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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA,

BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |Name of the candidate and address ( in |SOUMYA MATHEW |

| |block letters ) | |

| | |FIRST YEAR M.Sc NURSING CANARA COLLEGE OF NURSING PRAFULLA ENCLAVE, HALADY |

| | |ROAD KOTESHWAR POST, KUNDAPUR TALUK, UDUPI DISTRICT 576222 |

|2. |Name of the institution |CANARA COLLEGE OF NURSING, KUNDAPUR |

|3. |Course of study and subject |FIRST YEAR M.Sc. NURSING CHILD HEALTH NURSING |

|4. |Date of admission to the course | |

| | | |

| | |15/07/13 |

|5. |Title of the study |

| | |

| |EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE AND ATTITUDE REGARDING EAR INFECTION, MANAGEMENT AND ITS |

| |PREVENTION AMONG MOTHERS OF UNDER- FIVE CHILDREN IN A SELECTED RURAL AREA OF UDUPI DISTRICT. |

6 Brief resume of the intended work

6.1 Introduction.

“Children who hear acquire language without any particular effort; the words that fall from others lips they catch on the wing, as it were, delightedly, while the little deaf child must trap them by a slow and often painful process, the result is wonderful. Gradually from naming an object we advance step by step until we have traversed the vast distance between our first stammered syllable and the sweep of thought in a line of Shakespeare.”-

Helen Keller

Health is a state of complete physical, mental, emotional and social well- being and not merely the absence of disease or infirmity.1 In children, health includes the physical, mental, emotional and social well-being of children from infancy through adolescence.2 Infection states that, it is the invasion by and multiplication of pathogenic micro organisms in a bodily part or tissue, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms.3

Ear infections are common in babies and young children, especially those aged six to eighteen months. Most children will have an ear infection before the age of five. An ear infection medically termed otitis media generally refers to an infection of the middle part of the ear that lies behind the eardrum. About two-thirds of children will have at least one attack of Acute Otitis Media by age of 3, and a third of these children will have at least

3 episodes. Boys are more likely to have infections than girls. The earlier a child has a first ear infection, the more susceptible they are to recurrent episodes (for instance, 3 or more episodes within a 6-month period). As children grow, however, the structures in their ears enlarge and their immune systems become stronger. After age 5, most children have

outgrown their susceptibility to any ear infections.4

The incidence rate of acute otitis media is 10.85%, that is 709 million cases each year with 51% of these occurring in under- fives. Chronic suppurative otitis media incidence rate is 4.76% that is 31 million cases, with 22.6% of cases occurring annually in under-fives. Otitis media related hearing impairment has a prevalence of 30.82 per ten thousand. . WHO estimated that 28 thousand deaths every year are attributable to

complications of otitis media.5

Acute otitis media is usually due to bacterial and viral infection in the middle ear.6 The middle ear is a small space behind the ear drum that is supposed to be well ventilated by air that normally passes up from behind the nose, through the eustachian tube,

keeping the middle ear clean and dry. When there is not enough fresh air ventilating the middle ear, such as when the Eustachian tube, is clogged or blocked, the area becomes damp, stagnant, and warm, a perfect breeding ground for germs. In children and infants, the Eustachian tube is often too soft or immature and has a harder time staying open. Allergies, post nasal discharge, sinus infections, adenoid problems can all interfere with the eustachian tubes ability to let air pass into the middle ear. For children, the most common cause of an ear infection is an upper respiratory viral infection, such as a cold or the flu. These disorders can make the Eustachian tube swollen that air can no longer flow into the middle ear. Allergies to pollen dust, animal dander, or food can produce the same effect as a cold or flu, as can smoke, fumes, and other environmental toxins. Bacteria can cause an ear infection directly, but usually these organisms come on the heels of a viral infection or an allergic reaction, quickly finding their way into the warm, moist environment of the middle ear. Babies born with cleft palate or Down syndrome are also more likely to get ear infections. The differences in their anatomy make it harder to their Eustachian tubes to function properly. The ear infection mostly occurring in the bottle-fed babies is due to less

