Effect of Educational Program on Knowledge Regarding Leiomyomas among Women in Reproductive Age

Introduction

Uterine fibroids (UFs), also called uterine leiomyomas or myomas, are steroid hormone-responsive, benign tumors of the smooth muscle compartment (myometrium) of the uterus. They are the most common neoplasm affecting women in their reproductive age. It is estimated that up to 77% of women develop UF in their life. UFs are one of the leading causes of hospitalisations for gynaecological disorders and are the most frequent reason for hysterectomy. According to relevant literature, 40%-60% of all the hysterectomies performed are due to the presentence of uterine fibroids (Nashwa , 2020).

General nursing management of uterine fibroids includes educating women about the causes, risk factors, and how to detect and manage it early.Also, they should provide education and care for Women will present to their doctors with a wide range of symptoms, fertility requirements, and social circumstances, as well as a wide range in the size and number of fibroids within their uteri.There are many treatment options available for treating fibroids, and these will be tailored to the individual woman based on the assessment of the physician, the woman’s personal wishes, and lifestyle measures (Abdelrahim , et al , 2015).

Significance of the study.

The chances of the occurrence of uterine leiomyoma increase during the reproductive period and usually decrease after menopause. They are found in more than half of women over the age of 35 years but can also be present in adolescents. Their exact pathogenesis is still debatable, but hormonal stimulation by estrogen, progesterone, and other growth factors plays a pivotal role. (Wong , et al, 2016).

According to the National Institute of Health (NIH), uterine fibroid tumours affect up to 80% of women over the age of 50 (Brindles et al., 2018).

Every 10 minutes, 12 hysterectomies are performed in the United States. There are 600,000 hysterectomies performed annually in the US. 170,000 to 300,000 are due to uterine fibroids. .Over 250,000 uterine artery embolizations have been performed worldwide since 1996. Since fibroids are such a common problem that we might all face, it is essential that all women should be educated (http://www.nuff.org/health_statistics.htm, 2020).

In Egypt, the prevalence of uterine fibroids ranged from 9.8% to 17.8% in the age group of 40–49 years, and about 25 % of them underwent hysterectomy due to uterine fibroids.(Ragvendra, et al, 2018).

Aims of the study:-

Evaluate the effect of educational program on knowledge regarding leiomyoma among women in reproductive age.

Research hypothesis                                                                                                                             

H: utilization of the educational program will be effective in increasing the knowledge regarding leiomyoma among women in reproductive age.

Subject and Method

This study was aimed to evaluate the effect of educational program on knowledge regarding leiomyomas among women in reproductive age.

Research Design                                                                                          

A quasi-experimental research design was used in the present study (pre and post) which was suitable for the nature of the existing research problem

Research Hypothesis:

• H: utilization of the educational program will be effective in increasing the knowledge regarding leiomyomas among women in reproductive age

Setting:

This study was carried out at outpatient clinic and inpatient department of Obstetrics and Gynecology at Minia University Hospital for Obstetric & Pediatric (MUHOP) Hospital.

• Obstetrics, Gynecology and Pediatric Minia University Hospital was built in 2005.. The bed capacity of the hospital is three hundred beds

 Sampling

A convenient sample included 134 women accordingly.The sample size was estimated according to the Slovin’s formula which is computed as

n = N / (1+Ne²); whereas:

n = sample size

N = total population

e = desired margin of error

n= 202 / [1+ (202) (0.05)² = 134 women

Subjects

Inclusion criteria

• All women at reproductive age from 18 to 49 years old.
• Women not diagnosed with uterine fibroids.
• Women that accepted to participate in the study.

Tools for Data Collection

To achieve the goal of the study, data was collected using two tools:

The first tool (interviewing sheet) is used to collect socio-demographic data from the woman, such as age, residence, educational level, phone number, and occupation, as well as medical data, such as family history of uterine fibroids, age of menarche, menstrual regulation, and source of information about uterine fibroids.

Second tool (knowledge assessment): (pre-post educational programme test): it is a self-interviewing tool developed by the researcher after reviewing relevant literature (Doherty et al., 2014; Vilos et al., 2015; Bulun et al., 2015; Blitz et al., 2016; Donnez and Dolmans, 2016; Kalyan et al., 2018).

Part 1 is concerned with women's knowledge of uterine anatomy and physiology. It contains nine sections. questions regarding anatomy & physiology of the uterus in the form of MCQ questions. 1-The uterus is one of the female genitourinary organs; 2-uterine wall layers; 3-uterine nutrition; 4-uterine nerves; 5-uterine function; 6-uterine wall function; 7-uterine size changes depending on the age of the female; 8-uterine cervix function; and 9-three stages of the endometrium.)

