https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article Caregiver’s Knowledge regarding Homecare Management of Spastic Cerebral Palsy Children Under 12 Years Old in Rapareen Province ABSTRACT INTRODUCTION Cerebral Palsy (CP) is an umbrella term that “describes a collection of movement Background and objectives: Spasticity, sometimes called hypertonia, makes movement difficult or even impossible. Spastic children with Cerebral Palsy face many health problems that need significant attention at home. This study aimed to assess caregivers’ knowledge about home care management of spastic CP children in the Rapareen Region. Methods: A quantitative, descriptive cross-sectional study was carried out in the Rapareen Region of Sulaimani city. The period started from October 1st, 2020, to October 1st, 2021. Purposive (non-probability) sampling techniques of 115 caregivers, who attend rehabilitation centers in Ranya, Chwarqwrne, and Qaladeze in Rapareen province, were respectively recruited to the study. The investigators prepared a ques- tionnaire format after reviewing related literature. Direct interview (face to face) and a home visit was conducted to collect the data. Descriptive statistics SPSS version 25 was used, and statistics of frequencies, percentages, and inferential statistical analysis of Chi-square test and regression were used. Results: The vast majority (98.3%) of the primary caregivers were mothers of spastic CP children. Almost all (94.8) of the caregivers were married. The majority (88.7%) of caregivers were housewives. Less than half (48.7%) of the sample were between 31 to 40 years. More than three quarter (67%) of the sample were male children and more than half (65.2%) were School-age children with Spastic Cerebral Palsy. There was a statistically highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at a p-value of 0.020 and 0.003 respectively. Factors significantly associated with caregivers’ knowledge of homecare of spastic CP children include the level of education of caregiver, age of caregiver, and height of spastic Cerebral Palsy children. Conclusion: The findings of the present study showed that level of education, age of caregiver, and residency areas are associated with caregiver’s knowledge regarding homecare of spastic Cerebral Palsy children. Mothers are required educational programs to boost knowledge regarding homecare management of spastic CP children. Keywords: Spastic CP children; Caregiver; Internship and residency; Homecare services. Farida Salim Faqi-Rashid; Department of Pediatrics, College of Nursing, Sulaimania University, Sulaimania, Kurdistan region, Iraq. (Correspondence: faridasaleem20@hotmail.com) Shukir Saleem Hasan; Department of Nursing, College of Nursing, Hawler Medical University and Tishk International University, Erbil, Kurdistan region, Iraq. 61 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 29/11/2021 Accepted: 22/02/2022 Published: 30/11/2022 mailto:faridasaleem20@hotmail.com, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article and posture problems that cause activity restrictions and are related to nonprogres- sive disruptions in the developing fetus or infant’s brain” [1-2,8,11,17]. Motor disor- ders may be accompanied by cognition, communication, perception, and epilepsy disorders [1-2]. Cerebral palsy is one of the chronic diseases that has become a signifi- cant health concern worldwide [3]. Howev- er, the physical characteristics of CP in- clude neuromotor disorders and the pres- ence of pain [4]. CP manifests itself rela- tively early in childhood, despite being clas- sified as a nonprogressive condition [4]. The brain damage induced by CP has no cure, and it is neither continuous nor pro- gressive [6]. Clinical signs and symptoms vary depending on which part of the cen- tral nervous system (CNS) is damaged and range from average intelligence and well- functioning moderate monoplegia to se- vere spastic quadriplegia and mental retar- dation [5]. It affects about 2 out of every 1000 live births, making it the most preva- lent motor disability in children [7]. Injury to the developing brain has a variety of causes and consequences [5]. Agenesis, schizencephaly, hemimegaloencephaly, pachygyria, polymicrogyria, lissencephaly, and other migration and embryogenetic abnormalities are caused by regional ana- tomical deformities with motor deficien- cies [9]. Congenital, genetic, inflammatory, anoxic, traumatic, toxic, and metabolic var- iables all have the potential to develop CP [8]. One of the predictors of a better prog- nosis is the early detection of neurological impairment and its progression to a clinical manifestation of CP [9]. The affected limbs [hemiparesis, diplegia, and quadriplegia]; the motor impairment of the global motor functions (GMFCS I to V); and the anatomi- cal distribution, unilateral (monoprotic, hemiparetic) and bilateral (diparetic, triparetic, quadriparetic) can all be used to classify patients [10]. The difficulties in managing CP range from one sufferer to the next. The issues may be severe soon after birth in some people, while they are not apparent until early infancy in others [6]. Incontinence, constipation, tooth de- cay, skin sores, and chest infection are all symptoms of intellectual impairment, epi- lepsy, failure to thrive, vision and hearing problems, impaired touch and pain sensa- tion, hip dislocation, and spine curvature (scoliosis) there are the signs and symp- toms CP [11]. Medical treatment for sei- zures, spasticity, reflux, constipation and depression should be thoroughly re- searched, especially in terms of side effects and any combinations [5]. Following a di- agnosis, a detailed management regimen should be implemented. Different compo- nents of the condition are managed by parents, doctors, speech therapists, occu- pational therapists, and other medical practitioners or specialists [6]. Nursing management of children with CP is an op- tion and depends on ambulatory status. Thus, the family of a child with CP be- comes crucial and will be very much neces- sary to guide the child’s development in a favorable environment and to care for and maintain their health status [10]. The pri- mary medical care at home should include proactive care coordination, including monitoring, interpreting, and arranging with specialists and specialty teams, as well as communicating with therapeutic, educational, family support, and other community resources [12]. According to an official census in Rapareen Province Gen- eral Health Directorate of Rapareen, 160 Spastic CP cases have been registered and are receiving medical care and physiother- apy care in rehabilitation centers (GHDR, 2020). When assessing therapy choices for children with CP, their caregivers prioritize motor development. Physiotherapy inter- ventions are administered over the lifespan to improve motor capacities, 62 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article participate in the study. Caregivers who did not suffer from chronic diseases (diabetes, hypertension, asthma, etc.), took care of spastic CP children under 12 years old, spoke fluently Kurdish language, and did not complain of mental and psy- chological problems were included. Care- givers of children with other types of CP were excluded from the study. The re- searchers constructed a questionnaire con- sisting of two parts: part one assessed the socio-demographical characteristics of caregivers and CP children, such as the age of the caregiver, marital status, occupa- tion, level of education, type of family, economic status, and type of delivery, and part two the second consisted of 20 ques- tions related to caregiver’s knowledge re- garding spastic CP. A three-point scale was used (0 for bad knowledge, 1 for fair knowledge, and 2 for good knowledge) and overall knowledge was categorized into three groups: bad knowledge (0-6), fair knowledge (7-13), and good knowledge (14-20). Data were gathered through face-to-face interviews during the home visits and the investigator filled out the questionnaire tool. Nineteen experts in related fields validated the questionnaire, and the pilot study of 10 caregivers indicat- ed that the tool was eligible for data col- lection, the person correlation (r) was 0.87. Before starting data collection, the re- searcher explained the research process and the aim to participants and asked each of the agreement participants to fill in a consent form. Prior to the data collection, formal permission was obtained from the University of Sulaimani/ College of Nursing and Rapareen Health General Administra- tion in Ranya City/ Sulaimani/Kurdistan/ Iraq. The researchers explained the pur- pose of the study. All participants have the right to withdraw at any time. The re- searchers have promised to keep the data information for confidentiality