RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,

KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

“AN EXPERIMENTAL STUDY TO ASSESS THE

EFFECTIVENESS OF FRESH GOOSEBERRY JUICE WITH ELEMENTAL

IRON SUPPLEMENTATION VS ELEMENTAL IRON SUPPLEMENTATION ON

LEVEL OF ANEMIA AMONG ADOLESCENT GIRLS WITHANEMIA IN

SELECTED SCHOOL AT MALUR, KOLAR DISTRICT”

M. Sc Nursing Dissertation Protocol submitted to

Mr. Salic Rahuman . N

M .Sc NURSING 1ST YEAR

2011-2013

 

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, BANGALORE KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Name of the candidate : Mr. N. Salic Rahuman

Maulr - Hosur Road

Malur -563130, Kolar                                      

Name of the Institution :  Manasa College of Nursing 

Maulr - Hosur Road

Malur -563130, Kolar                                      

Course of study and subject   :  1st Year M.Sc. Nursing in Community Health Nursing.

Date of admission to course   : 19-10-2011         

Title of the topic                                 :  An experimental study to assess the effectiveness of fresh gooseberry juice with elemental iron supplementation Vs elemental iron supplementation on level of anemia among adolescent girls with anemia in selected school at Malur in Kolar district.

 

6.0 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“The adolescent girl still remains a young planet that neither gets

Light or water, She remains the flower that could have blossomed

But didn’t”

Adolescence Is The Period When The Individual Can Be Shaped And Molded Into

Great Adults Psychologically. The Sense Of Identity And Crisis Of Intimacy And

Isolation Increase As Adolescent Progress Towards Young Adulthood And Move From

Dependency To The Beginning Of Independence. Metamorphically Adolescents Change

Their Behavior Patterns And Values As well. The Rates Of Change In Attitude, Interest

Are Seen As Parallel To The Rate Of Physical Change In The Growth And Development

Of An Adolescent, The Emotional Disturbance Might Lead Them To React To

Frustration Through Maladjusted Behavior By Children Were More In Schools And

Colleges [Lalitha,1999]

Global database by WHO [2007]on child growth and malnutrition and national

family health survry-2 in India, had suggested that adolescent girls of urban, semi urban

& rural schools in India are found to be anemic & prevalence rate between 61.9 to 88.1

percentage, begin highest among rural girl of higher order as compare to urban poor girls

irrespective of their age menarcheal status. This could be due to difference in dietary

habits, worm infestation, poor hygiene, poor sanitation. anemia prevalence was more

among girls of low weight, height & BMR as compare to those who were heavier, tall

and having higher BMR

India is one of the fastest growing youth populations in the world with an estimate

190 millions adolescent of which 22% are girls. the government of Karnataka directorate

of public health and preventive medicine [2002] conducted a study on prevalence of

anemia among adolescent girls in the urban were anemic. directorate of public health

reports stated that 3.44% of school adolescents are anemic out of which 59% of them are

receive iron & folic tablets.

Anemia is one of the most widespread public health problems, especially in

developing countries like India &has important health &welfare, social & economic

consequences. these include repaired cognitive development, reduced physical work & in

severe cases, increased risk of mortality particularly during the perinatal period. There is

also evidence that anemia may result in reduced growth & increased morbidity. Given

the magnitude of the problem, greater efforts are needed to develop & implement

programs both to prevent & to control anemia. park[1998] suggested that iron deficiency

anemia is a major nutritional problem in India and in many other developing countries

20-40% of natural deaths are due to anemia during pregnancy.

Stoltzfus [2003] consider iron deficiency to be one of most prevalent forms of

malnutrition. yet there has been a lack of consensus about the nature & magnitude of

health consequences of iron deficiency in population. The public health importance of

iron deficiency anemia which was made as part of the global burden of disease [GBD]

2000 project, iron deficiency is consider to contribute to death & disability & also

through its direct contribution to cognitive impairment, decreased work productivity, and

death from severe anemia based on meta-analysis of observational studies, mortality risk

estimates as the decreased risk in mortality for each 1g/dl increase in mean hemoglobin

concentration. on average, globally 50% of the anemia is assumed to be attributable to

iron deficiency. globally iron deficiency ranks number among 26 risk factors included in

the GBD 2000,and accounts for 8,41,000 deaths & 35,057,000 disability adjusted life.

there is an urgent need to develop effective & sustainable intervention to control iron

deficiency anemia.

