|Year : 2019 | Volume
| Issue : 2 | Page : 122-127
A study assessing the knowledge, attitude, and practices of parents regarding childhood hypopigmented lesions
Akila Ravindra, Veranna Shastry, Chetana Prakash, Jaydev Betkerur
Department of Dermatology, Venereology and Leprosy, JSS Medical College, Mysore, Karnataka, India
|Date of Web Publication||29-Mar-2019|
Dr. Akila Ravindra
Department of Dermatology, Velammal Medical College Hospital and Research Institute, Ring Road, Anuppanadi, Madurai - 625 009, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Pigmentary disorders are believed to be the most common group of dermatoses in the pediatric age group. Loss of pigment can have a profound psychological impact on parents of the affected child. There are few studies available in India about the evaluation of hypopigmented lesions in the pediatric age group. Objectives: The objective of this study was conducted to assess the knowledge and attitude and various practices of parents toward hypopigmented disorders. Materials and Methods: A total of 130 pediatric patients were evaluated for hypopigmented lesions. Parent of each child was given a preformed questionnaire for the assessment of knowledge and attitude and various practices of their skin condition. Results: The frequency of hypopigmentary disorders among children was 3.28/1000. The mean age was 8.41 years. Nearly 9.33% of patients had onset at birth. In the study of 130 parents, 82 had low, 32 had moderate, and 14 had high knowledge levels, and 84 had unfavorable, and 46 had favorable attitudes. The parents, who had incorrect practices, were 53% and 35.67% had correct practices. Conclusion: The most common hypopigmentary conditions are benign and self-limiting, which requires proper counseling of the parents. A good knowledge and attitude will not only liberate them from traditional beliefs and home remedies that have been used in most of the Indian households but will also make them understand the magnitude of the problem their child could face if they do not seek proper advice from a doctor at the right time.
Keywords: Attitude, hypopigmentary disorders, knowledge, parents, practices
|How to cite this article:|
Ravindra A, Shastry V, Prakash C, Betkerur J. A study assessing the knowledge, attitude, and practices of parents regarding childhood hypopigmented lesions. Indian J Paediatr Dermatol 2019;20:122-7
|How to cite this URL:|
Ravindra A, Shastry V, Prakash C, Betkerur J. A study assessing the knowledge, attitude, and practices of parents regarding childhood hypopigmented lesions. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Sep 19];20:122-7. Available from: http://www.ijpd.in/text.asp?2019/20/2/122/255201
| Introduction|| |
Pigmentary disorders are believed to be the most common group of dermatoses in the pediatric age group. Hypopigmentation has been referenced in many ancient religious texts as a curse or contagious disease. An illustration stated in the Old Testament when Miriam speaks against Moses and is punished thus: “… suddenly Miriam became leprous, as white as snow.” Loss of pigment can have a profound psychological impact on the parents of the affected child.
Hypopigmented lesions in children can be as benign as pityriasis alba and pityriasis versicolor to as severe as leprosy. The other causes are nevus anemicus, postinflammatory depigmentation, polymorphic light eruption, hypomelanosis of Ito, vitiligo, nevus depigmentosus, and idiopathic guttate hypomelanosis.
Hypopigmentation refers to any form of decreased pigmentation whereas hypomelanosis refers specifically to a decrease in melanin content. Although the vast majority of hypopigmentation is neither contagious nor dangerous, fear, anxiety, and uncertainty continue to surround this problem for patient and physician alike. Even if these conditions cannot be cured, simple understanding may provide some relief.
Periodic evaluation of knowledge, attitude, and beliefs in a population group serves as an educational diagnosis and provides an important way to measure the changing beliefs and behaviors overtime. Health-seeking behavior of parents for the child is an important factor affecting child health. Regarding illness and behaviors overtime, it refers to activities undertaken by individuals in response to symptom experience. It is influenced by a large number of factors apart from knowledge and awareness, operating at individual, family, and community level including the biosocial profile of individual, his past experiences, influences at the community level, availability of alternative healthcare providers, and his perceptions regarding efficiency and quality of the services available.
