INTRODUCTION:

Jacques Cousteau, a French naval officer, the innovator of modern underwater diving, when first took cameras under water; he opened our eyes to a mysterious enchanted new world!

Surpassing this beauty was the first ultrasound turned toward the womb of a pregnant mother, a view so marvelous, astonishing and stunning had been hidden for ages was at our view, the very first sight was a baby sucking on its tiny thumb even before birth^[1],that’s where it all begins- ‘in the womb!’ A tiny mouth finds a diminutive thumb to suck on; a powerful satisfying habit has begun!^[2]

Thumb sucking is a common oral habit among children involving placement of; the thumb, other fingers or even at times the hand; in the mouth followed with rhythmic repeated sucking contacts for a prolonged duration. It starts as early as 15 weeks of intrauterine life to within a couple of months of birth and stops at the time of eruption of permanent teeth. ^[3]

Thumb Sucking is of little concern for children below 2; since most of them simply out grow the habit between the age of two and four, tapering off the habit by the time permanent front teeth are ready to erupt. ^[4]

Studies indicate that 92% infant’s engage in thumb sucking.^[5] Developmental psychologists advocate that thumb sucking releases endorphins to the brain, Newborn babies use this technique for calming and relaxation in fighting anxiety in the first months of their life. For infants it serves to be a pleasurable habit increasing a sense of well being.^[6] Breastfed babies are less likely to suck their thumbs, further Dr. David Levy found that babies who were fed every three hours did not suck their thumbs as avidly as those who were fed every four hours.^[7]

Thumb sucking habit when lingers after the preschool age is considered to be abnormal due to its ill effects on the developing oro-facial structures. However this habit varies from child to child and the severity of its effects depends upon three factors namely frequency, duration and intensity of thumb sucking..^[5] Other factors that prop up thumb sucking include: hunger, sleep, comfort, fatigue, teething, boredom, worry, shyness, and stress; etc.^[6][7][8][9]

The longer thumb sucking persists after the age of six years, the greater risk of permanent dental malocclusion and less likely to correct itself. No self-correction will occur if the habit persists after 12 to 14 years of age. Therefore if thumb sucking persists beyond the age of six years children should be referred to a pediatric dentist for evaluation and treatment if dental abnormalities are present.^[8]

Many nurse investigators have shown that malocclusion usually resolves spontaneously if thumb sucking ceases before eruption of the permanent teeth. As a part of preventive program, nurses must create awareness at community level so that early interception of this habit can be achieved by providing parents with information about thumb sucking and its types, etiology especially with emphasis on role of stress in development of habit and ways to manage and treat it at home.

Need:

‘Thumb-sucking’ the first coordinated activity of childhood! Strange yet true, Babies are born with sucking reflex and so have a natural urge to suck on just anything that touches their lips.^[10]Sucking is part of the normal development of the child, it plays an important role in muscle strengthening and growth of dento facial structures among the children till 3 ½ years of life.^[11]About 9 out of 10 children suck their thumb or fingers in the first year of life.^[12]

About 80% of babies suck their thumb and 30% of children continue this habit until preschool age.^[103Interestingly this urge tapers after the age of 6 months and gradually by the age of 3 - 6 years, majority of kids out grow this habit. Palo Alto Medical Foundation for Health Care, Research and Education stated in 2011 that thumb sucking is normal and soothing in babies and young children. Most of the children stop sucking their thumbs between the ages of 3 and 6.^[13] However, persistent thumb sucking after this phase is considered to hinder the development of facial bones and may be indicative of behavioral problems in children. 95% of the damage cause by thumb sucking begins between 3 and 4 years when permanent tooth starts to erupt.^[14]A research study reports that, 54(90%) out of 60 girls were breast-fed with a mean duration of 8 months breast-feeding and 67% of the girls were breast-fed for half a year or more. Forty-three children (72%) developed a pacifier-sucking habit, 6 (10%) developed a digit-sucking habit, and 11 (18%) had no sucking habits. The mean duration of breast-feeding was longer for the non-suckers (11 months) than for the pacifier- and digit-sucking children (5 months). Hence the study suggests that the shorter the duration of breast feeding the more likely of the children to develop sucking habits.^[15]

The studies revealed that incidence of finger sucking was high (74.2%) in children who were alone and was also associated to negligent parental attitude towards the habit. The children in industrialized countries are more likely to use pacifiers and bottle feeds than in non industrialized countries so the finger sucking habit was less common or nonexistent in the non industrialized countries and it is also found in lower socio economic status.^[16]

Problem Statement:

“A study on assessing the effectiveness of nurse teaching programme on knowledge and attitude regarding thumb sucking among the mothers of under-five children in selected rural areas of Belgaum, Karnataka.”

