PROFORMA
FOR
REGISTRATION
FOR DISSERTATION
Mrs. BEENA B.S
1st YEAR M.Sc. NURSING
CHILD HEALTH NURSING
2012-2014
PADMASHREE COLLEGE OF NURSING
GURUKRUPA LAYOUT NAGARBHAVI
BANGALORE-560072
1
OF
SUBJECT
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA
FOR
REGISTRATION
OF
SUBJECTS
FOR
DISSERTATION
1
NAME
OF
THE
Mrs. BEENA B.S
CANDIDATE
AND
1st YearM.Sc. Nursing
ADDRESS
Padmashree College Of
Nursing. GurukrupaLayout,
Nagarbhavi,Bangalore-560072
2
NAME
OF
THE
COURSE
OF
STUDY
College
Of
Nursing
INSTITUTE
3
Padmashree
THE
1’st Year M.Sc. Nursing
AND
Child Health Nursing .
SUBJECT
4
DATE
OF
27-07-2012
ADMISSION
5
TITTLE
OF
THE
A study to assess the
effectiveness of bibliotherapy
STUDY
on stress reduction among
orphan children in selected
orphanages of Bangalore.
2
6. BREIF RESUME OF INTENDED WORK
6.1 INTRODUCTION:
An orphan is a child permanently bereaved of or abandoned by his or her
parents. In common usage, only a child who has lost both parents is called an
orphan. Adults can also be referred to as orphans, or "adult orphans".1
Famous orphans include world leaders such as Nelson Mandela and
Andrew Jackson; the Muslim prophet Mohammed; writers such as Edgar Allan
Poe, and Leo Tolstoy. The American orphan Henry Darger portrayed the horrible
conditions of his orphanage in his art work. Other notable orphans include
entertainment greats such as Louis Armstrong, Marilyn Monroe, Babe Ruth, Ray
Charles and Frances McDormand, and innumerable fictional characters in
literature and comics.2
India has an orphan crisis. India has about three times the American
population living in one third of the space. Introduce intense poverty, famine,
drought, natural disasters, AIDS, and malaria, and you have a recipe for tragedy
and, most significantly, unaccompanied children. In such conditions, it is no
surprise that many parents die, leaving their children to a nation unable to take care
of them. On the streets, children are disturbingly vulnerable; evil adults will cripple
orphaned children in order to use them for works such as sexual abuse, physical
violence, begging and many more just for monetary benefits.3
Stress can be understood as a state of imbalance between demand placed on
an individual and the individual’s ability to deal with the demands. It also can be
considered as a stimuli that an individual perceives as challenging or harmful. The
effect on the person can usually be called the stress reaction, to distinguish it from
the provoking events. These reactions include autonomic responses, endocrine
changes and psychological responses such as a feeling of being locked up4
Stress can be caused by internal stressors(that which occurs from within the
body),external
stressors(that
which
3
originates
from
outside
the
body),developmental stressors(that which occurs at a predictable time throughout
the life)and situational stressors(unpredictable that occurs anytime during the life
.example: .hospitalization and illness, loss or death of parents or family members
especially orphan hood).5
Over the recent years, there has been growing concern about management
of stress in nursing. Stress can have an effect on an individual, in terms of both
physical and psychological health. Nurse in context with stress faces demands to
provide a service that is efficient, effective and economic. Nurses are accountable
for the quality of care. A relaxed mind is a focused mind, when stress increase the
person’s ability to handle the daily challenges becomes a quality-of-life issue, a lot
can be helped by a nurse to deal with these issues.5
Bibliotherapy has received considerable importance as one of the effective
stress management technique. The term bibliotherapy goes back to the beginning
of the twentieth century, when Crothes (1916) labeled it as such. Most of us
recognize the power of therapeutic reading. We find ourselves entering the world
described in the pages of a good book, and we become involved with the
characters. We feel happy or sad, we cry with the character who suffers, we want
the good ones to cope and the bad ones to be punished; we really care. We usually
end up gaining new insights and ideas for our own lives as well6.
The term bibliotherapy is made up of two words: biblio, originating from
the Greek word biblus (book), and therapy, referring to psychological help. Simply
stated, bibliotherapy can be defined as the use of books to help people solve
problems. Webster’s Dictionary (1985, p. 148) defines it as ‘‘guidance in the
solution of personal problems through reading. ’There are two major schools of
bibliotherapy: ‘‘cognitive’’ and ‘‘affective.’’ Most of the existing literature on
bibliotherapy with children is of affective bibliotherapy (Gladding, 2005).
