Rajiv Gandhi University of Health Sciences s87

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

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME AND ADDRESS OF THE MS. ASHA K THOMAS CANDIDATE I YEAR.M.SC. NURSING, RAJEEV COLLEGE OF NURSING, K.R PURAM, HASSAN-573201. 2. NAME OF THE INSTITUTION RAJEEV COLLEGE OF NURSING, K.R.PURAM, HASSAN. 3. COURSE OF STUDY AND MASTER OF SCIENCE IN NURSING, SUBJECT OBSTRETIC & GYNAECOLOGICAL NURSING. 4. DATE OF ADMISSION TO 12-06-2009 THE COURSE

5 TITLE OF THE TOPIC STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING IMPORTANCE OF DOCOSAHEXAENOIC ACID AND FOLIC ACID IN PROMOTION OF FETAL DEVELOPMENT AND PREVENTION OF NEURAL TUBE DEFECT AMONG ANTENATAL MOTHERS.

5.1 STATEMENT OF THE A STUDY TO ASSESS THE PROBLEM EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING IMPORTANCE OF DOCOSAHEXAENOIC ACID AND FOLIC ACID IN PROMOTION OF FETAL DEVELOPMENT AND PREVENTION OF NEURAL TUBE DEFECTS AMONG ANTENATAL MOTHERS IN SELECTED HOSPITALS AT HASSAN.

1 6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION:

“Mothers Reflect God’s Loving Presence On Earth”

-William R.Webb.

Docosahexaenoic acid (DHA) is a long chain-poly unsaturated fatty acid (LCPUFA) which plays an important role in the structural development of major membrane constituent of retinal photoreceptors, neurons, and synaptic membrane. It also influences important functions, such as ion transport, receptor activity, enzyme action, and membrane fluidity, thereby improving neurogenesis and synaptogenesis. Adequate supply of DHA, therefore, needs to be ensured from maternal circulation during embryonic life and from breast milk /infant diet in early postnatal life. DHA is formed denovo by conversion of its parent essential fatty acid (EFA) -α- linolenic acid (LNA, 18:3n/3) –through a series of desaturation and subsequent chain-elongation reactions.1

This omega-3 long chain fatty acid is the primary building block of the brain and retina of the eye. The brain is 60% fat and DHA is the most abundant essential fatty acid in the brain, comprising 25-35%. DHA is found in even greater concentrations 50-60% in the retina. DHA is critical for infant development. Compelling research links DHA to the rapid cerebral cortex and eye development that occurs during pregnancy and in the first few months after birth.2

DHA is an omega-3 fatty acid. It is found in cold water fatty fish and fish oil supplements along with eicosapentaenoic acid (EPA).3

A study conducted on role of omega-3 fatty acids as a treatment for depression in the perinatal period. Result shows that correlations between low omega-3 fatty acid levels and depression, as well as reduced levels of omega-3 in non-depressed women during the perinatal period. Studies using omega -3 in patients with mood disorders further support an omega-3 contribution, as do neuro scientific theories. Research into omega-3 and

2 infant development also highlights potential effects of depletion in the perinatal period and supports infant safely and benefits of supplementation. This study concluded that there is a relative lack of knowledge about the safely standard antidepressants in the perinatal period.4

Folic acid which is also known as folate .Folate is a water soluble vitamin B complex first isolated from the spinach leaf in 1941 and synthesize in 1946. In 1960 Nelson reported on the effects of folate deficiency on the development of rat embryos. Four years latter Hibbard suggested a possible relation between fetal malformation and defective folate metabolism. This relation was investigated in greater detail and in 1965. Hibbard and Smithells proposed the link between a defect in folate metabolism and NTD in humans. Further studies lead to the conclusion that folic acid intake before conception was an inexpensive, safe and effective method of primary prevention of open neural tube defects.5

Folic acid is an essential nutrient that aids the body in making healthy new cells by helping to produce DNA and RNA. It is particularly important for women who are trying or who are pregnant. If a woman has consumed enough folic acid prior to getting pregnant it can help to prevent neural tube defects such as spina bifida and anencephaly. 6

