CHAPTER I

INTRODUCTION

Metabolic syndrome, a growing issue in women’s health, is a cluster of health

findings that increase the risk of cardiovascular events. The prevalence of Metabolic syndrome is higher
in women and linked to several conditions unique to women’s health, including polycystic ovary
syndrome, Gestational diabetes, pregnancy induced hypertension and female sexual dysfunction. women
who have Gestational diabetes mellitus during pregnancy should be assessed for Metabolic syndrome.
Early diagnosis and healthy lifestyle interventions can prove to be a lifesaver in these women.

Hormonal changes during pregnancy can trigger gestational diabetes (GDM),

which is constantly increasing. Its main characteristic is pronounced insulin resistance, but it appears to
be a multi factorial process involving several metabolic factors; taken together, the latter leads to silent or
clinically evident cardiovascular (CV) events. Insulin resistance and central adiposity are of crucial
importance in the development of metabolic syndrome, and they appear to correlate with CV risk factors,
including hypertension and atherogenic dyslipidemia. Hypertensive disease of pregnancy (HDP) is more
likely to be an accompanying co-morbidity in pregnancies complicated with GDM.

There is still inconsistent evidence as to whether or not co-existent GDM and

HDP have a synergistic effects on postpartum risk of cardiometabolic disease; however, this synergism is
becoming more accepted since both these conditions may promote endothelial inflammation and early
atherosclerosis. Regardless of the presence or absence of the synergism between GDM and HDP, these
conditions need to be dealt early enough, in order to reduce CV morbidity and to improve health
outcomes for both women and their offspring.
 Metabolic syndrome (MS) is defined as a cluster of atherosclerotic risk factors,
including abdominal obesity, elevated serum triglycerides, decreased HDL cholesterol, elevated blood
pressure, and elevated serum plasma glucose [1–3]. Insulin resistance is a central feature in the
pathogenesis of MS in addition to an unhealthy diet and physical inactivity promoting overweight and
genetic factors. As obesity increases worldwide, this leads to an increased incidence and an earlier onset
of MS . Gestational diabetes mellitus (GDM), a disorder in glucose and insulin metabolism, is one of the
most common complications in pregnancy . Depending on the population and the diagnostic criteria used,
the prevalence is roughly 1%–14% of pregnancies ; and the occurrence is increasing worldwide . The
most important risk factors for GDM are pre pregnancy overweight, high maternal age and a family
history of type 2 diabetes . Women with a history of GDM are at increased risk of developing type 2
diabetes and also Metabolic Syndrome after delivery.

Women with previous gestational diabetes (GDM) are at a higher risk of

developing type 2 diabetes later in life, probably because both conditions share common risk factors .
Thus, early detection of the modifiable risk characteristics in GDM women may prevent or delay the
disease process, thereby improving their quality of life. In an earlier study, we measured glucose
tolerance in a cohort of pregnant South Indian women. The incidence of GDM (6.2%) was considerably
greater than that reported earlier in Chennai (<1%) and Kashmir in India (3.8%), but less than that
reported in another recent study from Chennai (16%) ].

The prevalence of Metabolic Syndrome has rapidly increased in parallel

with sedentary lifestyles, leading to major healthcare costs. The chance of developing
cardiovascular disease is six to eight times higher and that of mortality related to cardiovascular
disease two to three times higher among the Metabolic Syndrome population than among healthy
controls. Gestational diabetes mellitus shares common features with Metabolic Syndrome,
including dyslipidemia, insulin resistance and endothelial dysfunction . Several studies have
revealed an increased risk of Metabolic Syndrome in association with a history of GDM .
1.1 BACKGROUND OF THE STUDY:

Women with Diabetic Mellitus have increased risk of developing Metabolic Syndrome
after delivery. Recently, The prevalence of both GDM and Metabolic Syndrome has increased world
wide, in parallel with obesity. Investigated whether the presentation of metabolic syndrome and its
clinical features among women with previous GDM differs from that among those with normal glucose
tolerating during pregnancy, and whether excess body weight affects the results. Gestational diabetes
(GDM) has long been recognized as a strong predictor for the early development of Type 2 diabetes
mellitus (T2DM) and cardiovascular disease (CVD) . Women with a history of GDM have up to a 70%
chance of developing overt diabetes in their lifetimes. The risk of cardiovascular disease in women with a
history of GDM is at least twice that of women without that history, even after controlling for age, body
mass index, smoking, Townsend (deprivation) quintile, baseline lipid-lowering medication and baseline
hypertension . Some studies show that this increased CVD risk is independent of the development of
Type 2 diabetes mellitus .

Routine testing for glucose tolerance 4–12  weeks after delivery with a 2-h 75-g oral
glucose tolerance test is standard of care following a pregnancy complicated by GDM . Early postpartum
testing is done to distinguish women who had undiagnosed pre-existing diabetes from those who only
had gestational diabetes . For those with normal oral glucose tolerance test results postpartum, the
American College of Obstetricians and Gynecologists (ACOG) recommends assessment of glycemic
status every 1–3 years . The American Diabetes Association (ADA) recommends repeat testing of
glucose metabolism every 3 years .The Endocrine Society calls for “periodic glucose assessment” at
unspecified intervals .In Sweden, England and other countries, annual repeat testing is recommended .

Adherence to postpartum testing guidelines is notoriously poor. Only 50–60% of

women diagnosed with GDM, who are seen for postpartum care, are administered any postpartum
glucose testing in the year following delivery. Even more do not get tested because they do not return for
postpartum care. One recent study found that almost half of all postpartum women are not seen for any
postpartum care within 99 days of delivery, even when such services were available for free]. Patients
may not return for postpartum care because they are anxious about their condition or the visit costs. Low
testing rates may also be explained by the fact that significant gaps exist in clinician knowledge and
practice relating to postpartum care for women who have had GDM .The complexity of the oral glucose
tolerance test itself or a failure of clinicians to order the test may also contribute. Inadequate coordination
of care between the woman’s obstetrician and her primary care provider has also been identified as a
barrier to timely postpartum glucose tolerance testing ]. This lack of testing is so prevalent that some
experts have suggested oral glucose tolerance testing be done while the patient is still hospitalized on
postpartum day two.

Longer term adherence to screening test recommendations is also not common, even
though abnormalities in glucose tolerance can develop rapidly in the months and years following
delivery]. In a 15-year follow-up study of women with prior GDM, the authors observed that most
women did not seek medical care until they developed clinical symptoms of diabetes .

Most professional attention has been focused on the high lifetime risks that women
with a history of GDM face for developing T2DM. Even though these women are also at high lifetime
risk for cardiovascular disease, partial or complete formal testing for cardiovascular risks for women with
history of GDM is not routinely recommended by any professional organization . O’Higgins found that
women previously diagnosed with gestational diabetes mellitus are not even routinely screened for
cardiovascular risk factors. Metabolic syndrome, which is commonly used as a marker for cardiovascular
risk in the general population, is not listed in any postpartum practice guidelines for women following
pregnancy complicated by GDM. The latest guidance documents from both ACOG and ADA make no
mention of postpartum CVD risk assessment.That lack of direction is reflected in practice; screening for
cardiovascular risk factors such a smoking, high body mass index, hypertension and dyslipidemia occurs
to be no more often among women who had GDM than it is among control women.

In face of the rapid deterioration of glucose tolerance in women with a history of

CVD in the months immediately following delivery, it was hypothesized that metabolic syndrome might
also develop among women with GDM in their recent pregnancy. This study examines the prevalence of
MS immediately postpartum and within 12 months of delivery.

With the successful conquest of many of the old infectious diseases in the world,
non-communicable diseases (NCD) have become the major cause of morbidity and mortality not only in
the developed world but also in the underdeveloped countries. Among all these NCD, metabolic
syndrome had been the real scourge globally. Metabolic syndrome (MS), also variously known as
syndrome X, Insulin resistance, etc. in the literature, is really not a single disease but a constellation of
cardiovascular disease risk factors and had been defined slightly differently by various organizations.
Three most popular definitions [1] used for surveys and health care plan are:

WHO 1999:

Presence of insulin resistance or glucose > 6.1 mmol/L (110 mg/dl), 2 h glucose > 7.8 mmol (140 mg/dl)
(required) along with any two or more of the following:

1. HDL cholesterol < 0.9 mmol/L (35 mg/dl) in men, < 1.0 mmol/L (40 mg/dl) in women

2. Triglycerides > 1.7 mmol/L (150 mg/dl)
3. Waist/hip ratio > 0.9 (men) or > 0.85 (women) or BMI > 30 kg/m2
4. Blood pressure > 140/90 mmHg

NCEP (National Cholesterol Education Program) ATP3 2005:

Presence of any three or more of the following:

1. Blood glucose greater than 5.6 mmol/L (100 mg/dl) or drug treatment for elevated blood glucose
2. HDL cholesterol < 1.0 mmol/L (40 mg/dl) in men, < 1.3 mmol/L (50 mg/dl) in women or drug
treatment for low HDL-C
3. Blood triglycerides > 1.7 mmol/L (150 mg/dl) or drug treatment for elevated triglycerides
4. Waist > 102 cm (men) or > 88 cm (women)
5. Blood pressure > 130/85 mmHg or drug treatment for hypertension

IDF (International Diabetes Federation) 2006:

Waist > 94 cm (men) or > 80 cm (women) along with the presence of two or more of the following:

1. Blood glucose greater than 5.6 mmol/L (100 mg/dl) or diagnosed diabetes

2. HDL cholesterol < 1.0 mmol/L (40 mg/dl) in men, < 1.3 mmol/L (50 mg/dl) in women or drug
treatment for low HDL-C
3. Blood triglycerides > 1.7 mmol/L (150 mg/dl) or drug treatment for elevated triglycerides
4. Blood pressure > 130/85 mmHg or drug treatment for hypertension
 Other organizations like the American Association of Clinical Endocrinologist (AACE)
2003 and the European Group for the Study of Insulin Resistance (EGIR) used slightly different
definitions but they are not as commonly used.

YUHONG Xu (2014) performed a systemic review and meta-analysis to assess the

association between these two conditions. The aim was to better understand the risk of MS with prior
gestational diabetes, shows the results that women with GDM had a significantly higher risk of MS than
those who had a normal pregnancy (OR, 3.96;95% CI,2.99 to 5.26), but had significant heterogeneity
( I2 = 52.6%). The effect remind robust( OR, 4.54; CI 3.78 – 5.46) in the sub group of Caucasians, but no
association ( OR, 1.28; 95% CI 0.64 – 2.56) was found in Asians. Heterogeneity was reduced BMI
matched group I2=14.2%, BMI higher in the GDM group I2 =13.2% in subgroup of BMI. In addition
mothers with higher BMI in the GDM group had higher risk of MS than those in the BMI matched group

Hence BMI higher in GDM group OR,5.39;95% CI,4.47 – 6.50, BMI matched group
OR, 2.53; 95% CI,1.88- 3.41). This meta-analysis demonstrated increased risk of MS in GDM mothers,
particularly in Caucasian and obese mothers.
Gestational diabetes mellitus is a perfect window of opportunity for the prevention of
DM in two generations , and its incidence is increasing in our country . Knowledge of the condition
among mothers will translate into prevention and early diagnosis of the diseases.