Affective bibliotherapy uses fiction and other high-quality literature to help the
reader connect to emotional experiences and human situations through the process
of identification7
4
6.2NEED FOR THE STUDY:
It
is
estimated
that
143-210
million
orphans
are
living
worldwide.Approximately there are 12.44 million orphans, and close to 40 million
destitute children live in India.Each year, about a million new orphans are added to
the society in India. A walk through an orphanage, will be anunforgettable
experience, witnessing children in poverty, children discarded, children stunted
both physically and emotionally, thatstirsthe heart beyond belief 8.
India has the largest population of children under age 18 in the world –
about 400 million youngsters. Sadly, about 25 million of these are orphans who
must struggle each day against poverty and face many potential abuses8
Orphanhood is a curse, but it is bitter when associated with childhood. The
orphans face immense stress which gets created by varied, complex and intimately
connected needs for security, food, shelter, education and family connection. There
are many studies which portrayed the various causes of stress in orphans such as
losing opportunities for adequate education, health care, future, scarcity of basic
amenities, poverty, exploitation, stigma, sexual or physical violence, lack of access
to services, economical crisis, grief of being parentless, lack of affection, injustice,
lack of moral and emotional support and discrimination. 9
The problems the orphans mainly encounter in their life include: lack of
school fees, lack of scholastic materials, lack of love and care, loneliness, lack of
good clothes, lack of stable homes, discrimination, and cannot choose what they
want. Majority of the orphaned children try to cope with the problems by generally
working very hard, working in peoples’ gardens, fetching water, reading hard if in
school, and try to be well behaved. Others try to cope by begging from relatives
and friends, begging from one person to other. Some of them pray to god for divine
assistance and healing while others try shifting from one place to another.9
Orphan hood and problems faced by the orphans has emerged as a serious
threat to the community and national development. If the impending tragedy is to
5
be averted new and visionary policies and programs aimed at improving their
living condition and securing their future are urgently needed.9
A qualitative study was conducted to describe challenges and strategies for
coping with the challenges amongfourteen participants (11 males and 3 females)
ages 10-24 residing in an Indonesian residential institution (orphanage and Muslim
boarding school).The results found that insufficient access to educational resources
and basic necessities were major concerns of stress to the participants, as was the
residential institution's unresponsiveness and the lack of connection experienced by
residents. Individuals coped with these challenges by turning to others for social
support and by trying to change the focus of their thoughts, such as to more
pleasant thoughts or simply to mentally disengage10.
A study was conducted to examine the association of single and double
orphan hood with depressive symptoms and emotional distress among children and
adolescents in Namibia. A sample of 157 students from 3 schools including 84
non-orphans, 50 single orphans, and 23 double orphans were taken and children’s
depression inventory(CDI) was administered. The results found 21.9% of single
orphans and double orphans and 11.9% of non-orphans exhibited depressive(stress)
symptoms. The study provides evidence that orphan hood is associated with ill
mental health and that high rates of stress are present in approximately 1 in 6
children and adolescents in Namibia.11
The perceived stress among orphaned children has been portrayed in
different studies by researchers. All studies display a grave urgency because the
stress which is faced by orphaned children can cause thwarted deviation in the
developmental process of orphaned children. The results of studies are alarmingly
disappointing and suggest deep insightful further studies.12
Stress management is a creative and powerful tool as long as individuals
learn to use the methods appropriately.One of the recently developed stress
management technique is bibliotherapyThe process of providing advice and help
through books is called bibliotherapy. It is an old concept of library science. The
ancient greeks stressed the importance of literature by posting a sign above the
6
library doors describing itself as the “ healing place for the soul”. The basic
concept behind bibliotherapy is that reading is a healing experience. Literary
sources can assist with the resolution of complex problems.13
Apart from the bountiful educational and cultural benefits of encouraging
children to read, there are three other great therapeutic reasons to use children’s
books(bibliotherapy) to give advice:
1. Identification of character and social situation: This identification increases the
probability of learning different behaviors and receiving advice.
2. Catharsis: Through identification, an emotional connection with the character
or social situation allows children to act out and discuss their emotional responses
to the situation.
