RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE Mrs. N. SAVITHA

AND ADDRESS GOUTHAM COLLEGE OF NURSING
MANJUNATH NAGAR,
WEST OF CHORD ROAD,
RAJAJINAGAR,
BANGALORE – 560 010

2. NAME OF THE INSTITUTION GOUTHAM COLLEGE OF NURSING

MANJUNATH NAGAR,
WEST OF CHORD ROAD,
RAJAJINAGAR,
BANGALORE – 560 010

3. COURSE OF THE STUDY AND M.Sc. NURSING I YEAR

SUBJECT PEDIATRIC NURSING
4. DATE OF ADMISSION TO THE 23.08.2008
COURSE
5. TITLE OF THE TOPIC A STUDY TO ASSESS THE
EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAM ON “CARE
OF THE CHILDREN WITH
RHEUMATIC HEART DISEASE”
REGARDING KNOWLEDGE AND
ATTITUDE AMONG MOTHERS IN A
SELECTED GOVERNMENT
HOSPITAL AT BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK.
6.1 NEED FOR THE STUDY:

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“The child of today is citizen of tomorrow”

Children in the age group of 0-14 years constitute 40% of the

population. The well being of these children are the responsibility of parents as
well as health personals. As they are the most vulnerable section which under
go various types of health problems. The risk is connected to growth,
development and survival. The primary health cane in children aims at
prevention and promotion of health.

Rheumatic heart disease is a condition in which the heart valves are

damaged by rheumatic fever. Rheumatic fever begins with a strep throat from
streptococcal infection. Rheumatic fever is an inflammatory disease it can
affect many of the body’s connective issues especially those of the heart,
Joints, brain or skin1. If the heart valve damaged they will fail to open and
close properly. When this damage is permanent the condition is called as
Rheumatic heart disease. 2 Rheumatic heart disease usually occurs in children
age between 5-15 years. 3 Both male and female children are equally affected.
Rheumatic disease is primarily associated with poverty, illiteracy and low
socio economic status. 4

The Rheumatic heart disease that results can last for life. Rheumatic
heart disease places a heavy economic burden on health care system in low and
middle income countries because of the cost of the medical treatment and heart
valve surgery and also because it is a disease of young adults, who are most
economically active group of any population. 5

Developed countries have experienced a dramatic decline in the

incidence and prevalence of Rheumatic fever and Rheumatic heart diseases
caused by streptococcal throat infections. This is thought to have occurred as
result of improved living conditions and the wide spread use of penicillin for
the treatment of streptococcal pharyngitis.

However Rheumatic Fever / Rheumatic Heart Disease remain major

global problem in developing countries. Despite the wide spread availability of
effective antibiotic treatment of prophylaxis to prevent Rheumatic Fever and
cardiology services for those, with established Rheumatic Heart Disease as a

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sequel to Rheumatic Fever in these developing countries, which represent 80%
of the world population.

WORLDWIDE INCIDENCE: The prevalence of rheumatic fever was

0.75 per 1000 (rural 1.20, urban 0.42). cases of rheumatic heart disease were
distributed equally between the ages of 7 – 11 years and 12 to 15 years and
male female ratio 1:0.6. Recent research estimates that Rheumatic Fever
Rheumatic Heart Disease affects about 15.6 million people world wide, 2.4
million of whom are children between five and fourteen year old living in
developing countries. Half a million new cases are declared every year
Rheumatic Fever / Rheumatic Heart Disease leads to an estimated 3,50,000
deaths annually, and hundreds and thousands of survivors left disabled without
asses to the expensive medical and surgical care that the disease requires.

Africa, which contains 10% of the world population has a

disproportionately high share of people living with RHD / RF of the 2.4
million children with the RF / RHD living in developing countries, nearly half
(> 1 million) live in sub Saharan Africa a recent systematic review of
prevalence studies found exceptionally high rates of RHD in sub Saharan
Africa. With the high level in Kinshasa DRC at 14/1000. In school– aged
children.6 There is a high prevalence of rheumatic heart this case in the pacific
sub continent, Asian Mediterranean, Latin American, the Indian sub continent.
The incident in the middle east (Lebanon) is high. 7

