Download 3. Structured teaching programme will enhance the knowledge and

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Mr. DEEPAK.K
I YEAR M.Sc NURSING
PSYCHIATRIC NURSING
YEAR 2009-2010
PADMASHREE INSTITUTE OF NURSING
BANGALORE-560 060
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT
1.
NAME OF THE
CANDIDATE AND
ADDRESS
Mr.DEEPAK.K
I Year M.Sc Nursing,
Padmashree Institute of Nursing,
Bangalore-560 060.
2.
3.
4.
5.
NAME OF THE
INSTITUTION
Padmashree Institute of Nursing,
COUSE OF THE STUDY
AND SUBJECT
I year M.Sc Nursing,
Bangalore.
Psychiatric Nursing
DATE OF ADMISSION TO
THE COURSE
TITLE OF THE STUDY
19 / 06 /09
Assessment of effectiveness of
structured teaching programme on
knowledge and attitude regarding
prevention of anorexia nervosa among
the adolescent girls in selected high
schools.
1
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
Anorexia nervosa is an eating disorder characterized by extremely low body
weight and body image distortion with an obsessive fear of gaining weight. It is common
among adolescent girls.1
The causes of anorexia nervosa are not known. It may be due to genetics, family
and learned behaviour, culture and the media and restrictive eating. Severe trauma or
emotional stress during puberty or pre puberty, abnormalities in brain chemistry, a
tendency toward perfectionism fear of being ridiculed or humiliated and family history
of anorexia Approximately 95% of those affected by anorexia are female, but males can
develop the disorder as well. While anorexia typically begins to manifest itself during
early adolescence, it is also seen in young children and adults.2
The risk factors of anorexia nervosa are age and gender, anorexia is most common
in teens and young adult women. dieting, weight gain, unintentional weight loss, Puberty,
living in an industrialized country, having depression, obsessive-compulsive disorder
(OCD) or other anxiety, participation in sports and professions that prize a lean body,
difficulty dealing with stress, history of sexual abuse or other traumatic event .3
The subtypes of anorexia nervosa are Restricting Type: during the current episode
of anorexia nervosa, the person has not regularly engaged in binge-eating or purging
behaviour (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or
enemas). Weight loss is accomplished primarily through dieting, fasting, or excessive
exercise.
2
Binge-Eating Type or Purging Type: during the current episode of anorexia
nervosa, the person has regularly engaged in binge-eating or purging behaviour (that is,
self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). 4
The diagnosis of anorexia nervosa is lab tests may include: Blood tests,
electrocardiogram and bone density test. SCOFF questionnaire, developed in Great
Britain, is sometimes used when anorexia is suspected. A "yes" response to at least two
of the following questions is a strong indicator of an eating disorder:
S: "Do you feel sick because you feel full?"
C: "Do you lose control over how much you eat?"
O:"Have you lost more than 13 pounds recently?"
F: "Do you believe that you are fat when others say that you are thin?"
F: "Does food and thoughts of food dominate your life?"5
The signs and symptoms of anorexia nervosa are, the primary sign of anorexia
nervosa is severe weight loss. The physical signs include excessive weight loss, scanty or
absent menstrual periods, thinning hair, dry skin, cold or swollen hands and feet and
others.5
The psychological and behavioural signs include distorted perception of self,
being preoccupied with food, refusing to eat, inability to remember things, refusing to
acknowledge the seriousness of the illness, and depression.6
The treatment of anorexia nervosa includes a combination of treatments can give
the person the medical, psychological, support they need. Cognitive-behavioural therapy,
along with antidepressants, can be an effective treatment for eating disorders.
Complementary and alternative therapies may help with nutritional deficiencies. Other
treatment include lifestyle, nutrition and dietary Supplements, use of herbs, homeopathy,
therapies include family therapy and hypnosis.7
3
6.2 NEED OF THE STUDY
The Diagnostic statistical Manual (DSM IV) of Mental Disorders suggests that
those in late adolescence and early adulthood meet the full criteria for anorexia nervosa at
a rate of 0.5% to 1.0%8.
