RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTSFOR DISSERTATION

1. Name of the candidate and address ALKA PETERI YEAR M. Sc. NURSINGLAXMI MEMORIAL COLLEGE OF NURSINGBALMATTAMANGALORE – 575013

2. Name of the Institution LAXMI MEMORIAL COLLEGE OF NURSINGBALMATTAMANGALORE – 575013

3. Course of study and subject M. Sc. NURSINGCOMMUNITY HEALTH NURSING

4. Date of admission to the course 29.10.2010

5. Title of the study

ASSESSMENT OF THE KNOWLEDGE OF PEOPLE REGARDING

INDOOR AIR POLLUTION, ITS HEALTH HAZARDS AND

PREVENTION IN SELECTED RURAL AREAS OF MANGALORE

WITH A VIEW TO PREPARE AN INFORMATION BOOKLET

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6. Brief resume of the intended work

6.1 Need for the study

“All of us face a variety of risks to our health as we go about our day-to-day lives... Indoor air pollution is one risk you can do something about. ”

-USEPA Quotes

The immediate environment of man comprises of air on which depends all forms of

life. Apart from supplying the life giving oxygen, air and atmospheric conditions serve

several functions like cooling of human body, air transmission of stimuli for hearing and

smell, and also transmission of disease agents. Pollution of air by dust, smoke, toxic gases,

and chemical vapours results in sickness and death1. Healthy indoor air is recognised as a

basic right. People spend a large part of their time each day indoor: in homes, offices,

schools, healthcare facilities, or other private or public buildings. The quality of air they

breathe in those buildings is an important determinant of their health and wellbeing. Indoor

air pollution – such as from dampness and mould, chemicals and other biological agents – is

a major cause of morbidity and mortality worldwide2. Indoor air pollution is gaining

increasing prominence as a public health hazard in developing countries. According to World

Health Report 2002, indoor air pollution is responsible for 2.7 % of the global burden of

disease. Every year indoor air pollution causes death of 1.6 million people, that is, one death

every 20 seconds. The deaths occur due to pneumonia, chronic respiratory disease, and lung

cancer, with the overall disease burden [in Disability Adjusted Life Years or DALYs, a

measure combining years of life lost due to disability and death] exceeding the burden from

outdoor air pollution fivefold. In high mortality developing countries, indoor smoke is

responsible for an estimated 3.7% of the overall disease burden, making it the most lethal

killer after malnutrition, unsafe sex and lack of safe water sanitation3.

In people’s mind air pollution is associated with the contamination of urban air from

automobile exhausts and industrial effluents. Approximately, half the world’s population and

up to 90% of rural households in developing countries rely on unprocessed biomass fuels like

wood, dung, and crop residues. A recent report of the WHO asserts the rule of 1000 which

states that a pollutant released indoors is thousand times more likely to reach peoples lung

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than a pollutant released outdoor. It has been estimated that about half a million women and

children die each year from indoor air pollution in India. Compared to other countries India

has among the largest burden of disease due to the use of dirty household fuels and 28% of

all deaths due to indoor air pollution in developing countries occur in India. The 1991

National Census included for the first time questions about household fuels and it revealed

that 90% of rural population relied upon biomass fuels like dung, crop residues and wood.

Nationwide, about 81% of all household relied on these fuels; 3% on coal and 78% on

biomass. However, recent data as revealed by National Family Health Survey-3 [NFHS-3]

found that 71% of India’s households use solid fuels for cooking and 97% of rural

households do so4.

