Umbilical Cord Care Very Important Health And Social Care Essay

Umbilical Cord Care Very Important Health And Social Care Essay Health is the most important, sought-after thing in the world by all, no matter who we are, when well- cared for their earliest years, children are more likely to survive grow up the first month is crucial importance, in terms of health care. The health of women and children is the basis of a healthy family and a healthy nation. This is particularly true of children whose healthy future depends on proper care during the first year life (UNICEF, 2002).Newborns are the blessings for today and tomorrow. The newborns body is most supersensitive, delicate, immature and susceptible from which can easily harmed if not taken care of newborn. The birth of a baby is an event a moment which creates a great joy and wonder of gods gift, a gift of god in the life of parents. From the moment of birth, many parents are loved to involve in the care of the newborn. The first care given to a neonate include placing him/her in a warm environment , suctioning the oropharynx and nose , cleaning the eyes , clamping and cutting the cord ,checking the weight , tying the identification tag and mummifying the baby. First time the mother smiles when the newborn is cry and she forgets the pain. The newborn, once separated from the mother in the process of delivery, undergoes certain fundamental changes in which he/ she leaves the sterile environment of the uterus and moves into the outside environment .This separation occurs through the severing of the umbilical cord. After birth, the cord is no longer needed, and is cut, leaving a short stump Behind on-pathogenic bacteria such as coagulate -negative staphylococci, e-coli, and streptococci, clostrium tetani may also be present on the skin and can track up the umbilical stump causing infection (ZUPAN et a l à ¢Ã¢â€š ¬Ã‚ ¦, 2005). The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in India each year, 1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under five children deaths in India. Indias NMR significantly from 69/1000 live births in 1980-50/1000 -live births in 1990 .In recent years NMR has remained static only dropping four points from 48-44/1000 live birth in 1995 and 2000. The main causes of neonatal deaths are low birth weight and infections (Indian express, 2004). One million newborn infants die every day by multiple of organisms which often enter in to the body via the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis, repeated vaginal examinations during labour, duration of rupture of membrane, unhygienic practice of delivery, delivery conducted by untrained dais, environment factors like cleanliness of the ward and caregiver with severe infection, upper respiratory infection and neonatal factors like small for gestational age, preterm newborns ,birth condition during labor like me conium stained liquor, umbilical cord infection had caused many neonatal death before aseptic technique were used .In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infection continue to occur even in developed nurseries (Zupan et al 2000). The hospitalized neonates may get infection from various sources like tube feeding, unhygienic cloth, avoidance of baby bath, using many cosmetics, etc. Environment as the umbilical cord is a means of entry for systemic infective agents that colonize the skin of the newborn. Umbilical cord is the only route of entry for microbes, because it has opening in the umbilicus, even though the cord clamp was there in the cord It is therefore essential to keep the cord clean to prevent infection and promote a normal healing until the stump dries up and falls off by giving umbilical cord care during the transition period. SIGNIFICANCE OF AND NEED FOR THE STUDY In midwifery practices, the newborn care is an important aspect and the kind of care and attention given immediately after birth and later is greatly valued. Umbilical cord care is very important since infections of the cord can be so fatal that it may even lead to the death of the neonate. Despite the importance of umbilical cord care, both traditionally and medically, there have been few randomized trials investigating the impact of different cord care regimen on rates of local or systemic infections, particularly in developing countries (Mullany et al 2003) Also, nursing studies and literature pertaining to the care of umbilical care relatively limited and the procedures adopted for umbilical cord care is varied. The present study intends to investigate the effectiveness of lukewarm water application on the umbilical cord of newborns in terms of occurrence of umbilical cord infection. Bain (1994) undertook a study to find the effect of four different cord care regimens in preterm babies. The evidence of the trail suggested that cleaning the cord with alcohol, wiping