FACTORS CONTRIBUTING TO POOR PROGNOSIS IN PEADIATRIC COMA CASES AT ACUTE CARE UNIT MULAGO HOSPITAL

ACRONYMS

A and E                           –      Accident and Emergency

ABM                               –     Acute Bacterial Meningitis

CM                                  –     Cerebral Malaria

CNS                                –      Central Nervous System

GCS                                –      Glasgow Coma Scale

ICU                                 –      Intensive Care Unit

MNRH                            –      Mulago National Referral Hospital

NTC                                –      Non Traumatic Coma

Risks of Treatment

RPC’s                             –     Resource Poor Countries

SID                                  –      Sudden Infant Death

SUPPORT                      – Study to Understand Prognoses and Preferences of Outcome and

UMoH                             –      Uganda Ministry of Health

UNICEF                         –      United Nations Children’s Emergency Fund

WHO                               –      World Health Organization

CHAPTER ONE: INTRODUCTION

1.1 Introduction

This chapter contains the background, problem statement, purpose of the study, specific objectives, research questions and justification of the study.

1.2Background

According to the WHO, (2017) over the past 25 years, the world has made significant progress in improving the quality of health facilities in saving young children’s lives due to this great achievement the rate of Pediatric coma cases fell by 62 per cent from 1990–2016, with pediatric mortality  rates dropping from 12.7 million to 5.6 million, the WHO report further indicates that the leading cause of global poor prognosis of peadiatric cases are preterm birth complications, pneumonia, birth asphyxia, diarrhea and malaria. On the same note UNICEF (2012). Indicates that Pediatric coma remains one of the leading cause of child death and child disability globally making 62% of the Sudden Infant Death (SID), with death occurring within 3hours following onset of coma if no urgent intervention is sought.

In Pakistan Paediatric coma has been blamed on the countries poor health facilities which has contributed to the high levels of child mortality in the country , the WHO, (2017) specifically indicates that due to poor prognosis over 420,000 children died out of the country’s total 6.3 million children in 2016.

Sub-Saharan Africa has been faced with the challenge of poor prognosis though there has been a relative decline over the years, the health sector in sub-Saharan African countries has witnessed a rise in funding over the last 20 years by development partners however there still many challenges facing the health sector this has caused poor prognosis among children in the continent for example the number of neonatal deaths remained almost the same from 1990 to 2016. Moreover, 52 countries need to accelerate progress to reach the SDG target of a neonatal mortality rate of 12 deaths per 1000 live births by 2030 (WHO, 2016).

According to Kenya demographic health survey (2016) poor prognosis has led to increase in the death among children. In 2016, child mortality rate for Kenya was 49.2 deaths per 1,000 live births. Child mortality rate of Kenya fell gradually from 159.4 deaths per 1,000 live births in 1967 to 49.2 deaths per 1,000 live births in 2016, however despite the fall the number is still high as compared to western countries in Europe (MoK, 2017). The fact attributed to poor prognosis has been mainly malaria, non-communicable disease and malnourishment, in areas like Turkana over 73, 000 children are malnourished.

Paediatric coma is either traumatic or non-traumatic coma and it is a common problem in pediatric practice with high mortality and morbidity. Early recognition of the potential for catastrophic deterioration in a variety of settings is essential and several coma scales have been developed for recording depth of consciousness that are widely used in clinical practice in adults and children (Luban, et al., 2013)

Coma is a medical emergency which presents diagnostic as well as therapeutic challenges. The potential causes of coma are numerous, and the critical window for diagnosis and effective intervention (not only to ensure survival but also to prevent long-term squeal) is short. Pediatricians in the emergency services and intensive care units (ICU) have to frequently manage comatose patients. The incidence of non-traumatic coma is 30/100,000 children per year and that of traumatic brain injury is 670/100,000 (Ibekwe, et al., 2011).

1.2 Problem statement

Death rates as a result of paediatric coma varies from countries to countries but is more pronounced in third world countries than developed countries. There were 150,000 child death of paediatric coma in sub Saharan Africa in 2012 down from 230,000 deaths in 1990(WHO 2013).

