RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

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|1. |NAME OF THE CANDIDATE AND ADDRESS |Mr.Sudhakar Phlipdhas |

| | |First year M.Sc.Nursing, |

| | |Rajarajeswari College Of Nursing, Mysore Road, Kambipura |

| | |Bangalore- 560074. |

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|2. |NAME OF THE INSTITUTION |Rajarajeswari college of Nursing |

| | |bangalore |

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|3. |COURSE OF THE STUDY AND SUBJECT |M.Sc Nursing |

| | |Psychiatric Nursing |

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|4. |DATE OF ADMISSION TO THE COURSE |10-06 -2010 |

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|5. |TITLE OF THE STUDY |“A study to assess the effectiveness of Structured Teaching|

| | |Programme on Knowledge Regarding Eating Disorder among |

| | |adoloscent girls at selected colleges in Bangalore.” |

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“PREVENTION IS BETTER THAN CURE”

Eating disorders in adoloscents are illnesses that cause a person to adopt harmful eating habits. They are most common among teenage girls and women, and frequently occur along with other psychiatric disorders such as depression and anxiety disorders. The poor nutrition associated with eating disorders may harm organs in the body and, in severe cases, may lead to death.

An eating disorder is usually triggered by one or more events. Causes may range from a person's parents getting divorced, to emotional or sexual abuse, to a traumatic life-threatening event. After the person sufferers from a traumatic event similar to the above-mentioned examples, a trigger can initiate the disorder. A trigger can be a person commenting negatively on weight or appearance or exposure to the media or thin models and actresses. Once a trigger is introduced, the sufferer's energy is focused on food and weight and what starts out as a diet slowly escalates to a way of regaining control over situation.

Eating disorders commonly affect adolescent girls, but the number of males that suffer from these disorders is on the rise. These disorders can have their onset at any point in a person's life. It is important to understand that an eating disorder is not meant to be a weight loss tool, but often occurs as a way to cope with an underlying problem1.

Among the known eating disorders, anorexia nervosa, bulimia nervosa and binge eating rise as the most adamant cases particularly in western countries. Research sums up that over a span of one lifetime there are at least 50, 000 people who will die because of eating disorders. If untreated, a total of 20% of individuals inflicted with eating disorders will die. But if applied with treatment, it is trimmed down to between 2-3%2.

1 in 5 women struggle with an eating disorder or disordered eating. Eating disorders affect up to 24 million Americans and 70 million worldwide. An estimated 10 to 15 % of people with anorexia or bulimia are male. 90 % of those who have eating disorders are women between the ages of 12 and 25. It is estimated that currently 11 % of high school students have been diagnosed with an eating disorder. 35 % of normal dieters progress to pathological dieting. Of those, 20-25 % progress to partial or full syndrome eating disorders. According to a recent study, over 1/2 the females between the ages of 18-25 would prefer to be run over by a truck then be fat, and 2/3 surveyed would rather be mean or stupid. 51 % of 9 and 19 year-old girls feel better about themselves if they are on a diet. 42 % of 1st – 3rd grade girls want to be thinner. 46 % of 9-11 year olds are “sometimes” or very often” on diets, and 82 % of their families are “sometimes” or “very often” on diets3 .

Most people in India struggle to get enough to eat - one estimate is that 60% of India's women are clinically malnourished. But psychiatrists in urban areas are reporting cases of anorexia nervosa, the so-called slimming disease that can cause sufferers to starve themselves to death. Most people in India have still not heard of the condition but Delhi psychiatrist Sanjay Chugh says he has seen an explosion in anorexia cases over the past few years. He says a typical case could be a 17-year-old girl of around five feet six (1.68m) weighing just 4st 10lbs (30kg) who is convinced she is overweight4.

Schools and colleges are the place of learning for the children’s and adults and is in fact microcosms of the larger community. School counselors are in daily contact with the highest risk group for developing eating disorders--children and adolescents. School counselors are in a position to identify at-risk individuals, implement effective school-based prevention programs, make appropriate referrals, and provide support for recovering individuals. An overview of a theory of recovery for eating disorders reinforces the importance of early intervention5.

