RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 Name of the candidate and ALPHONSA MATHEW address SAHYADRI COLLEGE OF NURSING, SAHYADRI CAMPUS, (in block letters) ADYAR, MANGALORE-575007.
2 Name of the institution SAHYADRI COLLEGE OF NURSING, SAHYADRI CAMPUS, ADYAR, MANGALORE-575007
3 Course of the study and subject M. Sc. NURSING COMMUNITY HEALTH NURSING
4 Date of admission to the course 30.06.2012
5 Title of the study
EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE REGARDING
MALNUTRITION AND ITS MANAGEMENT AMONG
ANGANWADI WORKERS AT SELECTED CENTRES IN
MANGALORE
6 Brief resume of the intended work
1 Introduction
“In the 19th century health was transformed by clear, clean water. In the 21st century health will be transformed by clean clear knowledge.”1
- Sir Muir Gray
According to WHO, “health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity.” Health in the broad sense does not merely mean the absence of disease or provision of diagnostic, curative, and preventive services. The state of positive health implies the notion of “perfect functioning” of the body and mind.2
Good nutrition is an essential element of good health. People adopt prudent dietary habits in order to lead a quality of life. Food should be used as a tool for building strong bodies. Basic knowledge of nutrition is helpful for everyone. But the detailed and scientific background knowledge is essential for health professionals. Nutrition can be studied at various levels to appreciate its usefulness. The benefits of good nutrition are multiple. To maintain a healthy weight, good nutrition is essential for the body and all its systems to function optimally for a lifetime. In fact, the benefits of good nutrition can be found in physical and mental health because a healthy diet provides energy, promotes good sleep, and gives the body what it needs to stay healthy.3,4
Malnutrition is an iceberg; most people in the developing countries are under the burden of malnutrition. Pregnant woman, nursing mothers, are particularly vulnerable to the effects of malnutrition. Nutritional deficiency disorders are major public health problems in India and other developing countries.1 They affect vast majority numbers of population and are responsible for approximately 55% of childhood death. Malnutrition is an important cause of childhood mortality and morbidity. It also results in retarded physical and mental growth and development, lowered vitality leading to lower productivity and a reduced life expectancy.2,5
Malnutrition is defined as “a pathological state resulting from relative or absolute deficiency or excess of one or more essential nutrient.” It comprises four
2 forms – under nutrition, over nutrition, imbalance, and the specific deficiency. Protein-energy malnutrition, vitamin deficiency disorders, and mineral deficiency are important nutritional problems in our country.6
According to the WHO, malnutrition is the gravest single threat to global public health. Malnutrition is the condition that occurs when the body does not get enough nutrients. Malnutrition is the widespread condition affecting the health of children. Scarcity of suitable foods, lack of purchasing power of the family as well as traditional beliefs and taboos about what the baby should eat, often lead to an insufficient balanced diet, resulting in malnutrition. For designing a balanced diet, it is essential to know the daily requirement of energy and different nutrients which varies for different age group, occupation and health status. Total energy metabolism is a measure of total amount of energy required during 24 hours, whether the person is resting or working. There are certain factors which influence the energy metabolism in the normal human beings.7
Anganwadi Centres (AWC) are one of the important healthcare establishments in a rural setting besides dispensaries. In order to free rural India from the grasp of problems related to healthcare, lack of education and lack of hygiene, the Government of India instated AWCs in 1975 under the Integrated Child Development Service (ICDS) scheme, addressing health issues of villages all over the country. These institutions are run by trained anganwadi workers (AWWs). The AWW is the community-based voluntary frontline worker of the ICDS programme. Selected from the community, she assumes a pivotal role due to her close and continuous contact with the beneficiaries. The output or the ICDS scheme is to a great extent dependant on the profile of the key functionary, i.e., the Anganwadi worker, her qualification, experience, skills, attitude.1
6.1 Need for the study
Malnutrition can be identified into two constituents, protein-energy malnutrition and micronutrient deficiencies, where protein-energy malnutrition is
clearly observed in India and other developing countries. Many factors, including region and caste affect the nutritional status of Indians living in rural areas. Individuals are malnourished, or suffer from under nutrition if their diet does not
3 provide them with adequate calories and protein for maintenance and growth, or they cannot fully utilize the food they eat due to illness. People are also malnourished, or suffer from over nutrition if they consume too many calories.8