A study reported that prevalence rates of anorexia in western countries are higher
than they are in other parts of the world. Rates in women in western countries ranged
from 0.1% to 5.7%. In non-western countries, the range was 0.46% to 3.2%. But the
prevalence in non-western countries seems to be on the rise.9
The average age of onset of anorexia nervosa is 17 years. Those over 40 years of
age rarely develop anorexia (American Psychiatric Association, 1994). It is reported that
40% of newly identified cases of anorexia are in girls 15-19 years old. (National Eating
Disorders Association, 2006) But over the past forty years, incidence in young women
has tripled, while incidence in teenagers has remained unchanged (University of
Maryland Medical Centre, 2004). Gender Differences of those with anorexia are girls and
women--approximately 90-95%.10
The National Eating Disorders Association indicates that an estimated 5-20% of
those who have anorexia nervosa will not survive complications associated with it. This
means that anorexia has one of the highest mortality rates of all mental disorders for
those who receive treatment; the mortality rate is far lower, at 2-3%.11
The adolescent girls are dangerously thin and anorexic person may still perceive
themselves to be overweight because they have a distorted view of their body image.
They are likely to be in denial of the fact they are underweight.
4
A comparative study was conducted to show that the overall incidence rates of
anorexia nervosa remain stable during the 1990s compared with the 1980s. The study
concluded that the incidence of anorexia nervosa is around 8/1 lacks persons per year. An
upward trend has been observed in the incidence of anorexia nervosa in the past century
till the 1970s. The most substantial increase was among females aged 15-24 years, for
whom a significant increase was observed from 1933 to 1999.12
A study was done on increased mortality in bulimia nervosa and other eating
disorders. In this study they determined whether anorexia nervosa, bulimia nervosa, and
eating disorder not otherwise specified are associated with increased all-cause mortality
or suicide mortality. Using computerized record linkage to the National Death Index, a
longitudinal assessment of mortality over 8 to 25 years in 1,885 individuals with
anorexia nervosa (N=177), bulimia nervosa (N=906), or eating disorder not otherwise
specified (N=802) who presented for treatment. The study concluded that Crude
mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for
eating disorder not otherwise specified and there is an increased risk of suicide across
eating disorder diagnoses.13
A Retrospective study was conducted on to evaluate long term mortality rate of
anorexia nervosa patients in a southern Italy population compared to most recent
literature. The study involved 147 female anorexia patients, consecutively admitted
from 1994 to 1997 to the Outpatient Unit, were re-examined between June and
November 2003. Our data are compared with 10 other studies published since 1988. The
study concluded using integrated clinical nutritional and psychiatric approach it
suggested that anorexia nervosa demographic characteristics, that is young female
subjects in Westernized societies; mortality rate is confirmed to be dramatically high.14
5
An average prevalence rate of anorexia nervosa of 0.3% was found for adolescent
girls, the estimated prevalence of binge eating disorder is at least 1%. The incidence of
anorexia nervosa is 8 cases per 1 lack population per year and the incidence of anorexia
nervosa increased over the past century, until the 1970’s.15
The most effective way to prevent anorexia is to develop healthy eating habits and
a strong body image from an early age. Don't accept cultural values that place a premium
on thin, perfect bodies. Make sure you and your children are educated about the lifethreatening nature of anorexia.16
Now a day’s more adolescent girls i.e. age group between 13-21 years more
concerned towards the physical maintenance of the body.
Due to the inadequate
knowledge they are following wrong techniques such as over dieting, misuse of laxatives
and over exercising that may results in other somatoform disorders like malnutrition,
anaemia.17
The mental health professionals are crucial in prevention and early diagnosis and
treatment of anorexia nervosa. Anorexic eating behaviour is thought to originate from
feelings of fatness and unattractiveness and is maintained by various cognitive biases that
alter how the affected individual evaluates and thinks about their body, food and eating.18
The investigator from his personal experience had seen more adolescent girls i.e.
age group between 13-21 years are more concerned towards the physical maintenance of
the body. Due to the inadequate knowledge they are following wrong techniques such as
over dieting, misuse of laxatives and over exercising that may results in other
somatoform disorders like malnutrition, anaemia and anorexia nervosa disorders. So, the
investigator felt that it is important to create awareness and provide adequate knowledge
regarding anorexia nervosa in adolescent girls. It will prevent complication of eating
disorders and improve their physical and psychological health.
6
6.3 STATEMENT OF THE PROBLEM
A study to assess the effectiveness of structured teaching programme on
knowledge and attitude regarding prevention of Anorexia Nervosa among adolescent
girls in selected high schools, Bangalore.
