RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

MRS.STEFFI.S.ELIZABETH 1ST YEAR M.Sc Nursing Community Health Nursing Year 2012-2013

PADMASHREE INSTITUTE OF NURSING, BANGALORE.

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

1

NAME

OF

THE Mrs.Steffi.S.Elizabeth AND
1st Year M.sc Nursing , Padmashree Bangalore. Institute Of Nursing

CANDIDATE ADDRESS.

2

NAME

OF

THE

Padmashree Bangalore.

Institute

Of

Nursing

INSTITUTE. 3 COURSE OF STUDY

1st Year M.Sc Nursing , Community Health Nursing

AND SUBJECT.

4

DATE OF ADMISSION.

02.07.2012

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TITLE OF THE STUDY.

Assessment of effectiveness of IEC package on knowledge and attitude regarding management of malnutrition among children. mothers of malnourished

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6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION
Malnutrition is the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function.1 According to the World Health Organization (WHO), malnutrition has three commonly used comprehensive types named stunting, wasting and underweight measures by height for age, weight for height and weight for age indexes respectively.2 Stunting or growth retardation or chronic protein-energy malnutrition (PEM) is deficiency for calories and protein available to the body tissues and it is inadequate intake of food over a long period of time, or persistent and recurrent ill-health. This height-forage index (stunting) is less sensitive to temporary food shortages and thus seems to be considered as the most reliable indicator. Because studies have shown that wasting is volatile over seasons and periods of sickness and underweight shows seasonal weight recovery and being overweight for some children can also affect weight-for-age index. Wasting or acute protein-energy malnutrition captures the failure to receive adequate nutrition during the period immediately before the survey, resulting from recent episodes of illness and diarrhea in particular or from acute food shortage. Underweight status is a composite of the two preceding ones, and can be due to either chronic, acute malnutrition. Malnutrition is mainly caused by poverty and lack of food, poor environmental conditions, large family size, poor maternal health, failure of lactation, pre mature termination of breast feeding and adverse cultural practices.

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Symptoms

mainly

include

skin

becomes

pale,

thick,

dry,

and bruises easily, skinny or bloated. Rashes and changes in pigmentation are common. Hair is thin, tightly curled, and pulls out easily. Joints ache and bones are soft and tender. The gums bleed easily. The tongue may be swollen or shriveled and cracked. Visual disturbances include night blindness and increased sensitivity to light and glare. Other symptoms of malnutrition include anemia, diarrhea, disorientation, night blindness, irritability, anxiety, attention deficits, goiter (enlarged thyroid gland), loss of reflexes and lack of muscular coordination, muscle twitches, amenorrhea (cessation of menstrual periods), scaling and cracking of the lips and mouth. Malnourished children may be short for their age, thin, listless, and have weakened immune systems. Malnutrition is calculated by using the Gomez classification method; Weight for age (%) = weight of the child weight of the normal child of same age

X 100

Between 90-110% = normal nutritional status. Between 75-89% =1st degree or mild malnutrition. Between 60-74% =2nd degree or moderate malnutrition. Under 60% = 3rd degree or severe malnutrition.3 Preventive aspects are mainly divided into; 1.Health promotion 2.Specific protection 3.Early diagnosis and treatment 4.Rehabilitation. Health promotional measures include; measures directed to pregnant and lactating women, promotion of breast feeding, development of low cost weaning food, measures to improve family diet, promotion of correct feeding practices, family planning and space of births.

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The preventive aspects under the specific protection are; immunization, food fortification and ensuring that the child‟s diet will contain protein and energy rich foods. Early diagnosis and treatment includes; periodic surveillance, early diagnosis of any lag in growth, early detection and treatment of infections, development of supplementary feeding programmes and deworming of heavily infected children. Rehabilitation measures are; nutritional rehabilitation services, hospital treatment and follow up care. India , today is one of the most malnourished countries in the World. More than 40% of the World‟s underweight children below five years live in India. Poverty is a major, but not the only cause of malnutrition. Percentage of population suffering from various forms of malnutrition, far exceeds the percentage below poverty line. After National Nutrition Policy (1993) and National Plan of Action (1995) number of national programs or policies for eradicating malnutrition has appeared. India has no comprehensive National Program for the eradication of Malnutrition. The ICDS programme in governmental and general perception is seen as a programme to address malnutrition. However, ICDS is not a programme for the eradication of malnutrition, but for Integrated Child Development. Other Nutrition and related programmes such as the Mid-Day Meal Programme, Kishori Shakti Yojana, Vitamin A supplementation programme, National Nutritional Anemia Control Programme, and the National Iodine Deficiency Disorder Control Programme address some of the causes of Malnutrition but not all of them.5 The population of India suffers from a high Protein Calorie deficit. Studies reveal that 30% of the households in India consume less than 70% of the energy requirement and calorie intake. There is inadequate awareness and information regarding proper nutritional practices amongst the population. Crucial prescriptions of the National Nutrition Policy, 1993, were not translated into National Programmes, viz., popularization of low cost nutritious foods, reaching the adolescent girl, fortification of

