A STUDY TO EVALUATE THE EFFECTIVENESS OF

PLANNED TEACHING PROGRAMME ON

KNOWLEDGE OF NEONATAL MOTHERS

REGARDING NEONATAL TETANUS AT SELECTED

HOSPITALS, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT

FOR

DISSERTATION

MR. ANZAR RAZAC

1ST YEAR M.Sc. NURSING

PEDIATRIC NURSING

YEAR 2010-2012

HARSHA COLLEGE OF NURSING

HARSHA HOSPITAL CAMPUS

193/4, SONDEKOPPA CIRCLE

NH-4, NELAMANGALA,

BANGALORE-562123

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION

NAME OF THE CANDIDATE AND ADDRESS

MR. ANZAR RAZAC1ST YEAR M.SC.NURSINGHARSHA COLLEGE OF NURSING HARSHA HOSPITAL CAMPUS193/4, SONDEKOPPA CIRCLENH-4, NELAMANGALA,BANGALORE-562123

NAME OF THEINSTITUTION

Harsha College of NursingBangalore

COURSE OF THE STUDY AND SUBJECT

1 year M.sc.NursingPediatric Nursing.

DATE OF ADMISSION 23/04/10

TITLE OF THE STUDY

To evaluate the effectiveness of structured

teaching programme on knowledge of

neonatal mothers regarding neonatal

tetanus.

2

6. BRIEF RESUME OF INTENDED WORK:

INTRODUCTION

A baby is a blank cheque made payable to the human race.

~Barbara Christine Seifert

Healthy children are the greatest resources and pride of a nation. They

are precious and special in the lives of the parents. Children ought to be healthy

and happy to become productive and contented adults of the future. To give

them happy and healthy childhood, we must safeguard their total health right

from the beginning.

Neonatal tetatnus or "tetatnus neonatorum" is a tetanus infection of the

newborn baby. The infection is usually caught from another infected person

(e.g. unvaccinated mother) and enters the body through a wound such as the

umbilical stump or the circumcised region.

Tetanus is a medical condition characterized by a prolonged contraction of

skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a

neurotoxin produced by the Gram-positive, obligate anaerobic bacterium

Clostridium tetani. Infection generally occurs through wound contamination

and often involves a cut or deep puncture wound. As the infection progresses,

muscle spasms develop in the jaw (thus the name "lockjaw") and elsewhere in

the body. Infection can be prevented by proper immunization and by post-

exposure prophylaxis.

Tetanus begins when spores of Clostridium tetani enter damaged tissue. The

spores transform into rod-shaped bacteria and produce the neurotoxin

tetanospasmin (also known as tetanus toxin). This toxin is inactive inside the

bacteria, but when the bacteria die, toxin is released and activated by proteases.

Active tetanospasmin is carried by retrograde axonal transport to the spinal

3

cord and brain stem where it binds irreversibly to receptors at these sites. It

cleaves membrane proteins involved in neuroexocytosis, which in turn blocks

neurotransmission. Ultimately, this produces the symptoms of the disease.

Damaged upper motor neurons can no longer inhibit lower motor neurons (see

Renshaw cells), plus they cannot control reflex responses to afferent sensory

stimuli. Both mechanisms produce the hallmark muscle rigidity and spasms.

Similarly, a lack of neural control of the adrenal glands results in release of

catecholamines, thus producing a hypersympathetic state and widespread

autonomic instability. 1

Tetanus affects skeletal muscle, a type of striated muscle used in voluntary

movement. The other type of striated muscle, cardiac or heart muscle, cannot

be tetanized because of its intrinsic electrical properties. Mortality rates

reported vary from 48% to 73%. In recent years, approximately 11% of

reported tetanus cases have been fatal. The highest mortality rates are in

unvaccinated people and people over 60 years of age. 2

The incubation period of tetanus may be up to several months but is usually

about 8 days. In general, the further the injury site is from the central nervous

system, the longer the incubation period. The shorter the incubation period, the

more severe the symptoms. In neonatal tetanus, symptoms usually appear from

4 to 14 days after birth, averaging about 7 days. On the basis of clinical

findings, four different forms of tetanus have been described.

Tetanus was well known to ancient people who recognized the relationship

between wounds and fatal muscle spasms. The word "tetanus" is derived from

the Greek τέτανος tetanos meaning "taut", and τείνειν teinein to "stretch". In

1884, Arthur Nicolaier isolated the strychnine-like toxin of tetanus from free-

living, anaerobic soil bacteria. The etiology of the disease was further

elucidated in 1884 by Antonio Carle and Giorgio Rattone, who demonstrated

the transmissibility of tetanus for the first time. They produced tetanus in

rabbits by injecting pus from a patient with fatal tetanus into their sciatic

4

nerves. In 1889, C. tetani was isolated from a human victim by Kitasato

Shibasaburō, who later showed that the organism could produce disease when

injected into animals, and that the toxin could be neutralized by specific

antibodies. In 1897, Edmond Nocard showed that tetanus antitoxin induced

passive immunity in humans, and could be used for prophylaxis and treatment.

Tetanus toxoid vaccine was developed by P. Descombey in 1924, and was

widely used to prevent tetanus induced by battle wounds during World War II. 3

5

6.1 NEED FOR THE STUDY:

Neonatal tetanus is a form of generalized tetanus that occurs in newborns.

Infants who have not acquired passive immunity because the mother has never

been immunized are at risk. It usually occurs through infection of the unhealed

umbilical stump, particularly when the stump is cut with a non-sterile

instrument. Neonatal tetanus is common in many developing countries and is

responsible for about 14% (215,000) of all neonatal deaths, but is very rare in

developed countries.

India is the home to the largest child population in the world. “The

development of children is the first priority on the country’s development

agenda, not because they are the most vulnerable, but because they are our

supreme assets and also the future human resources of the country”. In these

words, our Tenth Five Year Plan (2002-07) underlines the fact that the future of

India lies in the future of Indian children. 4

Tetanus is an international health problem, as C. tetani spores are ubiquitous.

The disease occurs almost exclusively in persons who are unvaccinated or

inadequately immunized. Tetanus occurs worldwide but is more common in

hot, damp climates with soil rich in organic matter. This is particularly true

with manure-treated soils, as the spores are widely distributed in the intestines

and feces of many non-human animals such as horses, sheep, cattle, dogs, cats,

rats, guinea pigs, and chickens. Spores can be introduced into the body through

puncture wounds. In agricultural areas, a significant number of human adults

may harbor the organism. The spores can also be found on skin surfaces and in

contaminated heroin. Heroin users, particularly those that inject the drug,

appear to be at high risk for tetanus.

Tetanus – particularly the neonatal form – remains a significant public health

problem in non-industrialized countries. The World Health Organization

estimates that 59,000 newborns worldwide died in 2008 as a result of neonatal

tetanus. In the United States, 50-100 people become infected with tetanus each

6

year. Nearly all of the cases in the United States occur in unimmunized

individuals or individuals who have allowed their inoculations to lapse.Tetanus

is the only vaccine-preventable disease that is infectious but is not contagious. 5

shows that in the period of 1978 to the end of 1985--before the implementation

of EPI .the neonatal tetanus morbidity rate underwent a natural decline

equivalent to 98.5 percent. Upon introduction of EPI in late 1985, the natural

rate of decline continued for a brief period to 1987. However by 1988 the

incidence of neonatal tetanus had increased by nearly fivefold over its 1987

rate, and then by 1989 declined to a level still higher than it was in 1986. 6

 

In the US the incidence of tetanus is <0.2 per 1,000,000 people per year. Most

of the 800,000–1,000,000 yearly deaths from tetanus occur in sub-Saharan

Africa.eneralized tetanus is the most common form.eonatal tetanus is rare in

the US but ~150,000 cases occur each year worldwide.

Death statistics for Neonatal tetanus

The following are statistics from various sources about deaths and Neonatal

tetanus:

2 deaths from Neonatal Tetanus in Bolivia 2002 (Regional Core Health

Data Initiative, Pan American Health Organisation, 2008)

3 deaths from Neonatal Tetanus in Colombia 2007 (Regional Core

Health Data Initiative, Pan American Health Organisation, 2008)

5 deaths from Neonatal Tetanus in Haiti 2002 (Regional Core Health

Data Initiative, Pan American Health Organisation, 2008)

9 deaths from Neonatal Tetanus in Mexico 2007 (Regional Core Health

Data Initiative, Pan American Health Organisation, 2008)

3 deaths from Neonatal Tetanus in Venezuela 2007 (Regional Core

Health Data Initiative, Pan American Health Organisation, 2008) 7

7

A study was conducted on 3.6 million neonatal deaths-what is progressing and

what is not it shows that Each year 3.6 million infants are estimated to die in

the first 4 weeks of life (neonatal period)-but the majority continue to die at

home, uncounted. This article reviews progress for newborn health globally,

with a focus on the countries in which most deaths occur-what data do we have

to guide accelerated efforts. All regions are advancing, but the level of decrease

in neonatal mortality differs by region, country, and within countries. Progress

also differs by the main causes of neonatal death. Three major causes of

neonatal deaths (infections, complications of preterm birth, and intrapartum-

related neonatal deaths or "birth asphyxia") account for more than 80% of all

neonatal deaths globally. The most rapid reductions have been made in

reducing neonatal tetanus, and there has been apparent progress towards

reducing neonatal infections. Limited, if any, reduction has been made in

reducing global deaths from preterm birth and for intrapartum-related neonatal

deaths. 8

A survey was conducted in Poland to know about the incidence of neonatal

tetanus Number of cases of tetanus in Poland remains low. In 2008, 14 cases of

tetanus (10 women and 4 men) were reported in Poland. All those cases were

among people of age 60 or more. 7 deaths were reported. In 12 cases

vaccination status was unknown. In 2 cases patients were unvaccinated. Post

exposure anatoxine was applied only in 3 cases. The data show effectiveness of

vaccination program in younger age groups, but they also show need for

promotion of post exposure prophylaxis, especially among older people both in

rural and in urban areas. No case of neonatal tetanus was noted in Poland since

1984. 9

Hence the investigator felt that these studies help the mothers to enhance

their knowledge regarding neonatal tetanus, if they receive advance and

adequate information to lead a better life.

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6.2 REVIEW OF LITERATURE

A review of literature refers to activities involved in identifying and

searching for information on a topic, developing and understanding the state of

knowledge on a topic. It is an extensive, systematic selection of potential

sources of previous work, which acquaints the investigator with fact finding

work after scrutinization. Polit& Hungle state that review of literature provides

readers with a background for understanding the significant of the study. 10

The review of literature is divided in to following headings

Section A: Review of literature related to general information of neonatal

tetanus.

Section B: Review of literature related to causes of neonatal tetanus.

Section C: Review of literature related to management of neonatal tetanus

Section A: Review of literature related to general information of neonatal

tetanus.

A case report on tetanus epidemiology review and recommendations for

immunization compliance Tetanus is a forgotten disease in the United States

since many practicing primary care physicians have not seen a case of the

disease in their career. A neonate had exhibited the symptoms of tetanus.

Within days, the jaw spasms and subsequent respiratory compromise that

necessitated five weeks of ventilator support revealed the devastation that this

disease can cause. Tetanus spores are found in high concentration in the soils of

rural areas, especially where farm animals have grazed. Populations most at

risk in the U.S. include under- or non-immunized elderly and immigrant

populations. Barriers to immunization include patient and physician non-

compliance, missed opportunity for immunization and concern over vaccine

9

side effects. Targeting high-risk groups will enable primary care physicians to

be more proactive in providing immunization, and thus in preventing

prevention this disease. 11

In US During 2001-2010, 201 cases of neonatal tetanus were reported from 40

states, for an average annual incidence of 0.02 cases per 100,000 population.

Of the 188 patients for whom age was known, 101 (54%) were aged > or = 60

years and 10 (5%) were aged < 20 years. No cases of tetanus were reported.

Among childrens, the risk for tetanus increased with age; the risk for newborn

tetanus han 10 times greater than the risk for persons aged 20-29 years. All

deaths occurred among persons aged > or = 30 years. The case-fatality rate

(overall: 25%) increased with age, from 11% in persons aged 30-49 years to

54% in persons aged > or = 80 years. Only 12% of all patients were reported to

have received a primary series of tetanus toxoid before onset of illness. For

77% of patients, tetanus occurred after an acute injury was sustained. Of

patients who obtained medical care for their injury, only 43% received tetanus

toxoid as part of wound prophylaxis. 12

Section B: Review of literature related to causes of neonatal tetanus.

A community based cross-sectional study was performed. A pre-tested structured

questionnaire was administered to 565 women who had recently delivered.

Information was collected on neonatal morbidity, mortality and practices of women

regarding care during pregnancy, child birth and for newborn, till 28th day of birth.

Although 70% of women mentioned receiving antenatal care by a skilled provider,

only 54.5% had four or more visits. Tetanus toxoid was received by 79% of women

while only 56% delivered at a health care facility by a skilled attendant. Newborn care

practices like bathing the baby immediately after birth (56%), giving pre-lacteals

(79.5%), late initiation of breast feeding (80.3%), application of substances on

umbilical cord (58%) and body massage (89%) were common. Most neonates

(81.1%) received BCG injection and polio drops after birth. Neonatal mortality rate

was 27/1000 live births with the majority of deaths occurring during the first three

days of life mainly due to the neonatal tetanus and jaundice. 13

10

Neonatal tetanus is a severe, often fatal disease caused by the toxin Clostridium

tetani. Neonatal tetanus is a generalized tetanus, which occurs in a neonate

between 3-28 days of life. The findings indicated that tetanus in a newborn of

an unvaccinated mother occurred after the application of non-sterile clay to the

umbilical cord. This case was a seven-day-old male baby with progressive

difficulty in feeding, trismus, hypertonicity, opisthotonos, and heart murmur.

The patient was afebrile and eupneic, and had a history of non-sterile home

delivery. In the past, the area of Bujanovac, Medvedja and Presevo had been

exposed to mass immigration (especially due to the war in the territory of

former Yugoslavia), which caused a serious problem for general practitioners,

who had to be vigilant and ensure that all patients registered in their practice

were fully immunized. This case has provided a clear indication of the

necessity for strategies of both vaccination and ensuring hygienic conditions

throughout pregnancy and delivery to prevent neonatal tetanus. 14

A retrospective study on Risk factors for mortality in neonatal tetanus: a 15-

year experience in Sagamu, Nigeria, : Neonatal tetanus (NNT) is a major cause

of newborn deaths especially in the developing world. While efforts aimed at

eradicating NNT should be sustained, it is equally imperative to reduce death

among affected infants. Therefore, the factors associated with mortality rate in

this condition need to be studied Ninety-six of 151 newborns with NNT died,

giving a mortality rate of 63.6%. The case fatality rate during the study period

varied between 33.3% and 100%. More deaths occurred in the infants with low

birth weight (P=0.004) within 1 day at the onset of symptoms (P<0.001),

whose mothers aged 18 years or less (P=0.001) belonged to socio-economic

class V (P=0.001). Determinants of mortality in these infants with NNT

included low socio-economic class (P=0.002), no antitetanus vaccination

(P=0.006), presentation with spasms (P<0.001), and non-administration of anti-

tetanus serum during treatment (P=0.013). 15

11

Section C: Review of literature related to management of neonatal tetanus

Taiwan Pediatric Association Neonatal tetanus is a rare disease in developed

countries, but remains common in developing countries. Pregnant women

immigrating to Taiwan from developing countries may carry a risk of neonatal

tetanus to the child, because of inadequate tetanus toxoid immunization and

inappropriate postnatal cord care. Many young pediatricians in Taiwan are

unfamiliar with this disease. Herein, we describe the clinical course of a

newborn with neonatal tetanus, who was admitted with complaints of difficult

feeding and muscle rigidity. After mechanical ventilation for 58 days and a

prolonged hospital stay, the infant was discharged in good condition. It is

important to maintain a high index of suspicion for neonatal sepsis when

infants present with seizure-like symptoms, in order to allow its early diagnosis

and appropriate treatment. 16

A study was conducted on Tetanus in developing countries: a case series and

review. Few anesthesiologists have expertise in the diagnosis and treatment of

tetanus, a disease that remains prevalent in developing countries. We report on

a series of four cases of tetanus cases recently encountered in Rwanda. We

review the clinical epidemiology, pathophysiology, diagnosis and the treatment

of tetanus, and provide implications for anesthesiologists and critical care

physicians. These cases highlight the difficulties of diagnosis and management

of complicated diseases in the resource-challenged health care setting of

developing countries. 17

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6.3. STATEMENT OF THE PROBLEM

A Study to Assess the Effectiveness of planned Teaching Programme on

Knowledge of Neonatal Mothers Regarding Neonatal Tetanus at Selected

Hospitals, Bangalore.

6.4 OBJECTIVES

1. To assess the pre test level of knowledge among neonatal mothers on

Neonatal Tetanus.

2. To assess the post test level of knowledge among neonatal mothers on

Neonatal Tetanus.

3. To evaluate the effectiveness of structured teaching programme on Neonatal

Tetanus among neonatal mothers.

4. To associate pre test level of knowledge of neonatal mothers regarding

neonatal tetanus with selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. Effectiveness: Refers to gain in knowledge as determined by significant

difference in pre and post test knowledge scores

2. Planned teaching programme: It refers to systematically organized

teaching strategy on neonatal tetanus.

3. Knowledge: It refers to a level of understanding and awareness of

neonatal Mothers on neonatal mothers as assessed by self administered

questionnaire.

4. Neonatal Mothers: women who is having a neonatal baby

13

5. Neonatal tetanus: It is a medical condition seen in neonates, it is

characterized by a prolonged contraction of skeletal muscle fibers. It is

caused a neurotoxin produced by the Gram-positive, obligate anaerobic

bacterium Clostridium tetani.

6.6 ASSUMPTIONS.

1. Mothers may have insufficient knowledge regarding neonatal tetanus.

2. Planned teaching programme may have effect on knowledge of neonatal

mothers regarding neonatal tetanus.

6.7. HYPOTHESIS

H1- There will be a significant difference between pre and post test level of

knowledge on neonatal tetanus among neonatal mothers.

H2- There is a significant association between pre test level of knowledge

among neonatal mothers with selected demographic variables.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from mothers of selected hospitals, Bangalore.

7.2 METHODS OF DATA COLLECTION

i. Research Design :

Pre experimental: one group pretest & post test design

14

ii .Research Variables

1. Dependent variables: knowledge of neonatal mothers on neonatal

tetanus.

2. Independent variable: Planned teaching programme regarding neonatal

tetanus among neonatal mothers.

3. Demographic variables: Age, religion, family income, education,

source of information.

iii. Setting

The study will be conducted at selected hospitals, Bangalore.

iv. Population

The neonatal mothers who are admitted in postnatal ward at selected

hospitals, Bangalore.

v. Sample

The mothers who are admitted in postnatal ward at selected hospitals

who fulfills the inclusion criteria. Sample size is 60.

vi. Criteria for sample selection

Inclusion Criteria

The mothers between the age group of 20 to 40.

Who are willing to give consent.

Who are willing to give consent.

15

Exclusion Criteria

High risk cases.

vii. Sampling technique

Probability sampling, simple random sampling (lottery method).

viii. Tool for data collection

The tool consists of following sections

Section A: Consists of Demographic Performa of mothers like age,

religion, family income, education, source of information.

Selection B: Consists of structured questionnaire to assess the knowledge

of neonatal mothers regarding neonatal tetanus.

Section C: Consists of planned teaching programme on neonatal tetanus.

ix. Method of data collection

The researcher will collect the data from subjects after informed consent

and

Obtaining the permission from concerned authorities.

Phase I: Pre-test will be conducted to assess the existing knowledge with

the help of structured questionnaire of neonatal mothers on neonatal

tetanus.

Phase II: planned teaching programme on neonatal tetanus will be

conducted.

16

Phase III: After seven days post test will be conducted to assess the level

of knowledge.

Duration of the study: Four weeks

x. Plan for data analysis

The data collected will be analyzed by using descriptive & inferential

statistics.

Descriptive Statistics

Frequencies, percentage distribution, mean, median & standard deviation

will be used to assess the knowledge of neonatal mothers on neonatal

tetanus.

.

Inferential Statistics

Paired’ test will be used to compare the pre-test & post test knowledge.

Chi-square will be used to associate the knowledge of neonatal mothers with

selected demographic variable.

xi. Projected outcome

The investigator will be able to give appropriate instructions to the

neonatal mothers regarding the aspects of neonatal tetanus. It will help to

prevent it.

17

7.3. Does the study require any investigation to the patients or other

human beings of animals?

Yes. Planned teaching programme will be given as an intervention to

the neonatal mothers regarding neonatal tetanus at selected hospitals,

Bangalore

7.4. Has ethical clearance been obtained from your college?

YES, informed consent will be obtained from the institution,

authorities, privacy; confidentiality and anonymity will be guarded.

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8. LIST OF REFFERENCE

1. www.google.com

2. www.wikipedia.com

3. Fetuga BM, Ogunlesi TA, Adekanmbi FA, Risk factors for mortality

in neonatal tetanus: a 15-year experience in Sagamu, Nigeria. World J

Pediatr. 2010 Feb;6(1):71-5. Epub 2010 Feb 9.

4. Blencowe H, Lawn J, Vandelaer J, Roper M, Cousens S Tetanus

toxoid immunization to reduce mortality from neonatal tetanus. Int J

Epidemiol. 2010 Apr;39 Suppl 1:i102-9.

5. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ Tetanus

and trauma: a review and recommendations, J Trauma. 2005

May;58(5):1082-8.

6. Izurieta HS, Sutter RW, Strebel PM Tetanus surveillance--United

States, 1991-1994. 1997 Feb 21;46(2):15-25.

7. Cannarella R, Agbayani E. Tetanus: a case report, epidemiology

review and recommendations for immunization compliance. 2001 Sep-

Oct;97(5):253-6.

8. Chang SC, Wang CL, Neonatal tetanus after home delivery: report of

one case. Department of Pediatrics, Dalin Tzu Chi General Hospital,

Chia-Yi, Taiwan. csj.xx@msa.hinet.net2010 Jun;51(3):182-5.

9. Zieliński A. Tetanus in Poland in 2008. Zakład Epidemiologii,

Narodowego Instytutu Zdrowia Publicznego - Państwowego Zakładu

Higieny w Warszawie 2010;64(2):251-2.

10. Laura A. Talbot., Principles & Practice of Nursing Research , 1st

edition, Mosby Publications, 1995.1.

19

11. Omoigberale AI, Sadoh WE, Nwaneri DU, A 4 year review of neonatal

outcome at the University of Benin Teaching Hospital, Benin City. 2010

Sep;13(3):321-5.

12. Gogia S, Sachdev HS. Home visits by community health workers to

prevent neonatal deaths in developing countries: a systematic review.

2010 Sep 1;88(9):658-666B. Epub 2010 May 10.

13. Ilic M , Pejcic L, Tiodorovic B, Hasani B Neonatal tetanus--report of a

case. Department of Epidemiology, University of Kragujevac Faculty of

Medicine, Serbia. Research 2010 Jul-Aug;52(4):404-8.

14. Ayaz A, Saleem S. Neonatal mortality and prevalence of practices for

newborn care in a squatter settlement of Karachi, Pakistan: a cross-

sectional study. 2010 Nov 1;5(11):e13783.

15. Department of Microbiology, Aga Khan University Hospital, Karachi,

Pakistan. afsheen.ayaz@aku.edu 2010;64(2).

16. Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S. 3.6 million

neonatal deaths-what is progressing and what is not? . 2010

Dec;34(6):371-86.

17. Gibson K, Bonaventure Uwineza J Epidemiology and Surveillance

Division, National Immunization Program, USA2001 Sep-

Oct;97(5):253-6.

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9. Signature of the candidate :

10. Remarks of the guide :

.

11. Name and designation of

11.1 Guide :

11.2 Signature :

11.3 Co- guide (if any) :

11.4 Signature :

11.5 Head of the department :

12.1 Remarks of the principal :

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12.2 Signature :

22