Thermal Protection of Neonate

Mr. Suresh. S. Sataguni¹, Mr. Mahesh Rebinal², Dr.G.Radhakrishnan³, Dr. S. Anuchithra⁴

¹Lecturer, PDVVPF’s Institute of Nursing Education, Ahmednagar Maharashtra

²Asso.Prof, P.D. Bharatesh College of Nursing, Belgaum.

³Principal,P.D. Bharatesh College of Nursing, Belgaum.

⁴Vice-Principal, P.D. Bharatesh College of Nursing, Belgaum.

*Corresponding Author Email: sureshsataguni86@gmail.com

ABSTRACT:

Warmth is one of the basic needs of a newborn baby. It is critical to the baby’s survival and well being. Newborns body is not able to adjust itself, if environmental temperature changes which will results in the alteration of the newborns body temperature either it may be hypothermia or hyperthermia. The Department of Pediatric & Obstetrics of Indira Gandhi medical college, Shimla, report shown that about 3.4% perinatal deaths by hypothermia and At birth Hypothermia (6.3%) contributes 4^th rank in causes of neonatal deaths.

Objective: To assess the effectiveness of Nurse Intervention Programme on knowledge, attitude and practice regarding thermal protection of neonates among ASHA workers.

Methods: In order to achieve the objectives of the study, a Pre-experimental, i.e., one group pre-test post-test research design with a evaluative approach was adopted. Non probability purposive sampling technique was used to collect the data from the ASHA workers by using structured questionnaire.

Results: Revealed that 73.34% of the samples were in the age group of 25-30 years. 67% of were studied up to secondary education. Majorities (57%) were from Hindu religion and 77% belongs to nuclear family. Most (80%) of them were married. Majority (60%) of ASHA workers were having two children. Most of them (53.33%) had Rs. <6000 as their family’s monthly income. And (57%) of the study samples were having 3-4 years of experience after completion of ASHA training. Many (50%) of the participants had brought pregnant women to hospital for delivery. 40% of ASHA workers have taken care <20 number of postnatal mothers and newborns. The analysis of mean, SD and mean percentage of knowledge, attitude and practice scores in pre-test and post-test revealed that the total mean knowledge score increased by 26.08% with mean ±SD of 6.7±1.69, the total mean attitude score increased by 11.6% with mean ±SD of 9.3±0.96 and the total mean practice score increased by 17.57% with mean ±SD of 7.36±2.24 after the administration of NIP. Paired‘t’ test was used to analyse the difference between the pre-test and post-test knowledge, attitude and practice scores of the ASHA workers. The difference of knowledge (t₂₉=14.79 at p<0.001), attitude (t₂₉=9.18 at p< 0.001) and practice (t₂₉=6.85 at p< 0.001) scores was found to be highly significant. A significant increase was observed in knowledge, attitude and practice scores of the ASHA workers following the administration of nurse intervention programme on thermal protection of neonate. Findings revealed that the nurse intervention programme was effective on thermal protection of neonate. There was no significant association with other demographic variables like Age in year, Educational status of ASHA worker, Religion, Number of children, Income of family (monthly), Number of labour women brought to hospital for delivery ASHA workers, source of information regarding thermal protection of neonate among ASHA worker.

KEY WORDS: Knowledge, Attitude, Practice, Thermal protection of neonates, ASHA workers.

INTRODUCTION:

Birth of healthy newborn baby is one of the finest gifts of nature. Newborn undergoes profound physiological changes at the moment of birth. Although it is normal during the process of birth the baby has to face many physiological and environmental changes. Before the birth the foetus experiences thermo constant protective, comfortable, aquatic and life sustaining environment. It is safe in the amniotic fluid.^[1]

It is very easy for a newborn to become cold especially at the time of delivery when the baby is soaked with amniotic fluid. The temperature inside the mother’s womb is warm (38⁰C) as compared to the outside environment; thus once the baby is born; it starts to lose heat immediately in the following four ways: evaporation, conduction, convection and radiation (i.e. hypothermia). In similar to the process of heat loss, newborns gain heat in the following ways conduction, convection, radiation and non-shivering thermo genesis (i.e. hyperthermia).^[2]

In general, newborn need a much warmer environment than an adult. The smaller the newborn, the higher the temperature needs to be.^[3]Thermal protection of newborn is the series of measures taken at birth and during first day of life to ensure that the baby doesn’t become either too cold (hypothermia) or too hot (hyperthermia) and maintains a normal body temperature of 36.5-37.5⁰C (97.7 - 99.5⁰F).