The bio availability of iron can be enhanced by positive dietary habits & reduce

the intake of inhibitors and enhanced iron absorption through vit-C,vit-A rich fruits &

vegetables. [yegammai & A.swarnalatha,2003]

6.1

In India, the existing prevalence studies were carried out mostly in northern states,

agarwal had documented that the prevalence of anemia was 46% in pre menarcheal girls

as compared to 48% in post menarcheal girls in the urban shams of north east delhi. in

rural India a survey is conducted among 13 to 19 years old girls & found out anemia

prevalence rate of 83% among girls in schools & 93% among girls not in school.

[agarwal,1998]

Iron deficiency anemia is a major nutritional problem of both developed &

developing countries.4.5 billion people of the world’s population are anemic. the

incidence of anemia is highest among women & young children varying between 60% to

70%.[yegammai & swarnalatha,2003]

Dietary iron exists in 2 form heme iron found in hemoglobin, myoglobin & some

enzymes. heme iron found in planet foods but also in some animal food. the absorption

of heme iron is affected only minimally by the composition of food media & gastro

intestinal secretions. but non heme iron absorption is affected by other compounds in

food that inhibits or enhance its absorption, phytate, tamins which are polyphenols in tea

inhibits where as presence of calcium helps to improve absorption.

One of the major problem affecting adolescent girls is anemia, a familiar

nutritional problem to be concentrated more to improve their quality of life. since they

are going to be the future home makers.

NEED FOR STUDY

Anemia is the most form of malnutrition among adolescent today. It is of public

health significance in our country. Adolescent (10-19) constitute >20% of our population

in India & 50% suffer from iron deficiency anemia. Both urban % rural, suffer from

anemia & being more in girls than boys. Poor economical status faulty dietary pattern,

lack of awareness & education, urbanization prevalence malaria, hookworm & other

infestation, repeated bacterial infections also influence the incidence & nature of anemia

among growing children and adolescents.

Iron deficiency anemia reduces the work capacity of individuals and entire

population brings serious economical consequences and it may be obstacle to national

development. Also iron deficiency anemia is one of the leading causes for morbidity. Iron

deficiency has effect on all systems in the human bodies. Long standing severe anemic

may lead to congestive cardiac failure.

The adverse effect of iron deficiency anemia differs according ti the age group

example in case of pregnancy if hemorrhage and shock. So thereby increase the risk of

maternal and infant mortality. In case of school going children the concentration and

intellectual skills are affected.

Numerous morbidity studies among studies children have been carried out by

individual researches mostly in urban areas of India. The incidence of malnutrition

including anemia is 40-70%. Giving health education for prevention of preventable

problems and development of healthful living practices, among students, which is one of

the recommendations of the school Health Committee (Narayana 2001)

The investigator has selected gooseberry to provide vitamin C ( ascorbic acid)

because it is locally available than any other sources and it has value of Vitamin C (750

in 100gm of gosseberry) and ferrous sulphate with 30mg of elemental iron for iron

supplementation.

Also during the review of literature the investigator come across many studies on

synthetic ascorbic acid and iron absorption. Only few studies are a natural ascorbic acid

6.2

iron absorption. This gave to the investigator to study the effort of gooseberry juice on

iron absorption.

REVIEW OF LITERATURE

Studies related to influencing iron absorption

In the year 2000, Zijip conducted a study the effect of tea and other dietary factor on

iron absorption .Because several dietary factors can influence this absorption. He says that

absorption enhanced by ascorbic acid and meat, fish and poultry. Inhibitors are plant

components in vegetable, tea and coffee, calcium. The following recommendations are made to

increase home iron intake,

Increase meal time ascorbic acid intake, fortified food with iron. Recommendations with

respect to tea consumption include, consume tea between meals instead of during the meals,

and simultaneously consume ascorbic acid, acid, fish and poultry.

