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RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES,BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OFSUBJECTS FOR DISSERTATION
1 NAME OF THE CANDIDATE AND ADDRESS
MS.T. SIVAKUMARI1st YEAR M.Sc NURSING,INDIAN COLLEGE OF NURSING,TILAKNAGAR, BYPASS ROAD,CONTONMENT,BELLARY – 583104
2 NAME OF THEINSTITUTION
INDIAN COLLEGE OF NURSING,TILAKNAGAR, BYPASS ROAD, CONTONMENT,BELLARY – 583104
3 COURSE OF STUDY AND SUBJECT
DEGREE OF MASTER OF NURSING.PAEDIATRIC NURSING
4 DATE OF ADMISSION TOCOURSE
10-06-2009
5 TITLE OF THE TOPIC ANALYTICAL STUDYTO ASSES THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON MANAGEMENT AND PREVENTION OF TYPHOID FEVER AMONG THE MOTHERS OF SCHOOL AGE CHILDREN ADMITTED IN THE SELECTED HOSPITAL, AT BELLARY, KARNATAKA
6. BRIEF RESUME OF THE INTENDED WORK
1
INTRODUCTION:
“ Enteric fever ” is a global major public health problem . “ Typhoid fever
” , an acute systemic infectious disease seen only in humans. Enteric fever caused
by “salmonella typhi” . Almost 80% of the cases and deaths are in Asia and the rest
occur mostly in Africa and Latin America. Enteric fever is endemic in many
developing Countries , including India.1
The incidence of typhoid fever estimated 16-33 million cases of annually
resulting in 5,00,000 to 6,00,000deaths in endemic areas the world health
organization identifies typhoid as a serious public health problem. Its incidence is
highest in children and young adults between 5 and 19 years old. Typhoid fever is a
disorder of school age children and of adults. Typhoid is a common significant
cause of morbidity between 1 and 5 years of age.2
The name salmonella typhi is derived from the ancient Greek typhos. An
ethereal smoke or cloud that was believed to cause disease and madness. Primary
source of infection are stool and urine. Secondary sources of infection are
contaminated water, food, fingers or hands. Mode of transmission is mainly feco
oral route or urine oral route. Typhoid fever is characterized by a slowly
progressive fever ,( 104 degree f), profuse sweating, gastroenteritis, and diarrhoea,
rashes ,rose – colored spots may appear.3
2
The diagnosis of typhoid fever may be included blood culture , widal test ,
bone marrow culture , stool and urine culture and ELISA Specific treatment of
enteric fever used to be fluoroquinolones such as ciprofloxacin chloramphenicol,
cephalosporin including ceftriaxone. prompt treatment of the disease with
antibiotics reduces the case-fatality rate to approximately 1%. Death occurs in
between 10%, the case fatality rate in the united states in the pre-antibiotic era was
– 9 to 13%.4
The complications of typhoid fever mainly, encephalopathy, intestinal
hemorrhage, toxic myocarditis, bronchitis sanitation and hygiene are the critical
measures that can be taken to prevent typhoid. Care ful food preparation and
washing of hands are there fore crucial to preventing typhoid. 5
6.1 NEED FOR THE STUDY:
Typhoid fever occurs worldwide, primarily in developing nations whose
sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin
America, the Caribbean, and oceania. typhoid fever infects roughly 21.6 million
people and kills an estimated 2,00,000 people every year.6 With prompt and
appropriate antibiotic therapy, typhoid fever is typically a short term febrile illness
with a negligible risk of mortality. Un treated typhoid fever is a life – threatening
In 1920, 35 ,994 cases of typhoid fever were reported. Currently 200-400 cases of
typhoid fever are reported per year in the united states. 75% of which occur in
international travelers with in 30 days of entry. 7
3
A base line census was under taken in 1995. Between Nov 1,1995, and oct
31,1996, we visited 8172 residents of 1820 households in Kalkaji, Delhi, twice
weekly to detect febrile cases. 63 culture – positive typhoid fever cases were
detected. Of these 28 (44%) were in children aged under 5 years.The incidence rate
