“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON KNOWLEDGE REGARDING

PREVENTION OF LEPROSY AMONG THE PEOPLE

OF SELECTED RURAL AREA AT TUMKUR.”

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

LAKSHMEESHA.T

(COMMUNITY HEALTH NURSING)

ARUNA COLLEGE OF NURSING

Ring road, Maralur, Tumkur

1
 RAJIV GANDHI UNIVERSITY OF HEALTH .SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

NAME OF THE
Mr.Lakshmeesha.T,
CANDIDATE AND
I Year M.Sc.(Nursing),
ADDRESS
1. Aruna College of Nursing,
Maralur, Tumkur.

NAME OF THE
2. Aruna College of Nursing, Tumkur.
INSTITUTION

COURSE OF THE STUDY I Year M.Sc. Nursing,

3. AND SUBJECT People Health Nursing.

DATE OF ADMISSION 01-06-2011

4.

“Effectiveness of structured teaching

TITLE OF THE STUDY programme on knowledge regarding prevention
5.
of leprosy among the people of selected rural area
at Tumkur.”

6. INTRODUCTION:

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 Leprosy or Hansen's disease (HD) is a chronic disease caused by the bacteria
Myco1bacterium leprae and Mycobacterium lepromatosis. Named after physician
Gerhard Armauer Hansen, leprosy is primarily a granulomatous disease of the peripheral
nerves and mucosa of the upper respiratory tract; skin lesions are the primary external
sign. Left untreated, leprosy can be progressive, causing permanent damage to the skin,
nerves, limbs and eyes. Contrary to folklore, leprosy does not cause body parts to fall off,
although they can become numb or diseased as a result of secondary infections; these
occur as a result of the body's defences being compromised by the primary disease.
Secondary infections, in turn, can result in tissue loss causing fingers and toes to become
shortened and deformed, as cartilage is absorbed into the body1.

Mycobacterium leprae and Mycobacterium lepromatosis are the causative

agents of leprosy. M. lepromatosis is a relatively newly identified mycobacterium
isolated from a fatal case of diffuse lepromatous leprosy in 2008. An intracellular, acid-
fast bacterium, M. leprae is aerobic and rod-shaped, and is surrounded by the waxy cell
membrane coating characteristic of Mycobacterium species.

 Skin lesions are the primary external sign

 left untreated
 causing permanent damage to the skin, nerves, limbs, and eyes.
 involvement of the nasal mucosa resulting in nasal congestion and epistaxis (nose
bleeds), but, typically, detectable nerve damage is late.

At highest risk are those living in endemic areas with poor conditions such as
inadequate bedding, contaminated water, and insufficient diet, or other diseases that
compromise immune function. However, though hard evidence is limited, and fringe
publications have made passionate claims to the contrary, professional studies show little
evidence that HIV is an important factor in increasing the risk of leprosy infection1.

The mechanism of transmission of leprosy is prolonged close contact and

transmission by nasal droplet. In addition to humans, leprosy has been observed in nine-

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banded armadillo, (which, it has recently been confirmed, are among the primary sources
of new cases of leprosy in Americans, and three species of primates. The bacterium can
also be grown in the laboratory by injection into the footpads of mice. There is evidence
that not all people who are infected with M. leprae develop leprosy, and genetic factors
have long been thought to play a role, due to the observation of clustering of leprosy
around certain families, and the failure to understand why certain individuals develop
lepromatous leprosy while others develop other types of leprosy. It is estimated that due
to genetic factors, only 5% of the population is susceptible to leprosy. This is mostly
because the body is naturally immune to the bacteria, and those persons that do become
infected are experiencing a severe allergic reaction to the disease. However, the role of
genetic factors is not entirely clear in determining this clinical expression. In addition,
malnutrition and prolonged exposure to infected persons may play a role in development
of the overt disease1.