1.2 NEED FOR THE STUDY

“The past you cannot change, but today is yours. Live it to the fullest of your awakened
awareness”. Nowadays pregnant mothers are unaware about Metabolic syndrome which is more
prevalent. A substantial proportion of the worldwide burden of Metabolic Syndrome could be prevented
through the application of existing knowledge and by implementing programs for control and early
detection and treatment is important to prevent long term sequel and to develop a positive attitude and
follow healthy life style, as well as public health campaigns promoting physical activity and a healthier
dietary intake. Worldwide the incidence of overweight, type 2 iabetes and other conditions associated
with cardiovascular disease is rapidly increasing and having a major impact on public health. Therefore,
knowledge of pathogenesis and risk groups is urgently needed to target preventive strategies. Metabolic
syndrome is a cluster of metabolic disorders associated with increased risk of cardiovascular disease.
 An research result says that women with a history of gestational diabetes had a significantly
higher risk of Metabolic syndrome(MS) than those who had a normal pregnancy.

SACHDEV MEENAKSHI (2019) cross-sectional study, randomly selected adults (aged 20

years or more) attending the diabetology or cardiology OPD were included, Metabolic Syndrome was
classified based on the modified Adult Treatment Panel(ATP-III) and International Diabetes Federation
(IDF)criteria. Results, A total of 668 patients were included . A cross several subgroups, around two-
thirds had MetS and low high-density lipoprotein was the major contributing factor for Metabolic
Syndrome. High Prevalence of Metabolic Syndrome found Metabolic Syndrome is highly prevalent
among patients, identifying the high risk individuals using simple approach and act upon the possible risk
could prevent complications.

FATEMEH NASIRI-AMIRI1 , MAHDI SEPIDARKISH2(2019) The effect of exercise

on the prevention of gestational diabetes in obese and overweight pregnant women the standardized mean
difference (SMD) with 95% confidence interval (CI) for each study was calculated. Out of 5107 papers
identified, eight papers with 1441 participants included in meta-analysis. In the intervention group, 143
and in the control group, 196, pregnant women had diabetes. The RR of gestational diabetes was 0.76. In
studies that the time for the intervention was three times a week or less, effect of intervention was
significant in reducing the incidence of diabetes. However, in studies with repeat of intervention was
more than three times a week, the effect of intervention between two intervention and control groups was
not different. Concluded that the exercise activities, alone, in obese or overweight pregnant women did
not have a significant effect on the overall incidence of GDM, but considering the effect measure, the
incidence of GDM was 24% lower in the intervention group than control group. This difference is
considerable in the two groups. As the systematic review literatures both represent the information gap on
the research subject and pave the way for further studies so it seems that there is a need for more
randomized controlled trials so that we can make a complete conclusion on the type, intensity and
duration of exercise in preventing GDM.

ALKA PAWALIA (2017) Conducted an experimental study with pregnant women

having singleton pregnancy of >16 weeks of gestation, BMI>18.5 Kg/m2 and having a mobile phone.
They were randomly divided into 3 groups (i.e.) exercise , exercise with diet advise and control group.
Exercise groups attended weekly antenatal exercise sessions at the hospital during pregnancy; diet group
received regular diet counseling followed by mobile text-messages to maintain adequate diet. The data
was analyzed using IBM-SPSS software. Resulted that Exercise groups gained less weight then control.
Similarly, had mean GWG less as compared to control group though not statistically significant. The
mean WC changes were significant amongst the groups with the exercise groups having least gain in WC
( p < 0.05). Concluded Adopting an active lifestyle along with proper diet care can prevent development
of abdominal obesity and metabolic syndrome in Indian pregnant women which could prevent them from
other associated lifestyle diseases in future.

TINNA VILMI(2015) Performed hospital – based cohorts study among 120

women with a history of GDM and 120 women with a history of normal glucose metabolism during
pregnancy. They all underwent physical examination and had baseline blood samples taken. The risk of
developing Metabolic syndrome after pregnancy complicated by GDM was significantly higher than after
normal pregnancy, 19 vs.8 cases . He concluded that Cardiovascular risk factors were common in
participants with high BMI than in those with previous GDM.

JATA PUHKALA( 2013) followed study with 150 women of one year
postpartum (mean age 33.1 years, BMI 27.2kg/m2) for evaluating Metabolic syndrome. Result shows the
prevalence of Metabolic syndrome was 18% according to the International Diabetes Federation(IDF)
criteria and 16 % according to National Cholesterol Education Program(NCEP) criteria of Metabolic
Syndrome and concluded that nearly one-fifth of the women with an increased risk of GDM in early
pregnancy fulfilled the criteria of Metabolic syndrome at one year postpartum. The most important
factors associated with Metaboilc Syndrome was pregnancy overweight.

The investigator found from the above studies that antenatal mothers with GDM are prone to get
Metabolic syndrome in their postpartum and have lack of knowledge regarding Metabolic Syndrome and
its prevention. Improving knowledge on prevention and attitude of Metabolic Syndrome can prevent
them from the risk. Hence the researcher felt the need to educate the antenatal mothers with GDM
regarding Metabolic Syndrome and its prevention through Educational Intervention package.
1.3 STATEMENT OF THE PROBLEM
A study to assess the effectiveness of Educational Intervention Package on knowledge and attitude
regarding prevention of Metabolic Syndrome among antenatal mothers with GDM at SRM
General Hospital.

1.3.1 OBJECTIVES

• To assess the pretest & post test level of knowledge and attitude on prevention of Metabolic
Syndrome among antenatal mothers with GDM.

• To determine the effectiveness of Educational Intervention Package on prevention of Metabolic

Syndrome among antenatal mothers with GDM.

• To correlate the knowledge with attitude on prevention of Metabolic Syndrome among antenatal
mothers with GDM.

• To associate the pre test and posttest level of knowledge and attitude on prevention of Metabolic
Syndrome among antenatal mothers with GDM with their demographic variables.

1.4 OPERATIONAL DEFINITIONS

1.4.1 Assess: In this study, assess it refers to the statistical determination of the level of knowledge
and attitude regarding prevention of Metabolic Syndrome among antenatal mothers before and after an
Educational Intervention Package at selected hospital, Kattankulathur.
1.4.2 Effectiveness: In this study, it refers to the extent to which the Educational Intervention Package
has desired effect in gaining knowledge and attitude regarding prevention of Metabolic Syndrome in
terms of difference between pretest and posttest level of attitude by the Likert scale and knowledge
measured by structured questionnaire developed by the investigator.
1.4.3 Knowledge regarding Prevention of metabolic syndrome: In this study, it refers to the facts, the
information acquired through education by antenatal mothers regarding prevention of Metabolic
Syndrome as elicited through a structured questionnaire developed by the investigator.
1.4.4 Educational Intervention Package: Educational Intervention Package means the act of
providing knowledge. It refers to imparting the knowledge regarding prevention of Metabolic
Syndrome by means of power point presentation which includes definition , incidence , clinical
manifestation, prevention, management ,complication of Metabolic syndrome for 30 minutes which was
about 5 groups with 20 antenatal mothers in each group and clarify the doubts.
1.4.5 Attitude : In this study attitude refers to identify individuals response on prevention of metabolic
syndrome is assessed with Likert scale developed by the investigator.
1.4.6 Antenatal mothers: In this study it refers to the mothers who have Gestational Diabetes Mellitus
during their pregnancy.

1.5 RESEARCH HYPOTHESIS:

RH1 : There will be a significant difference between pretest and post test level of knowledge and attitude
regarding Prevention of Metabolic Syndrome.

RH2: There will be a significant relationship between knowledge with attitude on Prevention of
Metabolic Syndrome.

RH3: There will be a significant association on level of knowledge and attitude regarding prevention of
Metabolic Syndrome with their demographic variables.

1.6 ASSUMPTIONS

• All antenatal mothers with GDM may not aware about Metabolic syndrome disorder.

• All antenatal mothers with GDM will not have increased body mass index.

• Educational intervention package may improve the knowledge and attitude level on prevention
of Metabolic Syndrome among antenatal mothers with GDM .

1.7 DELIMITATIONS

The study is delimited to a period of 4 weeks of data collection

1.8 CHAPTERIZATION

CHAPTER 1 : Outline the backgrond of the study, need for the study, statement of the problem,
objectives of the present study, operational definitions, hypothesis, assumptions and delimitations.

CHAPTER 2 : Deals with theoretical information, empirical information and conceptual frame
work.
 CHAPTER II

REVIEW OF LITERATURE

This chapter deals with an extensive survey of related literature. An extensive review of
literature was done by the investigator to carry broad foundation for this study. A review is a critical
summary of the research on a topic of interest, often prepared to put research problem in contest. For
better conceptualization the chapter is classified as part I and part II.

2.1 EMPERICAL LITERATURE

The literature reviewed has been presented under the following headings:

1. Studies related to prevalence of Metabolic Syndrome

2. Studies related to prediction of developing Metabolic Syndrome after Gestational Diabetes
3. Studies related to knowledge regarding Metabolic syndrome

1. Studies related to prevalence of Metabolic Syndrome

MARIA DO CARMO PINTO LIMA, ALINE SUELY , ET AL( 2019) Evaluated
the prevalence of metabolic syndrome (MS) and the main associated maternal factors in women without
pre-gestational conditions, in early pregnancy and in the immediate postpartum with the diagnostic
criteria, anthropometric measures, blood pressure, metabolic profile, and visceral and subcutaneous fat
thickness (by ultra sonography) were collected from the pregnant woman. The student’s t-test was used
to compare the prevalence of MS and its components in the 16th week and in the postpartum. Multiple
logistic regression was performed to identify the principal factors associated with the syndrome. Resulted
prevalence of the MS was 3.0% in early pregnancy and 9.7% postpartum (p=0.01). Following multiple
logistic regression, the pre pregnancy body mass index (BMI) (p=0.04) and high-density lipoprotein
cholesterol (HDL-c) (p=0.02) remained associated with MS at 16 weeks, and triglyceride levels evaluated
in postpartum evaluated in postpartum (p<0.001) with MS in postpartum. Concluded the frequency of the
MS was high in the immediate postpartum. The factors associated were pre pregnancy BMI and HDL-c
at the 16th week, as well as triglyceride levels postpartum.
 NEETU K. SODHI AND ANITHA L. NELSON (2018): conducted a study to
estimate the prevalence of metabolic syndrome in women with GDM in recent pregnancy who were
followed for at least 1 year postpartum to quantify their cardiovascular risks as a retrospective study of
women who were diagnosed with GDM in a public hospital and followed for at least 1 year after delivery
and who had tests performed at a minimum 4–12 weeks postpartum and 6 and 12 months postpartum.
Primary outcomes were prevalence of glucose tolerance abnormalities and metabolic syndrome (MS)
defined by two prevailing sets of diagnostic criteria. Result says One hundred fifty-one indigent,
primarily Latina women who had been diagnosed in their last pregnancy with GDM comprised the study
population. At the first visit postpartum, 4.7% were found to have overt diabetes and between 24 and
31% met the criteria for MS. By the end of 12 months, another 14.5% were diagnosed with overt
diabetes, and 38.5% had pre diabetes. An additional 12–25% of the woman who had not had MS at
baseline developed MS by the end of the 1-year follow-up. Concluded the high prevalence of MS among
women with recent history of GDM immediately postpartum and its rapid development in the following
year, further research is needed to enable the development of practice guidelines that will define
appropriate short and long-term evaluations needed to assess risk for cardiovascular disease in these
women.

