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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE MRS. JASPREET KAUR, AND ADDRESS H.NO.230-C, RATTAN NAGAR, TRIPRI, PATIALA, PUNJAB. 2 NAME OF THE INSTITUTE NOOR COLLEGE OF NURSING, NO.5, NOOR BUILDING, RMV 2nd STAGE, BHOOPASANDRA MAIN ROAD, BANGALORE-94. 3 4 5 COURSE OF STUDY & M.SC., NURSING 1ST YEAR, PAEDIATRIC SUBJECT NURSING. DATE OF ADMISSION 01st JUNE 2010. TITLE OF THE TOPIC “A STUDY TO ASSESS THE KNOWLEDGE REGARDING IMPORTANCE OF PROTEIN INTAKE AMONG FIVE MOTHERS OF UNDER CHILDREN PAEDIATRIC WARD ADMITTED OF IN SELECTED HOSPITAL AT BANGALORE WITH A VIEW TO DEVELOP MODULE.” 1 SELF INSTRUCTIONAL 6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION Child health is the foundation of the family and wealth of a nation. Good nutrition is the basic component of growth and development for maintenance of health throughout life. “Nutrition is defined as combination of dynamic process by which the consumed food is utilized for nourishment, structural and functional efficiency of every cell of the body.” Under five children require balanced nutrition to become healthy for national growth and economic development1. Nutrition in early childhood can have lifelong implications. It is important to develop healthy eating practices in childhood to prevent or delay the development of lifestyle related diseases. Caregivers of this age must receive the best information and resources available. The health and nutrition of the children need protection in order to ensure sound foundation and secure the future of any society. In India, there are 53% of under five children in which 67% million – live without basic healthcare facilities. This means that India alone accounts for about one-third of all children in the world aged below five who don’t have basic health care2. Protein comes from the Greek word meaning “ To take first place.” Proteins are the chief substances in the cells of the body, they are composed of carbon, hydrogen, oxygen and nitrogen. Some proteins also contain sulphur, phosphorus and other elements. Proteins are made up to simpler substances called amino acids classified as essential and non-essential amino acids Amino acids are essential for building of body tissues for growth, maintenance and repair3. Weaning is gradual process started at 4-5 months of age. If supplemented by suitable foods rick in protein and other nutrient can improve the immunity, help in growth and 2 development. By the age of one year, the child should receive solid foods consisting of cereals, pulses, vegetables and fruits.4 Growth faltering and malnutrition are highly prevalent in most south Asian countries. Among the serious consequences, malnutrition is increased in risks of morbidity and mortality in children as well as deficits in physical stature and lowered cognitive measures. Protein malnutrition in poor households has been well documented in India, with the highest rates observed in those aged 12-23 months. Countrywide national Family Health Survey II data show mean underweight prevalence increases from 11.9% below 6 months infants to 58.4% at 12-23 months of age. The intervention group as a whole has improved feeding practices. Global hunger Index, South Asia, Shows that the highest child malnutrition rate is about 5.6 million leading to child mortality. The 2006 report mentioned the low status of women and lack of nutritional knowledge are important determinants of high prevalence of under weight children in the specific region. U.S. Census Bureau and Agriculture department 2007 shows estimated 3.5 million children under the age of five are at risk of hunger and protein malnutrition. The reason behind in under utilization of existing programmes as free distribution of food stamps and school meals. 5 The most recent estimate in October 2010 by FAO says that 925 billion people are undernourished. And the estimated proportions of deaths in which malnutrition is the underlying cause are roughly similar for diarrhea 61% malaria 57% pneumonia 56% and measles 45%.4 WHO estimates that more then 300 million children suffer from protein deficiency only and mortality rate is an high as 40% in under five children. ‘The Lancet’ says protein malnutrition in first two years is irreversible. Protein deficient children grow up to worse health and lower educational achievements.6 3 The Health status of under five children in 2001 census of Karnataka reported that under five mortality rate is 69/1000 live births. The census also included that there are about 6.2% of children with severe under nutrition, 45.4% with moderate under nutrition, 39.0%and only 9.4% are normal. Thus, from these data, it is evident that nutritional status of the under five children in Karnataka is poor.7 A National family Health Survey report shows that 4 out of every 10 children in the Karnataka stage are undernourished, born stunted or too short for their age. About 70% of the children in the state in the age group