A STUDY TO ASSESS THE EFFECTIVENESS OF

KANGAROO MOTHER CARE ON RESPONSES AMONG

LOW BIRTH WEIGHT NEONATES IN THE

POSTNATAL WARD OF

GOVERNMENT RAJAJI HOSPITAL AT MADURAI

M. Sc. (Nursing) Degree Examination

BRANCH II: CHILD HEALTH NURSING

COLLEGE OF NURSING

MADURAI MEDICAL COLLEGE, MADURAI

A dissertation submitted to

THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY, CHENNAI

In partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING

JULY 201

COLLEGE OF NURSING

MADURAI MEDICAL COLLEGE (Affiliated to the Tamilnadu Dr.M.G.R.Medical University)

MADURAI - 625020

_______________________________________________________________

CERTIFICATE

This is the bonafide work of Miss .R.SEMMALAR,M.Sc.,Nursing

(2009-2011Batch) II year student from College of nursing,Madurai medical

college,Madurai – 625020,submitted in partial fulfillment for the Degree of

Master of science in nursing,under the Tamilnad Dr.M.G.R.Medical

University, Chennai.

SIGNATURE: …………………………………… Dr.A.Edwin joe, M.D., B.L.,

Dean,

Madurai Medical College, Madurai.

SIGNATURE: …………………………………… Dr.(Mrs).Prasanna baby,M.Sc(N).,M.A.,Ph.d., Principal, college of nursing,

Madurai medical college, Madurai COLLEGE SEAL:

JULY 2011

A STUDY TO ASSESS THE EFFECTIVENESS OF

KANGAROO MOTHER CARE ON RESPONSES AMONG

LOW BIRTH WEIGHT NEONATES IN THE

POSTNATAL WARD OF

GOVERNMENT RAJAJI HOSPITAL AT MADURAI

Approved by the : ……………………................................

Dissertation committee on

Professor in nursing research: …………………………………………………..

Dr.(Mrs).Prasanna baby,M.Sc(N).,M.A.,Ph.d.,

Principal, college of nursing,

Madurai medical college, Madurai.

Clinical speciality expert : …………………………………………………..

Mrs.R.Jeya sundari,M.Sc(N).,M.A.,M.Phil.,

Faculty of child health nursing, college of nursing,

Madurai medical college, Madurai.

Medical expert : …………………………………………………..

Prof.Dr.G.Mathevan, MD., DCH.

Head of the department of paediatric medicine,

Institute of child health and research centre,

Government Rajaji Hospital, Madurai.

A DISSERTATION SUBMITTED TO

THE TAMILNADU DR.MGR.MEDICAL UNIVERSITY,

CHENNAI

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF

MASTER OF SCIENCE IN NURSING

JULY 2011

A STUDY TO ASSESS THE EFFECTIVENESS OF

KANGAROO MOTHER CARE ON RESPONSES AMONG

LOW BIRTH WEIGHT NEONATES IN THE

POSTNATAL WARD OF

GOVERNMENT RAJAJI HOSPITAL AT MADURAI

A DISSERTATION SUBMITTED TO

THE TAMILNADU DR.MGR.MEDICAL UNIVERSITY,

CHENNAI

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF

MASTER OF SCIENCE IN NURSING

JULY 2011

INTERNAL EXAMINER EXTERNAL EXAMINER

ACKNOWLEDGEMENT

ACKNOWLEDGEMENT

I Praise and thank the God Almighty for his abundant grace and blessing showered upon

me throughout my study.

With profound joy and gratitude, I acknowledge the help of all those who have

contributed towards the successful completion of this endeavor.

I am extremely grateful to Dr.A.Edwin joe, M.D.,B.L., Dean, Madurai Medical College,

for his approval for the study and providing the required facilities for the successful completion

of this study. I express my sincere thanks to Dr.S.M.Sivakumar,M.S., Medical superintendent,

Government Rajaji Hospital, Madurai ,for providing permission and necessary facilities to

conduct the study.

My deep sense of gratitude to Dr.(Mrs).Prasanna baby,M.Sc(N).,M.A.,Ph.d., Principal,

college of nursing, Madurai medical college, for her unequivocal concern, constant support,

encouragement, guidance and blessings during the study.

I am very thankful to Mrs.S.Poonguzhali,M.Sc(N).,M.A., Reader, college of nursing,

Madurai medical college, for being the initiator of my study and providing the environment to

start the study.

My sincere thanks to Mrs.R.Jeya sundari,M.Sc(N).,M.A.,M.Phil., Faculty of child

health nursing , college of nursing, Madurai medical college ,for her valuable suggestions and

guidance that contributed to the growth throughout the study.

I am thankful to Ms.A.R.Sudharma devi,M.Sc(N)., and Mrs.N.Maheswari,M.Sc(N).,

the faculty members of Department of child health nursing, college of nursing, Madurai medical

college for their support and encouragement.

I owe my thanks to Dr.G.Mathevan, MD.,DCH.,Professor and Head of the department

of paediatric medicine, Institute of child health and research centre, Government Rajaji Hospital,

Madurai ,for granting permission and guidance.

My special thanks to Dr.S.Sambath,MD.,DCH.,Professor of paediatrics ,Institute of

child health and research centre, Government Rajaji Hospital, Madurai, for his encouragement

and support.

My heart full thanks to Dr.Nanthini Kuppusamy MD.,DCH., Assisstant professor of

paediatrics ,Institute of child health and research centre, Government Rajaji Hospital, Madurai

,for her untiring guidance and suggestions.

My sincere thanks to all the experts, for their enlightening suggestions, constructive

criticism, valuable judgments and recommendation while validating the content of tool.

My special thanks to Mr.Partha sarathy,M.Sc(stat).,Lecturer in statistics for his expert

guidance in the statistical analysis procedure.

My thanks to Mr.S.Kalaiselvan,M.A.,BLIS.,Librarian, college of nursing,Madurai

medical college, for permitting me to utilize the library facilities.

I extend my thanks to the staff nurses in the postnatal ward who have extended their

co operation.

My special appreciation to Prof.Mr.Bhagruden,M.A.,B.Sc.,M.Ed.,M.Phil., Department

of spoken English, Madurai kamarajar university, Madurai, who make this thesis grammatically

error less .