Enough synthetic pharmaceuticals that are effective against leprosy have by now
been identified, and support a flexible choice of treatments. The WHO Study Group's
report on the Chemotherapy of Leprosy in 1993 recommended two types of standard
MDT regimen is adopted. The first was a 24-month treatment for multibacillary (MB or
lepromatous) cases using rifampicin, clofazimine, and dapsone. The second was a six-
month treatment for paucibacillary (PB or tuberculoid) cases, using rifampicin and
dapsone. At the First International Conference on the Elimination of Leprosy as a Public
Health Problem, held in Hanoi the next year, the global strategy was endorsed and funds
provided to WHO for the procurement and supply of MDT to all endemic countries1.

A single dose of rifampicin reduced the rate at which contacts acquired leprosy
in the two years after contact by 57%; 265 treatments with rifampicin prevented one case
of leprosy in this period. A non-randomized study found that rifampicin reduced the
number of new cases of leprosy by 75% after three years. BCG offers a variable amount
of protection against leprosy as well as against tuberculosis. Obstacles to the elimination
of the disease include improving detection, educating patients and the population about
its cause, and fighting social taboos about a disease that has caused its patients

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throughout history to be considered "unclean" or "cursed by God" as outcasts. Leprosy is
not a hereditary disease. Where taboos are strong, patients may be forced to hide their
condition (and avoid seeking treatment) to avoid discrimination. The lack of awareness
about Hansen's disease can lead people to believe (falsely) that the disease is highly
contagious and incurable. The ALERT hospital and research facility in Ethiopia provides
training to medical personnel from around the world in the treatment of leprosy, as well
as treating many local patients. Surgical techniques, such as for the restoration of control
of movement of thumbs, have been developed3.

6.1. NEED FOR THE STUDY

Worldwide, nearly 41000 new leprosy cases were detected in the year 2004, among
which 47% were multibacillary. Nearly 12% children were found to have leprosy. It is
estimated that approximately 1-2 million people are permanently disabled due to the
disease. According to the latest World Health Organization (WHO) report, 70% of cases
are present in South East Asian countries, with India having the majority case load4.

As reported to WHO by 115 countries and territories in 2006, and published in the
Weekly Epidemiological Record, the global registered prevalence of leprosy at the
beginning of the year was 219,826 cases. New-case detection during the previous year
(2005 - the last year for which full country information is available) was 296,499. The
reason for the annual detection's being higher than the prevalence at the end of the year
can be explained by the fact that a proportion of new cases complete their treatment
within the year and, therefore, no longer remain on the registers. The global detection of
new cases continues to show a sharp decline, falling by 110,000 cases (27%) during 2005
compared with the previous year. global annual detection has been declining since 2001.
The African region reported an 8.7% decline in the number of new cases compared with
2004. The comparable figure for the Americas was 20.1%, for South-East Asia 32%, and
for the Eastern Mediterranean 7.6%. The Western Pacific area, however, showed a 14.8%

5
increase during the same period. leprosy situation in the four major countries that have
yet to achieve the goal of elimination at the national level.
a) Elimination is defined as a prevalence of less than 1 case per 10,000
population;

b) Madagascar reached elimination at the national level in September 2006;

c) Nepal detection reported from mid-November 2004 to mid-November 2005;

and

d) D.R. Congo officially reported to WHO in 2008 that it had reached elimination
by the end of 2007, at the national level5.

A study was implemented on five Indonesian islands highly endemic for

leprosy to determine whether rifampicin can be used as chemoprophylaxis to prevent
leprosy. The population was actively screened before the intervention and subsequently
once a year for three years. In the control group, no chemoprophylaxis was given. In the
contact group, chemoprophylaxis was only given to contacts of leprosy patients and in
the blanket group to all eligible persons. The cohort consisted of 3,965 persons. The
yearly incidence rate in the control group was 39/10,000; the cumulative incidence after
three years was significantly lower in the blanket group (P = 0.031). No difference was
found between the contact and the control groups (P = 0.93). Whether this apparent
reduced leprosy incidence in the first three years in the blanket group is due to a delayed
development of leprosy or a complete clearance of infection needs to be determined.