and dusting with sterzac powder resulted in less cord related infection and a shorter time for cord separation compared to any other cord care regimen. All these conclusive evidences prove that the policy of leaving umbilical cords untreated is not a safe practice. In many studies reported clean the umbilical cord with warm water compare than antiseptic solution. Antiseptic solution may cause delay in healing and form the pus (NNT 2010). Zupan and Garner (1998) carried out a study on the effectiveness of topical agents for umbilical cord care to prevent cord care infection, illness and death in newborn infants in developed countries. They have included newborns of any gestation, using any of the following interventions topical antiseptic applications. Clean with warm water, Including the newborns who were born outsides well as inside the hospital, the incidence of umbilical sepsis was2001-10 cases,2002-24case,2003- 19 cases.,2004( Jan out) -15 cases. Early onset of neonatal sepsis is clinically apparent within 72 hours of life , with an overall mortality rate of 15-50% .Late onset neonatal sepsis is usually present after 72hours of life and includes nosocomially acquired infections .The overall mortality rate of late onset sepsis is 10-20% Bobak et al (1995).The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in Indi a each ye1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to the current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under five children deaths in India. Indias NMR significantly from 69/1000 live births in 1980-50/1000 -live births in 1990 .In recent years NMR has remained static only dropping four points from 48-44/1000 live birth in 1995 and 2000.India contributes to 20% global birth and highest number of neonatal death within a country, each year, 26 million infants are born in India of these 1.2 million die during the neonatal death period before completing the first four weeks of life. Two newborns deaths occur every minute in this vast country. The current neonatal mortality rate (NMR) is around 40/1000 live birth of less than five mortality rate. Between 1995and 2000, there was only a legible decrease 4 points in NMR from 48-44/ 1000 live birth. The tapering off the rate decline is a cause of concern requiring serious pl anning and newer strategies. The main causes of neonatal deaths are low birth weight and neonatal infections; maternal infections (Indian express, 2004). One million newborn infants die every day by bacterial infection which often enters the body via the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis , repeated vaginal examinations during labour, duration of rupture of membrane, place of delivery, environment factors like cleanliness of the ward and caretaker with URI , technical factors like method of cord care , hand washing technique, and transfer of infant and neonatal factors like gestational age, birth condition during labor , umbilical cord infection had caused many neonatal death before aseptic technique were used. In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infections continue to occur even in developed nurseries (Zupan et al 2000). The traditional practices of cord care in this area include application of hot fermentation (31.5%), use of rag and latern(19.5%), use of Vaseline (9,5%), ash/charcoal(9.3%), groundnut/palm oil (8.3%), use of powder (6.5%),and red sand (3.5%), These practices are harmful because these substances are often contaminated with bacteria and spores, thus increasing the risk of infection.(Konduga local government area of born state-2005) Traditional nursing procedures are being gradually substituted by more modern Practices. As technologic advance, Nursing practices also change. As many routine procedures like predelivery perineal shave, predelivery enema are questioned, the efficacy of the antiseptic solution usage for umbilical cord care has also become a question and a study is necessitated through comparing the existing practices with the key outcomes .Therefore, the investigator strongly felt need to do study, comparing the use of antiseptic solution with lukewarm water for umbilical c ord care in order to find out the effectiveness of lukewarm water. STATEMENT OF PROBLEM An experimental study to evaluate the effectiveness of umbilical cord care using lukewarm water among newborns in selected hospital at Madurai district. OBJECTIVES To assess the umbilical cord after cord care experimental group and control group. To compare the effectiveness of cord care experimental group and control group. To find the association between experimental group with selected demographic variables To find the association between control group with selected demographic variables. HYPOTHESIS There will be significant difference between experimental group and control group after cord care. There will be significant