Each year spina bifida and anencephaly the two most common forms of neural-tube defects, occur in 1 in 1000 pregnancies in the United States and an estimated 300,000 or more newborns world wide.7

A study conducted on folic acid awareness and intake survey in the United Arab Emirates. The aim of this study was to determine the level of knowledge and use of periconceptional folic acid supplementation in a sample of postpartum women recruited from three hospitals. Univariate analyses showed that overall 46.4% of the respondents had heard about folic acid and only 8.7% knew that it prevented birth defects. 45.5% of respondents took folic acid in the first trimester. The percentage of women who had ever heard about folic acid was higher in those with higher education. This study concluded

3 that awareness of the value of periconceptional folic acid was very low and use of folic acid was less prevalent among women of UAE nationality.8 . 6.2 NEED FOR THE STUDY The prevalence of neural tube defects has been reported at 5 per 1,000 births in the UK, 3 per 1,000 in Hungary 1 per 1,000 in USA, France, Australia, and Japan. The rate of recurrence in the sibling was 5, 3 and 1 per 1,000 in these countries, respectively in India; one study from Karnataka has reported a prevalence rate of 11.4 per 1,000.9

Incidence of neural tube defects in the least developed area of India. Hospital- based records from major cities of India where roughly a quarter of the population resides, identified, the frequency of neural tube defects as ranging from 3.9 to 8.8 per 1,000 births. A population based door-to door survey of mothers living in remote clusters of villages in Balarampur District in Uttar Pradesh a region ranked as the least-developed area in India. The data showed that the incidence of neural tube defects was 6.57-8.21 per 1,000 live births which is among the highest world.10

There is a decreased intake of omega-3 fatty acids or deficiencies of micronutrients are a global health problem. The daily periconceptionally intake of folate acid that has been shown to reduce substantially the occurrence and recurrence of neural tube defects. Deficiencies of omega-3 folic acid may be a contributing factor for severe complications in pregnancy and post partum.11

A study conducted on prevalence of anemia among pregnant women and adolescent girls in 16 districts of India. The sample was selected by two-stage random sampling method. The study results revealed that 84.9% of pregnant women (n=6,923) were anemic. 13.15 had severe anemia and 60.1% had moderate anemia. This study concluded that interventions strategy should be done for the population to prevent iron, folic acid and B12 deficiencies.12

4 A study conducted on the Washington DC based society for women’s Health Research conducted a public opinion survey involving 500 American women. The majority of women surveyed know the importance of including folic acid and calcium with vitamin D in their diet, but half of them do not know about the need for DHA omega-3, a critical nutrient for the development and health of a baby’s brain, heart and eyes.13

A study conducted on advice to pregnant: an omega-3 project. In stage one health care providers (n=17) were recruited and interviewed (midwives n=7, dietitians n=7, Gps n=3) about their knowledge of LC n-3 PUFA. In stage 2 pregnant women (n=190) were recruited from antenatal clinics and completed the survey regarding risk and benefits of LC n-3 PUFA and fish consumption. The study result shows that four of 17 interviewed health care providers had a wide knowledge of LC n-3 PUFA. Dietitian (with most knowledge of LC n-3 PUFA) only sees pregnant women if there are underlying nutritional disorders. This study concluded that pregnant women receive very limited amount of information on the importance of LC n-3 PUFA as a result of health care provider’s lack of knowledge and not providing women with adequate information.14

The investigator out of her own experience during her practice in the field of nursing found that many antenatal women were having lack of knowledge regarding Docosahexaenoic acid and folic acid for promotion of fetal development and prevention of neural tube defects. Thus the investigator felt that structured teaching programme is the basis to get rid from the ill effects caused by the failure in intake of DHA and folic acid in the apt time. Hence it is of paramount important to educate the antenatal mothers regarding the importance of DHA and folic acid. The student investigator acknowledges that no study has been conducted regarding DHA and folic acid among antenatal mothers in selected hospitals of Hassan.