Globally, about 3 billion people rely on biomass as their primary source of domestic

energy. Incomplete combustion of fuels produces carbon monoxide. A study by the National

Institute of Occupational Health [NIOH], Ahmadabad reported indoor air carbon monoxide

levels of 144,156, 94,108 and 48 mg/m³ air during cooking by dung, wood, coal, kerosene

and LPG respectively. It also revealed poly cyclic aromatic hydrocarbons like fluorine,

pyrene, chrysene, indenol in which some are carcinogens. Formaldehyde is another indoor air

pollutant which is released during cooking by different fuels. In an epidemiological study in

UK, excess mortality from lung cancer was observed in workers exposed to high

formaldehyde levels. Studies show that exposure to indoor air pollution is the causal agent

for acute respiratory infection, otitis media, chronic obstructive pulmonary disease, lung

cancer, asthma, nasopharyngeal and laryngeal cancer, tuberculosis, perinatal conditions and

low birth weight, and diseases of eye such as cataract and blindness. In rural Guatemala,

babies born to women using wood fuel were 63gm lighter than those born to women using

gas and electricity. A study carried out in Ahmadabad reported an excess risk of 50% of

stillbirth among women using biomass fuels during pregnancy 4.

Indoor air pollution and not smoking is the most important cause of chronic

obstructive pulmonary disease [COPD] in India, says a prevalence study conducted by Pune

based Chest Research Foundation [CRF] in collaboration with the KEM Hospital, Pune and

Imperial College, London. The CRF study found that the prevalence of the respiratory

disease was 6.9% in the Indian population. Among those identified with COPD, only 7%

were smokers while the remaining 93% were non-smokers. Over 700 million people in India

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suffer with high levels of indoor air pollution affecting women and children as 75% of homes

use biomass fuel like wood, crop residue and dung cakes.5

The effects on women and under five children from indoor air pollution were

described in the National Burden of Disease in India. Acute respiratory infections in children

is the largest single disease category for India, accounting for about 1/9 th of national burden,

13 % of under five death and 8.5% of the global burden. COPD or Chronic Obstructive

Pulmonary Disease causes 1.5% deaths in India, 0.9% of national burden of disease [NBD],

1.8% NBD for women. Cor-pulmonale, a serious heart condition secondary to COPD, is

often found among rural non-smoker women in India and has been attributed to chronic

biomass smoke exposure. Lung cancer in women as an outcome of cooking with open coal

stoves causes 0.4% deaths, 0.1% of NBD. Blindness [cataract] in women accounts for 1% of

NBD. A case control study in Delhi conducted found an excess cataract risk of about 80%

among people using biomass fuels [OR=1.6]. Analysis of 1992-93 National Family Health

Survey found a strikingly strong and statistically significant relationship between reported

use of biomass fuel and TB in India. Women using biomass fuels for over 20 years were

found 3 times more likely to have TB than women using clean fuels. In India it accounts for

8% of death, 5% of NBD and 5.5% of NBD for women. Asthma is associated with typical

solid fuel indoor smoke exposure and causes 0.2% death in India and 0.5% of NBD. Adverse

pregnancy outcomes due to using biomass fuels cause 6% of deaths and 7.5% of NBD6.

In the present scenario it is crucial to assess the knowledge of people regarding indoor

air pollution and its health hazards .The investigator during her field visits, came across many

houses in the rural area of Nandavara where people used biomass fuels for cooking, poor

housing conditions, house dust, and smoke which contributes to indoor air pollution.

Awareness is the first step towards bringing about a change and community nurses being

close to the public has got a critical role to play. The provision of patient information and

communication between patients and healthcare professionals are increasingly recognised as

important aspects of patient care. The investigator intends to assess the knowledge of rural

population towards indoor air pollution and its major health hazards and to prepare an

information booklet on the same.

6.2 Review of literature

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A study was conducted to assess the level of awareness and knowledge about indoor

air pollution and to identify factors that influence this awareness in the urban population of

Mumbai, India. A total of 754 subjects including 489 asthmatic patients and 265 control

subjects [aged >18 yrs] were recruited in the study. Knowledge of subjects was assessed in

terms of total scores obtained by them through responses to questionnaire about indoor air

pollution awareness. Ninety-eight percent of total subjects could not score more than 25

marks [considered as adequate awareness] out of 100. Out of 754 subjects 485 patients and

260 controls obtained failed score. The study showed that adults had more knowledge

compared to older people but statistically it was not significant [2.8%pass vs. 0.95% pass, P

not significant]. No difference was found regarding the extent of knowledge between males

and females [2.7%pass vs. 1.8% pass, P not significant]. The result of the study showed that

higher education was associated with more awareness compared to lower education but here

too difference was statistically not significant [2.9% pass vs. 1.5%pass, P not significant].