of 6 to 59 months are anaemic. The national Nutrition Monitoring Bureau report shows the consumption of green leafy vegetables, roots and tubers, milk and milk related products, fats and oils is low in Karnataka. Considering that some state-run programmes, like the integrated child Development Scheme ( ICDS), have been on since 1975, it is surprising that the state is still unable to address the issue of malnutrition. The ICDS programme is on in 54, 260 anganwadis in the state. Around 44 Lakhs beneficiaries, including pregnant women, lactating mothers and anganwadi workers are availing of the benefits. “With Rs.2 per beneficiary, it will take time to achieve complete control on malnutrition and the government is planning to increase the amount to Rs.4 per child beneficiary”.9 Protein deficiency constitutes a major health problem in India and other countries of the developing world. In infants and children every year over 50% of children are undernourished. The most vulnerable period of malnutrition is first five years. And it is basically the result of poor knowledge on part of the mothers regarding nutritional requirements. 4 6.1 NEED FOR THE STUDY “How wonderful it is that nobody need wait a single moment before starting to improve the world.” - Anne Frank. Today’s healthy child is tomorrow’s better citizen. Development of healthy child is influenced by many factors. Under five children are the most vulnerable groups who are prone to many infective disease and nutritional deficiencies. Proteins are very important for growth and development, wear and tear of tissue repair and maintenance, formation of immune bodies, enzymes and harmones. Proteins also act as sources of energy when consumed in excess of body need. Protein sources are basically classified as animal source (eg : Cheese, Milk, liver, Fish, meat and eggs) Plant sources (eg: pulses, nuts, beans and soya beans). Conventional sources (eg: oil seeds, cakes, sea weeds).10 The protein requirement depends upon the age, sex, physical, physiological and other factors. ICMR 1981 recommended 1.83 gm per kg of body weight of protein up to 1-3 years and 1.56 gm per kg of body weight of upto-4-5 years, i.e 22 gm and 29 gm of total requirement respectively. For infants 2.3gm per kg up to 3 months, 1.8gm per kg up to 3-9 months, 1.5 gm upto 9-12 months is the daily recommended protein allowance. The mental and social development of the child is dependent on the mother. The mother is the first teacher of the child, and that is why the mother and child are treated as one unit. A study conducted to find out the Effect of maternal factors on nutritional status of 15 year old children in urban slum population among 482 children in Punjab reported that education of mother significantly influenced the nutritional status of under fives as the prevalence of under nutrition was 60.9% where mother was illiterate and it was only 21.2% where education level was more than high school. Mother’s age showed highly significant 5 (p=0.001) effect on the prevalence of under nutrition. That is where mother’s age was less than 20 years; the prevalence was 75.0% as compared to 32.2% where mother’s age was more than 30 years.12 A vast majority of the children suffering from mild to moderate forms of malnutrition remain hidden in the community. PEM results from the interaction of several factors among which two are more as less directly responsible for the disease. First quantitatively insufficient and qualitatively inadequate dietary intake, second infections processes such as gastrointestinal and respiratory infections and other infections diseases of childhood. Infections experienced by children during first year of life represent the major factor in protein energy malnutrition. In child hood infections especially measles were traced in more then half of the children. Similar observation concerning of precipitating effect of infections processes such as measles, Germen measles, whooping cough, primary tuberculosis and malaria have been seen.13 Insufficiency of food the so-called “food –gap” and lack of awareness are chief cause of protein energy malnutrition, which is a major health problem particularly in first years of life. The majority of cases of protein energy malnutrition were nearly 30% are mild and moderate cases. The incidence of protein energy malnutrition is more in preschool children. This problem exists in all the states and the nutritional marasmus is more frequent than kwashiorkor. 