RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTSFOR DISSERTATION 1. NAME OF THE CANDIDATE AND ADDRESS MR. RAFIK R. 1 st YEAR, M.SC.NURSING. E.T.C.M. COLLEGE OF NURSING, E.T.C.M. Hospital, Post Box No. 4, Kolar – 563 101 2. NAME OF THE INSTITUTION E.T.C.M. COLLEGE OF NURSING, KOLAR 3. COURSE OF STUDY AND SUBJECT MASTER DEGREE OF NURSING. MEDICAL SURGICAL NURSING. 4. DATE OF ADMISSION TO COURSE 01-06-2009 5. TITLE OF THE TOPIC “A study to evaluate the effectiveness of structured
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTSFOR
DISSERTATION
1. NAME OF THE
CANDIDATE AND
ADDRESS
MR. RAFIK R.
1 s t YEAR, M.SC.NURSING.
E.T.C.M. COLLEGE OF NURSING,
E.T.C.M. Hospital , Post Box No. 4,
Kolar – 563 101
2. NAME OF THE
INSTITUTION E.T.C.M. COLLEGE OF NURSING,
KOLAR
3. COURSE OF
STUDY AND
SUBJECT
MASTER DEGREE OF NURSING.
MEDICAL SURGICAL NURSING.
4. DATE OF
ADMISSION TO
COURSE
01-06-2009
5. TITLE OF THE
TOPIC
“A study to evaluate the effectiveness of
structured teaching programme on dietary
management and compliance to drug therapy
among TB patients in a selected hospital at
Bangalore.”
BRIEF RESUME OF THE INTENDED WORK
6. INTRODUCTION
Communicable diseases are the major health problem of the
country. Some of them appear in epidemic form and some in endemic
form. Communicable diseases are caused by specific infective agent,
transmitting the infection from a reservoir to susceptible host 1 .So one
among them is tuberculosis which was first formally described by Greek
physician Hippocrates around 460 B.C.E. He called i t phthisis , which is
the Greek word for consumption; because it described the way the disease
consumed its victims. Consumption was the most widespread disease of
the t ime, and most of i ts victims died. The word consumption was used to
describe the disease until 1882, til l the tuberculosis bacteria were
identified as the cause of the disease. 1
Tuberculosis is a chronic infectious disease and one of the
major cause of illness and death in the underdeveloped countries as well
as the deprived sections of the developed countries. Malnutrition resulting
from poverty and ignorance combined with unhygienic living conditions
and poor ventilation makes and individual susceptible to the infection.
Tuberculosis is an infectious diseases caused by mycobacterium
tuberculosis. 2 It usually involves the lungs but i t also occurs in the
larynx, kidney, bones, adrenal glands, lymph nodes and meanings
tuberculosis kills more people world wide than any other infectious
diseases. It estimated that between 19% and 43% of the Worlds
populations is infected with M.tuberculosis 4 . The WHO estimated at more
than 8 mill ion new cases of TB occur each year. And approximately 3
million people die from the disease. 3
According to WHO, India is number one in terms of
tuberculosis (TB) prevalence and it is an alarming health problem of the
public. The global body in its latest report said that 299 Indians in every
100,000 population are infected with TB and the mortality rate is 28 per
100,000. Of all new cases in India, 1.2 percent is infected with HIV.
While 2.8 percent of the new cases have been diagnosed with multi-drug
resistant TB (MDR-TB), 17 percent of patients who have availed treatment
at some point have developed drug resistance. The global health watchdog
said the pace of TB control and diagnosis has slowed down across the
world including India the report said there were 9.2 million new cases of
TB during 2006, of which 700,000 cases are found among people with
HIV/AIDS up from 22,000 in 2002. Worldwide there are 500,000 cases of
MDR-TB and an estimated 1.5 million people died from the disease in
2006. Another 200,000 people with HIV died from HIV-associated TB,
WHO said. “The Revised National TB Control Programme (RNTCP) of
India has begun to operate in parts of the country that are particularly
challenging,” WHO said in its report. “The introduction of MDR TB
treatment as part of routine programme activities will succeed only if the
planned sub-national reference laboratories function properly and if a
reliable supply of high quality second-line drugs is available,” the global
health watchdog cautioned. 4
On the occasion of the World TB Day 2009 comes some relief
in a developing country such as India where the rate of cure is said to
have doubled and 85 per cent of the global and national target achieved.