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essential foods and control of micronutrient deficiencies. Most importantly, eradication of malnutrition should be articulated as high priority in the National Development Agenda. What does Malnutrition Cost the Nation? Malnutrition negatively impacts the GDP (gross domestic product) as it reduces physical/ cognitive growth reduces productivity and earnings of individuals, and results in economic loss to the nation. It lowers the resistance of the body to infections and capacity to recover from illness and adds to the health costs of the nation. Protein calorie intake, micronutrient intake, infections and illness, nature of occupation determines working capacity and income generation capacity. A National Strategy to combat Malnutrition was to introduce nutrition and micronutrient interventions for the three critical links of malnutrition viz. children 6 months – 6 years, adolescent girls, and pregnant and lactating women to be prepared by :Self Help Groups from low cost, locally available agricultural products, introduce nutrition and micro-nutrient interventions for the general population to bridge the protein-calorie gap by making available in the market, protein-energy dense foods, make available low cost energy foods for the general population (Corporate Sector/PPP) structure and monitor tightly integrated multi-sectoral interventions to address all or majority of the direct and indirect causes of malnutrition simultaneously, initiate a sustained general public awareness campaign regarding proper nutritional practices within existing family budgets, and to create demand.6

6.2 NEED FOR THE STUDY
Today‟s healthy child is tomorrow‟s better citizen. Development of healthy child is influenced by many factors. Under five children are the most vulnerable groups who are prone to many infective disease and nutritional deficiencies. Proteins are very important for growth and development, wear and tear of tissue repair and maintenance, formation of immune bodies, enzymes and hormones. Proteins also act as sources of energy when consumed in excess of body need. Protein sources are basically classified as

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animal source (e.g.: Cheese, Milk, liver, Fish, meat and eggs) Plant sources (e.g.: pulses, nuts, beans and soya beans). Conventional sources (e.g.: oil seeds, cakes, sea weeds). The protein requirement depends upon the age, sex, physical, physiological and other factors. ICMR (2006) recommended 1.8 gm per kg of body weight of protein up to 1-3 years and 1.6 gm per kg of body weight of upto-4-5 years, i.e. 22 gm and 29 gm of total requirement respectively. For infants 1.3gm per kg up to 3 months, 1.8gm per kg up to 3-6 months, 1.8 gm up to 6-9 months and 1.5gm per kg up to 9 to 12 months is the daily recommended protein allowance. The mental and social development of the child is dependent on the mother. The mother is the first teacher of the child, and that is why the mother and child are treated as one unit.7 According to WHO, in Karnataka during 2008-2011 the statistics showed, below -3 SD was 14.8%, -2 SD was 39.1% in weight for age, the percentage for height for age 3 SD was 20.8%, -2 SD was 42.9%, the weight and height ratio showed -3 SD was 6.2%,-2 SD was 17.9% for boys and girls respectively.8 According to the National Nutrition Monitoring Bureau (NNMB Rural Survey,2004) children in Karnataka are not consuming enough protein as the proposition of children with protein „calorie adequacy‟ is 23.3% of the children in the age group 1 -3 yrs and 31.6% of children in the age group of 4-6 yrs. The intake of green leafy vegetables among the age group of 1-3 yrs was 5gm/day and among the age group of 4-6 yrs was 12gm/ day which was relatively low when compared to the other dietary items consumed by the child.9 A study conducted to find out the Effect of maternal factors on nutritional status of 1-5 year old children in urban slum population among 482 children in Punjab reported that education of mother significantly influenced the nutritional status of under fives as the prevalence of under nutrition was 60.9% where mother was illiterate and it was only 21.2% where education level was more than high school. Mother‟s age showed highly significant (p=0.001) effect on the prevalence of under nutrition. That is where mother‟s age was less than 20 years; the prevalence was 75.0% as compared to 32.2% where mother‟s age was more than 30 years.10
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A vast majority of the children suffering from mild to moderate forms of malnutrition remain hidden in the community. Malnutrition results from the interaction of several factors among which two or more are less directly responsible for the disease. First quantitatively insufficient and qualitatively inadequate dietary intake, second infections processes such as gastrointestinal and respiratory infections and other infectious diseases of childhood. Infections experienced by children during first year of life represent the major factor in protein energy malnutrition. In child hood infections especially measles were traced in more than half of the children. Similar observation concerning of precipitating effect of infections processes such as measles, Germen measles, whooping cough, primary tuberculosis and malaria have been seen. Insufficiency of food the so-called “food –gap” and lack of awareness are chief cause of malnutrition, which is a major health problem particularly in first years of life. The majority of cases of malnutrition were nearly 30% are mild and moderate cases. The incidence of protein energy malnutrition is more in preschool children. This problem exists in all the states and the nutritional marasmus is more frequent than kwashiorkor.5 Infants and children under five are the most vulnerable group. They are seriously affected by deficiency of protein. Serious complications of advanced malnutrition can happen leading to superadded overt and hidden infections like septicemia, pneumonia, diarrheal, pyoderma, scabies, Urinary tract infections, tuberculosis infection. Mothers are the most wondrous care givers who nurture their kids. Thus they play a prime role in providing nutrition. So they should have adequate knowledge of protein‟s significance in diet of under five children. Malnutrition is the underlying cause of at least 50 per cent of deaths of children under five. Even if it does not lead to death, malnutrition, including micronutrient deficiencies, often leads to permanent damage, including impairment of physical growth and mental development. For example, iron, folic acid and iodine deficiencies can lead to brain damage, neural tube defects in the new born and mental retardation.11