of typhoid per 1000 person – years was 27.3 at age under 5 years, 11.7 at 5 – 19
years and 1.1 between 19 and 40 years. The difference in the incidence of typhoid
fever between those under 5 years and those age 5 – 19 years (15.6 per 1000 person
years ) 95% and those aged 19-40 years 26.2 was significant. Morbidity in those
under 5 and in older people was similar in terms of duration of fever, signs and
symptoms, and need for the hospital admission.8
When untreated, typhoid fever persists of three weeks to a month. Death
occurs in between 10% and 30% of untreated cases. Though in some communities
case fatality rates may be as high as 47%.9 Typhoid fever is a particularly difficult
problem in parts of the world with poor sanitation practices. In the United States,
most patients who contract typhoid fever have recently returned from travel to
another country where typhoid is much more common, including Mexico, Peru,
Chile, India and Pakistan.10
The timing of symptoms and host response may vary based on geographic
region, race factors, and the infected bacterial strain. The stepladder fever pattern
that was once the hallmark of typhoid fever now occurs in a few as 12% cases. In
appropriate treatment is initiated with in a few days of full blown illness, the
4
patients condition markedly improves with in 4 to 5 days. Any delay in treatment
increases the likelihood of complications.11
In Karnataka, Mysore city account for the highest number of typhoid fever
cases according to district health officer in Tumkur district merely 40 people in the
village. Our findings challenge the, common view that typhoid fever is a disorder
of school age children and of adults. Typhoid is a common and significant cause of
morbidity between 1 – 5 years of age. The optimum age of typhoid immunization
and the choice of vaccines needs to be reassessed.12
A prospective study was conducted on enhancing knowledge and awareness
of typhoid fever among mothers. The data was collected from the mothers, the
result revealed that only 0.3% the participants scored. The participants scored very
poor. The current medical nursing literature reflects the prevalence of typhoid fever
in high among school children. Based on the literature and investigator experiences
the investigator feels that it is the important to create awareness among mothers of
school age children to prevent the child mortality and morbidity. So the knowledge
of the mothers may be applied in early recognition of typhoid fever help in
selecting for early medical validation. Hence the investigator planned to impart the
knowledge by conducting planned teaching programme to mothers of school age
children.
5
6.2 REVIEW OF LITERATURE:
Review of literature is a key step in research process. Review of literature
refers to an extensive, exhaustive and systemative examination of publications
relevant to the research project.13
A prospective follow up study of residence of a low income urban area of
Delhi, India with active surveillance for case detection. Calculation of the incidence
of typhoid fever during pre school years is important to defined the optimum age of
immunization and the choice of vaccines for public health programmes in
developing countries. Hospital based studies have suggested that children younger
than 5 years do not need vaccination. Against typhoid fever, but this view needs to
be re examined in community based longitudinal studies. 63 culture positive
typhoid fever cases were detected. Of these, 28 were in children aged under 5
years. The optimum age of typhoid immunization and the choice of vaccines need
to be re assessed.14
The IVI-NICED study, which was supported by the gates foundation and the
governments of korea, Sweden, and Kuwait, also revealed that delivering the low-
cost vi typhoid vaccine is logistically and programmatically possible. The fact that
the level of overall protection was similar dr. Clemens, a co-author of the study. “ It
