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Rajiv Gandhi University of Health Science, Karnataka, Bangalore
A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON OPTIONAL VACCINES FOR CHILDREN
AMONG POSTNATAL PRIMI MOTHERS IN SELECTED RURAL AREAS
AT BANGALORE.
M.Sc Nursing Dissertation Protocol submitted to
By
Mrs.SWATHIKA DAS
M.Sc NURSING I ST YEAR 2011-2012
Under the guidance of
HOD, Department of CHILD HEALTH NURSING
Nightingale college of NursingGuruvanna Devara Mutt, Near Binnyston Garden,
Magadi Road, Bangalore-560023
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE,KARNATAKA,
BANGALORE
ANNEXURE-II
PERORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.NAME OF THE CANDIDATE
AND ADDRESS
Mrs.SWATHIKA DASI YEAR M.Sc NURSING
NIGHTINGALE COLLEGE OF NURSING,
GURUVANNA DEVARA MUTT,
NEAR BINNIYSTON GARDEN,
MAGADI ROAD ,BANGALORE-23.
2. NAME OF THE INSTITUTE
NIGHTINGALE COLLEGE OF NURSING,
GURUVANNA DEVARA MUTTU,NEAR
BINNIYSTON GARDEN,
MAGADI ROAD, BANGALORE-23.
3. COURSE OF STUDY AND SUBJECT M.Sc NURSING IN
CHILD HEALTH NURSING .
4. DATE OF ADMISSION 12-5-2011
5. TITLE OF THE TOPIC
A STUDY TO EVALUATE THE
EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON OPTIONAL
VACCINES FOR CHILDREN AMONG
POSTNATAL PRIMI MOTHERS IN
SELECTED RURAL AREAS
AT BANGALORE
2
3
4
6. BRIEF RESUME OF INTENDED WORK
6.1 INTRODUCTION
A vaccine is a biological preparation that improves immunity to a particular disease. A
vaccine typically contains an agent that resembles a disease-causing microorganism, and is
often made from weakened or killed forms of the microbe. The agent stimulates the body's
immune system to recognize the agent as foreign, destroy it, and "remember" it, so that the
immune system can more easily recognize and destroy any of these microorganisms that it
later encounters.
Vaccines can be prophylactic (e.g. to prevent or ameliorate the effects of a future infection
by any natural or "wild" pathogen), or therapeutic (e.g. vaccines against cancer are also
being investigated; see cancer vaccine).
The term ''vaccine'' derives from Edward Jenner's 1796 use of the term ''cow pox'' (Latin
''variolæ vaccinæ'', adapted from the Latin ''vaccīn-us'', from ''vacca'' cow), which, when
administered to humans, provided them protection against smallpox.1
Immunization describes the whole process of delivery of a vaccine and the immunity it
generates in an individual and population. A vaccine is a special form of a disease-
causing agent (e.g., virus or bacteria) that has been developed to protect against that
disease. Immunization forms one of the most important and cost effective
strategies for the prevention of childhood sicknesses and disabilities and is thus a basic
need for all children. The last 20 years have seen an explosion in the number of new
vaccines. Many other vaccines are available against many other diseases like typhoid
fever, chicken pox, pneumonia, meningitis etc.2
5
I A P (Indian Academy of Pediatrics) is working for the improvement and wellbeing
of all children. Although many optional vaccines have been launched in the Indian
market, I A P suggests the immunization only with those vaccines, for example
Rotavirus vaccination, Varicella vaccination, Pneumococcal vaccination, Typhoid
vaccination etc. which it feels is competent to prevent the child from acquiring the
diseases and is economic to the parents. These optional vaccines are given after
discussions with the parents.
