RAJIV GANDHI UNVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

VARUN PRASAD.S

1.

NAME OF THE CANDIDATE AND ADDRESS

1ST YEAR M.SC NURSING, INDIAN COLLEGE OF NURSING, TILAK NAGAR, BYPASS ROAD, CANTONMENT, BELLARY 583104

2. NAME OF THE INSTITUTION

INDIAN COLLEGE OF NURSING, TILAKNAGAR, BYPASS ROAD, CANTONMENT, BELLARY 583104

3. 4.

COURSE OF STUDY AND SUBJECT DATE OF ADMISSION TO COURSE

: :

DEGREE OF MASTER OF NURSING , PSYCHIATRIC NURSING 18-6-2011 A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING ANOREXIA NERVOSA AMONG ADOLESCENT GIRLS STUDYING IN INDIAN PRE-UNIVERSITY SCIENCE COLLEGE FOR WOMEN AT BELLARY, KARNATAKA.

5.

TITLE OF THE TOPIC

BRIEF RESUME OF THE INTENDED WORK

6. INTRODUCTION:
Eating is always a decision; nobody forces your hand to pick up food and put it into your mouth. Albert Einstein

The food what we eat is the main source of energy that help for the physical, mental and social development of an individual. There are people who knowingly abstain food for known and unknown reasons. There are related concerned about their how they look and can feel self conscious about their bodies. This can be especially true when they are going through puberty and undergo dramatic physical changes and face new social pressure. This will leads to a rare phenomenon of psychological disorder called Anorexia Nervosa.

The term anorexia nervosa was established in 1873 by Sir William Gull, one of the Queen Victoria Personal physicians. The term is of Greek Origin An prefix denoting negation and orexis prefix denoting appetite. This means a lack of desire to eat.1 People with anorexia have an extreme fear of weight gain and a distorted view of their body size and shape. As a result, they strive to maintain a very low body weight. Some restrict their food intake by dieting, fasting or excessive. They hardly eat at all and often try to eat as few calories as possible, frequently obsessing over food intake.

The small amount of food they do eat becomes an obsession. Anorexia nervosa or food phobia are also becoming increasingly common in adolescence.2

Anorexia Nervosa is a psychiatric disorder characterized by the refusal of an individual to maintain a minimum normal body weight often to the point of starvation. In both the DSM-IV and ICD-10 unification system World Health Organization has been viewed as a culturally bound disorder rare as absent except in western cultures where there is a pervasive pressure to diet to obtain a socially desirable weight and or shape British Medical Association and Board of science and education 2000. 1

It is often coupled with distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves to have small quantities of food. The average calorie intake of person with anorexia nervosa is 600 800 calories per day, but extreme cases of complete self starvation are known. It is a serious mental illness with a high incidence of co-morbidity and the highest mortality rate of any psychiatry disorder. They are so common in the United States that 1 or 2 out of every 100 adolescent had struggled with anorexia or bulimia.3

Anorexia most often has its onset in adolescents and in most prevalent among adolescent girls. Recent studies show that the onset of anorexia range from 13 to 17 years in average and it also reduced to 9 to 12 it can affect men and women of any

age, race and socio economic and cultural background. Anorexia nervosa occurs in females 10 times more than in males.4

6.1

NEED FOR THE STUDY

Anorexia nervosa has an average prevalence of 0.3-1 percentage in women

and 0.1 percentages in men for the diagnosis in developed countries. The condition largely affects young adolescent women, with between 15 and 19 years old making up 40 percentages of all cases. Approximately 75 percentages of people with anorexia are female. Anorexia nervosa is more prevalent in the upper social classes and it was declared to be rare in less developed countries.5

The world wide incidence of anorexia nervosa is around 8/1, 00,000 persons per year. An upward trend has been observed in the incidence of nervosa in the past century till the 1970s . The most substantial anorexia

increase was

among females aged 15-24 years. The average prevalence rates for anorexia and bulimia nervosa among young females where in the North-east Scotland register covers Aberdeen and its environs, with a total population of 4, 73,370 in 1966. In the four year period 1966 to 1969 30 new cases of anorexia nervosa were registered, 28 female and 2 male. The annual occurrence was 6, 4, 7, and 13. Their mean age was 24.7 years, and the median age was 20.3 years. This gave an average annual incidence of 1-6 per 100,000 population and a sex-age specific rate for the 27 females aged 1534 years of 10-8 per 100,000.6