My thanks to Mr.Rajkumar for typing this dissertation with much valued computer

skills.

My deep sense of gratitude to the all participants of the study for their whole hearted

participation, without whose cooperation this study would have been impossible.

My affectionate thanks to friends, classmates and juniors for their encouragement,

support and good wishes.

I am greatly indebted to my beloved parents Mr.S.Rajalingam and Mrs.R.Rajeshwari

and my lovable sister Miss.R.Kavitha,B.Ed.,M.Sc(chem)., for their full support ,encouragement

and motivation during the course of my study to achieve this goal.

My sincere thanks and gratitude to all others who have directly or indirectly contributed

to the successful completion of the dissertation.

CONTENTS

LIST OF CONTENTS

CHAPTERS CONTENTS PAGE NO I INTRODUCTION 1

Need for the study 3 Statement of the problem 5 Objectives of the study 5 Hypotheses 6 Operational definition 6 Assumptions 7 Delimitation 7 Projected out come 7 REVIEW OF LITERATURE 8 Studies related to low birth weight neonate 8 Studies related to low birth weight neonate’s responses 10 Studies related to feasibility of kangaroo mother care 12 Studies related to physiologic response in kangaroo mother care 14 Studies related to behavioural response in kangaroo mother care 16 Studies related to psycho social response in kangaroo mother care 18

II

Conceptual frame work 20 METHODOLOGY 24 Research approach 24 Research design 24 Setting of the study 25 Variables 25 Population 26 Sampling technique 26

III

Criteria for sample selection 27

Development of the tool 27 Description of the tool 29

Testing the tool 30

Pilot study 30 Method of data collection 30 Plan for Data Analysis 31 Protection of Human Subjects 32 Schematic representation of the study 33

IV ANALYSIS AND INTERPRETATION 34 V DISCUSSION 65 VI SUMMARY, CONCLUSION,

IMPLICATIONS,RECOMMENDATIONS AND LIMITATIONS OF THE S TUDY

71

BIBLIOGRAPHY

APPENDICES

LIST OF TABLEs

LIST OF TABLES

Table

No Title

Page

No

1 a Frequency and percentage distribution of demographic profile of neonates in

experimental and control group by age and sex

37

1 b Frequency and percentage distribution of demographic profile of neonates in 38

experimental and control group by birth weight and birth order.

1 c Frequency and percentage distribution of demographic profile of neonates in

experimental and control group by educational status and monthly income

39

1 d Frequency and percentage distribution of demographic profile of neonates in

experimental and control group by religion, residence and type of family

40

2 a Frequency and percentage distribution of Pre test assessment of physiological response ,behavioural response and psycho social response in experimental and control group

43

2 b Frequency and percentage distribution of Post test assessment of physiological response, behavioural response and psycho social response in experimental and control group

45

2 c Distribution of mean and mean percentage of pre test and post test among

experimental and control group

47

3 a Comparison of physiological response between pre test and post test among

experimental group

50

3 b Comparison of behavioural response between pre test and post test among

experimental group

51

3 c Comparison of psycho social response between pre test and post test among

experimental group

52

4 a Comparison of physiological response between experimental and control group 54

4 b Comparison of behavioural response between experimental and control group 55

4 c Comparison of psycho social response between experimental and control group 56

5 a Association of physiological response with birth weight and age of the neonate 58

5 b Association of behavioural response with age and sex of the neonate 60

5 c Association of psycho social response with sex and birth order of the neonate 62

LIST OF FIGUREs

LIST OF FIGURES

Figure No

Title Page No

1. Conceptual framework based on modified model of widenbach’s helping 23

art of clinical nursing theory

2. Schematic representation of the study 33

3. Percentage distribution of demographic profile of neonates-Age 41

4. Percentage distribution of demographic profile of neonates-Sex 41

5. Percentage distribution of demographic profile of neonates-Birth weight 42

6. Percentage distribution of demographic profile of neonates-Residence 42

7. Percentage distribution of pre test in experimental and control group 49

8. Percentage distribution of post test in experimental and control group 49

9. Comparison of pre test and post test mean in experimental group 53

10. Comparison of Post test between experimental and control group 57

11. Association of psycho social response with sex of the neonate 64

LIST OF ABBREVATIONS

LIST OF ABBREVATIONS

S. No ABBREVATIONS

1. KMC - Kangaroo mother care

2. LBW - Low birth weight

3. UNICEF -United nations international children’s emergency fund

4. WHO -World health organisation

5. FAO - Food and agricultural organisation

6. IAP - Indian academy of pediatrics

7. GRH - Government Rajaji hospital

8. LSCS - Lower segment caesarean section

9. IUGR - Intra uterine growth retardation

10. f - Frequency

11. % - percentage

LIST OF APPENDICES

LIST OF APPENDICES

Appendix Title A Data collection tool

ABSTRACT

INTRODUCTION

Low birth weight neonates are a special group that needs attention and care, it is the

significant factor contributing to neonatal morbidity and mortality. Simple measure to prevent

morbidity and mortality as care of low birth weight must be exercised with emphasis on

B Scoring and grading procedure C Assessment procedure D Informed consent-Tamil version E Kangaroo mother care procedure-English version F Kangaroo mother care procedure-Tamil version G Letter seeking permission for conducting the study H Letter seeking experts opinion for content validity of the

tool and certificate of content validity

kangaroo mother care. Kangaroo mother care is a humane, low cost and simple method of care of

low birth weight neonates.

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of Kangaroo mother care on responses among low

birth weight neonates in the postnatal ward of Government Rajaji Hospital at Madurai.