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According to the most recent information received under the Right to Information Act, the details of malnourished children in Karnataka is as follows: 12 Grade No Boys Mild of No. girls 21,00,818 of Total

10,50,006 10,50,812

Moderate 5,61,224

5,68,723

11,29,947

Severe

33,039

38,566

71,605

Table no.1: Details of malnourished children in Karnataka. Source: National family health survey, 2010-2012, National fact sheet, Karnataka.

The findings of the third National Family Health Survey (NFHS-3) reveals an unacceptable prevalence of malnutrition in our children: 13
   

42.5% of our children under the age of five years are underweight (low weight for age) 48 % of our children are stunted (low height for age – chronically malnourished) 19.8 % of our children are wasted (low weight for height – acutely malnourished) In poorer states the situation is even worse with over 50 % of children underweight.

People residing in slums face many problems like improper sanitation, unhygienic environmental conditions, social, economic, health, educational and cultural problems and many more. The basic problems inherent in slums are Health hazards; Lack of basic amenities like safe drinking water, proper housing, and drainage and excreta disposal services, make slum population vulnerable to infections. These further compromise the nutrition requirements of those living in slums.

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It is projected that more than half of the Indian population will live in urban areas by 2020 and nearly one third of this urban population will be slum dwellers. The ongoing process of rapid urbanization has deleterious repercussions on health and nutrition, especially for children. Malnutrition in young children has long-term negative effects on physical and cognitive development. The major causes of childhood malnutrition in slum population are inappropriate child feeding practices, infections, improper food security and suboptimal childcare besides poor availability and inadequate utilization of health care services. Addressing nutritional problems of urban poor is essential for overall development of the country.14 The nurse plays an important role in educating the mothers of under five children about significance of protein in daily diet. Ongoing health education and reinforcement while monitoring to reduce protein deficiency is an important challenge for nurses. Education of mothers is the process of assistance to learn and incorporate healthy eating behaviors in everyday life. Providing sound and sincere advice regarding the measures to take adequate protein will provide health promotion positively. Hence the investigator found need to assess the knowledge and provide the awareness package for the mothers in the urban slums about management of malnutrition. In view of the above facts, the investigator observed that malnutrition is one of the „silent emergencies‟ seen in children of age 0-5 yrs of age. The parents of the children especially the mothers should posses‟ adequate knowledge and attitude towards malnutrition to reduce the incidence and prevalence rate of malnutrition. These instances provoked the researcher to undertake the study.

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6.3 STATEMENT OF THE PROBLEM
A study to assess the effectiveness of IEC package on knowledge and attitude regarding management of malnutrition among mothers of malnourished children in selected urban slum areas, Bangalore.

6.4 OBJECTIVES
1. To assess the prevalence of malnutrition among under-five children in urban slum areas. 2. To assess the pre-test knowledge and attitude regarding management of malnutrition among mothers of malnourished children. 3. To assess the post-test knowledge and attitude regarding management of malnutrition among mothers of malnourished children. 4. To assess the effectiveness of IEC package on knowledge and attitude regarding management of malnutrition among mothers of malnourished children. 5. To correlate between knowledge and attitude regarding management of malnutrition among mothers of malnourished children. 6. To associate the knowledge and attitude regarding management of malnutrition among mothers of malnourished children with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS
1. Effectiveness
In this study, it refers to improvement in knowledge and attitude regarding

management of malnutrition among mothers of malnourished children after administration of IEC.

2. IEC package (Information, Education and Communication)
In this study, it refers to information, education and communication in the aspects of management of malnutrition. Information refers to the distribution of pamphlet regarding management of malnutrition among mothers of malnourished children.

