Performa for Registration of Subjects for Dissertation

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON PREVENTION OF PROTEIN ENERGY MALNUTRITION AMONG MOTHERS OF UNDERFIVE CHILDREN RESIDING IN SELECTED URBAN COMMUNITY, KOLAR DISTRICT

PARVATHI .T M.Sc., (N) 1st YEAR PEADIATRIC NURSING SPECIALTY MANASA COLLEGE OF NURSING KOLAR DISTRICT, KARNATAKA RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE AND Mrs. PARVATHI.T ADDRESS FIRST YEAR M.Sc. (NURSING)

2. NAME OF THE INSTITUTION MANASA COLLEGE OF NURSING

KOLAR-563130

3. COURSE OF STUDY AND FIRST YEAR M.Sc., (NURSING) SUBJECT PAEDIATRIC NURSING

4. DATE OF ADMISSION TO 25-10-2010 COURSE

5. TITLE OF THE TOPIC EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON PREVENTION OF PROTEIN ENERGY MALNUTRITION AMONG MOTHERS OF UNDERFIVE CHILDREN RESIDING IN SELECTED URBAN COMMUNITY, KOLAR DISTRICT. 6. Brief Resume of Intended Work

INTRODUCTION

Children are mankind’s seeds for the future. A god given gift, hope. They deserve the utmost care from us, for they are like wet clay in the hands of a potter. The way we mould them, the way the pot of the future will be. “Children’s growth rate reflects accurately the state of a nation’s public health and average nutritional status of its citizens”. - Eveleth.P.G and J.M.Tanner, 1976 Good nutrition promotes normal growth and development of children. The relationship between food, nutrition and health have long been recognized.1

A recent estimate by the Food and Agricultural Organization (FAO) puts the number of malnourished children in India at around 200 million, almost half of the world’s total. 2 Imbalanced between a child’s protein energy requirement and his or her dietary protein and calorie supply was the source of protein energy malnutrition. Which compounded the problems of any underlying diseases .It is recommended that catch-up growth may be achieved by using appropriate nutritional support .3

A study done report that malnutrition, with it constituents of protein-energy malnutrition and micronutrient deficiencies, continued to be a major health burden in developing countries. It was globally the most important risk factor for illness and death, with hundreds of millions of pregnant women and young children particularly affected. High prevalence of poor diet and infectious diseases regularly united into a vicious circle. Although treatment protocols for severe malnutrition have become more efficient, most patients (especially in rural areas) have little or no access to formal health services and were never seen in such settings. To be effective, all such intervention required accompanying nutrition – education campaigns and health interventions to achieve the hunger and malnutrition – related Millennium Development Goals.4

A study done reported that the nutritional status of slum children was worst amongst all urban groups and was even poorer than the rural average. Most common causes of malnutrition included faulty infant feeding practices, impaired utilization of nutrients due to infections and parasites, inadequate food and health security, poor environmental conditions and lack of proper child care practices.5 With increasing urban migration in the years ahead, the problem of malnutrition in urban slums would also acquire increasing dimension. Improving nutritional status of urban poor required a more direct, more focused, and more integrated strategy.6

6.1 NEED FOR THE STUDY Under-nutrition is widely recognized as a major health problem in the developing countries of the world. Severe protein energy malnutrition, often associated with infection contributes to high child mortality in under privileged community.7

Cases with mild to moderate under nutrition are likely to remain unrecognized because clinical criteria for their diagnosis are imprecise and difficult to interpret accurately.8

Anthropometric measurements are always an outcome of both, heredity and the environment in which children grow.10

A study done reported that in the 20th century, differences between socio economic classes caused greater differences between growths of children than differences due to ethnic factors across countries. The more deprived the population (in terms of access to nutrients, infection loads, hygiene and even care and attention) the lower were weight and height outcomes.11

A study done found that severe degree of malnutrition had highest prevalence under two years of age. The influence of variables like age, sex, religion, literacy status of parents and morbidity of the children were significantly associated with malnutrition.12

A study done evidenced that prevalence of severe malnutrition was noted to be three times higher in females (24.76%) than males (8.45%), and among families it increased in direct proportion to birth rate and inverse proportion to birth interval. Moreover, children of illiterate parents and non working mothers had a higher incidence of severe PEM.13

