Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s43

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE MONIKA CHAUDHARY CANDIDATE AND I YEAR M.Sc. NURSING STUDENT ADDRESS Smt. NAGARATHNAMMA COLLEGE OF NURSING, ACHARYA DR.SARVEPALLI RADHAKRISHNAN ROAD,BANGALORE – 90 2. NAME OF THE Smt. NAGARATHNAMMA COLLEGE OF INSTITUTION NURSING, ACHARYA DR.SARVEPALLI RADHAKRISHNAN ROAD,BANGALORE – 90 3. COURSE OF STUDY AND I YEAR M.Sc. NURSING SUBJECT CHILD HEALTH NURSING 4. DATE OF ADMISSION TO 30.6.2012 COURSE 5. TITLE OF THE TOPIC EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMMME ON KNOWLEDGE REGARDING “PREVENTION OF MUMPS IN UNDERFIVE CHILDREN,” AMONG THE MOTHERS ATTENDING UNDER FIVE CLINIC OF BANGALORE RURAL PHC.

1 6. BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION:

‘"Real knowledge, like everything else of value, is not to be obtained easily. It must be worked for, studied for, thought for, and, more that all must be prayed for." - Unknown Communicable diseases have in many occasions led to the death of children who could have contributed positively to the economic, social and political development of the society. It is therefore imperative for every individual and organizations to find solution to the problem of communicable diseases in the area of prevention and control, for an adage says prevention is better than cure.1 The epidemiology of mumps in India and the magnitude of the problem are still not fully appreciated. Mumps continues to occur in epidemic proportions, despite the availability of an effective vaccine. There were 301 children admitted with mumps between 1999 and 2003.2 In 2010, approximately 92% of all children had been exposed to mumps by the age of 15. In these pre-vaccine years, most children contracted mumps between the ages of four and seven. Mumps epidemics came in two to five year cycles. The greatest mumps epidemic was in 2011 when approximately 250 cases were reported for every 100,000 people.3 According to India Weekly outbreak reports 2012, there are 19 cases of mumps in Lakhisarai (Bihar), 13 cases of mumps in Thrissur (Kerala), 47 cases of mumps and 1 fatality in Osmanabad (Maharashtra), 27 cases of mumps in Bankura (West Bengal), and 93 cases of mumps in Leh (Lada ( Jammu and Kashmir). 4 Mumps is a moderately infectious disease caused by a virus of the paramyxovirus group. The infection is spread by airborne droplets and possibly also by urine. The first symptoms occur after an incubation period of 15-24 days (median 19 days). After a prodromal (warning signs) period of several days with non-specific flu-like symptoms of headache and fever, the classic swelling of the parotid glands (salivary glands) develops.5 Vaccination is probably one of the most cost effective intervention for infectious

2 diseases to reduce burden of childhood morbidity and mortality, provided used optimally and judiciously. Currently it is estimated that immunization saves the life of 3 million children a year but 2 million more lives could be saved by existing vaccines.6 So awareness of vaccines and its effects to all the mothers is an important factor to improve the health of the child. So, the mothers must have the primary responsibility of getting their child fully immunized and the child must not be made to suffer if the mothers are having lack of knowledge.7 Mothers are the primary care takers of the children because usually the children depend on their mothers for fulfilling their needs the mothers play a vital role in safe guarding their children against many disease conditions especially infectious disease like viral infections. So their knowledge regarding infectious diseases and their prevention is of vital importance. 8 6.1 NEED FOR THE STUDY Mumps cases reported in Kerala state, India, it has hit a three year high, total of 133 cases were reported in 2012 when in comparison to 97 cases in 2011, the number of cases were increasing drastically since October. Mumps cases are known to peak in the period between January to march. The reason for the rapid spread of the disease is that swelling occurs on the child only after 2 or 3 days, in these 2 or 3 days the only symptom will be fever or cold. So the parents keep sending their child to school. This results in spread to other students. For this reason awareness campaigns were launched.9 Over 100 children have been affected by a mumps outbreak in Marashda, Egypt, with 43 cases and 70 infections reported. Officials at the ministry of health insist that this is a serious outbreak. 10 As Because of the arrival of new mumps virus genotype, Mumps has re- emerged as an infection in the developed world. Its epidemiology has changed, while mumps is easily suspected if parotitis is present, parotitis is absent in 10%-30% of symptomatic cases. Mumps is a systemic infection with a variety of extra- parotid complications.11 Although there is only one serotype of mumps virus, according to recent update by WHO (June 2012), There are currently 12 genotypes A-N.12 According to “The Hindu National Newspaper” Incidences of infectious disease mumps are increasing in the city every year In the hospital of Bangalore there were 265 cases of mumps in 2000, this went down to 177 and 132 in 2001and 2002 respectively.

