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ASSESSMENT OF CONSCIOUSNESS, ATTITUDE AND PREPARATION TOWARDS OBSERVATION OF RETINOBLASTOMA AMONG MOTHERS OF UNDER-FIVE CHILDREN IN KADUNA STATE, NIGERIA
ABSTRACT
This study assessed awareness, attitude and practice towards observation of retinoblastoma among four hundred (400) mothers of under-five children in Kaduna State, Nigeria. The study employed descriptive survey research design. The population of the study comprised of all mothers of under-five children in Kaduna State which are 2,050,608. Three specific purposes, research questions and hypotheses were formulated to guide the study. A multi-stage sampling technique comprising of systematic, simple random, purposive and proportionate sampling technique was used in selecting the required number of respondents for the study as stated above. Four hundred (400) copies of the researcher-developed questionnaire were distributed using simple random sampling technique, of which 374 (93.5%) were retrieved and considered valid for the study. Data collected was analyzed using the Statistical Package for Social Science (SPSS) version 20. Frequency and simple percentages were used to describe the demographic characteristics of the respondents, while mean and standard deviations were used to answer the research questions. Inferential statistics of one-sample t-test was used to test the formulated hypotheses at 0.05 alpha level of significance. The findings of the study revealed that awareness of retinoblastoma among mothers of under-five children in Kaduna State was significant (t=29.730, p= 0.001), Attitude towards observation of retinoblastoma was also shown to be significant (t=19.327, p=0.001) and practice towards observation of retinoblastoma among mothers of under-five children was also significant (t=22.498, p=0.001). In conclusion, the study showed that mothers of under-five children are aware of retinoblastoma, have positive attitude towards observation of retinoblastoma and also have adequate practice towards observation of retinoblastoma. It was therefore recommended that health care workers should at all time give health talks on retinoblastoma to mothers of under-five children during their usual ante and post-natal days so as to further enlighten and help sustain their awareness of the disease. It was furthermore recommended that administrators of crèche and nursery schools should conduct periodic eye examination and screening in their schools as part of their school health services. This is for the purpose of screening for retinoblastoma since the age group predisposed to this cancer are mainly pre-school age children.
TABLE OF CONTENTS
Cover Page i
Title page ii
Declaration iii
Certification iv
Dedication v
Acknowledgements vi
Abstract vii
Table of Contents viii
List of Tables x
Appendices xi
Abbreviations xii
Operational Definition of Terms xiii
CHAPTER ONE: INTRODUCTION
1.1 Background of the Study 1
1.2 Statement of the Problem 6
1.3 Purpose of the Study 9
1.4 Research Questions 9
1.5 Hypotheses 9
1.6 Significance of the Study 10
1.7 Basic Assumptions 11
1.8 Delimitations of the Study 12
CHAPTER TWO: REVIEW OF RELATED LITERATURE
2.1 Introduction 13
2.2 Conceptual Framework 15
2.2.1 Concept of cancer 16
2.2.2 Concept of Retinoblastoma 19
2.3 Awareness of Retinoblastoma 37
2.4 Attitudes Towards Retinoblastoma Disease 42
2.5 Practices Relating to Retinoblastoma 43
2.6 Incidence of Retinoblastoma Around the World 45
2.6.1 Sex Distribution of Retinoblastoma 50
2.6.2 Cancer Incidence in Nigeria 51
2.6.3 Cancer Registration in Nigeria 52
2.7 Prevalence of Visual Impairment and Blindness in Children 56
2.7.1 Determining the Cause of Blindness in Children 62
2.7.2 Control of Blindness in Children 64
2.8 Empirical Studies 67
2.9 Summary 71 CHAPTER THREE: METHODOLOGY
3.1 Introduction 74
3.2 Research Design 74
3.3 Population of the Study 74
3.4 Sample and Sampling Techniques 75
3.5 Research Instrument 77
3.6 Validation of Research Instrument 78
3.7 Procedure for Data Collection 78
3.8 Procedure for Data Analysis 79
CHAPTER FOUR: RESULTS AND DISCUSSION
4.1 Introduction 80
4.2 Results 81
4.3 Discussion 89
CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Summary 92
5.2 Major Findings 92
5.3 Contribution to Knowledge 93
5.4 Conclusions 93
5.5 Recommendations 94
5.6 Suggestions for Further Studies 94
References 95
Appendices
Appendix I: Questionnaire 107
Appendix II: Vetting Letter 112
Appendix III: Introduction Letter 113
LIST OF TABLES
Table Page
- Incidence of retinoblastoma around the world 46
- The list of zones, L.G.As, health facilities, population and sample size 75
- Demographic characteristics of the respondents 81
- Mean score of respondents on awareness of mothers of under-five children towards observation of retinoblastoma 83
- Mean score of respondents on attitude of mothers of under-five children towards observation of retinoblastoma 84
- Mean score of respondents on practice of mothers of under-five children towards observation of retinoblastoma 86
- One-sample t-test on awareness of mothers of under-five children towards observation of retinoblastoma 87
- One-sample t-test on attitude of mothers of under-five children towards observation of retinoblastoma 88
- One-sample t-test on practice of mothers of under-five children towards observation of retinoblastoma 89 APPENDICES
Appendix I: Questionnaire 107
Appendix II: Vetting Letter 112
Appendix III: Introductory letter 113 ABBREVIATIONS
| AAO | American Academy of Ophthalmology |
| ACS | American Cancer Society |
| BL | Blindness |
| CTS | Computer Tomography Scan |
| HIC | High Income Countries |
| IARC | International Agency for Research on Cancer |
| LMIC | Low-Medium Income Countries |
| NCI | National Cancer Institute |
| NHCRN | National Headquarters of Cancer Registry in Nigeria |
| NRCT | National Registry of Childhood Tumour |
| NSCR | Nigerian National System of Cancer Registry |
| RB | Retinoblastoma |
| ROP | Retinopathy |
| SEER | Surveillance Epidemiology and end Results |
| SVI | Severe Visual Impairment |
| UCH | University College Hospital |
| UICC | Union of International Cancer Control |
| VI | Visual Impairment |
| WHO
|
World Health Organization |
OPERATIONAL DEFINITION OF TERMS
Awareness: ability of mothers of under-five children to identify or recognise retinoblastoma.
Attitude: the particular behaviour in which mothers of under-five children performs when they notice eye cancer.
Practice: those set of things done by mothers of under-five children in seeking help or remedy to eye cancer.
Retinoblastoma: is a cancer of the eye that mostly affects under-five children.
Mothers of under-five children: these are women with children who are below the age of five in Kaduna state.
CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
The eye is one of the five major sense organs of the body, which makes vision possible. Problems associated with early development of the eye results into diverse eye problems including retinoblastoma. Retinoblastoma (eye cancer) is a cancer of the eye that starts in the retina, the very back part of the eye (Boyd & Maturi, 2016). The retina is the inner layer of cells in the back of the eye. It is made up of special nerve cells that are sensitive to light. These light-sensing cells are connected to the brain by the optic nerve, which runs out the back of the eyeball. The pattern of light (image) that reaches the retina is sent through the optic nerve to an area of the brain called the visual cortex, allowing us to see. The eyes develop very early as babies grow in the womb. During the early stages of development, the eyes have cells called retinoblasts that divide into new cells and fill the retina. At a certain point, these cells stop dividing and develop into mature retinal cells. Rarely, something goes wrong with this process. Instead of maturing into special cells that detect light, some retinoblasts continue to divide and grow out of control, forming a cancer known as retinoblastoma. Retinoblastoma is the most common type of eye cancer in children of ages 0-5 years and represents 3% of all childhood malignancies. It is a cancer of the very young; two thirds of the cases are diagnosed before 2 years of age, and 95% before 5 years of age (American Academy of Ophthalmology (AAO), 2013).
