SOMASHEKHAR NIDAGUNDI

1STYEAR MSc NURSING

CHILD HEALTH NURSING

2010-2012

SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCE AND RESEARCH CENTRE, B.H.ROAD, TUMKUR-572102

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RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.

NAME OF THE

CANDIDATE AND

ADDRESS

Mr.SOMASHEKHAR NIDAGUNDI

1ST YEAR M.Sc. (NURSING),

SHREE SIDDAGANGA INSTITUTE OF

NURSING SCIENCES AND RESEARCH

CENTRE, B.H. ROAD, TUMKUR – 572 102.

2.NAME OF THE

INSTITUTION

SHREE SIDDAGANGA INSTITUTE OF

NURSING SCIENCES AND RESEARCH

CENTRE, TUMKUR

3COURSE OF STUDY

AND SUBJECT

1st Year M.Sc (NURSING)

CHILD HEALTH NURSING

4DATE OF ADMISSION

TO COURSE 10-06-2010

5STATEMENT OF THE

PROBLEM

“A STUDY TO EVALUATE THE

EFFECTIVENES OF SELF INSTRUCTIONAL

MODULE ON KNOWLEDGE REGARDING

TETANUS AMONG MOTHERS OF

UNDERFIVE CHILDREN IN SELECTED

AREAS AT TUMKUR”

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6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“The most important thing she'd learned over the years was that there was no

way to be a perfect mother and a million ways to be a good one”

-- Jill Churchill

Health is presented not as just the absence of disease, but as an active

optimization of each individual’s potential. It’s time to get organized around the four

major factors that intersect again over a person’s lifetime; risk, prevention, detection,

and control.

Health is a fundamental human right. It is central to the concept of quality of

life. Health and its maintenance is a major social investment and is World-wide social

goal. Health is multidimensional. This health may be assessed by such indicators as

death rate, infant mortality rate and expectation of life. 01

Children contribute around 40% of the population. Children are vulnerable,

who need to be protected and cared. According to Swami Vivekananda “A true

teacher is one who can immediately come down to the level of students and transfer

his soul to the student’s soul and see through and understand through his mind.

Teachers can have an immense impact on young people health as reported by

UNESCO; there are almost 43 million teachers around at the primary and secondary

level.02

The word "tetanus" is derived from the Greek tetanos meaning "taut", and

teinein to "stretch" In 1897, Edmond Nocard showed that tetanus antitoxin induced

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passive immunity in humans, and could be used for prophylaxis and treatment.

Tetanus toxoid vaccine was developed by P. Descombey in 1924, and was widely

used to prevent tetanus induced by battle wounds during 2nd World War.03

Tetanus is an acute disease associated with significant morbidity and delay in

treatment leads to mortality. It is caused by Clostridium tetani, an anaerobic, gram

positive, spore-forming bacilli commonly found in soil and faeces. Tetanus generally

occur 7-14days after inoculation of the organism. The shorter the incubation time, the

poor is the prognosis. The end result is spasms, rigidity and autonomic instability.

Tetanus is preventable with proper immunization. Tetanus toxoid, which is an

inactivated form of tetanospasmin, confers protective antibody levels in 81-95% of

people after 2 doses and 100% of people after 3 doses. Recommendations for primary

immunization depend on the age of the patient. If the patient is younger than 7 years

old, a diphtheria, tetanus, and pertussis (DTP) vaccine should be given at 2, 4, 6 and

15 months of age, with a booster at 4 to 6 years of age. If the patients are more than 7

years old, immunization can be accomplished by three injections of tetanus and

diphtheria (Td). The first two doses should be given at least 4 weeks apart with the

third dose 6 months after the second dose. Primary immunization in the pregnant

patient entails two injections of Td one month apart, preferably during the last two

trimesters. Td boosters are generally avoided during the first trimester, although there

is no evidence that they are harmful to the fetus. In the setting of an acute injury,

tetanus prophylaxis depends on the patient’s immunization history and the wound

characteristics. HTIG is needed only for tetanus-prone wounds in patients who have

never completed a primary immunization series. The dose is 500 IU IM.04

Tetanus is an international health problem, as C. tetani spores are ubiquitous.

The disease occurs almost exclusively in persons who are unvaccinated or

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inadequately immunized. Tetanus is occurs worldwide but is more common in hot,

damp climates with soil rich in organic matter. This is particularly true with manure

treated soils, as the spores are widely distributed in the intestines and feces of many

non-human animals such as horses, sheep, cattle, dogs, cats, rats, guinea pigs, and

chickens. Spores can be introduced into the body through puncture wounds. In

agricultural areas, a significant number of human adults may harbor the organism.