OBJECTIVES:

The objectives of the study are to

The objectives of the study are to

1. assess pre test and post test in the physiological response, behavioural response and

psycho social response in experimental group and control group

2. evaluate the effectiveness of kangaroo mother care in physiological response, behavioural

response and psycho social response among experimental group

3. compare the physiological response, behavioural response and psycho social response

between experimental group and control group

4. associate the physiological response, behavioural response and psycho social response

with selected demographic variables of experimental group and control group

HYPOTHESES:

H 1- There will be significant difference between pre test and post test among

experimental group

H2 - There will be significant difference in physiological response, behavioural response

and psycho social response between experimental group and control group

H3 - There will be significant association of the physiological response, behavioral

response and psycho social response with selected demographic variables of experimental

group and control group

METHODOLOGY

Quasi experimental approach was used in this study. The research design used for this

study was Non-equivalent control group design. The study was conducted in the postnatal ward

of Government Rajaji Hospital at Madurai. Purposive sampling method was used to select the

sample. The sample size was 60 low birth weight neonates and their mothers that was 30 low

birth weight neonates and their mothers in the experimental group and 30 low birth weight

neonates and their mothers in the control group.

MAJOR FINDINGS OF THE STUDY

In physiological response, there is a high significant difference between pre test and post

test among experimental group (‘t’ value -18.57, ‘p’ value- 0.006), in behavioural response,

there is a high significant difference between pre test and post test among experimental group

(‘t’ value -43.14, ‘p’ value 0.004) and in psycho social response, there is a high significant

difference between pre test and post test among experimental group (‘t’ value -14.31, ‘p’ value-

0.004).

By comparing both groups, in physiological response, there is a high significant

difference between experimental and control group (‘t’ value - 12.47, ‘p’ value 0.004), in

behavioural response, there is a high significant difference between experimental and control

group (‘t’ value -26.7, ‘p’ value- 0.002) and in psycho social response, there is a high significant

difference between experimental and control group (‘t’ value -13.09, ‘p’ value 0.005).

There was a significant association between the psycho social response and sex of the

neonate (χ2-4.35; ‘p’ value-0.03).

RECOMMENDATIONS

Based on this study, the following recommendations have been made for further study.

i. A similar study may be replicated with large sample.

ii. A comparative study may be conducted to evaluate the effectiveness of kangaroo mother

care versus other methods (incubator care, mummifying and traditional care etc) on low

birth weight neonates.

iii. A follow-up study may be conducted to assess the effectiveness of kangaroo mother care

in the community set up.

iv. Similar studies may be done by using other method of caring of low birth weight

neonates.

v. The study may be conducted to the low birth weight neonates in the neonatal intensive

care unit.

vi. The study may be conducted to the pre term babies.

vii. The study may be conducted to the low birth weight neonates born to the LSCS mother.

CONCLUSION

This study assessed the effectiveness of kangaroo mother care on the low birth weight

neonates. The findings of the study showed that the KMC has positive effect on the physiological

response, behavioural response and psycho social response. So that the investigator concluded

that the KMC is the safe method to care the low birth weight neonates and to implement this in

our settings.

CHAPTER I

INTRODUCTION

Suicide is the word rooted its meaning from many languages. In

Latin “sui” (genitive) of oneself + English –cide, and in Sanskrit “sva”

means oneself. Many of the Anthropologists remark that, the term

suicide was first used in the year 1647. The father of psychoanalytical

theory Sigmund Freud states, “Suicide as the murder turned 180

degrees”.

Suicide is a global public health problem (Cutcliffe, 2006). The

majority of suicides (85%) in the world occur in low and middle income

countries (Krug, Dahlborg, Mercy, Zwi, & Lozano, 2007).Suicide is

among the three leading causes of death among those aged 15-44 years

in some countries, and the second leading cause of death in the 10-24

years age group; these figures do not include suicide attempts which are

up to 20 times more frequent than completed suicide.

World Health Organization stated suicide as the world’s 13th

leading cause of death. Suicide is a deeply personal and individual act;

suicidal behaviour is determined by a number of factors. These can be

classified under the terms of predisposing factors and precipitating

factors. Predisposing factors are internal determinants operating at the

level of the individual. These include dynamics such as personality traits,

Suicide- The state of cry for help

Suicide victims are not trying to end their life

- they are trying to end the pain!

bonds with family and society, biological and genetic factors etc.Every

year, almost one million people die from suicide; a "global" mortality rate

of 16 per 100,000, or one death every 40 seconds.

In the last 45 years suicide rates have increased by 60%

worldwide. Suicide worldwide is estimated to represent 1.8% of the total

global burden of disease in 1998, and 2.4% in countries with market and

former socialist economies in 2020.Although traditionally suicide rates

have been highest among the male elderly, rates among young people

have been increasing to such an extent that they are now the group at

highest risk in a third of countries, in both developed and developing

countries. (National Bureau Of Crime Records 2009).

It is estimated that over 100,000 people die by suicide in India every

year. India alone contributes to more than 10% of suicides in the world.

The suicide rate in India has been increasing steadily and has reached

10.5 (per 100,000 of population) in 2006 registering a 67% increase over

the value of 1980. In the year 2006, 12,381 people in the state of Tamil

Nadu committed suicide, of which Chennai accounts for 2427.Majority of

suicides, occur among men and in younger age groups (Vijayakumar

2007). Despite the gravity of the problem, information about the causes

and risk factors is insufficient.. Suicide attempts can be up to 10-40

times more frequent than completed suicide (Schmidtke et al., 2006). It

can then be estimated that there are at least five million suicide attempts

each year and hence suicide attempts are a major public and mental

health concern in India.

(National Bureau of Crime Records 2009)

FIG 1: WORLD MAP OF SUICIDE RATES 2009

Table 1 Incidence and Rate of suicidal deaths in India

(2005-2009)

Year Suicide Incidence

Male Female Total

Estimated

Mid-year

Population

(in lakhs)

Suicide

Rate (per

100,000)

2005 69332 41085 110417 10506 10.5

2006 70221 40630 110851 10682 10.5

2007 72651 41046 113697 10856 10.7

2008 72916 40998 113914 11028 10.8

2009 75702 42410 118112 11198 11.2 (SNEHA SUICIDE PREVENTION CENTRE)

FACTS ABOUT SUICIDE:

The suicidal intent and behaviour comprises of three forms of

self destructive acts they are:

♣ Completed suicide

♣ Attempted suicide

♣ Suicidal gestures.

The ideas thoughts and further plans about suicide are

called as suicidal ideation.

