated to assess the correlation between knowledge and

barriers of health seeking behaviour on uterine prolapse among married women.


82

Table 8

Correlation between knowledge and barriers of health seeking behaviour on

uterine prolapse among married women

(n=371)
Variables Pearson correlation df P value

(r) coefficient

Knowledge and barriers of - 0.325 369 .000***

health seeking behaviour on

uterine prolapse

Two tailed table value t369=0.194

***Highly significant at p<0.001 level of significance.

Data presented in table 8 shows that the absolute value of calculated r = -

0.325 is greater than that of critical value (table value-0.194) at p< 0.001 level of

significance. The test is found to be statistically significant as the computed p< 0.001

level of significance. Therefore null hypothesis is rejected and research hypothesis is

accepted. Hence it is inferred that there is significant moderate negative correlation

between knowledge and barriers of health seeking behaviour on uterine prolapse

among married women. This shows that as the knowledge regarding uterine prolapse

increase, the barriers of health seeking behaviour decreases.


83

B:- Association between knowledge regarding uterine prolapse among married

women and selected socio personal variables

To test the association between knowledge on uterine prolapse among married

women and selected socio personal variables, the following hypotheses are

formulated and are tested at 0.05 level of significance.

H0- There is no significant association between knowledge regarding uterine

prolapse among married women and selected socio personal variables.

H2:- There is significant association between knowledge regarding uterine

prolapse among married women and selected socio personal variables.

The hypotheses are formulated and tested by using Chi- square test (χ2). The

knowledge score regarding uterine prolapse among married women is classified as

below median and above median. The median is 11. The value of χ2 is calculated to

find the association between knowledge score regarding uterine prolapse among

married women and selected socio personal variables such as age, education,

occupation, type of family, monthly income of family, number of children, exposure

to source of information on uterine prolapse and history of uterine prolapse among

sample and family members.


84

Table 9

Significance of Association between knowledge on uterine prolapse among

married women and selected socio personal variables

n= 371

2
Sl No Socio Personal variable χ value df P value Inference

1 Age 0.197 2 0.906 p>0.05 NS

2 Education 21.032 4 .000 p<0.001 S***

3 Occupation 14.494 3 .002 p<0.01 S**

4 Type of family 6.258 1 .012 p<0.05 S*

5 Monthly income of family 11.565 3 .009 p<0.01 S**

6 No: of children 8.193 4 .085 p>0.05 NS

7 Exposure to source of 4.508 1 .034 p<0.05 S*

information on uterine prolapse

8 History of uterine prolapse 3.790 1 .052 p>0.05 NS

among sample and family

members

2 2 2 2
Table value=χ 0.05 (2) =5.99,χ 0.05 (4 )=9.49,χ 0.05 (3) =7.810,χ 0.05(1)=3.84
***Highly significant at p< 0.001 level.
* Significant at p< 0.01 level.
* Significant at p< 0.05 level.
NS - Not Significant p>0.05 level
Data presented in table 9 reveals that all the chi square values related to

education, occupation, type of family, monthly income of family, exposure to source

information on uterine prolapse are larger than the critical value(tabled value) at

p<0.001, p<0.01 and p< 0.05 level of significance. Hence, the test is found to be

statistically significant as the computed p<0.001, p<0.01 and p<0.05 level of


85

significance. Therefore, the researcher accepts the research hypothesis. Thus, it can be

concluded that there is a significant association between knowledge score regarding


2
uterine prolapse and selected socio personal variables such as education (χ =21.032;

2 2
p<0.001), occupation (χ =14.494;p<0.01), type of family (χ =6.258; p<0.05),

2
monthly income of family (χ =11.565; p<0.01),and exposure to source of

2
information regarding uterine prolapse (χ =4.508;p<0.05).

However, the chi-square values related to age, number of children, history of

uterine prolapse among sample and family members, are smaller than that of critical

value (tabled value) at p> 0.05 level of significance. Therefore the test is not found to

be statistically significant as computed p value is greater than 0.05 level of

significance. Hence, the null hypothesis is accepted, and it can be concluded that there

is no significant association between knowledge regarding uterine prolapse and


2
selected socio personal variables such as age (χ =.197;p>0.05), number of children

2
(χ =8.193;p>0.05),and history of uterine prolapse among sample and family

2
members (χ =3.790;p>0.05).
86

Section C :- Association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio personal variables.

To test the association between barriers of health seeking behaviour on uterine

prolapse among married with selected socio personal variables the following

hypotheses are formulated and are tested at 0.05 level of significance.

H0 :- There is no significant association between barriers of health seeking behaviour

on uterine prolapse among married women and selected socio personal variables .

H3 :- There is significant association between barriers of health seeking behaviour

on uterine prolapse among married women and selected socio personal variables.

The hypotheses are formulated and are tested by using Chi- square test (χ2).

The barriers of health seeking behaviour score regarding uterine prolapse among

married women is classified as below median and above median. The median is 43.

The value of χ2 is calculated to find the association between barriers of health seeking

behaviour score regarding uterine prolapse among married women with selected socio

personal variables such as age, education, occupation, type of family, monthly income

of family, number of children, exposure to source of information on uterine prolapse

and history of uterine prolapse among sample and family members.


87

Table 10

Significance of Association between barriers of health seeking behaviour on

uterine prolapse among married women and selected socio personal variables

n= 371

2
Sl No Socio Personal variable χ value df P value Inference

1 Age .529 2 .768 p>0.05 NS

2 Education 24.211 4 .000 p<0.001 S***

3 Occupation 27.326 3 .000 p<0.001 S***

4 Type of family 12.419 1 .000 p<0.001 S***

5 Monthly income of family 22.677 3 .000 p<0.001S ***

6 No: of children 16.11 4 .003 p<0.01 S**

7 Exposure to source of 4.460 1 .035 p<0.05 S*

information on uterine prolapse

8 History of uterine prolapse 2.641 1 .104 p>0.05 NS

among sample and family

members

Tabled value= χ2 0.05 (2) =5.99, χ2 0.05 (4 )=9.49, χ2 0.05 (3) =7.810,χ2 0.05 (1)
=3.84,
***Highly significant at p< 0.001 level.
* Significant at p< 0.01 level.
* Significant at p< 0.05 level.
NS - Not Significant p>0.05 level

The data presented in the table 10 reveals that the Chi-square values related to

education occupation, types of family, monthly income of family, number of children

and exposure to source of information on uterine prolapse are greater than that of

critical value (tabled value) at p<0.001,p<0.01 and p< 0.05 level of significance.
88

Hence the tests is found to be statically significant as computed p<0.001, p<0.01 and

p<0.05 level. The null hypothesis is rejected and research hypothesis is accepted.

Hence it is inferred that there is a significant association between barriers of health

seeking behaviour on uterine prolapse and socio personal variables such as education

2 2
(χ =.24.211;p<0.001), occupation (χ =.27.326;p<0.001), type of family

2
(χ =12.419 ;p<0.001),monthly income of family (χ2=22.677;p<0.001),number of

children (χ2=16.11;p<0.01), exposure to source of information on uterine prolapse

(χ2=4.460;p<0.05).

However chi square value related to socio personal variables such as age and

history of uterine prolapse among sample and family members are less than that of

critical value (tabled value) at p>0.05 level of significance. Test is not found to be

statistically significant as computed p>0.05 level of significance .Hence the null

hypothesis is accepted. So it is concluded that there is no significant association

between barriers of health seeking behaviour on uterine prolapse and socio personal

variables such as age (χ2=.529, p > 0.05) history of uterine prolapse among sample

and family members (χ 2= 2.641, p > 0.05).


89

CHAPTER 5

RESULTS

· Objectives

· Hypotheses

· Results
90

CHAPTER 5

RESULTS

Result is the answer to research question obtained through an analysis of the

collected data; in a quantitative study, the information obtained through statistical


56
tests.

This chapter present the major result of the study. The chapter is organized

under three headings; objectives, hypotheses and major results of the study.

Objectives of the study

· Assess the knowledge regarding uterine prolapse among married women.

· Identify the barriers of health seeking behaviour on uterine prolapse among

married women.

· Find the correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women.

· Find the association between knowledge regarding uterine prolapse among

married women and selected socio-personal variables.

· Find the association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio-personal variables.

· Prepare an information booklet on uterine prolapse and its management

Hypotheses

Following hypothesis are tested at 0.05 level of significance

H1:There is significant correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women as measured by structured

interview schedule and five point rating scale .

H2:There is significant association between knowledge regarding uterine prolapse

among married women and selected socio-personal variables.


91

H3: There is significant association between barriers of health seeking behaviour on

uterine prolapse among married women and selected socio-personal variables.

Findings of the study

The findings of the study have been organized and presented under the

following sections:-

Section I:- socio personal characteristics

Among the sample, 45.3% are in the age group of 30-40 years, 36.9% are in

the age group of 41-50 years and 17.8% belongs to age group of 51-60 years.

Majority of the sample (83.3%) are Hindu.

Among the sample, 42% had high school education,18.6% had primary school

education, 18.9% had higher secondary, 17% and 3.5% had college and

professional/technical qualifications.

Most of the sample (45.3%) are homemakers, 20.80% are manual labour

9.70% private employees and, 23.70% are government employees.

Majority of the sample (89.8%) are married.

Among the subjects, 64.4% come from nuclear family, 31.3% belong to joint

family.

Most of the sample (59% ) have income of ≤ Rs 5000

Among the sample, (56.1%) have two children.

Most of the sample (52.80%) have no exposure to source of information on

uterine prolapse and 47.2% have exposure to source of information on uterine

prolapse

Among the sample, 35.4% got information on uterine prolapse from contact with

health care personnel 46.3% from friends / relatives, 18.3% from magazine and

medias.
92

Among the sample 3.5% of the women have history of uterine prolapse in

their family

Of 371 sample, only 13 sample reported uterine prolapse and also their family

members affected with uterine prolapse. Of the 13 sample, four sample

(30.8%) reported to be affected with uterine prolapse and having undergone

surgery. Nine sample (three sample each) reported their sister (23.10%),

mother (23.10%) and mother in law (23.10%) had uterine prolapse.

Section II:- Analysis of knowledge score regarding uterine prolapse among

married women.

Majority of the subjects (76.8%.) have moderate knowledge, 17.5% of them

have adequate knowledge and 5.7% have inadequate knowledge regarding

uterine prolapse.

The mean percentage of total knowledge score regarding uterine prolapse

among married women is 54.99% with Mean±SD of 11.0.97±2.638 .Hence it

is evident that knowledge regarding uterine prolapse among married women is

moderate.

Section III:- Analysis of barriers of health seeking behaviour score on uterine

prolapse among married women

Majority of sample ( 70.4%) have mild barriers, 26.4% have moderate and

3.2% of sample have strong barriers of health seeking behaviour on uterine

prolapse among married women.

Area wise mean percentage of the total score on barriers of health seeking

behaviour on uterine prolapse is 40.33 with mean ± SD of 48.39 ±18.367 Area

wise mean percentage of barrier score is 35.60% with mean± SD of 5.34 ±

2.791 in the area of knowledge and awareness. In the area of embarrassment


93

and fear, mean percentage of barrier score is 46.77% with a mean ± SD of

11.69 ± 4.933 .Mean percentage of barrier score is 38.58% with a mean ± SD

of 7.72± 3.440 in the area related to attitude and beliefs .In the area related to

lack of support and peer pressure, the mean percentage of barrier score is

33.26% with a mean ± SD of 4.99±2.390. In the area of time and cost mean

percentage of barrier score is 36.66% with a mean ± SD of 5.50± 3.173. Mean

percentage of barrier score is 43.27 % with a mean ± SD of 8.65±3.908 in the

area of cultural factors. In area related to accessibility to health care facility,

mean percentage of barrier score is 44.99% with a mean ± SD of 4.50± 2.737.

The findings indicate that married women in rural area have mild barriers of

health seeking behaviour on uterine prolapse (40.33%).

Area wise analysis of seven areas of barriers of health seeking behaviour on

uterine prolapse reveal that mean percentage of barrier score is more in the

area of embarrassment, fear (46.77%) when compared to other areas. Hence it

is inferred that embarrassment, fear act as moderate barriers of health seeking

behaviour of uterine prolapse among rural women.

Section IV: Testing of hypotheses.

The study reveals that 76.8% of married women have moderate knowledge

and 70.4% married women have mild barriers of health seeking behaviour on

uterine prolapse. The statistical significance of correlation between knowledge

and barriers of health seeking behaviour on uterine prolapse is tested using

Karl Pearson’s correlation coefficient. The calculated value (r = -0.325) is

statistically significant at p< 0.001 level of significance. Hence it is concluded

that there is significant moderate negative correlation between knowledge and


94

barriers of health seeking behaviour on uterine prolapse among married

women.

Chi-square values related to education, occupation, type of family, monthly

income of family, exposure to source of information on uterine prolapse are

larger than the critical value (tabled value) at p<0.001,p<0.01 and p<0.05 level

of significance. Hence, the test is found to be statistically significant as the

computed p <0.001, p<0.01 and <0.05 level of significance. So there is

significant association between knowledge score regarding uterine prolapse

and selected socio personal variables such as education, occupation, type of

family, monthly income of family, exposure to source of information on

uterine prolapse

Chi-square values related to age, number of children, history of uterine

prolapse among sample and family members, are smaller than that of critical

value (tabled value) at p> 0.05 level of significance. Therefore the test is not

found to be statistically significant as computed p value is greater than p >

0.05 level of significance. There is no significant association between

knowledge regarding uterine prolapse and selected socio personal variables

such as age, number of children, and history of uterine prolapse among sample

and family members.

Chi-square values related to education ,occupation, types of family, monthly

income of family, number of children and exposure to source of information

on uterine prolapse is greater than that of critical value (tabled value)at

p<0.001,p<0.01 and p< 0.05 level of significance. Hence the tests is statically

significant as computed p<0.001,p<0.01 and p<0.05 level of significance. So

there is a significant association between barriers of health seeking behaviour


95

and selected socio personal variables such as education, occupation, types of

family, monthly income of family, number of children and exposure to source

of information on uterine prolapse.

