Rajiv Gandhi University of Health Sciences s178

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON PREVENTION OF TUBERCULOSISAMONG THE PATIENTS ATTENDING THE OPD IN SNR HOSPITAL, KOLAR, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.

JENIFER. Y

A.E & C.S PAVAN COLLEGE OF NURSING KOLAR

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 NAME OF THE JENIFER.Y CANDIDATE &

ADDRESS IST YEAR M.SC., NURSING STUDENT A.E & C.S. PAVAN COLLEGE OF NURSING BANGALORE-CHENNAI BYEPASS ROAD, KOLAR – 563 101. 2 NAME OF THE A.E & C.S PAVAN COLLEGE OF NURSING INSTITUTION KOLAR-563101 3 COURSE OF MSc NURSING THE STUDY MEDICAL AND SURGICAL NURSING AND SUBJECT 4 DATE OF ADMISSION 31 – 05 - 2007

5 TITLE OF THE A STUDY TO ASSESS THE EFFECTIVENESS OF TOPIC STRUCTURED TEACHING PROGRAMME ON PREVENTION OF TUBERCULOSIS AMONG THE PATIENTS ATTENDING THE OPD IN S.N.R.HOSPITAL, KOLAR.

6. BRIEF RESUME OF INTENDED WORK 2 INTRODUCTION

“TB ANY WHERE IS TB EVERY WHERE” (WORLD TB DAY 2007)

Tuberculosis is one of the most important diseases in the history of humanity, and remains as an extra-ordinary burden on human health today. The Greek term ‘phthesis’ was used by the Hippocrates to describe the wasting disease, later known as TUBERCULOSIS. The term ‘Tuberculosis’ was introduced in the early 19th century, derived from the tubercles characterized in the study of pathological features of the disease. The first description of the tubercle bacilli as the cause of tuberculosis-Robert Koch in 1882 was scientific landmark. The discovery of streptomycin by Schatz and Waksman in 1943 was a major triumph; hence both Robert Koch and Waksman received Nobel Prize for their efforts1. Tuberculosis is an infectious disease known to have existed from ancient times. The disease has been perpetuated and maintained in the human population. It represents a dynamic balance between man and mycobacterium tuberclebacilli 2 . Tuberculosis kills more people than any other infection and its importance is increasing with the global pandemic and emergence of drug resistance. In 1998, 80% of the world’s tuberculosis cases occurred in 22high burden countries and India accounts for 1/5th of global incidence of tuberculosis and top the list of 22 - high burden countries. India alone is thought to have almost 2 million cases of active tuberculosis per year. WHO has estimated that 35million people will die of tuberculosis in the whole world between 2000 and 2020, if current trends continue and in present days International Health Organization are developing new interventions and scientists are investigating many aspects of tuberculosis disease and infection, all with the goal of improved diagnosis, treatment, control and prevention3.

3 Presently, the world faces three epidemics from tuberculosis; the first of these is the re- emergence of tuberculosis itself. The second epidemic is a cruelty of infection with HIV and third is Multi Drug Resistance tuberculosis. Currently tuberculosis is the leading cause of mortality among infectious diseases world wide, and 95% of 713 cases and 98% of deaths due to tuberculosis occur in developing countries 4 In the United States, the mortality take exceeded 250per 100000 prior to the discovery of tubercle bacilli. At the beginning of this century it was 100per 100000 population. Annual cumulative incidence of tuberculosis is 171 cases per 100000. Pakistanis has been ranked as one of the top developing countries affected by the current tuberculosis epidemic . In China, India and the Russian Federation accounted for 261,362 MDR-TB cases, or 62% of the estimated global burden. India, China, and Indonesia account for a half of the tuberculosis cases in the world. Nearly 40% of the world’s tuberculosis patients live in South-East Asia. Every day in India: More than 40000 people become newly infected with tubercle bacilli. More than 5000 develop tuberculosis disease. More than 1000 people die of tuberculosis, i.e., 1 death every one and a half minutes. The annual incidence of new cases of all forms of tuberculosis (pulmonary and extra- pulmonary) world wide is estimated to be approximately 88 lakhs, of which about 95% occurs in developing countries. Every year due to tuberculosis; More than 17crore workdays are lost Nearly 3 lakhs school children drop-out from the schools More than 1 lakh women are rejected by their families Tuberculosis affects the lungs in more than 85% of cases. 1/3rd of the world’s AIDS cases are suffering from tuberculosis. Every smear positive person, if left untreated, has the potential to infect 10-15 persons per year5.