In Uganda 2800 children every year die of paediatric coma despite the existence public health centers and hospitals where they are usually rushed. The deaths in public health facilities are much worrying as compared to private facilities like Nsambya Health care a faith based hospital in Kampala where only 17  children died of paediatric coma in 2010 (UMoH ,2012).

The documentation at acute care unit of MNRH , 1149 children are seen monthly and since April 5^th2018, 127 children were admitted to the ICU with pediatric coma, 61 children have died due to pediatric coma out of the 168 total deaths who were registered at the acute ward.

Though the government of Uganda in the financial year 2015/2016, recruited an additional 3,000 health workers who included  anesthetists, medical doctors, nurses, midwives and surgeons, targeting critical cadres to offer maternal and child health, anesthetists’ services in health centers III and IV countrywide, there is still poor prognosis in peadiatric coma cases at acute care unit Mulago Hospital, it’s against this background that this study intends to investigate into factors leading to this poor prognosis in pediatric coma at the acute care unit in Mulago National Referral Hospital.

1.3 Study objectives

1.3.1 Broad objective

To establish the factors contributing to poor prognosis in pediatric coma cases in acute care unit at Mulago national referral hospital.

1.3.2 Specific objectives

1. To establish the socio-economic factors that contributes to the poor prognosis in pediatric coma.
2. To identify the health facility based factors contributing to poor prognosis in pediatric coma.

1.4 Research questions

1. What are the socio-economic factors contributing to poor prognosis in pediatric coma in acute unit at MNRH?
2. What is the Health facility based factors contributing in pediatric coma at the acute care unit at MNRH?

1.5 Justification of the study

The study may help in creating awareness to the readers and the nation on how to handle coma children by managing and improving on the factors which have lead to the poor prognosis of comatose children, rehabilitating some with steady progress and also decrease on the Pediatric death among the coma cases suffered by children.

The study may provide information to the future academicians on Health facility based factors contributing in pediatric coma at the acute care unit at MNRH.

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter describes the review of literature about socio-economic factors and health facility related factors done elsewhere in the world. Literature was acquired from journals and database.

Socio-economic and health facility factors contribute more to the prognosis of non-traumatic coma than has previously been recognized (Bondi et al, 2011).These factors include socio-economic variables in the individual patients, their families, and the hospitals or health institutions (Cullen et al, 2010).

2.2 Socio-Economic factors that contribute to the poor prognosis in pediatric coma

According to a population based study in the UK, Bragatti, et al., (2010) Coma is a relatively common condition in critical pediatric care. Epidemiological studies generally divide studies by traumatic and non-traumatic causes, the incidence of non-traumatic coma was five-times greater in children under 16 years of age than in the general population (30.8 per 100,000 vs 6.0 per 100,000 per year, respectively), with a notably higher incidence in the first year of life (160 per 100,000 children per year).

In a study in USA, Infection is the most common overall cause of coma in childhood, with an overall mortality of 46%. Regarding traumatic brain injury in children, there were an estimated 546,240 children with head injuries not associated with motor vehicles in the USA during 1978 who required emergency room care. Head injuries account for 11% of hospital emergency room visits by children with non-motor vehicle trauma. A fifth of head injuries among adolescents were associated with concussion. Among the 33,635 cases of concussion in children studied, twice as many males had concussion than females (Marcovitch, 2011)

According to a study in northern parts of Nigeria there was high prevalence of pediatric coma cases in poor communities than in wealthier places. Coma can be produced by one of three situations: structural lesion with bilateral hemispheric damage; a focal brainstem lesion (especially with bilateral impairment of the upper pons); or a metabolic derangement, with suppression of the reticular activating system. Several primary neurological disorders and general medical conditions are able to cause coma. Most frequently, patients become comatose after a diagnosis of drug intoxication, hypoxic–ischemic insult secondary to cardiac arrest, stroke, trauma or medical disorders, such as hyperosmolar coma (Kallela et al., 2014).