Retinoblastoma is a cancer of the very young and mostly found among underfive children, this cancer has another name that is ―eye cancer‖, the disease can affect people of any age but commonly affects children aged less than 5 years (American Cancer Society (ACS), 2015). According to Broaddus, Topham and Singh (2009), the mean age-adjusted incidence of retinoblastoma in the United State of America was 11.8 per million children aged 0-4 years. They also confirmed that the incidence was similar to the rates reported in Europe. However, the incidence of retinoblastoma is not distributed equally around the world with 8000–9000 new cases recorded annually
(AAO, 2013). It appears to be higher in Africa, India, and among children of Native American descent in the North American continent (Ward, DeSantis, Robbins, Kohler, & Jemal, 2014; Bunin, & Orjuela, 2015). Whether these geographical variations are due to ethnic or socioeconomic factors is not well known. However, the fact that even in industrialized countries an increased incidence of retinoblastoma is associated with poverty and low levels of maternal education (De Camargo, de Oliveira Ferreira, de Souza Reis, Ferman, de Oliveira Santos, and Pombo-de-Oliveira, 2011: FajardoGutierrez, Juarez-Ocana, Gonzalez-Miranda, 2007) proves a point that awareness is requisite to early detection of the disease.
Awareness according to Merriam-Webstar Dictionary (2017) is having or showing realization, perception or knowledge of something. Therefore, awareness can be said to be knowledge. Zagzebski, (2017) stated that knowledge is a highly valued state in which a person is in cognitive contact with reality. Awareness in the context of this study is the knowledge of retinoblastoma, which is the ability of the subjects to identify the disease in their children or ability to recognize signs and symptoms of retinoblastoma in its early stage and form. In Nigeria today lack of proper awareness and mass media campaigns on evolving health issues is a major challenge to knowledge and awareness of evolving health issues. Cancers are a major cause of deaths in our society today, but major emphases are not made to help tackle the menace.
Retinoblastoma is a rare and life-threatening condition, but when it is managed optimally by a competent health team there is excellent prognosis for survival and good visual outcomes. But management of retinoblastoma continues to be a major challenge to health care providers as it is in most cases presented late in the healthcare centres, when eye salvage is not possible (Owoeye, Afolayan, & Ademola-Popoola, 2005). The ability to detect the disease while it is still in its earlier stage (intra-ocular) makes it possible for treatment and preservation of vision. Owoeye et al, (2005) reported that
65% of the cases died before completing the course of chemotherapy in Ilorin. Presumably this might be due to the poor awareness and attitudes towards health seeking which results to delays in reporting cases of retinoblastoma until it has spread to other parts of the eye.
According to a cross-sectional survey carried out by Ayanniyi, Jamda, Badmos, Adelaiye, Mahmoud, Kyari, and Nwana, (2010) on awareness and knowledge of ocular cancers in a resource-limited economy, it was reported that, awareness of ocular cancers compared to other cancers is low. Out of 280 respondents, 41.1% based their knowledge of patients having ocular cancers on sources other than hospital diagnosis. However, education was associated with awareness of ocular cancers and cancers in general. Epee, (2015) reported a limited knowledge of retinoblastoma among general practitioners in Cameroon. The study also revealed that a posting in ophthalmology during the training improve the awareness and practice pattern of general health practitioners. Latha, Chitralakshmi, Ravindran, Angeline, Kannan, and Scott, (2015) reported poor awareness of childhood malignancies among undergraduate students from all over South India in a undergraduate paediatric clinical training. This was attributed to the poor interest in pursuing paediatric oncology as their career, never had encountered any paediatric oncology patients in the ward and not having any lecture classes on paediatric oncology. An analytical cross-sectional study conducted by AtipoTsiba, and Itoua (2015), to assess the level of knowledge of this tumour by midwives in two hospitals (Talangaï and Makélékélé) in Brazzaville. The study reported that there was a poor level of knowledge among the midwives as only 40% of them were able to define retinoblastoma, and 10% had associated leucocoria and strabismus as two early signs of this cancer. In contrast to the above studies Ibrahim, Aseel, and Yacoub, (2017), conducted a research to study the impact of awareness of retinoblastoma in the affected families on the management and outcome of familial retinoblastoma patients. The study reports that, awareness of families of the possibility of retinoblastoma and adequate screening led to a significantly higher rate of eye salvage in patients with familial retinoblastoma. Thus the study sought to assess the awareness of observation of retinoblastoma disease among mothers of under-five children in Kaduna state.