Over the last three decades, we had a succession of child health programmes like
Integrated child development scheme (ICDS), Maternal And Child Health (MCH),
National Rural Health Mission (NRHM), Universal Immunization Programme, Oral
Rehydration Therapy, Child Survival And Safe Motherhood Programme etc. But still
there is high mortality and morbidity rate in pediatric clients. In 2009 infant mortality
rate is 30.15 deaths/1000 live births, in that male mortality rate accounts 34.61
deaths /1000 live births and female mortality rate accounts 25.17 deaths /1000 live
births. 3
W H O estimates that in 2007 the under five mortality was 78.8 deaths /1000 live
births. In that, most of the deaths were attributed to vaccine preventable diseases like
tuberculosis, typhoid, pneumonia, polio, diarrhoeal diseases, tetanus etc. 4
Sometime during the 1770s Edward Jenner heard a milkmaid boast that she would
never have the often-fatal or disfiguring disease smallpox, because she had already had
cowpox, which has a very mild effect in humans. In 1796 Jenner took pus from the
hand of a milkmaid with cowpox, inoculated an 8-year-old boy with it, and six weeks
later variolated the boy's arm with smallpox, afterwards observing that the boy did not
catch smallpox. Since vaccination with cowpox was much safer than smallpox
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inoculation, the latter, though still widely practiced in England, was banned in 1840.
Louis Pasteur generalized Jenner's idea by developing what he called
a rabies vaccine (now termed an antitoxin), and in the 19th century vaccines were
considered a matter of national prestige, and compulsory vaccination laws were
passed. These represent different strategies used to try to reduce risk of illness, while
retaining the ability to induce a beneficial immune response. 5
Killed
Vaccines containing killed microorganisms – these are previously virulent micro-organisms
which have been killed with chemicals or heat. Examples are vaccines against flu, cholera,
bubonic plague, polio and hepatitis A.
Attenuated
Some vaccines contain live, attenuated microorganisms. Many of these are live viri that have
been cultivated under conditions that disable their virulent properties, or which use closely-
related but less dangerous organisms to produce a broad immune response, however some
are bacterial in nature. They typically provoke more durable immunological responses and
are the preferred type for healthy adults. Examples include the viral diseases yellow
fever, measles, rubella, and mumps and the bacterial disease typhoid. The live
Mycobacterium tuberculosis vaccine developed by Calmette and Guérin is not made of a
contagious strain, but contains a virulently modified strain called "BCG" used to elicit
immunogenicity to the vaccine.
Toxoid
Toxoids – these are inactivated toxic compounds in cases where these (rather than the micro-
organism itself) cause illness. Examples of toxoid-based vaccines
include tetanus and diphtheria. Not all toxoids are for micro-organisms; for example,
7
Crotalus atrox toxoid is used to vaccinate dogs against rattlesnake bites.
Subunit
Protein subunit – rather than introducing an inactivated or attenuated micro-organism to an
immune system (which would constitute a "whole-agent" vaccine), a fragment of it can
create an immune response. Examples include the subunit vaccine against Hepatitis
B virus that is composed of only the surface proteins of the virus (previously extracted from
the blood serum of chronically infected patients, but now produced by recombination of the
viral genes into yeast), the virus-like particle (VLP) vaccine against human papillomavirus
(HPV) that is composed of the viral major capsid protein, and the hemagglutinin and
neuraminidase subunits of the influenza virus.
Conjugate
Conjugate – certain bacteria have polysaccharide outer coats that are poorly immunogenic.
By linking these outer coats to proteins (e.g. toxins), the immune system can be led to
recognize the polysaccharide as if it were a protein antigen. This approach is used in the
''Haemophilus influenzae'' type B vaccine.
Experimental
A number of innovative vaccines are also in development and in use:
Dendritic cell vaccines combine dendritic cells with antigens in order to present
the antigens to the body's white blood cells, thus stimulating an immune
reaction. These vaccines have shown some positive preliminary results for
treating brain tumors.
Recombinant Vector – by combining the physiology of one micro-organism
8
and the DNA of the other, immunity can be created against diseases that have
complex infection processes
DNA vaccination – in recent years a new type of vaccine called ''DNA
vaccination'', created from an infectious agent's DNA, has been developed. It
works by insertion (and expression, triggering immune system recognition) of
viral or bacterial DNA into human or animal cells. Some cells of the immune
system that recognize the proteins expressed will mount an attack against these
proteins and cells expressing them. Because these cells live for a very long
time, if the pathogen that normally expresses these proteins is encountered at a
later time, they will be attacked instantly by the immune system. One
advantage of DNA vaccines is that they are very easy to produce and store. As
of 2006, DNA vaccination is still experimental.
T-cell receptor peptide vaccines are under development for several diseases
using models of Valley Fever, stomatitis, and atopic dermatitis. These peptides
have been shown to modulatecytokine production and improve cell mediated
immunity.
Targeting of identified bacterial proteins that are involved in complement
inhibition would neutralize the key bacterial virulence mechanism.
