A STUDY TO DETERMINE THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON BRONCHOPNEUMONIA

AMONG MOTHERS OF UNDER FIVE CHILDREN IN A

SELECTED PEDIATRIC HOSPITAL AT BANGALORE.

M.Sc. Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By

Mr. MIDHUN ABRAHAM

M.Sc NURSING 1ST YEAR

2009-2011

Under the Guidance of

HOD, Department of Pediatric Nursing

Anuradha College of Nursing

Gandhadakaval,

Hegganahalli Cross

Vishwaneedam Post

Magadi Road

Bangalore –91

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, KARNATAKA CURRICULAM DEVELOPMENT CELL

CONFORMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Registration number :

Name of the candidate : Mr. Midhun Abraham

Address : Gandhadakaval, Hegganahalli Cross,Vishwaneedam Post, Magadi Road, B,lore-91

.Name of the institution : Anuradha College of Nursing

Course of study and subject : M.Sc Nursing in Pediatric Nursing..

Date of admission to course : 15-05-2009

Title of the topic : A study to determine the effectiveness ofStructured teaching programme on bronchopneumonia among mothers of under five children in a Selected pediatric hospital at Bangalore

Brief resume of the intended work : Attached

Signature of the student :

Guide Name :.

Remarks of the guide :

Signature of the guide :

Co-guide name :

Signature of co-guide :

HOD name :

Signature of HOD :

Principal Name : Mrs. Radhika K.

Principal Mobile No : 9945621112

Principal E-mail ID : radhu_prasad@rediffmail.com

Remarks of the Principal :

Principal signature :

RAJIVGANDHI UNIVERSITY OF THE HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

Mr.MIDHUN ABRAHAM

1st YEAR M.Sc NURSING

ANURADHA COLLEGE OF NURSING,

BANGALORE

2 NAME OF THE INSTITUTION ANURADHA COLLEGE OF NURING GANDHADAKAVALHEGGANAHALLI CROSSVISHWANEEDAM POST, MAGADI ROADBANGALORE-91

3 COURSE OF THE STUDY AND

SUBJECT

M.Sc. NURSING PEDIATRIC NURSING

(CHILD HEALTH NURSING)

4 DATE OF ADMISSION TO

COURSE

15TH MAY 2009

5 TITLE OF THE STUDY

A STUDY TO DETERMINE THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON BRONCHO

PNEUMONIA AMONG, MOTHERS OF UNDER FIVE CHILDREN

IN A SELECTED PEDIATRIC HOSPITAL AT BANGALORE.

6 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION

Bronchopneumonia or bronchial pneumonia (also known as  lobular  pneumonia)

is a type of pneumonia characterized by multiple foci of isolated, acute consolidation,

affecting one or more pulmonary lobes. It is one of two types of bacterial pneumonia  as

classified by gross anatomic distribution of consolidation (solidification), the other being 

lobar pneumonia. 1

Bronchopneumonia is less likely than lobar pneumonia to be associated

with streptococcus.The bronchopneumonia pattern has been associated with hospital

acquired pneumonia and with specific organisms such as Staphylococcus aureus,

Streptococcus pneumoniae, Escherichia coli, and pseudomonas.In bacterial pneumonia,

invasion of the lung  parenchyma by bacteria produces an  inflamatory immune response.

This response leads to a filling of the alveolar sacs with exudate. The loss of air space and

its replacement with fluid is called consolidation. In bronchopneumonia, or lobular

pneumonia, there are multiple foci of isolated, acute consolidation, affecting one or

more pulmonary lobes. In India, the main culprit is malnourishment — here, 47% of the

pediatric population suffers from low immune systems. “Incidence of pneumonia in

developing countries like India range between (20-30)%.Lack of good nutrition, polluted

air and poor hygiene are the main causes of pneumonia. 2

India looks indeed like a leading third world Country; malnourished

children breathe polluted air and suffer from lack of nutrition and hygiene. It leads the

world with 27% of the global pneumonia cases. Worse, every minute, a child dies of  in