Malnutrition resulted from or was the end result of diverse and inter – related factors that may operate singly or in combination. The immediate factors that affected nutrition were food availability and intake, and the state of health of the individual or community. Those factors interacted and were also affected by socio cultural, political, economical and environmental factors, collectively all those factors affected the dietary intake and health status of the population. A home –based therapy with ready-to-use therapeutic food developed during a food crises in Machinga district to treat the wide spresd childhood malnutrition, a rural area lacking health care facilities. The home- based therapy with ready-to-use therapeutic food administered by village health aides was an effective in treating malnutrition during food crises in areas lacking health services.14

Protein energy malnutrition affected every fourth child worldwide. 150 million were underweight while 182 million were stunted. Geographically, more than 70 percent of protein energy malnutrition children live in Asia, 26 percent in Africa, 4 percent in Latin America and the Caribbean.8

Kwashiorkor was observed in 3 – 5% of children. Other signs of protein calorie malnutrition were observed in 5 – 25 percent children. The problem among children in Karnataka state was of considerable magnitude. It was found that all the pathological changes due to protein malnutrition were reversible with appropriate protein therapy.9 (National Nutrition Monitoring Bureau)

Health Education focused on mothers at appropriate time, much before the children fall prey to many preventable diseases can certainly help in the promotion of child health and prevention of morbidity and mortality among infants and pre-school children.

We there should be an emphasize to reinforce and make the community an active participant in this endeavor. The over all recommendation to protect ,promote and support an infant and young child feeding, in addition to breast feeding is an important prevention strategy for protein energy malnutrition

Health education in this aspect has to be directed towards sensitizing the people of the developing countries to their legitimate rights for the basic needs of life.

6.1.1CONCEPTUAL FRAMEWORK The conceptual frame work of this study can be derived from Imogene King’s Goal Attainment Theory. This study focuses on prevention of protein energy malnutrition in under five children with interaction, transaction and good communication by taking up health teaching for mother of under five children which is necessary to prevent Protein Energy Malnutrition in under five children. So the goal of preventing protein energy malnutrition by administrating the structured teaching programme can be obtained by adopting this theory

6.2REVIEW OF LITERATURE

A prospective study done to assess the prevalence of malnutrition in hospitalized children found that the prevalence of acute malnutrition over the last 10 years in hospitalized children in Germany, France, the UK and the USA varied between 6.1 and 14%, whereas in Turkey upto 32% of patients were malnourished and was still highly prevalence in children with an underlying disease. The prevalence of acute malnutrition of children admitted to hospital was still considerably high.16

A study conducted on protein-energy malnutrition among preschool children in Oman and found that the prevalence rates of wasting, stunting and underweight were 7.0%, 10.6% and 17.9% respectively at the national level. There were no sex differences.17

A study done to evaluate the prevalence of protein energy malnutrition in children under five years in three randomly selected, state operated foster care institutions in Sri Lanka 52samples were selected. The prevalence of protein energy malnutrition, was (51.9%), underweight (63.5%) and wasting (25.0%) which was found to be considerably higher than the national prevalence (13.5%, 29.4%, 14.0% respectively).18

A cross-sectional descriptive survey study done to assess the nutritional status of young children. They evidenced that greater risk for chronic malnutrition was associated with families’ more than five people, mother low educational level, children who were breastfed for more than a year.19

A study conducted on nutritional status of 486 preschool children residing in urban slums at Delhi by making domiciliary visits. The overall prevalence of protein energy malnutrition was found to be 81.8%, while 31.8, 44.1, 5.7 and 0.2% of children had grades, I, II, III and IV PEM, respectively. Age, sex and education had a significant association with PEM.20

A study done to investigated the degree of chronic malnutrition in the context of socio- economic, demographic and other characteristics of the children and their households in the three selected states in India. They found that there was a close positive link between the nutritional status of pre-school children and the stages of development of the states. Mothers’ education and household condition were important influences on children’s health status irrespective of the stage of development.21

A study conducted to determine the growth pattern of upper arm muscle area (UAMA), upper arm fat area (UAFA) and upper arm muscle area by height (UAMAH) and assessment of magnitude of under nutrition on the basis of these parameters in Santal children. They evidenced that growth curves of UAFA-for-age and UAMA by height were good indicators of nutritional status in Santal children. They recommended for a comprehensive approach to identify the truly undernourished child.22

