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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE
KARNATAKA
A STUDY TO EVALUATE THE EFFECTIVENESS OF STP ON PREVNTION OF PROTEIN ENERGY MALNUTRITION [PEM] IN UNDER
FIVE AMONG THE MOTHERS AT SELECTED HOSPITAL AT BANGALORE
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.
Mrs. SADHUKRISHNA KUMARIBANGALORE CITY COLLEGE OF NURSING
BANGALORE – 560043 [KARNATAKA]
Page 2 of 34
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE
KARNATAKA
PROORMA FOR REGISTRATION OF SUBJECT FOR DISSERTAION
1 NAME OF THE CANDIDATE AND ADDRESS
Mrs. SADHU KRISHNA KUMARI
1st YEAR M.Sc., NURSING
BANGALORE CITY COLLEGE OF
NURSING, BANGALORE
2 NAME OF THE INSTITUTION BANGALORE CITY COLLEGE OF
NURSING.
1660, CHELLEKERE MAIN ROAD,
BANASAWADI OUTER RING ROAD
KALYAN NAGAR POST, BEHIND
BTS BUS DEPOT
BANGALORE – 560043
3 COURSE OF STUDY AND SUBJECT
M.Sc., NURSING
PEDIATRICS NURSING
4 DATE OF ADMISSION TO THE COURSE
26.10.2009
5 TITLE OF THE TOPIC A STUDY TO EVALUATE THE EFFECTIVENESS OF STP ON PREVNTION OF PROTEIN ENERGY MALNUTRITION [PEM] IN UNDER FIVE AMONG THE MOTHERS AT SELECTED HOSPITAL AT BANGALORE
Page 3 of 34
6. BRIEF RESUME OF THE INTENDED WORK
6.1. INTRODUCTION:
The world health organization [WHO] defines malnutrition as “the
cellular imbalance between the supply of nutrients and energy and the body
demand for them to ensure growth maintenance and specific functions. The
term protein energy malnutrition applies to a group of related disorders that
include Marasmus, Kwashiorkor and intermediate states of marasmus
Kwashiorkor. The term Marasmus is derived from the Greek word marasmos
which means withering or wasting. The term Kwashiorkor is taken from the
Ga language at Ghana and means “The sickness of the weaning” Williams first
used the term in 1933 and it refers it as an inadequate protein.1
In 2000 the W.H.O. estimated that malnourished children numbered
181.9 million [32%] in developing countries. In addition to an estimated 149.6
millions children younger than 5 years, are malnourished when measured in
terms of weight for age. In South Central Asia and eastern Africa about half the
children have growth retardation due to protein energy malnutrition. This figure
is 5 times the prevalent in Western Word.2
Approximately 50% of the 100 million deaths each year in developing
countries occur because of mal nutrition in children younger than 5 years.
Protein energy malnutrition affects the most because they have less
protein intake. The few rare cases found in the developed world are almost
Page 4 of 34
entirely found in small children as a result of fact diets or ignorance of the
nutritional needs of children, particularly in cases of milk allergy. 3
Hospital records show that 15 percent of hospital beds in the pediatrics
words are occupied by frank cases of malnutrition in the Southern and eastern
parts of India, surveys carried out by Indian council of Medical Research
Indicate that the PEM is prevalent in all the states. The prevalence ranging from
0.1 to 3.8 percent in pre school children.4
6.2. NEED FOR THE STUDY:
Marasmus most commonly occurs in children younger than 5 years. This
period is characterized by increased energy requirement and increased
susceptibility to viral and bacterial infections.Weaning is not sudden withdrawal
of child from the breast it is gradual process starting around the age of end of
the fourth months because the mother milk alone is not sufficient to sustain
growth beyond six months. It should be supplemented by suitable foods rich in
protein and other nutrients. It continues till the child is completely of the feed
breast. Weaning is often complicated by geography, economy, hygienic public
health culture and dietics. It can be ineffective when the food introduced
provide inadequate nutrients when the food and water are contaminated when
the access to health care is in adequate, and/or when the patient cannot access or
purchase proper nourishment 5.