Part 2: It  was consisted of 19 questions in the form of MCQs concerned with women's knowledge regarding uterine fibroids, for example (1-Definition of uterine leiomyoma, 2-First complaint of uterine leiomyoma 3-Signs and symptoms  of uterine leiomyoma, 4-Effect of uterine leiomyoma on the uterus,5- occur when there is pain from uterine fibroid. 6-Causes of uterine leiomyoma , 7-Risk  factors for uterine leiomyoma, 8-Precautions  that limit the incidence of the uterine leiomyoma 9-Complications Complications  of uterine leiomyoma , 10- Diagnosis of uterine leiomyoma , 11-Confirmation of  the diagnosis of uterine leiomyoma , 12- Factors  that alleviate signs and symptoms of the uterine leiomyoma, 13- Progress of the uterine leiomyoma to   malignant tumor., 14- Medications that alleviate signs and symptoms of the uterine leiomyoma , 15- Surgical treatment of uterine leiomyoma , 16- Nutrition  that can relieve anemia result from uterine leiomyoma , 17- Effect of menopause on uterine leiomyoma , 18- Fluids  that help to shrink the size of  uterine leiomyoma, and 19- Nutrition that help to prevent uterine leiomyoma ).

Knowledge scoring system.

The uterine fibroid knowledge scoring system was classified as follows:Each correct answer is given a score of "one" and each incorrect answer is given a score of ‘zero’ respectively. For each area of knowledge, the scores of the items are summed-up and the total is divided by the number of the items, giving a mean score for each area. 28 questions, taking 28 scores.

• Satisfactory  knowledge scored (≥ 60%) = (≥ 17)
• Un Satisfactory  knowledge scored (< 60%) = (< 17)

(https://grants.nih.gov/grants/.../scoring_system_and_procedure.pdf).

Validity and Reliability

To establish validity, the questionnaire was piloted on a panel of 5 experts of Obstetrics and Gynecological staff, and Nursing professors who reviewed the instruments for clarity, relevance, comprehensiveness, understanding, applicability, and easiness, and was used alpha Cronbach’s way to check the stability of the internal consistency of the Knowledge tool were 0.854 and .934.

Pilot Study:

     A pilot study was conducted on 10% of women (13 women) at the previous mentioned setting to assess the current study tools for its clarity, and time required to be applied.  According to the results of the pilot, all required and necessary modifications were done and the women who were tested in the pilot study were excluded in study sample.

Ethical consideration:

• Research proposal was approved from ethical committee and post graduate committee in faculty of nursing.
• An official permission was obtained from the Dean of the Faculty of Nursing and requested to the director of the hospital.
• Oral consent was obtained from women that are willing to participate in the study, after explaining the nature and purpose of the study.
• Study subject had the right to refuse to participate or withdrawal from the study without any rational any time.
• Study subject privacy was considered during collection of data
• Participants were assured that all their data are highly confidential.
• Do not contradict with the cultural, traditional and religious issues.
• No health hazards were being present.

Administrative design

An official written approval letter clarifying the purpose of the present study was obtained from the dean of the Faculty of Nursing, as well as the Director of the hospital as approval for data collection to conduct this study also an oral consent was obtained from included women in the study. It included a full explanation of the purpose of the present study, procedure, and rights for privacy and confidentiality.

Data Collection Procedure:

1. Assessment phase:

During the assessment phase, the researcher held the first meeting with women to introduce herself and give an explanation about the nature, purpose, and duration of the study. They were informed that participation in this study was voluntary.

After obtaining women's consent to participate in the current study, the researcher provided an overview and clarification of the assessment tool questions before distributing the self-interviewing questionnaire to each woman to assess data such as age, residence, education level, and source of information. Then the researcher distributed a pretest questionnaire to assess women's knowledge regarding anatomy and physiology of the uterus and women's knowledge regarding leiomyoma examples (definition, causes, ,risk factors, signs and symptoms, different types of food for uterine fibroid, complications , diagnosis, medical management, and nursing management.) were assessed. The questionnaire took about 15-20 minutes to complete.

Implementation phase:

After assessing women's knowledge regarding leiomyoma by means of a knowledge assessment questionnaire, the researcher met women two days per week (Sunday and Wednesday) from the beginning of the study. The research was conducted between the beginning of August, 2020, and the end of November, 2020.The researcher conducted face-to-face interviews in outpatient departments from 9:30 a.m. to 11:00 a.m. and inpatient departments from 11:00 a.m. to 1:00 p.m.

The total sample (134) was divided into small groups. The session number was around three sessions per day. The session lasted 45 minutes, from 9: 30 a.m. to 13:00 p.m., in the hospital escorts rest room, with five women present at each session.

Health education sessions were given to the women in the form of lectures and group discussions using the designed educational booklet and audio-visual aids. They emphasised improving women's knowledge regarding leiomyoma. For instance, (definition, causes, risk factors, signs and symptoms, various types of food for uterine fibroid, complications, diagnosis, medical management, and nursing management).and allowed women to ask, discuss, and reach a high level of understanding.

An additional 15 minutes were assigned at the end of the lecture for an open discussion with them about this topic. After the session, the researcher distributed the booklet to the women.

