FULL RESEARCH ON CHDR

TO DESCRIBE THE AWARNESS & ASSOCIATED FACTORS ON THE NEW CHDR AMONG MOTHERS HAVING CHILDREN BETWEEN 9-18 MONTHS OF AGE IN BORALESGAMUWA MOH


Group -7

14th Batch

Community Medicine Research Project

Faculty of Medical Sciences

University Of Sri Jayewardenepura.

AWARNESS & ASSOCIATED FACTORS ON THE NEW CHILD HEALTH

DEVELOPMENT RECORD AMONG MOTHERS HAVING CHILDREN

BETWEEN 9 -18 MONTHS IN BORALESGAMUWA MOH AREA

Our External supervisor Dr.Guwani Liyanage

Senior Lecture,

Department of paediatrics,

Faculty of medical sciences,

University of Sri Jayewardenepura.

Our Internal supervisor Dr.Sampatha Gunawardana

Senior Lecture,

Head of the department,

Department of community medicine,

Faculty of medical sciences,

University of Sri Jayewardenepura.

Students

MED 1699 S.Sakthibalan

MED 1864 B.M.D.R. Balangoda

MED 1919 D.A.G. Kumari

MED 1950 H.D.T.I.M. Perera

MED 1959 K.R.G. Priyanganie

MED 1978 A.A.D.T. Saparamadu

MED 1987 A.L.A.Shiyam

MED 2001 W.C.D.Weerasinghe

MED 2001 W.C.D.Weerasinghe

MED 2011 M.A.D.P.K.Wijesinghe

Contents

Page

Declaration

List of tables

List of figures

List of abbreviations

Acknowledgement

Abstract

CHAPTER 1: INTRODUCTION ………………………………………………….

CHAPTER 2: JUSTIFICATION …………………………………………………

CHAPTER 3: CONCEPTUAL FRAME WORK …………………………………

CHAPTER 4: LITERATURE REVIEW …………………………………………..

CHAPTER 5: OBJECTIVES……………………………………………………….

CHAPTER 6: METHODOLOGY …………………………………………………

CHAPTER 7: RESULTS AND ANALYSIS………………………………………

CHAPTER 8: DISSCUSSION ……………………………………………………..

CHAPTER 9: LIMITATIONS ……………………………………………………..

CHAPTER 10: CONCLUSIONS……………………………………………………

CHAPTER 11: RECOMMENDATIONS……………………………………………

CHAPTER 12: REFERANCES………………………………………………………

CHAPTER 13: ANNEXES……………………………………………………………

1 Questionnaire

2 Ethical approval

Declaration

We hereby certify that this thesis does not incorporate any material submitted for any degree or diploma in any university & also that to the best of our knowledge, it does not contain any material previously written or published by any other person except where due references are made.

Date: ……………. Signatures of research term

1. ……………….

2. ……………….

3. ……………….

4. ……………….

5. ……………….

6. ……………….

7. ……………….

8. ……………….

9. .. ..……………

Above student have been guided by me for research and closely supervised their work. I certify that, this was done by themselves and contents true and correct by the best of my knowledge.

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Signature of internal supervisor

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Signature of external supervisor

LIST OF TABLES

Page

Table 1 Nutritional state of children under 5 years (Demographic health statistics .2004)

Table 2 Identification of variables………………………………………………………..

Table 3 Frequency distribution of mothers Age………………………………………………………..

Table 4 Frequency distribution of living children………………………………………………………

Table 5 Frequency distribution of mother’s educational level……………………………………….

Table 6 Frequency distribution of parent’s occupation……………………………………

Table 7 Frequency distribution by sex of child………………………………………….

Table 8 Awareness of mothers on child growth………………………………………………………

Table 9 Awareness of mothers on developmental milestones………………………………………

Table 10 Distribution of mother’s completion of Hearing, vision and developmental milestones

Charts in CHDR………

Table 11 Awareness of mothers on immunization……………………………………………………..

Table 12 Awareness of mothers on infant care………………………………………………………..

Table 13 Awareness of mothers on exclusive breast feeding………………………………………..

Table 14 Awareness of mothers on complementary feeding………………………………………….

Table 15 Awareness of mothers on contraception……………………………………………………..

Table 16 Overall awareness of mothers on CHDR…………………………………………………….

Table 17 Comparison between number of living children & awareness on growth…………………

Table 18 Comparison between number of living children & awareness on developmental milestones

Table 19 Comparison between number of living children & awareness on immunization………

Table 20 Comparison between number of living children & awareness of infant care…………

Table 21 Comparison between number of living children & awareness on exclusive breast feeding

Table 22 Comparison between number of living children & awareness on Complementary feeding

Table 23 Comparison between number of living children & total awareness………………………

Table 24 Comparison between mother’s education and Growth awareness………………………

Table 25 Comparison between mother’s education and Developmental milestones………………….

Table 26 Comparison between mother’s education and immunization…………………………………

Table 27 Comparison between mother’s education and infant care…………………………………….

Table 28 Comparison between mother’s education and complimentary feeding……………………

Table 29 Comparison between mother’s education and exclusive breast feeding……………………

Table 30 Comparison between mother’s education and total awareness………………………..

Table 31 Frequency distribution of mothers on source of knowledge………………………………..

Chart 1 work plane (Gantt chart)……………………………………………..

LIST OF FIGURES

Page

Figure 1 Nutritional problem detected at SMI-2005……………………………………..

Figure 2 Dental problem detected at SMI ………………………………………………..

Figure 3 Other common defects…………………………………………………………..

Figure 4 conceptual framework…………………………………………………………..

Figure 5 Pie Chart of mothers who had filled the hearing component in CHDR………..

Figure 6 Pie Chart of mothers who had filled the vision component in CHDR…………

Figure 7 Pie Chart of mothers who had filled the developmental milestone component

in CHDR…………………………………………………………………………

LIST OF ABBREVIATIONS

  1. CHDR - Child Health Development Record
  2. CMC - Colombo Municipal Council
  3. CWC -Child Welfare Clinic
  4. EBF -Exclusive Breast Feeding
  5. MOH -Medical Officer of Health
  6. PGIM -Post Graduate Institute of Medicine
  7. PHM - Public Health Midwife
  8. SEP -Standard Error of Proportion
  9. WHO - World Health Organization
  10. FHB - Family Health Bureau
  11. USJP - University of Sri Jayawardenapura

ACKNOWLEDGEMENT

We wish to use this opportunity to offer our heartfelt gratitude to those who assisted us in numerous ways to make this study a success. First we thank the department of Community Medicine for providing us this valuable opportunity to carry out this research. We forward our gratitude to Professor Kumudu Wijewardene for encourages us since the beginning, spending her golden time for us though we are undergraduates. We are deeply indebted to Professor S. Sivayogan not only for imparting us with knowledge on research methodology, also for giving his precious advices to solved out problems that we encountered during the research process. We extend our gratitude to IRQUE project for providing funds to conduct the study.

We sincerely thank our external supervisor Dr.Guwani Liyanage, senior lecturer of department of Paediatrics, who generously contributed her time and effort to make our research success throughout our research despite her busy schedule. We also grateful to our internal supervisor Dr.Sampatha Gunawardena, head of the department of Community Medicine, you are the teacher who guide us in a correct path by assisting as well as encourage though the research .We thankful to the assistant librarian Mrs.Shirani Dharmartne for the guidance provided.

It is impossible to carry out our research without the support from the staff of Boralesgamuwa MOH office where the place of our research. We extend our sincere thank to Dr.Jayalath MOH Boralesgamuwa, Dr.H. Munasinghe assistant MOH Boralesgamuwa and their whole staff including all the doctors, PHNS(public health nursing sister), PHM(public health midwife) for giving their fullest co-operation.

We are grateful to Dr. Sudarshini Fernandopulle, consultant community physician, Family Health Bureau (FHB) and whole staff of FHB for the efforts taken to provide us facts on Child Health Development Record. We also extend our gratitude to the librarian of Post Graduate Institute of Medicine, for providing opportunity to find out further details.

At last, but not the least, we thank the mothers who volunteered to participate in this research.

ABSTRACT

Our study wich was on awareness and associated factors on the new CHDR among mothers having children between 9-18 months. This was a descriptive cross sectional study carried out in Boralasgamuwa MOH area, over a period of three months since 17th December 2007 to 8th January 2008

The objectives that we encountered were to describe the socio-demographic characteristics of mothers and children. As well as to describe the awareness of mothers on CHDR and to describe the socio-demographic characteristics associated with the awareness of mothers on the new CHDR, and finally to determine there sources of knowledge on awareness.

We were able to cover 120 mothers who were attended to the child welfare clinics and weighting centers during our period of study. Data collection was done by using interviewer administered questionnaire. Appropriate techniques were used to collect the data for the different sections of the questionnaire by questioning and the direct observation of the new CHDR. Data entry was done by using the Epidata package. Those data were analyzed manually and using stranded statistical package (SPSS). Stranded marking scheme was prepared relevant to the questionnaire and marks were allocated for each responses and awareness of mothers was assessed.