Chi square value related to socio personal variables such as age and history of

uterine prolapse among sample and family members are less than that of

critical value(tabled values) at p>0.05 level of significance. Test is not found to

be statistically significant as computed p>0.05 level of significance. So it is

concluded that there is no significant association between barriers of health

seeking behaviour on uterine prolapse and selected socio personal variables

such as age and history of uterine prolapse among sample and family

members.
96

CHAPTER 6

DISCUSSION, SUMMARY AND CONCLUSION

· Discussion

· Summary

· Conclusion

· Nursing implications

· Limitations

· Recommendations
97

CHAPTER 6

DISCUSSION, SUMMARY AND CONCLUSION

This chapter presents the discussion, summary of the study, major findings,

conclusions, nursing implications and recommendations.

Discussion

The study was conducted to assess knowledge and barriers of health seeking

behaviour on uterine prolapse among married women.

The findings of the study are discussed below in relation to the findings of

other studies the investigator has reviewed.

The first objective of the study is to assess the knowledge regarding uterine

prolapse among married women.

The present study reveals that most of the women (76.8%) have moderate

knowledge regarding uterine prolapse (54.99%).

These findings are in accordance with descriptive study conducted by

Vidhyalatha to assess the knowledge and risk factors for uterovaginal prolapse among

300 married women aged 30-60 year in selected villages of Udupi district, Karnataka,

which shows that majority (59%) of the married women had moderate knowledge on
26
uterovaginal prolapse, 6% had good knowledge and 35% had poor knowledge.

The study is incongruent with a study conducted by Goman HM, Fetohy EM,

Nosseir SA, Kholeif AE to investigate the perception of genital prolapse among

women attending the outpatient clinic in El-Shatby Maternity University Hospital in

Alexandria the results revealed that more than two thirds of cases (70.4%) had poor

(36.4%) or fair knowledge (34%) and only 29.6% had satisfactory knowledge. The

majority of women having positive perception to diagnosis and symptoms for genital
98

prolapse had high perception of "susceptibility" to and "severity" of complications of


57
genital prolapse (97.5% and 85% respectively).

The present study is in harmony with a cross sectional study conducted by

Baruwal A. to determine the prevalence of knowledge, attitude and preventive

measures of uterine prolapse among 267 married women of reproductive age in

Nepal, which shows that women had a moderate level of knowledge regarding uterine
6
prolapse (51.9%).

The present study is incongruent with a descriptive study conducted by Karki

S,Neraula A. to assess the awareness regarding uterovaginal prolapse among 118

parous women in Bhaktapur Municipality in Bhaktapur, Nepal, shows that only 39%
.1
of respondents were aware regarding the uterine prolapse

Second objective of the study is to identify the barriers of health seeking

behaviour on uterine prolapse among married women.

In the present study shows that majority of sample (70.4%) have mild barriers,

3.2% of sample have strong barriers, 26.4% have moderate barriers of health seeking

behaviour on uterine prolapse among married women. The total mean percentage of

barriers of health seeking behaviour on uterine prolapse is 40.33%.

The present study is in accordance with a community based cross sectional

study among 1046 ever married women of reproductive age group (15-49) at slums of

Rajkot city, Gujarat using two stage cluster sampling and the result shows that cost

and societal barriers were the reasons for not seeking care, whereas poor provider‘s

attitude, poor quality of services and long waiting time were the reasons for not
51
utilizing public health facilities.

The present study is incongruent with a descriptive study conducted by Joseph

J M among 300 women, between 30-60 years of age who were residing in Madayi
99

rural community area in Kannur district, shows that greater percentage (41.3%) of the

sample have very strong barriers, 35 % have strong barriers, 19.7% have moderate

barriers, 4 % have mild barriers in the health seeking behaviour on gynaecological


.58
problems

The present study is inconsistent with a study conducted by Kumari S,Walia I,

Singh A to estimate the prevalence of self reported uterine prolapse and to determine

the treatment-seeking behaviour among 2,990 married women of Dadu Majra colony,

Chandigarh, India. The results shows, of the 227 women with self-reported uterine

prolapse, 128 (57%) had not taken any treatment, 28 went to a traditional birth

attendant (TBA), and 47 (21%) consulted a doctor. Reasons for non-consultation

included shyness (80; 63%), lack of cooperation by the husband, lack of time (80;
50
63%) and lack of money (74; 58%).

Third objective of the study are to find the correlation between knowledge and

barriers of health seeking behaviour on uterine prolapse among married women.

In the present study, there is significant moderate negative correlation between

knowledge and barriers of health seeking behaviour among married women.

The present study is backed by a descriptive study conducted by Joseph J M

among300 women, between 30-60 years of age who are residing in Madayi rural

community area in Kannur district, which shows that there is an intermediate level of

negative co-relation between knowledge and barriers of health seeking behaviour on


58
cervical cancer.

Fourth objective to find the association between knowledge regarding uterine

prolapse and selected socio-personal variables.

In the present study there is significant association between the knowledge

score regarding uterine prolapse among married women and selected socio personal
100

variables such as education, occupation, type of family, monthly income of family,

exposure to source information on uterine prolapse (p<0.001,p<0.01 and p<0.05) .

In the present study there is no significant association between the knowledge

score regarding uterine prolapse among married women and selected socio personal

variables such as age, number of children, and history of uterine prolapse among

sample and family members (p>0.05).

The present study is in accordance with a descriptive study conducted by Karki

S, Neraula A to assess the awareness regarding uterovaginal prolapse among 118

parous women in Bhaktapur Municipality in Bhaktapur, Nepal. The results shows that
14
there is statistically significant association between knowledge and occupation.

The present study is also incongruent with the above study, which shows that
14
there is no significant association between knowledge and education.

The present study is inconsistent with a cross-sectional study conducted by

Eleje GU, Udegbunam OI, Ofojebe CJ, Adichie CV to determine the incidence, risk

factors and management modalities of pelvic organ prolapse among women who

attended the gynaecologic clinic in Nnamdi Azikiwe University Teaching Hospital,

Newi, South-east Nigeria and the results shows that there is significant association
24
between prolapse and advanced age (P <0.001).

The present study is backed by a cross-sectional study conducted by Shrestha

B, Devkota B, Khadka B B, Choulagai B, Pahari D P,Onta S to assess knowledge on

uterine prolapse among 4,693 married women aged 15– 49 years at urban and rural

settings in Nepal and the result shows that there is significant association between
.25
knowledge and education

The present study is opposed by cross-sectional study conducted by Shrestha

B, Devkota B, Khadka B B, Choulagai B, Pahari D P, Onta S to assess knowledge on


101

uterine prolapse among 4,693 married women aged 15– 49 years at urban and rural

settings in Nepal and the result shows that there is significant association between
25
knowledge and age.

The present study is in harmony with the study conducted by Vidhyalatha to

assess the knowledge and risk factors of uterine prolapse among married women in

Karnataka, which shows that there is significant association between knowledge with
26
education and monthly income .

Fifth objective of the study to find the association between barriers of health

seeking behaviour on uterine prolapse and selected socio-personal variables.

In the present study, there is significant association between the barrier score

regarding uterine prolapse among married women with selected socio personal

variables such as education, occupation, types of family, monthly income of family,

number of children and exposure to source of information on uterine prolapse

(p<0.001, p<0.01 and p<0.05).

In the present study there is no significant association between barrier score on

uterine prolapse and socio personal variables such as age , history of uterine prolapse

among sample and family members (p>0.05)

The present study is also in harmony with an exploratory study to assess

reproductive morbidities and treatment seeking behaviour among 200 married women

from Jamalpur Awana rural health center of Christian Medical College and Hospital,

Ludhiana and the result shows that there is no significant association between barriers
1
of health seeking behaviour and age.

The present study is also incongruent with the above study, which shows that

there is no significant association between barriers of health seeking behaviour and


1
education.
102

Summary

Gynaecological problems are universal in occurrence, however, the

prevalence, awareness and seeking treatment for these problems varies from region to

region. In the Indian scenario women face social and economic barriers in seeking

care. Uterine prolapse is one of the main gynaecological problem. Uterine prolapse

(UP), also known as pelvic organ prolapse or genital prolapse, is a reproductive health

problem .In this condition, failure of ligamentous and fascial supports causes the

uterus to descend into or beyond the vagina, resulting in protrusion of the vagina, the

uterus, or both. It may seriously influence the physical, psychological and social well

being of affected individuals and is associated with considerable resource implications

for the health service. So educate women on different symptoms of reproductive

infection and need for treatment so that women can themselves identify the symptoms

and seek timely treatment.

The present study was conducted to assess the knowledge and barriers of

health seeking behaviour on uterine prolapse among married women in selected rural

areas in Kannur District.

Objectives

o Assess the knowledge regarding uterine prolapse among married women

o Identify the barriers of health seeking behaviour on uterine prolapse among

married women.

o Find the correlation between knowledge and barriers of health seeking

behaviour on uterine prolapse among married women.

o Find the association between knowledge regarding uterine prolapse among

married women and selected socio-personal variables.


103

o Find the association between barriers of health seeking behaviour on uterine

prolapse among married women and selected socio-personal variables.

o Prepare an information booklet on uterine prolapse and its prevention.

Assumptions

o Women have some knowledge regarding uterine prolapse

o Women have barriers in health seeking behaviour on uterine

prolapse. o Health education promote early health seeking behaviour.

Hypotheses

H1: There is significant correlation between knowledge and barriers of health

seeking behaviour on uterine prolapse among married women as measured by

structured interview schedule and five point rating scale at 0.05 level of

significance

H2: There is significant association between knowledge on uterine prolapse

among married women and selected socio-personal variables

H3: There is significant association between barriers of health seeking

behaviour on uterine prolapse among married women and selected socio-

personal variables.

The conceptual framework used for the study is based on Rosenstock and

Becker’s Health Belief Model and this model is based on motivational theory. Health

belief model is a health behaviour change and psychological model for studying and

promoting the uptake of health services. The major concepts of this model are

individual perception, modifying factors and likelihood of action.

Quantitative non experimental study with descriptive survey design was used

for the study. The research variables are knowledge regarding uterine prolapse and

barriers of health seeking behaviour on uterine prolapse. The extraneous variables


104

refers to selected socio personal variable such as age, religion, education, occupation,

marital status, type of family, number of children, monthly income of family,

exposure to source of information on uterine prolapse and family history of uterine

prolapse.

The study was conducted in selected subcenters and areas of Chittariparamba

Panchayath in Kuthuparamba block of Kannur district. The investigator selected

subcentres –Manandheri (ward 11, 12), Kannavam (war d 9 ). Areas–Vattoli (ward 2),

Chittariparamba (ward 8), and Poovathinkeezhil (ward 9) of Chittariparamba

panchayat.

The sample consisted of 371 married women who fulfilled the inclusion

criteria. Non probability Convenience sampling technique was used for the study.

The technique adopted was self reporting and the tool developed for data

collection were structured interview schedule to assess the knowledge regarding

uterine prolapse among married women and five point rating scale to assess the

barriers of health seeking behaviour on uterine prolapse among married women.

A blue print on structured interview schedule items regarding uterine prolapse

was prepared which consists of causes, symptoms, management and preventive

aspects of uterine prolapse among married women. The knowledge domain had 9

items (45%), comprehension had 4 (20%), and application domain had 7 items (35%)

covering all the aspects of uterine prolapse.

The content validity of the tool was done by seven experts. Reliability

coefficient of the interview schedule was established by split half method using

Spearman-Brown Prophecy formula and was found to be 0.65.The reliable coefficient

of rating scale was estimated using Cronbach’s alpha correlation coefficient formula

and was found to be 0.75.Tool I and II was valid regarding language and equally
105

semantic. Pre testing of the tool was done to determine the clarity of item, feasibility,

ambiguity and time required to complete the items.

Pilot study was conducted at ward 6 of Ayithara, a rural community area of

Mangattidam Panchayath of Kannur district on 25.01.15 and 26.01.15.and tool was

found to b e comprehensible, feasible and acceptable.

The study was conducted after getting approval from the institutional ethics

committee and formal administrative permission from Chittariparamba panchayath

president. The investigator selected ward 11,12 and ward 9 of Manandheri and

Kannavam subcenters and ward 2, 8, 9 of Vattoli, Chittariparamba and

Poovathinkeezhil areas of Chittariparamba panchayat. Data collection period was

from 31.01.15 to 18.03.15.

Data was collected from 371 women residing in Chittariparamba panchayat by

using convenience sampling and descriptive survey approach. The purpose of the

study was explained and written informed consent was obtained after the assuring

confidentiality.

Investigator visited each house, identified women based on inclusion criteria.

It took 20-30 minutes for conducting interview for each subject .Investigator had

interviewed 10-15 sample per day. The investigator took 5-13 days for the interview

in one area. After the interview was completed, both individual and group health

education was given on the causes, symptoms, management and prevention of uterine

prolapse followed by the distribution of information booklets.


106

Major findings of the study

Most of the sample,52.80% have no exposure to source of information on

uterine prolapse and47.2% have exposure to source of information on

uterine prolapse

Among the sample, 35.4% got information on uterine prolapse from

contact with health care personnel, 46.3% from friends / relatives and

18.3% from magazines and media.

Among the sample 3.5% of women have history of uterine prolapse in

their family.

Of 371 sample only 13 sample reported uterine prolapse and also their

family members affected with uterine prolapse. Of the 13 sample ,four

sample (30.8%) reported to be affected with uterine prolapse and

undergone surgery. Nine sample (three sample each) reported their sister

(23.10%), mother (23.10%) and mother in law (23.10%) had uterine

prolapse.

Majority of the subjects (76.8%.) have moderate knowledge, 17.5% of

them have adequate knowledge and 5.7% have inadequate knowledge

regarding uterine prolapse.

Mean percentage of total knowledge score is 54.99% which shows that

knowledge regarding uterine prolapse is moderate among married women.

Majority of sample (70.4%) have mild barriers, 3.2% of sample have

strong barriers, 26.4% have moderate barriers of health seeking behaviour

on uterine prolapse among married women.


107

Mean percentage of total barriers score is 40.33% which shows that the

rural women have mild barriers of health seeking behaviour on uterine

prolapse.

There is a significant moderate negative correlation between knowledge

and barriers of health seeking behaviour regarding uterine prolapse.

(r=0.325 p< 0.001)

There is significant association between knowledge score regarding uterine

prolapse and selected socio personal variables such as education,

occupation, type of family, monthly income of family and exposure to

source of information on uterine prolapse.