Socioeconomic status also had no impact [3.7%pass vs. 1.6%pass, P not significant]. Thus

the study revealed that knowledge regarding the causes of indoor air pollution, which is

responsible for respiratory diseases, was very poor in the population irrespective of age,

gender, education and socioeconomic status7.

A descriptive cross-sectional study was conducted to determine awareness, attitude

and practices of residents of Oke-Oyi, a rural settlement in Nigeria towards indoor air

pollution. The 384 respondents interviewed were selected using a multistage sampling

technique. Data collection was by both qualitative and quantitative methods specially using

an interviewer administered questionnaire and an observational checklist. The results showed

that 83.9% of the respondents were aware of indoor air pollution and 81.3% were aware of

the hazards associated with indoor air pollution, among whom 63.8% were females and

36.2% males. Commonly known effects of indoor air pollution included cough [79.4%],

catarrh [82.6%] and eye irritation [65.6%]. Most of the respondents [78.6%] believed that

children and elderly were at higher risk. Awareness of sources of indoor air pollution was

highest for cooking in the living areas [77.95%] and lowest for use of pesticides [43.8%].

Information on indoor air pollution was given by media [23.1%], teachers [33.05%], and

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health workers [40.2%]. The result of the study showed that even though many of them were

aware of these effects, many still indulged in high risk behaviours that may lead to indoor

pollution8.

A descriptive study was conducted among 100 female domestic cook in Rajshahi city,

Bangladesh to understand their knowledge about relationship of indoor air pollution to

various diseases. The respondents were categorised into three classes, illiterate, from level 1

to level 12, and graduate and above, and were interviewed using a semi-structured

questionnaire interview method. Out of the respondents, 75% were aged between 30 and 60

years and 43% between 30-39 years. Only 26% had no education whereas 43% of them were

educated up to secondary school certificate level. It was found that 61% used mud oven and

25% used gas oven. Approximately 34% mud oven users were illiterate. All gas oven users

had certain level of education. Only 8% of wood users and 45% gas users had graduate level

education. Most of the respondents mentioned that asthma [48%], burning [84%], eye

problems [71%], low birth weight baby [37%], eye irritation [86%] and cardiac problems

[45%] could be result of indoor air pollution9.

A lung cancer case-control study in rural areas of China was conducted in order to

evaluate the effects of radon, wood and coal combustion, cooking fumes and environmental

tobacco smoke on lung cancer risk. Lung cancer cases 886, [656 males, 230 females] were

enrolled for the study who were aged 30-75 yrs and were diagnosed between 1994-1998.

Interviews were conducted with subjects or next of kin on smoking, housing characteristics,

fuel use, and cooking practices. Subjects primarily used coal [22%], wood [56%] or a

combination of both [22%] for heating. Odds Ratio [OR] for lung cancer rose with increasing

percent of time that coal was used to heat homes over past 30 years [OR=1.00, 1.17, 1.35,

1.23] compared to wood only. Among non-smoking females and males, the OR for ever

exposed to environmental tobacco smoke was 1.19 and fumes for cooking with rapeseed oil

increased risk of lung cancer [1.56 = OR] among non-smoking women10.

A study to examine the association between household use of biomass fuels for

cooking and birth weight in Zimbabwe was conducted among 3559 childbirths in the 5 yrs

preceding the 1999 Zimbabwe Demographic and Health Survey. Birth weights recorded by

trained professionals at local health clinics, were derived from health cards at home or from

mother’s recall. The study results showed that children born to mothers using wood, dung

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were 175 gm lighter [95% CI,-300,-50] on average, compared to babies born to mothers

using LPG or electricity. The health cards were given to those children in houses using

pollution fuels. A comparison of birth weight distribution from health card and from

mother’s recall showed that children from rich households tends to be heavier [3174 gm]

than those from poor households [3111 gm]. With child’s sex and birth order controlled,

children born to mothers cooking with biomass fuels are 75gm lighter at birth [p<0.01] and

girls were found to be much lighter than boys at birth [123gm]11.