The WHO says that malnutrition is by far the largest contributor to child mortality globally. Underweight births and intrauterine growth restrictions are responsible for about 2.2 million child deaths annually in the world. Deficiencies in Vitamin A or zinc cause 1 million deaths each year.7 In India there are about 60 million malnourished children and every month about one lack children die due to the effects of malnutrition. About 2.5 million children of our country are threatened by blindness in early childhood because of lack of Vitamin A and about 12000 to 14000 go blind every year because of this deficiency, which is eminently curable. About 75% to 80% of the hospitalised children suffer from some degree or type of malnutrition. Approximately 25% of paediatric beds are occupied patients whose major problem is malnutrition or in whom malnutrition is indirectly responsible for hospitalization.6
The 2011 Global Hunger Index (GHI) Report ranked India 15th amongst the leading countries with hunger situation. It also places India amongst the three countries where the GHI between 1996 and 2011 went up from 22.9 to 23.7, while 78 out of the 81 developing countries studied – including Pakistan, Nepal, Bangladesh, Vietnam, Kenya, Nigeria, Myanmar, Uganda, Zimbabwe and Malawi – succeeded in improving the hunger condition.9
New Delhi (Agenzia Fides) - "HUNGaMA" (Hunger and malnutrition) is the name of the first study carried out after years concerning the problem of child malnutrition. According to the report just submitted by the country's Prime Minister, Manmohan Singh, half the children who live in the 100 poorest districts of India suffer from atrophy or malnutrition already at the age of two. The Prime Minister noted that 42% of Indian children are malnourished and defined malnutrition a "national shame" for India.
According to the latest 2009 data provided by UNICEF there are about 61 million malnourished children in the Asian countries, one third of the global total. The current rates are alarming, 59% of children under five are suffering from
4 atrophy. In addition, because of poor information campaigns, 92% of mothers had never heard of the term "malnutrition." In fact, fewer than half of nursing mothers, and almost none know what malnutrition is. The study was carried out by the foundation Naandi in 112 districts of India, interviewing 73,000 families.
The Indian Prime Minister also said that the government has decided, among other things, to promote a multi-sectoral development programme, a communication campaign against malnutrition and initiatives to ensure the welfare of children. The fight against the scourge of malnutrition in India began in 1975 with the opening of centres dedicated to promoting nutrition and food education for their young ones. However, the programme goes on without obtaining the desired fruit. According to experts, the majority of Indian children have a diet based on a few and monotonous foods, mainly vegetables, apart from not being breastfed their mothers immediately and introduction of water as an element of the diet. Although it is a general problem that is concentrated in a few regions, particularly in the northern part of the country known by the acronym "BIMAROU" referring to Bihar-Jharkhand, Madhya Pradesh, Rajasthan, Orissa and Uttar Pradesh. In Hindi language, the word "Bimar" means sick, and these regions are generally at the top of the list as far as human development indicators are concerned.10
The anganwadi worker is the most important functionary of the ICDS scheme. The anganwadi worker is a community based front line voluntary worker of the ICDS programme. She plays a crucial role in promoting child growth and development, mobilising community support for better care of young children. Although much of the researches have been done on the nutritional status of the beneficiaries of ICDS evaluation of nutrition and health services rendered by anganwadi centres but very less focus has been shifted over to knowledge and awareness among the anganwadi workers, who are actually the main resource person of the programme and whose knowledge and skills do have a direct impact on the implementation of the programme.1,11
A cross sectional study was done in randomly selected six villages to estimate the prevalence and demographic and socio economic factors associated with malnutrition Sample size was calculated by the formula pq/L2. Six hundred and
5 fifty two under five children were examined from six villages during the period May-2006 to Nov-2007. Weight of the children was taken with the help of weighing scale. House to house survey was done and necessary data was collected with the help of pre-tested questionnaire by interviewing mothers and other care takers. Clinical examination of the children was done and anthropometric measurements were taken. Out of 652 under five children studied, 329 were malnourished. The prevalence of malnutrition was 50.46%. Children from lower socio economic status, with low birth weight were significantly malnourished.12
During community visit the researcher observed that the Anganwadi workers were not updated with current practices and trends and were poorly motivated. On a field visit it was noticed that few children were malnourished. As the anganwadi workers play an important role due to their close and continuous contact with the people of community, especially the children and women, so there is an utmost need to assess the level of knowledge in anganwadi workers regarding malnutrition and its management. Thus, the present study has been taken up with the main objective of assessing and improving the knowledge among anganwadi workers regarding malnutrition and its management.