association between experimental group with selected demographic variables. There will be significant association between control group with selected demographic variables OPERATIONAL DEFINITION Effectiveness In this study it refers to the outcome of an experimental study indentified with help of significant difference between tests among newborns. Newborn In this study it refers to the period from birth to28 days of life is called period and the infant in this period is termed as neonate or newborn baby. Umbilical cord care with lukewarm water In this study it refers to warm water with a degree of 70-97à ¢- ¦f or 26-36à ¢- ¦c to clean the umbilical cord and the cord is left dry and open. ASSUMPTION Application of lukewarm water will prevent infection of the umbilical cord. Application of lukewarm water it promotes early healing of umbilical cord. DELIMITATIONS `The study is limited to the newborn of the mothers who had LSCS. The study is confined to selected hospitals. PROJECTED OUTCOME The result of the study would help the investigator to identify the effectiveness of cord care using lukewarm water among newborns. The study will help to promote a early healing of the umbilical cord and to reduce the infections. The findings on demographic variables would help to identify the factors which affect the newborns with infection CHAPTER-II REVIEW OF LITERATURE Review of literature is an important, essential aspect of scientific treatment .It involves the systematic identification, location scrutiny and summarization of the written material that contains information on a research problem. It broadens the understanding and provides the insight necessary for the development of a broad conceptual context into which the problem fits (polit hungler, 1995). A review of related research and non- research literature was undertaken and an attempt was made to organize the materials. This includes Umbilical cord care Review on studies related to umbilical cord care using lukewarm water Review on studies related to cord care. UMBILICAL CORD CARE Umbilical cord Inspect the Umbilical cord area for the correct amount of blood vessels, two arteries and one vein. The umbilical vein is larger than the umbilical arteries. A yellow brown or green tinge to the cord indicates the me conium was released. The umbilical cord should be checked for bleeding or oozing during the early hours after birth. The clamp must be securely fastened with no skin caught and tissue injury. Pathophysiological background The umbilical cord is a tissue, which of consisting of two arteries and one vein covered by a mucoid connective tissue called Whartons jelly and a thin mucous membrane. During pregnancy, the placenta supplies all nutrients for fetal growth and development and removes waste products. Blood flowing through the cord brings nutrients and oxygen to the fetus and carries away carbon dioxide and metabolic wastes. After birth, until the placenta separates and while the cord is still pulsating, a small volume of blood may be transfused from the placenta to the newborn. The amount transfused depends on when the cord is cut and the level at which the baby is held in relation to the mother at the time of cord clamping Umbilical cord healing process The cord darkens and shrivels as it dries and falls off within 7-14 days. The cord should be dry and not have any drainage. After the cord falls, a small pink, granulating area about a quarter of an inch in diameter may remain. This should also be left clean and dry until it has healed (about 24- 48 more hours). umbcord Umbilical cord infection In umbilical cord if the ulcerous area has remained as long as one week it indicates of sign of infection. Source of infection Unhygienic environment of delivery Contaminated cord cutting instrument Infected hands of care giver or infected clothing Causative organisms Staphylococcus E-coli Clostridium tetani Signs and symptoms Swollen and moist per umbilical tissue with redness Foul smelling Serous or purulent discharge Delayed falling of umbilical cord Fever Management Umbilical cord should leave uncovered rather than application of dressing. Systemic antibiotic is given in complicated cases. Complication Jaundice Hepatitis Peritonitis Umbilical granuloma Prevention Aseptic technique and clean practices at birth. Administration of tetanus toxoid to antenatal mothers. Prognosis Prognosis depends upon the nature of infection, intiation of management and nursing care. Prevention of umbilical cord infection is more easy and important in neonates. Cord care DOs and DONTS Dos Cut the cord with a clean instrument. Tie the cord tightly with clean or sterile thread or clamp. Tie napkin or diaper below the umbilical cord. Donts Bandages are unnecessary and may delay in cord healing and introduce infection to the newborn. Alcohol cleaning may delay in healing and cause