NEHA A KAJALI AND VAMAN KHADHILKAR (2017): conducted a study to

find out the changes in maternal body condition postpartum (PP) to 1-year PP with reference to their pre
pregnancy body mass index (BMI) status as a 1-year follow -up study. Result shows Forty one women
were classified in Group A with normal pre pregnancy BMI (20.4 ± 2.0 kg/m2 ) and 24 women in Group
B with overweight/obese (OW/OB) pre pregnancy BMI (26.1 ± 1.9 kg/m2 ). At 1 year, 75% of women
returned to normal BMI in Group A, whereas all 100% of women from Group B remained in OW
category at 1-year PP. Nearly 43% of Group B women showed the presence of at least two metabolic
syndrome risk factors as compared to 36% in Group A at 1 year. Concluded that Women with OW/OB
pre pregnancy BMI accumulated higher visceral fat with a higher prevalence of metabolic risk factors at
1-year PP. Study underlines the importance of maintaining BMI status in reference range in reproductive
years.
 JUSTIN XAVIER MOORE, MPH; NINAD CHAUDHARY, MB, BS(2017) : conducted
a study to estimate the prevalence of metabolic syndrome overall, by race and sex, and to assess trends
in prevalence from 1988 through 2012. analyzed data from the National Health and Nutrition
Examination Survey (NHANES) for 1988 through 2012 ,among US adults aged 18 years or older, the
prevalence of metabolic syndrome rose by more than 35% from 1988–1994 to 2007–2012, increasing
from 25.3% to 34.2%. During 2007–2012, non-Hispanic black men were less likely than non-Hispanic
white men to have metabolic syndrome (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66–0.89).
However, non-Hispanic black women were more likely than non-Hispanic white women to have
metabolic syndrome (OR, 1.20; 95% CI, 1.02–1.40). Low education level (OR, 1.56; 95% CI, 1.32–1.84)
and advanced age (OR, 1.73; 95% CI, 1.67–1.80) were independently associated with increased
likelihood of metabolic syndrome during 2007–2012.concluded that Metabolic syndrome prevalence
increased from 1988 to 2012 for every socio demographic group; by 2012, more than a third of all US
adults met the definition and criteria for metabolic syndrome agreed to jointly by several international
organizations

TOMMI VASANKARI AND RITTA LUOTO (2013) conducted a study as a part of a

GDM prevention trial. At one year postpartum, 150 women (mean age 33.1 years, BMI 27.2 kg/m 2) were
evaluated for MS.  Result shows The prevalence of MS was 18% according to the International Diabetes
Federation (IDF) criteria and 16% according to National Cholestrol Education Program (NCEP) criteria.
Of MS components, 74% of participants had an increased waist circumference (≥80 cm). Twenty-seven
percent had elevated fasting plasma glucose (≥5.6 mmol /L), and 29% had reduced HDL cholesterol
(≤1.3 mmol/L). The odds ratio for the occurrence of MS at one year postpartum was 3.0 (95% CI 1.0–
9.2) in those who were overweight before pregnancy compared to normal weight women. Concluded as
Nearly one-fifth of the women with an increased risk of GDM in early pregnancy fulfilled the criteria of
MS at one year postpartum. The most important factor associated with MS was pre pregnancy
overweight. Weight management before and during pregnancy is important for preventing MS after
delivery.
 AMANDA FRIEND , LEONE CRAIGE ,ET AL (2013) study was to describe the
prevalence of metabolic syndrome in children allowing for differences in metabolic syndrome definitions
as a systematic review of the OVID, EMBASE, and CINAHL databases, capturing details of overall
prevalence and prevalence within groups categorized by obesity, gender, age, and ethnicity. Resulted  In
all, 378 studies published since 2003 were identified, and of these 85 papers were included in the present
review. When all studies were considered, the median prevalence of metabolic syndrome in whole
populations was 3.3% (range 0%–19.2%), in overweight children was 11.9% (range 2.8%–29.3%), and in
obese populations was 29.2% (range 10%–66%). Within-study analyses confirmed higher prevalence for
obese compared to overweight (P=0.012) and obese compared to non obese, non overweight children
(P<0.001). Within-study analyses also revealed higher median metabolic syndrome prevalence for boys
compared to girls (5.1% versus 3.0%, P<0.001) and also in older compared with younger children (5.6%
versus 2.9%, P=0.001). Limited evidence was found to suggest differences between ethnic groups, and
there were insufficient studies to determine whether metabolic syndrome prevalence was increasing over
time. Concluded This is the first systematic review of all of the relevant literature. It describes the
magnitude of associations between metabolic syndrome and obesity, age, and gender. We find evidence
that ethnicity and geography may be important to metabolic syndrome prevalence in children and these
associations require further study

AL.Ghareeb (2010) conducted a study to estimate the prevalence of Metabolic

Syndrome with cross sectional research design n was used and 495 participated and were interviewed in
detail about their social demographic, socio-economic, lifestyle and health disease status . The study
analysis showed that total number who met the ATP III guidelines for diagnosis of metabolic syndrome
was ( 39.79%) b and Metabolic Syndrome significantly increased with age. The study concluded that the
prevalence of metabolic syndrome is high and it recommended that doctors in PHC setting should be
aware of the risk factors related to metabolic syndrome with the view point of offering appropriate
treatment.

RAVI RETNAKARAN (2010) Hypothesized that gestational dysglycemia

may be associated with an unrecognized latent metabolic syndrome. Thus, we sought to evaluate the
relationship between gestational glucose tolerance status and postpartum risk of metabolic syndrome as a
prospective cohort study, 487 women underwent oral glucose tolerance testing in pregnancy and cardio
metabolic characterization at 3 months postpartum. The ante partum testing defined three gestational
glucose tolerance groups: GDM; gestational impaired glucose tolerance (GIGT); and normal glucose
tolerance (NGT). The postpartum prevalence of IDF metabolic syndrome progressively increased from
NGT (10.0%) to GIGT (17.6%) to GDM (20.0%) (over all P = 0.016). The same progression was
observed for AHA/NHLBI metabolic syndrome (NGT, 8.9%; GIGT, 15.4%; and GDM, 16.8%;
overall P = 0.046). On logistic regression analysis, both GDM (odds ratio, 2.05; 95% confidence interval,
1.07–3.94) and GIGT (odds ratio, 2.16; 95% confidence interval, 1.05–4.42) independently predicted
postpartum metabolic syndrome and concluded both GDM and mild glucose intolerance in pregnancy
predict an increased likelihood of metabolic syndrome at 3 months postpartum, supporting the concept
that women with gestational dysglycemia may have an underlying latent metabolic syndrome.

JACQUELINE AND CAROLINE (2009) conducted a study to examine the incidence

of diabetes mellitus and the factors Associated with diabetes mellitus. It was a cohort study in which 630
women of gestational diabetes mellitus were examined of these 526 were available foe follow up after 5
years and underwent a 2 hour OGTT. The study analysis showed that the incidence of DM was 37 % and
MS was 60%. The study concluded that increased DM and CV disease risks in women with previous
GDM

L.CHATZI, E.PLANA,ET AL (2009) conducted a study to determine whether or

not maternal metabolic syndrome in early pregnancy in women without previous diabetes is associated
with the development of gestational diabetes mellitus (GDM). Maternal fasting serum samples were
collected and blood pressure measured before gestational week 15. The metabolic syndrome in early
pregnancy was defined according to NHLBI/AHA criteria. Pregnant women were screened for GDM
between weeks 24 and 28 of gestation, as defined by Carpenter and Coustan criteria. Result says Women
with the metabolic syndrome were at high risk of GDM . Among the components of the metabolic
syndrome, the most significant risk factors were impaired fasting glucose and pre-pregnancy obesity. A
10-mmHg rise in systolic and diastolic blood pressure increased the relative risk of GDM by 49% and
34%, respectively, whereas a 1-unit increase in pre-pregnancy BMI increased the relative risk of GDM
by 6%.concluded with the findings suggest that women with the metabolic syndrome in early pregnancy
have a greater risk of developing GDM.
2. Studies related to prediction of developing Metabolic Syndrome after Gestational Diabetes
Mellitus.

IMRAN KUTCHI, PERIASAMY CHELLAMMAL (2020) conducted a study with the aim
to assess obesity-related adverse maternal, neonatal and perinatal outcomes using new Asian Indian
guidelines, between Pregnant women up to 16-week gestation as a comparative study analysis with their
complication. Result was a significant increase in risk among obese mothers compared to non-obese
mothers for maternal complications like hypertensive disorders of pregnancy, gestational diabetes
mellitus and insulin requirement and postpartum hemorrhage. Also, there was a significant increase in
risk among obese mothers compared to non-obese mothers for foetal and perinatal complications.
concluded that obesity defined by Asian Indian guidelines (BMI ≥ 25 kg/m2) is associated with adverse
pregnancy outcomes at odds comparable to western studies with obesity taken as BMI ≥ 30 kg/m2.

ELIZABETH W. DEHMER , MILIND A. PHADNIS(2018) conducted to evaluated whether

Gestational diabetes mellitus (GDM) is associated with increased risk for diabetes mellitus, metabolic
syndrome, and cardiovascular disease., controlling for pre pregnancy risk factors for both conditions with
Prospective cohort design among 2,747 women (aged 18-30 years) enrolled in the Coronary Artery Risk
Development in Young Adults (CARDIA) Study in 1985 to 86, they studied 820 who were nulli paras at
enrollment, delivered at least 1 pregnancy longer than 20 weeks’ gestation, and had kidney function
measurements during 25 years of follow-up. predictor that GDM was self-reported by women for each
pregnancy. By outcome CKD was defined as the development of estimated glomeular filtration rate
(eGFR) < 60 mL/min/1.73 m2 or urine albumin-creatinine ratio ≥ 25 mg/g at any one CARDIA
examination in years 10, 15, 20, or 25. Resulted During a mean follow-up of 20.8 years, 105 of 820
(12.8%) women developed CKD, predominantly increased urine albumin excretion (98 albuminuria only,
4 decreased eGFR only, and 3 both). There was evidence of a GDM-race interaction on CKD risk (P = 
0.06). Among black women, the adjusted HR for CKD was 1.96 (95% CI, 1.04-3.67) in GDM compared
with those without GDM. Among white women, the HR was 0.65 (95% CI, 0.23-1.83. concluded GDM
is associated with the subsequent development of albuminuria among black women in CARDIA.
 AKINCII AND CLENTTIC (2010) conducted a study to determine the predictors
of subsequent development of metabolic syndrome (MS) in women with previous gestational diabetes
mellitus (GDM) with One hundred sixty-four consecutive women with previous GDM were evaluated.
Sixty-five lean women with negative screening for GDM were included as a control group .Subjects were
evaluated for diagnosis of MS according to criteria of the National Cholesterol Education Program and
the International Diabetes Federation. Tests were performed including a 75-g oral glucose tolerance test
(OGTT), fasting insulin, lipids, plasma fibrinogen, blood pressure, and body measurements. The
homeostasis model assessment score was calculated. result says that The MS prevalence was higher in
women with previous GDM, according to both definitions. Univariate analysis showed that pre
pregnancy obesity, weight gain during follow-up, and fasting glucose level at the OGTT of the index
pregnancy were predictors of developing MS. Multivariate analysis showed that fasting glucose level
>100 mg/dL at the OGTT of the index pregnancy was an independent predictor of the MS development
and with conclusion they suggest that early prediction of women with previous GDM who are at high
risk for developing MS is possible, and it is vital to prevent MS-related complications.
SENA YESEI (2009) conducted a study on prediction of developing Metabolic
Syndrome after Gestational Diabetes Mellitus. It was a qualitative approach and an experimental design.
The sampling technique used was simple random sampling in which 164 women with previous
gestational diabetes were evaluated after a mean follow up of 40 months from the index pregnancy. Data
analysis findings revealed that univariate analysis showed pregnant obesity, weight gain during the
follow up and fasting glucose level at the oral glucose tolerance test ( OGTT) of the index pregnancy
were the predictors of developing Metabolic Syndrome. Multivariate analysis showed that fasting
glucose level of >100mg/dl at the OGTT of index pregnancy was an independent predictor for the
development of metabolic syndrome. The study concluded that early prediction of women with previous
gestational diabetes mellitus who are at risk of developing metabolic syndrome related complications.
 BARIS AKINCI, M.D.,A AYGUL CELTIK, M.D(2010) Conducted controlled clinical
study to determine the predictors of subsequent development of metabolic syndrome (MS) with
previous GDM were evaluated after a mean follow-up of 40.54 months from index pregnancy. Subjects
were evaluated for diagnosis of MS according to criteria of the National Cholesterol Education Program
and the International Diabetes Federation. Tests were performed including a 75-g oral glucose tolerance
test (OGTT), fasting insulin, lipids, plasma fibrinogen, blood pressure, and body measurements. The
homeostasis model assessment score was calculated and Result(s) says MS prevalence was higher in
women with previous GDM, according to both definitions. Univariate analysis showed that prepregnancy
obesity, weight gain during follow-up, and fasting glucose level at the OGTT of the index pregnancy
were predictors of developing MS. Multivariate analysis showed that fasting glucose level >100 mg/dL at
the OGTT of the index pregnancy was an independent predictor of the MS development. Concluded that
early prediction of women with previous GDM who are at high risk for developing MS is possible, and it
is vital to prevent MS-related complications.

