Abstract

Nocturnal enuresis is a common painful disorder that carries a significant burden. This disorder has psychological, social and financial implications for families and children. Aim: This study aimed to assess the effectiveness of educational intervention on mothers of children with nocturnal enuresis. Design: A quasi-experimental research design was used before and three months and six months after the intervention. A systematic random sample of 91 mothers and their children were recruited from the Urinary Incontinence outpatient clinic at Zagazig University Hospital, Egypt. Three tools were used for data collection which include; Tool I: A. Demographic characteristics of mothers and their children. B. Frequency of bedwetting of the children with nocturnal enuresis, C. Mothers' knowledge regarding nocturnal enuresis. Tool II: Mothers’ reported practices regarding nocturnal enuresis checklist. Tool III: Mothers attitudes toward nocturnal enuresis. Results: 87.9% of studied children had bedwetting every night per week before intervention, this percentage decreased to 60.4% and 19.8% post three months and six months respectively. There were statistically significant differences in mothers’ knowledge, practices and attitudes post intervention regarding nocturnal enuresis compared to before intervention. Conclusion: The implementation of the nocturnal enuresis health education showed a significant improvement in mothers ’knowledge, practices and attitudes. In addition, the clinical features among children with nocturnal enuresis decreased significantly after 3 and 6 months. Recommendations: Developing a health education program for mothers of children with urinary incontinence to update their knowledge and practices on advanced treatment strategies.

1. Introduction

Nocturnal enuresis (NE) is the most common urinary tract disease in children. It is defined as bedwetting or intermittent enuresis that occurs at least twice a week for three consecutive months with no history of a congenital urogenital defect or an acquired defect after the child completes 5 years of age. The NE can be a nuisance for both the child and the concerned parents ¹.

Nocturnal enuresis is classified into primary enuresis and secondary enuresis according to the time of onset, and primary incontinence when bladder control is not achieved from birth, while secondary enuresis occurs after children have had control of the bladder for at least six months. Moreover, they can be classified according to symptoms into non-monosymptomatic symptoms associated with daytime urinary symptoms and mono symptoms without symptoms of daytime urine ².

NE is a frequent condition, occurring in approximately 10% of children aged 6-7 years who suffer from urinary incontinence worldwide ³. In Egypt, there is no current document regarding the true incidence of urinary incontinence among children. Though, according to a study by Rady et al. ⁴, the prevalence of nocturnal enuresis in Egyptian children (6-12 years) was estimated to be between 10.4% and 15.7%. A previous Egyptian study showed that the prevalence was 14.5% with higher frequency among boys than girls (16.5% versus 12.6% in contrast) ⁵, while primary incontinence was prevalent at 11.5% and 3.2% in cases of bedwetting. Secondary enuresis ⁶. A recent study conducted at Mansoura University Children's Hospital found that 76.1% of children suffer from primary nocturnal enuresis ⁷.

The most common intervention to treat nocturnal enuresis is physical care, such as limiting the child's intake of water before going to bed, and waking the child during the night to use the bathroom. As well, advising the caregivers on diet and toileting patterns for their children suffering from NE. Furthermore important strategies as behavioural modification and psychological care involve caregivers motivation for their children's commitment in voiding, rewarding the child dry nights and recording his progress on charts, star charts and other reward systems can be used as positive reinforcement to encourage a desired behavior, maintenance of privacy to the child during voiding, clear explanation about the child's condition with considering the age and level of understanding. Moreover, avoidance of child's punishment for bedwetting, sharing experience with other families having children with the same diagnosis will give a psychological support for caregivers and their children ^{8, 9}.

Mothers of children with NE as the primary caregivers of their children must have sufficient knowledge and should be responsible for helping the child learn the skill of being dry. In addition, the child should be included in the treatment plan; This helps increase the child's motivation to become dry and cope with stress. The community health nurse plays a vital role as a primary health care provider that plays a major role in improving mothers' knowledge, attitudes and practices regarding nocturnal enuresis ⁷.

