SYNOPSIS

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAM ON KNOWLEDGE REGARDING PROTEIN
ENERGY MALNUTRITION AND ITS PREVENTION AMONG MOTHERS
OF PRE-SCHOOL CHILDREN AT SELECTED AREA IN GUNTUR”
Synopsis for registration
SUBMITTED BY
NARAYANA BULLA
SIMS College of nursing
Mangaldasnagar.
Guntur.
2018-2020

DR.NTR University of health sciences

Vijayawada
2018-2020

1
 CHAPTER – 1

INTRODUCTION
The world health organization (WHO): defines malnutrition as the cellular
imbalance between the suppy of nutrients and energy and the body’s demand for
them to ensure growth, maintenance, and specific function “The term protein
energy malnutrition (PEM) 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. Marasmus involves inadequate intake of
protein and calories and is characterized by emaciation. The term kwashiorkor is
taken from the Ga language of Ghana and means “The sickness of the weaning.
Williams first used the term in 1933, and it refers to an inadequate protein intake
with reasonable calorie intake. Edema is characteristic of kwashiorkor but is absent
in marasmus.

Nutritional deficiency disorders are major public health problem in

India and other developing countries they affect vast majority numbers if
population abd responsible for approximately 55% of childhood death, in India
there are about 60 million malnourished children and every month about 1 lakh
children die due to effect of malnutrition.Malnutrition is a man made disease of
human society. The ecology of malniturition is complet with numbers of
influencing factors like desease condition, Infection, Socioeconomic status,
Cultural practices and available health and other services.
Nutritional marasmus results from gross deficiency of energy
through protein deficiency also accompanies. There is overlap in the clinical
picture so it is apporiate to lable marasmic kwashiorkor. Growth failure and poor

2
tissue repair (due to protein lack) and energy shortage (due to calories deficiency)
is also common to all forms of PEM.

Protein energy malnutrition (PEM) is a potentially fatal body in

children in developing countries. Primary PEM results from a diet that lacks
sufficient sources of protein and/or energy. Kwashiorkor also called wet protein-
energy malnutrition is a form of PEM characterized primarily nby protein
deficiency. This condition usually appears at the age of about 12 months when
breast feeding is discounted. But it can develop at any time during a child’s
formative years. It causes fluid retention (edema) dry, peeling skin, and hair
discoloration.

Primarily caused by energy deficiency marasmus is characterized by

stunted growth and wasting of muscle and tissue.maramas usually develops
between the ages of 6 months and one year in children who have been weaned
from breast milk or who suffer from weakening conditions like chronic diarrhea.

Mild moderate and severe classifications have not been precisely

defined, but patients who lose 10-20% of their body weight without trying are
usually said to have moderate PEM. This condition is also characterized by a
weakened grip and inability to perform high energy tasks. Losing 20% of body
weight or more is generally classified as severe PEM.

Treatment is designed to provide adequate nutrition, restore normal

body composition, and cure the condition that caused the deficiency. In patients
with severe PEM the first stage of treatment consists of correcting fluid and
electrolyte imbalances, treating infection with antibiotic that don’t affect protein
synthesis and addressing related medical problems. The second phase involves
replenishing essential nutrients slowly to prevent taxing the patients weakened

3
system with more food than it can handle. Physical therapy may be beneficial to
patients whose muscles have deteriorated significantly.

Breast feeding a baby for at least six months is considered the best
way to prevent early childhood malnutrition. Preventing malnutrition in developing
countries is a complicated and challenging problems.

The world health organization (WHO): defines malnutrition as the cellular

imbalance between the suppy of nutrients and energy and the body’s demand for
them to ensure growth, maintenance, and specific function “The term protein
energy malnutrition (PEM) 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. Marasmus involves inadequate intake of
protein and calories and is characterized by emaciation. The term kwashiorkor is
taken from the Ga language of Ghana and means “The sickness of the weaning.
Williams first used the term in 1933, and it refers to an inadequate protein intake
with reasonable calorie intake. Edema is characteristic of kwashiorkor but is absent
in marasmus.

Nutritional deficiency disorders are major public health problem in

India and other developing countries they affect vast majority numbers if
population abd responsible for approximately 55% of childhood death, in India
there are about 60 million malnourished children and every month about 1 lakh
children die due to effect of malnutrition.Malnutrition is a man made disease of
human society. The ecology of malniturition is complet with numbers of
influencing factors like desease condition, Infection, Socioeconomic status,
Cultural practices and available health and other services.