There is no significant association between knowledge regarding uterine

prolapse and selected socio personal variables such as age, number of

children, and history of uterine prolapse among sample and family

members.

There is a significant association between barriers of health seeking

behaviour and selected socio personal variables such as education,

occupation, types of family, monthly income of family, number of children

and exposure to source of information on uterine prolapse.

There is no significant association between barriers of health seeking

behaviour on uterine prolapse and selected socio personal variables such as

age and history of uterine prolapse among sample and family members.
108

Conclusion

Based on the findings of the present study ,the following conclusions are made

Majority of the married women in the rural area have moderate knowledge

and mild barriers of health seeking behaviour on uterine prolapse

Rural women have moderate barriers of health seeking behaviour in the area

related to embarrassment, fear.

There is a significant moderate negative correlation between knowledge and

barriers of health seeking behaviour regarding uterine prolapse. As the

knowledge regarding uterine prolapse increases, the barrier decreases.

There is a significant association between knowledge regarding uterine

prolapse and selected socio personal variables such as education, occupation

type of family, monthly income of family and exposure to source of

information regarding uterine prolapse.

There is no significant association between knowledge regarding uterine

prolapse and selected socio personal variables such as age number of

children and history of uterine prolapse among sample and family members

There is a significant association between barriers of health seeking

behaviour and socio personal variables such as education, occupation, type

of family, monthly income of family, number of children, exposure to source

of information regarding uterine prolapse.

There is no significant association between barriers of health seeking

behaviour on uterine prolapse and socio personal variables such as age and

history of uterine prolapse among sample and family members.

It is concluded that the health education and distribution of information

booklet is effective in improving the knowledge regarding uterine prolapse


109

among married women. It creates an increased awareness among them,

which can empower them to take care of their own health as well as protect

themselves from possible Gynecological morbidity. So appropriate

utilization of available services and up gradation of services for the ultimate

benefit of the married women through proper and effective educational

intervention is mandatory.

Nursing Implications

The findings of the study have various implications in Nursing practice,

Nursing education, Nursing administration and Nursing research.

Nursing practice

Nursing is the profession within the health care sector focused on the care of

individual, families, and communities. They may help to maintain, recover, and attain

optimal health and quality of life. In the interest of safe and effective practice, nurses

and midwives are expected to maintain a current knowledge base and are responsible

for ongoing education in their chosen areas of practice. The status of nursing as a

profession is important because it reflects the value society places on the work of

nurses and the centrality of this work to the good of society. The study findings

indicate that uterine prolapse has a significant contribution to women’s health

problem. Hence they need to know about risk factors, symptoms and management of

uterine prolapse.

Nurses are considered as key persons to bring desired changes at the work

place by working as a consultant and counsellor between employer and employees in

various occupational settings. As a part of motivational strategies, nurses should

conduct health awareness programme. Health teaching is an essential part of nursing

practice. As a health care professional, the nurse must place emphasis on those
110

activities, which promote the health of women and protected them from disease as

well as improve their health seeking behaviour. Professional nurses can organize

health education, public awareness programme, organize screening camp in

community or hospital setting.

Nurse continence advisor, Urogynecological Nursing, (specialists in managing

incontinence and pelvic organ prolapse),having undergone a special course, can assess

these patients and provide care and educate them regarding management of prolapse

and incontinence. Nurses who initially assess the women should pursue this aspect of

care beyond handling patients on a sheet of paper with instructions for performing

kegel exercises.

Nursing personnel should be give special concern to plan and administer the

educational programme to the identified actual and potential problems of women.

This will help to empower women and protect their life in a healthy way.

Nurse with the unique knowledge and skill to assess these women with uterine

prolapse can provide health education to overcome barrier and promote early health

behaviour to promote optimum reproductive and sexual health.

Nursing education

Education about reproductive health is important, and it require special

attention in fulfilling their reproductive issues. Nursing education today have a

revolve around ideas and innovations because it will be extremely essential to learn

and them put into practice.

The purpose of nursing education is to prepare a person who can fulfil the

role, functions and responsibilities of a professional nurse within the society and

assisting the individual or family to achieve the potential for self-direction.


111

The nursing education curriculum should provide opportunity for students to

plan and implement programmes for women with Gynaecological morbidities along

with reproductive morbidities. Gynaecological morbidities have huge impact on the

physical and mental health in the reproductive age group women.

The nurse educator should take initiative in organizing periodic health

awareness programme by conducting educational programme regarding

Gynaecological morbidities and its prevention and management among women in

both hospital and community setting.

It may be beneficial to offer continuing nursing education to all nursing

personnel working in various setting of the health care system regarding

Gynaecological morbidities especially uterine prolapse, cervical cancer, menstrual

irregularities and in service education programme to ASHA (Accredited Social Health

Activists) workers, JPHN (Junior Public Health Nurses) in community to make

women aware of those hidden Gynaecological morbidities and promote early health

seeking behaviour.

Nursing administration

Nurses are the major human resource in health service management at all

levels and they are called upon to manage the health care delivery system. They can

also initiate policy making at community setting to develop public awareness

programme regarding management on uterine prolapse. The nurse administer should

understand the magnitude of the problem and should recognize the need for

educational programmes in this topic. The nurse administrator can arrange health

education regarding uterine prolapse. The administrator can use the findings of the

study to report to the concerned authority the need for effective communication and

explore their feelings towards the treatment of uterine prolapse. It is strongly


112

recommended to implement a clinic based health campaign to screen cases along with

a treatment and prevention program. Today nurses are called upon to take part in the

management of health care delivery system, as they are the major qualified human

resource agents responsible for health service management at all levels. In health care

institutions today nurses are involved not only in the management of individual

patients in the ward or unit or department but are also made to shoulder the

responsibility and accountability in the nursing practice. Government and various

organizations should involve mass media in order to spread awareness about the

preventive and curative aspects of uterine prolapse.

Nursing research

Nursing practice a needs to be based on scientific knowledge. Nurses

increasingly are expected to adopt an evidence based practice which is defined as the

best clinical evidence in making patient care decisions. Nurse researchers can conduct

research studies to assess the causes and risk factors of uterine prolapse and also

effect of non surgical interventions like pelvic floor exercises, and use of pessary for

management of uterine prolapse. Urogynaecological nursing and continence nursing

can make valuable contribution in these areas through research and clinical practice.

By this study, it is evident that rural area women are having moderate

knowledge regarding the uterine prolapse. With a strict regulatory frame work,

prospective clinical study, scientific progress could be secured for promotive patient

safety and care with uterine prolapse. Nurses should take initiation to conduct more

researchers in their working field so that they can provide better improvised care to

women with Gynaecological morbidities in community settings. Research based

practice in nursing has been regarded as means of ensuring that quality care is

provided.
113

Limitations

The investigator found it difficult to control the group.

The investigator took more time to complete the interview for some subjects.

Some subjects did not show interest in completing the interview schedule.

Recommendations

A study can be conducted to assess the prevalence and risk factors of uterine

prolapse among women in rural area.

A study can be conducted to evaluate the effect of self instructional module

regarding uterine prolapse among ASHA workers.

An exploratory study to assess Gynaecological morbidity and health seeking

behaviour among reproductive age group women in selected rural areas of

Kannur.

A cross sectional study can be done to assess the knowledge and preventive

measures of uterine prolapse among married women in rural areas in Kannur.

A comparative study to assess the knowledge and attitude towards uterine

prolapse among married women in rural and urban areas of Kannur.

An interventional study can be conducted to evaluate the effect of pelvic floor

exercises among married women in rural areas of Kannur.

A cross sectional study can be conducted to measure the barriers in seeking

treatment with uterine prolapse among married women in rural areas of

Kannur.
114

REFERENCES
115

REFERENCES

1. Kaur S, Jairus R, Samuel G. An exploratory study to assess reproductive

morbidities and treatment seeking behaviour. Nursing and Midwifery

Research Journal [internet]. 2013 July; 9(3):91-98.Available from: http://

medind.nic.in/ nad/t13/i3/nadt13i3p 91.

2. Sharma A, Zhang J P. Risk Factors and Symptoms of Uterine Prolapse: Reality

of Nepali Women. Asian Women[internet]. 2014 ; Vol.30 (1):81-95.Available

from: http://www.academia.edu/9519985.

3. Guidelines on Reproductive Health. New York: Secretariat of the United

Nations; July2015.

4. Abraham A, Varghese S, Satheesh M, Vijayakumar K, Gopakumar S, Mendez

AM. Pattern of gynaecological morbidity, its factors and Health seeking

behaviour among reproductive age group women. Indian Journal of

Community Health[Internet]. 2014 September[cited 2014 July 8];26(3):230-

237.Available from:http://www.iapsmupuk. org /journal/index. php/IJCH.

5. Susila T, Gautam R. Gynaecological Morbidities in a Population of Rural

Postmenopausal Women. The Journal of Obstetrics and Gynaecology of India

[Internet]. 2014 Feb [cited 2013 September 28]; 64(1):53-58.Available from:

http:// www.ncbinlm.nih. gov/pmc/articles/PMC3931905.

6. Baruwal, A. Knowledge, attitude and preventive measures amongst the

married women of reproductive age [PG thesis]. Chulalongkorn University;

2010. Available from http://cphs.healthrepository.org/ handle/ 1234567 89/

1506
116

7. Adhikari D. A qualitative study on Uterine prolapse and quality of life. [BSc

thesis].Nepal:2011[cited2011december27] Available from: http://archief.vrou

wenvo orvr ou wen.nl/upload.

8. Sengupta B S, Chattopadhyay S K, Varma T R. Gynaecology For


nd
Postgraduates. 2 edition. New Delhi: Elsevier publication;2007.

9. Poornima S, Katti SM,Mallapur M D, Vinay M. Gynecological problems of

married women in the reproductive age. Al Ameen Journal of Medical

Sciences [Internet] 2013; 6(3) :226-230.

10. Palm S. The Value of Sustainable Protocol to Address Uterine Prolapse in

Nepal: Health Camp, Awareness, and Employment Strategy Eighth Annual

Himalayan Policy Research Conference ; 2013 1-15.


nd
11. Saxena R .Bed side Obstetrics and Gynaecology. 2 edition. New Delhi:

Jaypee publication; 2014.


th
12. Dutta D C. Text book of Gynaecology. 4 edition. Kolkata: Jaypee

publication. 2013

13. Puri R . Prevalence, risk factors and traditional treatments of genital prolapse

in Manma[PG thesis]. University of Tromso;2011.Available from http:/ /mun

in.uit. no/ bitstream/handle/ 10037/4658/thesis.pdf? sequence.

14. Karki S, Neraula A .Awareness regarding uterovaginal prolapse among New

parous women. International Journal of Nursing Research and Practice

[Internet].2014 January ; 1(1):15-19.Availablefrom: http://www.upht r.com/

issue files/6%20Sita%201(1).pdf

15. Rortveit G, Brown JS, Thom DH, Creasman JM, Subak LL. Symptomatic

pelvicorgan prolapse: prevalence and risk factors in a population-based,

racially diverse cohort. International Journal of Obstetrics and Gynecology


117

[Internet]. 2007 Jun;109(6):1396-403.Available from: http://www .ncbi .nlm.

nih. gov/ pub med/17540813.

16. Bajracharya A J. Uterine prolapse: A Hidden Tragedy for women [Internet].

2007 [2007 Nov 23]; Available from: http://www.Shvoong .com/medicine.

17. Shah P. Uterine Prolapse And Maternal Morbidity In Nepal: A Human Rights

Imperative. Washington and Lee Law School [internet].2010 [cited 2010 may

5]; 2(2):491-536. Available from: http://drexel.edu/~/media /Files/ law/ law%

20review /spring2010/Shah491536.ashx?la=en.

18. Pakbaz M. Vaginal prolapse – perceptions and health care-seeking behaviour

among women. Acta Obstetrical and Gynaecological Scandinavica [Internet]

2011 October [cited 2011 JUL 27]; 90(10): 1115–1120 . Available from: http://

www.biomedcentral.com/1472-6874/10/18.

19. Kow, Nathan, Howard B. Goldman, Ridgeway B. Management options for

women with uterine prolapse interested in uterine preservation. New York:

Springer; 23 2013 may. 395-402.

th
20. Kozier and Erb’s. Fundamentals of Nursing. 8 edition. Australia: pearsons

publication;2014.
st
21. Kathleen masters. Nursing theories, A frame work for professional Practice.1

edition. Jones and Bartlet publishers.January,2011.

22. Holwerda V L. The Health Belief Model and Self Breast Examination in

Nurses [PG Theses]. Grand Valley State University.2000.


nd
23. Burns N.Grove SK .Understanding nursing research,2 edition. New Delhi

Saunders publication.2002

24. Eleje GU, Udegbunam OI, Ofojebe CJ, Adichie CV. Determinants and manage

ment outcomes of pelvic organ prolapse in a low resource setting


118

Annals of Medical Health Sciences and Research[internet]. 2014 September

[cited 2014]; 4(5): 796-801. Available from: www.researchgate.net/.../ 267

103195.

25. Shrestha B, OntaS, Choulagai B, Poudya A, Pahari D P, Uprety A, Petzold M

Krettek A. Knowledge on uterine prolapse among married women of

reproductive age in Nepal. International journal Women's Health

[internet].2014 [cited 2014 August 14];6(1):771-779. Available from: http://

www.biomed central .com/1472-6874/14/20.

26. Vidhyalatha.Unpublished PG Thesis].Manipal College of Nursing. Manipal.

Manipal University. 2013

27. Paneru DP .A Study of Prevalence and Associated Factors of Uterus Prolapse

in Doti District of Nepal. Indian Journal of Public Health Research &

Development[internet]. 2013 July[cited 2013 June26]; 4(3): 53-57.Available

from : http://connection.ebscohost.com/c/articles/96696791.

28. Tamrakar A.Prevalence of uterine prolapse and its associated factors in kaski

district of Nepal.Journal of Health and Allied Sciences[internet]. 2012; 2(1):

38-41.

29. Ravindran TK, Savitri R, Bhavani A. women's experiences of utero-vaginal

prolapse a qualitative study from TamilNadu. Popline Health [internet].

1999;166-172.Available from: http://www .pop line .org /node /525249.

