CHAPTER II

Related Literature

Chapter No. Content Page No.

2.0 Introduction 30
2.1 Studies related to ARI 31
2.1.1 ARI in under-five year children 31
2.1.1.1 Diagnosis and treatment of ARI in India 31
-fo
2.1.1.2 Misuse of antibiotics treat the common cold 32
2.1.1.3 Studies related to magnitude of the disease 32-34
2.1.1.4 Management of ARI 34-36
2.2 Factors influencing ARI 36-40
2.3 Mother's knowledge and practices regarding ARI in children 40
2.3.1 Care seeking 40-43
2.3.2 Views and practices 43-48
2.4 Health education to mothers 49-53
2.5 Developing self instructional materials 53-64
2.6 Implications for the present study 65-68
2.7 Related literature about the topics 68-82
2.8 Summery 83
 C H A P T E R II

Review of literature

"Review of literature does for us what a map does for the traveler."

2.0 Introduction:

According to Polit and Hungler (1991), the task of review of literature involves
the identification, selection, critical analysis and reporting of existing information on the
topic of interest.
A literature review usually begins with a defined problem. Problems may be
selected and defined as the result of a literature review alone. Literature review conducted
in search of topics assist students in clarifying ideas and in formulating specific problems
that can be investigated by research methods.
A review of relevant literature is important to research because the researcher
need to relate the proposed study to existing theory and to previous studies and to
develop sound hypotheses.
The investigator attempts to determine how the proposed study fits into the larger
universe of related knowledge. Thus it can be seen that previous studies will be help to
clarify the ideas and the design of the studies. The quantity of relevant literature available
for review will depend on the popularity of the topic. A timely topic would include
greater number of (studies) publications than relatively new topic with little popularity.
The related literature reviewed is categorized into five sections:
1) AR-I in under five year children
2) Factors influencing ARI
3) Mothers knowledge and practices regarding ARI in children,
4) Health education to mothers
5) Studies related to developing self-instructional material

30
2.1 Studies related to ARI:
2.1.1 ARI in under-five year children:
2.1.1.1 Diagnosis and treatment of ARI in India:
In 1991, the Indian medical association carried out a survey on the prescribing
practices of 1,000 of its members. The questionnaire asked about diagnosis and treatment
of both upper and lower respiratory tract infections, including preferred antibiotics.
Nearly 900 members, most of who was in general practice replied to the questionnaire.
Although nearly three quarters of the respondents use a stethoscope for
diagnosing pneumonia, using respiratory rate for^ is the first choice^f nineteen per cent,
and the second choice for nearly half the sample. Over half the respondents indicate that
they would only obtain an x-ray if a stethoscope and respiratory rate cannot have helped
them make a correct diagnosis.
The respondents were also asked to indicate how they treated viral respiratory
tract infections i.e. colds and coughs (see table D). The results are of concern in that over
half treat all cases with antibiotics, and further quarter give antibiotics to fifty percent of
their patients over a third said that ampicillin was their first choice of antibiotic; and a
similar proportion mentioned erythromycin. About a quarter preferred trimethoprim sulfa
methoxazole (cotrimoxazole).
The IMA also asked its members if they would be interested in attending training
workshops to discuss standard case management guidelines. Encouragingly ninety-four
percent were interested in participating.
Table D
Treatment of U.R.TI. by doctors in survey
Treatment All % >50% Up to 20% Never
Antibiotics 54 23 16 7
Cough syrup 32 34 14 20
Nasal drops 5 10 36 49
Steam inhalation 39 15 6 40
Herbal medication 1 3 8 88

31
2.1.1.2 Misuse of antibiotics to treat the common cold:
Godmoski IC^S^) Reviews studies that show antibiotics do not prevent pneumonia
from developing. Because of the pressure from families to do something health workers
often prescribe antibiotics for common colds.
Upper respiratory tract infections are a frequent childhood illness. Many children
under five experience three to eight episodes of URTI a year.
Many health workers prescribe antibiotics for cough and colds in the mistaken
belief that this may prevent pneumonia from developing.
A number of studies have looked at treating coughs and colds with antibiotics.
Results from the best of these studies (conducted in Indonesia, Thailand and the USA)
have been combined statistically. The Meta analysis showed that antibiotic treatment of
URTilS neither shortened the duration of cough and colds, nor prevented them from
progressing to pneumonia. In conclusion the Parental knowledge and awareness about
antibiotic indications and antibiotic resistance can be changed with educational
interventions directed at parents and clinicians.
2.1.1.3 Studies related to the magnitude of the disease:
Zhu, DaiO^.S^)carried out a survey, in June 1987, baseline household survey was
conducted in the Jianxin district of China to establish clearly the extent of problem before
starting on ARI control program. The study population included 101,521 people in 106
villages where they were 7126 under five children in 1986. During 1986, 165 children
died giving an IMR for the district Of 65.5/1000 live births and a mortality rate in one to
five year age group 4.6/1000 children fifty-nine out of 165 deaths were considered due to
pneumonia. Thirty-seven percent of pneumonia deaths occurred in the first month and a
further twenty percent between the ages of one to six months. Eleven ol fifty-nine
children who died of pneumonia were malnourished at the time of death.
Wadhiuzeaman,((5?4) froni Iran? d'<i ^ prospective study often villages with 6000
population for the period of March 1988 to March 1989. Out of total number of patients
12,942, he found ARI patients 2,474. The total number of deaths in a year was thirteen
percent death due to ARI.
The combined survey on ARI, Diarrhea (DGHS, NICD)^ 1988,the
Epidemiological Division of NICD (Delhi) has done two community based studies to find

32
out the morbidity and mortality due to ARI as a multicentric involving six branches of
NICD at Alvar, Coimbatore, East Godavari, Patna, Calicut, Varanasi and Delhi. The
study revealed that:
1. The incidence of ARI among under-five children was two to 5.4 episodes/ child/
year
2. In urban areas the incidence was more than rural areas
3. The mortality per 1000 live birth was 7.04 in infants and 1.29/1000 in one to four
years of children. Total M.R. 2.53/1000
A study was undertaken in Najatgarh, Delhi by Chawla U. (NICD). To find out
the ARI morbidity in relation to some predetermined variables.
The findings were:
• There is no sex difference was observed with regard to the incidence of ARI
among male and female children.
• Incidence of ARI was found significantly higher in poor households.
• ARI (Episode and attack rates) was found less in children whose mothers were
found to lit.erate.
WHO, (1999), Health situation in the South-east Asia Region 1994-1997,
Regional office for SEAR, New Delhi. According to WHO estimates, respiratory
infections caused about 987000 deaths in India of which 969000 were due to acute Uswev-
respiratory infections (ALRI), 10,000 due to acute upper respiratory infections (AURI)
and about 9000 due to otitis media.
Narain and Sharma did a review of medical records of health centers in Kangra
district, Himachal Pradesh during Oct 1984 to Sept 1985 revealed that of 3,72,000
attendances eighteen per cent were for acute respiratory infections (ARI) and twelve per
cent for diarrhoeal diseases. The annual incidence of visits for ARI among children below
five was higher than that of general population (8.2/1000 vs. 6.7/1000). ARI was more
common during the post-monsoon period and among people living in mountains areas.
The case fatality rate in hospitalized ARI patients was 10.5%. Interview of health center
physicians regarding ARI management practices indicated that chest in-drawing
(considered by WHO as pathognomonic of sever ARI) was not recognized as an
important sign by majority of physicians. Ninety One percent of physicians disagreed

33
(69% in strong terms) with the idea of providing health workers with antimicrobials for
management of ARI at community level.
2.1.1.4 Management of ARI:
Standard questioners were distributed on a random sample of health center
physicians to elicit infection on current treatment practices for ARI. ARI guideline in
Pakistan reduced child pneumonia deaths by fifty per cent.
In Pakistan the government has introduced WHO's guidelines for acute
respiratory infections nationwide after training doctors and the community health
workers. The WHO's standardized case management guideline of ARI were introduced
in the out patients and emergency departments of children hospitals. Acute respiratory
infections kill more children under five than any other infection disease, accounting for
almost two million deaths a year among this group. Among those most vulnerable to
infection are children with low birth weight whose immune systems have been weakened
by malnutrition or other causes. Without early treatment for ARI, children can die very
rapidly.
The children suffering from sever pneumonia were admitted, mild pneumonia
were given oral antibiotics and sent home. Children with upper respiratory infections
mainly cough and cold were sent home with medication, and advice on home care
(including the use of fluids, feeding care of the nose, and soothing the throat).
The study found that eighty per cent ARI cases were acute upper respiratory
infections, majority of these were viral which did not need antibiotics. Only a small
proportion needed treatment with antibiotics. The study shows the cost of antibiotic use
can be reduced by. using WHO guidelines and effective use of ARI treatment guideline
have a rapid impact in reducing pneumonia deaths among children.
Carvalho, N. (2002), "Association of Crackles and or wheezing with Tachypnea
or chest in-drawing in children with pneumonia." The WHO recommends that in
developing countries primary health care workers should use the respiratory rate
(tachypnea) for diagnosis of pneumonia and chest in-drawing for defining sever
pneumonia in children aged less than five years. These signs can be reliably detected by
paramedical staff as well as doctors. In several countries bronchial observation with or
without respiratory infection is a common cause of rapid breathing. Chest in drawing

34
occurs because of the contraction of the thoracic accessory muscles. Pneumonia (reduce
lung compliance) asthma (increase tissue/airway resistance) causes chest in drawing. A
two years prospective study enrolled 1416 children with pneumonia in two hospitals of
Salvador, Northeast Brazil. Tachypnea, chest in drawing, crackles and wheezing were
reported respectively, in sixty-five per cent, 45.4 per cent, 67.9 per cent, and 46.5 per cent
of the cases. Analysis by using chi-square, showed the presence of crackles was
associated with tachypnea and with chest in drawing as well as the presence of wheezing
was associated with tychypnea and with chest in drawing.
The study gave evidence, wheezing being as effect modifier of crackles in
children with pneumonia. The importance of using tachypnea as a diagnostic criterion for
childhood pneumonia is the ease of its use by primary health care workers for whom it is
not possible to use the stethoscope.
Reddiah, V.P. & Kapoor, S.K. (1991) conducted a study on "Effectiveness of ARI
Control strategy on under-five child mortality". A prospective intervention study was
conducted at Ballabhagarrh Block of Haryana. The study area has a population of 30,000
under a state Run P.H.C. area. The control area has got a populadon of 60,000. ARI
control strategies as advocated by WHO; was instituted in the study area. Measles and
DPT immunization was strengthened. ARI cases reported or detected by health workers
were managed as -per the STD cases manafjgement procedure. The under-five mortality
rate was higher in the study area. After two years reductions in the study area were
significant. The reduction of thirty-seven per cent in under-five mortality and twenty-six
per cent due to ARI mortality is substantial. More benefits were attained with measles
immunization. Therefore measles immunization coverage has to be improved and private
practitioners must be included in the effective case management.
WHO has established key indicators for the assessment of correct ARI
management. These indicators were measured through health facility survey in India in
1992. The findings of the survey performance indicators of ARI case management shows
that inappropriate antibiotic used for cough and cold'sixty-five per cent, children with
A

pneumonia not given antibiotic nineteen per cent, Respiratory rate counted twenty-two
per cent, chest in-drawing checked forty-eight per cent, care taker (mother) knows correct
home care four per cent. The findings are an indicator of quality of treatment given. The