Prevention of disability in people affected by leprosy is primarily seen as prevention

and management of impairments secondary to nerve function impairment. This article
describes four different levels at which appropriate interventions may lead to the overall
prevention of disability. These are-prevention of disease, timely diagnosis and adequate
treatment of the disease, early recognition and adequate treatment of nerve function
impairment and finally, prevention and treatment of secondary impairments due to nerve
function loss1.
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 Leprosy control is a long term activity. Therefore planning and programme
management are essential ingredients it is generally assumed that with existing tools. We
can achieve rapid control of leprosy, provided the “operational performance” is stepped
up to the maximum level required. This is the responsibility of programme managers.
Thus issues are discussed under evaluation (operational indicators and epidemiological
indicators. Among the resources that are needed are adequate infrastructure, trained
health personnel, adequate supply of drugs and vehicles, and financial allocation. The
National Leprosy Eradication programme incorporates all these elements1.

The above studies suggest that there are more number of people suffering from
leprosy in India. So investigator felt a need to conduct a study on prevention of leprosy
and structured teaching program will enhances the knowledge of people of rural area
regarding prevention of leprosy.

6.2. REVIEW OF LITERATURE

A Study was conducted on Advances and hurdles on the way toward a leprosy
vaccine. Prevalence rates for leprosy have declined sharply over the past 20 y, with this
decline generally attributed to the WHO multi-drug therapy (MDT) campaign to provide
free-of-charge treatment to all diagnosed leprosy patients. Evidenced by the stalled
decreases in both global prevalence and new case detection rates of leprosy. Mass BCG
vaccination for the prevention of tuberculosis (TB) at national levels has had a positive
effect on leprosy decline and is often overlooked as an important factor in current leprosy
control programs. Because BCG provides incomplete protection against both TB and
leprosy, newer more effective TB vaccines are being developed. The impact that
application of these vaccines will have on current leprosy control programs is unclear. In
this review, assess the need for vaccines within leprosy control programs. We summarize
and discuss leprosy vaccine strategies that have been deployed previously and discuss
those strategies that are currently being developed to augment recent breakthroughs in
leprosy control6.
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 A retrospective study was carried out on transmission of leprosy in thirteen
leprosy high endemic villages in Wenshan district, Yunnan Province, China. A special
questionnaire was designed for collecting the data. A total of 47 patients have been
registered in 13 villages since 1991. Among them, 25 (53.2%) were leprosy household
patients. The proportion of BI positivity was 57.4% (27). The average delay time from
disease onset to diagnosis of leprosy was 12 +/- 7.9 months with a range of 1-36 months.
The interval between 2 cases being detected in each village was in a range of 0.5 to 5.5
years. Reviewed some literature on chemoprophylaxis and discussed the importance.
Most patients could not be detected at the early stage. It may be necessary of considering
the chemoprophylaxis strategy among close contacts of leprosy to stop transmission in
leprosy pocket areas8.

Appearance of new skin and/or nerve lesions during or after fixed duration of
multidrug therapy (MDT), in leprosy, is not uncommon. It could be a lesion due to
leprosy reaction or relapse. Differentiation is easy in classical reactions both clinically
and histopathologically deformity progression. Out of them, 14 cases and 86 cases had
received paucibacillary (PB) and multibacillary (MB) multidrug therapy respectively.
Skin lesions either old or new were noticed in 74% cases which might be due to inactivity
or activity was noticed in 74% cases which might be due to inactivity or activity in forms
of relapse and reaction. Relapse was seen in 26 cases. Out of these, 10 and 16 cases were
previously diagnosed as PB and MB cases respectively. PB cases relapsed into MB cases
while MB cases relapsed into MB cases. 46 cases presented with either type 1 or type 2
reaction. After declared as RFT, paraesthesia in 34 cases, weakness in 18 cases, paresis
and paralytic deformity in 6 cases were seen. So, all the RFT cases need regular follow-
up, IEC and physiotherapy to prevent deformity and to diagnose relapse and reactions at
the earliest9.

The study was conducted on general population on prevalence of previously

undiagnosed leprosy (PPUL) in the general population was determined to estimate the
background level of leprosy in the population and to compare this with registered

8
prevalence and the known PPUL in different levels of contacts of leprosy patients.
Multistage cluster sampling including 20 clusters of 1,000 persons each in two districts
with over 4 million populations. Physical examination was performed on all individuals.
The number of newly found leprosy cases among 17,862 people above 5 years of age
from the cluster sample was 27 (19 SLPB, 8 PB2-5), giving a PPUL rate of 15.1 per
10,000. It significants that PPUL in the general population is six times higher than the
registered prevalence, but three times lower than that in the most distant subgroup of
contacts (neighbour of neighbour and social contacts) of leprosy patients in the same
area. Full village or neighbourhood surveys may be preferable to contact surveys where
leprosy is highly endemic10.