4
 Nutritional marasmus results from gross deficiency of energy
through protein deficiency also accompanies. There is overlap in the clinical
picture so it is apporiate to lable marasmic kwashiorkor. Growth failure and poor
tissue repair(due to protein lack) and energy shortage(due to calories deficiency) is
also common to all forms of PEM .

Protein energy malnutrition (PEM) is a potentially fatal body in

children in developing countries.Primary PEM results from a diet that lacks
sufficient sources of protein and/or energy.Kwashiorkor also called wet protein-
energy malnutrition, is a form of PEM characterized primarily nby protein
deficiency. This condition usually appears at the age of about 12 months when
breast feeding is discounted. But it can develop at any time during a child’s
formative years. It causes fluid retention (edema) dry, peeling skin, and hair
discoloration.

Primarily caused by energy deficiency marasmus is characterized by

stunted growth and wasting of muscle and tissue.maramas usually develops
between the ages of 6 months and one year in children who have been weaned
from breast milk or who suffer from weakening conditions like chronic diarrhea.

Mild moderate and severe classifications have not been precisely

defined, but patients who lose 10-20% of their body weight without trying are
usually said to have moderate PEM. This condition is also characterized by a
weakened grip and inability to perform high energy tasks. Losing 20% of body
weight or more is generally classified as severe PEM.

Treatment is designed to provide adequate nutrition, restore normal

body composition, and cure the condition that caused the deficiency. In patients
with severe PEM the first stage of treatment consists of correcting fluid and

5
electrolyte imbalances, treating infection with antibiotic that don’t affect protein
synthesis and addressing related medical problems. The second phase involve
replenishing essential nutrients slowly to prevent taxing the patients weakened
system with more food than it can handle. Physical therapy may be beneficial to
patients whose muscles have deteriorated significantly.

Breast feeding a baby for at least six months is considered the best
way to prevent early childhood malnutrition. Preventing malnutrition in developing
countries is a complicated and challenging problems

6
 NEED FOR THE STUDY

The most recent estimates about the distribution of PEM at a

worldwide level were compiled by the world health organization (WHO)
programme of nutrition, available in its global database on child growth and
malnutrition(de oxis and blossner 1997).This database covered 95 percent of the
total population of children under syeals of age who lived in 103 developing
nations in 1995, as was reported in nationally representative survey available at the
time.

According to these data, an estimated 206.2 million children, who

represent 38 percent of all children under 5 years old, were stunted (low height
forage); 167.3 million children (31 percent) were underweight (low weight for
age), and 48.8 million children(9 percent) were wasted(low weight for
height).PEM is most often found in the poor regions known as the “developing
world”.the largest number of affected children were found in asia, where 41
percent of all under 5 years old were stunted, 35 percent were under weight, and 8
percent wasted children of all those under 5 years old; latin America and the
Caribbean showed 17.9 percent stunted, 9.5 percent under weight and 3 percent
wasted children of all those under 5 years old. The proportion of children under 5
yearsa of age affected in oceania was 31.4 percent, 22.8 percent, and 5 percent
respectively but the total number of children living in this region is much lower, so
in reality, these percentages translate into many fewer children affected then in the
other regions.

The World Bank estimates that india is ranked 2 nd in world of the

number of children suffering from malnutrition, after Bangladesh (in 1998), where
47% of the children exhibit a degree of malnutrition. The prevalence of

7
underweight children in india is among the highest. In the world, and is nearly
double that of sub-saharan Africa with dire consequences for mobility, mortality,
productivity and economic growth. The UN estimates 2.1 million Indian children
die before reaching the age of 5 every year –four every minute- mostly from
preventable illness such as diarrhea, typhoid, malaria, measles and pneumonia.
Everyday, 1000 Indian children die because of diarrhea alone. According to the
1991 censes of India, it around 150 million children, constituting 17.5% of Indian
population, who are below the age of six years.

Though most of the population of india is still living below the

national poverty line, its economic growth indicates in the prevalence of chronic
diseases which is observed in at high rates in developed countries such as united
states, Canada & Australia. The combination of people living in poverty and the
recent economic growth of India has led to the co-emergence of two types
malnutrition: under nutrition & over nutrition

It has been recognized that malnutrition is the most common cause of

immune defecience world wide (Chandra 1991). Actually malnutrition and
infection interact in a vicious cycle: The presence of one more easily leads to the
development of the other (scrimshaw, taylor, etal, 1968). There are several
mechanisms involved in this relationship PEN impairs all-mediated immunity,
pdiagocitic immunoglobulin (IgA, IgM, and IgG) concentration, cytokine
production(Chandra 1991).