35
survey indicates the need for further improvement, especially in the areas of training,
communicating with caretaker and regular monitoring of national program.
Oral antibiotic for Pneumonia: Pneumonia is one of the world's deadliest diseases
among children in developing countries. Now a new study shows pneumonia could be
treated with the oral antibiotic amoxicillin, rather than injectable penicillin, to produce
better health outcomes and reduce treatment costs.
The W.H.O. has recommended penicillin given by injection as the treatment for
severe pneumonia. Yet, if oral amoxicillin proves equally effective, it could reduce
referral, admissioq and treatment costs. The study included 1,700 children below five
years of age from developing countries in Africa, Asia, and South America. The children
were randomly treated with injectable penicillin or oral amoxicillin. The outcome is the
same in both the groups. If these finding were applied to public health policy, oral
amoxicillin would reduce needle-borne infections, the need for referral and admission to
medical care, treatment costs, and transport, food and lost income costs for the family.
2.2 Factors influencing ARI:
Impact of Zinc Supplementation on morbidity from diarrhea and respiratory
infections among rural Guatemalan children was found out by Ruel M T, 1997.
In this community based trial, forty-five children aged six to nine months received ten mg
of zinc daily for an average of seven months while forty-four control children received a
placebo. The incidence of diarrhea was twenty-two per cent lower and the percentage of
children with persistent diarrhea was reduced by sixty-seven per cent in the zinc group.
No effects were found in the prevalence and incidence of respiratory infections.
Zinc supplementation reduces the incidence of acute lower respiratory infections
in infants and preschool children: a double blind, controlled trial was conducted by
(Sazawalas, et al, 1998). In poor community in urban India, 609 children aged 6-36
months were randomly assigned to receive daily supplements of ten mg of zinc (298)
children) opJa placebo (311 children) for six months. After supplementation, the zinc
group, while it increased in the placebo group. During the follow-up period of six
months, the incidence of acute lower respiratory infections, mainly pneumonia, was
forty-five per cent lower in the zinc group (0.19 episodes/child/ yr compared with 0.35 in
the placebo groupj. The benefits were greater in children aged more than eleven months

36
 with sever malnutrition. Where malnutrition and zinc deficiency are common, zinc
supplementation reduces the incidence of pneumonia and may improve the health and
survival of pre-school children.
Preventing Vitamin A deficiency may prevent some deaths from ARI. When there
is vitamin A deficiency, immunity is depressed (particularly T-cell ftinction); and mucus
production is decreased, so that bacteria can stick more easily to the respiratory mucosa.
Because of this, even mild vitamin A deficiency may more susceptibility to respiratory
diseaseCPlnkocJc^C' I11<'^
5o^^^g^(<}gHln a study in rural Indonesia, children were monitored for eighteen months and
examined at three, months intervals. It was found that children with symptoms of mild
vitamin A deficiency had a two fold increased risk of respiratory infection. The increased
risk was independent of the children's overall nutritional status. More recently, a similar
study of children in urban India also found that there was a two fold increased incidence
of respiratory disease in children who were vitamin A deficien; > In Ethiopia, it has been
found that the prevalence of both diarrhea and respiratory disease is twice as high in
children with xerophthalmia, as in those withoutf3>e-Sole/ ^^- <*i/i<^?7-)
^^avjo,2i2rDO Pacifier as a Risk factor for acute otitis media: A Randomized, controlled trial of
parental counseling was done, to evaluate the association between pacifier use and the
increased occurrence of acute otitis media in an intervention trial. The fourteen well baby
clinics were selected. It was a Controlled Cohort study. The nurses at the intervention
clinics were traine-d to instruct the parents of children less than eighteen months old to
limit pacifier use during their prescheduled visits to the clinic. The intervention consisted
of a leaflet explaining the harmful effects of pacifier use and instructions to restrict its
use. 272 children were successfully recruited from the intervention clinics and 212 from
the control clinics.
The pacifier use appeared to be a preventable risk factor for AOM in children. Its
restriction to the moments when the child was falling asleep effectively prevented
episodes of AOM
^cu>^^ 2^uD, Socio-Demographic and maternal determinants of low birth weight: A
multivariate approach in community based prospective study was conducted in rural
areas of Udipi taluka, Kamataka state to identify the socio-demographic, maternal and

37
obstetric determinants of low birth weight. All singleton line births that occurred in the
study area during a one year's period (Oct. 1991 to Sept 1992) Kere included. A total of
2919 singleton child-mother pairs formed the basis of the analysis. Information about
socio, demographic and economic condition of the families, maternal factors such as age,
parity quality of antenatal care and previous obstetric history was collected by
interviewing the mothers and family members and verifying the available medical
records through the field investigators especially recruited and trained for this purpose
collected history. Data was analyzed using multiple logistic regression model. Primes,
elderly mothers and mothers who had not received good quality antenatal care were
found to be more at risk of having low birth weight babies. Other significant determinants
were family customs, socio-economic statws and environmental sanitation.
Education improves health:
(Jones J. 1995)^ "Improving health through schools." Surveys in twenty-five
el
developing countries show^that all else being equal, one to three year schooling among
mothers reduced child mortality by about fifteen per cent, and by much more when
mothers had more education. In Peru for example seven or more years of schooling
reduced the mortality risks by nearly seventy-five per cent.
The data from thirteen African countries for 1975-85 shows that ten per cent
increase in female literacy rate was accompanied by a ten per cent reduction in child
mortality.
Singhi, S., and Singhi, P. (1987) say in prevention of ARI, the factors responsible
for ARI are breast feeding, nutrition, indoor environmental pollution caused by cooking
fire and parental smoking and immunization and this can be supported by
Mukhopadhyaya J. (1992). In his prospective study of factors affecting incidence of ARI
among children found that breast feeding, nutrition, indoor smoke pollution, parental
smoking habit and also immunization were the most important factors which affect the
incidence of ARI. All the factors have been recognized as amenable to change. Therefore
an effective preventive strategy has greater importance in reducing the ARI related
mortality in young children.
Functional illiteracy is a growing problem. Nurses often rely on educational
pamphlets of brochures as teaching aids for clients. However many are written at well

38
above the eighth grade level. A reading level below fifth grade is considered ftinctional
illiteracy.
Miller and Bodie chose a convenience sample of 100 subjects from in patients and
ambulatory care are as of a veteran's affairs center determined their reading levels, and
correlated the reading levels of the subjects with their highest grad^ompleted in school.
Approximately sixty per cent of the sample held a high school diploma, a general
education diploma, of a college degree, and the average grade completed was calculated
as 11.6. However, eighty per cent of the veterans included into each sample were
considered partially illiterate with the average veteran in the facility reading at a 5.6
grade level.
Implications for practice: The assumption that the last grade level completed
equals reading ability is unwarranted.
Health education materials for the veterans in this medical center should be
written at a fifth grade level. -Replication of this study to other population to increase the
generality of the findings should be completed.
Vidyuthllatha, conducted a study to assess the knowledge of mothers about risk
factors of low birth weight in government maternity hospital, Hyderabad. The objectives
of the study were to assess the knowledge of mothers about risk factors of low birth uieJQiAJt
and to analyze the relationship between knowledge and selected variables, to identify the
relationship between mothers knowledge and birth weigh of new born babies and to
prepare an information module for mothers on risk factors and prevention of low birth
weight births.
Population of the study was primi postnatal mothers with a normal live bom baby
admitted in postnatal wards. The sample size was 100, selected with purposive sampling.
Structured interview schedule was prepared for data collection. Findings of the study
revealed that eighty-six per cent of mothers were housewives and belonged to low
income group. Eighty-two per cent were in the age group of nineteen to twenty-five
years, sixty-eight per cent of mothers were from joint family. Forty-five per cent of
mothers were from urban slum area and fifty-two per cent of them were illiterates.
Knowledge scores revealed that majority of the mothers had medium level
knowledge about risk factors. There was significant relationship between mothers'

39
knowledge and age, type of family, place of living and socio-economic status. The
mothers with high knowledge scores gave birth to normal weight babies. This hypothesis
was supported by the findings of the study. The findings of the study revealed that about
50% of the mothers expressed their interest to know the prevention of low birth uJp-iguJ"
births. Based on the findings of the study an information module was prepared on risk
factors and prevention of low birth y>f:; births.
2.3 Mothers' knowledge and practices regarding ARI in children:
2.3.1 Care seeking:
Care-seeking for illness in young infants in urban slum of India (De Zoysa I, et al
1998) conducted a study. Interviews with eleven key informants (including five TBA),
thirty-seven mothers, one M.O, twenty-two private practitioners, and three folk healers,
were conducted in a slum of New Delhi to assess maternal recognition and interpretation
of illness in young infants (one week to two months of age) and constraints to adequate
provision of care. "In addition data were gathered through repeated household visits for
nine episodes of illness, unstructured observation of twenty-seven consultations, and
visits to four hospitals and three nursing homes to interview key health care providers.
The findings suggest that maternal recognition of illness is not a limiting factor in the use
of health care services for young infants in this setting. Mothers are usually prompt in
seeking care outside the home. They are not able; however, to discriminate among the
many sources of health care available, and give preference to local unqualified private
practitioners who show critical failures in the care of sick young infants. The
effectiveness of care is further compromised by discontinued prescribed courses, fi^equent
changes in practitioners and reluctance to seek hospital care.
An increasing proportion of infant mortality is concentrated in the 1^' two months
of life. In addition to social and economic development, and to better care during
pregnancy and childbirth, good care management care is needed to reduce that burden of
death. Prompt care seeking from an adequate provider is required for good case
management. Mothers must be able to recognize and interpret key signs of illness to take
proper action at home, and to timely seek adequate care out side home. Many factors
affect the way mother seek care and choose prescription 1) while social and economic
factors are hardly modifiable by health interventions, maternal knowledge and care-

40
seeking practices can be chang^hrough good information and communication. In some
setting, like in the urban slum of India mention above, recognition of illness may be
adequate, while care-seeking is a problem. But good care seeking above may not be
enough. 2) The appropriate referral and admission to hospital of sever cares, and the
quality of hospital care, are other important determinants of good outcome.
Mother's perceptions of sever pneumonia in their own children: a controlled study
in Pakistan by (Mull D S et al). In this study about 320 mothers were interviewed at
Pakistan's Rawalpindi General Hospital. The main goal was to find which of the
symptoms mothers saw in their children were most consistently linked with a clinical
diagnosis of pneumonia as apposed to a common cold. Four groups of mothers with
children were interviewed: pneumonia admission, out patient pneumonia cases, common
colds and children who were well. Mothers of children with either pneumonia or a
common cold spontaneously mentioned fever and cough. However, when questioned
about a list of symptoms, it seemed that mothers of children with pneumonia had
recognized fast breathing and chest in drawing. When prompted, their reporting of fast
breathing and or chest in drawing was highly correlated with pneumonia. (Sensitively
64%; specificity 90%K^^^An,^^• m^'^.
Recognition by mothers of the key signs of pneumonia (fast breathing or chest in
drawing) is essential if pneumonia deaths are to be reduced. Before designing health
educafion massages it is important to find out about mothers knowledge, local terms for
illness, and to learn more about what influences health seeking behavior. This is
especially important in countries with several languages, dialects and cultures. It is also
necessary to focus on other social and economic factors that favor the survival of certain
children and not others. . ^, ,
(Campbell H, et al, 1990), Acute lower respiratory infection in Gambian children:
' A.

maternal perception of illness. A study in seven villages in the Gambia looked at the
extent to which mother's perceptions of ARI matched clinical diagnosis. During weekly
visits by trained field workers over a period of a year, 500 children were examined for
signs of respiratory infection. All the children who had signs of pneumonia, as well as
any suspected cases, were referred to the project clinic for assessment and treatment.
Their mothers were asked about any symptoms they had seen during the previous week.

41
 Over the year the mothers reported about 4,500 episodes of respiratory illness.
Symptoms included blocked nose, fever, cough, chest pain, fast breathing, open chest and
refusal to feed. The term 'open chest' is used to describe a child whose chest is seen to be
bigger than normal. There is no specific local term for chest in drawing. The term for
chest pain, fast breathing and open chest were used to describe children with both fast
breathing and chest in drawing.
Mothers identified cough and fever as the most common symptom associated with
ARI. However, cough and fever are found equally with children with acute lower
respiratory infections and in those with upper respiratory infections, indicating that they
are not useful signs for recognizing pneumonia.
Mothers took children for treatment in forty per cent of episodes with fast
breathing. Over half the episode took for treatment for chest pain or open chest. But
mothers had also sought care for children with less serious symptoms such as fever and
blocked nose.
Comparing mother's reports with clinic based medical assessments showed that
cases where mothers had report chest pain, fast breathing or open chest were more likely
to be confirmed as pneumonia than as an upper respiratory tract infection.
Community education to raise mothers awareness of pneumonia should emphasis
these three symptoms as danger signs, and explain how children showing other symptoms
do not need to see health worker, but can be treated at home.
What made mothers to seek health facility:
In Montevideo, the capital of Uruguay, many children with pneumonia are treated
at the emergency section of the children's hospital. Health workers or doctor referred
some children for treatment, and their mothers bring others directly to the hospital.
During a two years survey, data were collected on over four hundred children under five
years old with ARI.
Hospital staff recorded the reason why each family decided to bring their child to
the hospital. WHO criteria (respiratory rate and presence of chest in-drawing) were used
to check whether or not the mother had correctly assessed the child's condition, and
whether or not referral had been appropriate and timely.

42
 Over eighty per cent had correctly assessed that their child needed treatment. The
most frequently mentioned sign, which prompted families to seek care, was fast or
difficult breathing. However, in children aged three months and older, fever was also
considered an important sign, often in conjunction with fast breathing.
Cough and/or being unable to drink were given as reasons for seeking treatment
in a lower, but still significant, proportion of cases. Other signs and symptoms reported
by a few mothers were bluish lips and tongue, general listlessness and vomiting, and
interruption of breathing.
None of the mothers mentioned chest in drawing. Earache or purulent discharge
was rarely mentioned as the sign that prompted them to seek care, even though
examination found that children with pneumonia often had otitis media too.
2.3.2 Views and practice:
A Focused Ethnographic study of ARI was conducted in Ile-Ife, Nigeria by a team
consisting of a social scientist from the local university, a ministry of health staff
members and three research assistants.
Key findings of the study are as follows:
Recognition of fast breathing:
Fast breathing was not generally recognized by mothers, and was rarely noted
when they watched videotape developed to assess recognition of ARI S/S. Because of the
importance of fast breathing, as an indicator for immediate care seeking, the investigators
recommended that mothers in lle-lfe should be taught to recognize this danger sign.
Interpretation of illness:
The mothers regarded many of the s/s of ARI, such as fever, cough and even
convulsions, as a normal part of a child's development. This belief may prevent them
seeking help when a child has signs of pneumonia and should be addressed in health
education messages.
Home treatment:
When children in lle-lfe have ARI,mothers often treat them with traditional herbal
teas (agbo) or home made remedies for cough. Mothers may also buy antipyretics and
antibiotics from the pharmacy or local drug sellers.

43
Antibiotic sales:
The study found that drug sellers and pharmacists routinely sell antibiotics to
parents seeking advice for children with ARI. The investigators pointed out the need for
interventions aimed at changing inappropriate behaviors of drug sellers and pharmacists
and suggested training them to give health education messages.KU<3-'l*^y C^"^^ A,4sKaj or^
Views and practice: (FES in Egypt) Key findings of the study are as follows:
• Mothers make a clear distinction between mild respiratory infection (such as
coughs and colds) and more serious illness that affects the chest (such as
pneumonia).
• The most commonly identified cause of ARI is rapid chilling of the body.
• 'Evil eye' is described as a possible but infrequent cause, and does not usually
interfere with seeking medical care.
• There are culture-specific childhood illness that mothers believe must treated by
traditional healers, but none of these include signs and symptoms of pneumonia.
• Respiratory symptoms in newborns thought to be caused by mishandling at the
time of birth, i.e. either failure to keep the baby warm or to adequately clean the
nose and mouth. The belief that nothing can be done for babies, have that
respiratory-symptoms are best treated by TBA, may prevent early care seeking.
• Mothers recognize the symptoms of rapid and or difficult breathing, but do not
believe them to be serious or a reason to seek care. Fever and noisy breathing are
of much greater concern.
• Respiratory infections are first treated at home with water flavored with sugar and
spices such as fenugreek, mink, cumin and anise, mothers continue to breast feed
'V' during ARI, although they note that children often have decreased
appetite.
• Fever is treated with aspirin preparation, often in combination with caffeine.
• Government health facilities are seen as sources of prescription but not of medical
care.
• Mother often seeks advice and medicines directly from pharmacies without first
going to see a doctor of other health worker.

44
 • Most mothers are realistic and expect medications to make child better after two
to three days. But there is a tendency to stop giving medicines when symptoms go
or to save them for future episodes.
The implication from these two studies is to:
- Improve the quality and effectiveness of training health workers is to improve
their skill in communicating with mothers, training materials must refer to terms
that mothers use and take into account their expectations about treatment.
- Design messages in social marketing and communication activities.
Because of the sinfiilarity of the results from the two studies, the ARI program has been
able to develop educational messages; which can be applied nationally.
• Initial home practices (use of tisanes, continued feeding during illness, and keeping
babies warms) are appropriate and mothers will be encouraged to continue these.
• Aspirin is commonly and discriminately used at home. To avoid the risk involved,
the program is stressing the use of paracetamol for the treatment of high fever.
• As mothers already recognize fast or difficult breathing the focus will be on
teaching mothers that it is a serious symptom. The key massage is to take children
to a health provider as soon as rapid or difficult breathing develops.
• Mothers need to be assured that staff at government health facilities can treat
serious illness; mothers should not wait until they have the money to go^a private
doctor.
• Mothers' expectations of medicines given for ARI are realistic. Instructions at
health facilities will focus on encouraging completion of the treatment course and
on discouraging keeping and sharing of medication.
As a result of the studies -The Egypt ARI Program: (decided to) -
• Direct health education massages not only to mothers to the family as a whole.
Mothers have little decision making power especially in rural areas.
• Include pharmacists in training programs
• Produce single dose packets of antibiotics and make them available at the clinics.
• Develop a safe cough syrup and make it available at clinics.

45
 Ashley, S. (1998) found in her study that there was a positive effect of teaching in
the mother's knowledge and practices regarding the care of children with upper
respiratory tract infection, in age group of 0-3 years.
Reena Bose conducted a study in republic of Maldives on knowledge and practice
of mothers in connection with prevention of diarrhoeal disease in children below five
years of age. The study indicated that lack of hygiene is most likely to have contributed
to the diarrhoeal disease. Therefore researcher views that health education on these
aspects may help in control of diarrhoeal disease.
Patil, A. (1994), found majority of mothers attribute the causes of ARI to bad
weather and consu'mption of cold foods. Mothers feel rapid breathing as an indication of
complication of ARI^can be improved by health education.
Bandyopadhyay (1989) conducted a study to find out ability of mothers about
providing care to their children with ARI and also to find out the relationship between
family support and care management practices in a selected rural Coiwvumipf West Bengal,
found that care ability of mothers were inadequate. Accepted pattern of health seeking
behavior was found in forty per cent of cases. There was positive significant relationship
with family support and ability to provide care.
Pradhan, I. (1991) had done a study to find out the effect of planned health
education on knowledge of the mothers of infants admitted with acute respiratory
infection. The study showed that knowledge and practices was improved significantly
after education.
Vastrad, S. (1990). In India health of under-five children is not satisfactory. Child
rearing practices play an important roe in determining the health of children. The
ignorance of the mothers is an important factor, which affect the health of her children,
with this background the study was conducted in the primary health center,
Nelamangalam to know the knowledge, attitude and practices of the mothers regarding
child rearing.
The study showed majority (78.83%) of mothers started breast feeding on third
day on an average they gave 5.78 times breast milk per day. Majority stopped breast-
feeding because of insufficient breast milk and pregnancy. Most (78.3%) of them weaned
their children after twelve month. Only few (6%) of the mothers gwe daily bath to their

46
children. This shows rendering of very poor personal hygiene of the child. Few (18%) of
the mothers took their children to doctors for minor ailments.
This shows that there is greater need of health education to the mothers regarding
child rearing.
Trepka M.J. (1997). The effect of a community intervention trial on parental
knowledge and awareness of antibiotic resistance and appropriate antibiotic use in
children: A baseline survey was conducted during June to July 1997 and post intervention
on survey of baseline participants during June to August 1998 in communities of northern
Wisconsin.
Parents of randomly selected children less than four years of age 430 participants
were in baseline, and 365 (80%) participated in the post intervention on survey.
Intervention- parent- oriented activities included distribution of material and
presentations. Physician- oriented activities included formal presentations and small
group meetings. Results: The percentage of parents with high degree of antibiotic
resistant awareness increased more in the intervention area that in the control area (65%).
In intervention area, there was also a larger increase in knowledge in knowledge
regarding appropriate indications for antibiotic use, compared with the control area. The
proportion of parents who expected an antibiotic for their child did not receive one
declined in the intervention area, while it increased in the control area. In addition the
percentage of parents in the intervention area who brought their child to another
physician because they did not receive an antibiotic decreased, while it increased in the
control area.
Mothers as a child health worker: Chaudhari, S. (1991) stated in his study that,
mothers both in the clinics and at home do not receive the type of support they need from
health workers, when their children fall sick. MA^'OH^ of mothers are able to manage the
scare commodities such as food, health care and other basic needs in a poverty situation
quite effectively, the exceptions being during periods of stress. The odds that the mother
has to struggle within a poor environment facing various kinds of discriminations and
later in her husband's household are analyzed.
be
The grass root health workers should^available locally when the mothers need
their help. The health workers should encourage the positive traditions prevailing. All

47
efforts should be rpade • .'/the peer group, so that the mothers continue to receive support
in bringing about the encouragement.
"Knowledge, attitude and practices regarding Acute Respiratory Infection."(1990):
This study conducted by S. K. Kapoor, V. P. Reddaiah and G V S Murthy. One hundred
and six mothers in a rural area were interviewed to determine as to how they recognize
pneumonia in children, what therapies they practice with mild acute respiratory illness
and pneumonias and the feeding practices they adopt. Most mothers recognized
pneumonia by noticing fast respiratory rate and difficulty in breathing. More sever cases
were recognized by these signs among a higher percentage of mothers. As regards
management of mild ARI episodes, more than half the mothers preferred not to give any
treatment of use only home remedies. In pneumonias a majority of them preferred to
consult a qualified doctor. Nearly a third of them were of the opinion that they would
take the child to hospital if the disease were severe. Regarding feeding practices, most of
them stated that they would continue feeding, fluid and breastfeeds. Only ten per cent
desired to stop and another fifteen per cent would decrease the amounts.
•Mothers were interviewed and responses were recorded on the pre-tested pro-forma.
Criteria- respondent had children below five years and not necessarily had a recent attack
of ARI in her children.
•Respiratory rate > 50/mt., cough, cold fever in combination is the criteria for
pneumonia.
•Pneumonia presence of chest in drawing, cyanosis, loss of consciousness, inability to
drink water and convulsions suggests severe pneumonia.
A good attitude Was observed regarding feeding of children during pneumonia. There
were more than seventy per cent who would continue feeding which was in contrast to
the findings of Kumar et al. However emphasis on continuing feeding during sickness
needs to be laid in hospital education program. Regarding breastfeeding only 10.4%
claimed restriction on which was for less than that reported by Kumar et al^ Hgi").

48
 2.4. Health education to mothers:
Akl^,linA study was carried out in a rural province in Turkey to find out the best way to
teach mothers about when, and when not to take their children to the health center.
One group about fifty local women was given a detailed account of how to
recognize pneumonia, when and why to seek medical help, and the use of supportive
therapy. A second group was taught two simple points:
• Go to a health facility if a child with cough has faster or more difficult breathing
than normal.
• If a child has cough and/or running nose and or sore throat, treat for fever with an
anti- pyretic (a brand specified by the educators), give food and drink more often
than usual, and check how fast he or she is breathing.
Local midwives taught both groups over a five-day period. Afterwards, health personnel
monitored the children of the women in both groups for six months. The women's
assessments of their children's respiratory infections were compared with medical
diagnoses. During this time the health-centers in the area covered by the project recorded
more ARI cases than during the previous six months winter period, suggesting that
mother's awareness of ARI had increased overall.
In the 1^' group, which received more detailed information, the doctors confirmed
only forty-six per cent of pneumonia cases identified by mothers. In the second group,
mothers recognized sixty-nine percent of the total number of cases.
The P' groups' poorer understanding of pneumonia meant that fever of their
assessments was correct. Many more women in the 2"'' group had made correct
assessments of their child s condition. Simple education had more success in teachmg
women to recognise pneumonia.
Focus ethnographic study: an ARI research tool.
Teaching parents when to seek medical help for their children is crucial to ARI
control. To get this information across, health worker need to understand local beliefs and
terms. ARI news looks at a new research method designed to improve communication.
People explain, classify and manage illness largely according to past experience,
cultural beliefs and tradiUon. When health workers know about local beliefs and

49
practices, and make use of familiar terms and concepts, communications with families
will be improved.
The WHO program has developed a research protocol called the Focused
ethnographic study (FES). The protocol is a standardized method for collecting
information about communities' perception and practices related to ARI. It aims to
streamline research and to ensure that results can be easily used.
The FES is an intended to be used by trained researchers. The information is collected
from:
• Six to eight key informants (grandmothers, mothers, teachers, traditional healers
and C. H. workers).
• A community based sample of 25-30 mothers or careers.
• A clinical sample of 25 -30 mothers seeking care for children with ARI.
• A representative sample of local health workers and
• Pharmacists and drug sellers.
Researchers use this information to identified commonly held local beliefs and to analyze
how locally recognized signs and symptoms related to the clinical definition of ARI, in
particular pneumonia. Information is also sought about the usual patterns of seeking out
side help for ARI, and the reasons why mothers do not seek medical advice.
This information can be used to construct massages that families understand, as
well as other aspects of ARI program planning.
Jenny (1978) says that the nurse ik the only person constantly at the bedside of the
patient. She is a defacto educator and coordinator of patient education in the complexity
of his care. The nurse has more opportunity for patient teaching than any other member
of the health care team.
, an.
Mcleod Clark (1981) found that nursci^ on average speni only ten per cent of their
time communicating with patients. It was therefore not surprising that little patient
teaching is being done.
Anne Close (1988) in her literature review about patient education on identified
barriers that came in the way of effective patient teaching. She stated that it is generally
agreed that it is the part of the nurse's role to educate patients, but often this is not carried
out in reality. Where it is done it is mostly unplanned and haphazard 'KeiA^^e, -' -^^ . the

50
effectiveness is uncertain. There are many reasons she cited such as inadequate education
and training of nurses for this role, lack of knowledge about the content of teaching, lack
of communication skills, lack of teaching skill, low priority to educating patients.
A study done by Kumar, J. on effect of planned health teaching to the mother on
selected area io 'denote care at home, the study showed that there is significant
improvement in the knowledge and practice of mothers. During home visit the practices
were observed and it was satisfactory.
It can be concluded that planned teaching brings effective change in mother's
knowledge and practice.
Frona's et al conducted a study to find out the effect of health education
compliance with anti-tuberculosis chemprophylasxis in school children in Poland, and
found that after health education by nursing personnel better result were obtained and
parents improved their practices related to the drug regime.
Noble (1991) discussed the importance of new well nurses educate their patients
and what strategies the profession may need to consider in order to meet educational
needs of the future. She concludes that nurses can fee effective educators. However they
need to improve the ski 11 scowledge, motivation and support to organize and implement
an adequate program of patient education.
Jones (1983) suggests that one of the underlying principles in deciding should
take responsibility for appropriate health education is that those have the closest contact
with the individual should do it.
According to Gupte S. (2001), health education is very effective in bringing about
a significant improvement in knowledge. What is most noteworthy and, perhaps, ignored
in the past, reinforcement of the awareness exercise periodically is necessary for deriving
optima benefit from health education/ awareness programs.
Health education impact depends on many points. In the first instance, equality
and intensity of health education with which it is delivered to the target mothers has a
considerable bearing on its impact. Half-hearted messages, delivered in haste, often prove
counterproductive. Friendliness, knowledge of the local dialect, customs and practices are
important for the competent educator. So are the conviction and enthusiasm! For
instance, a health worker who is, herself ambivalent about the benefit of feeding during

51
the diarrhoeal episode is not expected to pass on such an advice effectively to the
mothers.
Secondly, the "receptiveness" of the mothers is extremely important for health
education to be really effective. Patiently listening to the patient's problems and queries
is bound to enhance better communication and produce better confidence in her.
Thirdly, despite availability of several educations to parents, the one-to-one
approach remains matchless. There is evidence that face-to-face guidance ensures correct
instructions to all households.
Fourthly, though a large chunk of health education has rightly been directed at the
mothers in the past, there is now a felt need for involvement of the men too. Else, the
beneficial effect is likely to remain "poorly cooked" if not exactly half-cooked. Naturally,
such a massage is bound to be inadequately digested and absorbed with insufficient
dissemination of knowledge, including teaching of such vital skills as recognition of
dehydration signs, preparation of ORS, etc. to the family as also to the community.
And, finally, nutrition education must be considered a part and parcel of health
education in any disease. The major messages for the mother should include exclusive
breastfeeding for at least first five to six months, timely introduction of semisolids, and
continuation of feeding during an episode of illness.
Active participation of the community, which is central to the success of any
health education strategy, should rank supreme.
Mangala S. & et al. (2001), studied the impact of educational intervention on
knowledge of mothers regarding home management of diarrhoea. A pre and post
comparison study was carried out in Kamataka to assess the impact of educational
intervention on the knowledge of mothers of under five year children on home
management of diarrhoeal diseases. Sample of 225 mothers were included in the study.
The study was conducted in three stages. Stage 1 - initial knowledge, attitude and
practices of mothers were assessed. Stage II- one to one educational intervention was
conducted and supported by audiovisual aids and live demonstration. Stage III - included
post intervention knowledge, attitude and practice after two months and two years. In this
study knowledge questions were standardized using the sigma weightages.

52
 The study revealed that several aspects regarding knowledge of mothers in home
management;,; of diarrhoeal diseases improved significantly two months after the
educational intervention. Though the proportion of the mothers retaining the knowledge
dropped at the end of two years, there was statistically significant improvement when
compared to the baseline study.
This shows that there is a need to reinforce the knowledge at frequent intervals.
The use of instructional manual will be more appropriate because mother can repeatedly
go through the manual.
Narrow (1979), parallels patient education to the nursing process in terms of its
stages, therefore implying a need for a very detailed assessment before a teaching plan
cab be developed, implemented and evaluated. Therefore a solid knowledge base, good
communication skills and interpersonal skills are essential if the nurse is to carry out an
adequate assessment of the patient's educational needs and readiness to learn.
Teaching the patient what he already knows is a waste of time and energy (Wilson
Bamett 1985) and teaching an irrelevant mater becomes frustrating and conftising.
(Spice, 1982).
Smith (1989) insist that current cost containment in health services will bring
client education issues to the forefront of economic debate.
Indeed, the over riding argument for developing client education is a key facet in
nursing is emerging, not just on health grounds, but as a consequence of in creating
financial stringency. Therefore we have to direct our energies to develop client education
in nursing practice.
2.5 Developing self-instructional materials:

Studies have found that nurses and patients differ in rating the importance of
patient education topics. Generally, studies have found nurses information about
mediation more than patients' value this information.
In contrast to nurse's priorities, patient's rated risk factors as a higher priority for
learning than medication. Nurses ranked the psychological category as more important
than patients' ranked it. (Gerard and Pelerson 1984, Karlik and Yarcheski 1987, Karlik et
al 1990).

53
 Patients and nurses may value different information and that patients may not
believe it is realistic to learn all the information while hospitalized. Unfortunately, no
research has been reported documenting mothers or nurses' perceptions of ARI mothers
learning needs.
The nurse, as a key member of the health care team, share responsibility for
educating clients in a variety of health related settings. However, the challenge associated
with increasing client autonomy necessitates a shift in the thinking of many nurses.
Nurses are in a upique position to maximize the health potential of the client so it is
imperative that this responsibility is recognized as an inherent aspect of professional
practice.
Moran (1995) in the study of quality indicators of patient information in short-
stay surgery units, expressed that printed information appeared highly desirable. Benefits
of having printed information for support and advice were obvious with patients and
caregivers reporting frequently referral to the leaflets. Take home written information is
increasingly used to reinforce verbal instructions given in the health care settings.
Jacob, M (1996). Teaching using planned instructional material helped in
improving knowledge and practice of parents with regard to the care of their children
receiving chemotherapy. Parents gave opinion that the instruction material was useful to
them.
Pohl (1965) says lack of time, heavy work load and inadequate staffing were often
cited as reasons for not doing patient teaching, but it is occasionally due to lack of desire
or poor organization.
Dodge (1972) found that there is disagreement between patients and nurses over
information they should receive and concluded that the information the patient saw as
iv^ij)<x-t?4 was information they had not yet received.
According to Cartwright (1981) all patients have information needs and they are
keen to learn about their disease condition.
Robert V. (1978) described that patient education encompasses two important
objectives. The objective is to provide vital information which patients need in order to
manage their livesf in a better manvtier. The second objective should be to give support
and encouragement to individuals who are experiencing health crisis.

54
 Smith (1979) Nurses are often the most immediate source of information whom
patient can approach and they form largest group of health care workers.
Gregor (1981) conducted a study to compare the effect of a self-instructional
booklet designed to teach basic facts about myocardial information, unstable angina and
treatment with routine instruction. Those having instructional booklet and significantly
higher posttest and retention score that the patients receiving routine instructions.
Parinello (1983) conducted a survey among twenty-eight patients hospitalized for
vascular surgery, to determine the effectiveness of a preoperative teaching booklet. The
booklet was rated as very helpful a by eighty per cent of the patients. Its helpfulness was
increased when discussed with a member of the health care team.
Lamb (1984) in the study, patients understanding of a teaching manual on cardiac
catheterisation, found put patient fiilly cooperated with the medical plan of care since
they got a basic understanding of the procedure from the manual.
Russel (1974) says there is more to it than just pictures. Creating patient education
booklet requires more than just sitting down and writing.
The steps in preparing such a booklet are closely related to the six steps, which
are used for designing, developing and validating modular instruction. The steps are:
Specifying objectives, constructing criteria, analyzing learner characteristics and
specifying entry behavior sequencing instruction and selecting media, trying out the
module, and finally evaluating the module.
Patil, S.M. (1990) conducted a study of Audio Visual media adopted by health
educator for promoting personal hygiene education in the comiAruiuV^,
Finding of the study shows that policy makers and planners of health education
activities were interested in quantitative results, that's why fulfilling required targets,
were one of the major hindrances in adoption of A.V. media for health education.
Most of the time the selected A.V. media were not suitable for personal hygiene
health education. Inconvenient communicating facility was one of the hindrances in
making use of A.V. aids for health educafion in the comwuvO+y.
Time limitation, limited manpower, and lack of researchers, inconvenient
transportation system was some of technical problems behind not making proper use of
A.V. aids in the field.

55
 International consultation of representations of government and UN Agencies was
held in Washington, on control of acute respiratory infections amongst children. The
meeting endorsed the following six points global approach^wHcjiSi).
• Training.
• Supplies and logistics
• Information to mothers.
• Immunization.
• Vaccine for pneumonia.
• Preventive measures against low birth weight and
• Indoor pollution.
The most important out come of this meeting was the recognition that pneumonia
now ranks 'First' among the cases of child mortality, where the ORT is being
successfully implemented.
Training and education:
Kumar V. Has described a program in India in which primary health care workers
and the community is learning about ARI. A study was conducted in Haryana a province
of north India.
A part of ARI control program, training material and education aids, which
summaries simply what is known about ARI has been developed. These illustrated
materials are produced in English and local languages to help people to recognize sever
ARI, which requires treatment or referral. They are used as talking points during health
education along with other educational materials and include:
• Posters describing the signs of pneumonia, with spaces for the names of health
workers and place of treatment to be filled in to help families locate the place in the
village. The posters were displayed in prominent places in village schools, grocery
shops and community centers.
• A simple pocket size booklet for PHC workers, which contains guidelines on
diagnosis and treatment.
• A manual for trainers and supervisors of PHC workers and charts, which provide
overview of program activities.
• Illustrated cards use to make good starting points for discussions.

56
 • Families, which have experienced favorable outcomes with ARI following standard
management guidelines, are encouraged to discuss their experiences with their
friends, neighbors and relatives.
The impact of training and health education has become measured directly and
indirectly in Haryana. Randomly selected PHC workers have been given multiple-choice
questionnaires. Correct responses to twelve questions have varied from fifty-three to 100
per cent.
Increased use of standard treatment by PHC workers and a significant increased in
the acceptance of co-trimoxazole therapy have been documented. This is in contrast to
the poor utilization of existing health facility in other areas. The indirect impact of the
training program has been seen in a dramatic fall in ARI related mortality in children in
the province.
Lalramdini, (2002), conducted a study on development of self-instructional
module for mothers on care of L.B.W. infants. The approach was descriptive in nature.
The sample consists of thirty mothers of LBW infants whose infants are less than sixteen
weeks old. The samples were selected based on predetermined criteria and on their
availability. The technique employed for sampling was non-probability convenience
sampling. During the study, it was observed that all mothers needed information on care
of L.B.W. infants. Even though majorities of the infants (70%) were delivered in hospital,
mother usually not informed about the birth weight of infant being low and its
implication. The preparation of self-instructional module was well appreciated by the
mothers. All understood information in the module and module was given a rating of
very good by majority of the mothers.
Vishvasrao, (1998), conducted a study on development of an informational
booklet for patients attending the Cardiac Surgical O.P.D. The approach was descriptive,
evaluation in nature. The sample consisted of fifty patients who were selected according+o
availability, criteria laid down and willingness to participate in the study. The tool used
for data collection was questionnaire and the technique used for data collection was the
Interview method. Most of the patients expressed the need for information in all areas.
The response obtained from the interview contributed towards developing the booklet,
which was given to patients and their relatives. Most of the sample responded that the

57
booklet was very useful for them and the information was adequate. They also expressed
that having gained information; the cardiac surgical OPD environment was less
frightening to them. The findings supported that written information is useful in their
coping.
Sandler et al (1959), looked at the recall of patient who was given an information
booklet on discharge from the hospital. 130 patients discharged from the hospital were
alternately chosen to act as control or to review an information booklet. Result of the
study indicated that of those in the group that received the booklet, eighty-six per cent
knew the names of the drugs, ninety-five per cent knew how to take them and eighty-five
knew the reason for taking the drugs. This was for higher than in the control group of
whom forty-seven per cent knew the names, fifty-eight per cent the drug and only forty-
two per cent the reason for taking the drugs. This implies that those who were given a
booklet on discharge from the hospital has an increased level of recall about their drug
therapy thanthose who were not given written information.
A study was conducted by Gauld (1981) to evaluate the effect of written advice
on patient compliance and recall. Total samples in the study were 100. Two groups with
urinary tract information were randomly allocated to receive written and verbal
information or verbal information only. Result of the study at the follow up indicated
that, those who were given both sets of information were able to recall better and had
increased amount of information over those who had received only verbal information.
From these studies, it can be concluded that written information in various forms,
leaflet, booklet, module etc. help to strengthen and grow in the initial level of knowledge
and given guidance to put the knowledge to practice when needed.
Judith Noronha, (1998) conducted an experimental study to identify "information need"
of pregnant women. Based on this information, a booklet was developed and tested for its
effectiveness, in improving knowledge of warning signs for thirty-three pregnant women
using a one group pre-test, post-test design. The finding reveled that the mean post-test
score of eighty-nine per cent was significantly higher than the mean pre-test score of
twenty-six per cent. This indicated that the information booklet was effective in
increasing the knowledge of pregnant women regarding warning signs.

58
 • Many times patients and family members do not get complete health information,
which creates anxiety and causes difficulty in coping with disease condition or
health care'services.
Gulani, K. et al (1988), concluded an Experimental Pilot Study in an Indian rural
setting to assess father's level of knowledge of DPT immunization and to measure the
effect of a formalized teaching programme for fathers on completion of immunization
schedule for their infants.
A randomized, pretest, post-test control group design was used. The sample was
selected at random to include nine fathers in the experimental group and fourteen fathers
in the control group. A one-hour formal immunization target programme was developed
by researchers and taught to fathers in the experimental group. A questionnaire was used
to assess the fathers' level of knowledge about immunization before and after the formal
target programme.
The experimental group acquired significantly more knowledge thftn the control
group. A high the co-relation between father's education level and level of knowledge of
immunization was found.
Chatterjee, S. (1988), a study was conducted to assess the learning needs of
leukemia patients. A structured interview schedule was developed to assess the subjects'
knowledge and their expressed needs to know more about home management in
leukemia. The findings revealed that the leukemia patients and their attending relatives
had specific learning needs regarding home management of these patients, as revealed by
their low knowledge and high expressed desire to know.
A self-instructional module was prepared and tested on an experimental group of
patients and relatives. It was found that the module was effective in bringing about
changes in cognitive behavior of leukemia patients.
The study highlights that patients require self-instructional material to become
more responsible for their own health under the guidance of health professionals.
Lalramdini (2002), conducted a study on development of self-instructional
module for mothers care of low birth weight infants. The approach was descriptive in
nature. The samples consist of thirty mothers of low birth weight infants whose infants
are less than sixteen was old. The samples were selected based on predetermined criteria

59
and on their availability. The technique employed for sampling was non-probability
convenience sampling. During the study, it was observed that all mothers needed
information on care of low birth weight infants. Even though majorities of the infants
(70%) were delivexed in hospital, mother usually not informed about the birth weight of
infant being low and its implication. The preparation of self-instructional was a scientific
process involving various steps. The prepared self-instructional module was well
appreciated by the mothers. Information of the module was understood by all and module
was given a rating of very good by majority of the mothers.
Vishwasrao, (1998), conducted a study on development of an informational
booklet for patients attending the cardiac surgical out patient dept. The approach was
descriptive, evaluation in nature. The sample consisted of fifty patients who were selected
according availability, criteria laid down and willingness to participate in the study. The
tool use for data collection questionnaire and the technique used for data collection was
the interview method. Most of the patient expressed the need for information in all areas.
The response obtained from the interview contributed toward developing the booklet,
which was given to patients and their relatives. Most of the sample responded that the
booklet was very useful to them and the information was adequate. They also expressed
that having gained information; the cardiac surgical OPD environment was less
frightening to them. The findings supported that written information is useful in their
coping.

Sandler et al (1989) looked at the recall of patients who were given an

information booklet on discharge from the hospital. 130 patient discharged from the
hospital were alternately chosen to act as control or to review an information booklet.
Result of the study indicated that of those in the group that received the booklet, eighty-
six per cent knew the names of the drugs, ninety-five per cent knew how to take them and
eighty-five per cerit knew the reason for taking the drugs. This was for higher than in the
control group of whom forty-seven per cent knew the names, fifty-eight per cent the
drugs and only forty-two per cent the reason for taking the drugs. This implies that those
who were given a booklet on discharge from the hospital has an increased level of recall
about their drug therapy that those who were not given written information.

60
 A study was conducted by Gauld (1981) to evaluate the effect of written advice
on patient compliance and recall. Total samples in the study were 100. Two groups with
urinary tract infection were randomly allocated to receive written and verbal information
or verbal information only. Result of the study at the follow up indicated that, those who
were given both set of information were able to recall better and had increases amount of
information over those who had received only verba! information.
From these studies, it can be conducted that written information in various forms,
leaflet, booklet, module etc. help to strengthen and grow in the initial level of knowledge
and given guidance to put the knowledge to practice when needed.
Judith Noronha (1998) conducted an experimental study to identify "information
need" of pregnant women. Based on this information, a booklet was developed and tested
for its effectiveness, in improving knowledge of warning signs for thirty-three pregnant
women using a one group pre-test posttest design. The findings reveled that the mean
post-test score of eighty-nine per cent was significantly higher than the mean pre-test
score of twenty-six per cent. This indicated that the information booklet was effective in
increasing the knowledge of pregnant women regarding warning signs.
Many times patients and family members do not get complete health information, which
creates anxiety and causes difficulty in coping with disease condition of health care
service.
el
Downs and Fembach (1973), report on experimental study designed to assess the
effect of a prenatal leaflet series on knowledge and subsequent behavior. A Solomon four
group design was used with a starting sample of 286 subjects drawn from the Maternity
and Infant Care family planning projects. No differences in information level were found,
nor were knowledge and behavior related.
Garrey and Kramer (1983) compared the effects of a structured self-paced
educational program to the effects of a previous method of one-on-one teaching by a
nurse. The instruction was designed to help thirty-two cancer patients self-administer
chemotherapy with a portable infusion pump. Results showed that the self-paced program
decreased teaching time by fifty per cent, eliminated the need for outpatient teaching,
reduced the number of night time phone calls for help and resulted in higher patient
satisfaction.

61
 Young and Brooks (1986) used sixteen multiple sclerosis patients randomly
assigned to an experimental and control group to determine the effectiveness of a
teaching manual concerning medication. Both groups were given instruction by a
physician and a nurse, and the experimental subjects also received a patient information
manual. The experimental group had significantly higher post-test scores than the others.
Lamb (1984) evaluates the effectiveness of a teaching manual about cardiac
catheterization for use by patients. A total of thirty patients scheduled for elective cardiac
catheterization, served as subjects. They were pre-tested, given the booklet and then
given the post-test. Finding supported a significant increase in mean scores from pre-test
to post-test.
Gregor (1981) compared the effects of a self-instructional booklet designed to
teach basic facts about myocardial infarction, unstable angina, and treatment with routine
instruction. A total of 100 patients from two hospitals were assigned randomly to the
control or experimental group. The dependent variable was knowledge acquisition and
retention. Those completing the self-instructional booklet had significantly higher post-
test and retention scores.
Lalrinhlui, .conducted a study to develop an information booklet for caregivers on
care of a patient with depression. A descriptive research approach was used. The study
consisted of fifty samples. The caregivers existing knowledge was analyzed. The
caregivers needed information regarding care of a depressed patient. The caregivers
lacked the knowledge about the variance aspects of•rx^eof their depressed patients. The
information booklet was prepared and was given to the caregivers. They felt the content
was adequate in all the areas of care and the caregivers appreciated it.
A descriptive evaluative approach was used for development of a booklet for
parents of neonates admitted to the neonatal intensive care unit, based on the information
needs. The sample consisted to thirty mothers whose neonates were admitted to neonatal
intensive care unit and questionnaire was used for data collection. The result of the study
indicated that all the parents were in need of information, but they did not know what
kind of information they were entitled to, whom and when to approach for obtaining
information or what response they would get to their queries. The booklet helped the

62
parents in getting the information of the neonatal and regarding his care. (D' Souza, A
1996)
Alphonso, L. (1994), conducted an exploratory research approach study on
evolving an instruction manual for patients undergoing diagnostic cardiac catheterization.
The purpose of the study was to find out the view from doctors and nurses about the
same. Based on these findings an instruction manual was prepared. From three municipal
hospitals thirty patients, fifteen nurses and fifteen doctors were selected as samples. The
study concUjcifed that patients prefer to receive information in the OPD from the doctors
and later in the ward they would like the nurses to provide them further information.
Doctors and nurses felt that clients should be furnished with the necessary information.
Lalhlimpuli, M (2003), conducted a descriptive study to develop self explanatory booklet
on home care of hypertension for general public at a selected area of Malvani. The study
included thirty samples of variance categories such as skilled workers, semiskilled
workers, unskilled workers and housewives. The knowledge and learning needs were
assessed by interview method. Based on long needs the self-explanatory booklet was
prepared. The study showed that the subjects needed information on home care of
hypertension. Even-though majority had received information through various sources
their level of knowledge was not adequate. The booklet was understood and appreciated
by all the subjects.

Vasundhara T. (1999), conducted a study on "The effectiveness of the instructional

module on self care practices of renal transplant patients."
Helping patients to learn to care for themselves has been an integral part of
nursing practice. Self- instructional modules (SIM), which impart information and
develop new cognition offer potential, effective and relatively inexpensive tools for
patient education. The study was done in two phases. In the first phase a survey approach
was used for learning needs assessment. In the second phase a SIM was developed and
evaluated through pretest, post-test control group design. SIM was prepared in the form
of booklet based on findings of learning needs of such patients. The control and
experimental group had fifteen renal transplant patients in each. The finding of the study
revealed that the mean post-test knowledge score of experimental group was significantly
higher that that of the control group. The study reports the effectiveness of a (SIM) in the

63
self care of a patient with renal transplants. SIM is a simple, convenient and time saving
method for providing information to renal transplant patients. A specially designed
information booklet on 'warning signs in pregnancy for primigravid women' (Judith,
196lf) was found to be higher effective in self-care and assessment of pregnant women.
However, self instructional modules have a limitation that the self-instructional
module can be used only with educated patients
Bairwa, conducted a study to develop and evaluate the effectiveness of an
informational booklet on cancer risk factors. The study population was college students.
The one group pre-test post-test experimental research design was adopted for the study.
Convenient sampling method was used to select the population. The reliability of
knowledge questionnaire and opinionnaire were computed using Kudar Richardson
twenty formula and test-retest method was found 0.98 and 0.65 respectively. Pre-test was
given the informational booklet was given on day one and post-test was administered on
1^ day after collecting back the informational booklet. The data collected was analyzed
in terms of frequency, percentage, mean, median, standard deviation and 't' value.
Finding of the study were: The information book was effective in increasing the
knowledge of the college students as evident from 't' (29) = 52.44 P < 0.05 and 0.01
computed between pre-test and post-test knowledge scores. It was also indicated that the
informational booklet was acceptable and useful.
From these studies, it can be concluded that written information in various form
e.g. leaflet, booklet module etc. help to strengthen and increase level of knowledge and
helps to practice accordingly.

64
2.6 IMPLICATIONS FOR THE PRESENT STUDY
• Diagnosis of the pneumonia is done by stethoscope by seventy five per cent of the
practitioners, whereas only few use respiratory rate as first choice for diagnosis.
And maximum go for X-ray chest for diagnosis.
• Maximum practitioners use antibiotic and Ampicillin and Erythromycin as the
drug of choice and very few chooses to give cotrimoxazole whereas WHO has
recommended this in its standard case management of ARI.
• From the fact and figures, it is clear that ARI places a considerable strain on
health services throughout the developing world.
• ARI is an important cause of high morbidity and mortality among children under
five years. The threat posed by ARI to child survival in India is tremendous. It is
estimated about 0.75 million children below five years die of ARI every year in
India.
• There is inappropriate antibiotic use for cough and cold. Some children with
pneumonia do not receive antibiotic. Very few caretakers (mothers) know correct
home care of the children with ARI. Hence we have to promote the standard case
management of ARI and educate the mothers about the correct home care.
• The study in Pakistan shows that the cost of antibiotics use can be reduced be
using WHO guidelines. An effective use of ARI treatment guideline had a rapid
impact in reducing pneumonia deaths among children.
• The tachypnea is used as a diagnostic criterion for childhood pneumonia as the
primary health care workers cannot use stethoscope. The mothers also can be
tcaighthow to count the respiratory rate and they will seek the medical help if
tachypnea is observed.
• Zinc supplementation reduces the incidence of acute lower respiratory infections.
• Vitamin 'A' deficiency increases the risk of respiratory infection.
• Use of pacifier leads to risk factor for acute otitis media and when it was
restricted to use only when child was falling asleep effectively prevent episode of
acute media.

65
Breastfeeding, nutrition, indoor environment pollution caused by cooking fire,
parental smoking and immunization are the most important factors which affect
the incidence of ARl.
All the factors have been recognized as amenable to change. Therefore an
effective preventive strategy has greater importance in reducing the ARI related
mortality in young children.
Whereas the study conducted in UK to find out the association between URTI and
air temperature and humidity in the home found no association between URTI and
type of home, family size, level of occupancy, smoking habits, temperature and
humidity which were compared with non infected children.
These are the factors which influence ARl should be kept in mind while
collecting the data and developing the Self-Instructional manual.
Fever and cough and when questioned faster breathing these were the clinical
findings mothers saw in their children according to them it could be pneumonia.
Fast or difficult breathing and fever was an important sign for the mothers to seek
the care.
Mothers are prompt in seeking care but not able to discriminate from when to
seek health care. Many prefer to go to unqualified private practitioners and
traditional healers and also frequent changes in practitioners and reluctance to
seek hospital care.
Mothers identify cough and fever as common symptom of ARI. Mothers seek
medical help when there is fast breathing but also many seek help when there is
fever and blocked nose.
The Gambian use the term chest pain, fast breathing and open chest for fast
breathing and chest in-drawing. The mothers reported cases with these symptoms
were clinically diagnosed as pneumonia.
Hence mothers play a key roles for identifying the symptoms and seeking prompt
help and prevent moderate illness progressing towards sever illness.
Mothers know that fever is danger of death due to pneumonia. Maximum mothers
restrict the food during illness. Many mothers prefer modem system of medicine

66
but very few of them utilize the hospital service. Many of them go to traditional
local rural medical practitioners.
Majority of mothers in rural area start breastfeeding on the 3'^'' day and stop
breast-feeding early because of insufficient and pregnancy. And weaning is also
done late aci personal hygiene of the children is not given attention and few
mothers take their children for minor ailments to doctors.
These entire practices child rearing are the influencing factor for ARI.
Mothers feel bad weather and cold food consumption is the cause of ARI.
Study conducted in Nigeria shows that, fast breathing was not generally
recognized by mothers. But it is an indicator for immediate care seeking.
Therefore mothers should be taught to recognize this danger sign.
Maximum mothers believe the traditional local doctor to be sought and have
remedies for cough. Some mothers directly seek medicine advice from
pharmacies and give haphazard drug regime. There are frequent changes in
practitioners.
Accepted pattern of health seeking behavior is found in some mothers but care
ability of mothers is inadequate, whereas there is significant positive relationship
with family support and ability to^J»provide care.
Well-planned health education to the mothers shows a significant improvement in
the knowledge and practices of the mothers.
It is observed that simple, minimum to the point information is retained by the
mother than detailed information. Mothers are able to identify the danger signs,
seek the medical help in time, and initiate medical treatment on time if simple
instructions are given.
When mothers receive information they are able to see the symptoms in their
children and seek the medical help, and maximum cases the clinical diagnosis by
doctors regarding pneumonia and the mothers identifying the danger signs and
symptoms coincide, this shows education does make a significant improvement.
If health education improves health practices who will do this? I am sure the
answer is Nurse. Since she is the one who is constantly with the patient. And one

67
 -ff,e.
of role of the nurse is patient educator. In this study the mothers have to be
educated in childcare.
• Patients express the printed information, booklet as high desirable. The patients
fully co-operate with the medical plan of care because they get the basic
understanding from the procedure manual.
• The manual patient can go through it and retain the information. They can refer to
it repeatedly.
• Warning signs in pregnancy for primigravida women was found to be highly
effective in the self-care and assessment of pregnant women. The self-
instructional module in the self care of patient with renal transplant shouie<ian
effective teaching module. It is considered as a simple, convenient and time
saving method for patient teaching.
• The mothers understand the simple. Clear, specific and their local language
instruction, than the more complicated and difficult teaching.
While developing the instructional manual the patients needs use of language,
local terms for the symptoms, or medical jargon, literacy level of the group all these
aspects have to be kept in mind,
2.7 Related Literature about ARI
2.7.1 Introduction
ACUTE RESPIRATORY INFECTION

Acute respiratory infection (ARI) is not just another disease. It is a very important
cause of high morbidity and mortality among children under-five years. In India of all the
deaths among children under-five years of age, approximately fifteen to thirty percent are
contributed by ARI. Data from community based studies suggested ARI mortality rate of
642.5/100,000 children under-five years in India. It is estimated that about 0.75 million of
children under the age of five years die of ARI every year in India.
Different studies both within and outside the country has shown that, mortality
from ARI could be significantly reduced through proper case management. This resulted
in introducfion of ARI control programme. On a pilot basis in selected districts and later
it became a part of the primary health care system.

68
 Now we will discuss what is ARl? Acute respiratory infection comprises a group
of conditions caused by a variety of pathogens, including bacteria and viruses. ARI is
defined as an episode of a acute symptoms and signs resulting from infection of any part
>
of respiratory tract or any related structure including Para nasal sinuses, middle ear and
pleural cavity. A new episode is one occurring in an individual, who has been free of
symptoms for at least forty eight hours. ARI is often classified by clinical syndromes
depending on the site of the infection and is referred to as ARI of the upper (AURI) or
lower (ALRI) respiratory tract.
The working group of WHO which met in 1985 to draft proposals on the
classification of ARI for the tenth revision of the international of diseases recommended
that ARI should be broadly into two groups; that is upper and lower respiratory
infections. The upper include common cold, pharyngitis and otitis media. The lower
include epiglottitis, laryngitis, bronchitis, bronchiolitis and pneumonia.
2.7.2 Signs and Symptoms:
«
ARI may involve many areas of respiratory tract and there can be a wide variety
of signs and symptoms. They primarily include: cough, difficult breathing, sore throat,
runny nose, fever, ear pain etc. a commiiiMty based longitudinal study has observed the
following signs and symptoms in ARI:
Cough, Runny or blocked nose, Fever, Rapid breathing, In-suction, Ear discharge,
Ear pain, Wheezing, food refusal. Grunting, Irritable stridor. Sore throat, Horseness
Listless.
The above information can give some ideas about the presenting features of ARI.
However, sometimes ARI may present itself, particularly in 0-2 month's old infants,
which non-specific and vague manifestations.
2.7.3 Classification:
The classification of acute respiratory infection is complex and difficult. Some
commonly used classifications are as follows:
I Aetiological classification: * Viral, *Bacterial *Fungal * Mycoplazma *Allergic
II Anatomical classification: * Rhinitis *Otitis media *Phyryngitis *Sinusitis *Tonsilitis
•Epiglottitis *Laryngitis *Trcheitis *Pneumonia.
III Classification as per site of involvement:

69
 Upper: upper respiratory infection, pharyngitis.
Mid : epiglottitis, laryngo-tracheo bronchitis.
Lower: bronchiolitis, pneumonia.
IV The working group of W.H.O. in tenth revision of International classification of
diseases recommended that ARI should be classified broadly into two groups: upper
and lower respiratory infections.
Upper: Cold, ear problem (otitis media) and Sore throat (Pharyngitis).
Lower: Croup, obstructive laryngitis (epiglottitis, laryngitis. Tracheitis), Bronchitis,
Bronchiolitis and Pneumonia.
V Giving considerations to the management of ARI at primary health care level, W.H.O.
has classified ARI as follows:
ARI

Sore throat Ear problem Pneumonia

_J
'i
(0-2 Months) (2 Months to < than 5 yrs.)
* Very severe disease * Very sever disease
* Sever pneumonia * Sever pneumonia
* No pneumonia * Pneumonia
* No pneumonia
The Functional Basis of Respiratory Pathology:
Airways: The basis structure of the airways is already present at birth, and thus neonates
and adults share a common broncho-pulmonary anatomy. Airways within the lung,
however, are quite asymmetric at all ages. When airways divide, there is a variation in the
size and number of branches, and depending on the location there may be anywhere from
10 hilar region to 25 based region airway divisions before the gas-exchanging units are
reached. As the bronchi branch and decrease in size, they lose their cartilage and become
bronchioles. Ultimately, a terminal bronchiole opens up into the gas-exchanging area of
the lung.

70
 Nasal covity
Na5ol furbmotes
Nasopharynx - N a s a l cartiloge
Opening of auditory (Eustachian) lube Maxilla
Uvula (hord palate)
Polaline tonsi
Phoryn
Epiglottis

Vocal corch Hyoid bone

* Thyroid cartilage Thyroid cartilage
Crtcoid tar'ilavje
^^ Trocheai cortdages

Visceral pleura ..
Parietal pleura —
Left main bronchos
Right upper lobe of lung
Left upper lobe
Carina of trachea of lung
Pulmonary veins
Right main bronchus
Pulmonary trunk
Horizontal fissure and arteries
Aorta
Sup vena cava •Left atrium
Aortic valve
Right middle Pulmonary valve
Bronch
•Mitral valve
Oblique
l e f t ventricle
•Oblique fissure

R lovi^er lobe — L lower lobe

of lung of lung
Intercostal
Interventricular
muscles septum
Diaphragm

STRUCTURE OF RESPIRATORY SYSTEM

FIG NO 4
 The airways are lined with an epitheiicil membrane that gradually changes from
ciliated pseudostratified columnar epithelium in the bronchi to a ciliated cuboidal
epithelium near the gas-exchanging units. Ciliated cells predominate throughout this
epithelium and are responsible for propelling mucus from peripheral airways to the
pharynze. This mucociliary transport system is an important defense mechanism of the
lung.
Goblet cells are seen in the trachea and bronchi. They produce mucin within their
rough endoplasmic reticulum and Golgi apparatus. Mucin is a viscous mixture of acid
glycoproteins that contributes to the mucons larger; Goblet cells can increase in number
in disorders such as chronic bronchitis, the result being mucons hypersecretion and
increased sputum production.
Terminal Respiratory Unit: The terminal respiratory (gas-exchanging) unit coniVif of the
structures distal to the terminal bronchiole,the respiratory bronchiole (bronchiole with
alveoli budding from its wall), alveolar ducts, and alveoli. The alveoli are liyed by two
types of epithelial cells. The type I epithelial cell is an extremely broad, thin cell that
covers 95per cent of the alveolar surface. It is markedly differentiated cell possessive few
organ cells. The type II epithelial cells are more numerous than type I cells, but owing to
their cuboidal shape, type II cells occupy only five per cent of the alveolar surface area.
There is a thick side and a thin side to the alveolar capillary membrane. Gas
exchange occurs predominantly on the thin side.
Mechanism of Respiration:
Muscles of Respiration:
The importance of the muscles of respiration derives from the fact that these
muscles, like the myocardium, can fail under abnormal circumstances and can induce or
contribute to an impending or existing ventilatory failure. The principal muscle of
respiration is the diaphragm, a thin musculotendinous sheet that separates the thoracic
from the abdominal cavity. Other skeletal muscles located in the chest of abdominal wall,
such as the intercostals, the scaleves, and the abdominal muscles, can play an important
role in ventilation. During normal breathing, most of the accessory muscles are silent.
However, during abnormal conditions of disease states, these muscles are recruited to
stabilize the chest of abdominal wall so that the diaphragm may be more effective. In

71
addition, it has been demonstrated that the external intercostals muscles contract in acute
asthmatic attacks not only during inspiration but also during expiration; this contraction
maintains a higher lung volume and hence increases airway diameter.
When airways are occluded during inspiration, abdominal muscles contract
powerfully during expiration, pushing the abdominal contents and diaphragm toward the
thoracic cavity. This action lengthens diaphragmatic fibers and enhances the capability of
the diaphragm to -generate force during the subsequent inspiration. The upper airways
must be kept patent during inspiration, and therefore the pharyngeal wall muscles,
genioglossus, and arytenoid muscles are properly considered muscles of respiration.
Epidemiological Triad
Acute respiratory infection is the result of interactions between three
epidemiological factors i.e. host, agent and environment.
Host: children may vary not only in their genetic makeup, but also in the natural and
acquired immunity of their bodies and respiratory tracts. Previous infection and poor
nutrition can make them more susceptible to ARI. A genetic defect in the ability to
produce certain antibodies can reduce a child's capacity to fight infection. Upper
respiratory tract infections are several times higher in children than in adults. Rates for
pharyngitis and otitis media increase from infancy to a peak at the age of five years.
Illness rates are highest in the young children and decreases with the increasing age.
A study in urban Delhi, the incidence was 81/1000 in first year of life, and then
decreased to 68, 67 and 56 and 31/1000 during subsequent four years. ARI was most
commonly seen in the first year of life, followed by one to five years of age.
Respiratory infections tend to affect more frequently males than females. The
ratio is about 1.7 to 1. The difference may partly be due to preferential treatment to male
children, who when sick are more likely to be brought to hospitals or health care units.
Agent: The respiratory tract may be invaded by numerous microbial agents, ranging from
sub-microscopic viruses to large bacteria, fungi or even parasitic worms. Recent studies
have suggested a number of general conclusions about he agents causing ARI e.g. viruses
are the most important initiators of minor upper respiratory infections, and bacteria are
the agents which most often causes sever lower respiratory infections.

72
 The common bacteria are streptococcus pneumonia, staphylococcus aureus and
haemophilus influenza. The most common viral agents include respiratory syncytial
viruses (RSV), para-influenza and adenoviruses.
Environment: The infection is usually transmitted within the families. Children of
cigarette smokers are more prone to ARI in their early years. Respiratory infections
usually occur more frequently during cold weather than in any other season. Most studies
in Northern India show that incidence of ARI is highest during winter months. In
Colcutta, peak incidence was seen before during monsoon.
RISK FACTORS RELATED TO HOST AND ENVIRONMENT:

Related to host Related to environment

Low birth weight Clustering of houses
Failure of breastfeeding Poor socio-economic condition
Under nutrition Non use of antibiotics
Lack of childhood immunization Non utilization of service facility
Neonatal period vulnerable to ARI Over crowding
Vitamin 'A' deficiency Inaccessibility of health facility
Antecedent viral infection High level of outdoor pollution
Exposure to biomass fuel smoke
Passive smokmg.
Transmission: ARI is primarily transmitted by droplet infection when organisms in the
respiratory and nasopharyngeal secretions are expelled by an infected person by
coughing, sneezing or talking. Person to person contact spread in the home also has been
demonstrated. Enhanced production of respiratory secretions during viral infection may
play a role in transfer of bacterial agents to susceptible persons.
2.7.4 Laboratory Diagnosis of ARI:
The lab triangle of bacterial viral agents can be done through conventional or rapid
techniques:
A) Conventional technique:
1) Isolation of bacteria. -Nasal, Perinasal and throat swab.
2) Antigen detection of bacteria:
3) Conventional techniques for viruses.

73
B) Rapid techniques:
1) Rapid techniques for bacteria.
2) Rapid techniques for viruses.
Clinical Assessment: History taking is very important in the management of the acute
respiratory infections. The age of the child, for how long the child is coughing, where the
child is able to drink (if child is two months to five years), has the young infant stopi>ed
feeding well (child less than two months), has there been any antecedent illness such as
measles, does the child have fever, is the child excessively drowsy or difficult to wake (if
yes, for how long), did the child have convulsions, is there irregular breathing, short
periods of not breathing or the child turning blue, any history of treatment during the
illness.
Physical Examination: Look and listen for the following:
Count the breaths in one minute.
Look for chest in-drawing
Look and listen for stridor
Look for wheeze
See if child is drowsy
Feel for fever
Check for severe malnutrition
Look for cyanosis.'
2.7.5 ARI Control Program:
The W.H.O. which vital concerned with the health of human race on this planet,
could not sit idle and see some 4 million children dying from ARI each year. Studies in
different parts of the world have helped in developing the generalizations about ARI are:
• Most ARI deaths due to ALRI.
• Most of ALRI deaths occur in the developing countries
• Pneumonia is responsible for about 75% of all ALRI deaths.
• Almost all pneumonia (ALRI) in the developing countries is of bacterial etiology
and the bacteria are susceptible to common antibiotics.
The community based studies in India (Punjab) in 1970s had shown that:

74
 • In remote and rural areas where vast majority of people live, properly trained
health workers can identify pneumonia (ALRI) in children with the help of simple
observable signs and treatment successfully with antibiotic.
• Though occurrence of ARI could not stopped, or reduce the strategy of time and
proper management of pneumonia cases can reduce the ARI related mortality
in children.
With this background the WHO program for control of ARI in children was officially
established in 1982.
The important generalization made from the intervention studies, which helped to
formulate major pglicy decisions in respect of WHO ARI control program are:
• A properly implemented case management program approach to ARI can reduce
overall mortality specifically mortality due to pneumonia in children under five
years age group.
• It is feasible to put oral antibiotic (co-trimoxazole) in the hand of peripheral
health workers for treatment of pneumonia.
• As large number of ARI death in children occur in 0-2 months age group program
should be enhanced to provide better guidance for management of pneumonia in
this age group of infants.
• The program should discourage the inappropriate use of antimocrobials and other
drugs in mild ARI cases.
• Program mlist be continuously monitored and evaluated.
• Respiratory rates and stridor (chest in-drawing) would be used by peripheral
health workers as two sample observable signs for diagnosis of ALRI
(pneumonia).
Components of ARI Control program
Health service components:
Correct cases management is the central strategy to reduce mortality due to ARI,
particularly pneumonia
Immunization has been also been recognized as specific strategy to prevent respiratory
infection, caused by diphtheria, measles, whooping cough and tuberculosis.
To support and strengthen nutrition, MCH and family welfare programs.