immature immune system.7

The main symptom of ear infection is ear ache. Other symptoms are frequent tugging at the ears, trouble sleeping, loss of appetite, vomiting or diarrhoea, crying more than usual, failure to respond to sounds, increased irritability, fever and also a thick clear or yellowish, sometimes bloody, fluid drainages from the ear. Generally, an ear infection is a minor medical problem that gets better without complications. Most children will have a minor, short-term hearing loss during and after ear infection. Spread of infection from the ear and temporal bone causes intracranial complications. The fluid that collects behind the ear drum called effusion which last for weeks to months after the pain of an ear infection is

over.8 Spread of infection from the ear and temporal bone causes intracranial

complications. Spread of infection occurs through three routes, namely, direct extension, thrombophlebitis, a hematogenous dissemination. Other complications are chronic suppurative otitis media, post auricular abscess, facial nerve paresis, labyrinitis, labyrinthine fistula, mastoiditis, temporal abscess, petrositis, intra cranial abscess,

meningitis, otitic hydrocephalus, sigmoid sinus thrombosis and encephalocele. .Evidence

suggest that severe cases of ear infection leads to impaired hearing which will affect learning, behavioural and social attitude and speaking capacity.9

Ear infection may occur in anyone, but the condition most probably occurs in

children mainly among the under fives. Parents need correct awareness regarding the treatment. Or else the condition can worsen in children and lead to further complications. There are several treatment modalities present in order to prevent and control the disease. 8

The management include long term antibiotic for infection, analgesics for pain. The preventive measures are provision of zinc supplementations and pneumococcal conjugate vaccine.10

6.2 Need for the study

“Safety is something that happens between yours ears, not something you hold in your hands” - Jeff Cooper The children of today are the future of tomorrow; this powerful statement

assumes special significance in our context as children comprise one third of the total population in the country. Every child, on provision of a conducive and an enabling environment, may blossom into an ever fragrant flower, to shine in all spheres of life. This reminds us of the onerous responsibility that we have to mould and shape their present

conditions in the best possible way. 11

Every year, an estimated 26 millions of children are born in India. In 2011, the total number of children in the age group 0-6 years is reported as 158.79 million, which is down by 3.1%, compared to the child population in 2001 of the order of 163.84 million. The share of children (0-6 years) to the total population is 13.1% in 2011 whereas the corresponding figures for male children and female children are 13.3% and 12.9% respectively. Early childhood, that is the first six years constitutes the most crucial period in life, when the foundations are laid for cognitive, social and emotional language, physical or motor development and cumulative lifelong learning. The young child under 3 years is most vulnerable to the vicious cycles of malnutrition, disease or infection and resultant disability all of which influence the present condition of a child at micro level and the

future human resource development of the nation at the macro level.11

Otitis media is one of the leading causes of health care visit and drug prescription. Anyone can get an ear infection, but children get them more often than adults. Three out of four children will have at least one ear infection by their third birthday. In fact, ear infections are the most common reason parents bring their child to a doctor. The

scientific name for an ear infection is otitis media8. Incidence of otitis media is most

extreme in infancy and early childhood, because the eustachian tube is shorter, wider and in a more horizontal position, and the small muscles which control the opening of the tube

are less efficient in function, leaving the eustachian tubes and the middle ears open to the invasion of infection-producing organisms. It is generally thought that occlusion of the eustachian tube, which inhibits middle ear ventilation and prevents drainage, is a precipitating condition, causing inflammation and a buildup of mucous secretions in the middle ear cavity. Infection in the area may be caused by a number of organisms, streptococcus pneumonia and hemophilus influenza being the most common. These usually

enter through the eustachian tube. 12

The World Health Organization reported that otitis media was responsible for the deaths of 51,000 children under the age five years each year in developing countries. The chronic otitis media accounted for 60-80% of middle ear disease in underdeveloped countries, suppurative intracranial complications occurred in almost 10% of cases.9 In the US statistical report in the year 2010 states that, three out of four children experience ear

infection by the time they are 3 years of old.13 In the Australian statistical report from July