India, followed by Afghanistan, China, Pakistan and Bangladesh. Annually, two million

6.1

children under five dies from pneumonia and contributes to almost 20% of childhood

mortality cases . It has been estimated that 26 per cent of neonatal deaths, or 10 per cent of

all under-five deaths, are caused by severe infections during the neonatal period. And a

significant proportion of these infections is caused by pneumonia/sepsis.3

NEED FOR STUDY Broncho pneumonia is an illness usually caused by infection, in which

the lungs become inflamed and congested, reducing oxygen exchange and leading to

cough and breathlessness. It affects individuals of all ages, but occurs most frequently in

children. Among children pneumonia is the most common cause of death world wide.

Historically in developed countries deaths from pneumonia have been reduced by

improvements in living conditions, air quality and nutrition. In developing world today

many deaths from bronco pneumonia are also preventable by immunization or access to

simple, effective treatments.1

Every year 1.9 million children under five years of age die from bronco

pneumonia.Indeed,it is the leading cause of child death in the world. The millennium

development goal target of reducing the under five mortality rate by two-third by 2015 has

renewed interest in accurate assessment of the number of children affected and underlying

causes. A paper in the world health organization (WHO) bulletin reviews the history and

current status of knowledge on pneumonia in children’s among under fives. The 1993

world development report estimated the proportion of childhood deaths caused by acute

respiratory infections at around 30%.4

WHO established child health epidemiology reference group (CHERG) in

2001 to review epidemiological data on the main causes of death for the year

2000.Globally there were 156 million new episodes of childhood clinical bronho

pneumonia,occur 95% in developing countries.The incidence of clinical bronho

pneumonia –the risk of developing it with in a specified period of time –in children under

five in developing countries is almost 29%.In developing countries 8.7% of childhood

broncho pneumonia cases (13.1 million0 are life threatening and requires hospitalization.

Around 2 million children under five years die from broncho pneumonia

each year, mostly in the African and South East Asia regions.Over half of the new

broncho pneumonia cases occur in 6 countries – India (43 million),China (21 million),

Pakisthan (10 million).Bangladesh,Indonesia and Nigeria (6 million each).4

In Karnataka,age distribution of prevalence rate of major killer

disease like broncho pneumonia is 8% among under fives. Pneumonia ranks first amoung

health problems requiring attention in the healh centers.The most vulnerable members of

the population are children under fives who live in poverty around the coastal cities.In

developing contries over one-quarter of children have an episode of clinical broncho

pneumonia each year throughout the first five years of their life.On average 2-3% of

children each year have pneumonia severe enough to require hospitilisation and many of

these disease episodes are potentially fate.This suggest that of every thousand childrens

born alive 12-20 die from pneumonia before their fifth birthday.5

Recently WHO has decided to launch an annual “World pneumonia

day” on November 2nd,2009.This day will mobilize effects to fight pneumonia tightly

called a ‘neglected’ or ‘forgotten’ disease, that kills more than 2 million children under

the age of five each year world wide. World over pneumonia kills more than any other

illness – AIDS, Malaria and Measles. About 156 million new episodes occur each year

world wide, of which 151 million episodes are in the developing countries. Of all

community cases,7-13% are severe enough to be life threatening and requires

hospitalization. In India also 410,000 children under five years of age die of bronho

pneumonia each year.” Millennium development goals (MDG)”- to reduce under five

mortality by two-third by 2015 are to be achieved.4

To reach 2015 goal of reducing mortal under fives, effective

interventions such as breast feeding and complementary feeding, Hemophilus influenza

vaccines,zinc supplementations and the use of antibiotics to treat pneumonia are needed

to be implemented in all the countries. The developing world offers a huge market for the

vaccines and manufactures are obviously interested. 132 children with clinical and

radiological evidence of bronco pneumonia were studied over one year for isolation or

detection of bacterial or viral etiological pathogens. 6

The recent studies and statistics throws the light that

broncho pneumonia is an important problem in this contemporary epoch and more under

five childrens are affected with broncho pneumonia.This is mainly due to unhealthy

environment and poor knowledge among the parents regarding the disease condition.So

it is evident that children’s especially under fives are vulnerable to this disease condition

and through teaching programme the mortality and morbidity rate can be controlled and

prevented to a great extent. So the investigator is very much interested in doing this topic.

6.2 REVIEW OF LITERATURE

INTRODUCTION

Review of literature is a key step in the research process.The typical purpose

of analyzing a review of existing literature is to generate questions and to identify what is

known and what is unknown about the topic.The major goals of review of literature are to

develop a strong knowledge base to carry out research and non research scholalarly

activity.

The review has been divided under the following headings:

a)Studies related to incidence,riskfactors,etiology of broncho pneumonia. (b) Studies related to mortality of broncho pneumonia. (c) Studies related to assess knowledge of mothers regarding broncho pneumonia

STUDIES RELATED TO INCIDENCE, ETIOLOGY,RISKFACTORS OF

BRONCHO PNEUMONIA.

A study was conducted to determine the relation between malnutrition

and bronco pneumonia among under five childrens in developing countries Sixteen

relevant studies were identified, which universally showed that children with pneumonia

and moderate or severe malnutrition are at higher risk of death. For severe malnutrition,

reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For

moderate malnutrition, relative risks ranged from 1.2 to 36.5. Eleven studies evaluated

the aetiology of pneumonia in severely malnourished children. Commonly isolated

bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus

pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency

of organisms differed from those reported in children without severe malnutrition .7

A study was conducted to show the relation between seasonality and mortality

associated with influenza in subtropical low and middle income countries influenza

pneumonia hospital admissions and in-hospital deaths. Influenza was identified in 1,346

(10.4%) of pneumonia patients of all ages, and 10 influenza pneumonia patients died

while in the hospital. The average annual incidence of influenza pneumonia was greatest

in children less than 5 years of age (236 per 100,000) During 2005, 2006 and 2008

influenza A virus detection among pneumonia cases peaked during June through October.

In 2007 a sharp increase was observed during the months of January through April.

Influenza B virus infections did not demonstrate a consistent seasonal pattern. Influenza

pneumonia incidence was high in 2005, a year when influenza A(H3N2) subtype virus

strains predominated, low in 2006 when A(H1N1) viruses were more common, moderate

in 2007 when H3N2 and influenza B co-predominated, and high again in 2008 when

influenza B viruses were most common.8

A study was conducted to identify the causes and contributing

factors of persistent broncho pneumonia in under five children comprising of 41 cases

out of 41 cases, 8 had pulmonary tuberculosis and 12 had Gram negative bacterial

infections, 12 had aspiration due to gastroesophageal reflux disease or oil instillation, 3

had immunodeficiency due to HIV infection, 2 had congenital lung malformation, 2 had

cardiac disorders and one had foreign body aspiration as causes of persistent

bronchopneumonia. The most common underlying cause of persistent pneumonia were

persistent infection followed by aspiration and acquired immunodeficies.9

A study was conducted to determine the incidence,riskfactors, and pathogens

of broncopneumonia among 140 patients in a cardio thoracic intensive care unit in

Brescia,Italy.the study reported that 91.4%(128) were surgical and 8.6%(12) were

medical.Cumulative incidence of this pneumonia was 28.6%.The most common isolated

pathogens were were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus

pneumoniae, and Escherichia coli.10

STUDIES RELATED TO MORTALITY OF BRONCO PNEUMONIA.