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Education refers to teaching using flash cards regarding management of malnutrition among mothers of malnourished children. Communication refers to the conversation and exchange of thoughts regarding management of malnutrition through the local language among mothers of malnourished children.

3. Knowledge
In this study, it refers to the level of understanding of the mothers regarding management of malnutrition, elicited through structured interview schedule.

4. Attitude
In this study, it refers to the opinion and belief regarding management of malnutrition, elicited by likert scale. 5. Management of malnutrition In this study, it refers to the knowledge and attitude on measures taken to manage malnutrition such as exclusive breast feeding, supplementary feeding of children, fortifying diet with protein, protection of children from infections.

6. Mothers
Mothers of malnourished children. 7. Malnourished Children Children under five years of age suffering from malnutrition detected through Gomez Classification. 8. Urban slums A group of houses, blocks or flats, streets in an urban area characterized by poverty and inferior living conditions.

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6.6 ASSUMPTIONS
1. Malnutrition is prevalent among under-five children living in urban slum areas. 2. The mothers may have inadequate knowledge and unfavorable attitude regarding

management of malnutrition.
3. The IEC package may improve the mother‟s knowledge and attitude on

management of malnutrition.

6.7 RESEARCH HYPOTHESES
H1: There will be a significant difference between the mean pre test and post test

knowledge and attitude regarding management of malnutrition among mothers of malnourished children. H2: There will be a significant correlation between knowledge and attitude regarding management of malnutrition among mothers of malnourished children. H3: There will be a significant association between knowledge and attitude regarding management of malnutrition among mothers of malnourished children with their selected demographic variables.

6.8 REVIEW OF LITERATURE
A study was conducted on Infant feeding practices and chronic child malnutrition in the Indian states of Karnataka and Uttar Pradesh as measured by degree of stunting. Close to half of India's children suffer from chronic malnutrition and about a quarter from severe malnutrition. The evidence from NFHS supports some recommended practices, including the advice that mother not squeeze the colostrums from her breasts, exclusive breastfeeding for the first 4-6 months and feeding supplementary foods at about 7 months, and suggests that, for some children, better feeding practices could reduce the prevalence of severe stunting by up to 30%. The paper also examines a range of other issues related to stunting whether medical supplementations and inoculations have an effect, whether mothers more actively involved in health decisions have less stunted children, and the links between stunting,

13

diarrhea and anemia. An explanation is offered for the positive relationship between using oral rehydration salts and stunting.15

An intervention study was conducted using monthly nutrition education delivered by locally trained counselors targeted at caregivers of infants aged 5-11 months. Comparison of outcomes for 2 groups--one non-intervention group of infants enrolled in 1997 that did not receive the intervention in the first year of life, and an intervention group of infants enrolled 1998-1999 that received the nutrition education.11 randomly selected and 2 purposively selected villages of south Karnataka were the samples. Families were administered a monthly questionnaire on feeding and child care behaviour, and study infants were weighed at this time, using the SECA solar scales, developed for UNICEF. Statistically significant improvement was found in weight velocity for female infants in the intervention group. These infants were also more likely to exhibit at least four positive feeding behaviors--intervention infants had a higher mean daily feeding frequency (more likely to be fed solids at least four times a day, higher dietary diversity, and were more likely to be fed foods suggested by the counselors such as bananas compared to non-intervention infants.16 A study was conducted to explore the relationship between alternative indicators of poverty and childhood under nutrition in developing countries within the context of a multi-national cohort study (Young Lives). Approximately 2000 children in each of four countries - Ethiopia, India (Andhra Pradesh), Peru and Vietnam - had their heights measured and were weighed when they were aged between 6 and 17 months (survey one) and again between 4.5 and 5.5 years (survey two). The anthropometric outcomes of stunted, underweight and wasted were calculated using World Health Organization 2006 reference standards In survey one, the partial effects of wealth on the probabilities of stunting, being underweight and wasting was to reduce them by between 1.4 and 5.1 percentage points, 1.0 and 6.4 percentage points, and 0.3 and 4.5 percentage points, respectively, with each unit (10%) increase in wealth. In both surveys, children residing in the lowest wealth quintile households had significantly increased probabilities of being stunted in all four study countries and of being underweight in Ethiopia, India (Andhra

14

Pradesh) and Peru in comparison to children residing in the highest wealth quintile households. 17 A study was conducted to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children. Using National Family Health Survey-3 data, an attempt was made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition show much higher burden among the poor. 18