While most vaccines are created using inactivated or attenuated compounds from micro-
organisms, synthetic vaccines are composed mainly or wholly of synthetic
peptides, carbohydrates or antigens.6
Valence
Vaccines may be ''monovalent'' (also called ''univalent'') or ''multivalent'' (also called
''polyvalent''). A monovalent vaccine is designed to immunize against a single antigen or
9
single microorganism. A multivalent or polyvalent vaccine is designed to immunize against
two or more strains of the same microorganism, or against two or more microorganisms. In
certain cases a monovalent vaccine may be preferable for rapidly developing a strong
immune response.7
An important challenge of immunization safety is to ensure vaccine quality and safety. This
must occur from the development stages through clinical trials, vaccine production, quality
control and distribution, up to the point of use, where adequate practices for immunization
must be in place.8
In addition to sophisticated tests, vaccine regulation entails a number of other procedures to
ensure vaccine quality and safety. These include characterization of starting materials by
supplier audits, cell banking, seed lot systems, compliance with the principles of good
manufacturing practices, independent release of vaccines on a lot-by-lot basis by fully
functional national regulatory authorities, demonstration of production consistency and
enhanced pre and post-market surveillance for possible adverse events, following the use of
these vaccines. These procedures help assure vaccine quality, efficacy and safety.9
6.2 NEED FOR THE STUDY As soon as our children are born into this world, they receive what may seem like an
endless number of vaccinations. There are those which are part of the National
Immunization Schedule, which all children should receive. Then there are the optional
vaccinations, which are also important.10 We discuss these vaccines in this article.
Optional Vaccinations may include:
1. Hepatitis A Vaccine
10
2. Hib (Haemophilus Influenza Type B) Vaccine
3. Chicken Pox Vaccine
4. Influenza Vaccine
5. H1N1 Vaccine
6. Rotavirus Vaccine
7. Pneumococcal Vaccine
8. Human Papillomavirus Vaccine
The IAP Committee on Immunization has classified some vaccines as optional
vaccines, e.g., Hepatitis ‘A’ vaccine, Hib vaccine and Varicella vaccine. The word optional
means ‘not compulsory’, ‘which may be chosen or not as one wishes’ ‘discretionary’ or
‘elective’. Optional means that one may elect to have it or not without any risk or
disadvantage. For example in the school or college one may choose any combination from a
set of optional subjects. A may choose History and B may choose Geography as optional
subject. Both have to pass their subject. A will not be disqualified because he/she has not
passed Geography examination.
Hib vaccine has been put in optional category, which would imply that it is not essential. It
provides protection against H.influenzae type b infection which may cause fatal meningitis
or pneumonia in unprotected child. It is an expensive but not optional vaccine.
The British had made smallpox vaccine compulsory, if a child had not been administered the
vaccine by the age of 12 years, the parents could be prosecuted in the court of law. Presently
there is no compulsory vaccine in our country.
For any Indian going to USA for study or job, MMR vaccine is mandatory. We do not have
any mandatory vaccine, any person coming to our country gets Typhoid vaccine or Hepatitis
11
‘A’ vaccine in his or her own interest. We should calssify the vaccines as:
1. Vaccines recommendd for all,
2. Vaccines recommended for special circumstances:
(i) High risk persons, e.g., Influenza vaccine for persons with chronic cardiac or
bronchopulmonary disease, or Pneumococcal vaccine for the persons after splenectomy.
(ii) During epidemics, e.g., Japanese Encephalitis vaccine or Meningococoal vaccine.
(iii) When a person may be going to a place of high prevalance of a particular disease like
Hepatitis ‘A’ vaccine or Yellow Fever vaccine.
The option is with the persons or the parents to go for a particular vaccine or not, at their
own risk. The doctor should consider no vaccine as optional vaccine.11
Vaccine schedule varies from country to country. The policy is made by the Ministry of
Health, Government of that country. Mainly financial aspect and logistic considerations are
taken to decide as to which vaccines should be included in the schedule.
In our country only 6 diseases for vaccination have been included in vaccine schedule while
in developed countries like America more than 16 diseases have been included in the
vaccine schedule in their vaccine programme. Actually in India also, all these Vaccines
should be given to all the children but Government of India due to financial reasons have not
included these vaccines in their schedule.We Paediatricians, who have private practice, do
want to give all these vaccines to our patients and so on our vaccine schedules cards some of
us list these vaccines as optional. Optional is a misnomer. Actually all those vaccines that
are available and are safe, for diseases that occur in our country, should be given. The only
problem is that some of these vaccines are expensive. We explain to the parents why these
should be given and then we let the parents decide whether they want to give these are not.
12
In a busy practise sometimes there is not much time to explain and quite often parents do not
give these vaccines to their children even if they can afford to do so.Varicella-zoster
vaccine, which is for chicken pox is one such vaccine which is listed as optional. It should
be given between one to one and half years of age. Second dose is recommended at 5 to 6
years of age.12
Vaccines are actually very safe, despite implications to the contrary in many anti-vaccine
publications Most vaccine adverse events are minor and temporary, such as a sore arm or
mild fever. These can often be controlled by taking Paracetamol before or after vaccination.
More serious adverse events occur rarely (on the order of one per thousands to one per
millions of doses), and some are so rare that risk cannot be accurately assessed. As for
vaccines causing death, again so few deaths can plausibly be attributed to vaccines that it is
hard to assess the risk statistically. Of all deaths reported to VAERS (Vaccine Adverse
Event Reporting System in the USA) between 1990 and 1992, only one is believed to be
even possibly associated with a vaccine. Each death reported to VAERS is thoroughly
examined to ensure that it is not related to a new vaccine-related problem, but little or no
evidence suggests that vaccines have contributed to any of the reported deaths or serious
side effects. The Institute of Medicine in its report states that the risk of death from vaccines
is "extraordinarily low." Any such extremely low risks from vaccines pale in comparison to
the chances of complications of many serious diseases they protect against.13
For the vaccine safety , Do not compromise on quality for the sake of the savings of a few
rupees, the well being of your children is much more important:
1. Vaccines should be administered only by a Pediatrician or at least a nurse with
adequate pediatric training and experience.
2. Insist on mono- dose vaccines when available13
3. Check to make sure that the expiry and other information on the vaccine
bottle/packet is correct
4. Make sure that the facility has an effective cold-chain to keep the vaccines safe
5. Ask for a vaccine handout which provides details about the vaccine and any potential
side effects
6. Make sure that the vaccination card is updated by the doctor with the date of
vaccination and other information
7. It is better if the provider is keeping an electronic medical record system to keep
track of the vaccinations provided to your child with its batch number.
8. Know what the usual side effects from vaccine administration are including any pain
and fever and take medicines to reduce the impact when needed.14
6.3 REVIEW OF LITERATURE
The purpose of literature review is to discover what has previously been done about
the problem to be studied ,what remains to done, what methods have been employed in
other research and how the result of other research in the area can be combined to develop
knowledge. According to Abdellah and Levine, ”the material gathered in the literature
review should be created as an integral part of research data, since what is found in
literature not only can have an important influence on formulation of problem and design
of research, but also provide comparative material when the data collected in research is
analyzed”15
“ The review of literature is defined as a broad, comprehensive in depth,
systematic and critical review of scholarly publications, unpublished scholarly print
materials, audiovisual material and personal communications. “ 16
A study evaluates knowledge, attitudes, and behaviour of mothers regarding the 14
immunization of 841 infants who attended public kindergarten in Cassino and Crotone, Italy.
Overall, 57.8% of mothers were aware about all four mandatory vaccinations for infants
(poliomyelitis, tetanus, diphtheria, hepatitis B). The results of a multiple logistic regression
analysis showed that this knowledge was significantly greater among mothers with a higher
education level and among those who were older at the time of the child's birth.
Respondents' attitudes towards the utility of vaccinations for preventing infectious diseases
were very favourable. Almost all children (94.4%) were vaccinated with all three doses of
diphtheria ± tetanus (DT), oral poliovirus vaccine ( OPV), and hepatitis B. The proportion of
children vaccinated who received all three doses of OPV, DT or
diphtheria±tetanus±pertussis (DTP), and hepatitis B vaccines within 1 month of becoming
age-eligible ranged from 56.6% for the third dose of hepatitis B to 95.7% for the first
dose of OPV. Results of the regression analysis performed on the responses of mothers who
had adhered to the schedule for all mandatory vaccinations indicated that birth order
significantly predicted vaccination nonadherence, since children who had at least one older
sibling in the household were significantly less likely to be age-appropriately vaccinated..