According to parental social class a greater proportion of patients were in the Registrar General's social classes two and three than were the other cases on the register, but the proportion was the same as in the general population of the area. The Monroe County register covers the city of Rochester and its environs in New York State, United States of America with a total population of 586,000 in 1960 rising to 712,000 in 1970, of which 25,000 are reported to be non white. During the decade 1960 to 1069.There was 24 cases of anorexia nervosa were recorded of who 17 were female and seven male. The cases in successive years were three, zero, one, two, three, three, three, zero, three, and six. Their mean age was 22.2 years and median age between 15 and 19, with no significant difference in age between the sexes. The average annual incidence was 0.37 per 100,000 populations, but the sexage specific rate for females aged 15-34 years was only 0-8 per 100,000. Social class data were not recorded. The Camber well register covers an area in south-east London with a population of 172,000, of whom 10,000 are colored immigrants. From the start of the register in 1965 up to 1971 eight patients with anorexia nervosa were recorded, all female, with a mean age of 21.6 years. None was reported in the first four years there were two in 1969 and 1970 and four in 1971. The average annual incidence was 0-66 per 100,000 populations and the sex-age specific rate for females aged 15-34 years was four to one per 100,000. Five of these patients had parents in social classes one or two, which was a highly significant excess over other register patients and the general population. One patient was of Indian origin.6

In India prevalence of anorexia nervosa is lower than that of western countries but appears to be increasing due to westernization and industrialization. The symptoms of anorexia nervosa were mostly seen in pre-pubertal period belong to middle and lower socio economic group and or the family with only child. There are more females with anorexia nervosa having female and male ratio of 5:1 than in the psychogenic vomiting group having female and male ratio of 2:15 but this was not significantly different.7

A study was conducted in sample consisted mostly of females adolescents from middle socio economic status towns and villages of north-eastern India. The result indicated that north eastern states of India with a mean age of 12.6 years are more prone to anorexia nervosa. The mean age of onset of symptoms and duration of symptoms was 11.2 years and 19.2 years respectively.8

There are no prevalence or co-morbidity studies on eating disorders in India. This retrospective chart review studied the prevalence and psychiatric co-morbidity among juveniles with eating disorders. Forty-one cases with ICD-10 diagnosis of eating disorders were identified and analyzed. The prevalence of eating disorders was 1.25 percentages. Psychogenic vomiting was the commonest eating disorders and anorexia nervosa the emerging eating disorder. The most common co-morbidities were depression, intellectual disability, and dissociative disorder.9 Case reports of anorexia nervosa in subjects of Asian and in Indian sub continental extraction have been rare. Three Asian adolescents with anorexia nervosa are described, one of whom

is male. The impact of the Muslim festival of Ramadan is described in the two Muslim cases. There was a need for better understanding of attitudes towards body shape and food within the subculture.10

A study was conducted among general population in Lucas, United States of America the findings revealed that the most vulnerable group for anorexia nervosa comprised girls and young women aged 15 to 24 years. A continual rise in incidence was observed throughout the 55 years of this study. The study concluded the prevalence of anorexia nervosa were high. There are historical description of cases of self starvations without weight concern in cultures, where was no emphasis a slimness. A cross cultural comparison has suggested that anorexia nervosa does not necessarily follow the accepted Western form.11

The study conducted in Malaysia showed that 0.05 percentages of psychiatric patient samples were diagnosed with anorexia nervosa. Lee reported in 1989 anorexia nervosa sufferers were very few in Hong-Kong compared with western countries. A study was conducted among 732 general and female population of hospital Kabuki in Japan. The study result revealed that the female patient population had about 1.5 times more anorexia sufferers than the general population. Among the general population the rate had increased from 0.0036 percentages to 0.0045 percentages among the female patient population the rate had increased from 0.0063 percentages to 0.0097 percentages so patient bared estimates of anorexia nervosa in non western countries thus ranged from 0.002 percentages to 0.9 percentages.12

It is important to remember that anorexia nervosa can easily get out of hand and are difficult habits to break. Anorexia nervosa is serious clinical problems that require professional treatment by doctors, nurses, therapists and nutritionists. My work is to improve the knowledge of adolescent girls regarding anorexic nervosa. By that they will get the health teaching and they will be aware of being anorexia nervosa.

