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PROFORMA FOR THE REGISTRATION OF SUBJECT FOR DISSERTATION “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN SELECTED INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN EDUCATIONAL PAMPHLET” SUBMITTED BY; JOSE CHERIAN MEDICAL SURGICAL NURSING RAMANAMAHARSHI COLLEGE OF NURSING TUMKUR 2011-13 0 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA PROFORMA FOR THE REGISTRATION OF SUBJECT FOR DISSERTATION 1 NAME OF CANDIDATE AND ADDRESS Mr. JOSE CHERIAN 1 YEAR M Sc NURSING RAMANAMAHARSHI COLLEGE OF NURSING, TUMKUR 2 3 4 NAME OF THE RAMANAMAHARSHI COLLEGE INSTITUTION OF NURSING COURSE STUDY AND I YEAR M.SC. NURSING SUBJECT MEDICAL SURGICAL NURSING DATE OF ADMISSION TO COURSE 5 TITLE OF THE TOPIC A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN SELECTED INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN EDUCATIONAL PAMPHLET 1 6. BRIEF RESUME OF THE INTENDED WORK Introduction “To acquire knowledge one must study but to acquire wisdom one must observe” An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh. This type of hernia is called inguinal because fat or part of the intestine slides through a weak area at the inguinal ring, the opening to the inguinal canal. An inguinal hernia appears as a bulge on one or both sides of the groin. An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females. Inguinal hernias tend to become larger with time. The majority of hernias occur in males. Nearly 25% of men and only 2% of women in the United States will develop inguinal hernias. Inguinal hernias occur nearly three times more often in African American adults than in Caucasians. Among children, the risk of groin hernia is greater in premature infants or those of low birth weight. Indirect inguinal hernias will occur in 10–20 children in every 1,000 live births. The inguinal ligament is a tight band located between the thigh and the stomach and there are several weak spots along it. Obesity, pregnancy, heavy lifting, chronic coughing, constipation and straining to pass stools can cause the intestine to push against the abdominal wall, and a part of intestine may slip through a weak spot, creating a lump. This lump is called a hernia. A hernia consists of a sac - the peritoneum - which may contain a piece of intestine (an intestinal loop). It is often able to move inside your body, meaning that it disappears when you lie down, and reappears when you stand up or are straining to pass a stool. The hernia itself is harmless. However, a hernia can be dangerous if it gets trapped in the weak spot in the abdominal wall and becomes tender. This is known as a strangulated hernia. If the intestinal loop is damaged, its contents can leak out. Gangrene and peritonitis, which 2 can be life-threatening, may occur as a result. Strangulation is an emergency requiring urgent surgery. The two types of inguinal hernia have different causes. Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are much more common in males than females because of the way males develop in the womb. In a male fetus, the spermatic cord and both testicles—starting from an intraabdominal location—normally descend through the inguinal canal into the scrotum, the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the inguinal ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or the small intestine sliding into the groin through a weakness in the abdominal wall. Indirect hernias are the most common type of inguinal hernia. Premature infants are especially at risk for indirect inguinal hernias because there is less time for the inguinal canal to close. Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles, which causes weakening of the muscles during the adult years. Direct inguinal hernias occur only in males. The hernia involves fat or the small intestine sliding through the weak muscles into the groin. A direct hernia develops gradually because of continuous stress on the muscles. One or more of the following factors can cause pressure on the abdominal muscles and may worsen the hernia: sudden twists, pulls, or muscle strains lifting heavy objects straining on the toilet because of constipation weight gain chronic coughing Indirect and direct inguinal hernias usually slide back and forth spontaneously through the inguinal canal and can often be moved back into the abdomen with gentle massage 3 Symptoms of inguinal hernia include: a small bulge in one or both sides of the groin that may increase in size and disappear when lying down; in males, it can present as a swollen or enlarged scrotum discomfort or sharp pain—especially when straining, lifting, or exercising— that improves when resting a feeling of weakness or pressure in the groin a burning, gurgling, or aching feeling at the bulge To diagnose inguinal hernia, the doctor takes a thorough medical history and conducts a physical examination. The person may be asked to stand and cough so the doctor can feel the hernia as it moves into the groin or scrotum. The doctor checks to see if the hernia can be gently massaged back into its proper position in the abdomen. In adults, inguinal hernias that enlarge, cause symptoms, or become incarcerated are treated surgically. In infants and children, inguinal hernias are always operated on to prevent incarceration from occurring. Surgery is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient. The two main types of surgery for hernias are as follows: “Open” hernia repair. In open hernia repair, also called herniorrhaphy, usually the area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support—an operation called hernioplasty. Laparoscopy. Laparoscopic surgery is performed using general anesthesia. The surgeon makes several small incisions in the lower abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached to one end. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While viewing the monitor, the surgeon uses instruments to carefully repair the hernia using synthetic mesh1. 4 Diagnosis/Preparation Reviewing the patient's symptoms and medical history are the first steps in diagnosing a hernia. The surgeon will ask when the patient first noticed a lump or bulge in the groin area, whether or not it has grown larger, and how much pain the patient is experiencing. The doctor will palpate the area, looking for any abnormal bulging or mass, and may ask the patient to cough or strain in order to see and feel the hernia more easily. This may be all that is needed to diagnose an inguinal hernia. To confirm the presence of the hernia, an ultrasound examination may be performed. The ultrasound scan will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland. It is not usually possible to determine whether the hernia is direct or indirect until surgery is performed. Preparation Patients will have standard preoperative blood and urine tests, an electrocardiogram, and a chest x ray to make sure that the heart, lungs, and major organ systems are functioning well. A week or so before surgery, medications may be discontinued, especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before surgery, patients must not eat or drink anything. Once in the hospital, a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery. A sedative may be given to relax the patient. Aftercare The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. Patients should also report a fever, and men should report any pain or swelling of the testicles. The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. The postoperative activities of patients undergoing repeat procedures may be even more restricted. Prevention of indirect hernias, which are congenital, is not possible. However, preventing direct hernias and reducing the risk of recurrence of direct and indirect hernias can be accomplished by: 5 maintaining body weight suitable for age and height strengthening abdominal muscles through regular exercise reducing abdominal pressure by avoiding constipation and the build-up of excess body fluids, achieved by adopting a high-fiber, low-salt diet lifting heavy objects in a safe, low-stress way, using arm and leg muscles2 If a hernia is not surgically repaired, an incarcerated or strangulated hernia can result, sometimes involving life-threatening bowel obstruction or ischemia. 6.1 NEED FOR THE STUDY A hernia is a lump that results from a part of the intestine (bowel) slipping through a weakness in the abdominal wall. The most common hernias are inguinal hernias (groin hernias). There are three types of inguinal hernia: indirect inguinal hernia which is common in children - they may be present at birth - and young people. They are mostly seen in males but can also occur in females. direct inguinal hernias mostly afflict adults especially middle-aged and elderly men. femoral hernia is rarer than the other types and mainly affects women. The opinion of a specialist doctor is usually necessary to determine which type of hernia is present3. Importance An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh. An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females. 6 Direct and indirect hernias are the two types of inguinal hernia, and they have different causes. Symptoms of an inguinal hernia usually appear gradually and include a bulge in the groin, discomfort or sharp pain, a feeling of weakness or pressure in the groin, and a burning, gurgling, or aching feeling at the bulge. An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen. A strangulated hernia, in which the blood supply to the incarcerated small intestine is jeopardized, is a serious condition and requires immediate medical attention. Symptoms include extreme tenderness and redness in the area of the bulge, sudden pain that worsens quickly, fever, rapid heart rate, nausea, and vomiting. An inguinal hernia is diagnosed through a physical examination. Inguinal hernias may be repaired through surgery. Surgery is performed through one incision or with a laparoscope and several small incisions. Surgery for inguinal hernia is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient. Complications from inguinal hernia surgery are rare and can include general anesthesia complications, hernia recurrence, bleeding, wound infection, painful scar, and injury to internal organs4. Description About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men. Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified 7 as inguinal hernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance fails to close normally before birth. This condition is found in 2% of all adult males and in 1–2% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inguinal canal opening. In fact, women will more likely have an indirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of the large intestine protrudes through a weakened area of muscles in the groin. About 60% of hernias found in children, A congenital indirect inguinal hernia may be diagnosed in infancy, childhood, or later in adulthood, influenced by the same causes as direct hernia. There is evidence that a tendency for inguinal hernia may be inherited. A direct and an indirect inguinal hernia may occur at the same time; this combined hernia is called a pantaloon hernia. Because inguinal hernias do not heal on their own and can become larger or twisted, which may close off the intestines, the prevailing medical opinion is that hernias must be treated surgically when they cause pain or limit activity. Protruding intestines can sometimes be pushed back temporarily into the abdominal cavity, or an external support (truss) may be worn to hold the area in place until surgery can be performed. Sometimes, other medical conditions complicate the presence of a hernia by adding constant abdominal pressure. These conditions, including chronic coughing, constipation, fluid retention, or urinary obstruction, must be treated simultaneously to reduce abdominal pressure and the recurrence of hernias after repair5. Hernia operations are among the most common procedures performed today. Most hernias result from a tear in the lining, or fascia, beneath the abdominal muscles, allowing the intestines to protrude. In many cases, this process begins at birth and is an inherited condition. While far more common in men, they are quite frequent in women as well. These hernias affect people of all age groups, from infants to seniors. Four different types of hernias account for almost 100 % of the hernias repaired by surgeons: 8 Type Location Frequency Defect Inguinal Groin 93% Fascia Incisional Entire Abdomen 5% Fascia Ventral/umbilical Upper Abdomen 1% Fascia More common in males than females. Indirect hernias - most common overall Femoral hernias - more common in females. Most common side for inguinal and femoral hernias is the right side; explanation: delay atrophy of processus vaginalis A paediatric inguinal hernia can appear / occur at any age, but the peak incidence is during infancy and early childhood with 80 to 90% occurring in boys. About 3% to 5% of healthy, full-term babies may be born with an inguinal hernia and one third of hernias of infancy and childhood appear in the first 6 months of life. In premature infants the incidence of inguinal hernia is substantially increased, up to 30%. In just over 10% of cases, other members of the family have also had a hernia at birth or in infancy. The occurrence of an inguinal hernia in boys is related to the development and descent of the testes. The testes develop within the abdomen and at around the seventh month of pregnancy they descend into the scrotum. On their way through the abdominal wall, they pass through the inguinal canal. After they reach the scrotum, the opening behind should close. Failure to close adequately results in a hernia with an opening remaining in the abdominal wall at this point6. Statistics on Hernia Groin hernias occur in approximately 2% of the adult population and 4% of infants. Their relative frequencies are as follows: Inguinal 80% Incisional 10% Femoral 5% 9 Umbilical 4% Epigastric <1% Other: <1% Inguinal are approximately 10 times more common in males, while femoral and paraumbilical are more common in women. Prognosis of Hernia depends on whether the patient develops complications. Hernias are treatable surgically; although they may recur. The recurrence of a inguinal hernias after surgical repair may occur but should be less than 2%7. Based on the statistics available regarding inguinal hernia, there is a need to educate community regarding early detection of hernias and its prompt treatment. 6.2 REVIEW OF LITERATURE The review of literature is defined as broad, comprehensive in-depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audio visual materials and personal communications. Kang SK, Burnett CA et al conducted a study on “Hernia: is it a workrelated condition?” which says that development of hernias among active workers is a major occupational problem, however, the work-relatedness of hernias has not been well investigated. It is a difficult question for occupational and primary care physicians who must often address whether a worker with an inguinal hernia should be restricted from work requiring lifting of heavy objects. To evaluate the possible work-relatedness of inguinal hernias, a cross-sectional study was performed. The goal of the study was to determine hernia incidence according to occupation with the Annual Survey of Occupational Injuries and Illnesses from the Bureau of Labor Statistics in 1994. Hernia incidence rates (per 10,000 workers) for industry and occupation categories were calculated with the estimates of the number of hernias in males and the employed male workers from the Current Population Survey. Rate ratios (RR) of hernia incidence rates were calculated. In 1994, an estimated 30, 791 work-related hernias in males were reported by US private establishments. The 10 occupation groups with the highest RR were laborers and handlers (RR, 2.47; 95% confidence interval (CI), 2.14-2.80), machine operators (RR, 2.13; 95% CI, 1.812.44), and mechanics and repairers (RR, 1.72; 95% CI, 1.43-2.00). Rate ratios for hernias vary considerably within industries and occupations, with the highest ratios found in industries and occupations involving manual labor. This provides support for the hypothesis that the hernias are work-related, especially in work involving strenuous, heavy manual labor8. Liem MS, van der Graaf Y et al conducted a study on “Risk factors for inguinal hernia in women: a case-control study. The Coala Trial Group” which says that potential risk factors for inguinal