A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN

AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING CENTER OF RAICHUR, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

JINSON MATHEW

NAVODAYA COLLEGE OF NURSING RAICHUR, MAY 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. Name of the candidate : Mr. JINSON MATHEW M.Sc. Nursing, 1st Year Navodaya College of Nursing Navodaya Nagar Manthralayam Road, Raichur 2. Name of the Institute 3. Course of Study and Subject : Navodaya College of Nursing : M.Sc. Nursing, 1st Year Child Health Nursing 4. Date of Admission 5. Title of the Topic : :

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING CENTER OF RAICHUR, KARNATAKA.

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 NEED FOR THE STUDY:

Tomorrow is just an idea ,but today is happening right now

MAHATHMA GANDHI The world over, approximately 88,000 people will die with these nosocomial infections. These infections affect more than 1.4 million patients in a year and the rates have been rising steadily. With possibly the most stringent infection control in the world, only 5% of hospitalized patients in the USA suffer nosocomial diseases.1 Conservative WHO estimates put the figure for India at 10% -- one in every 10 patients will boomerang back to his hospital bed and endure additional medical costs and hospital stay. This is a common enough occurrence in understaffed or badlyfunded healthcare facilities across India. Bloodstream infections from intubation and infusion procedures like drips contribute 30%, while another 20% are surgical site wounds turning septic courtesy air-borne pathogens or non-sterile dressings. 1 Nosocomial infections in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 68%. The common nosocomial infections in PICU are bloodstream infections (2030% of all infections), lower respiratory tract infections (2035%), and urinary tract

infections (1520%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Nosocomial pneumonias predominantly occur in mechanically ventilated children. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; hand washing, judicious use of interventions and proper asepsis during procedures remain the most important practices.2 A study was conducted on Neonatal Nosocomial Infections in Bahrami Children Hospital. Neonatal nosocomial infections have been reviewed in Bahrami Children Hospital from fall of 1999 through fall of 2004. The result was Fifty-two patients had been diagnosed having nosocomial infections. NICU (Neonatal Intensive Care Unit) showed the highest portion of infections (40%) followed by neonatal surgery ward (35%) and neonates ward (25%). Frequencies of nosocomial infection by site were as follows: eyes (27%), septicemia, surgical wounds and location of drain or catheter (each one 21%), CSF (7%) and urinary (2%). Total number of hospitalized patients was 5990 and total number of hospitalized days was 39,095 in the five years. Infections per 100 hospital discharges and 100 hospital days by service were as follows, respectively: NICU (2.9, 0.26), neonatal surgery (1.7, 0.18) and neonates (0.3, 0.06). The differences were significantly meaningful (p value<0.001). These findings provide useful information for future surveillance in association with prevention programs. Subsequently, surveillance should be focused on high-risk patients in intensive care unit and/or who have undergone surgery and invasive procedures. 3 A study on incidence and impact of nosocomial infections conducted in hospitals in Delhi and Mumbai reported figures as high as 30% and their incidence have found their etiology from lack of hospital hygiene , human transmissions, surgical and other

invasive interventions. A major problem faced is that organisms present in the hospital environment are usually more virulent and even more importantly resistant to most antibiotics. assuming the national average for nosocomial infections in India, the study concluded that Indian health care is facing an enormous challenge in terms of the need to prevent and control these infections 6 Another study was conducted to assess the incidence of HAI, specially Ventilator Associated Pneumonia (VAP) and Hospital Acquired Pneumonia (HAP) in 10Asian countries and was found that the incidence and prevalence of HAP and VAP are higher in Asian countries than in western countries.7 4

A study was conducted on Health Care Workers Hand Decontamination Practices. The primary purpose of this quasi-experimental research was to observe health care workers compliance with hand-hygiene guidelines during patient care in an intensive care unit before (pretest) and after (posttest) implementation of a multifaceted hand-hygiene program. Health care workers attitudes, beliefs, and knowledge in relation to compliance with hand washing guidelines were also investigated. A convenience sample of nurses, doctors, physiotherapists, and care assistants (n = 73 observational participants, n = 62 questionnaire respondents) was used. Data (N = 314 observations, 62 questionnaires) were analyzed descriptively and cross-tabulated using chi-square (Pearsons) and Mann-Whitney statistical tests. Results revealed that a significant shift (32%) occurred in health care workers compliance with hand washing guidelines (pretest 51%, posttest 83%, p < .001) following the interventional hand-hygiene program. Significant changes were also found in relation to health care workers attitudes, beliefs, and knowledge (p < .05).5

A study was conducted on Controlling Nosocomial Infections Program. The infection control data collected and analyzed include surgical site infections, catheter-related bloodstream infections, urinary tract infections and ventilatorassociated infections. The analysis involves comparing the data with the national and international benchmarks. The isolated microorganisms in the clinical specimens and

their antibiogram are discussed to assess the trends and prevalence of antibiotic resistance and emergence of multidrug resistant bug. The measures taken after analysis help in taking corrective actions to reduce the average length of stay of patients and associated morbidity and mortality. The infection control programme has helped to preempt any outbreaks in the high dependency areas of the hospital. It has also reduced the overall stay of the patient in hospital as evinced by a decreasing Average Length of Stay (ALOS), there by decreasing cost of treatment to the patient and a faster turnover for the hospital a win win situation for all. 6

A study was conducted to examine compliance with hand washing and glove use among health workers. Nine nurses and 33 assistant physicians were monitored during the study. One researcher recorded 1,400 potential opportunities for hand washing during 15minute observation periods. Most healthcare workers (99.3%) used liquid soap during hand washing, but 79.8% did not dry their hands. For all indications, compliance with hand washing was 31.9% and compliance with glove use was 58.8%. Compliance with hand washing was better in dirty high risk situations. The study concludes that compliance with hand washing was low, suggesting the need for new motivational strategies such as supplying feedback regarding compliance rates.7

In the light of above and investigators experience working in the neonatal and pediatric intensive care units observed many children with nosocomial infection during their hospital stay. With the increased use of invasive procedures the risk of HAIs is also increasing. Moreover, the high frequency of nosocomial infection places a substantial burden on individual patients and on the health care system and as a result, there is increased morbidity, including delayed wound healing, increased exposure to antimicrobial therapy and its potential adverse effects, and prolonged hospitalization, failure to thrive. To minimize the risk of infection, nursing personnel should have adequate knowledge regarding nosocomial infections following admission and appropriate practice to control these infections. Investigator found that the nursing knowledge and practice in this area have remained inadequate. Therefore the investigator felt the need to educate junior health assistants female students before

they are exposed into the clinical conditions to create awareness among them related to risk factors, affects, prevention and control of nosocomial infections. 6.2 REVIEW OF LITERATURE : Review of literature is to ascertain what is already known In relation to a problem of interest, to develop a broad conceptual context in to which ,a problem will fit. It helps to know methodology and research tools, especially research strategies and specific procedures measuring instruments and statistical analysis that might be productive pursuing in the research problem and interpreting the result of the study. A) Studies related to risk factors of nosocomial infections among under five children . A retrospective case control study on Risk Factors Associated with Surgical Site Infection after Pediatric Posterior Spinal Fusion Procedure was conducted in Ohio. The mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater than the 95th percentile (OR, 3.5 [95% CI, 1.58.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.06.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5C) during surgery (OR, 0.4 [95% CI, 0.20.9]).8

A prospective study on Nosocomial Infections in Pediatric Patients was conducted in Europe. The documented the overall incidence of NI was 2.5%, ranging from 1% in general pediatric units to 23.6% in PICUs. Bacteria were responsible for 68%, Candida for 9%, and viruses for 22% of cases. The proportion of lower respiratory tract infections was 13% in general pediatric units and 53% in PICUs. Bloodstream infections were most frequent in neonatal units (71% of NIs) and were associated with a central venous catheter in 66% of cases. 11% of NI were urinary tract infections. Gastrointestinal infections were most commonly viral and accounted

for 76% of NIs in general pediatric units. Viruses were the main pathogens in general pediatrics units. Catheter related sepsis and CNS were frequent in newborns.9

In the hospital there are many potential sources of infection, including patients, personnel, visitors, equipments, and linen. The patient may become infected with organisms from either the external environment or as is often seen in the severely immunocompromised host from there own internal organisms. Most of the causative organisms are present in the external environment of the patient and are introduced into the body through direct contact or by contact with contaminated materials. In many instances nosocomial infections could be prevented by practicing strict aseptic technique when giving care to the patents. Predominantly, it is on the hand of hospital staff as good hand hygiene could help reduce the economic burden and present distress caused by HAI, but there is evidence that it is infrequently and poorly performed by nurses.5
10

A study was conducted to investigate a nosocomial and community outbreak of hepatitis B to establish how the infections might have occurred in India. The risk factor associated with it was failure of infection control in operation theaters. The study concluded that patients admitted to hospital following invasive medical procedures in high-prevalence countries should be nursed with stringent infection control measures until blood borne viral infections can be excluded.11
11

B) Studies related to knowledge of hospital-acquired infections among nurses:

A study was conducted the impact of universal precautions training programs on preclinical physician assistant studentss knowledge, attitudes, and behavior. Students (n = 170) completed pre- and posttraining questionnaires to assess universal precautions knowledge and to evaluate attitudes about their perceived risk for bloodborne pathogen infection, the importance of universal precautions procedures, Phlebotomy, intravenous catheter insertion, and arterial blood gas sampling

techniques were demonstrated, practiced, and evaluated during practical training sessions.. Universal precautions knowledge scores increased significantly after training (P < 0.0001). Observed compliance with universal precautions procedures during practical training ranged from 95 to 99% for glove use, 76 to 77% for direct sharps disposal without needle recapping, and 56 to 78% for hand washing after glove removal during phlebotomy and intravenous catheter insertion. The study concludes that the program is effective in increasing students knowledge of universal precautions. 12

A study was conducted to assess the knowledge, attitudes and practices among the different health care workers on nosocomial infections. A total of 150 health care workers i.e 50 doctors, 50 nurses and 50 ward aids were included and interventions in the form of an education module designed to suit the need of each of these categories. The study showed an increase in the number of subjects in each category scoring good after the intervention, however this declined with the progress of the time . The study proved that there is a need to develop a system of continuous education for all categories of staff in order to reduce the incidence of nosocomial infections. 9
13

A study was conducted to identify knowledge deficit concerning nosocomial pneumonia(NP) among critical care nurses in eastern Rajasthan States. The study revealed that, several important deficits in nosocomial pneumonia knowledge were identified indicating a need for critical care nurses to have greater exposure to nosocomial pneumonia prevention education, guidelines, and research. 15
14

A study was conducted on the efficacy of infection surveillance and control programs in preventing nosocomial infections. In a representative sample of US general hospitals. Essential components of effective programs included conducting organized surveillance and control activities and having a trained, effectual infection control physician, an infection control nurse per 250 beds. Programs with these components reduced their hospitals' infection rates by 32%.The establishment of intensive infection surveillance and control programs was strongly associated with

reductions in rates of nosocomial urinary tract infection, surgical wound infection, pneumonia, and bacteremia.15 A survey was conducted to assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs) on NICU HCWs (N = 215). 92% knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. 95% knew when to change gloves. 31% knew the recommended duration for hand washing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and hand washing (99%) prevent nosocomial infection (NI). Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixtyone percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails. The study concludes that HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.16

6.3 STATEMENT OF THE PROBLEM: A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING CENTER OF RAICHUR, KARNATAKA 6.4 OBJECTIVES OF THE STUDY: 1. To assess the knowledge of junior health assistant female student on nosocomial infections of under five as pretest scores.

2. To determine the effectiveness of structured teaching program among junior health assistant female student with pre and post test scores. 3. To explore the association with the knowledge scores and selected demographic variables.

6.5 OPERATIONAL DEFINITIONS: Effectiveness: Refers to difference in knowledge scores on nosocomial infections of under fives children of posttest scores from pretest scores. Structured teaching programme: Refers to a teaching learning aid on which systematic organized information regarding risk fact ors, prevention and control measures of nosocomial infections of under five children among junior health assistant female student will be provided. Nosocomial infections: Refers to the infection developing among under five children after admission to the hospital, which was neither present nor in the incubation period at the time of hospitalization. Selected Nosocomial infections: Refers to the blood stream infection, urinary tract infection, respiratory tract infection and surgical wound infections. Under fives children: Refers to children under/below five years of age admitted in hospital. Junior health assistant female student: Refers to auxiliary nurse midwife students.

6.6 HYPOTHESIS:H1 : There will be significant difference in the post test knowledge scores with that of

pre test knowledge scores among junior health assistant female student on nosocomial infections of under five children. H2: There will be significant association between knowledge scores and selected demographic variables.

6.7 LIMITATION:

The study is delimited to knowledge of nosocomial infections of under five children among junior health assistant female student in selected junior health assistant training centre, Raichur. 6.8 PROJECTED OUTCOME: 1. 2. recovery. 7. MATERIAL AND METHODS 7.1 SOURCES OF DATA DESIGN :The research approach adopted for the study is one group pre and post test experimental design SETTING OF THE STUDY:The present sstudy will be conducted in a junior health assistant female training center.the junior health assistant female training center of raichur has been selected purposively for the present study,which is functioning under government of karnataka The junior health assistant female training center of raichur was established in 1963.it is situated in raichur institute of medical sciences compound, LAL BAHADDUR SHASTRI nagar of raichur POPULATION:population included in the study is students,who are studying in junior health assistant female training center raichur SAMPLE; sample for the study consists of 60 junior health assistat female students who are studying in junior health assistant female training center raichur SAMPLING TECHINIQUE: random sampling method with lottery method 7.2 METHODS OF DATA COLLECTION SAMPLE CRITERIA The study will enhance the knowledge of the junior health assistant The study would equip junior health assistant female student to female student on nosocomial infections of under five children. practice with utmost care resulting in prevention of infection and hastens

INCLUSION CRITERIA

a) Junior health assistant female students only. b) Who can read and write English and Kannada c) Who is present during data collection

EXCLUSION CRITERIA

a) Students who are not willing to participate in the study.

VARIABLES INDEPENDENT VARIABLE Structured teaching programme

DEPENDENT VARIABLE

Knowledge on nosocomial infection and its prevention on under five children

TOOLS FOR THE RESEARCH The tool used for the study is knowledge questionnaire. Section A - Socio-demographic questions will be used to collect data. Section B - Structured knowledge questionnaire will be developed by researcher to assess knowledge infections regarding among selected five nosocomial children. COLLECTION OF THE DATA A prior permission will be taken from the concerned authorities of the training centre. Informed consent from the junior health assistant female student will be taken after explaining the purpose and objectives of the study. Data will be collected by the using Structured knowledge questionnaire on knowledge of nosocomial infections as pretest. Subsequently, under

Structured teaching programme will be given to respondents on the same day. On 7th day, after providing STP posttest will be administered using same tool. Proposed duration of the study will be 30 days. 7.3 METHODS OF DATA ANALYSIS AND INTERPRETATION: The investigators use data analysis in the terms of objective using descriptive statistical methods and inferential statistics.

The plan of the data analysis will be as 1. Assessing effectiveness of structured teaching programme among junior health assistant female student will be interpreted by descriptive statistics such as mean. 2. Association of the effectiveness of STP with selected demographic Variables by chi (2) square. The investigator will represent the analyzed data in the forms of tables diagrams, and graphs. 3. The pre-test, post test-knowledge scores will be expressed on mean + or standard deviation by using tables. 4. At test will be computed to determine the significant difference between mean post-test and mean pre-test knowledge scores of the junior health assistant female on nosocomial infections of under five children

7.4 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTRVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALES, IF SO PLEASE DESCRIBE BRIEFLY. Yes, the study will be conducted on students.

7.5 HAS ETHICAL CLERANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Yes, informed consent will be obtained from the institution, authorities and subjects. Privacy and confidentiality and anonymity will be maintained with honesty and impartially

8. LIST OF REFERENCES: 1. Smita Mitra. Regional Workshop on Initiatives Towards Making Health Care Published in Outlook Publishing (India) Private Limited, 30/04/2004 http://toxicslink.org/event-preview.php?eventnum=288. 2. Rakesh Lodha, Uma Chandra, Mouli Natchu, Mrinal Nanda and S. K. Kabra. Nosocomial infections in pediatric intensive care units. Indian Journal of Pediatrics.2007:oct; 68(11):1063-1070. 3. Payman Salamati, Ali Akbar Rahbarimanesh, Masood Yunesian and Mohsen Naseri. Neonatal Nosocomial Infections in Bahrami Children Hospital. Indian Journal of Pediatrics, 2006 march; 73;197-200. 4. Chawla R . Epidemiology, etiology and diagnosis of hospital acquired pneumonia and ventilator associated pneumonia in Asian countries. J Infect Control , 2008 May ; 36 (4 Supply) : S93-100. 5. 6. Sile A. Creedon. Health Care Workers Hand Decontamination Practices. Clinical Nursing Research. 2006; 15(1): 6-26.

7.

Nevin Kuzu, Fadime zer, Semra Aydemir, Ata Nevzat Yalcin, Mehmet Zencir. Compliance with Hand Hygiene and Glove Use. Infect Control Hosp Epidemiol 2002;23:S3S40.

8.

9. Josette Raymond, Yannick Aujard, Nosocomial Infections in Pediatric Patients. 10. Purohit A, Verma G, Kalla S. Critical care nurses knowledge in preventing nosocomial pneumonia. J infect control 1998; 12:697. available at http://gateway.nlm.nih.gov/Meeting. 11. Long Barbara C, Phipps Wilma J, Casseyer Virginial. Medical- Surgical Nursing A Nursing Process Approach.3rd ed. Mosby publication 1993. p.349350. 12. Diekema D J, Schuldt S S, Albanese M A, Doebbeling B N. Universal Precautions Training of Preclinical Students: Impact on Knowledge, Attitudes, and Compliance. American Health Foundation and Academic Press.2002 May. 13. Harling R, Jurbitt D, Millar M. Passage from India: an outbreak of hepatitis B linked to a patient who acquired infection from health care overseas; Public Health. 2007 oct; 121(10);734-41. 14. J B Suchitra. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections.2007. available from http:// www.ijmm.org/article.asp.

CENTER OF RAICHUR, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

JINSON MATHEW

NAVODAYA COLLEGE OF NURSING RAICHUR, MAY 2009

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. Name of the candidate : Mr. JINSON MATHEW M.Sc. Nursing, 1st Year Navodaya College of Nursing Navodaya Nagar

Manthralayam Road, Raichur 2. Name of the Institute 3. Course of Study and Subject : Navodaya College of Nursing : M.Sc. Nursing, 1st Year Child Health Nursing 4. Date of Admission 5. Title of the Topic : :

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING CENTER OF RAICHUR, KARNATAKA.

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 NEED FOR THE STUDY:

Tomorrow is just an idea ,but today is happening right now

MAHATHMA GANDHI The world over, approximately 88,000 people will die with these nosocomial infections. These infections affect more than 1.4 million patients in a year and the rates have been rising steadily. With possibly the most stringent infection

control in the world, only 5% of hospitalized patients in the USA suffer nosocomial diseases.1 Conservative WHO estimates put the figure for India at 10% -- one in every 10 patients will boomerang back to his hospital bed and endure additional medical costs and hospital stay. This is a common enough occurrence in understaffed or badlyfunded healthcare facilities across India. Bloodstream infections from intubation and infusion procedures like drips contribute 30%, while another 20% are surgical site wounds turning septic courtesy air-borne pathogens or non-sterile dressings. 1 Nosocomial infections in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 68%. The common nosocomial infections in PICU are bloodstream infections (2030% of all infections), lower respiratory tract infections (2035%), and urinary tract infections (1520%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Nosocomial pneumonias predominantly occur in mechanically ventilated children. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; hand washing, judicious use of interventions and proper asepsis during procedures remain the most important practices.2 A study was conducted on Neonatal Nosocomial Infections in Bahrami Children Hospital. Neonatal nosocomial infections have been reviewed in Bahrami Children Hospital from fall of 1999 through fall of 2004. The result was Fifty-two patients had been diagnosed having nosocomial infections. NICU (Neonatal Intensive Care Unit) showed the highest portion of infections (40%) followed by neonatal surgery ward (35%) and neonates ward (25%). Frequencies of nosocomial infection by site were as follows: eyes (27%), septicemia, surgical wounds and location of drain

or catheter (each one 21%), CSF (7%) and urinary (2%). Total number of hospitalized patients was 5990 and total number of hospitalized days was 39,095 in the five years. Infections per 100 hospital discharges and 100 hospital days by service were as follows, respectively: NICU (2.9, 0.26), neonatal surgery (1.7, 0.18) and neonates (0.3, 0.06). The differences were significantly meaningful (p value<0.001). These findings provide useful information for future surveillance in association with prevention programs. Subsequently, surveillance should be focused on high-risk patients in intensive care unit and/or who have undergone surgery and invasive procedures. 3 A study on incidence and impact of nosocomial infections conducted in hospitals in Delhi and Mumbai reported figures as high as 30% and their incidence have found their etiology from lack of hospital hygiene , human transmissions, surgical and other invasive interventions. A major problem faced is that organisms present in the hospital environment are usually more virulent and even more importantly resistant to most antibiotics. assuming the national average for nosocomial infections in India, the study concluded that Indian health care is facing an enormous challenge in terms of the need to prevent and control these infections 6 Another study was conducted to assess the incidence of HAI, specially Ventilator Associated Pneumonia (VAP) and Hospital Acquired Pneumonia (HAP) in 10Asian countries and was found that the incidence and prevalence of HAP and VAP are higher in Asian countries than in western countries.7 4

A study was conducted on Health Care Workers Hand Decontamination Practices. The primary purpose of this quasi-experimental research was to observe health care workers compliance with hand-hygiene guidelines during patient care in an intensive care unit before (pretest) and after (posttest) implementation of a multifaceted hand-hygiene program. Health care workers attitudes, beliefs, and knowledge in relation to compliance with hand washing guidelines were also investigated. A convenience sample of nurses, doctors, physiotherapists, and care assistants (n = 73 observational participants, n = 62 questionnaire respondents) was

used. Data (N = 314 observations, 62 questionnaires) were analyzed descriptively and cross-tabulated using chi-square (Pearsons) and Mann-Whitney statistical tests. Results revealed that a significant shift (32%) occurred in health care workers compliance with hand washing guidelines (pretest 51%, posttest 83%, p < .001) following the interventional hand-hygiene program. Significant changes were also found in relation to health care workers attitudes, beliefs, and knowledge (p < .05).5

A study was conducted on Controlling Nosocomial Infections Program. The infection control data collected and analyzed include surgical site infections, catheter-related bloodstream infections, urinary tract infections and ventilatorassociated infections. The analysis involves comparing the data with the national and international benchmarks. The isolated microorganisms in the clinical specimens and their antibiogram are discussed to assess the trends and prevalence of antibiotic resistance and emergence of multidrug resistant bug. The measures taken after analysis help in taking corrective actions to reduce the average length of stay of patients and associated morbidity and mortality. The infection control programme has helped to preempt any outbreaks in the high dependency areas of the hospital. It has also reduced the overall stay of the patient in hospital as evinced by a decreasing Average Length of Stay (ALOS), there by decreasing cost of treatment to the patient and a faster turnover for the hospital a win win situation for all. 6

A study was conducted to examine compliance with hand washing and glove use among health workers. Nine nurses and 33 assistant physicians were monitored during the study. One researcher recorded 1,400 potential opportunities for hand washing during 15minute observation periods. Most healthcare workers (99.3%) used liquid soap during hand washing, but 79.8% did not dry their hands. For all indications, compliance with hand washing was 31.9% and compliance with glove use was 58.8%. Compliance with hand washing was better in dirty high risk situations. The study concludes that compliance with hand washing was low, suggesting the need

for new motivational strategies such as supplying feedback regarding compliance rates.7

In the light of above and investigators experience working in the neonatal and pediatric intensive care units observed many children with nosocomial infection during their hospital stay. With the increased use of invasive procedures the risk of HAIs is also increasing. Moreover, the high frequency of nosocomial infection places a substantial burden on individual patients and on the health care system and as a result, there is increased morbidity, including delayed wound healing, increased exposure to antimicrobial therapy and its potential adverse effects, and prolonged hospitalization, failure to thrive. To minimize the risk of infection, nursing personnel should have adequate knowledge regarding nosocomial infections following admission and appropriate practice to control these infections. Investigator found that the nursing knowledge and practice in this area have remained inadequate. Therefore the investigator felt the need to educate junior health assistants female students before they are exposed into the clinical conditions to create awareness among them related to risk factors, affects, prevention and control of nosocomial infections. 6.2 REVIEW OF LITERATURE : Review of literature is to ascertain what is already known In relation to a problem of interest, to develop a broad conceptual context in to which ,a problem will fit. It helps to know methodology and research tools, especially research strategies and specific procedures measuring instruments and statistical analysis that might be productive pursuing in the research problem and interpreting the result of the study. A) Studies related to risk factors of nosocomial infections among under five children . A retrospective case control study on Risk Factors Associated with Surgical Site Infection after Pediatric Posterior Spinal Fusion Procedure was conducted in Ohio. The mean annual rate of SSI after posterior spinal fusion procedure was 4.4% (range, 1.1%6.7%). Significant risk factors associated with SSI in the univariate analysis included the following: a body mass index (BMI) greater

than the 95th percentile (OR, 3.5 [95% CI, 1.58.3]); antibiotic prophylaxis with clindamycin, compared with other antibiotics (OR, 3.5 [95% CI, 1.2 10.0]); inappropriately low dose of antibiotic (OR, 2.6 [95% CI, 1.06.6]); and a longer duration of hypothermia (ie, a core body temperature of less than 35.5C) during surgery (OR, 0.4 [95% CI, 0.20.9]).8

A prospective study on Nosocomial Infections in Pediatric Patients was conducted in Europe. The documented the overall incidence of NI was 2.5%, ranging from 1% in general pediatric units to 23.6% in PICUs. Bacteria were responsible for 68%, Candida for 9%, and viruses for 22% of cases. The proportion of lower respiratory tract infections was 13% in general pediatric units and 53% in PICUs. Bloodstream infections were most frequent in neonatal units (71% of NIs) and were associated with a central venous catheter in 66% of cases. 11% of NI were urinary tract infections. Gastrointestinal infections were most commonly viral and accounted for 76% of NIs in general pediatric units. Viruses were the main pathogens in general pediatrics units. Catheter related sepsis and CNS were frequent in newborns.9

In the hospital there are many potential sources of infection, including patients, personnel, visitors, equipments, and linen. The patient may become infected with organisms from either the external environment or as is often seen in the severely immunocompromised host from there own internal organisms. Most of the causative organisms are present in the external environment of the patient and are introduced into the body through direct contact or by contact with contaminated materials. In many instances nosocomial infections could be prevented by practicing strict aseptic technique when giving care to the patents. Predominantly, it is on the hand of hospital staff as good hand hygiene could help reduce the economic burden and present distress caused by HAI, but there is evidence that it is infrequently and poorly performed by nurses.5
10

A study was conducted to investigate a nosocomial and community outbreak of hepatitis B to establish how the infections might have occurred in India. The risk

factor associated with it was failure of infection control in operation theaters. The study concluded that patients admitted to hospital following invasive medical procedures in high-prevalence countries should be nursed with stringent infection control measures until blood borne viral infections can be excluded.11
11

B) Studies related to knowledge of hospital-acquired infections among nurses:

A study was conducted the impact of universal precautions training programs on preclinical physician assistant studentss knowledge, attitudes, and behavior. Students (n = 170) completed pre- and posttraining questionnaires to assess universal precautions knowledge and to evaluate attitudes about their perceived risk for bloodborne pathogen infection, the importance of universal precautions procedures, Phlebotomy, intravenous catheter insertion, and arterial blood gas sampling techniques were demonstrated, practiced, and evaluated during practical training sessions.. Universal precautions knowledge scores increased significantly after training (P < 0.0001). Observed compliance with universal precautions procedures during practical training ranged from 95 to 99% for glove use, 76 to 77% for direct sharps disposal without needle recapping, and 56 to 78% for hand washing after glove removal during phlebotomy and intravenous catheter insertion. The study concludes that the program is effective in increasing students knowledge of universal precautions. 12

A study was conducted to assess the knowledge, attitudes and practices among the different health care workers on nosocomial infections. A total of 150 health care workers i.e 50 doctors, 50 nurses and 50 ward aids were included and interventions in the form of an education module designed to suit the need of each of these categories. The study showed an increase in the number of subjects in each category scoring good after the intervention, however this declined with the progress of the time . The study proved that there is a need to develop a system of continuous education for all categories of staff in order to reduce the incidence of nosocomial infections. 9
13

A study was conducted to identify knowledge deficit concerning nosocomial pneumonia(NP) among critical care nurses in eastern Rajasthan States. The study revealed that, several important deficits in nosocomial pneumonia knowledge were identified indicating a need for critical care nurses to have greater exposure to nosocomial pneumonia prevention education, guidelines, and research. 15
14

A study was conducted on the efficacy of infection surveillance and control programs in preventing nosocomial infections. In a representative sample of US general hospitals. Essential components of effective programs included conducting organized surveillance and control activities and having a trained, effectual infection control physician, an infection control nurse per 250 beds. Programs with these components reduced their hospitals' infection rates by 32%.The establishment of intensive infection surveillance and control programs was strongly associated with reductions in rates of nosocomial urinary tract infection, surgical wound infection, pneumonia, and bacteremia.15 A survey was conducted to assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs) on NICU HCWs (N = 215). 92% knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. 95% knew when to change gloves. 31% knew the recommended duration for hand washing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and hand washing (99%) prevent nosocomial infection (NI). Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixtyone percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails. The study concludes that HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.16

6.3 STATEMENT OF THE PROBLEM: A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON KNOWLEDGE OF NOSOCOMOIAL INFECTION AND ITS PREVENTION ON UNDER-FIVE CHILDREN AMONG JUNIOUR HEALTH ASSISTANT FEMALE STUDENTS STUDYING IN SELECTED JUNIOUR HEALTH ASSISTANT TRAINING CENTER OF RAICHUR, KARNATAKA 6.4 OBJECTIVES OF THE STUDY: 4. To assess the knowledge of junior health assistant female student on nosocomial infections of under five as pretest scores. 5. To determine the effectiveness of structured teaching program among junior health assistant female student with pre and post test scores. 6. To explore the association with the knowledge scores and selected demographic variables.

6.5 OPERATIONAL DEFINITIONS: Effectiveness: Refers to difference in knowledge scores on nosocomial infections of under fives children of posttest scores from pretest scores. Structured teaching programme: Refers to a teaching learning aid on which systematic organized information regarding risk fact ors, prevention and control measures of nosocomial infections of under five children among junior health assistant female student will be provided. Nosocomial infections: Refers to the infection developing among under five children after admission to the hospital, which was neither present nor in the incubation period at the time of hospitalization.

Selected Nosocomial infections: Refers to the blood stream infection, urinary tract infection, respiratory tract infection and surgical wound infections. Under fives children: Refers to children under/below five years of age admitted in hospital. Junior health assistant female student: Refers to auxiliary nurse midwife students.

6.6 HYPOTHESIS:H1 : There will be significant difference in the post test knowledge scores with that of

pre test knowledge scores among junior health assistant female student on nosocomial infections of under five children. H2: There will be significant association between knowledge scores and selected demographic variables.

6.7 LIMITATION: The study is delimited to knowledge of nosocomial infections of under five children among junior health assistant female student in selected junior health assistant training centre, Raichur. 6.8 PROJECTED OUTCOME: 3. 4. recovery. 7. MATERIAL AND METHODS 7.1 SOURCES OF DATA DESIGN :The research approach adopted for the study is one group pre and post test experimental design SETTING OF THE STUDY:The present sstudy will be conducted in a junior health assistant female training center.the junior health assistant female training center of raichur has been selected purposively for the present study,which is functioning under government of karnataka The study will enhance the knowledge of the junior health assistant The study would equip junior health assistant female student to female student on nosocomial infections of under five children. practice with utmost care resulting in prevention of infection and hastens

The junior health assistant female training center of raichur was established in 1963.it is situated in raichur institute of medical sciences compound, LAL BAHADDUR SHASTRI nagar of raichur POPULATION:population included in the study is students,who are studying in junior health assistant female training center raichur SAMPLE; sample for the study consists of 60 junior health assistat female students who are studying in junior health assistant female training center raichur SAMPLING TECHINIQUE: random sampling method with lottery method 7.2 METHODS OF DATA COLLECTION SAMPLE CRITERIA INCLUSION CRITERIA a) Junior health assistant female students only. b) Who can read and write English and Kannada c) Who is present during data collection EXCLUSION CRITERIA a) Students who are not willing to participate in the study. VARIABLES INDEPENDENT VARIABLE Structured teaching programme

DEPENDENT VARIABLE

Knowledge on nosocomial infection and its prevention on under five children

TOOLS FOR THE RESEARCH The tool used for the study is knowledge questionnaire. Section A - Socio-demographic questions will be used to collect data.

Section B - Structured knowledge questionnaire will be developed by researcher to assess knowledge infections regarding among selected five nosocomial children. COLLECTION OF THE DATA A prior permission will be taken from the concerned authorities of the training centre. Informed consent from the junior health assistant female student will be taken after explaining the purpose and objectives of the study. Data will be collected by the using Structured knowledge questionnaire on knowledge of nosocomial infections as pretest. Subsequently, Structured teaching programme will be given to respondents on the same day. On 7th day, after providing STP posttest will be administered using same tool. Proposed duration of the study will be 30 days. 7.3 METHODS OF DATA ANALYSIS AND INTERPRETATION: The investigators use data analysis in the terms of objective using descriptive statistical methods and inferential statistics. under

The plan of the data analysis will be as 1. Assessing effectiveness of structured teaching programme among junior health assistant female student will be interpreted by descriptive statistics such as mean. 2. Association of the effectiveness of STP with selected demographic Variables by chi

(2) square. The investigator will represent the analyzed data in the forms of tables diagrams, and graphs. 3. The pre-test, post test-knowledge scores will be expressed on mean + or standard deviation by using tables. 4. At test will be computed to determine the significant difference between mean post-test and mean pre-test knowledge scores of the junior health assistant female on nosocomial infections of under five children

7.4 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTRVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALES, IF SO PLEASE DESCRIBE BRIEFLY. Yes, the study will be conducted on students.

7.5 HAS ETHICAL CLERANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Yes, informed consent will be obtained from the institution, authorities and subjects. Privacy and confidentiality and anonymity will be maintained with honesty and impartially

8. LIST OF REFERENCES:

15. Smita Mitra. Regional Workshop on Initiatives Towards Making Health Care Published in Outlook Publishing (India) Private Limited, 30/04/2004 http://toxicslink.org/event-preview.php?eventnum=288. 16. Rakesh Lodha, Uma Chandra, Mouli Natchu, Mrinal Nanda and S. K. Kabra. Nosocomial infections in pediatric intensive care units. Indian Journal of Pediatrics.2007:oct; 68(11):1063-1070. 17. Payman Salamati, Ali Akbar Rahbarimanesh, Masood Yunesian and Mohsen Naseri. Neonatal Nosocomial Infections in Bahrami Children Hospital. Indian Journal of Pediatrics, 2006 march; 73;197-200. 18. Chawla R . Epidemiology, etiology and diagnosis of hospital acquired pneumonia and ventilator associated pneumonia in Asian countries. J Infect Control , 2008 May ; 36 (4 Supply) : S93-100. 19. Sile A. Creedon. Health Care Workers Hand Decontamination Practices. Clinical Nursing Research. 2006; 15(1): 6-26. 20. 21. Nevin Kuzu, Fadime zer, Semra Aydemir, Ata Nevzat Yalcin, Mehmet Zencir. Compliance with Hand Hygiene and Glove Use. Infect Control Hosp Epidemiol 2002;23:S3S40.
22.

23. Josette Raymond, Yannick Aujard, Nosocomial Infections in Pediatric Patients. 24. Purohit A, Verma G, Kalla S. Critical care nurses knowledge in preventing nosocomial pneumonia. J infect control 1998; 12:697. available at http://gateway.nlm.nih.gov/Meeting. 25. Long Barbara C, Phipps Wilma J, Casseyer Virginial. Medical- Surgical Nursing A Nursing Process Approach.3rd ed. Mosby publication 1993. p.349350. 26. Diekema D J, Schuldt S S, Albanese M A, Doebbeling B N. Universal Precautions Training of Preclinical Students: Impact on Knowledge, Attitudes, and Compliance. American Health Foundation and Academic Press.2002 May. 27. Harling R, Jurbitt D, Millar M. Passage from India: an outbreak of hepatitis B linked to a patient who acquired infection from health care overseas; Public Health. 2007 oct; 121(10);734-41.

28. J B Suchitra. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections.2007. available from http:// www.ijmm.org/article.asp.

9. Signature of the Candidate 10. Remarks of the Guide 11. Name and Designation of 11.1 Guide :

: : :

Mrs. Shameem.G.U Associate Professor

Navodaya college of Nursing Raichur 11.2 Signature 11.3 Co-Guide 11.4 Signature : : : Mrs. Shameem.G.U Associate Professor Navodaya college of Nursing Raichur 11.5 Head of the Department 11.6 Signature : :