Attitude, according to Wood (2000), is a state of moderately intense emotions that prepares or predisposes individuals to respond consistently in a favourable or unfavourable manner when confronted with a particular object. Eagly and Shallz (1998) defined Attitude, as mental and neutral state of readiness organised through experience exerting a direction or dynamic influence upon the individual‘s responses to all objects and situations to which it is related. This has to do with the responses or feelings towards retinoblastoma disease, which mothers of under-five children have towards the disease, and ways to go about it when noticed on the child.
Epee, (2015), in a study on Knowledge, attitudes and practices of general practitioners on blinding eye diseases of children in Cameroon reported that, an average half of the general practitioners have a salvaging attitude especially in trauma and neonatal conjunctivitis with respective and with exposure in posting right attitude increases. Patenaude,Basili, Fairclough,and Li. (1996) conducted a study to assess attitudes toward testing for cancer susceptibility genes; they interviewed mothers of paediatric oncology patients and realised a significant attitude by mothers of paediatric oncology patients. The study reported that, if genetic cancer predisposition tests were available, 51% of mothers would test themselves and 42% would test healthy children, even with no medical benefit. This study sought to assess the attitudes towards observation of retinoblastoma disease among mothers of under-five children in Kaduna
state.
Practice can be defined as the act of doing something customarily, or habitually, or to do something regularly or constantly as an ordinary part of your life (MerriamWebster, 2017). Practice is also defined as a way of doing something regularly (Duvivier, 2011). In relation to this study practice is referred to as practice towards observation of retinoblastoma and health seeking. This is the practices in which mothers of under-five children perform in terms of finding remedy for the infected child, that is, either going to a health facility, applying local herbs, visiting spiritualist/native doctors and many more.
Nkansah, (2018) assessed the knowledge, attitude and practice of infant ocular health among midwives in the Bosomtwe District. Level of knowledge was categorized using Blooms cut-off points into good (> 80%), moderate (60 - 80%) and poor (< 60%). Results of the study revealed that, out of 62 respondents, 50.7% were knowledgeable in infant ocular conditions. Poorest level of knowledge was recorded in retinoblastoma (6.5%) whiles level of knowledge in Ophthalmia neonatorum (100%) was the best. Thirty-six (58.1%) of the respondents performed ocular examination on infants. Majority of the respondents (85.5%) referred all abnormalities detected. Education of mothers was done by 82.3% of respondents and only 29% indicated receiving some form of in-service training with regards to infant ocular health. Attitude of respondents was positive with 74.2% of respondents disagreeing that infant ocular health monitoring should only be done by an eye care professional. In conclusion respondents had poor level of knowledge in infant ocular conditions. However level of practice was satisfactory and there was generally positive attitude toward infant ocular health.
Despite the great paucity of epidemiological data‘s on cancer in Nigeria, some studies reported retinoblastoma to be the commonest childhood intraocular malignancy (Abdu, & Malami, 2011: Ochicha, Gwarzo, & Gwarzo, 2012). Retinoblastoma remains one of the major predominant cancers and second only to lymphoma as reported in most studies (Akang 1996; Mandong, Angyo, & Zoakah, 2000; Tijani, Elesha, & Bayo, 1995). Therefore since early detection of the disease is paramount to eye salvage and saving of the child‘s life, this study therefore, intends to assess the awareness, attitude and practice towards observation of retinoblastoma disease among mothers of underfive children in Kaduna State.