and increase function, and avoid subsequent impairments while considering the preferences and values of the patient and family. Children with CP and their caregiv- ers want to know everything they can about their child's health, including their prognosis and rehabilitation needs. On the other hand, caregivers frequently believe that health professionals undervalue their demand for information [28-29]. Caregivers’ understanding of how to man- age homecare for children with impair- ments is sometimes overlooked. Because of the potential for scorn and taunting from others, it is rarely carried outside the home. The greatest option to provide daily care and management for children with persistent disabilities is through home care [3]. This study aimed to determine the lev- el of caregiver’s knowledge regarding homecare management of spastic CP Chil- dren in the Rapareen province. A quantitative, descriptive cross-sectional study was conducted. The study was car- ried out in the Rapareen province in Sulai- mania city. A non-probability convenient sample of 115 caregivers was selected from three different rehabilitation centers with a total of 160 cases: Kewarash primary health center in Ranya city (90 Spastic CP cases), Qaladze center (60 Spastic CP cas- es), Chwarqurna rehabilitation center (10 Spastic CP cases). Data were collected from January 25th to April 25th, 2021, to identi- fy caregivers’ knowledge of homecare management of Spastic CP children in the Rapareen region. According to Rapareen General Health Directorate’s annual cen- sus, 160 Spastic CP children are registered in the three centers. Yamane formula has been used to estimate the sample size (n=N/(1+N(e)2), n=160/1+160 (0.05)2 and n=115. The study has recruited 115 spastic CP children with their caregivers willing to 63 METHODS Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article anonymity. The data were analyzed using SPSS software for statistical analysis Ver- sion 25, to calculate descriptive statistical analysis (frequency and percentage). Infer- ential statistical analysis (chi-square and regression) was used to determine the as- sociation between variables, the P-value ≤ 0.05 is considered statistically significant. The result shows that the majority (98.3%) of the main primary caregivers were moth- ers. Most caregivers were primary school graduates (33%). Less than half (48.7%) of caregivers were aged 31 to 40 years old and were of middle socioeconomic status. The majority of caregivers were house- wives (88.7%), more than one-third (38.3%) lived in urban and suburban areas, and less than three-quarters (72.2%) were in a tra- ditional nuclear family Table 1. The higher percentage (65.2%) of spastic CP children were school-age children. Sixty-seven per- cent were males, 63.5% were between one to six months of age at the time of diagno- sis, 53% did not have birth asphyxia, and 80% were on a normal diet. About 60.9% were born by normal delivery, and 91.3% were delivered in public hospitals. Most of the sample (80%) did not have a child pre- viously affected with CP, and less than half (40%) of the children were the middle child in the family. About 75.7% have one or more complications associated with CP, and less than half (44.3%) were in the level V of independence Table 2. A highly signifi- cant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at a p-value of 0.020 and 0.003, respectively was ob- served. Level of education, age of caregiv- er, and height of the spastic CP children were significantly associated with care- giver’s knowledge at p-values of 0.002. 0.050 and 0.012, respectively Table 3. 64 RESULTS Table 1: Distribution of sample according to caregivers’ socio-demographic character- istics Items F. (%) The main primary care- giver Mother 113 (98.3) Grandmother 1 (0.9) Aunt 1 (0.9) Level of edu- cation Illiterate 33 (28.7) Primary school 38 (33) Secondary school 28 (24.3) Institute Di- ploma 10 (8.7) University and above 6 (5.2) Age of care- giver/years 20-30 25 (21.7) 31-40 56 (48.7) 41-50 31 (27) 51 and above. 3 (2.6) Marital sta- tus Married 109 (94.8) Unmarried 6 (5.2) Occupation Housewife 102 (88.7) Governmental employee 8 (7) Non- government employee 5 (4.3) Place of resi- dence Rural 27 (23.5) Urban 44 (38.3) Suburban 44 (38.3) Socio- economic status High 11 (9.6) Middle 56 (48.7) Low 48 (41.7) Types of family Traditional nuclear family 83 (72.2) Nuclear family 13 (11.3) Blended fami- ly 2 (1.7) Extended fam- ily 13 (11.3) Single parent family 4 (3.5) Total 115 (100) F. frequency ** % percentages Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 65 Table 2: Distribution of sample according to spastic CP child socio-demographic characteristics. Items F.