3 In 2003, there were 275 cases and in 2004, it was 274. The incidences of these three infections continue to increase despite a vaccine to protect against them. This is mainly because the vaccines are expensive.13 Inspite of MMR vaccine; there are cases of mumps detected in India. According to India Weekly Outbreak reports 2012, Mumps in Belgaun (25 cases, Karnataka). Mumps in Chitradurga (10 cases, Karnataka), Mumps in Bangalore (46 cases, Karnataka). 14 In 2009 noted a five-fold increase in the incidence of the disease because of the reluctance of some states to adopt comprehensive school immunization laws. Since then, state-enforced school entry requirements have achieved student immunization rates of nearly 100% in kindergarten and first grade. 2012, the Centers for Disease Control and Prevention (CDC) reported 751 cases of mumps nationwide, or, in other words, about one case for every five million people.14 Mumps primarily affects young children, with increased incidence in winter and spring. This study is intended to highlight the increased number of mumps cases in children attending tertiary care centre in Nepal, so as to decrease the disease occurrence and disease burden. 15 Mumps outbreaks are likely caused by factors including incomplete protection following vaccination, waning of immunity, and intensive crowding. Mumps currently affects mainly people who were vaccinated more than 10 years ago. Outbreak response concentrates on surveillance, outbreak investigations, disease awareness, and provision of catch up vaccination to unvaccinated or incompletely vaccinated children. Adequate surveillance, important for building evidence for possible changes in mumps vaccination recommendations, depends on recognizing mumps and its complications.12 Mumps can cause major complications, particularly in male, in whom complications can result in sterility if not treated properly. CNS involvement - 15% of clinical cases like meningitis 50% to 60% of patients. , Orchitis - 20%-50% in post-pubertal males, Pancreatitis - 2%-5%, Deafness - 1/20,000 (80%), Oophoritis (ovarian inflammation) occurs in 5% of post pubertal females. Other less common complications of mumps include arthralgia, arthritis, and nephritis. An average of one death from mumps per year was reported during 1999-2010.16 Children in rural areas in India die due to infectious and communicable diseases.

4 This study was carried out to know the immunization status, nutritional status and to assess the levels of the mother’s knowledge regarding immunization and nutritional diet. The findings reveals, For those mothers who were well aware of the immunization and nutritional programmes, the children’s height and weight were well correlated against the mothers who were not aware of these programmes, whose children’s height and weight did not show significant correlation. The results showed that 16% of the children were under malnutrition.17 The result of a study on level of mother’s knowledge shows that the mother’s knowledge of child health related matters is deficient. It is the responsibility of health care personnel to disseminate information on child health matters among mothers in the community.18 A descriptive study was conducted to determine the relationship between the literacy status and immunization coverage among 100 mothers of school going children. The analysis revealed a fairly low immunization coverage (<33%) for all vaccines and it was found that literacy status of mothers had a significant influence on the immunization level. Lack of awareness and motivation was cited as the main reason for non-immunization.19 While working in the community the investigator found that there are so many children missed the opportunities of vaccination and some children contracted the condition despite vaccination hence, the investigator decided to undertake the study to assess the effectiveness of structured teaching programme for mothers in a selected area at Bangalore.20 6.2. REVIEW OF LITERATURE

Using a cross-sectional design, 790 HSS of Manipal University, Manipal, India, answered a questionnaire and provided a blood sample which was tested for specific IgG antibodies to measles, mumps, rubella and varicella by ELISA (Enzygnost).The study group was comprised of medical (53.9%), nursing (16.6%), and allied health (29.5%) students. Among the overall group (n = 790), the prevalence of serological susceptibility to measles, mumps, rubella, and varicella were 9.5%, 32.0%, 16.6%, and 25.8%, respectively. Among the subgroup of vaccinated subjects, susceptibility to