JŪRATĖ B. BUINAUSKIENĖ(2012) conducted retrospective study, with the obese

women with GDM were compared with the women with GDM and normal weight to analyze the impact
of obesity on women with gestational diabetes mellitus (GDM) and the association of obesity and GDM
with the metabolic syndrome. Result was Significantly higher fasting glycemia before the oral glucose
tolerance test (5.2±1.1 mmol / L vs. 4.5±0.8 mmol / L, P<0.00001) and higher frequency of hypertensive
disorders of pregnancy (26.2% vs. 9.4%, P=0.0003) were found in obese women with GDM than in
GDM women of normal weight. These women needed insulin therapy more often (18.9% vs.
8.3%, P=0.007). Also 31 (13.3 %) of them had chronic hypertension as compared with 3.1% in women of
normal weight (P=0.003). These 31 women had three components necessary for diagnosing of metabolic
syndrome according to the World Health Organization—impaired glucose tolerance, obesity, and
hypertension. No difference in gestational age and mean weight of their newborns was found, but
newborns of obese GDM women with metabolic syndrome components more often were significantly
macrosomic with features of diabetic fetopathy and ha d more often symptoms of hypoglycemia after
birth. Concluded The presence of obesity and GDM ha s a significant impact on both maternal and fetal
complications.
 NOUSITTOU P,MONBARAN D, ET AL(2005) conducted to investigate the
relationships between gestational diabetes mellitus (GDM) and the metabolic syndrome (MS), as it was
suggested that insulin resistance was the hallmark of both conditions. To analyse post-partum screening
in order to identify risk factors for the subsequent development of type 2 diabetes mellitus (DM) as a
retrospective analysis. Pre-pregnancy obesity, hypertension and dyslipidaemia were recorded as
constituents of the MS. Result says For 5788 deliveries, 159 women (2.7%) with GDM were identified.
Constituents of the MS were present before GDM pregnancy in 26% (n = 37/144): 84% (n = 31/37) were
obese, 38% (n = 14/37) had hypertension and 22% (n = 8/37) had dyslipidaemia. Gestational
hypertension was associated with obesity (OR = 3.2, P = 0.02) and dyslipidaemia (OR = 5.4, P=0.002).
Seventy-four women (47%) returned for post-partum OGTT, which was abnormal in 20 women (27%):
11% (n = 8) had type 2 diabetes and 16% (n = 12) had impaired glucose tolerance. Independent
predictors of abnormal glucose tolerance in the post-partum were: having > 2 abnormal values on the
diagnostic OGTT during pregnancy and presenting MS constituents (OR = 5.2, CI 1.8-23.2 and OR =
5.3, CI 1.3-22.2). concluded In one fourth of GDM pregnancies, metabolic abnormalities precede the
appearance of glucose intolerance. These women have a high risk of developing the MS and type 2
diabetes in later years. Where GDM screening is not universal, practitioners should be aware of those
metabolic risks in every pregnant woman presenting with obesity, hypertension or dyslipidaemia, in order
to achieve better diagnosis and especially better post-partum follow-up and treatment.

BONEY CM,VERMA A,ET AL( 2005)  examined the development of MS among large-
for-gestational-age (LGA) and appropriate-for-gestational age (AGA) children with the major
components of MS (obesity, hypertension, dyslipidemia, and glucose intolerance) were evaluated in a
longitudinal cohort study of children at age 6, 7, 9, and 11 years who were LGA (n = 84) or AGA (n =
95) offspring of mothers with or without gestational diabetes mellitus (GDM). Result has no differences
in baseline characteristics (gender, race, socioeconomic status, and maternal weight gain during
pregnancy) for the 4 groups except for birth weight, but There was a trend toward a higher incidence of
insulin resistance, defined as a fasting glucose/insulin ratio of <7, in the LGA/GDM group at 11
years.concluded that LGA offspring of diabetic mothers were at significant risk of developing MS in
childhood. The prevalence of MS in the other groups was similar to the prevalence (4.8%) among white
adolescents in the 1988-1994 National Health and Nutrition Examination Survey.
3.Studies related to knowledge regarding metabolic syndrome
QUIN WANG AND SEK YEING (2019) A cross-sectional, descriptive study was
conducted among hospitalized patients with at least one cardio metabolic risk factor to assess the MS
knowledgelevel(through MS Knowledge Scale, MSKS) and examined the potential predictors by
regression analysis. A total of 204 patients aged 58.5 ± 10.1 years (55% males) participated in this study.
The majority of participants had no history of hypertension (54%), dyslipidemia (79%), or diabetes
(85%). However, 56% of these participants had at least three cardio metabolic risk factors, indicating the
presence of MS. The average MSKS was very low (mean = 36.7 ± 18.8, possible range = 0–100),
indicating the urgent needs of MS education in current practice. Predictors of better MS knowledge
included higher educational level, history of dyslipidemia, and normal high-density lipoprotein
cholesterol (F (8, 195) = 9.39, adjusted R2 = 0.192, p < 0.001). In conclusion, the adults with cardio
metabolic risk factors are at risk of developing MS, but with a low level of knowledge. Specific health
education on MS should be provided, particularly for those with limited formal education or inadequate
lipid management.
KUSEMWA P, DOREEN MACHERERA MUKONA, ET AL(2018) : study to
examine the relationship between knowledge of gestational diabetes mellitus (GDM) and self-care
practice to prevent GDM in pregnant women with a Descriptive correlational design at Chitungwiza
Central Hospital Antenatal Clinic. With a random sample of 200 pregnant women aged 18 - 45 years.
Data Data were collected using a structured interview schedule that had “demographic”, “knowledge of
GDM” and “self-care practice” sections. Data were analysed the Statistical Package for Social Sciences
(SPSS) version 20. Descriptive statistics were used to analyse data on demographics, knowledge levels
and self-care practice. Inferential statistics were used to analyse the relationship between knowledge and
self-care practice. In result Mean knowledge on GDM was 20.28%. Mean score for self-care practice was
49.6%. There was a moderate positive correlation (r = 0.499; p < 0.01) between knowledge and self-care
practice. Regression analysis (R2 = 0.246, p < 0.001) indicated that knowledge explained 24.6% of the
variance observed in self-care practice. Conclusions: Knowledge of GDM was very poor as well as self-
care practice. However, self-care practice on GDM improved with increasing knowledge of GDM. It is
essential to upscale health education on GDM in pregnant women .
 SALLY WAI SZE LO AND SEK YING CHAIR ( 2015 ) conducted a study to
assess knowledge of metabolic syndrome (MS) as a cross-sectional design using a validated knowledge
of MS (K-MS) scale comprising 10 multiple-choice questions. The scores of K-MS can range from 0 to
100. The result say The mean K-MS score was 44.9 out of 100; most participants (61%) scored below 50,
indicating a poor level of MS knowledge, had a lower level of education or were unemployed scored the
lowest. Study concluded Acquiring knowledge of MS is crucial for preventing the development of type 2
diabetes and cardiovascular diseases. However, adults in a community setting exhibited poor
understanding of MS. Public health efforts regarding primary prevention of cardiovascular diseases
should be targeted at improving MS knowledge. Additional measures are needed to assist people in the
low socioeconomic classes.

YUHONG Xu (2014) performed a systemic review and meta-analysis to

assess the association between these two conditions. The aim was to better understand the risk of MS
with prior gestational diabetes, shows the results that women with GDM had a significantly higher risk of
MS than those who had a normal pregnancy (OR, 3.96;95% CI,2.99 to 5.26), but had significant
heterogeneity ( I2 = 52.6%). The effect remind robust( OR, 4.54; CI 3.78 – 5.46) in the sub group of
Caucasians, but no association ( OR, 1.28; 95% CI 0.64 – 2.56) was found in Asians. Heterogeneity was
reduced BMI matched group I2=14.2%, BMI higher in the GDM group I2 =13.2% in subgroup of BMI. In
addition mothers with higher BMI in the GDM group had higher risk of MS than those in the BMI
matched group. Hence BMI higher in GDM group OR,5.39;95% CI,4.47 – 6.50, BMI matched group
OR, 2.53; 95% CI,1.88- 3.41). This meta-analysis demonstrated increased risk of MS in GDM mothers,
particularly in Caucasian and obese mothers. Gestational diabetes mellitus is a perfect window of
opportunity for the prevention of DM in two generations , and its incidence is increasing in our country .
Knowledge of the condition among mothers will translate into prevention and early diagnosis of the
diseases.

ZAHID HUSSAIN, ZURAIDAH MOHD YUS0FF,ET AL(2014) study was to

evaluate the knowledge about GDM and its corresponding relation with glycaemic level in GDM patients
as a cross-sectional study was conducted in antenatal clinic using Gestational Diabetes Mellitus
Knowledge Questionnaire (GDMKQ) on the sample of 175 GDM patients. Three most recent fasting
plasma glucose (FPG) values (mmol/l) were taken from patients profiles and mean was calculated. In
result a total of 166 patients were included in final analysis. A total mean knowledge score of 166
patients was 10.01 ± 3.63 and total mean FPG value was 5.50 ± 1.13. Knowledge had a significant
negative association with FPG ( r = − 0.306, P < 0.01). Among different knowledge domains, highest
mean score was seen for diet/food values domain and lowest for management of GDM. Educational level
seems to be the most significant predictor of GDM knowledge and glycemic control. Highest mean
knowledge score and lowest mean glycemic levels were recorded for patients aged 25–29 years, Malay
ethnicity, working women and family history of DM. concluded Higher Knowledge about GDM is
related to better glycemic control. New educational strategies should be developed to improve the lower
health literacy.

BINITHA JOSE (2012) conducted a study on assessing the knowledge

regarding metabolic syndrome with GDM. It was a quantitative approach and an quasi experimental
design. The sampling techniques used was simple random sampling in which 100 samples with GDM
and concluded that the knowledge about metabolic syndrome was poor.