A study Was conducted to study the changing pattern of under-5 mortality

rate in china .The under-5 mortality rate (U5MR) in China dropped to, 20.6 per 1000 live

births in 2006, respectively, comparing to 39.7 per 1000 live births in 2000. In urban

areas, U5MR dropped to 9.6 per 1000 live births in 2006, respectively while they were

and 13.8 per 1000 live births respectively in 2000. In rural areas, U5MR dropped to and

23.6 per 1000 live births in 2006, respectively but they were 45.7 per 1000 live births

respectively in 2000. During this period, the mortality rates due to pneumonia had

dropped sharply. The proportion of deaths due to pneumonia, dropped from 19.5%, in

2000 to 15.6%, in 2006, respectively. In urban areas, the proportion of deaths due to

pneumonia dropped from 9.9% in 2000 to 9.8% in 2006, In rural areas, the proportion of

deaths due to pneumonia dropped from 20.1% to 16.2%.11

A study was conducted to review the effect of seasonal pattern among

children under 5 years on broncho pneumonia in Nairobi slums.The study population

included 17,787 under five children.Four hundred thirty-six deaths were observed and

cause of death was ascertained by verbal autopsy for 377 of these deaths. Using Poisson

regression, we modeled the quarterly mortality risk for pneumonia. The overall person-

years (PYs) were 21,804 giving a mortality rate of 20.1 per 1,000 PYs in the study

population. Pneumonia was the leading cause of death contributing 25.7% of the total

deaths. Pneumonia mortality was highest in the second quarter (risk ratio [RR] = 2.3,

confidence interval [CI]: 1.2-4.2 compared with the fourth quarter). The study provides

evidence that pneumonia-related mortality among under-fives in Nairobi's slums is higher

from April to June corresponding to the rainy season and the beginning of the cold

season.12

STUDIES RELATED TO ASSESS KNOWLEDGE OF MOTHERS REGARDING

BRONCHO PNEUMONIA.

A study was conducted to assess the Mothers' knowledge, attitudes and

practices regarding acute respiratory infections in children in Baringo District, Kenya.

A total of 309 mothers were interviewed. Their mean age was 31.5 years (range 16-51)

and 34% had no formal education. Only 18% of mothers described pneumonia

satisfactorily. 60.2% knew that measles is preventable by immunisation. 87.1% of the

mothers said they would seek health center services for severe ARI. Formal education

had a positive influence on the KAP of the mothers: The study reveals that the mothers

had good knowledge of mild forms of ARI but not the severe forms like broncho

pneumonia 13

A study was conducted to determine Maternal perception of pneumonia in

pre school children in Enugu, eastern Nigeria. 400 women were interviewed using a pre-

tested structured questionnaire. Sixty-one per cent of them would recognise pneumonia

by difficult breathing, 42% by fast breathing and 26.5% by severe cough. Few of the

6.3

mothers mentioned signs suggestive of 'chest indrawing' (8.5%) and 'central cyanosis'

(1%). The maternal knowledge score on pneumonia signs increased significantly with

educational status and social class (p < 0.05). While a substantial number of mothers

(51%) perceived fast breathing to be an indication of severe pneumonia, a sizeable

number (87.5%) were unsure if late signs such as chest indrawing and central cyanosis

suggested severe disease.14

A study was conducted among mothers to assess the knowledge and

recognition of broncho pneumonia.The study population consists of 501 mothers.The

findings show that about 84% of the mothers said that they knew what pneumonia

is.68.7% said that pneumonia is caused by lack of parenteral care.28.9% believed that

virus causes the disease. More than 80% correctly picked rapid breathing and chest

retractions from a list of possible signs and symptoms of pneumonia.The study throwed

the light that there is still a sizable percentage of mothers who remains uninformed about

pneumonia and its possible fatal consequences.15

A study was conducted among mothers to assess the change of

knowledge and practise.The target population consists of 299 mothers of under five

children after community health training and practice of integrated management of

childhood illness.The result revealed that out of the 90 ARI cases pneumonia was

correctly classified in 61 (68.8%) by community health worker.16

STATEMENT OF PROBLEM:

“A study to determine the effectiveness of Structured teaching

programme on bronco pneumonia among mothers of under five children in a

selected pediatric hospital at Bangalore”.