PEM can disrupt coginiton in several ways following the lessons

learned from the effect of PEM on the body during infections, the classic
explanation was that malnutrition caused physical damage to the brain, particularly
during sensitive periods of development, namely, during the first two years of life,

8
when about 80% of the brains growth is achieved (Guilarte, 1993, Levit sky and
Strupp, 1995).

Which will be reflected in cognitiue disabilities, Motor impairment, or

lower intelligent quotient (IQ) by means of micronutrient deficiencies such as
Vitamin B6 or iron, both of which are vital for normal brain function
(Guilarte,1993; Pollitt.1997)

Severe deficiency of essential nutrients (ie Zinc, iron, and vitamin A

required in the synthesis of DNA maintenances factors; deterioration of repair
mechanisms allowing the persistence of an unusually high number of structural
chromosomal aberrations ; and/or the absence of specific factors needed to protect
the cell against oxidative DNA damage

STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of structured teaching program on knowledge

regarding protein Energy malnutrition and its prevention among mothers of pre-
school children at selected area in Guntur”

OBJECTIVES OF THE STUDY

1. To assess the pre test and post test level of knowledge regarding protein energy
malnutrition and its prevention among mothers of pre-school children.

2. To determine the effectiveness of structured teaching programme on knowledge

regarding protein energy malnutrition and its prevention among mothers of pre-
school children in experimental group.

9
3. To compare the pre test and post test level of knowledge regarding protein
energy malnutrition and its prevention among mothers of pre-school children in
experimental and control group.

4. To associate the post test level of knowledge regarding prevention of protein energy
Malnutrition with Their selected demographic variables among mothers of pre-school
Children in experimental group and control group.

HYPOTHESIS
H1: There is a significant difference between pre test and post test level of
knowledge regarding protein energy malnutrition and its prevention among
mothers of pre-school children in experimental and control group.
H2: There is a significant association between post test level of knowledge
regarding prevention of protein energy malnutrition with their selected
demographic variables among mothers of pre-school children in experimental and
control group.

1. ASSESS:
It refers to gathering information regarding the protein energy malnutrition and its
prevention.
2. STRUCTRED TEACHING PROGRAMME:
It refers to systematically developed instructional programme using instructional aids,
design to provide information. Regarding the protein energy malnutrition and its
prevention.

10
3. KNOWLEDGE:
It refers to the response of adolescents to the question started in the questionnaire
regarding the protein energy malnutrition and its prevention.
4. PROTEIN ENERGY MALNUTRITION:
Protein–energy malnutrition (PEM) is a form of malnutrition that is defined as a range
of pathological conditions arising from coincident lack of dietary protein
and/or energy (calories) in varying proportions. The condition has mild, moderate, and
severe degrees.
5. PREVENTION:
It refers to prevent the occurrence of weight loss during hospitalization and
following discharge by daily oral supplementation.
6. PRE-SCHOOL CHILDREN:
It refers to pre-school children who belong to age group and 3 To 5Years
and their mothers
ASSUMPTIONS

1. Mothers of Pre-school children may have limited knowledge on protein

energy malnutrition.
2. The increase in level of knowledge will facilitate for the change of
favorable attitude of the mothers of pre-school children and protein
energy malnutrition
DELIMITATIONS:
The study is delimited to
 Mothers of pre- school children selected area at Guntur.
 4 weeks of data collection.
 Assess effectiveness of structured teaching programme.
 60 samples

11
 CHAPTER- II
REVIEW OF LITERATURE
This chapter presents review of literature related to the present study.
The role of literature review is to formulate and clarify the research problem, to
ascertain what is already known in relation to a problem of interest, for developing
a broad conceptual Contest, facilitate accumulation of scientific knowledge for
interpreting the results of the study.
Review of literature involves systematic identification, location,
scrutiny and summary of written materials that contain information on research
problem, the literature review is based on an extensive survey of books, journals
and international nursing index.
The researcher presents their review under the following headings.

SECTION-I Studies related to prevalence of protein energy malnutrition among

pre- school children.

SECTION-II Studies related to protein energy mal nutrition in relation with socio-
demographic and socio economic factor.

SECTION-III Studies related to knowledge and practice on diet for protein energy
mal nutrition.

SECTION-IV Studies related to health education on protein energy malnutrition.