3. Insight: Through beneficial discussion and follow-up play, the child integrates
the link between the story and their own life, with opportunities to practice how to
address and solve issues of concern. Reading creates different brain waves and
allows children to think in a new and different way. Followed with a bit of
positively manipulated play, reading a book may well be the best super nanny or
child therapist in the world14
Bibliotherapy can assist children in building confidence and self-esteem. It
attempts to normalize a child's world by offering coping skills and reducing their
feelings of isolation, reinforcing creativity, and problem solving.15
Orphaned characters are extremely common as literary protagonists,
especially in children's and fantasy literature. The lack of parents leaves the
characters to pursue more interesting and adventurous lives, by freeing them from
familial obligations and controls, and depriving them of more prosaic lives. It
creates characters that are self-contained and introspective and who strive for
affection. Orphans can metaphorically search for self-understanding through
attempting to know their roots. Orphans are common in fairy tales, such as most
variants of Cinderella. Many studies have been conducted to prove effectiveness of
bibliotherapy in reducing the stress in both adults and children.16
7
A study was conducted to determine whether bibliotherapy has an effect on
the anxiety levels of 5’th grade students as measured by Beck Anxiety Inventory.
. The sample included 2 groups of 5th graders in a local educational setting in a
southern U.S. state. Group A received 2 weeks of bibliotherapy intervention
including 3, one hour lessons per week while Group B received traditional
treatment. Post treatment anxiety was measured and compared after categorizing
participants into low stress or high stress. The findings suggested a significant
relationship between the use of bibliotherapy and lower levels of anxiety. The
implications for social change are that the findings may add to the body of
knowledge for educators and parents about a coping strategy, bibliotherapy, which
is gaining momentum in the fight against childhood stress and anxiety17.
An experimental study was done to identify the effectiveness of
bibliotherapy in reducing the stress of 20 inner city first grade students. A twenty
item stress questionnaire was given to assess pre test scores followed by
bibliotherapy intervention that was given for thirty minutes, 5 days a week, for 8
weeks. Post test was then assessed . Research results found that many stressors
were reduced when first grade students participated in bibliotherapy. The
researcher concluded that bibliotherapy is an effective approach for helping
children solve problems and reduce stress.18
There are several studies conducted by various researchers throughout the
world stressing the effectiveness of bibliotherapy in stress reduction among adults
and children of varied age groups.It is the need of the hour to expand the practical
implication and scope of bibliotherapy in solving the orphan stress and helping
them develop as productive citizens of the country. Henceforth this study has been
proposed.
6.3 STATEMENT OF PROBLEM:
A study to assess the effectiveness of bibliotherapy in reducing the stress
among orphan children in selected orphanages of Bangalore.
8
6.4 OBJECTIVES:
1. To assess the existing level of stress among orphaned children.
2. To select and administer the bibliotherapy material among orphan children.
3. To assess effectiveness of bibliotherapy on level of stress among orphan
children.
4. To associate level of stress among orphan children with their selected
demographic variables.
6.5 OPERATIONAL DEFINITIONS:
1. Effectiveness: In this study refers to the extent to which bibliotherapy was
effective in achieving the desired objective that is reducing the stress
among orphan children.
2. Bibliotherapy: In this study bibliotherapy refers to an intervention of
therapeutic book reading applied to reduce stress among orphan children
by providing selected reading materials fictional and nonfictional
3. Stress: In this study refers to any factor, mental or physical, the pressure of
which can adversely affect the functioning of subjects
4. Orphan children: All children in the age group of 10-14yrs who has lost
both their parents and living in orphanages
6.6 ASSUMPTIONS:
1. All orphan children in the orphanages may have stress.
2. All orphan children may have less coping skills to overcome stress.
3. Lack of parental love and affection, strangeness of the environment is the
major source of stress among orphan children.
4. Bibliotherapy may reduce stress among orphan children.
6.7 HYPOTHESIS:
1. H1: There will be significant difference between pre test and post test
scores for stress among orphan children receiving bibliotherapy.
2. H2:There is a significant association between thelevel of stress of orphan
children with their selected demographic variables.
9
6.8 REVIEW OF LITERATURE:
Review of literature is one of the most important steps in the research
process. Review of literature is a systematic identification, location, selection, and
summary of written material that contain information on the research problem. The
purpose of literature review is to convey the reader what knowledge and ideas have
been established on a topic and what are the strength and weaknesses.19
The review of literature of the present study was collected, organized and
has been presented under two sections.