According to a study in northern Nigeria Prognosis of coma depends principally on its causes, in the study it was assessed and duration of coma and age of patients are important measured, the findings also further revealed that Children younger than 2 years old have a very poor prognosis. There is no doubt that problem in pediatric practice accounting for 10-15% of all prolonged coma after a hypoxic ischemic insult in hospital admissions; it makes a heavy demand on childhood carries a very poor prognosis, later onset intensive care units (Lindsberg & Soinila 2015).

The age, sex, and occupation of the patients are important social determinants of the behavioral pattern. The family as a support system and decision makers for the patients’ health-seeking pathways or behavior appears to be relevant and the mode of intervention, measured in terms of time and quality of medical intervention and social support for the indigent patient contributes much too poor prognosis (Cullen et al, 2010).

2.2.1 Age

An exact age threshold for identifying children at high risk of paediatric coma following infections or head injury has not been identified, but it is clear that increasing age is associated with an increased risk and a poorer prognosis. Commonly used thresholds are1, 5, 10 and 15 years. There is evidence that the prevalence of paediatric coma in younger children and infants is much higher than in older children. However, this should be weighed against the fact that an unknown, but significant, proportion of infections or head injuries that are prevalent. These infections and injuries may result in a different pattern of morbidity to that seen in younger children, and obviously require investigation regardless of cause (Dehmer, et al, 2010).

Age has been identified in many studies as a strong prognostic factor in coma of any etiology. In the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), age of 70 years or older and infancy were one of five clinical independent variables associated with 2 month mortality in non-traumatic coma (Murphy et al., 2013).

2.2.2 Gender

According to a study in Ghana, (Kobe, 2017) there is not known difference between the males and female children on the risk factors and cause medical coma, this is because all children at young age presented the same level of vulnerability to pediatric medical coma cases.

In another study in Ethiopia indicates that female tend to suffer less cases of poor prognosis in pediatric coma cases ( Yamaura et al., 2011). Many reasons have been adducted to explain this trend, especially in Africa (Dada et al, 2009). Also, there is the tendency to care for the male child more than the female. Lastly, it is believed that males have more risky or disease promoting lifestyles than females and so are more likely to fall sick and present to hospital.

In another study in Uganda, One hundred and fifty-two of the 200 patients studied died giving an overall mortality of 76%. There was an overall male predominance of 66% (132) over the females’ 34% (68). However, the difference between the respective mortality rates of 78.8% and 70.6% was not of statistical significance and pediatrics suffer the same consequences (MoH, 2012).

2.2.3 Occupation

According to Fenella et al., (2011), occupational distribution showed that the self-employed (made up of small scale businessmen, traders, artisans, taxi drivers, commercial motorcyclists, farmers, clergymen) constituted 52.5% of the study population, followed by the unemployed (students, housewives, the retired/or disengaged from service/job) who constituted 28.5% and lastly the public/civil servants who made up the remaining 19%. The mortality rates, however, showed that the self-employed had the highest rate of 81% due to less time for their family in search of the small money to take care of their families, followed by the public/civil servants with 79% who are always occupied with office work and tight programs and the unemployed with the lowest rate of 65% because they are always in touch with their families.

2.2.4 Family Support

According to Hansmann, et al., (2017), in there study in Ethiopia revealed that,  Peadiatric coma patients who had above 50% family support and were able to pay for some relevant investigations had a better outcome than those who had poor or less than 50% family support or failed to pay for investigations. This report is in consonance with that of Gallaher, et al (2016). Less aggressive care for the pediatrics by family members and health care providers was responsible for poor functional outcome, while the presence of a spouse was a strong predictor of a good functional outcome in young patients with the most severe strokes (Kallela et al., 2014).Family support had a strong influence on outcome has a strong influence on the mortality rate which a percentage effect of 56.8% in patients who have excellent family support which is lower than 86.1% and 97.1%, respectively, for those who had good and poor family support (Castren et al., 2012.).

