Introduction

The senses have a major  impact on the life of all organisms. They are responsible for the perception of the world around us; they help  shape experiences and affect the ability to interact with the surroundings. Generally, life is richer with sharp and well- functioning senses, and their function is often taken for granted (Ze ng & Djalilian, 2010). Hearing loss is the most common sensory defect in humans. According to the World Health Organization, over 270 million people worldwide have moderate to profound hearing loss, with one fourth of these cases beginning in childhood. In most cases, hearing loss is a multifactorial disorder caused by both genetic and environmental factors (Kim et al., 2010).

Disabling hearing loss refers to hearing loss greater than 40 decibels in the better hearing ear in adults and a hearing loss greater than 30decibels in the better hearing ear in children. The overall development of a child is determined on how healthy a child is. It determines child ability to acquire knowledge and skill, though there are various reasons, a child is to be labeled as challenged, one of the most important reason is disruptive functioning of the five basic senses (to see, to hear, to smell, touch and to taste) (Ferrite et al., 2017).

Deafness is not simply the deprivation of sound. It is rather deprivation of language. Even this view is considered to be narrow at present. It is now believed that hearing impairments of a very mild and episodic kind do much more than interfere with what children can hear of the language around them. Hearing impairment affects not only the language development of the child but also many aspects of the child's social, emotional and educational development. When there is a more sever sensor neural loss, early social interactions between the parents and the child are disrupted. These early stages are crucial to later language development (Reddy, 2010).

Permanent childhood hearing impairment is best identified through newborn hearing screening programs. Early identification and effective management of hearing loss optimizes outcomes. It was making sound audible from the first months of life through hearing aids. It is possible to harness auditory plasticity and maximize lifetime auditory potential. Infants with profound hearing loss or auditory neuropathy the option of cochlear implantation may give improved hearing for speech, typically at around 12 months of age. The onus of responsibility for using hearing aids and providing a suitable sound environment for the child falls on the parents (Marriage et al., 2017).

The National Dissemination Center for Children with Disabilities (NICHCY) explains that hearing loss falls into four subcategories: conductive, sensor neural, mixed and central. These identify the location in the body in which the hearing impairment occurs (Johnson, 2017). Hearing loss is categorized as slight, mild, moderate, severe or profound, depending on how well an individual can hear the frequencies that are commonly associated with speech (Carew et al., 2018).

Possible causes of congenital hearing loss such as infections during pregnancy (German measles, toxoplasmosis and cytomegalovirus), ototoxic medication used during pregnancy, and disorder of the brain or nervous system. Possible causes of acquired hearing loss such as untreated middle-ear infections, perforation of the eardrum, and serious injury to the head (Meiklejohn et al., 2015).

Caregivers have a primary role in communicating with and offering care to residents of long-term elder care facilities. It is therefore important that they have the necessary knowledge, attitudes and behaviors to provide quality care to residents, also the decisions taken by them depend on their knowledge and attitude. Positive attitudes and interactions between caregivers and residents have been reported to improve residents‟ quality of life and their psychological and social well-being (Sorin-Peters et al., 2010). Attitude means manner effective communication despite the loss of normal hearing (Cole & Flexer, 2015).

The community health nurse may assess for the presence of a hearing impairment and refer the client for audio logical evaluation and treatment. The nurse provides support, counseling, and advice on locating affordable resources (e.g., funding for a hearing aid that is not covered by Medicare) and securing appropriate intervention (Smith, 2013)

Significance of the study

According to the last update of the WHO, (2017) 360 million people worldwide, equaling 5% of the world‟s population, have a disabling hearing loss (328 million adults and 32 million children). Most of these people live in low- income and middle- income countries where treatments for hearing loss are more  difficult  to obtain and consanguinity increases the risk of recessive disease (Mahmoud et al., 2016 & Diwan, 2017).

In Egypt, there have been no national surveys on the prevalence of hearing  loss and deafness and there are few hospita l-based academic studies that give an idea about the magnitude of the problem (Cohen, 2014). No conclusive data or recommendations could be drawn from such limited studies in Egypt, therefore, there is a need to conduct a study on a national level (Mahmoud et al., 2016).