The spores can also be found on skin surfaces.05

6.2 NEED FOR THE STUDY

Tetanus (sometimes called lockjaw) is caused by the toxin (poison) of a

bacterium (clostridium tetani) and are toxic to the nerves. The infection usually occurs

when the bacteria enter the body through a deep wound - these bacteria are anaerobic

and hence don't need oxygen to survive. The bacteria can enter the body through a

tiny pinprick or scratch but prefer deep puncture wounds or cuts like those made by

nails or knives. Tetanus bacteria commonly are found in soil, dust, and manure.

Tetanus occurs in several clinical forms, including generalized, cephalic, localized,

and neonatal disease

There are four clinical forms of tetanus representing the extent and location of

neurons involved: generalized, local, cephalic, and neonatal. In the US and other

developed countries, generalized tetanus is the most common form, occurring in 81%

of cases. The initial symptom is trismus “lockjaw” secondary to masseter muscle

spasm in 50-75% of cases. As the disease spreads, generalized muscle spasms occur,

either spontaneously or to minor stimuli such as touch or noise. Opisthotonus, a tonic

contraction very similar to decorticate posturing, is classically described with tetanus.

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Severe spasms can result in vertebral fractures, long bone fractures, and detachment

of tendons from their insertions.

In the acute phase, death results from acute respiratory failure due to

diaphragmatic paralysis or leryngeal spasms. With intensive medical intervention,

including paralysis and mechanical ventilation, such deaths can be averted. However,

with patients surviving beyond the acute phase, autonomic instability becomes the

major cause of death, with a fatality rate of 11-28%. Local tetanus presents as

persistent muscle rigidity close to the site of injury. The rigidity may linger for weeks

to months and often self-resolves without sequelae. A caveat is that what appears to

be localized tetanus may instead be the first symptom of generalized tetanus. The

incidence is 13%, and the fatality rate in about 1%. Cephalic tetanus is an uncommon

variant of localized tetanus that involves the cranial nerves. It has an incidence of 6%.

Cephalic tetanus uniquely results in nerve palsies as well as muscle spasms. The

seventh cranial nerve is most often involved, followed by the 6th, 3rd, 4th, and 12th in

decreasing order of frequency. Cephalic tetanus also presents with trismus, but in 42%

of cases, cranial nerve deficits precede the onset of trismus.

About 2/3 of the patients progress to generalized tetanus, and the

overall mortality is 15-30%. Neonatal tetanus is generalized tetanus that occurs in the

newborn around the first week of life. Symptoms begin with non-specific irritability

and poor feeding, and rapidly progress to generalized spasms. The portal of entry is

the freshly cut umbilical cord. The risk of contracting neonatal tetanus is directly

related to the cleanliness of delivery conditions and to maternal immunization, since

passive transfer of maternal immune globulins is protective.

Mortality is very high, 50-100%, due to the high load of toxin per body weight

in neonates. The global fatality rate was 6.5‰ live births in 1993, resulting in an

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estimated 515,000 deaths. Eighty percent of the cases occurred in 12developing

countries in Africa and Asia. Programs to immunize pregnant women in these high

incidence areas have dramatically decreased the incidence and fatality rates of

neonatal tetanus. In the US and other developed countries, neonatal tetanus is very

rare due to cleaner delivery conditions and a high rate of immunization among women

of childbearing years. There were no reports of neonatal tetanus in the US between

1991-99 06

A study conducted on acute and chronic complications are related to the

severe tetanic muscle contractions: Rhabdomyolysis and hyperkalemia, Vertebral

body and other fractures Muscle hemorrhages. Respiratory failure from spasms of the

upper airway or diaphragm is the most common cause of death in acute phase.

Arrhythmias and myocardial infarctions are most common cause of death later in

disease. Cerebrovascular hemorrhages may be seen in rare cases, especially in

neonatal tetanus. Pneumonia, including aspiration, can occur. 07

Overall burden of Neurological Diseases in the world is around 6.5%. It

ranges from 4-5% in lower income countries (Pakistan) as compared to 10-11% in

high income countries.1 Over all death and disability related to Neurological diseases

is higher than HIV/AIDS, neoplasms, ischaemic heart diseases and Tuberculosis.