2.2.5 Ignorance

Gallaher, (2016) also commented in their study in northern state of Nigeria that there is poor prognosis of children from illiterate parents because of lack of knowledge on the presence of better health facilities in a Similar study in Kenya as mortality was highest (84.1%) in patients whose family members had the least knowledge and lowest (64.8%) in those whose family members had excellent knowledge.

2.2.6 Nutrition.

Children who were previously exposed to poor nutritional status, with mothers or care takers who have full time jobs or busy with domestic work like farming, with no time dedicated to infants feeding behavior as well as those with low or little knowledge of infants feeding requirements increase the possibility of pediatric coma poor outcome resulting from reduced body immunity, poor brain development and brain growth (Nathaniel, et al, 2011).

2.2.7 Cultural beliefs and religious affiliation

Waweru-Siika, et al., (2017) states that although Christians (62%) were more than Moslems (38%) among the study population, religious affiliation did not have any significant impact on outcome. The impact of ethnicity could not be assessed, as 95% of these patients were Yoruba, while the other 4.5% were from other Nigerian tribes and 0.5% Senegalese.

Children and families have different cultural backgrounds which affect their medical approach and experience to the treatment setting. Treatment of children with Coma is individualized, is provided in the language(s) used by the individual, and is done so with sensitivity to cultural beliefs, values and norms. Different dimensions of culture may influence the family’s belief system in seeking care and external support, for example, some cultures may have a sense of shame or feel it is necessary to hide a disability and some believe in witchcraft, which may influence how an individual and caregivers approach and respond to coma in seeking care. (Amari, (2017).

2.3 Facility/hospital based factors

2.3.1 Delayed Referrals

Delayed presentation to hospital was a major factor in this study. About 45% of the patients were brought to hospital more than 6 hour after onset of coma, and this group had statistically significantly higher mortality. Many of these patients (32%) were referred from private hospitals and other primary and secondary health facilities where they were first seen. Many of these patients presented to UCH with co-morbid illnesses and complications, hence the higher mortality. This also agrees with the observations of other workers, particularly with respect to stroke (Laine, 2017) and hypoglycemia especially in Africa (Lester et al, 2012).

According to a study in Senegal , mortality was higher (76.7%) in the 45% (90) patients who presented after 6 hour than the 55% (110) who were brought within 6 hour (63.2%), although the difference was not statistically significant. 32.5% (65) of the patients who presented after 6 hour were referred from primary and secondary health facilities with a mortality rate of 89.6%, while the other 12.5% (25) brought in directly from their homes had a mortality rate of 68.7%(Venkatraman et al., 2011).

The management of paediatric coma child requires urgent intervention, with 12% of children under 1year requiring paediatric ICU in hospital set up because of the prognostic depression of respiratory centers in the brain., 94 % of the children if given immediate intervention in the hospital facility will improve and develop no neurological complications, however a delay to seek medical services is still a great menace especially in developing countries where only about 67% seek medical assistance  (Gillmore et al., 2011).

2.3.2 Facility equipments, investigation and supplies

According to study in Uganda most of the hospitals with good facilities have the ability to ensure better quality care for the patients (MoH, 2013). In a related study in Nigeria hospitals in rural areas were responsible for poor quality medical services (Kaisvuo & Uotila, 2013).

According to Storvik- Sydänmaa et al., 2013) the equipments in a given health facility is responsible for the quality of Health services most of the health facilities in sub-Saharan Africa do not have the necessary equipments needed to effect better health services to the people.

According to the findings in Manchester Hospital the size and proportions of child’s and adult’s organs are different. Compared to adults, child has quite large brain and liver, large head and long limbs. However, the reproductive organs do not begin to develop until puberty. Child’s metabolism is more active, bone fractures heal more rapidly and body has higher liquid content than adults. (Leppäluoto et al., 2013.) Examining a pediatric patient differs from examining an adult patient in many different ways. Physiological features related to child’s growth and development should be taken into account when examining a pediatric patient. Variety of diseases is partly different in adult and pediatric patients, and same diseases can show different kind of symptoms in different stages of age. In addition, the same symptom can be caused by different disease in adult and pediatric patients. (Salonen, 2009.)

In some countries where many hospitals lack equipment for electroencephalogram (EEG) and other neurophysiologic studies, mortality from non-convulsive status epilepticus might be high since many cases would be unrecognized. In a Lusaka hospital, only 3 out of 33 patients whose cause of coma could not be found, due to the lack of proper investigative tools and intensive care facilities, survived (Sinclair et al; 2009).

Although mortality rate is highest in patients admitted into the intensive care unit in a study in South Africa it was not significantly different from the rates observed in patients either in the accident and emergency unit or on the medical wards. The reasons for this result may not be far-fetched. All illnesses leading to coma portend a poor prognosis. High hospital charges, limited bed space, and no facilities for intensive care ensure exclusion of many who need these services and delayed resuscitation for the few patients who are privileged to access the care.
Mortality was worst in patients admitted into the intensive care unit (ICU) (83.3%), followed by those in the (A and E) unit with 80% and lastly 75.1% for patients admitted into the medical wards, although the differences were not statistically significant. Mortality was higher (85.4%) when diagnosis was delayed beyond 24 hours than when it was confirmed before 24 hours (73.6%), although the difference was also not statistically significant as more than two-third (79.5%) of the patients had their medical condition diagnosed within 24 hours (Zakharov, 2015).

Zakharov, (2015) further revealed that all 17.5% (35) patients who had no investigations died (100% mortality), while the remaining 82.5% (165) who had some or all relevant investigations had a mortality rate of 67.3%. This difference was statistically significant.

2.3.3 Early recognition and knowledge by the health workers

The early recognition of patients who may require aggressive therapeutic measures is important, since animal and human studies have proved that early intervention results in better outcome (Zakharov,et al 2015).With good and quick medical intervention, many patients now survive illnesses which would previously have proved fatal, especially those associated with acute failure in one bodily system or another. Coma occurring in the course of an illness, irrespective of cause, implies a poor outcome, and physicians and families of comatose patients often have to make difficult decisions as they consider whether life extending care will achieve desirable outcomes. Health care planners also need to know the outcome of intensive care and other life-support services offered to comatose patients, for the purposes of planning and resource allocation (Lynn et al, 2012).

Pediatric nursing has its own special features which should be taken into account while taking care of a critically ill child patient. The keystones of pediatric nursing are good treatment and monitoring. In addition, it is essential that the nurses are able to use the needed technical equipment, machines and aids in order to provide professional nursing care. Furthermore, one vital part of pediatric nursing is to provide support and comfort for the parents, siblings and other relatives. The aim of pediatric nursing is to support and maintain the vital functions, prevent further complications and support health promotion. Nurses are in charge of basic and specialized nursing care of the critically ill child patient. (Talvensaari et al., 2013)

According to Marcovitch (2011) “the brain is the organ of the mind” and it needs continuous adequate supply of oxygen and glucose in order to function normally. Interruption of either of them will lead to disturbances in consciousness. (Marcovitch 2011.) Consciousness and unconsciousness can be determined in several ways. Generally speaking, consciousness means awareness of oneself and the environment; it is the state of being aware of physical events and mental concepts. Awareness means the ability to combine the data in memory to the surrounding internal and external stimuli. When a person is conscious, he or she is awake, responds to his or her surroundings and behaves meaningfully. Unconsciousness means lack of this awareness. (Lindsberg et al., 2015.)

