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

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3

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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

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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,

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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

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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

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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

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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

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‘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.

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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.

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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.

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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.

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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

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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

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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.

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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

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11.3 CO-GUDE

11.4 SIGNATURE

11.5 HEAD OF DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARK OF PRINCIPAL

12.2 SIGNATURE

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