Rajiv Gandhi University Of Health Sciences, Bangalore, Karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. NAME OF THE CANDIDATE Mr. MALI SACHIN POPAT AND ADDRESS GOUTHAM COLLEGE OF NURSING, MANJUNATHNAGAR, WEST OF CHORD ROAD, RAJAJINAGAR, BANGALORE – 560 010. 2. NAME OF THE INSTITUTION GOUTHAM COLLEGE OF NURSING, MANJUNATHNAGAR, WEST OF CHORDROAD,RAJAJINAGAR, BANGALORE – 560 010. 3. COURSE OF STUDY AND I YEAR M.Sc. NURSING SUBJECT PAEDIATRIC NURSING 4. DATE OF ADMISSION TO 30.05.2007. COURSE 5. TITLE OF THE TOPIC A QUASI EXPERIMENTAL STUDY TO ASSESS EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF DOMICILIARY MANAGEMENT AND PREVENTION OF UPPER RESPIRATORY TRACT INFECTIONS AMONG MOTHERS OF UNDER FIVE CHILDREN IN SELECTED URBAN SLUM OF BANGALORE.

6. BRIEF RESUME OF THE INTENDED WORK:

1 6.1. NEED FOR THE STUDY Children constitute foundation of a nation. Healthy children grow to become healthy adults with optimal physical strength and emotional poise to become useful members of our society and contribute effectively in the nation building process. In India under-five children constitute about 13% of the total population of India.1 Health of the under-five children in India is not satisfactory. Every year some 12 million children in developing countries die before they reach their fifth birthday, many during first year of life. Seven in ten of these deaths are due to acute respiratory infections (mostly Pneumonia), diarrhea, measles, malaria, malnutrition or a combination of theses illness.2 Acute respiratory illness ranges from common cold, cough, ear infection and pneumonia. It is most common cause of morbidity and mortality in children under the age of five years. Hospital based statistic shows that about 13% in patient deaths of pediatric ward are due to Pneumonia.3 ARI means an infection of any part of respiratory tract of less than 30 days duration except otitis media, which is of less than 14 days.3 A child in urban area suffers from 5-9 episodes of respiratory infections annually during the first five years of life, each episode lasting for a mean duration of 7-9 days whereas in the rural areas the annual incidence per child is lower and ranging from 1-3 episodes per year thus accounting for about 238 millions attacks per year. Without adequate treatment the child may die within 4-5 days of onset of illness.3 WHO report of 2002 estimates the probability of dying for under-five children to be around 91 per 1000.1 Globally, acute respiratory infections (ARI) and acute diarrhoeal diseases (ADD) constitute 19% and 17% of mortality respectively in under-five age group.2 Morbidity is similar for ARI in developing and developed country but mortality 30 times greater in developing countries. In India mortality of under- five children is mainly due to acute respiratory infections (ARI) 23% and diarrhoeal diseases 18% as per WHO report 2002.1 As per WHO estimates, respiratory infections caused about 987000 deaths in India, of which 969000 were due to acute lower respiratory infections (ALRI). 10,000 due to acute upper respiratory infections (AURI), and about 9000 due to otitis media. The burden of the disease in terms of DALYs lost was 25.5 million of these 24.8 million were due to ALRI, 2.74 lacks due to AURI and 4.75 lacks due to otitis media.4

2 A study conducted on An evaluation of diarrhoeal diseases and acute respiratory infections controlled programme in Delhi slum with objective of effective early domiciliary management and health seeking behavior in case of appearance of danger signs in ARI. The result showed that one or more danger signs were known to 80% of mothers. Only 16% of mothers aware that ARI are mostly mild or self limiting. Though the mothers are aware of danger signs of ARI mothers still seeking Medical advice for mild cases of ARI and doctors are also prescribing drugs. Knowledge about domiciliary management was deficient in mother for mild ARIs.2

The child rearing practices play an important role in determining the health of children. Today teaching about prevention and health promotion are considered essential components of comprehensive health care. Since “Prevention is better than cure” teaching, giving information and involving the parents in the caring for the sick child will minimize complications. Studies show that a planned teaching programme is known to bring about changes in the existing knowledge.

A large number of diseases could be prevented with little or no medical interventions. Mothers play a key role in the management of child with URTI. Mothers has to understand that the appropriate decision making, recognize the mild, moderate and severe respiratory infection and initiate correct domiciliary management for upper respiratory infection at home as soon as possible to prevent the progression of the infection. The ignorance and inadequate knowledge are important factors, which affects health of child. If upper respiratory infection is not treated in early stage it may leads to certain complications like staphylococcal pericarditis, empyema, pneumothorax, and staphylococcal pneumonia. Which increases the risk of child mortality. Therefore the investigator felt the need to provide accurate information about prevention and domiciliary management of upper respiratory infection to the mothers to help them to provide effective home management to children suffering from upper respiratory infection. 6.2. REVIEW OF LITERATURE: “Review of literature does for us what a map does for the traveler.” The literature is reviewed and organized under following headings. 1. Studies related to incidence of upper respiratory tract infections. 2. Studies related to knowledge on prevention of upper respiratory tract infection among mothers.

3 3. Studies related to various management of upper respiratory tract infections. 4. Studies related to effectiveness of structured teaching programme. 1) Studies related to incidence of upper respiratory infection. A descriptive study conducted to correlate acute respiratory tract infection (ARI) among infants in selected area of udpai district. 110 mothers and infants above three months were selected for study. Structured interview schedule was used for data collection. Majority of children that is 60.9% had ARI 4 to 6 times in past three months. During one-month observation maximum number of children (48.6%) had at least suffered from ARI once. Chi square values computed between occurrence of ARI and selected variables revealed significant association between occurrences of ARI and physical health of the infant and environment pollution. The study showed that majority of children suffered 4-6 times with respiratory tract infection in three months of study period.5 A longitudinal a study conducted on ARI among rural under fives. This longitudinal study was formulated with the objective to determine the ARI morbidity among the rural under fives and to study some of the epidemiological factors responsible for such morbidity. All 63 children less than 5 years of age living in the village of Durgarampur (population 548) in Singur block of district Hooghly were included in the study. All children were followed up with periodic home visits at two weeks interval for 6 months. Frequency of ARI episodes was studied and association with study variables was analyzed. Overall incidence density rate of ARI episodes was 19.57 / 100 person / month at risk. Incidence was highest in infants 23.9/100 persons /month. Risk ratio analysis showed that low socio-economic class, low birth weight, under nutrition, inadequate immunization, children not exclusively breastfed and indoor smoke pollution were significantly associated with increasing number of ARI episodes. The study strongly point towards the importance of basic health promotional measures like proper infant feeding practices, proper nutrition of the child, improved general conditions of living in prevention and control of ARI.6 2) Studies related to knowledge on prevention of upper respiratory infection among mothers. A study conducted on knowledge and practice regarding Acute Upper Respiratory Tract Infection in selected rural area in South Bangalore. Conceptual framework adopted for the study was based on Nightingale’s Environmental model.

4 A descriptive and evaluative approach was adopted for the study. The data was collected by Semi structured interview schedule. Sample consisted of 60 mothers using simple random sampling technique. Main findings of the study were there is significant association between knowledge and practice with selected demographic variables like education occupation medium of cooking type of. There is high positive correlation between knowledge and practice. About 48.3% on mothers had inadequate knowledge about common cold. Majority 70% of mothers practice level regarding management of AURI was unsatisfactory, so the need for improving the level of knowledge and practice was widely recognized. Mass and individual education in regional languages to enlighten the mothers can be organized at all levels of health facilities.7 A study conducted on knowledge and practices of mothers in rural Haryana. In this study data was collected on knowledge and practices of mothers in two villages of block Beri of district Rohtak for devising a standard management plan. 304 mothers were interviewed. About 23% of mothers recognized pneumonia by fast breathing and 11.2% recognized severe pneumonia by chest indrawing. Only 1.3% mothers knew infective origin of ARI. Although most of them were convinced about continuation of breast-feeding, 70% of them were advising food restriction, use of herbal tea in ARI was widely prevalent and so was the practice of putting warm mustard oil in ear for curing ear pain. Primary health centre was the most frequent place for treatment of ARI.8 A study conducted on knowledge, attitude and practice regarding acute respiratory infection. 106 mothers in rural area were interviewed to determine how they would recognize pneumonia in children, what therapies they would practice with mild acute respiratory illness (ARI) and pneumonia and the feeding practices they have adopted. Most mothers recognized pneumonia by observing the quick respiratory ate and difficulty in breathing, with regard to management of mild ARI episodes, more than ½ of the mothers preferred not to give any treatment or to use only home remedies. In pneumonia a majority preferred to consult a qualified doctor. As far as feeding concerned, most of them stated that they would continue feeding, fluids, and breastfeeds. Only 10% said they would stop feeding.9 A study conducted on maternal knowledge attitude and practices regarding childhood acute respiratory infections in Kumasi, Ghana. 143 women traders were interviewed in open-air market in Kumasi, Ghana who had at least one child aged less than five years. The study showed that 73.4% had a child or children who had

