RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGLAORE, KARNATAKA, ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE SHANA .K .JAMES. AND ADDRESS 1ST YEAR, MSC NURSING. RAJEEV COLLEGE OF NURSING, HASSAN.

2. NAME OF THE INSTITUTION RAJEEV COLLEGE OF NURSING, HASSAN.

3. COURSE OF STUDY AND MASTER IN NURSING. CHILD SUBJECT HEALTH NURSING.

4. DATE OF ADMISSION TO THE 12/06/2009 COURSE

5. TITLE OF THE TOPIC EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PROBIOTC THERAPY ON PREVENTION AND MANAGEMENT OF DIARRHOEA AMONG MOTHERS OF UNDERFIVE CHILDREN.

5.1 STATEMENT OF THE A STUDY TO ASSESS THE PROBLEM EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PROBIOTIC THERAPY ON PREVENTION AND MANAGEMENT OF DIARRHEA AMONG MOTHERS OF UNDERFIVE CHILDREN IN A SELECTED HOSPITALS AT HASSAN.

1 6. BRIEF RESUME OF THE INTENDED WORK

6.1 Introduction “ Every individual organism that has a distinctive genetic has a distinctive nutritional needs which must be met for optimal wellbeing”. - Roger.J.Williams.

Health of the children has been considered as the vital importance to all societies because the children are the basic resources for the future of human kind. Child health depends up on prevention. Majority of child health problems are preventable. Modern approach of child health care emphasis on “Preventive care rather than curative care”. Most of the childhood diseases are prevented by mother’s role1.

Diarrhea is one of the most common manifestations of illness in infants and children. It is characterized by an increased in fluidity, frequency, volume as well as possible changes in color of faces in comparison with the usual stool pattern of the individual. The usual stool pattern of breast fed infants may be several stools a day, where as formula fed infants may be one stool every other day. Diarrhea is a symptom of variety of conditions, and it constitutes one of the main causes of morbidity and mortality among infants and children throughout the world2.

Diarrhea is usually defined as passage of 3 or more loose watery stool in a 24 hour period, loose stool being one that would take the shape of a container. Diarrhoea is one of the most common aliment in young children. A recent change in the consistency or character of stool is more important than the number of stools. The diarrhea [enteritis] is often proceded by vomiting [gastritis] as the infection travel from the stomach to the intestine a condition often referred as acute gastroenteritis.3

2 Breast fed babies are protected against development of diarrhea because breast milk is free from contamination and it contains several protective agents. Bottle fed babies are more prone to suffer from diarrhea. Feeding with a cup and spoon is associated with lower risk of development of diarrhea. Most episodes of diarrhea start when infant is weaned to semisolid diet unless strict personal and environmental sanitation 4

The acute diarrhea may last up to 14 days. Chronic diarrhea last more than 21 days. The signs of dehydration are increased thirst, Restlessness, Irritability, Decreased skin turgor. Dry mouth, and tongue , Absences of tears, Sunken eyes, .The signs of dehydration are two of the following should be present. Lethargic or unconsciousness, unable to drink, Floppy, Sunken eyes,, Skin goes back very slowly.4 Oral rehydration is accepted world wide as a primary tool for management of dehydration in acute gastroenteritis . The availability of use of oral rehydration has resulted in a significant decrease in morbidity and mortality with acute diarrhea.5

The diarrhea can be prevented by the foods like probiotics . A probiotic is a live microbial feed supplement which beneficially affect the host animal by improving it’s intestinal microbial balance. Examples of probiotics in commercial products are yogurt and buttermilk, fermented. and unfermented milk, fruit juices ,soy beverages .Probiotics are receiving a great deal of attention in many fields. Most probiotics fall in to two categories of bacteria Lactobacterium, Bifidobacterium. 6

6.2 Need for the study.

Diarrhea is common among children and contributes substantially to pediatric morbidity and mortality worldwide. Diarrhea is a major public health problem in developing countries. A estimated 1.8 Billion episodes of diarrhea occurs in each year in 3 million children under the age of 5 years die due to diarrhea7.

In India diarrheal disease is a major public health problem among children under the age of 5 years health institutions up to a third of total pediatric admission are

3 due to diarrheal diseases and up to 17 % of all death in indoor pediatric patients is diarrhea related.8 In 2009 one of the leading donor organizations in India ‘Rotary International has joined with government of India to help to fight against diarrhea. Diarrhea kills nearly 5 lack’s children a year in India. In Karnataka diarrhea kills 2% of neonates yearly.9

In developed countries an estimated 21 million to 37 million episodes of diarrhea occurs among 60.5 million children younger than 5 years of age annually. In the topical bet 15-40% of all death among children under 5 years are diarrhea related.10

In India oral rehydration therapy may now be preventing about 3 million dehydration deaths a year. A therapy that is safe like buttermilk relatively inexpensive and effective in ameliorating the course of illness is very important.11 In present situation many of the families are found to be nuclear and they are in back of fast foods. Many of the parents do not have adequate knowledge regarding the importance of probiotic foods and the health needs of children.

Numerous studies in a number of areas support the claims of health and nutritional benefits made for lactobacilli in fermented diary products. Direct measurement of vitamin synthesis and feed efficiency when fermented products are fed to animals confirm that fermentation of food by lactobacillai increases access to the nutrients in the food via enhance availability of digestion and assimilation. A number of intestinal infections and antibiotic associated diarrhea may prevented or treated by diary products. In case of crisis probiotics in our digestive system is a really good idea, not only does a healthy intestinal micros flora matter. In fighting infections it matters to the health of our GI System.11.

Our present concept is “We Two Our One”. So the precious child is to be given more importance in improving their health by providing probiotic foods. When the investigator come across the family members during her clinical experiences, she found that many of the children have diarrhea, gastro intestinal disturbances so she found that the mothers having limited knowledge regarding the naturally

4 occurring probiotic foods and its effect on improving dehydration. That’s why the investigator had taken the effort to give probiotic foods in managing diarrhea.

6.3 Statement of the problem “ A study to assess the effectiveness of structured teaching programme on knowledge regarding probiotic therapy on prevention and management of diarrhea among mothers of under five children in a selected hospitals at Hassan.”

6.4 Objectives of the study

 To determine the knowledge of mothers of under five children regarding probiotic therapy on prevention of diarrhea before structured teaching programme.  To administer structured teaching programme regarding prevention and management of diarrhea among mothers of under five children..  To evaluate the effectiveness of structured teaching programme regarding probiotic therapy on prevention of diarrhea after structured teaching programme.  To compare the pre test and post test knowledge of mothers of under fives regarding probiotic therapy on prevention of diarrhea.  To associate pre test and post test knowledge of mothers with selected socio demographic variables. .

6.5 Hypothesis H1: There is a significant difference between the pre test and post test score among mothers of under five .. H2: There is a significant association between the post test knowledge score and selected demographical variables.

6.6 Assumptions

5  Mothers of under five children have less knowledge regarding probiotic therapy.  Diarrhea is one of the most chronic problem and not prevented among under five children.  The awareness regarding prevention and management of diarrhea among under five children can be enhanced through structured teaching programme on probiotic therapy.

6.7 Operational definitions.  Assess-It refers to determine the existing knowledge of mothers of under five children..  Effectiveness- It refers to increase the level of knowledge of mothers of under fives after structured teaching programme...  Structured teaching programme.-It is a systematically prepared teaching method which will be taken to educate the mothers of under five children regarding probiotic therapy on prevention and management of diarrhea.  Knowledge –It refers to relevant information regarding probiotic therapy on prevention of diarrhea and its management among the mothers...  Probiotic therapy-It is a form of fermented foods such as yogurt ,butter milk ,sour cream, pickles, mushrooms.ect.to improve the health of gastro intestinal system..  Prevention-It refers to the action which halts before occurrence of diarrhea through probiotic therapy.  Management-It referred to the action which can reduce and treat the Symptoms of diarrhea in children.  Diarrhea-It referred to the passage of liquidity stool s more than 3 times a day in children.  Mothers of under five children-It refers to the mothers who are having children from birth to 5 years of age.

6.7 Conceptual frame work.

6 “General system theory is planned to apply for this study”

6.8 Delimitation  The study is limited to mothers of under five children in the selected hospitals at Hassan.  Sample size is limited to 60 mothers of under five children in a selected hospitals at Hassan ..  Study period is limited too 4-6 weeks

6.9 Review of Literature

Review of literature is a key step in research process. Review of literature is the reading and organizing of previously written materials relevant to the specific problems to be investigated: Framework and methods appropriate to perform the study 12.

The study conducted in poor Indian communities with a probiotic supplementation for improving the growth of children and preventing diarrhea. They selected children aged till 4 years and 100 children from urban slums of Delhi is selected. Intervention group received probiotics supplements for six months. After 6 month experimental group reduce the incidence of diarrhea 13

The study was conducted on probiotic for the prevention of pediatric antibiotic associated diarrhea. A randomized parallel control trial comparing co administered probiotics with antibiotics for the prevention of diarrhea secondary to antibiotic use in children birth to 18 years. Six studies used a single strain probiotic agent and four combined two probiotic strains, 9/10 trials reporting significant result favoring probiotics are active and concluded that probiotic shows promise for the prevention of pediatric antibiotics associated diarrhea.14

7 The study conducted on probiotics and neonatal intestinal infection. It examines the role of gut microbial colonization. The administration of probiotic to preterm neonates decreases both incidence And severity of subsequent necrotizing entrocolitis and summarizes as probioic represent a therapeutic effect to bolster natural host defenses via the normalization of abnormal gut micro flora of the premature infant at risk, reducing thread of necrotizing enterocolitis.15

The study was conducted on safety and possible antidiarrheal effect of the probiotic Lactobacillus reuteri after oral administration to neonates. The aim was to study safety aspects following daily intake of Lactobacillus reuteri given from the day of birth to following 28 day. The degree of Lactobacillus reuteri colonization measured as the number of living cells in the stool samples. The occurrence of watery diarrhea was significantly lower in children given Lactobacillus reuteri . 16

The study was conducted on bacteriotherapy with lactobacillus reuteri in Rota virus gastro entritis.Certain lactic acid bacteria may accelerate recovery from acute diarrhea among children between 6 to 36 months of age admitted for Rota virus associated diarrhea were randomized in to three groups to receive L. reuteri, The results shows Lactobacillus reuteri colonized the gastro intestinal tract after administration and significally shortened the duration of watery diarrhea.17

The study on Lactobacillus reuteri as a therapeutic agent in acute diarrhea in young children. A prospective randomized and placebo control study of 40 children aged 6 to 36 months, who were hospitalized due to acute diarrhea caused by Rota virus 75% .The children receiving active treatment were given Lactobacillus reteri daily dose for uto 5 days. A significant effect was apparent from the second day of treatment .74% active group were free from diarrhea. 18

The study conducted on use of probiotic lactobacillus preparation to prevent diarrhea associated with antibiotics to determine the efficiency of a probiotic drink contain lactobacillus for the prevention of any diarrhea associated with antibiotic use and that caused by Clostridium difficle . Randomized double blind

8 placebo control study, 135 hospital patients taking antibiotics consumption of a 100 gram drink contain lactobacillus casei . The absolute risk reduction was 17% 27%. The consumption of a probiotic drink contains Lactobacilli casei. This has the potential to decrease morbidity, health care costs and mortality 19

The study conducted on probiotics in the treatment and prevention of acute infections diarrhea in infants and children. Randomized double blind placebo controlled trials on probiotics in the treatment or prevention of acute diarrhea defined as .>3 loose watery stools per 24. hours in infants and children. They use of probiotics as compared with a significantly reduced the risk of diarrhea lasting >3 days. Probiotics significantly reduced the duration of diarrhea when compared with placebo. They concluded that there is evidence of clinically significant benefits of probiotics in the treatment of acute infectious diarrhea in infants and children.20

The study conducted on probiotic for the prevention of community acquired diarrhea in young Mexican children. A prospective randomized double blind and placebo controlled study of 258 healthy children aged 12-36 months living in Mexican city. The aim was to study the preventive effect of probiotics in relation to the diarrheal disease of different causes. For 4 months the children took a daily drink of a probiotic mixture of lacto bacillus reuteri per day, or a placebo drink. Lacto bacillus reuteri 76% were extremely free of diarrheal disease in control group 64% escaped diarrheal disease.21

The study conducted on the effect of probiotic lactobacillus strains in young children hospitalized with acute diarrhea. Oral bacterial therapy promotes recovery from acute childhood diarrhea. Sixty Nine children were randomized during hospitalization. And receive a mixture of Lactobacillus rhamnosus and Lactobacillus reuteri. In patients receiving probiotics, the diarrheal phase was reduced by 20%. In control group 3 of 30 patients from the treatment group had loose stools at the end of the study. In conclusion Oral bacteriotherapy reduced the length of hospital stay. The beneficial effects were most prominent in children treated early in the diarrheal phase.22

9

7. Material and method of study 7.1 Significance of study The purpose of the study is to improve the knowledge of under five children regarding probiotic therapy on prevention of diarrhea.

7.2 Source of data The Data will be collected from 60mothers of under five children who are admitted to selected hospital at Hassan.

7.3 Research design

Pre experimental study with one group pre and post test research design..

Group Pretest Intervention Post test Mothers of under 01 X 02 fives in a selected hospital at Hassan

01 - Pre test knowledge among mothrers of under five. X - Structured teaching programme regarding probiotic therapy on prevention and management of diarrhea.. 02 - Post test knowledge.

7.4 Method of data collection Part 1- Data will be collected after obtaining consent from the authority and subjects. The back ground information will be collected through socio demographic variables. Part 2- The level of knowledge will be assessed by the structured questionnaire

10 7.5 Sampling procedure 7.5.1 Criteria for sample selection Inclusion criteria:-  The mothers who are having under five children,.  Mother who are available during the period of data collection.  Mothers who can read write either Kannada or English. Exclusion Criteria:-  Mothers who are not available during the period of data collection  Mothers of under five children who are not willing to participate in the study  Mothers who cannot read write either Kannada or English..

7.5.2 Population This study includes all the mothers who have under five children in a selected hospital at Hassan.

7.5.3 Sample Mothers of under five the children who full fill the inclusive criteria.

7.5.4 Sample size In this study sample size will be 60 mothers who have children below 5 years. . 7.5.5 Sample technique Non Probability convenient sampling technique will be adopted for this study.

7.5.6 Setting

11 The study will be conducted in Rajeev Hospital and SSM Hospital at Hassan.

7.5.7 Pilot study Pilot study is planned with 10% population.

7.6 Variables Independent variables. ;- structured teaching programme. Dependent variables. ;-knowledge regarding the probiotic therapy for prevention of diarrhea among mothers of under fives.

7.7 Plan for data analysis The plan for data analysis includes descriptive and inferential statistics Descriptive statistics To describe demographic variavbles, and level of knowledge, number, frequency, mean percentage ,and standard deviation. Inferential statistics  “t” test will be used to compare pre and post test scores .  The chi-square test. Will be used to find the association between demographic variables with knowledge scores.  Paired t test value will be calculaterd to assess the effectivenss of structured teaching programme.

7.8 Ethical consideration 7.8.1 Does the study require any investigation or intervention to be conducted on mothers of under five children? Yes. The investigator needs to assess the knowledge of mothers of under five children regarding probiotics on prevention management of diarrhea.. 7.8.2 Has ethical clearance being obtained from your institution Yes Ethical clearance has been obtained from the principal.

12 8. REFERENCES 1. Parul Dutta..Pediatric nursing.1st ed .New Delhi: Jaypee brothers;.285 2. Dorothy R Marlow,Barbara A Redding .The Text Book of pediatric nursing. 6th ed . Penusylvania:Saunders publication.;2002.621 3. A Parthasarathy. IAP Text Book of Pediatrics.3rd ed .New Delhi;Jaypee publication .478 4. Meherban singh.Esssential Pediatrics for Nurses.2nd edNew Delhi;.Sagar Publication 298-301 5. Tonta J.etal.Acute Gastro enteritis:A Review of accepted and future therapies.division of Gastro enterology.2009;28-29 6. Maddie Ruud.Health benefits of probiotics-Food sources and supplements.2009; 74 7. S.Sarkar.Probiotic therapy for Gastro intestinal Allergic infants.British food Journal.2008;109(6):481-492 8. K Park.Preventive and Social Medicine.18th ed .india:M/S Bhanarsidas Bhanot Publishers.2005.184 9. Nabeal A Khan.Rotary plan antidiarrhea compagian in India.2009;2 10. Hockenberry,Wilson.etal.Wongs Nursing care of Infants and Children. 7th ed.Missouri:Mosby Publication.2006.1207 11. Guarner F.Probiotics:Giving your gut the “Friendliness”.2003;512-19. 12. Polit DE and Hungler.Text book of Nursing principles .Lippincott publications.57 13. Prasanna Krishna.etal.Use of fermented foodsto compact stunting and Failure to Thrive.New Delhi.May 2002;18(5)393-396 14. Johnson BC.etal.Probiotics for the prevention of Pediatric antibiotics associated diarrhea.April2007 15. Cathy Hammerman.etal.Probiotics and neonatal intestinal infection.june2006;19(3):277-282

13 16. Karvonen A etal Safety and possible antidiarrhoel effect of the probiotic lactobacillus reuteri after oral administration to neonates. Clinical nutrition 2001:. 20 (3).216. 17. Shornikova.etal.Bacteriotherapy with lactobacillus reuteri in rota virus gastro enteritis.Pediatric infective disease journal.1997;16(12):1103-1107 18. Casas I A et al . Lactobacillus reuteri as a therapeutic agent in acute diarrhea in young children. 1997; 24.399-404. 19. Hickson M.Use of probiotics lactobacillus preparation to prevent diarrhea associated with anti biotics.London:Imperical college .Apr 2008;11(2):57 20. Szajewska H.et al.Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children.Journal pediatric gastro enterology and nutrition.2001;33(20:17-25 21. Ruiz palacios G.etal.Feeding a probiotic for the community acquired diqarrhea in young Mexican children.1996;39(4) 22. Rosenfeldt,-V: et al. Effect of probiotc Lactobacillus strains in young children hospitalized with acute diarrhea. Pediatr-Infect-Dis-J.202 May; 21(5): 411-6.

14