SectionA:Studies related to stress among orphan children
Section B:Studies related to effectiveness of bibliotherapy
Section A: Studies related to stress among orphan children
A study was conducted to determine the stress related emotional and
developmental disorders among 294 orphan children in the age group of 6-12yrs in
Sharkia governorate. An assessment of depression, anxiety and stress, low self
esteem and developmental disorders using appropriate standardized scale revealed
that the prevalence rate of depression was 21%, anxiety and stress was 45%, low
self esteem was 23% and developmental disorder was 61%. The study concluded
that although the basic material needs could be met, orphans in orphanages were
almost totally separated from the outside world and could not access normal
families and society relations. This would very likely harm their personality in
adulthood and social skills. These results show distinct association between low
self esteem and depression were certain consequences of orphan hood and played a
significant role in lowering the children’s life quality.20
A study was conducted on perceptions of children on orphan circumstances
in rural district of Zimbabwe. Group discussions and interviews were conducted on
40 orphans, 25 caretakers and 33 community workers. The study revealed that
Orphan concerns included feeling different from other children, stress,
stigmatization, exploitation, schooling, lack of visits and neglect of support
responsibilities by relatives. Many community members, while recognizing their
10
limitations due to poverty, were already actively helping orphans and caretakers.
Extended family networks are the primary resource for orphans, though some
relatives exploit orphans or fail to fulfill their responsibilities.21
A study was conducted to explore the challenges and coping strategies
accompanying two possible life trajectories for orphaned children without adequate
adult care: 1) that they remain in rural areas in child-headed households, or 2) that
they are trafficked to an urban area. Two separate phenomenological studies were
conducted on12 orphaned children in a poor rural area and 15 orphan girls who
were trafficked from rural areas. Loss of parents, a lack of cash, and the need to
balance school attendance with food production were chronic stressors for the
children heading households. For the trafficked girls chronic stressors included
exploitation, long working hours, little or no pay, isolation and rape. The study
concluded that given physical and social assets the child-headed households were
able to cope with the challenges of caring for themselves and a younger child, but
isolation and dependency on employers made it difficult for the trafficked girls to
cope with this exploitation22
A study was done on the understanding of psychological well-being among
institutionalized orphans and vulnerable children. As the protective safety net
dissipates, many orphans and vulnerable children are forced to live in overcrowded
and understaffed orphanages. In the attempt to meet survival needs, psychological
health is pushed into the background. Qualitative interviews (N=12) and field
observations in orphanages (N=6) revealed that, institutionalized orphans and
vulnerable children were found living under poor general care with few
opportunities for lucid, educational, and social growth. Also among the findings
were neglect and abuse, attachment difficulties and traumatic stress symptoms.
This study opposes the disuse of orphanages and suggests interventions to improve
the orphans’ psychological well-being by reducing their stress.23
A comparative study was done to determine whether differences in stress
excess between school age orphaned children and non orphans. About 197
orphaned children and 528 non orphaned children in the age group of 8 - 15 years
11
participated in the study. The linear regression analysis showed a statistically
significant difference [P<0.05] in education, health and stress outcomes in
orphaned children than the non-orphaned children. The researcher concluded that,
the orphaned children experiences more stress than the non-orphaned children.24
Section B: Studies related to effectiveness of bibliotherapy
A study was conducted to assess the effectiveness of bibliotherapy as a
strategy to relieve transescent stress. Subjects for study included 160, 6’th grade
students selected through convenience sampling from four classrooms in Central
Arizona US. The results assessed through 1990 Iowa test of basic skills reading
comprehension subtest revealed significant increase in student’s reading
comprehension scores and thus a reduced transescent stress as a result of
bibliotherapy treatment.25
A study was conducted to assess effectiveness of bibliotherapy as a strategy
to help students with bullying and eve teasing. Salient research findings pertinent
to teasing and bullying have made their way into children’s literature over the
course of child adolescent teasing in schools (CATS). 85 6’th grade students were
exposed to fictional stories (bibliotherapy) about bullying and teasing after which
children have shared their own non fictional account of this often devastating
experience. The
investigator concluded that bibliotherapy was effective in
reducing stress experienced by the bullied students and helped them to develop
coping strategies to deal with bullying and teasing that takes place in schools
nationwide.26
12
A Social Stories intervention package was used to teach 2 students with
autism to read Social Stories, answer comprehension questions, and engage in role
plays. Appropriate social behaviors increased and inappropriate behaviors
decreased for both participants, and the effects were maintained for up to 10
months. The intervention package was found to be useful in inclusive classroom
environments and does not require intensive supervision of the child's behavior27.