12
 SECTION-I

Studies related to prevalence of protein energy malnutrition among pre-

School children

A study was conducted to determine the prevalence of protein-energy

malnutrition and its association with soil-transmitted helminthiases in children.
The results obtained from 368 children aged 2-15 years showed that the overall
prevalence of mild and significant underweight was 32.1% and 56.5% respectively.
The prevalence of mild stunting was 25.6% while another 61.3% had significant
stunting. The overall prevalence of mild and significant wasting was 39.0% and
19.5% respectively. The overall prevalence of ascariasis, trichuriasis and
hookworm infection were 61.9%, 98.2% and 37.0% respectively and of these
18.9%, 23.5% and 2.5% of the children had severe infection of the respective
helminthes. The overall prevalence of giardiasis was 24.9%. The present study
vividly shows that stunting and underweight are highly prevalent among children
and therefore of concern in this community. Identified as the main predictors of
stunting and wasting respectively, in addition to age between 2 to 6 years 10

A study was conducted on WHO Global Database on Child Growth,

which covers 87% of the total population of under-5-year-olds in developing
countries; we describe the worldwide distribution of protein-energy malnutrition,
based on nationally representative cross-sectional data gathered between 1980 and
1992 in 79 developing countries in Africa, Asia, Latin America, and Oceania. The
findings confirm that more than a third of the world's children are affected. For all
the indicators (wasting, stunting, and underweight) the most favorable situation--
low or moderate prevalence’s--occurs in Latin America; in Asia most countries
have high or very high prevalence’s; and in Africa a combination of both these

13
circumstances is found. A total 80% of the children affected live in Asia--mainly in
southern Asia--15% in Africa, and 5% in Latin America. Approximately, 43% of
children (230 million) in developing countries are stunted. Efforts to accelerate
significantly economic development will be unsuccessful until optimal child
growth and development are ensured for the majority. 11

A study was conducted on Malnutrition, with its 2 constituents of

protein-energy malnutrition and micronutrient deficiencies, continues to be a major
health burden in developing countries. It is globally the most important risk factor
for illness and death, with hundreds of millions of pregnant women and young
children particularly affected. Apart from marasmus and kwashiorkor (the 2 forms
of protein- energy malnutrition), deficiencies in iron, iodine, vitamin A and zinc
are the main manifestations of malnutrition in developing countries. In these
communities, a high prevalence of poor diet and infectious disease regularly unites
into a vicious circle. Interventions to prevent protein- energy malnutrition range
from

Promoting breast-feeding to food supplementation schemes, whereas

micronutrient deficiencies would best be addressed through food-based strategies
such as dietary diversification through home gardens and small livestock. all such
interventions require accompanying nutrition-education campaigns and health
interventions. To achieve the hunger- and malnutrition-related Millennium
Development Goals, we need to address poverty, which is clearly associated with
the insecure supply of food and nutrition.

A study was conducted study was undertaken from March to May 2004.
Anthropometric measurements of 798 children were done and data were
transformed into height-for-age, weight-for-age and weight-for-height ratios.

14
 Mothers were also interviewed with a semi-structured questionnaire. There was a
high prevalence of stunting, underweight and wasting that is, 54.6%, 35%, and 6%
respectively. It was also noted that children aged 12-23 months and Khmu ethnic
children had a higher prevalence of stunting (65% and 66%) and underweight
(45% and 40%), respectively., vegetables during illness, and low maternal
education it was also found that boys were more prone to be stunted and
underweight. Furthermore, restricted intake of meats. Socioeconomic-demographic
factors, low maternal education, poor nutrition knowledge for mother and feeding
practices for sick children are affecting children's health regarding stunting and
underweight.

A study was conducted on approximately 70.0% of the world's

malnourished children live in Asia, resulting in the region having the highest
concentration of childhood malnutrition. About half of the preschool children are
malnourished ranging from 16.0% in the People's Republic of China to 64.0% in
Bangladesh. Prevalence of stunting and underweight are high especially in South
Asia where one in every two preschool children is stunted. Besides protein-energy
malnutrition, Asian children also suffer from micronutrient deficiency. The socio-
economic cost of the malnutrition burden to the individual, family and country is
high resulting in lower cognitive outcomes in children and lower adult
productivity. Interventions that are cost-effective and culturally appropriate for the
elimination of childhood malnutrition deserve the support of all.

A study was conducted on Protein energy malnutrition (PEM) is a

global problem. Nearly 150 million children under 5 years in the world and 70-80
million in India suffer from PEM. The studies in experimental animals in the west
and children in developing countries have revealed the adverse effects of PEM on
the biochemistry of developing brain which leads to tissue damage and tissue
15
contents, growth arrest, developmental differentiation, myelination, reduction of
synapses, synaptic transmitters and overall development of dendritic activity.
Many of these adverse effects have been described in children in clinical data,
biochemical studies, reduction in brain size, histology of the spinal cord, Longer
the PEM, younger the child, poorer the maternal health and literacy, more adverse
are the effects of PEM on the nervous system. Just like the importance of nutrients
on the developing brain, so are the adverse effects on the child development of lack
of environmental stimulation, emotional support and love and affection to the
child.. Most important being in family, school, community and various
intervention programmes, local, regional and national. Moreover medical students,
health personnel, all medical disciplines concerned with total health care and
school teachers should learn and concentrate on the developmental stimulation and
enrichment of the child.