OBJECTIVES OF THE STUDY:

1. To assess the knowledge and attitude on thumb sucking among mothers of under-five children in selected rural areas of Belgaum.

2. To design and conducting the nurse teaching programme.

3. To assess the effectiveness of nurse teaching programme on knowledge and attitude regarding thumb sucking among mothers of under-five children.

4. To correlate the knowledge and attitude pre-test and post-test scores on thumb sucking among mothers of under-five children.

5. To associate pre-test and post-test knowledge and attitude score with the selected demographic variables.

Operational Definition:

Assess:

In this study it refers an appraisal process by the researcher regarding thumb sucking among mothers of under-five children

Effectiveness:

In this study it refers to significant increase in the level of knowledge and attitude among mothers of under-five children on thumb sucking.

Knowledge:

In this study, it refers to awareness or familiarity regarding thumb sucking among the mothers of under-five children.

Attitude:

In this study, it refers to feeling, behavior or thought exhibited regarding thumb sucking among the mothers of under-five children.

Nurse teaching programme:

In this study it refers to the planned teaching programme prepared by a nurse investigator which helps in the learning process of mothers of under-five children on thumb sucking.

Mothers of under-five children:

In this study it refers to the primary caregiver of children aged between 0 to 5 years in selected rural areas of Belgaum.

Thumb sucking:

In this study it refers to placing of the thumb and other fingers in the mouth and vigorous sucking contact for a prolonged duration.

Inclusion criteria:

Mothers:

Ÿ Of the children aged between 0 to 5years.

Ÿ In selected rural areas of Belgaum.

Ÿ Willing to participate in the study.

Ÿ Available during the time of data collection.

Ÿ Who can understand (read $ write) either Kannada or Marathi.

Exclusion criteria:

Mothers:

Ÿ Of the children aged above 5 years.

Ÿ Of children with other behavioral disorders.

Ÿ Who are not willing to participate in this study.

Delimitation:

This study is limited to:

Ÿ Only 50 mothers of under-five children.

Ÿ Data collection will be done within 4 to 6 weeks.

Ÿ Selected Rural Areas Of Belgaum.

THE REVIEW OF LITERATURE:

A longitudinal study was done at Sweden to compare the prevalence of malocclusion at ages 3 and 7 years children. The study sample comprised of 386 children (199 girls and 187 boys), aged 3 years at starting of the study from three public dental service clinics. Data were obtained from both child and parent by questionnaire answered in conjunction with the initial and final clinical examination. Malocclusion was diagnosed by clinical examination, using a specific protocol Anterior open bite and posterior cross bite showed significant associations with sucking habits.

A longitudinal study was conducted on evaluation of the change in the knowledge of community regarding infant dental care subsequent to intervention strategies through existing health manpower in rural areas of Haryana (India) at oral health sciences centre, Chandigarh. The knowledge about infant dental care was delivered by the existing health care team viz. Medical doctors, multipurpose workers, health workers, anganwadi workers , after due training from the dental experts, in the rural community of Raipur rani (Haryana). Evaluation of knowledge of community after 3 years revealed that 72 % of the community had the correct knowledge of prolonged breast/bottle feeding causing nursing bottle caries. 94 % had correct knowledge about harmful effects of thumb/finger sucking on teeth and jaw bones and 77 % about harmful effects of mouth breathing. 98 % of expecting mothers knew when to clean the gum pads and 62 % how to clean the gum pads in an infant. 100 % of the expecting mothers had the correct knowledge that pacifiers should not be used in small children.