An experimental study examined the value of modifying empirically
validated treatment for childhood anxiety for application through written materials
for parents of anxious children. Two hundred sixty-seven clinically anxious
children ages 6-12 years and their parents were randomly allocated to standard
group treatment, waitlist, or a bibliotherapy version of treatment for childhood
anxiety. In general, parent bibliotherapy demonstrated benefit for children with
anxiety resulting in around 15% more children being free of an anxiety disorder
diagnosis after 12 and 24 weeks post intervention. These results have implications
for the dissemination and efficient delivery of empirically validated treatment for
childhood anxiety.28
A study was conducted to investigate the effect of bibliotherapy in dealing
with problems of personal development and
interpersonal relationships
encountered by children affected with social violence The sample included 90
school children in the age group of 9-11yrs living in an area known for its gang
violence. The study concluded that bibliotherapy had meaningful effects on
subjects by increasing their self esteem in terms of appreciation of his/her own
worth and harmonious acceptance of the conditions of life at large. The
investigator also reported that bibliotherapy has the potential of exercising a
beneficial influence in psychological makeup of the individual29.
An experimental research was done to study coping with stress through
bibliotherapy for Taiwan college students using zhuangzi’s fables. About 343
samples were selected using convenient sampling method, quasi experimental
research design was used. The research concluded that there are significant effects
on reduction of the following stress: Financial Problems, Career Planning, School
13
Work, and Interpersonal Relationships. People with a “Type ABehavior Pattern”
can be helped in stress reduction. Females are more influenced than males in stress
reduction by bibliotherapy intervention; however, males are more influenced than
females in stress reduction by self-help bibliotherapy. The results show the
beneficial effects of the intervention, which can be recommended by educational or
health professionals as an alternative approach in coping with stress.30
A study examined the efficacy of supplementing bibliotherapy for child
anxiety disorders with therapist-initiated telephone or email sessions, or with
client-initiated contact in a randomised trial using a waitlist control. Participants
were 100 anxiety-disordered children and their parents from rural and remote
communities. All treatment conditions resulted in improvement on self-report
measures and clinician rated severity. The results suggest that therapist
supplemented bibliotherapy could provide an efficacious treatment option for
families isolated from traditional treatment services.31
A study was conducted to examine the use of an assisted bibliotherapy for
mild to moderate stress/anxiety in an adult clinical population referred by their
general practitioner. Assisted Bibliotherapy was provided for a brief period of 8
weeks, with limited therapist contact (20-min sessions). Non-parametric statistical
testing of scores from the Zung Anxiety Scale and the Clinical Outcomes in
Routine Evaluation (CORE) questionnaire indicated positive results. There was
significant improvement at post-treatment, which was maintained at 3 month
follow-up. The results from this trial and a previous trial of assisted bibliotherapy
by Kupshik and Fisher in 1999, indicate that it is an effective treatment which
could be used as part of a stepped care approach to managing and treating
stress/anxiety in primary care.32
A randomized control trial of cognitive therapy, a self help booklet and
repeated assessment on early intervention of PTSD was conducted in London UK.
The objective of the study was to determine whether cognitive therapy or self help
booklet given in initial months after a traumatic event is more effective in
preventing PTSD. The selected 97 subjects were motor vehicle accident survivors
14
who had PTSD in initial months. The results revealed that both cognitive therapy
and self-helpbooklet(bibliotherapy) were effective in reducing symptoms of
PTSD. 33
It is evident that society has changed. And, too, so have the children and the
teachers. Educators are recognizing the critical need for delivering literacy
instruction to at-risk and homeless children and their families (IRA, 1990). Four
books which may be used for homeless children and their families are Fly Away
Home (Bunting, 1991), The Polka Dot Horse (Thiel, 1992), Homelessness
(Seymour-Jones, 1993), and Changing Places — A Kid's View of Shelter Living
(Chalofsky, Finland, and Wallace, 1992). The role of the reading teacher cannot be
ignored in terms of crisis intervention,and the amelioration or attitudes can be a
legitimate cause in using bibliotherapy. The role of the reading teacher should
beviewed as that very special person who can break emotional barriers to learning
when crises arise34
7. MATERIALS AND METHOD:
7.1 SOURCE OF DATA:
The data will be collected from the children 10-14 years at selected
orphanages in Bangalore.