The current medical nursing literature reflects the prevalence of anorexia nervosa in adolescent girls. Based on the literature and investigator experiences the investigator feels that it is important to create awareness among adolescent girls regarding anorexia nervosa. So the knowledge of the adolescent girls may be applied in early medical validation. Hence the investigator planned to impart the knowledge by providing self instructional module to the adolescent girls studying in Indian PreUniversity Science College for Women at Bellary.

6.2

REVIEW OF LITERATURE:
The purpose of a research literature is to an assemble knowledge on a topic

literature review helps in the identification of research problem development of hypothesis identification of suitable designs, date collection method and it also

provides knowledge about data analysis and interpretation.13

A study was conducted in Spain to determine the percentage of adolescents with anorexia nervosa who present worse cognitive functioning according to

neuropsychological criteria of cognitive impairment and to study their clinical

characteristics in 37 adolescent in age group of 11-18years with a diagnosis of anorexia nervosa in an acute state of the illness and with low body mass index were comprehensive with 41 healthy subjects of the same sex and similar age once

intelligence using a comprehensive neuropsychological functioning. Anorexia nervosa over all took the control group (P=0.001) 30 percentage of patients showed impaired neuropsychological functioning. The sub groups of patients presented lower( P=0.023) and higher trait anxiety (P=0.028) cognitive performance varied in one by third of sample. The cognitive impairment sub group showed lower body mass index and higher anxiety longitudinal follow up studies are necessary to assess the stability of this profile after longer treatment.2

A study was conducted in Poland to determine an accurate anthropometric measurement for clinical assessment of fat depletion in girls with anorexia in connection with body composition measured by dual energy X-ray absorptiometry. In 64 female anorexia nervosa patients aged 12.8 23 years and the mean is 16.0 1.8 percentages, body mass index, skin fold thickness, mid-upper arm and thigh circumference, fat mass and lean mass were determined and compared with the data of 71 records. Girls with anorexia nervosa had lower anthropometric tracts and were fat depleted compared to controls 14.9 7.3 with 27.4 6.4 percentages of fat mass using dual energy x-ray absorptiometry all <0.00 percentage so thigh circumference strongly correlates with dual energy x-ray absorptiometry of fat depletion and demonstrates a slight clinical advantage.6

A comparative study was conducted among 174 girls and 194 boys divided into 12 work groups 6 for the experimental group and 6 for the control group, the primary prevention of eating disorder at Spain. The result revealed that participation in the intervention group reduced body dissatisfaction, the drive to thickness, and the influence of the media with respect to the aesthetic body shape model while self esteem and the use coping strategies both improved. There was also an important in the eating habits of participants with better out comes being achieved when intervening with females.14

The study was systematically compiled and analyzed the mortality rates in individuals with anorexia nervosa, bulimia nervosa, and other eating disorders which are not specified was conducted in United States of America. A systematic literature search, appraisal, and meta-analysis were conducted of the medline,pub med, Psyc info and embase data bases they published between January 1, 1986, and September 30, 2010 that reported mortality rates in patients with eating disorders. This case for early intervention in anorexia nervosa in exploration of maintaining factors.15

A study was conducted in Tamil Naidu, India about the prevalence and psychiatric comorbidity among juvenile with eating disorder 41 cases with ICD 10 diagnosis of eating disorder were identified and analyzed. The prevalence of eating disorder was 25 percentages psychogenic vomiting was the commonest eating disorder and anorexia nervosa the emerging eating disorder.9