A cross sectional study was conducted on attitude of Saudi Arabian mothers towards the digit-sucking habit in children at department of preventive dental sciences, Saudi Arabia. The sample size comprised of 50 Saudi mothers whose children currently had a digit-sucking habit. The data was collected by specially designed questionnaire by investigator to interview mothers. The results showed that 48% of mothers did not like to see the habit at any age, and no mother accepted the habit after the age of 4 years. Most mothers (86%) tried to stop their children digit-sucking. 66% of the present sample had noticed the adverse effect of this fixation on their child's occlusion, and this was given as the main reason for their attempts to stop the habit. The most common method used by Saudi mothers to stop their children sucking their digits was the application of a bitter tasting lotion to the fingers (66%). Although 48% of mothers had sought advice about digit-sucking from dentists and pediatricians (30% and 18%, respectively), 60% of the dentists and all of pediatricians had made no suggestions about any solutions.

A comparative study to assess the effectiveness of the crib and positive reinforcement in eliminating anterior open bites and increased overjets caused by digit-sucking was conducted at West Indies. The overjet and overbite were measured using an overjet ruler at the start and end of the seventeen-week observation period. 40 patients consented to participate but measurements were only obtained for 11 subjects. The trend in this study is that the crib is more effective than positive reinforcement in preventing digit-sucking.

RESEARCH METHODOLOGY:

Research approach and Research design:

Evaluative approach and Quasi Experimental research design was adopted for the study. Here only one group was observed twice, before and after introducing the independent variable by simple random selection method.

Setting of the study:

The study was conducted in Bastwad village, Belgaum.

Variables:

Independent Variables: In this study nurse teaching programme on thumb sucking is an independent variable.

Dependent Variables: In this study the dependent variables are knowledge and attitude among mothers of under-five on thumb sucking.

Attribute Variables: It includes the demographic variables of mothers of under-five such as age, educational status, religion, occupational status, type of family, family income, no of children and total years of breast feeding.

Population:

The population of the study was mothers of under-five from Bastwad area, Belgaum.

Sample size:

The sample size consists of 50 mothers of under-five from Bastwad village, Belgaum district, Karnataka.

Sampling technique:

Simple random sampling technique was used to select 50 mothers of Under-five from

selected areas of Belgaum.

Description of the tool:

The tool consists of three Parts:

Part A: Demographic data of mothers of under-five children.

Part B: Structured Knowledge questionnaire on thumb sucking comprised of 25 items

Part- C: Attitude Scale on Thumb Sucking

Ethical clearance:

Ethical clearance was obtained.

Reliability:

As researcher has used standardized tool so the existing reliability was 0.7 to 0.9. As the researcher was interested to find out the reliability of the tool and it was administered to 50 mothers of Under-five. And the reliability was calculated by split half method by using Karl Pearson co-efficient.

RESULTS:

Ÿ Majority (48%) of the samples were aged between21-25 years.

Ÿ Most (58%) of them had secondary education.

Ÿ 54% of the samples belong to jain religion.

Ÿ Nearly 98% of them were unemployed.

Ÿ Almost 50% of the samples had Rs.3001-6000 family income.

Ÿ About 76% of the samples belong to joint family.

Ÿ 34% of them were having 1 child.

Ÿ Nearly 22% of them breast fed their babies <1 year and 1.1-2 years.

Figure 3: Percentage Distribution of Age of Mothers of Under-Five Children.

Figure 4: Percentage Distribution of Educational Status of Mothers of Under-Five Children.

Figure 5: Percentage Distribution of Religion among Mothers of Under-Five Children.

Figure 6: Percentage Distribution of Occupational Status of Mothers of Under-Five Children.

Figure 7:Percentage Distribution of Family Income of Mothers of Under-Five Children.

Figure 8: Percentage Distribution of Type of Family among Mothers of Under-Five Children

Figure 9: Percentage Distribution of Number of Children among Mothers of Under-Five Children

Figure 10: Percentage Distribution of Total Years of Breast Feeding of Mothers of Under-Five Children

In the pretest, 58% of mothers of under-five children were having moderately adequate knowledge and 42% were having inadequate knowledge where as in posttest 70% mothers of under-five children were having adequate knowledge and 30% were having moderately adequate knowledge.