6.4 OBJECTIVES OF THE STUDY
1. To assess the existing knowledge and attitude regarding prevention of anorexia
nervosa among adolescent girls.
2. To assess the post test knowledge and attitude regarding prevention of anorexia
nervosa among adolescent girls.
3. To assess the effectiveness of structured teaching programme on knowledge and
attitude regarding prevention of anorexia nervosa among adolescent girls.
4. To correlate between pretest knowledge and attitude and posttest knowledge and
attitude regarding prevention of anorexia nervosa among adolescent girls.
5. To associate pre test knowledge and attitude regarding prevention of anorexia nervosa
among adolescent girls with their selected demographic variables.
6.5 OPERATIONAL DEFINITION
1. Effectiveness:
It refers to increase in level of knowledge and attitude regarding
prevention of
anorexia nervosa among adolescent girls after receiving structured teaching programme.
2. Structured teaching programme:
It refers to systematically developed instructional aids designed for
adolescent girls regarding prevention of anorexia nervosa among adolescent girls.
7
3. Knowledge:
It refers to level of understanding and awareness regarding prevention of
anorexia nervosa among adolescent girls.
4. Attitude:
It refers to the way of thinking or outlook towards the prevention of anorexia
nervosa among adolescent girls.
5. Prevention:
It refers to process of acting early to avoid the occurrence of anorexia nervosa by
taking suitable dietary measures.
6. Anorexia nervosa:
It is an eating disorder characterized by extremely low body weight and body
image distortion with an obsessive fear of gaining weight. It is common among
adolescent girls.
5. Adolescent girls
The adolescent girls aged between 13-19 years.
6.6 ASSUMPTIONS
1. Adolescent girls may have inadequate knowledge and attitude regarding anorexia
nervosa.
2. Adolescent girls may have increased risk for developing anorexia nervosa.
3. Structured teaching programme will enhance the knowledge and attitude regarding
prevention of anorexia nervosa among adolescent girls.
4. Adolescent girl’s knowledge and attitude regarding prevention of anorexia nervosa
may vary with their selected demographic variables
8
6.7 RESEARCH HYPOTHESIS
H1- There is a significant difference between the mean pre-test and post test knowledge
and attitude regarding prevention of anorexia nervosa among adolescent girls.
H2- There is significant correlation between pre test knowledge and attitude and post-test
knowledge and attitude regarding prevention of anorexia nervosa among adolescent girls
with their selected demographic variables.
H3- There is a significant association between pre test knowledge and attitude regarding
prevention of anorexia nervosa among adolescent girls with their selected demographic
variables.
6.8 REVIEW OF LITERATURE
Review of literature is defined as broad, comprehensive in depth systematic and
critical review of scholarly publication, unpublished scholarly print materials, audiovisual
materials and personal communications. Review of literature is a key step in research
process. Review of literature refers to an extensive, exhaustive and systemic examination
of publication relevant to research project. One of the most satisfying aspects of the
literature review is the contribution it makes to the new knowledge, insight, and general
scholarship of the researchers.19
A study was conducted to explore shame and shame –based responses in eating
disorder. This study involved 52 women with eating disorder were interviewed. The
study concluded that people with eating disorder experiences generalized shame in
relation to many aspects of their self and behaviour.20
9
A study was conducted on understanding the relation between anorexia nervosa
and bulimia Nervosa in a Swedish National twin Sample. In this study they determine
the extent to which shared genetic and environmental factors contribute to liability to
these disorders. They focused on females from the Swedish Twin study of Adults:
Genes and Environment (n = 7000), calculated heritability estimates for narrow and
broad anorexia nervosa and bulimia nervosa and estimated their genetic correlation. The
study concluded that genetic correlation for broad anorexia nervosa and bulimia nervosa
was 79 and the unique environmental correlation was 44.21
A study was conducted on the relationship between parental bonding, social
problem solving and eating pathology in an anorexic inpatient sample. The study
included forty three female in patients with anorexia nervosa and 76 student controls
were assessed using the Parental Bonding Instrument, the Social Problem Solving
Inventory and the Eating Disorders Examination or the Eating Disorders ExaminationQuestionnaire. The study concluded that the anorexic group reported significantly lower
levels of parental care than the student control group and used more negative and
avoidance style coping. In the anorexic group, disordered eating was significantly
correlated with low maternal care and high control. Maternal bonding was found to
mediate the relationship between avoidance style coping and eating pathology.22
A study was conducted on childhood anxiety associated with low BMI in women
with Anorexia Nervosa. The study included 326 women from the Genetics of Anorexia
Nervosa (GAN) Study who completed the Structured Interview for Anorexia Nervosa
and Bulimic Syndromes and whose mother completed the Child Behavioural Checklist
and/or Revised Dimensions of Temperament Survey. The study concluded that relation
between early childhood anxiety, caloric restriction, qualitative food item restriction,
excessive exercise, and low BMI and relation between childhood anxiety and caloric
restriction, which mediated the relation between childhood anxiety and low BMI in the
GAN sample only.23
10
A study was conducted on early response to family-based treatment for
adolescent anorexia nervosa. The study Sixty five adolescents with anorexia nervosa
from two sites Chicago and Columbia received a course of manualized family-based
treatment (FBT). Response to treatment was assessed using percent ideal body weight
with remission defined as having achieved >95% IBW at end of treatment (Session 20).