1.2 Statement of the Problem
It is estimated that, in almost half of the 1.4 million children who are blind today (WHO, 2017), the underlying cause could have been prevented, or the eye condition treated to preserve vision or restore sight (Gilbert, & Foster, 2001), thus emphasizing the critical role of early diagnosis and appropriate treatment in preventing childhood blindness, a role that should involve primary care physicians including paediatricians and parents. Childhood blindness poses educational, occupational and social challenges with affected children being at higher risk of behavioural, psychological, emotional difficulties, impaired self esteem and poorer social integration (Jan, 2005).
Globally, about 1 in 15,000 children develop retinoblastoma, and it is estimated that 8,600 – 9,000 children are newly affected each year. Due to global population distribution, 90% of these children live in developing countries (Gilbert & Foster, 2001). The number of children with retinoblastoma is increasing. This is not an increase in incidence, but a result of the growing global population and decreasing infant mortality in many developing countries (Gilbert, et al, 2001). Even though only a small proportion of children with retinoblastoma in developing countries are seen at hospitals that keep records of cancer diagnoses. Gilbert, et al, (2001) stressed that, where registers do exist, many cases of retinoblastoma are excluded for reasons such as lack of pathological diagnosis or treatment by ophthalmology or neurology – rather than oncology. As a result, global statistical data about retinoblastoma is inconsistent and incomplete. Kruger, Reynders, Omar, Schoeman, Wedi, and Harvey, (2014), report that, there is generally poor outcome in children with retinoblastoma at a single institution in South Africa, reflecting its late diagnosis. Overall survival was only 33 - 43%, compared with the 95% achievable in developed countries. Lack of effective screening and early diagnosis leads to this unacceptably high mortality rate, this can be significantly reduced through early detection of retinoblastoma that may be achieved by ensuring that the ‗red reflex‘ is tested for on all newborns and toddlers.
In Nigeria, there is great paucity of epidemiological data on ocular cancers among Nigerians, but studies have shown retinoblastoma to be the commonest childhood intraocular malignancy (Abdu, & Malami, 2011: Ochicha, Gwarzo, & Gwarzo, 2012). Almost all studies on ocular tumours in Nigeria are hospital-based and are concerned with the pattern especially, clinic-pathological reports of oculo-orbital tumours (Owoeye, Afolayan, & Ademola-Popoola, 2006). The researcher discovered that no study has been done or published anywhere in the world based on the knowledge of the researcher on awareness, attitude, and practices towards observation of retinoblastoma disease among mothers of under-five children. Most studies conducted on retinoblastoma are mostly on its Clinic and pathological pattern. A few studies were done on awareness and knowledge of retinoblastoma, which in terms of scope, population and location is different from this study.
In Kaduna there seems to be lots of children who have lost their lives because of retinoblastoma, some have been permanently impaired visually and their chances of becoming future leaders shattered due to this disease. Many had to be withdrawn from schools after the loss of sight and blurry vision. Reluctance on the part of the mothers who often ignore unusual noticeable signs seen in the eye of the child when nursing them have also lead to the escalation of the disease which often at times cannot be treated and leads to the loss of sight through enucleation and even death of the child. In some cases where the child might complain of blur sight or inability to see objects properly parents‘ failure to take their children to the hospital for proper diagnosis and possible treatment may be due to lack of knowledge of the disease.
The researcher observed that apparently there seem to be a wide gap in the awareness of eye cancers among the general public, compared to the clinical advances made in the pathology of eye cancers in children. Most studies conducted on retinoblastoma were more on the clinical presentations and histology of the disease or among medical practitioners, no study has been conducted on the study of awareness, attitude and practice towards observation of retinoblastoma disease among mothers of under-five children in Kaduna state. Thus this study intends to fill the gap of identifying the level of knowledge of mothers in regards to eye cancer, their attitudes towards eye cancer and their practices towards retinoblastoma disease. Most studies identified late presentation of cases with retinoblastoma which suggests that there would be need for awareness on eye cancer. Therefore the researcher is encouraged to conduct the study on assessment of awareness, attitude and practice of retinoblastoma among mothers of under-five children in Kaduna state, Nigeria.