VANISHREE SRIRAM, ANITHA RANI, ET AL (2013) study was done to determine the
awareness of GDM among all the antenatal women who attend a Primary Health Center (PHC) for
antenatal care. A pretested questionnaire consisting of details on background characteristics, 12 questions
focusing on Type 2 DM and GDM, and a question on the source of knowledge was administered to all
women attending the antenatal clinic. Their responses were scored and the women were graded as having
good, fair, or poor knowledge about GDM. In result One hundred and twenty antenatal women
participated in the study. Mean age of the women was 23.8 years (SD: 2.94). Overall, 17.5% women had
good knowledge, 56.7% had fair knowledge, and 25.8% women had poor knowledge about GDM. The
major sources of awareness of GDM were reported to be television/radio, neighbors/friends, and family
members. Concluded the awareness that untreated GDM may pose a risk to the unborn child was high
among the study women. Health care workers have to play a greater role in bringing about awareness
about GDM among antenatal women.
2.2 Section :B : Conceptual framework
The conceptual framework preferred for this deals with the interrelated ideas that are
assembled together in some rational systems are grouped together because of their significance to a
common theme ( Polit and Beck)
Conceptual framework preferred for this research is based upon the general system theory
developed by Von Ludwig Burtalanffy ( September 19,1901, Atzersdof near Vienna – June 12, 1972,
Buffalo, New York) was an Australian – born biologist known as one of the founders of general systems
theory (GST). GST is an interdisciplinary practice that describes components. Interacting system, that
apply to biology, cybermetics, and other areas. Burtalanffy suggested that the classical thermodynamics
laws apply to closed systems, but not to “ open systems,” like living things. In 1934, he released a
mathematical model of an organisms growth over time, is still in use today. Von Ludwig Burtalanffy,
who credited the concept of general systems theory, the philosophy of science movement is defined as ‘
general science of wholeness’ with elements communication. The four aspects are

1. Input
2. Throughput
3. Output
4. Feedback

Input
Input is any type of information, energy and material that enters the system from environment
through its boundaries. In this study, input refers to the information regarding prevention of Metabolic
Syndrome and level of knowledge and attitude regarding Metabolic Syndrome among antenatal mothers
with GDM . Level of knowledge depends upon the age, religion, education, occupation, income, socio
economic class, type of family and para, abortion, weight gain during pregnancy, infection during
pregnancy .The demographic variables influence the effectiveness of the intervention.

Throughput
It is the process that allows the inputs accepts changes so that is useful to the esteem. In this study,
throughput is the intervention provided to improve knowledge of antenatal mothers with GDM
regarding Metabolic Syndrome. The intervention namely Educational Intervention package on
prevention of Metabolic Syndrome includes definition, incidence ,causes, signs and symptoms,
management, lifestyle changes, complications, follow up and prevention using power point presentation
and distribution of pamphlets to antenatal mothers with GDM for 30 minutes which was about 5 groups
with 20 antenatal mothers in each group and clarify the doubts.

Output
Output is any information, energy and materials that leave the system and environment through the
system boundaries. In this study, output is an outcome of level of attitude measured using likert scale and
level of knowledge which was measured using structured questionnaire prepared by the investigator.

Feedback
Feedback is the emphasis to strengthen the input and throughput. It is necessary if the result shows
no improvement in knowledge regarding prevention of Metabolic syndrome. Feedback is not included.
 CHAPTER III
RESEARCH METHODOLOGY
This chapter deals with the description of different steps which are taken by the investigator for
the study. It comprises of the research approach , research design, variables of the study, setting of the
study, population, sample size, sampling technique, criteria of sample selection, development and
description of tool, pilot study, procedure of data collection and plan for statistical data analysis.
3.1 RESEARCH APPROACH
The research approach was adopted for this study was quantitative approach and evaluative in
nature.
3.2 RESEARCH DESIGN
The research design adopted for this study is pre experimental, one group pretest post test
design.
O1 E O2

O1 – Pretest level of knowledge and attitude regarding Metabolic Syndrome

E – Educational Interventional package on knowledge and attitude on prevention of
Metabolic Syndrome.
O2- Post test level of knowledge and attitude regarding prevention of Metabolic Syndrome

3.3 VARIABLES OF THE STUDY

3.3.1 Independent variable: Educational Intervention Package on prevention of Metabolic Syndrome.

3.3.2 Dependent variable : knowledge and Attitude on prevention of Metabolic Syndrome

3.3.3 Demographic variables: Age, education, occupation, income of the family, socioeconomic class
and type of family.
3.3.4 Clinical variables: Gravida , Abortion, weight gain during pregnancy and infection during
pregnancy.
3.3.5 Extraneous variable: Mass Media
3.4 RESEARCH SETTING
The study was conducted in SRM General Hospital, Potheri, Chengalpet.

3.5 POPULATION:
The population refers to the entire summation of cases that meet the designated inclusion
criteria.

3.5.1 Target Population: It comprises all the antenatal mothers with GDM

3.5.2 Accessible Population: It consist of all Antenatal Mothers with GDM attending SRM GH during
data collection period .

3.6 SAMPLE:

Antenatal mothers with GDM who fulfills the inclusion criteria.

3.7 SAMPLE SIZE:

According to Sample size calculation sample size is 89

n= zαtPq/d2
Z=1.96
p=0.18
d2=0.0025
=3.8416/0.0025=0.567020/0.0025=226/-
Z= 1.96
p=0.18
q=0.82
d2=0.08
=0.567020/0.0064=88.5 n=89
study sample is 100.

3.8 SAMPLING TECHNIQUE

Non probability purposive sampling technique was used to select the samples for the
present study.
3.9 CRITERIA FOR SELECTION OF SAMPLE

3.9.1 Inclusion criteria

• The antenatal mothers with GDM who are present at the time of visit.

• Who are attending OPD at SRM GH.

• Who are willing to participate in the study.

• Who speaks Tamil or English

3.9.2 Exclusion criteria

• Teenage pregnancy

• The antenatal mothers who are already taking medicines for cardiovascular disease .

• Treatment of or known clinical history of Psychiatric illness.

• Substance abuse.

• Mothers who have attended any class regarding metabolic syndrome

3.10 DESCRIPTION OF THE TOOL

PART A : A structured questionnaire to assess the Demographic variables such as age, religion,
education, occupation, family income, socio economic class and type of family.

Clinical variables

Clinical variables such as gravida, abortion, weight increase during pregnancy and infections during
pregnancy.

PART B : Likert scale to assess the Attitude on prevention of Metabolic syndrome which consists of
20 questions regarding GDM and Metabolic syndrome.

Scoring interpretation

1-40 (1-33%)Unfavorable, 41-80 (34-66%) Moderately Favorable, 81-120 (67-100%) Favorable

PART C : structured questionnaire to assess the knowledge regarding prevention of Metabolic
Syndrome which consist of 30 questions, each correct answer carries 1 mark and wrong answer carries
0 mark.

Scoring interpretation :

0 – 17 ( 0 – 50%)Inadequate knowledge ,18-25 (51-75%) Moderately adequate knowledge,

26 -35( 76 -100%)Adequate Knowledge.

3.11 DESCRIPTION OF INTERVENTION

Educational intervention package imparting the knowledge regarding prevention of

Metabolic Syndrome (MS) among antenatal mothers with GDM by means of Power Point
Presentation (PPT) and Pamphlet for 30 minutes which has 5 group with 20 antenatal mothers
with Gestational Diabetes Mellitus (GDM) in each group, it includes : Introduction of Metabolic
Syndrome , Incidence rate , Other Names for Metabolic Syndrome , Criteria , Overview of Metabolic
Syndrome , Risk factors, Causes of Metabolic Syndrome ,Signs and Symptoms of Metabolic
syndrome , Prevention of Metabolic Syndrome – Diet modifications, Exercises, Life style changes ,
Management of Metabolic Syndrome, Follow up and Conclusion.

3.12 CONTENT VALIDITY OF THE TOOL :

Content validity of the tool is obtained from 2 Obstetrics and Gynecologist and 3 Nursing
experts in the field of Obstetrics and Gynecology department ,requesting for their valuable suggestions.
Based on the suggestions given by experts, few modification were incorporated in the tool getting
consensus from all experts

3.13 RELIABILITY OF THE TOOL:

The reliability of the tool was assessed using test retest method . The reliability of the tool for
attitude r = 0.7 and knowledge r= 0.71. Henceforth the implement is considered feasible for continuing
with main project.
3.14 ETHICAL CONSIDERATION:

The proposed study was conducted after the approval of dissertation committee of SRM college
of nursing, SRM IST, Potheri, Chengalpet district. Setting permission were obtained from the Medical
superintendent of SRM General hospital, Potheri, chengalpet district and the written consent were
obtained from the participants before the collection of data. Assurance was given to the individuals and
the confindentiality of each individual was maintained and were free to withdraw from the study at
any time. Participants made aware of the benefits of being the study samples.

3.15 PILOT STUDY:

The pilot study was conducted to assess the feasibility and practicability of the study and also
determine the major flaws in the design used. It also helped to determine the plan of statistical analysis.

Prior permission was obtained from the Medical superintendent, SRM general hospital,
Kattangulathur, Chengalpattu. The pilot study was conducted from /12/2019 to /12/2019. For the
pilot study 10 Antenatal mothers With GDM were selected who fulfilled the inclusion criteria. Non
probability purposive sampling technique was used to collect the samples demographic data. The
antenatal mothers with GDM were pre assessed for the knowledge and attitude on prevention of
Metabolic Syndrome , after giving the Educational intervention package imparting the knowledge
regarding prevention of Metabolic Syndrome (MS) among antenatal mothers with GDM by means
of Power Point Presentation (PPT) and Pamphlet for 30 minutes which has 1 group with 10
antenatal mothers with Gestational Diabetes Mellitus (GDM) were reassessed for the knowledge on
prevention of metabolic syndrome by post test. The completion of the tool was ensured. Tool was
found to be satisfactory in terms of clarity and simplicity. The tool was feasible for the main study, it
showed the reliability of 0.71 for knowledge and 0.7 for attitude.
3.16 DATA COLLECTION PROCEDURE

The investigator had collected data within four weeks with effects from 2/1/2020 to 31/1/2020
and formal approval was obtained from the Medical superintendent of SRM general hospital ,
Kattangulathur, chengalpattu.

The investigator introduced herself to the participants and the purpose of the study was
ensured to ensure better co-operation during the data collection period. Attitude assessment tool and
knowledge assessing questionnaire regarding prevention of Metabolic Syndrome was devised and
used by the investigator. The data collection procedure was completed on 31/1/2020.

Approximately 40 minutes were spent to elicit data from the participants. Data collection
was done for 100 samples. The antenatal mothers were divided into 5 groups 20 antenatal mothers with
GDM in each group and pre test conducted and educated the mothers through Power Point Presentation
and Pamphlet,it includes : Introduction of Metabolic Syndrome , Incidence rate , Other Names for
Metabolic Syndrome , Criteria, Overview of Metabolic Syndrome , Risk factors, Causes of Metabolic
Syndrome ,Signs and Symptoms of Metabolic syndrome , Prevention of Metabolic Syndrome – Diet
modifications, Exercises, Life style changes , Management of Metabolic Syndrome, Follow up and
Conclusion.Post test was done 7 days after the intervention.

3.17 PLAN FOR DATA ANALYSIS

The data collected was arranged, tabulated and interpretation of the study was done. The
data was analyzed using both descriptive and inferential statistical methods.

3.17.1 Descriptive statistics

Mean and standard deviation, frequencies and percentage for the data analysis of the
background of the data.

3.17.2 Inferential statistics

1. paired “t” test was used to test the significance difference in the pre-test and post test
knowledge and attitude scores.

2. Karl Pearson’s co-efficient of correlation is used to find out the correlation between the pre
test and post test knowledge and attitude scores.
 3.chi square test was used to find out the association between selected variables, knowledge
and attitude scores.

CHAPTERIZATION

Chapter 3:

This chapter deals with the methodology; it includes research approach and design,
variables, research settings, population, sample size, sampling technique, criteria for selection ,
description of tool, validity, reliability of tool, ethical consideration, pilot study, data collection
procedure and plan for data analysis.