A study was conducted to estimate infant and young child feeding indicators and determinants of selected feeding practices in India. The sample consisted of 20,108 children aged 0 to 23 months from the National Family Health Survey India 2005-06. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Only 23.5% of mothers initiated breastfeeding within the first hour after birth, 99.2% had ever breastfed their infant, 89.8% were currently breastfeeding, and 14.8% were currently bottle-feeding. Among infants under 6 months of age, 46.4% were exclusively breastfed, and 56.7% of those aged 6 to 9 months received complementary foods. The risk factors for bottle-feeding included caesarean delivery, higher household wealth index quintiles, working by the mother, higher maternal education level, urban residence, and absence of postnatal examination. The rates of timely complementary feeding were higher for mothers who had more antenatal visits, and for those who watched television.19 A community-based cross-sectional survey was carried out in 40 Anganwadi centre villages of Medak district of Andhra Pradesh, India. A total of 805 children were selected for nutritional assessment in terms of under-weight, stunting and wasting using the new WHO growth standards. Wealth index was calculated using principal components analysis. A conceptual hierarchical framework was used as a basis for
15

controlling for the explanatory factors in multivariate analysis. Prevalence of underweight, stunting and wasting was ~39%, 30% and 22%, respectively. The risk of underweight and stunting was 1.80- and 3.02-times higher among 12-23 months and 3.13- and 5.50-times higher among 24-36 months children as compared to children under 12 months, respectively. The risk of under-weight was 2.74- and 1.73-times higher among children belonging to the lowest and middle household wealth index, respectively.20

A

study

was

conducted

to

assess

the

prevalence

of

childhood

acute malnutrition and under-five mortality rate in Darbhanga district, India, using a twostage 49-cluster household survey. A total of 1379 households comprising 8473 people were interviewed. During a 90-day recall period, U5MR was 0.5 [95% confidence interval (CI), 0.2-1.4] per 10,000 per day. The prevalence of global acute malnutrition among 1405 children aged 6-59 months was 15.4% (NCHS) and 19.4% (2006 WHO references). This survey suggests that in Darbhanga district, the population is in a borderline food crisis with few food resources. Appropriate strategies should be developed to improve the overall nutritional and health status of children.21

A study was conducted to assess the impact of Integrated Child Development Services (ICDS) on childhood under nutrition. A total of 803 under-five children, 547 children between 12-23 months age, and 218 women with an infant child were recruited for the study. Prevalence of underweight among under-five children remained almost stagnant in the last one decade from 51.6%; (1997) to 50.4%; (2007). There was insignificant difference (P=0.3) in prevalence of underweight among children registered under ICDS program (52.1 %;) and those not registered (48.4 %;) in 2007.22

A community-based cross-sectional study was conducted on Micronutrient deficiency disorders among the rural children of West Bengal, India to assess the prevalence of micronutrient deficiencies. Children of 6-12 years of age were selected by simple random sampling method and the assessment of the micronutrient deficiencies were conducted on them. The results revealed that out on 9228 children the prevalence of Bitot's spots, an objective sign of clinical VAD, was 0.6% and was significantly (p <
16

0.01) higher among children of 3-5 years. Prevalence of blood vitamin A deficiency (< 20 μg/dL) was 61% and ∼81% of children was anemic. About 25% children had both subclinical VAD and anemia. The children of Scheduled Caste and Scheduled Tribe were at higher risk of anemia, whereas children of Scheduled Tribe and 3-5 years were at risk for VAD. The prevalence of goiter was 9%.23 A study was conducted to assess the association between changes in state per capita income and the risk of under nutrition among children in India. Data for this analysis came from three cross-sectional waves of the National Family Health Survey (NFHS) conducted in 1992-93, 1998-99, and 2005-06 in India. The sample sizes in the three waves were 33,816, 30,383, and 28,876 children, respectively. The main exposure of interest was per capita income at the state level at each survey period measured as per capita net state domestic product measured in 2008 prices. We estimated fixed and random effects logistic models that accounted for the clustering of the data. In models that did not account for survey-period effects, there appeared to be an inverse association between state economic growth and risk of under nutrition among children. 24 A study was conducted to find out the trends in the (a) prevalence of under nutrition and severe anemia and (b) degree of association of under nutrition and severe anemia in children younger than 6 years in India with some socioeconomic variables. Using the Reproductive and Child Health Survey data, z score of weight for age and hemoglobin status were analyzed. The prevalence of malnutrition according to both the criteria was first seen to increase, attain a maximum value at some age between 12 and 48 months, and then decrease. State wise distribution showed a close link between the stage of development and the prevalence of malnutrition-prevalence rate being less for developed states. The rates were also less for the North-eastern states of India. The economic growth alone is not sufficient for substantially reducing malnutrition. It is necessary to improve the rate of literacy, especially of women, to reduce the prevalence of malnutrition and anemia among children.25