Newborn care comprised of several components, amongst them; important one is thermal protection of neonate.The baby must be kept warm at the place of birth (home or hospital) and during transportation for special care either from home to hospital or within the hospital. Satisfactory control, demands both prevention of heat loss and promotion of heat gain. The "warm chain" is a set of following ten interlinked procedures carried out at birth and later: warm delivery room, immediate drying, skin-to-skin contact, breast-feeding, bathing and weighing postponed, appropriate clothing and bedding, mother and baby together, warm transportation, warm resuscitation and training/awareness raising; aids minimizing the likelihood of hypothermia in all newborns.^[2]

Under National Rural Health Mission (NRHM) scheme, Government of India has appointed one Accredited Social Health Activist (ASHA) workers for 1000 population in village setup. The candidates selected as ASHA workers will be given training in all preventive healthcare aspects of pregnancy, antenatal care, delivery care, postnatal care, Newborn care, neonatal care, diarrhea, acute respiratory infections, first-aid and treatment of 30 minor ailments the overall organization, monitoring and coordination of the ASHA training is be entrusted to a Non-government Organization. It helps at the grass root level to prevent child mortality and morbidity rate at the earliest level.^[4]

NEED FOR STUDY:

Every minute, somewhere in the world…

8 babies die in the first month of life

6 babies die in the first week

8 babies are stillborn.

ANNE TINKER ^[5^]

Annually, there are approximately 3.7 million neonatal deaths and 3.3 million stillbirths’ occur worldwide.^[6] Approximately 38% of deaths among children younger than 5 years of age occur during the first 28 days of life, and 75% of the neonatal deaths occur within the first 7 days.^[7]

WHO estimates that over 4 million babies die every year in first 4 weeks of their life. 3 million of these deaths occur in the early neonatal period. In India alone among the 25 million babies who are born every year one million die, accounting for 25% of the mortality around the world.^[8]

The current Infant mortality rate in India is 47/1000 live births and in Karnataka is 45/1000 live births. The NMR is also 1/2 times higher in rural areas than in urban areas. The NMR is lower in states of India ranging from 11/1000 live births in Kerala and 48 is higher in Uttar Pradesh. The states of Uttar Pradesh, Madhya Pradesh and Bihar together contributed to over half of all newborn deaths in 2000. ^[9]The Department of Pediatric & Obstetrics of Indira Gandhi Medical College, Shimla, report shown that about 3.4% perinatal deaths by hypothermia and At birth Hypothermia (6.3%) contributes 4^th rank in causes of neonatal deaths.^[10]

As per the UNICEF report 2012, almost 19,000 children less than five years of age die every day across the world. India tops the list of countries for 2011, with the highest number of such deaths at 16.55 lakh. Even though India is one among the top listed country in global under five deaths it is in 49^th place for child mortality rate, 61/1000 live births in 2011.The MDGs (Millennium Development Goals),” are eight international development goals that all member states of the UN agreed to achieve by 2015. One of the MDGs is to reduce under-five mortality rate of 42/1,000 live births by 2015. ^[11]

A quantitative baseline survey was done on newborn care practices regarding thermal protection among slum area, Pakistan. The study findings were showed that majority of women delivered at home (98%). 37.2% women gave bath to baby immediately, 77.8% within 6 hours, while 18.3% within 7 - 24 hours and 4.2% after 24 hours. Only 18.8% babies were wrapped immediately before placenta was delivered while 71.5% of them were wrapped after delivery of placenta. Poor new born practices were seen through this study. ^[12]

ASHA training helps to provide primary medical care and inform about deaths and births in the village. ASHA workers are also one of the important health care persons to bring down neonatal mortality rate at the grass root level of health care system.

Statement of the Problem:

“A study to assess the effectiveness of nurse intervention program on knowledge, attitude and practice regarding thermal protection of neonate among ASHA workers in selected rural areas of Belgaum.”

OBJECTIVES OF THE STUDY:

1. To assess knowledge, attitude and practice regarding thermal protection of neonate among ASHA workers.

2. To assess the effectiveness of nurse intervention programme in terms of knowledge, attitude and practice regarding thermal protection of neonate among ASHA workers.

3. To find out the correlation between knowledge, attitude and practice regarding thermal protection of neonate among ASHA workers.

4. To find out the association between knowledge, attitude and practice with selected demographic variables of the ASHA workers.

OPERATIONAL DEFINITION:

EFFECTIVENESS:

In this study, it refers to the success or value of nurse intervention programme on thermal protection.

NURSE INTERVENTION PROGRAM (NIP):

It is a planned intercession comprising lecture cum demonstration done the nurse to improve the knowledge, attitude, practice regarding thermal protection of neonate among ASHA workers.

NURSE INTERVENTION PROGRAM (NIP):

It is a planned intercession comprising lecture cum demonstration done the nurse to improve the knowledge, attitude, practice regarding thermal protection of neonate among ASHA workers.

KNOWLEDGE:

In this study it refers to the awareness of ASHA workers about thermal protection of neonates.

ATTITUDE:

In this study, it refers to expression of feeling, or opinion, behavior or thought exhibited by the ASHA workers regarding thermal protection of neonates.

PRACTICE:

In this study, it refers to action performed or steps taken by the ASHA workers to maintain normal temperature of neonate.

THERMAL PROTECTION:

In this study, it refers to the measures taken during the neonatal period to ensure that the baby does not become either too cold or too hot and maintaining normal body temperature of 36.50 c to 37⁰c.

NEONATE:

A baby from birth to four weeks or 0-28 days.

ASHA WORKERS (ACCREDITED SOCIAL HEALTH ACTIVIST):

A trained female community health activist instituted by Govt. of India as a part of National Rural Health Mission and who works as an interface between community and public health system.

Hypothesis of the study:

H₁-The mean post-test score of subject exposed to nurse intervention programme on knowledge, attitude and practice will be significantly higher than their mean pre-test scores regarding thermal protection of neonates among ASHA workers.

H₂-There will be significant correlation of knowledge, attitude and practice regarding thermal protection of neonates among ASHA workers.

H₃-There will be significant association of knowledge, attitude and practice scores on thermal protection with selected demographic variables among ASHA workers.

Assumption:

The researcher assumes that:

1. ASHA workers possess some knowledge regarding thermal protection of neonates.

2. ASHA workers extend their co-operation in providing factual information regarding thermal protection of neonates.

3. The nurse intervention program creates awareness among ASHA workers regarding thermal protection of neonates.

Inclusion Criteria:

ASHA workers:

1. Belongs to Hirebhagewadi community health centre, Belgaum.

2. Who can understand, read and write Kannada.

3. Willing to participate in the study.

4. Available at the time of data collection.

5. Who completed ASHA training and now in service.

Exclusion Criteria:

1. ASHA trainee under training at the time of data collection

2. ASHA workers with additional training in health field

3. ASHA workers but dropout candidates from health related courses.

Delimitation:

The study will be limited to:

· 30 samples of ASHA workers in Hirebhagewadi, community health centre, Belgaum.

· Study design is limited to Pre- Experimental design.

· The data collection period limited to 4- 6 weeks.

Conceptual Framework:

A schematic representation of conceptual frame work based on transaction process model. From King’s goal Attainment Theory (1981)

THE REVIEW OF LITERATURE:

A descriptive study was conducted to evaluate the knowledge, attitude, and practices of neonatal hypothermia among medical and paramedical staffs at Jaipur, India. A structured questionnaire was administered to assess their pre-existing knowledge to 160 working in labor room, postnatal ward and nursery. The study revealed that only 47.8% members defined hypothermia correctly. 52.2% of the interviewers considered it to be an uncommon problem. Lethargy (97.5%), refusal of feed (80%) and cold to touch (77.5%) were mentioned as common symptoms of neonatal hypothermia by respondents respectively. Only 18.6% of the interviewers had good knowledge about correct method of recording the temperature in a newborn. The study revealed that there was a gross lacunae in knowledge and practices regarding various aspects of neonatal hypothermia among pediatric and obstetric residents and paramedical staff working in labor room and postnatal wards.^[13]

A pre-experimental study was done to evaluate the effectiveness of PTP on prevention of hypothermia in newborn among mothers in Belgaum; Karnataka. Pre-experimental design was used. 30 postnatal mothers were selected by non-probability sampling and pre-test questionnaire was administered through structured interview schedule. After 7 days of PTP post-test was conducted on same group. The study results shown that, in pre-test majority of the mothers 17(56.66) had average knowledge 2(6.66) had good knowledge, and 11(36.66) had poor knowledge, where as in post-test 100% of mothers had good knowledge. The area of knowledge by hypothermia was 64.44 and warm chain 34.59 and clothing and bathing 30.23.The’t’ tests value 15.6 at p < 0.05.pre-test and there was statistically significant association between knowledge of mothers and age and religion (p < 0.05). The results concluded that the PTP was the best teaching strategy as it enhances the knowledge on prevention of hypothermia.^[14]

A pre-experimental study was carried out to assess the effectiveness of structured teaching programme on knowledge and practice of kangaroo mother care at institute of obstetrics and gynecology, Chennai. Data was collected from 30 postnatal mothers of preterm babies. A pre-experimental one group pre-test – post-test design was used. A study results exposed that the improvement in mean score from 6.83 in the pre-test to 19.2 in the post-test with 't' value of 31.01 shows significant difference between pre-test and post-test knowledge score which was highly significant at P=0.0001 level.^[15]

RESEARCH METHODOLOGY:

Research approach and Research design:

A pre-experimental (i.e., one group pre-test post-test) design and evaluative approach was used in the study.

Setting:

The study was conducted in the selected rural areas of Belgaum, Karnataka (Hirebhagewadi).

Population:

In the present study the population comprised of ASHA workers

Independent variable:

In this study independent variable is the Nurse Intervention Programme

Dependent variable:

In this study dependent variables are Knowledge, Attitude and Practice regarding thermal protection of neonates.

Attribute Variables:

In this study dependent variables are Age, education, religion, type of family, marital status, number of children, family monthly income, year of experience after completion of ASHA training, number of women's brought to hospital for delivery, number of postnatal and newborns cared by ASHA workers, source of information regarding thermal protection of neonate

Sample and sample size:

The present study was conducted among 30 ASHA workers.

Sampling technique:

The Non-probability Purposive sampling technique was considered appropriate for the study.

Description of the tool:

The tools were divided into four parts;

Part A: It consists of 11 items of demographic variables of ASHA workers.

Part B: It consists of 25 items of Structured knowledge questionnaire on thermal protection of neonate

Part C: It consists of 25 items of three point likert scale used to assess the attitude among ASHA workers.

Part D: Check list consists of 21 items to assess the practice on thermal protection of neonate.

Ethical clearance:

Ethical clearance was obtained.

Reliability:

The reliability co-efficient of the whole test was then estimated by using Spearman-Brown Prophecy formula. The knowledge questionnaire was found reliable (0.86). The attitude questionnaire r value was also r = 0.80. The practice questionnaire reliability was (0.77).

RESULTS:

Major findings of the study:

Finding related to demographic variable of ASHA workers:

The results of the study showed that 73.34% of the samples were in the age group of 25-30 years (Fig-1). 67% of ASHA workers studied up to secondary education (Fig-2). Majority (57%) was from Hindu religion and 87.5% belongs to nuclear family (Fig-3). Most (80%) of them were married (Fig-4). Majority (60%) of ASHA workers were having two children (Fig-5). Most of them (53.33%) had Rs. <6000 monthly family income. Majority (57%) of the ASHA workers were having 3-4 years of experience after completion of ASHA training (Fig-6). Many (50%) of the participants had brought pregnant women’s to hospital for delivery by ASHA workers (Fig-7). 40% of ASHA workers have taken care <20 number of postnatal mothers and newborns (Fig-8). Most (100%) of the study samples reported that they learnt about Thermal protection of neonate during their training period.