Fishman, et.al (2000) their work provides a systematic review of vitamin

supplementation trials that reported changes in anemia or iron status. Resume of the study

shows vitamin a can improve hematological indicators and enhance the efficacy of iron

supplementation based data showing it is efficacy in reducing anemia or iron deficiency.

Skeaff, at. al (2001) investigated the efficacy of a dietary regimen involving increased

consumption of iron-rich foods and enhances of iron absorption and decreased consumption of

inhibitors of iron absorption and a low dose iron supplement for increasing iron stores in

young adult women with mild iron deficiency. The investigator concluded that intensive

dietary program has the potential to improve the iron status of women with iron deficiency.

In the year 2001, Cook et.al assessed the effect of ascorbic acid intake on non heme

iron absorption from a complete diet. The facilitating effect of vitamin C on iron absorption

from a complete diet is far less pronounced that from single meals.

Geerlings et. Al (2003) conducted a community based randomized control led

intervention trail to assess the effects of cooking in iron aluminum cooking pots in Malawian

households in an area with high malaria prevalence . They concluded that consumption of food

prepared in iron cooking pots shows a significant rise in hemoglobin after 6 week use. Using

iron cooking pots in developing countries could provide an innovative way to prevent iron

deficiency anemia in malarias areas where regular iron supplementation is problematic.

Ramakrishna, et. Al (2003) conducted a National Health and Nutrition Examination

Survey to examine the relationship between low iron stores and dietary pattern that might

affect iron status among Mexican American woman remained at increased risk for the

prevalence of iron deficiency in maternal woman warrants further investigation.

In the year 2003, Brach et. Al investigated the dose response effect of small amounts of

meat on non heme-iron absorption from a meal presumed to have low iron bioavailability.

Forty five health women with amen age of 24=/-3 years were randomly assigned to 1of 3

groups ,each of which was served (a) basic meal ( rice, tomato sauce , pea puree and a wheat

roll ) and (B) the basic meal with either 2s,30 or 75g pork. The researcher conclude small

amount of meal (> or = 50g) significantly increase non heme iron absorption from a phytate-

rich meal low in vitamin C.

A cross sectional study conducted by Hashizume et. al (2004) of 97 school aged

children living in Kzyl-Orda to investigate anemia related to the sufficiency of dietary iron

intake. The researcher concluded that low bioavailability of dietary iron seems related to

anemia in the region. Although iron fortification or supplementation programees can be useful

for promoting the anemia prevention control programme

Studies related to treatment of anemia

A true experimental study was conducted by Vijayalakshmi et. al (2000) to assess the

bio availability of iron from mug beans and its effect on the nutritional status of adolescent

girls, at Mulaivail, Karur. 150 samples were selected between the age group of 12-18 years.

The anthropometric measurement and serum hemoglobin, iron binding capacity tests were

done for them. The intervention was given for about 40 days. The findings revealed that socio-

economic background indicated that 91.6 percent were from nuclear families, 81.8 percent

were having a family size of 4-6, seventy four percent of girl’s mothers were being illiterate,

and over 75 percent in low income group, before the intervention it the mean value of

hemoglobin was 9.1 gl/dl and after the intervention was 11.3gmldl.There was a significant

seen in the hemoglobin level (p<0.001).

A quasi experimental study was conducted by Nalwade Vijaya et. al (2001)to assess the

nutritional intervention for iron and vitamin A deficiency among 70 adolescent girls, between

the age group of 12-18 years in Parbhani . Anthropometric measures, clinical sings and

symptoms of nutritional deficiency disorders were assessed and 7 hours recall method was

used to assess the food intake of the girls. Iron and vitamin A supplementation were

supplemented to them for 900 days which post test was done. At the end of the study there was

a decrease in the prevalence of anemia (48%) B complex (30%) and vitamin A deficiency

(28.11%) among the experimental group .However in the control group there was significant

differences. There was a significant improvement seen (p<0.001) after the interventions.

Swarnalatha et. al (2001) conducted an experimental study to assess the impact of iron,

vitamin A and vitamin C supplementation on anemic adolescent girls at Sri Narayana higher

secondary school, Ullipudhur.Hundred samples were selected between the age group of 13-15

years. The findings showed that initially over all 35.7 percent adolescent girls was anemic.