17

A study was conducted to assess whether the geographic regions that were underprivileged in terms of wealth, female literacy, child nutrition, or safe delivery were also grappling with the elevated risk of child mortality. The present paper attempted to investigate these critical questions using data from household surveys like NFHS 19921993, NFHS 1998-1999 and DLHS 2002-2004. The result reveals that geographic regions that were underprivileged in child nutrition or wealth or female literacy were also likely to be disadvantaged in terms of infant and child survival irrespective of the state to which they belong. While the role of economic status in explaining child malnutrition and child survival has weakened, the effect of mother's education has actually become stronger over time.26 A study was conducted to assess factors contributing to positive deviance among the urban poor of Vadodara city. Mothers of sixty 6-18 months old children- 30 each in positive deviant (PD: normal by weight-age) and negative deviant (ND: grade II by weight-age) groups-were interviewed through home visits using semi-structured questionnaires. Results revealed that factors contributing significantly to PD (p < 0.01): PD children (vs. ND), were older (12-18 mo vs. 6-11 mo); families were smaller (5-7 vs. >7 members), of lower parity (1-2 vs. 3-4), greater birth interval (>3 y vs. 1-2 y); received colostrums (96% vs. 26%), breastfed at least 8-9 times/d (86% vs. 20%); were started on complementary feeds (CF) at 6-8 mo (53% vs. 23%); given thicker consistency CF (73% vs. 36%); fed actively (40% vs. 23%), fewer had diarrhea episodes in past 15 d (26% vs. 83%). Mean calorie intake (% RDA) from CF among PD was significantly higher than in ND (68% vs.42%).28 A study was conducted to assess the implications of using the WHO standard in rural India and to investigate the factors responsible for any departure from optimal growth. Mixed-effects models were applied to serial weight and length data from 384 rural south Indian infants. Weight growth was more similar to the WHO standard than the NCHS reference and in late infancy the WHO standard was less likely to classify underweight (RR at 15 months = 0.45; 95% CI = 0.31-0.65). Adjusting the serial data shifted the curves 0.25 Z-scores closer to the median of either chart; variations in household socioeconomic status and morbidity were largely responsible for this shift.29

18

A community based cross-sectional study was undertaken to determine the prevalence of under nutrition using mid-upper arm circumference (MUAC) among adult (> 18 years) Santals of Purulia District, West Bengal, India. It was undertaken at 10 villages of the district. A total of 520 (217 males and 303 females) subjects were measured. Commonly used indicator i.e., MUAC and BMI, were used to evaluate the nutritional status of the subjects. More women (64.7%) then men (54.4%) based on MUAC and women (59.4%) then men (34.6%) based on BMI were undernourished. Significant sex difference both in MUAC (t=2.378, p<0.05) and BMI (t=4.971, p<0.001) were observed. Significant age group difference for MUAC was observed (F=8.93***, df=3) for men and (F=9.52***, df=3) for women. For BMI, these values were F=10.10*** (df=3) F=6.17*** (df=3) respectively. In conclusion, researcher found that adult Santals of both sexes were under critical nutritional stress, women and the oldest among them were the most.30

7. MATERIALS AND METHODS 7.1 SOURCE OF DATA
The data will be collected from the mothers of malnourished children at selected urban slums, Bangalore.

7.2 METHODS OF COLLECTION OF DATA
i. Research design

Quasi-experimental –one group pre test and post test design.

ii.

Research Variables

Dependent variables: Knowledge and attitude of mother of malnourished children regarding management of malnutrition.

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Independent variables: IEC package on knowledge and attitude regarding management of malnutrition. Demographic variables: Demographic data of mothers includes base line information of the mothers such as age, religion, educational status, occupation, income, dietary habits, and number of children. Demographic data of the children includes base line information of children such as age, sex, weight, height, mid arm circumference, degree of malnutrition.

iii.

Setting

The study will be conducted at slums located in Gangondanahalli, Hegganahalli and Kamakshipalya, urban communities, Bangalore.

iv.

Population

All the mothers of malnourished children in slums of Gangondanahalli, Hegganahalli and Kamakshipalya, Bangalore.

v.

Sample

The mothers who fulfill the inclusion and exclusion criteria will be considered as samples. Sample size is 60.

vi.

Criteria for sample selection

Inclusion criteria: The study includes, 1. Mothers of under-five children suffering with malnutrition detected using Gomez Classification. 2. Mothers of children with I degree, II degree and III degree malnutrition. 3. Mothers who are able to understand Kannada.

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Exclusion criteria: The study excludes, 1. The mothers who are not available at the time of study. 2. The mothers who are not willing to participate in the study.

vii.

Sampling technique
Stratified random sampling technique

viii.