An exploratory study was conducted among 577 adolescent girls on eating and weights concerns at Sikkim, India. The findings revealed that concern with weight reduction is growing among adolescent girls, particularly among urban girls of affluent families. Girls from families with a higher economic status are about two times more likely to report dissatisfaction with their body weight and these girls are five times more likely to report the need for dieting.16

A retrospective study was conducted at London on 102 anorexia nervosa patients where reported with case records and follow up announcements after a mean lapse of 5.9 years. Over 80 percentages of the patients had an onset of illness within 7 years of menarche and on the whole the group was pre morbidity obese. Over 70 percentages came from professional and managerial class function, and 80 percentages were described as complaint childrens.17

A study conducted in Delhi, India on adolescents with anorexia nervosa have low bone mineral density in a prospective observational study lumbar and whole body bone mineral density was measured at 0 , 6 and 12 months in 34 anorexia nervosa girls aged 12 18 years and 33 controls. The result of the studies are neuroendocrine, gastro intestinal derived peptide regulating food intake are independent predictors of changes in bone mass in anorexia nervosa.18

A study to determine whether there was any cases of anorexia nervosa in female students attending two secondary schools in the North east region of Ghana.

In this study the Body Mass Index of students was calculated after measuring their height and weight. Of the 668 students who were screened for body mass index, 10 with a body mass index below 17.5 Kg/mc appear self starvation. All 10 viewed food restriction positively and in religious terms.1

A study was conducted at United States of America was to compare the set shifting scores of 24 adolescent females with anorexia nervosa with 37 matched normal adolescent controls ages from 14 to 20. The method used for the study in socio demographic, psychological and biological data. The sociodemographic data and intelligence quotient of the study and control were similar. Adolescent females with anorexia nervosa had significantly worse set shifting score than the control group.19

6.3

STATEMENT OF THE PROBLEM

A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING ANOREXIA NERVOSA AMONG ADOLESCENT GIRLS STUDYING IN INDIAN PRE-UNIVERSITY SCIENCE COLLEGE FOR WOMEN AT BELLARY.

6.4

OBJECTIVES OF THIS STUDY

1) To assess the pre test knowledge regarding anorexia nervosa among adolescent

girls in Indian Pre-university Science College for Women at Bellary.

2) To assess the post test knowledge regarding anorexia nervosa among

adolescent girls in Indian Pre-University Science College for Women at Bellary.

3) To evaluate the effectiveness of self instructional module on knowledge

regarding anorexia nervosa among adolescent girls studying in Indian PreUniversity Science College for Women at Bellary.
4) To determine the association between the post test knowledge score regarding

anorexia nervosa among adolescent girls in Indian Pre-University Science College for Women at Bellary with selected demographic variable.

6.5 RESEARCH HYPOTHESIS:

H1: There will be a significant increase in knowledge regarding anorexia nervosa among adolescent girls in Indian Pre-university Science College for Women at Bellary after administering self instructional module. H2: There will be significant association between the post test knowledge regarding anorexia nervosa among adolescent girls in Indian Pre-University Science College for Women at Bellary.

6.6 OPERATIONAL DEFINITIONS OF TERMS

Evaluate: In this study, evaluation is the process of assessing knowledge regarding anorexia nervosa.

Effectiveness: If refers to the extent to which the self instructional module on anorexia nervosa has achieved the desired effect in improving the knowledge of adolescent girls as an evident from gain in knowledge scores

Knowledge: In this study, knowledge refers to the correct response from the respondents during interview schedule regarding anorexia nervosa.

Self Instructional Module: It refers to a booklet prepared by the investigator which contains information about etiology, signs and symptoms, management, preventive measures,

complications of anorexia nervosa.

Anorexia Nervosa: It is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight.

Adolescent Girls: In this study, it refers to the girls who are in the post puberty period between age group of 15 17 years.

6.7 ASSUMPTIONS:
The study is based on the following assumption:
1) Adolescent girls can identify the complications of anorexia nervosa. 2) Self Instructional Module is an accepted teaching strategy that can enhance the

knowledge of adolescent girls studying in Indian Pre-University Science College for Women at Bellary regarding anorexia nervosa.
3) The knowledge regarding anorexia nervosa can prevent developing eating

disorders among adolescent girls studying in Indian Pre-University Science College for Women at Bellary.