4 Currently the prevalence of the multi drug resistance is 2% per WHO, (1999-2002) . Surveillance showed that 0.5%-3% of new cases were found to harbour multi drug resistance bacilli. Studies among previously treated patients showed multi drug resistance level is 12%. The National Tuberculosis Control Programmes of 199 countries reported that in 2005, 2.3 million new smear positive cases were diagnosed under WHO’s DOTS strategy, out of an estimated 3.9 million. The comprehensive review in 1992 by a committee of national and international level observed that National Tuberculosis Control Programme (NTCP) has not achieved the desired results. The WHO declared TB as a global emergency in 1993 and recommended the Revised National Tuberculosis Control Programme (RNTCP) with Directly Observed Therapy Short course (DOTs) as a solution for its control. DOTs has expanded rapidly in the South-East Asia region over the period of the partnerships first global plan (2001-2005) with almost 100% geographical coverage achieved in 20056. Accomplishing the objectives outlined in this document will require sustaining the progress in all countries and particularly in the five high burden countries, one being India for achieving major regional and global impact.

6.1 NEED FOR THE STUDY Tuberculosis is a major health problem in India. It affects people of all age and is highly infectious and preventable, communicable disease that dates as for back to the existing records on human issues. Tuberculosis is the world evokes feelings of fear anxiety stigma and despair. Many infected persons transmit the infection to others who come in close contact with them. It spread from person to person by exposure to air, it is air-brone disease .An infected person through talking, coughing, sneezing or laughing, releases large (greater than 100µ) and small (1-5µ) droplets. Someone somewhere in the world is currently getting infected with tuberculosis literally with every tick of the clocked one person per second In the next decade it is estimated that 300million more people will become infected, 90million people will develop the disease. 5 WHO 2007 reported that 3276 cases were suspected to be affected with tuberculosis in kolar district of Karnataka7 Samson (1955) conducted a study on knowledge and attitudes regarding tuberculosis among the people residing in Vellore town. He reported that there was lack of awareness about the prevention of tuberculosis among them8. Pruotit.H. (1998) conducted a study on prevention of tuberculosis among the people residing in Jaipur. He found that the people had poor knowledge regarding preventive aspects of tuberculosis9. Allinger (1998) suggested that lack of knowledge may be one of the significant factor for non-adherence to drug intake. These clients require education and support from skilled nurse in this area. Health education by nurses can help people to gain knowledge and improve their health status and contribute to prevent further transmission of the disease 10. Mfinanga.S.G. (2005) conducted a cross sectional study in 426 (274 Iraqw 126.non Iraqw ) adenitis patients to assess the knowledge and practices related to tuberculosis. They found that the knowledge of tuberculosis spread by air droplets was poorer in Iraqw (74.1%) than in non-Iraqw (61.1%)patient. About 35.07 of non Iraqw and 27.3% of Iraqw patients were not aware that tuberculosis could be transmitted from animals to humans11 Cheryl.P. Sterling (2005) conducted a cross sectional survey on the present knowledge, attitudes and practices regarding tuberculosis among medical students and residents house staff. They found that students doing the clinical Component of medical school scored higher M=76.3 than the group of students in their pre-clinical component of medical school. Also it was shown that those students with previous practical experience had a significantly higher self-efficacy score (M=30.4, SD=480), than those without previous practical experience12. Gurdeesh kaur (2005) conducted a descriptive cross sectional study on 120 respondents regarding knowledge , attitude and practices among the adults of the three ethnic groups namely Malays, Chinese, and Indians. The majority of the respondents of 107(89.2%) said they know about tuberculosis, which comprised mainly of 62(96.9%). Malays and 30(88.2%) Chinese when compared to 15(68.2%) Indians. The Indians had a comparatively poor knowledge of T.B when 6 compared to the Malays and Chinese. Health education, health systems and psychological researches are the major approaches to compact this situation13. Javaid Ahmed Khan (2006) conducted a cross sectional studies on 170 patients to assess the knowledge about tuberculosis. He found that 11 patients thought TB was not an infectious disease and 18 patients thought TB was not a preventable disease, contaminated food was considered the source of infection by 81 patients and 96 patients considered emotional trauma/stress is the causative agent of TB . Thirty one patients would have discontinued their medications following relief of symptoms. Thirty nine of the respondents thought that tuberculosis could lead to infertility and 66 believed that there were reduced chances of getting married following infection14. “Prevention is better than cure”. Lack of knowledge and awareness about prevention of TB are influenced by illiteracy, low socio-economic status, unemployment, over crowding etc. In developing countries there are varied factors which affect the health of the people. Majority of these can be prevented by adopting preventive measures and raising the level of knowledge of the people. Many experts have produced enough truths and government had developed many strategies to eradicate tuberculosis. Even then the intensive efforts take by them shows that the alternative methods and related educations have not reached the population’s properly. Based on the review of literature and personal experience of the investigator during her clinical experience in the tuberculosis ward found that many patient does not have sufficient knowledge regarding prevention of TB. Hence the investigator would like to explore the knowledge of the people attending the OPD and to give education regarding prevention of tuberculosis. 6.2 REVIEW OF LITERATURE Review of literature is an essential component of research study as it provides a broad understanding of the research problem. The typical purpose for analyzing or reviewing existing literature is to generate research question to identify conceptual or theoretical tradition within the bodies of literature. Hence the investigator intends to review the literature available on prevention of Tuberculosis15. The available literature is given in the following sections: 7 Review of literature is an essential compared of related study as it provides a broad under standing of the research problem. Keeping this in mind the investigator has been helpful in projecting the widened perspective of the study. The available literature is given in the following section: A : Review related to risk factors of TB B : Review related to prevention of TB A) Literature related to risk factors of tuberculosis:- Kolappan C, Gopi PG, Subramani R, Narayanan PR (2007) conducted a cross-sectional survey on 93945 individuals regarding independent association of risk factors (age, sex, smoking and alcoholism) with pulmonary tuberculosis. They found that 429 bacteriologically positive cases were detected during the survey. The association between age, sex, smoking and alcoholism were 3.3%, 2.5%, 2.1% and 1.5%. Risk factors such as age, sex, smoking, and alcoholism are independently associated with pulmonary T.B16 Radhakrishna.S. Frieden TR, Subramani R, Santha T, Narayanan PR (2007) conducted a study to assess the additional risk to house hold contacts from a infections cases TB in 3506 samples thought cox’s proportional hazard models and found the hazard rate of 3.4% for contacts of smear- positive cases and 1.7% for contacts of smear negative cases17 Bates M.N, Khalakdina. A, Pai M, Chang L, Lessa F, Smith KR (2007) conducted a meta analysis method of study which comprised of 24 studies to quantity the relationship between active tobacco smoking and TB infection. They found that the relative risk estimate was 1.73% for TB infection and 2.33% to 2.66 for TB disease This meta-analysis produced evidence that smoking is a risk factor for TB infection and TB disease18.