6
also suggest the need for consideration of herd protective effects in future
deliberations about the use of this vaccine in developing countries. The production
of technology for the high yield vi polysaccharide is being transferred to
high – quality produces in developing countries. The International vaccine institute
( IVI ) is the world’s only International organization devoted exclusively to
developing and introducing new and improved vaccines to protect the world’s
poorest people , especially children in developing countries. Established as an
initiative of the united Nations development programme in 1997, the IVI operates
under research in 28 countries of Asia, Africa and Latin America, on vaccine
against diarrheal infections.15
A US – based study of imported strain noted an increase in the number or
MDR and nalidixic acid resistant S. typhi globally, although all isolates remained
sensitive to ciprofloxacin and ceftriaxone. In Bangladesh there has been a reported
decrease in MDR isolates with no corresponding increase in sensitive strains. The
exact mechanism of resistance is not fully understood but various studies have
found that a single mutation in the gyrA gene is sufficient to confer resistance to
nalidixic acid and reduced susceptibility to fluoroquinolones.16
A study on salmonella enterica serovar paratyphi A revealed that high-level
resistance to ciprofloxacin is also associated. The variation in the susceptibility
patterns reported for S-typhi, it is important to constantly monitor it to provide
suitable guidelines for treatment. S-para typhi A resistant to ciprofloxacin with a
MIC value of 8µg/ml and 32µg/ml has been reported from our centre. Here we
7
report the isolation of a strain of S-typhi showing high level resistance to
ciprofloxacin.17
In this study the strain was isolated from the blood sample of a 19 year old
male presenting with enteric fever at government general hospital, Pondicherry,
India, in September 2007. The antimicrobial susceptibility was determined, by the
disc of diffusion method. The MIC of ciprofloxacin as determined by the E-test
method was found to be > 32µg/ml. In this study was found to be sensitive to most
antibiotics except quinolones and intermediately susceptible to ampicillin.
Explained by the fact that resistance to other antibiotic is plasmid mediated. Cases
reported in India where S-typhi strains are resistant to first line antibiotics. 2008
there are reports of high level ciprofloxacin resistant salmonella enterica from
many centers in india. In developing countries such as India, ciprofloxacin
continues to be the main stay in the treatment of enteric fever as it is orally
effective and economical.18
Van state hospital study and 18 years old female patient admitted with the
complaints of fever and fatigue beginning 15 days, accompanied by headache,
weakness, palpitations. The patient was transferred to the infectious disease
department of the medical faculty of “ yuzuncu ” university on the physical
examination, temperature, pulse rate, B·P, respirations increased. In laboratory
examinations, leukocytes 2.500/mm³, erythrocytes, 3.360.000/mm³, Hb 9.9gr/dl,
platelets, 31.000/mm³, deficiency was determine. After sample were taken for
8
microbiological analyses, oral treatment of ciprofloxacin and electrolyte
replacement was maintained.19
In Gruber widal test study, to antibody was 1:200 and TH antibody 1:100.
After two days of admission, S.typhi was grown in blood culture. Repeated gruber-
widal test revealed that to antibodies increased to 1:800 and TH antibodies to 1:200
one week later.Her platelets came to 199.000 and also her leucopenia improved.
After two weeks of antibiotic therapy, the patient was discharged with full
recovery.20
WHO study for uses of vi vaccines in developing countries, its use has been
limited. The IVI in collaboration with NICED conducted a phase four cluster.