30. Baruwal A. Somronthong R. Pradhan S. Knowledge, attitude and preventive

measures amongst married women of reproductive age towards uterine

prolapse in the eight villages of surkhet district of Nepal. http://www. jhr.cphs.

chula.ac.th Journal of Health Reearch[internet]. 2011 September[cited 2015


119

May 2015]; 25(3): 129-133 Available from: http://www.kmutt.ac.th/jif /public

html /general search .php.

31. Dr.Shrestha A D,Dr Lakhey B, Sharma J , Singh M, Shrestha B, Singh S.

Prevalence of Uterine Prolapse amongst Gynecology OPD Patients . Available

from: http://www.who.int/woman_child_accountability/ierg/reports/.

32. Bodner AB, Srivastavan C, Bodner K. Risk factors for uterine prolapse.

International Urogynecologic Journal[internet].2007Nov;18(11):1343-6.

http://www.ncbi.nlm.nih.gov/pubmed/.

33. Wiegersma M,R Panman C M C,Kollen BJ,Berge M Y,Leeuwen Y L V,

DekkerJH. Effect of pelvic floor muscle training compared with watchful

waiting BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g7378 (Published

22 December 2014), pgno ;349:g7378

34. Chhabra S, Ramteke M, Mehta S, Bhole N, Yadav Y. Trends in hysterectomy

for genital prolapse: rural experience. Clinical Medicine Insights:

Reproductive Health [internet]. 2013 January; 29 (7): 11-16. Available from:

http://www.la-press.com.

35. Shrestha B, OntaS, Choulagai B, Poudya A, Pahari D P, Uprety A,

Petzold M Krettek A. Women’s experiences and health care-seeking

practices in relation to uterine prolapse in a hill district of Nepal. BMC

Women's Health [internet]. 2014;Available from: http://www.biomed

central.com/1472-6874.

36. Frawley H, Galea M P ,Janet Logan, Donald A M C ,Pherson G M , Moore K

H, Norrie Individualised pelvic floor muscle training in women with pelvic

organ prolapse. Biomedical Central[internet] 2013 November.[cited 2013 Oct

25]; 14(2): Available from :http://dx.doi.org/10.1016/ S0140-6736(13)61977.


120

37. Good MM, Korbly N, Kassis NC, Richardson ML, Book NM, Yip S, Saguan

D, Gross C, Evans J. Prolapse-related knowledge and attitudes toward the

uterus in women with pelvic organ prolapse symptoms. American Journal of

Obstetrics and Gynaecology[internet]. 2013 Nov;209(5):481

38. Radl CM, Rajwar R, Aro A R. Uterine prolapse prevention in Eastern Nepal:

the perspectives of women and health care professionals. International Journal

of Women Health [internet]. 2012; 4(1): 373–382.Ava ilable from: www.ncbi.

nlm.nih.gov/pubmed/2374810.

39. Hagen S, Stark D, Maher C, Adams E.Conservative management of pelvic

organ prolapse in women. Cochrane Database Systematic Reviews [internet].

2004 October; 18(4):Available from: www.sciencedirect.com/ science /article/

pii/S 175172 .

40. Meyer S, Hohlfeld P, Achtari C, De Grandi P.Pelvic floor education after

vaginal delivery. Journal of Obstetrics and Gynaecology [internet].2001 May ;

97(5): 673-6.

41. Powers K, Lazarou G, Wang A, LaCombe J, Bensinger G, Greston WM,

Mikhail MS. Pessary use in advanced pelvic organ prolapse. International

Urogynecology Journal[internet]. 2006 Feb; 17(2):160-4

42. Crepin G,Cosson M, lucot JP, Coiinet P. Genital prolapse in young women.

Bull Acad natl med. 2007 May; 191 (4-5): 827-836.

43. Ottesen M. Pelvic floor muscle training incontinence in women. Ugeskr

Laeger. 2009 Feb; 171 (6): 404-8.

44. Pratee S, Bansal R, Batra A, Minocha B. An overview of gynaecological

geriatric indoor patients. Journal of Obstetrics and Gynaecology of India

[internet].2002Mar/Apr;52(2):105-7.
121

45. Piya-Anant M, Therasakvichya S, Phatandit LC, Techatrisak K. Prevalence of

uterine prolapse and effectiveness of pelvic floor exercise to prevent

worsening of uterine prolapse. Journal of the Medical Association of Thailand

[internet] 2003 June; 86(6): 509-15. Available at: Pubmed-indexed for

MEDLINE.

46. Handa VL, Jones M. Do pessories prevent the progression of uterine prolapse.

International Urogynecological Journal[Internet]2002 November; 13(6):349-

51. Available at: Pubmed-indexed for MEDLINE.

47. Oliveira D C. Lopes B A M. Pereira L C L. Zugaib M. Effect of pelvic floor

muscle training. 2007. Available from: http://worldwidescience.org/wws/link.

http://www.scielo. br/scielo. php?script

48. Roets L. The experience of women with genital prolapse Curationis.

September 2007 .Journal of the Democratic Nursing Organization of South

Africa [internet].2007[cited 2007 September 28];30(3):Available from: http ://

www .curationis.org.za/index.php/curationis/article/view/1090.

49. Subedi A. Barriers in health seeking from health facilities among women with

uterine prolapse[PG thesis].Institute of Medicine: Tribhuvan University; 2015

50. Kumari S, Walia I, Singh A. Self-reported uterine prolapse in a resettlement

colony of north India. Journal of Midwifery & Women’s Health.

[Internet].2000 July-August[cited 2011January 27]; 45( 4): 343–350, 2000.

51. Bhanderi MN, Kannan S. Untreated reproductive morbidities among ever

married women of slums of Rajkot City, Gujarat: the role of class, distances,

provider attitudes, and perceived quality of care. Journal of Urban

Health[internet].2010[cited 2010 march 1]; 87(2):254-63.


122

st
52. Sharma K S. Nursing Research and Statistics.1 edition. New Delhi. Elsevier

publication;2013.

53. Kothari C R. Research Methodology- methods and techniques. 2nd ed. New

Delhi: New age International; 2004.


nd
54. Bhaskararaj D E .Nursing Research and Biostatistics. 2 edition. Bangalore.

Emmes Medical Publishers ; 2012.

55. Beck CT, Polit DF. Nursing Research:Principles and methods. 7th ed.

Philadelphia: Lippincott Williams and Willkins; 2003.


th
56. Polit D F. Beck C T. Nursing Research. 9 edition.New Delhi. Lippincott

William and Wilkins.2013.


1
57. Goman HM , Fetohy EM, Nosseir SA, Kholeif AE. Perception of genital

prolapse: a hospital-based study in Alexandria. Journal of Egypt Public

Association [internet] 2001;76(5-6):337-56.

58. Joseph J M. Knowledge and barriers of health seeking Behaviour on cervical

cancer among women [PG thesis].Kerala University of Health Science.2014.


123

APPENDIX A

List of Abbreviations

ACME Academy Of Medical Sciences

ASHA Accredited Social Health Activists

HBM Health Belief Model

ICS International Continence Society

JPHN Junior Public Health Nurses

MDG Millennium Development Goal

PFR Pelvic Floor Repair

POP Pelvic Organ Prolapse

POP-Q Pelvic Organ Prolapse Quantification System

UP Uterine Prolapse

UVP Utero Vaginal Prolapse

WHO World Health Organization

VDCs Village Development Committees

n number of sample

SD Standard Deviation

P Probability

df degree of freedom
124

APPENDIX B

List of experts for content validity of the tool

`1 Dr.(Prof.) Geethakumari V P, 5. Mrs.Mollykutty Joyichan,

Vice principal, Assistant Professor,

Govt. College of Nursing, College of Nursing,

Calicut. ACME, Pariyarm

2 Mrs. Laly K.S , 6 Dr.Reshmi V.P,Assistant

Associate Professor, Professor,

Govt. College of Nursing, Obstetrics and Gynaecology,

Calicut. ACME, Pariyaram .

3 Mrs. Gigy John, 7 Dr. Jayasree A.K.

Assistant Professor, HOD

Govt. College of Nursing, Community Medicine,

Thrissur. ACME,Pariyaram.

4 Dr.Ramesan C .K, 8 Mrs.Mayamol T.R,

MBBS, MD, Senior Lecturer,

Junior Consultant, Community Medicine,

Obstetrics And Gynaecology, ACME, Pariyaram.

THQ Govt.Hospital

Taliparamba .
125

APPENDIX C

Approval letter of Ethics committee


126

APPENDIX D

Letter granting permission to conduct pilot study


127

APPENDIX E

Letter granting permission to conduct actual study


128

APPENDIX F

Letter seeking expert guidance for content validation of tool


129

APPENDIX G

Acceptance form for validation of tool


130

APPENDIX H

CRITERIA CHECKLIST TO VALIDATE THE TOOL

Criteria checklist to validate the tool to assess the knowledge regarding uterine

prolapse among married women.

Kindly review the items in the research tool and give your valuable

suggestions. Please put a tick mark against the specific column. If there are any

suggestions please mention it in the 'Remarks' column.

Tool I-Structured interview schedule to assess the Knowledge regarding uterine

prolapse among married women.

Section A: Socio personel data

ITEM VERY RELEVANT SOMEWHAT NOT REMARKS


NO. RELEVANT (3) RELEVANT RELEVANT
(4) (2) (1)

1
2
3
4
5
6
7
8
9
9a
10
10a
131

Section B– Assessment of knowledge regarding uterin e prolapse among married

women.

ITEM NO. VERY RELEVANT SOMEWHAT NOT REMARKS

RELEVANT (3) RELEVANT RELEVANT

(4) (2) (1)

10

11

12

13

14

15

16
132

17

18

19

20

Tool II- Five point Rating scale to assess the barriers of health seeking behaviour

on uterine prolapse among married women.

ITEM NOT SOMEWHAT RELEVANT VERY REMARKS

NO. RELEVANT RELEVANT (3) RELEVANT

(1) (2) (4)

1.

2.

3.

4.

5.

6.

7.

10

11

12

13
133

14

15

16

17

18

19

20

21

22

23

24
134

APPENDIX I

Informed consent

CODE NO

Consent Form

In signing this document, I am giving consent to the investigator Ms. Akhila .P

2nd year MSc Nursing student, College Of Nursing, ACME, Pariyaram, to participate

in the research study of her MSc Nursing course titled, “assess the knowledge and

barriers of health seeking behaviour on uterine prolapse among married women in the

selected rural areas in Kannur district”.

I have been explained and made understood the need and importance of this

study and voluntarily willing to participate in the study.

I have been ensured that the study doesn’t include any foreseeable risk or harm

and my confidentiality will be maintained.

Signature of the subject

Date:

Place: Signature of the investigator


135

APPENDIX J

Tool I: Structured interview schedule to assess the knowledge on Uterine

Prolapse among married women.

Instruction to the interviwer

1. Ask the questions listed below

2. Put a tick mark (√ ) in most appropriate space as per response given by the participants

or complete the respective places.

Section A

Socio personal data Code No:


1. Age in years
a) 30-40 [ ]

b) 41-50 [ ]

c) 51-60 [ ]

2. Religion

a) Hindu [ ]

b) Christian [ ]

c) Muslim [ ]

d) Others [ ]

3. Education

a) Primary [ ]

b) High school [ ]

c) Higher secondary [ ]

d) College [ ]

e) professional/technical [ ]
136

4. Occupation

a) home maker [ ]

b) manual labour [ ]

c) private employee [ ]

d) govt. employee [ ]

5. Marital status

a) married [ ]

b) widow [ ]

c) Divorced/ Separated [ ]

6. Type of family

a) nuclear [ ]

b) joint [ ]

c) extended [ ]

7. Monthly income of family in rupees :

a) ≤ 5000 [ ]

b) 5001- 10000 [ ]

c) 10001- 20000 [ ]

d) > 20001 [ ]

8.Number of children

a) Nil [ ]

b) One [ ]

c) Two [ ]

d) Three [ ]

e) four or more [ ]
137

9 . Do you have any information regarding Uterine prolapse ?

a) yes [ ]

b) no [ ]

9a. If yes, Specify the source

a) health personnel [ ]

b) friends /relatives [ ]

c) media/magazines [ ]

d) any other specify [ ]

10. Do you or any of your family members have a history of Uterine prolapse ?

a) yes [ ]

b) No [ ]

10a.If yes , specify the relationship with member

Section B : Assessment of knowledge regarding Uterine Prolapse among

married women

1. Female reproductive organ consist of

a) ovaries, pancreas, intestine, fallopian tubes [ ]

b) ovaries, kidney, liver, uterus [ ]

c) ovaries, spleen, uterus, large intestine. [ ]

d) ovaries, fallopian tubes, uterus, vagina [ ]

2. Structures support the reproductive organs

a) fat tissue [ ]

b) pelvic muscles and ligaments [ ]

c) pelvic girdle [ ]

d) vertebral column [ ]
138

3.Normal position of uterus

a) tilted backward [ ]

b) tilted to right [ ]

c) tilted forward [ ]

d) tilted to left [ ]

4.The organ which is situated in front of vagina

a) rectum [ ]

b) cervix [ ]

c) bladder [ ]

d) intestine [ ]

5.Uterine prolapse means

a) slip down of uterus into or outside vagina [ ]

b) bulging of bladder to vagina [ ]

c) bulging of rectum to vagina [ ]

d) Dropping down of top of vagina [ ]

6. Cause of uterine prolapse is

a) ovarian tumour [ ]

b) child birth trauma [ ]

c) tubal pregnancy [ ]

d) use of contraceptive [ ]

7.The risk factor of uterine prolapse is

a) caesarean birth [ ]

b) early menarche [ ]

c) frequent urinary tract infection [ ]

d) obesity [ ]
139

8. Symptoms of uterine prolapse are

a) Abdominal pain ,vomiting [ ]

b) Feeling of mass in the vagina, urinary problems [ ]

c) Head ache, fever [ ]

d) Menstrual irregularities sores on genitals [ ]

9. Uncontrollable loss of urine during coughing, sneezing, laughing is due to

a) Stroke [ ]

b) weak pelvic floor muscle [ ]

c) spinal cord injury [ ]

d) bladder cancer [ ]