The coverage for the optional vaccines was only 22.5% and 31% for
measles±mumps±rubella and for all three doses against pertussis, respectively. Education
programmes promoting paediatric immunization, accessibility,and follow-up should be
targeted to the entire population.17
A study was done in maternal socio demographic factors together with mother’s
education, knowledge and perception of immunizations which can affect the uptake of
optional vaccinations. Interviews of mothers were performed using a structured
questionnaire. The study concludes that mother’s attitudes, educational level and socio
demographic characteristics, as well as socio economic factors and local health
policies, can influence children’s immunization uptake. Health promotion based on
partnership between parents and health professionals should become a priority in 15
vaccination policies. 18
6.4 STATEMENT OF PROBLEM :-
A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME ON OPTIONAL VACCINES FOR CHILDREN AMONG
POSTNATAL PRIMI MOTHERS IN SELECTED RURAL AREAS
AT BANGALORE .
6.5 OBJECTIVES OF THE STUDY To assess the level of knowledge among post natal primi mothers regarding Optional
vaccines.
To evaluate the effectiveness of Structured teaching programme on optional vaccines
among postnatal primi mothers.
To associate the level of knowledge with selected socio-demographic variables such
as age, education, occupation, family size, previous knowledge ect.,
6.6 HYPOTHESIS
H1-- There will be a significant difference in knowledge regarding optional vaccines
among postnatal Primi mothers.
H2-- There will be a significant association between knowledge with selected
demographic variables.
6.7 OPERATIONAL DEFINITION :-
Evaluate In this study it refers to producing the desired or intended result of structured
teaching programme on optional vaccines among postnatal primi mothers.
16
Structured Teaching Programme
It is a formal and specific teaching developed for rural primi postnatal mothers
regarding types and administration of optional vaccines and its uses and Guide.
Optional vaccines
It refers to vaccines like Rotavirus vaccination, pneumococcal vaccination, typhoid
vaccination, varicella vaccination, hepatitis A vaccination, H P V vaccination.
Postnatal primi mothers
It refers to the mothers who given birth to the first baby with minimum 3 months
intervels..
6.8 ASSUMPTIONS
It is assumed that:
Mothers may have inadequate knowledge regarding optional vaccines.
The level of knowledge of mothers may increase after the structured
Teaching programme.
6.9DELIMITATIONS
The study is delimited to
Primi mothers
Postnatal period of 3 months.
Selected rural areas at Bangalore
Who knows kannada or English
Who are willing to participate.
17
7
6.10 PROJECTED OUTCOME This help the postnatal primi mothers to understand about the optional vaccines and
hence it will help to practice safe and effective administration of vaccines to the
children’s
MATERIALS AND METHODS 7.1. SOURCE OF DATA
Data will be collected from postnatal Primi mothersin selected rural areas at
Bangalore .
7.1.1 RESEARCH DESIGN The research design adopted for this study is quasi experimental one group pre test
post test design.
7.1.2 RESEARCH APPORACH The research approach for this study is Evaluative approach.
7.1.3 RESEARCH SETTING This study will be conducted in selected rural areas at Bangalore.
7.1.4 POPULATIONPopulation in this study includes all postnatal primi mothers.
7.2 METHODS OF DATA COLLECTION
7.2.1 SAMPLE SIZE
Total sample of the study consists of 60 .
7.2.2 SAMPLING TECHNIQUE
The sampling technique adopted for this study is Purposive sampling .
7.2.3 INCLUSION CRITERIA
Who are willing to participate in the study.
18
Who are available during the study.
Staff nurses who knows Kannada or English.
Only primi postnatal mothers
Postnatal period within 3 months
7.2.4 EXCLUSION CRITERIA
Who are not willing to participate in the study.
Multigravida postnatal mothers.
Postnatal mothers after 3 months
7.2.5 INSTRUMENT INTENDED TO BE USED SELECTION OF
TOOL
This consist of three parts;
PART-1 : It consist of socio-demographic variables such as age, education,ect
PART-2 : Questionnaire will be used to assess the knowledge,30 questions will be
used.
PART 3: Structured teaching programme on optional vaccines.
SCORING PROCEDURE:
For knowledge assessment total score is -30
If the answer is correct the score is -1
If the answer is wrong the score is -0
SCORING INTERPITATION:
Good : 25 to 30.