* (%)** Developmental stage Toddler 7 (6.1) Preschool-age 33 (28.7) School-age 75 (65.2) Gender Male 77 (67) Female 38 (33) Age at diagnosis/months 1 to 6 73 (63.5) 7 to 12 29 (25.2) 13 to 18 4 (3.5) 19 to 24 1 (0.9) 25 or more 8 (7) Birth asphyxia Yes 54 (47) No 61 (53) Type of feeding Breastfeeding Bottle feeding 9 (7.8) Mixed 14 (12.2) Normal diet 92 (80) Mode of delivery Normal delivery 70 (60.9) Cesarean Section 45 (39.1) Place of delivery Home 10 (8.7) Hospital 105 (91.3) Another affected child with CP Yes 23 (20) No 92 (80) Child’s order in the family Firstborn 38 (33) Middle born 46 (40) Young child 31 (27) Complications associated preg- nancy Yes 87 (75.7) No 28 (24.3) Level of independence Level I 14 (12.2) Level II 6 (5.2) Level III 19 (16.5) Level IV 25 (21.7) Level V 51 (44.3) Total 115 (100) *F. frequency ** % percentages Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article 66 Table 3: Association between caregiver's knowledge and socio-demographic characteristics. Knowledge Socio-demographical characteristics Fair K.*** Good K. X2 (Sig.) F. (%) F.(%) Primary caregiver Mother 81 (71.5) 32 (28.5) 2.895(0.2350) Father 0 (0.0) 0 (0.0) Grandmother 0(0.0) 1 (100.0) Aunt 1(100.0) 0 (0.0) Level of education Illiterate 18 (54.5) 15 (45.5) 11.652(0.020) Read and wright 0 (0.0) 0 (0.0) Primary school 25 (65.8) 13 (34.2) Secondary school 25 (89.3) 3 (10.7) Diploma institute 9 (90.0) 1 (10.0) University and above 5 (83.3) 1 (16.7) Age/ years old 20-30 21 (84.0) 4 (16.0) 5.645(0.227) 31-40 41 (73.2) 15 (26.8) 41-50 17 (56.7) 13 (43.3) 51 and above. 3 (66.7) 1 (33.3) Occupation Housewife 70 (68.6) 32 (31.4) 3.395(0.183) Public employee 7 (87.5) 1 (12.5) Private employee 5 (100.0) 0 (0.0) Marital status Unmarried 5 (83.3) 1 (16.7) 448(0.503) Married 77 (70.6) 32 (29.4) Residency areas Rural 13 (48.1) 14 (51.9) 11.968(0.003) Urban 38 (86.4) 6 (13.6) Suburban 31 (70.5) 13 (29.5) Socio-economic status Low 7 (63.6) 4 (36.4) 4.378(0.112) Middle 45 (80.4) 11 (19.6) Low 30 (62.5) 18 (37.5) Type of family Traditional nuclear family 62 (74.7) 21 (25.3) Nuclear family 7 (53.8) 6(46.2) 3.841(0.428) Blended family 2 (100.0) 0 (0.0) Extended family 8 (61.5) 5 (38.5) Single parent family 3 (75.0) 1 (25) ***K. Knowledge Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article the parents were mothers aged 21 to 82 years old [12]. Most (88.7%) of the caregivers were housewives. The result is in agreement with a study done in King Saud Medical City, Riyadh, Saudi Arabia which states that almost 90% of the sam- ple were unemployed and took care of their children [13]. Regarding the residen- tial areas of the participants, the current study found that more than one-third (38.3%) of the caregivers live in urban and suburban areas. This finding is in contrast with other studies that reported that more than half of caregivers were living in urban areas [3], and more than two-thirds of the caregivers were living in rural areas [16]. These results indicate that the residential areas of the caregivers sometimes create problems for the CP child because the par- ents are facing a lack of service facilities for their child’s treatment such as hospitals, clinics, pharmacies, and private and public sector physiotherapy departments. There- fore, in this case, the CP child and his/her family might face great health difficulties. Regarding socioeconomic status, less than half (48.7%) of the caregivers were of mid- dle socioeconomic status. One study found that a moderate level of income was most frequently reported (79.3%) [13] and an- other study in Egypt found that most CP children and their families were low- income. A study in China reported a monthly family income of less than US $500 [15]. Most of the caregivers (72.2%) are living in a traditional nuclear family, similar to another study which found that the family size of their study sample mainly consisted of three to five people [21]. Assessment of socio-demographic charac- teristics of spastic CP childrenThe results show that about two-thirds (65.2%) of spastic CP children were school-age. This result is supported by other studies re- porting SP children aged 2-10 years [22], and aged 2-6 years [20]. The result is in That level of education, age of caregiver, and height of the spastic CP were factors associated with the caregiver’s knowledge and shows a highly significant p-value of 0.002. 