Suicide usually results from the interaction of many factors,

usually including depression. Some methods, such as guns, are more

likely to result in death, but choice of a less lethal method does not

necessarily mean that the intent was less serious. Any suicide threat

or suicide attempt must be taken seriously, and help and support

should be provided. Telephone and email hot lines are available for

people who are considering suicide.

Suicidal behavior has two dimensions. The first dimension is

the degree of medical lethality or damage resulting from the suicide

attempt. The second dimension relates to suicidal intent and

measures the degree of preparation, the desire to die versus the

desire to live, and the chances of discovery. The clinical profiles of

suicide attempters and completers overlap. Suicide "attempters"

who survive very lethal attempts, which are known as failed

suicides, have the same clinical and psychosocial profile as suicide

"completers

A suicidal person may not ask for help, but that does not mean

that help isn’t wanted. Most people who commit suicide doesn’t

want to die they just want to stop hurting. Suicide prevention

starts with recognizing the warning signs and taking them

seriously.

“People who attempt suicide are just trying to get the attention

but truth is, it does not matter if that is the motivation! If they do

not get attention, the results could be fatal! It has been clearly

established that individuals who have attempted suicide have an

increased risk for subsequent suicidal behavior. This is a

recognized risk factor. Most suicidal people will not tell anyone or

seek help but many people thinking about suicide will tell someone

of their plans and some will certainly seek professional help for

suicidal thinking.

Fig 2 Age and Gender wise profiles of those who died by suicide in India (Year: 2006)

(SNEHA SUICIDE PREVENTION CENTRE)

(National Bureau of Crime Records 2009).

Fig 3 Occupational profiles of those who died by suicide in India (Year: 2006)

When accounting the age and gender profile of suicide

attempters the males attempt suicide twice when compared to female

(fig2) (Sneha Suicide Prevention Centre). People who are self

employed and House wives were at higher rate in attempting suicide

(fig 3) (National Bureau Of Crime Records 2009).

Table 2 shows the statistics of suicide attempters at Poison Control

Training and Research centre RGGGH from (2007 to 2010)

The cause and risk factors related to suicidal attempt is always

not very clear which in turn makes the strategies and the preventive

measures more complicated. So there is an urgent need for the

Psychiatric Nurses to identify the risk factors associated with suicide

attempt.

S.NO YEAR TOTAL

1

2

3

4

2007

2008

2009

2010 till Nov

1564

1792

1827

1983

30

1.1 NEED FOR THE STUDY

The suicidal behavior is ascertained by various numbers of

personal, social and other factors. Esquirol quoted that all the person

committing suicides are insane, and Durkheim suggested that suicide

was the outcome of social problems, individual vulnerability and

social stressors. Suicide is believed to be multifactorial and

multidimensional. In our country suicide is perceived as one of the

social problem and along with this mental illness is also given same

abstractable status with maladjustment, marital conflicts …etc.

According to the W.H.O data, the reason for suicide is not known for

about 43% of suicides while illness and family problems contribute to

about 44% of suicides.

The risk of completed suicide is more among the suicide

attempters. The world wide study conducted on suicide lethality

proved that suicide attempters has 10 times more chance for

progressing to the state of completed suicide during the course of the

years (W.H.O survey).Suicide attempts are more than the completed

suicide this is due to the ignorance of the suicide attempters about its

consequences (Log raj et al 2OO6)

Suicide attempts are up to 20 times more frequent than

completed suicide. Nearly 20- 30% of registrations in hospital

emergency departments are due to attempted suicide. In India more

than one lakh lives are lost every year due to suicide. The southern

states like Kerala, TamilNadu, Karnataka and Andhra Pradesh have a

suicidal rate of 15% that is greater than the northern states where it

is than 3%.the majority of the suicidal rates (37.8%) in India are by

those below the age of 30 years. Suicidal rates are increased among

middle age men and women than others (SNEHA SUICIDE

PREVENTION CENTRE)

31

The majority of suicides (37.8%) in India are by those below the

age of 30 years. The fact that 71% of suicides in India are by persons

below the age of 44 years imposes a huge social, emotional and

economic burden on our society. The near-equal suicide rates of

young men and women and the consistently narrow male: female ratio

of 1.4: 1 denotes that more Indian women die by suicide than their

Western counterparts. Poisoning (36.6%), hanging (32.1%) and self-

immolation (7.9%) were the common methods used to commit suicide.

Two large epidemiological verbal autopsy studies in rural Tamil Nadu

revealed that the annual suicide rate is six to nine times the official

rate. If these figures are extrapolated, it suggests that there are at

least half a million suicides in India every year. It is estimated that

one in 60 persons in our country are affected by suicide. It includes

both, those who have attempted suicide and those who have been

affected by the suicide of a close family or friend. Thus, suicide is a

major public and mental health problem, which demands urgent

action (National Bureau of Crime Records 2009).

Stressful life events before the six months of attempting suicide

contributes more to the suicidal ideation among the suicide

attempters (Pompili M et al., (2007)). Low socio economic group are

more prone for attempting suicide because of lower educational

attainment, Unemployment and alcohol use Disorders. Hence, there is

need for careful assessment of risk factors for early detection and

prevention of suicidal lethality (Giupponi G et al., (2009) )

In this study the researcher takes this opportunity in identifying

the various risk factors contributing to suicide as the time is ripe for

psychiatric nurses to adopt proactive and leadership roles in suicide

prevention

32

1.2 STATEMENT OF THE PROBLEM:

Identify the risk factors associated with attempted suicide

among suicide attempters at Government General Hospital at Chennai

1.4 OBJECTIVES:

1. To describe the socio demographic characteristics of

suicide attempters

2. To identify the risk factors associated with attempted

suicide among suicide attempters

3. To assess the mental health of the suicide attempters

4. To correlate the risk factors of attempted suicide and

mental health of suicide attempters

5. To associate the risk factors of attempted suicide and

mental health of suicide attempters with selected

demographic variables

1.5 DEFINITION OF TERMS:

SUICIDE ATTEMPTERS:

It refers to a person who has made deliberate act of self harm

consciously aimed at self destruction irrespective of his / her

intention to die with non-fatal outcome

RISK FACTORS:

It refers to all the predisposing factors and the stressful life

events, perceived by an individual as the potential cause for

attempting suicide.