5 6.3 STATEMENT OF PROBLEM A study to assess the effectiveness of structured teaching programme on knowledge regarding importance of Docosahexaenoic acid and folic acid in promotion of fetal development and prevention of neural tube defects among antenatal mothers in selected hospitals at Hassan.

6.4 OBJECTIVES 1. To assess the level of knowledge regarding the importance of Docosahexaenoic acid and folic acid in promotion of fetal development and prevention of neural tube defects before the structured teaching programme. 2. To evaluate the effectiveness of structured teaching programme on knowledge regarding the importance of Docosahexaenoic acid and folic acid in promotion of fetal development and prevention of neural tube defects among antenatal mothers. 3. To associate the knowledge level of antenatal mothers with selected demographic variables.

6.5 HYPOTHESIS H1-There is a significant increase in the post knowledge level of antenatal mothers after the structured teaching programme. H2-There is a significant association of post test knowledge level regarding the importance of Docosahexaenoic acid and folic acid with the selected demographic variables.

6.6 OPERATIONAL DEFINITIONS Assess It refers to the estimation of knowledge on antenatal mothers regarding importance of Docosahexaenoic acid and folic acid.

6 Effectiveness It refers to the extend to which the structured teaching programme has achieved the desired effect in improving the knowledge level of antenatal mothers regarding the importance of Docosahexaenoic acid and folic acid. Knowledge It refers to the sources obtained by the antenatal mothers through a structured questionnaire regarding the importance of Docosahexaenoic acid and folic acid. Structured teaching programme It is a systematically prepared teaching programme which will be taken for 45 minutes to educate the antenatal mothers regarding the importance of Docosahexaenoic acid and folic acid in promotion of fetal development and prevention of neural tube defects. Antenatal mothers It refers to the mother who are conceived will be taken for the study from the period of first to second trimester. DHA (Docosahexaenoic acid) DHA is a building block of the brain. Its is important for the fetal brain development and function throughout life. Regular consumption of Docosahexaenoic acid by a pregnant woman helps to prevent postpartum depression, suicide and violence. Folic acid It is an essential nutrient that aids the body in making healthy new cells by helping to produce DNA and RNA. It helps to prevent neural tube defects such as spina bifida and anencephaly. Prevention The measures are instructed to the antenatal mothers to control post partum depression and neural tube defects before the occurrence.

7 Neural tube defects It refers to congenital malformations produced during intrauterine life (between 20th and 28th day) by fails to closure of the neural tube, which eventually forms the central nervous system. Selected Hospitals It refers Hassan Institute of Medical Science, Rajeev Hospital and Bharathi Hospital at Hassan.

6.7 DELIMITATIONS 1. The study is limited to antenatal mothers. 2. Sample size is limited to 60 antenatal mothers. 3. The data is collected from selected Hospitals. . 6.8 CONCEPTUAL FRAME WORK This study is based on “Wieden Bech’s Helping Art of Clinical Nursing Theory’’.

6.9 REVIEW OF LITERATURE It is a key step in research process. Review of literature provides you with the current theoretical and scientific knowledge about a particular problem and resulting in a synthesis of what is known or not known.15

A. Studies related to knowledge on DHA and folic acid. B. Studies related to effectiveness of DHA. And folic acid

A. Studies related to knowledge on DHA and folic acid. A study conducted on maternal knowledge, attitude and practice on folic acid intake among Arabian Qatari women. A multi stage sampling design was used and a representive sample of 1800 Qatari women aged between 18 and 45 years were surveyed during the period June to November 2004. The results shows that 1480 women (82.2%)

8 expressed their consent to participate in this study .Out of 1480 women surveyed53.7% of them reported that they heard of folate overall,20.3% of the respond ants took folic acid. The most common information sources on folate were physician (63.4%) and news papers/magazine/books (21.7%). From those who heard of folate, only 14% knew that it can prevent birth defects 40.6% of the subjects who heard folate were aware that green leafy vegetables were fortified with folic acid. In univariate analysis awareness of folic acid was significantly associated with education of mother. Higher educated women (41.3%) new more about folic acid and used it more often in the periconceptional and first trimester period. This study findings suggested possible a venue for intervention to increase awareness and intake of folic acid.16