To the best of our understanding, no study has been undertaken to comprehend knowledge, attitude, and practices (KAPs) of parents toward hypopigmented lesions in children.
| Materials and Methods|| |
Study design and setting
A cross-sectional descriptive study was conducted in our department from December 2014 to August 2016.
This study was approved by the Ethics Committee and Institutional Review Board. Informed consent was obtained from all participants at the study entry. Written consent was obtained from the participants to use their data.
All the parents with children having hypopigmented lesions below 18 years of age were included in the study:
Parents who have not given consent for the study, children with postburn, or posttraumatic lesions were excluded from the study.
Respondents were given a self-administered structured questionnaire written in English which was translated to the local language and validated through a pretested survey. The assessment of content validity reflects a judgment whether the question samples all relevant and important domains. The mean content validity ratios were calculated as 0.85 based on the opinions expressed by a panel of total of four academicians. Test of reliability comprised two components as follows: question-to-question reliability, which was assessed by the percentage of agreement (90%) and internal reliability for the relevance of questions, which was assessed using Cronbach's alpha (0.82).
There were a total of 25 proposed questions under the following sections:
- Section 1: It incorporated five questions to gather information related to the parent's demographic data which included gender, age, employment, educational level, and monthly income
- Section 2: It integrated 10 questions to assess the knowledge of hypopigmented lesions among the parents. The response was given as “Yes,” “No,” and “Don't Know”
- Section 3: It consisted of 16 questions, aimed to assess the attitude of parents. Answers were scored on a five-point Likert scale as “Strongly Agree (SA),” “Agree (A),” “Uncertain (U),” “Disagree (D),” and “Strongly Disagree (SD)”
- Section 4: It had four questions aimed to investigate the practices of parents regarding hypopigmented lesions. These responses were recorded as “Yes,” “No,” and “Don't Know.”
Every item about the knowledge was scored as low, moderate, and high. Attitude questionnaire was coded from 1 to 5 (disagree to agree). Attitude items were recorded to ensure that, for all items, a high score indicated a positive attitude toward hypopigmented lesions, and a low score indicated a negative attitude. Regarding various practices, the right answer was coded as 1 and the wrong answer as 0. These individual scores were then summed up to yield a total score. These scores were correlated with the respondent's parity, education, and occupation.
The Student's t-test and one-way analysis of variance were used to assess the relationship between the KAP scores and the demographic characteristics. A statistically significant relationship was assumed to exist between the groups if the P value was found to be lesser than 5% (P ≤ 0.05). Data were analyzed using the Statistical Package for the Social Sciences (SPSS, IBM Corporation, New York, United States) software version 21.0.
| Results|| |
The analysis of the demographic data as shown in [Table 1]a and [Table 1]b showed that the majority of the participants were in the age group of 1–5 years (30%), with equal number of males to females and unemployed (93%). Most of the unemployed were mothers. Almost half of the population had a higher education, and the income group belonged to middle socioeconomic status.
Most of the parents did not have proper knowledge of their child's hypopigmented lesions as shown in [Table 2]. About 61.6% of the respondents thought that these lesions were contagious and feared that the patches could be vitiligo or leprosy; if so were not treatable and cause a lifelong illness.
[Table 3] shows the attitude of the parent toward the hypopigmented lesions. Most of their statements showed that they were uncertain about sending their children to social gatherings (36.9%). Almost half of the respondents disagreed that the lesions could be due to the lack of cleanliness and requires management.
The mean knowledge scores of the multipara were higher as compared to the primipara mothers (P ≤ 0.05). There was no significant difference in the attitude scores between the multipara and primipara mothers (P ≥ 0.05). Hence, parity did influence the knowledge of the mother and not her attitude toward her child's hypopigmented lesions.