1.3 Purpose of the Study
The main purpose of this study was to assess the awareness, attitude and practice towards observation of retinoblastoma (eye cancer) among mothers of underfive children in Kaduna State. The specific objectives are to assess:
- awareness of mothers of under-five children towards observation of retinoblastoma in Kaduna State.
- attitude of mothers of under-five children towards observation of retinoblastoma in Kaduna State.
- practice of mothers of under-five children towards observation of retinoblastoma in Kaduna State.
1.4 Research Questions
This research answered the following questions:
- Are mothers of under-five children in Kaduna State aware of retinoblastoma?
- Do mothers of under-five children in Kaduna State have the right attitude towards observation of retinoblastoma?
- Do mothers of under-five children in Kaduna State practice observation of retinoblastoma?
1.5 Hypotheses
On the basis of the structured research questions, one major hypothesis and three sub-hypotheses were formulated for the purpose of this study.
Major Hypothesis
There is no significant awareness, attitude and practice towards observation of retinoblastoma among mothers of under-five children in Kaduna state.
Sub-Hypotheses
- Mothers of under-five children will not significantly be aware of observation of retinoblastoma in Kaduna State.
- Mother of under-five children will not have significant positive attitude towards observation of retinoblastoma in Kaduna State.
- Mothers of under-five children will not significantly practice observation of retinoblastoma in Kaduna State.
1.6 Significance of the Study
The findings of this study will hopefully be of benefit to all mothers and women of childbearing age in Kaduna and even beyond. It will benefit them by providing them with information and awareness on retinoblastoma, its dangers and the need to observe and diagnose their little infants for retinoblastoma during their early stage of life. The study would help correct poor attitudes and practices of mothers of under-five children towards health seeking.
Also the findings of this research would be of benefit to health educators; it will provide them with the information on awareness, attitude and practice of mothers of under-five children towards retinoblastoma in Kaduna State, which would help them to structure their educational/sensitization efforts thereby creating awareness of retinoblastoma.
The findings will also benefit healthcare workers such as; nurses, physicians, and community health extension workers. It would provide them with information regarding the level of awareness, attitude, and practice of mothers of under-five children towards retinoblastoma in Kaduna State; thereby, helping them intensify efforts in their encouragement of mothers about the disease signs and symptoms during children clinics or health talks during post-natal care since they happen to be in close contact with mothers and their children (either for immunization or healthcare).
The findings would also be of benefit to health-related agencies such as; Ministry of Health, and Non-governmental organizations. It will provide them with information on the level of awareness of retinoblastoma disease among mothers in Kaduna State, and the practices carried out by these mothers in terms of health seeking for the disease. These will help them focus their intervention efforts and direct their campaigns towards creating awareness and developing new policies to help improve lives and reduce the chances of sight loss.
Lastly, the findings would benefit fellow researchers with relevant literature for further studies on retinoblastoma.
1.7 Basic Assumptions
On the basis of research evidence and professional opinions, the following assumptions were made for the purpose of this study.
- Awareness of retinoblastoma would help in early detection of the disease, preservation of sight and survival of children under the age of five.
- Poor attitudes and practices of parents towards screening and healthcare seeking could lead to loss of sight and death of children with retinoblastoma.
- Delays in diagnosis and time of presentation would increase mortality globally in less-developed countries.
1.8 Delimitations of the Study
This study was delimited to the assessment of awareness, attitude, and practice towards observation of retinoblastoma among mothers of under-five children in Kaduna
state.
It is also delimited to;
- awareness of mothers of under-five children towards observation of retinoblastoma in Kaduna State.
- the attitude of mothers of under-five children towards observation of retinoblastoma in Kaduna State.
- the practice of mothers of under-five children towards observation of retinoblastoma in Kaduna State. iv. It is also delimited to six (6) local government areas in Kaduna State, Nigeria.
ASSESSMENT OF CONSCIOUSNESS, ATTITUDE AND PREPARATION TOWARDS OBSERVATION OF RETINOBLASTOMA AMONG MOTHERS OF UNDER-FIVE CHILDREN IN KADUNA STATE, NIGERIA