5 measles, mumps, rubella, and varicella were 7.9%, 34.7%, 10.7%, and 35.2%, respectively.21 The duration of the presence of maternal mumps antibodies in a prospective cohort study is presented. Immunoglobulin G against mumps was portioned with a commercial ELISA test (Euroimmun anti-mumps Virus AT ELISA, Germany) on samples from 213 mother–child pairs at seven time points between pregnancy and 12 months of age. Non-linear mixed models were used to model maternal antibody decay in infants. The model-based median time to loss of antibodies was 3.6 months. The median child-specific time to loss of antibodies in children of naturally immune women (3.8 months) and children of vaccinated women (2.4 months) differed significantly (p = 0.025). The log antibody level of the mother and the log birth weight were correlated with the duration of maternal antibodies in infants (p < 0.0001). Children of vaccinated women loose maternal mumps antibodies significantly earlier in life compared to children of naturally infected women. If early administration (<12 months) of the combined measles, mumps, and rubella vaccine is needed, maternal mumps antibodies are not expected to interfere with infant humoral vaccine responses.22 Comparative prospective or retrospective trials assessing the effects of the MMR vaccine compared to placebo, do nothing or a combination of measles, mumps and rubella antigens on healthy individuals up to 15 years of age. We included five randomized controlled trials (RCTs), one controlled clinical trial (CCT), 27 cohort studies, 17 case-control studies, five time-series trials, one case cross-over trial, two ecological studies, six self controlled case series studies involving in all about 14,700,000 children and assessing effectiveness and safety of MMR vaccine. Effectiveness of at least one dose of MMR in preventing clinical mumps in children is estimated to be between 69% and 81% for the vaccine prepared with Jeryl Lynn mumps strain and between 70% and 75% for the vaccine containing the Urabe strain. Vaccination with MMR containing the Urabe strain has demonstrated to be 73% effective in preventing secondary mumps cases. 23 A retrospective cohort study was conducted among the students in four elementary schools and their siblings. The vast majority (98%, 95% CI 96-99%) of the cases occurred among the unvaccinated children. The attack rates across the four

6 schools varied widely, which could be expected in light of the major differences in vaccination coverage. For the subgroup of unvaccinated children, the attack rates also varied across the schools with the rates much higher for those children with a connection to the orthodox protestant schools A and B than for those children with a connection to schools C and D (p < 0.05). Furthermore, 59% (109/186) of the cases among the students at school A and 53% (68/128) of the cases among the students at school B could be classified as possibly secondary cases of mumps (i.e., onset of symptoms one incubation period past the infectious period of another case in the same grade, thus in the third week following onset of symptoms of the other case). Using the same definition, there were no possibly secondary cases at schools C and D. Almost half of the respondents (47%, 95% CI 45-50%) reported clinical signs of mumps.24 This was a prospective study done in Civil Service Hospital of Nepal over a period of 2 years from November 2009 to October2011. All children less than 14years of age with symptoms of fever and parotid swelling were included in the study group. A detailed history pertaining to the disease was taken, Children were asked to follow up either after 5 days or in case of noticing any signs and symptoms of complication. There were total 113 cases diagnosed clinically as mumps of which there were 71 males (62.83%) and 42 females (37.16%) with the peak incidence of disease in the month of March and September with 22 cases (19.46%) in each month. The increase incidence was seen in 4-6 years of age with 58 cases (51.32%). There were 70 patients (61.94%) that had history of exposure to mumps infection. There were large number of children with mumps and none of them were vaccinated. Child can be prevented from the infection by vaccination and thus avoiding possible sufferings and complications. Thus they recommend the use of mumps vaccination in Routine immunization programme.25 A study was conducted among children, according to the study Children under the age of 5 years generally spend most of their time with their parents and guardians, especially mothers, even when they attend pre-schools or nurseries. It has been found that young children's health maintenance and outcomes are influenced by their parent's knowledge and beliefs. This study was done to assess the mother's knowledge about the infectious diseases of their pre-school children in Moradabad, India. Mothers of children aged 1-4 years, attending the hospital for vaccination or regular checkups in