6.1 NEED FOR THE STUDY

Excessive dieting - dieting to the extent that you lose more weight than is healthy - is seen by some as "trendy" or even necessary to be slim and fashionable. From belly-baring fashions, to gaunt, skeletal runway models; women have taken the idea that "thin is in" to new extremes in the new millennium. Eating disorders represent a mental health effect of this preoccupation with body weight, shape and diet. Typically, if you have an eating disorder, you'll have unhealthy eating behavior. This may include extreme and unhealthy reduction of the amount of food intake or may severely overeat. If an individual have an eating disorder, she or he almost always will feel bad about eating, body shape, weight -- or all three 6.

A study was conducted in Fiji, to examine the effect of the introduction of television on eating behavior in a formerly media-naïve population, has produced some very interesting findings . The study reported parallel increases in the rate of disordered eating behaviours and in attitudes favouring thinner body image and self-induced vomiting in young girls . The results add considerable weight to the theory that the emphasis on women's thinness by the media and fashion industries, which are becomingly increasingly homogenized due to globalization, is now leading to a rise in disordered eating behaviours in the less developed world 7.

An exploratory study was done to evaluate the prevalence of weight concerns, and subsequent eating behavior modifications among a group of adolescent girls in Sikkim. A total of 577 girls were selected from several blocks of all four districts of Sikkim. Pre-tested FFQ and dietary behaviour questionnaire were canvassed through direct interviews. The results show that concern with weight reduction is growing among adolescent girls, particularly among urban girls of affluent families. Girls from families with a higher economic status are about two times more likely to report dissatisfaction with their body weight (OR = 1·96; P ≤ 0·05) and these girls are five times more likely to report the need for dieting 8.

A Comparitive study was done to determine the nature of family distress in families of girls with anorexia nervosa (AN) to girls with a chronic illness and girls without a condition. Participants consisted of 25 adolescent girls with a primary DSM-IV diagnosis of AN, 20 girls with an ICD-10 diagnosis of insulin dependent diabetes mellitus (IDDM), and 20 girls from the community. participants completed questionnaires of family functioning and psychological symptoms. When compared with mothers of daughters with IDDM, families of girls with AN experienced greater family conflict, reduced parental alliance, and increased feelings of depression. Once the emotional impact of the illness on the mothers was statistically controlled, group differences were no longer significant 9.

A study was done to investigate the Prevalence of overweight and obesity in Indian adolescent school going children: its relationship with socioeconomic status and associated lifestyle factors. The study was carried out in 5664 school children of 12-18 years of age and having different SES. The obesity and overweight were considered using an updated body mass index reference. SES and life style factors were determined using pre-tested questionnaire. The result suggests that the prevalence of overweight and obesity varies remarkably with different socioeconomic development levels 10.

A study was done to determine the period Prevalence of Eating Disorders and Psychiatric Co-morbidity among Children and Adolescents. Consecutive children and adolescents up to 18 years of age (n = 3274) attending the Child and Adolescent Psychiatry Unit, CMC Hospital, Vellore, from January 2000 to December 2005 were studied and those with an ICD-10 diagnosis of eating disorders (F 50.0 to F 50.9) were identified from unit registry. A psychiatrist reviewed the case notes for demographic and illness details made by a multi-disciplinary treating team. Appropriate bivariate statistical analyses were done using SPSS and EPI-INFO. Results revealed that the Eating disorders are prevalent among children and adolescents in India with co-morbidities similar to Western and other non-Western populations11.

Therefore, the investigator himself saw most of the adolescent girls are prone to eating disorders due to the various changes in life style and advancements in technology and the investigator strongly believe in the proverb “Prevention is better than Cure”. so the investigator selected this study to assess the effectiveness of Structured Teaching Programme on Knowledge Regarding Eating Disorder among adoloscent girls at selected colleges in Bangalore, Karnataka.