A cross sectional study done from randomly selected Anganwadi to estimate the prevalence of and identify risk factors for xerophthalmia in children aged 6 – 71 months living in slums in Pune, India in 2003. It suggested the importance of female education and indicated that Vitamin A supplementation and other approaches to control need to be improved in children living in deprived areas like urban slums.23

A descriptive and prospective study of 335 children under the age of 6, admitted and cared by clinicians and medical staff trained under World Health Organization guidelines. They evidenced if World Health Organization guidelines were implemented, low mortality rates were achieved in children with severe acute malnutrition in class I hospitals.24

A study to compare prescription and delivery of nutrition to predefined nutritional targets, and identify risk factors associated with inadequate nutritional intake. They recommended that nutritional therapy should be started in the early phase of critical illness, including adequate supply of protein and in order to prevent deficits to accumulate, parenteral nutrition should be added in an early phase, if nutritional needs cannot be met by enteral nutrition.25

A study reported that diet plays a crucial role in the management of a case of protein energy malnutrition. Severe malnutrition was best managed in the hospital as such cases usually have life threatening complications. He suggested that when the child was critically ill, a cautious approach to feeding was vital. By the end of the first week the acute problems were overcome and oral feeds was introduced. In the rehabilitation phase, the emphasis was on weight gain and so a more vigorous approach was needed. Upto 200 kCal / kg / day was to be given for maximum ‘catch-up growth’. Transfer to family type diet was an important final step in rehabilitation before the patient was discharged from the hospital. Mild to moderate cases of malnutrition were treated at home or in a nutrition rehabilitation centre. Important aspects of domiciliary treatment and nutrition education for the mother and feeding the child ‘from the family pot’ with close supervision and encouragement.26

A study done to assess implemented a standardized protocol at the Dhaka Hospital and prospectively evaluated a day – care clinic approach that provided antibiotics, micronutrients and feeding during the day with continued care by parents at home at night as an alternative to hospitalization. Severely malnourished children aged 6 – 23 months denied admission to hospital were enrolled at Radda Clinic, Dhaka and received protocolized management with antibiotics, micronutrients and milk – based diet from 8.00 am to 5.00 pm each day, while mothers were educated on continuation of care at home. They were transitioned to the day – care nutrition rehabilitation (NR) unit of Radda Clinic following resolution of acute illness, received NR diet (Khichuri, halwa and milk based) daily until children attained 80% weight – for – length. They evidenced that severely malnourished children could be successfully managed at existing day – care clinics using a protocolized approach.27

A study done to found that ready – to – use therapeutic food was an important recent advance in the dietary management of malnutrition in ambulatory settings, allowing more effective prevention programmes and earlier discharge from hospital where community follow – up was available, which could be included in future protocols. There was very good evidence on the use of micronutrients such as zinc, and that smaller doses of daily Vitamin A were preferable to a single large dose on admission for severe malnutrition.28

6.3 STATEMENT OF THE PROBLEM Effectiveness of structured teaching programme on prevention of protein energy malnutrition among mothers of underfive children residing in a selected urban community, Kolar District

6.4 OBJECTIVES OF THE STUDY 1. To assess the existing knowledge of mothers of underfive children on prevention of protein energy malnutrition. 2. To assess the existing knowledge of mothers of under five children on prevention of Protein Energy Malnutrition in control group. 3. To asses s the post test knowledge of mothers of under five children on prevention of Protein Energy Malnutrition in experimental group. 4. To evaluate the effectiveness of structured teaching programme on the knowledge of prevention of protein energy malnutrition among mothers of underfive children in experimental group. 5. To associate the level of knowledge of mothers with selected demographic Variables in experimental group. 6. To associate the level of knowledge of mothers with selected demographic Variables in control group.

6.5 OPERATIONAL DEFINITION Effectiveness It refers to the rate of gain of knowledge of mothers of underfive children on prevention of protein energy malnutrition after the structured teaching programme. Structured Teaching Programme It refers to the systematically organized and developed instructions and teaching aids designed for the group of the mothers of underfive children regarding prevention of protein energy malnutrition. Prevention It refers to the health educational measures taken to prevent the children from acquiring protein energy malnutrition. Protein Energy Malnutrition It refers to the group of illness arising out of inadequate intake of food and protein calories. Mothers of Underfive Children It refers to the mothers of children from 1 to 5 years residing in a selected community.