7 the paediatric division of government hospitals, were invited to participate in the study. A 20-item questionnaire covering socio-demographic characteristics, dietary practices, hygiene practices was distributed to their mothers, during their visit to the hospital. Responses of the mothers were recorded on a Likert Scale. The sample comprised 406 mothers, with the mean age of children being 3.8 years. Three hundred (73.8%) mothers had some knowledge about diet and dietary practices, while only 110 (27.1%) and 103 (25.4%) mothers were found to have not good knowledge about the importance of hygiene practices.26 A study evaluated the vaccine effectiveness of 1 and 2 doses of the MMR vaccine during an outbreak of mumps in Ontario, Canada that occurred between September 1, 2009, and June 10, 2010. The study also aimed to estimate the coverage level required to achieve “herd” immunity and interrupt community transmission. Using data from Ontario's Public Health Information System, 134 confirmed cases were identified; 114 of those reported receipt of MMR vaccine. Of those, 63 received 1 dose (49.2-81.6% effectiveness), while 32 received 2 doses (66.3-88% effectiveness). The study concludes that vaccine coverage of 88.2% and 98% would be needed to interrupt community transmission of mumps, emphasizing the need for routine vaccination and warning against complacency in vaccination programs. 27 According to a study currently, treatment of mumps is generally supportive for both parotid and extra-parotid manifestations, including mumps meningitis. The use of local measures, such as heat or cold packs, and a combination of antipyretics and analgesics is generally recommended. Treatment with intramuscular mumps immune globulin may be of benefit in the early stages in certain cases, but this product is not available in Australia. Intravenous immunoglobulin therapy appears to have reduced certain complications of mumps, but this has not led to universal recommendations for its use. The role of subcutaneous interferon alpha-2b in preventing testicular atrophy in mumps orchitis has been examined, but there are conflicting data on outcome, presumably reflecting the small numbers of both subjects and studies.28 A Prospective office-based study was conducted to determine the incidence of hearing loss in children with mumps. Forty pediatric practices participated in this survey. The study population consisted of patients < or =20 years old with mumps seen

8 between January 2004 and December 2006. Clinical diagnosis of mumps was made by experienced pediatricians. Among those from whom written consent was obtained, parents were asked to conduct hearing screening tests by rubbing fingers near the ears twice daily for 2 weeks. Patients suspected with hearing loss were further examined by an otolaryngologist. Among 7400 children who underwent hearing ability assessment after clinical onset of mumps, 7 had confirmed hearing loss; none had been previously vaccinated against mumps. In all cases, hearing loss was unilateral but severe and did not improve over time. The incidence of hearing loss in children due to mumps was 7/7400 (approximately 1/1000 cases), which is higher than previously suggested. Prevention of deafness is another important reason for assuring universal immunization against mumps. 29

6.3. STATEMENT OF THE STUDY Effectiveness of Structured Teaching Programme on Knowledge regarding, “Prevention of Mumps in Under Five Children,” among the Mothers attending under five clinic of Bangalore Rural PHC.

6.4. OBJECTIVES OF THE STUDY 1. To assess the knowledge regarding prevention of mumps among subjects. 2. To assess the effectiveness of Structured Teaching Programme among subjects. 3. To determine the association between knowledge scores and selected demographic variables of subjects.

6.5. OPERATIONAL DEFINITIONS Effectiveness: Refers to significant gain in knowledge and practice as determined by significant difference in pretest and posttest scores. Structured teaching programme: It refers to a systemically planned and organized teaching of one hour duration which includes meaning, incidence, etiology, clinical features, complications, treatment and prevention of Mumps. Knowledge: Refers to the correct responses of subjects on structure interview schedule

9 regarding prevention of mumps. Mother: Refers to mothers of under five children attending the under 5 clinic at a selected rural PHC, Bangalore. Prevention: Refers to the measures initiated by the mothers of under 5 children like immunization, isolation and hand washing to prevent the occurrence of mumps. Mumps: Refers to the condition characterized by fever, swelling of parotid gland, cold, headache, it is a viral infection caused by mumps virus (paramyxovirus). Children: Refers to the children who are below five year of age.