Randomized effectiveness trial, which randomized 80 geographic clusters of an
urban Kolkata slum. Over two years of follow up, the vi group was shown to have
61 % fewer episode of typhoid than the control group. Protection of vaccinated
children under 5 years of age by vi was even higher, 80%, interestingly, un
vaccinated neighbors of vi vaccinated persons had a 44% lower risk of typhoid,
indicating that vi vaccine conferred substantial herd protection.The over all level of
protection among all residents of the vi clusters, regardless of whether they were
vaccinated was 57%. Since the coverage of residents of the vi clusters, was about
60% this observation indicates that vi vaccine prevented as many cases of typhoid
in the total population as a vaccine that was nearly 100% protective in vaccinated
persons.21
9
A study was conducted in laboratory testing the current recommendation are
that isolates should be tested simultaneously against ciprofloxacin and against
nalidixic acid (NAL) and that isolates that are sensitive to both CIP and NAL
should be reported as “ sensitive to ciprofloxacin ”, but that isolates testing
sensitive to CIP. An analysis of 271 isolates showed that around 18% of isolates
with a reduced susceptibility to ciprofloxacin would not be picked up by this
method.22
A study by WHO according to statistics from the united states center for disease
control, the chlorination of drinking water has led to dramatic decreases in the
transmission of typhoid fever in the U·S. currently the W·H·O is recommended by
the two vaccines for typhoid fever. These are the live, oral Ty 21a vaccine (sold as
vivotif Berna) and the injectable typhoid polysaccharide vaccine both are between
50 to 80 % protective and are recommended for travelers to areas where typhoid is
endemic. W·H·O estimated 16 – 33 million cases of annually resulting in 5,00,000
to 6,00,000 deaths in endemic areas. Older killed whole cell – vaccine that is still
used in countries where the newer preparations are not available, but this vaccine is
no longer recommended for use. Because it has a higher rate of side effects.23
Astudy conducted by american clinician as members of this cohort often
come to the United States for higher degrees. The risk factors often also predispose
to other intra cellular pathogens, the case fatality rate in the United States in the pre
10
– antibiotic era was 9 – 13% since 1900, improved sanitation and successful
antibiotic treatment have steadily decreased the incidence of typhoid fever in the
united states. In 1920, 35,994 cases of typhoid fever were reported. Currently 200-
400 cases of typhoid fever are reported per year in the united states, 75% of which
occur in International travelers with in 30 days of entry. In most contemporary
presentations of typhoid fever, the fever has a steady insidious onset.24
6.3 STATEMENT OF THE PROBLEM:
Analytical study to assess the effectiveness of planned teaching programme
on management and prevention of typhoid fever among the mothers of school age
children admitted in the selected hospitals at Bellary, Karnataka.
6.4 OBJECTIVE OF THE STUDY:
1. To assess the knowledge among mothers of school age children regarding
typhoid fever.
2. To develop and conduct the planned teaching programme.
3. To evaluate the effectiveness of planned teaching programme by post test
knowledge score.
4. To find the association between the knowledge scores and selected
demographic variables.
11
6.5RESEARCH HYPOTHESIS:
H1: There will be significant difference between pre-test and post-test of
knowledge score on typhoid fever among mothers of school age children at 0.05
level.
H2: There will be a significant association between knowledge scores among
mothers of school age children with selected demographic variables.
6.5 VARIABLES UNDER STUDY:
INDEPENDENT VARIABLES
Planned teaching programme on typhoid fever management and its prevention.
DEPENDENT VARIABLES
knowledge among mothers of school age children regarding typhoid fever and
management and its prevention
ATTRIBUTE VARIABLE
Age, education, occupation, religion, family size, income etc
12
6.6 OPERATIONAL DEFINITIONS:
1. Analytical study: Using analytical method, detailed examination and analysis of
mothers knowledge regarding management and prevention of typhoid fever.
2. Assess: In this study assessment refers to an systematic collection of data.
3. Effectiveness: refresh to extent to which the planned teaching program has
achieved the desired effect in improving the knowledge of mothers of school age
children on typhoid fever management and its prevention.
4. Planned teaching programme : refers to drawing to systematically organized
teaching strategies for a group of mothers that enhances she knowledge regarding
typhoid fever management and its prevention.
5. Knowledge: refers to correct responses from the mothers of school age
children during interviews schedule regarding typhoid fever management and its
prevention.
6 Mothers: the female parents of school age children.
7 Typhoid fever: an a acute bacteria infection caused by salmonella typhi. The
illness is characterized by prolonged typical continuous fever for 3 to 4 weeks with
prostration relative bradycardia and involvement of spleen and lymph nodes.
13
6.8 ASSUMPTIONS :
The mothers school age children may not have adequate knowledge
regarding typhoid fever.
Teaching strategy regarding typhoid fever management and its prevention may
have to improve the knowledge among mothers
6.9 DELIMITATIONS:
Study is delimited to mothers of school age children only.