6.2 Review of literature
Review refers to an extensive through and systematic examination of publications related to the research project, critical review refers to the examination of the strengths and weakness of appropriate publications (Seeman 1987). Review literature gives an insight in to various aspects of the problem under study. It helps the investigator in designing the framework, developing the methodology and tools for data collection and planning the analysis of data.
A cross sectional study was conducted to assess the educational qualification and experience of angawadi workers. Purposive and convenient sampling techniques
were used to select the samples and the sample size was 30. All the selected anganwadi workers were interviewed after getting the ethical clearance for the project. Pre tested questionnaire was used to collect the data. The result shown that 37% of AWW’s studied up to secondary level, 37% up to higher secondary level,
6 23% up to more than higher secondary level. Only 3% studied up to primary level. The study concluded that the mean Population served by AWWs was 1082.05 ± 366.82 in present study, where study by Datta S et al was 1202.40 ± 562.82 people. As the present study population was younger experience (mean experience of study population- 7.30 ± 6.33) was also less when compare to Datta s et al (16.14 ± 10.44) study. 13
A descriptive study was conducted to assess the prevalence of malnutrition among children .The sample size was 1661 children aged between 6 months to 2 years of age, convenient sampling technique was used to select the samples. The data was collected by using pre tested and pre structured questionnaire. The mothers were interviewed to collect the information regarding socio-demographic factors, breast feeding and weaning practices. Status of the child was assessed with the help of anthropometric measurements and using weight for age criteria. The NCHS standards for weight for age were utilized for classification of children in various grades of nutritional status. The weight of the subjects was recorded using weighing scale with minimal clothing and bare feet. The result of the study was 1474 (88.7%) of the father's were literate as against 1124 (67.7%) of the mothers. A total of 1009 (60.7%) of the subjects were malnourished. Colostrum was given by 712(42.9%) as against 949(57.1%) who had not given. 64.8% of those who were not exclusively breast fed for the first four months of life were malnourished as compared to 35.2% of those who were exclusively breast fed till four months of age and the difference is statistically significant.(p<0.05). Similarly, significant association was found between practice of commercial formula feeding and malnourishment. As high as 1425 (85.8%) of the subjects were given diluted top milk. Only 335 (20.2%) had used a katori and spoon to feed the children. Over half of the subjects were given solid/semi-solid food by the age of 6-7 months. The study concluded that The prevalence of malnutrition was 60.7% in the present study. According to NFHSII, 47% of the children aged less than 3 years are malnourished.14
A study was conducted among Anganwadi workers regarding knowledge about nutritive value of common foods, dietary beliefs during antenatal period, lactation and a few common diseases. The sample consists of 92 anganwadi workers. The study revealed that all the workers were aware about the fact that during
7 pregnancy, mothers require extra calories in order to meet the demands of foetus. 79.3% believed that multimix of cereals, pulses and oil prepared at home is much more nutritive than commercial weaning foods besides being cheaper. Nearly ¼ of the workers believed that both non-vegetarian foods as well as pulses should be avoided during the later half of pregnancy. Only 14.2% Anganwadi workers were not in favour of giving any food during episode of diarrhoea. While 27.2% believed that less food should be given to children suffering from pneumonia. It is suggested that there is need for improving the knowledge of Anganwadi workers by continued in service health teaching.15
A descriptive study was conducted to assess the knowledge and attitude regarding protein energy malnutrition among mothers of under 5 children with the sample size of 30. Non probability convenience sampling was used to select the samples. The study concluded that 6.7% of mothers had adequate knowledge, 40% had inadequate knowledge and 53.3% had inadequate knowledge regarding PEM. In regulation to attitude 63.3% had neutral attitude, 36.7% had unfavourable attitude.16
An experimental study was conducted to assess the knowledge regarding PEM among the mothers of under five children. The sample size was 60. Convenient sampling technique was used to select the samples. One group pre-test post test design was adopted to conduct the study. Instruments used in this study were demographic variable and structured questionnaire consisted of 25 multiple choice questions regarding knowledge on PEM. The pre-test score revealed that 88.33% had inadequate knowledge, 11.66% had moderate knowledge, and none of the samples had adequate knowledge. The post test result was none of the samples had inadequate knowledge, 68.33% had moderate knowledge, 31.66% had adequate knowledge. The study concludes that the STP on PEM was effective in enhancing the knowledge among mothers of under five children.17
A descriptive cross sectional survey design was used to assess the knowledge and attitude of anganwadi workers on care of under five children. The sample size was 80 and the samples were selected by non probability convenient sampling technique. Close-ended multiple choice questionnaire was used to assess the knowledge and 5 point Likert scale was used assess the attitude of the anganwadi
8 workers on the care of under five children. Result revealed that 69.81%, 75.85%, 71.60% had good knowledge on breast feeding, care in illness and growth monitoring respectively. 80% of the samples had positive attitude towards starting complementary feeding after 6 months, 70% had positive attitude towards exclusive breast feeding.18
A descriptive cross sectional study was used to identify the malnourished children. Sample size was 100 and purposive sampling technique was used. Semi structured interview schedule and check list were used to collect the data. Data were analysed by descriptive and inferential analysis. The result revealed that highest and more or less similar percentage of malnourished children were in the age group of 2.6-3.5 years (39% and 38% respectively). In that 57% and 51% female and male children were malnourished respectively.19
6.3 Problem statement
EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING MALNUTRITION AND ITS MANAGEMENT AMONG ANGANWADI WORKERS AT SELECTED CENTRES IN MANGALORE
6.4 Objectives of the study
The objective of the study are to:
assess the pre-test and post- test knowledge score regarding malnutrition and its management among anganwadi workers in selected centres.