MENTAL HEALTH STATUS:

It refers to the mental well being of the suicide attempters for

coping and adaptation

33

1.5 ASSUMPTION:

1. Stressful life events potentiates the risk of attempting

suicide

2. Suicide attempters possess decreased level of tolerance

1.6 HYPOTHESIS:

There is a significant relationship between the risk factors

of attempted suicide with the selected demographic

variable

There is a significant relationship between the risk factors

of attempted suicide with the mental health status of the

suicide attempters

1.7 DELIMITATION OF THE STUDY:

1. The data collection period is limited to one month

only

2. Suicide attempters above the age of 20 years only

3. The samples from the department of Toxicology and

Medical Wards of GGH only

34

CHAPTER II

REVIEW OF LITERATURE

The primary purpose of reviewing relevant literature is to gain

broad background of knowledge and understanding of the information

that is related to the research problem of interest. This enhances the

researcher view about the researchable problem and gives direction to

the study

The literature found relevant and useful, has been presented in this

chapter under the following headings;

♣ Studies related to suicide

♣ Studies related to suicidal ideation

♣ Studies related to factors contributing to suicide

STUDIES RELATED TO SUICIDE

Evans S 2009 conducted a case control study to identify the

relationship between the deliberate self harm and attempted suicide.

77 cases were selected as the case group. The cases were selected

from the geographically contagious population. The results showed

that cases were very impulsive and at high risk for suicide attempt

than the control group.

Allement z 2009 performed a retrospective study at South Delhi

with the primary objective to determine the factors contributing to

suicide risk. 769 suicide attempters were selected by convenient

sampling technique, from the psychiatric department. The samples

were assessed using suicide lethality and intent scales. They

concluded that unemployment, bank mort age, marital conflicts and

impulsive behavior as the major factors for suicide risk. The results

also proved that unemployment and financial crisis were the risk

35

factors for the male suicide attempters and marital conflicts and

family problem were the risk factors for the female suicide attempters

Chavan BS 2008 conducted a psychological autopsy of 101

suicidal cases from northwest region of India .They assessed the socio

demographic characteristics, psychosocial factors and physical co

morbidity associated with completed suicide. Psychosocial stressors

were found in 61.3% of suicide victims, co morbidity was found in 39

cases. The study revealed the need of specific preventive strategies to

reduce suicide death in India

Sharma R 2008 conducted a study to assess the prevalence of

suicide among the Delhi people. A total of 550 samples were selected

by random sampling method form the out patients of private hospital.

The findings revealed higher prevalence (14.5%) of suicidal behavior

Siddhartha T 2006 assessed the suicidal behavior among the

college students in Orissa.1232 samples between the age group of 19 -

23 were selected. A self structured questionnaire on deliberate self

harm was used. The results showed that 31.4% of them had the life

time prevalence of suicidal ideation, 12.8% had attempted suicide in

their life time. The results proved higher prevalence of suicidal

ideation, and deliberate self harm among college students

Karen dineen 2006 conducted a study on cognitive factors

related to suicidal ideation and resolution. The cognitive factors of

attribution style, hopelessness and self esteem were assessed among

subjects aged 21 – 35 years (50 with and 50 without suicidal ideation).

The results revealed that suicidal ideation; attribution style became

significantly more positively contributed to suicidal risk

36

STUDIES RELATED TO SUICIDAL IDEATION

Scott M et al 2009 assessed the risk of suicide among the

college students of Columbia University. They used 641 students for

high suicide risk (recent ideation or lifetime attempt and depression,

or anxiety, or substance use) and the students were assessed with

diagnostic interview schedule. The results showed that about 96% of

the students are at high risk .The major risk factors identified were

lifetime stressors, recent depression, and substance use problems.

Mabey D 2009 conducted a study among female sex workers in

Goa (India).The objective of this study is to determine the prevalence

of suicidal behavior and its association with sex work , health

factor.326 sex workers were selected by respondent driven sampling,

an interviewer-administered questionnaire regarding self-harming

behaviors. Nineteen percent of sex workers in the sample reported

attempted suicide in the past 3 months. They concluded that Suicidal

behaviors among sex workers were common and associated with

gender disadvantage and poor mental health

Matthew K 2007 conducted a Cross-national study on

prevalence and risk factors for suicidal ideation, plans and attempts.

A total of 84,850 adults from 17 countries were interviewed regarding

suicidal behaviours and socio-demographic and risk factors. The

results showed that cross-national lifetime prevalence of suicidal

ideation, plans, and attempts is 9.2%, 60% of transitions from

ideation to plan and attempt occur within the first year after ideation

onset. The risk factors included being female, younger, less educated,

and unmarried and impulse control disorders in low- and middle-

income countries

37

STUDIES RELATED TO FACTORS CONTRIBUTING TO SUICIDE

Karl N 2010 conducted a study on risk factors associated with

suicide attempts in Orissa. totally 149 suicide attempters were

evaluated for psychosocial, situational and clinical risk factors using

the risk rescue rating scale, suicide prevention centre scale , lethality

of suicide rating scale and presumptive stressful life event scale . the

findings suggest that the suicide potential was high in almost half of

the cases , more than 80% of all attempters had psychiatric disorder

and only 31.5% had treatment . The results show that the Factors

like middle age, family history of psychiatric disorder physical illness ,

failure in examination , family conflicts , increases the risk of suicide

attempt.

(News Line 2010) reported that in a developing country like

Pakistan, where many of the 170 million people earn less than two

dollars a day, a little surge in the price of flour and edible oil can be

devastating. The suicide rate has been increased from 10.2% (2006) to

11.4% (2009). So there is greater relationship between unemployment

and poverty.

Satheesh V 2009 conducted a study to assess the psycho socio

demographic and clinical profile of suicide attempters. 1000 suicide

attempters were evaluated with the history , physical assessment ,

mental status examination and psychological assessment .The results

show that the male subjects were associated with low socio economic

class , unskilled work , past psychiatric illness and female subjects

were below 35 years , upper socio economic class , highly educated ,

had marital conflicts, failure in examination and less severe disorders.