Mothers of school age children who are available at the time data collection
7. MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
The data will be collected from mothers accompanying with school age
children selected hospital at Bellary.
7.2 METHOD OF COLLECTION OF DATA:
7.2.1 RESEARCH DESIGN:
The research design chosen for the study is pre-experimental “one group
pretest and post test design”.
14
7.2.2 RESEARCH APPROACH:
An evaluative research approach.
7.2.3 RESEARCH SETTING:
Study will be conducted in selected hospital at Bellary.
7.2.4 POPULATION:
The population included in the present study is the mothers of school age
children.
7.2.5 SAMPLE SIZE:
The total sample size consists of 60 mothers of school age children in
selected hospitals, at Bellary.
7.2.6 SAMPLING TECHNIQUE:
Non-probability, purposive sampling technique will be used.
7.2.7 SAMPLING CRITERIA:
Inclusion criteria:
Mothers accompanying with school age children in selected hospitals at
bellary.
Mothers of school age children who are willing to participate in the study.
15
Mothers of school age children who can understand and speak Kannada and
English or Hindi.
Exclusion criteria
Mothers who are not available at the time of data collection.
7.2.8 DATA COLLECTION TOOLS:
Structural interview schedule will be conducted into two parts.
Part 1: Demographic data such as age, sex, education, occupation, religion,
family size etc.
Part 2: Knowledge questionnaire regarding typhoid fever management and its
prevention.
7.2.9 COLLECTION OF DATA:
The investigator herself collection the data from the mother of school age
children who are accompanying to selected hospitals, at bellary
Structural interview schedule is used to assess the knowledge by taking
pretest on typhoid fever management and its prevention.
Conducted planned teaching programme for who are accompanying to
selected hospitals, at bellary.
Same structured interview schedule for the pre-test will be used for post- test
7.2.10 DATA ANALYSIS METHODS:
16
The investigation will be use descriptive and inferential statistics.
Paired “ t ” test will be used to test the significant difference in the
knowledge scores between pre-test and post test scores
Chi-Square test is used to determine the knowledge scores with demographic
variables
It is presented in the form of table, diagrams and graphs, pie charts based
findings.
7.3 DOES THE SUDY REQUIRE ANY INVESTGATION OR
INTERVENTION TO BE CONDUCTED ON PATIENTS OR
OTHER HUMANS OR ANIMALS ? IF SO, PLASES DESCRIBE,
BRIEFLY.
No
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUION IN CASE OF?
Yes,
8. LIST OF REFERENCES:
1. The World Health Report, Report of the Director General WHO (1996)
world health Organization: Geneva.
2. The world health report, Report of the Director General WHO (1996) world
health Organization: Geneva.
17
3. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. 4th
Ed. Edinburgh, Scotland: Churchill Livingstone; 1987.
4. Jesudason MV, John TJ (1992) Plasmid mediated multidrug resistance in
Salmonella Typhi. Indian J Med Res 95:66-67.
5. Chambers HF, Infectious Diseases: Bacterial and Chlamydial. In: Tierney
LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment.
37th ed. London: Prentice Hall International Inc, 1998:1267-303.
6. Crump JA, Ludy SP, Mintz ED. The global burden of typhoid fever. Bull
World Heatlth Organ. May 2004;82(5) :346-53. [Medline].
7. Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Part I. Analysis of
data gaps pertaining to Salmonella enterica serotype Typhi infections in low and
medium human development index countries, 1984-2005. Epidemiol infect. Apr
2008;136(4):436-48. [Medline].
8. Steinberg EG, Bishop R, Haber P, Dempsey AF, Hoekstra RM, Nelson JM,
et al. Typhoid fever in travelers: who should be targeted for prevention?. Clin infect
Dis. Jul 15 2004;39(2):186-91. [Medline]
9. Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Part I. Analysis of
data gaps pertaining to Salmonella enterica serotype Typhi infections in low and
medium human development index countries, 1984-2005. Epidemiol infect. Apr
2008;136(4):436-48. [Medline].
