RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE
ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE MR.SREEJESH.P.K.

AND ADDRESS I YEAR MSC. NURSING
(IN BLOCK LETTERS) CITY COLLEGE OF NURSING
SHAKTHINAGAR
MANGALORE -575 016

2. NAME OF THE INSTITUTION CITY COLLEGE OF NURSING

MANGALORE – 575 016.

3. COURSE OF STUDY AND M. Sc. NURSING

SUBJECT PSYCHIATRIC NURSING

4. DATE OF ADMISSION TO THE 04.05.2007

COURSE

5. TITLE OF THE TOPIC

“ THE EFFECTIVENESS OF BIBLIOTHERAPY IN REDUCING STRESS

AND IMPROVING COPING ABILITIES AMONG CANCER PATIENTS

ADMITTED IN SELECTED HOSPITALS AT MANGLORE”

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6 BRIEF RESUME OF THE INTENDED STUDY
Introduction
Cancer is often viewed as an acute and usually fatal disease. Cancer is a
compendium of stresses which includes the fear and the diagnosis of cancer, the
nature of treatment decisions, confronting one’s mortality physical implications as
well as emotional pain, the ardous treatments to be endured and the changes that
one’s social and family environment under go.
To many patients, stunned by the diagnosis, suffering numerous losses and
discomforts, moved from one place to another for one procedure after another, the
experience is bewildering and frightening1. It is only recently that oncologists in
general have begun to recognize the emotional impact of these ordeals and the fact
that emotional states play a role in the tolerably of the treatment, the quality of life
perhaps, the outcome of cancer as well 2
6.1 Need for the study
Cancer patients face many struggles relating to diagnosis and treatment of their
disease. Self-esteem is a major concern among cancer patients3. Globally it is
estimated that there are 7.6 million new cancer cases, of which 52% occur in
developing countries.4 The magnitude of the problem of cancer in the Indian Sub-
Continent in terms of sheer number is most alarming. The estimated new cases of
cancer in India per year are nearly 6.5 lakhs and at the start of the next millenniums
estimated to be 806 lakhs. The crude incidence of cancer in India is approximately 100
per lakhs populations. This is only a third or fourth of the incidence in the affluent
countries of Europe and North America. The Cancer in women in the Indian Sub-
continent constitutes more than 50% of the total cancer. The most common cancer
observed by Indian registries are those related to tobacco usage in males while among
females, the most common cancer are those of the Uterine Cervix, Breast and Oral
cavity. In Karnataka, it is estimated that annually there are about 35,000 incident
cancers whereas, the prevalent cancer accounts to about 1, 50,000.5
Stress, disappointment were soon followed by such a growth and increase in
cancer so that it would be quite realistic mental depression is a weighty addiction to
the other influences favoring the development of cancer. The patients under go stress

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because of the nature of the illness, concept about caner, prognosis of the disease and
nature of the treatment modalities. Especially the middle age people have more stress
because of they are more concern about their roles in family, responsibilities and their
life’s. 6
Research has revealed that psychological interventions not only improve the
quality of life but may also prolong survival in patients with cancer. Psychosocial
interventions may help the patient to reduce stress; reducing risk behaviours improve
coping and quality of life.
Bibliotherapy or therapeutic reading is one such psychological treatment for
the cancer patients to enhance the coping ability refers to the process of dynamic
interaction between the personality of the reader and character, which may be used for
personality assessment, adjustment growth. Bibliotherapy is an interaction between the
reader and literature in which the emotions are fed for productive use. Bibliotherapy
works in a manner similar to psychotherapy and that here a body of imaginative
literature can be used to diagnose and treat emotional problems. Sandor (1991)
reported changes in adolescent coping and self-regulative behaviours using what she
called “problem solving” bibliotherapy. 7
Many studies have proved that bibliotherapy was an effective treatment
modality in reducing stress, depression, and anxiety, distress and improve coping of
clients with various life issues.
Hence the investigator felt that bibliotherapy would be effective in reducing the
stress of cancer patients, which has made him to select the present study.