10. The right statement regarding uterine prolapse

a) doing heavy work during pregnancy and after delivery increases risk

of prolapse [ ]

b) taking herbs can prevent uterine prolapse [ ]

c) having many children reduce the risk of prolapse [ ]

d) not having enough food during pregnancy cause prolapse [ ]

11. Complication of uterine prolapse is

a) cancer [ ]

b) ulcer formation on cervix and vagina [ ]

c) infertility [ ]

d) dysfunctional uterine bleeding [ ]

12.The management of uterine prolapse includes all except


a) pessary [ ]
b) surgery [ ]
c) medications [ ]
d) pelvic floor exercises [ ]
140

13.Measure taken to prevent uterine prolapse after child birth is to

a) promote future pregnancy too soon [ ]

b) avoid strenuous activities for at least six months [ ]

c) take complete bed rest [ ]

d) keep the leg elevated while lying [ ]

14.The management of stress incontinence include all except

a) Frequent voiding [ ]

b) Maintain healthy weight [ ]

c) Pelvic floor muscle exercise [ ]

d) Take caffeine containing and spicy foods [ ]

15. Pessary is used

a) to support uterus and pelvic organ to stop them from coming down[ ]

b) as a contraceptive [ ]

c) to strengthen pelvic muscles [ ]

d) to reduce pelvic pain [ ]

16.The best method to clean Pessary is

a) wash with mild soap and rinse well [ ]

b) wash with perfumes [ ]

c) soak in chemicals [ ]

d) boiling [ ]

17. Pessary need to be changed

a) every month [ ]

b) every 2-3 months [ ]

c) every 4-6 months [ ]

d) after 1 year [ ]
141

18.The main complication of pessary use is

a) allergic reactions []

b) infection or ulcers in vagina []

c) narrowing of vagina []

d) difficulty in passing urine []

19. The following are self care measure to prevent prolapse except

a) do house hold activities in sitting position []

b) eat low fibre diet []

c) take low fat diet []

d) avoid heavy lifting []

20. The ways to improve genital health include all except

a) keep genital area clean and dry []

b) take well balanced diet []

c) routine early pap smear and pelvic examination []

d) wear nylon undergarments/clothes []


142

APPENDIX K

Answer key

Section B : Structured interview schedule to assess the knowledge regarding

Uterine Prolapse among married women

1 d 11 b

2 b 12 c

3 c 13 b

4 c 14 d

5 a 15 a

6 b 16 a

7 d 17 b

8 b 18 b

9 b 19 b

10 a 20 d
143

APPENDIX L
Blue print of Tool I

Sl Content Knowledge Comprehension Application No of %


No
items
1 Knowledge 5 5 25%
Regarding anatomy of 1,2,3,4,
female reproductive
system.
2 Knowledge regarding 6,7 10 3 15%
etiology and risk
factors of uterine
prolapse
3 Knowledge regarding 8,11 9 3 15%
symptoms of uterine
prolapse
4 Knowledge regarding 18 17 12,13,14,15, 9 45%
management and 16,19,20
prevention of uterine
prolapse
Total 9 4 7 20
100%
Percentage 45% 20% 35%
144

APPENDIX M

Tool II- Rating scale to assess the barriers of health seeking

behaviour on uterine prolapse among married women

The following are the few statements reflecting barriers of health seeking

behaviour on uterine prolapse among married women.

Instruction to the investigator:

· Please read the statement and put a ( √ ) mark against five point scale

Instruction to the participants:

 Please feel free to express your opinion

Code No:

SL Item Strongly Agree Uncertain Disagree Strongly

NO Agree Disagree

Knowledge and awareness

1 Gynaecological problems are

part of women hood and not

consider as serious to be

treated

2 I don’t know where to seek

treatment for Gynaecological

problems

3 Gynaecological examination

are unnecessary after attaining

menopause
145

Embarrassment, fear

4 Hesitate to discuss about

uterine prolapse within

family or health care

provider due to shame and

embarrassment

5 Being examined by a male

doctor would discourage

me from undergoing

examination

6 Gynaecological procedure

is too painful

7 Positioning for examination

is embarrassing for me.

8 Reluctant to do

Gynaecological

examination due to fear of

violation of confidentiality

Attitude and beliefs

9 Women of my age are more

prone to be affected with

uterine prolapse
146

10 Uterine prolapse are more

prevalent in low

socioeconomic status

11 There is no need to

approach health care team

for treating uterine prolapse

12 Uterine prolapsed is an

embarrassing disease

Lack of support and Peer

pressure

13 I feel embarrassed to

disclose my gynaecological

problems

14 Family members are not

interested in my health

problem

15 No one to accompany me

to seek health care

Time and cost

16 I do not have enough time

to seek healthcare

17 Gynecological tests are too

expensive.
147

18 Transportation cost is not

affordable to our family

Cultural factors

19 Social stigma associated

with Uterine Prolapse

prevents me from seeking

heath care

20 Our customs will not allow

me to go outside alone.

21 Lack of decision making in

home make me difficult to

seek services

22 Being accompany with

male person prevent me in

communicating symptoms

to doctor.

Accessibility to health

care Facility

23 Health centres are too far

from home.

24 I have to wait a long time in

front of clinic for getting

examined.
148

APPENDIX N

SCORING AND RATING

Tool I–Structured interview schedule to assess the knowledge regarding uterine

prolapse among married women. (20 items)

SCORING

Right answer- ‘1’ score

Wrong answer- ‘0’ score

Interpretation of knowledge score

0-6 Inadequate

7 – 13 Moderate

14 – 20 Adequate

Tool II -Five point rating scale to assess the barriers of health seeking behaviour

on uterine prolapse among married women.(24 statements)

SCORING AND RATINGS

Strongly Agree – 5

Agree – 4

Uncertain – 3

Disagree - 2

Strongly Disagree – 1

Interpretation of barrier ratings

24-56 Mild

57-88 Moderate

89-120 Strong
149

APPENDIX O
k½X]{Xw
]cnbmcw \gvknwKv tImtfPv c−mw hÀj Fw.Fkv.kn

\gvknwKv hnZymÀ°n\nbmb ankv. AJne. ]n, ]T\¯nsâ `mKambn \S¯p¶

“ KÀ`]m{Xw sX¶n Xmtgm«v Cd§p¶Xns\¡pdn¨v hnhmln

Xcmb kv{XoIfpsS Aht_m[hpw {]Xntcm[amÀ¤§Ä kzoIcn¡p ¶

Xn\pÅ XSʧfpw” F¶ KthjW ]T\¯n ]s¦Sp¡m³ F\n¡v k½XamWv. Cu

KthjW ]T\¯nsâ FÃm hi§fpw BhiyIXbpw {]m[m\yhpw F\n¡v ]dªp

a\Ênem¡n X¶n«p−v. Rm³ CXn kzta[bm ]s¦Sp¡m³ X¿mdmWv.

CXn\pth−n F\n¡v A[nI¨nehpIÄ D−mhpIbnsöpw


Fs¶¡pdn¨pÅkzImcy hnhc§Ä aämÀ¡pw shfns¸Sp¯pIbnsöpw F\n¡v
Dd¸pX¶n«p−v.

]T\¯n ]s¦Sp¡p¶ BfpsS H¸v:

Xo¿Xn:

t]cv:

Øew: ]T\w \S¯p¶ BfpsS H¸v:


150

APPENDIX P

KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xns\¡pdn¨v hnhmlnXcmb

kv{XoIÄ¡nSbnepÅ Adnhv ]cntim[n¡p¶ A`napJw

A`napJw \S¯p¶ BÄ¡pÅ \nÀt±i§Ä

1. Xmsg]dªn«pÅ tNmZy§Ä tNmZn¡pI

2. A\ptbmPyamb {]XnIcW¯n\pt\sc [√] amÀ¡v sN¿pI

Asæn BhiyapÅ `mKw ]qcn¸n¡pI

tImUv \¼À:

hn`mKw F:

kmaqlnIhpw hyàn]chpamb hnhc§Ä

1. {]mbw

a) 30þ40 hbÊv [ ]

b) 41þ50 hbÊv [ ]

c) 51þ60 hbÊv [ ]

2. aXw

a) lnµp [ ]

b) {InkvXy³ [ ]

c) apÉow [ ]

d) aäpÅh [ ]

3. hnZym`ymk tbmKyX

a) {]mYanI hnZym`ymkw- [ ]

b) sslkvIqÄ hnZym`ymkw- [ ]
c) lbÀsk¡âdn [ ]

d) tImtfPv hnZym`ymkw- [ ]

e) sXmgnÂ]camb/ kmt¦XnI ]camb hnZym`ymkw- [ ]


151

4. sXmgnÂ

a) Krl`cWw [ ]

b) Iqen¸Wn [ ]

c) Khs×âv tPmen [ ]

d) kzImcytaJebn tPmen [ ]

5. hnhmlmhØ

a) hnhmlnX [ ]

b) hn[h [ ]

c) hnhmltamN\w t\SnbhÀ/ [ ]

]¦mfnbn \n¶v AI¶v Xmakn¡p¶hÀ

6. GXpXcw IpSpw_w

a) AWpIpSpw_w [ ]

b) Iq«pIpSpw_w [ ]

c) hnkvXrXamb IpSpw_w [ ]

7. amkhcpam\w

a) 5000 tam AXn Xmsgtbm [ ]

b) 5001þ15000 [ ]

c) 15001þ25000 [ ]

d) 25000\v apIfn [ ]

8. Ip«nIfpsS F®w

a) CÃ [ ]

b) H¶v [ ]

c) c−v [ ]

d) aq¶v [ ]

e) \mtem AXne[nItam [ ]
152

9. KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xns\¡pdn¨v \n§Ä¡v Fs´¦nepw

Adnhv In«nbn«pt−m?

a) D−v [ ]

b) CÃ [ ]

9F. Ds−¦n Adnhnsâ DdhnSw

a) BtcmKzhnZKvZÀ [ ]

b) _\v[p¡Ä/ kply¯p¡Ä [ ]

c) Zyiy{ihyam[ya§Ä [ ]

d) aäpÅhhyIvXam¡pI [ ]

10 . \n§Ät¡m \n§fpsS IpSpw_¯nse BÀs¡¦nepw KÀ`]m{Xw

sX¶nXmtgm«v \o§p¶ AhkvY h¶n«pt−m?

a) D−v [ ]

b) CÃ [ ]

10F. Ds−¦n hyIvXam¡pI


153

hn`mKw: _n

KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xns\¡pdn¨v hnhmlnXcmb


kv{XoIfn \S¯nb Adnhv tiJcWw
1. kv{XobpsS {]XypÂ]mZ\hyhkvYbn DÄs¸Sp¶ `mK§Ä

a) AWvUmib§Ä,BKvt\b{K\vYn,IpSÂ,

AWvUhmln\n¡pgepIÄ [ ]

b) AWvUmib§Ä,hy¡,IcÄ,KÀ`mibw [ ]

c) AWvUmib§Ä, ¹ol,KÀ`mibw,h³IpS [ ]

d) AWvUmib§Ä, AWvUhmln\n¡pgepIÄ, [ ]

KÀ`mibw, tbm\n

2. {]Xyp¸mZ\ Ahbh§sf Xm§n \nÀ¯p¶ LS\bmWv

a) sImgp¸v]mfnIÄ(sImgp¸vIeIÄ) [ ]

b) CSp¸nset]inIfpw X´p¡fpw [ ]

c) CSps¸Ãv [ ]

d) \s«Ãv [ ]

3. KÀ`]m{X¯nsâ km[mcW kvYm\w

a) ]pdIntem«vsNcnªv [ ]

b) heXvhit¯¡vsNcnªv [ ]

c) apt¶m«v sNcnªv [ ]

d) CSXvhit¯¡v sNcnªv [ ]

4. tbm\nbpsS ap³]nembn kvYnXn sN¿p¶ Ahbhw

a) aemibw [ ]

b) KÀ`mibapJw [ ]

c) aq{Xmibw [ ]

d) IpSÂ [ ]
154

5. KÀ`]m{Xw Xmtgm«vCd§pI F¶XpsIm−ÀXvYam¡p¶Xv

a) KÀ`]m{Xw tbm\nbntet¡m tbm\nhgn ]pdt¯t¡m

DuÀ¶phcp¶ AhkvY [ ]

b) aq{Xk©ntbm\nbnte¡v XÅn\n¡p¶ AhkvY [ ]

c) aemibw tbm\nbnte¡v XÅn\n¡p¶X AhkvY [ ]

d) tbm\nbpsS apIÄ`mKw Xmtg¡nd§p¶ AhkvY [ ]

6. KÀ`]m{Xw Xmtgm«v Cd§p¶Xnsâ ImcW§Ä

a) AÞmib¯nse apg [ ]

b) P\\kab¯p−mIp¶ apdnhv [ ]

c) AÞhmln\n¡pgense KÀ`[mcWw [ ]

d) KÀ`\ntcm[\ amÀ¤§fpsS D]tbmKw [ ]

7. KÀ`]m{Xw Xmtgm«v Cd§p¶Xn\v ImcWamtb¡mhp¶ LSIw

a) kntkdnb³ ikv{X{Inb [ ]

b) t\ct¯bpÅ BÀ¯hw [ ]

c) ASn¡nSbpÅ aq{Xmib¯nse AWp_m[ [ ]

d) s]m®¯Sn [ ]

8. KÀ`]m{Xw Xmtgm«v Cd§p¶Xnsâ e£W§Ä

a) DZcthZ\, O˱n [ ]

b) XethZ\, ]\n [ ]

c) tbm\nbn apgbpÅXpt]mse tXm¶epw [ ]

aq{Xmib kw- Ôamb {]iv\§fpw

d) BÀ¯hkw-_ÔambAkzØXIfpw [ ]

P\t\{µnb¯nse ---{hW§fpw
155

9. Xp½pt¼mgpwNncn¡pt¼mgpwNpabv¡pt¼mgpwA\nb{´nXambn

aq{Xwt]mIp¶XnsâImcWw

a) ]£mLmXw [ ]

b) CSp¸nset]inIfpsS _e¡pdhv [ ]

c) kpjpav\m\mUnbn apdnhv [ ]

d) aq{Xmib¯nse AÀ_pZw [ ]