Supportive material (health education guidelines):

It was created to increase women's understanding of uterine fibroid.It was designed by the researcher in the form of a handout (booklet) using simple Arabic language and different illustrative pictures in order to facilitate understanding its content (definition, causes, risk factors, signs and symptoms, different types of food for uterine fibroid, complications, diagnosis, medical management, and nursing management.).

1. Evaluation phase:

For each woman, three evaluations were done, the first one at the beginning of the study as a baseline data (pre-test) for the pre-educational programme. The second evaluation was conducted immediately after the educational programme in order to detect the level of women's knowledge post-health education regarding uterine fibroid . The third evaluation was conducted after three months of the educational programme by communicating with women by telephone in order to detect the level of women's knowledge post-health education regarding uterine fibroid (posttest) for final evaluation . The same assessment tools were used during the pre and post-test.

Limitations of the Study

• The finding is less amenable to generalisation because the sample was selected from one geographical area in Egypt. As well, few Egyptian studies were done in this area of research.

• The findings of this study were limited to a small sample size of 134 as the study sample. Therefore, it may not necessarily be representative of the general population.

• Not empowering the researcher to apply the educational programme about leiomyoma to all patients in the hospital.

Statistical Design:

The collected data was tabulated, computerized, analysed and summarised by using descriptive statistical tests to test research hypotheses by using SPSS version (IBM 23) and excel for figures. Data was presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and means and standard deviations for quantitative variables. The level of significance was accepted at P< 0.05 and was considered highly significant when the P-value was less than or equal to 0.01. A Fisher exact test/chi test was used to detect the relationship between women's knowledge based on their selected socio-demographic characteristics.

Correlation is used to test the nature and strength of the relationship between women's knowledge pre and post nursing instruction. The sign of the coefficient indicates the nature of the relationship (positive/negative), while the value indicates the strength of the relationship, as follows: A weak correlation of less than 0.25, a fair correlation of 0.25-0.499, a moderate correlation of 0.5-0.739, and a strong correlation of 0.740-0.99

Table: Daily educational Program Schedule about  leiomyoma .

Results

Table (1): frequency Distribution of women according to socio-demographic  characteristics. (n=134)

             X ² = Chi-square test   / *= statistically significant difference P – value ≤ 0.05 /  **= high statistically significant difference P – value ≤ 0.01  

 Table (5)  shows that the mean age of women is 28.9 ± 3.9 & 47.8  % of the women can read and write, also 62.3 % women were  house wives .

Figure (1): Distribution of Women According to Sources of Knowledge about Leiomyoma's (n=134)

Figure (1) illustrates that 44% of women gain their knowledge about uterine fibroid from their friends.

Figure (2): Distribution of Women Regarding their Menstrual Regularity (N=134)

Figure (2) reveals   that 84% of women have irregular menstruation.

Figure (3): Distribution of Women According to their Family History of Leiomyoma's (N=134)

Figure (3) shows   that 75% of women don’t have    family history of uterine fibroid

Table (2) : Frequency Distribution of Women 's   Knowledge about leiomyoma in Pre and Post the Educational Program (N=134)

Table (2) : Frequency Distribution of Women 's  Knowledge about leiomyoma in Pre and Post the Educational Program (N=134)                                                                   (Continued…)                                                                                                                                                                         

X ² = Chi-square test   / *= statistically significant difference P – value ≤ 0.05 /  **= high statistically significant difference P – value ≤ 0.01  

Table (2) presents that 70.1 % of Women's knowledge improved regarding Diagnosis of uterine leiomyoma, Factors that alleviate signs and symptoms of the uterine leiomyoma and Progress of the uterine leiomyoma to   malignant tumor.  Post educational program than the pre-educational program with highly statistically significance P-value = 0.000**respectively

Table (3): : frequency   Distribution of women  according to Mean Score of Knowledge about Anatomy and Functions of the Uterus and total knowledge about Leiomyoma among women   in Pre and Post the Educational Program (N=134)

X ² = Chi-square test   / *= statistically significant difference P – value ≤ 0.05 / **= high statistically significant difference P – value ≤ 0.01  

Table (3)  illustrated  that there are a statistical significance differences between women mean knowledge level before and after implementing the educational program with highly statistically significance P-value = 0.000**respectively

Table (4): Comparison between pre and Post - educational program according to Total Knowledge score of women (n = 134 )

X ² = Chi-square test   / *= statistically significant difference P – value ≤ 0.05 / **= high statistically significant difference P – value ≤ 0.01    

Table(4)  shows that there is a  highly statistical significance difference  between women level of total knowledge post educational program then pre-educational program  with a highly statistically significance P-value = .000 respectively

Table (5): Correlation between Socio-Demographic Characteristics and total Knowledge about Leiomyoma's among Women  (N= 134)

Table (5) illustrates that there is a statistical significance correlation between women level of education their level of knowledge about Leiomyoma's post educational program with statistically significance P-value = .024 respectively