INCIDENCE IN INDIA: Approximately 1to1.25million cases of

R.H.D are present in India. In Delhi in 1999, out of 191 children below 12
years of age with definite acute R/F 7.9% were below 5 years, 31.4% between
5 & 9 years and 60% above 9 years. 378 patients from Orissa below 19 years,
the mean age was 15.1 I 4.4 years. In 2000 the school survey involving 3963
children from the district of Kanpur, the prevalence of RHD was 4.54 per 1000
(urban 2.56 and rural 7.42).8

A study was conducted in North Western Indian town to determine

influence of socio economic status. 3292 school children age range 5 – 14
years in two private school ten middle socio economic status Govt. school and
six low socio economic status government school were participated. 3002 were

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clinically examined of which 1042 were in private schools, 1002 in middle
socio economic status schools and 958 in low socio economic status schools.
Prevalence of cardiac murmur and rheumatic heart disease clinical diagnosis
was determined. Those with a murmur were further evaluated by Doppler –
echocardiography in hospital. Results were, a significant murmur was
observed in 55 subjects with similar prevalence in boys & girls. The
prevalence of murmur was greater in children belonging to low socio
economic schools (29.12/1000) as compared to middle (18.9/1000) & higher
socio economic status schools (7.6/1000). 9

A prevalence of rheumatic heart disease of 3.9/1000 in the last school

study in primary school children 6 – 10 years of age is unexpectedly high.
Further proof of the continuing large reservoir of rheumatic heart disease cases
is the large number of patients in their teens and twenties coming in for the
new modality of balloon mitral valvotomy, pediatrics clinics in large hospitals
from various parts of India have reported several cases with acute
manifestations of rheumatic heart disease such as carditis, chorea, nodules and
poly arthritis. 10

A study was conducted by Department of pediatrics, king Faisal,

specialist hospital & research centre, Riyadh, kingdom of Saudi Arabia. To
investigate parental knowledge of pediatric Rheumatic diseases in general, and
in particular information regarding their children’s diseases. Majority of
parents have wrong beliefs, regarding rheumatic diseases. The treating
physician is the main source of parental information and in the majority of the
parents, their in formation was satisfactory. The questionnaire was simple and
easy to test to investigate parental knowledge regarding pediatric Rheumatic
diseases. The survey shows the need for health education programs and a
future general public health education plan to improve awareness of pediatric
Rheumatic diseases. 11

There is a lack of knowledge and awareness among parents and care givers
about so streptococcal infection, Rheumatic fever, and its complications which
makes the children to lead a miserable life and it is the responsibility of the
health personnel to make them accept and understand the consequences and

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 how to mange. Mothers consistently reported a lack of knowledge and they
expressed stress full life style. So, the parents and care givers should be
provided adequate importance of treating sore throat, streptococcal infection,
Rheumatic Fever and prevention of complications and the availability of
treatment. Psychological and emotional support for children as well as parents
which in turn helps to improve the health and to live a healthy lives by
controlling complications. Hence the researcher is interested to take up the
study in this aspect to provide knowledge and try to develop positive attitude
among mothers in caring Rheumatic heart diseased children.
6.2 REVIEW OF LITERATURE:

A. Literature related to incidence of Rheumatic heart disease

A study was conducted in rural area Rajasthan among the school
children regarding Rheumatic heart disease prevalence. Thirty for of 10168
school going children were found to have Rheumatic heart disease in a school
survey in the rural areas of charu district the prevalence rate was 3.34 per
1000. A high prevalence of Rheumatic Heart Disease was found in 11 to 15
years age group. Maximum was in low socio economic group. Out of these 34
cases of RHD isolated Mitral stenosis was present in sixteen, isolated Mitral
regurgitation in four, combined Mitral stenosis and Mitral regurgitation in ten
patients. 12

An echo cardiograph study was conducted in Bikaner Urban School.

3292 eligible children 3002 children examined. 1555 children were in between
the age group of 5-9 years and 1447 in age group of 10-14 years. A significant
cardiac murmur was observed in patients diagnosed with acute rheumatic fever
in both studies were treated with salycylates and antibiotics. Conclusion was
“Systemic screening with echo cardiography, as compared with clinical
screening, reveals a much higher prevalence of Rheumatic heart disease. 13

A cross sectional study to determine the prevelance of rheumatic heart

disease was conducted in rural block in Gandubal, Srinagar in 2003 Out of
4125 children from 54 schools selected randomly 21 children male - 10
female – 11 had evidence of R.H.D giving overall prevalence rate of
5.09/1000children of parents belonging to low economic group were more

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effected. The prevalence was least in high socio economic condition private
school. The greater prevalence was in low socio economic govt. school. 14

B. Literature related to complication of Rheumatic heart disease

A study conducted to determine the cardiac sequel of rheumatic fever
and rheumatic heart disease pre completed case protocol of patients with
rheumatic fever and rheumatic heart disease were analyzed to record the
demographic data clinical features on admissions/presentation recurrence
cardiac valvular affection and outcome. The study included 550 patients, mean
age of presentation was 9.62 years and sex ration was 1.15:1. Average duration
of follow up was 3.19 years, 74.72% of cases lost to follow up Benzathine
pencillin prophylaxis was regular in 42.18% cases. Positive family history of
rheumatic heart disease was present in 2% of cases. 23 patients died.
Conclusion – Arthritis was most common in patients presenting manifestation
in the initial attack of rheumatic fever while carditis most common with pre
existing RHD and mitral regurgitation was most common valuvlar leision.
Rate of patient dropout from pencillin prophylaxis was high. 15

C. Literature related to influence of rheumatic heart disease on growth

and development of children.
A study to determine the effect of left ventricular and endocrine
functions on linear growth in children with RHD. 100 children & adolescents
were studied with RHD over a period of 1 year. Growth was assessed by
determining both height standard deviation scores & growth velocity standard
deviation scores every 4 months & sexual maturity was assessed according to
Tanner’s criteria. 200 age matched normal children were control group. The
height standard & growth standard of children with RHD were significantly
lower than the normal group. They had high evidence of delayed sexual
development secondary to delayed maturation of their hypothalamic pitutary
gonadal axis. 16

D. Literature related to secondary prophylaxis for controlling rheumatic

fever and rheumatic heart disease in a rural area of northern India.
A study was conducted in a community development block of a district
in Haryana to evaluate the compliance of secondary prophylaxis for controlling

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rheumatic fever and rheumatic heart disease. The patients were interviewed
using a semi – structured schedule at home. Currently 110 patients are
registered in rheumatic fever/rheumatic heart disease registry of which
53(48.2%) are males. Mean age of patients was 18.4 + / - 8.6 years, ranging
from 6 to 50 years with majority (48, 43.7%) of patients in the age group of 6 –
15 and 16 – 25 years. Out of 110 patients, more than 90 percent had taken 11
out of the 12 due doses of secondary prophylaxis every year in the last eight
years in the program except in 1995 when 92 (83.6%) patients took the
prophylactic doses. Only one patient reported recurrent attacks of rheumatic
fever after irregular secondary prophylaxis. Eighteen (16.4%) patients are
defaulters at the time of interview and were motivated to take secondary
prophylaxis regularly. Ninety – seven (88.2%) patients were satisfied with the
ongoing program. In developing countries, it is possible to successfully apply a
secondary prevention program for control of RF/RHD by using existing health
infrastructure. 17

E. Literature related to diagnosis of rheumatic heart disease

A study was carried out to assess the accuracy of clinical evaluation of
valvular hear disease and compare it with that of an echocardiography
evaluation. 50 children between the age of 5 – 16 years, attending the out
patient department or admitted in a large teaching hospital, satisfying the
criteria of RHD, were included in the study. Each patient underwent detailed
clinical evaluation and relevant investigations including echocardiography.
Results was mitral valve was involved most often both by echocardiography
and clinically. Isolated aortic valve involvement was rare. The most common
lesion was mitral regurgitation both by auscultation and by echo. Mixed
lesions were seen more often than pure lesions. Mitral stenosis had the highest
sensitivity while tricuspid regurgitation had the highest specificity. Mitral
regurgitation had the highest positive predictive value and mitral stenosis the
highest negative predictive value. Sensitivity and specificity of aortic
regurgitation was very low when compared to earlier studies. There was a
statistically significant difference between echo diagnosis and clinical
diagnosis (p< 0.05). Conclusion was recommended that echocardiography be
done routinely for the diagnosis of cardiac lesions in patients of RHD as

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clinical examination alone can miss various lesions, especially when the
lesions are mild or when multiple lesions are present. 18

F. Literature related to need for awareness regarding prevention of

complication in parents of children with heart disease :
A prospective survey of parents of children with heart diseases
conducted to determine their awareness as regards to importance of oral
prophylaxis against infective endocarditis. The results of this study
demonstrated that only 8% of parents of children of heart diseases were aware
of need for infective endocarditis prophylaxis. Hence a serious attempts has to
be made by health care professionals to educate the parents on importance of
good oral hygiene the need for prophylaxis in children with heart disease. 19

G. Literature relating to effectiveness of structured teaching program.

WHO (1996): The aim of health education is to help people achieve health by
their own action and effort. Health education, therefore, begins with the
interest of people improving their conditions of living and developing a sense
of responsibility for their own betterment as individuals and as members of
families and communities.

A study states that the evaluation of any health education program is to

measure the change in the knowledge, change in attitude and change in
behavior. Evaluation may be required concurrently or terminally. The
effectiveness of the health education can be assessed by evaluating the
program by various methods like face-to-face questions or questionnaire or
asking them to narrate or by observing their practices.

A pre-experimental study was conducted to assess the effect of

structural teaching program on knowledge and practice among 50mothers of
children with convulsion, regarding to selected aspects of care of convulsion
who are attending the govt. hospital, Madurai. A structural interview schedule
used to asses the knowledge and practice of mothers regarding convulsion The
study revealed that there was a significant increase in knowledge practice of

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 mothers in the experimental group. 20
6.3 STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of Structural Teaching Program on care of
children with Rheumatic heart disease regarding knowledge and attitude
among mothers in a selected hospital at Bangalore.
6.4 OBJECTIVES OF THE STUDY:
1. A study to assess the effectiveness of Structural Teaching Program on care
of children with Rheumatic heart disease regarding knowledge and attitude
among mothers in a selected hospital at Bangalore.
2. To assess the effectiveness of structured teaching program on care of
children with rheumatic heart disease among mothers.
3. To find the association between knowledge and attitude scores and
demographic variables of mothers of RHD children.
6.5 OPERATIONAL DEFINITIONS:
1. Effectiveness: Refers to the evaluation of knowledge regarding
Rheumatic heart disease among mothers determined by pre test and post
test knowledge scores.
2. Knowledge: Refers to the correct responses of subjects on self
administered questionnaire on Rheumatic heart disease.
3. Attitude: Refers to the responses of subjects in the level of
understanding of structured interview schedule on Rheumatic heart disease.
4. Children: Refers to the Patients who are suffering from Rheumatic
heart disease.
5. Structural Teaching Program: Refers to statistically organized
planned teaching programmed providing information regarding rheumatic
heart diseases, etiology clinical manifestations laboratory test, knowledge
on taking care of children in their daily life which helps to control the
complications of the disease.
6. Rheumatic heart disease: Rheumatic heart disease is a condition in
which permanent damage to heart valves in caused by rheumatic fever.
7. Demographic Variables: Refers to age sex, education types of family
number of siblings, family income.
6.6 HYPOTHESIS:
H1 - There will be significance between pre test and post test on knowledge
and attitude among mothers of RHD children.

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 H2 -There will be significant association between knowledge and attitude
scores and demographic variable.
6.7 ASSUMPTIONS:
1. Mothers will be willing to express their knowledge regarding care of
RHD children.
2. Mothers will be willing to express their attitude regarding care of RHD
children.
3. Mothers may have some knowledge on care of the RHD children.
6.8 DELIMITATIONS:
1. The study is delimited to the parents of RHD children in pediatric
medical ward with rheumatic heart disease.
6.9 PROJECTED OUTCOMES:
1. The study will enhance the knowledge of mothers in caring RHD children.
2. The study will generate new knowledge on attitudes of care of RHD
children.
7. MATERIAL AND METHODS:
7.1 SOURCE OF DATA Mothers of children RHD in selected
Government Hospitals.
7.2 METHOD OF COLLECTION OF DATA:
7.2.1 SAMPLING CRITERIA
INCLUSION CRITERIA 1. Mothers of children between the age
group of 6 to 12 years
2. Mothers who are not expose to any
educational programmes on RHD.
EXCLUSION CREITERIA 1. Those who are not willing to participate
in the study
2. Mothers of children who are critically ill.
7.2.2 RESEARCH DESIGN Pre-experimental design. One group pre test and
post test design
7.2.3 VARIABLES UNDER
STUDY
Independent Variable:  Structured Teaching Program
Dependent Variable:  Knowledge and Attitude
Attribute Variables  Demographic variables of
 Mother – Age, Socio economic status,
Education etc.