75
Key elements are mentioned in ARI treatment charts, in which the recognition and
treatment of pneumonia is the most important feature.
Research Component:
WHO has recommended that ARI control program shouldC^JS focus its support on the
problem of ALRI in under five children in developing countries. Priority research topics
were outlined in the broad areas of epidemiology, aetiology, disease prevention, case
management, vaccination and development of diagnostic tests.
2.7.6 National ARI Control Program
In India the ARI control activities are as old as the medical profession itself but
now the introduction of organized activities against ARI which can be performed
simultaneously to achieve effective and desired impact. The studies have been conducted
in Chandigarh, Jhansi, Delhi and Varanasi through l.C.M.R. with UNICEF and WHO
support. The results of these projects and other global projects gave enough direction to
start an ARI control program in India. The program was included in 7* five-year plan and
separate budgetary allocation was sought.
The objective of ARI control program is to reduce the pneumonia mortality in
under-five year children.
The strategy adopted to achieve the objectives is standard case management.
Standard Case Management
I) Sub center/PHC without in-door beds: Child with ARI -assessed
*Cough or cold - mother is advised how to take care at home.
*If pneumonia - standard antibiotic + home care, and advised when to return to health
worker.
*Serve pneumonia Or Danger signs - Referred for admission to PHC/hospital.
II) At hospital/PHC with in-door beds:
Serve pneumonia Standard treatment by health staff.
Or (02, injectable antibiotics etc.)
Danger signs.. Wheezing child treated with bronchodilators.
And
(Young infants with If Ear infection —• local care and antibiotics given.
Pneumonia)
Or If not responded to standard case management
Sepsis then referred to specialized hospital.

76
 Studies conducted in developing countries by WHO, have found that 40% of
deaths due to acute lower respiratory infections can be prevented by standard case
management at first level of health facility. Treatment at first referral a center
(PHC/hospital) can prevent another 20% of deaths, and a still another 20% of deaths can
be prevented by proper treatment at specialized hospitals.
Program is implemented through Primary Health Care.
Management of cough or difficult breathing:
(1) Management chart
WHO has a few charts for use by health staff at first level of health facilities, to
manage cases of cough or difficult breathing. These charts have been adopted by our
national ARI control program with some modifications. The steps involved c^j"^";..-to
follow the charts are:
a. Assessment of the child i.e. obtaining information about the child's illness, by asking
the mother the few questions, looking faituL- listening to the child.
b. Classification of the illness i.e. making decision about the type and severity of the
disease. This is done by self- answering of questions by health staff about the signs
those have been observed during the assessment.
c. Management i.e. extending of treatment as per the class of illness and it includes,
giving atv antibiotic, advice to mother to give home care, treatment of fever and
referral action, if needed.
2. Classes of illness and treatment of guidelines:
As mentioned above, the illness of cough and difficult breathing is classified
under two age groups (viz.:0-2 months & 2 months to <5 years). For treatment purpose
each age group is further subdivided in to different categories as per the presenting
features and there are specific guidelines for management of each class of illness:
(I )Young infants (0 to 2 months):
a) Very sever disease: the presenting features are, stopped feeding well, convulsion,
abnormally sleepy or difficult to wake, stridar in calm child, wheezing, fever of feels
too cold. In such cases the scope of treatment is very limited at first level of health

77
 facility. After giving first dose of paediatric cotrimoxazole tab., the cases are to be
referred to next higher level.
b) Server Pneumohia: This illness is presented with fast breathing (60 or more/minute)
and sever chest in-drawing. Here also after giving first dose of antibiotic, the case is
to be referred.
c) No pneumonia: in this case the child will have a breathing rate of <6o/minute and there
will be no severe chest in-drawing. Antibiotic is not needed in this case. Only the
mother is to be advised to giving "Home Care".
In young infants all pneumonia cases are to be taken as severe and to be referred after
giving first dose of antibiotic.
(II) Children (two months to less than five years):
a) Very severe disease: the presenting features are, not able to drink, convulsion,
abnormally sleepy, stridor in calm child and clinically severe malnutrition. Before
referring the child, (which is must) first dose of antibiotic is to be given. Moreover if
there is fever, necessary first dose of paracetamol is to be given.
b) Sever pneumonia: here the only presenting feature is chest in-drawing. For
management, after giving first dose of antibiotic and first dose of medicine for fever
(if present), the child is to be referred.
in.
c) Pneumonia: there will be not any chest drawing. But fast breathing will be present
(rates are fifty or more/minute for two months to one year age-group and forty or
more/minute for one year to below five years age-group). In this class of illness, the
first level health facility has got a lot to offer. Oral antibiotic (tab. Co-trimoxazole)
for five days is to be given along with treatment of fever, if present. The mother is to
be advised for "Home care". Reassessment of the condition of the child is to be made
after two days. If condition gets worsen, the child is to be referred.
d) No pneumonia: the child will come with cough and cold without any fast breathing of
chest in-drawing. Treatment is very simple in this case, as no antibiotic is needed.
Only treatment of fever, if present, is to be given orally. Mother must be advised to
give "Home care". However, if the cough is there for more than 30 days, the child is
to be referred.
3. Dose schedule of Cotrimoxazole:

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 The dose schedule of Tab. Cotrimoxazole (pediatric) for treating different age
groups is as follows:
0-2 months 1 tab 12 hourly for 5 days.
2 months- 1 year 2 tabs 12 hourly for 5 days.
1 year- <5 years 3 tabsl2 hourly for 5 days.
4. When referral is not possible:
If referral services for needed cases are not available or if mothers are unwilling
or unable to go to PHC/hospital, the above dose schedule has to be followed by the
concerned health care providers for respective cases instead of doing nothing.
5. Treatment of fever:
Fever: all fever cases in young infants are to be referred to PHC of hospital. In
case of childbetween2 months and <5 years, if the fever is low i.e. 38-39 degree C.
mother is only advised to give more fluid to the child. But if the fever is more than 39
degree C. paracetamol tablet, in appropriate dose, at 6 hourly intervals is to be given.
Mother too is to be advised to keep the child lightly clothed. If fever dose not come down
within five days, the child is to be referred.
6. Home care:
Home care of the child is a very important aspect in the management to ARI.
Mother should be explained properly about the following aspect:
* Why and how to give antibiotic regularly and for five days.
* Why antibiotic is to be taken in proper dose.
* Need for feeding a child during illness & to increase feeding after recovery.
* To clear the nose if it interferes with feeding and to keep young infant warm.
* To increase'!^ the fluid intake either by increasing the breastfeeding or giving extra
drinks.
* Cough can be relieved only by using the simple home made decoctions viz: honey and
lime juice, hot tea, ginger and tea etc.
* To bring back the child after two days for reassessment.
* To watch for "danger signs" viz. breathing is difficult, child becomes sicker and
in such conditions the child should be brought back urgently.

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2.7.7 Health education in ARI:
The thrust area of education will be the development of skill in mothers of
observing respiratory rates, chest in-drawing and other danger signs in children.
Modification of behaviors of mothers in respect of home care would be another important
component.
Management during illness
Pneumonia: can be treated at home-{co-trimazazoQ
Sever pneumonia/ very sever pneumonia: child should be hospitalized; they will be given
antibiotics, O2. aAwU vUsVt^otn.
No pneumonia/AURI, cough, cold and fever: then give the child symptomatic treatment
and care at home.
Essential elements of home care:
Feeding of the child to be continued. Frequency of feeding to be increased to prevent
malnutrition.
Intake of fluid should be increased.
Fever should be treated with paracetamol.
If nose is blocked the mucous can be cleaned with saline drop or moist swab stick..
For soothing the throat and relieving cough, home remedies such as lime, honey, tulsi,
ginger and warm water can be used. (These should not be given to less than two month
old child.)
Commercially available cough syrups of antibiotics do not alter the duration of cojd or
cough. Neither do they prevent pneumonia or otitis media.
Keep the child warm.
Mothers must be informed to look after danger signs: Fast breathing - Difficult breathing.
Not able to drink - refusal of feed, Excessively sleepy and difficult to wake. Condition
gets worse than before, in such condition child should be brought back urgently.
Mothers should be explained why and how to give antibiotics regularly and for five days
and proper dose.
To bring back the child after two days reassessment when treated at out patient dept.
2.7.8 Prevention of ARI:
• Nutritional education to mothers. -Breast feeding, weaning.

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 Reduction in the incidence of L.B.W. babies by good antenatal care.
Good ventilation in kitchen.
Prevention of air pollution.
Avoiding the child from cold exposure.
Child hood immunization.
Vitamin A 'supplementation.
Children with cough and cold should be treated with home remedies.
Mothers should be educated to identify symptoms and early signs of
pneumonia and told to get the child early for treatment.
Peripheral health staff should be trained to detect cases of pneumonia, give
prompt treatment and identify cases for early referrals to the specialist.
SUMMARIZED CHART

The child (Age 2 months up tofiveyears)

No pneumonia
Classify Very sever disease. Sever pneunnonia. Pneumonia.
(Cough or cold)

Sign •Not able to drink.' •Chest in-drawing. •No chest in

•No chest in drawing.
•Convulsions. drawing &
•Abnormally sleepy or diffic >i\+ •Fast breathing, '^^ •No fast
•(SOV^int or > if child 2 months, breathing
Tiwake
40/mt or more if child 12 months (<50/mt if
•Stridor in calm child up to 5 years. '^ child 2 months
•Wheezing in calm child. up to 12 months
•Sever under-nutrition. to 5 years.)

Treatment •Refer urgently to hospital. •Refer urgently to •Advice mother to give home care. •If coughing
•Give l" dose antibiotic. hospital. more than 30
•Give antibiotic.
•Treat fever if present. •Give r ' dose days, refer for
antibiotic. •Treat fever if present. assessment.
•Treat fever if •Assess & treat
•Advice mother to return with chiL
present. other problems.
days reassessment or earlier if the •Advice mother
is getting worse.

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(Reassess in 2 days a child who is taking an antibiotic)
i
Sign: Worse
T
The same
1
Improving
*Not able to drink. •Breathing slower>
*Has chest in-drawing. •Less fever.
*Has other danger signs. •Eating better.

Treatment: •Refer urgently to hospital. • Review antibiotic •Finish 5 days

or refer the child. of antibiotic

The Child (Age less than 2 months)

Very sever Sever

Classify No
Disease Pneumonia
as pneumonia

Signs -Stopped feeding well Fast breathing No fast

-Convulsions 60/mt or more and breathing
-Abnormally sleepy or or (<60/mt) &
difficult to wake Sever chest in drawing No sever chest
-Stridor in calm infant in drawing.
-Wheezing in calm infant
-Fever oTT low body
temperature
Advice mother to
Treatment Refer urgently to hospital. Refer urgently to give home care:
Give 1^' dose antibiotic. hospital for antibiotic by Keep baby warm
injection. Breastfeed
Give first dose of anti- frequently.
biotic (if referral is not Clear nose, if it
feasible treat with >^ interferers
antibiotic and follow with feeding.
closely.) Advice mother to
Keep the young infant return if:
warm during transfer. -Illness worsens
Breast feed frequently -Breathing is
during transfer. difficult
-Feeding
becomes a
problem.

Reference: (Tulloch J and Richards L; The Medical Journal of Australia 1993 (159): pp. 46-51.)

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2.8 Summary:

A review of relevant literature is important to research because the researcher

need to relate the proposed study to existing theory and to previous studies and to
develop sound hypotheses.
A literature review usually begins with a defined problem. Problems may be
selected and defined as the result of a literature review alone. Literature review conducted
in search of topics assist students in clarifying ideas and in formulating specific problems
that can be investigated by research methods. Literature review, development of topics
and research as a "... slow and gradual process in which ...one group of investigators
builds on the works of others and in turn, contributes their bit or bits, which may then
serve as starting points for others."(Selltiz, Wrightsman and Cook, 1976, p57).
Thus, the students understand the building blocks that provide the foundation for
the construction of new theories. It is these blocks that form the basis for the development
of a researchable topic. Once the area had been determined and the blocks identified, the
student would review the literature related to that specific area. Further refinement of the
topic occurs as the review progresses, and more specific concepts are developed.
The investigator attempts to determine how the proposed study fits into the larger
universe of related knowledge. Thus it can be seen that previous studies will be help to
clarify the ideas and the design of the studies. The quantity of relevant literature available
for review will depend on the popularity of the topic. A timely topic would include
greater number of (studies) publications than relatively new topic with little popularity.

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