Aim of the study

The aim of this study was to assess of knowledge and attitudes of caregivers regarding hearing impairment among children at Minia City

Research questions

• Are there a relationship between caregivers‟ socio-demographic and their knowledge regarding hearing impairment?
• Are there a relationship between caregivers‟ knowledge and attitudes regarding hearing impairment?

Subject and Methods

Research Design:

A descriptive design was used to conduct this study.

Setting:

• This study was conducted at Alamel School for the Deaf and Hearing impairment at Minia city beside Minia University Hospital. Alamel School is a governmental school followed to the Ministry of Education. It serves all districts of Minia Governorate, student age in entering school from 6yrs to 12yrs with hearing impairment degree 70db, it contains primary school, preparatory school and secondary. It contains 75 teachers, 2 social teachers and one school Bachelor nurse

Subjects:

Selected random sample of 226 caregivers were recruited,26 of them were in pilot study and were excluded from sample .

Inclusion criteria:

• All caregiver who were cooperative and their deaf children.

Exclusion criteria:

• Caregivers' who were refuse to participate in this study.

 Data collection Tools

• The data were collected using the following tools:

First tool: Interviewing questionnaire, it was containing two parts as the following:

1. Socio demographic data of the caregivers: -

Caregiver socio demographic question; it  was used to  assess socio- demographic characteristics it consisted of question such as age, sex, education, marital status, occupation…. etc.

1. Knowledge regarding hearing impairment: Knowledge was assessed via 23 questions; it was used to assess general knowledge, symptoms, diagnosis, risk factors, complication, management, prevention and treatment.

Second tool: Attitude scale

It was used to assess caregiver's attitudes regarding children with hearing impairment by using attitude scale. It was adopted from Oketch (1982) and modified to suit the situation in Egypt. It was consist of twenty four items, used to find out attitudes of caregivers .it measures feelings, beliefs and behavior of caregivers towards children with hearing impairment.

Validity of the tool:

The tool was submitted to a jury of 5 experts in the field of community health from faculty of nursing at Minia Universities and Ain- shams Universities. Tool content validity was done to identify the degree to which tools supposed to be measured. The tools were examined for content coverage, sequence of items, clarity relevance, applicability, wording, length, format, and overall appearance. Some modification was done.

Reliability of the tool:

Reliability of the tool was performed to confirm consistency of tool. The internal consistency measured to identify the extent to which the items of the tool measured what it was intended to measure. Internal consistency of the tool was assessed with the Cronbach's alpha coefficient. Cronbach's alpha coefficient of 0.00 indicates no reliability and a coefficient of 1.00 indicates perfect reliability. However, a reliability coefficient of 0.70 is acceptable. The internal consistency was assessed and showed 84% reliability rate by using cronbach‟s Alpha test.

Ethical Consideration

Permission from ethical committee of the faculty of nursing to conducted the study. Approval from the director of Alamel School for the Deaf and Hearing impairment was taken. Oral consent was taken to be included in the study subject. Before carrying out the study the investigator was clarify the aim of the study and its expected outcomes.

Administrative design

Before starting data collection, two(2) formal letters were issued from faculty of nursing, Minia University to directorate of education in Minia governorate, then to  the director of Alamel School the Deaf and Hearing impairment to  gain the administrative approval. The aim and importance of the study were explained at first.

The Preparatory Phase:

A review of the past and  current  local  and  international  related  literature including book, articles, and magazines was done to collect data about knowledge  of hearing   impairment   including   definition,   causes,    diagnosis,    treatment,    prevention, and attitude of caregivers regarding child impairment.

Pilot Study:

The pilot study was conducted  before  starting  actual  data  collection.  It  was done on 26 participants (10%) to  investigate and ensure the feasibility, objectivity, applicability, clarity and adequacy of the study tools and to  determine possible problems in the methodological approach.  The  results  of  the  pilot  study  used  to  test  the proposed statistical and data analysis methods. The tools were completed without difficulty,  adding  support  to  the  validity  of  the  instrument.  The  pilot   study  sample was excluded from the main study sample. The necessary  correction  and  modification were carried out, also  revealed  that  the  questionnaire  takes  25  minutes  to  be  filled out by investigator.

Field Work:

Data were collected within three months from beginning of October to end of the December 2018, six sheet/day and two days/week at official school time from 8Am: 12Pm. The investigator met participants and they were interviewed in their schools at times that were convenient for them. The time spent to fill the questionnaire ranged between 25 minutes according to the needed explanation. Measures were taken to protect ethical rights of participant.