6.4

6.5

6.6

OBJECTIVES OF THE STUDY

The objectives of the study are:

To assess the existing knowledge of under five mothers on broncho pneumonia.

To study the effectiveness of knowledge of under five mothers after Structured

teaching programme on bronco pneumonia.

To compare pretest and post test knowledge of under five mothers.

To associate the knowledge with selected demographic variables such as

age,religion,education of the parents, type of family, number of children, area of

residence, income.

To develop a Structured teaching programme on broncho pneumonia.

HYPOTHESIS

The hypothesis will be tested at 0.05 level of significance.

H 1: There will be significant difference in the pre test and post test knowledge

scores of under five mothers on bronco pneumonia

H 2: There will be significant association between knowledge of under five

mothers and selected demographic variables such as age,religion,education.

of the parents, type of family, number of children, area of residence,

income.

OPERATIONAL DEFINITIONS:

DETERMINE In this study it refers to firmly decide on the effect of Structured teaching

programme on bronco pneumonia as measured by the semi -structured questionnaire and

expressed as the post test scores of the experimental group.

EFFECTIVENESS

In this study it refers to producing the desired or intended result of structured

teaching programme on bronco pneumonia as measured by the instrument and shown by

the post test scores of the experimental group.

STRUCTURED TEACHING PROGRAMME

It is a formal and specific teaching developed for mothers of under five aged

children regarding meaning, causes,transmission,clinical manifestation,prevention and

management of broncho pneumonia

KNOWLEDGE

In this study it refers to the correct responses of the mothers to the knowledge

part of the questionnaire of the interview schedule and expressed as knowledge scores

BRONCHO PNEUMONIA

It is formally defined as the inflammation with consolidation of lungparenchyma.

MOTHERS

In this study the word refers to the mothers with underfive children with bronco

Pneumonia.

UNDERFIVE CHILDREN In this study the term refers to the children between the age group 1 to 5 years of

age.

6.7

6.8

6.9

7.0

ASSUMPTIONS

Mothers will have inadequate knowledge regarding causes, prevention and

management of broncho pneumonia

Structured teaching programme on broncho pneumonia to mothers Under five

children will promote health of a children and better prevention.

Mothers are best conveyors of health information to other mothers and to family.

DELIMITATIONS:

The study is delimited :

to mothers of under five children suffering from broncho pneumonia

who knows kannada or English

children between the age group of 1 to 5 years.

PROJECTED OUTCOME:

The present study will help the under five mothers to understand about the

causes, prevention and management of bronco pneumonia and hence it will help to bring

down the under five mortality.

MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from mothers of under five children who are

admitted in the hospital.

7.1.1 RESEARCH DESIGN

The research design adopted for this study is pre experimental study.

RESEARCH APPROACH

The research approach is evaluative.

7.1.2 SETTING:

The study will be conducted in K C G hospital. at Bangalore. It is 10 km away

from the College.

7.1.3 POPULATION

The population selected are mothers of under five children who are affected with

broncho pneumonia.

7.2 METHOD OF DATA COLLECTION

7.2.1 SAMPLING PROCEDURE

The Sampling Technique adopted for this study is purposive.

7.2.2 SAMPLE SIZE

The sample size is 60.

7.2.3 INCLUSION CRITERIA

The criteria for sample selection are mothers of under five who

Have children aged between 1 to 5 years

willing to participate in the study

know kannada or English language

7.2.4 EXCLUSION CRITERIA

Children above 5 years of age

under five children who are affected with diseases other than bronco pneumonia

7.2.5 INSTRUMENT INTENDED TO BE USED

SELECTION OF TOOL

This consist of three parts :

PART 1 :consist of demographic variables such as age,religion,education of the parents,

type of family, number of children, area of residence, income.

