CHAPTER I

The Problem

Background of the Study

Urinary Tract Infections (UTIs) are among the most

common conditions causing individuals to seek medical

care. They are also among the most common bacterial

infections in humans, both in the community and hospital

settings (Hooton et al., 1997).

Likewise, urinary tract infections are one of the

most frequent bacterial infections in children (Kalantar

et al., 2008). At least 8% of girls and 2% of boys will

have a urinary tract infection in childhood, and between

30% and 40% will have another episode within two years.

(Shaw et al., 1998). According to Ross (1994), urinary

tract infection in children is a significant source of

morbidity, particularly when associated with

abnormalities.

This infection may be asymptomatic in many cases,

while it may show symptoms in other patients (Karaou and

Hanna, 1981). Untreated asymptomatic bacteruria

predisposes the individual to recurrent bouts of the

infection which can cause renal disease (Baqai et al.,

2008).

UTI can happen anywhere along the urinary tract-

the kidney (pyelonephritis), the ureters, the bladder

(cystitis), or the urethra (urethritis). Left untreated,

it can lead to acute or chronic pyelonephritis which can

permanently damage the kidneys (The Filipino Doctor,

2017).

Many renal and urinary tract disorders may be

asymptomatic for a long period of time. Routine urine

screening programs are recommended as a basic

fundamental step in the early identification of renal

damage. This has proved to be extremely important in

reducing the growing burden of chronic kidney disease

(CKD) in both developed and developing countries (Hajar

et. al., 2011).

Urinary tract infections that are associated with

high fevers in young children may sometimes cause kidney

damage if not treated promptly. This damage may lead to

poor kidney function and high blood pressure in the

future (A to Z Health Guide, 2017).

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 Therefore, even a single documented urinary tract

infection in an adolescent must be taken seriously.

(Aiyegoro et. al., 2007).

Johnson, (1989), pointed out that the main factor

predisposing to urinary tract infection has been

attributed to poor personal hygiene and culture habit

imposition. Ani, (2008), also wrote that masses should

be educated on the importance of personal hygiene in

order to help them elevate their health status and

manage themselves properly.

As contained in DepEd Order number 10, s. 2016,

hygiene and sanitation are essential to good health.

Adequate water supply and adequate toilet and proper

hand washing are required to achieve good hygiene and

sanitation. The lack of access to these facilities poses

risk to peoples health. However, the mere presence of

these facilities is not enough to achieve better hygiene

and sanitation among the community members. Proper and

correct practices in the use of these facilities must be

practiced to maximize the benefits and achieve the

impact to the well-being of the community.

In the school setting however, a lot of our public

schools are still unable to provide adequate water

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supply necessary to promote good health among the school

children.

Schools are grandly called a home away from home,

where children and young adults spend anywhere between

seven to eight hours in a day. However, only select

schools make the cut when it comes to providing quality

sanitation to its students. Padmasari Venkatramanan,

professor and head of department, Sri Ramachandra

Medical College, in an article in The Hindu, said that

the habit of holding (ones urine) can lead to

adverse health conditions. Inadequate water intake and

infrequent urination can lead to urinary tract

infection, kidney stone formation, fatigue, constipation

and dehydration (Sridhav, 2016).

Hence, pupils must be allowed to go to toilets up

on their request during their stay at school and they

must be educated on how to use the toilets by themselves

in a safe and hygienic way (Sawalha, 2009).

Proper use of toilets includes frequent

micturition and complete emptying of the bladder.

Infrequent micturition and incomplete emptying of the

bladder in children represent important factors in the

4
causation of incontinence during the day, and of urinary

tract infections. (Lindstorm et. al., 2000).

Sawalha, R. M. H., (2009) said that parents must be

careful in noticing urinary tract infection in their

children as children cannot express their feelings well

as adults, as a result they should take their children

immediately to the doctor to avoid any complication that

may result from any delay in both diagnosis and

treatment of these children.

In the study conducted by Sawalha, (2009), findings

revealed that in a sample of 1338 children in the age

group of six to twelve years old, fifty-four or 4% were

positive for urinary tract infection through dipstick,

microscopy and urine culture.