6.2 Review of literature :

In 1995 Govt. of India and W.H.O to find out the incidence rate of cancer
in India conducted a descriptive survey in India. The study compared the incidence
rate in rural and urban areas. The crude incidence rate of cancer in India varied
between 57.5and 78.5 per 1000 men and 57.5 and 89.7 per 1000 women in urban
registry areas. Incidence rate in rural registry are lower [46.2 and 57.7 per 1000 in
males and females respectively] compared to urban area.8
A cross sectional study was conducted about the mental symptoms
hostility features and stress in people with cancer. The sample consisted of 100
patients (59 men and 41 females) suffering from cancer. Women reported lower scores

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than men on total hostility (women SD-3.07, r=0.16 and men SD-3.64, r=0.18,
P<0.05). On anxiety 58% of the females and 49% of the men patients experience
severe anxiety (women SD-4.13, r=0.29, P<0.01 and Men SD- 3.86,r=0.10,p<0.01).
On depression 32% of the females and 24% men reports depression (females SD-3.17,
r=0.46, p<0.001, males SD-3.22, r=0.15 p<0.05). On the modified schedule of life
experiences the female patients reported statistically high significant score than males
incase of stress. (Men SD-63.56, r= 0.02 & females SD-62.53 r=0.24, p<0.001.). This
study showed that cancer patients experience severe stress, anxiety, depression and
hostility features. 9
A study was conducted which aimed at reviewing the evidence regarding
possibility of a relationship between psychological interventions and survival time of
the cancer patients. 120 patients were randomly assigned to a therapy (n=62) or
‘standard care’ control (n=58) the intervention consists of supportive counselling. At
three months after commencement of the intervention, therapy recipients showed
reduced stress, depression, self-esteem and life satisfaction. The experimental study
revealed that psychological interventions are effective in terms of increasing the
survival time of the cancer patients. 10
A study was conducted to determine the effectiveness of music as a
diversional therapy on the patients with cancer pain in oncology department of a
selected hospital, Udupi district. In this experimental study 30 samples were used. The
extreme score of mean pre therapy pain intensity scores in the morning from day 1 and
day 10 were 5.96-3.116 and post therapy 4.70-1.38 respectively. The mean difference
between 1.26 to 1.73, which was statistically significant, at 0.001 levels, suggesting
that the music therapy could be used as a diversional therapy for reduction of cancer
pain (t-6.62 to 8.4, p<0.001). The study findings showed music therapy is an effective
diversional therapy to reduce pain in cancer patients. 11
A study conducted on “stress, optimism and social support: Impact on immune
responses in cancer”. The purpose of this co relational study was to examine the direct
and stress buffering effect of optimism and satisfaction with social support on immune
responses. Participants were 54 postoperative cancer patients who completed
questionnaires on stress optimism and satisfaction with social support and provided
blood to measure killer cell activity (N K C A) and interferon gamma (IFN-) from
whole blood. The centered variables and their interaction revealed acceptable

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correlations (r<0.45). The centered main variables and their products
(stressoptimism SD= 0.28 P<0.05) and (stress satisfaction with social support
SD=0.32 P<0.05) were used in the regression model to test main and interaction
effects. Two-step hierarchical multiple regression analysis was used to examine the
interaction effects of psychological stress optimism and satisfaction with social
support on NKCA and IFN-. Results shows the stress were associated with
decrements in NKCA and IFN-. Optimism moderated the relationship of stress on
NKCA. The results suggested that interventions aimed at reducing stress and optimism
in cancer patients might promote optimal immune response. 12
A study was conducted on regarding the effectiveness of bibliotherapy on
stress reduction among Hansen’s disease patients in selected setting in Mangalore. A
Quasi-experimental approach with pre test post-test group design was used for the
study. The sample consisted of 40 Hansen’s disease patients selected by purposive
sampling method. Data were collected by administering stress rating scale prepared by
the investigator. The mean post-test score x2=107.15 was less than the pre test score
x1=131.65 in-group-I and in-group- II (132.65). The ‘t’ value computed between the
pre test and post test score of group- I was statistically significant at 0.001 level
(t=13.26, df=19 p<0.05) the findings showed a highly significant difference in stress
score in the experimental group that bibliotherapy was effective in reducing stress of
Hansen’s disease patients.13
An experimental study was conducted in Canada about the effectiveness of
bibliotherapy on psychosocial distress in lung transplant patients and their families. 36
lung transplant patients and their support people were examined for psychosocial
distress, coping style and orientation to independent learning before and after receiving
a self help book in a programme designed to alleviate psychosocial distress and
adaptive coping.Subjectes rated the book as highly acceptable and non reported
increased psychosocial distress. Bibliotherapy appears to be a safe, well-received
means of providing information about emotional distress and coping to patients and
their families who face the trials of a life-threatening illness and the potential for
disabling consequences. An avoidant coping style may be associated with difficulty
undertaking a self-directed approach to therapy in some persons, whereas older age and
a tendency to engage may predict greater use of such a program. Results of the study
revealed significant changes in the coping strategies used by the experimental group. 14