Mild and severe anemia in two percent of the subjects. At the end the study overall 26.72

percent adolescent girls were anemic, 9.2 % were mild anemic and severe anemia in 0.98% of

the subjects. There was a significant improvement seen after the intervention (p<0.05).

Brady et. al (2003) conducted a clinical study on iron supplementation and absorption

in the presence and absence of ascorbic acid. The study revealed that fortification with ascorbic

acid increases the bio availability in both presence and absence of inhibiting substances (coco,

caffeine items).ascorbic acid contains micro encapsulation with Lecithin, which birds and

protect the iron particles from the action of inhibiting substances (84%) when human takes the

iron supplements along with ascorbic acid helps to get the higher amount of iron absorption

(p=0.02).

In the year 2005, Juinil was conducted a clinical correlation study on the impact of

vitamins in iron absorption among 200 adolescent girls. Hemoglobin and serum retinol studies

were done for the samples. The study revealed that there is an observed correlation between

serum retinol and hemoglobin levels. The girls with a low serum retinol concentration are more

likely to have iron-deficiency anemia (76.1%),compared to those with normal to high levels of

retinol (24.9%).While vitamin A deficiency has an adverse effect on hemoglobin synthesis,

even a slight increase in vitamin A intake can lead to significant rise in hemoglobin

levels(p<0.001). However, vitamin A is less effective in alleviating severe iron-deficiency

anemia. Without doubt, low levels of iron in the body cannot be relieved by vitamin A

supplementation alone. Additionally, a low ascorbic acid stores in the body causes impairment

in the release of stored iron in the reticuloendothelial cells. Ascrobic acid plays an important

role in modulating ferritin synthesis iron storage.

Studies related to the effectiveness of gooseberry juice and elemental iron

ICMR bulletin (200) the national nutritional anemia prophylaxis programme was

initiated in 1970 iron deficiency anemia in the vulnerable group through daily supplements of

iron-folic acid tablets. The suggested prophylactic doses of iron and folic acid respectively

were 200-240 mg for children per day for 100 days. These tablets were distributed to the high

risk groups by the local health workers.

In the year 200 Sharma Anshu et. al conducted a study on identification of an

appropriate strategy to control anemia in teenaged girls of poor communities of Delhi and

reported that sixty two percent of the respondents in the urban and eighty five percent in the

rural area were anemic. The response of the levels to daily iron/folate supplementation was

better in comparison to once weekly supplementation. The increment in Hemoglobin levels of

respondents due to addition of vitamin C to iron/folate supplementation was more than that

with supplementation of iron/folate alone.

An experimental study was conducted by Februthartanty et. al (2002) to assess the

efficacy of two different iron supplement administered either no a weekly basis or during

menstruation, among post menarcheal female adolescent students in Kupang The study

revealed that weekly supplementation of iron tablets continued for 16 weeks contributed a

higher improvement to hemoglobin concentration compared with supplementing iron tablets

for four consecutive days during menstruation for four menstruation cycles. This suggests that

weekly iron supplementation is preferable.

In 2002, Gopaldas conducted an experiment study among young women 18-23 years of

age in Tara consultancy services, Bangalore. Four small factories were selected in periurban

Bangalore, with a sample of 302 women. The 180 days interventions were supervised at the

workplace. In unit 1 (72 woman), the intervention consisted of idli four times a week plus

information, education, and communication (IEC) related to iron deficiency anemia. Unit 2 (80

woman) received 20 ml of gooseberry juice (containing 40 mg of vitamin C) three times a

week plus IEC once a month. Woman in unit 3 (70 women) , the positive control, received

400mg albendazole once plus ferrous sulfate tablets (60 mg elemental iron ) two times a week.

No IEC was given. Unit 4 (70 women) served as the negative control and received no

intervention. The pre-post impact were in unit 1,2 and 3, the hemoglobin status of the women

improved significantly from 11.10 to 12.30 g/dl, 11.20 to 12.70g/dl, and 11.50 to 13.00 gm/dl,

respectively. In unit 4 there was no change; the values were 10.90g/dl before and after

intervention.