In Jordan, a study was conducted to determine

conditions that result in pediatric nephrology

consultations in the academic hospital of Jordan

University in the age group from one day to 16 years and

found that urinary tract infections account 14.2% of

consultations. An Egyptian study conducted on 5% of

primary school children from 6-12 years of age in

Ismailia Governorate to measure the prevalence of

urinary tract infection in primary school children

5
showed 2.4% overall prevalence of UTI, 1.7% among males

and 2.7% among females. (Sawalha, 2009).

Likewise, local data taken from the Kabayan

Municipal Health Services Office from the years 2014 to

2016 revealed that urinary tract infection constantly

remains to be within the top five leading causes of

morbidity among all age groups; renal failure ranked

fifth in the leading cause of mortality in 2014 and

chronic kidney disease, fifth in 2016.

Hence, the current situation of the relatively high

incidence of urinary tract infection worldwide and

particularly in Kabayan, as well as the unavailability

of water supply in some schools prompted the researcher

to conduct this study.

Statement of the Problem

This study aims to assess the incidence of urinary

tract infection through dipstick urinalysis among school

children in Ballay Elementary School, Kabayan, Benguet.

Specifically, it aims to answer the following

questions:

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 1. What are the health practices of the school

children in terms of:

a. hygiene

b. water intake

c. frequency of urination

2. What is the incidence of urinary tract infection

along the following leukocyte esterase?

2.1. Is there a difference in the incidence of

urinary tract infection among the pupils when grouped

according to sex and age?

3. What are the common signs of urinary tract

infection that the pupils have experienced as perceived

by their parents?

4. What are the contributory factors that lead to

urinary tract infection among school children as

perceived by parents?

Hypotheses of the Study

1. There are significant differences on the

Incidence of urinary tract infection among the pupils

when grouped according to sex and age.

Importance of the Study

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 This study shall be a mirror to assess the

incidence of urinary tract infection among school

children and other relevant programs which shall benefit

the following:

To DepEd officials. The results of this study will

provide data in coming up with plans that will further

enhance school health especially on the Renal Disease

Control Program (ReDCoP), Water, Hygiene and Sanitation

(WASH) and other related programs.

To school heads and teachers. The results of this

study will provide feedbacks on how well they are

implementing the school health programs and assess their

own school stations. It will enlighten them on the

significance of health in developing a childs full

educational potential.

To local government unit heads. The school co-

exists with the local government unit as a partner. The

findings of this study shall help assess the health

status of the vulnerable habitats of the school-the

school children, and provide data relevant to the

planning of more enhanced school and community health

programs.

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 To parents. Rarely do parents bring their well

children for urinalysis. This study shall provide

baseline data on the urinary health status of their

children and help them provide better health education

to their children at home.

To school health personnel. The results of this

study shall help school health personnel in planning,

monitoring and evaluating their work and to provide

better perspective in their implementation of these

tasks.

To the researcher. The study shall enhance the

researchers knowledge on the topic, and shall enable

the researcher to prioritize school health program

implementation being school health personnel.

To future researchers. This study shall serve as a

resource for similar studies.

To the school children. Children learn more when

they are able to correlate experimental activities with

actual results/findings. The findings of this study will

help them understand the concept of urinary tract

infection in relation to their current health habits.

Scope and Delimitations of the Study

The study determined the incidence of urinary

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tract infection among school children enrolled in Ballay

Elementary School, Kabayan, Benguet, through dipstick

urinalysis. It focused on the leukocyte esterase test as

well as the nitrite test. It also focused on the health

habits of the school children, the symptoms of urinary

tract infection and the factors leading to the disease.

Other components of the dipstick urinalysis, such

as protein, blood, specific gravity, PH and others were

not be included in the scope of this study, but were

cited by the researcher in school health reports.

Pupils who are under antibiotic therapy during the

urine collection shall not be included to ensure

reliability.

Theoretical/Conceptual Framework

Acute urinary tract infections are relatively

common in children. The most common pathogen is

Escherichia coli, accounting for approximately 85

percent of urinary tract infections in children. Renal

parenchymal defects are present in 3 to 15 percent of

children within one to two years of their first

diagnosed urinary tract infection. Clinical signs and

symptoms of a urinary tract infection depend on the age

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of the child, but all febrile children two to 24 months

of age with no obvious cause of infection should be

evaluated for urinary tract infection (with the

exception of circumcised boys older than 12 months).