6.2 REVIEW OF LITERATURE

a. Literature related to prevalence of eating disorder among adolescent

A study was conducted to examine sex- and race/ethnicity-specific relationships between adolescents' self-esteem and weight perception. Descriptive analysis and logistic regression of Wave II of the National Longitudinal Study of Adolescent Health (N = 6,427 males, 6,574 females; ages 11–21) examined associations between low self-esteem and perceived overweight within body mass index (BMI) percentile categories, controlling for socio-demographics and stratified by sex and race/ethnicity. 25.1% and 8% of normal weight females and males, respectively, perceived themselves as overweight, with variation by race/ethnicity. Low self-esteem was most strongly associated with misperceived overweight in moderate BMI percentile categories. Odds of correctly perceived overweight were higher for low (versus high) self-esteem in white and black females but not males of any race/ethnicity. Understanding subgroup differences by race/ethnicity in perceived overweight-self-esteem relationships may inform eating disorders' prevention strategies12.

A comparative study was conducted on eating disorders and body image disturbances between Eastern and Western countries. Factors associated with the development of eating disorders in countries with non-Western cultures have not been adequately investigated in relation to Westernized countries. The sample size was 243 girls [age =16.5+/-1.2 (SD)], recruited from schools in India, Tibet, the US and France. The result did not observed greater body image discrepancy and eating pathology in Western cultures, whether or not controlling for age, SES, and BMI. Results found no differences in eating and depression pathology between those in the US, France, or India. Indeed, the Tibetans, after controlling for their low BMI and SES, had the greatest body image discrepancy 13.

A cross sectional study was done to measure the prevalence of eating disorders in Spanish early-adolescent students . A two-stage survey of prevalence of ED in a representative sample of 12 to 13 year old students in 2007 in Zaragoza (Spain). A two-phase cross sectional design, which involved the screening with questionnaires (EAT at a cutoff score of 20) and subsequent semi-structured interviews (SCAN) of screen-positive and screen-negative subjects. The ICD-10 point prevalence rates of ED population in Spanish preteen students is similar to those reported for other developed countries. The prevalence of subclinical ED is substantially higher than that of full-syndrome 14.

A study was done to determine the Eating Disorders among Indian and Australian University Students. 297 Australian and 249 Indian university students completed the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982) and the Goldfarb Fear of Fat Scale (GFFS; Goldfarb, Dykens, & Gerrard, 1985). Contrary to predictions, the Indian participants scored significantly higher than the Australian participants on both measures. The Indian women scored significantly higher than the Australian women on the EAT-26 but not on the GFFS. The Australian men showed significantly fewer symptoms than all other groups. The Indian men did not differ from the Australian or Indian women on either the EAT-26 or GFFS. The urban Indians did not differ from their rural counterparts on the GFFS, but the rural Indians had significantly higher EAT-26 scores than the urban Indians 15.

A study was conducted on early identification and treatment of disordered eating and weight control behaviors may prevent progression and reduce the risk of chronic health consequences. The National Eating Disorders Screening Program coordinated the first-ever nationwide eating disorders screening initiative for high schools in the United States in 2000. Students completed a self-report screening questionnaire that included the Eating Attitudes Test (EAT-26) and items on vomiting or exercising to control weight, binge eating, and history of treatment for eating disorders. Multivariate regression analyses was used Overall, 25% of girls and 11% of boys reported disordered eating and weight control symptoms severe enough to warrant clinical evaluation 16.

b. Literature related to effectiveness of teaching programme on eating disorder among adolescent girls.

A study was conducted on an effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Adolescent girls with body image concerns (N = 306; M age = 15.7, SD = 1.1) randomized to the dissonance intervention showed significantly greater decreases in thin-ideal internalization, body dissatisfaction, dieting attempts, and eating disorder symptoms from pretest to posttest than did those assigned to a psychoeducational brochure control condition, with the effects for body dissatisfaction, dieting, and eating disorder symptoms persisting through 1-year follow-up. Effects were slightly smaller than those observed in a prior efficacy trial, suggesting that this program is effective under real-world conditions, but that facilitator selection, training, and supervision could be improved 17.

A study was conducted to evaluate the effectiveness of universal school-based Eating Disorder prevention administered to female secondary school students. Students received either the full prevention programme, a partial version of the programme (without nutritional education), or no prevention programme. Students were also classified on the presence or absence of distinct risk factors for ED: Early menarche, overweight, dieting, negative attitudes to food and perceived pressure to be thin. Pre & post test data were collected .Results suggested that both the full and partial prevention programmes reduced perceived pressure to be thin and improved eating attitudes and knowledge of nutrition in all the participants (regardless of risk); however, greater effect sizes were found among particular high-risk groups 18.