The study revealed that male suicide attempters have more of

biological disorder, while female suicide attempters have more of

stress related disorder

Leventhal T 2009 conducted a study to determine whether

living in poor neighborhood is associated with suicidal thoughts.

38

Totally 2776 participants were selected and using Canadian census

suicidal behavior and risk factors were self reported. The results

showed suicidal thoughts were about twice as high in poor than in the

non poor neighbors. The study concluded that there is greater risk of

suicide thought and attempt among the people in poor neighborhood

Sourander A 2009 conducted a study to assess the childhood

predictors of completed and severe suicide attempts. 5302 people who

born in1981 were examined at the age of 8 years to gather information

about psychopathologic conditions, school performances, family

demographics from parents, teachers and children. Out of 8-24 years

of age, 54 males have completed suicide whereas only 27 female have

completed suicide. The results showed that there are less predictive

factors available with completed suicide among females

J Joseph et al , 2009 conducted a verbal autopsy among the

elderly members of the kaniyanbadi village, Vellore district. The

setting for the study was a comprehensive community health program

in a development block in rural South India. The main outcome

measure was death by suicide diagnosed by a detailed verbal autopsy

and census, birth and death data to identify the population base.The

average annual suicide rate was 189 per 100,000 for people over 55

years of age. The ratio of male to female suicides was 1: 0.66. The age-

specific suicide rate for men and women increased with age. Hanging

(52%) and poisoning with organo-phosphorus compounds (39%) were

the commonest methods employed for committing suicide.

Significantly more women chose drowning or burning than men who

preferred poisoning or hanging (χ2 19.75; df 1; p�<�0.001)

Aravind Pillai 2009 conducted a study among young people to

estimate the prevalence and risk factors for suicidal behavior. 3662

youth (16–24 years) from rural and urban communities in Goa, India

were selected. Suicidal behaviour during the recent 3 months and

39

associated factors were assessed using a structured interview.

Premarital sex, independent decision making, physical abuse and

alcohol use were the major independent risk factor for suicidal

behavior. They concluded that violence and psychological distress

were the dependent risk factors for suicidal attempts. Prevention

programs for youth suicide in India need to address both the

structural determinants of gender disadvantage, and the individual

experiences of violence and poor mental health.

George Davey Smith 2009 performed an Ecological study of

social fragmentation, poverty, and suicide. The aim of the study was

to investigate the association between suicide and deprivation and

social fragmentation. The results proved a strong association between

suicide and area based measures of deprivation and social

fragmentation.

Jessica R 2008, analyzed the risk factors of suicide, 693 out

patients were selected for this prospective study. Subsequent deaths

for the sample were identified through the National Death Index.

Forty-nine (1%) suicides were determined from death certificates

obtained from state vital statistics offices. Univariate analysis revealed

that severity of depression, hopelessness, and suicide ideation were

significant risk factors for eventual suicide. A multivariate survival

analysis indicated that several modifiable variables were significant

and unique risk factors for suicide, including suicide ideation, marital

conflicts, and unemployment status.

D Feskanich 2008 conducted a cohort study with 14 years of

follow up. Stress at home and at work were assessed by questionnaire

and scored on a four point scale: minimal, light, moderate, or severe.

Female nurses (n=94 110) between 36 to 61 years of age were selected

from eleven parts of USA. 73 Suicide were reported and the risk of

suicide was over eightfold among women reporting high stress or

40

diazepam use compared with those reporting low stress and no

diazepam use.

Klein J et al 2008 performed a study with the primary

objective of determining the factors contributing to suicide. Semi-

structured interview schedule was planned and patients between the

age group of 18 -70 were selected from the primary care setting. The

researchers concluded that factors contributing to suicide were

complex and majority of the factors were stress, hopelessness, family

conflicts, recent major life change event.

Fordwood Sr 2007 conducted a study to identify additional risk

factors of suicide among depressed individuals. 451 suicide

attempters were examined among the depressed between 18-31 years

of age. The results showed along with depression the environmental

stress increased the suicidal attempt

Jacob et al 2006 from the department of community health

nursing conducted a study on the rates and factors associated with

suicide in Kaniyambadi Block, Tamil Nadu. The aim of this study was

to prospectively determine the suicide rate in Kaniyambadi Block,

Tamil Nadu, and South India. The setting for the study was a

comprehensive community health programme in a development block

in rural South India. The average suicide rate was 92.1 per 100,000.

The ratio of male to female suicides was 1:0.66. The age-specific

suicide rate for men increased with age. They concluded that the

suicide rate documented is very high and is a major public health

concern.

Innamorati M 2006 the primary aims of this study was to

investigate risk factors for suicide attempts. 263 suicide attempters

admitted in the Division of Psychiatry of the Department of

Neurosciences of the University of Parma were compared with non-

attempter clinical control subjects. Multifactorial analysis

41

questionnaire was used for both the experimental and the control

group. The results were analyzed between the suicide attempters and

non-attempters, they concluded that suicide attempters life events in

the last 6months, life events during age 0-15years and their

interaction was the major factor triggering for attempting suicide.

Dr.Selwyn Stanley 2006 conducted a study to assess family

interaction patterns and the dysfunction in suicide attempters in

India. 50 suicide attempters from a private psychiatric hospital were

assessed of their family interaction as well as the extent of

dysfunctions on several domains. The result revealed that female

respondents had better family interactions than men and unmarried

respondents.

Beautrias Al 2006 conducted a study to identify the risk factors

of suicide and attempted suicide. The evidence about the risk factors

of suicidal behavior in young people was gathered by review of

articles, papers which were published since 1980s. The evidence

suggested that increase in stressful life events, childhood and family

adversity, psychopathology will increase suicidal behavior.

42

2.2 CONCEPTUAL FRAME WORK

Conceptual framework or a model helps the researcher in

identifying the flow or direction of researchable question tentatively.

This deals with convergence of various phenomenon to a common

topic. A conceptual framework helps in representing the researcher

views, interests, and ideas in a positively approachable and acceptable

way as it is a proven concept.

Betty Neumann’s system model provides holistic approach for all

the interrelated problems of the client. This system model views each

person in a multi dimensional concept. The conceptual model selected

by the researcher for the present study modified form of Betty

Neumann’s system model (1989). The main focus of this model is on

stress and consequences of stress on physiological and psychological

health of an individual.