Joshi R, Reingold A.L, Merzies D, Pai .M,(2006) studied is the risk of transmission of mycobacterium tuberculosis from patients to health care workers through systematic review of electronic databases and journals and contacted experts in the field. From this study it is estimated that the annual risk of latent TB infection ranged from 0.5% to 14.3% and the annual incidence of TB disease in health care workers ranged from 69to 5,780 per 100,000. The attributable risk for TB 8 disease in health care workers, compared to the risk in the general populations ranged from 25to 5,361 per 100,000 per year19. B) Literature related to prevention of tuberculosis:- Escombe AR, Oeser CC, Gilman RH, Navincopa M, Ticona E, Pan W etal (2007) conducted a study to investigate the rate determinants and effects of natural ventilation in health care setting in prevention of tuberculosis by studying the designs of 8 hospitals with 70 naturally ventilated clinical rooms where infectious patients are likely to be encountered and these rooms were compared with 12 mechanically ventilated negative pressure respiratory isolation rooms Ventilation was measured using carbon dioxide tracer gas technique in 368 experiments and the infection risk was estimated for Tb exposure using the wills Riley mode of airborne infection. The Wells Riley airborne infection model predicted that in mechanically ventilated rooms 39% of susceptible individuals woulds become infected following 24 hours of exposure to untreated TB patients and the infection rate is 33% in modern and 11% in pre 1950 naturally ventilated facilities with windows and doors open. Opening windows and doors maximises natural ventilations so that the risk of air borne contagion is much lower that with costly maintenance requiring mechanical ventilation systems20. Chang L.C, Hung L.L, Chou Y.W, Ling L.M. (2007) conducted a cross sectional study in 865 samples to investigate knowledge and perception of tuberculosis. Study results showed a moderate level of general knowledge about TB, misunderstandings regarding transmission vectors, and low perceptions regarding susceptibility. The knowledge score was associated with perceived benefits in preventing TB21 Fochser G.K, Desh pande (2006) conducted a population based cross sectional survey on 45719 individuals regarding health care seeking behavior among men and women with cough of more than 3 weeks. The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69%vs 71%), but only 23% visited a public provider at some point during their illness, 13% of those seeking care reported having had a sputum smear examination since the onset a caught . Health care services for continues cough helps in early diagnosis and treatment22. 9 Stroud L.A, Tokars J.I, Grieco M.H, Crawsord J.T, Culver D.H, Edlin B.R etal (1995) conducted a retrospective cohort study in 3 periods ( between 1989 and 1992) to evaluate the efficacy of centers for disease control and prevention in infection control measures among AIDS patients and health care workers who are more prone to develop T.B. Period I is before changes in infection control, Period II is after aggressive use of administrative control and period III is while engineering changes were made. The epidemic (38 patients )of TB waned during period II and only one TB patent is presented during period III. TB patients were 8.8% during period I and decreasing to 2.6% in period II. Transmission of TB among AIDS patients decreased markedly after enforcement of readily implementable administrative measures. 23 PROBLEM STATEMENT : A Study to assess the effectiveness of structured teaching programme on prevention of tuberculosis among the patients attending the OPD in S.N.R.Hospital, Kolar.