6.6HYPOTHESES

H1: There will not be a significant difference between the pretest and post test level of knowledge of mothers of underfive children.

H2: There will not be a significant association of level of knowledge among mothers of underfive children with selected demographic variables.

6.7 ASSUMPTIONS 1. Protein energy malnutrition may affect the under five children when children are deprived of adequate protein and calories.. 2. Underfive children are more vulnerable for protein energy malnutrition. 3. Health education focused on mothers will help in the prevention of protein energy malnutrition in under five children.

6.8 CRITERIA FOR SELECTION OF SAMPLES Inclusion Criteria 1. Mothers of underfive age children residing in selected community. 2. Mothers who are willing to participate in the study. 3. Mothers who can speak Kannada.

Exclusion Criteria 1. Mothers of underfive children who are sick. 2. Mothers of underfive children with clinical manifestation of PEM.

6.9 LIMITATIONS OF THE STUDY 1. The study is delimited to 60 mothers of under five children. 2. The study is delimited to mothers of children residing in a selected urban community.

7. MATERIALS AND METHODS

S0URCES OF DATA

Data will be collected from mothers of underfive children in selected urban community

Method of data collection

a) RESEARCH APPROACH Quantitative approach b) RESEARCH DESIGN The quasi experimental non equivalent control group design was selected for the study to assess the effectiveness of structured teaching programme on prevention of protein energy malnutrition admitted in pediatric wards of RMMCH.

O1 - Pretest assessment X - Structured teaching programme

O2 - Post test assessment

c) SETTING OF THE STUDY Selected urban community, Kolar District. d) POPULATION Mothers of underfive age children e) SAMPLE Mothers of underfive age children residing in selected urban community

f) SAMPLE SIZE 60 mothers of underfive children.

g) SAMPLING TECHNIQUE Purposive non random sampling.

h) CRITERIA FOR SELECTION OF SAMPLES Inclusion Criteria 1 Mothers of underfive children residing in selected community. 2 Mothers who are willing to participate in the study. 3 Mothers who can speak Kannada.

Exclusion Criteria  Mothers of underfive children who are sick.  Mothers of underfive children with clinical manifestation of PEM i)TOOL DESCRIPTION The instrument consists of 2 sections:

Section I: Demographic Variables It includes age of the mother and child, education and occupation of parent, their income, number of children, family size, and type of family and area of residence. Section II: Structured Questionnaire It consists of 50 closed ended questions to assess the knowledge regarding meaning, causes, manifestations, complications, diagnosis, treatment, management, diet and preventive measures for protein energy malnutrition. The tool was translated in Kannada and medical terminologies were simplified according to the level of understanding of mothers. j) COLLECTION OF DATA Data will be collected by using structured questionnaire prepared by investigator for mothers to assess the level of knowledge k) VARIABLES Independent variable Structured teaching programme Dependent variable Level of knowledge l)Method of data analysis