Basic Core Structure

The basic core structure in this study comprises of physical,

psychological, social components of health of the suicide attempters.

Lines of resistance

Lines of resistance are the lines surrounding the basic core

structure of the suicide attempters. When an individual is affected by

an interpersonal, intrapersonal, and extra personal stressors they

guard themselves by adopting appropriate coping mechanisms to

support during stressful situation. In this study the suicide attempters

fails to adapt coping mechanisms to restore basic core structure.

Normal line of defense

The solid line outside the line of defense is the normal line of

defense. This line indicates the state of equilibrium developed by the

43

individual over time. In this study suicide attempters attains a state of

disequilibrium and results in failure to adaptation

Flexible line of defense

These are the dotted broken lines outside the normal line of

defense. These lines help in protecting the normal line of defense.

Strengthens the line of defense can be achieved by

a. Crisis intervention

b. Relaxation techniques

c. Anger and aggression management skill

d. Suicidal tendency management tips

e. Counseling sessions

f. Group therapy

g. Behavior modification programs

h. Soft skills and personality building programs

i. Family support

j. Divertional activities

Stressors

Neumann classified the stressors under three divisions; they are

interpersonal, intrapersonal and extra personal stressors. The intensity

and frequency of stressors determines the devastation of normal line of

defense and further leads to demolition of the basic core structure

44

Figure 4: Modified Betty Neumann’s System Model

Coping mechanisms

Preventive strategies • Crisis intervention • Relaxation techniques • Anger and aggression

management skill • Suicidal tendency

management tips • Counseling sessions • Group therapy • Behavior modification

programs • Soft skills and

personality building programs

• Family support • Divertional activities

Suicide attempters

Stressors

Interpersonal stressors • Broken relationship • Marital conflict • Family problems • Poor understanding • Pre/extra-marital

relationship

Intrapersonal stressors • Guilt • Failure • Foiling • Anger • Illness • Lack of support • Unemployment

Extra personal stressors • Financial crisis • Problems in working place • Societal isolation • Demotion • Transfer

Failure in coping

Distortion of lines of resistance

Adaptive coping

mechanisms

Strengthening of line of defense

45

CHAPTER – III

METHODOLOGY

This chapter deals with the description of research design,

variables, sample, sampling technique, inclusion & exclusion criteria,

tool description, content validity, pilot study report, data collection

procedure and plan for data analysis

3.1 RESEARCH DESIGNS

In this study the researcher selected Retrospective Descriptive study

design. Risk factors associated with attempted suicide are analyzed

after the suicidal attempt

3.2. VARIABLES

Independent variable – Risk factors of suicide

Dependent variable – Attempted suicide

Attributable variable – Age, education, monthly income,

occupation, marital status, history of suicidal exposure and attempts,

stressful life events

3.3 RESEARCH SETTING

Poison Control Training and Research Centre and medical wards at

Government General Hospital Chennai. Toxicology is the poison

control centre with research laboratory. More than 1800 cases of

attempted suicide are treated each year in this department. It is one of

the famous and the biggest poison control centres in India

3.4 STUDY POPULATION

Suicide attempters admitted in the toxicology and medical wards at

GGH

46

3.5 SAMPLE CHARACTERISTICS AND SELECTION

3.5.1. Sample Size

100 patients of suicide attempters with non –fatal outcome

admitted at Toxicology and medical ward

3.5.2. Sampling Criteria

Sampling Criteria

Inclusion criteria:

1. Clients with the history of attempted suicide

2. Clients above the age of 20 years

3. Clients whose general health condition is stable

4. Clients who are willing to participate in this study

5. Clients who can understand Tamil & English

Exclusion criteria:

1. Clients with the history of burns

2. Clients with hearing impairment

3. Client with diagnosis of psychiatric disorders

3.5.3. Sampling Technique

The samples admitted in the poison control and research centre

for each day were less than 10; the samples fulfilling the sampling

criteria were minimal. So all suicide attempters admitted in the poison

control and research centre and Medical wards at RGGGH who

fulfilled the sampling criteria were conveniently selected and

interviewed by the researcher for this study

3.6 TOOLS USED FOR DATA COLLECTION

The tools selected for this research study are:

♣ Socio-Demographic Information Schedule

♣ Pre- Designed Proforma for Assessing Personal History,

History of Past Illness, Family History of Suicide, No. Of.

Suicide Attempts ,Pre/Extra-Marital Relationship, Religiosity

♣ The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)

47

♣ Modified recent life events checklist( Miller And Rahe 1995)

3.7. DESCRIPTION OF THE TOOLS AND SCORING TECHNIQUE

1) Socio-demographic Information Schedule

Socio demographic information schedule was developed by the

researcher itself for the present study. It has 8 questions, data

regarding age, sex, occupation, education, marital status, domicile,

religion are included in this schedule

2) Pre Designed Proforma

This predesigned Proforma was developed by the researcher itself to

get the additional information regarding the personal habits, long term

illness, number of suicidal attempt, family history of suicidal

attempts, social support, type of marriage, pre/ extra relationship, pre

–dominant mood, failure(love exam others), religiosity. These

questions are included to compare the stressful life events with these

data to demarcate the risk factors appropriately

3)a. Modified recent life events scale

In 1967, psychiatrists Thomas Holmes and Richard Rahe examined

the medical records of over 5,000 medical patients to determine

whether stressful life events might cause illnesses. Patients were

asked to tally a list of 43 life events based on a relative score. A

positive 0.1 correlation was found between their life events and their

illnesses. Thus, the Social Readjustment Rating Scale (SRRS) or the

Holmes and Rahe Stress Scale were born. Each event, called a Life

Change Unit (LCU), had a different "weight" for stress. The more

events the patient added up, the higher the score. The higher the

score, and the larger the weight of each event, the more likely the

patient was to become ill. Miller and rahe in the year 1995 modified

the SRRS and grouped the question under five dimensions which was

called as the miller and rahe recent life change event questionnaire.