A pilot study was done to establish the efficacy of the eating disorders prevention programme for schoolgirls of secondary schools. The sample size was 109 adolescents participating in sessions and 117 adolescents in the control group. Participants were examined at the beginning of the programme, after the operation and 6 months later. Assessment was made with EDI, EAT-26. Analysis of participants' feedback information emphasises that the changes the programme brought appeared feasible in the social functioning area (with peers,parents relations). Differences in results between schoolgirls from college and from technical college suggest some differences in risk and protective factors 19.

A study was done to evaluate the effectiveness and feasibility of a primary prevention program for risk factors for eating disorders in adolescent girls. Nearly 500 seventh-grade girls participated in "Full of Ourselves: Advancing Girl Power, Health, and Leadership," and were assessed at baseline, immediately after program completion, and 6 months later on several self-report measures of knowledge, body image, and eating and weight-related behaviors. The program was feasible, safe, and resulted in positive and maintained changes in knowledge and weight satisfaction for adolescent girls 20.

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of Structured Teaching Programme on Knowledge Regarding Eating Disorder among adolescent girls at selected colleges in Bangalore.

6.3 OBJECTIVES

1. To assess the pre-test knowledge of adolescent girls regarding Eating Disorder.

2. To assess the post-test knowledge of adolescent girls regarding Eating Disorder.

3. To evaluate the effectiveness of structured teaching programme on knowledge regarding Eating disorder among adolescent girls.

4. To associate the post-test knowledge, with their selected demographic variables.

6.4 RESEARCH HYPOTHESES

H1- There is significant difference between the mean pre-test and post-test knowledge, regarding eating disorder among adolescent college girls.

H2- There is significant association between the post test knowledge, among adolescent college girls with their selected demographic variables.

6.5 ASSUMPTIONS

1. Adolescent college girls may have inadequate knowledge, regarding Eating Disorder.

2. Structured teaching programme may improve the knowledge regarding Eating Disorder among Adolescent college girls.

3. Adolescent college girls knowledge may vary with their selected demographic variables.

6. OPERATIONAL DEFINITIONS

1. Effectiveness

Effectiveness refers to the extent to which the STP developed has achieved the desired results as evidenced in terms of gain in knowledge score regarding Eating disorder as measured by structured interview schedule.

2. Structured teaching program

Refers to systematically developed instruction and teaching aids, designed for adolescent college girls to provide information regarding Eating disorder which includes causes, signs & symptoms, management and preventive measures.

3. Knowledge

It refers to correct responses of adolescent college girls on a structured interview schedule regarding Eating disorder as evidenced from knowledge scores.

4. Eating disorder

It refers to involve self-critical, negative thoughts and feelings about body weight and food, and eating habits that disrupt normal body function and daily activities.

5. Adolescent

It refers to the girls in a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood between the ages of 10 and 19 (acc to WHO) years but largely characterized as beginning and ending with the teenage stage.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from the adolescent girls of selected college, Bangalore.

7.2 METHODS OF DATA COLLECTION

i. Research design:

Pre experimental – one group pre test post test design.

ii. Variables:

Dependent variable

Knowledge regarding Eating Disorder among adolescent girls

Independent variable

Structured Teaching Programme

iii. Setting

The study will be conducted in selected Girls College, Bangalore.

iv. Population

The population of the study will comprise all the Adoloscent girls in selected College , Bangalore.

v. Sample:

Adoloscent Girls who fulfill the inclusive criteria are considered as sample and the sample size is 60.

vi. Criteria for sample selection:

Inclusion criteria:

The study includes

1. Girls in adolescent age group.

2. Adoloscent Girls Interested to participate in this study

3. Adoloscent Girls who can understand Kannada or English.

Exclusion criteria:

The study excludes

1. Adoloscent Girls who are not available at the time of data collection.

2. Adoloscent Girls who are not willing to participate in the study.

vii. Sampling technique:

Non probability- convenience Sampling technique.

viii. Tool for data collection:

The tool consists of the following sections:

Section A: Demographic data which gives base line information of Adoloscent Girls such as age, sex, family income, occupation of parents, type of family, Religion, and Source of Information.