The study concluded that receiver operating characteristic analyses showed that a gain
of at least 2.88% in ideal body weight by Session 4 best predicted remission at end of
treatment.24
A study was conducted on Salient components of a comprehensive service for
eating disorders. The interventions for eating disorders include medical management,
nutritional rehabilitation, and individual psychotherapy with cognitive behavioural
techniques, family therapy, group therapy and pharmacological treatment. The study
concluded that multidisciplinary team approach provides the most effective treatment.25
A Retrospective comparisons study was conducted on Childhood risk factors in
Korean women with anorexia nervosa. The study included two sets of case-control
comparisons were conducted, in which 52 women with lifetime anorexia nervosa from
Seoul, S. Korea, were compared with 108 Korean healthy controls and also with 42
women with lifetime anorexia nervosa from the UK in terms of their childhood risk
factors. A questionnaire designed to conduct a retrospective assessment of the childhood
risk factors was administered to all participants. The study concluded that the Korean
anorexia nervosa women were more likely to report premorbid anxiety, perfectionism,
and emotional under eating and were less likely to report having supportive figures in
their childhood than the Korean healthy controls.26
11
A study was conducted on treatment of anorexia nervosa in young patients in a
special care unit. The study included intervention like medical care, nutritional care,
and psychological care. The study concluded that it requires multidisciplinary outpatient
medical follow-up, including the intervention of a general practitioner and a psychiatric
team.27
A study was conducted on assessment of the impact of eating disorders on quality
of life using the disease-specific, health-related quality of life for eating disorders
questionnaire. The study included
358 patients with eating disorder completed the
health related quality of life for eating disorders questionnaire and the eating attitudes
test, 273 patients completed the same instruments after 1 year of multidisciplinary
treatment. The study concluded that Patients with anorexia nervosa had higher baseline
scores (indicating worse perception of quality of life) on the health-related quality of life
for eating disorders questionnaire and experienced smaller improvements than patients
with other diagnoses after 1 year of treatment. Quality of life in patients with eating
disorder improved after 1 year of treatment.28
A qualitative study was conducted on Comparing views of patients, parents, and
clinicians on emotions in anorexia. In this study patients with anorexia nervosa may
experience difficulties in emotional processing that can adversely affect treatment and
maintenance of the illness. Questionnaires were undertaken with patients with anorexia
nervosa, parents and clinicians, with the aim to explore the most salient issues pertaining
to emotions and social cognition in anorexia nervosa. The study concluded that seven
primary themes were identified showing congruence across groups: emotional awareness
and understanding, emotional intolerance, emotional avoidance, emotional expression
and negative beliefs, extreme emotional responses, social interactions and relationships,
and lack of empathy.29
12
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA
Data will be collected from adolescent girls studying in selected high schools, at
Bangalore.
7.2 METHODS OF DATA COLLECTION
I. Research Design
Quasi Experimental - one group pre-test post test design.
ii. Variables
Dependent variableLevel of knowledge and attitude regarding prevention of anorexia nervosa among
adolescent girls
Independent variableStructured teaching programme regarding prevention of anorexia nervosa among
adolescent girls
iii. Setting
The study will be conducted in selected high schools at Bangalore.
iv. Population
All the adolescent girls in selected high schools, Bangalore.
13
v. Sample
Adolescent girls who fulfil the inclusive criteria will be considered as the samples.
The sample size will be 60.
vi. Criteria for sample selection
Inclusion Criteria: The study includes
1. The adolescent girls who have been studying in the school age between 13-19
years
2. The adolescent girls who are available at the time of data collection
Exclusion Criteria: The study excludes
1. The adolescent girls who are not willing to participate in the study.
vii. Sampling technique
Non- probability convenience Sampling technique
viii. Tool for data collection
Tool consists of two sections:
Section A: Demographic Profile of adolescent girls consisting of age, religion,
education, monthly income of family, dietary pattern, residence and previous
source of information.
Section B: Structured questionnaire will be used to assess the knowledge
regarding prevention of anorexia nervosa among adolescent girls.
Section C: Likert scale will be used to assess the attitude regarding prevention of
anorexia nervosa among adolescent girls.
14
ix. Method of data collection
After getting formal administrative approval from concerned authorities and
informed consent from the samples the investigator personally collects the demographic
data. After which data will be collected in following three phases:
Phase I: Pre-test will be conducted to assess existing knowledge and attitude regarding
prevention of anorexia nervosa among adolescent girls with the help of structured
questionnaire.
Phase II: On the same day structured teaching programme will be given regarding
prevention of anorexia nervosa among adolescent girls by instructional aid for 45mt -1 hr
duration.
Phase III: After a period of one week post test level of knowledge and attitude regarding
prevention of anorexia nervosa among adolescent girls will be assessed using same
questionnaire.
Duration of data collection period is four to six weeks.
x. Plan for data analysis
The data collected will be analyzed by means of descriptive statistics and
inferential statistics.
Descriptive statistics:
Frequency, Percentage distribution, Mean and Standard deviation will be
used to analyze the level of knowledge and attitude regarding prevention of
anorexia nervosa among adolescent girls. Correlation co-efficient will be used to
assess correlation between knowledge and attitude regarding prevention of
anorexia nervosa among adolescent girls.30
15
Inferential statistics:
Paired ‘t’ test will be used to compare the pre test and post test knowledge
and attitude regarding prevention of anorexia nervosa among adolescent girls.
Chi-square test will be used to analyze the association of pre test knowledge
and attitude regarding prevention of anorexia nervosa among adolescent girls
with their selected demographic variables.31
xi. Projected outcome
There will be significant increase in the level of knowledge and attitude regarding
prevention of anorexia nervosa among adolescent girls after administering
structural teaching programme. This will help in improving their health status and
preventing anorexia nervosa disorder.
7.1 Does the study require any investigation or interventions to be conducted on
patients or other human or animals?
Yes, structured teaching programme will be administered regarding prevention of
anorexia nervosa among adolescent girls in selected high schools at Bangalore.
7.2 Has ethical clearance been obtained from your institution?
Yes, permission will be obtained from concerned authority of the high schools
and informed consent will be obtained from samples. Confidentiality and privacy of
data will be maintained.
16
8. LIST OF REFERENCES
1. Anorexia Nervosa available from: URL:
http://www.nimh.nih.gov/health/publications/eating-disorders/anorexianervosa.shtm
2. Lask B, et al, Anorexia Nervosa and Related Eating Disorders in Childhood and
Adolescence. Psychology Press. 2002: 804-46.
3. Anorexia Nervosa available from: URL:/.
http://www.umm.edu/altmed/articles/anorexia-nervosa-000012.htm
4. Diagnostic and Statistical Manual of Mental Disorders World Health
Organization's International Statistical Classification of Diseases and Related
Health Problems Anorexia Nervosa statistics available from: URL: E:/
http://www.eatingdisordershelpguide.com/anorexia.html
5. Anorexia nervosa available from URL: E:/ http://www. Wikepedia signs and
symptoms /health/publications/eating-disorders/anorexia-nervosa.shtm
6. Palazidou E, et al, Neuroradiological and neuropsychological assessment in
anorexia nervosa. Psychology Medicine.1990/ 20 ;(3): 521-27.