Hinton, Sinclair (2006) conducted a study to determine the effect of iron

supplementation on iron status and endurance capacity. In study twenty iron deficient men and

women were participated. A 30 mg measure of elemental iron as ferrous sulfate daily for 6

weeks was given to the study participants. The results were iron supplementation significantly

improves iron status and endurance capacity in iron deficient male and female subjects

(p<0.05).

An experimental study was conducted by Pereira et.al (2007) to evaluate the efficacy of

weekly iron supplementation in the treatment of iron deficiency anemia. 267 school children,

6-14 years of age group were randomized into two treatment groups. One group (144) received

200 mg iron sulfate alone, With 40 mg of elemental iron, while the other group (123) received

the same iron supplementation dose plus 10,00 IU of vitamin A. Finally, anemia prevalence

was reduced from 48.4% to 17.7% (p<0.001) in the group receiving iron supplementation

alone and 58.1% to 14.3%.(p<0.001).

STATEMENT OF PROBLEM 

“AN EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF FRESH

GOOSEBERRY JUICE WITH ELEMENTAL IRON SUPPLEMENTATION VS

6.3

6.4

ELEMENTAL IRON SUPPLEMENTATION ON LEVEL OF ANEMIA AMONG

ADOLESCENT GIRLS WITH ANEMIA IN A SELECTED SCHOOL AT

MALUR ,KOLAR DISTRICT ”

OBJECTIVES OF THE STUDY

1)To asses the pre interventional level of anemia among the adolescent girls in group A and B.2)To asses the post interventional level of anemia among adolescent girls in group A and B.3)To compare the pre interventional and post interventional level of anemia among adolescent girls in group A4)To compare the pre interventional and post interventional level of anemia among adolescent girls in group B5)To compare the pre interventional level of anemia among adolescent girls between group A and B 6)To compare the post interventional level of anemia among adolescent girls between group A and B 7)To associate the mean score level of anemia with selected demographic variables among adolescent girls in group A8)To associate the mean score level of anemia with selected demographic variables among adolescent girls in group B

HYPOTHESIS 

H1 : There will be a significant difference between pre interventional and post

interventional level of anemia among adolescent girls in group A

H2 : There will be a significant difference between pre interventional and post interventional level of anemia among adolescent girls in group B

H3 : There will be a significant difference in level of anemia between group A and BH4 : There will be a significant association in the mean score level of anemia with selected demographic variable in group A

H5 : There will be a significant difference between pre interventional and post interventional level of anemia among adolescent girls in group B.

OPERATION DEFINITIONS

6.5

06.6

\

6.7

EFFECTIVENESS : It refers to the decrease in serum hemoglobin level after the administration of fresh gooseberry and elemental iron supplementation for a period of 30 days to the adolescent girls.

ANEMIA : Anemia refers as a reduction of the serum hemoglobin level below the range of 12gm/dl in healthy adolescents.

ADOLESCENT GIRLS : In this present study adolescent girls refer to the belonging to the age group of 13-18 years

FRESH GOOSEBERRY JUICE AND ELEMENTAL IRON : Administration of fresh goose berry juice 20ml and elemental iron 30mg/day after lunch for the period of 4 weeks.

ASSUMPTIONSThe study assumed that,

Most of the adolescent girls are anemic

Vitamin C enhances the iron absorption and thereby increasing the hemoglobin level

Increased iron absorption is reflected with an increase in haemoglobin level

DELIMITATIONS The study will be conduct among adolescent girls who were studying in a selected

school at Malur in Kolar district

The study limited to girls in the age group of 13-18 years

PROJECTED OUTCOME

The present study will help the adolescent girls to enhance their absorption and

thereby increasing the hemoglobin level.

MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from the adolescent girls who were studying in

6.8

6.9

7.0

a selected school at Malur in Kolar district

7.1.1 RESEARCH DESIGN

Pretest And Post Test Design Only, Which Is True Experimental Design In Nature Is

Adopted For Conducting The Study.