Tool for data collection

The tool consists of the following sections:
Section A:

Demographic data which gives base line information of the mothers such as age, religion, educational status, occupation, income, dietary habits, number of children. Demographic data of the children such as age, sex, weight, height, mid arm circumference, degree of malnutrition.
Section B:

Gomez classification method will be used to assess the prevalence of malnutrition among under-five children. Weight for age (%) =weight of the child weight of the normal child of same age

X 100

Between 90-110% = normal nutritional status. Between 75-89% =1st degree or mild malnutrition. Between 60-74% =2nd degree or moderate malnutrition. Under 60% = 3rd degree or severe malnutrition.

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Section C:

Structured interview schedule will be used to assess the knowledge regarding management of malnutrition among mothers of malnourished children.
Section D:

Likert scale will be used to assess the attitude of the mothers of malnourished children regarding management of malnutrition.

Procedure of data collection
After obtaining the official permission from the authorities of BBMP and Primary health center and informed consent from the samples, the investigator will personally collect the data in the following phases. Phase I: Prevalence of malnutrition will be assessed using Gomez Classification. The mothers of children who are identified with malnutrition will be taken as samples for the study. Phase II: Assess the existing knowledge and attitude regarding management of

malnutrition among the mothers of malnourished children with the help of structured interview schedule. Phase III: IEC package will be given to the mothers through; Providing information by distributing pamphlet regarding management of malnutrition and educating them by using flash cards on individualized basis for 45 minutes and communicating by conversation through local language among mothers of malnourished children. Phase IV: After a period of one week of IEC package post test knowledge and attitude will be assessed using same structured interview schedule. Duration of data collection: 4-6 weeks.

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ix.

Plan for data analysis

The data collected will be analyzed by using descriptive and inferential statistics. Descriptive statistics  Frequency, percentage distribution, mean and standard deviation will be used to analyze the knowledge and attitude regarding management of malnutrition among mothers of malnourished children.  Correlation coefficient will be used to analyze the correlation between knowledge and attitude regarding management of malnutrition among mothers of malnourished children. Inferential statistics  Paired„t‟ test will be used to compare the pre test and post test knowledge and attitude of mothers regarding management of malnutrition among mothers of malnourished children.  Chi square test will be used to analyze the association between knowledge and attitude regarding management of malnutrition among mothers of malnourished children with their selected demographic variables.

x.

Projected outcome
The study will improve the knowledge regarding management of malnutrition among mothers. This could help to create awareness and help to reduce the risk of malnutrition among under-five children.

7.3 Does the study require any investigation or interventions to be conducted

on patients or other human or animals?
Yes, the study involves structured IEC package administered regarding management of malnutrition to the mothers in Gangondanahalli, Hegganahalli and Kamakshipalya, Bangalore.

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7.4 Has ethical clearance obtained from your Institution?
Yes, permission will be obtained from concerned authorities and informed consent will be obtained from the samples. Confidentiality and privacy of data will be maintained.

8. LIST OF REFERENCES
1. K.Park. Text book of preventive and social medicine.18thedition.Jabalpur: M/S Baranasidas Bhanot publishers;2005 2. World health organization. Available from URL http://www.whoindia.org. 3. K.Park. Text book of preventive and social medicine.20th edition. Jabalpur: M/S Baranasidas Bhanot publishers;2009 4. K.K Gulani .Community health principles and practices. 6th edition .Delhi: Kumar publication house;2005 5. Community health care. Sited on 9 Oct 2012.Available from URL http://e health care.com. 6. National child health resource centre. Sited on 9 Oct 2012.Available from URL http://www.nihfw .org/NCHRC/about NCHRC.html. 7. Ministry of health and family welfare. Sited on 10 oct 2012.Available from URL http://mohfw.nic.in 8. National children health survey. Sited on 10 Oct 2012.Available from URL www.nchs/who:report of underweight among under five children. 9. National nutrition monitoring bureau. Sited on 12 oct 2012.Available from URL http://nnmb.nic.org 10. Mittal A, Singh j, Abluwalia. Effect of Maternal factor on Nutritional status of 1 – 5 year old children in urban slum population. Indian journal of Community Medicine 2007; 32(4): 264 – 267 11. Health topics on malnutrition. Sited on 12 oct 2012. Available from URL http://www.emro.who.int/health topics/malnutrition 12. National family health survey, 2010-2012, National fact sheet, Karnataka. 13. National family health survey, 2010-2012, National fact sheet, India.

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14. Overlook

at

the

slum

health

problems.