6.6. HYPOTHESIS

H1: The mean posttest scores of subjects exposed to Structured Teaching Programme on ‘Prevention of Mumps’ will be more than their mean pretest scores as measured by structured knowledge and practice test at 0.05 level of significance.

6.7. ASSUMPTIONS It is assumed that : 1. Mothers are able to understand the importance of prevention of mumps. 2. Mothers will be willing to express their knowledge regarding prevention of mumps. 3. Structured teaching programme is an accepted teaching strategy.

6.8. DELIMITATIONS 1. The study is delimited to mothers in the selected rural area only. 2. The mothers who are available at the period of study. 3. Effectiveness of structured teaching programme in terms of knowledge scores only. 4. Measurement of knowledge scores of mothers once before and after the effectiveness of structured teaching programme.

6.9. PROJECTED OUTCOME 1. The study will enhance the knowledge of mothers and help them in taking decisions about prevention at appropriate time.

10 2. This study will encourage the mothers to immunize their children at appropriate time

7 MATERIALS AND METHODS 7.1. SOURCE OF DATA Data will be collected from mothers of under five children attending the under 5 clinic, at selected rural PHC, Bangalore.

7.2.1. INCLUSION CRITERIA Mothers of Under 5:  Presently attending Under 5 clinic only.  Who give consent for the study.  Who come under selected PHC for the study. 7.2.2 EXCLUSION CRITERIA Mothers of Under 5:  who do not attend the under 5 clinic.  who have not given consent for the study. 7.2.3. RESEARCH DESIGN Quasi experimental pretest, posttest one group design. 7.2.3. SETTING Under 5 clinic, at selected rural PHC, Bangalore. 7.2.4. SAMPLING TECHNIQUE Purposive sampling technique.

7.2.5. SAMPLE SIZE 50 Mothers of Under 5 children. 7.2.6. TOOL OF RESEARCH Structured interview schedule will be developed and used to assess the knowledge component of the subject. 7.2.7. COLLECTION OF DATA The investigator will administer the structured interview schedule to assess the knowledge component of the subjects. 7.2.8. METHOD OF DATA The investigator will analyze the data obtained by ANALYSIS AND using descriptive and inferential statistics. The plan PRESENTATION of data analysis will be as follows:  Organize the data in a master sheet/ computer.  Frequencies and percentages for the analysis of background data.

11  Mean, Median, SD and ‘t’ values to determine the significance.  Chi-square test to determine the association. 7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY. Yes, the study will be conducted on mothers of under 5 children attending under 5 clinic of a selected rural PHC, Bangalore. 7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3? Yes, informed consent will be obtained from the institution authorities and subjects. Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartiality.

8. LIST OF REFERENCES 1. Barbara, C.C. & Baurer, W.W.(1977). Community health preventive medicine and social services., London: Bailliere Tindall. 2. M.G. Geeta, Mumps-Need for Urgent Action, Indian Paediatrics 2004; 41:1181- 1182. 3. Centers for Disease Control and Prevention. Mumps. In: Atkinson W, 11th 2009– January 2010. MMWR 2010;59(05):125–129. 4. India Weekly Outbreak reports 2012 - Page 2 - FluTrackers 5. Malen A. Link, Recent Mumps Outbreaks in Vaccinated Populations, 2012 January; 86(1): 615–620, doi: 10.1128/JVI.06125-11 6. W.H.O. Global Forum for Health Research 2o1o. www.pubmed.com. 7. WHO, UNICEF and World Bank, state of the world’s vaccines and immunizations, 3rd edition, Geneva world health organization 2010. 8. Aggarwal K,Kannan A T Chabra P,kumar P, Trikha V K.Knowledge,Attitudes,beliefs and practises regarding mumps in a rural area of Delhi. 2002 Jun.34(2); 128-34.. 9. Amritha K R, Sharp rise in mumps cases in district KOCHI, Updated Feb 03, 2012 at 08:56am IST