15 An cross sectional study was conducted to examine the nutritional status of children (aged 1-5 years) who lived in the Klong Taey slum Bangkok. Anthropometric measurements were made for 232 children; socio economic background information was obtained by interviewing their mothers using a structured questionnaire. The results showed that family income, maternal housewifely or unemployment food practice and a maternal education level 6 lower than primary school were associated with low nutritional status of under five children. Findings implied that protein nutrition is remains as threat to the health of urban poor in Bangkok. The finding should not be over looked countermeasures or indicated. A study was conducted to determine the prevalence of PEM and its associated with soil transmitted in Orang Aslu children Malaysia. The study result obtained from 368 children aged 2-15 years showed that the overall prevalence of mild and significant under weight was 32.1 % and 56.5% respectively. The present study vividly showed that stunting and under weight are highly prevalent among Orong Aslu children.17 Infants and children under five are the most vulnerable group. They are seriously affected by deficiency of protein. Serious complications of advanced Protein energy malnutrition(PEM) can happen leading to superadded overt and hidden infections like septicemia, pneumonia, diarrhea, pyoderma, scabies, U.T.I, tuberculosis infection. Mothers are the most wondrous care givers who nurture their kids. Thus they play a prime role in providing nutrition. So they should have adequate knowledge of protein’s significance in diet of under five children. The nurse plays an important role in educating the mothers of under five children about significance of protein in daily diet. Ongoing health education and reinforcement while monitoring to reduce protein deficiency is an important challenge for nurses. Education of mothers is the process of assistance to learn and incorporate healthy eating behaviors in every day life. Providing sound and sincere advice regarding the measures to take adequate protein will provide health promotion positively. Hence the investigator found need to assess the knowledge of giving protein diet to the under five children among mothers. 7 6.2 REVIEW OF LITERATURE The review of literature is defined as broad, comprehensive in depth, systematic and critical view of scholarly publications, unpublished scholarly print material, audio-visual materials and personal communications. Review of literature provides the basis for future investigation, feasibility of study and indicates constraints of data collection. Review of literature is extensive, exhaustive examination of publication relevant to research project. It is under taken to establish the need for the study methodology , development of a tool and structured teaching programme. The review of literature in this chapter is presented under as follows. Literature related to protein sources Literature related to feeding practices among under Five children Literature related to demographic variables of protein malnutrition Literature related to knowledge of mothers of under five children regarding protein energy malnutrition Literature related to protein sources An experimental study was conducted in among 3-5 years children living in rural area who were below the 90th percentile of standard weight for age to compared the nutritional status with serum protein and lipid to determine the effect of protein source egg on them. The result shows that because of addition of three eggs per week, total cholesterol HDL level has decreased and albumin prealbumin and HDL levels demonstrated significant increasing levels so in conclusion three eggs for week can provide adequate protein for children of 3-5 years of age. 18 An Article stated for children 1-3 years the average daily intake of cereals and millets among 1-2 years children was 136 g forming 78% of RDI. The intake of cereals of millets 8 was lower than the RDI in all the states except in Madhya Pradesh (106% of RDI). The extent of deficit was the highest in Kerala and Gujarat (36%), followed by Tamil Nadu and Maharashtra (33%), Karnataka, Orrisa West Bengal (20%)and Andra Pradesh(10%). The mean intake of pulses of legumes(12g) was about a third of the RDI (35g). the consumption of green leafy vegetables, a rich source of B carotene, was negligible(6g).19 A study was conducted to measures the levels of proteins in different vegetarian sources by The Ralston Purina Company of St. Louis. The study revealed that soyabeans contains 42% protein 33% carbohydrates, 20% oil, 5% hulls. It is clear from the study that 10-15% of babies in U.S. are raised on soy-based formula and almost 60% of their favourite food supplements contain soy protein . Study concluded that soy a or bean protein is best out of vegetarian sources of protein. 20 The study was conducted at Harvard University to assess the level of proteins in vegetarian diets. Results showed that dairy and egg products are the complete sources for lacto -ovo vegetarians only vegetable sources contain significant amounts of all eight types of essential amino acids. It further concluded that essential amino acids can be obtained by eating a variety of plant sources. 21 Literature related to feeding practices of under Five children An article on “ Additional Reasons For a Vegetarian Diet” Stated that various ethical reasons for choosing vegetarianism. Jainism teaches vegetarianism as a moral conduct, so prohibit meat eating. Hinduism hold vegetarianism as an ideal and have conviction that non-vegetarian food is detrimental for the mind and spiritual development. In Buddhism there are several Sanskrit texts where Buddha instructs his followers to avoid meat. The Sikhism prohibits Sikhs to eat meat and eggs. The article showed there is definitely a concern of vegetarianism with protein deficiency. 22 9 A study was conducted to assess the nutritional status of 100 pre-schoolers from anganwadi centers in slum areas of Udaipur city. Interview schedule containing questions on background information about the family was used. Detailed information was also collected from records of Anganwadi survey and beneficiary survey register. The assessment of nutritional status of the subjects was based on weight for age. The study result reveals that 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. Classifications for degree of malnutrition as per IAP showed that majority of these subjects (66%) were under weight (Grade I and II). Water low’s classifications revealed that majority of these preschoolers were wasted (30%) or wasted and stunted (42%).23 A study was conducted to examine the association between complementary feeding practices and mother’s education status in Islamabad among mothers of 500 infants attending the Pediatric Outpatient department. The study results showed a positive relationship between the nutritional status of infants and educational status of mothers (P<0.001). A similar relationship was observed between the educational status of respondents and the introduction of complementary foods at an appropriate age (six months) on infants (p<0.001).24 A study was conducted on physicochemical properties and nutritional traits of milletbased weaning food suitable for infants in Kumaon hills, northern India. A weaning food based on malted foxtail millet flour (30%), malted barnyard millet flour (30%), roasted soybean flour (25%) and skin milk powder (15%) was prepared. The mix contained 18.37 grams proteins and 398 kcal energy per 100 grms, The nutrient composition of this fortified weaning mix met the prevention of food adulteration standards. So, this met the acceptability of criteria for weaning food. 10 A Study wad conducted on early in weaning increase infants’ acceptance of new foods for up to two months at Nestle Research Center, Switzerland. Infants receiving their first vegetable(carrot puree) and over the next 9 days either carrots every day, 3 vegetables changed for every 3 days or 3 vegetables changed daily. On the 12th and 23rd days receive new vegetable purees, tomato then peas. Several weeks later, they received 2 more new foods, meat and fish. Results showed that variety in weaning increased new food acceptance. Frequency of change was more effective than number of vegetables fed. They concluded that these interventions correspond to differences in milk and vegetable feeding have practical consequences for acceptance of new foods. The findings of the study on the influence of infant feeding practices on nutritional status of under five children in selected four Anganwadi areas of urban Allahbad showed that among all under five children surveyed, 36.4% underweight, 51.6% stunted and 10.6% wasted. The result also revealed that initiation of breast feeding after six hours of birth, deprivation from colostrums and improper complementary feeding were found significant (P<0.05) risk factor for underweight.25 A study was conducted to assess the nutritional status and feeding practices of underfive children in Tanzania. Face –to-face interviews with the sampled mothers were conducted using a semi-structured questionnaire. Anthropometric measurements using weight-for-age criterion were employed to assess the nutritional status. The study showed that 31% of the children were undernourished, some (6%) of them severely. Breast feeding duration of more than one year was common among the mothers. Fifty-four percent of the weaned their children as early as two months after birth. The most common type of weaning food was maize porridge mixed with cow’s milk (46%). An educated mother was less likely 11 to have an undernourished child, while a child from a teenage mother was more likely to be undernourished.26 Literature related to demographic variables of protein malnutrition. A descriptive study was conducted to find underlying causes of protein malnutrition in under five children on Nigeria. It was found using modified Wellcome classification that prevalence of PEM was 27% in rural Nigerian community. It also concluded poverty, inadequate food production, ignorance and uneven distribution of food are also the underlying causes of malnutrition in under five children. 27 A case controlled study was conducted to determine the socio-economic factors predisposing under five children to severe protein malnutrition in 66 children age 3-36 months attending out patient department Moi Teaching and Referral Hospital in Eldoret, Kenya. The result showed social rick factors were single mothers (OR 14.93), young mothers (OR 3.95), living in temporary house (OR 3.627), caretaker who was not married to child’s parent (OR 0.10). It conclude that socio –economic for protein malnutrition are single mothers, poverty, social conditions, sex of the child and incomplete immunization. 28 A study was undertaken to assess the impact of drought on childhood illnesses and nutrition among 914 under five children of rural population using three stage sampling design in Rajasthan. The findings of the study revealed that children suffered from recent and long term malnutrition were 39% and 26% respectively as per National Centre for Health Statistics (NCHS) standards. The extent of malnutrition was significantly higher in females than in males (P<0.01). Vitamin A & B complex deficiencies were 0.7% and 3% respectively. 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%). The 12 comparison of present drought results with earlier studies in normal and drought conditions showed higher prevalence of PEM and deficiencies of calories & proteins in their diet.29 A survey was conducted to examine how economic inequality was associated with chronic childhood PEM, Information was collected on 32-35 children aged 0-59 month. Household wealth status was measured by an index based on household ownership of durable assets. The results of this study indicated that children in poorest 20% household were more than twice as likely to suffer from stunting as children in richest 20% households. The study concluded the wealth inequality is associated with chronic childhood under nutrition and emphasizes that reducing poverty and making services accessible to poor will be key to improve nutritional status of under five children in Combodia. 30 A repeated cross sectional study was conducted to measure rates of hunger and food insecurity among young U.S born Latino children with Mexican immigrant parents compared with a non-immigrant non-latino in a low income clinic population. A survey was done on 4278 caregivers of children <3 years of age in a pediatric clinic for 5 years period. The results showed young Latino children has higher rates of child hunger than non-Latinos 6.8 vessus 0. 5% It concluded that young children in Mexican immigrant families are especially high rick for hunger, household in security and in turn malnutrition. 31 A study was conducted among 90 mothers of weaning age children on infant feeding practices of Pakistani mothers in England and Pakistan. 45 were in England and 45 in Pakistan. A questionnaire available in English and Urdu was used to find out about general beliefs about weaning. Result showed that mothers in both groups commence weaning between 3-4 months, common weaning foods included rice, cereals and eggs with progression to fruit and vegetables and family food in Pakistan, and fruit, Vegetables, meat 13 and convenience foods( especially sweet options) in England. Both groups of mothers wanted more information about infant feeding practices. It was concluded that mothers in Pakistan demonstrated more confidence in weaning practices than in England because of experiences with other siblings and advice from relatives. More advice from health professionals was requested and is needed by all mothers in order to improve weaning practices of the infants. 32 A cross- sectioned study was conducted to determine the prevalence and to identify risk factors associated with protein-energy malnutrition (PEM) in 798 children under five years of age in Luangprabang province, Laos. Anthropometric measurements of children were done and data were transformed into height-for-age, weight-for-age and weight-forheight ratios. Mothers were also interviewed with a semi-structured questionnaire. The findings reveled that there was a high prevalence of stunting, underweight and wasting, which 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. However, it was also found that boys were more prone to be stunted and underweight. Furthermore, restricted intake of meats, vegetables during illness, and low maternal education were main risk factors for child malnutrition in the study area.33 A study was conducted to examine the factors causing Malnutrition in Bangladesh among 560 under Five Children. The analyses revealed that 45 percent of the children under age five were suffering from chronic malnutrition, 10.5 percent were acutely malnourished and 48 percent had under-weight problem. The main contributing factors for under five malnutrition were found to be previous birth interval, size at birth, mother’s body mass index at birth and parent’s education.34 14 Literature related to knowledge of mothers of under five children regarding protein energy malnutrition A study was conducted on intensive nutritional education with or without supplementary feeding improves the nutritional status of moderately malnourished children in rural Bangladesh. About 282 moderately malnourished children aged 6-24 months were considered. Mother of them were divided in two groups; one with intensive nutrition education group and other with both intensive nutrition education, and their children received additional supplementary feeding. Ability of mothers to identify malnutrition improved from 15% to 99% in the intensive nutrition education group and from15% 0 100% in the intensive nutrition education and supplementary feeding. It was concluded the study that intensive nutrition education improves the status of children with or without supplementary feeding. 35 A study was conducted to find the relationship between the maternal nutritional knowledge and nutritional status in Ghana. The data were collected from 55 well nourished and 55 malnourished mothers – child pairs. A questionnaire designed to collect data on mother’s knowledge and practices related to child care and nutrition was administered to the mothers. The data on mother’ demographic and socioeconomic characteristics as well as child anthropometric data were also collected. Maternal education on the other hand was not found to be independently associated with nutritional status. These results imply that mother’s practical knowledge about nutrition may be more important than formal maternal education for child nutrition outcome.36 A cross-sectional study conducted on Evaluation of nutritional knowledge of thirty mothers (house wives) about their children in Pakistan revealed that early weaning was noted in 12 (11.4%) infants, 41 (39%) infants were weaned in 4-6 months and delayed weaning was noted in 52 (49.5%) infants. Boiled water was used by 14(46.6%) mothers and filtered 15 water by 4(13.3%) while 12 (40%) mothers used tap water. 80(76.19%) infants received Gutti as first feed while colostrums was given to 25(23.80%) . 28(93.3%) mothers did breast feeding, 10(33.3%) gave cow’s milk along with breast milk and 11(36.6%) formula milk along with breast milk.37 A case control study was conducted to find out maternal knowledge of malnutrition and health care seeking attitudes of 68 mothers in rural Tamil Nadu. The study reported that 34 mothers of well nourished children have more knowledge (59%) regarding role of lack of food or nutrition in mild marasmus – kwashiorkor mixed malnutrition compared to the 34 mother of severely malnourished children (35%). There were 67.6% of poor and illiterate mothers out of 68 mothers. The study also reported that only 28% of mothers would seek medical care for malnutrition.40 6.3 STATEMENT OF THE PROBLEM “A Study To Assess the knowledge regarding importance of protein intake among mothers of under five children admitted in peadiatric ward of selected hospital at Bangalore with a view to develop self instructional module”. 6.4 OBJECTIVES OF THE STUDY To assess the level of knowledge regarding importance of protein intake among mothers of under five children. To find out association between level of knowledge among mothers of under five children with their selected demographic variable. To prepare Self instructional module (SIM) regarding importance of protein intake. 6.5 OPERATIONAL DEFINITIONS Assess: It is the statistical measurement of level of knowledge regarding importance of protein intake among mothers of under five children observed by 16 structured knowledge questionnaire. Knowledge : It refers to the verbal responses given by mothers of under five children regarding importance of protein intake. Mothers : In this study it refers to the mothers who have children below five years of age and taking care of them. Under five Children : In this study it refers to the children who were below the age group of five years. Protein intake: Protein is the chemical compound composed of carbon, oxygen and nitrogen. It is needed for growth and development of children. Self instructional module : It refers to the informational booklet which include the definition, meaning of protein, sources of protein, functions, importance/ need of protein intake and deficiency problems with management and preventive measures of protein. 6.6 ASSUMPTIONS Mothers of under five children possess some knowledge regarding importance of protein intake. Self instructional module regarding importance of protein intake will help them to enhance their knowledge to follow during practice. 6.7 DELIMITATIONS The Study is Limited to Mothers of under five children Pediatric wards of selected hospitals at Bangalore. The study is limited to 6 weeks. 17 7 MATERIAL AND METHOD 7.1 Primary source : Mothers who are having under five children admitted in Peadiatric ward of selected hospital at Bangalore. 7.2 Research Approach : Descriptive approach 7.3 Research Design : Descriptive design. 7.4 Settings of the Study: The study will be conducted in Mediscope, Republic, Green View Hospital of Peadiatric ward at Bangalore. These hospitals approximately 5 to 10 Kms away from Noor College of Nursing. 7.6 Population : Mothers of under five children who are admitted in peadiatric ward of selected hospital at Bangalore. 7.7 Sample : In this study mothers those who all are having under five children admitted in peadiatric ward of selected hospital at Bangalore. 7.8 Sample Size : The sample size of this study is 60. 7.9 The Sampling Technique : Non Probability Convenience sampling. 7.10 SAMPLING CRITERIA (i) INCLUSION CRITERIA : The mothers Who have under five children. Who all are having either male or female babies. Who are willing to participate in the study Who can read and write English or Kannada. (ii) EXCLUSION CRITERIA : The mothers Who have children more than the age of five years. Who are not willing to participate in study Who don’t know Kannada or English. 18 8 DESCRIPTION OF VARIABLES The study variable is knowledge of mothers of under five children regarding protein in take. 9 METHOD OF DATA COLLECTION Prior to data collection, permission will be obtained from the concerned authority for conduction of study. After obtaining consent from the subject, the investigator will explain the purpose of the study and the structured knowledge questionnaire will be administered to collect the data, followed by self instructional module regarding importance of Protein in take will be provided. The study period is 4-6 weeks. 10 DESCRIPTION OF TOOL As per expert opinion structured knowledge and occupation of mother questionnaire will be prepared. It will consist of : Demographic variables like age and sex of child, education of mother, occupation, religion and residential area etc. Structured knowledge questionnaire regarding importance of protein intake among under five children’s mothers. 11 STATISTICAL ANALYSIS Data obtained will be assessed in terms of objectives of the study by using descriptive and inferential statistics. Descriptive statistics Frequency and percentage distribution will be used to analyse the demographic data of mothers of under five children. Mean and standard deviation will be used to assess the level of knowledge regarding importance of protein intake among mothers of under five children. 19 Inferential Statistics Chi square (x2) will be used to find out the association between the knowledge score of mothers of under five children with their selected demographic variable. 12. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION ON PATIENT OR OTHER HUMAN BEINGS ANIMALS. IF SO PLEASE DESCRIBE: Yes, SIM will be administered and level of knowledge will be assessed. 13. ETHICAL CONSIDERATIONS TOWARDS SAMPLE RELATED TO STUDY YES Permission will be obtained from concerned authority in the selected pediatric hospital to conduct the study. A written consent will be obtained from the participants of this study 20 14. LIST OF REFERENCES 1) Mrs.Vasundra, Community health nursing 1994, 2nd edition, JP Brothers P135. 2) Park. K, Text Book of Preventive and Social Medicine 200, 18th edition, Banarasidas Bhanot Publishers. P 432, 435, 654. 3) http://e b health care . com / http://: goggle.com 4) http://iresearch. World bank .org/Povcal Net. Life Style lounge. http//i love india com. 5) Tada Y, Keiwkarnaka B, Pancharuniti N, Chamroonsawasdi K. Nurtritional status of the preschool children of the klong Toey slum Bangkok. Southeast Asian J Trop Med Public Health.2002 Sep;33:628-37. 6) Nirmala M Nagaraj. Nutrition still a distant dream. 4 out of 10 kids in Karnataka are under nourished. The Times of India, Bangalore 2008 Dec 2; Times city(col.7). 7) Karnataka’s Health Action 2001 Aug: 36-39. 8) Suraj Gupta, the short Text Book of Pediatrics, 2009, 11th edition Jaypee Brothers Medical Publishers P. Ltd P146. 9) Ghai OP Essential pediatrics, 1996, 4th edition, Inter print Publishers New Delhi P47-48. 10) Iqbal Hossain M, Yasmin R, Kabir I, Nutritional and immunization status, weaning practices and socio-economic conditions of under five children in three villages of Bangladesh. Indian J Public Health.1999 Jan-Mar;43(1):37-41. 11) Dorothy R. Marlow, Barbara A, Redding Text Book of Pediatric Nursing 2001 6 th edition Philadelphia W.B. Saunders Company. 675-677. 21 12) Al-Mekhlafi HM, Azlim M, Aini UN, Shaik A, Saiah A, etal, Protein energy malnutrition and soiled-transmitted helminthiasis among orang Asli children in Malaysia Asia Pac J Clin Nutr.2005;14(2): 188-94 13) Mayurasakorn K, Supplement of three eggs per week, BMJ 1998, Nov;326(8112):1122-1125. 14) Shanthi Ghosh Nutrition and Child Care A Practical Guide 2nd edition JP publisher p35. 15) http://made in atlantis : com /life/bean protein. 16) http:en.Wikipedia.org.wiki/vegetarianism. 17) Igbedish S.O. Articles from BMJ 249K. 18) East Afr. Med J. 2004 Aug;(8):415-21. 19) Hong R, Mishra V. Effect of wealth inequality on chronic under-nutrition in Cambodian children. J Health Popul Nutr.2006 Mar;24(1):89-99. 20) Kersy M. Geppert. J Getts DB. Hunger in young children. Public Health Nutr.2007 April;10(4):390-5. 21) Sarwar T. infant feeding practices. 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