6.3 OBJECTIVES OF THE STUDY (1) To assess the Knowledge of the clients regarding prevention of Tuberculosis among clients . (2) To assess the post test knowledge on prevention of tuberculosis after structured teaching programme. (3) To determine correlation between pretest and post test knowledge (4) To associate the selected demographic variables with post test knowledge 6.4 OPERATIONAL DEFINITIONS: Effectiveness: It refers to the described change brought about by the teaching Programme and it is measured in terms of significant knowledge gained in the post test. Structured Teaching Programme:

10 It refers to the systematically developed information regarding prevention of TB and imparting those information to the patients attending OPD of SNR Hospital. Prevention: It deals with control the spread of infection of tuberculosis. 6.5. ASSUMPTIONS : 1. knowledge is very minimal for the people attending OPD in SNR Hospital . 2. Knowledge has a strong influence on the adoption of healthy practices. 3. People would explore their knowledge regarding prevention of tuberculosis. 4. Relevant health educations are necessary to save the people from tuberculosis. 5. Nurse has an important role in educating the people regarding tuberculosis. 6. Group teaching will provide an opportunity for active learning among participants. 6.6.HYPOTHESIS H1 The mean post test knowledge score of OPD patients who received structured teaching programme will be significantly higher than their pre test score. H2 There will be a significant association between knowledge and selected demographic characteristics. 6.7 VARIABLES UNDER STUDY 6.7.1 Dependent variable Knowledge regarding prevention of TB. 6.7.2 Independent variable Structured Teaching Programme. 6.7.3 Attributed variable Socio demographic variables (Age, sex, education, occupation) 7.MATERIAL AND METHODS 7.1 Source Of Data: Patients attending OPD in SNR Hospital, Kolar 7.2 Method Of Data Collection : 7.2.1 Research Design: 11 Pre – experimental Design (one group pre – test and post - test ) 7.2.2. Setting: The study will be conducted in Sri Narasimha Raja (SNR) Hospital, Kolar which is 2kms away from Pavan College of Nursing having 400 bed strength. 7.2.3 Population Population consist of who are attending OPD in SNR Hospital 7.2.4. Sample Size: Total sample- 100 7.2.5. Sampling Technique: Convenient sampling 7.2.6 Sampling Criteria Inclusion criteria Patients those who are in the age group of 20-60 years. Both male and female were selected Patients who could understand Kannada and English Patients those who are willing to participate in structured teaching programme. Exclusion criteria Patients of age group below 20 and above 60 years. Patients who cannot understand Kannada and English. Patient who are not willing to participate in the study. 7.2.7. Tools of data collection Structured questionnaire will be used for data collection, which consists of 2 sections. SECTION-A: Contains question regarding demographic data of subjects (age, sex, education, occupation). SECTION-B: Contains question regarding prevention of Tuberculosis. 7.2.8 Data collection method The structured questionnaire will be distributed to the subjects or interviewed by the investigator. Prior to the study the purpose of the study will be explained and consent of the 12 participants will be obtained to involve in the study. Pilot study will be conducted before the original study and then necessary modifications and further refinement of the tool will be done. Researcher herself will collect data. 7.2.9 Data Analysis and Interpretation Descriptive and inferential statistical study such as frequency distribution and central tendency measurements (Mean, Median), standard deviation, chi-square and correlation-coefficient will be used for data analysis and present in the from of tables, graphs and Diagrams. 7.3 Does the study require any investigation or intervention to be conducted on patients/ sample population / other humans or animals? The study will be conducted on the clients of age between 20 -60 years attending the OPD of S.N.R Hospital, Kolar. Since it is a pre experimental study it requires intervention. (Structured Teaching Programme) 7.4 Has ethical clearance been obtained from your institutes? Prior permission will be obtained from the concerned authorities of SNR Hospital to conduct a study and also from research committee of A.E.& C.S. Pavan College of Nursing, Kolar. The purpose of the study will be informed and explained to the patient of the respective area. 8 . LIST OF REFERENCES : 1. Vijayalakshmi G, Dr K.Lalitha, “TB Any Where is TB Every Where”, Nightingale Nursing Times, Vol 2 , Issue 12, March 2007; 7 – 8 . 2. John M .Watson, Punam Mangtani, Damien J. Jolly, Laura C. Rodrigues, “Socioeconomic Deprivation and notification rates for tuberculosis”, British Medical Center Public Health 2006, June (19); 6:156. 3. Simon A. Donkor , Jacob Otu , “TB is a curable disease” British Medical Journal, 1995 April (15) ; 310:963 – 966. 4. Shamputa, “Cause of mortality among infectious disease in world wide” , Respiratory Research, 2006 July 17th , 7:99. 5. World Health Organization “The work of WHO Annual Report”, 2004. 6. World TB day DOTs “The work of WHO Annual Report 2001”.