16
 SECTION-II

Studies related to protein energy mal-nutrition in relation with

Socio-demographic and socio economic factor.

A study was conducted on protein energy malnutrition (PEM) is a

common problem worldwide and occurs in both developing and industrialized
nations. In the developing world, it is frequently a result of socioeconomic,
political, or environmental factors. In contrast, protein energy malnutrition in the
developed world usually occurs in the context of chronic disease. recognition,
prompt management, and robust follow up are critical for best outcomes in
preventing and treating. Early recognition, prompt management and robust follow
up are critical for best outcomes in preventing and treating PEM.

A study was conducted on children from a low socio economical level

where under nutrition is prevalent are shorter than those from higher
socioeconomic levels. We examined the effects of severe and early protein energy
malnutrition on growth and bone maturation. We studied 40 preschool children
who had been admitted to hospital in infancy with protein energy malnutrition and
38 children from the same socioeconomic level, paired for age and sex, who had
never been malnourished. Growth measurements were made over a period of 4-6
years, and bone age was determined in a subgroup through wrist roentgenograms.
Results showed a correlation between protein energy malnutrition, birth weight of
infants, and mother's height and head circumference. The group with protein
energy malnutrition showed a significant delay in stature after four years,
especially the girls (p less than 0.001). Weight: height ratio was reduced in boys
compared with controls but not in girls. Both groups showed a delay in bone
maturation, but there were no significant differences between them. We found a

17
positive correlation between bone age and arm fat area in control boys and between
bone age and height for age in boys with protein energy malnutrition. The finding
that rehabilitated children were shorter than the control group. 17

A study was conducted on demonstrates that the metabolic changes

in PEM include water and electrolytes imbalance, amino acids and proteins
deficiencies, carbohydrates and energy deficiencies, hypolipidaemias,
hypolipoproteinaemias, hormonal imbalance, deficiency of anti-oxidant vitamins
and enzymes, depression of cell-mediated immune complexes and decrease in
amino acids and trace elements in skin and hair. The review therefore suggests that
assessment of these conditions in PEM patients could improve the management of
this group of patients and hence reduce the rate of morbidity and mortality from
PEM.

18
 SECTION-III

Studies related to knowledge and practice on diet for protein-energy mal

nutrition.

A study was conducted on children indicate that the addition of

lysine to either supplemental breads provided at school, or to all wheat products
consumed, resulted in no observed beneficial effects. Other field studies report an
increase in either weight or height with addition of lysine to breads. A laboratory
study with human adults suggests that wheat flour: soy flour mixture has a higher
biological value than wheat flour alone. The role, in human nutrition, of breads
with improved protein quality remains somewhat obscure. 19

A study was conducted on case-control method with a food

frequency questionnaire was used to assess the habitual diet. Children with severe
childhood malnutrition presenting to the central hospital in Blantyre, Malawi
during a 3-month period in 2001 were eligible to participate. The food frequency
questionnaire collected data about foods consumed by siblings <60 months of age
in the home. It was assumed that the habitual diet of all siblings 1-5 years old in
the same home was similar. Dietary diversity was assessed using a validated
method, with scores that ranged from 0 to 7. Regression modelling was used to
control for demographic and disease covariates. A total of 145 children with
kwashiorkor and 46 with marasmus were enrolled. Children with kwashiorkor
consumed less egg and tomato than those with marasmus: 17 (15) vs. 24 (31)
servings per month for egg, mean (SD), P < 0.01 and 27 (17) vs. 32 (19) servings
per month for tomato, P < 0.05. Children with kwashiorkor had a similar dietary
diversity score as those with marasmus, 5.06 (0.99) vs. 5.02 (1.10), mean (SD).

19
Further research is needed to determine what role consumption of egg and tomato
may play in the development of kwashiorkor.