10.KÀ`]m{Xw Xmtgm«v Cd§p¶Xns\¸änbpÅ icnbmb {]kvXmh\ bmWv

a) KÀ`[mcW kab¯pw AXn\ptijapÅ ITn\m[zm\hpw [ ]

KÀ`]m{Xw Xmtgm«v Cd§p¶Xn\pÅ km[yX Iq«p¶p.

b) Huj[ kky§fpsS D]tbmKw KÀ`]m{Xw

Xmtgm«v Cd§p¶Xn\pÅ km[yX XSbp¶p. [ ]

c) IqSpX Ip«nIÄ DÅhcn KÀ`]m{Xw Xmtgm«v Cd§m³

ImcWamtb¡mhp¶ km[yX Ipdbpw [ ]

d) KÀ`mhØbnepÅ Blmc¯nsâ Ipdhv KÀ`]m{Xw

Xmtgm«v Cd§p¶Xn\v ImcWamIp¶p [ ]

11. KÀ`]m{Xw sX¶n Xmtgm«v Cd§p¶XpsIm−pÅ k¦oÀ®XbmWv

a) AÀ_pZw [ ]

b) tbm\n`mK¯pÅ AÄkÀ [ ]

c) hÔyX [ ]

d) kvXoIfnse Akm[mcW cIvX{kmhw [ ]


156

12. KÀ`]m{Xw Xmtgm«v Cd§p¶Xn\pÅ NnInÕbnÂs]Sm¯Xv

a) s]kdn [ ]

b) ikv{X{Inb [ ]

c) acp¶pIÄ [ ]

d) CSp¸nset]inIÄ¡p \ÂIp¶ hymbmaw [ ]

13.{]kh¯n\ptijw KÀ`]m{Xw Xmtgm«v Cd§p¶Xv XSbm\pÅ {]Xnhn[n

a) `mhnbnepÅ KÀ`[mcWw thK¯nem¡pI [ ]

b) GItZiw Bdpamkw- hsc ITn\m[zm\w sN¿p¶Xv

Hgnhm¡pI [ ]

c) k¼qÀ®amb hn{iaw [ ]

d) InS¡pt¼mÄ Im s]m¡nhbv¡pI [ ]

14. A\nbn{´nXambn aq{Xwt]mIp¶Xnsâ {]Xnhn[nIfnÂs]Sm¯Xv

a) ASn¡SnbpÅ aq{Xsamgn¡Â [ ]

b) BtcmKyIcamb icoc`mcw \ne\nÀ¯pI [ ]

c) CSp¸nset]inIfnepÅ hymbmaw [ ]

d) I^o³ AS§nbXpw ( Nmb,Im¸n, tNmIvteäv) Fcnhpw]pfnbpw

DÅXpamb `£Ww Ign¡pI [ ]

15.s]kdn D]tbmKn¡p¶Xv

a) KÀ`]m{Xt¯bpw CSp¸nse Ahbh§tfbpw ]pdt¯¡v

Cd§nhcp¶Xv XSbm³ klmbn¡p¶p [ ]

b) KÀ`\ntcm[\amÀKvvKambn [ ]

c) CSp¸nset]inIÄ _es¸Sp¯p¶Xn\v [ ]

d) CSp¸vthZ\ Ipdbv¡p¶Xn\v [ ]
157

16. s]kdn hy¯nbm¡phm³ Gähpw \ÃamÀKvKamWv

a) hocyw IpdªXpamb tkm¸v D]tbmKn¨v \¶mbnIgpIpI [ ]

b) kpK\v[apÅhkvXp¡ÄD]tbmKn¨vIgpIpI [ ]

c) cmk]ZmÀXvY¯n ap¡nshbv¡pI [ ]

d) Xnf¸n¡pI [ ]

17. s]kdn amänbntS−Xv

a) FÃmamkhpw [ ]

b) 2--- ‐3 amk¯n Hcn¡Â [ ]

c) 4‐ 6 amk¯n Hcn¡Â [ ]

d) Hcp hÀj¯n\ptijw [ ]

18.s]kdnbpsS D]tbmKwaqew D−mtb¡mhp¶ Hcp {][m\ k¦oÀWXbmWv

a) AeÀPn [ ]

b) tbm\nbnseAWp_m[bpw{hWhpw [ ]

c) tbm\o`mKw Npcp§p¶Xv [ ]

d) aq{Xw Hgn¡p¶Xnep−mIp¶ XSkw [ ]

19.XmsgsImSp¯ncn¡p¶hbn KÀ`]m{Xw Xmtgm«v Cd§p¶Xv


XSbp¶Xn\pÅ kzbw ]cnNcWamÀ¤§fn s]Sm¯Xv

a) Ccp¶psIm−v ho«ptPmen sN¿pI [ ]

b) \mcS§nb `£Ww Ipdbv¡pI [ ]

c) sImgp¸v AS§nb `£Ww Ipdbv¡pI [ ]

d) `mcapÅ hkvXp¡Ä DbÀ¯mXncn¡pI [ ]


158

20. P\t\{µnb BtcmKy kw-c£W¯n s]Sm¯Xv

a) Kply`mKwipNnbmbpwCuÀ¸clnXambpw kq£n¡pI [ ]

b) kaoIrXmlmcw Ign¡pI [ ]

c) {Iaamb ]m]vkvanbÀ ]cntim[\bpw

CSp¸v ]cntim[\bpw \S¯pI [ ]

d) ss\tem¬sIm−p−m¡nb ASnhkv{X§Ä D]tbmKn¡pI [ ]


159

APPENDIX P

KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xv XSbp¶Xn\pÅ

amÀ¤§Ä kzoIcn¡phm³ hnhmlnXcmb kv{XoIÄ t\cnSp¶

XS椀 Adnbphm\pÅ AfhptImÂ


KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xv XSbm\pÅ amÀ¤§Ä

kzoIcn¡phm³ hnhmlnXcmb kv{XoIÄ t\cnSp¶ XSʧsf {]Xn]mZn¡p¶

{]kvXmh\IÄ NphsS tNÀ¡p¶p.

KthjI\pÅ \nÀt±i§Ä

XmsgsImSp¯ncn¡p¶ {]kvXmh\IÄ {i²tbmsS hmbn¨v {]XnIc Ww

IyXyambn tImf¯n (√ )tcJs¸Sp¯pI

klImcn¡pÅ \nÀt±i§Ä

\n§Ä¡v A\p`hs¸Sp¶ {]iv\§Ä aSnIqSmsX Xpd¶p]dbpI


]qÀ®ambntbmPn¡p¶p

]qÀ®ambnhntbmPn¡p¶p
hntbmPn¡p¶p
XoÀ¨bnÃ
tbmPn¡p¶p

\w {]kvXmh\IÄ

Adnhv, t_m[y§Ä

1 kv{XotcmK§Ä, kv{Xo klPamsW¶pw


AXp KpcpXcambn ]cnKWn¨v NnInÕnt¡−

BhiyanÃ

2 kv{XoIÄ¡p−mIp¶ {]iv\§fpsS NnInÕ


bv¡v FhnsSbmWv t]mtI−Xv

Fs¶\n¡dnbnÃ

3 BÀ¯hhncma¯n\ptijw kv{XoP\y
]cntim[\bpsS BhiyanÃ
160

\mWt¡Sv, `bw

4 kv{Xo tcmK]camb Imcy§Ä \mWt¡Spw


eÖsIm−pw ho«pImcpw BtcmKy {]hÀ¯

Icpambn ]¦phbv¡pt¼mÄ F\n¡v

hnapJX tXm¶p¶p.

5 ]pcpj tUmÎÀ ]cntim[n¡p¶Xp


sIm−mWv Rm³ ]cntim[\bv¡v hnapJX

ImWn¡p¶Xv

6 kv{XotcmK ]cntim[\ XnI¨pw thZ\m


P\IamWv

7 kv{XotcmK ]cntim[\bv¡mbn InS¡p¶


coXn F\n¡v hnjaIcamWv

8 kv{XotcmK]camb ]cntim[\IÄ \S¯p


t¼mÄ AXnsâ clkykz`mhw Im¯p

kq£n¡ptam F¶ `bw A\p`hs¸Sp¶p.

kao]\hpw hnizmk§fpw

9 Fsâ {]mb¯nepÅ kv{XoIÄ¡v KÀ`]m{Xw


sX¶nXmtgm«v Cd§p¶Xv IqSpXembn

ImWs¸Sp¶p.

10 km¼¯nIambn ]nt¶m¡w \n¡p¶hcnÂ


IqSpXembpw KÀ`]m{Xw sX¶nXmtgm«v

Cd§p¶Xv ImWs¸Sp¶p.

11 KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xv


NnInÕn¡p¶Xn\mbn BtcmKy kw-c£W

cwKs¯ BfpIsf kao]nt¡− BhiyanÃ

12 \mWt¡Spfhm¡p¶ Hcp tcmKmhkvYbmWv


KÀ`]m{Xw Xmtgm«v Cd§p¶Xv
161

IpSpw_ klmb¯nsâ A`mhw kplr¯p

¡fpsS k½À±w

13 kv{XotcmK§sfÃmw Xs¶ Xpd¶p ]dbp


¶Xv eÖmIcamWv

14 Fsâ BtcmKyImcy¯n IpSpw_¡mÀ


H«pw Xs¶ {i² sNep¯p¶nÃ

15 Fsâ IqsS BtcmKytI{µ¯n hcm³


BcpanÃ

kabhpw, km¼¯nIhpw

16 BtcmKyImcy§Ä¡pth−n sNehgn¡m³
F\n¡v kabanÃ

17 kv{XotcmK ]cntim[\IÄ hfsc Nnethdn


bXmWv

18 hml\ sNehv Fsâ IpSpw_¯n\v


Xm§m³ IgnbnÃ

kmwkvImcnI LSI§Ä

19 KÀ`]m{Xw sX¶nXmtgm«v Cd§p¶Xv


kw_\v[nbmb kmaqlnI A]am\w NnInÕ

tXSp¶XnÂ\n¶pw Fs¶XSÊs¸Sp¯p¶p.

20 X\n¨v ]pd¯pt]mIphm³ R§fpsS


BNmc§Ä A\phZn¡p¶nÃ

21 kz´amb Xocpam\w FSp¡m³ Ignbm¯


AhØ Fs¶ ]cntim[\bn \n¶pw hn«p

\n¡m³ t{]cn¸n¡p¶p.

22 `À¯mhnsâ ap¼n h¨v tUmÎtdmSv {]iv\


§Ä Xpd¶p]dbm³ aSntXm¶p¶p.

23 kv{XotcmK ]cntim[\mtI{µ§Ä Fsâ


ho«n \n¶pw hfsc AIsebmWv
162

24 kv{XotcmK ]cntim[\tI{µ¯nÂ
hfsct\cw Fsâ Dugw Im¯v
\nÂt¡−nhcp¶p.
163

APPENDIX Q

INFORMATION BOOKLET

(ssI¸pkvXIw)

KÀ`]m{X w sX¶n Xmtgm«v C d§p¶

AhØ bpw AXp XSbp¶X n\pÅ

amÀ¤§fpw
Prepared by, Suggestions B y,
Prof.(Mrs).Sre eja
Akhila.p
G.Pillai And
nd
II year MSc Nursing Mrs.Mollykut ty Joyichan

College of Nrsing, ACM E, Dept.of Obstetrics and


Pariyaram Gynaecologica l nursing
College of Nrsing, ACME,
Pariyaram
164

BapJw

C´ybn {]Xyp¸mZ\tijnbpÅ kv{XoIfpsSbnS bn apJyambpÅ


BtcmKy{]iv\amWv kv{XotcmKmhØ. an¡ kv{XoIfpw ip{iqjsbm¶pw tXSmsX
BtcmSpw Xpd¶p ]dbmsX sh¡pIbmWv ]Xnhv.

kv{XotcmKmhØ F¶Xv KÀ`[mcWw, {]khw, KÀ`aek F¶nh bpambn


_Ôs¸«ÃmsX D−mIp¶ tcmK§tfm {]Xyp ¸mZ\ Ahb h§fpsS {]hÀ¯ \
sshIey§tfm BWv. Ch ssewKnI ioe§fpambn
_Ôs¸«XmWv.

{]Xyp¸mZ\ hyhØbnse AWp_m[, BÀ¯h kw_Ôamb tcmK

§Ä, KÀ`]m{Xhpw CSp¸n\pÅnse Ahbh§fpw sX¶n Xmtgm«nd§p¶

AhØ KÀ`miapJ s¯ tImi§fn ep−mIp¶ amä§Ä, hÔyX, aq{Xmib

¯nse AWp_m[ ChsbÃmw kv{XotcmK§fnÂs]Sp ¶p. CXpt]mse

AkpJhpambn F ¯p¶ kv{XoIfpsS F®w IqSnh cnIbmWv. Cu

{]iv\s¯ kv{XoIÄ s]mXpsh Kucht¯msS ImWmdnÃ. AXp henb

{]iv\sam¶paà F ¶ Nn´bmWv ]eÀ¡pw.


165

KÀ`]m{Xw sX¶ n Xmtgm«v Cd§p¶ AhØ

KÀ`]m{Xhpw C Sp¸n\pÅnse aäv Ahb h§fpw (aq{X k©n, aemibw)


AXnsâ bYmØm ¯p \n¶p thÀs]«v sX¶n\o§n tb m\nbneqsS ]pd t¯¡p
XÅnhcp¶ AhØbmWv s]Â

hnIv HmÀK³ s{]mem]vkv. KÀ`]m{Xw


Xmtg¡v Cd§p¶ Xv GItZiw 20%
{]Xyp¸mZ\ ti jnbpÅ kv{XoIfnÂ
ImWs¸Sp¶p.

KÀ`]m{Xw sX¶n\o§Â Ht«sd


kv{XoIÄ t\cnSp¶ ZpÊlamb AhØ bmWv.
CXv AhcpsS ssZ\wZn\ PohnX

s¯ hfsctbsd _m[n¡mdp−v. eÖImcWw ]pd¯p ]dbmsX AkzØ XIsfÃmw kln¨p


Pohn¡pIbmWv ]ecpw. ]pdt¯¡p XÅnhcp¶ `mKw hnc sIm−v X ÅnbmÂ
ho−pw DÅnte¡v Xs¶t]mI pw AXpsIm−v NnInÕ tXSmsX an ¡ kv{XoIfpw
Imew XÅn \o¡pw.