PART 2:Questionnaire will be used to assess the knowledge.25 Questions will be used.

PART 3:Structured teaching programme regarding meaning, causes, transmission,

clinical manifestation, prevention and management of bronco pneumonia will also be

used.

SCORING PROCEDURE

For knowledge assessment

For Answers. If answer is yes 1

If answer is no 0

SCORING INTERPRETATION Good :- 75-100%

Average :- 50-75%

Poor :- Below 50%

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?

YES, Ethical clearance will be been obtained from the research committee

of Anuradha college of nursing.

Consent will be taken from the hospital and permission will be taken from

the study subjects before the collection of data.

8.0 LIST OF REFERENCES

1.A.Parthasarathy ,P.S.N Menon ,Piyush Gupta, M.K.C Nayar .”Text book of Pediatrics”

4th edition.New Delhi:Jaypee brother’s Publishers;2009;pno 578.

2. Cotran, Ramzi S,Kumar, Vinay, Nelso Fausto, Robbins.” Pathologic basis of disease”

6th edition . St. Louis: Elsevier Saunders; (2005) ; pno 749.

3.International child disease and developmental research.” Health and Science Bulletin”;

4(2); June 2006.

4 WHO Bulletin”Global estimate of clinical incidence of clinical pneumonia among

children under five years of age”;2004.

5.Agnihotrao, V.Ramana kumar, etal.”Respiratory disease burden in rural India”:2005.

6. Vipin m vasighte, et al. “fight against pneumonia”. Indian paediatri journal;2009 july

17(46):59.

7.Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T. “Pneumonia in

severely malnourished children in developing countries”. Tropical medicine and

international health : 2009 Oct;14(10):1173-89.

8. Simmerman JM, Chittaganpitch M et al.”.Incidence, seasonality and mortality

associated with influenza pneumonia”.American journal on pediatrics: 2009 Nov;

11;4(11):e7776.

9. Kumar M, Biswal N, Bhuvaneswari V, Srinivasan S. “Persistent pneumonia:

Underlying cause and outcome”.Indian Journal of Pediatrics: 2009 Nov 26.

10 . Rosa maestro peuro etal.’Pneumonia in cardio thoracic icu;incidence and risk factors

journal of cardio thoracic vascular anaesthesia”. 2009:May 12.

11Wang YP, Zhu J, Et al. “Analysis on under-5 mortality rate and the leading kinds of

diseases”. 2009 May;30(5):466-70.

12.Ye Y,Zulu E,et al.”seasonal pattern of pneumonia mortality among under-five

children”.Journal on tropical medicine and hygiene:Nov;81(5):770-5.

13 .Simyu D.E,Wafula E.M,Nduati R.W.”Mothers knowledge,attitudes and practices

regarding acute respiratory infections in children”.East African medical

journal:2003;June;80(6):303-7.

14 .Uwaezuoke SN, Emodi IJ, Ibe BC.” Maternal perception of pneumonia in children”.

Annals of Tropical Paediatrics:2002 Sep;22(3):281-5.

15 .S.fuchg, etal.”The burden of pneumonia in children in Latin America”. Paediatric

respiratory review: vol 6; 2000.

16 .Shuene g.edwin, etal.” Planned teaching programe of acute respiratory tract infections

among mothers of under five children”:2007.

9. SIGNATURE OF THE CANDIDATE

MIDHUN ABRAHAM

10. REMARKS OF THE GUIDE The study is suitable and feasible

11. NAME AND DESIGNATION OF

11.1 GUIDE

Sathyavathi

11.2 SIGNATURE

11.3CO-GUIDE

11.4SIGNATURE

11.5 HEAD OF DEPARTMENT

Sathyavathi

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL The study is suitable and feasible

12.2 NAME & SIGNATURE OF THE

PRINCIPAL

Radhika .K

.

9