2007 to June 2012 it was found that 67% of the 5,474 children received ear consultations. More than one-half (51%) of the children received an audiology check up.14

A study conducted in Delhi from 2008 to 2011 by Maulana Azad Medical College in 30 primary schools in government sector , found that impacted cerumen or gross ear wax leading to deafness was found among 7.93% of children; out of which 4.79% suffered from chronic otitis media or severe ear infection in the ear canal or ear drum; 3.06 per cent suffered from otitis media with effusion - ear infection with presence of residual

fluid.15

Ear infection is one of the leading causes of pain experiencing in children and to be brought to hospitals by parents. The infection from the ear spreads to other structures and the child develops problems in the nearby structures also. Research on ear infection indicates that children who have had more than 9 ear infection in the first 3 year are at greater risk for inattention in class, and may struggle with phonics, comprehension and other school task. Even when the ear infections are cleared up, and the Childs acuity appears to be normal, the processing of auditory stimuli remains weak. Other problems are difficulties with attention, articulation, phonics, spelling, memorization, timed test, sequencing, reversals, handwriting, and long written assignments. So it will affect the overall development of social, physical, emotional, personality and learning factors.

Therefore studying about ear infection, management and its prevention is very useful.16

Complications of middle ear infection are now less common than they were in

the past. Very young children have an increased risk of developing complications as their immune system is still developing.8 In severe or untreated case, the tympanic membrane may rupture, allowing pus in the middle ear space to drain into the ear canal. If there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic membrane suggests a highly painful and traumatic process, it is almost always associated with the dramatic relief of pressure and pain.10 Otitis media may be regarded as a largely medical problem, it is being recognized that long term effects of an educational and social nature are concomitant. The teachers in reserve schools are in a good position to observe and refer children having ear infections, and also to have an influence on community awareness and understanding of this serious problem.9

6.3 Review of literature

Review of related literature is an integral component of any study or research project. It enhances the depth of the knowledge and inspires a clear insight into the crux of the problem. Literature review throws light on the studies and their findings reported about the problem under study. The review of literature is a broad, comprehensive, in depth, systemic and critical review of scholarly publications, unpublished scholarly print materials, audio visual materials and personal communications. Reviewing and evaluating

the literature is central to the research process.17

The purpose of review of literature, is to obtain comprehensive knowledge and in depth information about ear infection, management and its prevention.

In the present research, the review of literature is presented under the following headings.

• Literatures related to factors responsible for ear infection in under five children

• Literatures related to management of ear infection in under five children

• Literatures related to prevention of ear infection in under five children

• Literatures related to knowledge and attitude of mothers related to ear infection

Literatures related to factors responsible for ear infection in under five children

A longitudinal study was conducted to investigate and identify the risk factors, co morbidity, and health service usage related to ear infection among Australian children. The study involved 4,983 children aged 4 to 5 years. The prevalence of parent- reported ear infection was 7.9% (394) among children aged 4-5 years. The study found that risk factors associated with ear infection were indigenous status, not being breastfed, mother or father smoking at least once a day, and father’s school completion at year 9 or lower. This empirical evidence can be used to inform the development of intervention and

management programs for ear infection.18

A dynamic cohort study was conducted in University of Medical Centre, Utrecht Netherlands about pacifier use as a risk factor for acute otitis media. Samples of