Figure11: Percentage Distribution of Pre and Post test Knowledge Scores of Mothers of Under-Five Children Regarding Thumb Sucking.

Table 5: Frequency and Percentage Distribution of Attitude Score.

Variables

Low positive

(0-50%)

Positive

(51-75%)

High positive

(76-100%)

Attitude score

Pretest

Posttest

Figure 12: Percentage Distribution of Pre and Post test Attitude Scores of Mothers of Under-Five Children Regarding Thumb Sucking.

In the pretest, 86% mothers of under-five children were having positive attitude, 8% were having high positive attitude and 6% were having low positive attitude where as in posttest 78% were having high positive attitude and

22% were having positive attitude.

Table 6: Part-wise mean, mean percentage and S.D of knowledge

and attitude scores.

Areas	Maximum score	Statistics
Areas	Maximum score	Mean	Mean%	SD
Knowledge	12	7.54	30.16	9.63
Attitude	41	31.18	62.36	11.79

The mean percentage of knowledge scores was (30.16%) with a mean ±SD of 7.54±9.63 Part C the mean percentage of attitude (31.18%) with a mean ±SD of 62.36±11.79. The findings reveal that the knowledge of mothers of under-five children on thumb sucking is inadequate, and attitude is positive.

Table 7: Part-wise mean, mean percentage and S.D of knowledge and attitude scores.

Areas	Maximum score	Statistics
Areas	Maximum score	Mean	Mean%	SD
Knowledge	22	17.54	70.16	7.37
Attitude	48	41.1	82.2	9.59

The mean percentage of knowledge score was 70.16% with a mean ±SD of 17.54±7.37 Part C the mean percentage of attitude was 82.2% with a mean ±SD of 41.1± 9.59. The findings revealed that the knowledge of mothers of under-five children on thumb sucking was adequate and attitude was highly positive.

Table 8: Comparison of Pretest and Posttest Knowledge Scores.

Knowledge	Mean	Mean (%)	SD(±)	Minimum Score	Maximum Score
Pretest	7.54	30.16	9.63	03	12
Posttest	17.54	70.16	7.37	15	22

The pre-test mean percentage of knowledge was 30.16% with a mean ±SD of 7.54±9.63 with minimum and maximum scores 3 and 12 respectively. The post test mean percentage of knowledge was 70.16% with a mean ±SD of 17.54± 7.37 with minimum and maximum scores 15 and 22 respectively.

Table 9: Comparison Of Pretest and Posttest Attitude Scores.

Attitude	Mean	Mean (%)	SD(±)	Minimum Score	Maximum Score
Pretest	31.18	62.36	11.79	24	41
Posttest	41.1	82.2	9.59	30	48

The pre-test mean percentage of attitude was 62.36% with a mean ± SD of 31.18± 11.79 with minimum and maximum scores 24 and 41 respectively. The post test mean percentage of attitude was 82.2% with a mean ± SD of 41.1±9.59 with minimum and maximum scores 30 and 48 respectively.

The data presented in the above table shows that the total mean percentage of knowledge score is increased by 40% with mean ±SD of 10±2.26 and the total mean percentage of attitude score is increased by 19.84% with mean ±SD of 9.92±2.2 after the administration of NTP. The ‘t’ value of knowledge (37.03) and attitude (23.69) scores were found more than the table value 3.489, p< 0.001 with degree of freedom 49. Hence the NTP was found to be effective in terms of knowledge and attitude.

Table11: Correlation Between Knowledge and Attitude among Mothers of Under- Five Children.

Variables	Knowledge	Attitude
Knowledge	1	0.279*
Attitude	0.279*	1

r=0.273 **Significant (p< 0.01) *Significant (p< 0.05)

Data in above table shows that there is positive correlation between knowledge and attitude in post test conducted among mothers of under-five children towards thumb sucking.

Association of Pre-test Knowledge with Selected Demographic Variables among Mothers of Under-Five Children.

There was no significant association between the pretest knowledge score and the demographic variables such as age, educational status, religion, occupational status, family income, no of children, type of family and total years of breast feeding experience of mothers of under-five children.