The community health nurse plays an important role as primary health care providers by improving maternal performance regarding nocturnal enuresis. It is essential to determine maternal performance and design and implement a valid and effective educational package to help mothers adhere to the management plan according to recommended treatment guidelines ⁷. Hence, this study is designed to provide an educational intervention for mothers to enhance their knowledge, attitudes and practices towards their children with nocturnal enuresis.

This study aimed to assess the effectiveness of educational intervention on mothers of children with nocturnal enuresis.

• The educational program will have a positive effect on mothers' knowledge, practices, and attitudes regarding their children with nocturnal enuresis.

• Frequency of bedwetting among the enuretic children after application of educational learning package will decrease.

2. Subjects and Methods

A quasi experimental was carried out to achieve the aim of the study.

The study was conducted at the Urinary Incontinence Out-patient Clinic in Zagazig University Hospital.

Systematic random sample was used in this study. It included 91 mothers and their children 91 with nocturnal enuresis at the pre-mentioned setting. They were selected to be compatible with the inclusion criteria: Children aged 5 to 15 of sexes, children diagnosed with non-organic nocturnal enuresis, and mothers and children willing to participate in the study.

Systematic random sample of 91 mothers and their children 91 with nocturnal enuresis at the urinary incontinence Out-patient Clinic in Zagazig University Hospital

The calculation of sample size was done based on power analysis.

The sample size was calculated based on the following equation:

• Type I error with significant level (α) = 0.5.

• Type II error by power test (1-B) = 95% ⁷.

Three tools were designed and used in this study after reviewing and guiding previous relevant studies by Osman et al. ¹⁰; Salem et al. ¹¹.

Tool (I): Composed of four parts:

Part (I):

Demographic characteristics of mothers of children with NE It was used to collect information as regards mother’s age, marital status, educational level, work status, residence, and family income.

Part (II):

Demographic characteristics of children with nocturnal enuresis. It was used to collect information as regards child’s age, child gender, order, number of siblings, positive family history of enuresis, academic class, types of nocturnal enuresis, and outcome of academic level. As well, covering questions about health status development as general health status, movement, language and social development.

Part (III):

Frequency bedwetting of the children with nocturnal enuresis. It was classified into every night, more than once a week and once a week pre, post three months and post six months after intervention.

Part (IV):

Mothers knowledge regarding structured nocturnal enuresis interview questionnaire. It was used to determine a mother's knowledge of nocturnal enuresis before, three months, and six months later. It is classified into eight categories covering 42 questions related to: urinary tract anatomy (3 Marks), definition of enuresis (2 Marks), types (2 Marks), risk factors (6 Marks), clinical features (7 Marks), diagnostic procedures (3 Marks), complications (4 Marks), and management of enuresis (15 Marks).

Scoring system:

The knowledge score level was categorized into three categories: poor grades were <50% of total scores, fair scores were 50% to 65% and good grades were> 65% of total scores.

Tool (II):

Mother’s practices have been reported regarding nocturnal enuresis checklist. It was used to evaluate mother’s regarding nocturnal enuresis before, three months, and six months after the intervention. This checklist is categorized into four categories; First, physical care composed of 10 questions as avoiding water intake for the child after dinner, awaking up the child once/or twice at night to urinate, lifting up the children during the night kindly, avoiding taking caffeine drinks for the child at night, caring for child to go to bathroom before bedtime, cleaning child perineal area after bedwetting, giving the child adequate fluids during the day time, caring for child to go to bathroom frequently during the daytime, lightening the distance between the child's room to the bathroom, and making the child 's room close to the bathroom as possible. Second, psychological care covering 5 questions as providing privacy to the child during voiding, explaining the child‘s condition according to his/her age, sharing experience with other families having the same problem, keeping the disease confidentiality from others, and avoiding of criticism the child‘s condition /or behavior. Third, therapeutic therapy covering 2 questions as giving therapy at regular time, and giving the prescribed dose of the therapy. Finally, rewarding for behavior modification composed of 2 questions as provide incentive for independent toileting, and rewarding the child for dry nights.

Scoring system:

One score is awarded for each item. Overall scores for each item were calculated by adding up the item's scores (possible range was 0--19 marks). The level of reported practice was categorized as satisfactory 65% and unsatisfactory level <65% of the overall score.