F¶m Hmtcm L«w Ignbpt´mdpw {]iv\w IqSnh cpw. Xosc Ak


l\obamb Ah Øbnse¯pt¼mgmWv an¡hmdpw tUmÎsd tXSnsb ¯p¶Xv. Ahbh§
Ä ]pdt¯¡v XÅnh¶v aq{Xhpw aehpw t]mIm\mhmsX _p²n ap«\p`hn¡p¶
kµÀ`¯n am{XamWv an¡hcpw NnInÕ tXSp¶Xv. KÀ`w [cn¡p¶Xn\p ap³]pw
{]khw Ignªhcnepw ]n¶oSv KÀ`]m{Xw \o¡w sNt¿−n h¶hcnep saÃmw Cu
{]iv\w I−phcp¶p−v. F ¶m {]kh¯n \ptijamWv Cu AkpJw IqSpXembn
hcp¶Xv {]tX yIn¨v BÀ¯h hncma¯n\ptijw ]pd¯p]dbmsXbpw NnInÕ tXSmsX
bpw Cu {]bmkw-sIm−p\S¡p¶Xv kv{XoIÄ¡v imcocnI_p²nap«v F¶t XmsSm¸w
ISp¯ am\knI k½À±§ Ä¡pw CXv CSbm¡mdp−v.

CXpsIm−p Xs¶ KÀ`]m{Xw Xmtgm«v Cd§p¶ ImcW§Ä, e£ W§Ä,


k¦oÀ®XIÄ F§s\ ]cnlcn¡mw F¶nhsb¡pdn¨v kv{XoIÄ Adnªncnt¡−XmWv.
AXphsc sIm−p\S¶ Akz ØXIfn \n¶v
166

tamN\hpamhpw. icnbmb kab¯p Xs¶ ]cnNcWw \ÂIpIbmsW¦n `qcn`mKw


tcmKmhØbpw CÃmXm¡m\mhpw. KÀ`]m{Xw sX¶nXmtgm«p \o§p¶
AhØbpsS ImcW§Ä. e£W§Ä, ]cnNcn¡p¶ coXn, F§s\ XSbmw F¶nh Cu
sNdnb ]pkvXIw \n§Ä¡v hniZoIcn¨p Xcp¶p. tcmK§Ä t\ct¯Xs¶ a\Ênem¡m\pw
AXn\pth− ]cnNcWw tXSp¶Xn\pw Cu ssI ]pkvXIw klmbn¡p¶p.

kvv{XobpsS CSp¸nse Ahbh§fn DÄs¸Sp¶XmWv KÀ`]m{Xhpw


aq{Xmibhpw. aemib¯nsâ Xmsgs¯ `mKhpw km[mcWbmbn Cu
Ahbh§sfÃmw Xs¶ ]n´m§n \nÀ¯p¶Xpw Xm§n\nÀ¯p¶Xpw CSp¸nse X´p¡fpw
Xmgv`mK
¯pÅ t]inIfpamWv.

KÀ`-]m-{X-t¯bpw \s«-Ãn
sâ Iogv`m-Ks¯ km{I-s¯bpw _Ôn-
¸n-¡p¶ ensÜâmWv bqt{Sm-km-
{IÂ ensÜâv. Cu ensÜâp-I-fmWv
KÀ`-]m-{Xs¯ Dd-¸n¨p \nÀ

¯p¶ {][m\ LS-I-§-fn-sem-¶v. CXn\v _e-£-b-ap-−m-hp-Itbm henªv s]m«n-


t¸mhp--Itbm sN¿pt¼mÄ KÀ`-]m-{X-¯nsâ Xm§v \jvSs¸--Spw. CXv bq«-ssd³
s{]mem]vkv AYhm KÀ`-]m{Xw sX¶n\o-§Â F¶ Ah-Øbv¡v Imc-W-am-Ipw.
KÀ`]m{Xw `mKoIamtbm apgph\mtbm tbm\nhgn ]pdt¯¡p XÅn\n¡pItbm
AYhm tbm\nbneqsS ]pdt¯¡v apgph\mbpw hogpItbm sN¿p¶ ØnXn
D−mImw.

KÀ`]m{X¯n\p]pdta aq{Xk©n h³IpSÂ, aemibw F¶nhsbÃmw C¯c¯nÂ


sX¶n\o§mdp−v.
167

KÀ`]m{Xw Xmtgm«v Cd§p¶ hnhn[ AhØIÄ


KÀ`]m{Xw sX¶n\o§en\v {][m\ambpw

\mev L«§fp−v.

· KÀ`]m{Xw tbm\nbpsS DÄ`mK¯v


sX¶n \o§ nsb¯p¶XmWv ^ÌvUn{Kn
s{]mem]vkv.

· sX¶n\o§nb KÀ`]m{Xw tbm\nbpsS

]pdw`mK¯n \v ASps¯¯pt¼mÄ AXv sk¡âv Un{Kn s{]mem]vkv Bbn


IW¡ m¡pw.

· KÀ`]m{X¯nsâ `mKw tbm\nbneqsS ]pdt¯¡v F ¯p¶ L«amWv tXÀUv


Un{Kn s{]mem]vkv F¶p ]dbpw Cu L«s¯ Iw¹oäv s{]mem]vkv F¶pw ]
dbp¶p.

KÀ`]m{Xw apgph\mbn Xs¶ tbm\nbneqsS ]pdt ¯¡v F¯p¶

AhkvYsb t^mÀ ¯vUn{Kn s{]mem]vkv F¶p]dbpw, Cu L«s¯ Iw¹oäv

s{]mem]vsk¶pw ]dbp¶p.
168

ImcW§Ä

· KÀ`]m{Xw sX¶n\o§p¶Xn\v Ht«sd ImcW§ Ä D−v. {][m\ ImcWw t]i


nIÄ¡pw enKsaâpIÄ¡pw kw-`hn¡p ¶ _e£bamWv. Nnecn Cu _e£bw
P·\mXs¶ D−msb¶phcmw. ]mc¼cyambn t]io_e£b w DÅhÀ¡v aäp
ImcW§Ä IqSnbm Ipt¼mÄ {]iv\w IqSpX k¦ oÀ®amIpw.

· {]khkab¯ p−mIp¶ {]iv\§fpw

KÀ`]m{Xw s X¶n \o§m³ ImcWamIpw.

· {]khkab¯ p−mIp¶ apdnhv {]tXyIn¨pw


tbm\nhgnbpÅ {]khw (D]IcW
klmbt¯msSbpÅ {]khw)

· H¶nÂIqSpX  inip¡Ä DÅ KÀ`mhØ, km[mc Wbn IqSpX `mcapÅ Ip


ªp§sf {]khn¡p¶Xv F¶nhaqew

{]kh kab ¯v ASnhbänse t]inIÄ¡v _e£bw D−mtb

¡mw. Cu t]inIÄ¡v _ew hos−Sp¡m³ ]n¶oSv Ignª

nsæn Ahbh§Ä sX¶n\o§m³ CSbm¡pw.

· H¶n IqSp X {]khn¨hÀ.

· {]mbhpw BÀ¯h hncmahpw: 60% kv{XoIÄ¡pw BÀ¯h hncmat¯ms


SbmWv Cu {]iv\w t\cntS−nhcp¶Xv. tlmÀtam¬ \nebnep−mI p¶
hyXnbm\amWv CXn\p Imc Ww. BÀ¯h hncmat¯ms S Cukv{SP³
tlmÀtamWnsâ Afhv I pdbpw. CtXmsS t]inIfpsSb pw
enKsaâpIfpsSbpw _ew Ipdbpw. CXv Ahbh§Ä sX¶nt]mIm\pÅ km[yX
Iq«pw.
169

· DZc`mK¯v k½À±w D−mIp¶ coXnbnepÅ


AhØIÄ

s]m®¯Sn

XpSÀ¨ mbpÅ iàamb Npa (izmk tImi ¯nse


AWp_m[, Bkvß XpS§nbh aqew)

XpSÀ¨ mbmbpÅ AanX`mcw Npa¡Â


ae_Ô w
CSp¸ne p−mIp¶
AÀ_p±w \mUoh
yql¯n\p−mIp¶
XIcmdpIÄ

· hnäman\pIfp sSbpw [mXp¡fpsSbpw Afhv Ipdhv (t]inIÄ ZpÀ_


es¸Sm³ CXp ImcWamIpw)

· KÀ`]m{Xw F Sp¯pIfbp¶Xv (Nne kµÀ`§fn CSp¸p`mKs¯ aäp


Ahbh§fp sS Øm\Ne\¯n\v CShcp¯mdp−v. KÀ`]m{Xw \o¡w sN¿p¶tXm
sS AXn\p A\p_Ôamb Ahbh§ Ä¡v Xm§p Ipd bp¶XmWv I mcWw).

· ]mc¼cy LSI§Ä

· P·\mbpÅ sshIeyw
e£W§Ä
· AkzØX tXm¶pwhn[w tbm\nbn \n¶pw F t´m ]pdt¯¡v
XÅnhcp¶Xpt]mepÅ tXm¶emWv BZyw A\p`hs¸ SpI

· CSp¸v `mK¯ v aÀ±w IqSp¶Xpt]msebpÅ tXm¶Â

· ASnhbÀ `
mcapÅXmbpw \ndªp \nÂ
¡p¶Xp t]mepÅ tXm¶Â

· ssewKnIamb n _Ôs¸Spt¼mÄ tbm\nbn Gsdt\cw thZ\ A\p`hs¸SpI

· aq{Xsamgn¡ pt¼mgpw aehnkÀÖ\ kab¯p−mIp ¶ _p²nap«v


170

· \m`n{]tZi¯ pw \Sp`mK¯pw thZ\ A\p`hs¸SpI

· XfÀ¨, £oWw, AkzØXbpw hnjmZhpw \S¡mt\m \n¡mt\m DÅ _p²nap«v

· tbm\nbn \n¶pÅ cà{kmhw

KÀ`]m{Xw Xmtg¡nd§nbm D−mIp¶ k¦oÀ® XIÄ

· AanX cà{ kmhw

· aq{Xmib¯nse AWp_m[

· tbm\nbnepw KÀ`mibapJ¯pÅ {hWw

KpcpXcamb AhØIfn tbm\nbpsS Hcp

`mKw]pdtIm«v XÅnhcp¶ KÀ`]m{Xw ImcWw Øm\{`wiw kw-`hn¨v Xmtg¡v


h¶v ASnhkv{X§ fpambn Dckn tbm\nbn {hW§ Ä D−mIp¶p. Kply`mKw
\¶mbn IgpIn hr¯nbm¡n DW¡pIbpw sN¿pI \Ãhyàn ipNnXzw ioeam¡pIbmWv
CXp XSbm\pÅ amÀ¤w.

\nb{´WanÃmsX aq{Xwt] mIÂ :


aq{X k©n DÄs¸sSbpÅ CSp¸nse Ahb h§Ä
sX¶n \o§p¶XpImcW w kv{XoIÄ t\cn Sp¶ henb
{]iv\amWv A\nb{´nXamb aq{Xw t]mIÂ.
Npabv¡pt¼mgpw Xp½ pt¼mgpw
Dds¡ Nncn¡pt¼mgpw sNdnb hkvXp ¡Ä hsc
FSp¡pt¼mgpsaÃmw IpdtÈbm bn aq{Xw
t]mhp¶ AhØ. aq{Xw \ nb{´n¡p ¶XnÂ
kzm`mhnIambpÅ tijn CtXmsS \ãs¸SpIbmWv
sN¿p¶Xv. CXp

ImcWw s]mXp Ø e§fn t]mImt\m aäpw IgnbmsX _p²n ap«p¶hÀ


GsdbmWv. ]ecpw eÖImcWw C¡mcyw ]dbpItbm Nn InÕ tXSpItbm
sN¿p¶panÃ.
171

aq{Xk©nsb _Ôn¸n¨p \nÀ¯p¶ CSp¸nse t]in IÄ¡pw enKsaâp IÄ¡pw


_e£bw hcp¶XmWv A\nb{´nXamb aq{Xw t ]mIen\v ImcWw. KÀ`]m{Xw
am{Xaà Nnecn aq{Xk©nbpw bYmØm\¯ p \n¶v ]nSnhn«v
sX¶n\o§mdp−v. CXns\ kntÌmko F¶p ]dbpw. CtXmsSm¸w aq{X\mfnbpw
sX ¶n\o§mw CXmWv bqdot{XmkoÂ. Ch sX¶n\o§n tbm\nbn aÀ±w
D−m¡pIbpw sN¿p¶p. sX¶n\o§nb Ahbh§Ä bYmØm\¯v Dd¸n¡p¶
emt{]mkvtIm¸nIv ikv{X{InbbneqsS A\nb{´nXambn a q{Xw t]mIp¶
{]iv\hpw ]cnlcn¡m\m Ipw.

KÀ`]m{Xw Xmtg¡nd§p¶Xv NnInÕn¡p¶sX§s\?

KÀ`]m{Xw X mtg¡v Cd§nbXv IpdªtXmXnemsW¦n CSp¸nse


t]inIfpsS hymbmahpw s]kdnbpamWv ^e{]Zamb NnInÕ.

hymbmaw
hymbmaw 1
KÀ`]m{Xw X mtg¡v Cd§nbXv Ipdª tXmXnemsW¦n CSp¸nse
t]inIfpsS hymbmaw ^e{]ZamWv. CXp KÀ`

]m{Xw Xm§n \nÀ ¯p¶ t]inIsf _es¸ Sp¯m³


klmbn ¡pw IoKÂ hymbmaw F¶mWv CXns\
hnfn¡p¶Xv.

Znhtk\ ]¯ pan\näv IoKÂ hymbmaw sN¿p¶Xphgn Øm\ {`wiw kw-`hn¨

KÀ`]m{X s¯ bYmkab¯v \ne\nÀ¯m³ km[n¡pw. aq{XhnkÀÖ\w \nb{´n¡p¶Xn\p

klmbn¡p¶ AtX t]inIÄ Xs¶bmWv KÀ` ]m{Xs¯ Xm§n\nÀ¯p¶Xv. Cu

t]inIsfbmWv hymbmaw hgn _es¸ Spt¯−Xv.