hernia in women were investigated and the relative importance of these factors was quantified. In women, symptomatic but nonpalpable hernias often remain undiagnosed. However, knowledge on this subject only concerns hernia and operation characteristics, which have been obtained by review of case series. Virtually nothing is known about risk factors for inguinal hernia. The authors performed a hospital-based case-control study of 89 female patients with an incident inguinal hernia and 176 age-matched female controls. Activity since birth with two validated questionnaires was measured and smoking habits, medical and operation history, Quetelet index (kg/m2), and history of pregnancies and deliveries were recorded. Response for cases was 81% and for controls 73%. Total physical activity was not associated with inguinal hernia (univariate odds ratio (OR) = 0.8, 95% confidence interval (CI) 0.6-1.1), but high present sports activities was associated with less inguinal hernia (multivariate OR = 0.2, 95% CI 0.1-0.7). Obesity (Quetelet index > 30) was also protective for inguinal hernia (OR = 0.2, 95% CI 0.04-1.0). Independent risk factors were positive family history (OR = 4.3, 95% CI 1.9-9.7) and obstipation (OR = 2.5, 95% CI 1.0-6.7). In particular, smoking, appendectomy, other abdominal operations, and multiple deliveries were not associated with inguinal hernia in females. The protective effect of present sports activity may be explained by optimizing the resistance of the abdominal musculature protecting the relatively small inguinal weak spot in the female. The individual predisposition for inguinal hernia may be quantified by these risk factors, and, with this in mind, the authors advise that further evaluation might be needed for the patient with unexplained inguinal pain9. 11 Lau H, Fang C et al conducted a study on “Risk factors for inguinal hernia in adult males: a case-control study” which says that inguinal hernia is one of the most common surgical pathologies. Research studies on clinical factors predisposing a person for the development of inguinal hernia, however, remain scarce. The objective of the present study was to evaluate the risk factors for the development of inguinal hernia in adult males, using a case-control design in a hospital-based population. Between January 2002 and January 2004, a total of 1,418 male patients were recruited at the general surgical or hernia clinic of a University-affiliated teaching hospital. Patients were divided into case and control groups according to the presence of a primary inguinal hernia. Each patient was interviewed by a research assistant using a standardized questionnaire. Clinical data were studied by multivariate, logistic regression analyses to identify independent predictors of inguinal hernia in adult males. Clinical factors associated with the presence of inguinal hernia included a higher work activity index (P = 0.03), a higher total activity index (P = 0.01), a positive family history of inguinal hernia (P < 0.01, odds ratio = 8.73), and chronic obstructive airway disease (P = 0.04, odds ratio = 2.04). After adjustments for the type of hernia, chronic obstructive airway disease was a risk factor only for direct hernia, whereas total activity index and family history of hernia remained significantly related to both direct and indirect hernias. On logistic regression analyses, positive family history of hernia was the only independent predictor for inguinal hernia. Family history of hernia was the most important determinant factor for developing inguinal hernia in adult males. A male subject who has a positive family history of hernia is 8 times more likely to develop a primary inguinal hernia10. Ruhl CE, Everhart JE conducted a study on “Risk factors for inguinal hernia among adults in the US population” which says that inguinal hernia among US adults (5,316 men and 8,136 women) participating in the First National Health and Nutrition Examination Survey (1971-1975) who were followed through 1992-1993 for a hospital (International Classification of Diseases, Ninth Revision, Clinical Modification, code 550) or physician diagnosis of inguinal hernia. Ninety-six percent of the baseline cohort was recontacted, with a median follow-up of 18.2 years (range, 0.02-22.1 years). Because the cumulative incidence of inguinal hernia was higher among men (13.9%) than among women (2.1%), more detailed analyses were 12 conducted in men. Among men in multivariate analysis, a higher incidence (p < 0.05) of inguinal hernia was associated with an age of 40-59 years (hazard ratio (HR) = 2.2, 95% confidence interval (CI): 1.7, 2.8), an age of 60-74 years (HR = 2.8, 95% CI: 2.2, 3.6), and hiatal hernia (HR = 1.8, 95% CI: 1.2, 2.7), while Black race (HR = 0.58, 95% CI: 0.42, 0.79), being overweight (HR = 0.79, 95% CI: 0.66, 0.95), and obesity (HR = 0.51, 95% CI: 0.36, 0.71) were associated with a lower incidence. Among women, older age, rural residence, greater height, chronic cough, and umbilical hernia were associated with inguinal hernia. In the United States, inguinal hernias are common among men, especially with aging. The lower risk among heavier men was unexpected and bears further study11. Wu XY, Huang MZ et al conducted a study on “A case-control study on the risk factors for inguinal hernia in children” which says that inguinal hernia is a common birth defect in children, but there is limited information about the risk factors for this disorder. The study aimed to explore the risk factors for the