0.050 and 0.012 respectively Table 4. The demographic characteristics of care- givers of children with CP. The results of the present study reflected that the major- ity (98.3%) of primary caregivers of Spastic CP children were mothers. This result agreed with previous studies which men- tioned that the caregivers of CP children were mothers and states that they are more effective in initiating and recipro- cating the child’s needs [13-17]. Regarding the caregiver’s marital status, the majority (94.8%) of caregivers in the present study were married. The current results showed that most of the caregivers were primary school graduates and illiterates. A similar study was conducted by Hasan in Erbil city of the Iraqi Kurdistan region which report- ed that 43% of the sample were illiterate, [3]. Other studies report caregivers were literate and a high percentage of them had reached high school education (33.3% and 37.0%, respectively) [13]. Around half of the sample were aged 31 to 40 years old with a mean age of mothers of 32.5 years old [3]. In another study, the majority of 67 Table 4: Factors associated with caregiver’s knowledge regarding homecare of spastic CP. Factors Score df Sig.* Exp [B] Formal years of education 9.313 1 0.002 0.680 Age of caregiver 3.715 1 0.050 1.986 Height of SCP child 6.312 1 0.012 0.209 P-value < 0.05 significant * Significant DISCUSSION Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article conducted in Baghdad’s Children’s Welfare teaching hospital found that, out of 100 CP participants, 70 were normal vaginal deliv- ery, in which one only had assisted delivery (forceps), and 29 were cesarean section (13% of them were elective procedures and 16% were emergency ones) [24]. Al- most all the CP children were delivered in the public hospitals in the present study, and only a few (8.7%) were delivered at home. This is in contrast to a study con- ducted in Nigeria where the majority of the CP children were delivered at home (310, 37.17%), and only 24 children (2.88%) were delivered at the University of Port Harcourt teaching hospital [25]. An- other study reported that most patients were born at a hospital or in a private clin- ic, and very few were born at home [11]. This could mean that the place of the CP childbirth varied across settings and could be interpreted in a way that the place of delivery is less associated with the cause of CP in children. In the present study, most of the caregiver families (80%) haven’t had any child previously affected by CP. The recurrence of CP in the same family is un- common [26] indicating that the CP condi- tion in children is not hereditary. Less than half (40%) of the CP children were the mid- dle child in the family, 33% of them were firstborn, and 27% were the last-born child in the family. Studies report that 48% of children with CP were the first children in the family [19], and about one-fourth of them were the first born [16]. This could be interpreted in the way that CP condi- tion in children can happen in any child- birth ordinal. three-quartier of respond- ents have one or more complications relat- ed to spastic CP Studies have reported that the majority of the sample report epilepsy as the onset symptom (78.0%), and mental retardation was the least mentioned (6.0%) [19]. In the current study, the com- plications associated with spastic CP child disagreement with a study in Erbil city stating that more than half (53%) of CP children were in the toddler develop- mental stage [3]. The CP children of the present study are mainly between the toddler ages to school ages. Results of the current study show that two-thirds of Spastic CP children were males. This re- sult is in agreement with other studies reporting a higher sample proportion of boys [20], [22], [16], [19]. Regarding the diagnostic age of spastic CP children, the study reveals that less than two-thirds were between one to six months of age at the time of diagnosis. Another study reported that most of the children were less than one year at the time of their diagnosis [19]. CP condition is usually de- tected at the early ages of six months to one year. In