The mean knowledge score increased with education, highest being in the graduate group (P < 0.05). In this study, however, we did not obtain a statistically significant association between parent's educational status and attitude scores (P > 0.05).
Attitude and knowledge of the parent toward hypopigmented lesions had a significant association with their occupation (P < 0.05). Number of parents with unfavorable attitude was seen maximum in the laborer/farmer group whereas highest was seen in parents who were professional and self-employed.
Knowledge and attitude scores were correlated with each other, and we found that as the knowledge increased the attitude score also increased as shown in [Table 4].
As regards various practices of the parents, most of the parents visited a local doctor for treatment (43%) and waited until the lesions became prominent (39%). Nearly 88% of the parents used traditional practices, such as application of oil, neem leaves, and turmeric before visiting a doctor, as shown in [Table 5]. We found incorrect practices in 53.45% of parents and the statistically significant association between the attitude scores and the various practices of the parents (P ≤ 0.05).
|Table 5: Practice: Various practices of the parent toward the hypopigmented lesions|
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| Discussion|| |
Hypopigmentary disorders are more common in children and have been studied by Pinto and Bolognia and Sori et al. in the past. In our study, the most common disorders were pityriasis alba (45%), followed by pityriasis versicolor (12%), vitiligo (11%), postinflammatory hypopigmentation (9%), Hansen's disease (4%), and miscellaneous conditions such as epidermodysplasia verruciformis, nutritional hypomelanosis, pityriasis lichenoides chronica, and idiopathic guttate hypomelanosis in 3%. Primary disorders constituted 16%. According to Pinto and Bologniaand Sori et al., the most common disorders of hypopigmentation in children were pityriasis alba, vitiligo, leprosy, nevus depigmentosus, and tinea versicolor.,
The most common primary disorder of hypopigmentation in our study was nevus achromicus (4.61%), followed by hypomelanosis of Ito (3.8%), lichen striatus (2.3%), tuberous sclerosis complex (2.3%), incontinentia pigmenti (1.5%), and oculocutaneous albinism (0.8%).
In the present study, KAPs of a parent toward hypopigmented lesions of all the examined children were assessed by a preformed questionnaire. A total of 82 (63.08%) had low, 32 (26.15%) had moderate, and 14 (10.77%) had high knowledge scores regarding the cutaneous manifestations in the child whereas 84 (64.62%) had unfavorable and 46 (35.38%) had favorable attitude toward the same.
In our study, the parity of the mother did influence their knowledge (P < 0.0001) but not their attitude (P > 0.07). A mother always learns from a previous child's experience; hence, we expected an increase in awareness with parity, but here the mother's anxiety remained the same irrespective of the child. Our findings were similar to the findings of Egube et al., who found no statistically significant association between the parity of the mothers and their knowledge and attitude.
Knowledge score of the parent increased from 11 to 17 as the education status increased from illiteracy to postgraduation. Total attitude score also showed an increase from 43 to 51 with an increase in the educational status. Knowledge but not the attitude scores had a very strong association with the education of the parent in our study (P < 0.05). This shows that education helps in breaking the pattern of using the old and traditional remedies used for the treatment of hypopigmented lesions in children.
Both attitude and knowledge showed a statistically significant rise as their occupation status rose from unemployment to a professional job (P < 0.05). As the unemployed group mostly consisted of mothers, their awareness is likely to be influenced by the knowledge imparted by elders in their family and they are likely to follow the traditional home remedies for treating their child. Association between education, occupational status, and knowledge of various medical conditions has been evaluated in various studies.
According to Cheuk et al., significant determinants of parent's knowledge in the nature of congenital heart disease were the occupation of parents and their education level; they found that professionals, administrators, and skilled workers were more aware about congenital heart disease. Mothers with less education also performed poorly in the evaluation of nutritional knowledge. Mother's education and occupation are important factors in determining child's health, and measures should be initiated for providing assistance to mothers with low education and unemployment.