development of this disorder in children. A frequency matching case-control study based on hospital group data was performed. One hundred and thirty-two 0-6 years old children with inguinal hernia and 132 aged-matched controls were enrolled. Children's general characteristics and their mothers' general characteristics before and during pregnancy were obtained by a questionnaire survey. Risk factors for inguinal hernia were investigated by logistic regression analysis. Multivariate logistic regression analysis showed that the development of inguinal hernia was related to children's cry and unease records (OR=3.70195%CI1.724-7.945), maternal consumption for pickles (OR=2.53495%CI: 1.279-5.021) and maternal anemia (OR=3.76195%CI1.497-9.450) one year before pregnancy and during the first 3 months of pregnancy, and the family history of inguinal hernia (OR=13.50595%CI5.825-31.307). Children's cry and unease records, maternal anemia and pickle consumption one year before pregnancy and during the first 3 months of pregnancy, and family history of inguinal hernia are risk factors for the development of inguinal hernia in children12. Carbonell JF, Sanchez JL et al conducted a study on “Risk factors associated with inguinal hernias: a case control study” with an objective to assess reported risk factors for the development of inguinal hernias, to develop a method of quantifying physical effort, and to correlate them. Case control study at District 13 hospital, Valencia, Spain. 290 selected patients who had undergone inguinal hernia repair, and 290 age and sex matched controls. Each patient was interviewed and data collected on a specially designed questionnaire, and an "effort score" calculated. Incidence of specified risk factors. The only significant risk factor was physical effort (lifting heavy objects repeatedly over long periods of time), relative risk 2.92, 95% confidence interval 2.11 to 4.04. In addition, there were significant differences between index cases and controls in standard of education (p < 0.001), consumption of alcohol (p = 0.02), chronic cough (p < 0.001), net monthly income (p = 0.04), and amount of physical effort expended (p < 0.001). Patients with indirect hernias expended significantly more physical effort and were both heavier and taller, and patients with femoral hernias waited significantly longer than the others before having their hernias repaired. Inguinal hernias are associated with the expenditure of a considerable amount of physical effort, and are commoner among younger, poorly educated manual workers13. Mbah N conducted a study on “Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria” which says that treatment of uncomplicated inguinal hernia is relatively simple and the outcome is often favourable. Complicated hernias are fraught with increased mortality with and without operative management. To determine the scope of adverse events which attend the management of inguinal hernia in extreme northwestern region of Nigeria. Subjects From the hospital records department, the case folders of all patients with the clinical diagnosis of hernia seen between January 2000 and December 2002 were retieved. Of the cases identified, 227 patients diagnosed of inguinal hernia, either alone or in combination with other forms of hernia formed the basis of this report. Relevant data extracted and analyzed included the patient's demographics, clinical details, treatment offered and outcome. Two hundred and fifty three inguinal hernias in 227 individuals were seen.. This represented 76.9% of patients diagnosed of external abdominal hernias., 16 times more commonly in males than females. Fifty two (20.6%) hernias presented as acute abdominal emergencies while 225 hernias in 199 patients were repaired. Local anesthesia was used in 32 (16.1%) of the patients with 33 (14.7%) inguinal hernias. 14 Four (1.8%) individuals were managed on day case basis. Twelve (5.3%) deaths occurred in this series, three of which were pre-operative. At a mean follow up of 7 months (range 1-23 months), 1 (0.4%) hernia recurrence was noted. Complicated inguinal hernias and their emergency surgical treatment are associated with increased mortality in our environment. Prophylactic elective herniorrhaphy is recommended as a safeguard for inguinal hernia as soon as identified irrespective of patient's age14. Holzheimer RG conducted a study on “Inguinal Hernia: classification, diagnosis and treatment—classic and traumatic hernia” which says that inguinal hernia repair is performed in more than 600,000 cases every year in the United States. However, the true prevalence may be even higher. Many groin hernias are not diagnosed, e.g., Sportmans' hernia, or are asymptomatic. The etiology of classic inguinal hernia, Sportsman's hernia or traumatic hernia may be different. The hernia repair is performed in agreement with a classification of the hernia, e.g., Nyhus classification. According to recent randomized controlled trials and meta-analyses open-mesh repair demonstrates several advantages in comparison to laparoscopic procedures. Laparoscopic procedures require more time and cost more, show a potential for serious complications and may be followed by an increased rate of recurrence. There may be a faster reconvalescence after laparoscopic procedures. However, there may be also a selection bias. Laparoscopic procedures are associated with specific complications, e.g., pneumomediastinum, pneumothorax, gas extravasation, trocar injuries, intraabdominal adhesions, bowel