determine the effectiveness of structured teaching programme on knowledge regarding malnutrition and its management among anganwadi workers.
find association between the pre-test knowledge level of anganwadi workers and selected demographic variables.
6.5 Operational definitions
Effectiveness: In this study, it refers to the extent to which the structured teaching programme on malnutrition and its management is able to produce desired effect as 9 measured by gain in post test knowledge score.
Knowledge: In this study, awareness is gained by experience of a fact of situation (Oxford Reference Dictionary). In this study it refers to the subject’s correct response to questions on malnutrition and its management as measured by structured knowledge questionnaire.
Structured teaching programme regarding malnutrition and its management: In this study, it refers to systematically developed instructions designed to provide information regarding imbalanced consumption of nutrients leading to diseases like protein energy malnutrition, deficiencies of minerals and vitamins consisting of meaning, causes, signs and symptoms, diagnostic measures, management and preventive measures of malnutrition.
Anganwadi workers: In this study, anganwadi worker is an employee (woman) who has undergone training for a specified period, under ICDS chosen from the community who cover the population of 1,000 and working at selected anganwadi.
6.6 Assumptions
The study assumes that:
1. anganwadi worker will have some knowledge regarding the malnutrition.
2. knowledge is the base for practice.
6.7 Delimitations
The study is delimited to,
1. selected anganwadi workers.
2. malnutrition and its management.
6.8 Hypotheses (All hypotheses will be tested at 0.05 level of significance)
10 H1: The mean post-test knowledge score of anganwadi workers on malnutrition and its management will be significantly higher after structured teaching programme than the mean pre-test knowledge score.
H2: There will be a significant association between the pre-test knowledge level of anganwadi workers and selected demographic variables.
7. Materials and methods
7.1 Source of data
The data will be collected from anganwadi workers working at selected centres in Mangalore.
7.1.1 Research design
Research design used for the study is pre-experimental, one group pre-test post-test design.
Pre-test Treatment Post-test
O1 X O2
O1: Pre-test assessment of knowledge of anganwadi workers regarding the malnutrition and its management.
X: Administration of structured teaching programme on malnutrition and its management.
O2: Post-test assessment of knowledge of anganwadi workers on malnutrition and its management after the administration of structured teaching programme.
7.1.2 Setting
The study will be conducted at selected anganwadi in Mangalore.
7.1.3 Population
11 The population consists of anganwadi workers working at anganwadi in Mangalore.
7.2 Method of data collection
7.2.1 Sampling procedure
Non-probability convenience sampling will be used to select the samples
7.2.2 Sample size
Sample consists of 60 anganwadi workers of selected centres in Mangalore.
7.2.3 Inclusion criteria for sampling
The subjects who are,
1. able to speak and understand Kannada.
7.2.4 Exclusion criteria for sampling
The subjects who,
1. had undergone nutritional training programme.
7.2.5 Instruments used
1. Baseline proforma.
2. Structured knowledge questionnaire on malnutrition and its management.
7.2.6 Data collection method
1. The investigator will get the permission prior to data collection from concerned authority
2. The investigator will introduce herself to the subjects and obtain consent from them.
3. Structured knowledge questionnaire will be administered to assess the pre-
12 test knowledge on malnutrition and its management.