A study was conducted on Quality protein maize (QPM), with twice

the amount of tryptophan and lysine than conventional maize, has improved the
nutritional status of severely malnourished children. This double-blind clinical
study evaluated the impact of QPM on the growth and morbidity of mild and
moderately malnourished children. In a Nicaraguan day care center, 48 children 1
to 5 years old who were malnourished (> 2 indicators with < -1 Z for weight-age,
height-age or weight-height) were identified and randomly assigned to consume
for 5 days/week for 3.5 months a snack prepared with QPM or conventional maize.
QPM positively influenced children's growth: weight (0.80 vs. 0.19 kg gained from
baseline to end line between the QPM and conventional maize groups,
respectively), height (2.02 vs. 1.23 cm in QPM vs. conventional) and Z score for
weight-age (0.17 vs. -0.26 Z in QPM vs. conventional) and height-age (0.06 vs. -
0.23 Z in QPM vs. conventional). When other factors that could affect growth with
respect to weight, height, weight-age Z score and height-age Z score were
controlled for, the intervention group (QPM > conventional) was a statistically
important factor (P < 0.01). The QPM snack, however, had no effect on the
incidence of diarrheal episodes or respiratory infections. In conclusion, QPM
improves the nutritional status of pre-school children who are mild or moderately
malnourished.

A study was conducted on Few Senegalese mothers are skilled in

handling the dietary transition from nursing to adult food for their children. At
least 20% of the children aged 1 to 4 are affected by 2 broad types of protein-
calorie malnutrition, marasmus and kwashiorkor. To correct these diets, nutritional
rehabilitation centers (NRCs) have been established in 2 villages. Children and
20
mothers come to these centers for periods of up to 3 weeks. Mothers learn to use
locally available, inexpensive food products to prepare well-balanced meals high in
calories and protein. Traditional cooking techniques of the typical rural home are
used (examples of recipes used in NRCs are given), and mothers are also taught
better methods of selecting, cultivating, and preserving foods.

21
 SECTION-IV

Studies related to health education on protein energy

Malnutrition

A study was conducted on Current guidelines for the management of

severe malnutrition are mainly based on new concepts regarding the causes of
malnutrition and on advances in our knowledge of the physiological roles of
micronutrients. Severely malnourished children require special micronutrients, a
mineral-vitamin mix is added to the milk-based formula diets, which are specially
designed for the initial treatment and the rehabilitation phase. To further improve
nutritional rehabilitation and reduce cases of relapse, 'ready-to-use therapeutic
food' and 'ready-to-eat nutritious supplements' with relatively low protein (10%
protein calories) and high fat content (54-59% lipidic calories) have been
developed. Although current dietary recommendations do not differentiate between
oedematous and nonoedematous forms of malnutrition or between adults and
children, there are indications that further clarification is still needed for applying
dietary measures for specific target groups.

A study was conducted on Protein-calorie malnutrition is found in

environments characterized by ignorance, illiteracy, poverty, poor hygiene, and
absence of food processing industries. At the Mondongo rural health center in
Zaire, malnourished children are not rare, although they live in an environment
rich in the foods necessary for growth and development. Mothers are poorly
informed about the desirable age at weaning, the nutritional requirements of
weaned infants, and appropriate diet and food preparation for weaned children. The
income of local residents does not permit purchase of imported foods. Children
must thus be nourished with local foods. Manifestations of protein-calorie
22
malnutrition range from slight retardation of growth to serious disease, including
marasmus and kwashiorkor. Among 337 children studied in Mondongo, 66
(19.5%) were seriously malnourished, with upper arm circumferences of less than
13 cm, or weight being 60% of normal weight for their age. 81 children (21%) had
moderate malnutrition, with are circumferences of barely 15 cm, or weight for age
60-80% of normal. 190 children were adequately nourished, with arm
circumferences of at least 16 cm and weight over 80% of normal for their age. A
formula for a weaning food called Mariso proposed by a group of researchers in
1984 was found to be poorly accepted because it included soybeans, which are not
widely available or well accepted. Two mixtures more appropriate to local realities
were developed. Mariche combines maize, rice, and locally harvested and smoked
caterpillars, while mariop combines maize, rice, and eggs. The mixtures can be
stored for short periods in ordinary containers in a dry place. Sugar or salt may be
added during cooking. Two mixtures are sufficiently inexpensive to be available to
all population sectors. Mariop was found to be slightly more effective than
Mariche in treatment of malnourished children. But protein-calorie malnutrition is
a curable deficiency avoidable at low cost using locally available resources.
Mothers must be trained to provide adequate nutrition for their young children. 24

23
 CHAPTER -III
METHODOLOGY
The research methodology of research indicates general pattern of organizing the
procedures for gathering valid and reliable data for investigation. Research
methodology is scientific and systemic way to solve research problems.

A system of models, procedures and techniques used to find the results of a

research problem is called as research methodology. Methodology is a significant
part of the study, which enables the researcher to project a blue print of research
under takes.

The chapter deals with the methodology adopted for the study. It includes the
research approach, research design, variables under study, setting, population,
sample, sample size, and sample technique, criteria, development and description
of tools, procedure for data collection and plan for data analysis and interpretation
of the results regarding dengue fever and its prevention among intermediate
students.