12 10. Lauren Edmundson, 2012, The Disease Daily Newspaper in Egypt 11. University of Maryland Medical Center (UMMC), 2011, UMMC is a member of the University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD 21201. TDD: 1-800-735-2258 or 1.866.408.6885. 12. Bedford H, Mumps: current outbreaks and vaccination recommendations, Nurs Times. 2005 Sep 27-Oct 3; 101(39):53-4, 56. 13. Divya Ramamurthi,, june 2005, The Hindu National Newspaper (Karnataka) ,Incidences of infectious diseases on the rise in city. 14. The Centers for Disease Control and Prevention Update: Mumps Outbreak— New York and New Jersey, June 2009–January 2010. MMWR 2010;59(05):125–129. 15. Keyal K, 2011, Study of Mumps in Children attending a Tertiary Care Centre. 16. El Comercio, http://www.elcomercio.es/v/20121206/asturias/salud-detecta- brote-paperas-20121206.htmlomersio, Mumps - Spain (06): (Asturias) www.nihe.org.vn/new-en/about.../Mumps--Spain-06-Asturias.vhtm. 17. Elangovan R, The Immunization And Nutritional Status Among children Aged Under Five In A Major District In India, Journal of Indian Pediatrics, 2001, Vol.38,. 927. 18. http;//adc.bmj.com/cont/95//6/el.11. Abstract. Knowledge of mothers about vaccines preventable diseases. 19. Polkki T, Pietila AM, Julkunen KV, Laukkala H, Ryhanen P. Determine the relationship between the literacy status and immunization coverage among mothers of underfive children in Kolar district in Bangalore. Journal of Paediatric Nursing 2001 Aug;17(4):270-2. 20. Dr. David Perlstein, Mumps Vaccine, Treatment , Symptoms, Prognosis - eMedicineHealth,www.emedicinehealth.com, children's health az list http://www.umm.edu/altmed/articles/mumps-000112.htm#ixzz2AynzCNUJ 21. E. Leuridan,N. Goeyvaerts, Maternal mumps antibodies in a cohort of children up to the age of 1 year, August 2012, Volume 171, Issue 8, pp 1167-1173 22. Rivetti A, Vaccines for measles, mumps and rubella in children, 2012 Feb 15; 2:CD004407. doi: 10.1002/14651858.CD004407.pub3. 23. Wilhelmina LM Ruijs, The role of schools in the spread of mumps among

13 unvaccinated children: a retrospective cohort study, BMC Infectious Diseases 2011, 11:227 doi:10.1186/1471-2334-11-227. 24. Jeannine LA Hautvast, Department of Primary and Community Care, Academic Collaborative Centre AMPHI, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands, 2011, 11:227 doi:10.1186/1471- 2334-11-227. 25. Joshi BG, Study of Mumps in Children attending a Tertiary Care Centre, 2011 Mother's knowledge about pre-school child's oral health, DOI: 10.4103/0970-4388.76159 PMID: 21273717. 26. Germaine L Defendi, Management of Acute Presentation of Mumps, emedicine.medscape.com/article/966678-treatment, 2010. 27. A Fylaktou, Surveillance and outbreak reports of mumps in Greece, 28. Eurosurveillance, Volume 13, Issue 16, 17 April 2008. 29. Sanjaya N Senanayake, Mumps: a resurgent disease with protean manifestations, Med J Aust 2008; 189 (8): 456-459.

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF: 11.1. GUIDE PROF MARIAM JAISY G., M.Sc[N], HOD, PAEDIATRIC NURSING, Smt. NAGARATHNAMMA COLLEGE OF NURSING, BANGALORE. 11.2. SIGNATURE

14 11.3. CO-GUIDE ESTHER SHIRLEY DANIEL., M.Sc. [N].,Ph.D., PROFESSOR- CUM- PRINCIPAL Smt. NAGARATHNAMMA COLLEGE OF NURSING, BANGALORE. 11.4. SIGNATURE

11.5. HEAD OF THE PROF. MARIAM JAISY G., M.Sc[N]. DEPARTMANT 11.6. SIGNATURE

12. REMARKS OF THE CHAIRMAN/ PRINCIPAL

12.1. SIGNATURE