Average :20 to 25
Poor : Below 20
7.2.6 METHODS OF DATA ANALYSIS Data analysis will be done using descriptive and inferential statistics:
1. Descriptive statistics: mean, median, mode and standard deviation is used for
assessing knowledge scores.
2. Inferential statistics: Chi-square will be used to find the association between
19
7.3
7.4
knowledge score and selected demographic variables.
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO
BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
- No
HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
YES, Ethical clearance will be been obtained from the research committee
of Nightingale college of nursing.
Consent will be taken from the panchayat president and medical officer Phc
and permission will be taken from the study subjects before the collection of data.
REFERENCES
1. " Dorland's Medical Dictionary
20
8.
http://www.cdc.gov/vaccinesafety/Vaccines/HPV/gardasil.html
2. UNICEF-Immunization.introduction.6 December 2007.
URL:http://www.unicef.org/immunization/index.html.
3. Facts and statistics about the Infant mortality rate of India. 2009.
URL:http://www.indexmundi.com/India/infant_mortality_rate.html
4. Mortality rate, under 5.2007.
URL:http://www.google.com/publicdata?ds=wb-
wdi&met=sh_dyn_mort&idim=country:IND&q=under+five+mortality+rate
5. http://www.nhs.uk/news/2009/09September/Pages/Cervical-cancer-vaccine-
QA.aspx
6. Stern AM, Markel H (2005). "The history of vaccines and immunization:
familiar patterns, new challenges".Health Aff 24 (3): 611–
21. doi:10.1377/hlthaff.24.3.611.PMID 15886151.
7. Dunn PM (January 1996). "Dr Edward Jenner (1749-1823) of Berkeley, and
vaccination against smallpox".Arch. Dis. Child. Fetal Neonatal Ed. 74 (1): F77–
8.doi:10.1136/fn.74.1.F77. PMC 2528332.PMID 8653442.
8. Van Sant JE (2008). "The Vaccinators: Smallpox, Medical Knowledge, and the
'Opening' of Japan". J Hist Med Allied Sci 63 (2): 276–
9.doi:10.1093/jhmas/jrn014.
9. http://www.news-medical.net/health/What-are-Vaccines.aspx
10. Dellepiane N, Griffiths E, Milstien JB. New challenges in assuring vaccine
quality. WHO Bulletin, 2000, 78: 155-162
11. Dudgeon JA (1963). "Development of smallpox vaccine in England in the
eighteenth and nineteenth centuries".BMJ (5342): 1367–
72. doi:10.1136/bmj.1.5342.1367.PMC 2124036. PMID 20789814.
21
12. Yash Paul,A-D-7, Devi Marg,Bani ParkJaipur 302 016, India
http://www.indianpediatrics.net/jan2001/jan-99-101.htm
13. R Raj Rani Mitra,http://easybabycare.wordpress.com/2011/06/02/optional-
vaccines/
14. http://www.allforkidsindia.com/allforkids/Resources/VaccineOptions.aspx
15. http://www.allforkidsindia.com/allforkids/Resources/VaccineOptions.aspx
16. . Neelam Makhija,”Introduction to nursing research”:1st edition :A.P Jain & co.
New delhi:2005:30-35.
17. 16. B T Basavanthappa :”Text book of Nursing research”:2nd edition; , Jayapee
brothers medical publishers(p) ltd New Delhi;2009; p 92-115.
18. . P Impicciatore, C Bosetti, S Schiavio, C Pandolfini, M Bonati .
Mothers as active partners in the prevention of childhood diseases:
maternal factors related to immunization status of preschool
children in Italy. Prev.2000 july 31.
19. I.F. Angelillo et al., “ mothers and vaccination knowledge,attitude,and behavior
in Italy, Available from http://www.who.int/bulletin/archives/77(3)224.pdf
20. http://singaporedoc.com
21. Article Source: http://EzineArticles.com/?expert=Dr_Ang_C._D.
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9 SIGNATURE OF CANDIDATE
10 REMARK OF GUIDE
11 NAME AND DESIGNATION
11.1 GUIDE
11.2 SIGNATURE
23
11.3 CO-GUDE
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT
11.6 SIGNATURE
12 12.1 REMARK OF PRINCIPAL
12.2 SIGNATURE
24
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