7. Le Grange. The Maudsley family-based treatment for adolescent anorexia
nervosa. World Psychiatry. 2005 /10; 4(3): 142–46
8. Mary C Townsend. Psychiatric mental health nursing: Philadelphia: F A Davis
publication; 2003.Pp435-442
17
9. University of Maryland Medical Centre, "Who Develops Eating Disorders?"
2/12/06. Available from: URL:
<http://www.umm.edu/patiented/articles/who_develops_eating_disorders_2.htm
10. Matthew Tiemeyer. Diagnostic and Statistical Manual of Mental Disorders,
American Psychiatric Association (APA), 2007/ 7; (4): 135-37.
11. Eating disorders and their precursors. National Eating Disorders Association
2/12/2006; Available from: URL: <http://www.edap.org.
12. Hoek, Hans Wijbrand. Incidence, prevalence and mortality of anorexia nervosa
and other eating disorders. Journal of eating disorders. 2004/10; 114 (4): 1106-13.
13. Crow SJ et al. American Journal of Psychiatry. Increased Mortality in Bulimia
Nervosa and Other Eating Disorders. 2009/10(15).
14. A Signorin et al. Long-term mortality in anorexia nervosa: a report after an 8-year
follow-up and a review of the most recent literature. European Journal of Clinical
Nutrition. 2007/ 8; 61, 119–22.
15. Matthew Tiemeyer. Anorexia statistics. 2007/1; Available from: URL:
E:/
<http://www. about.com/health/review.htm
16. Anorexia nervosa Available from: URL:
http://www.umm.edu/altmed/articles/anorexia-nervosa-000012.htm
17. Bimla Kapoor. Textbook of Psychiatric nursing: New Delhi: Kumar publishing
house; 2004.Pp187
18
18. Dr (Mrs).K.Lalitha. Mental Health and Psychiatric Nursing, An Indian
Perspective: Bangalore.2008: \Pp 480-518.
19. B.T. Basavanthappa. Textbook of Nursing Research. Review of Literature, Jaypee
Brothers:New Delhi;2007.92
20. Korina Ioannou et al. Perception of threat from emotions and its role in poor
emotional expression within eating pathology. Journal of clinical psychology.
2009. Available from: URL: [email protected]
21. Bulik CM et al. Understanding the Relation between Anorexia Nervosa and
Bulimia Nervosa in a Swedish National Twin Sample. Biology Psychiatry.
2009/11; 13
22. Swanson H et al. The relationship between parental bonding, social problem
solving and eating pathology in an anorexic inpatient sample. : Eating Disorder
Review. 2009/10;13.
23. Dellava JE et al. Childhood anxiety associated with low BMI in women with
Anorexia Nervosa. Behaviour Research Therapy. 2009/9; 25
24. Doyle PM et al. Early response to family-based treatment for adolescent anorexia
nervosa. Int J Eat Disord. 2009 /10; 8.
25. Halmi KA. Salient components of a comprehensive service for eating disorders.
World Psychiatry. 2009/10;8(3):150-55.
19
26. Kim Y.R. et al. Childhood risk factors in Korean women with anorexia nervosa:
Two sets of case-control studies with retrospective comparisons . International
Journal of Eating Disorder. 2009/10;5.
27. Yon L et al. Treatment of anorexia nervosa in young patients in a special care
unit at Robert-Debré Hospital (Paris): Guidelines and practical methods. Arch
Pediatr. 2009 /9; 30
.
28. Muñoz P et al. Assessment of the impact of eating disorders on quality of life
using the disease-specific, Health-Related Quality of Life for Eating Disorders
(HeRQoLED) questionnaire. Quality Life Research. 2009/9; 29.
29. Kyriacou O et al.
Comparing views of patients, parents, and clinicians on
emotions in anorexia: a qualitative study. Journal of Health Psychology. 2009
/10;14(7):843-54.
30. Denise F.Polit and. Cheryl Tatano Beck. Nursing Research: Data Analysis and
Interpretation. William and Willkims publication: New Delhi; 2008.506-642.
31. Barbara Hazard Munro. Statistical Method for Health Research. Inferential
statistics: Philadelphia: Lippincott, 1997. 73.
20
9. Signature of the Candidate
10. Remarks of the guide
:
:
11.1 Name and Designation of the Guide:
11.2 Signature
:
11.3 Co-guide
:
11.4 Signature
:
11.5 Head of the Department
:
11.6 Signature
:
12.1 Remarks of the Principal
:
12.2 Signature
:
21