PLAN FOR DATA ANALYSIS The data will be analyzed based on the objectives of the study using descriptive and inferential Statistics. The plan for analysis is as follows: 1. Frequencies and percentages for the analysis of the demographic data. 2. Means, percentages and standard deviation for knowledge score. 3. Paired‘t’ test and ‘p’ value were used to test the effectiveness of structured teaching programme. 4. Chi-square will be used to determine the association in the level of knowledge with selected demographic variables m) Duration of data collection 4 weeks n) Projected outcome The study will help to assess the effectiveness of structured teaching programme among mothers of under five children to prevent P E M 7.3 Does the study require any investigation or intervention to be conducted on patient or other human beings or animals? Yes 7.4 As ethical clearance been obtained from your institution? Yes LIST OF REFERENCES: 1. Marlow Dorothy R. Redding Barbara .A, Textbook of Pediatric Nursing,6th edition. New Delhi: Elsevier, publishers 2004. 2. Parthasarathy, Fundamental of pediatrics, First edition .New Delhi: Jaypee medical publishers, 2007. 3. Pillitteri Adele, Nursing care of the child and family, First edition. Philadelphia :Lippincott publishers,2006 4. Muller and Krawinkel. A study done to assess the prevalence of protein energy malnutrition and micro nutrient deficiency in developing countries, Journal of nutrition, 2008 Dec;17(6): 439-440. 5. Ghosh and Shah. A study done to compare the nutritional status of slum children with urban and rural group of children, Journal of Tropical Pediatrics, 2006 March; (18): 120- 123.. 6. Viswanathan .J. Desai A.B, Achar’s textbook of pediatrics, 3rd edition. New Delhi: orient Longman publishers, 2006. 7. Behrman, et al. Nelson Textbook of Pediatrics. London: First edition. London: Saunders publishers, 2000. 8. Cheda, K.M. Practical Aspects of Pediatrics. First Edition. New Delhi: Bhalani publishers, 2006. 9. Dutta, .P. Pediatric Nursing. First Edition. New Delhi: Jaypee publishers, 2007. 10. Ghai, O.P. Ghai Essential Pediatrics. Second Edition. New Delhi: Jaypee publishers, 2005. 11. Anuradha, Rajivan, A study done to determine the factors causing difference of growth in children, Journal of Pediatrics, 2005 Dec; 32(12): 640. 12 Ray, Haldeer. A study done to assess the prevalence of malnutrition in children under two years , journal of Maternal Child Nutrition, 2007April;(4), 100-104. 13 Rohrer .T, Retl. A study done to assess the factors influencing protein energy malnutrition in children, East American medical Journal, 2004 Jan;2(14); 36 – 40.. 14 Gupta, S. The Short Textbook of Pediatrics .Second Edition. New Delhi: Jaypee publishers, 2007. 15 Hocken Berry, J.M. Wong’s Essentials of Pediatric Nursing. 6th Edition. New Delhi: Elsevier publishers, 2007. 16. Joosten, Hulst. A prospective study done to assess the prevalence of malnutrition in hospitalized children, Journal of Maternal Child Nutrition in under five children, Journal of Nutrition , 2005 Feb;15(8): 224-22617 17. Alasfoor, D., Elsayed, M.K., Qasmi, A.M., Malankar, P., & Sheth, M. (2007). Protein – energy malnutrition among preschool children in Oman; results of a national survey. Journal of East Mediterranean Health Journal, 13(5), 1022 – 30. 18. Jayasekara. A study done to evaluate the prevalence of protein energy malnutrition in underfive children, Journal of nutrition, 2005 Feb;15(8):224-226. 19. Cornejo, W., Figuerroa, N., & Munera, M. Nutritional status and living conditions in children in an urban area of Turbo, Journal of tropical pediatrics. 2008 Feb;2(15):100-20. 21 Esamoi, F.O., Rotich, J., & Olwambula, A.R. Socio-economic factors predisposing under five- year-old children to severe protein energy malnutrition at the Moi Teaching and Referral Hospital,. East African Medical Journal, 2008 March; 81(8), 415 – 21. 22 Beard, J.I., Gomez, L.H., & Haas, J.D. Study to assess complication protein-energy malnutrition at high altitude, American Journal of Clinical Nutrition, 2005 Feb 44(2): 181 – 7. 23 Appoh, L.Y., & Krekling, S. (2005). Maternal nutrition knowledge and child nutritional status in the Volta region of Ghana, Journal of Maternal Child Nutrition, 2006 Dec 1(2), 100 – 10. 24 Bernal, C. Velasquez. Treatment of severe malnutrition in children: experience in implementing the World Health Organization guidelines in Turbo, Colombia, Journal of Pediatric Gastroenterology Nutrition, 2008 March; 46(3), 322 – 8. 25 Ayaya, S.O. A corporative study in presentation & implementing of nutrition to under five-year- old children with severe protein energy malnutrition at the Moi Teaching and Referral Hospital, Eldoret, Kenya. East African Medical Journal, 2006 Feb; 6(12): 212-16. 26. Hossain, M.I., Alam N.H., & Mahmud, R. Day-care management of children with severe malnutrition in an urban health clinic in Dhaka, Journal of Tropical Pediatrics, 2007 Feb; 14(3) : 343-6 27. Antio Amthor, R.E., Cole, S.M., & Manary, M.J. The use of home-based therapy with ready – to – use therapeutic food to treat malnutrition in a rural area during a food crisis. Journal of American Diet Association, 2009 Dec; 13(18) : 7-21.