Protein energy malnutrition also involves an inadequate intake of many
essential nutrients low serum levels of zinc have been implicated as the cause of
Page 5 of 34
skin uncertain in many patients. In 1979 study of 42 children with Marasmus
investigations found that only those children with low serum levels of zinc
developed skin ulceration. Serum levels of zinc correlated closely with the
presence of edema stunting of growth and severe wasting 6.
The basic etiological factors are inadequate diet both in quantity and
quality. This is primarily due to poverty, ignorance, infection and parasitic
diseases, notably diarrhea, respiratory infections and parasitic disease. Infection
contributing to malnutrition and malnutrition contributing to infection by
weakening the child other factors are poor environmental condition, large
family size, poor maternal health failure of lactation, premature termination of
breast feeding, cultural practices, immature immune systems; dependence on
others, ineffective weaning child who is physically weak will be mentally weak
and cannot be expected to take full advantage of schooling studies in India,
Many study have shown that nutrition disorders are widely prevalent among
school children particularly deficiencies relating to proteins vitamin A.C.
thiamine and riboflavin calcium iron4.
After the large heterogeneous survey carried in U.S. researchers felt that
PEM is seriously affects children’s mentally and physically growth 7.
It is a major responsible of professional nurse to help mothers to gain
necessary knowledge regarding prevention of PEM among children. Through
the review of related literature and clinical setting the investigator did not find
appropriate study conducted about prevention of PEM. Before teaching Mothers
Page 6 of 34
researcher observed that many mothers because of their negligence did not feed
properly to children, it could be prevented by adequate knowledge and balance
diet and prevention of PEM. Today’s children’s are wealth of tomorrow. Hence
the researcher was interested in this study.
6.3. REVIEW OF LITERATURE:
Review of literature is an essential activity of scientific research
project, helps to familiarize with the practical issue related to the problem and
enable the researcher to avoid unintentional duplication of studies. The typical
purpose for analyzing or reviewing existing literature is to generate research
question to identify conceptual or theoretical tradition within the bodies of
literature. Hence the investigator intends to review the literature available on
degrees of PEM and its problems using both research and non-research
materials. 8
Review of literature done for this study is arranged under the following
headings.
1. REVIEW OF LITERATURE RELATED TO THE DEGREES OF
PROTEIN ENERGY MALNUTRITION.
2. REVIEW OF LITERATURE RELATED TO THE MANAGEMENT OF
PROTEIN ENERGY MALNUTRITION.
3. REVIEW OF LITERATURE RELATED TO THE PREVENTION OF
PROTEIN ENERGY MALNUTRITION.
Page 7 of 34
1. REVIEW OF LITERATURE RELATED TO THE DEGREES OF
PROTEIN ENERGY MALNUTRITION
Protein energy malnutrition is a potentially fatal body depletion disorder. It is
the leading cause of death in children in developing countries.PEM is also
referred to as protein calorie mal nutrition. It develops in children and adults
whose consumption of protein and energy is insufficient to satisfy the body’s
nutritional needs. While pure protein deficiency can occur when a persons diet
providing enough energy but lacks the protein minimum in most cases the
deficiency will be dual. Indian hospital records shows that 15 percent of
hospital beds in the pediatric wards one occupied by frank case of malnutrition
in the southern and eastern parts of India. Surveys carried out by Indian councils
of medical Research indicate that PEM is prevalent in all the States 9.
The study was conducted to examine the composition of weight gain in
severally undernourished children who underwent nutrition rehabilitation in a
hospital in Hyderabad in India in 2010. Body composition of 80 severally
malnourished children (age 6-60 months) was assessed using skin-fold
thickness measurements on admission and after 1 month of supplementary
feeding. The study demonstrated that it is possible to achieve rapid weight gain
with recovery of lost tissue in severally malnourished children with mixed diets.
Children with lowest weight for height z [WHZ] scores at baseline gained
higher fat free mass [FFM] during nutrition rehabilitation when compared to the
Page 8 of 34
children with relatively higher WHZ score probably in an attempt to recover the
lost tissue. 10
.