495 children selected in between 0 to 4 years were included. Two hundred and sixteen children that used a pacifier at baseline, 76 (35%) developed at least one episode of acute otitis media, and of the 260 children did not use a pacifier, 82 (32%) developed at least one acute otitis media. The study concluded that pacifier use appears to be a risk factor for recurrent acute otitis media. Parents should be informed about the possible negative effects of using a pacifier once their child has been diagnosed with acute otitis media to avoid

recurrent episodes.19

Literatures related to management of ear infection in under five children

A randomized controlled study was conducted in the University of Manitoba, Canada. The main objective of the study was to determine the effectiveness of a short course antibiotics (less than seven days) in comparison to a longer course (seven days or greater) for the treatment of acute otitis media. Two groups had participated in the study. In group one one thousand five hundred and twenty four children were participated and they were treated with short- acting antibiotics for five days versus eight to ten days. The second group had 2,115 children and they were treated with long-acting antibiotics for 20 to 30 days. The result indicated that the treatment failure rate following less than seven days of antibiotic treatment was similar to the failure rate following seven days or more of antibiotic. The study concluded that five days of short-acting antibiotic is effective

treatment for uncomplicated ear infections in children.20

A cohort, non randomized retrospective study was conducted in a private chiropractic practice in a Minneapolis. The main objective of the study was to assess the success rate and number of treatment needed to recover from ear infection and also to find out the associated factors. Forty six children aged five year and under participated in the study. All treatments were done by a single chiropractor, who adjusted the subluxations found and paid particular attention to the cervical vertebrae and occiput. Typical treatment regimen was three treatments per week for 1 wk, then two treatments per week for 1 wk, then one treatment per week. The result showed that 93% of all episodes improved, 75% in

10 days or fewer and 43% with only one or two treatments. Young age, no history on antibiotic use, initial episode (vs. recurrent) and designation of an episode as discomfort rather than ear infection were factors associated with improvement with the fewest

treatments. The conclusion states that, this study's data indicate that limitation of medical intervention and the addition of chiropractic care may decrease the symptoms of ear infection in young children. 21

Literatures related to prevention of ear infection in under five children

A randomized double blind, placebo- controlled trial was conducted in a hospital based general paediatric clinic and a private paediatric practice in Denver. The main objective of the study was to determine the effectiveness of amoxicillin administration continuously twice daily vs. once daily vs. placebo to prevent new episodes of acute otitis media. One hundred and ninety four children participated in the study. They were enrolled with 3 documented acute otitis media. Thirty- six were non complaint and were excluded from the study. Finally 158, subjects were involved in the study. The amoxicillin dosage 20 mg/kg/day administered either twice daily or once daily. After randomization to placebo twice daily, amoxicillin once daily or placebo once daily or amoxicillin twice daily, patients were followed monthly and were also seen for upper respiratory infection symptoms during enrollment in the trial. There were no significant differences in the incidence density between amoxicillin once daily vs. twice daily or amoxicillin (twice daily or once daily) vs. placebo. The proportion of subjects remaining otitis-free was 63% for the placebo group, 64% for once daily amoxicillin and 61% for twice daily amoxicillin. The study concludes that while once-a-day dosing was equivalent to twice-a-day dosing for amoxicillin prophylaxis, there was no benefit of amoxicillin prophylaxis compared with a placebo control in preventing new acute otitis media

episodes.22

A randomized double-blind efficacy trial was conducted to evaluate the efficacy of a pneumococcal conjugate vaccine against acute otitis media. Study involved

1662 infants. The children received either the study vaccine or hepatitis B vaccine as a control at 2, 4, 6 and 12 months of age. There were 2596 episodes of acute otitis media during the follow-up period between 6.5 and 24 months of age. The vaccine reduced the number of episodes of acute otitis media from any cause by 6 percent, culture-confirmed pneumococcal episodes by 34 percent and the number of episodes due to the serotypes contained in the vaccine by 57 percent. The number of episodes attributed to serotypes that are cross-reactive with those in the vaccine was reduced by 51 percent, whereas the number of episodes due to all other serotypes increased by 33 percent. The study concludes that the heptavalent pneumococcal polysaccharide-CRM197 conjugate vaccine is safe and

efficacious in the prevention of acute otitis media caused by the serotypes included in the vaccine.23

Literatures related to knowledge and attitude of mothers related to ear infection

A study was conducted to assess the “knowledge and attitudes about otitis media risk factors and implications for prevention” among women in USA. Questionnaires mailed to a systematic sample of 50 women >/=18 years old. According to report, 29 per cent of infants (age 8 to 13 month) had recurrent otitis media (>/=3) and 2 per cent had tympanostomy tubes. 46 per cent attended day care 29 per cent had >/=1 months. Women were mote knowledgeable about otitis media sign and symptoms than about risk factors. Mean otitis media knowledge score (the sum of correct true-false responses) was 7.0

(standard deviation=1.6).24

A prospective study was conducted on “Exclusive breast feeding against bacterial colonization and day care expose to otitis media” on infants in USA. Samples of

306 of infants at well-baby visits were taken. The study results shown that between 6 to 12 month of age cumulative incidence of first otitis media episodes increased from 25 per cent to 51 per cent in infants exclusively breastfed and from 54 per cent to 76 per cent in infants formula-fed from birth. Peak incidence of acute otitis media and otitis media with effusion episodes was inversely related to rates of breastfeeding beyond 3 month of age. A hazard health model suggested additionally that breastfeeding, even for short durations (3 months),

reduced onset or otitis media episodes in infancy.25

6.4 Statement of the problem

A study to determine the effectiveness of structured teaching programme on knowledge and attitude regarding ear infection, management and its prevention among mothers of under five children in a selected rural area of Udupi District .

6.5 Objectives of the study

The objectives of the study are to:

• assess the knowledge of mothers of under five children regarding ear infection, management and its prevention.

• assess the attitude of mothers of under five children regarding ear infection, management and its prevention.

• evaluate the effectiveness of structured teaching programme on knowledge and attitude regarding ear infection management and its prevention among mothers of under five children in a selected rural area of Udupi District.

• find out an association between knowledge on ear infection, management and its prevention and selected demographic variables.

• find out an association between attitude on ear infection, management and its prevention and selected demographic variables.

6.6 Operational definitions

• Effectiveness: In this study, effectiveness determines the extent to which the structured teaching program has achieved the described effect as expressed by gain in knowledge score with an aim to develop positive attitude.

• Structured Teaching Programme: In this study, structured teaching programme refers to systematically organized written plan of teaching on ear infection, management and its prevention for achieving pre specified objectives which is used as an independent variable to enhance the knowledge and attitude of mothers of under five children.

• Knowledge: In this study, knowledge refers to the correct responses of the mothers of under five children to the items included in the structured knowledge questionnaire regarding ear infection, management and its prevention and is expressed in terms of knowledge score.

• Attitude: In this study, attitude refers to the attitude of mothers of under five children towards ear infection, management and its prevention as measured by using attitude scale.

• Ear infections: In this study, ear infection refers to infection occurring in the ear, mainly middle ear, inner ear and outer ear.

• Management: In this study, management refers to the act of practice of therapies or treatment modalities to manage or handle the ear infection of the under five child.

• Prevention: In this study, prevention refers to the act or practice of avoiding ear infection from happening in the under five children by the mothers.

• Mother: In this study, mother refers to a woman who has a child between the age of 0 to 5 years.

• Under five children: In this study, under-five children refers to the children with the age between 0 to 5 years

6.7 Assumptions

The study assumes that:

• Mothers of under five children may not have adequate knowledge and attitude

| |regarding ear infection, management and its prevention. |

| | |

| |• Structured teaching program may improve the knowledge and attitude of mothers of under five children regarding ear |

| |infection, management and its prevention. |

| |6.8 Delimitations |

| | |

| |This study is delimited to: |

| | |

| |• Mothers of under five children only. |

| | |

| |• Mothers residing in selected rural area of Udupi District. |

| | |

| |• Mothers of under five willing to participate in the study. |

| | |

| |• Approximately 50 samples. |

| | |

| |• The prescribed data collection period is limited 4 – 6 weeks. |

| | |

| |6.9 Hypothesis |

| | |

| |• H1 – There will be significant difference between mean pre test and post test knowledge scores of |