Tool III: It consisted of two parts:

Part A:

This tool was intended to identify mother’s attitudes toward nocturnal enuresis; it was adapted by Mohamed et al. ⁷. The mothers were asked to respond by any of 3 options: “Agree,” “Disagree,” or “Not sure,” for each statement.

Scoring system:

A scoring system was used to measure maternal attitudes. Three scores were assigned to agree response, two scores for the neutral response and one scores for the disagree response. Attitude level was rated as positive attitude ≥65% and negative attitude <65% of total score.

Part B: Nursing educational learning package sessions about nocturnal enuresis:

The duration of each session was 20-25 minutes in the pre-detected preparation. The researchers developed an intervention in the form of an educational illustrated booklet for responding to the needs of the mothers in following the educational sessions and to serve as a reference at hospital. The intervention was implemented at the Urinary Incontinence Out-patient Clinic in Zagazig University Hospital.

3. Field work:

Data collection took a period of 12 months, from January 2020 to January 2021; the implementation of the program in ten sessions for mothers of each session was 20-25 minutes at the Urinary Incontinence Out-patient Clinic in Zagazig University Hospitals. The study was accomplished according to the following steps

Administrative and ethical considerations:

Informed consent was obtained after explaining the purpose of the study to the mothers and their children included in the study. They have had the opportunity to decline to participate. They were advised that they could withdraw at any stage of the research without giving any reason. In addition, they were assured that the information would be treated confidentially and would only be used for the benefit of children and for research purposes.

2. Tools development:

The tools were developed by researchers based on a review of relevant recent literature.

3. Tools Validity:

All study tools were examined for validity by a jury consisting of five experts in the field of community health and pediatric nursing from the College of Nursing and the Department of Urology at the College of Medicine. Zagazig University and the proposed amendments have been made.

4. Tools Reliability:

The reliability test was performed with Cronbach's alpha and the tools seemed to be reliable: Too I: Knowledge Scale (r = 0.85), Tool II: Mothers’ practices reported on nocturnal urinary incontinence (r = 0.99), and Tool III: Mothers’ attitudes toward urinary incontinence nocturnal (p = 0.74).

5. Pilot study:

Prior to conducting the main study, a pilot study was conducted on 10 mothers and their children who were subsequently excluded from the main study sample. The purpose of the pilot study was to test questions about any ambiguity and usefulness of the tools. It also helped researchers estimate the time required to fill out the forms.

Program:

The educational intervention was developed and implemented according to the following phases: -

I. Assessment phase (Pre-intervention phase):

Once permission was granted to proceed with the study, the researchers visited the study setting and explained the questionnaire. The researchers usually started by introducing themselves to the mothers, and explaining the aim and nature of study briefly, and reassured them that information obtained is strictly confidential and would not be used for any purposes other than research.

II. Planning phase:

Based on the literature review, sample characteristics, and results obtained from the assessment phase, researchers designed the content of the intervention sessions. The educational booklet was prepared by researchers and its content was validated and then distributed to mothers for use as a guide for self-learning at home. The educational intervention was developed by researchers for the study group according to the following steps: -

a. Setting the program objectives

General objective:

To assess the effectiveness of health education intervention for mothers of children with nocturnal enuresis.

Specific objectives:

To improve the knowledge, practices and attitudes as a positive effect on mothers' performance regarding their children with nocturnal enuresis. Additionally, to decrease the frequency of bedwetting among the enuretic children after application of the educational learning package.

b. Preparation of the content

The nocturnal enuresis educational intervention content has been designed by researchers to cover all pre-set goals. Developed based on relevant recent literature review, results of pre- assessment as well as characteristics of mothers and their children.

III. Implementation phase:

All mothers and their children were subject to the health education intervention. The message was delivered using a question-and-answer approach to ensure all mothers and their children are involved. Sessions focused on the anatomy of the urinary system, the definition of urinary incontinence, its types, risk factors, clinical features, diagnostic measures, complications, and management of enuresis. This was supported through a PowerPoint presentation.

Evaluation phase:

Post three months and six months the program implementation program, was carried out at the Outpatient at Zagazig University Hospital to assess the effectiveness of the educational program on the mothers having children with nocturnal enuresis. The same data collection tools were used for this purpose.