pus. Apply traditional remedies to the cord may cause infection World Health Organization,  (1999) Current standards of cord care is based on the principles of aseptic techniques. The aim of WHO to prevent the cord infections. However, the introduction of infection in neonatal care unit and well baby clinic for newborns in hospitals in the 1940s increased the risk of staphylococcal skin and cord infections by facilitating the spread of bacteria among infants in hospital. Clean the cord at birth and in the days following birth is effective in preventing cord infections and tetanus neonatrum. Clean cord care practices at birth include washing hands with clean water and soap before delivery and again before cutting and tying the cord, laying the newborn on a clean surface and cutting the cord with a sterile instrument and sterile clamp. Clean cord care in the postnatal period includes washing hands with clean water and soap before and after care and keeping the cord stump dry and exposed to air or loosely covered with clean clothes. If soiled, the cord should be washed with clean warm water (cleaning with alcohol seems to delay healing). The napkin should be folded below the umbilicus. REVIEW RELATED TO CORD CARE USING LUKEWARM WATER Kimberly Dow,(2010 ) reported news about the umbilical cord, After the umbilical cord is cut at birth, a stump of tissue remains attached to the umbilical cord. The cord will dry and shrinks. It is important to keep the umbilical cord stump and surrounding skin clean and dry. This cord care helps to prevent infection. It may also help the umbilical cord stump to fall off and the cord to heal 90% more quickly; gently clean the umbilical cord once a day. Soak a cotton swab in warm water. Squeeze out the excess water. Gently wipe around the sides of the cord and around it. Wipe away any wet, sticky, or dirty substances. Gently pat dry the area with a soft cloth. The stump usually falls off in a week or two but sometimes it takes longer. Continue to clean around the umbilical cord at least once a day until the cord has completely healed. Keeping the area Wyeth (2010) reported news about the umbilical cord. Keep the stump of the umbilical cord clean and dry until it falls off, which usually happens within a few weeks Clean the cord at each napkin change to help to dry out and to prevent entry of infection Wipe gently around the cord with a damp cotton swab .Keep the napkin folded below the navel area to keep the cord from being soaked with urine. Evidence-based clinical practice guidelines(2010) was reported about umbilical cord Sometime between five and 15 days after birth, the cord will dry up, turn black and drop off, leaving a small wound that may take a few days to heal. It must be kept clean and dry to prevent infection. Harmful bacteria that live naturally on the skin can enter in to the cord causing infection. Avoid the traditional practice of taping a coin to retract the belly button as it may encourage infection and delay the healing process. Avoid the cord stump getting urine by folding the napkin down away from it, leaving the cord exposed to the air. If the cord gets urine, wash it off using clean warm water or just water alone. When the stump falls off, it may shows of signs of little blood on the umbilical cord which is normal. In the past, cord stumps have been cleaned with antiseptic tissues or sprinkled with an antiseptic powder. Studies of the healing process have found no advantage to using antiseptics ove r simply keeping the cord clean, unless the baby is premature or in intensive care. Antiseptics also cause the cord to take longer to fall off, which causes anxiety to parents and increases the number of postnatal consultations with doctors. Satish Chandra. V.Naik etal (2009) in pune, study was to conduct impact of training of traditional birth attendants on the newborn care. The setting of the study was PHC, 45 TBAs attended 2 days training programme. Different AV- aids were used to interact the sessions by LCD, flipcharts, videoclipings. Pretest evaluation showed that there was a difference in the depth of knowledge regarding newborn care between previously trained tai and untrained tai .this difference was statistically difference p( Luke C Mullany.g.etal (2009) reported a study was to conduct cluster-randomized, community-based trial to assess the impact of three cord care regimens either A large community-based trial in rural southern Nepal conducted between 2002 and 2006 randomized babies within clusters to receive one of three cord care regimens: (1) 4.0% chlorhexidine cleansing for 7 of the first 10 days after birth or (2) soap and warm water cleansing for 7 of the first 10 days after birth, or (3) dry cord care. Overall, mortality among enrolled infants was 24% lower in the chlorhexidine group compared to dry cord care. Clinical evidence of a protective of