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 A study conducted about the role of bibliotherapy in health anxiety. This
experimental study investigated the effects of bibliotherapy on patients who had been
identified as demonstrating health concerns. The 40 participants were randomly
allocated to two groups, one receiving bibliotherapy and the other not. Structured self-
help materials (bibliotherapy) using a cognitive behaviour therapy (CBT) treatment
approach have been shown to be clinically effective. Half the patients had a medically
diagnosed problem. Anxiety was assessed before and after the bibliotherapy
intervention, which took the form of a cognitive-behavioural self-help booklet for
health anxiety sufferers. Patients in the bibliotherapy group showed reduced levels of
anxiety at post-test, even when they also had an identifiable physical problem. These
results are consistent with the idea that self-help materials can be an effective and
accessible intervention in CBT, although further research is recommended. 15

6.3 Statement of the problem :

“THE EFFECTIVENESS OF BIBLIOTHERAPY IN REDUCING STRESS AND
IMPROVING COPING ABILITIES AMONG CANCER PATIENTS
ADMITTED IN SELECTED HOSPITALS AT MANGLORE”.

6.4 Objectives of the study

1) To determine the stress level in cancer patients by using a stress scale.
2) To determine the level of coping abilities of cancer patients using coping check
list.
3) To find out the association between the pre-test stress score and coping score
with selected demographic variables .
4) To determine the effectiveness of bibliotherapy in terms of reduction of stress
and improving coping abilities.

6.5 Operational definitions

 Effectiveness; - Effectiveness refers to which an action produces on intended
outcome. In this study effectiveness refers to the extent to which bibliotherapy has
achieved the desired objective that is stress reduction and improving coping in
cancer patients as measured by stress scale and coping check list
 Bibliotherapy; - Bibliotherapy or therapeutic reading refers to the process of
dynamic interaction between personality of the reader and character, which may be
used for personality adjustment and growth. In this study bibliotherapy refers to a

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 form of intervention applied to reduce stress of cancer patients which includes
providing selected reading materials consists of encouraging stories of eminent
personalities (like Helen Keller, Sudha chandran & Wilma Rudolph), cartoons and
power of positive thinkers.
 Stress; - Canadian psychologist ‘Hans selye’ the father of modern stress theory
defined stress as “the non specific response of the body to any demand made on it”
In this study stress refers the negative impact of the cancer on physical, mental,
social and Spiritual health tension as measured by stress assessment scale.
 Coping: - Coping is constantly changing cognitive and behavioural efforts to
manage specific internal or external demands as taxing or exceeding the recourses of
the person minimize reduce tolerate or manage external or internal demands that tax
or exceed individuals recourses. In this study coping means the problem focused and
emotion focused coping by which the patients cope with the stress as measured by
coping checklist.
 Cancer: -Cancer is a disease of the cell in which the normal mechanisms of the
control of growth and proliferation have been altered. It is invasive, spreading
directly to surrounding tissue as well as to new sites of the body. In my study cancer
means patient who diagnosed as the 1st and 2nd stages of cancer and having stress and
reduced coping.

6.6 Assumptions
1. Stress in cancer patients can be assessed using stress scale.
2. Cancer patients will have decreased coping due to the severity of the illness.
3. Clients are willing to participate in the study.

6.7 Hypothesis
Hypothesis will be tested at 0.05 level of statistical significance.
 H1 -The mean post test stress score of cancer patients under going
bibliotherapy will be lower than their mean pre stress score.
 H2- The mean post test coping score of cancer patients under going
bibliotherapy will be higher than their mean pre coping score.
 H3 -There will be significant association between the stress & coping abilities
of cancer patients with selected demographic variables.

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 6.8 Delimitations
 Study limited to cancer patients with stress and decreased coping.
 Study limited to cancer patients who are admitted in selected hospitals at
Mangalore only.
 Study limited to those willing to participate.

Material and methods

7.1 Source of data
Patients with cancer who admitted in selected hospitals at Mangalore.

7.1.1 Research design

7. In this study quasi-experimental design (one group pre test, post test only
method) is used.

7.1.2 Setting
The study is planned to conduct at selected hospitals at Mangalore.
7.1.3 population
Cancer patients who are residing in selected hospitals at Mangalore.
7.2 methods of data collection
7.2.1 Sampling procedure- simple random sampling using lottery method will be
used to select 50 samples from patients who have cancer based on inclusion criteria.
7.2.2 Sampling size -The sample size will consist of 50 cancer patients who meet
the inclusion criteria.
7.2.3 Inclusion criteria
1. Patients who are diagnosed as having 1stand 2nd stages of cancer and
experiencing stress and decreased coping abilities.
2. Patients who are residing in selected hospitals at Mangalore.
3. Patients who are not sensitized with any type of relaxation technique.
4. Patients who are interested in reading.
5. Patients who can read Kannada or English.