Section B: Structured interview schedule on knowledge regarding Eating Disorder.

ix. Method of data collection:

After obtaining the official permission from concerned Institution and informed consent from the samples, the investigator personally, collect the baseline demographic data. After which the data will be collected using structured knowledge . On the same day structured teaching programme will be conducted in a class room setting. After a period of one week post test will be conducted to assess the knowledge with the same instrument to find the effectiveness of STP.

Duration of data collection: 4 -6 weeks.

x. Plan for data analysis

The data collected will be analyzed by using descriptive and inferential statistics.

Descriptive statistics:

Frequency, percentage distribution, means, standard deviation and mean score percentage will be used to analyze the knowledge regarding Eating Disorder among adolescent girls .

Inferential statistics:

Paired‘t’ test will be used to compare the pre test and post test knowledge. Chi- square test will be used to analyze the associate between post test knowledge, regarding Eating Disorder among adolescent girls with their selected demographic variables.

7.3 Does the study require any investigation or interventions to the patients or other human beings or animals?

Yes, the study will be conducted on adolescent girls regarding Eating Disorder at selected colleges, Bangalore.

7.4 Has ethical clearance obtained from your institution?

The permission will be obtained from the concerned authorities and the informed consent from the sample. Confidentiality and privacy of the data will be maintained.

8. LIST OF REFERENCE

1. Glen F. Aukerman, MD, Jason Barker, ND, Ernie-Paul Barrette, MD, FACP, et.al. Eating Disorders Overview – Right Health 2007-2010 Kosmix™ Corporation. Available on URL:

2. Ken Marlborough , Eating Disorder Statistics, June 27, 2006, . Available on .

3. Blundell, Relationship between streuors and the resulting changes in eating patterns.European Journal of epidemiology, 1990 Aug; 15(7):P 643-8. Available on URL:

4. Dr Sanjay Chugh , Jill McGivering. Anorexia takes hold India. BBC News, 2003 June. Available on

5. Angela D. Bardick "Eating disorder intervention, prevention, and treatment: recommendations for school counselors". Professional School Counseling. . 11 Dec, 2010.



6. Leonard Holmes, Eating Disorders: Facts About Eating Disorders and the Search for Solutions. National Institute of Mental Health. 2006 NIH Publication No. 01-4901.

7. Patel, Vikram, Gender in mental health research- Eating Disorder. Department of Gender, Women and Health Family and Community Health 2005, . pages 17-21.

8. Mishra SK, Mukhopadhyay S. Eating and weight concerns among Sikkimese adolescent girls and their biocultural correlates: an exploratory study. Biological Anthropology Unit, Indian Statistical Institute, Kolkata, India. Public Health Nutr. 2010 Sep 21:1-7. PMID: 20854717

9. Sim LA, Homme JH, Lteif AN etal. Family functioning and maternal distress in adolescent girls with anorexia nervosa. Int J Eat Disord. 2009 Sep;42(6):531-9.PMID: 19189407.

10. Goyal RK, Shah VN, Saboo BD etal.Prevalence of overweight and obesity in Indian adolescent school going children: its relationship with socioeconomic status and associated lifestyle factors. Sterling Hospital and Department of Pharmacology, L.M.College of Pharmacy, Ahmedabad, India. J Assoc Physicians India. 2010 Mar;58:151-8. PMID: 20848812

11. P. Mammen, S. Russell and P.S. Russell. Prevalence of Eating Disorders and Psychiatric Co-morbidity among Children and Adolescents. Child and Adolescent Psychiatry Unit, Christian Medical College, Vellore , Tamilnadu, India. INDIAN PEDIATRICS. 2007 MAY 44(17):357-359.

12. Eliana M. Perrin, Janne Boone-Heinonen ,Alison E. Field etal. Perception of Overweight and Self-esteem During Adolescence. Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine.Int J Eat Disord. 2010 July; 43(5): 447–454 .

13. Rubin B, Gluck ME, Knoll CM, Lorence M. Comparison of eating disorders and body image disturbances between Eastern and Western countries. New York Obesity Research Center, Departments of Medicine and Psychiatry. USA.Eat Weight Disord. 2008 Jun;13(2):73-80.