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  Child – Age, Sex, Education. Health
condition etc.
 Health variable of child.
7.2.4 SETTING OF STUDY: Study will be conducted in selected
Government hospital at Bangalore
7.2.5 SAMPLING Convenience sampling
TECHNIQUE
7.2.6 SAMPLE SIZE: 40 Mothers
7.2.7 TOOL FOR RESEARCH: Section A- structured interview schedule for
demographic variable.
Section B- structured interview schedule to
asses the knowledge of mothers on RHD.
Section C- structured interview schedule to
asses the attitude of mother on RHD.
7.2.8 DATA COLLECTION  A prior permission will be taken from
institution for conducting study.
 Informed consent from parents will be
taken by explaining the purpose and
objectives of study.
 Structured questionnaire will be
administered to asses the knowledge and
attitude of the mothers in terms of pre test.
 Structured teaching program will be given
on care of R.H.D children
 Investigator will asses the knowledge and
attitude score in terms of post test.
7.2.9 METHOD OF DATA The investigator will use descriptive and
ANALYSIS inferential statistical analysis
1. Organize the data in a master
sheet\computer
2. Descriptive statistics: Mean and
standerd deviation
3. Inferential statistics:
a. Paired ‘t’ test to find out the
significance of difference between

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 the mean knowledge and attitude
score.
b. Chi-Square (x) test to determine the
association between the selected
demographic variables and the
knowledge and attitude level.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY,
Yes, study requires administration of structured questionnaires for data
collection form parents selected Government Hospital, Bangalore.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE
HOSPITAL AUTHORITIES OF THE PARTICULAR INSTITUTION IN
CASE OF 7.3?
Yes, Ethical clearance will be obtained from Institution Authorities. Informed
consent will be taken from subjects under study. Privacy, confidentiality and
anonymity will be guarded. Scientific objectivity of the study will be
maintained with honesty and impartiality.
8. LIST OF REFERENCES.

1. Nelson Text book of pediatrics 15th edition p. 1347.

2. Cardio vascular diseases, rheumatic heart disease. Health system.
Virgenia. http://www.healthsystem.virginaedu/uvahealth/adultcardiac
/rheumal.cfm.
3. Essential pediatrics OP Ghai second edition interprint.
4. In medical Indian Journal for the practicing doctor. Vol. 4, No.6 (2008
– 01 – 2008 - 02) rheumatic heart disease: challenges and opportunities
Author: Gaash B, Ahamed M, Bashir S.
5. British Medical Journal. 2006/2/December clinical review, rheumatic
fever and its management Author: Antonette M. Cilliers.
6. The control of rheumatic fever and rheumatic heart disease in
developing countries (prof. Anthony D MDEWU, IAMP CO. Chair)
http://www.iamp–online
7. Journal of pediatrics and child health current issue June 2002

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 www.ovid.com.
8. Rheumatic fever and rheumatic heart disease in India at the term of the
century.
9. Prevalence of rheumatic heart disease in Bikaner. Jaipur association of
pediatrics in India. www.japi.org. April 2006.
10. Burden of rheumatic heart disease. Prevention of heart disease in India
in 21st century need for a concerned effort. S. Padmavathi.
11. Evaluation of parental knowledge of pediatric rheumatic diseases.
Department of pediatrics king Faisal specialist hospital & research
centre, Riyadh. www.pubmed.com
12. Prevalence of rheumatic heart disease in school children in rural areas
of Rajasthan www.pubmed.com
13. Prevalence of rheumatic heart disease in a school of Bikaner Rajasthan.
A echocardiograph study. www.pubmed.com
14. Prevalence of R.H.D in rural Srinagar, Kashmir,, www.pubmed.com
15. Rheumatic fever and rheumatic heart disease. A clinical profile. Arch
Med. Res. 2003 Sep – Oct; 34(5): 382 – 7.
16. Effect of left verticular and endocrine functions on lenear growth in
children with rheumatic heart disease, Journal of tropical pediatrics.
CAT insist Oxford University press Oxford.
17. Compliance of secondary prophylaxis for controlling RF/RHD in a
rural area of Northern India. Kumar. R. Thakur J. S. Aggarwal. A.
www.pubmed.com
18. Clinical evaluation versus echocardiography in the assessment of RHD.
19. Annals of pedicatric cardiology. A Journal by online year 2008/Vol.1
Issue. 1 Page. 1. Authors. Parimalanath. V. Kiran, Sunitha Maheswari.
20. Kavitha. Dissertation structural teaching program on episiotomy care
2001.

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