It is the systematic, theoretical analysis of the methods applied to a field of study.

It comprises the theoretical analysis of the body of methods and principles
associated with a branch of knowledge. Typically, it encompasses concepts such
as paradigm, theoretical model, phases and quantitative or qualitative techniques.

RESEARCH APPROACH:

“Research approach is an overall plan (or) blue print (or) sketches (or) strategies (or)

sequence of answering the research question”.

“B.T.Basavanthappa(2007)”.

In this study research approach will be quantitative research approach.

24
RESEARCH DESIGN:
Research design refers to strategies that the researcher adopt to develop
information that is accurate objectives and meaningful the selection of the research
design is the most important step as it provides the framework for study.
The research design selected for this study will be quasi experimental design.
Tabular presentation of the research design

Subject Pre – post Treatment Post -test

Experimental group O1 X O2

Control group O1 --- O2

O1=Pre-test (assessment of pre-school children regarding protein energy

malnutrition and its prevention)

X=Intervention (structured teaching program on protein energy malnutrition and

its prevention)

O2= post –test (reassessment of pre-school children knowledge regarding proten

energy malnutrition its prevention)

POPULATION:
Population refers to the entire aggregation of cases that means a designated set of
criteria the requirement of defining a population for a research project arises from
the need to specify the group to which the result of the study can be applied.

“Polit and Hungler”.

This study population refers to mothers of pre-school children (3-5 years)

25
TARGET POPULATION:

The entire population which researchers are interested and which they would like
to generalize the research findings.

Target population of the study will be the universal mothers of pre-schools

children.

ACCESSIBLE POPULATION:

Accessible population will be the mothers of pre-school children at selcted area

SAMPLE:

Population refers to the entire aggregation of cases that means a designated set of
criteria the requirement of defining a population for a research project arises from
the need to specify the group to which the result of the study can be applied.

“Polit and Hungler”.

Sample will be mothers of preschool children who got selected to participate

in the study through sampling techniques.

SAMPLE SIZE:

The sample size will be 60mothers of pre-school children in which 30 mothers and
experimental group and 30mothers of control group,

SAMPLING TECHNIQUE:

The samples will be selected by purposive sampling technique, as it will be the

most suitable one for the present study.

26
INCLUSION CRITERIA:

The mothers of preschool children.

 Willing to participate in the study.

 Able to read or speak Telugu and English
 Available at the time of data collection

EXCLUSION CRITERIA:

The study sample exclude

 Who have attended the health talk on protein energy malnutrition and its
home based diet management.
 Who had a child diagnosis with protein energy malnutrition

DESCRIPTION OF VARIABLES:

 Variables are characters that can have more than one value, the categories of
variables discussed in the present study were.

INDEPENDENT VARIABLE:

It is the stimulus or activity that will be manipulated or varied by the researcher to

create the effect on the independent variable.

 In this study the independent variable will be structured teaching program.

27
DEPENDENT VARIABLE:

It is the outcome or response due to the effect of the independent variable, which
researcher wants to predict or explain.

 In the present study the dependent variable will be is knowledge regarding

protein energy malnutrition among mothers of toddler and pre-school
children.

DESCRIPTION OF TOOL:

The tool consists of 2 sections;

Data will be collected by using self administered knowledge questionnaire.

Section 1: Demographic variables. Like age of the mother, parity, education,
economic status and occupation, religion, age of child, source of information

Section 2: Structured knowledge questionnaire. It content 30mothers choice

questionnaire, correct answer carries one mark and wrong answer carries zero
marks
Scoring interpretation:
Level of Knowledge Scores Percentage
Inadequate knowledge 0-20 0-50
Moderately adequate knowledge 14-15 51-75
Adequate knowledge 17-20 75-100

28
PROCEDURE:

The researcher will be selected mothers of preschool children, Pre – test will be
conducted to mothers and the researcher will be educated them through structured
teaching program me regarding protein energy malnutrition and its prevention.
After post – test will be conducted to mother. Each mother for three days samples
will be followed by investigation for 7 days, on 8th day post – test will be
conducted to assigned samples.

ETHICAL CONSIDERATIONS:

 Permission will be obtained from concerned authorities.

 Informed consent will be obtained from samples.
 Privacy and confidentially of the data will be maintained

VALIDITY:
The content validity of questionnaire will be ensured by submitting the tool to the
experts in field of community and nursing – modifications of items in terms of
simplicity and made.
RELIABILITY:
In order to establish the reliability of the tool it is administered to children in
selected slum area at Guntur.
DATA COLLECTION PROCEDURE: -
Formal permission will be obtained from concern authorities.
PHASE –1: Child teachers will be selected mothers of pre-school children, and
teaching program will be conducted to there with the help of charts and models.

29
PHASE –2: Samples will be selected by sampling techniques, pre – test will be
conducted with the help of structured knowledge questionnaire. Child to child
approach teaching will be conducted.
PHASE –3: Post – test will be conducted. Data will be arranged for the data
analysis.

30
ANALYSIS OF DATA: -
Both descriptive and inferential statistics analyzed on the basis of the
objectives and hypothesis of the study are as follows: -

Data analysis Method Objective

Descriptive Mean. 1. To assess the pre – test and post –
statistics test level of knowledge regarding
Standard deviation protein energy malnutrition and its
prevention among mothers of pre-
school children.
Paired ‘ t ‘test
2. To determine the effectiveness of
structured teaching programme on
knowledge regarding protein energy
malnutrition and its prevention among
mothers of pre-school children in
experimental group.
Inferential Independent ‘t’ test
statistics 3. To compare the pre test and post test
level of knowledge regarding protein
energy malnutrition and its prevention
among mothers of pre-school children
in experimental and control group.
Chi – Square To associate the post test level of
Knowledge regarding protein energy
Malnutrition and its prevention
With their selected demographic
variable among mothers of pre school
children in experimental and control
group

31
LIST OF REFERENCES:

1. Available from http:/www.pubmad.com;introduction to malnutrition.

2. Parul Datta “pediatric Nursing” department of neonatology IPGGMER and

SSKM Hospital Kolkatta WB India 2nd edition 2009.

3.Balram Chowdhry “Pediatric Lecture notes” 7/31 Amari road daryagunj New
Delhi 1st edition 2007.

4.American College of nutrition, 722 Robert ELee drive,Wilmington(2008) NC

20412- 0927,(919)152-1222.

5.ACC/SCN.third report on the world nutrition situation,Geneva,Switzerland 1997.

6.”World Bank report” world bank report on malnutrition in India;2009-03-13.

7.journal of the American medical association “ the global burden of chronic

diseases” JAMA 2004,2009-11-23

8.Allen ,Lindsay H.” The nutrition CRSP:what is marginal malnutrition and does it
affect human function” nutrition review 51(1993):255-267.

9.Susana A.salcedac.etal” protein-energy malnutrion contributes to increased

structural chromosomal alteration frequencies” 2008 may.

10.Al-Mekhlafi HM,et.al “ protein-energy malnutrition and, soil-transmitted

helminthiases? Kualalumpur Malaysia 2005:14(2):188-94

32
11. de Onis M,et.al “ The world wide magnitude of protein-energy malnutrition: an
overview from the WHO Global data base on child growth” 1993;71(6):703-12.
data base on child growt 1993;71(6):703-12.

12. Muller O,krawinkelm. “malnutrition and health in developing

countries”.Heide;berg,Germany, 2005 aug;2:173(3):279-86.

13.Phengxay m,et.al “risk factor protein-energy malnutrition in children under 5

years” Tokyo japan 2007 apr 49(2):260-5.

14.Khor GL. “Update on the prevalence of malnutrition” serdang Malaysia 2003

dec:5(2):113-22.

15.Udani PM “ protein energy malnutrition (PEM), brain and various facet’s of

child development” Mumbai hospital, 1992 mar-apr;59(2)165-86.

16.Grover Z, Ee LC “ protein energy malnutrition” queensland 4029, Australia

2009 oct.56(5):1055-68.

17.JAlvear,et.al, “ physical growth and bone age of survivors of protein energy

malnutrition” 1986 mar,61(3):257-62.

18.S A Akuyam “ a review of some metabolic changes in protein-energy

malnutrition” Zaia Nigeria 2007 jun.14(2):155-62.

19 Brschart AA “improving protein quality of bread-nutritional benefits and

realities” 1978,105:703-34.

20. Sullivan J,et.al “ the quality of th diet in children with kwashiorkor and
Marasmus” st.louis Missouri, USA 2006 apr,2(2),114-22

33
21. Ortega Aleman edel C “ The effect of consuming quality protein maize or
conventional maize on the growth and morbidity of malnourished children”
Managua, Nicaragua 2008 dec:58(4):377-85.

22. DE Lauture H,et.al “a model for combating malnutrition in children :

nutritional rehabilitation centres” 1982;1(2)18-21.

23.Scherbaum “New concepts on nutritional management “ 2000 jan;3(1)31-8

24. kalissa V,Monziba B “ local food mixturefor treatment of protein. Calorie

malnutrition” 1993;(103):24-9.

34