IoK hymb maw sN¿p¶Xn\pth−n InS¡bn InS¶psIm−v Im ap«pIÄ


aS¡n CSp¸nse t]inIsf 3þ5- sk¡âv hsc _eambn apdp¡pI ASp¯ 3þ5 sk¡âv
kabt¯¡v t]inIÄ Ab¨p hnSp I. Hmtcm XhW hymbmaw sN¿pt¼ mgpw CXv
GItZiw 5þ7 {]mhiyw BhÀ¯n¡pI.
172

Znhtk\ 3 XhW sN¿pI. {ItaW Hmtcm L«¯nepw 10þ15 {]mhiyw BhÀ¯n¡pI.

IoK hymbmaw sN¿pt¼mÄ izmkw- ]nSn¨p \nÀ¯mt\m aäp t]inI fnÂ

_ew {]tbmKn¡mt\m ]mSnÃ. AXp ]n¶oSv KpW¯n\p]Icw tZmjw sN¿pw.

\n§Ä hymbmaw sN¿pt¼mÄ CSp¸nse t]inIsf am{XamWv


ZrUamt¡−Xv. \nXw_¯nsebpw Imensebpw t]inIsf D]tbmKn¡m³ ]mSnÃ. IoKÂ
hymbmaw Øncambn sN¿pI. CSbv¡v \nÀ¯cpXv. GItZiw

3þ6 amk¯n\pÅn ^ew I−pXpS§pw.

hymbmaw 2

· IoKÂ hymbm-a-¯n\p ]pdsa Cu hymbm-ahpw sN¿mhp¶-Xm-Wv.


cmhnse `£Ww Ign¡p¶Xn\v ap³]v shdpw hbänemWv Cu hymbmaw
sNt¿−Xv. \nc¶ {]Xe¯n InS¶Xn\p tijw ImepIÄ Hs¶m¶mbn
ap«paS¡msX DbÀ¯pIbpw Xmgv¯pIbpw sN¿pI. AXn\ptijw ImepIÄ
apIfnte¡v DbÀ¯n ssk¡nÄ Nhn«p¶Xpt]mse sN¿pI. CXp Hcp an\näv
sN¿pI. CtX coXnbn InS¶psIm−v ImepIfpw Xebpw XdbnÂ
Dd¸n¨psIm−v Acs¡ «nsâ `mKw DbÀ¯pI, At¸mÄ Xs¶ DÅnte¡pw ]
pdt¯¡pw XÅpI Hcp an\ntämfw BhÀ¯n¡pI.

· s]kdn D]tbmKn¡Â

s]kdn F¶Xv knent¡m¬ sIm−p−m¡nb hebw AYhm


XInSp t]mepÅ km[\amWv. AXp tcmKnbpsS
icoc¯n \nt£]n¡p¶Xv tUmÎ tdm \gvtkm BWv
s]kdn tbm\nbnte¡v IS¯n h¨v CSp¸nse Ahbh §sf
Xm§n\nÀ¯m\pw Ah Xmtg¡v Cd§p ¶Xv XSbm\pw
klmbn

¡p¶p. kz´ambn s]kdn CSm\pw ]pdt¯¡v FSp¡m\pw \n§sf ]Tn¸n¡p


173

¶Xmbncn¡pw.XpSÀ¨bmbpÅ D]tbmKw s]kdnbpsS \nd hyXymk¯n\p


ImcWamIp¶p. AXn hnÅepIÄ D−m bm am{Xta amän D]tbmKn t¡−XpÅq.
2 apXÂ 4 BgvNhscbpÅ

D]tbmK¯n\ptijw XpSÀ ]cntim[\ \S¯Ww.

s]kdn D]tbmKn¡p¶XpsIm−pÅ A]IS km²yXIÄ


· tbm\nbnse AWp_m[bpw {hWhpw
· cà{kmhhpw cq£KÔhpw

ikv{X{Inb coXnIÄ

KÀ`]m{Xw apgph\mbpw ]pdt¯¡v XÅnh¶

AhØbnepw CSp¸nse t]inIÄ¡v apdnthm £Xtam

kw-`hn¨n«ps−¦nepw ikv{X{InbbmWv ^e{]Zw.

· KÀ`]m{Xw FSp¯pIfbpI (lnkv{SÎan)

· sX¶n\o§nb Ahbh§sf emt{]mkvtIm ¸nIv


kÀÖdnbneqsS IrXyX tbmsS bYm
Øm\¯pXs¶ Dd¸n¡m \mIpw. Ch c−p hn[¯nÂ
Dd¸n¡m dp−v. kn´änIv sajv D]tbmKn¨pw
AÃmsXbpw KÀ`]m{Xs¯

bpw aäpw ]nSn¨p\nÀ¯p¶ enKsaâpIÄ¡v _eaps−¦n s]m«n t¸mb


\nehnepÅ enKsaâpIÄ Iq«nt¨À¯v KÀ`]m{Xs¯ bYmØm \¯v Dd¸n¡mw.
enKsaâpIfpw t]inIfpw hfsc ZpÀe`ambn«ps−¦n Ah Iq«nt¨À¡m³
IgnbnÃ. am{Xaà sX¶n\o§Â aq¶mas¯tbm \memat¯tbm L«¯nte¡v F¯n
bmepw CXn\v km[ns¨¶v hcnÃ.
174

At¸mÄ Ahbv¡v ]Icw _eapÅ kn´änIv sajv D]tbmKn¡pw. sajv


D]tbmKn¨v KÀ`]m{Xs¯ bYm Øm\¯v hen¨v Dd¸n¡pw. sajnsâ Hcp
`mKw KÀ`]m{Xt¯mSqw atä Aäw km{It¯mSpamWv tbmPn¸n¡pI. sajv
D]tbmKn¡pt¼mÄ 4 apX 6 iXam\w t]cn Nne kµÀ`§fnÂ
AWp_m[ sajv icocw XÅn¡fb XpS§nb k¦oÀ®XIÄ D−msb¶p hcmw.

ikv{X{Inbbv¡v tijw

· emt{]mkvtIm¸nIv kÀÖdn¡v tijw aq¶p Znhkw- am{Xta Bip]{XnbnÂ


Igntb−XpÅq. ]¯pZnhks¯ hn{iaw thWw. AXn\ptijw ssZ\wZn\ Imcy§Ä
sNbvXp XpS§mw. BdmgvNhsc ITn\tPmenIÄ Hgnhm¡Ww. AXp Ignªv
km[mcW PohnX¯nte¡v hcmw. emt{]mkvtIm¸nIv kÀÖdnbmbXn\mÂ
aäp kÀÖdnIÄ ¡pÅXpt]mse henb apdnhpIsfm¶pw th−nhcp¶nÃ.
am{Xaà ikv{X{Inbbv¡v tijw ho−pw Ahbh§Ä sX¶n \o§m\pÅ
km[yXbpw IpdhmWv.

· emt{]mkvtIm¸nIv kÀÖdnbneqsS KÀ`]m{Xw bYmØm\¯v Dd¸n¨p


Ignªm KÀ`[mcW¯n\v XSÊsam¶pw D−mImdnÃ. ikv{X{Inb Ignªv
Bdpamk¯n\p tijw KÀ`w [cn¡mw. km[mcW coXnbn Xs¶ KÀ`w
[cn¡m\pw {]khn¡m\pw km[n¡pw.

· KÀ`]m{Xw bYmØm\¯v Dd¸n¡p¶ ikv{Xn{Inbbv¡v tijw skIvkv


BkzZn¡p¶Xn bmsXmcp XSÊhpw D−mInÃ. AXphsc
A\p`hn¨psIm−ncn¡p¶ imcocnIhpw am\knIhpamb AkzØ XIsfÃmw
amdp¶tXmsS am\knIambn skIvknt\mSpÅ XmXv]cyw IqSp¶Xpw
kzm`mhnIamWv.

· KÀ`-]m{Xw \o¡w sN¿Â ikv{X-{In-b¡v tijw H¶p-ap-XÂ A©p-Zn-hkw


hsc Bip]--{XnbnÂ- InS-t¡-−-Xmbn hcpw. AXn-\p-tijw ho«n \n¶pÅ
hn{iaw Hcp-am-k-t¯mfw thWw. AtXm-sSm¸w Xs¶ `mc-apÅ hkvXp-
¡Ä DbÀ¯m-Xn-cn-¡p-I, ae-_-Ô-kw-_-Ô-amb {]iv\§Ä-
175

hcmsX {i² n¡p--I, [mcmfw shÅw-Ip-Sn-¡p-Ibpw ]g-hÀ¤§Ä Ign-¡p-


Ibpw sN¿p I.6 BgvN-hsc ssewKo-I-_-Ô¯nÂ- GÀs¸-Sm-Xn-cn-¡pI.

KÀ`]m{Xw Xmtg¡v Cd§p¶Xv XSbp¶ coXnIÄ

 Ccp¶psIm −v ho«ptPmenIÄ
sN¿pI

 InS¡pt¼mÄ

Acs¡«n\p Xmsg XebnW

h¨pInS¡pI. C§s\ InS¡p ¶Xv KÀ`]m{Xs ¯

KpcpXzmIÀj W _e¯nsâ klmb¯m ] gb

Øm\¯v Xn cn¨p t]mIm³ klmbn¡p¶p.

· IrXyambn IoKÂ hymbmaw sN¿pI: KÀ`]m{Xw sX ¶n

\o§p¶Xns â {]mcw` e£W§Ä Ds− ¦n DZct]inIsf _es¸Sp¯m³ klmbn¡p¶

IoKÂ hybmaw ioeam¡pI. CXv CSp¸nse t]inIsf _es¸Sp¯p¶p.

· DZcmib¯n\v aÀ±w hÀ²n¸n¡p¶ Xc¯n `mcw IqSnb hkvXp¡Ä


DbÀ¯mXncn¡pI.

· {]khw Ign ªXp apXÂ GItZiw Bdpamk t ¯mfw ITn\amb tPmenIÄ


Hgnhm¡pI.

· ITn\amb Npabps−¦n NnInÕ tXSpI

· icoc `mcw I pdbv¡pI

· Dbc¯n\\pkcn¨pÅ icoc`mcw \ne \nÀ¯Ww

· IrXyambn aehnkÀÖ\w \S¯pI

· ae_Ôw D−mhmsX t\m¡Ww

\mcpIÄ AS§nb `£Ww Ign¡pI

]bdphÀ¤§Ä, [m\y§Ä, ]ghÀ¤§Ä, ]¨¡dnIÄ


F¶nh `£W¯n DÄs¸ Sp¯pI
176

8 apXÂ 10 ¥mÊphsc shÅw IpSn¡pI.


kaoIrXm lmcw Ign¡pI.

sImgp¸v AS§nb `£Ww Hgnhm¡pI.

· IrXyamb hym bma¯n GÀs¸SpI


· e£§Ä A[n Icn¨m XpSÀNnInÕ tXSpI.

aq{X¯nse AWp_m[ XSbp¶Xn\pÅ coXnIÄ

· aq{Xsamgn¡ m³ tXm¶pt¼mÄ aq{Xsamgn ¡pI

· aq{Xw ]nSn¨p \nÀ¯cpXv

· [mcmfw shÅ w IpSn¡pI

· Abª tIm«¬ ASnhkv{X§Ä [cn¡pI

· Kply`mKw ap³]n \n¶pw ]pdInte¡v


hr¯nbm¡p I

· ssewKnI_Ô ¯n\ptijw

aq{Xsamgn¡ pIbpw Kply`mKw \¶mbn IgpIn


hr¯nbm¡pIbpw sN¿pI.

· ITn\amb Npabps−¦n NnInÕ tXSpI.

· {]khw Ign ªXp apXÂ GItZiw Bdpamkt ¯mfw ITn\amb tPmenIÄ


Hgnhm¡pI, IoKÂ hymbmaw ]Xnhm¡pI.

· kaoIrXmlmcw Ign¡pI.

· sImgp¸v AS §nb `£Ww Hgnhm¡pI.


· IrXyamb hy mbma¯n GÀs¸SpI.
177

A\nb{´nXambn aq{Xw t]mIp¶Xv XSbp¶Xn\pÅ amÀ¤§Ä

· IrXyamb hymbmahpw t]mjImlmchpw Ign¡p¶Xphgn BtcmKy Icamb


`mcw \ne\nÀ¯mw.

· Znhk¯n 8 apX 10 ¥mÊp hsc shÅw IpSn¡Ww

· ae_Ôw Hgnhm¡pI

· I^o³ AS§nb Nmb, Im¸n, tImf Ir{Xnaambn D−m¡nb


a[pc ]elmc§Ä Fcnhpw ]pfnbpw DÅ Xpamb `£Ww
F¶nh Hgnhm¡pI.

kw-{Klw

kv{XoIÄ t\cnSp¶ hensbmcp {]bmkambn Cu AkpJw amdnbn«p−v.


PohnX¯nsâ Gähpw IÀ½\ncXhpw DuÀÖkzehpamb Ime¯v Cu AkpJw
ImcWw {]bmks¸tS−n hcp¶Xv kv{XoIfpsS PohnXs¯ ZpÊlam¡namäpIbpw
sN¿p¶p. s]mXp]cn]mSnbn ]s¦Sp¡m\pw tPmensN¿m\pw {]bmkw- F¶mÂ
CtX¡pdn¨v aäpÅhtcmSv ]dbm³ aSnImcWw t\cnSp¶ am\knI kw-LÀj§Ä
ChsbÃmw tNÀ¶v kv{XoIsf hensbmcp imcocnI am\knI {]bmk¯nte¡mWv
XÅnhnSp¶Xv, Zm¼Xys¯t¸mepw CXp ]et¸mgpw _m[n¡p¶p. Cu AhØamän
PohnXw ho−pw kt´mj`cnXam¡m³ NnInÕ klmbIcamIp¶p. e£W§Ä
I−pXpS§pt¼mÄXs¶ NnInÕ tXSpIbmWv {][m\w. kv{XoIfpsS
PohnXKpW\nehmchpw CtXmsSm¸w DbcpIbmWv sN¿p¶Xv. A]IÀjXm
t_m[w amdn km[mcW coXnbn kt´mjt¯msSbpw kzØambpw AhÀ¡v
IÀ½\ncXcmImw.
178