There are 3 types of PEM. Marasmus, deficiency of both energy, and
protein. Kwashiorkor deficiency of only protein an inter mediate of Marasmus
and Kwashiorkor. Most commonly occurs in children below 5 years and failure
to thrive is a common presentation, poor weight gain, weight loss, short in
height for age, stunting gross muscle wasting and loss of sub cutaneous fat
Emaciated and looks like a baby monkey, irritable does not allow the touch
apathy, Anxiety, Decreases responsiveness be behavioral change, No edema,
wrinkled skin and loose like tissue paper loss of even buccal pad of fat. 11
Cross sectional study did in 2007 and found that 24 hours dietary recall
method was used to access dietary intakes to children. Height and weight were
recorded and children were classified by WHO criterion (Z-score) using
nutritional indices i.e. weight for age, height for age and weight for height.
Mean energy and protein intake per day were measured and compared with
Recommended Dietary Allowances (RDA) of Indian standards, and the results
were more than 90 percent of children (both boys and girls) in the age group of
4-6 years suffered by underweight, which was comparatively lower in 7-9 and
10-12 years age group children. In that 84.51% of boys suffered by stunting,
which was much higher than girls [47.54%] in 4-6 years age group? Similarly,
80 percent of 4-6 years age group children were affected by wasting. They
Page 9 of 34
conclude that under nutrition in the form of underweight, stunting and wasting
and low consumption of dietary intake (energy and protein) was found to be
widely prevalent among Kamar tribal children in Chattishgarh. Therefore, an
urgent dietary intervention programme is necessary. 12
Prevalence of PEM was 20.5% whereas the prevalence of underweight,
wasting and stunting using the WHO/National centre for health statistics
standards were 23.1%, 9%, and 26.7% in rural Nigerian children. They
conclude that improved living standard of families, empowerment of mothers
with the aim of augmenting family income and parental education on
appropriate feeding practices may help in reducing the incidence of under-five
malnutrition in communities. 13
Study was conducted in 2006 in pre-schoolers (2-60 years ten different
slums of Udaipur City in Rajasthan with the aim to their nutritional status. From
the data collected and observations and recorded was observed that majority of
the subjects were from nuclear family with monthly family income of less than
Rs.1500/-. More than 50% of these pre-schoolers showed symptoms of protein
energy malnutrition and anemia, while 22% had pigeon chest deformity due to
vitamin D and calcium deficiency. It included the classification of degrees of
malnutrition as per IAP showed that majority of the subjects (66%) were under
weight [Grade I and Grade II].Waterlows classification revealed that majority of
these preschoolers were wasted (30%) and stunted (42%)14.
Page 10 of 34
Study conducted in Jodhpur in 2006 which includes the protein energy
malnutrition [PEM] was observed in 44.4%. Overall mean calorie and protein
intake deficit was observed to be very high (76.0 & 54.0%) Due to inadequate
consumption of daily food, the children were suffering from PEM resulting in
several childhood illnesses. Effective measures making availability of adequate
calories and proteins to all age groups especially to under five children through
the ongoing nutrition programs needs to be ensured. 15
Cross sectional study conducted in Egypt in which group were classified
into three according to their weight for age percentiles, underweight children,
borderline malnourished children and normal weight children. They concluded
that there is a high prevalence of wasting, stunting and underweight among
infants and children of the studied sample in sharkia governorate explained by
the low socioeconomic status and unbalanced diet. 16
Prevalence of protein energy malnutrition [PEM] was found in
Chandigarh to be about 42%, 22.7% and 14.5% children had grade I, II and III
PEM respectively. The prevalence of PEM was significantly higher among
females (47.6%) in 1-3 years age group (53.80%) in slum area (67%) and
children of labor class (60%). With increase in family size, the prevalence of