Association of Post-test Knowledge with Selected Demographic Variables among Mothers of Under-five Children.

There was significant association between the posttest knowledge and demographic variable like occupational status of mothers (c²=29.04, p<0.05). There was no significant association found between the posttest knowledge and selected demographic variables such as age, educational status, religion, family income, no of children, type of family and total years of breast feeding experience of mothers of under-five children.

Association of Pretest Attitude Score with Selected Demographic Variables Among Mothers of Under-Five Children.

There was association between the pretest attitude score and family income of mothers of under-five children (c²=17.71 df=6 at p<0.05). There was no association found between the pretest attitude scores and the demographic variables such as age, educational status, religion, and occupational status, no of children, type of family and total years of breast feeding experience of mothers of under-fivc children.

Association of Posttest Attitude Score with Selected Demographic Variables among Mothers of Under-Five Children.

There was association between the posttest attitude score and occupational status of mothers of under-five children (c²=29.04 df=2 at p<0.05). There was no association found between the posttest attitude scores and the demographic variables such as age, educational status, religion, family income, no of children, type of family and total years of breast feeding experience of mothers of under-five children.

IMPLICATIONS:

The nurse investigator has drawn the following implications from the study which is of vital concern to the field of nursing service, nursing administration, nursing education and nursing research.

Nursing Service:

The findings of the present study will facilitate the Nurses and other health care personnel to understand the need for educating the mothers of under-five children about the importance of thumb sucking. The community health nurse should conduct education and training programmes for mothers of under-five children not only to create awareness but also to enhance the mothers to gain knowledge regarding the prevalence, causes, risk factors, types, effects, management and preventive measures of thumb sucking among children.

The magnitude of effects of thumb sucking is wide and severe so it is prime duty of the nurses working in various settings to screen the children and provide apt information regarding the thumb sucking to mothers and children as well. Nurses should take keen interest in implementing diverse instruction strategies suitable to the community and to inspire parents as well as teachers to educate the children regarding cultivation of healthy habits as a preventive approach.

Nursing Education:

The findings of the study suggest that there is a need for education regarding the thumb sucking. So, the curriculum should encompass the content on thumb sucking to prepare the future nurses to impart education along with community health nurse services. This would enable the nurses to get adequate knowledge and skills to screen and treat the children at the community level and also to educate the mothers of under-five children in better way. The study also advocates the nurses to employ formal as well as informal ways of teaching to the parents to improve their knowledge about thumb sucking.

Nursing Research:

The findings of present study help the nurse researchers to understand the level of knowledge and attitude regarding thumb sucking. The findings also helps to conduct further research on knowledge, attitude, practice and effectiveness of educating mothers of under-five children regarding thumb sucking and its prevalence, causes, risk factors, benefits, effects, treatment and preventive measures.

Nursing Administration:

Community nursing services are on integral part of high quality, cost effective care. The nursing administrators should see that the health promotion aspect is included in care. The nurse administrator as planning member should organize educative sessions for the nursing personnel on thumb sucking so that they can educate the mothers, parents and community. Awareness about thumb sucking and its effects and education on prevention of thumb sucking can be conducted for all mothers of under-five children as preventive measures.

Apart from this, the nursing administrators should think of appointing community health nurse or give definite job responsibilities for existing personnel which enable to provide the required knowledge and awareness about thumb sucking to the school health personnel, parents and community.

Implications in General:

Ÿ The present study would help to understand the level of knowledge and attitude of the mothers of under-five children on Thumb Sucking.

Ÿ The Nurse teaching program can be utilized by other health professionals in improving the knowledge of mothers and children regarding Thumb Sucking.

LIMITATIONS:

Ÿ The study is done in only 50 samples hence the generalization is possible only for the selected samples.

Ÿ The content of the NTP was prepared on selected areas due to limitation of time.

Ÿ The tool used to assess the knowledge and attitude of mothers of under-five children was prepared by the researcher and was standardized after validation of experts.

Ÿ The study did not use a control group.

Ÿ The time interval between pre-test and post-test was less. So test memory effect is a threat to the internal validity.

RECOMMENDATIONS:

The following studies can be undertaken to strengthen the community based awareness about Thumb Sucking.