The study revealed that 64.2 % of mothers had average awareness on new CHDR, and 35% had satisfactory awareness. Only 0.8 % had poor awareness. Regarding mother’s educational level 32.18 % mothers who had educated up to O/L had satisfactory awareness on new CHDR, while 66.66 % had average awareness, and also 1.14 % had poor awareness on new CHDR. As well as 42.42 % mothers who had educated over O/L had satisfactory awareness and 57.57 % had average awareness. But there were no mothers who had educated over O/L in poor awareness. It was noted that the mother’s having more than one child had 46.3 % of satisfactory awareness, while 53.6 % mothers had average awareness. There were no mothers found who had more than one child with poor awareness. As well as most of the mothers (69.6 %) who had one child had average awareness. Only 29.1 % had satisfactory awareness and 1.26 % had poor awareness. When considering the sex of the child 68.33 % of mothers who had male children had average awareness.31.66 % satisfactory awareness and there were no mothers with poor awareness. On the other hand 60 % of mothers having female children had average awareness while 38.33 % had satisfactory awareness and 1.6 % had poor awareness.

There was statistically significant association between number of living children in the family & awareness of mothers on developmental milestones as well as on immunization.

There was also statistically significant association between the mother’s educational level & awareness of mothers on growth & EBF. The statistically significant association between the mother’s educational level & awareness of mothers on the overall new CHDR had been found.

PHM was the commonly use source of knowledge (72%) to be aware on new CHDR. It is followed by self study of new CHDR by the mothers (64%).

CHAPTER: 1

INTRODUCTION

The Child Health Development Record (CHDR) is a book document on growth, survival and development of children from birth to age fourteen.

Using CHDR among parents, help them become active participants in child welfare and develop a greater understanding of their child’s development. It serves as an interactive vehicle for communication between family health care workers and it strengthen the relationship between parents and health care workers.

In 1956 a community base study was done in Illesha by Dr.David Morley in order to develop and appropriate heath care programme .As a result if that he impressed the usefulness of regular weighing of young children & he designed growth chart “Road to Heath chart” or Malawi. (Dr.David Morley, 1956)13. In 1959 these charts were spread to Nigeria, Africa & Asia. Then WHO & UNICEF published standard growth charts for developing counties including Sri Lanka

Now in Sri Lanka the new version of CHDR are freely distributed among hospitals of both government & private sectors.

The changes that are made to the new CHDR

The earlier card (care) was used more as a ration card for issue “Thriposha” rather than for monitoring growth. Therefore due to the importance of monitoring growth, development and survival of infants and preschool children; a CHDR was issued on 1994.But an important section of it was briefly described. Therefore to make mother more aware on their children descriptive booklet was introduced on 2004.(FHB)4

Problems encountered in old version:

The health messages are outdated, Cover picture gives responsibility only to mother, Important messages on new concepts were not included ,Not geared to cater to low birth weight / pre term infants.

Reference growth curves used are those developed in USA for infants who had been given artificial foods before the fourth month. There were no growth potentials shown above the 50th centile and no space to refer or back refer for curative services. As well as developmental assessment of children was also inadequate.

Therefore to correct these deficiencies a new CHDR was issued which consist of the following contents in more desirable with a cover page to include the family concept.

Objectives of the new CHDR

To promote the healthy growth & development of the child by the level of knowledge of the health worker & the members of the family by regular weighing, recording, interpreting against the important invents in the child‘s life which have a bearing on its physical & psychosocial development & providing appropriate intervention according individual child’s needs

Maintaining of the new CHDR

After the delivery, the book is given to the mother from the hospital. If it is a home delivery, it is given by the PHM of the area. It contains both A & B parts. Part A is given to mother and part B retained with PHM. Both parts are update at child welfare clinic & at the field weighing posts.

Components of the new CHDR

Detail regarding the new born: child’s name, sex, date of birth, PHM area & number, date & number of registration, name & age of the mother, address.

  • Care of the new born : apgar score, birth weight, occipito frontal circumference at birth, length of the new born, health condition of new born, vitamin K supplementation, position & relation during breast feeding.

  • Reasons for special care : premature delivery, low birth weight, congenital deformities, post partum complications, artificial formula feeding during first 4 months after delivery, failure to thrive, feeding difficulties, death or departure of mother or father, skin colour and nature of the umbilical stump.

  • Details of immunization: giving an idea to the mother about the appropriate ages for each EPI vaccine, where the previous one gave only names of the vaccines. In addition to that the new CHDR consider on the BCG scar & the adverse effects of immunization.

  • Details on growth: The new CHDR consists of more accurate & detailed centile chart on growth, separate charts for boys & girls, weight and height are included in the sane graph. The trend or pattern of healthy growth of a child from birth to 5 years of age is presented visually by the graph. Rate of growth during the first year is higher than during the other years. Mothers are instructed to measure the weight from birth to 2 years of age once a month, from 2 – 3 years of age once in 2 months and From 3 – 5 years of age – once in 3 months

  • Developmental milestones: Health means physical, mental & social wellbeing.

The physical growth is assessed by plotting the weight against the age & the assessment of developmental milestones is essential to monitor the degree of growth & maturity of various organs. Considering these inclusions the children who are developmentally late can be detected, thereby permitting simple interventions

  • Child assessment by the parents: Child’s vision, hearing & developmental milestones should be assessed by the parents & fill the appropriate cages within certain periods.

  • School health inspection: Considered on child’s: age, height, weight, BMI, deficiencies, strabismus & vision, hearing, speech, dental care, goitre, ENT, leprosy, bones, heart & lungs. Antihelminthics & micronutrients.

Attendance & learning difficulties discussed by the teacher

  • Health messages: On new born care, complementary foods, diet on illnesses, & assessing psychological development

  • Referral: On delay of developmental milestones.

  • Family planning:

To measure the awareness of mothers on new CHDR the most suitable population is the mothers who are having children between 9-18 months of age because they are the people who have to know the most fractions of the contents of the CHDR

To determine the awareness of mothers on new CHDR we selected Boralesgamuwa MOH area which contains 9 PHM areas.

CHAPTER 2

JUSTIFICATION OF STUDY

Since early 1970’s maternal & child health services received greater emphasis & was given priority in overall health delivery system. As a result of this, service intra structure was strengthened to provide an efficient family health service throughout the country.

Government has granted a major fraction from 2002 budget for both curative & preventive aspects of health service. Child health is an important component of prevailing health care system as children are backbone of future development of country.

Health facilities provided by government sector and Mother’s awareness & actions are key factors painted to promote the healthy growth & development of the child. “CHILD HEALTH DEVELOPMENT RECORD “is the reliable document introduced by the government to achieve the objectives mention above.

By the government with collaboration of UNICEF has continued to support to print & distribute of over 350,000 CHDR annually to monitor & promote growth of the child. Family health bureau which is the responsible institution introducing CHDR pay more attention to publish new version of CHDR frequently to minimize deficiencies of old version & enhancing the awareness among parents. On 2004 booklet form of CHDR was introduce more attractively rather than old versions, which was mainly used more as ration card for issue of Thriposha.(FHB)4

Though Sri Lanka has low maternal mortality rate 38 deaths per 100,000 births, low neonatal mortality rate 9.2 to 11.7 per 1000 live births and low infant mortality rate 11.2 to 15.2 per 1000 live births & high literacy around 98%, relative to other developing countries nutritional state of

children are not in satisfactory level in Sri Lanka. 30% of children fewer than 5 years suffer from iron deficiency

Table 1: Nutritional states of children under 5 years (Demographic health statistics .2004)

Height for age (stunted)

weight for height (wasted)

weight for age

Year

2000

2000

2000

Total

13.5%

14.0%

29.4%

.

Figure 1 Nutritional problem detected at SMI-2005 (FHB) 4

It is essential that area public health midwives (PHM) should ensure than infants & preschool children within her area are brought either to the clinics or field weighing centres as per instructions given so that their growth patterns could be effectively monitored & mothers advised accordingly.

For a country that suffers no significant food shortage & provides extensive free maternal & child health services it’s rather paradoxical that malnutrition affects about 1/3 of children.

Figure 2 Dental problem detected at SMI (FHB) 4

Figure 3 Other common defects (FHB) 4

Early detection of above conditions may improve the prognosis or early rehabilitation.

All the things supplied by the government & implemented by health care providers are not fruitful, unless awareness of mothers & actions taken by her are not adequate.

According to previous research accepted on 28 / 6/1996 on maternal comprehension of two growth charts in Sri Lanka. 62.4% (324) of mothers had good comprehension and 20.6% had similar comprehension with regard to health. (FHB) 4

Education up to or beyond grade 8 in school significantly improved comprehension

Over effort is to describe the awareness on the new CHDR among mothers and look for relationship between their awareness & socio demographic factors. Hence sources that they acquire knowledge on awareness.


CHAPTER 3

CONCEPTUAL FRAME WORK

Fig 4 conceptual framework

CHAPTER 4

LITERATURE REVIEW

Literature on topics similar to this study was accessed through the internet and some previous research done in Sri Lanka, referred from PGIM library.