More than half of the disability due to neurological diseases is related to stroke

followed by Dementias, Migraine, Epilepsy and tetanus.

The burden of neurological diseases in developing countries is rising due to

increasing life expectancy, urbanization of population and better diagnostic facilities.

Although information on epidemiological aspects of neurological diseases is available

from some developing countries like India, Sri Lanka and China but disease

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prevalence and pattern are based on geographical, social, cultural, religious, and

ethnic factors it is vital to conduct these epidemiological studies in each country. A

population based study conducted in India surveyed 102,557 individuals in pakisthan

found 3355 individuals with neurological disorders per 100000 population. The most

frequent disorders were tetanus, Epilepsy& Stroke. 08

The true incidence of tetanus is not known, but is estimated to be between

500,000 to one million cases per year worldwide. The majority of cases occur in

developing countries, with 50% of those cases occurring in neonates. In contrast,

tetanus is uncommon in developed countries, with most cases occurring in older

adults. In the US, there were 201 cases of tetanus reported between 1991 and 1994.

The average incidence was 40-60 cases per year, or 0.02 cases per 100,000 population

annually. This rate has remained relatively stable since the late 1980s. An acute injury

precedes most cases of tetanus. The most common injuries are puncture wounds and

lacerations. Recent surgery also accounts for several cases. Non-acute etiologies

include chronic wounds, IV drug use, and complications of diabetes. Case reports

have implicated other less obvious etiologies, including otitis media, intranasal

foreign bodies, corneal abrasions/ulcers/foreign bodies, dental procedures, injections,

abortion, childbirth and burns of 6-8%. 09

It has been estimated that about a million deaths occur from tetanus each year

worldwide. Tetanus is not rare in the developing countries. In 2005, World Health

Organization (WHO) reported 112 cases of tetanus in Nepal of which 29(25.8%) was

neonatal tetanus. However, by the end of 2005, WHO validated elimination of

neonatal tetanus in the country. Yet, the risk of tetanus remains among people ≥ 50

year of age with no primary vaccination or persons who failed to maintain immunity

against tetanus.10

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Tetanus is still widely prevalent in India. The extent of the problem is revealed

by the occurrence of cases of Neonatal Tetanus (NNT). Reporting of NNT cases by

hospitals and other treatment facilities has been made mandatory. Neonatal tetanus is

one of the most under reported notifiable diseases. Yet, in India in 1995, around

5,600 cases of tetanus reported. Uttar Pradesh, Madhya Pradesh, Rajasthan, Orissa,

Bihar and Assam have the highest rate of the prevalence of neonatal tetanus in the

country. This is mainly due to the low tetanus immunization coverage levels in these

states and over 70% of the deliveries are conducted by untrained personnel.

NNT has a marked seasonal incidence in India, More than 50% of the total annual

cases of NNT occur in the months of July, August and September. 11

The investigator found during his clinical exposed of many cases of tetanus

among under five children. the investigator’s decision for selecting the topic on

tetanus for the study grew out of his clinical experience during his period with the

clients who had limited awareness regarding the origin, treatment, prevention and

control measures of tetanus. Therefore it is very clear that the mothers must need to

update their knowledge regarding tetanus.

6.3 REVIEW OF LITERATURE

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A prospective hospital based study of childhood (<15 yrs) and neonatal

tetanus cases from July 2004 – May 2006 was done to study the demography, clinical

features and outcome of pediatric and neonatal tetanus cases at BPKIHS NEPAL.

During the study, 24 cases of tetanus were admitted from 9 districts including 5

neonatal tetanus among children with tetanus, 31.5% received 3 doses of DPT and

10.5% received TT vaccine as tetanus prophylaxis. In 16.0% children there was no

recognizable injury preceding the disease. Otitis media preceded tetanus in 16.0%. All

neonatal tetanus cases occurred following umbilical sepsis. Despite their mothers

receiving 2 doses of TT during pregnancy, 2 neonates developed tetanus. A neonate

delivered in hospital also developed neonatal tetanus. Average incubation period was

7.7 days and average onset time was 16.9 hours. Short onset time predicted the

favorable outcome (p= 0.005). Generalized tetanus cases were 75.0%, neonatal

tetanus 21.0% and cephalic tetanus 4.0%. Generalized spasm was present in all cases.