7.2 METHOD OF DATA COLLECTION:
I. RESEARCH DESIGNThe research design for this study is one group pre test post test design.
II. RESEARCH VARIABLES1. Independent variables: Bibliotherapy
2. Dependent variable: Stress
3. Demographic variables:Age, sex, educational status, duration of stay in the
orphanage, any visitors and the number of visits.
15
III. SETTING-Thisstudy will be conducted in selected orphanages of Bangalore.
IV. POPULATION-Orphanchildren in the age group of 10-14 years living in in
selected orphanages in Bangalore.
V. SAMPLE SIZE: The sample size in the study will be 60 Orphan children’s of
age group of 10-14 years who will fulfill the inclusion criteria of the study.
VI. CRITERIA FOR SAMPLE SELECTION:
Inclusion criteria1. All orphan children in the age group of 10-14years living in orphanages
suffering from considerable stress.
2. Conscious and mentally alert.
3. Children who are cooperative.
4. Children having the ability to read and /or write kannada
Exclusion criteria:
1. Children who are critically ill.
2. Children with neurological deficit.
3. Children who are not interested in reading.
VII.
SAMPLE TECHNIQUE:Children will be selected using simple random
sampling technique(lottery method) and would be allotted to interventional
strategy
VIII. TOOL FOR DATA COLLECTION:
Tool consists of two sections
1. Section A: Demographic data of children: This section contains items of
demographic characteristics of orphan children including age, sex, educational
status, duration of stay in the orphanage, number of visitors and the visiting
status.
2. Section B:Stress assessment scale: standard stress assessment questionnaire
will be used to assess the stress of orphan children.
16
IX. METHOD OF DATA COLLECTION:
Phase I: Prior administrative permission will be obtained from trustees of
orphanages. Informed consent will be obtained from the guardians of orphan
children (samples) also. The samples will be selected according to the inclusion
criteria of the study.
Phase II: Pre test will be conducted by administering the stress assessment
questionnaire.
Phase III: Bibliotherapy is administered for four weeks. Each session lasts for
one hour and includes story reading followed by post interventional activities and
discussion.
Phase IV: Post test stress score will be assessed by administering the stress
assessment questionnaire.
X.
PLAN FOR DATA ANALYSIS:
The data collected will be analyzed using descriptive and inferential statistics
Descriptive statistics:
Frequency and percentage distribution will be used to study the demographic
variablesof orphanchildren.
Mean and standard deviation will be used to analyze the effectiveness of
bibliotherapy on level of stress among orphan children.
Inferential statistics:
Paired “t” test will be used to analyze the significant difference between the
mean pretest and post test level of stress scores of orphan children.
Chi-square test will be used to associate the post test level of stress among
orphan children with their selected demographic variables.
XI. PROJECTED OUTCOME:
As the investigator has planned for use of bibliotherapy for stress reduction
there will be a reduction in the level ofstress experienced by orphan children
living in orphanages.
7.3 Does the study require any investigation or intervention to be conducted
on patients or other human beings or animals.
17
Yes, with prior consent from the guardians of orphan children(sample) the
study will be conducted in selected orphanage of Bangalore. The study will
require intervention in the form of bibliotherapy(book reading) only. No other
intervention which cause any harm will be done for the subject.
7.4 Has ethical clearance been obtained from your institution:
Yes, the permission will be obtained from concerned authority and
guardians of the subjects.
1. Privacy, confidentiality and anonymity will be guarded
2. Scientific objectivity of the study will be maintained with honesty and
impartiality.
3. Ethical clearance report has been enclosed for the verification
18
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5. Kurtz C, Bunzell M, Nagler S. Anxiety and autonomy among orphaned
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Double Orphan hood With Symptoms Of Depression Among Children And
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20
19. Polit E, Beck T. Nursing Research. 8th ed. .New York: Lippincott Williams
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21. Foster G, Makufa C, Drew R, Mashumba S, Kambeu S. Perceptions of children
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9. Signature of the Candidate :
10. Remarks of the guide
:The study will be appropriate, feasible and relevant to
enhance the knowledge in the field of pediatrics
speciality
11Name and Designation of the
11.1 Guide
: Mrs. Renuka V
Asst. Professor
11.2 Signature
:
11.3 Co-guide
:
11.4 Signature
:
11.5 Head of the Department : Mrs. Renuka .V
Asst. Professor
11.6 Signature
:
12.1 Remarks of the Principal : The study is feasible and relevant to the
specialty chosen.
12.2 Signature
:
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