7.1.2 SETTING

The study will be carried out from adolescent girls in selected school at Malur in Kolar

district

7.1.3 POPULATION

In this study target population comprises of adolescent girls with anemia

METHOD OF DATA COLLECTION  

7.2.1 SAMPLING PROCEDURE

According to inclusion and exclusion criteria, the sample will be selected

Simple random sampling technique will be used

7.2.2 SAMPLING SIZE

Sample size will consists of 60 adolescents girls.

30 adolescent girls in group A

30 adolescent girls in group B.

7.2.3 INCLUSION CRITERIA

The study included girls who were

In the age group 13-18 years

7.2

Students present during the study period

Interested to participate in the study

With the hemoglobin levels less than 12gm%

Attained menarche

7.2.4 EXCLUSION CRITERIA

The study excluded girls who were

Psychologically depressed students

With any systemic disease

With history of menorrhagia

Students taking treatment for anemia.

7.2.5 INSTRUMENT INTENDED TO BE USED

SELECTION OF TOOL

Data Collection Instrument Are Extensive Literature,Consultation With Expert And

Opinion Of Faculty Members. Tool Are Prepare on The Basis Of Objectives.

The Tools Use In The Study

Part 1 : Demographic Variable PROFORMA,

Part 2 : Clinical Variable PROFORMA,

Part 3 : Check List For Signs And Symptoms Of Anemia,

Part 4 : Questionnaire To Asses The Knowledge Regarding Anemia Among Adolescent

Girls

Part 5 : Rating Scale on The Level of satisfaction Of Fresh Gooseberry Juice And

Elemental Iron Supplementation.

DEMOGRAPHIC VARIABLE PROFORMA

Demographic Variable PROFORMA Consists Of Age In Years, Religion, Education,

Family Income Per Month In Rupees, Dietary Pattern, Type Of Family, Number Of

Children In The Family.

CLINICAL VARIABLE PROFORMA

Clinical Variable Proforma Consists Of Weight In Kg, Hoight In Cm, Body Mass

Index, Level Of Hemoglobin, Age At Menarche, Frequency Of Menstrual Cycle,

Number Of Days Of Menstruation, Amount Of Menstrual Flow,Receive Of Any

Blood Products,. Habit Of Drinking Coffee

CHECK LIST FOR SIGNS AND SYMPTOMS OF ANEMIA

Check List For Signs And Symptoms Of Anemia Consists Of 20 Items. The Total

Score Is 20. The Scores Were Arbitrarily To

Mild (0-7),

Moderate (8-14),

Severe (15-20).

QUESTIONNAIRE FOR KNOWLEDGE ASSESSMENT ON ANEMIA

Questionnaire For Knowledge Assessment On Anemia Includes The Questionnaire To

Asses The Knowledge Regarding Anemia Adolescent Girls. It Comprises Of 25

Questions With Four Options. Each Question Has One Correct Option.

The Correct Option Score is 1

Wrong is 0

SCORING INTERPRETATION 

LEVEL OF KNOWLEDGE RANGE

Adequate Knowledge >50%

Average Knowledge 51-75%

Inadequate Knowledge <50%

 LEVEL OF SATISFACTION :

Rating scale on the satisfaction of gooseberry juice and elemental iron supplementation.

SCORE INTERPRETATION

>75% Highly satisfied

51-75% satisfied

<50% dissatisfied

7.2.6 DATA COLLECTION METHOD  

Data Collection will be do for a period of One Month.

Researcher collect the data from the Anemic Adolescent Girls.

PILOT STUDY

10 samples will be selected and study will be conducted to find the feasibility and

practicability of the study

7.2.7 DATA ANALYSIS PLAN

The Plan For Data Analysis Was As Follows

Data Analysis Is The Systematic Organization And Synthesis Of Research Data And

Testing Of Research Hypothesis By Using The Obtained Data, Descriptive Statistics

And Chi-Square And Paired 't' And Inferential Use To Analyze The Data Collection.

 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?

-No-

7.4 HAS THE ETHICIAL CLEARANCE BEEN OBTAINED

FROM YOUR INSTITUTIONS?

YES, Ethical clearance will be obtained from the research committee of Manasa College

of Nursing, consent will be taken from concerned authority and permission will be taken

from the study subjects before the collection of data.

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9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE