A STUDY TO ASSESS THE EFFECTIVENESS OF INDIVIDUAL HEALTH

EDUCATION ON LEVEL OF KNOWLEDGE REGARDING PULMONARY

REHABILITATION AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD) IN SELECTED HOSPITALS AT

MANGALORE

by

Ms. MINU AUGUSTINE

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfilment

of the requirements for the degree of

MASTER OF SCIENCE

IN

MEDICAL SURGICAL NURSING

Under the guidance of

Asst. Prof. UMA MAHESWARI. R

HOD

DEPARTMENT OF MEDICAL SURGICAL NURSING

UNITY ACADEMY OF EDUCATION, COLLEGE OF NURSING

MANGALORE

2013
i
 Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “A STUDY TO ASSESS

THE EFFECTIVENESS OF INDIVIDUAL HEALTH EDUCATION ON LEVEL

OF KNOWLEDGE REGARDING PULMONARY REHABILITATION AMONG

PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

IN SELECTED HOSPITALS AT MANGALORE” is a bonafide and genuine research

work carried out by me under the guidance of Mrs. Uma Maheswari. R, Assistant

Professor and H.O.D, Medical Surgical Nursing, Unity Academy of Education,

College of Nursing, Mangalore.

Date: Signature of the candidate

Place: Mangalore

Ms. Minu. Augustine

ii
 CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled “A STUDY TO ASSESS THE

EFFECTIVENESS OF INDIVIDUAL HEALTH EDUCATION ON LEVEL OF

KNOWLEDGE REGARDING PULMONARY REHABILITATION AMONG

PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

IN SELECTED HOSPITALS AT MANGALORE.” is a bonafide research work done

by Ms. Minu. Augustine in partial fulfilment of the requirement for the degree of

Master of Science in Nursing (Medical Surgical Nursing).

Date: Signature of the guide

Place: Mangalore

Asst. Prof. Uma Maheswari. R

Assistant Professor and HOD

Dept. of Medical Surgical nursing

Unity Academy of Education, College of

Nursing

iii
 ENDORSEMENT BY THE HOD, PRINCIPAL /

HEAD OF THE INSTITUTION

This is to certify that the dissertation titled “A STUDY TO ASSESS THE

EFFECTIVENESS OF INDIVIDUAL HEALTH EDUCATION ON LEVEL OF

KNOWLEDGE REGARDING PULMONARY REHABILITATION AMONG

PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

IN SELECTED HOSPITALS AT MANGALORE” is a bonafide research work done

by Ms. Minu. Augustine under the guidance of Mrs. Uma Maheswari. R, Assistant

Professor and H.O.D, Medical Surgical Nursing, Unity Academy of Education,

College of Nursing, Mangalore.

Seal & Signature of the HOD Seal & Signature of the Principal

Asst. Prof. Uma Maheshwari. R Lt. Col. (Prof). Suma. K.S

Dept of Medical Surgical Nursing Principal

Unity Academy of Education, Unity Academy of Education,

College of Nursing College of Nursing

Date: Date:

Place: Mangalore Place: Mangalore

iv
 COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka,

shall have all the rights to preserve, use and disseminate this dissertation/thesis in print or

electronic format for academic/research purposes.

Date:

Place: Mangalore Ms. Minu. Augustine

© Rajiv Gandhi University of Health Sciences, Karnataka

v
 ACKNOWLEDGEMENT

Any endeavour is possible only with the co-operation, support and contribution of

the person concerned. At the verge of the completion of thesis, with profound joy and

gratitude I acknowledge the help of all those who have been involved in the success of

this study.

First of all I praise and thank the My God Lord Almighty for his abundant

blessings, showered upon me throughout the study.

I extend a great deal of thanks to the Management of Unity Academy of

Education, for providing me an opportunity to pursue post graduation in nursing in this

esteemed institution.

I am grateful to Dr. C. P. Habeeb Rehman, Chairman Unity Academy of

Education, for his good wishes.

I express my sincere gratitude to Lt.Col.Prof.K.S.Suma, Principal, Unity

Academy of Education, College of Nursing for her continuous support, encouragement

and timely help.

This study has been undertaken and completed under the inspiring guidance of

Mrs.Uma Maheswari. R, Asst.Professor & H.O.D, Medical Surgical Nursing Unity

Academy of Education College of Nursing, Mangalore. I am greatly privileged to have

her as my HOD and guide. I express my sincere gratitude to my mentor for her inspiring

and illuminating guidance, suggestions and constant encouragement to make the work

successful learning experience.

vi
 I am grateful to my co-guide and respected teacher Mrs. Florine Fernandez, Unity

Academy of Education, College of Nursing, Mangalore for her valuable guidance and

encouragement and continuous support during the entire course of the study.

I am grateful to, Prof. G Chithra, Vice Principal, Department of Pediatric

nursing, Mrs. Kavitha.R, Associate Professor Department of Obstetrics and

Gynecological nursing, Ms.Sumithra.M, Associate professor Department of psychiatric

nursing and Ms. Sruthi Sannidhi, Lecturer Department of Obstetrics and Gynecological

nursing for their valuable advice and suggestions which helped to shape the study in

many ways.

A word of thanks to my former guide Prof. Mrs. Mary Sham Bhat and former

co-guide Mrs. U. Poongodi, Associate Professor, Medical Surgical Nursing for giving

me constant encouragement.

I am grateful for the best wishes and blessings of the Medical superintendent,

Govt. Wenlock Hospital for her appreciation and willingness in allowing me to conduct

the study.

I extend my gratitude to Mrs. Sucharita Suresh, Statistician, Father Mullers

College of Medical Sciences., Mangalore, for her advice and assistance in the statistical

analysis of data.

I express my sincere thanks to all the experts for their valuable judgements,

constructive recommendations and enlightening suggestions while validating the tool.

I express my sincere thanks to the Library staff and Office staff of Unity

Academy of Education, College of Nursing, Yenepoya Medical College for allowing me

to utilize their library facilities.

vii
 I am greatly indebted to all my Classmates, Seniors and Friends who helped

me during the course of my study.

I am greatly indebted to my Parents, Mr. Augustine. K. K and Mrs. Gracy

Augustine, for their endless love, support, and constant prayers in the successful

completion of this study.

Gratitude is extended to Mr. Roshan Patrao for giving shape to this

dissertation.

I owe my sincere thanks and gratitude to all those who directly or indirectly

helped me in the successful completion of this endeavour.

With heartfelt and everlasting gratitude and prayers…

Date: 10.02.2013

Place: Mangalore Ms. Minu. Augustine

viii
 LIST OF ABBREVIATIONS

BCKQ : Bristol COPD Knowledge Questionnaire

COPD : Chronic Obstructive Pulmonary Disease
CRDQ : Chronic Respiratory Disease Questionnaire
CRF : Chronic Respiratory Failure
CAT : COPD Assessment Test
DDD : Defined Daily Dosage
ESQ : Evaluated By A Specific Questionnaire
EP : Education Program Group
EG : Educational Group
FEV : Functional Expiratory Volume
f : Frequency
GEP : General Exercise Programme
GP : General Practitioner
HbALc : Glycolated Hemoglobin
HRQoL : Health Related Quality Of Life
ITEP : Individually Targeted Exercise Programme
LINQ : Lung Information Needs Questionnaire
MSHQ : Mount Sinai Hospital Questionnaire
n : Sample
PR : Pulmonary Rehabilitation
PaO2 : Partial Pressure Of Oxygen
PaCO2 : Partial Pressure Of Carbon dioxide
SD : Standard Deviation
USA : United States of America
% : Percentage
6-MWT : 6-Minute Walking Test

ix
 ABSTRACT

Background of the study

Pulmonary rehabilitation is an integral part of the clinical management and health

maintenance of those patients with chronic respiratory disease Pulmonary rehabilitation

aims to reduce symptoms, decrease disability, increase participation in physical and

social activities, and improve the overall quality of life for patients with chronic

respiratory disease. These goals are achieved through patient and family education,

exercise training, psychosocial and behavioral intervention, and outcome assessment.

Considering this major problem, a study was carried out with a purpose of identifying the

effect of individual health education on pulmonary rehabilitation among the COPD

patients of a selected hospital at Mangalore.

Objectives of the study

1. To assess the level of knowledge regarding pulmonary rehabilitation among

patients with COPD using structured knowledge questionnaire.

2. To evaluate the effectiveness of individual health education on level of

knowledge regarding pulmonary rehabilitation among patients with COPD.

3. To find the association between the pre-test knowledge score and selected

baseline variables.

Method

An evaluative approach with pre-experimental one group pre-test post-test design

was used for this study. The study was carried out in a Govt. Wenlock hospital at

Mangalore. The samples, 50 COPD patients, were selected by a non-probability

x
purposive sampling technique. The data collection was done from 14/09/12 to 20/10/12

after obtaining permission and consent. Pre-test was conducted by administering a

structured knowledge questionnaire. After the pre-test the individual health education

was administered. Post-test was conducted on 7th day using the same structured

knowledge questionnaire. The data was analyzed using descriptive and inferential

statistics. Paired‘t’ test was used to find the effectiveness of individual health education

and chi-square was used to find the association of pre-test knowledge score with selected

baseline variables.

Results

The findings showed that the mean post test knowledge score (18.1) is higher

than the mean pre test knowledge score (9.0833) after the individual health education.

The mean percentage knowledge score of pre-test was higher in the area of anatomy and

physiology of respiratory system with mean percentage of 70% and the mean percentage

of knowledge score was found to be lower in the area of relaxation techniques (24%).

whereas the mean percentage knowledge score of post-test was higher in the area of

nutrition with mean percentage of 78.66%. The mean percentage of knowledge score

was found to be lower in the area of knowledge regarding disease condition (67.33%).

The mean difference between the mean post test and the mean pre test knowledge score

was found to be statistically significant (t49 = 30.56) at 0.05 level of significance. Hence

the null hypothesis was rejected and research hypothesis was accepted, indicating that the

individual health education was an effective method of increasing the knowledge of the

COPD patients, on pulmonary rehabilitation.

xi
 The findings of the study reveal that there is no significant association (NS)

between the pre-test knowledge score and selected baseline data like age (χ21=0.4798),

gender (χ22=0.083), educational status (χ23=0.8557), occupation (χ24=0.5577), family

monthly income (χ25=0.3517), history of smoking (χ26=0.0831), under regular treatment

(χ27=0.2430), hospitalization for COPD(χ28=1.000), and previous information about

pulmonary rehabilitation(χ29=1.000), at 0.05 level of significance.

Interpretation and conclusion

The study showed that majority of the patients had an inadequate knowledge on

pulmonary rehabilitation; however the knowledge has significantly improved after the

administration of a individual health education. Hence it was concluded that individual

health education was an effective teaching strategy in improving the knowledge of COPD

patients on Pulmonary rehabilitation.

Keywords

Knowledge; Pulmonary rehabilitation; Individual health education; Chronic

respiratory disease; Chronic obstructive pulmonary disease (COPD); Quality of life.

xii
 TABLE OF CONTENTS

Chapter no: Title Page No.

1. Introduction 1-10

2. Objectives 11-17

3. Review of literature 18-32

4. Methodology 33-47

5. Results 48-79

6. Discussion 80-85

7. Conclusion 86-89

8. Summary 90-93

9. Bibliography 94-102

10. Annexure 103-176

xiii
 LIST OF TABLES

Table Title Page

No. No.

1 Frequency and percentage distribution of the selected baseline 50-52

variables of the COPD patients

2 Distribution of overall pre-test knowledge score of COPD 63

patients on pulmonary rehabilitation in terms of frequency and

percentage on knowledge.

3 Mean Median and Standard Deviation of Pre-test knowledge 65

score of COPD patients on pulmonary rehabilitation.

4 Area-wise distribution of pre-test Mean knowledge score, 66

Standard deviation and Mean percentage of COPD patients on

pulmonary rehabilitation.

5 Distribution of overall post-test knowledge score of COPD 68

patients on pulmonary rehabilitation in terms of frequency and

percentage on knowledge.

6 Mean Median and Standard Deviation of Post-test knowledge 70

score of COPD patients on pulmonary rehabilitation.

7 Area-wise distribution of post-test Mean knowledge score, 71

Standard deviation and Mean percentage of COPD patients on

pulmonary rehabilitation.

xiv
8 Frequency and percentage distribution of pre and post test 73

knowledge scores of COPD patients on pulmonary

rehabilitation.

9 Over all mean, mean difference, standard deviation, ‘t’ value, 75

standard error mean of pre test and post test knowledge scores

of COPD patients on pulmonary rehabilitation.

10 Area-wise mean, mean difference, standard deviation, ‘t’ value 76-77

and standard error mean of pre-test and post-test knowledge

score of samples

11 Chi square test showing the association between pre-test 78

knowledge score of COPD patients and selected baseline

variables.

xv
 LIST OF FIGURES

Figure Title Page

No. No.

1 Conceptual frame work based on Danial Stufflebeam programme 17

evaluation model

2 The schematic representation of the methodology 34

3 Schematic representation of the study design 36

4 Bar diagram showing the percentage distribution of samples according to 53

the age.

5 Pie diagram showing the percentage distribution of samples according to 54

the gender.

6 Conical diagram showing the percentage distribution of samples according 55

to their education.

7 Cylindrical diagram showing the percentage distribution of samples 56

according to their occupation.

8 Conical diagram showing the percentage distribution of samples according 57

to their family monthly income.

9 Bar diagram showing the percentage distribution of samples according to 58

the history of smoking.

10 Cylindrical diagram showing the percentage distribution of active smokers 59

according to the number of packets smoked per day.

11 Pyramidal diagram showing the percentage distribution of samples taking 60

regular treatment for COPD.

xvi
12 Conical diagram showing the percentage distribution of samples according 61

to their previous hospitalization for COPD.

13 Pie diagram showing the percentage distribution of samples according to 62

their previous information regarding pulmonary rehabilitation.

14 Cylindrical diagram showing the distribution of samples according to the 64

pre test level of knowledge.

15 Bar diagram showing the distribution of samples according to the post test 69

level of knowledge.

16 Bar diagram showing the percentage distribution of samples according to 74

the pre test and post test level of knowledge

xvii
 LIST OF ANNEXURES

Annexure Title Page No.

No.

1 Letter requesting and granting permission for conducting the reliability, 103

pilot study and main study.

2 Letter requesting for expert opinion to establish content validity of the 104

research tool.

3 Acceptance form for tool validation. 105

4 Content validation certificate. 106

5 Blue print of structured knowledge questionnaire. 107

6 Letter requesting consent for participation in the study 108-109

(English & Kannada).

7 Description of the tool (English & Kannada version). 110-125

8 Answer Key. 126-127

9 Criteria checklist for validation of the tool. 128-131

10 Criteria checklist for the validation of the content of the individual health 132-134

education.

11 Lesson plan (English & Kannada version). 135-165

12 Power point slides on pulmonary rehabilitation. 166-169

13 List of experts who have validated the tool and individual health education. 170

14 List of formulae. 171-172

15 Master data sheet. 173-176

xviii
INTRODUCTION
 1. INTRODUCTION

“Remember to breathe. It is after all, the secret of life.”

-Gregory Maguire

COPD is characterized by chronic airflow obstruction and limitation and

interferes with breathing reduces energy and vitality, and produces progressive worsening

and fluctuating symptoms which can be disabling for both the patients and their families.

The individual with COPD often has several problems (physical, psychological and

social) and requires more than a prescription aimed at symptom relief. Many patients and

their families are left alone to cope with the functional and emotional difficulties caused

by this irreversible and progressive disease which can severely impair their quality of life.

The past thirty years had seen the development of pulmonary rehabilitation in treating

patients with COPD. The primary goal of pulmonary rehabilitation has been to restore the

patient to the highest possible level of independent functioning1.

Pulmonary rehabilitation is an exercise and education program that can greatly

benefit those with lung disease such as asthma, emphysema, and chronic bronchitis.

Whether caused by smoking, occupational, environmental, or genetic factors, these

conditions leave people chronically shortness of breath and can be very debilitating2.

Pulmonary rehabilitation for patients with COPD is well established and widely accepted

as a means to alleviate symptoms and optimize functional status, increase participation,

and reduce health care costs by stabilizing or reversing systemic manifestations of the

disease. It is a form of rehabilitation dealing with respiratory disorders and limited

participation in daily life3.

1
 Pulmonary rehabilitation includes patient education, exercise training,

psychosocial support and advice on nutrition. Pulmonary rehabilitation has been shown to

improve exercise capacity, reduce breathlessness, improve health-related quality of life,

and decrease healthcare utilization. Pulmonary rehabilitation should be offered to all

patients who consider themselves functionally disabled by COPD4. Patients with chronic

obstructive pulmonary disease (COPD) often decrease their physical activity because

exercise can worsen dyspnea. The progressive deconditioning associated with inactivity

initiates a vicious cycle, with dyspnea becoming problematic at ever lower physical

demands. Pulmonary rehabilitation aims to break the cycle5.

Education about the disease is a very important step in improving the health, and

this may be part of the rehabilitation program. COPD patients may learn about their

symptoms, available treatments, and techniques to manage the symptoms including what

to do in an exacerbation6. The education component of each pulmonary rehabilitation

program is different. Some of the topics are Medications used to treat chronic lung

disease, Breathing techniques or managing breathlessness, Sputum clearance, Benefits of

physical exercise, Energy conservation techniques, Nutrition or healthy eating and

information on how the lung works. Following pulmonary rehabilitation, most people

feel they are able to do more and feel less breathless7.

Patient education is necessary to improve skills, ability to cope with illness and

the health status. The people who learn about their COPD and treatment plan are better

able to recognize symptoms and take appropriate action. Health education is particularly

effective for sustained smoking cessation. In addition, appropriate information about the

2
nature of the disease, instructions on how to use different medications and inhalers, and

clues to recognize symptoms of exacerbation are mandatory8.

The rehabilitation process incorporates a programme of physical training, disease

education, nutritional assessment, advice, psychological, social, and behavioral

intervention and it is provided by a multi professional team, with involvement of the

patient's family and attention to individual needs. Respiratory rehabilitation is effective in

helping to relieve dyspnoea and improve control of COPD. Pulmonary rehabilitation for

patients with COPD has also been shown to relieve fatigue, improve emotional function

and enhance patients' sense of control over their condition 4. Education is an important

part of a pulmonary rehabilitation program for both the person and family. Education can

be given by one to one teaching, written materials and group classes. Videos and other

visual aids may also be used. Teaching sessions will help to provide information about

specific medications, treatments and self management at home9.

Pulmonary rehabilitation is exercise for the muscles, including the muscles of

breathing10. It is indicated for patients with chronic respiratory impairment who, despite

optimal medical management, are dyspnoeic, have reduced exercise tolerance, or

experience a restriction in activities. Indication for pulmonary rehabilitation is based not

on the severity of physiologic impairment of the lungs but on the persistence of

symptoms, disability, and handicap11.

Patients with COPD have anxiety, depression, fatigue, and difficulty coping with

symptoms. Disability and decreased capacity to participate in social and recreational

activities are common. Psychosocial intervention and support are important parts of

pulmonary rehabilitation. It has been shown that the patient’s mood is improved with

3
reduced anxiety and depression with pulmonary rehabilitation. Evaluation of the patient’s

psychological state should be done. Support groups are offered in pulmonary

rehabilitation programs, where patients support one another, as well as receive support

from Health Care professionals12.

Some patients with COPD are underweight which also results in pulmonary

dysfunction. Malnutrition is associated with respiratory failure and increased mortality in

COPD. Assessment for malnourished states, especially in the acute care settings, is an

essential early step in the care of patients with COPD and respiratory decompensation.

Adequate nutrition repletion for the patient must fulfill the individual’s energy

requirements, as well as incorporate the proper proportions of protein, fat and

carbohydrate12.

The rehabilitation intervention is geared towards the unique problems and needs

of each patient. It helps the people with moderate to severe breathing problems to

overcome the physical limitations resulting from their disease11. Most people who

complete a pulmonary rehabilitation course feel better at the end. They are able to

perform more activity without becoming shortness of breath, and they report their overall

quality of life is better13.

4
NEED FOR THE STUDY

Chronic obstructive pulmonary disease (COPD) is a progressive disease that

makes it hard to breathe. The disease can limit the ability to do routine activities. Severe

COPD may prevent the patient from doing even basic activities like walking, cooking, or

taking care of himself14. Patients consistently report lower levels of functional

performance for ambulation, sleep and rest, and home management as well as recreation

and other activities. Patients with moderate or severe COPD report at least 15%

impairment in each of these categories, while oxygen-dependent patients report 25% to

40% impairment15.

Worldwide, COPD is the only cause of death that still has a rising mortality rate.

It has been estimated that by the year 2020 COPD will be the fifth leading cause of death

in the world16. In 2010, almost 24 million adults over the age of 40 in India had COPD.

Datamonitor expects this number to increase 34% to approximately 32 million by 2020.

COPD is predominately a disease of men and only 40% of cases in India occur in

women17. Depending of disease severity, the five-year mortality rate of patients with

COPD varies from 40% to 70%18.

A study was conducted to describe the prevalence of chronic obstructive

pulmonary disease in patients attending chest clinic in a tertiary hospital in India. Three

year retrospective analysis of all subjects who underwent pulmonary function tests

between January 1999 to December 2001. Out of 13860 patients 946 patients were

diagnosed to have COPD. Out of 964 patients, 284 had mild COPD (30%), 286 had

moderate disease (30%) and the remaining 387 patients (40%) had severe COPD. The

result showed an overall prevalence of 6.85% in South India19.

5
 The impact of pulmonary rehabilitation are to control and alleviate as much as

possible the symptoms and pathophysiologic complications of respiratory impairment

and teach the patient how to achieve optimal capability for carrying out activity of daily

living11. Pulmonary rehabilitation programs instruct patients on breathing control

techniques to reduce the effects of hyperinflation at rest and with exertion 20.

A randomized, prospective, parallel-group controlled study was conducted in

Norway to assess the effectiveness of outpatient pulmonary rehabilitation in chronic lung

disease. 65 patients were participated in this study. The active group (n=36) took part in a

6-week program of education (2 h weekly) and exercise (1 h weekly). The control group

(n=29) were reviewed routinely as medical outpatients. The St. George’s respiratory

questionnaire was administered under supervision at study entry, 12 weeks, and 24

weeks. The study result showed that there was a difference of 10.4 points between the

two group at 12 weeks and of 8.1 points at 24 weeks. The study concluded that 6-week

outpatient-based program significantly improved quality of life in patients with moderate-

to-severe COPD21.

Pulmonary rehabilitation (PR) is recognized as an evidence-based treatment in

improving dyspnea and quality of life in patients with COPD22. Pulmonary rehabilitation

is an integral component of the optimal management of patients with chronic respiratory

disease and has been clearly demonstrated to reduce dyspnea, increase exercise

performance, and improve health-related quality of life (HRQoL) and effective in

reducing health-care costs and in reducing the number and severity of COPD

exacerbations23.

6
 The effectiveness of pulmonary rehabilitation in COPD is well established. A

meta-analysis of 6 randomized controlled trials was conducted in Brazil to discuss the

safety and efficacy of pulmonary rehabilitation in patients with unstable COPD. 219

patients were participated in this study. The result showed that a significant reduction in

hospital admissions and mortality rate. The study concluded that pulmonary rehabilitation

is both effective and safe in patients with unstable COPD with a recent exacerbation24.

A randomized controlled study was conducted in Netherlands to assess the effect

of community based pulmonary rehabilitation program on exercise tolerance and quality

of life. 66 patients were participated in this study. Exercise tolerance was assessed using

submaximal cycle ergometer tests and 6 min walking tests. Quality of life was evaluated

by means of the Chronic Respiratory Disease Questionnaire (CRDQ). The results showed

that improvements in endurance time (421 s) and cardiac frequency (6 beats·min-1)

during cycling, walking distance (39 m), and total CRDQ score (17 points). The study

concluded that community based pulmonary rehabilitation program was effective in

improving the exercise tolerance and quality of life of the COPD patients25.

Pulmonary rehabilitation involves both exercise and educational programmes.

Through the educational process, patients can become more skilled at collaborative self

management and more adherences to their treatment plan which in turn may result in a

reduction in hospital admissions26. Participants in a successful pulmonary rehabilitation

program will receive education about the pathophysiology of their disease process,

recognizing symptoms and exacerbations, and appropriate use of medications20.

Therefore, education has to be recommended in association with the usual rehabilitation.

Education is fundamental in COPD patients in order to maintain a proper compliance to

7
treatment, such as medication, oxygen therapy, smoking cessation, exercise retraining,

and nutrition27.

A prospective study was conducted in Brazil to evaluate the effectiveness of

educational program in patients who undergo pulmonary rehabilitation. 22 patients

participated in this study. A questionnaire was developed and applied to evaluate the

patient’s knowledge about the disease before and after the educational intervention. The

results showed that the patients who underwent the educational program presented an

increase in the percentage of correct answers, after the intervention (69% versus 84%,

respectively). The study concluded that the educational program applied to patients in the

pulmonary rehabilitation program was effective to increase the patients' knowledge about

their disease, its consequences and its treatment28.

Individuals with COPD who participate in pulmonary rehabilitation are actively

working to improve their lives through education and self management

programs. Education is considered an important component of comprehensive pulmonary

rehabilitation and is integrated into virtually all programmes. Because of this, its effect in

isolation cannot be readily determined. Among the potential benefits of education are:

active participation in healthcare, increased coping skills, a better understanding of the

physical and psychological changes of chronic illness, more skill in collaborative self-

management and better adherence to the treatment plan. In addition to standard didactic

sessions, education may also incorporate breathing strategies, such as pursed-lip and

diaphragmatic breathing, energy conservation and work simplification, and advance

directives29.

8
 A study was conducted in USA to effect of education alone and in combination

with pulmonary rehabilitation on self efficacy in patients with COPD. 37 patients

participated in the pulmonary rehabilitation program, and 22 patients participated in the

education-only program. Self-efficacy was measured before and after the programs. The

results showed that Patients’ self-efficacy scores significantly improved after the

pulmonary rehabilitation program and remained significantly improved 6 months later.

Education alone was also effective in significantly improving self-efficacy scores. This

study concluded that a rehabilitation program that combines education and exercise

training is more effective in improving long-term self-efficacy in patients with COPD30.

Education is a very necessary part of the program in the care of patients with

COPD. The health care professionals of the program will provide education focused on

behavioural changes and enhancing patient understanding and adherence to prescribed

therapy. The knowledge of the potential benefits of treatment will increase patient

adherence to therapy. The program emphasizes education of both patients and families to

improve understanding of the disease process, self-care, and to develop practical ways of

coping with disabling symptoms and acute exacerbations12.

A study was conducted in Ireland to evaluate the effectiveness of a structured

pulmonary rehabilitation program for improving the health status of people with COPD.

32 patients participated and they were divided into experimental group and control group.

The experimental group received a structured education pulmonary rehabilitation

program and control group received usual care. Health status of the patients were

measured by the Chronic Respiratory Desease Questionnaire (CRDQ). The results

showed that experimental group had improvement in the health status as compared with

9
the control group. The study concluded that structured pulmonary rehabilitation program

was effective in improving the health status of the patients with COPD31.

The researcher’s clinical experience found that the patients with COPD are having

inadequate knowledge regarding pulmonary rehabilitation and its importance in restoring

their functional abilities. This motivated the researcher to select the present study and the

researcher felt that individual health education improve their level of knowledge

regarding pulmonary rehabilitation among patients with COPD.

10
OBJECTIVES
 2. OBJECTIVES

Objectives are the specific accomplishment the researcher hopes to achieve by

conducting the study. Specific achievable objectives provide clear criteria against which

proposed research methods can be used32.

Statement of the problem

“A study to assess the effectiveness of individual health education on level of

knowledge regarding pulmonary rehabilitation among patients with chronic obstructive

pulmonary disease (COPD) in selected hospitals at Mangalore.”

Objectives of the study

The following are formulated to carry out the study are to:

1. assess the level of knowledge regarding pulmonary rehabilitation among patients

with COPD using structured knowledge questionnaire.

2. evaluate the effectiveness of individual health education on level of knowledge

regarding pulmonary rehabilitation among patients with COPD.

3. find the association between the pre-test knowledge score and selected baseline

variables.

Operational definitions

Effectiveness

It refers to the extent to which the individual health education has achieved the

desired effect on increasing the level of knowledge regarding pulmonary rehabilitation

among patients with COPD as denoted by increase in knowledge score by post test

measurement.

11
Individual health education

It refers to the systematically developed instructional aid designed to improve the

knowledge on pulmonary rehabilitation to patients with COPD by one to one and face to

face interaction which includes breathing exercises, relaxation techniques, adherence to

medications, life style modifications and nutrition.

Knowledge on pulmonary rehabilitation

It refers to the correct responses by the patients with COPD to the structured

knowledge questionnaire regarding pulmonary rehabilitation in terms of knowledge

score.

Patient with chronic obstructive pulmonary disease

Refers to the patients who are diagnosed as chronic obstructive pulmonary

disease, irrespective of age, sex, onset of disease, duration of hospital stay and type of

treatment prescribed.

Assumptions

The study assumes that:

1. Patients with COPD may have inadequate level of knowledge regarding

pulmonary rehabilitation.

2. Individual health education regarding pulmonary rehabilitation may improve the

level of knowledge in patients with COPD.

12
Delimitations

The study is delimited to,

1. Patients with COPD who are admitted in selected hospitals at Mangalore.

2. Patients with COPD who are available during the data collection period.

3. Patients with COPD who are willing to participate in the study.

Hypotheses

All hypotheses will be tested at 0.05 level of significance.

H1: The mean post-test knowledge scores of patients with COPD attending the individual

health education on pulmonary rehabilitation will be significantly higher than the mean

pre-test knowledge scores.

H2: There will be significant association between pre-test knowledge scores on

pulmonary rehabilitation among patient with COPD and their selected baseline variables.

Inclusion criteria for sampling

Patients with COPD who are:

• able to follow instructions in English or Kannada.

• admitted in selected hospitals at Mangalore.

• present during the period of data collection.

• willing to participate in the study.

13
Exclusion criteria for samplings

COPD patients who are:

• on ventilator care.

• unconscious.

• with acute exacerbations.

• who are not stable

Conceptual frame work

Conceptual model is a set of highly abstract related constructs that broadly

explains phenomena of interest, express assumptions and reflects a philosophical

stance33.

Conceptual frame work of this study is based on context, input, process, and

product (CIPP) model by Danial Stufflebeam (figure 1). It consists of a four- step model

of programme evaluation, developed for obtaining information and for taking decision. It

provides comprehensive, systematic and continuously ongoing framework for

programme evaluation34.

It includes 4 aspects

• Context evaluation

• Input evaluation

• Process evaluation

• Product evaluation

14
Context evaluation:

It highlights the environment in which the proposed programme exists, describes

the plan for decisions and collections of data apart from providing rationale for the

determination of objectives. It helps in making programme planning and decisions35.

The present study is carried out to assess the effectiveness of individual health

education on level of knowledge regarding pulmonary rehabilitation among patients with

chronic obstructive pulmonary disease (COPD) in selected hospitals. Based on the

findings from the literature, it is assumed that significant number of individuals lack

knowledge on pulmonary rehabilitation. The pre-test scores support this concept.

Input evaluation:

It serves as a basis for structuring decisions; it specifies resources, strategies and

designs to meet the programme goals and objectives. In the present study, input refers to

• Literature review

• Discussion with experts

• Preparation of structured knowledge questionnaire

• Preparation of individual health education

• Validation of the structured knowledge questionnaire

• Framing a research design

• Preparation of appropriate teaching aids

Process evaluation:

It depicts implementing decisions, involves identifying decisions, limitations and

records its activities and events. In the present study it refers to:-

• Pilot study

15
 • Assessment of knowledge of subjects before individual health education through

the administration of structured knowledge questionnaire.

• Administration of individual health education

• Assessment of knowledge after the individual health education by re-

administering the same questionnaire.

Product evaluation:

It includes determining and examining the general and specific outcomes of the

programme. It enables recycling of decisions as it is related to the goals and objectives of

the input information and the process information. In the present study it refers to the

comparison of the pre-test and post-test scores.

Summary

This chapter dealt with the statement of the problem, objectives, operational

definitions, assumptions, delimitations, hypothesis, inclusion criteria and exclusion

criteria of the study.

16
 CONTEXT EVALUATION
INPUT EVALUATION PRODUCT EVALUATION
PROCESS EVALUATION

C I P P
Knowledge assessment of
Pulmonary rehabilitation • Formulation of • Comparing
• Pilot study pre-test and
among the COPD patients objectives
admitted in selected • Assessment of knowledge post-test
• Development of
hospitals through structured through structured knowledge
teaching strategies
knowledge questionnaire score.
knowledge questionnaire material on
• Administration of • Analyzing
pulmonary
individual health education. effectiveness
rehabilitation.
• Assessment of knowledge of the
• Development of
after individual health planned
the tool
education. teaching
• Validation of the Teaching strategies:
tool and teaching programme.
• Lecture cum discussion
material.
method
• Power point slides

Out
No significant gain in
knowledge
come

Fig: I Conceptual frame work based on Danial stufflebeam programme evaluation model 1971

Significant gain in
knowledge
17
 REVIEW OF
LITERATURE
 3. REVIEW OF LITERATURE

A review of literature refers to activities involved in identifying and searching for

information on a topic and developing and understanding the state of knowledge on the

topic36.

The researcher carried out an extensive review of literature on the research topic

in order to gain an insight into the selected problem under study as well as to collect

maximum relevant information for building up the study. It helped to develop the

instruments and select variables to be included in the study.

For the present study, the review of literature is categorized under the following

headings:

1. Knowledge on pulmonary rehabilitation among COPD patients.

2. Effectiveness of pulmonary rehabilitation in COPD patients.

3. Effectiveness of health education.

1. Knowledge on pulmonary rehabilitation among COPD patients

A telephone survey was conducted in Canada to determine whether Canadians

with COPD are properly educated or supported. 389 Canadians were surveyed who were

above 40 years of age. The results showed that knowledge was found poor in several

domains including the causes of COPD, the consequences of inadequate therapy and the

management of exacerbations. Only 34% had ever received a written action plan and only

33% had been told how to prevent an exacerbation. The study concluded that there were

significant gaps in patients’ knowledge about the management of COPD and little contact

18
with lung health educators and increased use of self-management education programs

may help to increase the knowledge of the patients.37

A study was conducted in USA to evaluate the disease related knowledge of

COPD patients entering pulmonary rehabilitation. A sample of 311 patients with COPD

responded to 50 statements about pulmonary and extra pulmonary features of COPD.

The results showed that 1/3 of the patients did not know what the abbreviation “COPD”

stands for; a minority knew the meaning of “an exacerbation”; a majority believed that

pulmonary rehabilitation has a positive effect on pulmonary function; 1/3 thought that too

much physical exercise could overload the lungs; 1/3 considered swollen ankles and chest

pain as typical symptoms of patients with COPD; 1/5 believed that “self-management”

means that no doctor should be visited. The study concluded that the patients with COPD

entering pulmonary rehabilitation had limited knowledge regarding pulmonary

rehabilitation and their disease condition. Therefore, individualized educational programs

should be considered to increase patient’s knowledge and in turn improve self-

management38.

A study was conducted in Canada to assess information needs and knowledge of

patients with COPD. 81 patients were participated in this study. The Lung Information

Needs Questionnaire (LINQ) and the Mount Sinai Hospital Questionnaire (MSHQ) were

used. The LINQ identifies what COPD information the patient has, or is lacking. The

MSHQ assesses a patients’ COPD knowledge. The results showed that Patients on

average had 14% need for information in that 34% need for information on diet and 25%

for self-management as assessed by the LINQ and 13% need for information as assessed

19
by MSHQ. The study concluded that Patients with COPD have poor knowledge and there

is a need for receive information about the disease condition39.

A study was conducted in United Kingdom to assess the educational component

of pulmonary rehabilitation, and to assess the information needed to understand lung

diseases and to maximize self-management skills. 217 patients were participated in the

study as experimental group and they attended 8-week outpatient pulmonary

rehabilitation program. 11 patients were participated as control group and they were

attended a home exercise program. The lung information needs questionnaire was used.

All 217 patients completed LINQ pre- and post-PR. The results showed that LINQ score

improvement was significantly greater after PR compared with home exercise program.

The study concluded that knowledge regarding the lung disease and its self management

skill is very poor in patients, and pulmonary rehabilitation program will help to increase

the knowledge and self management skill40.

A qualitative study was conducted in USA to point out the educational component

of pulmonary rehabilitation and how it should be delivered, and to compare those

perspectives with the views of health professionals. Purposive samples of 32 patients

with chronic obstructive pulmonary disease were taken. The results showed that, deficits

in patients’ knowledge, regarding management of their disease. The study concluded

with six key educational topics that are disease education, management of breathlessness,

management of an exacerbation, medication, psychosocial support, welfare and benefits

systems41.

20
 A telephone survey was conducted in New York to evaluate the prevalence of co-

morbid conditions, patient knowledge and disease management in a national sample of

patients with COPD. 1003 patients with COPD were evaluated. The results showed that

among 1003 patients with COPD, 61% reported moderate or severe dyspnea and 41%

reported a prior hospitalization for COPD. The most prevalent co-morbid diagnoses were

hypertension (55%), hypercholesterolemia (52%), depression (37%), cataracts (31%), and

osteoporosis (28%). Only 10% of respondents knew their forced expiratory volume in 1

second compared with 79% who knew their blood pressure. The study concluded that

most patients with COPD were symptomatic and many had been hospitalized for COPD,

COPD self-knowledge was low and COPD was undertreated compared with generally

asymptomatic, less morbid conditions such as hypertension42.

The above mentioned studies revealed the low level of knowledge of COPD patients

regarding pulmonary rehabilitation and disease condition.

2. Effectiveness of pulmonary rehabilitation in COPD patients

A non experimental, prospective comparative study was conducted in north

California to determine the effects of short term and long term pulmonary rehabilitation

on functional capacity, and quality of life of patients with COPD. 309 women and 281

men who were 20 to 93 years of age with chronic lung disease participated in this study.

All 6 minute Walking tests and health surveys were administered prior to and

immediately following 12 and 24 weeks of supervised pulmonary rehabilitation

participation. The results showed that quality of life and functional capacity was

improved after 12 weeks of pulmonary rehabilitation participation and this improvement

21
was maintained by 24 weeks of pulmonary rehabilitation participation. The study was

concluded that the pulmonary rehabilitation program is effective in improving quality of

life and functional capacity of patients with COPD43.

A prospective, randomized, controlled study was conducted in United Kingdom

to establish whether pulmonary rehabilitation improves domestic function and daily

activity levels in COPD and whether individually targeted exercise (ITEP) is more

effective than general exercise (GEP). 180 patients were recruited to the study. 90

patients were randomized to the general exercise program group and 90 patients to the

individually targeted exercise program group. Daily activity, domestic function, exercise

performance and health status were assessed. The results showed that activity monitoring

count increased by 28.18% for GEP and 40.63% for ITEP. Domestic function increased

by 1.71% for the GEP and 1.46 for the ITEP. The study concluded that pulmonary

rehabilitation is effective in improving the domestic function and physical activity of the

patients with COPD44.

A study was conducted in United Kingdom to assess the effects of pulmonary

rehabilitation on patients with different stages of COPD. 225 patients were participated in

the study. Data on pulmonary function, arterial blood gas analysis, the 6- minute walk

test, respiratory muscle strength and activities of daily living were analyzed before and

after 4 to 8 weeks of inpatient pulmonary rehabilitation program. The results showed that

there were significant differences in FEV1% in stages III and IV, vital capacity in stages

II, III and IV, and lung capacity in stage II when comparing the changes between pre and

post pulmonary rehabilitation. Significant differences of PaO2 in stage III and IV and

PaCO2 in stage IV were found when comparing the changes between pre- and post-

22
pulmonary rehabilitation. The 6-min walk distance was significantly increased after

pulmonary rehabilitation by an average of approximately 50m for all staged patients.

Respiratory muscle strength was also significantly increased in stages III and IV.

Activities of daily living were significantly improved in all stages. The study was

concluded that the patients with COPD had benefited from pulmonary rehabilitation45.

A controlled randomized study was conducted in USA to assess the effect of

breathing exercises on COPD patients. 40 patients were participated in the study as

experimental group. 42 patients were participated as control group. Control group

patients are not participated in the breathing exercise program. The initial duration of

breathing exercises was 10 minutes with 1 additional minute increase after each 2 days.

All patients were discharged from the hospital on 18th day. Their medication reduction

was 20% on 18 th day. The control group had reduction in medication 10% at the time of

their discharge. The study concluded that the breathing exercises were effective in

patients with COPD46.

A study was conducted in Iran to assess the Effects of pulmonary rehabilitation on

exercise capacity in patients with COPD. The study enrolled 284 patients aged 41 to 86

years and divided into two groups: a study group (222 patients) undergoing a PR program

and a control group (62 patients) treated only with drugs. Six- minute walk test was used

to evaluate the exercise capacity of the patient. The results showed that in the study

group, 142 out of 222 patients (64%) had an increase of at least 54 m in the 6MWT

following PR and in control group 8 out of 62 patients (13%) had improvement in the

6MWT. The study concluded that PR is highly effective in improving the exercise

capacity of patients with COPD47.

23
 A study conducted on “effects of home-based pulmonary rehabilitation among

patients with COPD” in Canada. Samples of 252 cases were selected. Dyspnea sub scale

analysis was done. The study revealed that after 4 weeks of education programme, patient

took part in home based rehabilitation or out patient, hospital- based rehabilitation for 8-

weeks. The study results revealed that improvement in dyspnea was (95%) in the home

intervention and 93% in the outpatient intervention. The study concluded that home

rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients

with COPD48.

A retrospective observational study was conducted in Netherland between June

2006 and June 2010 to assess the impact of disease on health status and the effects of

pulmonary rehabilitation on COPD patients. 437 COPD patients were participated in the

study. Patients participated in this program for 12 weeks for a weekly average of 20-25

hours. Before and directly after this program several measures of physical performance

and health related quality of life were evaluated. The results showed that exercise

performance of 68% of the COPD patients was improved after the rehabilitation and 75%

of the patients showed improvement in the quality of life. Thus the study concluded that

the pulmonary rehabilitation program was effective in improving the health status of the

COPD patients49.

A study was conducted in Italy to verify the effects of PR in patients with CRF,

and compare the level of improvement with PR in these patients to that of COPD not

affected by CRF. 1047 COPD inpatients (327 with CRF) were evaluated. Lung function,

arterial gases and walk test (6MWT) were evaluated. The result showed that in patients

with CRF all parameters improved after pulmonary rehabilitation. The mean changes are

24
FEV1, 112 ml; PaO2, 3.0 mmHg; PaCO2, 3.3 mmHg; 6MWT, 48 m. these changes were

similar to those observed in patients without CRF. The study concluded that pulmonary

rehabilitation is equally effective in COPD patients with and without CRF50.

A study was conducted in Tokyo to evaluate the long term effects of pulmonary

rehabilitation in elderly COPD patients. 59 elderly COPD patients were studied. They

underwent a comprehensive 2-week inpatient pulmonary rehabilitation program with 10

exercise sessions. The effects of pulmonary rehabilitation were evaluated at 3, 6, and 12

months after completion of the program. The result showed that overall patient’s quality

of life, dyspnoea and exercise capacity were improved after the pulmonary rehabilitation

program. The study concluded that Pulmonary rehabilitation is an effective treatment in

terms of improving dyspnoea, exercise capacity and HRQoL in elderly COPD patients51.

A study was conducted in Singapore to assess the effect of a pulmonary

rehabilitation programme on physiologic and psychosocial outcomes in patients with

chronic respiratory disorders. 34 patients were participated in the study and they

completed a 6-week outpatient PR program that included education, physical and

respiratory care instruction and supervised exercise training. Outcome assessment was

performed at baseline, on completion of PR program and 3 months after PR program.

The result showed that 6MWT distance improved significantly by a mean of 67.3 m (P <

0.0001). Dyspnoea scores decreased significantly by 1.2 +/- 0.5 (P < 0.038). The study

concluded that pulmonary rehabilitation program was effective to improve the

physiologic and psychological outcomes in patients with chronic respiratory disorder52.

25
 A study was conducted in Brazil to evaluate the effectiveness of pulmonary

rehabilitation performed once a week in a exercises at home among patients with

obstructive pulmonary disease. 34 patients of both sexes with obstructive pulmonary

disease were evaluated. These subjects all underwent physiotherapeutic evaluation and

reevaluation with the CRDQ and measurements of maximum inspiratory pressure,

maximum expiratory pressure and 6MWD. The results showed that significant

differences between evaluations before and after rehabilitation were found for all CRDQ

domains (p< 0.05), maximum inspiratory pressure (p= 0.01) and maximum expiratory

pressure (p= 0.002). The study concluded that pulmonary rehabilitation was effective in

patients with obstructive pulmonary disease53.

A study was conducted in Ireland to assess the efficacy of pulmonary

rehabilitation. 170 patients were participated in the study. The study evaluated the results

after 8 and 52 weeks of a comprehensive pulmonary rehabilitation. The results showed

that Significant improvements in exercise tolerance, (shuttle p<.001, treadmill p<.001),

QoL,(Breathing problem questionnaire p<.001, CRDQ p<.001,) and dyspnoea (p<.001)

were demonstrated after 8 weeks. These improvements were maintained at 1 year. The

study concluded that pulmonary rehabilitation can increase exercise tolerance and

improve QoL in patients with COPD54.

The above mentioned studies revealed that the effectiveness of pulmonary

rehabilitation to improve the quality of life of COPD patients.

26
3. Effectiveness of health education

A randomized controlled study was conducted in Japan to describe the effects of

patient education in COPD. 62 patients with mild to moderate Chronic Obstructive

Pulmonary Disease randomly allocated to intervention group and control group. The

intervention group participated in patient education. The results showed that, patient

education reduced the need for GP visits with 85%. 73% of the experimental group had

independent of their GP during 12-months of follow-up, compared with control group

15%. Reduced the need for reliever medication from 290 to 125 Defined Daily Dosages

(DDD), and improved patient satisfaction. The study concluded that, the health education

of patients with COPD was effective in improving patient outcomes and reduced costs in

12-months of follow-up55.

An observational cohort study was conducted in Italy to assess the impact of

education during pulmonary rehabilitation program among COPD patients. 285 COPD

patients were taken and then grouped into interventional group and control group. The

ESQ scores and pulmonary rehabilitation outcomes were assessed. The result showed that

ESQ-Aids score improved to a greater extent in interventional group than in Control

group. The study concluded that attending educational sessions produces a specific short-

term learning effect during rehabilitation of COPD patients. But there was similar

improvement in pulmonary rehabilitation outcomes in both groups56.

A study was conducted in France to assess the effect of supervised exercise

program and self management educational program among COPD patients. 38 moderate-

to-severe COPD patients were taken and divided into an intervention group and usual

27
care group. The hospital-based intervention program provided a combination of 8

sessions of supervised exercise with 8 self-management education sessions over 1-month

period. Data were collected before and one year after the program. After one year, in the

result there were significant differences in intervention group in 6MWT (+50.5 m), and

control group. The study concluded that hospital-based intervention combining

supervised exercise with self-management education provides significant improvements

in patient's exercise tolerance and significant decrease of COPD medication costs,

compared to usual care57.

A study was conducted in Briton to examine the effect of brief disease-specific

education on individuals who recently diagnosed with chronic obstructive pulmonary

disease (COPD). 93 individuals were participated in the study. 50 and 43 participants

were randomized to the experimental and control groups, respectively. The experimental

group received 2h of education delivered by a certified COPD educator and a control

group received usual care. The Bristol COPD Knowledge Questionnaire (BCKQ) was

administered at the time of randomization and approximately three months later. The

result showed that the BCKQ increased from 27.6+/-8.7 to 36.5+/-7.7 points in the

experimental group, which was greater than the control group. The study concluded that

2h of education was effective in increasing disease-specific knowledge among patients

with COPD58.

A randomized controlled study was conducted in Japan to assess the patients’

need for education. 59 subjects, (50 males and 9 females) with stable COPD were

randomly allocated into 2 groups. The education program group (EP) received 6

outpatient education sessions from trained nurses and an information booklet. The control

28
group received routine instruction from trained nurses, without booklets. Needs of

information were evaluated at the beginning and end of this study using Japanese version

of LINQ. The results showed that EP group had significantly higher total LINQ scores

(EP 24.2 vs. CO 22.9, p<.0005). The study concluded that an education programme

significantly improved the knowledge of patients as compared to normal care59.

A descriptive pilot study of patient centered COPD education was conducted in

Columbus to assess the effect of disease knowledge on hospital readmission. Researcher

administered a knowledge questionnaire and a COPD Assessment Test (CAT) to identify

knowledge deficits and quantify the severity of COPD symptoms. The researcher

delivered a education session, followed by a post-test COPD knowledge evaluation. Eight

eligible subjects (3 female, 5 male) participated in the study. Only 3 participants had

received prior COPD education. The results showed that the control group had deficit

knowledge in the areas of medication and symptom management whereas the

experimental group had adequate knowledge in all the areas. The study concluded that

the personalized educational session positively influenced overall COPD patient

knowledge60.

A prospective randomized controlled study was conducted in Germany to find out

whether education improves the effectiveness of rehabilitation with regard to quality of

life and morbidity. 90 patients were randomly selected as control group and 93 patients

were selected as education group. Control group received multidisciplinary rehabilitation

programme with the usual care and education group received additional patient

education. Pulmonary function tests and QoL as measured by the Saint George

Respiratory Questionnaire were tested at baseline and at follow-up after 1 year. The result

29
showed that in both groups the total number of hospital admissions was diminished after

1 year (CG: 24.7% to 11.5%, p = 0.02; EG: 30.8% to 9.9%, p = 0,001). Only the EG

needed less intensive care (11.8 days to 2.2, p = 0.02), received less home emergency

medical service (18.3 to 5.5%, p = 0.01) and had less emergency hospital admissions

(19.6% to 8.7%, p = 0.03). One year after rehabilitation, patients of the EG had a higher

chance of improved quality of life (OR = 2.5; CI 1.07-5.84), and they could maintain a

longer duration of weekly exercise training (more than 1 hour/week: EG n = 58, CG n =

34, p < 0.01). The study concluded that education program improves the effectiveness of

rehabilitation regarding quality of life and morbidity61.

An interventional study was conducted in Zagazig University, in Egypt, from

January 2009 to April 2009 to assess the effectiveness of health education on knowledge,

attitude, blood sugar and HbALc levels in type 2 diabetics.122 patients were participated

in the study. The result showed that the majority of patients had low levels of knowledge

regarding different aspects of diabetes in the pre test. After implementation of the

educational message, a significant improvement was revealed in patients' knowledge. .

The study concluded that health education was an effective tool that implicated change in

diabetic patients' knowledge, attitude, blood sugar and HbALc levels in type 2

diabetics62.

A quasi experimental study was conducted in Sudan to evaluate the

effectiveness of health education on home care of under five children with diarrheal

disease. The researcher selected 118 mothers who have at least one child less than five

years with diarrhea needed home management. The results showed that knowledge of the

mothers about definition of diarrhea, its danger, when to seek medical help and the three

30
rules of home management which was found to be 35, 28, 13 in the pretest. After the

health education the score was improved to 91, 94, and 92. The total mean percentage of

the pre test was 29% whereas the mean percentage of the post test was 95%. The study

concluding that the health education was effective in improving the knowledge of

mothers regarding home care management of diarrhea in under five childrens63.

A study was conducted in Delhi to evaluate the effectiveness of the planned

health education program regarding risk factors and care of low birth weight babies in

terms of knowledge and practice of mothers. A sample of 60 mothers was selected using

purposive sampling technique with 30 mothers each in Experimental and Comparison

group. A structured interview schedule for knowledge and observation checklist for

practice of mothers was used. Planned health education was given only to the mothers of

experimental group. The results showed that the post test computed r value (0.714) was

significantly higher than pretest computed r value (0.138) of experimental group. Thus

the study was concluded that the teaching program was effective in enhancing the

knowledge as well as practice of mothers regarding risk factors and care of low birth

weight babies64.

An interventional study was conducted in Nagpur in India to assess the

effectiveness of health education on increasing knowledge about breast feeding practices

among post-natal women. 50 post-natal womens were participated in this study.

Knowledge was assessed as pre-test and post-test using pre-structured questionnaire

through interview method. The results showed that there was significant difference

between average score of pre test knowledge (14.25) and post test knowledge

31
(18.40). The study concluded that Health education session was effective in improving

the knowledge about breast feeding practices among the postnatal women 65.

A study was conducted in Karnataka to determine the effectiveness of a health

educational program on knowledge of reproductive health among adolescent girls. A total

of 791 rural girls in the age group 16-19 years were randomly selected. Adolescent girls

were educated regarding reproductive health and their awareness levels were evaluated

immediately following intervention. The results showed that a significant increase in

overall knowledge after the intervention (from 14.4 to 68%, P < 0.01) was observed

regarding contraception. Knowledge regarding ovulation, first sign of pregnancy and

fertilization improved by 37.2% (95% CI = (35.2, 39.2), P < 0.001). Knowledge

regarding the importance of diet during pregnancy improved from 66 to 95% following

the intervention. The study concluded that a health education program can bring about a

desirable change in knowledge among adolescent girls regarding reproductive health 66.

All above mentioned studies revealed that individual health education is one of

the methods to educate people regarding certain aspects.

Summary

The reviews that were done on the selected topic of pulmonary rehabilitation

showed that the COPD patients are getting benefit from pulmonary rehabilitation. Many

patients were not having adequate information about the pulmonary rehabilitation. These

reviews reveal the importance of educating the patients regarding the pulmonary

rehabilitation to ensure their complete participation in the care.

32
METHODOLOGY
 4. RESEARCH METHODOLOGY

Methodology of research organizes all the components of the study. The research

methodology indicates the general pattern for organizing the procedure for gathering valid and

reliable data for the study. It includes the research approach, research design, population, sample

and sampling technique, selection and development of data collection tools, research setting,

preparation of individual health education, data collection procedure and data analysis. Research

methodology is a way to solve the research problem systematically67.

This research study is aimed to assess the effectiveness of individual health education on level of

knowledge regarding pulmonary rehabilitation among patients with chronic obstructive

pulmonary disease (COPD) in selected hospitals at Mangalore.

The schematic representation of the methodology is given below.

33
Population Sample size and Variables Data collection tool Data analysis
sampling

• COPD • 50 COPD Independent variable Tool Descriptive

patients patients statistics
• Individual health education on • Tool 1 :
admitted in admitted in
pulmonary rehabilitation. baseline • Frequency
Government Government
Wenlock Wenlock proforma of and
Dependent variable COPD percentage,
hospital at hospital at
Mangalore. • Knowledge of the COPD patients. mean,
Mangalore.
patients regarding pulmonary • Tool 2: mean
• Non probability
rehabilitation. structured percentage,
purposive
knowledge median,
sampling
Extraneous variable questionnaire SD
technique.
to assess the
• Age Inferential
knowledge of
• Gender statistics
the COPD
• Educational status patients • Paired ‘ t’
• Occupation regarding test
• Family income pulmonary • Chi-
• Duration & severity of the illness rehabilitation square.
• Treatment for the disease .
• Previous information about Interpretation of
pulmonary rehabilitation data

Figure 2: Schematic representation of the methodology.

34
Research approach

In order to accomplish the main objective of determining the effectiveness of

individual health education on level of knowledge regarding pulmonary rehabilitation among

patients with chronic obstructive pulmonary disease (COPD) in selected hospitals, an Evaluatory

Research Approach was selected.

Research design

The research design is the overall plan for obtaining answers to the questions being

studied and for handling some difficulties encountered during the research process69.

Pre-experimental one group pre-test, post-test design is adopted for this study. The

pre-test (O1) was carried out to determine the knowledge of COPD patients regarding the

pulmonary rehabilitation and followed by the administration of the individual health education

(X). Post-test (O2) was conducted on the 7th day following the pre-test and individual health

education.

Pre-experimental, one group pre-test post-test design.

E - O1 X O2

E : Experimental group

O1: Level of knowledge regarding pulmonary rehabilitation

X : Individual health education.

O2: Measurement on level of knowledge regarding pulmonary rehabilitation on 7th day

The schematic representation of the study design is given below.

35
 Phase I Phase II Phase III
Preparation of the structured After post-test
knowledge questionnaire and Pre-test on day – 1 Treatment on day – 1 Post-test on day - 7
Group individual health education O1 X O2
50 COPD • Review of existing Assessment of the Administration of Post-test • Determining
patients literature prior knowledge of individual health knowledge the post-test
admitted in • Discussion with experts the samples education regarding assessment on knowledge
Government through the pulmonary seventh day using
• Preparation of blue print score.
Wenlock administration of rehabilitation among the structured
hospital at • Preparation of structured structured COPD patients knowledge • Analysis and
Mangalore • knowledge questionnaire knowledge admitted in questionnaire interpretation
• Content validity of the tool questionnaire Government Wenlock of data.
hospital at Mangalore. • Testing of the
• Pre-testing of the tool
• Testing the reliability of hypotheses.
the tool • Interpretation
• Content validity of of the data
individual health with tables and
education. diagrams
• Pilot study

Figure3: Schematic representation of the study design.

36
Variables under study

Variables are qualities, properties or characteristics of persons, objects or situations that

change or vary70. Three types of variables were identified in this study. They are independent,

dependent and extraneous variables.

Independent variable

An independent variable is a stimulus or activity that is manipulated or varied by the

researcher to create an effect on the dependent variable70. In the present study, independent

variable was individual health education regarding pulmonary rehabilitation.

Dependent variable

A dependent variable is the response, behaviour or outcome the researcher wants to

predict or explain70. In the present study dependent variable is the knowledge of the COPD

patient regarding pulmonary rehabilitation.

Extraneous variable

Any uncontrolled variable that greatly influences the result of the study is called as

extraneous variable68. The extraneous variables in this study are age, gender, educational status,

occupation, family income, duration of illness and severity of the illness, treatment of the disease

and previous information about pulmonary rehabilitation.

Setting of the study

Setting is the physical location and condition in which data collection take place in the

study32.

The study was conducted in district Government Wenlock Hospital Mangalore. It is a

well known General Hospital with 700 number of bed strength. The hospital is well established

37
and equiped general hospital. The present study was conducted among COPD patients admitted

in this hospital.

Population

Population is any group of individuals that have one or more characteristics in

common that are of interest to the researcher69.

In this study, population includes the COPD patients admitted in Government Wenlock

hospital at Mangalore.

Sample and Sampling Technique

Sample

Sample consists of a subset of the units that compose the population. In this study,

sample comprised of 50 COPD patients admitted in Government wenlock hospital at Mangalore,

and who fulfilled the sampling criteria.

Sampling Technique

The samples are selected using a non-probability purposive sampling technique. The

samples were selected according to the inclusion and exclusion criteria.

Sample Size

The study consisted of 50 COPD patients admitted in the Government Wenlock

hospital at Mangalore.

Criteria for sampling selection

Inclusion criteria for sampling

Patients with COPD who are:

• able to follow instructions in English or Kannada.

• admitted in Government Wenlock hospital at Mangalore.

38
 • present during the period of data collection.

• willing to participate in the study.

Exclusion criteria for sampling

COPD patients who are:

• on ventilator care.

• unconscious.

• with acute exacerbations.

• Who are not stable

Data collection instrument

Data collection tools are the procedures or instruments used by the researcher to observe

or measure the key variables in the research problem. Baseline data was collected using a

baseline pro-forma prepared by the investigator. A structured knowledge questionnaire was used

to find the knowledge on pulmonary rehabilitation.

Development of the tool

The tool was prepared on the basis of the objectives of the study. A structured

knowledge questionnaire was an appropriate technique for assessing the knowledge on

pulmonary rehabilitation among COPD patients based on the assumption that they will have less

knowledge regarding pulmonary rehabilitation.

The following steps were adopted in the development of the tool:

• Review of literature that provided adequate content area for tool preparation.

• Consultation and discussion with experts from nursing and medical profession.

• Preparation of the knowledge questionnaire.

39
Preparation of the blueprint

A blue print on structured knowledge questionnaire on selected aspects of pulmonary

rehabilitation was prepared. It depicted the distribution of items according to the content areas on

three domains as knowledge, comprehension and application. The knowledge domain had ten

items (40%), comprehension had seven items (28%) and application had eight items (32%).

Development of the checklist criteria

A checklist criterion for validation of the tool was developed with Section I which

comprised of Baseline proforma. Section II comprised of structured knowledge questionnaire on

selected aspects of pulmonary rehabilitation which had “agree”/ “disagree”/“remarks”/

“suggestions of experts regarding accuracy, relevancy and appropriateness of the content. The

validator was asked to put a tick (√) mark against the specific column. Suggestions were to be

mentioned in the ‘remarks’ column.

Testing of the tool

Content validity of the tool

Validity refers to the degree to which an instrument measures what it is supposed to be

measuring32. To ensure the content validity, the prepared instrument along with the problem

statement, objectives, hypothesis, operational definitions, blueprint and criteria checklist were

submitted to 9 experts in the nursing and medical field. There was 100% agreement for the

baseline data of the COPD patients.

Content validity of the structured knowledge questionnaire was established by

submitting it along with the objectives and blue print to nine experts; seven from nursing, and

two physiotherapists. They were requested to give their opinion on accuracy, relevance, and

appropriateness of the items in the tool. There were 30 items in the knowledge questionnaire.

40
Twenty items had 100% agreement with experts. For item number 10(8), 13(11), 14(12), 25(23)

and 27(24) three experts suggested modification in the question form and options and was done

accordingly. Item number 6, 9, 26, 28 and 30 had disagreement from the experts so it was

removed from questionnaire. And the final drafts contained 25 knowledge questions.

Translation of the tool

A language expert translated the knowledge questionnaire on pulmonary rehabilitation

into Kannada and the validity of the translated tool was re-established by translating back to

English by another expert.

Pre-testing of the tool

Pre-testing is a trial administration of a newly developed instrument to identify flaws or

to assess the time requirements. The purpose is to reveal problems related to the instrument and

point out the weakness in the administration, organization and distribution of the instrument32.

Structured knowledge questionnaire was pre-tested by administering it to 6 COPD

patient’s fulfilling the sampling criteria. The respondent found it easy to understand the items.

They took an average of 25-30 minutes to complete the questionnaire.

Reliability of the tool

The reliability of an instrument is the degree of consistency with which it measures the

attribute it is supposed to be measuring. The reliability of the tool was established using Split-

Half method which measured the coefficient of internal consistency. The items were equally

divided into two groups. Reliability of the half test was found by using Karl-pearsons product

moment correlation formula. Spearman Brown Prophesy formula was used to find out the

reliability of the full test. The reliability of the tool was to be r = 0.83 which indicated that tool

was reliable.

41
Preparation of the final draft of the tool

The tool consisted of a self administered questionnaire. It was used to elicit the

knowledge of COPD patients regarding pulmonary rehabilitation. The tool was consisted of two

sections.

Section 1: Baseline pro-forma:

It is composed of 10 items in relation to the basic information of the sample. It consists

of identification data such as age in years, gender, educational qualification, occupation, family

monthly income, history of exposure to smoke, number of packets per day, treatment and

hospitalization for COPD, and whether they are having any previous information about

pulmonary rehabilitation.

Section II: structured knowledge questionnaire:

It consists of 25 multiple choice questions covering the aspects of knowledge on

pulmonary rehabilitation. The respondents were requested to place a tick (√) mark against any

one of the four options which the respondent felt as most suitable. There is only one correct

response for each question and every correct answer was scored ‘1’ mark. The total score was

25; the score obtained by the COPD patients were arbitrarily classified into four levels.

0-10 <40% Poor

11-15 41-60% Average

16-20 61-80% Good

21-25 81-100 % Very good

A score of average, good and very good knowledge was considered as adequate

knowledge; poor knowledge was considered as inadequate knowledge.

42
Development of the individual health education

Individual health education for COPD patients regarding pulmonary rehabilitation was

developed after reviewing the literature, seeking opinion of the experts and from discussion with

COPD patients. The individual health education was prepared in form of a detailed lesson plan.

The steps involved in the development of the individual health education were,

• Preparation of the first draft of individual health education.

• Development of the checklist criteria of the individual health education.

• Content validation of individual health education.

• Preparation of the final draft of individual health education.

Preparation of first draft of individual health education

The first draft of the individual health education was developed after reviewing the

available literature and consulting with experts. A criteria checklist was prepared to assess the

clarity, appropriateness and feasibility of the individual health education.

The objectives were distributed under 12 broad learning areas. These were,

• Anatomy and physiology of respiratory system

• Concepts of COPD

• Risk factors of COPD

• Signs and symptoms of COPD

• Meaning of pulmonary rehabilitation

• Purposes of pulmonary rehabilitation

• Benefits of pulmonary rehabilitation

• Component of pulmonary rehabilitation

• Breathing and coughing exercises and relaxation techniques

43
 • Inhalation of medication

• Nutritional management of the COPD patients

• Life style modifications

The same blue print was considered for the construction of individual health education.

Development of criteria checklist of individual health education

A criteria checklist was prepared to develop individual health education based on

review and the opinion of experts. The criteria checklist consists of 19 criteria statements under

the broad headings of:

• Formulation of objectives

• Selection of content

• Organization of the content

• Teaching aids

• Feasibility and practicability

• Other suggestions.

Content validation of individual health education

The initial draft of the individual health education was given to 9 experts. The experts

were requested to validate the individual health education based on the criteria check list and to

give suggestions on adequacy and relevance of content. Experts suggested the simplification of

certain medical terms into easy language and their suggestions were accepted. AV aids were

changed according to the suggestion of experts and the final draft was prepared that ensured the

clarity and the validity of the individual health education.

44
Preparation of the final draft of individual health education

The final draft of teaching package was prepared after incorporating the suggestion

of experts. The teaching package was given to an expert in Kannada language who translated it

into Kannada. It conveyed the same idea when it was translated back into English.

Pilot study

“A pilot study is a small-scale version or trial run of the major study32. The study was

conducted in district Government Wenlock Hospital from 06/09/2012 to 12/09/2012. The

investigator obtained written permission from the concerned authority prior to the study. The

structured knowledge questionnaire was administered to six subjects who fulfilled the sampling

criteria.

The purpose of the study was explained to the subjects and an informed consent was

obtained, and the tool was administered. Pre-test was assessed and individual health education

was administered, the post-test was conducted by using the same tool on the 7th day. An average

of 25 to 30 minutes was taken by the respondent to complete the tool. The data analysis was

done using the descriptive and inferential statistics. The findings revealed that the obtained “t”

value (t= 10.43) was higher than the table value (t=1.96). This showed that the individual health

education was effective in terms of increasing the knowledge of COPD patients regarding

pulmonary rehabilitation.

Process of data collection

The main study was conducted from 14/09/12 to 20/10/12 on 50 COPD patients. A

formal written permission was obtained from the District surgeon and Superintendent of

Government Wenlock Hospital, Mangalore to conduct the research study in the Wenlock

Hospital. The purpose of the study, method of data collection and time duration were explained

45
to the subjects for getting good response. They were also given assurance regarding

confidentiality of the information. An informed consent was obtained from the respondents

indicating their willingness to participate in the study. Subjects who fulfilled the sampling

criteria were selected from the medical wards by a non-probability purposive sampling

technique. The pre-test was conducted among the selected COPD patients. After the pre-test the

individual health education was administered. The education session lasted for about 20 minutes.

The investigator used power point slides to teach the different components of pulmonary

rehabilitation. All the subjects who attended the pre-test were given post-test with the same

questionnaire on the seventh day. The collected data was complied for analysis.

Plan for data analysis

Data analysis is the systematic organization and synthesis of the research data and the

testing of research hypothesis using the data32.

Data was planned to be analyzed on the basis of objectives and hypotheses.

• Baseline data would be analyzed in terms of frequency and percentage.

• The significant difference between the mean pre-test and post-test score. The knowledge

score of the patients before and after the individual health education would be analyzed in

terms of frequency, percentage, mean, median and standard deviation.

• Knowledge scores would be determined by paired‘t’ test.

• The significant association between pre-test knowledge scores and selected baseline

variables would be determined by Chi-square test.

46
Summary

This chapter has dealt with the research methodology adopted for the study. It

includes research approach, research design, research setting, population, sample and sampling

technique, sample size, criteria for sample selection, study instruments and development of tool,

preparation of the blue print, testing of the tool, development of checklist criteria, content

validity, pre-test of the tool, description of the tool, reliability of the tool, description of the final

tool, development of individual health education, preparation of draft of individual health

education, pilot study, method of data collection and plan for data analysis. The analysis and

interpretation of the same are presented in the following chapter.

47
RESULTS
 5. RESULTS

The description of ‘result’ is the heart of the research study. It is the communication of

facts, measurement and observations gathered by the researcher.

This chapter deals with the analysis and interpretation of the data collected from 50

COPD patients through structured knowledge questionnaire to evaluate the effectiveness of

individual health education on pulmonary rehabilitation among the COPD patients admitted in

Government Wenlock hospital at Mangalore. The data was analyzed according to the objectives

of the study.

The purpose of the analysis is to summarize, compare the test, proposed relationship

and to infer findings. The collected data was tabulated on the master sheet and analyzed using

descriptive and inferential statistics.

Objective of the study are to:

• assess the level of knowledge regarding pulmonary rehabilitation among patients with

COPD using structured knowledge questionnaire.

• evaluate the effectiveness of individual health education on level of knowledge regarding

pulmonary rehabilitation among patients with COPD.

• find the association between the pre-test knowledge score and selected baseline variables.

Hypotheses:

All hypotheses will be tested at 0.05 level of significance.

H1: The mean post-test knowledge scores of patients with COPD attending the individual

health education on pulmonary rehabilitation will be significantly higher than the mean pre-test

knowledge scores.

48
H2: There will be significant association between pre-test knowledge scores on pulmonary

rehabilitation among patients with COPD and their selected variables.

Organization of findings

The data is analyzed and presented under the following headings.

1. Section I: Description of the baseline variables of the COPD patients.

2. Section II: Pre-test knowledge score of the COPD patients on pulmonary rehabilitation.

a. Part I: Overall pretest knowledge score of the COPD patients on pulmonary

rehabilitation.

b. Part II: Area wise pretest knowledge score of the COPD patients on pulmonary

rehabilitation.

3. Section III: Post test knowledge score of the COPD patients on pulmonary rehabilitation.

a. Part I: Overall post test knowledge score of the COPD patients on pulmonary

rehabilitation.

b. Part II: Area wise post test knowledge score of the COPD patients on pulmonary

rehabilitation.

4. Section IV: Effectiveness of individual health education on pulmonary rehabilitation

among COPD patients admitted in Government Wenlock hospital at Mangalore.

a. Part 1: Comparison of overall pre-test and post test knowledge score of COPD

patients on pulmonary rehabilitation.

b. Part 2: Comparisons of area-wise mean pre-test and post-test knowledge scores.

5. Section IV: The association of the pre-test knowledge scores with selected baseline

variables.

49
 Section I

Description of the baseline variables of the COPD patients.

This section deals with the description of the baseline characteristics of the COPD

patients admitted in Government Wenlock hospital at Mangalore, and has been presented in the

form of frequency and percentage.

Table 1: Frequency and percentage distribution of the selected baseline variables of the

COPD patients

n = 50
SL. Variable Frequency (f) Percentage (%)
NO:
1 Age (in years)

30 – 40 0 0

41 – 50 10 20

51 -60 11 22

Above 60 29 58

2 Gender

Male 32 64

Female 18 36

3 Educational qualification

Primary education 37 74

High school 9 18

Pre university 4 8

Graduate and above 0 0

50
4 Occupation

Self employed 16 32

Private employed 7 14

Government employed 0 0

Health professional 0 0

Unemployed 27 54

5 Family monthly income in Rs

≤ 3000 32 64

3001-6000 18 36

6001-10000 0 0

>10000 0 0

6 History of smoking

Active Smoking 32 64

Passive smoking 13 26

No history of smoking 5 10

7 If active smoker, smokes

< 1 packet /day 8 25

2-3 packets /day 17 53

4-5 packets /day 7 22

Above 6 packets /day 0 0

8 Are you on regular treatment for COPD?

Yes 36 72

No 14 28

51
 9 Any previous history of hospitalization for

COPD?

Yes 43 86

No 7 14

10 Have you had any previous information about

pulmonary rehabilitation?

Yes 8 16

No 42 84

Data presented in the Table I and figures 4-13 shows that out of 50 samples majority

(58%) of the samples belong to an age group of above 60 years, majority (64%) of the samples

were males and majority (74%) of the samples had primary education. A total of (54%) of the

samples are unemployed. Majority (64%) of the samples has a family income of < 3000 and

majority (64%) of the samples are active smokers. A total (53%) of the active smokers smokes 2-

3 packets/day. Majorities (72%) of the samples are on regular treatment and majority (86%) of

the samples have been hospitalized for COPD. Majority (84%) of the samples have no

information about pulmonary rehabilitation.

The selected baseline variables of the COPD patients are also presented in the form of

various diagrams, in figure 4-13.

52
 60 58%

50

P 40
e
r
c
e 30
n
t 22%
a 20%
g 20
e

10

0%
0
30-40 41-50 51-60 above 60

Age in years

Figure 4: Bar diagram showing the percentage distribution of samples according to the age.

53
 36%

64%
male
female

Figure 5: Pie diagram showing the percentage distribution of samples according to the

gender.

54
 80
74%

70

60
P
e
50
r
c
e
40
n
t
a 30
g
e
18%
20

8%
10

0%
0
primary education high school pre university graduate and
above
Education

Figure 6: Conical diagram showing the percentage distribution of samples according to

their education.

55
 60

54%

50

p
e 40
r
c 32%
e
30
n
t
a
g 20
e 14%

10

0% 0%
0
Self employed private government health unemployed
employed employed professional

Occupation

Figure 7: Cylindrical diagram showing the percentage distribution of samples according to

their occupation.

56
 70
64%

60

50
p
e
r
c 40 36%
e
n
t 30
a
g
e
20

10

0% 0%
0
< 3000 3001-6000 6001-10000 >10000

family monthly income

Figure 8: Conical diagram showing the percentage distribution of samples according to

their family monthly income.

57
 70

60

50
p
e
r
c 40
e
n 64%
t 30
a
g
e 20

26%

10
10%

0
active smoking passive smoking no smoking

History of smoking

Figure 9: Bar diagram showing the percentage distribution of samples according to the

history of smoking.

58
 60

53%

50

p
40
e
r
c
e
30
n 25%
t
22%
a
g 20
e

10

0%
0
<1 packet/day 2-3 packets/day 4-5 packets/day above 6
packets/day
Active smoker smokes

Figure 10: Cylindrical diagram showing the percentage distribution of active smokers

according to the number of packets smoked per day.

59
 80%

70%

60%

p
50%
e
r
c
40%
e 72%
n
t 30%
a
g
e 20%

10% 28%

0%

yes
no

Under regular treatment

Figure 11: Pyramidal diagram showing the percentage distribution of samples taking

regular treatment for COPD.

60
 86%
90

80

70

60
P
e
r 50
c
e
n 40
t
a 30
g
e
20 14%

10

0
yes no

Hospitalized for COPD

Figure 12: Conical diagram showing the percentage distribution of samples according to
their previous hospitalization for COPD.

61
 16%

yes
no

84%

Figure 13: Pie diagram showing the percentage distribution of samples according to their

previous information regarding pulmonary rehabilitation.

62
 Section II

Pre-test knowledge score of the COPD patients on pulmonary rehabilitation.

This section deals with the analysis and interpretation of the data of the pre-test

knowledge of COPD patients on pulmonary rehabilitation, which was assessed using a structured

knowledge questionnaire.

Part I: Overall pretest knowledge score of the COPD patients on pulmonary

rehabilitation.

This section deals with the analysis and interpretation of the data of the overall pre-test

knowledge of COPD patients on pulmonary rehabilitation

The obtained data is tabulated below.

Table 2: Distribution of overall pre-test knowledge score of COPD patients on pulmonary

rehabilitation in terms of frequency and percentage on knowledge.

n= 50
Pre test

Level of knowledge Frequency (f) Percentage (%)

Poor 38 76%

Average 12 24%

Good - -

Very good - -

63
 80 76%

70

60

p
e
50
r
c
e
40
n
t
a 30
g 24%
e
20

10

0% 0%
0
poor average good very good

Level of knowledge

Figure 14: Cylindrical diagram showing the distribution of samples according to the pre

test level of knowledge.

64
 The data presented in the Table 2 and figure: 14 shows that in the pre-test, majority

(76%) of the samples had poor knowledge and 24% of the samples had average knowledge.

None of the sample had good or very good scores.

Table 3: Mean, Median and Standard Deviation of Pre-test knowledge score of COPD

patients on pulmonary rehabilitation.

n=50
Pre test
Mean Median SD

9.0833 9 1.4117

The data presented in Table 3 shows that the pre-test knowledge scores are in the range

between 7-11. The mean pre-test knowledge score was 9.0833 ± 1.4117.

Part II: Area wise pretest knowledge scores of the COPD patients on pulmonary

rehabilitation.

This section deals with the analysis and interpretation of the data of the area wise pre-test

knowledge of COPD patients on pulmonary rehabilitation.

65
Table 4: Area-wise distribution of pre-test Mean knowledge score, Standard deviation and

Mean percentage of COPD patients on pulmonary rehabilitation.

n=50
Pre-test

SL. Area Maximum Mean Standard Percentage

NO possible score deviation mean (%)
score
1. Anatomy and physiology of 3 2.1 0.462 70%

respiratory system

2. Knowledge regarding 3 1.24 0.476 41.33%

disease condition

3. Meaning and purposes of 3 1.18 0.3880 39.33%

pulmonary rehabilitation

4. Components of pulmonary

rehabilitation

a. Breathing exercises 7 2.06 0.619 29.42%

b. Relaxation techniques 2 0.48 0.504 24%

c. Nutrition 3 0.9 0.303 30%

d. Medication 2 0.54 0.503 27%

e. Life style modification 2 0.58 0.574 29%

The data presented in the Table 4 shows that the pre-test knowledge score was higher in

the area of anatomy and physiology of respiratory system with mean percentage of 70%, mean

score was 2.1 and standard deviation was 0.462. The mean percentage of knowledge score was

66
found to be lower in the area of relaxation techniques (24%), mean score was 0.48 and standard

deviation was 0.504. However the mean percentage of knowledge score reveals that the

knowledge of COPD patients on pulmonary rehabilitation was poor in six areas like meaning and

purposes (39.33%) and components of pulmonary rehabilitation such as breathing

exercises(29.42%), relaxation techniques(24%), nutrition(30%), medication(27%) and life style

modification(29%), average in knowledge regarding disease condition(41.33), and good in

anatomy and physiology of respiratory system area(70%), and need to be educated further.

Section III

Post-test knowledge score of the COPD patients on pulmonary rehabilitation.

This section deals with the analysis and interpretation of the data of the post-test

knowledge of COPD patients on pulmonary rehabilitation, which was assessed using the same

structured knowledge questionnaire.

Part I: Overall post-test knowledge score of the COPD patients on pulmonary

rehabilitation.

This section deals with the analysis and interpretation of the data of the overall post-test

knowledge of COPD patients on pulmonary rehabilitation.

The obtained data is tabulated below.

67
Table 5: Distribution of overall post-test knowledge score of COPD patients on pulmonary

rehabilitation in terms of frequency and percentage on knowledge.

n= 50
Post-test
Level of knowledge Frequency (f) Percentage (%)

Poor 0 0

Average 4 8%

Good 38 76%

Very good 8 16%

68
 80

70

60

p
e 50
r
c
e 40
n 76%
t
a
g 30
e

20

10
16%

8%
0%
0
Poor Average Good Very good
Level of knowlege

Figure 15: Bar diagram showing the distribution of samples according to the post test level

of knowledge.

69
 The data presented in the Table 5 and figure: 15 shows that in the post-test, majority

(76%) of the samples had good knowledge, 16% of the samples had very good knowledge and

8% of the samples had average knowledge. None of the sample had poor knowledge.

Table 6: Mean, Median and Standard Deviation of Post-test knowledge score of COPD

patients on pulmonary rehabilitation.

n=50
Post-test
Mean Median SD

18.1 18 1.775

The data presented in Table 6 shows that the post-test knowledge scores were in the range

between 15-21. The mean post-test knowledge score was 18.1 ± 1.775.

Part II: Area wise post-test knowledge scores of the COPD patients on pulmonary

rehabilitation.

This section deals with the analysis and interpretation of the data of area wise post-test

knowledge of COPD patients on pulmonary rehabilitation.

70
Table 7: Area-wise distribution of post-test Mean knowledge score, Standard deviation and

Mean percentage of COPD patients on pulmonary rehabilitation.

n=50
Post-test

SL. Area Maximum Mean Standard Percentage

NO possible score deviation mean (%)
score
1 Anatomy and physiology of 3 2.22 0.418 74%

respiratory system

2 Knowledge regarding 3 2.02 0.6223 67.33%

disease condition

3 Meaning on purposes of 3 2.12 0.435 70.66%

pulmonary rehabilitation

4 Components of pulmonary

rehabilitation

a-Breathing exercises 7 4.76 0.743 68%

b-Relaxation techniques 2 1.52 0.504 76%

c- Nutrition 3 2.36 0.562 78.66%

d-Medication 2 1.56 0.5406 78%

e-Life style modification 2 1.52 0.5046 76%

The data presented in the Table 7 shows that the post-test knowledge score was higher

in the area of nutrition with mean percentage of 78.66%, mean score was 2.36 and standard

deviation was 0.562. The mean percentage of knowledge score was found to be lower in the area

of knowledge regarding disease condition (67.33%), mean score was 2.02 and standard deviation

71
was 0.6223. However the mean percentage of knowledge score reveals that the knowledge of

COPD patients on pulmonary rehabilitation was good in all other areas.

Section IV

Effectiveness of individual health education on pulmonary rehabilitation among COPD

patients admitted in Government Wenlock hospital at Mangalore.

This section deals with the analysis and interpretation of the data collected to evaluate the

effectiveness of individual health education on pulmonary rehabilitation among the COPD

patients admitted in Government Wenlock hospital at Mangalore.

Part 1: Comparison of pre-test and post test knowledge score of COPD patients on

pulmonary rehabilitation.

To find the significant difference between the mean pre-test and post-test knowledge

score, “paired” “t” test was used. To test the statistical significance between the mean pre- test

and post-test knowledge score, the following null hypothesis was formulated.

H0 1: There will be no significant difference between the mean pre-test and post-test knowledge

scores of the COPD patients attending an individual health education on pulmonary

rehabilitation at 0.05 level of significance.

72
Table 8: Frequency and percentage distribution of pre and post test knowledge scores of
COPD patients on pulmonary rehabilitation.
n=50
Pre test Post test

Level of Frequency (f) Percentage (%) Frequency (f) Percentage (%)

knowledge

Poor 38 76% - -

Average 12 24% 4 8%

Good - - 38 76%

Very good - - 8 16%

73
 80 76% 76%

70

60
p
e
r 50
c
e
40
n pre tesst
t post test
a 30
24%
g
e 20 16%

8%
10

0
poor average good very good

Level of knowledge

Figure 16: Bar diagram showing the percentage distribution of samples according to the

pre test and post test level of knowledge.

The data presented in Table: 8 and Figure: 16 shows that majority of the samples

(76%) had poor knowledge score in the pre-test and 24% had average knowledge score. In the

post-test 76% of the samples had good knowledge score and 16% had very good knowledge

score, only 8% had average knowledge score. None of the samples had poor knowledge score on

post test. This data shows that the individual health education was effective in increasing the

knowledge of the samples.

74
Table 9: Over all Mean, Mean difference, Standard deviation, ‘t’ value, Standard error

mean of pre test and post test knowledge scores of COPD patients on pulmonary

rehabilitation

n = 50

Mean Mean SD SEM ‘t’ value

difference

Pre test 9.0833 8.98 1.4117 0.294 30.56

Post test 18.1 1.775

‘t’ 49 = 1.68, at 0.05 level. Highly significant (p<0.05)

Data in table 9 depicts that the mean post test knowledge score (18.1+ 1.775) is higher

than the mean pre test knowledge score (9.0833+ 1.4117). The obtained “t” value (t49 = 30.56,

p<0.05) was found to be greater than the table value (t49= 1.68) at 0.05 level of significance.

Hence the null hypothesis was rejected and the research hypothesis was accepted.

Hence it concluded that the individual health education on pulmonary rehabilitation was

effective in improving the knowledge score of the COPD patients on pulmonary rehabilitation.

Part 2: Comparisons of area-wise mean pre-test and post-test knowledge scores.

To determine the Significance difference in the area-wise mean pre-test and post-test knowledge

score of COPD patients on Pulmonary rehabilitation, paired “t” test was computed between the

area and have been presented in Table 10

75
Table 10: Area-wise Mean, Mean difference, Standard deviation, ‘t’ value and Standard

error mean of pre-test and post-test knowledge score of samples

n = 50
SL Area Max. Pre Post Mean Pre Post ‘t’ value
No: possible test test difference test test
score mean mean SD SD
1 Anatomy and 3 2.1 2.22 0.10 0.462 0.418 1.218*

physiology of

respiratory system

2 Knowledge 3 1.24 2.02 0.76 0.476 0.6223 7.0396*

regarding disease

condition (COPD)

3 Meaning and 3 1.18 2.12 0.94 0.388 0.435 15.333*

purposes of

pulmonary

rehabilitation

4 Components of

pulmonary

rehabilitation

a-Breathing 7 2.06 4.76 2.67 0.619 0.743 21.380*

exercises

b- Relaxation 2 0.48 1.52 1.04 0.504 0.504 12.651*

techniques

c- Nutrition 3 0.9 2.36 1.45 0.303 0.562 17.501*

76
 d- Medication 2 0.54 1.56 1.02 0.503 0.5406 11.588*

e- Life style 2 0.58 1.52 0.94 0.574 0.5046 9.7399*

modification

P<0.05, *= significant, d.f = 49, table value = 1.68

The data presented in Table 10 indicates that the mean post-test knowledge score in all

areas were significantly higher than the mean pre-test knowledge score. The overall findings

reveal that the individual health education is effective in increasing the knowledge of COPD

patients, in all aspects of the topic undertaken.

Section V

The association of the pre-test knowledge scores with selected baseline variables.

This section deals with the findings of the association with pre-test knowledge score of

COPD patients and selected baseline data like age, gender, educational status, occupation, family

monthly income, history of smoking, number of packets smokes per day, under regular

treatment , hospitalization for COPD, previous information about pulmonary rehabilitation. To

test the association of the knowledge scores with baseline data, the following null hypothesis was

formulated.

H02: There will be no significant association between pre-test knowledge score of the COPD

patients with selected baseline data like age, gender, educational status, and occupation, family

monthly income, history of smoking, number of packets smokes per day, under regular

treatment, hospitalization for COPD, previous information about pulmonary rehabilitation at

0.05 level of significance.

77
 A chi square, and fishers exact test was calculated to find the association between the

pre-test knowledge scores and selected baseline variables. The median of the pre-test knowledge

score was calculated and was found to be 9.

The number of samples who were above and below the median were identified and grouped

according to their baseline characteristics.

Table 11: Chi square test showing the association between pre-test knowledge score of

COPD patients and selected baseline variables.

n=50
Variables χ2 P value Inference
Age 0 0.4798 NS

Gender 3.004 0.083 NS

Education 0.033 0.8557 NS

Occupation 0.344 0.5577 NS

Family income 0.867 0.3517 NS

History of smoking 3.004 0.0831 NS

Taking regular treatment for COPD 1.363 0.2430 NS

Previous hospitalization for COPD 0 1 NS

Any previous Information about 0 1 NS

pulmonary rehabilitation
P < 0.05, NS = Not significant

78
 The data presented in table 11 shows that there was no significant association (NS)

between the pre-test knowledge score and selected baseline data like age, gender, educational

status, occupation, family monthly income, history of smoking, number of packets smokes per

day, under regular treatment, hospitalization for COPD and previous information about

pulmonary rehabilitation. The calculated chi-square values were less than the table value 3.84, at

0.05 level of significance. Hence the null hypothesis was accepted. So it concluded that there

was no significant association with pre-test knowledge score and selected baseline variables.

Summary

This chapter has dealt with the analysis and interpretation of the result of the study. Both

descriptive and inferential statistics are employed to analyze the data. The data analysis is carried

out on the basis of the objectives and hypotheses of the study. The data analysis and

interpretation has been organized and presented as sample characteristics, knowledge of COPD

patients on pulmonary rehabilitation, the effectiveness of individual health education, testing the

hypotheses and association of pre-test knowledge score of the COPD patients with selected

baseline data. Frequency and percentages are used to analyze the sample characteristics. Mean,

mean percentage and standard deviation are also used to analyze the knowledge. The

effectiveness of the individual health education is assessed using paired’ test. The association of

knowledge with selected baseline data was calculated using chi-square test.

79
DISCUSSION
 6. DISCUSSION

The aim of the present study was to evaluate the effectiveness of individual health

education on pulmonary rehabilitation among the COPD patients admitted in Government

Wenlock hospital Mangalore. This chapter presents the major findings of this study and

discussion in relation to similar studies conducted by other researchers.

The objectives of the study

The following are formulated to carry out the study:

1. To assess the level of knowledge regarding pulmonary rehabilitation among patients with

COPD using structured knowledge questionnaire.

2. To evaluate the effectiveness of individual health education on level of knowledge

regarding pulmonary rehabilitation among patients with COPD.

3. To find the association between the pre-test knowledge score and selected baseline

variables.

Hypotheses:

All hypotheses will be tested at 0.05 level of significance.

H1: The mean post-test knowledge scores of patients with COPD attending the individual health

education on pulmonary rehabilitation will be significantly higher than the mean pre-test

knowledge scores.

H2: There will be significant association between pre-test knowledge scores on pulmonary

rehabilitation among patient with COPD and their selected variables.

80
Major findings of the study and discussion:

Section I: Description of the baseline variables of the COPD patients.

• Most of the samples (58%) were in the age group of above 60 years.

• Most of the samples (64%) were males and 74% of them had primary education.

• Majority of the samples (54%) are unemployed.

• Majority of the samples (64%) has a family income of < 3000.

• Majority of the samples (64%) are active smokers. Among this (53.1%) smokes 2-3

packets/day.

• Majorities (72%) of the samples are under regular treatment and majorities (86%) of the

samples have been hospitalized for COPD.

• Among the samples (84%) have no previous information about pulmonary rehabilitation.

The above findings are consistent with a study was conducted to describe the prevalence

of chronic obstructive pulmonary disease in patients attending chest clinic in a tertiary hospital in

India. Three year retrospective analysis of all subjects who underwent pulmonary function tests

between January 1999 to December 2001. Out of 13860 patients 946 patients were diagnosed to

have COPD. Out of 964 patients, 284 had mild COPD (30%), 286 had moderate disease (30%)

and the remaining 387 patients (40%) had severe COPD. The result showed an overall

prevalence of 6.85% in South India19.

Section II: Pre-test knowledge score of the COPD patients on pulmonary rehabilitation.

Data collected prior to the administration of individual health education reflected that

majority of the samples (76%) had poor knowledge on pulmonary rehabilitation. The remaining

24% of samples had average knowledge score.

81
 And in the area wise pre-test knowledge score was higher in the area of anatomy and

physiology of respiratory system with mean percentage of 70% and the mean percentage of

knowledge score was found to be lower in the area of relaxation techniques (24%). However the

mean percentage of knowledge score reveals that the knowledge of COPD patients on pulmonary

rehabilitation was poor in six areas like meaning, purposes (39.33%) and components of

pulmonary rehabilitation such as breathing exercises (29.42%), nutrition (24%), medication

(27%) and life style modification (29%), average in knowledge regarding disease condition

(41.33%), and good in anatomy and physiology of respiratory system area (70%), and need to be

educated further.

A study was conducted in United Kingdom to assess information needs and knowledge of

patients with COPD. 81 patients were participated in this study. The Lung Information Needs

Questionnaire (LINQ) and the Mount Sinai Hospital Questionnaire (MSHQ) were used. The

LINQ identifies what COPD information the patient has, or is lacking. The MSHQ assesses a

patients’ COPD knowledge. The results showed that Patients on average had 14% need for

information in that 34% need for information on diet and 25% for self-management as assessed

by the LINQ and 13% need for information as assessed by MSHQ. The study concluded that

Patients with COPD have poor knowledge and there is a need for receive information about the

disease condition39.

The findings of the above study highlighted the alarming lack of knowledge among

hospitalized patients regarding pulmonary rehabilitation, and would actively put the samples

under study.

82
 Section III: Post-test knowledge score of the COPD patients on pulmonary rehabilitation

Data collected after the administration of individual health education reflected that

majority (76%) of the samples had good knowledge, 16% of them had very good knowledge and

8% of them had average knowledge. None of the sample had poor knowledge.

And the post-test knowledge score was higher in the area of nutrition with mean

percentage of 78.66%. The mean percentage of knowledge score was found to be lower in the

area of knowledge regarding disease condition (67.33%). However the mean percentage of

knowledge score reveals that the knowledge of COPD patients on pulmonary rehabilitation was

good in all the other areas like anatomy and physiology of respiratory system (74%), knowledge

regarding disease condition (67.33%), meaning and purposes of pulmonary rehabilitation

(70.66%), breathing exercises (68%), relaxation techniques (76%), medication (78%) and life

style modifications (76%).

A prospective study was conducted in Brazil to evaluate the effectiveness of educational

program in patients who undergo pulmonary rehabilitation. 22 patients participated in this study.

A questionnaire was developed and applied to evaluate the patient’s knowledge about the disease

before and after the educational intervention. The results showed that the patients who

underwent the educational program presented an increase in the percentage of correct answers,

after the intervention (69% versus 84%, respectively). The study concluded that the educational

program applied to patients in the pulmonary rehabilitation program was effective to increase the

patients' knowledge about their disease, its consequences and its treatment28.

The findings of the above study highlighted the effectiveness of education among

hospitalized patients regarding pulmonary rehabilitation.

83
Section IV: Effectiveness of individual health education on pulmonary rehabilitation

among COPD patients admitted in Government Wenlock hospital at Mangalore.

The mean post test knowledge score (18.1) is higher than the mean pre test knowledge

score (9.0833) after the individual health education.

The difference between the mean post test and the mean pre test knowledge score was

found to be statistically significant (t49 = 30.56) at 0.05 level of significance which showed that

the individual health education was effective in increasing the knowledge of COPD patients on

pulmonary rehabilitation.

An intervention study was carried out on 122 randomly selected type 2 diabetics

attending diabetes outpatient clinic in Zagazig University in Egypt, from January 2009 to April

2009 to assess the effectiveness of health education on knowledge, attitude, blood sugar and

HbALc levels in type 2 diabetics. The majority of patients had low levels of knowledge

regarding different aspects of diabetes in the pre test. After implementation of the educational

message, a significant improvement was revealed in patients' knowledge. The study concluded

that health education was an effective tool that implicated change in diabetic patients'

knowledge, attitude, blood sugar and HbALc levels in type 2 diabetics58. This finding supports

the findings of the present study.

The above mentioned study and the findings of the present study clearly show that the

individual health education is an effective method in enhancing the knowledge score of patients.

Section IV: The association of the pre-test knowledge scores with selected baseline

variables.

The findings of the study reveal that there is no significant association (NS) between the

pre-test knowledge score and selected baseline data like age, gender, educational status,

84
occupation, family monthly income, history of smoking, number of packets smokes per day,

under regular treatment, hospitalization for COPD and previous information about pulmonary

rehabilitation at 0.05 level of significance.

Summary

This chapter discussed the significant findings of the study in relation to other studies.

This helped the investigator to prove that the findings were true and the individual health

education was effective in increasing the knowledge of COPD patients on pulmonary

rehabilitation.

85
CONCLUSION
 7. CONCLUSION

The purpose of this study was to evaluate the effectiveness of individual health education

on pulmonary rehabilitation among the COPD patients admitted in Government Wenlock

hospital.

The following conclusions were drawn on the basis of the findings of the study:

• Majority of the subjects had poor knowledge score on the pre-test.

• The mean post-test knowledge score was significantly higher than the mean pre-test

knowledge score.

• It was also found that the area of anatomy and physiology of respiratory system had

maximum score in pre-test and the area of nutrition, in the post-test.

• Findings showed that individual health education was an effective method to improve the

knowledge of patients on pulmonary rehabilitation.

• There was no association between pre-test knowledge scores and selected baseline

variables.

Nursing implications

The findings of the present study have implications in the field of nursing education,

nursing practice, nursing administration and nursing research.

The healthcare delivery system at present days more emphasis on rehabilitative aspect.

The finding of the study has shown that COPD patients have inadequate knowledge on

pulmonary rehabilitation. The individual health education could be used as an illustrative

informational aid to staff, student nurses, nurse educators and patients.

Although today’s nursing curriculum includes course on communication skills, it needs to

further emphasis on information as a process. Continuing nursing education should be conducted

86
for need awareness, effective teaching material and AV aids to express the content area clearly

for patients should be utilized.

Nursing practice

Health education is one of the cost effective interventions used for educating the public

on various aspects. The nurse should take initiative for arranging health talks and seminars by

gathering all the persons in the community based on their felt needs. The knowledge they receive

will help to prevent many communicable and non-communicable diseases. This acquired

knowledge will be disseminated to others by interaction.

The present study revealed that the individual health education on pulmonary

rehabilitation was an effective method to improve the knowledge of patient. The nurse can take

the role of a facilitator and educator and can educate the patients they care for, during their

practice. This can improve the patient’s knowledge and the nurses can participate actively in the

patient care.

Nursing Administration

The nursing administrator takes part in the making of health policy, development of

protocols and standing orders with respect to various patient problems. The findings of the study

can be used by the nurse administrator to assess the need for educating the patients regarding

pulmonary rehabilitation. The administrator, based on the felt needs, can plan the education

program and also encourage staff nurses to educate their patients.

Nursing education

The Medical Surgical Nursing curriculum needs to be reorganized to enable nursing

personnel to identify high risk for COPD so as to provide supportive education to cope with

proper management of COPD.

87
 As a nurse educator, there are ample opportunities, for the nursing professional to educate

the COPD patients on pulmonary rehabilitation and provide care in the clinical setting.

The study emphasizes the significance of the short term courses or in-service education

for nurses in advanced knowledge on pulmonary rehabilitation and in making use of facilities

available in the management of COPD.

Nursing Research

The study helps the nurse researcher to develop insight into the development of teaching

module and materials for Pulmonary rehabilitation towards promotion of quality of life of the

COPD patients. Nurse researcher can investigate various aspects of pulmonary rehabilitation and

can add to the knowledge base. The present study also gives various recommendations, which

can be considered and taken up as researches or project in different settings and population.

Limitations

1. The study was confined to only 50 COPD patients admitted in District Government

Wenlock hospital at Mangalore.

2. The generalization of the study findings is limited to the sample studied.

3. COPD patients who were able to communicate in English or Kannada only had been

included in the study.

4. The study did not use a control group. The investigator had no control of the event that

took place between pre test and post test.

Recommendations

On the basis of findings of the study, the following recommendations are being made.

• A similar study can be replicated on a large sample to generalize the findings

• A similar study can be conducted amongst with other associated diseases.

88
 • An experimental study can be undertaken with control group for effective comparison.

• A comparative study can be undertaken to compare the findings from the rural and urban

hospitals.

• A study can be conducted at private and government hospitals and the results of the study

may be compared to find out the knowledge.

Summary

Based on the findings of the study, investigator has drawn many conclusions. In this

chapter, the investigator dealt with the various nursing implications of the study and the

limitations, which the investigator experienced in the study. The experience of the investigator

during the study helped to give suggestions and recommendations for further studies.

89
SUMMARY
 8. SUMMARY

This chapter presents a summary of the study. The topic of the research study was “A

study to assess the effectiveness of individual health education on level of knowledge regarding

pulmonary rehabilitation among patients with chronic obstructive pulmonary disease (COPD) in

selected hospitals at Mangalore.”

Objectives of the study were to

• Assess the level of knowledge regarding pulmonary rehabilitation among patients with

COPD using structured knowledge questionnaire.

• Evaluate the effectiveness of individual health education on level of knowledge regarding

pulmonary rehabilitation among patients with COPD.

• Find the association between the pre-test knowledge score and selected baseline

variables.

The study attempted to examine the following hypotheses

H1: The mean post-test knowledge scores of patients with COPD attending the individual health

education on pulmonary rehabilitation will be significantly higher than the mean pre-test

knowledge scores.

H2: There will be significant association between pre-test knowledge scores on pulmonary

rehabilitation among patient with COPD and their selected variables.

The study had the following assumptions

1. Patients with COPD may have inadequate level of knowledge regarding pulmonary

rehabilitation.

90
2. Individual health education regarding pulmonary rehabilitation may improve the level of

knowledge in patients with COPD.

The conceptual framework adopted for the study

The conceptual framework for the present study was based on context, input, process,

product (CIPP) model by Danial Stufflebeam.

Review of literature and related studies helped the investigator to collect the appropriate

and relevant information to support the study design, methodology, conceptual frame work,

development of the tool, individual health education and to plan the analysis of the collected

data.

Research methodology of the study

Research approach adopted for the study was an evaluative approach. The researcher

used a pre-experimental one group pre-test post-test design. The study was conducted at District

Government Wenlock Hospital Mangalore among 50 COPD patients as samples, and was

selected by a non-probability purposive sampling technique. A structured knowledge

questionnaire was used to assess the knowledge of the COPD patients on pulmonary

rehabilitation. There were 10 items in the baseline proforma and 25 questions were included in

the structured knowledge questionnaire regarding selected aspects of pulmonary rehabilitation.

Nine experts established the content validity of the tool. The reliability of the tool was

established using Spearman Brown’s Prophesy formula (r = 0.83) which indicated that tool was

reliable.

The pilot study was conducted on six COPD patients admitted in Government Wenlock

hospital at Mangalore. This gave the basis for the investigator to conduct main study. No major

problems were identified during the pilot study.

91
Data collection

The main study was conducted among fifty COPD patients from 08/09/12 to 15/10/12 .

Following the pre-test, a individual health education was administered and the post-test was

conducted on seventh day after the administration of the individual health education. The

obtained data was analyzed in terms of objectives and the hypotheses using the descriptive and

inferential statistics.

Results

The data collected from 50 COPD patients shows that majority of the samples (76%) had

poor knowledge score in the pre-test and 24% had average knowledge score. In the post-test 76%

of the samples had good knowledge score and 16% had very good knowledge score, only 8%

had average knowledge score. None of the samples had poor knowledge score on post test. This

data shows that the individual health education was effective in increasing the knowledge of the

samples.

Interpretation and conclusion

The findings of the study proved that the patients have inadequate knowledge on selected

aspects pulmonary rehabilitation. The individual health education conducted by the investigator

helped them to improve their knowledge. The effectiveness of individual health education was

tested in the terms of gain in knowledge and the findings showed that the mean post-test

knowledge score was significantly higher (18.1) than the mean pre-test knowledge score

(9.0833) and “t” value was 30.56. Hence the individual health education was considered as an

effective method to enhance the knowledge of the patients on pulmonary rehabilitation.

92
Summary

The entire process of carrying out the present study was an enriching experience to the

investigator. It also helped to explore and improve the knowledge and ability of the investigator

and the samples. The constant encouragement and guidance of the guide and co-operation and

interest of the samples to participate in the study contributed to the fruitful completion of the

study.

93
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68. Singh V, Khandelwal DC, Et all, Indian J Chest Dis Allied Sci. 2003 Jan-Mar;45(1):

p13-7.

101
69. Kothari CR. Research methodology: Methods and Techniques. 2nd ed., New Delhi: New

Age International; 2004.

70. John WB. Research in Education. New Delhi: Vikas Publishing House; 1998.

71. Burns NG. The Nursing research conducts critique and utilization. 1st ed. Philadelphia:

WB. Saunders company; 1996.

102
ANNEXURES
 Annexure-1
Letter requesting and granting permission for conducting the reliability, pilot study and
main study

103
 Annexure-2
Letter requesting for expert opinion to establish content validity of the research tool
From,
Ms. Minu Augustine
Unity Academy of education, College of nursing
Dambel road, Ashok Nagar post .
Shediguri, Mangalore 575006
To,
Respected Sir/ Madam,
Subject: Request for expert opinion and suggestions to establish content validity of the
research tool.
I Ms. Minu Augustine, II nd year Msc nursing student of Unity academy of Education,
College of nursing have selected the following topic for my dissertation to be submitted to Rajiv
Gandhi University of Health Sciences in Partial fulfilment for the requirement of award of Master
of Science in nursing.

TOPIC: “A STUDY TO ASSESS THE EFFECTIVENESS OF INDIVIDUAL HEALTH

EDUCATION ON LEVEL OF KNOWLEDGE REGARDING PULMONARY
REHABILITATION AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD) IN SELECTED HOSPITALS AT MANGALORE.”
Here with I have enclosed
1. Objectives of the study, operational definitions and hypothesis.
2. Baseline proforma of the patients with COPD.
3. Structured knowledge questionnaire.
4. Lesson plan on pulmonary rehabilitation

I humbly request you to go through the items and give your valuable suggestions and
opinions to develop the content validity of the tool. Kindly suggest modifications, additions and
deletions, if any, in the remark column.

Thanking you in anticipation,

Yours faithfully

Date: Ms. Minu Augustine

Place: Mangalore

Forwarded for content validation and approval

Principal

104
 Annexure-3

Acceptance form for tool validation

Name : ………………………………………..

Designation : …………………………………………

Name of the college / hospital : ………………………………………….

Statement of acceptance /non-acceptance

I give my acceptance / non acceptance to validate the tool.

Topic: “A STUDY TO ASSESS THE EFFECTIVENESS OF INDIVIDUAL HEALTH

EDUCATION ON LEVEL OF KNOWLEDGE REGARDING PULMONARY

REHABILITATION AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD) IN SELECTED HOSPITALS AT MANGALORE.”

Place:

Date: Signature of the expert

105
 Annexure-4

Content validation certificate

I hereby certify that I have validated the tool of Ms. Minu Augustine II nd year

M.Sc nursing student, Unity academy of education, college of nursing who is undertaking this

study:

“A STUDY TO ASSESS THE EFFECTIVENESS OF INDIVIDUAL HEALTH

EDUCATION ON LEVEL OF KNOWLEDGE REGARDING PULMONARY

REHABILITATION AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE

PULMONARY (COPD) IN SELECTED HOSPITALS AT MANGALORE.”

Place:

Date: Signature of the expert

Designation & Address

106
 Annexure-5

Blue print for structured knowledge questionnaire on pulmonary rehabilitation

SL Contents Knowledge Comprehension Application Total number Percentage

NO. of question
1 Anatomy and physiology of respiratory system 1,2,3 - 3 12%

2 Knowledge regarding disease condition 4,5,6 - - 3 12%

3 Meaning and purposes of pulmonary rehabilitation 8 7, 13 - 3 12%

4 Components of pulmonary rehabilitation

a-Breathing exercises 12,18 9,10,19 11,17 7 28%

b-Relaxation techniques - 15 14 2 8%
c-Nutrition - 23 16,22 3 12%
d-Medication 20 - 21 2 8%
e-Life style modification - - 24,25 2 8%

Grand total 10 7 8 25 100%

107
 Annexure-6

Letter requesting consent for participation in the study

I, Ms. Minu Augustine, a final year M.Sc. Nursing student of Unity Academy of

Education, College of Nursing. I am conducting a study to assess the effectiveness of individual

health education on level of knowledge regarding pulmonary rehabilitation among patients with

chronic obstructive pulmonary disease (COPD) in selected hospitals at Mangalore. I request you

to kindly participate and answer the questions without any hesitation. I assure you that the

information given by you will be kept as confidential and used for the research purpose only.

Your participation will help me to complete the study and contribute to the knowledge in

the field of nursing.

Thanking you,

Yours sincerely

Minu Augustine

Consent by participant

I hereby consent to participate in the research study on “A study to assess the

effectiveness of individual health education on level of knowledge regarding pulmonary

rehabilitation among patients with chronic obstructive pulmonary disease (COPD) in selected

hospitals at Mangalore.”

Signature of the participant

108
 Annexure-6

CzsÀåAiÀÄ£ÀzÀ°è ¨sÁUÀªÀ»¸À®Ä ¸ÀªÀÄäw

£Á£ÀÄ, «Ä£ÀÄ CUÀ¹Ö£ï, AiÀÄĤn CPÁqÉ«Ä D¥sï JdÄPÉñÀ£ï, EzÀgÀ CAwªÀÄ ªÀµÀðzÀ JA. J¹ì. £À¹ðAUï

«zÁåyðßAiÀiÁVzÀÄÝ “ªÀÄAUÀ¼ÀÆj£À D¸ÀàvÉæAiÉÆAzÀgÀ°è zÁR¯ÁzÀ G¹gÁlzÀ vÉÆAzÀgɬÄgÀĪÀ gÉÆÃVUÀ¼À ªÉÄÃ¯É G¹gÁlzÀ

vÉÆAzÀgÉAiÀÄ G¥À±ÀªÀÄ£ÀzÀ ¥ÀæQæAiÉÄAiÀi ²PÀët PÁAiÀÄðPÀæªÀÄzÀ ¥ÀjuÁªÀÄPÁjvÀé” JA§ CzsÀåAiÀÄ£ÀªÀ£ÀÄß £ÀqɸÀÄwÛzÉÝãÉ. vÁªÀÅ F

CzsÀåAiÀÄ£ÀzÀ°è ¨sÁUÀªÀ»¸À¨ÉÃPÉAzÀÄ ¤ªÀÄä°è «£ÀAw¸ÀÄvÉÛãÉ. ¤ÃªÀÅ ¤ÃrzÀ ªÀiÁ»wAiÀÄ£ÀÄß UË¥ÀåªÁVqÀ¯ÁUÀĪÀÅzÀÄ ºÁUÀÆ

CzÀ£ÀÄß CzsÀåAiÀÄ£ÀPÉÌ ªÀiÁvÀæ §¼À¸À¯ÁUÀĪÀÅzÀÄ JAzÀÄ F ªÀÄÆ®PÀ D±Áé¸À£É ¤ÃqÀÄvÉÛãÉ.

¤ªÀÄä ¨sÁUÀªÀ»¸ÀÄ«PɬÄAzÀ F CzsÀåAiÀÄ£ÀªÀ£ÀÄß AiÀıÀ¹éAiÀiÁV ¥ÀÇwðUÉƽ¹ £À¹ðAUïUÉ ¨ÉÃPÁzÀ CUÀvÀå

ªÀiÁ»wAiÀÄ£ÀÄß ¥ÀqÉzÀÄPÉƼÀÀÄzÀÄ.

Ew vÀªÀÄä «±Áé¹,

«Ä£ÀÄ CUÀ¹Ö£ï

CzsÀåAiÀÄ£ÀzÀ°è ¨sÁUÀªÀ»¸À®Ä ¸ÀªÀÄäw

£Á£ÀÄ “ªÀÄAUÀ¼ÀÆj£À D¸ÀàvÉæAiÉÆAzÀgÀ°è zÁR¯ÁzÀ G¹gÁlzÀ vÉÆAzÀgɬÄgÀĪÀ gÉÆÃVUÀ¼À ªÉÄÃ¯É G¹gÁlzÀ

vÉÆAzÀgÉAiÀÄ G¥À±ÀªÀÄ£ÀzÀ ¥ÀæQæAiÉÄAiÀi ²PÀët PÁAiÀÄðPÀæªÀÄzÀ ¥ÀjuÁªÀÄPÁjvÀé” JA§ CzsÀåAiÀÄ£ÀzÀ°è ¨sÁUÀªÀ»¸À®Ä

¸ÀªÀÄäw¸ÀÄvÉÛãÉ.

¨sÁUÀªÀ»¸ÀĪÀªÀgÀ ¸À»

109
 Annexure- 7

Description of the tool

Part I – Baseline proforma of COPD patients

Participant’s number :…………………………………..

Date :………………………………….

Instructions:

• Kindly read all the questions carefully

• Select the option applicable to you for each question given in the questionnaire.

1. Age (in years)

a) 30 – 40 [ ]

b) 41 – 50 [ ]

c) 51 -60 [ ]

d) Above 60 [ ]

2. Gender

a) Male [ ]

b) Female [ ]

3. Educational qualification

a) Primary education [ ]

b) High school [ ]

c) Pre university [ ]

d) Graduate and above [ ]

110
4. Occupation

a) Self employed [ ]

b) Private employed [ ]

c) Government employed [ ]

d) Health professional [ ]

e) Unemployed [ ]

5. Family monthly income in Rs

a) ≤ 3000 [ ]

b) 3001-6000 [ ]

c) 6001-10000 [ ]

d) >10000 [ ]

6. History of exposure to smoke

a) active Smoking [ ]

b) passive smoking [ ]

c) no history of smoking [ ]

7. If active smoker, smokes

a) < 1 packet /day [ ]

b) 2-3 packets /day [ ]

c) 4-5 packets /day [ ]

d) Above 6 packets /day [ ]

8. Are you on regular treatment for COPD?

a) Yes [ ]

b) No [ ]

111
 9. Have you been hospitalized for COPD?

a) Yes (if yes, specify the number of times…….) [ ]

b) No [ ]

10. Have you heard of pulmonary rehabilitation?

a) Yes (if yes specify the source……..) [ ]

b) No [ ]

Part II

Self administered knowledge questionnaire to assess the knowledge of COPD patients

regarding pulmonary rehabilitation.

Instructions to the participants:

• Read the questions carefully and answer all the questions

• Kindly place a tick mark (√) for the correct response with appropriate space or in the

space provided

• Choose the best option/response from the following

• Only one correct answer for each question

• Information collected will be used only for the purpose of the study

1. The organ of respiration is:

a) heart [ ]

b) lung [ ]

c) skin [ ]

d) kidney [ ]

112
2. Respiration is a process of exchanging:

a) gas [ ]

b) blood [ ]

c) fluid [ ]

d) salt [ ]

3. The functional unit helps in respiration is:

a) nose [ ]

b) alveoli [ ]

c) wind pipe [ ]

d) mouth [ ]

4. COPD is a type of:

a) lung disorder [ ]

b) heart disease [ ]

c) kidney disease [ ]

d) stomach disorder [ ]

5. The risk factor of COPD is:

a) alcoholism [ ]

b) smoking [ ]

c) gutka chewing [ ]

d) beetal chewing [ ]

6. COPD is a condition in which:

a) air gets trapped in the lungs [ ]

b) blood gets collected in the lungs [ ]

113
 c) air leakage in the lungs [ ]

d) pus gets collected in the lungs [ ]

7. Pulmonary rehabilitation helps to relieve symptoms of:

a) heart problem [ ]

b) brain problems [ ]

c) lung problem [ ]

d) kidney problem [ ]

8. One of the important components of pulmonary rehabilitation is:

a) progressive muscle relaxation [ ]

b) breathing exercises [ ]

c) biofeed back [ ]

d) guided imagery [ ]

9. The purpose of pursed lip breathing is to:

a) increase amount of air inhaled through the mouth. [ ]

b) keep smaller airways open during exhalation [ ]

c) increase the rate of breathing. [ ]

d) hold air in the alveoli [ ]

10. During inhalation the muscle of respiration moves :

a) upward [ ]

b) downward [ ]

c) back ward [ ]

d) no movement [ ]

114
11 During pursed lip breathing the lips should be:

a) widely opened [ ]

b) tightly closed [ ]

c) pouting [ ]

d) opened with teeth closed [ ]

12. The muscle used in diaphragmatic breathing is :

a) back muscles. [ ]

b) abdominal muscles. [ ]

c) facial muscles. [ ]

d) neck muscles [ ]

13. During pulmonary rehabilitation the use of cupping helps to:

a) increase circulation [ ]

b) loosen mucus. [ ]

c) decrease breathing rate. [ ]

d) decrease abdominal distension. [ ]

14. The best position used for controlled breathing pattern:

a) Lying down. [ ]

b) Sitting. [ ]

c) Bending. [ ]

d) Walking. [ ]

15. Breathing rhythm that is most recommended for COPD patients is:

a) breath in and out equally . [ ]

b) breath in longer than breath out [ ]

115
 c) breath out longer than breath in. [ ]

d) whatever rhythm is natural for the client. [ ]

16. The best way to keep mucus thin is by drinking:

a) a glass of cold water. [ ]

b) 8-10 glasses of fluid daily. [ ]

c) a glass of milk daily [ ]

d) a glass of juice [ ]

17. The most effective way to cough is:

a) inhale through the mouth prior to the coughing. [ ]

b) exhale through the mouth prior to coughing [ ]

c) use several small coughs. [ ]

d) use several large coughs. [ ]

18. Coughing exercise is effective to remove:

a) dust [ ]

b) smoke [ ]

c) sputum [ ]

d) air [ ]

19. Coughing exercise should be ideally performed:

a) ½ hour before meals. [ ]

b) ½ hour after meals. [ ]

c) immediately after meals. [ ]

d) any time [ ]

116
20. Using an inhaled bronchodilator before exercising helps to :

a) Increase breathing. [ ]

b) Prevent shortness of breath. [ ]

c) Enhance shortness of breath. [ ]

d) Decrease breathing. [ ]

21. In meter dose inhaler push down the top of the inhaler while:

a) breathing in slowly [ ]

b) breathing in quickly [ ]

c) breathing out slowly [ ]

d) breathing out quickly [ ]

22. If a person feels shortness of breath while taking food, he can:

a) Eat small meals. [ ]

b) Chew food quickly. [ ]

c) Talk in between meals [ ]

d) Drink water during meals [ ]

23. patients with COPD should take food:

a) 6 times a day [ ]

b) 3 times a day [ ]

c) 2 times a day [ ]

d) 4 times a day [ ]

24. The best technique to use when getting dressed up is:

a) Move rapidly to finish in a short period of time. [ ]

b) Sit and get dressed. [ ]

117
 c) Stand while getting dressed. [ ]

d) Dress upper body first. [ ]

25. COPD patients are advised not to go bed:

a) immediately after meals [ ]

b) 2 hour after meals [ ]

c) 1 ½ hour after meals [ ]

d) 2 ½ hour after meals [ ]

118
 Annexure-7

«¨sÁ UÀ J: ªÉÊ0iÀÄQÛPÀ ªÀiÁ»w

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UÀÄgÀÄvÀÄ ºÁQ.

PÀæª ÀÄ ¸ÀASÉå: ___ ¢£ÁAPÀ: __________

1. ªÀAiÀĸÀÄì (ªÀµÀðUÀ¼À°è)
a. 30-40 [ ]
b. 41-50 [ ]
c. 51-60 [ ]
d. 60 QÌAvÀ ºÉZÀÄÑ [ ]

2. °AUÀ
a. ¥ÀÅgÀĵÀ [ ]
b. ¹Ûçà [ ]

3. «zÁå¨sÁå¸À
a. ¥ÁæxÀ«ÄPÀ ±Á¯Á ²PÀët [ ]
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c. ¦AiÀÄĹ [ ]
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4. ªÀÈwÛ
a. ªÁå¥ÁgÀ [ ]
b. SÁ¸ÀV ¸ÀA¸ÉÜAiÀÄ°è PÉ®¸À [ ]
c. ¸ÀgÀPÁj E¯ÁSÉAiÀÄ°è PÉ®¸À [ ]
d. DgÉÆÃUÀå ¹§âA¢ [ ]
e. EvÀgÀ, £ÀªÀÄÆ¢¹ _______________

5. PÀÄlÄA§zÀ wAUÀ¼À DzÁAiÀÄ (gÀÆ¥Á¬ÄUÀ¼À°è)

a. 3,000 CxÀªÁ CzÀQÌAvÀ PÀrªÉÄ [ ]
b. 3,001-6,000 [ ]

119
 c. 6,001-10,000 [ ]
d. 10,000 QÌAvÀ ºÉZÀÄÑ [ ]

6. zsÀƪÀÄ¥Á£ÀzÀ ºÉÆUÉAiÀÄ ¸ÀA¥ÀPÀðPÉÌ §gÀĪÀÅzÀgÀ §UÉÎ ªÀiÁ»w

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b. EvÀgÀgÀÄ ¸Éâ ©lÖ ºÉÆUÉAiÀÄ£ÀÄß ¸Éë¸ÀĪÀÅzÀÄ [ ]
c. £À£ÀUÉ zsÀƪÀÄ¥Á£À ªÀiÁqÀĪÀ C¨sÁå¸À«®è [ ]

7. ¤ªÀÄUÉ zsÀƪÀÄ¥Á£ÀzÀ C¨sÁå¸À«zÀÝgÉ ¢£ÀPÉÌ JµÀÄÖ ©Ãr/¹UÀgÉÃlÄUÀ¼À£ÀÄß ¸ÉÃzÀÄwÛÃj?

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b. 2-3 ¥ÁåPÉmï [ ]
c. 4-5 ¥ÁåPÉmï [ ]
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8. ¤ÃªÀÅ ¤AiÀÄ«ÄvÀªÁV G¹gÁlzÀ vÉÆAzÀgÉUÉ aQvÉì ¥ÀqÉzÀÄPÉƼÀÄîwÛ¢ÝÃgÁ?

a. ºËzÀÄ [ ]
b. E®è [ ]

9. G¹gÁlzÀ vÉÆAzÀgÉUÉ aQvÉì ªÀiÁr¹PÉƼÀî®Ä ¤ÃªÀÅ D¸ÀàvÉæUÉ zÁR¯ÁV¢ÝÃgÁ?

a. ºËzÀÄ, ºËzÁzÀgÉ JµÀÄÖ ¸À® ______________________ [ ]
b. E®è [ ]

10. G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ ®PÀëtUÀ¼À£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸ÀĪÀ «zsÁ£ÀUÀ¼À §UÉÎ ¤ªÀÄUÉ

w¼ÀĪÀ½PɬÄzÉAiÉÄÃ?
a. ºËzÀÄ, ºËzÁzÀgÉ J°èAzÀ ______________________ [ ]
b. E®è [ ]

120
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UÀÄgÀÄvÀÄ ºÁQ.

1. G¹gÁl £ÀqɸÀĪÀ zÉúÀzÀ CAUÀ

a. ºÀÈzÀAiÀÄ [ ]
b. ±Áé¸ÀPÉÆñÀ [ ]
c. ZÀªÀÄð [ ]
d. ªÀÄÆvÀæ¦AqÀ [ ]

2. G¹gÁlzÀ°è £ÀqÉAiÀÄĪÀ ¥ÀæQæAiÉÄ

a. C¤®UÀ¼À «¤ªÀÄAiÀÄ [ ]
b. gÀPÀÛzÀ «¤ªÀÄAiÀÄ [ ]
c. zÀæªÀzÀ «¤ªÀÄAiÀÄ [ ]
d. G¦à£À CA±ÀzÀ «¤ªÀÄAiÀÄ [ ]

3. G¹gÁlzÀ ¥ÀæQæAiÉÄAiÀÄ°è ¥ÁvÀæ ªÀ»¸ÀĪÀ ¥ÀæªÀÄÄR CAUÀ

a. ªÀÄÆUÀÄ [ ]
b. D°éAiÉÆïÉÊ [ ]
c. ±Áé¸À£Á¼À [ ]
d. ¨Á¬Ä [ ]

4. G¹gÁlzÀ vÉÆAzÀgÉAiÀÄÄ F «zsÀzÀ PÁ¬Ä¯É

a. ±Áé¸ÀPÉÆñÀ PÁ¬Ä¯É [ ]
b. ºÀÈzÀAiÀÄzÀ PÁ¬Ä¯É [ ]
c. ªÀÄÆvÀæ¦AqÀzÀ PÁ¬Ä¯É [ ]
d. ºÉÆmÉÖUÉ ¸ÀA§A¢ü¹zÀ PÁ¬Ä¯É [ ]

5. G¹gÁlzÀ vÉÆAzÀgÉUÉ PÁgÀtªÁUÀĪÀ C¨sÁå¸À

a. ªÀÄzÀå¥Á£À [ ]
b. zsÀƪÀÄ¥Á£À [ ]
c. UÀÄmÁÌ w£ÀÄߪÀÅzÀÄ [ ]
d. J¯ÉCrPÉ w£ÀÄߪÀÅzÀÄ [ ]

121
6. G¹gÁlzÀ vÉÆAzÀgÉ JAzÀgÉ
a. ªÁAiÀÄÄ ±Áé¸ÀPÉÆñÀ¢AzÀ ºÉÆgÀ§gÀzÉà EgÀĪÀÅzÀÄ [ ]
b. ±Áé¸ÀPÉÆñÀzÀ°è gÀPÀÛ ¸ÀAUÀæºÀªÁUÀĪÀÅzÀÄ [ ]
c. ±Áé¸ÀPÉÆñÀUÀ½AzÀ ªÁAiÀÄÄ ¸ÉÆÃgÀĪÀÅzÀÄ [ ]
d. ±Áé¸ÀPÉÆñÀzÀ°è QêÀÅ vÀÄA§ÄªÀÅzÀÄ [ ]

7. G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ ®PÀëtUÀ¼À£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸ÀĪÀ «zsÁ£ÀUÀ¼À£ÀÄß §¼À¸ÀĪÀ GzÉÝñÀ

a. ºÀÈzÀAiÀÄzÀ PÁ¬Ä¯ÉAiÀÄ£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸À®Ä [ ]
b. ªÉÄzÀĽ£À PÁ¬Ä¯ÉAiÀÄ£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸À®Ä [ ]
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d. ªÀÄÆvÀæ¦AqÀzÀ PÁ¬Ä¯ÉAiÀÄ£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸À®Ä [ ]

8. G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ ®PÀëtUÀ¼À£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸ÀĪÀ «zsÁ£ÀUÀ¼À ¥ÀæªÀÄÄR CAUÀ

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b. G¹gÁlzÀ ªÁåAiÀiÁªÀÄ [ ]
c. zsÁå£À [ ]
d. ªÀÄ£À¹ìUÉ G¯Áè¸À ¤ÃqÀĪÀ zÀȱÀåUÀ¼À£ÀÄß PÀ°à¸ÀĪÀÅzÀÄ [ ]

9. vÀÄnUÀ¼À£ÀÄß ¹Ãn HzÀĪÀAvÉ vÉgÉzÀÄ G¹gÁqÀĪÀ GzÉÝñÀªÉãÀÄ

a. ¨Á¬Ä¬ÄAzÀ M¼ÀUɼÉzÀÄPÉƼÀÄîªÀ ªÁAiÀÄÄ«£À ¥ÀæªÀiÁtªÀ£ÀÄß ºÉaѸÀĪÀÅzÀÄ [ ]
b. G¹gÀÄ ©qÀĪÁUÀ ªÁAiÀÄÄ ºÉÆgÀºÉÆÃUÀĪÀ zÁjAiÀÄ£ÀÄß QjzÁV¸ÀĪÀÅzÀÄ [ ]
c. G¹gÁlzÀ ªÉÃUÀªÀ£ÀÄß ºÉaѸÀĪÀÅzÀÄ [ ]
d. ±Áé¸ÀPÉÆñÀzÀ°è ªÁAiÀÄĪÀ£ÀÄß »r¢lÄÖPÉƼÀÄîª ÀÅzÀÄ [ ]

10. G¹gɼÉzÀÄPÉƼÀÄîªÁUÀ G¹gÁlzÀ ¸ÁßAiÀÄÄUÀ¼À°è PÀAqÀħgÀĪÀ ZÀ®£É

a. ªÉÄïÁãUÀPÉÌ ZÀ°¸ÀĪÀÅzÀÄ [ ]
b. PɼÀ¨sÁUÀPÉÌ ZÀ°¸ÀĪÀÅzÀÄ [ ]
c. »A¨sÁUÀPÉÌ ZÀ°¸ÀĪÀÅzÀÄ [ ]
d. AiÀiÁªÀÅzÉà ZÀ®£É PÁt¹PÉƼÀÄîªÀÅ¢®è [ ]

11. ¹Ãn HzÀĪÀAvÉ vÀÄnUÀ¼À£ÀÄß vÉgÉzÀÄ G¹gÁqÀĪÁUÀ vÀÄnUÀ¼ÀÄ ºÉÃVgÀÄvÀÛªÉ

a. CUÀ®ªÁV vÉgÉ¢gÀÄvÀÛªÉ [ ]
b. ©VAiÀiÁV ªÀÄÄaÑgÀÄvÀÛªÉ [ ]

122
 c. ¸Àé®àªÉà vÉgÉ¢gÀÄvÀÛªÉ [ ]
d. ºÀ®ÄèUÀ¼ÀÄ ªÀÄÄaÑzÀÄÝ vÀÄnUÀ¼ÀÄ vÉgÉ¢gÀÄvÀÛªÉ [ ]

12. ªÀ¥ÉAiÀÄ£ÀÄß §¼À¹ G¹gÁqÀĪÁUÀ §¼À¸À®àqÀĪÀ ¸ÁßAiÀÄÄUÀ¼ÀÄ

a. ¨É¤ß£À ¸ÁßAiÀÄÄUÀ¼ÀÄ [ ]
b. GzÀgÀzÀ ¸ÁßAiÀÄÄUÀ¼ÀÄ [ ]
c. ªÀÄÄRzÀ ¸ÁßAiÀÄÄUÀ¼ÀÄ [ ]
d. PÀÄwÛUÉAiÀÄ ¸ÁßAiÀÄÄUÀ¼ÀÄ [ ]

13. G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ ®PÀëtUÀ¼À£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸ÀĪÀ «zsÁ£ÀªÀ£ÀÄß §¼À¸ÀĪÁUÀ CAUÉÊ UÀÄAqÀUÉ

»rzÀÄ ¨É£ÀߣÀÄß vÀlÄÖªÀÅzÀjAzÀ DUÀĪÀ G¥ÀAiÉÆÃUÀ
a. gÀPÀÛ ¸ÀAZÁgÀ ºÉZÀÄÑvÀÛzÉ [ ]
b. PÀ¥sÀ ¤ÃgÁUÀÄvÀÛzÉ [ ]
c. G¹gÁlzÀ ªÉÃUÀ PÀrªÉÄAiÀiÁUÀÄvÀÛzÉ [ ]
d. ºÉÆmÉÖ G§âj¸ÀĪÀÅzÀÄ PÀrªÉÄAiÀiÁUÀÄvÀÛzÉ [ ]

14. ¤AiÀÄAwævÀªÁV G¹gÁqÀ®Ä GvÀÛªÀÄ ¨sÀAV

a. CAUÁvÀ ªÀÄ®UÀĪÀÅzÀÄ [ ]
b. PÀĽvÀÄPÉƼÀÄîªÀÅzÀÄ [ ]
c. ¤AvÀÄPÉƼÀÄîª ÀÅzÀÄ [ ]
d. ªÀÄÄAzÀPÉÌ ¨ÁUÀĪÀÅzÀÄ [ ]

15. G¹gÁlzÀ vÉÆAzÀgÉ EgÀĪÀ gÉÆÃVUÀ¼ÀÄ G¹gÁqÀ¨ÉÃPÁzÀ «zsÁ£À

a. MAzÉà jÃw G¹gɼÉzÀÄPÉƼÀî¨ÉÃPÀÄ ªÀÄvÀÄÛ G¹gÀÄ ©qÀ¨ÉÃPÀÄ [ ]
b. G¹gÀÄ ©qÀĪÀÅzÀQÌAvÀ ºÉZÀÄÑ ºÉÆvÀÄÛ G¹gɼÉzÀÄPÉƼÀÄîªÀÅzÀÄ [ ]
c. G¹gɼÉzÀÄPÉƼÀÄîªÀÅzÀQÌAvÀ ºÉZÀÄÑ ºÉÆvÀÄÛ G¹gÀÄ ©qÀĪÀÅzÀÄ [ ]
d. vÀ£ÀUÉ C£ÀÄPÀÆ®ªÁUÀĪÀ jÃwAiÀÄ°è G¹gÁqÀĪÀÅzÀÄ [ ]

16. PÀ¥sÀªÀÅ ¤ÃgÁUÀĪÀAvÉ ªÀiÁqÀĪÀ «zsÁ£À

a. MAzÀÄ ¯ÉÆÃl vÀtÂÚÃgÀÄ PÀÄrAiÀÄĪÀÅzÀÄ [ ]
b. ¥Àæw¢£À 8-10 ¯ÉÆÃl ¤ÃgÀÄ PÀÄrAiÀÄĪÀÅzÀÄ [ ]
c. ¥Àæw¢£À MAzÀÄ ¯ÉÆÃl ºÁ®Ä PÀÄrAiÀÄĪÀÅzÀÄ [ ]
d. ¥Àæw¢£À MAzÀÄ ¯ÉÆÃl ºÀtÂÚ£À gÀ¸À PÀÄrAiÀÄĪÀÅzÀÄ [ ]

123
17. ¥ÀjuÁªÀÄPÁjAiÀiÁV PɪÀÄÄäªÀ «zsÁ£À
a. PɪÀÄÄäªÀ ªÉÆzÀ®Ä ¨Á¬ÄAiÀÄ ªÀÄÆ®PÀ G¹gɼÉzÀÄPÉƼÀÄîª ÀÅzÀÄ [ ]
b. PɪÀÄÄäªÀ ªÉÆzÀ®Ä ¨Á¬ÄAiÀÄ ªÀÄÆ®PÀ G¹gÀÄ ©qÀĪÀÅzÀÄ [ ]
c. ºÀUÀÄgÀªÁV ºÀ®ªÀÅ ¸À® PɪÀÄÄäªÀÅzÀÄ [ ]
d. §®¥ÀǪÀðPÀªÁV ºÀ®ªÀÅ ¸À® PɪÀÄÄäªÀÅzÀÄ [ ]

18. PɪÀÄÄäªÀ ªÁåAiÀiÁªÀÄ¢AzÀ DUÀĪÀ G¥ÀAiÉÆÃUÀ

a. zsÀƼÀÄ ºÉÆgÀºÁPÀ®àqÀÄvÀÛzÉ [ ]
b. ºÉÆUÉ ºÉÆgÀºÁPÀ®àqÀÄvÀÛzÉ [ ]
c. PÀ¥sÀ ºÉÆgÀºÁPÀ®àqÀÄvÀÛzÉ [ ]
d. UÁ½ ºÉÆgÀºÁPÀ®àqÀÄvÀÛzÉ [ ]

19. PɪÀÄÄäªÀ ªÁåAiÀiÁªÀĪÀ£ÀÄß ªÀiÁqÀ¨ÉÃPÁzÀ ¸ÀªÀÄAiÀÄ

a. HlzÀ CzsÀð UÀAmÉAiÀÄ ªÉÆzÀ®Ä [ ]
b. HlªÁzÀ CzsÀð UÀAmÉAiÀÄ §½PÀ [ ]
c. HlªÁzÀ vÀPÀët [ ]
d. AiÀiÁªÁUÀ®Æ ªÀiÁqÀ§ºÀÄzÀÄ [ ]

20. ªÁåAiÀiÁªÀÄ ªÀiÁqÀĪÀ ªÉÆzÀ®Ä ¨ÁæAPÉÆÃqÉʯÉÃlgï §¼À¹ G¹gÁl £ÀqɸÀĪÀÅzÀjAzÀ DUÀĪÀ

G¥ÀAiÉÆÃUÀ
a. G¹gÁlªÀ£ÀÄß ºÉaѸÀÄvÀÛzÉ [ ]
b. G¹gÁqÀ®Ä PÀµÀÖªÁUÀĪÀÅzÀ£ÀÄß vÀqÉAiÀÄÄvÀÛzÉ [ ]
c. G¹gÁqÀ®Ä PÀµÀÖªÁUÀĪÀÅzÀ£ÀÄß ºÉaѸÀÄvÀÛzÉ [ ]
d. G¹gÁlªÀ£ÀÄß PÀrªÉÄ ªÀiÁqÀÄvÀÛzÉ [ ]

21. «ÄÃlgï qÉÆøï E£ïºÉîgï §¼À¸ÀĪÁUÀ CzÀgÀ ªÉÄïÁãUÀªÀ£ÀÄß PɼÀPÉÌ MvÀÛ¨ÉÃPÁzÀ ¸ÀªÀÄAiÀÄ
a. ¤zsÁ£ÀªÁV G¹gɼÉzÀÄPÉƼÀÄîªÁUÀ [ ]
b. ªÉÃUÀªÁV G¹gɼÉzÀÄPÉƼÀÄîªÁUÀ [ ]
c. ¤zsÁ£ÀªÁV G¹gÀÄ ©qÀĪÁUÀ [ ]
d. ªÉÃUÀªÁV G¹gÀÄ ©qÀĪÁUÀ [ ]

22. Hl ªÀiÁqÀĪÁUÀ G¹gÁqÀ®Ä PÀµÀÖªÁzÀgÉ K£ÀÄ ªÀiÁqÀ¨ÉÃPÀÄ

a. ¸Àé®à ªÀiÁvÀæ Hl ªÀiÁqÀ¨ÉÃPÀÄ [ ]
b. ¨ÉÃUÀ ¨ÉÃUÀ£Éà DºÁgÀªÀ£ÀÄß dVAiÀĨÉÃPÀÄ [ ]

124
 c. HlzÀ £ÀqÀÄªÉ ªÀiÁvÀ£ÁqÀÄwÛgÀ¨ÉÃPÀÄ [ ]
d. Hl ªÀiÁqÀĪÁUÀ ¤ÃgÀÄ PÀÄrAiÀĨÉÃPÀÄ [ ]
23. G¹gÁlzÀ vÉÆAzÀgÉ EgÀĪÀªÀgÀÄ ¢£ÀPÉÌ JµÀÄÖ ¸À® Hl ªÀiÁqÀ¨ÉÃPÀÄ
a. 6 ¸À® [ ]
b. 3 ¸À® [ ]
c. 2 ¸À® [ ]
d. 4 ¸À® [ ]
24. G¹gÁlzÀ vÉÆAzÀgÉ EgÀĪÀªÀgÀÄ §mÉÖ zsÀj¸ÀĪÀ GvÀÛªÀÄ «zsÁ£À
a. ¸ÁzsÀåªÁzÀµÀÄÖ ¨ÉÃUÀ §mÉÖà zsÀj¸ÀĪÀÅzÀÄ [ ]
b. PÀĽvÀÄPÉÆAqÀÄ §mÉÖ zsÀj¸ÀĪÀÅzÀÄ [ ]
c. ¤AvÀÄPÉÆAqÀÄ §mÉÖ zsÀj¸ÀĪÀÅzÀÄ [ ]
d. ¸ÉÆAlzÀ ªÉÄïÁãUÀzÀ §mÉÖAiÀÄ£ÀÄß ªÉÆzÀ®Ä zsÀj¸ÀĪÀÅzÀÄ [ ]
25. G¹gÁlzÀ vÉÆAzÀgÉ EgÀĪÀªÀgÀÄ HlªÁzÀ §½PÀ AiÀiÁªÁUÀ ªÀÄ®UÀ®Ä ºÉÆÃUÀ¨ÁgÀzÀÄ
a. HlªÁzÀ vÀPÀët [ ]
b. HlªÁzÀ 2 UÀAmÉUÀ¼ÀªÀgÉUÉ [ ]
c. HlªÁzÀ 1 ½ UÀAmÉUÀ¼ÀªÀgÉUÉ [ ]
d. HlªÁzÀ 2 ½ UÀAmÉUÀ¼ÀªÀgÉUÉ [ ]

125
 Annexure-8

Answer key

Question no. Answer

1 b

2 a

3 b

4 a

5 b

6 a

7 c

8 b

9 b

10 b

11 c

12 b

13 b

14 b

126
 15 c

16 b

17 c

18 c

19 a

20 b

21 a

22 a

23 a

24 b

25 a

Arbitrarily classification of knowledge

0-10 <40% Poor

11-15 41-60% Average

16-20 61-80% Good

21-25 81-100 Very good

127
 Annexure-9

Criteria checklist for validation of the tool

Instructions:

• Please review the items in the tool and give your valuable suggestions regarding accuracy,

relevance and appropriateness of the content.

• Kindly place a tick mark (√) in the appropriate column. If there are any suggestions or

comments please mention in the column.

Part I –Baseline pro-forma of the patients with COPD

Item Agree Disagree Remarks

no:

1.

2.

3.

4.

5.

6.

128
 7.

8.

9.

10.

Part II

Checklist for structured knowledge questionnaire to assess the knowledge on pulmonary

rehabilitation among patients with COPD

Item Agree Disagree Remarks

No:

1.

2.

3.

4.

5.

129
6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

130
19.

20.

21.

22.

23

24

25

131
 Annexure-10

Criteria checklist for the validation of the content of the individual health education

Respected Madam/Sir,

• Please go through the criteria listed below, which have been formulated for evaluating and validating

the structured knowledge questionnaire on pulmonary rehabilitation.

• Please read each statement and place a tick (√) mark against the appropriate column which expresses

your opinion about the individual health education. Please give the suggestions in the “Remarks”

column.

SL NO: Criteria Agree (A) Disagree (D) Remarks

I. Formulation of objectives

1. Comprehensive enough for the

patients with COPD

2. Realistic to achieve the

objectives are in terms of

nursing practice

3. Objectives are in term of

behaviour of the samples

II Selection of the content

1. content provides accurate

information as per the objectives

132
 2. Content is adequate as per the

objectives

3. Content is according to the level

of understanding of samples

III Organization of the content

1. Logical sequence

2. Continuity in presentation

3. Integration of the content

IV Training aids

1. Simple and understandable

2. Appropriate

3. Relevant

4. Easy to follow

V Feasibility and practicability

1. The individual health education

is acceptable to the patients with

COPD

2. The individual health education

is conventional to handle and

conduct.

3. The individual health education

133
 is to the level of understanding

of the patients with COPD

4. The individual health education

is interesting to the patients with

COPD.

5. The individual health education is

economical in terms of cost.

VI Any other suggestions

Date:

Place: Signature of the Validator

134
 Annexure: 11

Lesson plan on pulmonary rehabilitation

NAME OF TEACHER : MINU AUGUSTINE

TOPIC OF LESSON : Pulmonary rehabilitation

TYPES OF TEACHING : Individual health education

GROUP : COPD patients

NUMBER OF PARTICIPANTS : 50

DURATION : 20 minutes

METHODS OF TEACHING : Lecture cum demonstration

A.V Aids : Power point slides on pulmonary rehabilitation

CENTRAL OBJECTIVE

O n completion of the individual health education, the patients with COPD will acquire knowledge regarding pulmonary rehabilitation

and will apply this knowledge in their day to day life.

135
BEHAVIOURAL OBJECTIVES

On completion of individual health education, the Patients are able to:

• Describe the anatomy and physiology of respiratory system

• Identify the concepts of COPD

• Specify the risk factors of COPD

• Discuss the signs and symptoms of COPD

• Explain the meaning of pulmonary rehabilitation

• List down the purposes of pulmonary rehabilitation

• enumerate the benefits of pulmonary rehabilitation

• discuss the component of pulmonary rehabilitation

• Demonstrate breathing and coughing exercises

• Demonstrate the relaxation techniques

• Demonstrate the inhalation of medication

• Explain the nutritional management of the COPD patients

• Adopt the life style modification

136
TIME SPECIFICO TEACHER LEARNER’S A.V EVALUATION
BJECTIVE CONTENTS ACTIVITY ACTIVITY AIDS
1/2 On INTRODUCTION
mts completion
of COPD is a condition that affects the lungs and airways. COPD Lecture Listening
individual stands for chronic obstructive pulmonary disease. It is not cum
health curable but controllable. Pulmonary Rehabilitation program discussion
education
helps people with moderate to severe breathing problems
,the Patients
is able to : overcome the physical limitations resulting from their disease.
Describe the
1mts anatomy ANATOMY AND PHYSIOLOGY OF RESPIRATORY Lecture Listening Power Explain the
and SYSTEM cum point structure and
physiology discussion slides on functions of
of The respiratory system is the anatomical system of an anatomy respiratory
respiratory organism that introduces respiratory gases to the interior and and system?
system performs gas exchange. Molecules of oxygen and carbon physiolo
dioxide are passively exchanged. This exchange process gy
occurs in the alveoli of the lungs.

Oxygen enters the respiratory system through the mouth and

the nose. The oxygen then passes through the larynx and the
trachea. In the chest cavity, the trachea splits into two smaller
tubes called the bronchi. Each bronchus then divides again
forming the bronchial tubes. The bronchial tubes lead directly
into the lungs where they divide into many smaller tubes
which connect to tiny sacs called alveoli. Alveoli are the
functional unit which helps in exchange of air. The inhaled
oxygen passes into the alveoli and then diffuses through the
capillaries into the arterial blood.

137
 The diaphragm is a sheet of muscles that lies across the bottom
of the chest cavity. When the diaphragm contracts, oxygen is
pulled into the lungs. When the diaphragm relaxes, carbon
dioxide is pumped out of the lungs.
1 1/2 Identify the Lecture Listening Power What is
mts concepts of CHRONIC OBSTRUCTIVE PULMONARY cum point COPD?
COPD DISEASE(COPD) discussion slides on
COPD
Chronic obstructive pulmonary disease (COPD) is a condition
that affects the lungs and airways. Chronic means the
condition is long term. Pulmonary refers to lungs and
airways. The condition is obstructive because it limits the
flow of air into and out of your lungs. COPD cannot be fully
reversed. There are 2 main diseases that cause this
obstruction. Most patients have both.

Chronic bronchitis produces excess mucus that blocks in the

bronchial tubes (airways).Emphysema affects the air sacs in
the lungs. The air sacs, called alveoli become enlarged and
cannot be reversed to their normal size. The larger air sacs do
not work well and trap air inside. The smallest airways, which
are called the bronchioles also, weaken. They become less
able to stretch. When you breathe out (exhale), these very
small airways may collapse before they empty out. Then even
1 mts Specify the more air is trapped in the air sacs.
risk factors Lecture Listening Power What are the
of COPD Risk factors of COPD cum point risk factors of
discussion slides on COPD?
• Cigarette smoking risk
• Exposure to dust and chemicals(vapors, irritants and factors

138
 fumes) of
• Indoor air pollution from fuels used for cooking. COPD
• Passive smoking
• Genetic factor
• Childhood respiratory infections.
1 mts Discuss the
signs and Signs and symptoms Lecture Listening Power Which are the
symptoms cum point signs and
of COPD • Difficulty in breathing(dyspnea) discussion slides on symptoms of
• Wheezing signs COPD?
• Chest tightness and
sympto
• Coughing
ms of
• Excessive mucus production COPD.
• Tiredness or fatigue.
1 mts Explain the
meaning of Lecture Listening Power What is
PULMONARY REHABILITATION
pulmonary cum point pulmonary
rehabilitatio discussion slides on rehabilitation?
MEANING
n pulmona
ry
Rehabilitation is the restoration of the patient to the fullest
rehabilit
medical, mental, emotional, social, and vocational potential of
ation
which they are capable. Pulmonary rehabilitation is a program
for patients with chronic lung disease to relieve the symptoms
of respiratory diseases.

1 mts List down

the purposes Lecture Listening Power What are the
PURPOSES
of cum point purposes of
pulmonary • Increase exercise tolerance and reduce dyspnea. discussion slides on pulmonary
rehabilitatio • Increase muscle strength and endurance (peripheral purposes rehabilitation?
n and respiratory). of
• Improve health related quality of life.

139
 • Increase independence in daily functioning. pulmona
• Increase knowledge of lung condition and promote self ry
management. rehabilit
• Promote long term commitment to exercise. ation

1 mts enumerate Lecture Listening Power What are the

the benefits BENEFITS OF PULMONARY REHABILITATION cum point benefits of
of discussion slides on pulmonary
pulmonary • Less shortness of breath benefits rehabilitation?
rehabilitatio • More energy of
n • A greater sense of control over their COPD pulmona
ry
• Less hospitalizations
rehabilit
1 mts discuss the ation
component Lecture Listening Power Which are the
COMPONENTS OF PULMONARY REHABILITATION
of cum point components of
pulmonary discussion slides on pulmonary
(1)Specific measures
rehabilitatio compon rehabilitation?
n ents of
• Breathing retraining
pulmona
• Relaxation techniques ry
rehabilit
(2)General measures ation
• Medications
• Nutrition
• Life style modifications

SPECIFIC MEASURES

BREATHING RETRAINING
4 mts Demonstrat Lecture Listening Power How to do the
e breathing Breathing retraining techniques, include: low frequency cum and point breathing and
breathing; pursed lips breathing, and abdomino diaphragmatic
140
and breathing. discussion observing slides on coughing
coughing , breathin exercises?
exercises Pursed-Lip Breathing demonstra g and
tion coughin
Benefits of pursed lip breathing g
exercise
• helps to keep the air sacs open longer so that air is not s
trapped in lungs.
• It prevents the very small airways from collapsing
when breathe out.
• Pursed-lip breathing helps more stale air to get out of
the lungs so that more fresh air with oxygen can get in.
• Pursed-lip breathing may help to control shortness of
breath. With this method, the client breathe out
through pursed lips for twice as long as the client
breathe in.

Steps of pursed lip breathing

• Breathe in (inhale) slowly through the nose, with the

mouth closed. As you inhale, count “1, 2.”
• Pucker your lips in a whistling position.
• Breathe out (exhale) slowly. Try to exhale twice as
long as inhaled. As you exhale, count “1, 2, 3, 4.”
• Relax.
• Repeat these steps until you no longer feel short of
breath. If you get dizzy, rest for a few breaths. Then
begin again with Step 1.

141
Diaphragmatic Breathing

The diaphragm is the main muscle we use to breathe. This

muscle sits below the lungs and above the stomach. In COPD,
air gets trapped in the air sacs in the lungs. The extra air
makes the lungs push against diaphragm.

Benefits of diaphragmatic breathing

• It helps to make the diaphragm stronger.

• A stronger diaphragm helps to get more fresh air into
the lungs and more stale air out of lungs.

Instructions

• first, practice while you are lying down or sitting.

Then begin to practice while you are walking.
• The more you do it, the easier it becomes.
• Use diaphragmatic breathing daily while you talk, eat,
bathe, and dress. Your diaphragm will become
stronger.

Steps of diaphragmatic breathing

• Place one hand on the abdomen, just below the ribs.

Place the other hand on the chest.
• Breathe in (inhale) through your nose. As you inhale,

142
 let your abdomen and hand move out. Keep your
upper chest relaxed. The hand on the chest should not
move or move very little.
• Purse your lips in a whistling position. Then breathe
out (exhale) slowly. Your hand and belly should
move inward. Try to breathe out twice as long as you
breathe in.
• Relax.

Controlled Coughing

Clearing mucus from your lungs helps keep your airways

open. This makes it easier to breathe and helps prevent
infections. There are a variety of methods and devices
designed to help clear mucus. When you learn to control your
cough, you can clear mucus more easily.

Steps
• Sit in a chair with your feet flat on the floor. Hug the
pillow against your diaphragm (upper abdomen).
• Breathe in (inhale) and breathe out(exhale) through
your nose slowly and deeply.
• Repeat the above step 3 to 4 times
• Inhale again, bend forward, and push the pillow against
your belly. Cough 2 or 3 times while pushing against
your belly.
• Relax.

Repeat as needed to clear your mucus.

143
 RELAXATION TECHNIQUES

2 mts Demonstrat Lecture Listening Power How to do the

e the Shortness of breath causes fear and anxiety. When you become cum and point relaxation after
relaxation anxious, you begin to take small, fast breaths. The breathing discussion observing slides on the activities?
techniques muscle stire faster, and fresh air cannot get deep into your , relaxatio
lungs. To help prevent this cycle, you can use methods of demonstra n
relaxation. tion techniqu
Steps es

• Sit upright in a chair, with your arms hang- ing

loosely at your sides. Breathe deeply, slowly, and
evenly.
• Clench your fists while you continue to breathe.
• Shrug your shoulders, and tighten your fists. Count
“1, 2.”
• Let your shoulders fall down. Open your hands, and
let your arms hang loosely. Count to 4.
• Tighten your legs and feet. Count to 2.
• Completely relax. Let all your muscles go loose.
Count to 4.
• Repeat as needed.

GENERAL MEASURES

1 mts Demonstrat MEDICATION Lecture Listening Power How the

e the cum and point medication
inhalation of Bronchodilator medication is central to the symptomatic discussio, observing slides on inhalation has
medication management of COPD. It will help to prevent shortness of demonstra medicati to be
breath. Inhaled drugs are preferred to oral preparations. tion on performed?
inhalatio
n

144
 METERED DOSE INHALER

The metered dose inhaler (MDI’s) is the fundamental device

for the delivery of aerosolized medicines. Bronchodilators are
most commonly delivered by an MDI.

• Remove dust cap and check that canister fits

securely into mouthpiece.
• Shake inhaler vigorously.
• Hold inhaler upright.
• Extend neck comfortably.
• Breathe out gently and fully.
• Place inhaler between lips and form a seal.
• As you begin to breathe in, press canister firmly.
• Continue to breathe in slowly until lungs are full.
• If unable to press down on canister with one hand,
two hands can be used.
• Hold breath for 10 seconds or as long as is
comfortable.
• Breathe out gently.
• Wait 30 to 60 seconds between puffs of reliever
medication.
1 mts Explain the
nutritional NUTRITION Lecture Listening Power What food can
managemen cum point on be taken by a
t of the Diet discussion nutrition COPD
COPD • Eat 5-6 smaller meals throughout the day instead of al patients?
patients three large ones. manage
• Take protein rich food. ment of
• Avoid gas-producing foods, such as apples, broccoli, COPD

145
 dhal, potato, cabbage, corn, cucumbers, and patients
carbonated beverages.
• Talk less while you are eating.
• Slow down when you are eating.
• Select foods that are easy to chew
• Eat slowly, take smaller bites, and
breathe deeply while chewing
• Clear airways of mucus at least 1 hour
before eating
• Use bronchodilators ½ hour before meals if prescribed
by the physician.
• Eat while sitting up to make it easier for
lung expansion

Fluids

• Avoid drinking before or during the meal.

• Try to drink liquids at the end of the meal.
• Drink8-10 glasses of water per day to keep airway
mucus thin and free-flowing.

1½ Adopt the
mts life style LIFE STYLE MODIFICATIONS Lecture Listening Power What are the
modificatio cum point life style
n Breathing Control discussion slides on modifications
• use pursed-lip breathing and diaphragmatic breathing. life style done by COPD
• When you do a physical task, do the hardest part of the modifica patients?
work while you are breathing out. tions
Lifting
• First, breathe in slowly. Then lift and place objects as
you breathe out.

146
Pushing or pulling
• First, breathe in slowly. Then push or pull objects as
you breathe out.
Walking uphill or upstairs
• Stop and breathe in slowly.
• Walk a few steps as you breathe out slowly.
Daily Planning
• You should wait about an hour after you eat before
doing any physical activity.
• Put a restful activity between activities that use a lot of
energy.
• Gather items needed for a specific task to the same place.
This way, you do not need to walk back and forth while
doing the task.
• A small utility cart (with 3 shelves) can help you move
things around as you do your tasks.
• A pair of tongs with long handles can help you reach for
things.
Cooking or ironing
• Sit on a high stool, rather than standing.
Shaving or putting on makeup
• Put a mirror on a table. Sit and rest your elbows.
Bathing
• Use a bath seat.
• Wash your hair in the shower.
• Instead of towel drying, slip on a terry robe after
bathing.

147
 • leave the door open when you shower.
• Use a clear shower curtain if you feel closed in while
showering.
Dressing.
• Wear loose-fitting clothes that do not restrict the
movements of your chest or belly.
• Avoid socks or stockings with tight elastic bands that
could restrict your blood flow
• Wear shoes with non-slip soles to avoid falls.

Sleeping

• Avoid sleeping immediately after meals.

• you should wait about an hour after you eat before
going to sleep.

SUMMARY
1½
mts Pulmonary rehabilitation reduces symptoms, increases
functional ability, and improves quality of life in individuals
with chronic respiratory disease, even in the face of
irreversible abnormalities of lung architecture.

148
BIBLIOGRAPHY

1. Black J M, Medical surgical nursing.7 th ed.

Thomson press (India): Elsevier publications;
vol 1;2005
2. Lewis L.S, Heitkemper M.M, Dirksen R.S,
BrienG, Bucher L. Medical surgical nursing.7th
ed. Mosby Elsevier publications;2009
3. Smeltzer C.S, Bare B. Text book of medical
surgical nursing. 10 th ed. Lippincott Williams &
wilkins: a wolters kluwer publications; 2004
4. Grant.A, Waugh.Anne, Ross And Wilson
anatomy and physiology in health and illness.
9 th ed.elseviers:Philadelphia;2005
5. http://www.upmc.com/patients-
visitors/education/Documents/COPDBooklet.pd
f
6. Chaurassia B.D. Human anatomy. 4th ed. CBS
publishers and distributors:delhi;2005

149
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• MAzÀÄ PÉʬÄAzÀ PÁ夸ÀÖgÀ£ÀÄß MvÀÛ®Ä ¸ÁzsÀåªÁUÀ¢zÀÝgÉ JgÀqÀÆ

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PÁ°¥sÀèªÀgï, ¨ÉüÉ, D®ÆUÀqÉØ, PÁå¨ÉÃeï, eÉÆüÀ, ªÀÄļÀÄî ¸ËvÉ
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• Hl ªÀiÁqÀĪÀ 1 UÀAmÉAiÀÄ ªÉÆzÀ®Ä ¹A§¼À vÉUɬÄj.

• HlzÀ CzsÀð WÀAmÉAiÀÄ ªÉÆzÀ®Ä ¨ÁæAPÉÆÃqÉʯÉÃlgï §¼À¹.

• PÀĽvÀÄPÉÆAqÀÄ Hl ªÀiÁr.
• HlzÀ ªÉÆzÀ®Ä CxÀªÁ Hl ªÀiÁqÀĪÁUÀ ¤ÃgÀÄ PÀÄrAiÀĨÉÃr.

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CªÀ¢ü GzÉÝñÀ «µÀAiÀÄ ZÀlĪÀnPÉ ZÀlĪÀnPÉ ¸ÁzsÀ£ÀUÀ¼ÀÄ ªÀiË®åªÀiÁ¥À£À
• HlªÁzÀ §½PÀ ¤ÃgÀÄ PÀÄr¬Äj.
• PÀ¥sÀ vɼÀîUÁUÀ®Ä ¢£ÀPÉÌ 8-10 ¯ÉÆÃl ¤ÃgÀÄ PÀÄr¬Äj.
11/2 fêÀ£À fêÀ£À±ÉÊ°AiÀÄ°è ªÀiÁqÀ¨ÉÃPÁzÀ §zÀ¯ÁªÀuÉUÀ¼ÀÄ ¥Àæª ÀZÀ£À D°¸ÀĪÀÅzÀÄ ¥ÀªÀgï G¹gÁlzÀ
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UÀ¼À §UÉÎ G¹gÁr. ±ÉÊ°AiÀÄ°è
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• PÉ®¸À ªÀiÁqÀĪÁUÀ PÀpt PÉ®¸ÀUÀ¼À£ÀÄß G¹gÀÄ ºÉÆgÀ©qÀĪÁUÀ
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vÀ¼ÀÄîª ÀÅzÀÄ CxÀªÁ J¼ÉAiÀÄĪÀÅzÀÄ
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CxÀªÁ J¼É¬Äj.
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• ¤AvÀÄ ¤zsÁ£ÀªÁV G¹gɼÉzÀÄPÉƽî.

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• PÉ®ªÀÅ ºÉeÉÓ £ÀqÉzÀÄ G¹gÀÄ ©r.
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ªÀiÁr.
• PÀpt PÉ®¸ÀzÀ £ÀqÀÄ£ÀqÀÄªÉ «±ÁæAw vÉUÉzÀÄPÉƽî.
• MAzÀÄ PÉ®¸ÀPÉÌ ¨ÉÃPÁzÀ ªÀ¸ÀÄÛUÀ¼À£ÀÄß MAzÉà ¸ÀܼÀzÀ°è ¸ÀAUÀ滹 Er.
EzÀjAzÁV ªÀ¸ÀÄÛUÀ¼À£ÀÄß vÀgÀ®Ä ºÉZÀÄÑ ±ÀæªÀÄ¥ÀqÀ¨ÉÃPÁV®è.
• vÀ¼ÀÄîUÁr §¼À¹ ªÀ¸ÀÄÛUÀ¼À£ÀÄß ¸ÁV¹.

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ªÀiÁr CxÀªÁ E¹Ûç ªÀiÁr.
UÀqÀØ ¨ÉÆý¸ÀĪÀÅzÀÄ CxÀªÁ PÀÆzÀ®Ä ¨ÁZÀĪÀÅzÀÄ
• ªÉÄÃf£À ªÉÄÃ¯É PÀ£Àßr ElÄÖ PÀÄaðAiÀÄ ªÉÄÃ¯É PÀĽvÀÄPÉƽî.
¸ÁߣÀ
• PÀĽvÀÄPÉÆAqÀÄ ¸ÁߣÀ ªÀiÁr.

164
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• µÀªÀgï §¼À¹.
• ¸ÁߣÀzÀ PÉÆÃuÉAiÀÄ ¨ÁV°UÉ a®PÀ ºÁPÀ¨ÉÃr.
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• ¸Àr®ªÁzÀ §mÉÖ zsÀj¹.
• ©VAiÀiÁzÀ ¸ÁPïì zsÀj¸À¨ÉÃr.
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¤¢æ¸ÀĪÀÅzÀÄ
• HlªÁzÀ vÀPÀët ªÀÄ®UÀ®Ä ºÉÆÃUÀ¨ÉÃr.
• HlªÁzÀ MAzÀÄ UÀAmÉAiÀÄ §½PÀ ªÀÄ®UÀ®Ä ºÉÆÃV.
¸ÁgÁA±À
G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ ®PÀëtUÀ¼À£ÀÄß G¥À±ÀªÀÄ£ÀUÉƽ¸ÀĪÀ
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gÉÆÃVUÀ½UÉ G¥À±ÀªÀÄ£À ¤ÃqÀÄvÀÛzÉ. PÁ¬Ä¯ÉAiÀÄ£ÀÄß UÀÄt¥Àr¸À®Ä
¸ÁzsÀå«®è¢zÀÝgÀÆ PÁ¬Ä¯ÉAiÀÄ ¤¨sÁªÀuÉ ¸ÁzsÀå.

165
 Annexure-12
Power point slides on pulmonary rehabilitation

¤ªÀÄUÉ G¹gÁlzÀ vÉÆAzÀgÉAiÀÄ §UÉÎ

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G¹gÁlzÀ vÉÆAzÀgɬÄAzÀ ±Áé¸ÀPÉÆñÀUÀ¼ÀÄ ªÀÄvÀÄÛ
±Áé¸À£Á¼ÀPÉÌ vÉÆAzÀgÉAiÀiÁUÀÄvÀÛzÉ.

G¹gÁqÀ®Ä PÀµÀÖªÁUÀÄvÀÛzÉ.

CzÀ£ÀÄß UÀÄt¥Àr¸À¯ÁUÀĪÀÅ¢®è DzÀgÉ

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G¹gÁlzÀ vÉÆAzÀgÉ JAzÀgÉãÀÄ...?
JAzÀgÉãÀÄ...?

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PÁgÀtªÁUÀ§
PÁgÀtªÁUÀ§ºÀÄzÁzÀ CA±
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• G¹gÁqÀĪÁUÀ UÉÆgÀ UÉÆgÀ ±À§ÝªÁUÀĪÀÅzÀÄ.

• C£ÀĪÀA²PÀvÉ.
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• ¨Á®åzÀ°è
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GAmÁVgÀĪÀÅzÀÄ. • PɪÀÄÄä, JqÉ©qÀzÉ ¹A§¼À ¸ÀÄjAiÀÄĪÀÅzï.

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gÉÆÃVUÀ¼À G¹gÁlzÀ ªÀÄvÀÄÛ ±Áé¸ÀPÉÆñÀzÀ ¸ÁßAiÀÄÄUÀ¼ÀÄ).
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• ±Áé¸ÀPÉÆñÀzÀ ¹ÜwAiÀÄ §UÉÎ w¼ÀĪÀ½PÉ
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PÀ°AiÀÄĪÀÅzÀÄ.
• ¤gÀAvÀgÀªÁV ªÁåAiÀiÁªÀÄ ªÀiÁqÀĪÀÅzÀÄ.

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JzÉAiÀÄ ªÉÄÃ¯É Ej¹.
• ªÀÄÆV£À ªÀÄÆ®PÀ G¹gÁr.
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• «±ÁæAw vÉUÉzÀÄPÉƽî.

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• ¤zsÁ£ÀªÁV ªÀÄvÀÄÛ ¢ÃWÀðªÁV • ªÀÄĶ×UÀ¼À£ÀÄß ©V»rzÀÄ G¹gÁqÀĪÀÅzÀ£ÀÄß ªÀÄÄAzÀĪÀgɹ.
G¹gɼÉzÀÄ G¹gÀÄ ©rÃ.
• ¨sÀÄdUÀ¼À£ÀÄß ©V »rzÀÄ ªÀÄĶ×UÀ¼À£ÀÄß ©V»r¬Äj. 1, 2 Jt¹.
• ªÉÄð£À JgÀqÀ£ÀÄß 3-4 ¸À®
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• ¥ÀÅ£ÀB G¹gɼÉzÀÄPÉƽî, ªÀÄÄAzÀPÉÌ §VÎ £Á®ÌgÀªÀgÉUÉ Jt¹.
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vÀ¯É¢A§£ÀÄß ¤ªÀÄä ºÉÆmÉÖUÉ MwÛ. • ¸ÀA¥ÀÇtðªÁV zÉúÀªÀ£ÀÄß ¸Àr®UÉƽ¹. £Á®ÌgÀªÀgÉUÉ Jt¹.
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• ¢£ÀPÉÌ 3 ¸À® zÉÆqÀØ ¥ÀæªÀiÁtzÀ°è Hl ªÀiÁqÀĪÀ

§zÀ®Ä 5-6 ¸À® ¸Àé®à ¸Àé®à Hl ªÀiÁr.
• ¥ÉÇæÃn£ï C¢üPÀ«gÀĪÀ DºÁgÀªÀ£ÀÄß ¸Éë¹.
• ªÁAiÀÄÄ«£À vÉÆAzÀgÉ GAlĪÀiÁqÀĪÀ DºÁgÀUÀ¼ÁzÀ
DºÁgÀ ¸ÉêÀ£É ¸ÉçÄ, PÁ°¥sÀèªÀgï, ¨ÉüÉ,
D®ÆUÀqÉØ, PÁå¨ÉÃeï, eÉÆüÀ,
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¥Á¤ÃAiÀÄUÀ¼À£ÀÄß ¸Éë¸À¨ÉÃr.

15 16

• HlzÀ ªÉÆzÀ®Ä CxÀªÁ Hl ªÀiÁqÀĪÁUÀ ¤ÃgÀÄ

• ¤zsÁ£ÀªÁV Hl ªÀiÁr, ¸ÀtÚ ¸ÀtÚ CUÀļÀÄ wAzÀÄ PÀÄrAiÀĨÉÃr.
¢ÃWÀðªÁV G¹gÁqÀÄvÁÛ dV¬Äj. • HlªÁzÀ §½PÀ ¤ÃgÀÄ PÀÄr¬Äj.
• Hl ªÀiÁqÀĪÀ 1 UÀAmÉAiÀÄ ªÉÆzÀ®Ä ¹A§¼À vÉUɬÄj. • PÀ¥sÀ vɼÀîUÁUÀ®Ä ¢£ÀPÉÌ 8-10 ¯ÉÆÃl ¤ÃgÀÄ PÀÄr¬Äj.
• HlzÀ CzsÀð WÀAmÉAiÀÄ ªÉÆzÀ®Ä ¨ÁæAPÉÆÃqÉʯÉÃlgï
§¼À¹.
• PÀĽvÀÄPÉÆAqÀÄ Hl ªÀiÁr.

17
18

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• PÀpt PÉ®¸À ªÀiÁqÀĪÁUÀ £ÀqÀÄ£ÀqÀÄªÉ «±ÁæAw
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• ¤AvÀÄ PÉÆAqÀÄ PÉ®¸À ªÀiÁqÀĪÀ §zÀ®Ä PÀĽvÀÄPÉÆAqÀÄ
PÉ®¸À ªÀiÁr.
• HlªÁzÀ vÀPÀët ªÀÄ®UÀ¨ÉÃr.

19 20

21

169
 Annexure-13

List of experts who validated the tool and individual health education

1. Prof. (Mrs.) B.V. Kathyayani 2. Prof. (Mr.) B.A. Yathi Kumara Swamy Gowda

Principal Principal

M. V. Shetty College of Nursing Alva’s College of Nursing

Mangalore. Moodabidri (D.K)- 574277.

3. Dr. Larissa Martha Sams 4. Mrs. Beena. A. Nair

Principal Principal

Laxmi Memorial College of Nursing New Mangalore College Of Nursing

Mangalore. Mangalore.

5. Mr. Gireesh G.R 6. Prof. A Raja

Associate Professor &HOD Professor &HOD

Medical Surgical Nursing Medical Surgical Nursing

Sridevi College of Nursing Sahyadiri College of Nursing

Mangalore. Mangalore.

7. Mrs. Soumya christabel 8. Mr. Subramaniyam

Assistant professor & HOD Associate professor

Manipal College of Nursing Dept. of physiotherapy

Mangalore. M. V. Shetty college, Mangalore.

9. Mr. sheriff

Physiotherapist

Unity health complex,

Mangalore.

170
 Annexure-14

List of formulae

1. Karl-Pearson’s coefficient of correlation

r=
∑( x − x )( y − y)
∑(x − x) ∑( y − y)
2 2

r = correlation coefficient computed on Split- Half

2. Spearman-Brown Prophecy formula

2r
r1 =
1+ r

r1= Reliability Coefficient of the whole test

r = Reliability Coefficient of the half test

3. Chi-square test with 2 X 2 contingency table

N (ad − bc) 2
2 (a + b)(c + d )(a + c)(b + d )
χ=

4. Chi-square test with Yates correction

N (| ad − bc | − N / 2) 2
χ2=
(a + b)(c + d )(a + c)(b + d )

5. fisher’s exact test

(a + b)!(c + d )!( a + c )!(b + d )!

P=
N !a!b!c!d !

6. Mean

x
X= ∑
n

171
7. Standard deviation

∑ − x )2
(x
σ =
n
8. Mean (%) = mean / max. possible score

9. Paired ‘t’ test

d
t =σ
d
n

172
 Annexure-15

Master data sheet baseline pro-forma

BASE LINE PROFORMA

D1 D2 D3 D4 D5 D6 D7 D8 D9 D10
1 d a a a b a b a a b
2 c a b e b a b a a b
3 d b a e a b - a a b
4 d b a b b c - a a b
5 b a a a a a c b b b
6 c a b e b a b a a a
7 d a a e a a b b a b
8 d b b e b b - a a a
9 d a a a a a c a a b
10 c a b e b a a b a b
11 c b c a b b - b b b
12 d a a e a c - a a b
13 d b a e a a c b b b
14 d a a e a a b a a b
15 d a a a a a a a a a
16 b a c e b a b a a b
17 d b a e a b - a a b
18 d b a b b b - a a b
19 b a a a a a b a a b
20 c a b a b a b b a b
21 d b a e a b - a a a
22 d a a e a a a a a b
23 d a a e a a c b b b

173
24 d a a e a a c a a b
25 b a b e a a c a a b
26 d b a b b b - a a a
27 c a a a a a b a a b
28 b a c a b a a b b b
29 d b a a a b - b a b
30 b a a b b a a a a b
31 d b a e a c - a a b
32 d a a e a a b a a b
33 d a a b b a c a a b
34 c b a a a c - a a b
35 b a c e b a b b b b
36 d a a e a a b a a a
37 d a a a a a a a a b
38 d b a e a b - a a b
39 c b b e a b - b a b
40 d a a a a a b a a b
41 b b a e a b - a a b
42 d a a a a a a a a b
43 c a a a a a b b a b
44 b b a b b c - b a a
45 c a a e a a b a a b
46 b a b e b a a a a b
47 d a a e a a b a a b
48 d a a b a a b b b b
49 d b a a a b - a a b
50 c b b e b b - a a a

174
 Master data sheet pre-test knowledge score

grant
total
Q10

q11

q12

q13

q14

q15

q16

q17

q18

q19

q20

q21

q22

q23

q24

q25
Q9
q1

q2

q3

q4

q5

q6

q7

q8
1 1 0 1 0 1 0 1 0 0 1 0 1 0 0 0 1 0 1 1 0 0 1 0 0 1 11
2 1 1 0 1 0 1 0 1 0 1 0 0 0 1 1 1 0 0 0 0 1 0 1 0 0 11
3 1 1 1 1 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 1 0 0 0 1 0 10
4 1 0 1 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 0 1 0 0 0 1 1 9
5 1 1 1 0 1 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 1 0 1 11
6 1 1 0 1 1 0 1 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 0 0 0 10
7 0 1 1 0 0 1 0 1 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 1 1 9
8 0 1 1 1 0 1 0 1 0 1 0 0 0 1 1 0 0 0 0 1 0 1 0 1 0 11
9 1 1 0 1 1 0 0 0 1 0 0 1 0 0 0 1 1 0 0 0 1 0 0 0 1 10
10 1 0 1 0 1 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 7
11 1 1 1 1 0 1 0 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 1 0 0 10
12 1 0 1 0 1 0 0 0 1 1 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 8
13 0 1 1 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 7
14 0 1 1 0 0 1 0 1 1 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 8
15 1 0 0 1 0 0 1 0 0 0 0 1 0 0 1 0 1 0 0 1 0 0 0 1 0 8
16 1 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 0 0 0 0 1 0 0 0 8
17 1 1 1 0 0 1 1 0 0 0 1 0 0 0 0 1 0 1 1 0 0 0 1 0 1 11
18 1 1 1 0 1 0 1 0 1 0 0 0 1 1 0 0 0 0 0 0 1 0 0 1 0 10
19 1 0 1 1 0 1 0 1 0 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 0 9
20 1 0 1 0 1 0 0 0 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 8
21 0 1 1 0 1 0 1 0 0 1 0 1 1 0 0 0 1 0 0 1 0 0 1 1 0 11
22 1 1 0 1 0 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 9
23 1 1 0 0 0 1 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 8
24 0 1 1 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 7
25 1 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 1 0 0 1 1 0 8
26 1 0 1 0 0 1 0 1 0 1 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 8
27 1 0 1 0 1 0 0 0 1 0 0 0 0 1 0 1 1 0 0 0 0 1 0 0 1 9
28 0 1 1 1 0 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 8
29 1 1 0 0 0 1 1 0 0 0 0 1 0 0 1 0 0 0 0 0 1 0 1 0 0 8
30 1 1 0 0 1 1 0 0 1 1 0 1 1 0 0 0 0 1 1 0 0 0 0 1 0 11
31 0 1 1 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 9
32 1 0 1 0 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 1 0 7
33 1 1 0 0 0 1 1 0 0 1 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 8
34 1 1 1 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 0 0 1 0 1 1 0 11
35 1 0 1 1 1 1 1 0 0 0 0 1 0 0 0 1 0 1 0 1 0 0 0 0 1 11
36 1 0 1 1 0 0 1 1 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 8
37 0 1 1 0 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 0 1 0 0 8
38 1 1 0 0 1 0 0 0 1 0 1 0 0 1 0 1 1 0 0 1 0 1 0 0 0 10
39 1 1 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 7
40 1 0 1 0 1 0 1 0 0 0 0 0 1 1 1 0 1 0 1 0 0 0 1 1 0 11
41 1 1 1 0 1 1 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 0 0 11
42 1 0 1 1 0 0 0 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 0 0 0 8
43 0 1 1 0 0 1 0 0 1 0 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 7
44 1 1 0 1 0 0 0 1 0 1 0 1 0 0 0 0 1 0 0 0 1 0 0 1 0 9
45 1 0 1 0 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 1 0 0 8
46 1 1 1 1 0 1 0 0 1 0 0 1 1 0 0 0 0 1 1 0 0 1 0 0 0 11
47 1 1 0 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 0 0 1 0 1 0 1 10
48 0 1 0 1 0 0 1 0 1 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 9
49 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 0 1 0 1 0 0 1 0 0 8
50 0 1 1 1 0 0 1 0 1 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 10
Total 454

175
 Master data sheet post-test knowledge score

Q9

Grant
q1

q2

q3

q4

q5

q6

q7

q8

Q10

q11

q12

q13

q14

q15

q16

q17

q18

q19

q20

q21

q22

q23

q24

q25

total
1 1 1 1 0 1 0 1 0 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 21
2 1 1 0 1 1 1 0 1 0 1 0 1 0 1 1 1 0 1 0 1 1 1 1 0 1 17
3 0 1 1 1 1 0 1 0 1 1 1 0 1 1 0 1 1 1 1 1 0 1 1 1 1 19
4 1 1 1 0 1 0 0 1 1 0 1 1 0 1 0 1 0 1 0 1 1 1 1 1 1 17
5 1 0 1 1 1 1 1 0 1 1 0 1 1 0 1 1 1 0 1 0 1 1 1 1 1 19
6 1 1 1 1 0 0 1 0 1 0 1 0 1 0 1 1 1 1 1 1 1 1 1 0 1 18
7 0 1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 21
8 0 1 1 1 0 1 0 1 1 1 1 1 1 1 1 0 1 0 0 1 1 1 1 1 0 18
9 1 1 0 1 1 0 0 1 1 0 1 1 0 1 0 1 1 1 0 1 1 0 1 1 1 17
10 1 0 1 0 1 0 1 1 0 1 0 1 1 1 0 1 0 1 1 1 1 1 0 1 0 16
11 1 1 1 1 0 1 1 1 1 0 1 0 1 0 1 1 1 0 0 1 1 0 1 0 1 17
12 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 0 1 0 1 1 1 1 1 1 1 21
13 0 1 1 1 0 1 1 0 1 0 1 1 1 1 0 1 0 1 0 1 0 0 1 1 0 15
14 0 1 1 1 1 1 0 1 1 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 0 19
15 1 0 1 1 1 0 1 1 0 1 1 1 0 1 1 1 1 1 0 1 1 0 1 1 1 19
16 1 1 0 1 1 0 0 1 1 0 1 0 1 1 1 1 1 0 1 1 1 1 1 1 0 18
17 1 1 0 1 1 1 1 0 1 0 1 0 1 1 0 1 1 1 1 1 1 0 1 0 1 18
18 1 1 1 1 1 0 1 1 1 1 0 1 1 1 0 0 1 0 1 1 1 0 1 1 1 19
19 1 0 1 1 1 1 0 1 0 0 1 1 0 1 1 0 0 1 1 0 1 1 0 1 0 17
20 1 0 1 1 1 0 1 0 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20
21 0 1 1 1 1 0 1 1 0 1 0 1 1 1 0 0 1 1 0 1 1 1 1 1 0 15
22 1 1 0 1 1 0 0 1 1 0 1 1 1 0 1 1 0 1 0 1 1 1 0 1 1 17
23 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1 0 1 1 0 19
24 0 1 1 0 1 1 1 1 0 0 1 1 0 0 1 1 0 1 1 1 1 1 0 0 1 16
25 1 1 0 1 0 1 0 1 1 0 1 1 0 1 1 1 1 1 1 1 0 0 1 1 0 17
26 1 0 1 1 1 1 1 1 0 1 0 1 1 0 1 0 0 1 0 1 1 1 1 1 1 18
27 1 0 1 1 1 0 0 1 1 0 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 19
28 0 1 1 1 0 0 1 0 1 1 0 1 1 1 0 0 1 0 1 1 1 1 1 1 1 17
29 1 1 0 1 0 1 1 1 0 0 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 19
30 1 1 0 1 1 0 1 0 1 1 0 1 1 0 1 0 1 1 1 1 0 1 1 1 1 18
31 0 1 1 1 1 0 1 1 1 0 1 1 1 1 0 1 1 1 0 1 1 1 1 0 1 19
32 1 0 1 0 1 1 0 1 1 0 0 1 1 0 1 0 0 1 1 1 1 1 1 1 1 17
33 1 1 0 1 0 1 1 0 1 1 1 0 1 0 1 0 1 0 1 1 0 1 1 0 1 16
34 1 0 1 1 1 0 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 21
35 1 0 1 1 0 1 1 1 0 1 0 1 0 1 1 1 0 1 0 1 0 1 0 1 0 15
36 1 0 1 1 1 0 1 1 1 0 1 1 1 1 1 0 1 1 1 0 1 1 0 1 0 18
37 0 1 1 0 1 1 1 1 0 1 0 1 1 0 1 1 0 1 0 1 1 0 1 0 1 16
38 1 1 1 0 1 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 21
39 1 1 0 1 1 0 1 1 0 1 1 1 0 1 0 1 0 1 0 1 1 1 0 0 1 16
40 1 0 1 1 1 0 1 1 0 1 1 0 1 0 1 0 1 0 1 1 0 0 1 1 0 15
41 1 1 1 0 1 0 1 0 1 1 0 1 0 1 0 1 0 1 1 1 1 1 1 1 1 18
42 1 0 1 1 1 0 1 1 0 0 1 0 1 1 1 1 1 1 0 1 1 1 0 1 0 17
43 0 1 1 0 0 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 19
44 1 1 0 1 0 1 0 1 1 1 0 1 0 1 1 1 1 0 0 1 1 1 0 1 1 17
45 1 0 1 0 1 0 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 18
46 1 1 1 1 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 21
47 1 1 0 1 1 1 1 1 0 1 1 1 1 0 1 1 0 1 0 1 1 1 1 0 1 19
48 1 1 0 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 21
49 1 1 1 1 0 1 1 0 1 1 1 0 1 1 1 0 1 0 1 0 1 1 1 1 1 19
50 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 1 1 0 21
total 905

176