A study was done on Prevalence & some factors influencing growth retardation of children of 6months to 3 years in low income families in Kotte area by Dr. (Mrs.) D.A.L. Fernando on 1994.

Objectives of this study were to study the prevalence of growth retardation among children between 6 months to 3 years of age in low income families of Kotte area & to study the effects of socio demographic characteristics on maternal knowledge of nutrition, Biological & environmental characteristics on growth of children. A descriptive cross sectional study was carried out for one month duration (From 1st of June 1994) and the study population was all children 6 months to 3 years aged in low income families. Data was collected by using anthropometric measurements of child & interviewer administrated questionnaire to mother or caretaker of child.

According to this study, growth retardation was 44%, wasting was 29%, stunting was 9%, concurrent growth retardation was 41%.This study also shown to be significantly associated with maternal/caretaker’s knowledge on growth & nutrition. None of other factors (socio-demographic, biological & environmental) was shown any significant association.

(D.A.L. Fernando, 1994)6

A study was done by Dr.G.D.T. Senevirathne on comprehensive study on immunization in rural, urban & estate area in Sri Lanka.

This was conducted to determine vaccine coverage of Sri Lankan children & to describe the economical & demographic characteristics in relation to immunization. Descriptive cross sectional study was conducted by interviewer administrated questionnaire. Cluster sampling

Method was used 740 children, between 12 -35 months on the day of the survey were evaluated.

The study showed statistically proven significance between immunization & number of children born. The coverage of BCG in this study was found to be 97.2%, but only 34.1% of the parents knew the significance of BCG. (G. D. T Senevirathne ,1994)7.

A research was done by Dr. H.V.B.S. Wijayathilake on assessment of growth monitoring & activities related to the growth promotion of children age between 1 – 3 years in Colombo municipal council over period of one month since 1st of September 2002.

The general objective was to determine some factors influencing growth monitoring, to assess growth promotion activities provided by the CWC staff & skills of interpreting growth curves in CHDR by mothers of children age 1 -3 years in CMC .The specific objectives were to identify socio-demographic factors associated with dropping out of children aged 1 -3 years from the growth monitoring program in CMC. As well as to determine the skills of mothers of these children to interpret growth curves in CHDR and to determine service factors affecting dropping out of children aged 1 -3 years from the growth monitoring programme in CMC area. Study design was a descriptive cross sectional study of representative sample of 330 children born during the period of 31st August 1999 to 31st August 2001, living in CMC using a structured pre-coded questionnaire. This study was consisted of two components; Community based & clinic based study.

According to this study, 85% of the children of the study area attended to CWC in CMC.

Only 31.5% of the children in the sample have been weighed more than 50% of the standard required frequency appropriate to the ages of them.75% of children have been visited by PHM more than once at home. Exclusive breast feeding has not been continued on 21% of the children in the sample at least up to the age of 4 months. Around 50% of mothers have interpreted growth curves correctly. (H.V.B.S. Wijayathilake, 2002)8

A study was done in1994 on Influence of employment status of the mothers on the physical growth, development & behaviour of the pre-school children age 12 -59 months by Dr: G.A.T.K. Athauda.

The general objective was to assess the influence of the employment status of the mothers with special emphasis on mothers employed overseas on physical growth, development & behavior of pre- school children. Study design was community based descriptive study which had two components. Cross sectional component & longitudinal component.

Three groups of children were included, Children of mothers employed overseas continuously for a period exceeding 6 months, Children of mothers employed in Sri Lanka and Children of mothers not formally employed. This was carried on 3 MOH areas from the Colombo Regional Director of Health Services (RDHS) division, Kollonnawa, Kotte, & Nugegoda.

Data on the cross sectional component was obtained from using a interviewer administrated questionnaire with structured & pre- coded questions, making observations to collect information on the checklists on development, home environment & home risk factors, taking anthropometric measurements. Data of longitudinal component were obtained by the PHM using questionnaire.

There was no significant difference in the performance of 3 groups with regard to the fine motor, language, cognitive & social aspects of development. And children with mothers employed in Sri Lanka had best overall performance regarding all the functions of development, than the children with mothers employed overseas (G.A.T.K. Athauda.1994)9

Another study was done by Dr: S.C.Wickramasinghe on some reasons for inadequate use of CWC for growth monitoring in the municipal council area of Negombo.

General objective was to determine some reasons for inadequate use of municipal CWCs for growth monitoring by mothers of children 4 months to 3 years old in the municipal council area of Negombo & to make necessary recommendations for the improvement of the use of CWC. Specific objectives were to determine the socio-economic & demographic factors influencing the use of CWCs for growth monitoring. And assess the adequacy of use of CWCs for growth monitoring by mothers. As well as relate the knowledge of mothers on growth monitoring to attendance at clinics for growth monitoring. Thus make necessary recommendations for the improvement of attendance at CWCs for growth monitoring.

The study was a descriptive cross sectional study of a representative sample of 850 children born during the period of 1st of July 1991 to 28th of February 1994, in the area of administration of the municipal council of Negombo. Structured pre-coded questionnaire was the main instrument. The data was collected by interviewing & the direct observation of the CHDR.

The results showed when the child was a first born, parents brought to the clinic more often than the others. The mothers, who age between 18 years to 29 years, brought their children more frequently to the clinic.

99% of the children were brought to the CWCs by mothers. 34.7% of the children were not brought to the clinic, when the mother was employed.

The study showed that the mothers’ knowledge on the frequency of growth monitoring was poor. 65% of the mothers said that a child should be brought to the clinic once a month up to age of one year, But only 28.5% mothers said that child should be brought to the clinic once a month till the age of 2 -3 years. (S.C.Wickramasinghe,1994) 10

A study on breast feeding practices in a public health field practice area in Sri Lanka, conducted by Suneth B Agampodi, Thilini C Agampodi and Udaga Kankanamge D Piyaseeli in Beruwala MOH area on 2006.

A clinic base cross sectional study was done. Study population was mothers with infant aged 4 to 12 months attending the 19 CWC s in the Beruwala MOH area. Cluster sampling method was used to select 218 mothers.

This study revealed that the rates of exclusive breast feeding at 4 and 6 months were 61.6% and 15.5% respectively. Bivariate analysis showed that the Muslim ethnicity, lower levels or parental education and being an unemployed mothers were important association of early cessation of EBF.( Suneth B Agampodi, Thilini C Agampodi, Udaga Kankanamge D Piyaseeli,2006)12

CHAPTER 5

OBJECTIVES

GENERAL OBJECTIVES

To describe the awareness & associated factors on the new CHDR among mothers having children between 9-18 months of age in Boralesgamuwa MOH area.

SPECIFIC OBJECTIVES:

· To describe the Socio demographic characteristics of mothers.

· To describe the awareness of mothers on new CHDR.

· To describe the association between selected socio demographic characteristics and awareness of mothers.

· To determine the sources of knowledge on awareness.

CHAPTER 6

METHODOLOGY

6.1 Study design.

The research was done as a descriptive cross sectional study.

6.2 Study population.

All mothers having children 9 to 18 months of age who were attending to child welfare clinics at Boralesgamuwa MOH area for 3 weeks duration were selected for this study.

Inclusion criteria.

Mothers who are having children between 9 to 18 months of age inclusive of 9 &18 months and mothers who are carrying new CHDR (issued after 2004)

Exclusive criteria

Children came accompanied with father or care giver other than mother, and the mothers who refused to answer.

6.3 Place of study.

The study was carried out in Child welfare clinics at Boralesgamuwa, Diwulpitiya and Werahera with their relevant weighing centres of Boralesgamuwa MOH area (.Map)

6.4Sampling technique.

All mothers, who met the above criteria and attended the child welfare clinics and weighing centres of Boralesgamuwa MOH area during period of 3 weeks, were selected, it was 120 mothers.

6.5 Sample size.

A total of 120 mothers were recruited during the period of study.

6.6.a Identification and definition of variables.

Variables

Measurements

Scale

1. Mothers age

Child’s age

Years

Months

Quantitative/Interval scale

Quantitative/Interval scale

2. Race

_

Qualitative/Nominal scale

3. Educational level of Mother

School attendance and

Higher education

Qualitative/Ordinal scale

4. Occupations

_

Qualitative/Ordinal scale.

5. Number of living

Children in family

Number

Quantitative/Ratio scale

6. Awareness of the

Mothers on

· New born care.

· Growth.

· Survival.

· Developmental milestones.

· Exclusive breast feeding.

· Complementary feeding.

· Family planning

Total marks

Qualitative/Ordinal scale

7. Assessing mother’s

Activities

Marks

Qualitative/Ordinal scale

8. Sources of knowledge

-

Qualitative/Nominal scale

Table 2 Identification of variables

6.6.b Definitions of variables.

1.) Age

Mother’s age was taken in years up to the last birthday and the child’s age was taken up

to the nearest month, up to the date of data collection.

2.) Race.

Mother’s race was categorized as Singhalese, Tamil and Muslim.

3.) Educational level of mother.