obstruction, which are rarely or never seen in open-mesh repair. In the United States we could observe an uncoupling of hernia repair from classification. In more than 90% of cases the treatment was open-mesh. In many hernia studies the hernias were classified as direct or indirect, primary or recurrent. The existing classifications are based on anatomical findings in relation to the development of the hernia: posterior floor integrity, enlarged interior ring and size of the hernia. However, the size of the hernia may not always be associated with the severity of the hernia and it may be difficult to estimate. The outcome of hernia repair may be influenced by other factors. There may be differences in the presentation of the hernia to the surgeon based on the damage done to the surrounding tissue in the inguinal canal, e.g., external ring, aponeurosis of the 15 external oblique, inguinal ligament, which is most often accompanied by severe adhesions. Further factors influencing outcome of hernia repair may be patient-related factors, e.g., constipation, ASA classification, diabetes, smoking. A classification should be simple to use and easy to remember: (A) indirect hernia, (B) direct hernia, (C) scrotal or giant hernia, (D) femoral hernia. A and B can be classified as (0) uncomplicated, (1) posterior floor defect, (2) posterior floor defect plus defect in the anterior part of the inguinal canal. All four types (A-D) may be either primary or recurrent. In this classification combined femoral, indirect and/or direct hernias can be categorized by using the types A, B, C, or D as in a modular construction system. The category "other" is reserved for rare types of hernia, e.g., obturator hernia, Spieghelian hernia. Aggravating factors are included: Diabetes, obesity, age above 65, constipation, ASA III or more and cigarette smoking. This classification may be helpful to evaluate outcome of hernia repair with regard to patient related factors and the increased demands for the surgeon and the staff. In some health care systems the general belief is that all hernias are equal and be managed equally. However, groin hernias may be complex and need individual treatment15. Flich J, Alfonso JL et al conducted a study on “Inguinal hernia and certain risk factors” which says that there are several studies on inguinal hernias that give some clues about the association between this type of hernia and certain risk factors. This association was suspected long ago but had not been demonstrated. The present study tries to correlate the origin of inguinal hernias and the physical effort of the subjects in accordance with their work activity. The results of this study show that physical effort, as a risk factor, is closely related to the appearance of inguinal hernias. A person whose work involves lifting or other strenuous exertion has a higher risk than those whose jobs are less strenuous (p less than 0.05). This conclusion was reached after taking into account not only the weight lifted but also the number of years in this activity16. Sanjay P, Woodward A conducted a study on “Single strenuous event: does it predispose to inguinal herniation?” which says that there is a general belief that inguinal hernias are often caused by a single strenuous event, however there are no data to support this association. This study aims to assess the frequency with which inguinal hernia is attributed to a single muscular strain and to identify predisposing 16 factors. All patients who underwent inguinal hernia repair under the care of one surgeon over a nine-year period were studied. Five hundred and twenty patients were sent a structured postal questionnaire. There was a 62% response rate (320). The median age of the study group was 61.5 (range 19-88) years. Out of a total 320 hernias, 51% (163) of the hernias were gradual in onset and in 42.5% (137) of hernias there was a history suggesting an association between a particular strenuous event and the sudden onset of hernia. In the sudden-onset group 101 (74%) patients had indirect hernias while in the gradual-onset group, 93 patients (57%) had indirect hernias (P < 0.05). Thirty-four patients (25%) had direct hernias in the sudden-onset group and 63 (39%) in the gradual-onset group (P < 0.05). The various predisposing factors were lifting (67.8%, 93), coughing (14.5%, 20), exercise (10.2%, 14), and gardening (7.3%, 10). Heavy work was associated with sudden inguinal herniation. This study supports the hypothesis that the appearance of inguinal herniation may be attributed to a single strenuous event. Indirect hernias are more likely to present following such an event17. Ohene-Yeboah M, Abantanga FA conducted a study on “Inguinal hernia disease in Africa: a common but neglected surgical condition” which says that hernia surgery is one of the most frequent procedures done by surgeons - paediatric and general surgeons -in the African continent. To review the surgical literature, on the epidemiology, clinical features, treatment and outcome of inguinal hernia surgery in Africa. The search terms used were groin hernias in Africa, hernia surgery in Africa, inguinal hernias in Africa, hernias in adults and hernias in children in Africa using Medline, Cochrane Central Register of Controlled Trials and EMBASE. All journal articles on inguinal hernias performed in Africa and published in the world journals from 1990-2010 were retrieved. All articles containing information on inguinal hernias in children and adults were carefully studied for