14. Ruiz-Lázaro PM, Comet MP, Calvo AI etal.Prevalence of eating disorders in early adolescent students. Hospital Clínico Universitario Lozano Blesa de Zaragoza. Actas Esp Psiquiatr. 2010 Jul;38(4):204-11. PMID: 21104465.

15. John P. Sjostedt , John F. Schumaker , S. S. Nathawat . Eating Disorders Among Indian and Australian University Students. Department of Psychology, University of Newcastle, Australia, University of Rajasthan, Jaipur, India. The Journal of Social Psychology. 1998 June; 138(3):351 – 357.

16. Austin SB, Ziyadeh NJ, Forman S etal. Screening high school students for eating disorders: results of a national initiative. Division of Adolescent Medicine, Children's Hospital, Boston, USA. Prev Chronic Dis. 2008 Oct; 5(4):A114.

17. Stice E, Rohde P, Gau J. An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescent girls. Oregon Research Institute, Eugene, USA. J Consult Clin Psychol. 2009 Oct; 77(5):825-34.

18. Raich RM, Portell M, Peláez-Fernández MA. Evaluation of a school-based programme of universal eating disorders prevention: is it more effective in girls at risk. Universitat Autònoma de Barcelona. Eur Eat Disord Rev. 2010 Jan; 18(1):49-57.

19. Zechowski C, Namysłowska I, Korolczuk A etal. Eating disorder prevention program--pilot study. Kliniki Psychiatrii Dzieci i Młodziezy IPiN w Warszawie. Psychiatr Pol. 2004 Jan-Feb; 38(1):51-63.

20. Steiner-Adair C, Sjostrom L, Franko DL. etal. Primary prevention of risk factors for eating disorders in adolescent girls: learning from practice.Harvard Eating Disorders Center, Boston, USA. Int J Eat Disord. 2002 Dec; 32(4):401-11.

9. Signature of the candidate :

10. Remarks of the guide : The present study helps the adolosent college girls to understand about causes, signs and symptoms, complications, treatment and preventive measures of Eating Disorder.

11.1 Name and designation of the Guide : MR. SATHEESKUMAR, M.Sc(N)

LECTURER AND HOD, RAJARAJESWARI                                                                           COLLEGE OF NURSING, BANGALORE.

11.2 Signature :

11.3 Co-guide [if any] : MRS.PARVATHI, MSC(N),

LECTURER AND HOD, RAJARAJESWARI COLLEGE OF NURSING, BANGALORE.

11.4 Signature :

11.5 Head of the department : MR.SATHEESKUMAR M.Sc(N)

       LECTURER AND HOD, RAJARAJESWARI                                                                           COLLEGE OF NURSING, BANGALORE.

11.6 Signature :

12.1 Remarks of the principal :The topic selected for study is relevant and                                                                           forwarded for needful action

12.2 Signature :

ETHICAL COMMITTEE CLEARANCE

13. TITLE OF THE DISSERTATION: “A study to assess the effectiveness of Structured

Teaching Programme on Knowledge Regarding Eating Disorder among adoloscent girls at selected colleges in Bangalore.”

14. NAME OF THE CANDIDATE : Mr.Sudhakar Phlipdhas

      AND ADDRESSS First year M.Sc.Nursing,

Rajarajeswari College Of Nursing,

Bangalore- 560074.

15. SUBJECT : M.Sc Nursing

Mental Health Nursing

16. NAME OF THE GUIDE : Mr.Sateeshkumar M.Sc(N)

17. APPROVED/NOT APPROVED : Approved

(if not approved, suggestion)

Head of the department of Head of the department of

Psychiatric Nursing Medical surgical Nursing

Rajarajeswari College of nursing Rajarajeswari College of nursing

Bangalore. Bangalore.

Head of the department of Head of the department of

Peadiatric Nursing OBG Nursing

Rajarajeswari College of nursing Rajarajeswari College of nursing

Bangalore. Bangalore.

Head of the department of

Community Health Nursing Principal

Rajarajeswari College of nursing

Bangalore.

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