Only one case received Intensive Care Unit (ICU) care. Survival rate was 21.1% for

childhood tetanus and 40.0% for neonatal tetanus.. Study finds tetanus as an important

disease in eastern Nepal, with substantial morbidity and mortality, primarily affecting

the unvaccinated and inadequately vaccinated individuals. 12

The study was conducted in Karachi was divided into five districts at the time

of the study: East, West, South, Central and Malir. The hospitals located in each of

the five districts function as sentinel sites for NNT and report to the office of the

Expanded Programme of Immunization (EPI). Only two hospitals viz. National

Institute of Child Health and Civil Hospital Karachi cater to the needs of NNT cases

Since NNT is one of the most underreported diseases in Pakistan.we conducted a

matched case control study to identify risk factors for NNT in Karachi. A total of 125

cases of NNT reported by two hospitals during the period January 1998 to February

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2001 were recruited in the study. Addresses for the cases of NNT were obtained

through the office of EPI in Karachi and mothers of cases were interviewed in their

homes after obtaining signed informed consent from the head of the household.

Control infants (n = 250) were matched on gender for the effects of circumcision in

males, while matching on area of residence was undertaken to minimize the possible

variations in delivery practices in different areas. Controls were selected from the

same street in the district of residence of the case. Matching by date of birth was done

to assure equivalent degree of recall among mothers of cases and controls.13

A study was conducted regarding the mother’s educational level and children

illness severity. The parent’s educational condition is one of the factors of health

inequalities among children. During may 2008 parents instruction level of children

admitted at the triage unit of a pediatric service in Antanonarivo and Madagascer

evaluated and related to the severity of their children's health status with tetanus

infection and to the mode of reference. All the survived children [from 2 months to 15

year old] were included in this study. Patients were classified by IMCI guide lines, we

analyzed the educational levels of their mothers. Each patient was classified as severe

illness or without severe illness according to IMCI algorithm. Despite the fact that

access to hospital care was respectful of a two-third (85.3%) the number of patients

with severe illness was high among families with low educational level. These study

suggest to educate in priority the mother with low education, in order to recognize the

general signs of danger and to facilitate early first health care. 14

A cross- sectional study was conducted in 1980 on neonatal tetanus and

poliomyelitis in India. Surveys were prepared by the Directorate General of Health

Services, along with the Indian Council of Medical Research and WHO. Each state

consisting of populations with more than 20,000,000 were surveyed separately; union

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territories were surveyed along with neighboring states. States with less than

20,000,000 were grouped together, forming one unit. Rural and urban areas were

surveyed separately, 16 urban, 15 rural. Samples of 2,000 live births were collected

with 67 live births recorded at each of the 30 birth sites throughout wards and

villages. House to house visits by health workers recorded the survey's findings.

Estimates based on the mortality rates of neonatal tetanus in 12 states in the survey

suggest 90,657 to 115,935 neonatal deaths occur annually. Annually 159,818 to

204,380 children die within the 1st months of life due to tetanus. Total number of

cases of tetanus deaths reported is, however 48,651 on an annual average. Neonatal

tetanus can be prevented by safe delivery services and successfully immunizing

pregnant women.. Tetanus toxoid vaccination is included in the expanded program on

immunization (EPI), and during the year covered 8,000,000 pregnant women, 35% of

the eligible populations with 2 doses of TT vaccine. By 1990, 100% of the pregnant

women will be provided with vaccination services. Children have been given TT

vaccinations since 1980, these in the last classes of secondary schools. Girls were

given only a booster shot during subsequent pregnancies. Overall, both maternal and

child health services are being significantly improved and upgraded to include

antenatal, natal, and postnatal care with an inclusion of Dias training. 15

A prospective study was carried out for 12 months to May 1984 at the

departments of surgery of the University of Indonesia and the Dr Cipto

Mangunkusumo Hospital, Jakarta. All patients admitted with a clinical diagnosis of

tetanus were considered for inclusion in the study. The severity index of each case

was determined according to the variables suggested by Phillips, and only those who

scored within the range 9-19 (disease of moderate severity) were accepted into the

trial. Patients whose severity index exceeded 19 were regarded as having severe

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intoxication, and it was considered unethical to include them in the study. Patients

whose score was <9 had mild intoxication, from which spontaneous recovery should

occur, and they were also excluded. Exclusions from the moderately severe index

group included those patients who required immediate artificial ventilation and those

who required antimicrobial treatment other than that permitted by the trial protocol.