Fig-1: Percentage Distribution of Age of ASHA workers.

Fig-2: Percentage Distribution of Education status of ASHA workers.

Fig-3: Percentage Distribution of Type of Family ASHA workers.

Fig-4: Percentage Distribution of Marrital status of ASHA workers

Fig-5: Percentage Distribution of Number of children of ASHA workers.

Fig-6: Percentage Distribution of Year of Experience of ASHA workers.

Fig-7: Percentage Distribution of Number of labor women brought to hospital for delivery by ASHA workers.

Fig-8: Percentage Distribution of Number of Postnatal Mothers and Newborns cared by ASHA workers.

Assessment of Knowledge, Attitude and Practice among ASHA workers

H₁-

The mean post-test score of subject exposed to nurse intervention programme on knowledge, attitude and practice will be significantly more than their mean pre-test scores regarding thermal protection of neonates among ASHA workers.

Fig. 9:- Percentage Distribution of Knowledge, Attitude and practice Scores of ASHA workers

Table 1: Effectiveness of NIP on thermal protection of neonate. (n= 30)

Areas	Pre test			Post test			Effectiveness of NIP			Paired ‘t’ value
Areas	Mean	Mean %	SD±	Mean	Mean%	SD±	Mean	Mean%	SD±	Paired ‘t’ value
Part B Knowledge	10.9	43.6	12.62	17.6	70.4	10.93	6.7	26.8	1.69	14.79*
Part C Attitude	29.2	58.4	9.62	38.5	70	8.66	9.3	11.6	0.96	9.18*
Part D Practice	22.4	53.3	10.72	29.76	70.87	8.48	7.36	17.57	2.24	6.85*

t ₍₂₉₎ 3.66 p<0.001 * significant

Fig-10. Scatter diagram showing the Correlation between attitude and practice regarding thermal protection of neonate among ASHA workers

The ‘r’ value (0.362) is greater than the table value (0.355, p <0.05). So there is positive correlation between attitude and practice.

In pre test, 40% ASHA workers had inadequate knowledge, 56.66% had moderate knowledge and 3.33% had adequate knowledge. In post test 6.66% ASHA workers had inadequate knowledge, 26.66% had moderate knowledge and 66.66% had adequate knowledge. In pre test 17% ASHA workers had low positive attitude, 80% had moderately positive attitude and 3% had highly positive attitude. In post test 6.66% low positive attitude, 26.66% had moderately positive attitude and 66.66% had highly positive attitude. In pre test 46.66% ASHA workers had poor practice techniques, 50% had fair practice techniques and 3.33% had good practice techniques. In post test 10% mothers had poor practice techniques, 43.33% had fair practice techniques and 46.66% had good practice techniques. (Fig.9)

The data presented in the above table shows that the total mean knowledge score is increased by 26.8% with mean ±SD of 6.7±1.69, the total mean attitude score is increased by 11.6% with mean ±SD of 9.3±0.96 and the total mean practice score is increased by 17.57% with mean ±SD of 4.36±2.24 after the administration of NIP. The ‘t’ value of knowledge (14.79 ), attitude(9.18) and practice(6.85) scores were found more than the table value 3.66, p< 0.001 with degree of freedom 29. Hence the NIP was found to be effective in terms of knowledge, attitude and practice.

Correlation between knowledge, attitude and practice regarding thermal protection of neonate among ASHA workers.

H₂: There will be significant correlation of knowledge, attitude and practice regarding thermal protection of neonates among ASHA workers.

In order to find out the relationship between knowledge, attitude and practice towards thermal protection of neonate, Karl-Pearson co-efficient of correlation formula was used and computed. The data is presented in table 2.

Table2: Multiple Correlation between knowledge, attitude and practice among ASHA workers (n=30)

Variables	Knowledge	Attitude	Practice
Knowledge	1	0.063	0.003
Attitude	0.063	1	0.362*
Practice	0.003	0.362*	1

*Significant (p< 0.05)

The above table Data shows that the ‘r’ value (0.063) is lower than the table value (0.301, p <0.10). So there is very low positive correlation between knowledge and attitude. The ‘r’ value (0.003) is less than the table value (0.301, p <0.10). So there is very low positive correlation between knowledge and practice. The ‘r’ value (0.362) is greater than the table value (0.355, p <0.05). So there is positive correlation between attitude and practice. Hence the second research hypothesis is accepted.