13 7. World Health Organization (WHO) Statistical data for TB 2007 in Karnataka State. 8. Samson , “Knowledge and attitudes regarding tuberculosis” , Indian Journal of Tuberculosis, 1995 , 45 (6) 47 . 9. Pruotit. H , “Knowledge regarding Prevention of Tuberculosis” , Indian Journal of Tuberculosis, 1998 , 50 (33) , 33 – 34 . 10. Allinger, “ Knowledge regarding prevention of Tuberculosis transmission”, Indian Journal of Tuberculosis,1998, 50(34) 34– 38. 11. Mfinanga . SG , “Knowledge , Practices and challenges to health care system in early diagnosis of mycobacterium adenitis”, East African Medical Journal , 2005 April ; 82 (4) : 173 – 80 . 12. Cheryl P Sterling, “Knowledge , Attitude and Experiences Regarding Tuberculosis” , Department of Medicine, Division of Infectious Diseases, Atlanta , 2005 , May; 70 (4) 142 – 149. 13. Javaid Ahmed Khan , “ Knowledge , Attitudes and Misconceptions regarding TB” JPMA , 2006 , 56 : 211 . 14. Gurdesh Kour “ Knowledge , Attitudes and Practices Regarding Tuberculosis among new Diagnosed adult”, 2005. 15. B.T. Basavathappa , “Nursing Research” , 2nd Edition , Jaypee Brothers Publications, New Delhi, 2007 , 92 pp. 16. Kolappan C, Gopi P.G, Subramani R, Narayanan P.R , “ Risk factors associated with Pulmonary Tuberculosis”, International Journal of Tuberculosis and Lung Diseases, 2007 September ; 11 (9) : 999 – 1003. 17. Radhakrishna S, Friden T.R, Subramani R, Santha T, Narayanan P.R, “Additional risk of developing TB for house hold members with a TB” , International Journal of Tuberculosis and Lung Diseases, 2007 March; 11 (3) : 282 – 8 18. Bates M.N. , Khalakdina A, Pai M , Chang L, Lessa F , Smith K.R, “Risk of TB from exposure to tobacco smoke” , Arch International Medicine , 2007 February 26; 167 (4) : 335 – 42 . 19. Joshi R, Reingold A.L., Menzies D, Pai M, “TB among healthcare workers in Low – and Middle – income Countries”, PLoS Medicine, 206 December ; 3 (12) : e 494. 20. Escombe A.R. , Oeser C.C, Gilman R.H, Navincopa M , Ticona E, Pan W, etal , “Natural Ventilation for the Prevention of airborne contagion”, PLoS Medicine , 2007 February; 4 (2) : e 68.

14 21. Chang L.C , Hung L.L, Chou Y.W, Ling L.M, “Preventive pulmonary tuberculosis is chest X-ray examinations among indigenous Nursing students”, Journal of Nursing Research , 007 March ; 15 (1) : 78 – 87 . 22. Foschen G.K, Deshpande , “Health care seeking among individuals with cough and tuberculosis”, International Journal of Tuberculosis and Lung Diseases, 2006 ,10 (9) : 995 – 1000 . 23. Stroud L.A , Tokars J.I, Grieco M.H, Crawford J.T, Culver D.H, Edlin B.R, etal , “Prevention of TB infection control measures”, Infection Control Hospital Epidemiology ,1995 March ;16(3) :141– 7.

15 9 SIGNATURE OF THE CANDIDATE: 10 REMARKS OF THE GUIDE:

11 NAME AND DESIGNATION OF 11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 CO-GUIDE

11.6 SIGNATURE

12 REMARKS OF CHAIRMAN AND PRINCIPAL

12.1 SIGNATURE: