Study on Immunization among the Mothers

of Under five Children, HalagaVillage,

Belgaum, Karnataka.
Mr. Hazaratali Panari1, Mrs. Anuchithra2
1
Assistant Professor. Dr. J. J. Magdum Institute of Nursing, Jaysingpur. Kohapur, Maharashtra.
2
Professor, Bharatesh College of Nursing, Belgaum, Karnataka.
*Corresponding Author Email: [email protected]

ABSTRACT:
A descriptive survey was conducted to assess the knowledge and attitude on immunization among the mothers
of under five children, Halaga village, Belgaum, Karnataka.
Objectives of the study:
1. To assess the knowledge on immunization among the mothers of under five children.
2. To assess the attitude towards the immunization among the mothers of under five children.
3. To co-relate the knowledge and attitude of immunization.
4. To find out the association between knowledge and attitude of immunization with the selected demographic
variables.
Descriptive approach and non experimental design was used in this study. The setting of the study
was Halaga village of Belgaum, Karnataka. The sampling technique used was convenient and purposive
sampling .A sample size of 50 mothers of under five children were selected for the study. A self reporting
questionnaire prepared by the researcher was used as the tool. The tool consisted of three parts .Part 1-The
demographic data. Part 2-Questionnaire to assess the knowledge on immunization and Part 3- Attitude scale on
immunization. The data was analyzed by using both descriptive and inferential statistics. The demographic
variables were analyses by frequency and percentage. To determine the relationship between knowledge on
immunization and square test was used to associate demographic variables with knowledge and attitude on
immunization.
MAJOR FINDINGS OF THE STUDY ARE AS FOLLOWS:
Majority of the respondents were in the age group of 21-25 years, 64% were belongs to Hindu religion, 56% of
family’s income below 2000, 42% of mothers were having 2 children, 76% of mothers stayed in joint family,
92% of mothers were educated, 98% of mothers possessed immunization card, 50% came from middle class,
92% of mothers had earlier heard about immunization. The mean knowledge value on immunization of mothers
of under five children was 58.1and attitude score was 41.4 .This indicates that the mothers of under five children
have moderately adequate knowledge on immunization and positive attitude towards immunization. The
correlation between knowledge on immunization and attitude of mothers showed that there is a positive
correlation between knowledge on immunization and attitude (r=0.483). This suggests that the mothers of under
five children had positive attitude though they possess moderately adequate knowledge. Chi-square test revealed
that there is no significant association between knowledge on immunization and selected demographic variables.
Based on the findings of the researcher has drawn the following implications which are of vital concern for the
field of nursing practice, administration, education and research, which are as follows:
 The nurse should give adequate health education to the people in the community setting as well as hospital
set up on immunization, immunization schedule, advantages, contraindications etc and prevention of
communicable diseases.
 The nursing students must have a topic on immunization in nursing curriculum.
 The nursing administrator should focus on health programme through home visit, mass health programmer
etc. Health workers can be given training in practice and management of immunization.
 For nursing research further steps can be taken to assess the effectiveness of nursing staffs in handling
immunization.
CONCLUSION: The mothers of under five children of rural community area had moderately adequate
knowledge on immunization and moderate positive attitude towards immunization. These findings reveal that
the community health nurses should make little more efforts in educating the mothers so as to achieve 100% of
immunization.

KEYWORDS: Immunization, Halaga Village, Belgaum, educating the mothers.

INTRODUCTION:
Immunization is defined as the process of inducing the immunity in an individual against an infectious organism
or agent, through the vaccination (Satish Gupte 2002). In May 1974, the WHO officially launched a global
immunization programme known as Expanded Programme of Immunization (EPI), to protect all the children of
the world against six vaccine preventable diseases namely- Diphtheria, Whooping Cough, Tetanus, Polio,
Tuberculosis and Measles by the year 2000. In India, the EPI was launched on January 1978.(K. Park) In 1990,
by United Nations Integrated Children’s Emergency Fund (UNICEF), EPI was renamed into Universal Child
Immunization and it was launched in India on November 19, 1985 and was dedicated to the memory of
Smt. Indira Gandhi. (K. Park) An important contribution of microbiology to medicine has been immunization.
By this, many vaccine preventable have been virtually eliminated. (C. P. Baveja, 2005) Vaccine is an
immunological substance designed to confer specific protection against a given disease. It stimulates immune
system (either humoral or cell mediated) to generate specific protection against an infectious agent. Vaccine
may be prepared from live modified organisms, inactivated or killed organisms, toxoids, or combination of
these. Polio vaccine was invented by Jonas Edward Salk in 1952. The immune system protects an individual
against invasion by foreign bodies, specifically microbial agents and their toxoid products. (Ananthanarayan,
2004).

NEED FOR THE STUDY:

One of the key and most cost effective health interventions is achieving hundred percent immunization status. It
was formulated to attain the goal of Health For All.

Anderson LM, Wood DL and Sherbourne (2005) conducted a study and examined the relationship between the
occultation levels of poor Latina woman (688) in Los Angels and children’s immunization status. Receipt of
three doses of DPT vaccine and two doses of OPV by age 12 month was considered adequate immunization.
Results show that 1/4th were inadequately immunized children. Less occult rated mothers were more likely to
have adequate immunized children. Poor prenatal care, lack of close family members, child birth position, and
more than one family relocation during child’s life time were associated with inadequate immunization.
Findings challenged the notation that children of recent immigrants bear a higher risk of under immunization.

A stratergy for 21st century focuses on certain emerging infectious diseases and people at risk historically.
Childhood vaccination rates have been higher in white population than racial and ethnic population. Vaccination
rates for preschool children in racial and ethnic groups with lower vaccination rates however have been
increasing at a more rapid rate, significantly narrowing the gap. Recommendations of the immunization
practices advisory committee (ACIP, 2005) addressed the issues such as-
a) The risk and benefits if Pertusis vaccine for children with family history of convulsions.
b) Antipyretic use in conjunction with DPT vaccine absorbed.

Jonas Edward Salk (1952) discovered first polio vaccine. Many physically handicapped people still live in
Kerala. In 1952 alone, 57628 polio cases were reported in America. He first experimented on his body and gave
to 1830000 school students in 1953 and vaccine was introduced to public in 1955. Six years later, in 1961,
another American, Albert Sabin, discovered the medicine drops that are popular now Number of researchers
said that immunization will be highly beneficial to implement this approach to mothers who have under five
children. Nurse working in community has an important role in immunization programme and to have the
mother to develop knowledge, attitude and for such mothers nurse can well plan an organize programme and
nurses have greater opportunity to assess knowledge and attitude of mothers and to prevent many communicable
diseases. Hence, the assessment of knowledge and attitude about immunization among the mothers has a
greater significance in the present world.

STATEMENT OF THE PROBLEM:

A study to assess the knowledge and attitude on immunization among the mothers of under five children,
at Halaga village, Belgaum, Karnataka.

OBJECTIVES:
1) To assess the knowledge on immunization among the mothers of under five children.
2) To assess the attitude towards the immunization among the mothers of under five children.
3) To correlate the knowledge and attitude on immunization.
4) To find out the association between knowledge and attitude on immunization with selected demographic
variables.

OPERATIONAL DEFINITIONS:
Knowledge on Immunization:
In this study, it refers to the awareness of mothers on meaning, types, storage, importance and complications of
immunization.

Attitude on Immunization:
In this study, it refers to the opinion or belief of mothers regarding immunization.

Immunization:
In this study, it refers to the act of creating immunity by artificial means or vaccines.

Mothers:
In this study, mothers refer to those who are having under five children.

ASSUMPTIONS:
1. Immunization is necessary to prevent much of diseases.
2. The mothers will have good knowledge on immunization.
3. The mothers will have positive attitude towards immunization.

DELIMITATIONS:
The study is limited to:
1. The mothers who have under five children.
2. The mothers of Halaga village, district Belgaum.
3. 50 mothers who have under five children

REVIEW OF LITERATURE:
The review of literature is an extensive systematic securitization of potential sources of previous study and
work. This process helps in identification and selection of problems, background of the study, formation of tool,
choosing methodology, formulating hypothesis. The review of literature is done from published articles,
textbooks, reports, Google, yahoo, medline, pub med search. Prema (2006) conducted a descriptive study on
utilization of immunization services among under five children at Raichur district Karnataka.150mothers (75 in
rural and75 in urban areas) have been selected and interview technique followed to
assess knowledgeand utilization of immunization services. The findings shows that the total knowledge score
was 50.In urban area 80% were having low awareness, 16% were having average awareness, 4% having no
awareness .In rural area 96%of mothers were having low awarenessand 4%mothers having average. And lack of
knowledge both in urban and rural area are related to mothers andtheir belief.

Szilagyi P et al (2001) assessed the effectiveness of recall systems in improving immunization

rates andcompared the effects of various types of reminder in different settings and children (birth to18year) or
adults (18andup) were selected data collection was done and each study was independently by to reviewers .
The results shows that the patient recall system was effected in improving immunization rates in 33of 41
included studies, irrespective of baseline immunization rates, patient age type of setting or type of vaccination
.The patient reminder recall system in primary care settings or effective in improving immunization rates.

Datta PK, VazL Singh H (2003) conducted a study on knowledge, attitude and beliefs about
measles andvaccination coverage in a rural area in Jammu region. The data was collected on the attitude, belief
and customs of mothers regarding occurrence of measles among children in rural area in Jammu region
.Simultaneously an effort was also made to evaluate the vaccination coverage of measles vaccine in the study
area 2 and half year after its introduction into the universal immunization programme (UIP). This study brings
out the scope of the health education in the eventual goal of eradicating measles in the country.

Salman DA, et al (2005) conducted a study to assess knowledge, attitude and beliefs of school nurses and
personnel and associations with non medical immunization exemption surveys were done and random sample of
thousands schools in Colorado, Massachusetts, Missour and Washington. Surveys were returned by 69.6% of
eligible participants. A child attending a school with a respondent who was a nurse was significantly less likely
to be have an exemption than a child attending a school with a respondent who was not a nurse (odds ratio
0.39;95%). The majority of respondents believed that children (95.6%) and the community (96.1%) benefit
when children are vaccinated.
Terrero C et al (1991) conducted a study to assess mother’s attitude and behaviors regarding vaccination and the
outpatient clinic of hospital in Santo Domingo. 200 mothers were prospectively interviewed. 57 % of children
were incompletely vaccinated and 7.5% were completely unvaccinated. 98.5% of mothers stated their belief that
vaccination protects children.125 of the mothers reported they had access to orientation about vaccination.

Anderson LM, Wood DL, Sherebouren CD (2005) conducted a study to assess maternal acculturation and
childhood immunization levels among children in Latino families in Los Angels. The household interviews were
conducted in east Los Angels and south central Los Angels with mothers (n=688) of one randomly selected
child aged 12 to 36 months. Results shows that ¼ of the children were inadequately immunized. Less
acculturated mothers were more likely to have adequately immunized children .The findings challenge the
notion that children of recent immigrants bear high risk of under immunization.

Singh MC, Badole CM, Singh MP(2003) conducted a study to assess the immunization coverage and
knowledge and practice of mothers regarding immunization in rural area. 130 mothers (15-44 yrs) and 142
children aged 12-59 months were selected by cluster sampling method from nine villages in Wardha district.
Out of these 100 mothers, 122 children could contact regarding immunization, 52.5% children were fully
and45.1% were partially immunized. Vaccine coverage of BCG and OPV/DPT was 95.9 % and 85%
respectively. Mothers had fair knowledge regarding need for immunization but a poor knowledge regarding
disease prevented and doses of vaccines.

Abbas Bhuiya, Ismat Bhuiya, Mustaque Choudhury (1989) conducted a survey to assess the factors affecting
acceptance of immunization among children in rural Bangladesh. Acceptance of DPT, Measles and BCG
vaccines were dependent variables. The independent variables includes proximity to health facilities, frequency
of visit by health worker, respondents mobility , media exposure , education , age , economic status , region of
residence and gender of child. Logistic analysis was performed to assess the net effects of the variables in
addition to univariate analysis. Among independent variables age, education, gender of child, economic
condition, and proximity of health facility showed statistically significant association with acceptance of
immunization. The effect of mother’s ability to visit health centre alone was also dependent on ownership of
radio, economic condition and education.

Angelillo, Ricciardi, Partisans, E Langiano, M Pavia (2000) conducted a descriptive study to assess knowledge,
attitude and behavior about vaccination among mothers of Italy. 841 samples have been selected and evaluated.
The result shows that overall 57.8% 0f mothers were aware about all vaccines and knowledge was significantly
greater in educated mothers and older mothers. Attitude were very favorable and education programmers
promoting child immunization.

Moultan LH, et al (2001) conducted a study on factors associated with refusal of child hood vaccines among
parents of school aged children. Surveys were mailed to the parents of 815 exempt children and 1630 fully
vaccinated children recruited from 112 private and public elementary schools. Surveys were completed by 2435
parents (56.1%). The results shows that most children [209(75.5%) of 277] with non medical exemptions
received at least some vaccines. The most common vaccine not received was Varicella [147 (53.1%) of
277exempt children].The most common reason stated for requesting exemptions [190 (69%) 0f 277] was
concerned that vaccines might cause harm.

Mount Sonai, Tong A, Biringer A and Upshur R (2006) conducted a cross sectional study of maternity care
providers and women’s knowledge, attitude and behaviors towards influenza vaccination. Two cross sectional
surveys, one maternity care providers and one of post partum woman were carried out. Results shows that there
is high level of knowledge about vaccination (95%) and positive attitude towards vaccination (95%).

Soeung SC, Grundy J, Morn C and Samnang C (2005) conducted a study for evaluation of immunization
knowledge, practices and service delivery in the private sector in Cambodia. A questionnaire survey was
conducted with 127 private facilities. Results shows that the prevalence of private sector provision of
immunization services, 93% of private inpatient clinics survey provided immunization services and have
adequate knowledge.

Chhabra P et al (2007) conducted a study to assess the immunization coverage of BCG, DPT, OPV, Measles,
MMR and Hepatitis B in two urbanized villages of East Delhi. Children of 24-47 months were selected using
systematic random sampling by house to house visit. The coverage levels were 82.7% for BCG, 81.5% for DPT
and OPV 1, 76.8% for DPT and OPV 2, 70.7% for DPT and OPV 3, 65.3% for Measles vaccines. It was 41.4%
and 41.6% for DPT booster and MMR vaccines.

RESEARCH METHODOLOGY:
This chapter includes research approach and design, setting, population, sample size, sampling techniques,
development and description of the tool, scoring procedure, data collection procedure and plan for data analysis.

RESEARCH APPROACH AND DESIGN:

Descriptive approach and non-experimental design was used in this study. The descriptive studies are aimed at
accurate portrayal of the characteristics of person, situation or group and the frequency with which certain
phenomenon occur. Here in this study the descriptive approach was used and aimed at investigating the
knowledge on selected immunization measures and attitude of mothers of under five children on immunization.

SETTING OF THE STUDY:

The study was conducted among the mothers of under five children at Halaga village, Belgaum, Karnataka.

VARIABLES:
Independent Variables:
Age, religion, family income, number of children, type of family, education, socioeconomic status, information
on immunization.

Dependent Variables:
knowledge and attitude of mothers of under five children.

POPULATION:
The target population of the study was mothers of under five children in Halaga village, Belgaum district,
Karnataka.

SAMPLE SIZE:
The total enumerated sample consists of 50 mothers of under five children at Halaga village, Belgaum.

SAMPLING TECHNIQUE:
Sampling is the process of selecting a portion of population to represent the entire population. In this study
convenient and purposive sampling technique was used.

DEVELOPMENT AND DESCRIPTION OF TOOL:

The tool for data collection was developed by the researcher on his own. This self reporting questionnaire
consists of three parts. They are:
 Demographic data
 Structured knowledge assessment questionnaire on immunization.
 Structured attitude scale on immunization.

DESCRIPTION:
Part A:
Comprised of demographic data consisting of 10 items.

Part B:
Questionnaire to assess knowledge on immunization, which comprised of 15 questions with multiple
choices. The total score of questions was 15. The correct response was given score one.

Part C:
Structured attitude scale on immunization. It measured the opinion or belief of the mothers of under five
children about immunization, which comprised of 10 statements. The total score of tool was 20. It was a five
point scale which consisted of both positive and negative statements. Every correct response was awarded 2 and
1. The scoring was done in following ways:

Type of Statement Strongly Agree Uncertain Disagree Strongly

Agree Disagree
Positive Statement 2 1 0 0 0
Negative Statement 0 0 0 1 2
DATA COLLECTION PROCEDURE:
The data was collected by distributing the self reported questionnaire developed by researcher after getting due
permission from the medical officer, rural PHC, Yellur. The mothers of under five children were included in the
sample. After a brief introduction on research and immunization, they were allowed 25 minutes to complete the
questionnaire including demographic variables.

PLAN FOR DATA ANALYSIS:

Both descriptive and inferential statistics were used to analyse the data collected.
I. Descriptive Statistics:
1. Frequency and percentage distribution were used to analyze the demographic data of mothers of under five
children.
2. Mean and standard deviation to identify the knowledge and attitude on immunization of mothers of under five
children.
3. Distribution of scores of knowledge on immunization to be interpreted by summarizing the scores into 3
categories – Inadequate, Moderately adequate and Adequate and Attitude scores into 3 categories –
Low positive Attitude, Positive Attitude and High positive Attitude.

II. Inferential Statistics:

1. Intra co-relation method to find the correlation between knowledge and attitude.
2. Chi-square test used for association of knowledge and attitude with demographic variables.

DATA ANALYSIS AND INTERPRETATION

This chapter deals with the analysis and interpretation of data collected from 50 mothers of under five children
from Halaga village, at Belgaum, Karnataka. The data has been tabulated and analyzed according to the
objectives

PRESENTATION OF DATA:
SECTION I:
Demographic variables of mothers of under five children.

Table 1: Frequency and Percentage distribution demographic variables of mothers of under five children
on immunization. n=50
Table 1 describes the demographic data of the samples regarding their age 72% belongs to 21-25 years and 64%
were Hindus.
56% of samples family income was below 2000, 42% of mothers had 2 children, 76% lives in joint family and
92% were illiterate.
98% of samples possessed immunization card, 50% were middle class and 92% samples earlier heard about
immunization.

Section II: Assessment of knowledge on immunization among mothers of under five children.

Table 2: Distribution of knowledge on immunization among mothers of under five children. n= 50

Knowledge Number Percentage
Inadequate (1-49) 12 24
Moderately Adequate (50-74) 29 58
Adequate (>75) 9 18

Table 2 describes that 58% of mothers had moderately adequate knowledge on immunization, 24% had
inadequate knowledge and 18% had adequate knowledge (Fig.11).

Table 3: Mean and standard deviation of knowledge on immunization among mothers of under five children. n = 50
Statistics Knowledge Score
Mean 58.1
Standard deviation 12.10

The above table explains that the mothers have a mean knowledge on immunization of 58.1 with a standard
deviation of 12.10. (Fig.12)

Table 4: Distribution of Attitude on immunization among mothers of under five children. n = 50

Attitude Number Percentage
Low Positive Attitude (1-49) Positive 25 50
 Attitude (50-74) 25 50
High Positive Attitude (>75) - -
Table 4 explains that 50% of mothers, have low attitude on immunization and 50% have moderate attitude and
nobody has more attitude.

Table 5: Mean and Standard Deviation of Attitude on immunization among mothers of under five children. n = 50
Statistics Attitude Score
Mean 41.4
Standard Deviation 16.1

Table 5 shows that the mothers have mean attitude of 41.4 on immunization with the standard deviation of 16.1.

Section III: Correlation between knowledge and attitude on immunization. r=0.483

The above ‘r’ value shows that there is a positive correlation between knowledge and attitude of mothers on
immunization.

Section IV: Association of demographic variables with knowledge and attitude on immunization.
Table 6: Association between knowledge and demographic variables among mothers of under five
children. n=50

Table 6 denotes that there is no significant association between knowledge on immunization and demographic
variables such as religion, family income, type of family, education, and socioeconomic status. There is
association between knowledge on immunization and age, number of children, immunization card and
information on immunization.

Table 7: Association between Attitude and demographic variables. n=50

Immunization and demographic variables such as age, religion, family income, number of children, education,
immunization card and information on immunization. There is significant association between attitude on
immunization and demographic variables such as type of family and socioeconomic status.

DISCUSSION:
Characteristics of selected demographic variables of the samples.72% were in the age group of 21-25
years,64% were belongs to Hindu religion,56% of family’s income below 2000,42% of mothers were having
two children,76% mothers stayed in joint family,92% of mothers were educated,98% of mothers were
possessing immunization card,50% came from middle class,92% of mothers were earlier heard about
immunization,

Assessment of Knowledge on Immunization among Mothers of Under five Children.

The mean value of knowledge on immunization of mothers of under five children was 58.1 which falls in the
level of moderately adequate knowledge .This findings contradicts with the findings of the study conducted
by Angelillo, Ricciardi (2000) on assessment of knowledge, attitude and behavior of vaccination among mothers
from Italy which stated that the mothers had adequate knowledge and favorable
attitude. Sangamesh Nidagunni (2006) conducted a study to assess the knowledge and practice of mothers of
under five children regarding universal immunization programme. The results showed that overall mean
knowledge score among respondents was found to be 52.72 % which coincides with the findings of the present
study. Based on the present study findings revealed that 58% of the mothers of under five children had
moderately adequate knowledge on immunization.

Assessment of Attitude on Immunization among Mothers of Under five children.

The mean value of attitude of mothers of under five children on immunization was 41.4 with standard deviation
of 16.1%. This findings show that the mothers have low positive attitude towards immunization. It also depicts
that mothers are possessing false belief regarding immunization. But if proper education is provided to the
mothers then they will be capable of preventing communicable diseases among their children.

Correlation between Knowledge and Attitude of Mothers of Under five Children on Immunization.
The finding showed that there is a positive correlation between knowledge on immunization and attitude of
mothers of under five children (r =0.483). This suggests that the mothers will develop positive attitude towards
immunization though they posses moderately adequate knowledge.

Association of Demographic Variables with Knowledge on Immunization among Mothers of Under five
children.
The findings depicts that there is no association between knowledge on immunization and demographic
variables such as religion, family income, type of family, education and socio economic status. There is an
association between knowledge on immunization and age, number of children, immunization card and
information on immunization.

Association between Attitude on Immunization and Demographic Variables.

It denotes that there is no association between attitude on immunization and demographic variables such as age,
religion, family income, number of children, education, immunization card and information on
immunization. There is significant association between attitude and demographic variables like type of family
and socio economic status.

SUMMARY:
As said “Prevention is better than cure”, immunization is one of the world wide methods for preventing many
of the infectious diseases. It is essential to prevent many of the childhood diseases .So the knowledge on
immunization among the mothers of under five children have greater significance. The present study is aimed at
assessing the knowledge and attitude on immunization among mothers of under five children in rural
community area Belgaum. The research approach used in this study was descriptive approach and research
design was non experimental design .The setting of the study was rural community area of Halaga village
Belgaum. The sample technique used was non – probability, convenience sampling. The tool used for the study
was self reporting questionnaire on knowledge and attitude. The study was conducted after getting permission
from the medical officer Yellur PHC, Belgaum .The data collected were analyzed by using descriptive and
inferential statistics. There is a positive correlation between the knowledge and attitude on mothers of under five
children in rural community area.

CONCLUSION:
The mothers of under five children of rural community area had moderately adequate knowledge on
immunization and moderate positive attitude towards immunization. These findings reveal that the community
health nurses should make little more efforts in educating the mothers so as to achieve 100% of immunization.

IMPLICATIONS:
The investigator has drawn the following implications from the studies which are vital concerns to the field of
nursing services, nursing education, nursing administration, and nursing research.

Nursing Services:
The nurse should give adequate health education in the community as well as hospital set up on immunization,
immunization schedule, advantages, contraindications etc and prevention of communicable diseases .So that the
people will be able to take all scheduled vaccines. The main purpose should be on prevention of communicable
diseases by educating the mothers about immunization.

Nursing Education:
The nurses and midwives are closer with the mothers and children in the hospital as well as in the community
during their practices .So it is essential to include a topic on immunization in nursing curriculum. So that the
emerging nurses can more emphasis on immunization and there by reduces many of the communicable diseases.

Nursing Administration:
The nursing administrators should focus on health promotion and prevention of diseases through home visit,
mass health education programmes etc. The health workers in the hospital as well as community should be
trained regarding immunization for the prevention of major communicable diseases and its prevalence.

Nursing Research:
Nursing research should focus on immunization and prevention of communicable diseases and effectiveness of
education and training of the health workers and mothers in various aspects of immunization, to improve the
health of children.

RECOMMENDATIONS:
The following studies can be under taken to strengthen the nursing research.
 The same study can be conducted in different regions of the state or nation so as to compare the results.
 The same study can be repeated on larger sample so as to generalize the results.
 The short term training program its effectiveness can be analyzed through a pre and post test method.
 Similar kind of study can be conducted among different population.
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