In fig.-10, the ‘r’ value (0.362) is greater than the table value (0.355, p <0.05). So there is positive correlation between attitude and practice.

Association between knowledge, attitude and practices scores of the ASHA workers on thermal protection of neonate with selected demographic variables.

H3:

There will be significant association between knowledge, attitude and practice scores on thermal protection of neonate with selected demographic variables among ASHA workers

There was no significant association between pre-test and post-test knowledge with demographic variables like Age, Education, Religion, Type of family, Marital status, Number of children, Income of family (monthly), Year of experience, Number of labour women brought to hospital for delivery by ASHA workers, number of postnatal mothers and newborns cared by ASHA workers, source of information regarding thermal protection of neonate.

There was only significant association between post- test attitude with demographic variables Number of postnatal mothers and newborns cared by ASHA worker. (χ²=11.05, p<0.10). There was no significant association with other demographic variables like Age, Education, Religion, Type of family, Marital status, Number of children, Income of family (monthly), Years of experience, Number of labour women’s brought to hospital for delivery by ASHA workers, source of information regarding thermal protection of neonate among ASHA worker.

The findings presented in table reveals that there was only significant association between pre-test practice and demographic variable like Type of family (²=30.06, p<0.001), Marital status (χ²=30.34, p<0.001).

The findings presented in table reveals that there was significant association between post-test practice and demographic variable like Type of family (χ²=10.45, p<0.05), Marital status (χ²=9.81, p<0.05), Years of experience after completion of ASHA training (χ²=11.19, p<0.10). There was no significant association found with other demographic variables like Age, Education, Religion, Number of children, Income of family (monthly), Number of labour women brought to hospital for delivery ASHA workers, Number of postnatal mothers and newborns cared by ASHA workers, source of information regarding thermal protection of neonate among ASHA worker.

IMPLICATIONS

Implications for Nursing Education

The nursing curriculum should having emphasis on thermal protection of neonates and its consequences which help the nurses to interview the target group in the form of health awareness, prevention of hypothermia and hyperthermia among ASHA workers.

Implications for Nursing Practice and Administration

The nurse administrators should see that the aspect of health promotion while providing nursing care. Nursing administration should implement the program should organize Continuing Nursing Education (conferences, workshop, seminar and education) on thermal protection of neonates. The Community Nurse Administrator should educate ASHA workers under them on various aspect of thermal protection of neonates such as immediate newborn care, health awareness, prevention, and its treatments.

Implications for Nursing Research:

There is a need for more and in depth nursing research on thermal protection of neonates in order to provide evidenced based nursing care. Hence there is a need for comprehensive nursing research on thermal protection of neonates which helps in finding effective measures and solutions in the management of hypo and hyperthermia.

Recommendations:

Based on the findings of the present study recommendations are offered for further researchers:

· The similar study can be conducted to evaluate the effectiveness of self Instructional module (SIM) on thermal protection of neonate among postnatal mothers, lady health visitors (LHV), ANM nurses.

· Health education programmes can be done for the ASHA workers and dais, regarding thermal protection of neonate.

· A large scale study needs to be carried out to generalize the findings.

· A planned teaching program can be conducted to improve the knowledge, attitude and practice of thermal protection of neonates.

CONCLUSION:

The assessment of the knowledge, attitude and practice on thermal protection of neonates revealed that, Majority of ASHA workers had moderately adequate knowledge on thermal protection of neonates, the ASHA workers attitude on thermal protection of neonates explains that, Majority of ASHA workers had positive attitude on thermal protection of neonates ,the ASHA workers practice on thermal protection of neonates explains that, Majority of ASHA workers had fair practice on thermal protection of neonates. So the Nurse Intervention Programme was very effective in order to improve thermal protection of neonates among ASHA workers.

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Received on 03.07.2014 Modified on 25.07.2014

Int. J. Nur. Edu. and Research 2(4): Oct.- Dec. 2014; Page 277-285