5 suffered from cough, fever within the last 6 months. 73.4% said that cold as a direct cause of cough. Many women said worm infestation for causing cough and fever (21%), and constipation for causing cough (25.9%). None mentioned pathogens as cause of cough and fever. None said that good ventilation and avoidance of over crowding prevent cough and fever. If there are more serious symptoms the mothers are more likely to seek treatment of a health care facilities ( e .g cough only 0.7%; cough with fever 6.3%; cough, fever and anorexia 30%; cough, fever and lethargy 57.3%). Honey and cough syrup were often used to treat cough and fever but some herbal and home care therapies had potentially harmful effects for example 25.9% said that they used castor oil and enema to prevent ARI. The women had an acceptable knowledge score on severity of symptoms. These findings indicate need for health education programme on domiciliary management and prevention of URTI targeting mother of children aged less than five years.10 3) Reviews related to knowledge of various management of upper respiratory infection. A study conducted on “How do mothers recognize and treat pneumonia at home?” Two hundred mothers of under-five children having lower respiratory tract infection were interviewed with the help of pre-tested unstructured questionnaire to know the danger signs perceived by her in a child suffering from pneumonia and home remedies used by them before seeking medical help. Retraction and refusal to feed were the most common symptoms perceived as dangerous. Retraction in 91.1% and fast breathing in 8.1% cases. Honey 25% and ginger 27% were the most common home remedies used for the relief of cough, self advised medications were used by 24% of mothers and majority 58.4% gained this knowledge from mass media.11 A study conducted on ARI concepts of mothers in Punjabi villages, a community based study. Pneumonia is a major child killer in the developing world; to prevent such deaths, mothers must be able to differentiate pneumonia from common cold. Local concepts regarding these illnesses were studied by interviewing 315 mothers of young children in their homes in Punjabi villages. Mother described Pneumonia differently from cough and cold but only few said fast breathing as a sign of pneumonia. Both illness were thought to be caused by “coldness” and initially treated with “heat-producing” home remedies and feeding was continued in both. Spiritual healers were not consulted for cough and cold or pneumonia virtually all mothers said that allopathic medicines were necessary for

6 both illness and 2/3rd said that if child is not improved after 2 days of a given medicine they would change the medicine or the doctor.12

A study conducted on health behavior of rural mothers to acute respiratory infections in children in Gondar, Ethiopia. 132 mothers with at least one child younger than 5 years old living in the village of Dembosge, researcher took one- month duration to assess the mothers, knowledge, attitudes and practices regarding acute respiratory infections in their children. Most mothers recognized that respiratory rate (77.3%) high fever (76.5%) and decreased feeding (62.8%) were important signs of pneumonia. They all new that grunting was also new an important sign. Only 35.6% would take their child with these symptoms to a nearby health center. Other common treatment was taking child to a traditional healer (64.4%) and applying butter and herb to the chest via a massage at home (95.5%). The traditional practices were predominant interventions proposed by the mothers for mild ARI (e.g. cold, sore throat and ear discharge). Most 58.3% mothers proposed to clean the ear and to keep it dry. 85.6% of mothers would take their child with a sore throat to a traditional healer for tonsil extraction, a hazardous practice.13 4) Reviews related to effectiveness of structured teaching programme. A pre-experimental study was carried out in the field practice area of M.S. Ramaiah Medical College Bangalore, Karnataka to assess the impact of educational intervention on the knowledge of mothers of under five children on home management of diarrhoeal diseases. Sample of 225 mothers were included in the study. The study was conducted in 3 stages. Stage I-initial knowledge, attitude and practice of mothers were assessed. Stage II-one to one educational intervention was conducted and supported by audiovisual aids and live demonstration. Stage III- included post intervention knowledge, attitude and practice after 2 months and 2 years. After the educational intervention, there was significant improvement on knowledge of mothers regarding definition of diarrhea, signs of dehydration, awareness of ORS solution, correct preparation of ORS solution, shelf life of ORS solution, seeking health care and rational drug therapy during diarrhea. McNemar test was used to find out the change in knowledge before and after the educational intervention. The overall knowledge scores improved significantly after 2 months as well as 2 years of the educational intervention. Though the proportion of mothers retaining the knowledge at the end of 2 years dropped, yet there was significant