Statistical Design:

The collected data analyzed by statistical analysis were completed using the Statistical Package for Social Sciences (SPSS), version 20. Descriptive statistical methods were used including the frequency distribution as arithmetic mean, standard deviation of continuous variables, and percentages of categorical variables. Analytical statistics such as Chi-square test and Monte Carlo test were used for comparison between groups. In order to compare average scores before application, 3 months after application, and after 6 months, F (Repetitive Scales - ANOVA) was used for the normally distributed variables. The p-value ≤0.05 was considered significant.

3. Results

Table 1 reveals that, the mean age of the studied mothers was 32.1868 ± 6.79037 years, 92.3% of them were housewives. As well, 65.9% had diploma degree, while all of them (100%) were married. Concerning residence, 84.6% of mothers were living in rural areas, and 46.2% had sufficient income.

Table 2: It is obvious that the mean age of the studied children was 8.2088 ± 2.88489, as for genders 52.7% of them were boys, and 68.1% of them were in primary school, it can be revealed that 59.3% of studied children had 1-3 siblings. The highest birth order was fourth birth (35.2%) followed by first birth (31.9%). This table also shows that 90.1% had positive family history of enuresis.

Table 3 shows distribution of studied children with nocturnal enuresis according to their development, 62.6% of studied children are having good level of academic outcome and 97.8% of them have normal health status. As well, their movement, language and social development represent 95.6%, 91.2% and 79.1% respectively.

Figure 1 illustrates the types of nocturnal enuresis, 96.7% of studied children are suffering from primary enuresis.

Table 4 describes the distribution of studied children with nocturnal enuresis related to frequency of bed wetting per week, 87.9% had bed wetting every night per week before implementation of the educational program, this percentage decreased to 60.4% and 19.8% post three months and post six months respectively. On the other hand, 30.8% of studied children had bed wetting once a week before intervention, the previous percentage decreased to 15.4% and 0.0% post three months and post six months intervention.

Table 5 reveals that the total mean scores of knowledge were 1.9341±6.86991 related to nocturnal enuresis before intervention. However, post three months and post six months of implementation of educational program were of 38.5495±8.94584 and 34.1538±12.64816 respectively. Highly significant differences were observed between pre, post three months and post six months intervention (F= 509.843, at P 0.001).

Figure 2 illustrates that 96.7% of the mothers mentioned poor total score of knowledge related to nocturnal enuresis before intervention. However, post three months and post six months of implementation of educational program 92.3% and 74.7% of them mentioned good total score of knowledge respectively.

Table 6 shows that total means scores of practices related to nocturnal enuresis before intervention were 0.7143±2.7009. However, post-three months of educational program implementation were 11.3626±6.37271 improved to 14.6044±6.044 post six months intervention. There were highly statistically significant differences between pre, post three months and post six months intervention (F= 264.502, at P <0.001).

Figure 3 illustrates that 97.8% of the mothers showed an unsatisfactory total score of practices related to nocturnal enuresis before intervention. While, post-three months of educational program implementation 45.1% of them showed a satisfactory level of practices compared to 69.2% post six months intervention.

Figure 4 illustrates that 38.5% of the studied mothers had negative attitude score before intervention. This percentage decreased to 7.7% and 5.5% in post three months and post six months after intervention.

Figure 5 illustrates that the mothers' total positive attitudes means scores regarding nocturnal enuresis were 33.3626±5.54079 before intervention of educational program. However, post three months intervention, it reached to 48.0110±6.09826 compared to 48.9011±5.16625 post six months of implementation program.

Regarding correlations among personal characteristics, knowledge, practices and attitudes before intervention, Table 7: reveals negative correlations among mothers’ work status, and knowledge and practices of enuresis, which mean working mothers are more knowledgeable and skillful comparing with housewives. Meanwhile, there were no significant correlations between other personal characteristics, and knowledge practices and attitudes where P => 0.05.

Regarding correlation among personal characteristics, and knowledge, practices and attitudes after intervention, Table 8 describes that a negative correlation between education and knowledge of enuresis, as well as a negative correlation results between child’s age and attitude of enuresis. Additionally, it shows that a strongly positive correlations between child’s age and practices of enuresis which means that older child had better practices of enuresis where P = <0.01 and a positive correlations exists between family income and attitudes toward enuresis where P = <0.05. Meanwhile it shows that there were no significant correlations between other variables where P = > 0.05.

4. Discussion

Educating a mother to manage a child's incontinence is a process of teaching parents about behavioral therapy strategies such as positive reinforcement that can be initiated by setting up a diary or chart to monitor progress and creating a system to reward the child for every night that they do dry. Additionally, dry bed training may be part of a comprehensive enuresis treatment program. This treatment includes an age-appropriate explanation of how the brain and bladder communicate, demystifying enuresis by educating the child and family, teaching relaxation techniques, and having the child practice waking-up photography to urinate in the toilet or staying dry all night. Dry bed training involves waking the child on a gradual schedule at decreasing intervals over several nights ¹² According to the mothers' demographic characteristics, the results of the current study revealed that the about two thirds of the mothers’ age ranged between twenty five to less than thirty five years, as well, most of them were housewives, about two thirds were secondary education, and all of them were married. Moreover, majority of mothers resided in rural areas. This might be explained by the prevalence of enuresis which occurs in families where mothers have a lower level of education. A similar finding was demonstrated in the study of Elbahnasawy and Elnagar ¹³, which proved that a higher relative risk of enuresis in children was observed in families with a mother with a relatively lower education and resided in rural areas.

The present study findings were in agreement with those of a study carried out by Osman et al. ¹⁰, in El Fayoum University Hospital Egypt, which aimed to provide an educational program for mothers to enhance their knowledge, attitudes and practices toward their children with nocturnal enuresis, they found that for 86% of mothers age was in the group 30 or more years, also 68% of the mothers had intermediate education. Additionally, a recent study carried out by Mohamed et al. ⁷, in Mansoura University Children's Hospital, Egypt, they found that majority of mothers were housewives. This result goes on line with that of Salem et al. ¹¹, in Zarka District, Damietta Governorate, Egypt, who reported that the highest percentages of mothers were housewives and reside in a rural area. On the same context, El Bahnasawy and Elnagar ¹³, in Egypt, found a higher relative risk of enuresis in children of a mothers with relatively lower education and resided in rural areas.

Regarding a family history of urinary incontinence, the results of the current study revealed that most of the children had a positive family history of enuresis. This result may be attributed to the presence of genetic factors in the occurrence of nocturnal enuresis and intrusive marriage in Sharkia Governorate. This finding is in agreement with that of the study carried out by Osman et al. ¹⁰, on El Fayoum University Hospital Egypt, which reported that 70% of the studied subjects had positive family history. The result of the current study is also consistent with those Aljefri et al. ¹⁴., in Saudi Arabia; and Ismail et al. ⁶, in Egypt who found that enuresis commonly runs in families and its incidence among children increases when the mothers have apositive history of bed wetting.

Regarding the gender of children, a higher proportion of boys than girls were observed among children with urinary incontinence under study. This result may be attributed to the culture of mothers of enuretic children who reside in rural areas and who care more about boys than girls, and the difference in the anatomical structure of the urinary system between boys and girls. These study results are almost in line with those of the study by Ali et al. ¹⁵ in southeastern Turkey; which showed that nocturnal enuresis is more prevalent and prolonged in boys than in girls. Also, this result is consistent with the results of the Alsharani et al. ¹⁶ in Riyadh City, KSA who mentioned that the number of boys exceeds the number of girls, and this was explained by worries of parents for their boys. Moreover, Mohamed et al. ⁷ did the study in Mansoura University Children's Hospital, Egypt, nocturnal enuresis was found to be more prevalent and prolonged in boys than in girls.

Concerning, the age of children in the current study sample almost three fifths was at the age of 5 to less than 10 years. This result may be due to mothers' insufficient experience and knowledge about correct toilet use and a lack of awareness about how to treat their children. Also, incontinence rates decline gradually with age. This finding is similar to that of a study conducted in Egypt, by Elsayed et al. ¹⁷ who found that the highest incidence of enuresis in a sample of Egyptian children was among children in the age 8-10 years.