The highest educational level which was acquired by her from the school or higher education was taken and if it is not educated it was mentioned.

4.) Occupation.

It was taken as, if she is working, it is categorized under professional, skilled and unskilled or if else as house wife.

5.) Number of living children in the family.

It was taken as an index for mother’s experience on the child and number of hours she can spend on the new child,

6.) Awareness of mother on following categories was considered.

a) Infant care- New born care, alarm signs of the child, and causes of special care on the child were considered.

b) Growth: – Frequency of weighing up to one year was taken and according to the CHDR from birth up to 2 years weighing is done in once a month. Between 2 to 3 years once in 2 months & between 3 to5 years of age once in 3 months. Under the awareness on the Centile chart, a clear knowledge on the colour zones which indicate appropriate height & weight, the present condition of child & interpretation of growth faltering were considered.

c) Survival: – Immunization. From birth up to 14 years the schedule of EPI vaccines has been included in the CHDR. But we assessed only a very basic & simple knowledge on it considering only B.C.G. & Polio vaccines.

d) Developmental milestones: – Mothers awareness on the appropriate period of certain activities of a healthy child such as head control, speech & sitting was assessed. They are the milestones which are waited by the mother specially.

e) Exclusive breast feeding: – correct duration of exclusive breast feeding was assessed and it was 6 months.

f) Complementary feeding: -The initiation, content, amount, texture of the meal and the frequency according to the age of the child were given an important role .As well as

feeding during an illness and feeding with a balance diet within 24 hours was also

considered.

g) Family planning:-the appropriate time period, to start the contraception after the delivery (6 weeks.) was assessed.

7.) Assessing the completion of hearing, vision and developmental milestones charts on their child was checked and it is categorized as complete, incomplete, and not filled.

8.) Souses of knowledge: – the ways, from where they acquiring their knowledge on contents of CHDR was asked. .

6.7 Study instrument for data collection.

Data collection was carried out by using an interviewer administrated questionnaire. (annex-1)

Activities

Number of weeks

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Topic discussion

Literature review

Key informant interview

Preparation of protocol

Ethical clearance

Training for data collection

Pre test

Data collection

Data entry

Data analysis

Report writing

Meet supervisors

Chart 1 Work plane (Gantt chart)

6.8 Key informant interview was done to identify the important areas of CHDR with, a

Paediatrician, a community health physician, a MOH and Family Health Bureau-

Colombo-10. Questionnaire was prepared based on priority given by them to obtain the

information from selected sample on awareness of mothers and socio-demographic

characteristics associated.

6.9 Organization of field work.

STAGE 1 –

- Before visiting the field.

We prepared and printed questionnaires in adequate amounts and designed a system to

Allocate marks. Consent forms were also prepared. Protocol was printed in adequate

amounts. Training sessions was held for data collectors to be familiar with the questionnaire

& to ask the Questions in the same manner. Written permission was obtained from ethical

committee of U.S.J.P.

- Pre test :

Written permission from the University Community Medicine Department was obtained for this purpose at Maharagama MOH office. Ten mothers who had children between 9 to 18 months of age in Maharagama MOH area. It was interviewed based on the questionnaire prior to conducting the data collection to detect any problems that would occur due to the wording, content & interviewer length.

- Method of data collection

Questionnaire was modified according to the pre test. We went to Werahera MOH office with a written permission from the University Community Medicine Department. Topic & objectives were discussed with him. As well as we met PHM in all nine PHM areas & gathered information on venues & dates of immunization clinics and weighing centres, rough number of participants who fulfils our criteria. According to information obtained by PHM, we allocated ourselves for each visit

6.10 The data collection was started after obtaining ethical clearance

The ethical clearance was obtained from ethical clearance committee of USJP for MOH office

Boralasgamuwa and verbal consent was obtained from mothers. The details they revealed were dealt

Confidentially by de-identifying the data.

6.11 Our schedule was,

DATE

TIME

VENUES

17.12.2007

Monday

11.00 am – 1.00 pm

Werahera clinic

19.12.2007

Wednesday

10.00 am12.00 noon

12.30 pm – 3.00 pm

1.00 pm – 3.00 pm

Boralesgamuwa A/B clinic

Werahera North weighing centre

Diulpitiya weighing centre

20.12.2007

Thursday

10.30 am – 12.30 pm

Bellanwila clinic

26.12.2007

Wednesday

12.30 pm – 2.30 pm

Katuwawala weighing centre

27.12.2007

Thursday

10.30 am – 1.00 pm

Bellanwila clinic

04.01.2008

Friday

12.30 pm – 3.00 pm

Papiliyana weighing centre

08.01.2008

Tuesday

12.00noon – 3.00pm

Rattanapitiya weighing centre

STAGE 2- Data collection in the field

We introduced ourselves and state the purpose of visit. Verbal consent was obtained from mothers .A suitable place with seating arrangement was prepared for interview with mothers. Interview was conducted professional and systematic manner and responses were recorded accurately. Interviewer was made sure that the questionnaire was filled completely before finishing the interview. It was concluded by thanking mother who was participated.

STAGE 3- After the data collection

After the data collection was completed questionnaires were checked for accuracy and completeness. Questionnaires were stored carefully and safely. Data entry was done in Epidata according to our objectives and the data was analyzed in SPSS manually.

The distribution of socio-demographics were assessed in our population. Considering on our Questionnaire there was 46 responses. +1 was given for each correct response and 0 for each incorrect response. Then according to the contents of CHDR and also taking the CHDR as a whole, the awareness was categorised as poor, average, satisfactory. For each component below 50 marks were categorised as poor, 50-74 as average and 75≤as satisfactory. But for EBF and family planning we considered as correct and incorrect answer. Then the presence of a statistically significant association between selected variable was described. Finally the sources of knowledge by which mothers gain knowledge on CHDR was assessed.

CHAPTER 7

RESULTS

Our research, was to determine the awareness of mother­­­­s on the new CHDR and was carried out in Boralesgamuwa MOH area as a cross sectional study using 120 mothers who were having children between age of 9 months to 18 months attending to CWC and weighing centres during one month duration.

v Our first objective was to describe the Socio demographic characteristics of mothers and children.

Majority of mothers 98.4% were Sinhalese.

Table 3 Frequency distribution of mothers Age

Age

Frequency

Percentage

Teenage

Others

4

116

3.3

96.7

Total

120

100

Majority of mothers were more than 20years of age, where as only 3.3%of mothers were teenagers. (< 20 years of age)

Table 4 Frequency distribution of living children

Number of children

Frequency

Percentage

1

2

3

4

79

26

13

2

65.8

21.7

10.8

1.7

Total

120

100

This table shows that 65.8% of mothers had one child and rest of them had more than one child.

Table 5 Frequency distribution of mother’s educational level

Mother’s educational level

Frequency

Percentage

Primary education

Up to O/L

Up to A/L

Higher education

5

82

32

1

4.2

68.3

26.7

.8

Total

120

100

The above table revealed that 68.3% had studied up to O/L among this population and about 26.7% had studied up to A/L.

Table 6 frequency distribution of parent’s occupation

Father’s occupation

Father

Mother

Skilled

Unskilled

Others

Frequency

Percentage

Frequency

Percentage

94

26

0

78.3

21.7

0

2

1

117

1.7

0.8

97.5

Total

120

100

120

100

According to father’s occupation, 78.3%fathers were involved in skilled occupation while others were in unskilled occupation. Within our sample most of the mothers (97.5%) were house wives & only 1.7%mothers were employed (skilled occupation).

Table 7 Frequency distribution by sex of child

Sex

Frequency

Percentage

Male

Female

60

60

50.0
50.0

Total

120

100

In considering child’s sex, male and female were similarly distributed in our sample.

v Our second objective was describing the awareness of Mother on new CHDR.

Regarding the awareness of mothers on CHDR, there were 46 responses & marks were given. Each correct response carried +1 and 0 was given for a incorrect response.

Then we categorized mother’s awareness as poor, average and satisfactory according to the following basis.

<50 = poor

50-74 = average

≥75 = satisfactory

Ø The awareness of mothers on each section as follows

Table 8 Awareness of mothers on child growth

Awareness

Frequency

Percentage

poor

8

6.7

Average

5

4.2

satisfactory

107

89.2

Total

120

100.0

89.2% of mothers had satisfactory awareness on child’s growth & around 11% had either poor or average.

Table 9 Awareness of mothers on developmental milestones.

Awareness

Frequency

Percentage

poor

55

45.8

average

43

35.8

satisfactory

22

18.4

Total

120

100.0

It is interesting to know that only 18.4% mothers had satisfactory awareness while 45.8%mothers had poor awareness on developmental milestones.

Table 10 Distribution of mother’s completion of Hearing, vision and developmental milestones charts in

CHDR

Hearing

Vision

development milestone

Frequency

Percentage

Frequency

Percentage

Frequency

Percentage

Complete

25

20.8

28

23.3

21

17.5

incomplete

31

25.8

35

29.2

25

20.8

not filled

64

53.3

57

47.5

74

61.7

Total

120

100.0

120

100.0

120

100.0

There are some components in new CHDR, and mothers should fill these. But there was only about 20 % of mothers who had completely filled these components in CHDR.