6.8 DELIMITATIONS:
The study is delimited to
1) The girls above age group between 15 to 17 years.

2) The adolescent girls who are not present during data collection period. 3) This studies is limited to 4 to 6 weeks.

7. MATERIALS & METHODS: 7.1 RESEARCH METHOD:

The research method used for this study is quasi-experimental method.

7.2 RESEARCH DESIGN:

One group pretest and post test design will be employed in the study. O1 X O2 O1 : Administration of questionnaires regarding knowledge of anorexia

nervosa in Indian Pre-University Science College for Women at Bellary. X: Providing self instructional module regarding problems associated with anorexia nervosa on the same day after pre test. O2: Administration of questionnaires after one week of providing the self instructional module.

7.3 SETTING OF STUDY:

The study will be conducted in Indian Pre-University Science College for Women at Bellary.

7.4 POPULATION:
In this study population comprise of adolescent girls studying in Indian Pre-University Science College for Women at Bellary.

7.5 VARIABLES: INDEPENDENT VARIABLE- Independent variable is the presumed cause of the
resulting effect on the dependent variable. In the present study the independent variable is self instructional module on anorexia nervosa.

DEPENDENT VARIABLE- Dependent variable is the variable that the researcher

is interested in understanding, exploring or predicting. In present study the dependent variable is knowledge level of adolescent girls studying in Indian Pre-University Science College for Women at Bellary regarding anorexia nervosa.

8 METHOD OF DATA COLLECTION: 8.1 SAMPLING TECHNIQUE:

The sample of the study will be selected by random sampling technique method.

8.2 SAMPLING SIZE:

In this study the sample size will be 60 adolescent girls in Indian University Science College for Women at Bellary. Pre-

8.3 INSTRUMENT USED:

Structured questionnaires that consist of two sections: Section A: Demographic profoma consists of age, family income, education of parents, religion, and residential area etc. Section B: A structured knowledge questionnaire will prepare to assess the knowledge of Pre-University girls students regarding anorexia nervosa.

Validity: The content validity of the tool will be ascertained in consultation with guide and experts from various fields like psychiatric nursing and psychologist.

Reliability: The reliability of research tool will be done by using split half technique in deviation method Spearman Brown prophecy formula and prior to the study; written permission will be obtained from the concerned authority.

8.4 CRITERIA FOR SELECTION OF SAMPLE: INCLUSION CRITERIA

1) This study includes adolescent girls who are studying in Indian Pre-

University Science College for women at Bellary.

2) This study includes adolescent girls who are willing to participate.

EXCLUSION CRITERIA
1) This study may exclude adolescents girls above the age of 17 years. 2) This study may exclude the adolescent girls who are not available at the

time of data collection.

3) This study may exclude adolescent girls who are un cooperative

8.5 DATA ANALYSIS METHOD

Section A: Data analysis will be done by using description and inferential statistics mean, median, frequency and percentage distribution will be used for descriptive data analysis. At test will be done to comparativeness of the self instructional module. Section B: A chi square test will be done to find out the association between the mean pre test knowledge score and the selected demographic variable.

8.6

DOES THE STUDY REQUIRE ANY INTERVENTION OR INVESTIGATION TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS

Only a self instructional module on anorexia nervosa will be used and no other in varies physical or laboratory procedures will be done on the samples.

8.7 HAS ETHICAL CLEARANCE BEEN OBTAINED

1) Confidentiality and anonymity of the subject will be maintained.

2) Consent will be obtained from the samples regarding their willingness to participate. 3) A written permission from institution authority will be obtained.

9. BIBILOGRAPHY
1. Wikipedia,Essentional data. Anorexia Nevosa:An article from Townson

university and duke eating disorder program.2010 2. Westenhoefer J. Prevalence of eating disorders and weight control practices in Germany in 1990 and 1997. Int J East disorder 2001; 29 : 477 481
3. Andres-perpina s ,Lozano-serra.e.clinical and biological correlation of

adolescent anorexia nervosa in Spain.2011 Oct 8.www.pubmed.com

4. Nakamura K, Yama moto M. Prevalence of Anorexia nervosa and

bulima nervosa in a geographically define area in Japan. Int J East disorder 2000; 28: 173 180
5.