7.2.4 Exclusion criteria

1. Patients who have been sensitized with any type of relaxation technique.
2. Patients who are not under stress based on pre-test scores of stress
assessment scale.

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 3. Patients who are in third stage of cancer.

7.2.5 Instruments intended to be used

Instruments intended to be used is rating scale, observation check list, semi
structured interview technique which will be validated by experts before conducting
study

7.2.6 Data collection method

Step 1
The hospitals are selected depending up on feasibility, and getting permission to
conduct study
Step 2
Conduct general survey to check the availability of the samples
Step 3
Randomized selection of samples using lottery method based on the inclusion
criteria.
Step 4

Informed consent will be taken from the patients

Step 5
Assessing the stress level of cancer patients using stress scale and coping
abilities by coping check list.
Step 6
Provide bibliotherapy to cancer patients for 7 days who experience stress and
having decreased coping strategies.
Step 7
Conduct post-test after 7 days following the administration of bibliotherapy to
find out the effectiveness
Step 8
Prepare the data for the analysis

7.2.7 Plan for data analysis

After data collection process the data will be organized, interpreted and
analyzed using descriptive and inferential statistical methods and tests. The
demographics of cancer patients will be presented by using frequency table, diagrams
and graphs. The effectiveness of bibliotherapy in reducing stress and improving

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coping strategy of cancer patients will be tested by paired‘t’ test. The association
between stress and coping strategy can be studied by chi-square test. The results will
be presented in the form of frequency tables, mean + , standard deviation and graphs.

7.3 Does the study require any investigation / intervention to be conducted?

Yes. Bibliotherapy is used as an intervention to reduce stress and improve coping
abilities among cancer patients.

7.4 Has ethical consideration been obtained from your institution in case of 7.3?
Yes. Ethical clearance has been obtained.

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LIST OF REFERENCES

1. Ignatavicius, Donna D Workman, Linda M. “Medical Surgical Nursing”,(2002)

2nd ed ; Saunders publications; Philadelphia 187-192.
2. Suddarth’s and Brunner, “Medical Surgical Nursing”, 9 th ed; Lippincott
publications; Philadelphia 868-873.
3. Mary Vachon, ‘psychosocial distress and coping of cancer patients’ American
journal of nursing March 2006; 106 (3): 26-30
4. Incidence of cancer –worldwide, The Hindu 2005 Jan 30, Sunday.
5. http://www.kidwai.kar.mc 2002/general.htm #incidence of cancer worldwide.
6. Phyllis N. butow & Janet E Hiller, ‘Epidemiological events for a relationship
between life events, coping strategies and personality factors in the development
of cancer’ Journal of psychosomatic research- 2000; 49(5): 169-181.
7. Laura J.Cohen, ‘Bibliotherapy: a valid treatment modality’ Journal of
psychosocial nursing 1995; 32 (9): 40-42.

8. Sreevani R.Cancer in India. Health Action 2005 Jun;33-5.

9. Angelopoulos N.V.et. al ‘Mental symptoms, hostility features stressful life
events in people with cancer’ Scandinavica 1997 Feb; 27-34, 44-50.
10. Sarah Edelman, can psychotherapy increase the survival time of cancer patients?
Journal of psychosomatic research 2000; 49: 149-156.
11. Flossy Rodrigues, The effectiveness of music as a diversional therapy on the
patients with cancer pain journal of psychosocial nursing 2000; 23(5):32-33
12. Diane Von Ah, ‘stress, optimism and social support: impact on responses in
cancer. Research in nursing and health 2000; 30: 72-83.
13. Reena George, ‘effectiveness of bibliotherapy in stress reduction among
Hansen’s disease patients Nuses of India 2007;23(10):9-12
14. B Hodges, ‘Bibliotherapy for psychosocial distress in lung transplant patients
and their families’ Journal of psychosocial oncology 1999; 7 (3): 40-43
15. Freda A Jones ‘The role of bibliotherapy in health anxiety’ British journal of
community nursing 2002; oct. 7 (10): 498-504.

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