Figure:5 Pie Chart of mothers who had filled the hearing component in CHDR

Figure: 6 Pie Chart of mothers who had filled the vision component in CHDR

Figure: 7 Pie Chart of mothers who had filled the developmental milestone component in CHDR

Considering on above all three components there were more than 75 % of mothers who hadn’t filled completely.

Table: 11 Awareness of mothers on immunization

Awareness

Frequency

Percentage

Poor

13

10.8

Average

30

25.0

Satisfactory

77

64.2

Total

120

100.0

Regarding the awareness of mothers on immunization 64.2% of mothers had satisfactory awareness and 25% had average awareness whereas about 10.8% had poor awareness.

Table:12 Awareness of mothers on infant care

Awareness

Frequency

Percentage

poor

2

1.7

average

42

35.0

satisfactory

76

63.3

Total

120

100.0

63.3% of mothers had satisfactory, 35% had average awareness and 1.7% had poor awareness regarding infant care.

Table: 13 Awareness of mothers on exclusive breast feeding

Awareness

Frequency

Percentage

satisfactory

103

85.8

unsatisfactory

17

14.2

Total

120

100.0

85.8% of mothers had correct comprehension about six months exclusive breast feeding.

Table: 14 Awareness of mothers on complementary feeding

Awareness

Frequency

Percentage

poor

5

4.2

average

68

56.7

satisfactory

47

39.2

Total

120

100.0

Regarding complementary feeding 56.7% mothers had average awareness & about 39% had satisfactory awareness.

Table: 15 Awareness of mothers on contraception

Awareness

Frequency

Percentage

satisfactory

99

82.5

unsatisfactory

21

17.5

Total

120

100.0

82.5% of mothers knew about contraception after pregnancy, While 17.5%of mothers were not able to give the correct response.

Table: 16 Overall awareness of mothers on CHDR

Awareness

Frequency

Percentage

poor

1

0.8

average

77

64.2

satisfactory

42

35.0

Total

120

100.0

There were 64.2%of mothers who had average awareness and 35%of mothers had satisfactory awareness on CHDR. It is interesting to note that only 0.8%of mothers had poor awareness.

v Our third objective was to describe the association between socio-demographic characteristic and awareness.

The association between mother’s awareness on CHDR and no: of living children in the family was as follows. We wished to determine the association between the number of children and mother’s awareness on growth.

Table: 17 Comparison between number of living children & awareness on growth

growth awareness

No. Live children

Total

one child

more than one

poor

4

4

8

(5.1%)

(9.8%)

(6.7%)

average

3

2

5

(3.8%)

(4.9%)

(4.2%)

satisfactory

72

35

107

(91.1%)

(85.4%)

(89.2%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Relatively mothers with one child had satisfactory awareness on growth curves (91.1%) than mothers with more than one child (85.4%).

We amalgamated poor and average in to one group and chi² test was applied. There was no statistically significant association between the number of living children in the family and mother’s awareness on growth

(X²=0.91, df=1, P<0.05)

Table: 18 Comparison between number of living children & awareness on developmental milestones.

development milestone awareness

No. Live children

Total

one child

more than one

poor

41

14

55

(51.9%)

(34.1%)

(45.8%)

average

29

14

43

(36.7%)

(34.1%)

(35.8%)

satisfactory

9

(11.4%)

13

(31.7%)

22

(18.3%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Percentages of mothers with one child and mothers with more than one child were almost equal in average category (Respectively 36.7% and 34.7%).But there was a difference in poor category among mothers with one child and mothers with more than one child (Respectively 51.8%and 34.1%).

The Chi-Square Test was applied and it revealed a statistically significant association between the 2 variables.

(x²=7.981, df=2, P=5.99)

To confirm the significance, SEP was applied and it was 16.69. So the test of proportion showed that the difference statistically significant (P<0.5)

Table: 19 comparison between number of living children & awareness on immunization.

immunization awareness

No. Live children

Total

one child

more than one

poor

10

3

13

(12.7%)

(7.3%)

(10.8%)

average

24

6

30

(30.4%)

(14.6%)

(25.0%)

satisfactory

45

32

77

(57.0%)

(78.0%)

(64.2%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

In our sample most of the mothers who were having one living child and more than one respectively 57% and 78% had satisfactory level of awareness on immunization.

There were only few mothers (7%) in poor level out of mothers with more than one living child. Chi-Square Test was applied only for the mothers with average and satisfactory level. The result showed a statistically significant association between mother’s awareness on immunization and number of children. (x²=4.37, df=1, P=3.84)

Test of proportion showed that the difference was significant.

( SEP=10.39, P< 0.05 )

Table: 20 Comparison between number of living children & awareness of infant care

infant care awareness

no. living children

Total

one child

more than one

poor

2

0

2

(2.5%)

(.0%)

(1.7%)

average

31

11

42

(39.2%)

(26.8%)

(35.0%)

satisfactory

46

30

76

(58.2%)

(73.2%)

(63.3%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Considering mothers with one child and more than one child were largely fallen under satisfactory level which was respectively 58 % and 73 %.

The Chi-Square Test was applied for the average and satisfactory groups and it revealed that there was no significance between mother’s awareness on infant care and number of living children.

Table: 21 Comparison between number of living children & awareness on exclusive breast feeding

exclusive breast feeding

no. living children

Total

one child

more than one

one child

Satisfactory

68

35

103

(86.1%)

(85.4%)

(85.8%)

Unsatisfactory

11

6

17

(13.9%)

(14.6%)

(14.2%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Percentages of mothers with one child & mothers with more than one child were almost equal in answering correctly on exclusive breast feeding (respectively 86% & 85%).

According to the Chi square test there no statistically significant association between numbers of living children and mother’s awareness on exclusive breast feeding.

(x²=0.11, df=1, P=3.84)

Table: 22 Comparison between number of living children & awareness on Complementary feeding

Complimentary awareness

no. living children

Total

one child

more than one

poor

5

0

5

(6.3%)

(.0%)

(4.2%)

average

48

20

68

(60.8%)

(48.8%)

(56.7%)

satisfactory

26

21

47

(32.9%)

(51.2%)

(39.2%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Most of the mothers with one child (out of 79) showed satisfactory awareness 33 on Complementary feeding while mothers with more than one showed satisfactory level of awareness (51%).

As the poor category was negligible, we applied Chi-Square Test for average and satisfactory levels of education. According to the result there was no significant association between mother’s awareness on infant care and number of children.

(x²=2.8, df=1, P=3.84)

Table: 23 Comparison between number of living children & total awareness.

total awareness

parity no. living children

Total

one child

more than one

poor

1

0

1

(1.3%)

(.0%)

(0.8%)

average

55

22

77

(69.6%)

(53.7%)

(64.2%)

satisfactory

23

19

42

(29.1%)

(46.3%)

(35.0%)

Total

79

41

120

(100.0%)

(100.0%)

(100.0%)

Considering on the total awareness, most of the mothers who had one child and more than one child showed average awareness on CHDR which was respectively 70 %and 54 %.

The Chi-Square Test was applied and there was no statistically significant association between total awareness of mothers and number of children.

(x²=3.32, df=1, P=3.84)

Table: 24 Comparison between mother’s education and Growth awareness

Growth awareness

mother’s education

Total

Up to o/l

Over o/l

poor

7

(8.0%)

1

(3.0%)

8

(6.7%)

average

4

(4.6%)

1

(3.0%)

5

(4.2%)

satisfactory

76

(87.4%)

31

(93.9%)

107

(89.2%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

When considering the relationship between mother’s education and awareness on Growth, 87 % of mothers who educated up to o/l got satisfactory awareness and 94 % of mothers who educated over O/L got satisfactory awareness. Number of mothers got poor and average comparably very few with total mothers.The test of proportion revealed that there was a significant difference between mother’s education and awareness on growth.

Table: 25 Comparison between mother’s education and Developmental milestones

Development milestone awareness

mother’s education

total

Up to o/l

Over o/l

poor

43

49.4%

12

36.4%

55

45.8%

average

30

34.5%

13

39.4%

43

35.8%

satisfactory

14

16.1%

8

24.2%

22

18.3%

Total

87

100.0%

33

100.0%

120

100.0%

Of the 87 mothers who had educated up to O/L 49 % had poor awareness on developmental milestones. Of 33 mothers, who had educated above O/L 36% had poor awareness on developmental milestones. In satisfactory group there were 16 % of mothers who had studied up to O/L as opposed to 24 % who studied above O/L.

The Chi-Square Test revealed that there was no significant association between mother’s education and the awareness of mothers on Developmental milestones.

Table: 26 Comparison between mother’s education and immunization

Immunization awareness

mother’s education

Total

Up to o/l

Over o/l

poor

9

(10.3%)

4

(12.1%)

13

(10.8%)

average

21

(24.1%)

9

(27.3%)

30

(25.0%)

satisfactory

57

(65.5%)

20

(60.6%)

77

(64.2%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

There were nearly equal percentages of mothers in satisfactory category among both up to O/L and above O/L groups.