18
10. According to Rosalyn Carson-DeWitt, MD
11. Butler T, Islam A, Kabir I, et al. Patterns of morbidity and mortality in
typhoid fever dependent on age and gender: review of 52 hospitalized patients with
diarrhea. Rev infect Dis.Jan-Feb 1991;13(1):85-0. [Medline]
12. Anju Sinha MD a, Sunil Sazawal MD a d, Ramesh Kumar Md a, Seema
Sood MD b, Vankadara P Reddaiah et al undertook a prospective follow-up study
of residents of a low-income urban area of Delhi, India.
13. BT Basavanthappa. “Nursing Research”. New Delhi : Jaypee Publication :
2005. P 49.
14. Anju Sinha MD a, Sunil Sazawal MD a d, Ramesh Kumar Md a, Seema
Sood MD b, Vankadara P Reddaiah et al undertook a prospective follow-up study
of residents of a low-income urban area of Delhi, India.
15. National Institute of Cholera and Enteric Diseases (NICED) in kolkata,
India, was published in the July 23 issue of the New England Journal of Medicine
(NEJM)
16. Rahman M, Ahamad A, Shoma S (2002) Decline in epidemic of multidrug
resistant Salmonella Typhi is not associated with increased incidence of
antibiotiscusceptible strain in Bangladesh. Epidemiol infect.
19
17. Harish BN, MAdhulika U, Parija SC (2004) Isolated highlevel ciprofloxacin
resistance in Salmonella enterica subsp. Enterica serotype Paratyphi A. J Med
Microbiol 53:819.
18. Raveeendran R, Wattal C, Sharma A, Oberoi J K, Prasad K J, Datta S (2008)
High level ciprofloxacin resistance in Salmonell enterica isolated from blood.
Indian J Med Microbiol 26:50-53.
19. Turan Buzoan, Omer Evirgen, Hasan Irmak, HAsan Karsen, Hayrettin
Akdeniz Yuzuncu Yyl University, Faculty of Medicine, Department of Infectious
Diseases and Clinical. Microbiology, Van, Turkey.
20. Eur J Gen Med 2007; 4(2):83-86: Dr. Omer Evirgen Yuzuncu Yyl
Universitesi Typ Fakultesi ARabtyma Hastanesi, Enfeksiyon Hastalyklary Servisi
65200 Van, Turkey.E-mail: [email protected].
21. National Institute of Cholera and Enteric Diseases (NICED) in kolkata,
India, was published in the July 23 issue of the New England Journal of Medicine
(NEJM)
22. WHO Report, According to statistics from the united States Centre for
disease control. WHO World Health Report, Report of the Director General WHO
(1996) World Health Organisation : Geneva.
23. WHO Report, According to statistics from the united States Centre for
disease control. WHO World Health Report, Report of the Director General WHO
(1996) World Health Organisation : Geneva.
20
24. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. 4th
Ed. Edinburgh, Scotland: Churchill Livingstone; 1987.
9 Signature of the student
1
0Remarks of guide
The research topic selected for the study
is relevant and forwarded for the needful
action.
1
1Name and designation of the
guide
Mrs. SUMITHRA DEVI
H.O.D. Department of Child Health
Nursing, Indian College Of Nursing,
Bellary.
1
2
Guide
Mrs. SUMITHRA DEVI
Department of Child Health Nursing,
Indian College Of Nursing,
Bellary.
1
3
Signature
1
4
Co-Guide ( If any ) Mrs. PATEL NIRUPAMA
1
5
Signature
1
6Head of the Department
Mrs. SUMITHRA DEVI
HOD. Dept. of Child Health Nursing,
Indian College Of Nursing, Bellary.
21
1
7
Signature
1
8
Remarks of the chairman &
principal
I discussed with the research committee.
I felt that research problem is good &
feasible
1
9
Signature
22