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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]

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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

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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

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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

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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

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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.

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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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:

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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