epidemiology, clinical presentation, method of hernia repair, complications (including morbidity and mortality rates) and the future of hernia surgery in Africa. There was an absolute dearth of knowledge of the burden of inguinal hernias in the various communities in Africa, especially, in sub-Saharan Africa. There were non-existent population-based studies in the sub-Saharan context that could inform us about the epidemiology of inguinal hernias and hence estimate the necessity for surgery in Africa. The studies 17 were all clinical in nature and did not reflect the true burden of the disease among Africans. In many of these hospital-based studies, the method of inguinal hernia repair used most was the Bassini repair. Not much was found in the literature about the use of the Lichtenstein tension-free mesh repair of inguinal hernias, the reason being that the mesh was too expensive for the patients to afford. Scarcely, was laparoscopic hernia repair mentioned. Based on the clinical studies reviewed, there is a large disease burden of inguinal hernias in Africa. There is, understandably, also a limited surgical capacity to reduce this burden. The authors advocate the formation of an African Hernia Society to partner with corporate and international organizations to make hernias a public health problem and to attempt to determine, using population-based studies, the actual burden of the disease in Africa and then to take modern hernia surgery to most parts of the continent to help reduce the hernia burden, especially its complications18. Ouellette LR, Dexter WW conducted a study on “Inguinal hernias: value of preparticipation examination, activity restriction decisions, and timing of surgery” which says that though groin pain is common, the differential diagnosis is broad, and narrowing down the diagnosis of an inguinal hernia can be challenging. Once a hernia is diagnosed, play becomes limited based on severity of symptoms and physician and patient comfort, and the athlete should be closely monitored for worsening symptoms. Several surgical approaches are available for the repair of inguinal hernias, but without knowing the true natural history of this disorder, it is difficult to know when it is appropriate to have a hernia repaired19. 18 6.3 STATEMENT OF THE PROBLEM “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN SELECTED INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN EDUCATIONAL PAMPHLET” 6.4 OBJECTIVES OF THE STUDY 1. To assess the knowledge regarding the inguinal hernia among industrial workers. 2. To evaluate the effectiveness of structured teaching programme among industrial workers regarding inguinal hernia. 3. To find out the association of knowledge of industrial workers regarding the inguinal hernia with selected demographic variables. 4. To develop and distribute educational pamphlet. 6.5 OPERATIONAL DEFINITIONS Knowledge: In this study knowledge refers to the information possessed by industrial workers regarding inguinal hernia as assessed by structured knowledge questionnaire. Structured teaching programme: It refers to organized group teaching method to impart knowledge for industrial workers regarding the inguinal hernia. Industrial workers: In this study industrial workers refers to those who are working as labourers in different industries of Tumkur. Inguinal hernia: In this study inguinal hernia refers to a condition in which intraabdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. Educational pamphlet: In this study, educational pamphlet refers to systematically prepared health package which includes information regarding inguinal hernia which can be easily understood by industrial workers irrespective of their knowledge. 19 6.6 HYPOTHESIS 1. H1- There is a significant difference between knowledge of industrial workers regarding the inguinal hernia. 2. H2- There is a significant association between the knowledge of industrial workers regarding inguinal hernia with selected demographic variables. 6.7 ASSUMPTIONS 1. Industrial workers may have minimal knowledge about the inguinal hernia. 2. Administration of structured teaching programme may have impact on the knowledge of industrial workers regarding the inguinal hernia. 3. Educational pamphlet enhances the knowledge regarding inguinal hernia among industrial workers. 6.8 VARIABLES UNDER STUDY Dependent Variables: Knowledge of inguinal hernia among industrial workers. Demographic Variables: Age, sex, education, duration of work, socioeconomic status, source of information. 6.9 DELIMITATIONS The study is limited to the industrial workers who, Will be present during the period of data collection. Are willing to participate in the study. The sample size is limited to 40 industrial workers. 6.10 PILOT STUDY The pilot study will be conducted with 4 industrial workers and who will be excluded in the main study. The purpose of pilot study is to find out the feasibility of conducting study and design on plan of statistical analysis. The findings of the pilot study samples will not be included in main study. 20 7.0 MATERIALS AND METHODS A written permission will be obtained from the concerned authority prior to the onset of the study, the purpose of the study and method of data collection will be explained to the participants and informed consent will be taken, confidentiality will be assured to all subjects to get their co-operation. Data will be collected from 40 industrial workers in selected industries as per the inclusion criteria for the study. At the end subjects will be thanked for their co-operation during the study. 