1. The same study can be repeated in different regions of the state or nation so as to compare the results.

2. The alike study can be repeated on larger sample so as to generalize the results.

3. The similar study assessing the effectiveness of short term training program on knowledge and attitude regarding thumb sucking can be conducted.

4. Comparative studies can be carried out on knowledge attitude and practice regarding thumb sucking.

5. The akin study can be conducted on the samples with thumb sucking habit.

CONCLUSION:

The assessment of teaching programme regarding knowledge and attitude of mothers of under five children on thumb sucking was improved. It indicates that the mothers will adapt the suitable and healthy measures in preventing or stopping thumb sucking habit ; instead of using any of the impolite behavior or measures in the prevention of this habit. The investigator concludes that nurse teaching programme has an impact in the improvement of the knowledge and attitude of mothers in reducing the habit.

REFERENCES:

1. Greene A. Introduction to thumb sucking. Published on 2Nov 2002 page no1.Available at: www.drgreene.com/azguide/thumb-sucking.

2. Lady G. Thumbsucking 101Available at http://www.squidoo. com/thumbsucking101

3. Zacharias KL. Oxford Companion to the Body-Thumb sucking. Available at http://www.answers.com/topic/thumb-sucking#ixzz1cvYCXSkM ttp://www.answers.com/topic/thumb-sucking#ixzz1cvXMALEQs

4. Smith. E.N. Comprehensive Dental Expertise for Your Child Age 1-23. THUMB SUCKING. Pediatric Dentistry Topics. 2010. Available at: http://www.gentledds4kids.com

5. Peterson D. Family dental care. Thumb sucking’. Published on Feb 06 2008. Available at www.dentalgentlecare.com/ thumbsucking.htm

6. Lindsay. D, Burger J. What Is Adult Thumb Sucking?2013. Available at: http://www.wisegeek.com/what-is-adult-thumb-sucking.htm.

7. Green S. A Parents Guide to Childhood Thumb Sucking Issues and Tongue Thrust Behaviour. International Association of Orofacial Myology. Available at http://www.iao.com.pubications.html

8. Hatfield H, Benaroch R. 9 Ways to wean a child off Thumb Sucking. 2012.Dec 02.available at http://www.empowher.com/media/reference/breaking-your-childs-thumb-sucking-habit.

9. Masella. S. R, Morris-Olson L. Breaking Your child’s Thumb Sucking Habit.2010.May. Available at: http://www.empowher.com/media/reference/breaking-your-childs-thumb-sucking-habit

10. Thumb sucking habit, reasons or causes of thumb sucking, types. 2010. Available at: http://www.identalhub.com/article_causes-of-thumb-sucking-26.aspx.

11. Alexander .K.C, Lane. Wm, M. Robson. Thumb sucking. 1991. Available at:
http://www.drplace.com/Thumb_sucking.16.19417.html

12. Green. E. S. Confirmational study: a positive-based thumb and finger sucking elimination program. International Journal of Orofacial Myology, 2010.Vol36. Available at
http://www.thumblady.com/images/Thumb_Study._Shari_Green,_C.O.M.-1.pdf

13. ADA. Thumb sucking and pacifier use. International Jouranl of American Dental Asssociation. 2007. Vol138. Available at http://www.ada.org/sections/scienceAndResearch/pdfs/patient_77.pdf

14. Stop. Thumbsucking! 2008. Available at: www.your handaid.com

15. Barbosa C , Vasquez S, Parada.M A et al. The relationship of bottle feeding and other sucking behaviors with speech disorder in Patagonian preschoolers. 2009 October 21. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2773774.

16. Dr. Punithavathy.Dr. John B et al . tiny tots and thumb sucking. Tamil Nadu, India. JIADS VOL -1 Issue 2 April - June,2010.

Received on 07.08.2017 Modified on 22.11.2017

Asian J. Nursing Education and Research. 2018; 8(3):349-356.

DOI: 10.5958/2349-2996.2018.00071.X

Variables		Inadequate K (0-30%)	Moderate Adequate K (31-65%)	Adequate K (66-100%)
Knowledge score	Pretest	42	58	0
Knowledge score	Posttest	0	30	70