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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