Patients admitted into the trial were allocated to one or other of two antimicrobial

treatment groups. In one group patients received procaine penicillin 1 5 MU

intramuscularly eight hourly; in the other group patients received metronidazole 500

mg orally six hourly or 1 g rectally by suppository eight hourly. Antimicrobial

treatment was continued for 7-10 days. The general management was essentially the

same for each patient. Suspected wounds were excised or debrided immediately and

samples taken or microbiological study. Tetanus antitoxin 20 000 units

intramuscularly was given immediately and repeated daily for five days. Patients were

nursed in a quiet semi-darkened room with full nursing care.. 16

A cross- sectional study was conducted by a total number of 150 patients with

tetanus were admitted to the special eight-bed ward of the J. J. Hospital, Bombay

during a 27-month period from October 1983 to January 1986. Allowing for minor

modification, the severity of tetanus was graded according to the criteria devised by

Ablett (1967).Grade I (mild). Mild to moderate trismus, general spasticity, mild or

no respiratory embarrassment; no spasm; little or no dysphagia - 49 patients. Grade II

(moderate). Moderate trismus and well-marked general spasticity; mild to moderate

but short-lasting spasms; moderate respiratory embarrassment with tachypnoea <

30/min; mild dysphagia - 36 patients. Grade IIIA (severe). Severe trismus and

severe general spasticity; severe prolonged spasms both spontaneous and on

stimulation; severe respiratory embarrassment with tachypnoea > 40/min; apnoeic

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spells - 36 patients. Grade IIIB (very severe). Features of grade IIIA plus autonomic

dysfunction-29 patients. The above grades were given when the disease was at its

most severe and not necessarily at the time of admission or immediately prior to

death. This is because some patients admitted with grade II, and at times even with

grade I severity progressed within a varying period of time (1-6 days) to grade IIIA or

grade III B.17

6.4 STATEMENT OF THE PROBLEM

“A study to evaluate the effectiveness of self instructional module on

knowledge regarding tetanus among mothers of under five children in selected

areas at Tumkur”

6.5 OBJECTIVES OF THE STUDY

1. To assess the knowledge regarding tetanus among mothers of under five children

in selected areas at Tumkur”

2. To evaluate the effectiveness of self instructional module on knowledge regarding

tetanus among mothers of under five children

3. To find an association between the level of knowledge with the selected socio

demographic variables

6.6 OPERATIONAL DEFINITIONS

1. Effectiveness – it refers to gain in knowledge regarding the prevention of tetanus

among mothers by significant difference between pre-test and post-test score.

2. Self instruction Module- It refers to the planned self learning information material

which will be developed by the investigator regarding Tetanus according to the

objective of the study

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3. Knowledge-In this study the knowledge refers to the correct response given by the

mothers that is measured by self administered knowledge questionnaire

4. Mothers-In this study it refers to mothers of under five children who are residents

of selected areas of Tumkur district.

6.7 ASSUMPTIONS

1. Mothers may have limited knowledge regarding tetanus in under five children.

2. Self Instructed Module is considered as an effective teaching method which helps

to enhance the knowledge of the mothers of under five children regarding

tetanus.

6.8 HYPOTHESIS

H1: There is significant difference between the pre test and post test knowledge

scores.

H2: There is significant association between the level of knowledge with

selected socio demographic variables.

6.9 VARIABLES

Independent Variable- Self instruction Module

Dependent Variable – knowledge score of the mothers.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA:

Data will be collected from the mothers of under five children.

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7.2 METHOD OF DATA COLLECTION:

7.2.1 Research design. A Research Design selected for this study is “Quasi

experimental one group pre test post test research design ”, to assess the knowledge

of mothers regarding tetanus.

7.2.2 Settings of the study

Selected areas at Tumkur.

7.2.3 Population

Mothers staying in selected areas at Tumkur.

7.2.4 Sample

The samples selected for the study are mothers who are fulfilling the criteria.

7.2.5 Sampling technique

The samples will be selected by Simple convenient sampling technique.

7.2.6 Sample size

Total sample size for the study is 60.

7.2.7 Sampling criteria

Inclusive criteria:

1. Mothers who are in the selected areas at Tumkur.

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2. Mothers who are willing to participate in the study.

3. Mothers who are available at the time of study.

Exclusive criteria:

1. Mothers who are not available during data collection.

2. Mothers who can’t read and write Kannada language.

7.2.8 Tool for data collection

Data will be collected by using self administered knowledge questionnaire.

Section A- Socio- demographic variable.

Section B- Self administered knowledge questionnaire regarding tetanus.