4. A structured teaching programme will be administered to the anganwadi workers on malnutrition and its management on the same day of pre-test.
5. Post-test assessment of knowledge is done after seven days using the same structured knowledge questionnaire.
7.2.7 Data analysis plan
1. Demographic data will be analysed using frequency and percentage.
2. Effectiveness of STP on malnutrition and its management will be analysed using the paired ‘t’ test.
3. Chi-square test will be used to find out association between pre-test knowledge level & selected demographic variables.
7.3 Does the study require any investigation to be conducted on patients or other humans or animals (if so, please describe briefly)
Yes. The investigator administers STP on knowledge regarding malnutrition and its management.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes. Ethical clearance will be obtained from the concerned authority.
13 8. LIST OF REFERENCES
1. Gray SM. On clean, clear knowledge and health transformation. [Internet]. 2005 Available from : URL:http//www.gurteen.com
2. Park K. Textbook of preventive and social medicine. 21st ed. Jabalpur: Banarsidas Bhanot Publishers; 2011. p. 483,506-7,611,839.
3. Daved D. General nutrition. [internet]. 1999 Available from: URL:http//www.davedraper.com
4. Wurzbach M E. Community health education and promotion. 2nd ed. Canada: Jones and Bartlett Publishers; 2004. p. 20.
5. Gupta MC, Mahajan BK. Textbook of preventive and social medicine. 3 rd ed. New Delhi: Jaypee Brothers Medical Publishers; 2003. p. 347-50.
14 6. Datta P. Paediatric nursing. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2009. p. 202.
7. Kitchen H. What is malnutrition? [internet]. 2012 Available from: URL:http//www.theheartskitchen.com
8. Kamalam S. Essentials in community health nursing practice. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2012. p. 420-7.
9. Global hunger index. [internet]. 2012 Available from: URL:http//www.en.wikipedia.org/wiki/global_hunger_index
10. Asia/India-first study on malnutrition. [internet] 2012 Available from: URL :www.news.va/en/news/asiaindia.
11. Manhas S, Dogra A. Awareness among Anganwadi workers and the prospect of child health nutrition. [ICDS thesis]. Jammu and Kashmir: University of Jammu; 2012.
12. Shubhada S, Avachat, Vaishali DP, Deepak BP. Epidemiological study of malnutrition among under five children in a section of rural area, India. [2009]. Available from: URL:http//www.pravara.com
13. Desai G, Pandit N, Sharma D. A study to assess the educational qualification and experience of anganwadi workers. [internet]. 2012. Available from: URL:http//www.iapsmgc.orgindex_pdf11.pdf
14. Khokhar A, Singh S, Talwar R, Rasania SK, Badhan SR, Mehra M. A study of malnutrition among children aged 6 months to 2 years. [internet]. 2003. Available on: URL:http//www.indianjmedsci.org/article.asp?issn=0019-5359
15. Kandala BN, Madungu TP, Emina JBO, Nzita KPO, Cappuccio FP. Malnutrition among children under the age of five. [internet]. 2011. Available on: URL:http//www.biomedcentral.com/1471-2458/11/261/prepub
16. Chetan KMR. Protein energy malnutrition. Nightingale Nursing Times 2012
15 Oct;8(7):14-16,44.
17. Muthumari P. Effectiveness of STP on PEM among mothers of under five children. Nightingale Nursing Times 2010 Jun;6(3):61-5.
18. Maheshwari K. Knowledge and attitude of anganwadi workers on care of under five children. Nightingale Nursing Times 2010 Nov;6(8):21-3.
19. Maheshwari K. Identifying malnourished children. Nightingale Nursing Times 2011 Feb;6(11).
9. Signature of the candidate
10. Remarks of the guide
11. Name and designation of (in block letters)
11.1 Guide NEETHA KAMATH ASSISTANT PROFESSOR AND HOD COMMUNITY HEALTH NURSING SAHYADRI COLLEGE OF NURSING ADYAR MANGALORE – 575 007.
11.2 Signature
16 11.3 Co-guide (if any)
11.4 Signature
11.5 Head of the NEETHA KAMATH department ASSISTANT PROFESSOR AND HOD COMMUNITY HEALTH NURSING SAHYADRI COLLEGE OF NURSING ADYAR MANGALORE – 575 007.
11.6 Signature
12. 12.1 Remarks of the Chairman and Principal
12.2 Signature
17