Chapter 4:

This chapter deals with analysis and interpretation of data

 TARGET POPULATION
All antenatal mothers with GDM

SETTING
SRM General Hospital , Potheri
Demographic variables

Age, religion, education,

SAMPLE AND SAMPLE SIZE occupation, income, socio
economic class, type of the
100 Antenatal mothers with GDM family

Clinical variables
SAMPLING TECHNIQUE
Gravida, number of
Non probability purposive sampling technique abortion, weight increase
during pregnancy , infection
during pregnancy

TOOL

Likert scale to assess attitude and structured

questionnaire to assess knowledge regarding
prevention of MS

Pre test

Assessment of demographic variables, attitude and

knowledge on prevention of MS

EDUCATIONAL INTERVENTION PACKAGE

Consist of information regarding MS for 30 minutes with the

help of PPT and Pamphlet

Post test

Assessment of attitude and knowledge regarding MS

Data Analysis

SCHEMATIC REPRESENTATIONOF RESEARCH

 CHAPTER IV

4. ANALYSIS AND INTERPRETATION

It is dealt with data analysis and interpretation. It deals with the investigation and
understanding of 100 samples of antenatal mothers with GDM to evaluate the effectiveness of
Educational Intervention Package on knowledge and attitude regarding Metabolic Syndrome. The
data findings have been analyzed and interpretation as follows

ORGANIZATION OF DATA

4.1 Section A

Frequency and percentage distribution of Demographic and Clinical Variables of antenatal

mothers with GDM.

4.2 Section B

The pre and post test level of knowledge and attitude regarding Metabolic Syndrome among
antenatal mothers with GDM.

4.3 Section C

Determine the effectiveness of Educational Intervention Package on knowledge and attitude

regarding Metabolic Syndrome.

4.4 Section D

Correlate the knowledge with attitude on prevention of Metabolic Syndrome among antenatal
mothers with GDM.

4.4 Section E

Association on pretest and posttest level of Knowledge and attitude regarding Metabolic
Syndrome among antenatal mothers with GDM with their demographic variables.
 PRESENTATION OF DATA

4.1 SECTION A : Frequency and percentage distribution of Demographic and clinical variables
of antenatal mothers with GDM.

( n =100)

S. Percentage
Demographic Variables Class No. of respondents
No %
20 – 25 46 46
1 Age (in years) 25 – 30 40 40
> 30 14 14
Hindu 70 70
Muslim 10 10
2 Religion
Christian 20 20
Others 0 0
Profession or honours 1 1
Graduate 35 35
Intermediate or diploma 20 20
3 Educational status High school education 28 28
Middle school education 12 12
Primary school education 1 1
No formal education 3 3
Legislators senior officials and managers 0 0
Professionals 0 0
Technicians and associate professional 0 0
Clerks 2 2
4 Occupation Skilled workers and shop sales workers 2 2
Crafts and related trade workers 3 3
Plant & machine operators and assemblers 1 1
Elementary occupation 6 6
Unemployed 86 86
> Rs 47348 1 1
Rs 23674 – 47347 0 0
Rs 17756 -23673 20 20
5 Income Rs 11837- 17755 60 60
Rs 7102 -11836 11 11
Rs 2391 – 7101 4 4
< Rs. 2391 4 4
Upper 0 0
Upper middle 66 66
6 Socio Economic Class Lower middle 25 25
Upper lower 0 0
Lower 9 9
Joint family 29 29
7
Type of family
Nuclear family 71 71
Clinical variables
II

Primi 51 51
8
Gravida Two 38 38
More than two 11 11
None 81 81
One time 17 17
9 Abortion
Two times 2 2
Three times 0 0

S.
Demographic Variables Class No. of respondents Percentage
No
1.5 - 2 kg/month 87 87
Weight gain during
10 2 - 3.5 kg/month 7 7
pregnancy
3.5-4.5 kg/month 6 6
Genito urinary tract infection 26 26
Reproductive tract infection 0 0
11 Infections during pregnancy
Sexually transmitted infection 0 0
No infection 74 74

Table 4.1 Related to the age group majority 46 (46%) of antenatal mothers were among age group of
20 – 25 years.
With respect to religion 70 (70%) were Hindu and 20 (20%) were christians .
The educational status of antenatal mothers 35(35%) were graduates.
In occupation of antenatal mothers 86(86%) were unemployed.
In income of the antenatal mothers family is 60 (60%) Rs.11837- 17755.
The 66 (66%) antenatal mothers belongs to upper middle socio economic class.
Respective to the family type 71(71%)belongs to nuclear family.
The 81 (81%) antenatal mothers has no history of abortion.
In weight gain during pregnancy 87(87%) were 1.5 – 2kg / month
In infection during pregnancy 74(74%) has no infection

60%

50% 46%

40%
40%

30%

20% 14%

10%

0%
20 - 25 25 - 30 > 30

Fig 4.1.1 Column diagram depicting of age in years among antenatal mothers with GDM

Hindu
Muslim
Christian

70% 10%

20%
Fig 4.1.2 Pie diagram depicting percentage of religion among antenatal mothers with GDM

40%
35%
35%

30% 28%

25%
20%
20%

15%
12%
10%

5% 3%
1% 1%
0%

Fig 4.1.3 Column diagram depicting percentage distribution of Education of antenatal mothers with GDM

100% 86%
90%
80%
70%
60%
50%
40%
30%
20% 2% 2% 3% 6%
1%
10%
0%
 Fig 4.1.4 Column diagram depicting percentage distribution of occupation among of antenatal mothers
with GDM

70%
60%
60%

50%

40%

30%
20%
20% 11%

10% 4% 4%
1%
0%
0%

Fig 4.1.5 Column diagram depicting percentage distribution of income of the family among antenatal
mothers with GDM
 80%
66%
70%

60%

50%

40%
25%
30%

20%
9%
10%
0% 0%
0%
Upper Upper middle Lower middle Upper lower Lower
Fig 4.1.6 Column diagram depicting percentage distribution of socio economic status among antenatal
mothers with GDM

Joint family
Nuclear family

71% 29%

Fig 4.1.7 Pie diagram depicting percentage distribution of type of family among antenatal mothers with
GDM
 Primi
Two
More than two
38%

11%
51%

Fig 4.1.8 Doughnut diagram depicting percentage distribution of gravida of antenatal mothers with GDM

100%

90% 81%
80%

70%

60%

50%

40%

30%
17%
20%

10% 2% 0%
0%
None One time Two times Three times
Fig 4.1.9 Column diagram depicting percentage distribution abortion of antenatal mothers with GDM
 100%
87%
90%

80%

70%

60%

50%

40%

30%

20%
7% 6%
10%

0%
1.5 - 2 kg/month 2 - 3.5 kg/month 3.5-4.5 kg/month
Fig 4.1.10 Column diagram depicting percentage distribution of weight increased during pregnancy /
month of antenatal mothers with GDM

80%
74%
70%

60%

50%

40%

30% 26%

20%

10%
0% 0%
0%

Fig 4.1. 11 Column diagram depicting percentage distribution of infection during pregnancy of antenatal
mothers with GDM
 Table 4.2.1: Frequency and percentage distribution distribution of pre and post test level of attitude
regarding prevention of Metabolic syndrome

Pre test Post test

S. No. Level of attitude
Percentag No. of
No. of respondents respondents Percentage
e

1 Unfavorable 2 2% 0 0%

2 Moderately Favorable 94 94% 7 7%

3 Favorable 4 4% 93 93%

The analysis revealed that majority of the antenatal mothers with GDM had moderately favorable attitude
94 (94%) in the pretest level and 93 (93% ) had favorable attitude in post test.

Pre test
120% Post test

94% 93%
100%

80%
Percentage

60%

40%

20% 7%
2% 4%
0%
0%
Unfavorable Moderately Favorable Favorable
Level of attitude

Fig 4.2.1 Pie diagram depicting percentage distribution of pre test and post test level of attitude regarding
prevention of Metabolic syndrome
Table 4.2.2 : Frequency and percentage distribution distribution of pre and post test level of knowledge
regarding prevention of Metabolic syndrome

Pre test Post test

S.
Level of knowledge
No. Percentag No. of
No. of respondents Percentage
e respondents

1 Inadequate knowledge 70 70% 0 0%

Moderately adequate
2 28 28% 7 7%
knowledge

3 Adequate Knowledge 2 2% 93 93%

Pre test
120% Post test
95%
100%

80% 70%
Percentage

60%

40% 28%

20%
2% 3% 2%

0%
Inadequate knowledge Moderately adequate Adequate Knowledge
knowledge
Level of knowledge

Fig 4.2.2 Column diagram depicting the pre and post test level of knowledge regarding prevention of MS
 Table 4.3.1 Paired t test between Pre and Post test scores of Attitude regarding Prevention of Metabolic
syndrome

N = 100

S. No. Test N Mean SD t value df p value

1 Pre test attitude scores 100 54.36 12.210

-30.412 99 0.000**
2 Post test attitude scores 100 96.37 6.648
*- Significant at 5% level **- Significant at 1% level

The p value from the above table is highly significant since it is less than 0.01 hence we can say that there
is high significant difference between the pre and post test scores of attitude regarding prevention of metabolic
syndrome.
The mean value of attitude scores at post test level (96.37) is greater than the attitude scores at pre test
level (54.36), hence we can say that the level of attitude regarding prevention of metabolic syndrome is
significantly improved due to the educational intervention package.

120
96.37

100

80
54.36
Mean

60

40

20

0
Pre test attitude scores Post test attitude scores

Fig 4.3.1 Column diagram depicting the difference between the means of attitude scores regarding
prevention of MS at pre and post test level
Table 4.3.2 Paired t test between Pre and Post test scores of Knowledge regarding Prevention of Metabolic
syndrome

Mea
S. No. Test N SD t value df p value
n
1
Pre test knowledge scores 100 14.08 3.180
-38.179 99 0.000**
2 Post test knowledge scores 100 28.11 2.339
*- Significant at 5% level **- Significant at 1% level

The p value from the above table is highly significant since it is less than 0.01 hence we can say that there
is high significant difference between the pre and post test scores of knowledge regarding prevention of metabolic
syndrome.
The mean value of knowledge scores at post test level (28.11) is greater than the knowledge scores at pre
test level (14.08), hence we can say that the level of knowledge regarding prevention of metabolic syndrome is
significantly improved due to the educational intervention package.

40

35 28.11

30

25
Mean

14.08
20

15

10

0
Pre test knowledge scores Post test knowledge scores

Fig 4.3.2 Column diagram depicting the difference between the means of knowledge scores regarding
prevention of MS at pre and post test level
Table 4.4.1 Correlation between Attitude and Knowledge regarding prevention of metabolic syndrome at
pre test level

(Karl Pearson’s co-efficient of correlation)

S. No. Test N Mean SD r value p value

12.21
1 Pre test attitude scores 100 54.36
0
0.147 0.145
2 Pre test knowledge scores 100 14.08 3.180
*- Significant at 5% level **- Significant at 1% level

The p value from the above table is not significant since it is not less than 0.05 hence we can say that there
is no significant correlation between attitude and knowledge scores regarding prevention of metabolic syndrome at
pre test level.