A study conducted on comparison of folic acid awareness and intake among young women aged 18 to24 years. A written questionnaire designed by the researcher was administered to 138 young women. A total of 88 complete questionnaires were used for the data analysis. This study concluded that young women were not aware of the importance of folic acid were not taking multivitamins containing folic acid and not consuming enough folic acid in their diets. No relationship existed between pregnancy intention and folic acid intake, suggesting that those who were planning a pregnancy in the near future were not consuming adequate amounts of folic acid. A lack of knowledge regarding the importance of folic acid may lead to poor pregnancy outcomes.17

A study conducted on preconceptional folic acid supplement use in Lebanon and analysis was performed on 5280 mothers. The overall use of preconceptional folic acid supplementation was only 14.0%. Higher socio-economic status, lower parity and having a history of previous spontaneous abortions were significantly associated with preconceptional folic acid use. The study shows that Lebanon currently has a low rate of preconceptional folic acid supplement use. Interventions through the means of awareness campaigns need to be implemented on a national level.18

A study conducted on awareness of the benefits of folic acid and prevalence of the use of folic acid supplements to prevent neural tube defects among Thai women. Out of

9 401 women surveyed, 76.1% of them reported that they had heard of folate. Of these, only 24.4% of the total subjects knew that folate was something important. Overall, 9.7% of the total women took folic acid during periconsumptional period. This study concluded that the need to take folic acid to prevent neural tube defects by medias and health care personnel seem to improve the final intake pf folic acid during the protective period.19

A study conducted on women’s awareness of the importance of long-chain omega-3 poly unsaturated fatty acids. Consumption during pregnancy 190 pregnant women participated in the study. The result shows that three quarters of the women had not received information regarding Lcn-3PUFA. Approximately half of the women were aware of issues relating to Lcn-3PUFA. This study concluded that pregnant women lack knowledge of Lcn-3PUFA and health care services do not provide pregnant women with adequate information on the importance of eating foods high in Lcn-3PUFA during pregnancy.20

B. Studies related to effectiveness of DHA and folic acid. In a randomized, longitudinal, double-blinded conducted to determine whether a DHA-functional food during pregnancy would benefit infant visual acuity at four and six months of age. 30 pregnant women received either the DHA functional food (n=16) or the placebo (n=14). There were significant main effects for visual acuity at four months of age (p=0.018). The mean acuity scores were 3.8 ± 1.1 cycles/degree in the DHA group versus 3.2 ± 0.7 cycles/ degree in the placebo group. At six months there were no group differences. The study concluded that the DHA supplemented during pregnancy place a role in the maturation of the visual system.21

A randomized study conducted on essential n-3 fatty acids in pregnant women and early visual acuity maturation in term infants. An intervention was done to establish a distribution of developmental scores for infants of women DHA intakes considered to be above requirements against which to compare the development of infants of mothers consuming their usual diet. Results shows that more infant girls in

10 the placebo than in the DHA intervention group had a visual acuity below average (p=0.048) maternal red blood cell ethanolamine phosphoglyceride docosatetraenoic acid was inversely related to visual acuity in boys (p= -0.37, p< 0.05) and girls (p= -0.48, p< 0.01). This study concluded that some pregnant women in the study population were DHA deficient.22

In a randomized, controlled, double-blind study, 6 women at 18 weeks of pregnancy were given cod liver oil (containing 1183mg of DHA) or corn oil (placebo) until three months after delivery. All infants in the study were breast-fed until at least three months of age. Children whose mothers received the cod liver oil supplement scored significantly higher on intelligence tests at four years of age than those whose mothers received corn oil. This stud concluded that maternal DHA intake during pregnancy was the only significant variable associated with the mental processing score at four years of age.23