the present study, more than half (53%) of the CP children did not have birth asphyxia, which is supported by a study done in Osun State, Nigeria which showed that the h asphyxia was 57.2% [23]. This is an indication of the fact that it is not always the case for chil- dren to experience birth asphyxia at the time of delivery. Birth asphyxia was in 42 (36%) of cases [11], the contrast pattern occurred in the study by birth asphyxia (17.3%) of the child with CP condition [12], [29], Only 6% or 7% of asphyxia at birth [12]. Concerning the type of feed- ing, the study found that the majority (80%) of the CP children were on a nor- mal diet. This result is in agreement with a study reporting that the majority of CP children were on oral feeding while only 18% of them were on tube feeding [16]. The current study also reveals that most spastic CP children were born by normal delivery. One study reported more than half of SP children were born by cesarean section delivery, three-quarter by vaginal deliveries, and less than one-fifth or few by caesarian sections [11]. A study 68 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2022 Original Article level of education of caregivers and total family caregivers’ knowledge regarding hemiplegic CP (x² = 127.8, p= 0 .000) [21]. The age of the caregiver was significantly associated with the caregiver’s knowledge (p=0.050). One study showed a significant association between the age of the mother and knowledge about homecare (p = 0.024) and revealed that caregivers aged 24 to 30 were less knowledgeable about homecare [3]. The height of the spastic CP was significantly associated with the care- giver’s knowledge (p= 0.012). A study in Brazil found a statistically significant height difference, according to the reference curves specific for CP and those commonly used in pediatrics, with a Kappa index ob- tained by comparing the caregiver’s awareness [30]. There was no significant association between any of the selected socio-demographic caregiver variables and the level of knowledge of the caregivers. [27]. Another study reported significant differences were found, in caregivers’ knowledge of height (p = 0.001) [31]. The results of the present study indicated a highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge regarding home care manage- ment of spastic CP children. The level of education of the caregiver, age of the care- giver, and height of the spastic CP were factors significantly associated with the caregiver’s knowledge regarding home care management of spastic CP children. The authors (s) report no conflict of interest. The authors (s) report no funding support . reported include mental retardation, convulsion, epilepsy, strabismus, blind- ness, deafness, and heart problems. Less than half (44.3%) of the CP children par- ticipating in the current study were in level V (five) of independence. A similar pattern of 17 caregivers of CP children in Iran found that of the participating chil- dren, 29.4% were in level III of Growth Motor Function Classification System Ex- panded and Revised, (GMFCS E&R), 29.4% were in level V, 17.6% were in lev- el IV, 17.6% in level I, and 6% were in the level II [22]. This is the indication that children with CP can perform inde- pendently in almost all the five levels ex- cept Spastic CP who will be staying in IV and V levels. Association between care- giver's knowledge and socio- demographic characteristics. A highly sig- nificant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at p-value of 0.020 and 0.003 respective- ly. Also, independent factors that had a positive impact on observed knowledge scores were the caregiver's urban resi- dence and higher family income. Mean- while, caregivers’ higher education had a negative impact, which means that the improvement of observed knowledge was higher among those caregivers with lower levels of education [16]. However, there is a significant association between the educational status of family caregiv- ers with total knowledge scores (r = .521, p = .000) [21]. The other socio demo- graphic variables of the other caregivers had no significance on their knowledge score [16].Factors associated with care- giver’s knowledge regarding homecare of spastic CP The level of education of the caregivers of spastic CP is significantly associated with caregivers’ knowledge (p=0.002). 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