The current study revealed that almost one third of children ranked between each first, second and fourth in birth order. Obviously, the mothers of those children having many children with additional loads in providing care to the enuretic child As well as other siblings, which increases the burden of mothers in addition to the parents' lack of awareness of the psychological factors associated with the occurrence of urinary incontinence, also the repercussions of families with a lot of kids were found not only on the economic conditions, but also on family dynamics. This finding is in consistence with that of a study done in El Fayoum University Hospital, Egypt, by Osman et al. ¹⁰, who found that children ranked between first and second or higher in birth order. The Yemeni and Iranian studies showed that the higher frequencies of enuresis were observed in children of lower socioeconomic status especially in cases of large crowded families ^{18, 19}.

Regarding the prevalence of nocturnal enuresis in present study the results revealed that most of children with nocturnal enuresis have primary nocturnal enuresis type. This finding indicates a great need for health education in structured interventions related to nocturnal enuresis. This findings was in agreement with that of Mohammed et al. ⁵ in Qaluobia Governorate Egypt, who found that 67.1% was primary nocturnal enuresis. As well, on other more recent study conducted at Mansoura University Children's Hospital, Egypt, found that 76.1% of the children suffered from primary nocturnal enuresis ⁷.

A marked decrease in the frequency of bedwetting is observed between pre, post three months and post six months of program application after the implementation of the health education intervention. This might be due to because the results provided evidence that was actually explained by the improvement in mothers’ performance after implementing the intervention, which in turn led to positive health conditions among the studied children. Moreover, mothers were required to adhere to the treatment procedures recommended by the health education letter provided. This result was also consistent with a study by Osman et al. ¹⁰, at Fayoum University Hospital Egypt, they found that 42.04% of the study children suffered bedwetting every night before the intervention was applied. However, the recurrence rate decreased to 32.95% and 20.45% after three months and after six months of application correspondingly.

Based on the results of the current study, the majority of mothers demonstrated a poor level of knowledge regarding prior intervention for nocturnal enuresis. This may be due to the lack of health education provided to them by qualified healthcare professionals. However, the results of the present study reported statistically significant improvements between before, after, and after three months and after six months (P- <0.001), in particular, for anatomy, definition, clinical features, complications, and management. Overall, the minority of mothers who were good pre intervention improved to most of them after three months, and reduced after six months to nearly three quarters. These consistent results were demonstrated by examining four evidences study. Firstly, Moulhee ²⁰, a study conducted in the pediatric department hospitals in Al Hudaydah aimed to evaluate the effect of the educational program on parents’ knowledge of children with enuretic, and found that the educational program had a positive effect on parent’s knowledge. Second: An Egyptian study conducted by Elsayed ²¹, at Menoufia University in Egypt, which aimed to identify the effect of the educational program on self-esteem of children with nocturnal enuresis and their mothers ’anxiety and depression, which stated that the educational program had a positive effect on parents’ knowledge. Third, Osman et al. ¹⁰, at Fayoum University Hospital, Egypt, they revealed that mothers' levels of knowledge of urinary incontinence increased after implementing the educational program, with statistically significant differences between pre-post implementation. Fourth, an innovative study in selected urban slums conducted by Paste ²², indicated that the educational program had a positive effect on mothers' knowledge of nocturnal urinary incontinence. Also, the results of this study were in line with those of Moulhee ²⁰, who reported that the structured educational program significantly reduced the relapse rates of nocturnal enuresis, and achieved perfect and excellent results in their study conducted in Yemen.