Evaluation of older children may depend on the clinical

presentation and symptoms that point toward a urinary

source: leukocyte esterase or nitrite present on

dipstick testing; (pyuria of at least 10 white blood

cells per high-power field and bacteriuria on

microscopy). (White, B. 2011).

Dulczak, S., (2005), as cited by Sawalha, R. M.

H.,(2009), claimed that dipstick screening test and

microscopy are the components of urinalysis, and they

are very useful in the evaluation and rapid screening of

urinary tract infection.

Urine dipstick consists of chemically treated

paper, which displays different colors indicating the

presence of leukocyte esterase, nitrites, blood, and

protein when dipped into urine sample. Normal urine

contains nitrates. Gram negative bacteria present in the

urinary tract produce the enzyme reductase which

reduces nitrate to nitrite. The presence of nitrites on

urinalysis may be indicative of urinary tract infection.

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Leukocyte esterase is an enzyme made up by the breakdown

of neutrophils white blood cells (WBCs) in the urine

secondary to bacterial invasion. (Lamond and Ryan-

Wenger, (2005).

The UTI Guideline Team of Cincinnati Childrens

Hospital Medical Center, as cited by White, (2011),

claimed that clinical signs and symptoms of a urinary

tract infection depend on the age of the child. Newborns

with urinary tract infection may present with jaundice,

sepsis, failure to thrive, vomiting, or fever. In

infants and young children, typical signs and symptoms

include fever, strong-smelling urine, hematuria,

abdominal or flank pain, and new-onset urinary

incontinence. School-aged children may have symptoms

similar to adults, including dysuria, frequency, or

urgency. Boys are at increased risk of urinary tract

infection, if younger than six months, or if younger

than 12 months and uncircumcised. Girls are generally at

an increased risk of UTI, particularly if younger than

one year

Wein, A. J., (2007), as cited by Sawalha (2009),

claimed that gender is an important factor in urinary

tract infection. Tanagho and Mcaninch, (2004), as cited

12
by Sawalha, (2009), further agree that sex shows a

preponderance of the infection in boys during the first

year of life, but after the first year of life more

girls than boys have urinary tract infection.

Leukocyte esterase is the most sensitive single

test in children with a suspected UTI. The test for

nitrite is more specific but less sensitive. A negative

leukocyte esterase result greatly reduces the likelihood

of UTI, whereas a positive nitrite result makes it much

more likely; the converse is not true, however. Dipstick

tests for blood and protein have poor sensitivity and

specificity in the detection of UTI and may be

misleading. Accuracy of positive findings is as follows:

Nitrite: 53 percent sensitivity, 98 percent

specificity, 75 percent probability of UTI; Bacteria on

microscopy: 81 percent sensitivity, 83 percent

specificity, 35 percent probability of UTI; Leukocytes

on microscopy: 73 percent sensitivity, 81 percent

specificity, 30 percent probability of UTI; Leukocyte

esterase: 83 percent sensitivity, 78 percent

specificity, 30 percent probability of UTI; Leukocyte

esterase or nitrite: 93 percent sensitivity, 72 percent

specificity, 27 percent probability of UTI Blood: 47

13
percent sensitivity, 78 percent specificity, 19 percent

probability of UTI;

Children > 3 years of age

Perform urine dipstick test

Positive for leukocyte Negative for leukocyte Positive for leukocyte Negative for
esterase & nitrite esterase & positive for esterase & negative leukocyte esterase
nitrite for nitrite & nitrite

Diagnose UTI
Initiate antibiotic
treatment; send urine
sample for culture only if
patient is intermediate or
high risk of serious illness
or has a history of UTI
Initiate antibiotic
treatment & send urine
sample for culture
Treat depending on
culture results
Send urine sample for Explore other
microscopy and culture; causes of illness
initiate antibiotic
treatment only if there
is good clinical evidence
of UTI
Treat depending on
culture results

Figure 1. Algorithm for urine testing in children with

suspected urinary tract infection (UTI) aging more than
3 years old

Protein: 50 percent sensitivity, 76 percent specificity,

19 percent probability of UTI (White, B. 2011).

The National Institute for Health and Clinical

Excellence in the United Kingdom endorses incorporating

specific strategies for urine testing based on the

childs age (White, B. 2011).

A study by Eigbefoh et al. (2009) was designed to

evaluate the diagnostic accuracy of the rapid dipstick

14
test to predict urinary tract infection in pregnancy

with the gold standard of urine microscopy, culture and

sensitivity acting as the control. The urine dipstick

test uses the leukocyte esterase, nitrite and test for

protein singly and in combination. The result of the

dipstick was compared with the gold standard, urine

microscopy, culture and sensitivity using confidence

interval for proportions. The reliability and validity

of the urine dipstick was also evaluated. Overall, the

urine dipstick test has a poor correlation with urine

culture (p = 0.125, CI 95%). The same holds true for

individual components of the dipstick test. The overall

sensitivity of the urine dipstick test was poor at 2.3%.

Individual sensitivity of the various components varied

between 9.1% for leukocyte esterase and the nitrite test

to 56.8% for leukocyte esterase alone. The other

components of the dipstick test, the test of nitrite,

test for protein and combination of the test (leukocyte

esterase, nitrite and proteinuria) appear to decrease

the sensitivity of the leukocyte esterase test alone.

The ability of the urine dipstick test to correctly rule

out urinary tract infection (specificity) was high. The

positive predictive value for the dipstick test was

15
high, with the leukocyte esterase test having the

highest positive predictive value compared with the

other components of the dipstick test. The negative

predictive value (NPV) was expectedly highest for the

leukocyte esterase test alone with values higher than

the other components of the urine dipstick test singly

and in various combinations. Compared with the other

parameters of the urine dipstick test, singly and in

combination, leukocyte esterase appears to be the most

accurate (90.25%). The dipstick test has a limited use

in screening for asymptomatic bacteriuria. The leukocyte

esterase test component of the dipstick test appears to

have the highest reliability and validity. The other

parameters of the dipstick test decreases the

reliability and validity of the leucocyte esterase test.

A positive test merits empirical antibiotics, while a

negative test is an indication for urine culture. The

urine dipstick test if positive will also be useful in

follow-up of patient after treatment of urinary tract

infection. This is useful in poor resource setting

especially in the third world where there is a dearth of

trained personnel and equipment for urine culture.

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 Figure 1 presents the interplay of the different

variables. The independent variables are the health

habits of the pupils, results on the levels of leukocyte

esterase and nitrite on the urine of the pupils

determined through dipstick urinalysis, probable

symptoms of UTI, factors leading to UTI in children. The

dependent variable is the diagnosis of urinary tract

infection which is dependent on the leukocyte esterase

and nitrite counts of the pupils urine samples. The

moderating or intervening variables are the sex and age

of the pupils.

INDEPENDENT VARIABLES DEPENDENT VARIABLE

1. Health practices 1. Identified health
of school children practices of
children
2. Extent of
incidence of 2. Extent of
urinary tract incidence of urinary
infection among tract infection
children among children

3. Signs and 3. Common signs and

symptoms of urinary 17 symptoms of urinary
tract infection tract infection

4. Factors that 4. Factors that

 MODERATING/INTERVENING VARIABLES
Pupils sex and age

Figure 2. Paradigm of the Study

Definition of Terms

The following terms are defined according to how

they shall be used in the study:

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 Urinary Tract Infection. It refers to a disease of

the urinary tract that is determined by the presence of

leukocyte esterase and nitrite on dipstick testing.

Leukocyte esterase. It is a type of enzyme produced

by leukocytes (white blood cells). A leukocyte esterase

test is a urine test for the presence of white blood

cells and other abnormalities associated with infection.

Nitrite.It is a breakdown product of nitrogen waste

in the urine. Bacteria that cause urinary tract

infection make an enzyme that changes urinary nitrates

to nitrite. Nitrites in urine show that urinary tract

infection is present.

Dipstick urinalysis. It is a method of urinalysis

that uses a narrow plastic strip which has several

squares of different colors attached to it. Each small

square represents a component of the test used to

interpret urinalysis. The entire test strip is dipped in

the urine sample and color changes in each square are

noted. Each color change on a particular square may

indicate specific abnormalities in the urine sample

caused by a certain chemical reaction.

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 Incidence. It is the rate of new cases of the

disease. It is generally reported as the number of new

cases occurring within a period of time.

School children. These are pupils enrolled at

Ballay Elementary School from Kindergarten to grade six

for the school year 2017-2018.

Sign/Symptom. This refers to experiences of

children suffering from UTI as perceived by their

parents.

Factor. This refers to activities of children that

may contribute to UTI as perceived by their parents.

