RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE – IIPROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. Name of the candidate and address (in block letters)

MR. SHAJIL JOSEPHI YEAR M. Sc. NURSING MASOOD COLLEGE OF NURSINGBIKARNAKATTE, MANGALORE

2. Name of the Institution MASOOD COLLEGE OF NURSINGBIKARNAKATTE, MANGALORE

3. Course of Study and Subject M. Sc. NURSINGPAEDIATRIC NURSING

4. Date of Admission to the course

16.06.2012

5. Title of the Topic

“A STUDY TO ASSESS THE EFFECTIVENESS SELF-

INSTRUCTIONAL MODULE ON KNOWLEDGE

REGARDING VIRAL HEPATITIS A IN CHILDREN

AMONG MOTHERS OF UNDER FIVE CHILDREN IN A

SELECTED URBAN COMMUNITIES, MANGALORE”.

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6. Brief resume of the intended work

“Mother is the name of God in the lips and heart of little child”

-William Mark

6.1 Need for the study

Child is the mirror of his or her family and society in which he or she

grows. The first five years of life lays a crucial foundation for the healthy growth

and development of the children1. Despite the health improvement in India over

the last 30 years, lives continue to be lost to early childhood diseases. More than

two million children die every year from preventable infections. Children in India

continue to lose their life to vaccine preventable diseases, which remains the big

killer disease among children2.

The National Institute of Virology, India has identified hepatitis A as

predominant cause of sporadic acute viral hepatitis in children, National Institute

of Virology have stated that India is experiencing transition in the epidemiology

of viral hepatitis A and there is more likely hood for explosive outbreaks. During

2002-2004, total six out breaks of hepatitis where reported among children in

urban and rural India. Ninety Percentage of Indian children are exposed to viral

hepatitis A virus by the age of 6 years. In Pune, Maharashtra, blood samples of

499 children between the age group of 3 days to 6 years where collected and

tested for presence of antibodies against hepatitis A Exposure to HAV was 28.9

per cent soon after the waning of maternal antibodies in the 13-15 month age

group which increased to 52.5 per cent by two years of age and 90.9 per cent by 6

yr ,they concluded that preventive measures like immunization, hand washing,

food sanitation, toilet training of children, environment sanitation must be taken

to action and vaccination should be given at 9th month when the maternal

antibodies disappear3.

Viral hepatitis A is primarily faeco-orally transmitted and a common

disease in India. Hepatitis is the acute or chronic inflammation of the liver that

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can be classified into non-viral and viral hepatitis, out of these 90% of the cases

are reported as viral hepatitis. Viral hepatitis is one of the rare diseases which are

still unconquered even in the west. The major reason of spread of this disease is

due poor food hygiene, lack of proper environmental sanitation, contamination of

drinking water with infected faecal material and poor knowledge of the public

regarding the prevention of the infection which causes the infection to transmit

from one child to the other child. In children it can cause post hepatic cirrhosis,

chronic Cholestasis, sub-acute necrosis and hepatic failure. The chances for

complication are great; particularly in India due to poor hygiene and nutrition

status. Therefore it is important to assess the knowledge of public and provide

adequate health teaching and information to the general population4.

A prospective hospital-based study was conducted in a large leading

paediatric hospital in Karnataka. Two hundred and twenty-four consecutive

patients with acute viral hepatitis were studied for their presentation, aetiology

and clinical features. Result showed that Hepatitis-E was detected in 102 (45.4%),

hepatitis A in 74 (33%) and hepatitis B in 28 (12.5%) patients. Acute hepatitis C

was detected in two patients. 15 patients had a mixed infection. Hepatitis A

constituted 41.2% and 31.3% of all cases in the age groups 3-16 years

respectively. Cholestasis was present in 68 (30.4%) patients with hepatitis E

accounting for most (61.8%) cases. There were four (1.8%) cases of acute liver

failure. Two cases were due to hepatitis E and one case each was due to hepatitis

A and hepatitis B. A relapsing course was seen in four cases due to hepatitis-A5.

Viral hepatitis is a condition which is highly prevalent among children,

but a large section of the society still has an idea that viral hepatitis is an adult

disease. However, children are just as susceptible to viral hepatitis as adults.

Despite this fact, majority of the research and information about viral hepatitis is

limited to adult population. Unfortunately, this means there are many unanswered

questions how these diseases affects children and how best to manage in

paediatric age group. Parents of children with viral hepatitis are often frustrated

and confused about what to do and where to turn. So it is important to educate

and create awareness among mothers regarding viral hepatitis.5.

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Many studies have been conducted by various researchers around the

globe to find out the relationship between the mothers knowledge and prevention

of infectious diseases among children. A study was conducted in Magna Gracias,

Italy, to assess mother’s knowledge and attitude regarding prevention of infection

among children. The study result showed that mothers with good education and

better knowledge had more information regarding immunization and other

preventive aspects related to child’s health, thus it shows that knowledge of

mothers have direct relationship with prevention of infection among children .So

creating awareness among mothers will help in preventing diseases among

children. The investigator from the above information felt the need to undertake

the present study to evaluate the knowledge and practice of mothers of under five

children regarding viral hepatitis A in a selected urban community, Mangalore to

improve their knowledge and practice on viral hepatitis A by administering a self-

instructional module6.

6.2 Review of literature

A cluster sampling survey was carried out to investigate community

perceptions of pilia (the local word for hepatitis) in east Delhi (India). Of 416

samples (mothers of children aged < 2 years) interviewed, 339 (81%) were aware

of pilia as an illness. Only 322 (77%), 164 (39%), 73 (18%) and 71 (17%) people

knew about correct symptoms, dangers, causes and prevention of pilia. Most of

the correct responses were related to the faeco-orally transmitted viral hepatitis.

Literate respondents were significantly more aware of pilia (2=52.81, P<0.0001),

its symptoms (2=48.88, P<0.0001), causes (2=39.34, P<0.0001), dangers

(2=19.3, P=0.0007), and prevention (2=60.8, P<0.0001). However, age of the

respondents had no significant bearing (P0.05) on the correctness of responses.

About 293 (70%) subjects considered pilia as a treatable illness; of them, 193

(66%) and 77 (26%) respectively expressed their preference for the 'modern' and

indigenous systems of medicine for its treatment. In contrast, 110 (38%)

respondents said that they would prefer faith healers for the treatment of pilia.

Although only 31 (7%) persons were aware of a vaccine against pilia (hepatitis

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A&B vaccine), virtually all agreed to have their children immunized if such a

vaccine were made available. The study underscores the usefulness of pilia in lay-

reporting of viral hepatitis and epidemiological studies on hepatitis-associated

illnesses and the need for educating the community about its causes and

prevention to increase people's participation in controlling viral hepatitis7.

A study was conducted to investigate hepatitis A vaccine coverage among

3-17.9-year-olds in San Diego county and examine predictors of child and

adolescent hepatitis A immunization. A total of 1455 participants completed a

random-digit dial telephone survey that assessed hepatitis A immunization status

of 3-to 17.9-year –old children. Analysis was limited to the 983 respondents with

available immunization records or verified immunization histories. The

differences in the frequencies of getting vaccinated depended on vaccine

availability, sex, ethnicity, type of health care provider, mother’s highest level of

education, and parental knowledge of the hepatitis A vaccine recommendation.

The participant response rate was 77.1%. Among all respondents aged 3 to 17.9

years, 59% received at last one hepatitis A vaccine and 41% completed the two

shot regimen. The adjusted odd that a child received at last one hepatitis A

vaccine was 3.6 times greater among Hispanic children compared with non-

Hispanic children. Other predictors of hepatitis A immunization included child’s

age, having a public health care provider, lower maternal education, and parental

knowledge of the vaccine recommendation8.

A descriptive study was conducted to investigate knowledge, attitudes and

related behaviour on food borne hepatitis and food-handling practices among

mothers in Italy. A self-administered questionnaire was offered to a random

sample of mothers of children attending public schools. Of the 394 responding

mothers, 11.1% correctly indicated six related different food vehicles; education

level was a predictor of this knowledge. A positive attitude towards food borne

hepatitis control, significantly higher in older and more educated women, was

reported by the great majority, who agreed that improper storage of food

represents a health hazard (95.7%), that washing hands before handling

unwrapped raw or cooked food reduces the risk of food contamination (93.2%),

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and that the awareness of the temperature of the refrigerator is crucial in reducing

risk of food contamination (90.1%). Only 53.9% reported washing hands before

and after touching raw or unwrapped food and 50.4% reported using soap to wash

hands. A total of 75.6% clean kitchen benches after every use and 81.1% use hot

water and soap for this purpose. Washing hands before and after touching

unwrapped food was significantly higher in women living in larger families and

who had been informed by physicians about food-borne hepatitis9..

A qualitative study was done on parents difficulties and information needs

in coping with acute hepatitis in preschool children in Newcastle UK, sample

consists of 95 parents of preschool children and the study was done using semi

structured one to one and group interviews with parents of preschool children .the

researcher found that parents felt disempowered when dealing with acute hepatitis

in their children because of difficulties making sense of the illness. Central to

parents difficulties were their experience of inadequate information sharing by

their general practitioners and variations in their doctors decision and behaviour.

Disparity between parent’s belief s and expectations for a range of accessible and

specific information to support them through their negotiation of children’s

illness. Thus researcher concluded that communication with parents requires

greater recognition of parent’s difficulties. Professionals have considerable

potential to empower parents by sharing more information and skills. Such

information should be consistent and address parents concern, beliefs and

expressed needs if this potential to be realized10.

A random cluster sample survey was conducted of parents of children who

attended kindergarten in California. Because of a history epidemics, an aggress

hepatitis A vaccination program was ongoing during the time this study was

conducted, of 896 surveys sent, 648 (72%) were completed. The vaccination

coverage for at least 1 dose of hepatitis A vaccine was 398 (62%) and for 2 doses

were 272 (42%). Factors associated with not receiving the vaccine included lack

of provider recommendation (vs. having recommendation; odds ratio [OR]: 7.8;

95% confidence interval [CI]: 4.9-12.2), not having heard of the vaccine (OR:

2.4; 95% CI: 1.2-4.9), and parent's not perceiving child is likely to get hepatitis A

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(vs. perceiving child might get disease; OR: 2.1; CI: 1.6-2.9). Thus the study

concluded that Vaccination coverage among kindergartners did not reach high

levels (i.e., >90%), despite aggressive vaccination efforts in this community. Lack

of provider recommendation and lack of parental awareness of hepatitis A

vaccine were the 2 most significant factors associated with failure to receive

vaccine. These findings will facilitate the development of vaccination strategies

for communities in which hepatitis A vaccination is recommended11.

6.3 Statement of the problem

A study to assess the effectiveness self-instructional module on

knowledge regarding viral hepatitis A in children among mothers of under five

children in selected urban communities, Mangalore.

6.4 Objectives of the study

The objectives of the study are to

1. To assess the level of knowledge regarding viral hepatitis A among

mothers of under five children in experimental and control group.

2. To evaluate the effectiveness of self-instructional module regarding viral

hepatitis A among mothers of under five children.

3. To find the association between pre-test level of knowledge regarding

viral hepatitis A in children and their selected demographic variables.

6.5 Operational definitions

1. Effectiveness: In this study, effectiveness refers to the extent to which the

self-instructional module will enhance the knowledge of mothers with

under five children regarding viral hepatitis A in terms of difference in

pre-test and post-test.

2. Self-instructional module: In this study, self-instructional module is a

self-contained written material prepared by the researcher to promote self-

learning of mothers with under five children about viral hepatitis A. It

includes meaning, incidence, aetiology, pathophysiology, clinical features,

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diagnostic evaluations, management and preventive measures.

3. Knowledge: Knowledge refers to the information obtained from the

mother of under five children about viral hepatitis A as measured by

structured knowledge questionnaire and interpreted in terms of levels such

as good, average and poor.

4. Viral hepatitis A: Hepatitis A is an acute inflammatory disease of the

liver caused by hepatitis A virus, which spreads through the faeco-oral

route.

5. Mothers of under five children: Mothers of under five children refers to

those mothers who have children with age below five years residing in

selected urban communities, Mangalore.

6.6 Assumptions

The study assumes that:

1. Mothers of under five children may have some knowledge regarding viral

hepatitis A.

2. Self-instructional module regarding viral hepatitis A in children may

enhance the knowledge of mothers of under five children.

6.7 Delimitations

The study will be delimited to:

1. mothers of under five children.

2. selected urban communities, Mangalore

6.8 Hypotheses

The hypotheses will be tested at 0.05 level of significance.

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H1: There will be significant difference between the mean pre-test and post-

test level of knowledge regarding viral hepatitis A in children among

mothers of under five children in experimental group.

H2: There will be significant difference between the mean post-test level of

knowledge regarding Viral hepatitis A in children of experimental and

control group mothers of under five children.

H3: There will be significant association between pre-test knowledge score of

mothers of under five children on viral hepatitis A in children and their

selected demographical variables.

7. Material and Methods

7.1 Source of data

The data will be collected from the mothers of under five children residing

in urban communities, Mangalore.

7.1.1 Research design

Quasi experimental research design will be employed in this study.

Pre-test Treatment Post-test

E O1 X O2

C O1 - O2

Day 1 Day 1 Day 7

E – Experimental Group

C – Control Group

O1: Administration of structured knowledge questionnaire to assess the pre-

test level of knowledge regarding viral hepatitis A in children.

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X: Self-instructional module regarding viral hepatitis A is given.

O2: Administration of structured knowledge questionnaire to assess the post-

test level of knowledge regarding viral hepatitis A in children on 8 th day

after administering structured knowledge questionnaire.

7.1.2 Setting of the study

Study will be conducted in selected urban communities, Mangalore.

7.1.3 Population

The population selected for the study will be mothers of under five

children in selected urban communities, Mangalore.

7.2 Method of data collection

7.2.1 Sampling procedure

In this study non-probability purposive sampling technique will be

adopted to select the samples and convenient sampling technique to select the

areas.

7.2.2 Sample size

The data will be collected from 60 mothers who meet the inclusion

criteria. The mothers will be equally divided into 30 mothers in experimental

group and 30 mothers in control group.

7.2.3 Inclusion criteria for sampling

Mothers,

1. who are willing to participate.

2. present on the day of data collection.

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3. with children below five years.

4. who can read or write Kannada or English.

7.2.4 Exclusion criteria for sampling

Mothers,

with psychological illness.

who are in the health profession.

7.2.5 Instruments intended to be used

The tool will consist of two sections.

Section A: demographic performance of mothers such as age, sex, education,

income, type of family, occupation previous exposure to knowledge on viral

hepatitis, previous history of viral hepatitis A in children or in family.

Section B: Structured knowledge questionnaire on viral hepatitis.

7.2.6 Data collection method

Written permission will be obtained from the concerned authority for

conducting a study through proper channel and also from the subjects with

assured confidentiality. The sample will be selected by purposive sampling

technique. One area under urban health and family welfare centre will be allotted

for the experimental group and the other for the control group. Pre-test will be

conducted by administering the structured knowledge questionnaire to both the

experimental and control group after which a self-instructional module will be

given to the experimental group. On the 8th day post-test will be conducted for

both experimental and control group using the same structured knowledge

questionnaire. Period of data collection will be for one month.

7.2.7 Plan for data analysis

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Data Analysis is a systematic organization and synthesis of research data

and testing of research hypothesis using the Data. The data obtained was planned

to analyzed by both descriptive and inferential statistics, on the basis of the

objectives and hypothesis of the study. Demographic Data containing sample

characteristics would be Analyzed using the frequency and percentage. The level

of knowledge regarding viral hepatitis A and after administration of self-

instructional module will be calculated by using frequency, percentage, mean, and

standard deviation. The difference between the mean Pre-test and post-test

knowledge scores would be found by paired (t) test and indipendent (t) test.

Association between the knowledge Scores and demographic variables would be

found out by using Chi-Square test. Analyzed data would be represented in tables

and graphs.

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

No, this study does not require any investigation or interventions to be

conducted on patients or animals.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, ethical clearance is obtained from the ethical committee on

05/11/2012.

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8. List of references

1. Danielle F. Role of mother in child development. [ONLINE].

Available from:

URL:suite101.http:/www.suite101.com/content/attachment-

a27099.2007 Jul 25.

2. Khosala I. Vaccine recommendation for Indian children. IJE 28 (4).

3. Arankalle A. Hepatitis A epidemiology: India the Journal of Virology

2009 Aug 8;72(4):81-9.

4. Reddi Y, Rohini, Kusuma G. Role of liv. 52 and steroids in the

management of viral hepatitis in children. NCBI 1974 Feb 16;14(1):35-

50.

5. Nandi B, Hadimani P, Arunachalam R. Spectrum of a viral hepatitis in

south India. MJAFI 2009 Jan 8;65(4):7-9.

6. Angelillo F, Ricciardi G, Rossi P. Mothers and vaccination:

Knowledge, attitude and behaviour in Italy. Bull World Health

Organization 2003 Aug 18;77(3):224-9.

7. Kai J. Parents' difficulties and information needs in coping with acute

hepatitis in preschool children: A qualitative study. Department of

Primary Health Care, Newcastle, UK. BMJ 2005 Oct 19;313 (98):90-

102.

8. Alyssa V, Bizu G, Nigusu A. Knowledge, attitudes, and practices

(KAP) of hygiene among school children in Angolela, Ethiopa. J Prev

Med Hyg 2010 Jun;51(2):73-9.

9. Ghahramani F, Mohammadsalhi N. A survey of the students’

knowledge about hepatitis in Shiraz University of Medical Science.

Hepatitis Monthly Journal 2006;6(2):59-62.

10. Bardenheier B , Gonzalez IM, Washington ML, Bell BP. Parental

knowledge, attitudes, and practices associated with not receiving

hepatitis. A vaccine in a demonstration project in Butte County,

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California. Paediatrics 2003 Oct;112(4):26-9.

11. Kamath SR, Sathiyasekaran M, Raja TE, Sudha L. Profile of viral

hepatitis A in Chennai. Indian Paediatr 2009 Jul;46(7):642-3.

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9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of (in block letters)

11.1 Guide MRS. JANET SYLVIA SALDANHAASSOCIATE PROFESSORMASOOD COLLEGE OF NURSINGMANGALORE

11.2 Signature

11.3Co-guide (if any) MRS. VEENA GRETTA TAUROPRINCIPALMASOOD COLLEGE OF NURSINGMANGALORE

11.4Signature

12 12.1Head of the department MRS. VEENA GRETTA TAUROPRINCIPALMASOOD COLLEGE OF NURSINGMANGALORE

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal

13.2 Signature

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