6.3 Statement of the problem

Assessment of the knowledge of people regarding indoor air pollution, its health

hazards and prevention in selected rural areas of Mangalore with a view to prepare an

information booklet.

6.4 Objectives of the study

1. To measure the knowledge of people regarding indoor air pollution, its health

hazards and prevention using structured knowledge questionnaire.

2. To find out the association of knowledge regarding indoor air pollution, its health

hazards and prevention with selected demographic variables.

3. To prepare and validate an information booklet on factors causing indoor air

pollution, health hazards and its prevention.

6.5 Operational definitions

Knowledge: The word knowledge means facts, information and skills acquired

through experience or education; the theoretical or practical understanding of a

subject or it is the awareness or familiarity gained by experience of a fact /situation12.

In this study Knowledge refers to the extent of sum of what is known to the

people in rural area about indoor air pollution, its health hazards, and prevention.

People: Human beings in general or considered collectively or they are distinct

groups based on variety of common factors including culture, beliefs, morals and

religion13.

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In this study People refers to a significant family member more than 18 years

and who is literate and able to follow the instructions either in Kannada/ English and

who are present in the house at the time of data collection.

Indoor air pollution: It refers to chemical, biological and physical contamination of

indoor [house, institution, school, factory] 14.

In this study Indoor air pollution refers to pollution of the air within the

houses of people due to cooking fumes, mosquito coils, oil paints, wood polish,

tobacco smoke, house dust, foot wear dust, domestic cats and dogs, rat faeces and

urine and cockroaches.

Information booklet: A small booklet with a paper that contains information about a

particular subject13.

In this study Information booklet refers to the printed material prepared by

the researcher to provide information on selected areas of indoor air pollution: causes,

health hazards and prevention.

Health hazards: Substance that is carcinogen, corrosive, irritant, toxic, or can

damage eyes, lungs, mucous membranes, or skin, or which produces acute or chronic

health effects15.

In this study health hazards refers to effects of indoor air pollution on

respiratory system [COPD, TB, Asthma, ARI, Lung cancer], cardiac system [Heart

disease], Blindness and adverse pregnancy effects [Abortion, Still birth, Low birth

weight].

6.6 Assumptions

The study assumes that:

People in the rural community are more prone to get affected by indoor air pollution.

The people will be having some knowledge regarding indoor air pollution, its health

hazards, and prevention.

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6.7 Delimitation

The study is delimited to people living in the rural community who are above 18

years of age.

The study is delimited to only one significant member of the family.

6.8 Hypotheses

The hypothesis will be tested at .05 level of significance.

H1: There is a significant association of knowledge scores with selected demographic

variables.

7. Material and methods

7.1 Source of data

People above 18 years in a selected rural community of Mangalore.

7.1.1 Research design

The design adopted is descriptive survey design.

7.1.2 Setting

The study will be conducted in selected rural community Nandavara] of Mangalore.

The community belongs to Balthila PHC and consists of 420 families

7.1.3 Population

The target population of the study include people aged above 18 years in a selected

rural community of Mangalore.

7.2 Method of data collection

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7.2.1 Sampling procedure

Random sampling technique.

7.2.2 Sample size

In this study the sample size will be 100 families in a selected rural community of

Mangalore.

7.2.3 Inclusion criteria

1. People who are residents of the selected rural community of Mangalore.

2. People who are aged above 18 years.

3. People who can read and write Kannada or English.

7.2.4 Exclusion criteria

1. People who are health professionals.

2. People who have previously attended any teaching session related to indoor air

pollution.

7.2.5 Instruments intended to be used

In this study a structured knowledge questionnaire will be used to collect the relevant

data.