warm water cleansing among this newborns subset was increased. Warm water cleansing reduced severe infection by 87% and mortality by 34% among those enrolled within 24 hours. Alam .M. Ali .etal (2008) in Bangladesh, the study conducted by cluster- randomized. Unstructured interview (n-60), structured interview (n=20), rating and ranking exercises (n=40),83% of umbilical cord care revolved around the bathing. Over all 40% of newborns are clean with warm water during newborn age of period only 9% of reported of infections and other application of cord care (83%) of reported of infections. Jane heiza in health and safety (2008) reported news about the umbilical cord is cut at birth, a stump of tissue remains attached umbilical cord. The stump gradually dries and shrivels until it falls off, usually between 1 and 2 weeks after birth. Gently clean umbilical the cord stump and the surrounding skin at least once a day and as needed during diaper changes or baths. Soak a cotton swab in warm water. Squeeze out the excess water. Gently wipe around the sides of the stump and the skin around it. Wipe away any wet, sticky, or dirty substances. Gently pat dry the area with a soft cloth. The stump usually falls off in a week or two but sometimes it takes longer. Continue to clean around the cord at least once a day until the cord has completely healed Medves JM, OBrien BA.etal (2008) reported study was to identify differences in time to cord separation and bacterial colonization when using alcohol or warm water to clean the cord area in healthy newborn infants. Randomized controlled trial designed was selected. 148 newborn infants who were enrolled within 3 hours of birth. Gestational age was >36.7 weeks and all infants had an Apgar score of à ¢Ã¢â‚¬ °Ã‚ ¥7 at 5 minutes. Follow up was 92%. Parents were shown a video on cord care that was developed for the study. Parents applied warm water. Cleaning with 95% alcohol did not reduce umbilical cord separation time. 95% of warm water groups had reduces the infection and early healing of cord. Khatry .C.Mullany .etal (2005) in Nepal, conducted a study on the impact of umbilical cord care. The selected sample is 15123 infants were assigned randomly selected within communities, the following 3- cord regimens: cleansing with 4.0%, cleansing with warm water. The mean separation time was shorter in warm water (4.25days) and in chlorhexidine (5.23days). Janssen PA, Dobson. R.etal (2003) reported study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus warm water. The investigator was randomly allocated 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or warm water cord care (n = 382). hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the dry care group were significantly more likely to be colonized with Escherichia coli (34.2% vs. 22.1%), coagulase-negative staphylococci (69.5% vs. 50.5%), Staphylococcus aurous (31.3% vs. 2.8%), and group B streptococci (11.7% vs. 6.0%). Community health nurses were significantly more likely to observe exudates (7.4% vs. 0.3%) and foul odor (2.9% vs. 0.7%) among infants allocated to the dry care group during the home visit. Patricia A. Barbara L .etal (2003) reported study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus warm water cord care. The sample was randomly selected 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or dry care (n = 382). The umbilical stump was colonized with {alpha}-hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the warm water group were significantly more likely to be colonized with Escherichia coli (34.2% vs. 22.1%), coagulase-negative staphylococci (69.5% vs. 50.5%), Staphylococcus aurous (31.3% vs. 2.8%), and group B streptococci (11.7% vs. 6.0%). Community health nurses were significantly more likely to observe exudates (7.4% vs. 0.3%) and foul odor (2.9% vs. 0.7%). M. Bello .j.p Ambe etal (2005) in Kondugal, the study was conducted, the survey which was cross-sectional was conducted over eighth period. Systemic random sampling method was used to select the newborns. 400 samples was selected, majority of the mothers 74.3% delivered at home have same results for other groups. Warm water 2.0% results of infection. This will go reduce in mortality and morbidity in the newborns. Andrea guala (2003) study was reported about the time of cord separation, a controlled clinical trial was carried out of healthy full- term neonates. The study was to evaluate the cord separation. According to the hospital protocol, umbilical cord cleaned with cotton soaked warm water. This was statistically difference (p Luke C Mullany.g.etal (2002 ) study was conducted to assess cord care the Within a community-based, cluster-randomized study of the effects of 4.0% chlorhexidine on omphalitis and mortality risk, we aimed to describe the distribution of times to separation and the impact of topical chlorhexidine