A study conducted on prevention of neural tube defects with folic acid in China. Among the fetuses or infants of 130,142 women who took folic acid at any time before or during pregnancy and 117,689 women who had not taken folic acid, they identified 102 and 173 respectively with neural tube defects. Among the fetuses or infants of the women with periconceptional use of folic acid, the rates were 1.0 per 1000 in the southern region. This study concluded that periconceptional intake of 400mg of folic acid daily can reduce the risk of neural tube defects in areas with low rates.24

7. MATERIAL AND METHODS OF STUDY 7.1 SIGNIFICANCE OF THE STUDY The purpose of the study is to improve the knowledge level of antenatal mothers regarding the importance of Docosahexaenoic acid and folic acid who are attending selected antenatal clinics at Hassan.

11 7.2 SOURCES OF DATA The data will be collected from 60 antenatal mothers in selected hospitals at Hassan.

7.3 RESEARCH DESIGN Quasi experimental research design with one group pre and post test design. For the study (manipulation and randomization without control group). SHEMATIC REPRESENTATION OF RESEARCH DESIGN GROUP PRE-TEST INTERVENTION POST -TEST

E O1 X O2

Key Words E - Experimental group O1 - Pre -test (assessment of knowledge before structured teaching programme) X - Structured teaching programme on importance of Docosahexaenoic acid and folic acid in promotion of fetal development and prevention of neural tube defects. O2 – Post-test (assessment of knowledge after structured teaching programme).

7.4 METHODS OF DATA COLLECTION Data will be collected after obtaining consent from the authority and subjects. The background information will be collected through socio demographic variables and level of knowledge will be assessed by structured questionnaire which is prepared by the investigator.

7.5 SAMPLING PROCEDURE 7.5.1 CRITERIA FOR SAMPLE SELECTION Inclusion Criteria All the antenatal mother who, 1. are attended antenatal clinics during first and second trimester. 2. are willing to participate in study.

12 3. can understand English / Kanada. Exclusion Criteria All the antenatal mother who, 1. are associated with other obstetric complications. 2. have other chronic illness.

7.5.2 POPULATION All the antenatal mothers who are attending antenatal clinics at selected hospitals, Hassan.

7.5.3 SAMPLES The samples selected for the study are antenatal mothers who are fulfilling the inclusive criteria.

7.5.4 SAMPLE SIZE The sample size for the study is 60.

7.5.5 SAMPLING TECHNIQUE The samples will be selected on the basis of simple random sampling technique.

7.5.6 SETTING The setting for the study is such as Hassan Institute of Medical Science, Bharathi Hospital and Rajeev Hospital at Hassan.

7.6 VARIABLES 1. Independent variable- Structured teaching programme. 2. Dependent variable- Knowledge level of antenatal mothers regarding importance of DHA and folic acid for promotion of fetal development and prevention of neural tube defects. 7.7 PLAN FOR DATA ANALYSIS

13 It includes descriptive and inferential statistics. 1. Descriptive statistics: Demographic variables, level of awareness will be analyzed using frequency, percentage, mean and standard deviation.

2. Inferential statistics: Pre and Post-test difference will be analyzed using paired t –test within the group. Association between the demographic variables and post-test level of awareness will be analysed using Pearson chi-square test (or) ANOVA test

7.8 . PILOT STUDY Pilot study is planned with 10% of population

7.9. ETHICAL CONSIDERATION 1. Does the study require any investigation (or) intervention to be conducted on Patients (or) other human beings (or) animals? Yes .Intervention will be given to the antenatal mothers in the selected Hospitals. 2. Has ethical clearance being obtained from your institution? Yes. Ethical clearance has been obtained from the Principal. 3. Has the consent being taken from authority? Yes. Consent has been taken from the medical officers of selected Hospitals at Hassan and also copy of the same letter will be sent to nursing superintendent and ward incharge. 4. Has consent being taken from the subjects? Yes. Consent has been taken from the subjects.