7.2.6 Data collection method

Prior to the data collection, permission will be obtained from the concerned authority

for conducting the study. The researcher will introduce herself to the participants and will

obtain written consent from them to participate in the study. Investigator will assure that

subjects’ response will be kept confidential. The data will be obtained using structured

knowledge questionnaire. After assessing the knowledge an information booklet will be

prepared and distributed to the samples.

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7.2.7 Data analysis plan

Data will be analysed using the descriptive and inferential statistics.

7.3 Does the study require any investigation or intervention to be conducted on

patients or other humans or animals?

Yes. A structured knowledge questionnaire will be administered.

7.4 Has ethical clearance been obtained from your institution?

Yes, ethical clearance has been obtained from the concerned authority.

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List of references

1. Park K. Textbook of preventive and social medicine. 17th ed. Jabalpur: Banarsidas

Bhanot Publishers; 2002.

2. WHO guidelines for indoor air quality: dampness and mould. [online]. Available

from: URL:http://www.euro.who.int/_data/assets/pdf_file/0017/43328/E92645.pdf.

3. Indoor air pollution and health. WHO Fact sheet 292. 2005 Jun.

4. Mathur JN. Indoor air pollution in India-A major environmental and public health

concern. ICMR Bulletin 2001 May;31(5).

5. India-indoor air pollution behind COPD. Indoor air quality updates. [online].

Available from: URL:http://iapnews.wordpress.com/2010/11/18/

6. Smith RK. National burden of disease in India from Indoor air pollution. Proceedings

of the National Academy of Sciences of the United States of America 2000

Nov;97(24):13286-93.

7. Nipadhkar VP, Rangnekar K, Tulaskar P, Deo S, Mahadik S, Kakade MA. Poor

awareness and knowledge about indoor air pollution in the urban population of

Mumbai, India. Journal of Association of Physicians India 2009 Jun;57:447-50.

8. Osagbemi GK, Adebayo ZB, Aderibigbe SA. Awareness, attitude and practice

towards indoor air pollution amongst residents of Oke-Oyi in Ilorin. Internet Journal

Of Epidemiology 2010;8(2).

9. Banik KB. Female perceptions of health hazards associated with indoor air pollution

in Bangladesh. International Journal of Sociology and Anthropology 2010

Nov;2(9):206-12.

10. Kleinerman RA, Wang ZY, Lubin JH, Zhang SZ, Metayer C, Brenner AV. Lung

cancer and indoor air pollution in rural China. Annals of Epidemiology 2000

Oct;10(7):469.

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11. Mishra V, Dai X, Smith RK, Lasten M. Maternal exposure to biomass smoke and

reduced birth weight in Zimbabwe. Annals of Epidemiology 2004 Nov;14(10):740-7.

12. http://en.wikipedia.org/wiki/knowledge

13. Compact Oxford Dictionary. Thesaurus and Word Power Guide. New Delhi: Oxford

University Press; 2005.

14. http://stats.oecd.org/glossary/details.asp?ID=1336.

15. http:www.businessdictionary.com/definition/health-hazard.html.

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8. Signature of the candidate

9. Remarks of the guide

10. Name and designation of (in block letters)

10.1 Guide MRS VINUTHA D’SOUZA MSC(N)ASSISTANT PROFESSORDEPT. OF COMMUNITY HEALTH

NURSING.LAXMI MEMORIAL COLLEGE

OF NURSING, MANGALORE

10.2 Signature

10.3 Co-guide (if any) MRS. JENIFER D’SOUZA MSC (N) M PHIL (N)

ASSOCIATE PROFESSOR AND H.O.D

DEPT. OF COMMUNITY HEALTH NURSING.

LAXMI MEMORIAL COLLEGE OF NURSING, MANGALORE.

10.4 Signature

11 11.1 Head of the department MRS. JENIFER D’SOUZA MSC (N) M PHIL (N)

ASSOCIATE PROFESSOR AND H.O.D

COMMUNITY HEALTH NURSING.

LAXMI MEMORIAL COLLEGE OF NURSING, MANGALORE

11.2 Signature

12. 12.1 Remarks of the Chairman and Principal

12.2 Signature

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