treatment on cord-separation times infants were assigned randomly within communities in southern Nepal to receive 1 of the following 3 cord-care regimens: cleansing with 4.0% chlorhexidine, cleansing warm water, or dry cord care. In intervention clusters, field workers cleansed the cord in the home on days 1, 2, 3, 4, 6, 8, and 10 after birth. The mean separation time was shorter in dry cord care (4.24 days) and warm water (4.25 days) clusters than in chlorhexidine clusters (5.32 days; mean difference: 1.08 days). Cords of infants who received chlorhexidine were 3.6 times more likely to separate after 7 days. Facility-based birth and birth attendant hand-washing were associated with cord sepa ration after 7 days of age. REVIEW RELATED TO CORD CARE. Mullany .Katz. etal (2007) reported study was to assess to umbilical cord care trial in Nepal during (2002-2005). Newborns were evaluated in the home for signs of cord infection (pus, redness, and swelling) omphalitis was identified in 954 of 17.198 newborns (5.5%) infection risk was 29%- 62% higher in infants receiving topical application , skin-skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI) =o.43,0.95) and hand washing (RR=0.73, 95% CI 0.64, 0.84). In this community, unhygienic newborn care practices lead to continued high risk for omphalitis. Ahmadpour -kacho.z.etal (2006) reported study was to compare the effect topical application of human milk, ethyl alcohol 96% and silver sulfadiazine on umbilical cord separation time in infants. This study was undertaken place at a primary- level newborn nursery at a university teaching hospital and a private hospital. Samples are randomly selected. Mothers milk, ethyl alcohol, silver sulfadiazine ointment for group 3 were applied to the days after umbilical cord separation. It was observed a significant difference in the mean cord separation time along the four groups. No significant complications were observed in any group. Breast milk could be substituted for topical agents for umbilical cord care. Gilson .k .etal (2006) reported large urban university hospital in Turkey and participant homes after discharge Umbilical cord care consisted of one of three methods: topical application of povidine-iodine twice daily, topical application of mothers milk twice daily, or dry care (keeping the cord dry and clean).Outcome was measured in terms of the presence or absence of omphalitis and the number of days elapsed before cord separation. An ongoing questionnaire was administered by telephone every other day after the participants left the hospital. There were no significant differences between the three groups in terms of omphalitis occurrence. The cultural practice of applying human milk to the umbilical cord stump appears to have no adverse effects and is associated with shorter cord separation times than are seen with the use of antiseptics.   Kelley  Evens  .j.etal (2006)reported study was to compare alcohol versus natural drying for umbilical cord care in preterm infants and to examine its effects on bacterial colonization and cord detachment randomized to receive either umbilical cleansing with 70% isopropyl alcohol at each diaper change or natural drying. Umbilical stump cultures were performed at 12 to 24 hours, 72 hours, 7 days, and 14 days of age. A total of 109 infants were enrolled; 102 completed the study. There was significantly shorter in the natural drying group compared to the alcohol group (13.0 versus 16.0 days;  p=0.003). There were no cases of local umbilical infection in either group. It appears that natural drying is a safe and effective means of umbilical cord care in preterm infants. Chamnanvanaki.S.etal (2005) conducted a randomized controlled trial was to compare time of cord separation, among 3 regimens of cord care at home1) triple dye, 2) alcohol, 3) no antiseptic solution.185 infants were recruited. Time to cord separation in infants of group1 was significantly longer than in group 2(p=0.036) and group 3 (p=0.003).The satisfaction score of group1 were significantly lower than group 2 and group 3.Triple dye delayed time to cord separation and was less satisfactory. The authors conclude that using alcohol or dry clean could be alternative ways of cord care at home Sezer.G (2005) conducted a quasi-experimental study to comparing topical human milk, Povidine iodine, and dry care.150 sample was selected, convenience sampling used, results there was no significant difference between the three groups in terms of omphalitis occurrence in the Povidine-iodine group, cord separation occurred of 9.9days. in the dry care and topical human milk groups, cord separation occurred at a mean of 7.7 days, respectively.Therewas a statistical relationship between the groups in terms of cord separation time (f=13.24, p Shoaeib Barrawy .J.etal (2005) conducted a quasi-experimental study that aimed to compare the