7.2.9. Method of data collection:

The data will be collected from mothers by using Self Administered

Knowledge Questionnaire for knowledge assessment. Written permission will be

taken from the concerned Authority.

7.3.0. Data analysis and interpretation

Descriptive statistics

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Descriptive statistical techniques such as Mean, Mean deviation , mode,

frequency and percentage

Inferential statistics

Paired t- test & Chi-square test

7.4 Ethical clearance

Does the study require any investigation or interventions to be conducted on

patients or other human beings or animal?

No

7.5. Has ethical clearance been obtained from your institution in case of 7.4?

Yes. Ethical clearance will be obtained from the institution.

8. BIBLIOGRAPHIC REFERENCES

01. World Health Organization, The world health report 2000, health systems:

improving performance. Geneva: World Health Organization; 2000. P. 28-31

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02. Prabhu Joseph (2006), Educational Institutions and philosophies, Traditional and

Modern, Encyclopedia of India. (vol.2) edited by Stanley Wolpert, P. 23-28.

03. Veronesi R, Focaccia R, The clinical picture. In Veronesi R (ed.) Tetanus,

important new Concepts. Amsterdam; Excerpta Medica, 1981, P. 183-206.

04. Pearce JM (1996),Notes on tetanus (lockjaw) . J Neurol Neurosurg Psychiatry &

Collins English Dictionary – Complete and Unabridged 6th Edition 2003.http://www

http://www.ncbi.nlm.nih.gov/pmc. & thefreedictionary.com/tetanus. P. 332.

05. Maternal and Neonatal Tetanus(MNT)elimination . WHO.

http://www.who.int/Retrieved 2010-11-02. P.256 &259

06. Sam Hsu, MD, Division of Emergency Medicine, Department of SurgeryPra,

University of Maryland Medical System, Baltimore, Maryland, USA. Department of

Emergency Medicine, Mercy Medical Center, P. 357-365 (May 2001)© 2001 Elsevier

Science Inc.

07.http://www.wrongdiagnosis.com/t/tetanus/book-diseases-

08. Neurological disorders; public health challenges, Geneva, Switzerland:

WHO,2006. P.27-35.

09. Tetanus in the emergency department: A current review Samuel S   Hsu , MDa,

Georgina   Groleau , MD, FACP, FACEPa Received 23 August 2000; received in

revised form 20 November 2000; accepted 5 December 2000.P.547&48

10. Dr. Sumati Joshi Assistant Professor, Department of Anaesthesiology and Critical

Care B.P Koirala Institute of Health Science Dharan-18, Nepal E

mail:www.wrongdiagnosis.com/t/tetanus/book-diseases-20a.htm?ktrack=kcplink

gs_malla@yahoo.coms, P. 125-134

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11. www.aarogya.com.

12. Dr. Prakash Poudel, Senior Resident, Department of Pediatrics and Adolescent

Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal,Department of

Pediatrics and Adolescent Medicine, BP Koirala Institute of Health

Sciences(BPKIHS), Dharan, Nepal e-mail: prakashpdl@yahoo.com,

prakashpdl@hotmail.com

13. Syed Ahsah Raza, M.B.B.S Epidemiology and Biostatics Division, faculty of

Health Science Department of Family Medicine. AGA Khan University. Karachi

Pakistan Email ;Ahsan.Raza@AKu.Edu. P.247&48.49,

14. Relomanana t, Rakotomahefam, Randrianairo N, et.al. Mother's. educational level

and children’s illness severity emergency unit of Joseph-Raseta. Befelatanana

Hospital.Bull Sac Pathol exot 2010 May; P.75-9.

15. National Center for Biotechnology Information, U.S. National Library of

Medicine 8600 Rockville Pike, Bethesda MD, 20894 USA.P.477

16. Hall MK, Chng PK, MacGillivray I. Is routine antenatal care worthwhile? Lancet

1980;P.78-80. & Antenatal care in practice. In: Enkin M, Chalmers I, eds.

Effectiveness and satisfaction in antenatal care. London: Heinemann, P.231-453

17. By F.E Udawadia, LALL .Z.F Udwadia, M.Sekhar and A Vora ,The tetanus

ward J.J. Groups of Teaching Hospital Bombay INDIA(Accepted 13th July 1987). P.

224 &226.

9.0 Signature of the candidate

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10. Remarks of the guide

11.

Name and designation of ( in block

letters)

11.1 Guide

11.2 Signature

11.3 HGead of the department

11.4 Signature

12. 12.1 Remarks of the principal

12.2 Signature

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