Brain are involved in the regulation of consciousness, a relatively extensive disorder in the brain is underlying the state of unconsciousness. (Puumalainen 2005.) Unconsciousness is a sign of different degrees of malfunction either in the brain stem activating system (ARAS) or in both cerebral hemispheres simultaneously. Hence, for example, one-sided hemisphere damage does not lead to unconsciousness, unless its mass effect extends to the other side of the brain or to the brain stem. (Kallela et al., 2014.) According to Castren et al., (2012) an unconscious patient is always a high risk patient. It is essential to monitor the patient and document patients’ actions and consciousness level in regular basis especially in the beginning of the treatment. Once the patient is stable and the cause of unconsciousness is clear, monitoring can be reduced step by step. (Kallela et al. 2014)

CHAPTER THREE:  METHODOLOGY

3.1 Introduction

This chapter presents, study design and rational, study setting and rational, study population, sample size determination, sampling procedure, inclusion criteria, definition of variables, research instruments, data collection procedures, data management, data analysis, ethical considerations, limitations of the study and dissemination of results.

3.2 Study Design and rationale

This will be a cross sectional descriptive study design employing both qualitative and quantitative methods in which a questionnaire will be used to collect data. The   Participants will be recruited once in the study and interviewed once during the study to allow completion of the study within the academic schedule.

3.3 Study setting and rationale

The study will be carried out in Mulago National Referral Hospital situated in Kampala District in the central Uganda. Mulago National Referral Hospital, commonly known as Mulago Hospital. It is the largest public hospital in the country, with capacity of 1,500 beds.

The hospital is on Mulago hospital is located in Mulago Hill in the northern part of the city of kampala, It is approximately 5 kilometers (3.1 mi), by road, north-east of Kampala’s central business district.

The hospital is the teaching hospital of the Makerere University College of Health Sciences. It is also one of the two national referral hospitals in the country, the other one being Butabika National Referral Hospital. The hospital offers services in most medical and surgical sub-specialties, in addition to dentistry, emergency medicine, pediatrics, and intensive care.( MNRH 2014)

3.4 Study population

The study will be focused on Mulago National Referral Hospital acute care unit targeting the care takers of children suffering pediatric coma and the health workers in the acute care unit of Mulago Hospital during the time of data collection.

3.4.1 Sample Size Determination

A sample size is a representative sub-group of the population that meets the research criteria. The sample will be 30 respondents who will be picked from both mothers/caretakers of the children with pediatric coma and staffs who will be present during that time at acute care unit Mulago National Referral Hospital as recommended by UNMEB.

3.4.2 Sampling Procedure

The study will employ a probability sampling technique this will mainly use simple random sampling, which will be used in selecting patient care takers.

According to Creswell, & Creswell, (2017), simple random sampling is probabilistic sampling technique in which all the samples have equal chances of being selecting in the study. This technique will also be used because it is not biased.

Using this technique the researcher will write pieces of paper and puts them in a box and then will give the respondents an opportunity to choose. The papers will be written with numbers one and two with number one meaning No and number two meaning Yes. Therefore those who choose number two will be chosen to participate in the study.

3.4.3 Inclusion Criteria.

The study will consider only adult care takers of Mulago National Referral Hospital of which both men and women who will be available at the date of data collection.

Only those care takers who will pick number two will participate.

Only those aged 20-40 years will participate.

3.5 Definition of Variables

A variable represents a measurable attribute that changes or varies across the experiment whether comparing results between multiple groups, multiple people or even when using a single person in an experiment conducted over time, In all, there are six common variable types, (Fetters, Curry, & Creswell, (2013). In this study the research will focus on only two variables mainly independent and dependent variables.

3.5.1 Independent variables

An independent variable is a variable that is manipulated to determine the value of a dependent variable.

In this study independent variable is factors contributing therefore the study indicates that there specific factors contributing to poor prognosis.

3.5.2 Dependent variable

The dependent variable is what is being measured in an experiment or evaluated.

Dependent variable can also be defined as a factor whose characteristics can be influenced by other factors.

In this study dependent variable will be poor prognosis in peadiatric coma cases.

3.6 Research Instruments

The researcher will use questionnaire for data collection, and the questions will be designed basing on the study objectives.

The questionnaires will comprise of both open and closed ended questions. The purpose of the study will be comprehensively explained to the respondents using the consent form.