Table: 27 Comparison between mother’s education and infant care

infant care awareness

mother’s education

Total

Up to o/l

Over o/l

poor

2

(2.3%)

0

(.0%)

2

(1.7%)

average

30

(34.5%)

12

(36.4%)

42

(35.0%)

satisfactory

55

(63.2%)

21

(63.6%)

76

(63.3%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

There were nearly equal percentages of mothers who had either average or satisfactory awareness in both categories of educational level. The Chi-Square test revealed that there is no significant association between mother’s education and awareness on infant care.

(x²=0.012, df=1, P=3.84)

Table: 28 Comparison between mother’s education and complimentary feeding

complimentary feeding awareness

mother’s education

Total

Up to o/l

Over o/l

poor

5

(5.7%)

0

(.0%)

5

(4.2%)

average

51

(58.6%)

17

(51.5%)

68

(56.7%)

satisfactory

31

(35.6%)

16

(48.5%)

47

(39.2%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

Considering the relationship between mother’s education and awareness on complimentary feeding, 48 % mothers who educated over o/l got satisfactory awareness which is more than the mothers who educated up to o/l (36%). There were no mothers with poor knowledge who had educated over o/l.

Chi-Square Test was applied for average and satisfactory groups and it revealed that there is no statistical significant association between mother’s education and awareness on complimentary feeding.

(x²=1.11, df=1, P=3.84)

Table: 29 Comparison between mother’s education and exclusive breast feeding

exclusive breast feeding

mother’s education

Total

Up to o/l

Over o/l

Satisfactory

73

(83.9%)

30

(90.9%)

103

(85.8%)

Unsatisfactory

14

(16.1%)

3

(9.1%)

17

(14.2%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

There were 84 % of mothers who knew the correct duration of exclusive breast feeding among the mothers who had educated up to O/L where as it was 91 % in the case of mothers who had educated above O/L.

Test of proportion revealed that there was statistically significant association between mother’s education and awareness on exclusive breast feeding. (SEP=6.78)

Table: 30 Comparison between mother’s education and total awareness

total awareness

mother’s education

Total

Up to o/l

Over o/l

poor

1

(1.1%)

0

(.0%)

1

(0.8%)

average

58

(66.7%)

19

(57.6%)

77

(64.2%)

satisfactory

28

(32.2%)

14

(42.4%)

42

(35.0%)

Total

87

(100.0%)

33

(100.0%)

120

(100.0%)

There were 32 % of mothers who had satisfactory awareness among the mothers who had educated up to O/L, where as it was 42 % in the case of mothers who had educated above O/L.

The Chi-Square test revealed that there was a significant association between mother’s education and overall awareness on CHDR.

(x²=4.41, df=1, P=3.84)

The test of proportion showed that there was a significant association between these two variables.

(SEP=12.91)

Table: 31 Frequency distribution of mothers on source of knowledge

Source of knowledge

Frequency

Percentage%

PHM

86

71.7

CWC

73

60.8

News papers

44

36.7

Radio & TV

37

30.8

Parents

43

35.8

Self studying the CHDR

77

64.2

Regarding the sources from that mothers get knowledge on CHDR, PHM is the commonly used sources (72 %). Also 61 % mothers had used CWC and 37 % had used news papers. Radio and TV contribute as a source in least (31 %). 36 % of mothers had got knowledge from their parents while 64 % mothers had gained their knowledge by self studying the CHDR.


CHAPTER 8

DISCUSSION

· The first objective was to describe the socio-demographic characteristics of mothers and children.

We found the majority of mothers were Sinhalese in our sample (98%) And around 97% of mothers were more than 20 years. Also there were 60% of mothers who had only one child. Regarding the level of education majority were studied up to O/L (72%). Also there were around 78% of mothers whose husbands had skilled occupation and there were none of them were professional. In the case of children there were equal distributed genders among them.

The above description represents socio-demographic characteristic factors of a semi urban area; which was consisting of lower and middle lower class families. The results may be get vary if we consider on urban, rural or estate sector.

In our sample some socio-demographic characteristics were not evenly distributed. These were mother’s race, occupation and age. So we wished to determine the association of awareness between with the number of living children in family and mother’s education.

· Our next objective was to describe the awareness of mother’s on the new Child Health Development Record.

In our study remarkably high percentage of mothers (89%) had satisfactory awareness on their child’s growth charts. There is an improvement with the time in contrast to the findings of a previous study on skills of interpreting growth charts was; 75% of mothers interpret upward growth curve correctly, 70% of mothers downwards growth curve correctly, 59% of mothers horizontal growth curve correctly. (De Silva, 1989)

Overall awareness of mother’s on immunization was good (64.2%).Also there were only 83%of mothers were knew the importance of BCG. We found that a comprehensive study on immunization in rural, urban and estate sector in Sri Lanka where the coverage of BCG was 97.2%, only 34% of the parents knew the importance of BCG. (G. D. T Senevirathne ,1994).

Unfortunately, 46% of mothers had poor awareness on developmental milestones. The reason for above result could be; this is a field which has got more attention recently. Therefore healthcare workers may not skilled enough too tackled with this.

This is similar to the finding in a previously conducted research on recording developmental milestones and it was 37% satisfactory and their knowledge on “reasons for special care” was not statistically significant. (De Silva, 1991)

Around 63% of mothers had satisfactory awareness on infant care whereas 2% mothers had poor awareness. We included warning signs of an infant and reasons for special care under this topic. Poor knowledge regarding this topic may lead to high morbidity and mortality among children. Mothers have to be educated on these topics by both preventive and curative health care systems, as she is the person, who initially identifies problems in infant.

There were around 86% of mothers who knew the correct duration of exclusive breast feeding. While it is interesting to note around 14% of mothers didn’t know that it is six months. This may be due to controversy on this subject earlier. Some of the mothers still had not get the new message on new WHO recommendation on breast feeding.

The initiating time, quality, quantity, frequency and implementation during an illness were considered under the complementary feeding. We found there were only about 39% of mothers with satisfactory awareness. Majority had average awareness (57%). We felt most of the mothers in our sample still believe myths on feeding practices.

Heath care services give consulting to mothers each and every time. But only about 83% of mothers who had get the real benefit of it. Around 17% of mothers were unsatisfactory on that section.

While considering on the total awareness, there were only 0.8% of mothers under poor category, but 35% of mothers had got satisfactory awareness. And 64% had average awareness. This condition may be due to well organized infrastructure in Sri Lankan primary health care system.

There is a separate part in the new CHDR to fill by the mother herself on hearing, vision and achievement on developmental milestones. The objective of introducing this was to motivate and get active participation of mothers on their children’s development. Although about 75% CHDRs we found were uncompleted or not filled at all.

(On hearing 25.8% uncompleted, 53.3% not filled. On vision 29.2 uncompleted, 47.5% not filled. On development 29.2% uncompleted, 47.5% not filled)

If mothers got used to fill these charts at appropriate time, the chances of increasing their awareness may be high.

· Our third objective was to describe the association between socio-demographic characteristics and awareness of mother’s on the new Child Health Development Record.

We wished to describe the awareness on CHDR not only as and overall awareness but also awareness on main contents of CHDR such as;

Awareness on growth and socio-demographic characteristics

The child’s growth is presented in CHDR as a graphic form, which is easily understandable through visual illustration.

There were 91 % had satisfactory awareness among mothers with one child, while it is 85 % regarding the mothers had more than one child. This result revealed that there was no statistically significant association.

The mothers who had no previous experience on growth of the child are very attended and curious on knowledge of growth of the child. As well as PHM based health staff is a great help to them. In our visits we saw usually PHMs explained mothers about the present condition of the child. Therefore the mother’s awareness was not correlated with parity.

When considering on mother’s educational level, there were 87 % mothers had satisfactory awareness among the mothers who had educated up to O/L. whereas it was around 94 % in the case of those who were educated beyond O/L. these results revealed a statistically significant association. Mothers could be able to acquire more knowledge when their educational level is higher. As well as they are more aware on the incidence of malnutrition, obesity and their effects. There for they are very keen on interpretation of centile charts.

Awareness on developmental milestones and socio-demographic characteristics

In this concern we focused our special attention on head control, sitting without support and speaking. Irrespective to the number of living children in the family, majority of mothers had poor awareness on developmental milestones. About 51 % belonged to poor category in the case of mothers who had one child, while it was 34 % regarding the mothers who had more than one child.

The results showed, a statistically significance. It may be due to when the number of children is increased they get more experience and they can easily recall the appropriate time; as this knowledge is not only depend on just reading books but also on early experiences. Usually the mothers compare their child’s developmental milestones with the neighbouring children of same age. So mothers who had not early experience are less aware on developmental milestones.

Considering as a whole irrespective to mother’s educational level, the poor category was high. It was respectively around 49 % up to O/L and around 36 % regarding beyond O/L mothers. There was no statistically significant association. Mothers were not properly focused to such an important topic by the primary health care workers. Developmental milestones represent the gross motor; fine motor, behavioural, speech & language development of the children. When the mothers are less aware on that topic the early identification and inference on problems may be missed.