7 improvement when compared to the baseline study.14

A study was designed to determine the effect of the health education program in terms of changes in mothers' knowledge, practices and beliefs using Health Belief Model, and to determine the hemoglobin and hematocrite levels of the children of the target group before and after the program. The sample size was 200 anemic children aged 6-24 months and their mothers, 100 of them were randomly assigned to face-to-face intervention program (experimental group) (I), the other 100 were the control group (II). Only 16% of mothers of group I and 18% of mothers of group II got satisfactory level of knowledge. After the conduction of health education program, the mothers' knowledge was significantly increased among group I, while almost there was no change of the knowledge's level among group II. Only 28% of mothers of group I and 21% of those of group II had good dietary practice. After the program, 74% of mothers in-group I showed good dietary practice. There were highly significant increases in the levels of hemoglobin and hematocrite of children of group I after the program, while the increases were not significant in-group II.15 6.3. STATEMENT OF THE PROBLEM A quasi-experimental study to assess effectiveness of structured teaching programme on knowledge of domiciliary management and prevention of upper respiratory tract infections among mothers of under five children in selected urban slum of Bangalore. 6.4. OBJECTIVES OF THE STUDY: 1) To assess the level of knowledge on domiciliary management and prevention of upper respiratory tract infections among mothers of under-five children. 2) To assess the effectiveness of structured teaching programme on domiciliary management and prevention of upper respiratory tract infections 3) To determine the association between knowledge on domiciliary management and prevention of upper respiratory tract infections and the selected demographic variables. 6.5. OPERATIONAL DEFINITIONS: 1. Effectiveness – Refers to determine the extent to which structured teaching programme has achieved the desired effect which will be measured in terms of significant gain in knowledge as determined by difference in post-test knowledge scores of mothers of under-five children.

8 2. Assess – Knowledge of mothers of under-five children on domiciliary management and prevention of upper respiratory tract infections by using structured interview schedule. 3. Knowledge-Refers to the information and understanding of mothers of under five children about domiciliary management and prevention of URTI. 4. Structured teaching programme – Refers to systematically organized teaching programme of one hour duration for group of mothers of under- five children to provide knowledge regarding ‘domiciliary management and prevention of upper respiratory tract infections. 5. Domiciliary management – Activities provided by mothers for treating the children suffering from upper respiratory tract infections with things available at home like honey, ginger, turmeric, tulsi etc. 6. URTI- Upper respiratory tract infections are inflammation of upper respiratory tract that is ear, nose and throat leads to common cold, pharyngitis and otitis media. 7. Mothers of under-five children – Refers to urban slum community women who were having children in the age group of 0-5 years. 8. Urban slum –Refers to setting or place where the study conducted that is an overcrowded area which is unfit for human habitation.

6.6. HYPOTHESES:

H1: There will be significant difference between post test and pre test knowledge score of mothers of under five children among experimental group.

H2: There will be significant difference in knowledge score of mothers of under five children between experimental and control group. 6.7. ASSUMPTIONS: It is assumed that: 1. Education to mothers through structured teaching programme will bring about changes in caring the children with domiciliary management and prevention of URTI. 2. Structured teaching programme is an accepted and effective way to provide adequate knowledge to mothers of under five children. 3. Mothers play vital role in minimizing the morbidity and mortality rate among under-five children.