| |mothers of under five children regarding ear infection, management and its prevention. |

| |• H2- There will be significant difference between mean pretest and post test attitude scores of mothers of under five |

| |children regarding ear infection, management and its prevention. |

| |• H3- There will be significant association between the pretest knowledge scores of mothers of under five children |

| |regarding ear infection, management and its prevention and selected demographic variable |

| |7.0 Materials and methods |

| |7.1 Sources of data |

| | |

| |Data will be collected from mothers of under-five children in a selected rural area of |

| | |

| |Udupi District. |

| | |

| |7.1.1 Research design |

| | |

| |Pre-experimental design with one group pre and post test research design will be adopted for this proposed study. |

| | |Group |

| | | | |

| | |Mothers of under-five children in a selected rural area of Udupi | |

| | |District |O1 X O2 |

| | |

KEY :

O1 - Pre test

X - Intervention (Structured teaching programme regarding ear infection, management and its prevention)

O2 - Post test

7.1.2 Setting

The study will be conducted at selected rural area of Udupi District.

7.1.3 Population

The population of the proposed study consist of mothers of under five children in selected rural area of Udupi District.

7.2 Method of data collection

7.2.1 Sampling procedure

Non probability, purposive sampling technique will be adopted to select the samples for this proposed study

.7.2.2 Sample size

The sample size of the proposed study will be approximately 50 mothers of under five children in selected rural area of Udupi District.

7.2.3 Inclusive criteria

The study include mothers of under five who are:

• residing at selected rural area of Udupi District.

• willing to participate in the study.

• able to read and write Kannada and English.

• present at the time of data collection.

7.2.4 Exclusion criteria

The study excludes mothers of under five children who are:

• not willing to participate in the study.

• cannot read and write English and Kannada.

• not present during the time of study.

7.2.5 Instruments intended to be used

The tools for the data collection consists of :

• Socio demographic proforma.

• Structured knowledge questionnaire regarding ear infection, management and its prevention.

• Structured attitude questionnaire regarding ear infection, management and its prevention.

• Structured teaching program on ear infection, management and its prevention.

7.2.6 Data collection method

• Subjects will be selected according to the selection criteria and assured the confidentiality of the sample.

• Written consent will be obtained from subjects to participate in the study.

• Samples will be selected by non-probability purposive sampling technique.

• On day one, pre test will be conducted for the group by administering the structured knowledge questionnaire.

• On day one, pre test will be conducted for the group by administering the structured attitude questionnaire.

• On the same day structured teaching program regarding ear infection, management and its prevention will be given to the group followed by the post test on 8th day.

7.2.7 Data analysis method

The data will be analyzed using inferential statistics. The plan of data analysis will be as follows:

• Organize the data in a master sheet.

• Frequency and percentage for the analysis of socio demographic data.

• Mean, median, SD, ‘F’ values to determine the significance.

• Chi-square test to determine the association between selected variables with the level of knowledge and attitude.

• The findings will be presented in the form of tables and figures.

7.3 Does the study require any investigation or intervention to be conducted on patients or other human beings or animals?

Yes, the study requires administration of structured teaching programme on ear infection, management and its prevention among mothers of under five children at selected rural area in Udupi District.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, the proposed study will obtain permission from,

• Ethical committee, Canara College of Nursing, Kundapur.

• The Principal, Canara College of Nursing, Kundapur.

• Informed written consent will be obtained from the mothers of under five children who will participate in the study at selected rural area in Udupi District.

8. Bibliography

1. WHO Definition. [Online]. 1946 Jul 22 [cited 1948 Apr 7];Available from: URL: h

2. Children’s Health-Medical Dictionary. [Online]. Available from: URL: dictionary.Children's+Health

3. Infection-Definition of Infection By The Free Online Dictionary. [Online]. Available from: URL:

4 Otitis Media – NHS Choices. [online].[cited 2012 Apr 23];Available from: URL:http://

nhs.uk/conditions/otitis-media/pages/introduction.aspx

5 Lorenzo M, Luca R, Federic M, Marcella M, Liza VB, Alessandro B, et al. Burden of disease caused by otitis media systemic review and global estimation.[online]. 2012 [cited 2012 Apr 30]. Available from: URL:.

6 Harvey S. Ear infection. University of Maryland medical reports. [Online]. 2012 May

31; Available from: URL:.

7 Roy B. Understanding ear infection-the basis. [Online]. 2011 Jan 13; Available from: URL: overview.

8 Peter A. Understanding ear infections. [Online]. 2013 Jul 11; Available from: URL:.

9 Kangsanarak J, Fooanant S, Ruckphaopunt K. Extracranial and intracranial complications of suppurative otitis media. [Online]. J Laryngol Otol. 1993

Nov;107(11):999-1004.

10 American Academy of Pediatrics and American Academy of Family Physicians. [Online]. 2011 May 11; 113(5): 1451-65. Available from: URL:.

11 Children in India 2012- A statistical appraisal. [Online]. 2012 Sep. Available from: URL:.

12 Win AS, Janet EF. Prevalence of otitis media in Cree and Ojibway school children in six Ontario communities. American Indian J. 1985 Oct;25(1). Available from: URL:.

13 National institute on deafness and other communicable disorders. [Online]. 2010 Jun

16. Available from: URL:.

14 Overview of Australian indigenous health status 2012. [Online]. Available from: URL: condition/ear-health.

15 Pritha C. High prevalence of hearing disorder in school kids. [Online]. 2013 Jan 7. [cited 2013 Nov 25];Available from: URL:http:// hospital/972809/.

16 Silverman LK. Invisible gifts invisible handicaps. [Online]. 1989; 12(1). 37-42.

Available from: URL:.

17 Dense FP, Cheryl TB. Essentials of nursing research. 7th ed. Philadelphia: Wolters

Kluwer publishers; 2011. P.74.

18 Vasoontara Y, Anthony H. Ear infection and its associated risk factors, comorbidity and health service use in Australian children. International journal of paediatrics.13

May 13;58(5):235-55.

19 Maroeska MR, Mattijis EN, Esther L, Diederick EG, Theo JV, Anne GMS. Is pacifier use a risk factor for acute otitis media. J Oxford. 2008 May 18;25(4):233-6.

20 Frank MP. Are antibiotics indicated as initial treatment for children with acute otitis media?A meta analysis. British Medical J. 1997 May 24;314(7093):1526-152

21 Spigelblatt L, Laine AG, Pless IB, Guyver A. The use of alternative medicine by children. [Online]. 1994; 94(6): 811-4.

22 Mandel EM, Casselbrant ML, Rockette HE, Bluestone CD, Kurs LM. Efficiacy of 20 versus 10 day antimicrobial treatment for acute otitis media. [Online]. 1995; 96(8): 5-

13.

23 Eskola J, Kilpi T, Palmu A, Jokinen J, Herva E, Takala A, et al. Efficacy of a pneumococcal conjugate vaccine against otitis media. N Engl J Med. 2001 Feb 8;

344(6):403-9.

24. Daly KA, Selvius RE. Knowledge and attitude about otitis media: implications for prevention. [Online]. 1997 Dec; 100(6): 931-6.

25 Duffy LC, Faden H. Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media. [Online]. 1997 Oct; 100 (4): E7.

| | | |

|9 |Signature of the candidate | |

|10 |Remarks of the guide |SATISFACTORY |

|11 |Name and designation of | |

| | | |

| |(in block letters) | |

| |11.1 Guide |MR.DEEPAK |

| |11.2 Signature | |

| |11.3 Co- guide | |

| |11.4 Signature | |

| |11.5 Head of the department |MR.DEEPAK |

| |11.6 Signature | |

|12 |Remarks | |

| |12.1 Principal and chairman | |

| |12.2 Signature | |

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