The questionnaire will be used to collect quantitative data. The researcher will administer the questionnaire to the respondents. Respondents will read and answer the questionnaire themselves.

3.7 Data Collection Procedure

An introductory letter from the school administration will be obtained and presented to Mulago hospital for permission to conduct this study. The Questionnaires will be administered to the respondents whose individual rights will be respected.

3.7.1 Data Management

Data collected will be tabulated and presented using either frequency tables, graphs and or pie charts.

3.7.2 Data analysis

After collection of data, responses from the questionnaires will be studied so as to make sure that the information obtained is complete, consistent, accurate and reliable. Analysis of the data will be done using quantitative method in order to make the findings easy to understand and make conclusion to the stakeholders. Quantitative data will be processed by coding and sorting it to ensure that they match with study objectives. After this, it will be entered into computer and then will be analyzed using SPSS and later interpretation derived using mean scores which later will be used to interpret the findings. A higher mean score for a positive statement will mean that majority of the respondents tended to agree with such a statement and vice versa. For negative statements a lower mean score will mean that majority of the respondents agreed to the statement and vice versa.

3.8 Ethical Considerations.

A letter of introduction will be obtained from the Principle of Mulago School of Nursing and Midwifery introducing the researcher to the in charge of Mulago national referral hospital to be granted permission to carry out the study and will be introduced to the respondents.

Informed consent will be obtained from the respondents before enrolling into the study. Respondents will be assured of maximum confidentiality of all the information given and numbers will be used instead of respondents’ names.

3.9 Limitations of the study

Since research is an expensive exercise, financial resources might be inadequate.

There is also a problem of limited literature specific to the subject under study.

The available data is old and out-dated.  Current data will have to be obtained from Internet and recent journal articles.

Access to new material on Internet is not easy since some files require one to have a password and username in order to access them and at times not easy to understand

3.10 Dissemination of Results

A report on findings of this study will be compiled and seven copies of the report will be produced and distributed as follows;

• Mulago School of Nursing and Midwifery
• Uganda Nurses and Midwives Examination Board
• Mulago National Referral Hospital
• Researcher
• Ministry of Health Uganda
• Research supervisor

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APPENDICES

APPENDIX I: Consent Form

Factors contributing to poor prognosis in peadiatric coma cases at acute care unit Mulago Hospital

Respondent’s information and informed consent form

I, am a student at Mulago School of Nursing and Midwifery carrying out a research study on the above mentioned topic request you to kindly participate in this study by answering the questionnaire provided to you. Your participation in this study is voluntary and you are free to withdraw from it at any time you so wish.

Your participation in this study will be a 30 minutes session while filling the questionnaire. The information you give is valuable and is completely confidential and your identity will not be revealed in the findings of this study.

I have been clearly explained to the purpose and objectives of the study and I willingly consent to participate.

Respondent’s Signature: ………………………………….               Date: ………

Researcher’s Signature: ………………………………….                Date: ………

MOTHERS AND CARETAKERS IN PAEDIATRIC UNIT

APPENDIX I1: Respondent’s Questionnaire

Factors Contributing To Poor Prognosis In Peadiatric Coma Cases At Acute Care Unit Mulago Hospital.

Please answer all questions.

Do not write your name in this paper.

Tick (√) against the answer of your choice or fill in the blank spaces where applicable.

SECTION A: Demographic data

1. Age of respondents
2. a) 20-25
3. b) 26-30
4. c) 31-35
5. d) 36-40
6. Gender of respondents
7. Male
8. Female
9. Do you know how to write and read?
10. Yes
11. No
12. Level of education that you have attained?
13. No formal education
14. Adult education
15. Primary education
16. Secondary education
17. Tertiary education
18. Religion?
19. Muslim
20. Christian
21. Pagan
22. Other specify;…………………………
23. Marital status?
24. Single
26. Divorced
27. Widowed
28. Separated
29. Occupation?
30. House wife
31. Peasant
32. Pastoralist
33. Self employed
34. Employed by Government
35. Others …………………
36. What is your husband’s /wife’s Occupation?
37. Peasant
38. Pastoralist
39. Self employed
40. Employed by Government
41. None

SECTION B: Socio-Economic factors that contribute to the poor prognosis in pediatric coma

9 (i) Do you stay in an urban area?

1. Yes
2. No
3. Are you formally employed?

Yes

No

10. What is your annual income range?
11. a) >1,000,000
12. b) 1,000,001-3,000,000
13. c) <3000,001
14. How many members of the house hold do you have?.
15. a) less than 2 members
16. b) 3-4 members
17. c) 5 -7 members
18. d) More than 8 members
19. Can you afford medical treatment of your child?
20. Yes
21. No

13) How many meals do you have in a day?

1. a) Once a day
2. b) Twice a day
3. c) Three time a day
4. d) Four and above a day

14) How many children’s do you have?

1. a) Less than 3 children
2. b) 4-5 children
3. c) More than 6 children.
4. Does your culture accept seeking medical help?
5. a) Yes
6. b) No
7. Do you feel it is right to seek medical help?
8. a) Yes
9. b) No

16 (ii). If yes how often do you seek medical help when your child is sick?

1. rarely
2. whenever he/she is sick

16 (iii) If no why?

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

17) Do you help in bringing the child to medical facility whenever she/he is sick?

1. Yes
2. No
3. Did you bring the sick child to the hospital immediately?
4. Yes
5. No
6. if no why?
7. a) I did not have money.
8. b) I did not know that it is necessary.
9. c) My partner did not allow me?
10. How far is your home from the Health facility?
11. ½ a Kilometre to 1 Kilometre
12. 2 to 3 Kilometres
13. 4 and above Kilometres
14. Other specify ……………….……………………………………
15. How much do you spend on transport travelling to the Health facility?
16. 500/- to 1000/-
17. 1500/- to 2000/-
18. 3000/- and above
19. Less than 10,000 /-
20. None

SECTION C:  HEALTH FACILITY RELATED FACTORS

22. What is the quality of Health service delivery?
23. Good
24. Very good
25. Fair
26. Poor
27. I don’t know
28. According to you what are the facility/hospital based factors causing poor prognosis of children.
29. delayed refferals
30. lack of well equiped hospital
31. few medical personnel

27). Do health workers give your child the required attention?

1. a) Yes
2. b) No

28) The required medical personnel is available.

1. a) Yes
2. b) No

29) Medical workers attend to the patient with urgency?

1. a) Yes
2. b) No

THANK YOU FOR YOUR ACTIVE PARTICIPATION AND COOPERATION

.

APPENDIX IV: Observational Tool Guide

This tool guide is designed in such a way that you start observation from the time the Paediatric  unit is opened, code patients you are going to observe and note the following;-

• Time of arrival of Service providers ………………………………………………..
• Time the Department is opened …………………………………………………
• Time of arrival of other patients under your observation ……………………………………..
• How long did the first patient take to be seen by Health Worker? ………………………………………………………………………………………………………
• Time the first patient left the unit and other subsequent patients under your observation
• ……………………………………………………………………
• How did the health worker receive this first patient in coma if any (approach?) …………………………………………………………………
• What service did they start with the patient in paediatric coma? …………………………………………………………………………
• Is the infrastructure user friendly in form of health service delivery? ……………………………………………………………………………………………
• Are drugs and sundries like gloves inadequate? ………………………………………………………………………………………
• Are patients overwhelming the health workers? ………………………………………………………………………….
• List all the services provided to paediatric coma patient in the paediatric unit
• …………………………………………………………………………………………
• What are the services you see which are not provided and yet is essential to paediatric coma patients?
• ………………………………………………………………………………………
• Are health workers behaving in professional manners? …………………………………………………………………………………………………….

APPENDIX V : BUDGET.

APPENDIX VI:  WORK PLAN

The work plan for the research study will be as follows.