Table 4.4.2 Correlation between Attitude and Knowledge regarding prevention of metabolic syndrome at
post test level
(Karl Pearson’s co-efficient of correlation)

Mea
S. No. Test N SD r value p value
n

1 Post test attitude scores 100 96.37 6.648

0.632 0.000**
2 Post test knowledge scores 100 28.11 2.339
*- Significant at 5% level **- Significant at 1% level

The p value from the above table is highly significant since it is less than 0.01 hence we can say that there
is high significant positive correlation (r = 0.632) between attitude and knowledge scores regarding prevention
of metabolic syndrome at post test level.
 Table 4.5.1 Chi-Square test for testing the association between the demographic variables and attitude
regarding metabolic syndrome at pre test level

Level of Attitude Degrees

Chi-
S. Demographic of
Class Unfavorabl Squar p value
No Variables Moderately Favorabl freedo
e e
Favorable e m
20 - 25 2 43 1
1 Age (in years) 25 - 30 0 39 1 6.815 4 0.146
> 30 0 12 2
Hindu 2 66 2
2 Religion Muslim 0 10 0 3.359 4 0.500
Christian 0 18 2
Profession or honours 0 1 0
Graduate 1 34 0
Intermediate or
1 19 0
diploma
Educational High school education 0 26 2 0.003*
3 29.588 12
status Middle school *
0 11 1
education
Primary school
0 0 1
education
No formal education 0 3 0
Clerks 0 1 1
Skilled workers and
0 2 0
shop sales workers
Crafts and related
0 3 0
trade workers
0.000*
4 Occupation Plant & machine 43.079 10
*
operators and 0 0 1
assemblers
Elementary
1 5 0
occupation
Unemployed 1 83 2
> Rs 47348 0 1 0
Rs 17756 -23673 1 19 0
Rs 11837- 17755 1 59 0 0.006*
5 Income 24.862 10
Rs 7102 -11836 0 8 3 *
Rs 2391 - 7101 0 4 0
< Rs. 2391 0 3 1
Socio Upper middle 2 64 0
6 Economic Lower middle 0 23 2 12.466 4 0.014*
Class Lower 0 7 2
Type of Joint family 1 26 2
7 1.367 2 0.505
family Nuclear family 1 68 2
Primi 1 48 2
8 Gravida Two 1 35 2 0.945 4 0.918
More than two 0 11 0
 Level of Attitude Chi- Degrees
S. Demographic p
Class Moderately Favorabl Squar of
No Variables Unfavorable value
Favorable e e freedom
None 1 76 4
9 Abortion One time 1 16 0 2.505 4 0.644
Two times 0 2 0
Weight gain 1.5 - 2 kg/month 2 82 3
10 during 2 - 3.5 kg/month 0 7 0 3.152 4 0.533
pregnancy 3.5-4.5 kg/month 0 5 1
Infections Genito urinary tract
2 24 0
11 during infection 7.108 2 0.029*
pregnancy No infection 0 70 4
*- Significant at 5% level **- Significant at 1% level

From the above table, the p values corresponding to the demographic variables “Educational Status,
Occupation and Income” are highly significant at 1% level since they are less than 0.01 hence we can conclude that
there is high significant association between “Educational Status, Occupation and Income” and attitude regarding
metabolic syndrome at pre test level.
Also, from the above table, the p values corresponding to the demographic variables “Socio Economic
Class and Infections during pregnancy” are significant at 5% level since they are less than 0.05 hence we can
conclude that there is significant association between “Socio Economic Class and Infections during pregnancy”
and attitude regarding metabolic syndrome at pre test level.
The p values corresponding to all other demographic variables are not significant since they are not less
than 0.05 hence we can say that there is no significant association between the demographic variables “Age,
Religion, Type of family, Gravida, Abortion and Weight gain during pregnancy” and attitude regarding metabolic
syndrome at pre test level.
 Table 4.5.2 Chi-Square test for testing the association between the demographic variables and knowledge
regarding metabolic syndrome at pre test level

Level of Knowledge
S. Demographi Inadequat Moderately Adequate Chi- Degrees of p
Class
No c Variables e adequate Knowledg Square freedom value
knowledge knowledge e
20 - 25 30 16 0
1 Age (in years) 25 - 30 31 7 2 6.165 4 0.187
> 30 9 5 0
Hindu 51 18 1
2 Religion Muslim 8 2 0 3.469 4 0.483
Christian 11 8 1
Profession or honours 1 0 0
Graduate 20 14 1
Intermediate or
17 2 1
diploma
Educational High school education 20 8 0
3 15.124 12 0.235
status Middle school
11 1 0
education
Primary school
0 1 0
education
No formal education 1 2 0
Clerks 2 0 0
Skilled workers and
2 0 0
shop sales workers
Crafts and related
3 0 0
trade workers
4 Occupation Plant & machine 7.118 10 0.714
operators and 0 1 0
assemblers
Elementary
3 3 0
occupation
Unemployed 60 24 2
> Rs 47348 0 1 0
Rs 17756 -23673 15 5 0
Rs 11837- 17755 44 15 1
5 Income 16.149 10 0.095
Rs 7102 -11836 6 5 0
Rs 2391 - 7101 2 1 1
< Rs. 2391 3 1 0
Socio Upper middle 46 19 1
6 Economic Lower middle 19 6 0 4.960 4 0.291
Class Lower 5 3 1
Type of Joint family 22 7 0
7 1.235 2 0.539
family Nuclear family 48 21 2
 Level of Knowledge
S. Demographi Inadequat Moderately Adequate Chi- Degrees of p
Class
No c Variables e adequate Knowledg Square freedom value
knowledge knowledge e
Primi 34 15 2
8 Gravida Two 29 9 0 2.847 4 0.584
More than two 7 4 0
None 55 24 2
9 Abortion One time 14 3 0 2.078 4 0.721
Two times 1 1 0
Weight gain 1.5 - 2 kg/month 62 23 2
10 during 2 - 3.5 kg/month 6 1 0 5.468 4 0.243
pregnancy 3.5-4.5 kg/month 2 4 0
Infections Genito urinary tract
20 5 1
11 during infection 1.804 2 0.406
pregnancy No infection 50 23 1
*- Significant at 5% level **- Significant at 1% level

The p values corresponding to the demographic variables are not significant since they are not less than
0.05 hence we can say that there is no significant association between the demographic variables and knowledge
regarding metabolic syndrome at pre test level.
 Table 4.6.1 Chi-Square test for testing the association between the demographic variables and attitude
regarding metabolic syndrome at post test level
Degrees
Chi-
S. Demographic of
Class Moderately Favorabl Squar p value
No Variables freedo
Favorable e e
m
20 – 25 4 42
1 Age (in years) 25 – 30 3 37 1.272 2 0.529
> 30 0 14
Hindu 6 64
2 Religion Muslim 0 10 1.141 2 0.565
Christian 1 19
Profession or honours 0 1
Graduate 1 34
Intermediate or diploma 2 18
Educational
3 High school education 3 25 6.042 6 0.419
status
Middle school education 0 12
Primary school education 0 1
No formal education 1 2
Clerks 0 2
Skilled workers and shop
0 2
sales workers
Crafts and related trade
0 3
4 Occupation workers 1.225 5 0.942
Plant & machine operators
0 1
and assemblers
Elementary occupation 0 6
Unemployed 7 79
> Rs 47348 0 1
Rs 17756 -23673 1 19
Rs 11837- 17755 6 54
5 Income 3.777 5 0.582
Rs 7102 -11836 0 11
Rs 2391 – 7101 0 4
< Rs. 2391 0 4
Upper middle 6 60
Socio Economic
6 Lower middle 1 24 1.466 2 0.480
Class
Lower 0 9
Joint family 1 28
7 Type of family 0.791 1 0.374
Nuclear family 6 65
Primi 4 47
0.007*
8 Gravida Two 0 38 9.860 2
*
More than two 3 8
 Chi- Degrees
S. Demographic p
Class Moderately Squar of
No Variables Favorable value
Favorable e freedom
None 6 75
9 Abortion One time 0 17 6.981 2 0.030*
Two times 1 1
1.5 - 2 kg/month 5 82
Weight gain
10 2 - 3.5 kg/month 1 6 1.642 2 0.440
during pregnancy
3.5-4.5 kg/month 1 5
Genito urinary tract
Infections during infection 2 24
11 0.026 1 0.872
pregnancy
No infection 5 69
*- Significant at 5% level **- Significant at 1% level

From the above table, the p value corresponding to the demographic variable “Gravida” is highly
significant at 1% level since it is less than 0.01 hence we can conclude that there is high significant association
between “Gravida” and attitude regarding metabolic syndrome at post test level.
Also, from the above table, the p value corresponding to the demographic variable “Abortion” is
significant at 5% level since it is less than 0.05 hence we can conclude that there is significant association between
“Abortion” and attitude regarding metabolic syndrome at post test level.
The p values corresponding to all other demographic variables are not significant since they are not less
than 0.05 hence we can say that there is no significant association between the demographic variables other than
“Abortion and Gravida” and attitude regarding metabolic syndrome at post test level.
 Table 4.6.2 Chi-Square test for testing the association between the demographic variables and knowledge
regarding metabolic syndrome at post test level

Level of Knowledge
Degrees
S. Demographic Moderatel Chi- p
Class Inadequate Adequate of
No Variables y adequate Square value
knowledge Knowledge freedom
knowledge
20 - 25 1 1 44
1 Age (in years) 25 - 30 1 2 37 1.460 4 0.834
> 30 0 0 14
Hindu 1 3 66
2 Religion Muslim 0 0 10 2.530 4 0.639
Christian 1 0 19
Profession or honours 0 0 1
Graduate 0 0 35
Intermediate or diploma 0 1 19
Educational High school education 2 2 24
3 8.962 12 0.706
status Middle school education 0 0 12
Primary school
0 0 1
education
No formal education 0 0 3
Clerks 0 0 2
Skilled workers and
0 0 2
shop sales workers
Crafts and related trade
0 0 3
4 Occupation workers 0.857 10 1.000
Plant & machine
0 0 1
operators and assemblers
Elementary occupation 0 0 6
Unemployed 2 3 81
> Rs 47348 0 0 1
Rs 17756 -23673 0 0 20
Rs 11837- 17755 2 3 55
5 Income 3.509 10 0.967
Rs 7102 -11836 0 0 11
Rs 2391 - 7101 0 0 4
< Rs. 2391 0 0 4
Upper middle 1 3 62
Socio Economic
6 Lower middle 1 0 24 2.337 4 0.674
Class
Lower 0 0 9
Joint family 0 2 27
7 Type of family 2.900 2 0.235
Nuclear family 2 1 68
 Degrees
Chi-
Level of Knowledge of p value
Square
S. Demographic freedom
Class
No Variables Inadequat Moderately Adequate
e adequate Knowledg
knowledge knowledge e
Primi 2 0 49
8 Gravida Two 0 1 37 12.150 4 0.016*
More than two 0 2 9
None 2 2 77
9 Abortion One time 0 0 17 16.253 4 0.003**
Two times 0 1 1
1.5 - 2 kg/month 1 3 83
Weight gain
10 2 - 3.5 kg/month 1 0 6 6.247 4 0.181
during pregnancy
3.5-4.5 kg/month 0 0 6
Genito urinary tract
Infections during infection 1 1 24
11 0.709 2 0.701
pregnancy
No infection 1 2 71
*- Significant at 5% level **- Significant at 1% level

From the above table, the p value corresponding to the demographic variable “Abortion” is highly
significant at 1% level since it is less than 0.01 hence we can conclude that there is high significant association
between “Abortion” and knowledge regarding metabolic syndrome at post test level.
Also, from the above table, the p value corresponding to the demographic variable “Gravida” is significant
at 5% level since it is less than 0.05 hence we can conclude that there is significant association between “Gravida”
and knowledge regarding metabolic syndrome at post test level.
The p values corresponding to all other demographic variables are not significant since they are not less
than 0.05 hence we can say that there is no significant association between the demographic variables other than
“Abortion and Gravida” and knowledge regarding metabolic syndrome at post test level.
 CHAPTER 5

DISCUSSION

This chapter deals with the discussion of the result of the data analyzed based on the objectives of
the study. The problem statement was “ A study to assess the effectiveness of Educational Intervention
Package on knowledge and attitude on prevention of Metabolic Syndrome among Antenatal mothers with
GDM at SRM General Hospital , Kattankulathur”.
The research design was a pre experimental , one group pre test post test research design and
evaluative in nature. It was decided to do study on 100 samples and given Educational Intervention
Package. The study was done among 100 antenatal mothers with GDM in SRM General Hospital ,
Kattankulathur

Regarding the demographic variables of antenatal mothers with GDM

Related to the age group majority 46 (46%) of antenatal mothers were among age group of 20
– 25 years. With respect to religion 70 (70%) were Hindu and 20 (20%) were christians .The
educational status of antenatal mothers 35(35%) were graduates. In occupation of antenatal mothers
86(86%) were unemployed.In income of the antenatal mothers family is 60 (60%) Rs.11837- 17755 .
The 66 (66%) antenatal mothers belongs to upper middle socio economic class. Respective to the family
type 71(71%)belongs to nuclear family. The 81 (81%) antenatal mothers has no history of abortion.
In weight gain during pregnancy 87(87%) were 1.5 – 2kg / month In infection during pregnancy 74(74%)
has no infection.
The result of the present study is consistent with the findings of the study conducted by
Pauliina Husu ( 2017) carried out a study on the prevalence and risk of Metabolic Syndrome among
pregnant women with GDM in Primary Healthcare maternity clinics. The data collected

The first objective of the study was to assess the pretest & post test level of knowledge and attitude
on prevention of Metabolic Syndrome among antenatal mothers with GDM.
 CHAPTER VI

SUMMARY , CONCLUSION , IMPLICATIONS

RECOMMENDATIONS AND LIMITATIONS

This chapter is devoted to the consideration of the findings , understanding limitations ,interpretation
of results and recommendations that incorporate the implications of the study . It also gives the meaning
to the result obtained in the study.