Sited

on16

oct

2012.

http://rameshkumar.co.in/a_look_at_slum_problem.php 15. Brennan L, McDonald J, Shlomowitz R.Infant feeding practices and chronic child malnutrition in the Indian states of Karnataka and Uttar Pradesh. School of Business Economics, Flinders University, GPO Box 2100, Adelaide 5001, Australia. Econ Hum Biol. 2004 Mar; 2(1):139-58. 16. Kilaru A, Griffiths PL, Ganapathy S, Ghosh S.Community-based nutrition education for improving infant growth in rural Karnataka. Belaku Trust, 697 15th Cross Road, J.P. Nagar Phase II, Bangalore 560 078, Karnataka. Indian Pediatric. 2005 May; 42(5):425-32. 17. Petrou S, Kupek E.Poverty and childhood under nutrition in developing countries: a multi-national cohort study. University of Oxford, Oxford, UK. Sci Med. 2010 Oct; 71(7):1366-73. 18. Kanjilal B, Mazumdar PG, Mukherjee M, Rahman MH.Nutritional status of children in India: household socio-economic condition as the contextual determinant. Int J Equity Health. Future Health Systems India, Institute of Health

Management Research, Kolkata. 2010 Aug 11; 9(1):19. 19. Patel A, Badhoniya N, Khadse S, Senarath U, Agho KE, Dibley MJ; South Asia Infant Feeding Research Netwoork.Infant and young child feeding indicators and determinants of poor feeding practices in India: secondary data analysis of National Family Health Survey 2005-06. Indira Gandhi Government Medical College, Nagpur, India..Food Nut Bull. 2010 Jun; 31(2):314-33. 20. Meshram II, Laxmaiah A, Gal Reddy Ch, Ravindranath M, Venkaiah K, Brahmam GN.Prevalence of under-nutrition and its correlates among under 3 year-old children in rural areas of Andhra Pradesh, India. Ann Hum Biol. Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, JamaiOsmania (PO), Tarnaka, Hyderabad, India.. 2011 Jan; 38(1):93-101. Epub 2010 Sep 3. 21. Espie E, Pujol CR, Masferrer M, Saint-Sauveur JF, Urrutia PP, Grais

RF.Acute malnutrition and under-5 mortality, northeastern part of India. J Trop Pediatric. Epicenter, Paris, France. 2011 Oct;57(5):389-91.
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22. Thakur JS, Prinja S, Bhatia SS.Persisting malnutrition in Chandigarh: decadal underweight trends and impact of ICDS program. Indian Pediatric. School of Public Health, Department of Biostatistics, Post Graduate Institute of Medical Education and Research, Chandigarh, India.2011 Apr;48(4):315-8. 23. Subramanyam MA, Kawachi I, Berkman LF, Subramanian SV.Is economic growth associated with reduction in child under nutrition in India? PLoS Med. Center for Integrative Approaches to Health Disparities, School of Public Health. 2011 Mar;8(3). 24. Bharati S, Pal M, Chakrabarty S, Bharati P.Trends in socioeconomic and nutritional status of children younger than 6 years in India. Asia Pac J Public Health. Indian Statistical Institute, Kolkata, West Bengal.2011 May5; 23(3):324-40. 25. Singh A, Pathak PK, Chauhan RK, Pan W.Infant and child mortality in India in the last two decades: a geospatial analysis. PLoS One. Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, Maharashtra, India. 2011; Nov 6(11):e26856.. 26. Arlappa N, Laxmaiah A, Balakrishna N, Harikumar R, Kodavanti MR, Gal Reddy Ch, Saradkumar S, Ravindranath M, Brahmam GN.Micronutrient deficiency

disorders among the rural children of West Bengal, India. Division of Community Studies, National Institute of Nutrition, Hyderabad, India.. 2011 May; 38(3):281-9. 27. Kanani S, Popat K.Growing normally in an urban environment: positive deviance among slum children of Vadodara, India. Department of Foods and Nutrition, Vadodara 390007, India. Indian J Pediatric. 2012 May; 79(5):606-11. 28. Johnson W, Vazir S, Fernandez-Rao S, Kankipati VR, Balakrishna N, Griffiths PL.Using the WHO 2006 child growth standard to assess the growth and nutritional status of rural south Indian infants. Division of Epidemiology & Community Health, School of Public Health, University of Minnesota,. 2012 Mar; 39(2):91-101. 29. Das S, Bose K.Nutritional assessment by mid-upper arm circumference of santal adults of Purulia, West Bengal, India. Department of Anthropology, Vidyasagar University, Midnapore, West Bengal, India.2012 Jun; 36(2):581-4.

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9. Signature of the candidate

:

10. Remarks of the guide

:

11.1 Name and Designation of the Guide :

Prof.Dinesh Selvam HOD of Community Health Nursing

11.2 Signature

:

11.3 Co-guide

:

11.4 Signature

:

11.5 Head of the Department

:

Prof.Dinesh Selvam

11.6 Signature

:

12.1 Remarks of the Principal

:

12.2 Signature

:

27

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