Awareness on immunization and socio-demographic characteristics

In order to assess basic awareness on immunization we concerned only about BCG and Polio, as these are more familiar to mothers. There were 78 % had satisfactory awareness among the mothers who had more than one child, whereas it was around 57 % in the case of mothers who had one child. There was a statistically significant association between immunization and number of living children in the family. This significance was also showed by Dr G. D. T. Senevirathne in 1994. (G. D .T .Senevirathne, 1994).

Mothers may be more familiar with the names of the vaccine when they have more than one child. It may also be due to these two vaccines were included since the period of initiation of EPI schedule. 15% of the mothers in our sample were unsatisfactory of awareness on immunization, as the vaccination is a nearly a sole duty of the preventive health care staff and mothers play a minor role.

Concerning on mother’s educational level, there were 65 % mothers had satisfactory awareness among the mothers who studied up to O/L. While it was 60 % regarding mothers who studied over O/L. We concerned only on BCG and Polio vaccines in order to assess a basic awareness on immunization. This may limit the determination of association. Nearly equal percentages of mothers were there in satisfactory category among both up to O/L and beyond O/L.

Awareness on infant care and socio-demographic characteristics

Regarding infant care, we paid a special attention for birth weight, alarm signs of child and reasons for special care. These facts are critical signs, symptoms and condition which should be identified. So the mother is the main responsible person regarding those.

There were around 58 % had satisfactory awareness among the mothers who had one child, whereas it was around 73 % in the case of mothers who had more than one child. None of them had poor awareness among mothers had more than one child. There was no statistically significant association between these variables.

Regarding educational level, we saw equal distribution of percentages under satisfactory category. It was about 63 %. This may be due to mothers are more keen on the infant care irrespective of experiences and educational level. PHM based preventive health sector and the doctors in curative services have given education to mothers satisfactorily.

Awareness on exclusive breast feeding and socio-demographic characteristics

There was not a statistically significant association between awareness and number of living children in the family. There were around 85 % of mothers in both categories who knew the duration of the exclusive breast feeding, Irrespective of number of living children. Around 15 % of mothers had not got the new message on this.

Our sample results showed that there was a statistically significant association between mother’s education and exclusive breast feeding. There were around 84 %of mothers gave correct answers among who had educated up to O/L and it was 91 % regarding beyond O/L.

Awareness on complementary feeding and socio-demographic characteristics

Regarding number of living children in the family, around 50% mothers had satisfactory awareness among mothers with more than one child, while it was around 32% in the case of mothers with one child. Though the percentage was as such, there was no statistically significant association between awareness and number of living children.

On considering the educational level of the mother, it was around 36% who educated up to O/L and around 48% in the case of over O/L. There was no statistically significant association between these two variables.

The complementary feeding plays a major role to meet the increasing nutritional gap between requirement and that supplied by breast milk alone. Irrespective of mother’s education and number of living children in the family there were less than 50% had satisfactory awareness. This may be due to myths and early incorrect weaning practices were still there with mothers.

Overall awareness on CHDR and associated characteristics

Among the mothers who had one child, there were around 29% mothers had satisfactory awareness; while it was around 46% in the case of mothers with more than one child. There was no statistical significant association between number of living children in the family and the overall awareness on CHDR. However mothers who had average awareness it was around 70% among mothers who had one child and around 53% of mothers with more than one child. Irrespective of parity around 98% of mothers had average and satisfactory awareness collectively.

Considering the mother’s educational level, there were 32% mothers had satisfactory awareness among up to O/L and it was 42% in the case of beyond O/L. There were 67% mothers had average awareness among up to O/L mothers and it was 58% of over O/L mothers.

Almost all mothers (99%) had either average or satisfactory knowledge up to O/L group. Results revealed that there was statistically significant relationship as we expected.

This is a newly introduced booklet; therefore irrespective of number of children in the family, mothers are more eager to read this. The mothers who had previous experiences in growing children had not neglected this booklet.

As we already explained more educated mothers were more interested to read and gather knowledge.

  • Our next objective was to determine the sources of knowledge on awareness.

We had found some common sources which mothers obtained information in our research. The results showed that, PHM was the vital character conveying health messages to the mother (72%).It was followed by self studying of new CHDR by mothers (64%), whereas radio and television contribute as a source in least percentage (31%) when comparing with the other sources.

This may revealed that, PHM based health education is satisfactory and mothers refer CHDR by themselves under the promotion of primary health care system. Most of the mothers give more attention towards the entertainment programmes rather than educational programmes.

CHAPTER 9

LIMITATIONS

· More than 98% of mothers who attended to the clinic were Sinhalese. Therefore it became a limitation in assessing awareness on race basis.

· It was unable to assess awareness of all mothers who away from their children on day time as they are involved in occupations. And this was the same regarding mothers who couldn’t come to the clinic due to other reasons such as illness and pregnancy. Few of them came to the clinic with their fathers and other care givers.

· The duration of the study had to be limited to only one month. . If the data collection was extended beyond one month we would achieve a high sample size.

· The parents, who can afford, preferred to carry their children to private sector for immunization.

· The results of our study can’t be apply to rural urban or state population because our population represents semi urban population which is consist of middle lower and lower families


CHAPTER 10

CONCLUSIONS

Ø In our sample majority of the mothers were Sinhalese (98%) & above the age of 20 years (97%) also most of the mothers were house wives (98%).

Ø Among them 73% were educated up to O/L. And 66% of mothers had only one child.

Ø 78% of fathers involved in skilled occupations.

Ø Female & male children were equally distributed in our sample.

These socio-demographic details represent a semi urban area which consists of lower & middle lower classes.

Ø Awareness of mothers on some contents of the new CHDR was highly significant. 89% of mothers had satisfactory awareness on child growth, 86% mothers knew the duration of EBF, 83% mothers knew about the beginning of contraception after delivery, 64% had satisfactory awareness on immunization & 63% of mother had satisfactory awareness on infant care.

Ø Only 39% of mothers had satisfactory awareness on complementary feeding.

Ø There were only 18% of mothers had satisfactory awareness on developmental milestones & also considering on completion of hearing vision & developmental milestones charts by mothers were very poor. 21%, 23%, 18% of mothers completed above charts respectively.

Ø There were only 35% of mothers had satisfactory awareness on new CHDR as a overall aspect.

Ø There was statistically significant association between number of living children in the family & awareness of mothers on developmental milestones as well as immunization.

There was no statistically significant association between number of living children in the

family & awareness of mothers on growth, infant care, EBF & complementary feeding.

Ø The statistically significant association between number of living children in the family & awareness of mothers on the overall new CHDR had not been found.

Ø There was statistically significant association between the mother’s educational level & awareness of mothers on growth & EBF.

There was no statistically significant association between the mothers’ educational level & awareness of mothers on developmental milestones, infant care & complementary feeding.

Ø The statistically significant association between the mother’s educational level & awareness of mothers on the overall new CHDR had been found.

Ø PHM was the commonly use source of knowledge (72%) to be aware on new CHDR. It is followed by self study of new CHDR by the mothers (64%).


CHAPTER 11

RECOMMENDATIONS

1. Ensure that PHMs are knowledgeable enough on developmental milestones & on importance of assessment of cognitive behavior of the child.

2. Ensure that the PHM checks the completion of hearing, vision, & developmental milestones charts according to the age of the child in her home visits.

3. Ensure that the new concept of duration of exclusive breast feeding had gained by the mothers.

4. Ensure that PHMs sweep off the myths on complementary feeding among the mothers as well as ensure that PHMs observe the way of preparation, contents, & feeding habits of mothers during their home visits.

5. Ensure that PHMs identify the components in which mothers are less aware & educate on them in her home visits. (Especially on developmental milestones & complementary feeding).

6. Ensure that PHM based health care system recognize the less educated mothers & make more aware on CHDR specially on growth.

7. PHMs are the common use source of knowledge among mothers. Mothers had got used to self study CHDR in a considerable proportion.

8. Ensure the self study & educations by PHMs are promoted on developmental milestones & complementary feeding.


CHAPTER 12

REFERENCES

1. Lissauer T. and Clayden G. Illustrated text book of Pediatrics: 2nd edition: Elsevier Limited: 2003: 21 -38 & 155 -168.

2. Ghai O. P. Piyush Guptha, Paul V.K. Essential Pediatrics: 6th Edition: 2004: 4 -5, 48, 54 -57, 96 -99, 147 -151, 189, 199.

3. Family Health Bureau Modules for training of public health field staff on child growth & development: WHO offset publication (No.59 guidelines for training community health workers in nutrition) 1980: 1 -18, 34 -36, 48 -55.

4. Family health bureau: Instruction booklet on the use of the CHDR for PHMs: WHO offset publication: 1980: 1 – 17.

5. De Silva C., Karunaratne V. Annual report on family health Sri Lanka2004 -2005: Ministry of health: Volume 17: 2007: 17 -20, 29.

6. Fernando D.A.L. prevalence & some factors influencing growth retardation of children of 6 months to 3 years in low income families in Kotte area: 1994.

7. Seneviratne G.D.T. Comprehensive study on immunization in rural, urban & state area in Sri Lanka.

8. Wijayathilaka H.V.B.S. Assessment of growth monitoring & activities related to the growth promotion of children aged 1 -3 years in Colombo municipal council are: 2002.

9. Athauda G.A.T.K. Influence of employment status of the mothers on the physical growth, development & behavior of the pre-school children: 1994.

10. Wickamsinghe S.C. Some reasons for inadequate use of CWC for growth monitoring in municipal council area of Negombo: 1994.

11. Abraham S. Developmental states of children at 5 years & influencing factors at community & household levels in Trincomale district.

12. Agampodi S. B. Agampodi T.C. Piyaseeli U.K.D. breast feeding practices in public health field practice area in Sri Lanka: 2006. http://www.internationalbreastfeedingjournal.com/content/2/1/13

13. ,Dr.David Morley, develop and appropriate heath care programme, Illesha , 1956

CHAPTER 13

ANNEXES

Annex 1

Questionnaire

PART ONE No: …………

PHM area: ……………………

1. Mother’s age …………..

2. Mother’s race Sinhala Tamil Muslim others

3. Number of children alive……………..

4. Mother’s occupation………………………………… How many hours per day does mother spend away from the child……………

5. Father’s occupation…………………………………….

6. Highest level of education of mother a) No school education b) Primary school education c) Up to GCE O/L d) Up to GCE A/L e) Higher education

PART TWO

1. Does mother know child’s birth weight yes no If knows birth weight……………..

2. Infant care Yes No a) The best heat that can be given to the new born

is by wrapping by a blanket

b) The breast milk secretion get reduced when the frequency

of breast feeding is Increased.

c) The warning of infant care,

1) Prolong silence

2) Discoloring & discharge from the umbilicus

3) Prolong breast feeding

4) Abnormal movements of limbs

3. Reasons for special care a) Premature baby b)Formula feeding during first 4 months c) Birth weight is <2.5 kg d)Difficulty in feeding child with breast milk &other foods

4. Up to one year of age how frequently you should carry your baby to the clinic (clinic visit) a)Once in a two weeks b)Once a month c)Once in a two month d)Don’t know

5. A) If your child’s growth curve is in green area of centile chart that indicates a)Over weight b)Normal weight c)Under weight d)Severely underweight

B) According to child’s CHDR assess whether the mother is aware on current

growth situation of her child known ……… not known………

6. if child with normal growth curve shows crossing of centiles in two consecutive measurements, that indicate e.g. green to orange a)Normal growth b)Reduced growth c)Don’t know

7. What is the vaccine which has to be given to child before leaving the hospital a) BCG /TB vaccine b) Don’t know

8. what is the oral vaccine a) Polio

b) Don’t know

9. in which age a normal child start to control his head , at the age of a) 6 weeks to 3-months d) Don’t know

10. In which age normal child can sit without support , at the age of a) 9-months to 12 months b) Don’t know

11. when does a normal child start to speak small words(AMMA,THATHTHA) a) 9-months to 12 months b) Don’t know

12. Exclusive breast feeding has to be given a) 6weeks b) 6 month c) 8 months

13. Regarding complimentary feeding correct incorrect a) After six months child should be given 2 to 3 meals per

day with in between breast feeding.

b) First complimentary food should give in solid form.

c) Avoid adding oil and coconut milk to child complimentary food.

d) Chopped meat and fish can be given in the very first day of

complementary feeding.

e) Normal family diet can be introduced at the age of 18 months.

f) Number of meals which given to child have to be reduced

when the child get ill.

h) Breast milk and other fluid should be given continuously when

child has diarrhoea. h)Allow child to eat alone only after two years of age i) Need to visit the dentist once per six months after appearing

deciduas teeth j) Water, Koththamali, milk powder are weaning foods k)On formation including meals taken within last 24 hours

· Number of main meals

· Number of extra meals

· Eggs or other meat products were added

Yes

No

· Dairy products were added

Yes

No

· Dairy products were added

Yes

No

· Green vegetables were added

Yes

No

· Yellow vegetables were added

Yes

No

· Fruit were added

Yes

No

· No of times breast milk was given to the child

· The time of child breast feeding relative to main meals

· Amount of foods including the main meals.(relative to cup)

14. Part on a) Child hearing component is filled by mother complete not filled

Incomplete b) Child vision component filled by mother complete not filled

Incomplete c) Achievement of developmental milestone Complete not filled

component filled by mother incomplete

15. Mother should not follow a family planning method

after 42 days of delivery , If she breast fed the child, correct incorrect

16. Source of knowledge regarding CHDR acquired by mother by a )Public health midwife b) News papers c)Radio & T.V. programs d)Parents & neighbors e)Self learning of CHDR

MARKING SCHEME

Part 1

01) Mother’s age

02) Mother’s race

03) Number of children alive

04) Mothers occupation and how many hours does mothers spend aware from the child.

Fathers occupation is a rough index of family income and family environment.

05) Educational level (annex-literature review)

According to the previous research we realized about socio demographic factors may affect mother’s awareness and there by child’s growth, survival and development.

Part 2

· Infant care

Q1) Birth weight of child is major factor that affect child’s growth, development & survival. So it has become a content of the CHDR .On the other hand this is a situation which special care for child is needed & mother should become alert / knowledgeable

· On child’s developments.

Q2)

a)The best warmth that can be given to the child by cuttling of mother.

b) Breast empting is the best stimulation for secretion of milk. But there is a secretion.

c) Recognition of alarm sign on infant reduces infant mortality & morbidity. Prolong silence of a previously active child. Redness of umbilicus with secretions in neonate & abnormal limb movements are warning sings.

Q3) Specific problems of infants should be identified by mothers & attention should be given in such situations. Preterm infants, low birth weight< 2.5 Kg, early complementary feeding in less than 6 months. Feeding difficulties are some of aspect where the special care is required.

· Growth.

Q4) To assess the physical growth of the child regular monthly weighing until 2 years is essential.

Q5) A mother should be able to interpret the centile charts on both weight to age & height to age. The green zone of the centile charts indicates the appropriate weight while orange & red zones indicate the low weight & severe low weight respectively. Purple zone indicate over weight. The mother should have knowledge to interpret growth faltering & the current situation of her child on centile chart.

· Immunization.

Q7) Tuberculosis prevalence in Sri Lanka is high. But now severe complications of TB are under control due to BCG vaccination. As BCG is given before discharging the hospital leads to draw more attention of mothers.

Q8) The drawing attention is same as the Polio vaccine as it is given orally. So to assess the awareness on immunization these two vaccines are very reasonable indicators. Polio is the only oral vaccine which draws more attention from mothers. These two questions were included to assess only the knowledge on immunization.

· Development.

Q9, 10, 11) Assessing on importance of developmental milestones mothers are waiting for. Head control is achieved at the age of 6 weeks_ 3 months

Sitting without support at the age of 9 months _12 months.

Speaking small words at the age of 9 months _12 months.

· Exclusive breast feeding

According to WHO recommendations 6 months exclusive breast feeding is now accepted. Breast milk meets all nutritional & fluid requirements in a child under 6 month of age.

Q13) Regarding complementary feeding

a) Complementary feeding has to start after 6 months. Because as iron & other nutrition are not in adequate amount for 6 months old child. Early Commencement of complementary feeding increases the risk of allergies to the child. Breast feeding has to be continued up to 2 years of age the in between other meals.

b) First complementary food should be given in semi solid form to increase the nutritional value of the food.

c) Gradually ad oil, coconut milk for the complementary feeding to increase amount of fat in diet &increase palatability.

d) Add grinded meat fish & child’ dish.

e) Normal family diet can be given to the child at 1 year of age.

f) Finger fords is given to the child when he is 1 year of old to eat by his own.

g) When child get ill quality, quantity & frequency of feeding should be increased to make child nutritionally stable to withstand the disease.

h) Breast milk, other fluid including oral rehydration solutions has to given to the child with diarrhea continuously to prevent dehydration.

i) It is needed to visit dentist once per six months after appearing deciduas teeth.

j) Water, koththamalli, milk powder are not considered of complementary food.

k) Regarding feeding to the child during last 24 hours.

v Eggs should be added as it contains good quality protein otherwise another animal food has to be added.

v Dairy products have to be given Eg.yourgurt, curd etc.

v Cearls have to be added.

v Green vegetables & yellow vegetables have to be added for vitamin A requirement.

v Fruits have to be given for vitamin C requirements.

v Frequency of breast feeding depends on the child age. Frequent on demand feeding should be continued within the first year of life. Continue breast feeding up 2 years.

v Thereafter breast milk should be given after the three main meals. It should never replace the main meals.

v From 9_12 months should given 3 main meals one cup per meals & 2 short meals. After 12 months family diet should be given as 3 main meals with 2 short meals.

Q14) Family planning method should be followed by parents 42 days after delivery though mother is breast feeding.


NEW CHDR -FEMALE NEW CHDR - MALE


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