7.1 SOURCES OF DATA Data will be collected from industrial workers in selected industries of Tumkur. RESEARCH DESIGN The design is selected for the present study is Single group pre test, post test design. RESEARCH APPROACH The experimental survey approach will be considered appropriate for this study. RESEARCH SETTING The study will be conducted in selected industries of Tumkur. POPULATION Population in the study consists of industrial workers in selected industries of Tumkur. SAMPLE SIZE Total sample of the study will consist of 40 industrial workers in selected industries of Tumkur. SAMPLE TECHNIQUE Non-probability convenient sampling will be used for the study. SAMPLING CRITERIA INCLUSION CRITERIA 1. Industrial workers those who are working in selected industries. 2. Industrial workers those who are available at the time of data collection. 21 EXCLUSION CRITERIA 1. Industrial workers who are not willing to participate in the study. 2. Industrial workers who are not available at the time of data collection. 7.2 METHODS OF COLLECTION OF DATA TOOL FOR DATA COLLECTION Tools for data collection are divided into following categories: Part I: Items on demographic variables will be listed under structured questionnaire. Part II: Items on knowledge of industrial workers regarding the inguinal hernia will be assessed by structured knowledge questionnaire. Part III: Structured teaching programme on inguinal hernia among Industrial workers. METHOD OF DATA ANALYSIS & INTERPRETATION The data will be organized, tabulated and analyzed by using descriptive and inferential statistics. The data will be planned to present in the form of tables and figures. Descriptive statistics: To describe demographic variable by percentage, mean, mode, median and standard deviation. Inferential statistics: 1. Chi-square test will be used to test the association between the knowledge of Industrial workers and the demographic variables. 2. Independent “t” test to be used to find out the difference between Pre-test and Posttest scores. TIME AND DURATION OF THE STUDY: The time and duration of the study will be limited to 6 weeks as per the guidelines of the university. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMAL? Yes, structured teaching program will be conducted on industrial workers. 22 7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION? Yes, the pilot study and the main study will be conducted after the approval from the research committee of Ramanamaharshi College of Nursing, Tumkur. Permission will be obtained from the concerned head of the institutions. The purpose and details of the study will be explained to the study subjects and an informed consent will be obtained from them. Assurance will be given to the study subjects on the confidentiality and anonymity of the data collected from them. 23 8.0 LIST OF REFERENCES 1. Inguinal hernia, http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/ 2. Inguinal hernia, http://www.tour2india4health.com/inguinal-hernia-surgeryindia.htm 3. Inguinal hernia, www.righthealth.com 4. Inguinal hernia, http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/ 5. Inguinal hernia, http://www.tour2india4health.com/inguinal-hernia-surgeryindia.htm 6. Hernia, http://www.aphernia.com/herniastatistics.htm 7. Statistics of hernia, http://www.virtualmedicalcentre.com/diseases.asp?did=217&title=Hernia 8. Kang SK, Burnett CA et al, Hernia: is it a work-related condition?, American journal of industrial medicine, 1999 Dec;36(6):638-44. 9. Liem MS, van der Graaf Y et al, Risk factors for inguinal hernia in women: a case-control study. The Coala Trial Group, American journal of epidemiology. 10. Lau H, Fang C et al, Risk factors for inguinal hernia in adult males: a casecontrol study, Surgery. 2007 Feb;141(2):262-6. Epub 2006 Jul 31. 11. Ruhl CE, Everhart JE, Risk factors for inguinal hernia among adults in the US population American journal of epidemiology ,2007 May 15;165(10):1154-61. Epub 2007 Mar 20. 12. Wu XY, Huang MZ et al, A case-control study on the risk factors for inguinal hernia in children, Zhongguo Dang Dai Er Ke Za Zhi. 2008 Aug;10(4):489-92. 13. Carbonell JF, Sanchez JL et al, Risk factors associated with inguinal hernias: a case control study, European journal of surgery, 1993 Sep;159(9):481-6. 14. Mbah N, Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria, West African journal of medicine, 2007 OctDec;26(4):288-92. 15. Holzheimer RG, Inguinal Hernia: classification, diagnosis and treatment— classic and traumatic hernia, European journal of medical research, 2005 Mar 29;10(3):121-34. 16. Flich J, Alfonso JL et al, Inguinal hernia and certain risk factors, European journal of epidemiology, 1992 Mar;8(2):277-82. 24 17. Sanjay P, Woodward A, Single strenuous event: does it predispose to inguinal herniation?, Hernia. 2007 Dec;11(6):493-6. Epub 2007 Jun 23. 18. Ohene-Yeboah M, Abantanga FA, Inguinal hernia disease in Africa: a common but neglected surgical condition, West African journal of medicine, 2011 Mar-Apr;30(2):77-83. 19. Ouellette LR, Dexter WW, Inguinal hernias: value of preparticipation examination, activity restriction decisions, and timing of surgery, current sports medicine reports, 2006 Apr;5(2):89-92. 25 9 SIGNATURE OF THE CANDIDATE 10 REMARKS OF THE GUIDE 11 11.1 NAME AND DESIGNATION OF GUIDE 11.2 SIGNATURE 11.3 CO-GUIDE 11.4 SIGNATURE 11.5 HEAD OF THE DEPARTMENT 11.6 SIGNATURE 12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL. 12.2 SIGNATURE 26 27