SUMMARY

Metabolic syndrome (MS) is a cluster of atherosclerotic risk factors, including abdominal

obesity, elevated serum triglycerides, decreased HDL cholesterol, elevated blood pressure, and elevated
serum plasma glucose [1–3].

Insulin resistance is a central feature in the pathogenesis of MS in addition to an unhealthy

diet and physical inactivity promoting overweight and genetic factors. As obesity increases worldwide,
this leads to an increased incidence and an earlier onset of MS . Gestational diabetes mellitus (GDM), a
disorder in glucose and insulin metabolism, is one of the most common complications in pregnancy .

Depending on the population and the diagnostic criteria used, the prevalence is roughly 1%–
14% of pregnancies ; and the occurrence is increasing worldwide . The most important risk factors for
GDM are pre pregnancy overweight, high maternal age and a family history of type 2 diabetes . Women
with a history of GDM are at increased risk of developing type 2 diabetes and also Metabolic Syndrome
after delivery.
 This study was done to assess the effectiveness of Educational Intervention Package on
knowledge and attitude regarding prevention of Metabolic Syndrome among antenatal mothers with
GDM at SRM General Hospital.

OBJECTIVES

1. TO assess the pretest and post test level of knowledge and attitude on prevention of Metabolic
Syndrome among antenatal mothers with GDM.

2. To determine the effectiveness of Educational Intervention Package on prevention of Metabolic

Syndrome among antenatal mothers with GDM.

3. To correlate the knowledge with attitude on prevention of Metabolic Syndrome among antenatal
mothers with GDM.

4. To associate the pretest and posttest level of knowledge and attitude on prevention of Metabolic
Syndrome among antenatal mothers with GDM with their demographic variables.

RESEARCH HYPOTHESIS

RH1: There will be a significant difference between pretest and posttest level of knowledge and attitude
regarding Prevention of Metabolic Syndrome with the demographic variables at p <0.05.

RH2: There will be a significant relationship between with attitude on Prevention of Metabolic
Syndrome with their demographic variables p < 0.05.

RH3: There will be significant association on level of knowledge and attitude regarding prevention of
Metabolic Syndrome with their demographic variables p < 0.05.

ASSUMPTIONS

1. All antenatal mothers with GDM may not aware about Metabolic Syndrome disorder.
 2. All antenatal mothers with GDM will not have increased body mass index.
3. Educational intervention package may improve the knowledge and attitude level on prevention of
Metabolic Syndrome among antenatal mothers with GDM.

LITERATURE REVIEW

Section A: Empirical Literature

The Empirical literature on Metabolic Syndrome

Section B: Conceptual Framework

The investigator adopted General System Theory developed by Von Ludwig Burtalanffy as a base
for developing the conceptual framework.

Related studies on Metabolic Syndrome facilitate the investigator to collect relevant information of
facts to support the study and to develop methodology and the tools. Pre experimental , one group pretest
post test design were used.

The tool used for data collection consisted of Part A – Demographic variables, Part B- Likert Scale
to identify the attiude of antenatal mothers with GDM regarding Prevention of Metabolic Syndrome and
Part C – Structured questionnaire to assess the knowledge regarding Metabolic Syndrome

The pilot study was conducted to assess the feasibility and practicability of the study and also
determine the major flaws in the design used. It also helped to determine the plan of statistical analysis.
Prior permission was obtained from the Medical Superintend , SRM general Hospital , Kattangulathur.
The pilot study was conducted from 23/12/19 to 29/12/19. For the pilot study, 30 antenatal mothers were
selected who fulfilled the inclusion criteria. Non probability purposive sampling technique was used to
collect the samples of demographic data. The antenatal mothers were pre assessed for the attitude and
knowledge on prevention of Metabolic Syndrome, after giving the intervention the antenatal mothers
were reassessed for the attitude and knowledge on prevention of Metabolic Syndrome by posttest. The
completion of the tool was ensured. The tool was feasible for the main study, it showed the reliability of
0.71 for knowledge and 0.7 for attitude.

The investigator has collected data within four weeks with effect from 1/1/20 to 31/1/20 and formal
approval was obtained from the Medical superintend of SRM General Hospital, Kattangulathur ,
Chengalpattu . The investigator introduced herself to the participants and the purpose of the study was
ensured to ensure better cooperation during the data collection period .Likert scale for attitude and
structured questionnaire for assessing knowledge regarding prevention of Metaoblic Syndrome were
devised and used by the investigator. The data collection procedure was completed . Approximately 40
minutes were spent to elicit data from the participants. Data collection was done with 100 samples. The
Educational Intervention Package was given on prevention of Metabolic Syndrome for 30 minutes . The
antenatal mothers were divided into 5 groups ,20 antenatal mothers in each group and pre test conducted,
then teaching was given. Post test was done 7 days after the intervention.

The main findings of the study

Findings related to the pre test and post test level of attitude regarding prevention of Metabolic
Syndrome among antenatal mothers with GDM

The findings reveals that maximum antenatal mothers with GDM were 94( 94%) had moderately
favorable attitude in pretest and majority of antenatal mothers with GDM 93(93%) had favorable attitude
in post test and concluded that there was a significant improvement in the level of attitude regarding
prevention of Metabolic Syndrome in post test after the Educational Intervention Package.

Findings related to the pre test and post test level of knowledge regarding prevention of Metabolic
Syndrome among antenatal mothers with GDM

The findings reveals that maximum of antenatal mothers with GDM 70 (70%) had inadequate
knowledge in pre test and majority of antenatal mothers with GDM 93 (93%) had adequate knowledge in
post test and concluded that there was a significant improvement in the level of knowledge regarding
prevention of Metabolic Syndrome in post test after the Educational Intervention Package.

Findings related to the effectiveness of an Educational Intervention Package on attitude and

knowledge regarding prevention of Metabolic Syndrome among antenatal mothers with GDM
 Analysis depicted that the mean value of 54.36 with standard deviation 12.210 of pre test when
compares with the mean value of 96.37 with standard deviation 6.648 in the post test with respect to “t”
value – 30. 412 which was highly significant at “p”= 0.000 for attitude. The mean value of 14.08 with
standard deviation 3.180 of pre test when compares with the mean value of 28.11 with standard deviation
2.339 in the post test with respect to “t” value – 38. 179 which was highly significant at “p”= 0.000.
Hence the research hypothesis RH1 stated that “ There is a significant difference between pretest and
posttest level of knowledge and attitude regarding prevention of Metabolic Syndrome among antenatal
mothers with GDM” was accepted at p = 0.000.

Findings related to the relationship between knowledge with attitude on prevention of Metabolic
Syndrome among antenatal mothers with GDM with their demographic variables

The correlation between attitude and knowledge regarding prevention of Metabolic Syndrome with
the demographic variables by using Karl Person’s co-efficient of correlation reveals that pre test is not
significant since the p value is not less than 0.05. There is a high significant positive correlation with
p<0.01 between attitude and knowledge scores regarding prevention of Metabolic Syndrome at post test
level. Hence the research hypothesis RH2 stated that “ There is a significant relationship between
knowledge with attitude on prevention of Metabolic Syndrome.

Findings related to the association of pretest and posttest level of knowledge and attitude regarding
prevention of Metabolic Syndrome among antenatal mothers with GDM

The association of demographic variables with pretest level of attitude and knowledge by using chi-
square test revealed that there was a significant association with variables such as educational status,
occupation and income level p< 0.01, socio economic class and infection during pregnancy at level
p< 0.05. The association of the demographic variables with post test level of attitude and knowledge by
using chi-square test revealed that there was a significant association with variables such as gravida at
level p = <0.01 and abortion at level p = < 0.05 with attitude and knowledge. Hence the research
hypothesis RH3 stated that “ There is significant association on level of knowledge and attitude
regarding prevention of Metabolic Syndrome with their demographic variables .
CONCLUSION

The present study assessed the effectiveness of an Educational Intervention Package on knowledge
and attitude regarding prevention of Metabolic Syndrome among antenatal mothers with GDM at SRM
General Hospital , Kattangulathur. The result of the study concluded that Educational Intervention
Package formulated by the investigator was effective in improving the knowledge of antenatal mothers
with GDM regarding Metabolic Syndrome.

IMPLICATIONS

The findings of the study which enable us to conclude that an Educational Intervention Package will
improve the knowledge regarding prevention of Metabolic Syndrome among antenatal mothers with
GDM.

NURSING PRACTICE

Several implications can be drawn from the present study for nursing practice. Regular health
education program can be conducted by the nursing personnel in hospital and community areas also .
Measures to be taken to prevent Metabolic Syndrome and to improve the health.

NURSING EDUCATION

1. Educational Intervention Package can be used by the student to improve the knowledge on
prevention of Metabolic Syndrome to the antenatal mothers with GDM in both urban and rural
while giving health education.
 2. A nurse educator can prepare nursing students about prevention of Metabolic syndrome using
teaching aids.

NURSING RESEARCH

 Being nurse researchers enhance more research on lifestyle modification of Metabolic Syndrome.
 Disseminate the findings of the research through conference , seminars and publishing in nursing
journals.
 Promote effective utilization of research findings.

NURSING ADMINISTRATION

 Conduct in-service program and continuing education program and continuing education program
on Metabolic Syndrome among GDM mothers and its life style modification.
 Provide opportunities for nurses to prepare and organize teaching programs in the hospital.
 Provide resources to organize educational sessions as well as attend such continuing education.

RECOMMENDATIONS

 A similar study can be conducted in a larger sample to identify the level of attitude and to assess
the knowledge regarding Metabolic syndrome among GDM mothers
 A comparative study can be conducted to evaluate the effectiveness of Educational Intervention
Package.

LIMITATIONS

 The study is limited to a period of 4 weeks of data collection.

 The Educational Intervention package was provided only due to time constraints.

6.1 CHAPTERIZATION

6.1.1 This chapter deals with the Summary , Conclusion, Implication ,Recommendation, and limitation
of the study
The study reports ends with references and annexure