Statistical Design:

The collected data were coded, categorized, tabulated, and analyzed using the Statistical Package for the Social Science (SPSS 20.0). Data were presented using descriptive statistics in the form of percentages, frequency, mean and standard deviation. Inferential statistical tests of significance such as chi squared, Pearson correlation, and student t test were used to identify group differences and the relations among the study variables. Level of significance < 0.05 was used as the cut off value for statistical significance.

Limitation of the study

• Lack of caregivers‟ cooperative

Some caregivers‟ unwilling to participate in the study

Results

Table 1: Demographic and baseline characteristics of study participants (n=200)

Table (1) shows demographic and baseline characteristics of caregivers. The majority of the sample 95.5% are parents, less than half 45.5% of caregivers aged 30- 40years, 53% of them are first degree relatives. Regarding educat ional level, 53.5% are illiterate; also 74.5% of them are not working or housewife

Table 2: percentage distribution of caregivers’ knowledge about hearing loss (n=200)

Table (2) shows that there was lack of general knowledge regarding hearing loss. About one quarter of caregiver know that hearing loss may be partial or complete and there were degrees of impairment (26%) & (26.5%) respectively.  About  72% from them know that ear wax prevents foreign body to enter the ear.

Regarding knowledge about symptoms & signs, feeling of pain in ears was the most frequently known symptoms (83%) followed by presence of secretions (55. 5%).More than half of caregiver (58%%) did not know about screen test for early detection hearing loss. Considerable portion of caregivers know about the common risk factors of hearing loss. The majority (95.5%) of the sample know about the maternal causes during pregnancy and (67.5) know about excessive use of antibiotic &ototoxic drugs as a risk factor of hearing loss. However, more than two thirds (68.5%) of caregiver did not know about the preventive measures to guard against hearing loss. As regard available treatment of hearing loss (HL) 84% of caregiver knows medicine available to treat hearing loss in children

Table 3: Relation between knowledge score and characteristics of caregivers (n=200)

Table (3) Regarding the mean knowledge score, the table above shows that urban caregiver, University and Professional have higher significant mean knowledge scores (11.85± 3.30), (13.16 ±1.88) and (13.11 ±1.86) respectively than rural, illiterate and free workers (9.44± 2.74),( 8.84± 2.89) and (7.30± 2.17),respectively .As regard gender and marital status there are no significant differences

Figure (1) Grades of knowledge among caregivers (n=200)

Figure (1) shows that (70%) of caregivers have adequate knowledge and (30%) of them has inadequate knowledge about hearing loss

Table 4: frequency distribution of caregivers’ attitude towards children with hearing impairment (n=200)

Table 4 (Cont): frequency distribution of caregivers’ attitude towards children with hearing impairment (n=200)

Table (4) shows attitude of caregiver which include positive attitude and negative attitude towards children with hearing impairment. Regarding to positive attitude 71.5% of caregiver reported that hearing impaired child can be manageable if helped and supported, 45% of caregiver agreed that taking care of a hearing impaired child is a blessing. Also, 77% of caregiver accepts their hearing impaired child. Also 89% of caregiver not except their hearing impaired child from the duties, tasks obedience properly demanded from all other children

Domains of negative attitude the majority (98%) of caregiver in favor to strongly disagreed that hearing impairment is punishment by God, 97.5% of caregiver strongly disagreed that hearing impairment is a result of witchcraft and 80% of caregiver strongly disagreed that a hearing impaired child is not a burden.  Also  52% of caregiver agree with felt confused when they learnt that their child was hearing impaired ,60% of them disagreed about get isolated because of their hearing impaired child ,65.5% of caregiver disagreed that get bothered by my hearing impaired child's activities.

Table 5: Relation between attitude score and characteristics of caregivers (n=200)

Table(5) shown that there are statistical difference between attitude and marital status with (p=0.002), also there are no statistical difference between socio demographic characteristics (the main caregiver, age, gender, residence, educational level and occupation) and attitude

Table 6: Relation between level of knowledge and attitude score among study participants regarding children with hearing impairment (n=200)

Table (6) shows that there are no significant differences between attitude and knowledge score of both participants who have adequate & inadequate knowledge.