Rooney B. The prevalence of Anorexia nervosa South west London. Int

J Eating disorder 1995; 18: 209 307

6. Konstanty nowicz J, Abramowicz P. Thigh circumference as a useful

predictor of body fat in adolescent girls with anorexia nervosa in Poland. Publish Karga AG; 2011. www.pubmed.com 7. Kuboki P, Nomura S. Epi dermological data on anorexia nevosa in Japan Psychiatry Re 1996 ; 62 : 11- 16 8. Sjostedt J P, Nathawat SS. Eating disorders among Indian and Australian University Students. J Soc Psychol 1998; 138:351-357 9. Mamman P, Russell S. Prevelance of Eating disorder & psychiatric comorbidity among children and Adolescent in Tamil Naidu, India. 2011. www. pubmed.com

10. B. R Bhadrinath. Anroexia nervosa in adolescents of Asian

extraction.Department of Child and Family Consultation, Chatham, Kent; 2006. 11. Khandelwal SK, Saxene S. Eating disorder An Indian perspective. Int J Soc Psychiatry 1995; 41: 132 146 12. Buhrich N. Frequency of presentation of Anorexia Nervosa Aust NJZ Psychiatry. 1981;15 : 153-155
13. Polit F Denise, Hungler P. Bernadette, Nursing Research principal and

method. 7th ed Philadelphia J.B: Lippnicott Company; 2004 P. 1-5, 104109, 194. 14. Jauregui Lobera I, Leon Lozano P. Traditional and new strategies in the primary prevention of eating disorders in Spain. 2010; 3: 263-72
15. Treanure J, Russell G. A Systemativity compile and Analysis the

mortality rates in individual with Anorexia nervosa and Bulimia Nervosa. 2010. www.pubmed. com
16. Mishera S.K, Eating disorder and weight concerns among Sikkim

Adolescent girl in Kolkata, India. 2010 Sept. 21: 1 7 www.pubmed.com 17. A.H. Grisp, L.K.G Hsu, Brittien Harding. A Study of 102 female patient of eating disorder in London. 2002. www. pubmed.com 18. Madhusmita Misra, Rajani Prabhakaran. Prognostic Indicator of changes in Bone Density Measure in Adolescent Girls with Anorexia in New York. 2007 Oct 31. www. pubmed.com

19. MC Anasrney ER, Zarcone J, Singh P. Restrictive Anorexia and set shifting in Adolescence in New York, USA. Publish: Ersevier Inc; 2011.

10. SIGNATURE OF THE STUDENT 11. REMARKS OF THE GUIDE

: : The research topic selected by

the student is quite appropriate and felt need of the hour to improve the knowledge instructional by effective module selfamong

adolescent girls studying in Indian pre university Science College for women at Bellary.

12. NAME AND DESIGNATION OF

12.1 GUIDE NAME AND ADDRESS

Prof S.VANITHA,(MscN) PSYCHIATRICNURSING, INDIAN COLLEGE OF NURSING, BELLARY

12.2 SIGNATURE OF GUIDE

12.3 CO GUIDE (IF ANY)

: Assist Prof RAJ KANNAN,M Sc(N) PSYCHIATRIC NURSING, INDIAN COLLEGE OF NURSING, BELLARY.

12.4 SIGNATURE

12.5 HEAD OF THE DEPARTMENT:

Prof S.VANITHA, M.Sc (N) PSYCHIATRICNURSING, INDIAN COLLEGE OF NURSING, BELLARY

12.6 SIGNATURE

13.1 REMARKS OF THE PRINCIPAL:

The research topic selected by the candidate is relevant as it focuses on the knowledge regarding anorexia nervosa, which in turn will reduce the morbidity and mortality rate of the nation.

13.2 SIGNATURE OF THE PRINCIPAL :