malnutrition also significantly increased, and decreased with high literacy rate
in parents. 17
A cross sectional study was done. And found that, according to weight-
for-age, 57.1% of the children were suffering from underweight and 21.3 per
Page 11 of 34
cent of children had very low body weights. Height-for-age and weight-for
height data showed that 41.8 per cent of children suffered from stunting and
27.9 per cent recorded wasting. The children below one year of age had
relatively lower prevalence of malnutrition than the other age groups. The
prevalence of clinical PEM in the form of Marasmus was found in 0.7 per cent
of children, while kwashiorkor was absent. This study showed that malnutrition
is still a leading problem among preschool children of Kalahandi district in
Orissa and this has not improved in spite of nutrition intervention programmes
which are currently in operation. 18
The study (1997) had conducted in a house-to-house survey for the
clinical assessment of child nutritional status, and the anthropometric
measurement of the children using accepted standard techniques. The
anthropometric measurement of the children was compared to the 50th percentile
of the Harvard Standard, while the classification recommended by the Indian
Academy of Paediatrics was adopted for the categorization and grading of
protein energy malnutrition. 60.45% of the children were malnourished,
comprised of 33.22%, 20.89% and 6.34% of children with grade I, II and III
degrees of malnutrition, respectively. Higher prevalence of malnutrition is
associated with higher age, female sex, lower per capita income, higher birth
order, and lower parental literacy. Parental literacy status followed by birth
order and per capita income were the most important factors associated with
preschool child malnutrition. 19
Page 12 of 34
The study was conducted on [1995] they found that auditory brainstem
potential (ABPs) were studied in children with protein energy malnutrition
[PEM] to determine the effects of PEM on the developing brain in children in
Turkey. A total of 31 children, aged 3-36 months with moderate/severe PEM
and 25 healthy children, age 3-48 months were included in the study.
Nutritional status assessed by the Gome’z classification. Recordings of ABPs
were performed by using Nihon Kohden Neuropack 2 device. The results of 31
children, 22 (71%) had severe malnutrition 9 (29%) had moderate malnutrition.
They concluded that children with moderate/severe PEM had ABPs
abnormalities in different degrees, which reflect defects in myelination of
auditory brainstem pathways in children with moderate/severe PEM. However,
we found contradictory results between abnormalities in ABPs and degree of
malnutrition. We think that more extensive studies should be performed to
determine whether or not there was a relationship between these parameters. 20
The (1993) study was conducted on the prevalence of vitamin A
deficiency and the efficacy of vitamin A prophylaxis in preventing
xerophthalmia co-existing with malnutrition in Baroda. The findings have
important implications for the existing national Vitamin A Prophylaxis
Programme, and suggest that: normal and mild to moderately malnourished
children less than 6 years old, should be preferably considered for vitamin A
mega dosing; in the management of protein energy malnutrition, vitamin A
Page 13 of 34
status of the children should be monitored and the coverage should be improved
as most children are in the mild and moderate degrees of malnutrition. 21
The study conducted on anthropometric measurements, Somatic Quotient
(SQ) Development Quotient (DQ), Motor Quotient (MoQ) and Mental Quotient
(MeQ) in 136 children in the age group 1-24 months with varying degrees of
protein energy malnutrition [PEM] were compared with an equal number of
comparable well nourished children. There was progressive reduction in SQ,
DQ, MoQ, and MeQ as the degree of PEM advanced. There was a direct linear
correlation between SQ and DQ and between height and DQ in 4 degrees PEM.
However, there was no direct correlation between head circumference and
either DQ or MeQ. 21
2. REVIEW OF LITERATURE RELATED TO THE MANAGEMENT
OF PROTEIN ENERGY MALNUTRITION.
Study done on 2010 indicated that the impact of nutritional therapy on
quality of life and food intake. The nutritional therapy group (NT Group)
received individual nutritional counseling and interventions, including oral
nutritional supplements if appropriate, by a dietician. The oral nutritional
supplement group (ONS Group) received oral nutritional supplements in
addition to hospital meals without further instruction or counseling. They
concluded that the both interventions caused a significant increase in energy and
protein intakes and quality of life. In the NT group every patient received an
Page 14 of 34
efficacious individualized intervention. In contrast, the 7 of 18 patients in the
ONS group who did not consume ONS had no intervention at all. Therefore,
undernourished patients should be counseled individually by a dietitian. 22
A study was conducted on 2009 on Pathophysiological changes in
children with PEM that may affect the disposition of drugs frequently used for
their treatment. This review has established abnormal disposition of drugs in
children with PEM that may require dosage modification. However, the
relevance of these abnormalities to the clinical management of PEM remains
inconclusive. At present there are no good indications for drug dosage
modification in PEM; but for drug safety purposes, further studies are required
to accurately determine dosages of drugs frequently used for children with PEM
in Nigeria. 23
Research was done on Systematic failure to recognize and approximately
treat children with severe malnutrition has been attributed to the elevated case-
fatality rates, often as high as 50%, that still prevail in many hospitals in Africa.
Children admitted to Kilifi District Hospital, on the coast of Kenya, with severe
malnutrition frequently have life threatening features and complications, many
of which are not adequately identified or treated by WHO guidelines. Four
main areas have been identified for research; early identification and better
supportive care of sepsis; evidence-based fluid management strategies;
improved antimicrobial treatment; rational use of nutritional-strategies. The
Page 15 of 34
present paper focuses on the identification of children with sepsis and on fluid
management strategies. 24
Study was conducted to assess the clinical profile and outcomes of
severally malnourished cases admitted at Zewditu Memorial Hospital in
Ethiopia in 2009. Observed case fatality rate is unacceptably high and the risk
factors for death are identified. In the face of many shortcomings in the hospital
setting, managing uncomplicated cases of severe acute malnutrition is not
encouraging when compared with the promising results of community based
therapeutic care. They recommend the staffs to be trained and retained.25
Study was conducted in Bhopal stated that serum zinc levels in Grade I
and Grade II malnourished were 82.7 and 67.7µg/dl respectively and in Grade
III and IV combined was 53.2 µg/dl as compared to 109.5 µg/dl in the control
group. These levels were significantly lower in children who had skin lesions
than in those without such lesions. Total antioxidant capacity was found to be
significantly lowered in malnourished children. Serum trace element deficiency
leading to depleted antioxidant protection may be a contributing factor to the
pathophysiology of protein energy malnutrition and replacement of these
elements in the management of this condition might be important. 26
Research was done on implementation of WHO Guideline. The care of
the children was provided by clinicians and medical staff trained under World
Health Organization guidelines. Overall, mortality during the 5 years was 5.7%
with sepsis the most common cause. Once the World Health Organization
Page 16 of 34
guidelines were implemented, low mortality rates were achieved in children
with severe acute malnutrition in class I hospitals. 27
The study conducted in 2007 recommended that greater impact in the
group given Soya, in which there was clear improvement. The degree of
malnutrition dropped and in some cases nutritional status was restored. [28]
Observational study conducted in 8 rural villages in USA. A total of 43
(2.6) of the 1651 healthy children ages 1 to 3 years enrolled developed
kwashiorkor. Children who developed kwashiorkor were younger and had more
nutritional wasting than those who did not. Thirty children (70%) who
developed kwashiorkor were breast-fed. In the combined regression model no
foods or nutrients were found to be associated with the development of
kwashiorkor. There were no differences in the dietary diversity between
children who developed kwashiorkor and those who did not. They concluded
that there is no association between the development of kwashiorkor and the
consumption of any food or nutrient was found. 29
Study was conducted and analysed three cohorts of severally
malnourished patients in terms of daily weight gain, length of stay, recovery,
case fatality and defaulting. For all cohorts, average time in the programme and
average weight gain met the international standard (30-40 days, < 8 g/kg/day).
Default rates were 28.1, 16.8 and 5.6% for therapeutic feeding centre (TFC)
only, TFC plus home based and home-based alone strategies, respectively. The
overall case fatality rate for the entire programme was 6.8%. Case fatality rates
Page 17 of 34
were 18.9% for TFC only and 1.7% for home-based alone. No deaths were
recorded in children transferred to rehabilitation at home. This study suggested
that satisfactory results for the treatment of severe malnutrition can be achieved
using a combination of home and hospital based strategies. 30
The rehabilitation phase of treatment of severe malnutrition should take
place in the community rather than in the hospital but only of caregivers can
make energy and protein-dense food mixtures or RUTF. 31
Research was done in Africa determined the practices of primary heath
care (PHC) nurses in targeting nutritionally at-risk infants and children for
intervention at a PHC facility in a urban area of the Western Cape Province of
South Africa. The researcher identified 67 (50%) infants and children as being
nutritionally at – risk compared with 14 (10%) by the nurses. The nurse’s poor
detection and targeting of nutritionally at – risk children were largely a result of
failure to plot weights on the weight – for – age chart (55%0 and poor
utilization of the Road to Health Chart. 32
Study was done on intervention to reduce protein – energy malnutrition
among children in rural areas was piloted in 3 provinces of the Islamic Republic
of Iran. The study was based on an initial situation analysis, a range of
interventions were implemented through local nongovernmental organizations,
including nutrition, health and literacy education for mothers, improved growth
monitoring and fostering rural cooperatives and income generation schemes.
Malnutrition before and after the intervention (in 1996 and 1999) was assessed
Page 18 of 34
using anthropometric measurements of random samples of children aged 6 – 35
months in control and intervention areas. Three years into the intervention, all
indicators of malnutrition had consistently decreased in all intervention areas
and the prevalence of underweight and stunting was significantly lower. Control
areas showed a mixed pattern of small increases and decreases in malnutrition
indicators.33
3. REVIEW OF LITERATURE RELATED TO THE PREVENTION
OF PROTEIN ENGERGY MALNUTRITION.
Antioxidants may be able to curb excessive free radical activity and
prevent the development of kwashiorkor in susceptible children. To evaluate the
benefits of supplementation of vitamin E, selenium, cysteine and riboflavin
(alone or in combination) in preventing kwashiorkor. We could draw no firm
conclusion for the effectiveness of supplementary antioxidant micronutrients for
the prevention of kwashiorkor in pre-school children. 34
Greater efforts should be taken to increase the use of protein enriched
foods and oral supplements for patients with eating problems in order to prevent
or treat protein energy malnutrition.[35
PEM is prevalent among school children in rural Malaysia and therefore
of public health concern since PEM diminishes immune function and impairs
cognitive function and educational performance. School – based programs of
prevention through health education and interventions should be considered as
Page 19 of 34
an essential part of measures to improve the quality of life of school children in
rural Malaysia. 36
Current public health strategies should be redirected to address overall
protection, promotion and support of infant and young child feeding, in addition
to breast – feeding; overweight, in addition to underweight and stunting and
malnutrition as a whole, in addition to micronutrient deficiencies. An equity
lens should be used in developing policies and plans and implementing and
monitoring programmes. Capacity building, cross – sect oral action, improved
data collection within adequate legal frameworks and community engagement
should be the pillars of redirected strategies. 37
Improvement in social infrastructure, better maternal education and
nutrition are needed to prevent the child malnutrition issue. 38
Preventing malnutrition in developing countries is a complicated and
challenging problem. Energy distribution among macronutrient should be about
16% protein, 50% fat and 34% carbohydrates. An example in a combination of
powdered cow’s skimmed (110g), sucrose (100g) and water (900ml) may
prevent adequate feeding space. 39
Study conducted on consumption of less micro nutrients they found that
Malawian children with severe malnutrition, those with kwashiorkor consume a
diet with less micronutrient and antioxidant – rich foods, such as fish, eggs,
tomatoes and orange fruits (mango, pumpkin and papaya), than those with
Marasmus. 40
Page 20 of 34
Research conducted personal interviews using questionnaires and 24-h
dietary recall were used. Weights and heights were recorded, body mass index
was calculated, and children were classified as normal or malnourished using Z
scores and growth charts from the Centers for Disease Control and Prevention.
Sociologic community factors are required to facilitate implementation of a
nutritional package and availability of key nutrients to ensure growth in
children. 41
Study identified mother’s attitude and concern regarding child weight and
feeding practices and also to explore the importance of growth monitoring
activity in preventing, Protein Energy Malnutrition. Data regarding child
feeding practices show mothers of a well nourished child have timely and
appropriate starting of these practices. It is inferred from the recent finding that
mothers who had received growth monitoring program since delivery have
better preventive behaviour for PEM and the role of basic health staff in these
activity is also acknowledged. 42
New dietary guidelines for Americans, (2003) had described that talking
to a Doctor before putting a child on any kind of diet such as vegetarian or low
carbohydrate, can help assure that the child gets the full supply of nutrients that
he or she needs. Every child being admitted to a hospital should be screened for
the presence of illnesses and conditions that could lead to protein energy
malnutrition.43
Page 21 of 34
Effect of supplementary feeding on the prevention of wasting in
preschool children in a rural area of Guatemala with a high prevalence of
malnutrition. Supplementary feeding of children aged 6 – 24 months in
populations with inadequate dietary intakes can prevent the onset of wasting in
a large proportion of children.44
Study was conducted on Weaning stated that Weaning food was started at
4 Months. Low household income, parental illiteracy, small family size, early or
late weaning and absence of BCG vaccination were significantly associated
with severe PEM. Timely weaning, education and promotion of essential
vaccination may reduce childhood malnutrition especially severe PEM.45
Research was conducted on rehabilitation of grade III protein energy
malnutrition on out patients basis and it was simple health messages adapted
according to local cultural practices in native language. This simple strategy can
go a long way in prevention and treatment of PEM in all the developing
countries.46
Malnutrition in India is related to both food production and poverty. This
study explored whether the children belonging to families who joined dairy
cooperatives were better nourished than those who do not have such additional
income. Considerable amounts of milk are being procured from rural families
and increasing their income. This higher milk production is associated with the
adequacy of protein and calorie intake of pre-school children.47
Page 22 of 34
Children can be effectively rehabilitated at home by educating the mother
and convincing her that care can be effected by simple modifications in child is
home diet without external food supplements and within ten economic
constraints of a family. This concept is known as nutritional rehabilitation
which was originally formulated by Bengoa and has been developed and
modified in various countries. The national institute of nutrition Hyderabad has
formulated an energy protein rich mixture to treat pem at home level It consist
of Whole Wheat- 409g, Bengulgram -169g, Ground Nut-109g, Jagery-209g
Energy - 3.30 Kcal, Protein - 1.39g Many children with PEM have been
treated with this food mixture they were cured at PEM within 3 months48
As soon as children are able to take normal food and infection is under
control, it is economical for medical services to discharge them to a centre
where their nutritional rehabilitation can be supervised. Follow up studies done
at the Institute of Child Health and hospital for children at Chennai revealed that
one – third of the children who had been treated in hospital for PEM were dead
within a year from the disease for which they had been successfully treated and
still others were malnourished. Causes can be attributed to poverty or failure to
involve parents particularly mother in treatment and recovery. The concept of
nutritional rehabilitation is based on practical nutritional training for mothers in
which they learn by feeding their children back to health, under supervision and
using local foods49.
Page 23 of 34
6.3 STATEMENTS OF THE PROBLEM:
A study to evaluate the effectiveness of STP on prevention of Protein
Energy Malnutrition [PEM] among the mothers in selected hospital at
Bangalore.
6.4 OBJECTIVES:
1. To assess the levels of knowledge regarding prevention of PEM in under
five among the mothers.
2. To evaluate the effectiveness of S.T.P on knowledge of mothers
regarding the prevention of PEM in under five.
3. To find out the associate between pretest knowledge and post test
knowledge with selected demo graphic variables.
6.5 OPERATIONAL DEFINITION
a) Effectiveness: refers to determining the extent to which the true
experimental study has achieved the desired effect in improving the
knowledge of working women and its management.
b] STP: Structured teaching program refers to self contained written
material which be used to teach the mothers.
c] PEM: Protein energy Malnutrition.
6.6 HYPOTHESIS
H1:- There will be a significant difference between pretest & post test
knowledge levels regarding prevention of PEM among mother.
Page 24 of 34
H2 :- There will be a significant association between the pretest
knowledge and post test knowledge levels of mothers regarding
prevention of PEM with selected demographic variables.
6.7 ASSUMPTION
(1) Mothers – may have some knowledge regarding the role of prevention
of PEM.
(2) S.T.P. on prevention of PEM help in improving their knowledge
there by it reduced complication.
6.8. DELIMITATION:
The study will be delimited to the mothers in selected hospital.
7. MATERIAL AND METHODS
7.1. SOURCES OF DATA:
Data will be collected from mothers.
7.2. METHOD OF COLLECTIONS OF DATA:
Structural interview method will be used collected the data.
VARIABLES:
Dependent variable refers to knowledge level of mothers.
Independent variable refers to S.T.P. on prevention of PEM
Extraneous variable – Demographic variables refers to age religion,
education, occupation, type of family, income etc.
DURATION: 6 Weeks
7.2.1. RESEARCH APPROACH:
Page 25 of 34
Evaluate approach will be used to carry out the study.
7.2.2. RESEARCH DESIGN:
Pre-experimental design, where one group pre-test, post test design
without control group will be used for the study.
7.2.3. SETTING:
Selected Paediatric hospital, Bangalore
7.2.4. POPULATION:
The population of the present study consists of mothers.
SAMPLE:
The sample of the present study consists of mothers who visit Paediatric
OPD and Paediatric Wards, at Bangalore.
7.2.5. SAMPLE SIZE:
Sample size of the study will be 50 mothers
7.2.6. SAMPLING TECHNIQUE:
Convenient sampling technique will be adopted to select the sample.
7.2.7 SAMPLE CRITERIA:
Inclusion Criteria:
1. The mothers who are willing to participate
2. Available during the period of data collection
Exclusion Criteria
1. Who are not willing to participate.
2. Study will not include other women
Page 26 of 34
7.2.8 TOOL FOR DATA COLLECTION:
A structured questionnaire will be prepared to assess the knowledge of
mothers regarding prevention of PEM in under five and it consist of two
section
Section A: Socio-demographic Proforma of the study participants.
Section B: STP to assist the levels of knowledge regarding prevention of
Protein Energy Malnutrition [PEM] among the mothers.
7.2.9. METHOD OF DATA ANALYSIS AND PRESENTATION:
Data analysis will be through descriptive and inferential statistics.
Descriptive Statistics:
Frequency, percentage, mean, median, and standard deviation will be
used to explain demographic variables and to compute the levels of
knowledge.
Inferential Statistics:
‘t’ test will be used to find the effectiveness of STP on prevention of
PEM. Chi square test will be used to find out the association between pre-
test & post knowledge levels with selected demographic variable among
the mothers.
Page 27 of 34
PROJECTED OUTCOME:
The finds of the study would reveal:
1. The existing knowledge of mothers regarding prevention of PEM
2. Administration of STP will be to update knowledge in mothers regarding
prevention of PEM.
3. The study will motivate the mothers more information regarding PEM
and diet and prevention.
4. The study will emphasis the role of STP on prevention of PEM.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTION TO BE CONDUCTED ON PATIENTS OR
OTHER HUMANS OR ANIMALS? IF SO PLEASE DESIRABLE
BRIEFLY.
Yes. STP will be administered to the study participants at the part of the
research study.
7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
Yes.
Page 28 of 34
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Page 34 of 34
SIGNATURE OF CANDIDATE
REMARKS OF THE GUIDE
NAME AND DESIGNATION
11 .1 GUIDE
11.2 SIGNATURE
11.3 CO –GUIDE
11.4 SIGNATURE
11. 5 HEAD OF THE DEPARTMENT
11. 6 SIGNATURE
12.1 REMARKS OF THE PRINCIPAL
12 .2 SIGNATURE
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