According to mothers' practices regarding their children with enuresis, there were statistically significant differences between pre, post three months and post six months of program application of health education intervention for mothers under study regarding nocturnal enuresis. Overall, all domains of practices as physical care, psychological care, therapeutic therapy, and rewarding for behavior modification, before intervention representing minorities of the mothers who have satisfactory practices which increased at post three months and are improved at more post six months of program application. These findings are in agreement with those of study done in Mansoura University Children's Hospital, Egypt, by Mohamed et al. ⁷, which found that pre-application results showed with a mean of 3.12±2.35, however, post-three months of intervention, 95.5% of them showed a satisfactory level of practices with a mean of 13.7±1.29 marks compared to 97.7% with a mean of (14.1±1.16 marks) post six months of intervention. In the same context, a study had done in Alexandria, Egypt, by Essawy et al. ⁹, who found that, were statistically significant differences between pre, post intervention of application. These results are consistent with those of several studies as the study by Senbanjo et al. ²³, which aimed to assess the micturitional dryness and attitude of parents towards enuresis in children attending outpatient unit of a tertiary hospital in Abeokuta. In this respect Schlomer et al. ²⁴, in Southwest Nigeria carried out a study aimed to determine parental beliefs about nocturnal enuresis, causes, treatments, and whether a provider can help. As well, Fagundes, et al. ²⁵, conducted a study which aimed to evaluate the impact of a multidisciplinary evaluation in pediatric patients with nocturnal monosymptomatic enuresis and Caldwell et al. ²⁶, which aimed to describe simple behavioural interventions for nocturnal enuresis in children, reported that, most parents treat their children by home behavioral therapy including limited fluids intake prior to sleep, reward child for dry nights, and regularly wake the children during night.

Additionally, these results come in parallel with studies done by Mohammed et al. ⁵, which aimed to determine the frequency and risk factors of nocturnal enuresis among school children in Qaluobia Governorate, Egypt, they found that there was a high significant difference among various treatment strategies with the highest applicable one was medications and the physical therapy. These findings were in agreement with those of Osman et al. ¹⁰, in El Fayoum University Hospital and El Fayoum General Hospital, Egypt, who found that mothers' practices have dramatically improved after the educational program implementation with statistically significant differences between pre-post implementation.

When looking at mothers ’attitudes towards their children with urinary incontinence, the results of the current study showed that there were statistically significant differences between the three months before, after and six months after the program was implemented. Researchers attribute this finding to gain knowledge and improving observed practices. Nocturnal enuresis health education sessions provided mothers with the necessary information on nocturnal enuresis. This finding was supported by that of Mohamed et al. ⁷, in Mansoura University Children's Hospital, Egypt, who found that there are statistically significant differences between pre, post three months and post six months of attitudes after program intervention. In the same way Cederblad et al. ¹², who carried out a study that emphasized positive attitudes in particuler on toilet training schedule, which is a simplified method of treatment, reducing time, costs and extending the availability of effective treatment to families with limited social and financial resources. A similar study was performed by Fagundes et al. ²⁵, that mothers have an encouraging attitude towards children with nocturnal enuresis; they expressed words of comfort, and praised their children for their dehydration. Also, a study by Osman et al. ¹⁰, supports the findings of the present study.

In the current study, there were statistically significant relations between mothers' level of knowledge about enuresis, attitudes and practices. As well, strongly positive correlations between child’s age and practices of enuresis which means that older children had better practices of enuresis and strongly positive correlation between residence and practice of enuresis. This means that mothers with satisfactory knowledge scores easily practice the gained information more effectively, and their children experienced less bed wetting rate per week and per night. Moreover, mothers who live in urban areas had better practice of enuresis. These results were in accordance with that of similar study done in Nigeria, which reported that mothers with satisfactory knowledge scores their children have experienced more bed dry rate per week and per night ²³. These findings were in agreement with those of Osman et al. ¹⁰, in El Fayoum University Hospital and El Fayoum General Hospital, who found that there were statistically significant relations between mothers' level of knowledge about enuresis, attitudes and practices.

5. Conclusion

Based on the results of the current study, it can be concluded that the two research hypotheses were justified and the educational intervention was effective in reducing bedwetting among the enuretic children, by enhancing their mothers' level of knowledge, practices and attitudes that reflected positively on their children suffering from nocturnal enuresis.

6. Recommendations

Based on the results of the current study, the following recommendations are suggested.

- Establish a health education program for mothers of children with urinary incontinence to update their knowledge and practices on advanced treatment strategies.

- Early counseling and investigation should be directed at mothers with regard to toilet training, especially for families with a positive history of incontinence among their children.

- In-service training programs should be conducted for health care workers, especially nurses, to implement a health education in the care of mothers and their children suffering from nocturnal enuresis.

References