In the present study, majority of the parents were not aware about their child's skin lesions, and whether the presence of skin lesions is a common occurrence in a child. The most important causes of these skin lesions were thought to be mother taking inadequate diet during pregnancy (P < 0.05), hereditary causes, mother's ill health, and cesarean section. About 62% of the parents thought that the hypopigmented lesions are contagious which enforced them to visit the hospital. Most of our parents thought that the skin lesions were vitiligo or leprosy, which strongly affected their social well-being. They assumed that these diseases are not curable and persist throughout the life. There are plenty of false beliefs which exist in the society about vitiligo and leprosy, and hence, in our study, also we found low knowledge and attitude scores toward the same.
Most of the parents agreed that lack of cleanliness and dirty clothes (66.2%) are important causative factors for skin lesions whereas 90% of the parents attributed the child's skin lesions to touch by infertile woman or widow and his/her past misdeeds. Seven of 130 parents strongly agreed that God's curse is responsible for their child's skin problem. Nearly 30.8% of the parents strongly agreed that their child's skin lesions could be transmitted through touch (P < 0.05). This signifies that such beliefs have come down in our society.
Majority of the parents thought that improving the child's diet will help in resolving his/her skin lesion. From eons, oil massage and sunbathing have been practiced in Indian households, and they are considered imperative for the well-being of a child. Hence, in our study, also we found that oil application, sun exposure, and regular bathing were considered good for treating skin lesions by the majority of the parents whereas 45.6% thought that neem leaves are curative.
Nearly 18.7% and 2.3% of the parents agreed and strongly agreed, respectively, that a boy child's skin lesions need more importance than a girl child's skin; however, 63% of the parents disagreed with it. This implies that there was no discrimination, according to sex in our study. However, an epidemiologic study carried out on healthcare-seeking behavior of children under 5 years of age by sex in developing countries confirmed the existence of discrimination against girls. In comparison to boys, observations of girls showed underrepresentation among outpatients; longer duration of the development of symptoms before first resort (leading to increased severity of symptoms); and less investment in healthcare and detrimental feeding practices.
Parents agreed that untreated skin lesions of a child could lead to complications (56.7%). This could be partly due to the belief that any skin lesion may spoil the appearance of the girl and in majority of Indian households that is considered as a stigma which could harm the girl's prospects of marriage later in life.
Mothers (92 of 130) thought that as the child grows new skin will come and only 28.3% agreed that they would get upset by their child's skin problem. Majority of the parents in our study did not consult a doctor for their child's skin lesions, and on asking, they said that they would consult a local doctor after 1 week of onset of skin lesions. The most important reason for not consulting a doctor was not noticing the lesions (46%). Only 16.7% of the parents thought that a dermatologist should be consulted for their child's skin problems. In this study, a local practitioner and pediatrician were preferred over a dermatologist for the treatment of skin lesions implying either unawareness about consulting a dermatologist for a skin problem or unavailability of the dermatologist.
Nearly 63% of the parents agreed that skin lesions cannot be treated by faith healers and 18% of parents thought that elder's advice was insufficient. This explains the importance given to the knowledge imparted by an elderly person in an Indian household. Majority of the parents thought that skin lesions in a child could disappear on their own whereas 48.9% agreed with the need for allopathic treatment.
With good knowledge and attitude, a parent is more likely to understand and interpret their child's condition and the need for a doctor's intervention to treat the condition.
| Conclusion|| |
Knowledge and attitude of a parent about hypopigmented lesions in children have not been evaluated before. It is imperative for a parent to be aware of the various changes that their child can present with so that they can make appropriate decisions regarding the treatment of their child. A good knowledge and attitude will not only liberate them from traditional beliefs and home remedies that have been used from eons in most of the Indian households but will also make them understand the magnitude of the problem their child could face if they do not seek proper advice from a doctor at the right time. This study has brought to our notice various challenges that our society is still undergoing when it comes to health-seeking behavior of parents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]