CHAPTER 2

Design and Methodology

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 This chapter discusses the research design, locale

and population of the study, data gathering tools and

procedures and the treatment of data.

Research Design

The study made use of the quantitative-descriptive

research design through dipstick urinalysis and the

descriptive-normative survey method, through

questionnaire and checklists as instruments in gathering

data. Informal interviews were conducted to supplement

the questionnaire.

It is quantitative because it determines the

relationship between one thing (an independent variable)

and another (a dependent or outcome variable) in a

population. It is also descriptive because the subjects

are measured only once and no attempt is made to change

behavior or conditions.

Population and Locale of the Study

For the dipstick urinalysis, the participants were

the elementary pupils of Ballay Elementary School from

Kindergarten to grade six levels. Total enumeration

shall was used. For the questionnaire, it was answered

21
by the pupils with the aid of their parents. The study

was conducted during the school year 2017-2018.

Table 1. Population of the Study

A. Pupils

Respondents Male Female Total

Kindergarten 10 11 21
Grade I 16 16 32
Grade II 25 7 32
Grade III 20 14 34
Grade IV 12 16 28
Grade V 30 18 48
Grade VI 17 17 34
Total 130 99 229

B. Parents

Respondents Number of Parents

Kinder to grade 6 125

Data Gathering Tools

This study utilized a dipstick test pack to

determine the presence of leukocyte esterase and nitrite

in the urine samples of the population. Clean plastic

cups served as containers in the urine specimen

collection. The lists of respondents were obtained from

the respective teachers. A systematic recording form was

22
devised to record the results of the urinalysis. There

were designated comfort rooms for the pupils to collect

their urine specimens, separating males from females.

Aside from the dipstick urinalysis, a self-made

questionnaire was administered to these pupils or to

their parents for assistance. Part 1 of the

questionnaire dealt with the personal information of the

participants. Part 2 determined the health practices of

the pupils in terms of hygiene, water intake and

frequency of urination in school. Part 3 dealt with the

signs and symptoms of UTI among children while part 4

dealt on the contributory factors that lead to UTI among

children

Data Gathering Procedures

Preparatory activities. The initial step to be

conducted shall be to obtain permission from the Schools

Division Superintendent of Benguet Division and the

school head of Ballay Elementary School through a

letter. Before the conduct of the study, an information

campaign shall also be done during the Parents-Teachers

Meeting to explain the activity, as well as to obtain

written consent from the parents of the respondents.

After which, the date for dipstick urinalysis shall be

23
 scheduled by grade levels. The parents shall be asked

for any antibiotic treatment that their child may be

taking in the course of the collection dates; hence

these children shall be exempted from the study. The

recording forms shall be prepared with the list of names

of the pupils contained in the forms per grade level.

Urine Collection and Testing. The pupils will be

instructed to wash properly to avoid contamination. The

clean catch midstream urine shall be explained prior to

the collection proper. After the collection, the samples

shall be tested according to the specifications of the

dipstick test pack. Pupils will be instructed to wash

hands properly with soap and water after the collection.

Recording. Results shall be recorded accurately in

the corresponding forms.

The questionnaire shall be answered by the pupils

themselves, especially for the higher grades after a

very thorough explanation. For the younger pupils, the

researcher shall conduct informal interview or the

parents shall answer the questionnaire if needed, data

elicited from their children.

Treatment of Data

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 Data that will be gathered from the urinalysis

shall be tallied, tabulated and analyzed using

appropriate statistical tools.

To answer specific problems number one on the

health practices of school children, 2 on the incidence

of urinary tract infection when grouped according to

their a) leukocyte esterase test, b) nitrite test, c)

both leukocyte and nitrite,3, on the symptoms of UTI and

4,on the factors causing UTI in children, the frequency

count shall be used. Percent shall be determined by

dividing the categorized frequency with the number of

cases and multiplied by one hundred. The percent formula

is:

Percent = ___Frequency___ x 100

Total Population

To answer specific problems number 1.1 on the

determination if a significant difference exists on the

health practices and problem number 2.1,on the

difference in the incidence of UTI when grouped

according to sex, the t-test shall be utilized to

analyze the data; the formula is:

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 On the other hand, the f-test shall be utilized to

determine if a significant difference exists between the

health practices as well as the incidence of UTI when

the respondents will be grouped according to age. The

formula for F-test is:

26