The study was conducted by Ron P Schuring collected data, in which we

determined the discriminative ability of a previously published rule and an updated rule
with a concordance statistic, analysed with a Cox proportional hazards regression model.
The population consisted of 1,037 leprosy patients newly diagnosed between 2002 and
2003 in the health care facilities of the Rural Health Program in Nilphamari and Rangpur
districts in northwest Bangladesh. The primary outcome was the time until the start of
treatment. An NFI event was defined as the decision to treat NFI with corticosteroids
after diagnosis. NFI occurred in 115 patients (13%; 95% confidence interval 11%–16%).
The original prediction rule had adequate discriminative ability (c = 0.79), but could be
improved by substituting one predicting variable: ‘long-standing nerve function
impairment at diagnosis’ by ‘anti-PGL-I antibodies’. The adjusted prediction rule was
slightly better (c = 0.81) and identified more patients with NFI (80%) than the original
prediction rule (72%) .Concludes that NFI can well be predicted by using the risk
variables ‘leprosy classification’ and ‘anti-PGL-I antibodies’. The use of these two
variables that do not include NFI offer the possibility of predicting NFI, even before it
occurs for the first time. Surveillance beyond the treatment period can be targeted to
those most likely to benefit from preventing permanent disabilities11.

A study was conducted on multilevel study of risk factors of leprosy is an infectious

disease that can lead to physical disabilities, social stigma, and great hardship. Endemic
in developing countries, like Brazil and India. Effective treatment has been available

9
since 1960, studied 6,158 contacts of 1,201 patients under surveillance from 1987 to
2007. We evaluated the ways patient and contact demographics and epidemiological
characteristics were associated with the detection of leprosy. Total 6,158 contacts and
1,201 leprosy patients of the cohort who were diagnosed and treated at the Leprosy
Laboratory of Fiocruz from 1987 to 2007 were included. The contact variables analyzed
were sex; age; educational and income levels; blood relationship, if any, to the index
case; household or non-household relationship; BGG vaccine and presence of BCG scar.
Among the co-prevalent cases, the leprosy-related variables that remained associated
with leprosy included type of household contact, [odds ratio (OR) = 1.33, 95%
confidence interval (CI): 1.02, 1.73] and consanguinity with the index case, (OR = 1.89,
95% CI: 1.42–2.51). With respect to the index case variables, the factors associated with
leprosy among contacts included up to 4 years of schooling and 4 to 10 years of
schooling (OR = 2.72, 95% CI: 1.54–4.79 and 2.40, 95% CI: 1.30–4.42, respectively) and
bacillary load, which increased the chance of leprosy among multibacillary contacts for
those with a bacillary index of one to three and greater than three (OR = 1.79, 95% CI:
1.19–2.17 and OR: 4.07–95% CI: 2.73, 6.09), respectively. Among incident cases,
household exposure was associated with leprosy (OR = 1.96, 95% CI: 1.29–2.98),
compared with non-household exposure. Among the index case risk factors, an elevated
bacillary load was the only variable associated with leprosy in the contacts. Results that
biological and social factors appear to be associated with leprosy among co-prevalent
cases, whereas the factors related to the infectious load and proximity with the index case
were associated with leprosy that appeared in the incident cases during follow-up12.

The study was conducted on neuropathic pain has been little studied in
leprosy..The association of neuropathic pain with psychological morbidity was also
evaluated. One hundred and one patients were recruited, and 22 (21.8%) had neuropathic
pain. The main sensory symptoms were numbness (86.4%), tingling (68.2%),
hypoesthesia to touch (81.2%) and pinprick (72.7%). Neuropathic pain was associated
with nerve enlargement and tenderness, painful skin lesions and with psychological
morbidity. The Douleur Neuropathique 4 had a sensitivity of 100% and specificity of
92% in diagnosing neuropathic pain. The Douleur Neuropathique 4 is a simple tool for
the screening of neuropathic pain in leprosy patients. Psychological morbidity was
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detected in 15% of the patients and 41% of the patients with neuropathic pain had
psychological morbidity13.

The study was conducted on the controversy within the National Academy of
Medicine over compulsory isolation of leprosy sufferers. Brazilian society's view of
leprosy in the early twentieth century, patient segregation was considered the only way to
protect the healthy. The policy enforced by the Inspectorship for the Prevention of
Leprosy and Venereal Diseases deemed isolation in leprosaria the preferred approach.
Belisário Penna criticized the work of the Inspectorship, arguing that the best way to
isolate patients would be to create municipalities located a good distance from urban
centers. In 1926, Penna came head to head over the subject with Eduardo Rabello, the
Inspectorship's former chief. Part of a broader debate on the best way to control leprosy,
this controversy sheds light on the changes to leprosy policies introduced in the 193014.

The study was conducted data for 2223 leprosy cases detected from 1952 to 2008
were analysed. Large-scale house-to-house surveys were launched in 1957-1958 and
1964-1965, and a remarkable number of new cases were identified during these two
surveys. The overall prevalence rate of leprosy in the Yuxi region presented a roughly
unimodal distribution between 1952 and 2008, with a peak (9.27 per 10000 population)
in 1965. This reflects a combination of case detection and duration of treatment. Overall,
the age distribution of the patients changed dramatically over the years, and there were
only two childhood cases between 1995 and 2008 (both occurring in 1998). Nearly half
of the total cases (49.1%) were classified as multibacillary leprosy type. With the
introduction and ubiquitous coverage of the WHO multi-drug therapy (MDT) in this area,
leprosy elimination was achieved in 1992. In recent years, the majority of cases (> 80%)
were detected by passive approaches, and there is an increasing tendency to find
multibacillary leprosy patients. Results that he trend in detection of new cases in recent
years suggested that the transmission of leprosy has stopped in the area or, at least,
dramatically declined15.

6.3 STATEMENT OF THE PROBLEM

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 “A study to assess the Effectiveness of structured teaching programme on
knowledge regarding prevention of leprosy among the people of selected rural area at
Tumkur.”

6.4 OBJECTIVES OF THE STUDY

 To assess the knowledge of people regarding prevention of leprosy .

 To assess the effectiveness of structured teaching programme on knowledge
regarding prevention of leprosy among people.
 To compare the mean scores of pre-test and post-test scores of rural people
regarding prevention of leprosy.
 To associate the knowledge of people regarding prevention of leprosy with their
selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

 ASSESS: Is the systematic and organised way of collecting information from

people people on knowledge regarding prevention of leprosy .
 KNOWLEDGE: It refers to the correct response of questionnaire given by the
respondents.
 EFFECTIVENESS: effectiveness refers to the differences between the pre-test
knowledge scores and post-test knowledge scores.
 STRUCTURED TEACHING PROGRAM: it refers to the organized and
structured way of teaching to people to enhance the knowledge on prevention of
leprosy.
 PEOPLE: it refers to people who residing in selected rural area.
 PREVENTION: it refers avoiding the occurrence of diseases and prevention of
complication of leprosy.

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 LEPROSY: is a chronic disease caused by the Mycobacterium leprae and
Micobacterium lepromatosis

6.6 ASSUMPTIONS

 Knowledge regarding prevention of leprosy among people may vary from

individual to individual.
 Structured teaching programme will improve the knowledge of rural
people regarding prevention of leprosy.

6.7 HYPOTHESES

H1: There will be significant difference in the knowledge scores regarding

prevention of leprosy before and after the structured teaching programme.

H2: There will be significant association between the pre-test knowledge scores
of rural people with their selected demographic variables.

7 MATERIALS AND METHODS

7.1 SOURCE OF DATA: Data will be collected from the people of selected rural
area at Tumkur.
 RESEARCH APPROACH: Quantitative Evaluative research approach
 RESEARCH DESIGN: Quasi Experimental one group pre-test and post-
test research design.
 SETTING OF THE STUDY: people of selected rural area at Tumkur.
 SAMPLE SIZE: 60people.
 SAMPLING TECHNIQUE: Convenience sampling technique will be
used.
 SAMPLING CRITERIA:
Inclusive criteria:

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 People who are
 willing to participate.
 at the age group of 20 – 55 years.
 understand Kannada and English.
 Both male and female.