8. REFERENCES

14 1. http://www.ncbi.nlm.nih/gov/pubmed/16796150 2. http://www.brainy-child.com/article/brainfood.html 3. http://www.umm.edu/altmed/articles/docosahexaenoic-acid-000300.htm 4. http://www.ncbi.nlm.nih.gov/pubmed/15777365 5. Vidia L persad, michiel C. van den Hof, Johanne M. Dube,Pamela zimmer, Incidence of open neural tube defects in Nova Scotia after folic acid fortification,Canadian Medical Association Journal,2002,Vol 167[3]. 6. http://vitamins-minerals.suite 101.com/article.cfm/folic-acid. 7. Lorenzo D. Botto,Cynthia A. Moore, Muin J. Khory,J David Erckson,Neural- Tube Defects,The New England Journal Of Medicine ,2000 ,Vol 341[20],p 1509- 1519. 8. Yousef M Abdulrazzaq, Lihadh I.Al-Gazali,Abdulbari Bener,Moshadeque Hossein,Mani verghese,R.padmanabhan et.al.folic acid awareness an dintake survey in the united Arab Emirates.Reproductive toxicology 2003, Vol 17[2],P 171-176. 9. Nasib C Digra Primary Prevention Of Neural Tube Defects ,Editorial J K Science ,2004,Vol 6[1]. 10. Ani Cherian,SIju seena,Robyn K .Bullock, Asok C.Antony. Incidence of neural tube defects in the least –developed area India. The lancet 2005, Vol 366[9489]. 11. Hosli l,zanetti-Daellenbach R ,Holzgreve W, Lapaire O. Role of omega 3- Fatty acids and multivitamins in gestation.Journal Of Perinatal Medicine ,2007,Vol 35[SI]p S19-S24. 12. Totega G S ,Singh P,Dhillon B S, saxena B N , Ahmed F U ,Singh R P et.al Prevalence of anemia among pregnant women an adolescent girls in 16 districts of India. 13. Society for women’s Health Research . http://www. Womens health research .org/site/News2?page=News Article &id=6097. 14. Danka Sinikovic, Barbara Meyer.Advice to pregnant women:an omega -3 project.http://www.omega-3centre.com/wp- content/uploads/images/2009/04/drbarbarameyer.pdf.

15 15. Basavanthappa,B.T. Nursing Research,New Delhi;Jaypee Brothers Medical Publishers (p)ltd;1998. 16. Bener A.Al Maadid M G ,Al-Bast DA,Al-marris.Matrenal knowledge, attitude and practice on folic acid intake among Arabian Qatari women.Reproductive Toxicology ,2006,Vol 21[1],p 21-25. 17. Hilton J J .A Comparison of folic acid awareness and intake among young women aged 18-24 years.Journal Of The American Academy of Nurse practitioner,2007,Vol.19[10],p 516-522. 18. Tammim H ,Harrison G ,Atovi M,Mumtaz G,El-kak F,Seoud M .et.al.Pre conception of folic acid supplenment use in Lebanon,Public health nutririon,2008, Vol 12[5],p 687-692. 19. Katika Nawapun,Vorapong Phupong.Awareness of the benefits of folic acid and prevalence of the use of folic acid supplements to prevent Neural tube defects among Thai women, Archieves of gynaecology and obstetrics,2007,Vol 276[1],p 53-57. 20. http://www.ncbi.nlm.nih.gov/pubmed/18507886 21. Michelle p.Judge,OferHarel,Carol J.Lammi-Keefe.A Docosahexaenoic acid functional food during pregnancy benefits infant visual acquity at four but not six months of age.Journal of lipids ,2007,Vol 42[2],p117-122. 22. Sheila M Innis, Russel W Friesen.Essential n-3 fatty aicd in pregnant women and early visual acuity maturation in term infants .American Journal of clinical nutrition ,2008.Vol 87[3],p 548-557. 23. Julius G.Goepp.DHA and the Developing Brain.Life extension magazine ,2006. 24. Robert J Berry.Zhu Li,J David Erickson,Song Li,Cynthia A Moore,Hongwang et.al,prevention of neural tube defects with folic acid in China.The New England Journal Of Medicine,2000,Vol 341[20],p 1485-1490.