The detection rate is almost 70 per cent (72 per cent in 2004 and 66 per
cent in 2005) while the fatality rate has reduced to 4 per cent from 29 per
cent in NSP (new sputum positive) cases. Deaths due to TB have come
down from 5, 00,000 to less than 3, 70,000.
Over six million patients have been init iated on DOT
(Directly Observed Treatment) and over 10 lakh lives have been saved.
These figures display early signs of a good beginning of the decline of TB
incidence and prevalence as a direct impact of Revised National
Tuberculosis Control Programme (RNTCP) being implemented by the
Government, according to C.C. Kardiguddi, District Tuberculosis Officer
and he said TB remains a major public health problem in India with
approximately 18 lakh people developing TB and about four lakh
succumbing to the disease.
India accounts for one fifth of the global incidence rate and
tops the l ist of 22 high TB-burdened countries. Every day, more than
40,000 people get infected by tubercle bacill i, 5,000 develop the disease
and 1,000 die of TB. Globally, the estimated figures show that 18 lakh
people die of TB, a majority of them in developing countries. The annual
incidences of new cases of all forms of TB account for about 88 lakh, 95
per cent of which occur in developing countries 5 .
Many patients with active TB experience severe weight loss
and some show signs of vitamin and mineral deficiencies. It is important
to consume a balanced diet to provide body with the nutrients that needed
to fight tuberculosis. It particularly important to avoid consuming any
alcohol during the entire course of treatment as this could result in
treatment complications and side effects. Weight gain generally improves
during appropriate tuberculosis treatment and appropriate nutri tional
supplementation. However, persons who complete treatment are at risk of
losing weight that was gained.
The ult imate aim of any prescribed medical therapy is to
achieve certain desired outcomes in the patients concerned. These desired
outcomes are part and parcel of the objectives in the management of the
diseases or conditions. However, despite all the best intention and efforts
on the part of the healthcare professionals, those outcomes might not be
achievable if the patients are non-compliant. This shortfall may also have
serious and detrimental effects from the perspective of disease
management. Hence, therapeutic compliance has been a topic of clinical
concern since the 1970s due to the widespread nature of non-compliance
with therapy. Therapeutic compliance not only includes patient
compliance with medication but also with diet, exercise, or life style
changes. In order to evaluate the possible impact of therapeutic non-
compliance on clinical outcomes, numerous studies using various methods
have been conducted in the United States (USA), United Kingdom (UK),
Australia, Canada and other countries to evaluate the rate of therapeutic
compliance in different diseases and different patient populations.
Generally speaking, i t was estimated that the compliance rate of long-term
medication therapies was between 40% and 50%. The rate of compliance
for short-term therapy was much higher at between 70% and 80%, while
the compliance with l ifestyle changes was the lowest at 20%–30%
Furthermore; the rates of non-compliance with different types of treatment
also differ greatly. Estimates showed that almost 50% of the prescription
drugs for the prevention of bronchial asthma were not taken as prescribed.
Patients’ compliance with medication therapy for hypertension was
reported to vary between 50% and 70% In one US study, found that
antihypertensive compliance averaged 49%, and only 23% of the patients
had good compliance levels of 80% or higher. Among adolescent
outpatients with cancer, the rate of compliance with medication was
reported to be 41%, while among teenagers with cancer it was higher at
between 41% and 53%. For the management of diabetes, the rate of
compliance among patients to diet varied from 25% to 65%, and for
insulin administration was about 20% More than 20 studies published in
the past few years found that compliance with oral medication for type 2
diabetes mellitus ranged from 65% to 85%. As previously mentioned, if
the patients do not follow or adhere to the treatment plan faithfully, the
intended beneficial effects of even the most carefully and scientifically-
based treatment plan will not be realized. The above examples illustrate
the extent of the problem of therapeutic non-compliance and why it should
be a concern to all healthcare providers. 6
These can be achieved by creating awareness among the
tuberculosis patients regarding dietary management and compliance to
drug therapy so i t is necessary that nurses as a member of health care team
should take init iative to create awareness among the public.
6.1 NEED FOR STUDY
Tuberculosis is a disease of time. It is a chronic infectious
disease and is one of the major cause of il lness and death in the
underdeveloped countries, as well as the deprived sections of developed
countries . Because of the high mortali ty rates tuberculosis is considered as
a social disease. Being a social and chronic natural disease the
tuberculosis affects the l ife style of the persons suffering from
tuberculosis and also affects his family life style activities like sleeping
pattern, dietary requirements compliance with medicine regime 7 .
According to World Health Organization (WHO) estimates,
each year, eight mill ion people worldwide develop active tuberculosis and
nearly two million die. One in 10 people who are infected with
tuberculosis may develop active TB at some time in their lives. The risk
of developing the active disease is greatest in the first year after
infection, but active disease often does not occur until many years later.
Globally the estimated figures show that 18 lakh people die of
TB, a majority of them in developing countries. The annual incidence of
new cases of all forms of TB accounts for about 88 lakh 95% of which
occur in the developing countries 5 .
Tuberculosis is a major public health problem in India. India
accounts for one-fifth of the global TB incident cases. Each year nearly 2
million people in develop TB of which around 0.87 million are infectious
cases. It is estimated that annually around 3, 30,000 Indians die due to TB
and every day more than 40,000 people get infected by tubercule bacill i,
5000 develop the disease and 1000 die of TB 5 .
The one year census of District Tuberculosis Centre shows
that nearly 4000 people are affected with Tuberculosis in Kolar district.
Among them, 1745 per lakh patients are receiving DOT’S treatment 8 .
Recommendation in tuberculosis there is a considerable
wasting body tissue. Therefore i t is essential to increase protein intake in
the form of cereal and pulse combination include a liberal amount of
calcium in your diet to promote healing of tuberculin lesions. If patient
suffers from hemorrhage high iron supplementation is necessary. The diet
should provide as mush retinol as possible by giving milk, milk product,
eggs and meat. The tuberculosis being an infectious disease results in
increased urinary loss of ascorbic acid. As the recommended in the diet in
the form of guava, amla, orange, lemon and sprouted pulses. 9
Department of Nutrition, School of Public Health and Health
Sciences, University of Massachusetts, Amherst, Massachusetts 01003,
USA conducted a study on vitamin D and tuberculosis. They reported that,
Vitamin D influences the immune response to tuberculosis, and vitamin D
deficiency has been associated with increased tuberculosis risk in
different populations. Genetic variabili ty may influence host
susceptibility to developing active tuberculosis and treatment response.
Studies examining the association between genetic polymorphisms,
particularly the gene coding for the vitamin D receptor (VDR), and TB
susceptibility and treatment response are inconclusive. However,
sufficient evidence is available to warrant larger epidemiologic studies
that should aim to identify possible interactions between VDR
polymorphisms and vitamin D status. 1 0
Compliance to therapy is one of the important factors that
affect the out come of therapy. Compliance can be defined as the extent to
which a patient’s behavior coincides with medical advice. Non-compliance
to self administered multi-drug tuberculosis treatment regimens is
common and most important cause of failure of initial therapy and
relapse.1 Non-compliance may also result in acquired drug resistance2,
requiring more prolong and expensive therapy that is less l ikely to be
successful than the treatment of drug susceptible tuberculosis.1 Studies on
acquired resistance (drug resistance among previously treated cases) from
Gujarat (1980-86) showed an increase resistance to isoniazid and
rifampicin and MDR - TB rates of 30%.3,4,5 The adoption of DOT has
been associated with reduced rate of treatment failure, relapse and drug
resistance.2 Despite the impressive gains in compliance associated with
the use of DOT, non-compliance with DOT also occurs when patients fail
to make themselves available for the administration of drug therapy.
Based on the above review literature and researchers experiences it
is felt that education on dietary management and compliances to drug
therapy for tuberculosis patients is important to develop awareness.
6.2 REVIEW OF LITERATURE
Review of l iterature is the task of reviewing li terature which
involves the identification, selection critical analysis and reporting of
existing information on the topic of interest. it provides the bases to
locate the data, new ideas that need to be included in the present study it
helps the researcher to find the accurate data that could be used for
supporting the present finding and drawing conclusion
This chapter deals with a review of published and
unpublished research studies and related material for the present study the
review helped the researcher to develop on insight into the problem area
and helped to build the foundation of the study
The Review of li terature is presented under the following
broad heading
6.2.1 Studies related to dietary management of tuberculosis.
6.2.2 Studies related to compliance to drug therapy
6.2.3. Studies related to knowledge among TB patients .
6.2.1. REVIEW OF LITERATURE RELATED TO DIETARY
MANAGEMENT OF TUBERCULOSIS.
A randomized controlled trial of nutri tional supplementation
in patients with newly diagnosed tuberculosis and wasting was conducted
in department of infectious disease, Tan Tock Seng hospital in Singapur .
The nutri tional support is often recommended as part of the treatment of
tuberculosis, but it has never been properly tested so the objective of the
study was to assess the effects of early nutri tional intervention on lean
mass and physical function in patients with tuberculosis and wasting .The
Patients who started antituberculous therapy within the previous 2 wk
were randomly assigned to receive standard nutritional counseling
(control group) or nutrit ional counseling to increase their intake through
diet and high-energy supplements (nutrit ional supplement group) for 6 wk.
Body composition was measured by dual-energy X-ray absorptiometry,
and physical function was assessed by maximum grip strength.The result
of this study was patients in the nutrit ional supplement group (n=19) had
a significantly greater increase in body weight (2.57+/- 1.78 compared
with 0.84 +/- 0.89 kg, P = 0.001), total lean mass (1.17 +/- 0.93 compared
with 0.04 +/- 1.26 kg, P = 0.006) than did the control subjects (n = 17) at
week 6. During subsequent follow-up, the increase in body weight
remained greater in the nutritional supplement group, but this increase
was due mainly to a greater gain in fat mass in the nutri tional supplement
group than in the control group. This study concluded that the intervention
to increase nutri tional intake increases lean mass and physical function.
This adjunct to tuberculosis therapy could confer socioeconomic and
survival benefits that deserve investigation in large-scale trials.
Nutritional intervention after the init ial phase of treatment could be less
beneficial because i t mainly increases fat 1 1 .
Tuberculosis is a serious infection affecting mainly the lungs.
It may contribute to nutrit ional deficiencies which in turn may delay
recovery by depressing immune functions. Nutritional supplements might
therefore promote recovery in people being treated for tuberculosis. The
objective was to assess the provision of oral nutri tional supplements to
promote the recovery of people being treated with antituberculous drug
therapy for active tuberculosis. The method of this study was randomized
controlled trials comparing any oral nutrit ion supplement given for at
least four weeks with no nutrit ional intervention. Placebo, or dietary
advice only for people being treated for active tuberculosis the data
collection and analysis of this study was two authors independently
selected trails, extracted, data, and assessed risk bias, we calculated risk
ratio for dichotomous variables. And mean differences for continues
variables, with 95% confidence interval. We pooled data from the similar
interventions and outcome the result was twelve trials (3393 participants)
were included. Five trials had adequate allocation concealment.
Interventions included a high energy supplement, high cholesterol diet,
Vitamin D, Vitamin A, Zinc, arginine, multiple micronutrient
supplements, combined multiple micronutrient supplements and zinc,
combined Vitamin A and zinc and combined vitamin A and selenium. The
following supplements were associated were associated with increased
body weight at follow up: high energy supplements (MD 1.73 kg, 95% Cl
0.81 to 2.65, 34 participants, 1 trial); multiple micronutrients plus