Exclusive criteria:
People who are
 not willing to participate.
 seriously ill during data collection period.
 already exposure to similar teaching programmes on prevention of
leprosy.

7.2 METHODS OF DATA COLLECTION

DATA COLLECTION TECHNIQUE: After obtaining prior permission from

concerned authorities the investigator will introduce himself to the study subject
and explains the purpose of the study. Data will be collected using structured
questionnaire by self-administration of questionnaire.

DESCRIPTION OF THE TOOL:

Tool – I: PART – A: Proforma for collecting Demographic Variables.

PART – B: Structured Questionnaire to assess the knowledge

regarding prevention of leprosy among the people of selected rural
area at Tumkur.

Tool – II : Structured teaching programme on prevention of leprosy.

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 DATA ANALYSIS AND INTERPRETATION
Data will be analysed according to the objectives of the study using descriptive
and inferential statistics

DURATION OF THE STUDY: 6 weeks

7.3 Does the study require any investigation or intervention to be conducted on

patients or other human or animals? If so describe briefly?

NO

7.4 Has ethical clearance been obtained from your institution?

Yes, an ethical clearance will be obtain from the institutional ethical committee.

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8. LIST OF REFERENCES:
1. . K.PARK, “PREVENTIVE AND SOCIAL MEDICINE”. Chapter 5,Pp253-264.In
18th Ed.M./Banarsidas publications, JABALPUR.
2. Polit FDand Hungler B.P. Nursing Research Principles and Methods.6th ed.p.125-
140 Phileadelphia, Lippincott Company,2004.
3. En.wiki.pedia.org/wiki/Leprosy.
4. leprosy: History and Incidence — Infoplease.com.

5. www.whoindia.org/en/Section3/Section122_1699.htm.

6. Sasaki S, Takeshita F, Okuda K, Ishii N (2001).University of Maryland Medical

Center.

7. Infectious Disease Research Institute; Seattle, WA USA.

8. Department of Leprosy Control, Institute of Dermatology, Chinese Academy of

Medical Sciences, National Center for Leprosy Control, China.
jianping_shen2@yahoo.com.cn

9. ncbi.nlm.nih.gov/pubmed/15827283

10. Department of Skin and VD, Medical College and SSG Hospital, Raopura,
Vadodara, India. nipulvara@yahoo.co.in

11. Department of Leprosy Control, Institute of Dermatology, Chinese Academy of

Medical Sciences, National Center for Lepros Control, China.
jianping_shen2@yahoo.com.cn
12. Clinical Infect Dis. 2001 Mar 15;32(6):930-7. Epub 2001 Mar 9.World Health
Organization.
13. National Institute of Allergy and Infectious Diseases, National Institutes of Health,
Bethesda, MD, USA.
14. Center for Infectious Diseases and International Health, Royal Free and University
College Medical School, Windeyer Institute of Medical Sciences, London, UK.
azumla@ucl.ac.uk

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15. Department of Bio regulation, Leprosy Research centre, National Institute of
Infectious Diseases (NIID), Tokyo, Japan. norishii@nih.go.jp
16. Casa de Oswaldo Cruz, Fundação Oswaldo Cruz, - Rio de Janeiro, RJ, Brasil,
21235-180.
17. Campinas Catholic University, Brazil.
18. doi:10.1371/journal.pntd.0000198.t003.

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9. SIGNATURE OF THE CANDIDATE :

10. REMARKS OF THE GUIDE :

11. NAME AND DESIGNATION OF THE

GUIDE :

11.2 SIGNATURE :

11.3 CO GUIDE (IF ANY) :

11.4 SIGNATURE :

11.5 HEAD OF THE DEPARTMENT :

11.6 SIGNATURE :

12.
12.1 REMARKS OF THE CHAIRMAN
AND PRINCIPAL :

12.2 SIGNATURE :
9

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