6.8. DELIMITATIONS:

9 1. Mothers of under-five children of urban slum of Bangalore will be included in the study. 2. The study will be conducted in urban slum area only and will not be included rural area. 3. The practices may not be observed but through the questions the practices of mothers will be found out.

6.9. PROJECTED OUTCOME: 1. Structured teaching programme on domiciliary management and prevention of URTI can be useful for the mothers of under-five children in slum area of Bangalore for caring their under-five children with URTI.

2. The study will generate new knowledge on domiciliary management of URTI and potentially more cost-effective teaching method.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA Mothers who are having under-five children

7.2 METHOD OF COLLECTION OF DATA

7.2.1. SAMPLING CRITERIA 1. Mothers who are having under-five INCLUSION CRITERIA children

2. Residing in urban slum area at Bangalore.

3. Able to understand Hindi, English and Kannada

4. Available at the time of data collection.

EXCLUSION CRITERIA 1. Mothers who had undergone health education programme on domiciliary management of URTI. 2. Residing in rural slum area.

3. Not willing to participate in the 10 study.

7.2.2. RESEARCH DESIGN Quasi-experimental design will be adopted to conduct the study. 7.2.3 VARIABLES UNDER STUDY:

1. INDEPENDENT Structured teaching programme on VARIABLE domiciliary management and prevention of upper respiratory tract infection.

2. DEPENDENT VARIABLE Knowledge of mothers of under-five children.

Age, Number of children, Education, Scio- 3. DEMOGRAPHIC economic status, Type of family. VARIABLE 7.2.4. SETTING Selected urban slum area at Bangalore.

7.2.5. SAMPLING TECHNIQUE Investigator will use convenience-sampling technique, which is a non-probability sampling method to draw samples. 7.2.6. SAMPLE SIZE The size of the samples consists of 60 mothers of under-five children. 30 samples in experimental group. 30 samples in control group. 7.2.7. TOOL OF RESEARCH Section I- Structured interview schedule to obtain demographic data. Section II- Structured interview schedule to elicit the knowledge regarding- 1. Domiciliary management of URTI 2. Prevention of URTI.

7.2.8. COLLECTION OF DATA A prior formal permission will be obtained from medical officer of urban health centre. Informal permission will be obtained from the subjects after explaining the purpose of study. A structured interview will be conducted to assess the demographic data 11 and pre test knowledge related to domiciliary management and prevention of URTI of experimental and control group. A structured teaching programme will be given to experimental group. Post-test for both the group conducted after 7 days. Duration of data collection will be 30 days. 7.2.9. METHOD OF DATA 1. Descriptive and inferential statistics ANALYSIS AND will be used for data analysis. PRESENTATION 2. The analyzed data will be presented in the form of tables, diagrams and graphs

3. Paired ‘t’test will be used to test the significance difference in the knowledge scores between pre-test and post test knowledge scores.

4. Chi-square (χ2) test will be applied to measure the association between the level of knowledge and selected demographic variables.

7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY. Yes, the study will be conducted on mothers of under-five children in selected slum area at Bangalore. 7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Yes, informed consent will be obtained from medical officer of urban health centre and from subjects. Privacy confidentiality and anonymity will be guarded scientific objectivity of the study will be maintain with honesty and impartiality. 8. LIST OF REFERENCES: 1. Sudharshana MB.Risk factors for sick children in fisherman community in

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12. Rehman GN, Qazi SA, Mulla DS, Khan MA. ARI concepts of mothers in Punjabi villages a community - based study. Journal of Pakistan medical association 1994 Aug;44(8):185-8.

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14. Mangal S, Gopinath D, Narasimhamurthy NS, Shivaram C. Impact of educational intervention on knowledge of mothers regarding home management of diarrhea. Indian journal of pediatrics 2001 Sept;68(9):901-02. 15. Hassan AE, Kamal MM, Fetohy EM, Turky GM. Health education program for mothers of children suffering from iron deficiency anemia in United Arab Emirates. J Egypt Public Health Assoc. 2005;80(5-6):525- 45. 16. Basavanthappa BT. Nursing Research.1sted. New Delhi: Jaypee brothers medical publisher; 1998.p.109-112.