This questionnaire provokes information about the life change event

48

contributed to suicide attempt .Totally it consists of 55 questions

divide under five dimensions / factors

1. HEALTH

2. WORK

3. PERSONAL AND SOCIAL

4. HOME AND FAMILY

5. FINANCIAL

Each life change event is provided life change unit (scores)

• Low – if score is below 100

• Mild - if score is between 101-150

• Moderate - if score is between 151-200

• High - if score is above 200

ABOVE 200: This score indicates a major life crisis and is highly

predictive (80%) of serious physical illness within the next 2 years.

FROM 151 TO 200 POINT: Moderate life crisis. 50% chance of illness

such as: headache, diabetes, fatigue, hypertension, chest and back

pain, ulcers, infectious disease etc

FROM 100 TO 151POINTS: Mild life crisis. 33% chance of illness such

as: headache, diabetes, fatigue, hypertension, chest and back pain,

ulcers, infectious disease etc.

If the score is below 100 - no significant crisis

3) b. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)

This scale helps in assessing the mental well being of the individual.

Totally it consists of 14 questions , in a 5 point scale from 1-5. This

scale explores the mental well being of the clients

♣ None of the time - 1

♣ Rarely - 2

♣ Some of the time - 3

49

♣ Often- 4

♣ All of the time – 5

Interpretation

a. More than 50 = mentally healthy

b. 50 – 30 = moderately mentally healthy

c. Below 30 = mentally unhealthy

4) Interview with suicide attempters

Ten suicide attempters were interviewed separately to determine

the various factors contributing to suicide attempt

3.8 CONTENT VALIDITY

After construction of questionnaire for “Identify the risk factors

associated with attempted suicide among suicide attempters at

Government General Hospital, Chennai” It was tested for its validity

and reliability. Content validity was obtained from various experts

from the field of Nursing, Medicine, and psychology. They suggested

certain modifications in tool. As per the suggestions given by them

corrections were made in the socio demographic schedule and also in

the predesigned Proforma.

After pilot study reliability of the tool was assessed by using

Cron bach Alpha method. Risk factors questionnaire reliability was

assessed using Cron bach Alpha method and its correlation

coefficient value is 0.82. Mental health questionnaire reliability was

assessed using Cron bach Alpha method its Alpha coefficient value

is 0.80. These correlation coefficients are very high and it is good tool

for assessing risk and mental health.

50

3.9 PILOT STUDY REPORT

A pilot study was conducted to check the feasibility, reliability

and validity of the tool. After the pilot study the researcher found that

the questionnaire took approximately 30 – 40 minutes to administer

and was easy to collect the needed information

3.10. DATA COLLECTION

To conduct the study permission was obtained from the Head of

the department Toxicology and medical wards at Government General

Hospital Chennai. The data collection period was from 16/12/2010 to

15/01/2011. Suicide attempters fulfilling the selection criteria were

selected and was interviewed between 9am to 5pm. Informed consent

was obtained from all the samples. About 3 -5 patients were

interviewed each day for about 30 -40 minutes

3.11. PLAN FOR ANALYSIS OF DATA

♣ Percentage, mean and standard deviation to identify the risk

factors

♣ Chi-square to associate the identified risk factors with selected

demographic variables

♣ Karl person correlation method to correlate mental health of

suicide attempters and risk factors of attempted suicide

3.12. PROTECTION OF HUMAN SUBJECTS

The proposal was approved by the experts prior to the pilot study and

permission for conducting the main study was obtained from the Head

of the Department, Department of Mental Health Nursing, College of

Nursing, Madras Medical College, Chennai-03 and Head of The

Department of Toxicology at RGGGH Chennai. The study proposal was

presented before the members of the ethical committee. Acceptance

was given by the panel of members to precede the study. An informed

consent was obtained from the study participants, assurance was

given to them that confidentiality and privacy would be maintained.

51

SSCCHHEEMMAATTIICC RREEPPRREESSEENNTTAATTIIOONN OOFF TTHHEE SSTTUUDDYY

Research Approach

(Quantitative Approach)

Research Design

(Retrospective study Design)

Target Population

(Suicide attempters)

Accessible Population

(Suicide attempters admitted at RGGGH Chennai)

Sample

(suicide attempters admitted in PCTRC and medical wards)

Sample Size

(100 suicide attempters)

Sampling Technique

(Convenience Sampling)

Tool

(Recent life change event questionnaire)

Analysis and Interpretation (Descriptive and Inferential Statistics)

Findings of the Study

52

CHAPTER IV

DATA ANALYSIS AND INTERPRETATION This chapter deals with the detailed description of the data

gathered from the suicide attempters admitted at Poison Control

Training and Research Centre RajivGandhi Government General

Hospital. The data were analyzed based on the objectives formulated

by the researcher. The analyzed data are tabulated under tables and

figures under the sections given below

SECTION I:

A. This deals with description about the socio- demographic

characteristics of the suicide attempters

B. This deals with the description of data from the pre-

designed Proforma

SECTION II: This deals with the risk factors associated with

attempted suicide among suicide attempters

SECTION III: This deals with the analysis of mental well being of the

suicide attempters

SECTION IV: This deals with correlation of the risk factors of

attempted suicide with mental health status of suicide attempters

SECTION V: This deals with the association of the risk factors and

mental health of suicide attempters with selected demographic

variables

53

Section I: A:

Table 3: The demographic information of suicide attempters

Among the samples higher proportion of them were from the age

group of 31-40 yrs, majority of the samples 65% were males, only 9% of

them were graduates, nearly half of them were unemployed. Among the

employed 23.1% were self employed and only 5.8% were from Government

sectors. When considering the place of residence more than half of the

samples 56% were from rural area

Socio-demographic

characteristics

No. of

persons %

20 -30 yrs 31 31.0% 31 -40 yrs 56 56.0%

Age

41 -50 yrs 13 13.0% Male 65 65.0% Sex Female 35 35.0% Primary 12 12.0% High school 47 47.0% Higher secondary 13 13.0%

Graduate 9 9.0%

Education

Non formal education 19 19.0%

Employed 52 52.0% Occupation Unemployed 48 48.0% Private 20 38.5% Government 3 5.8% Self business 12 23.1%

Nature of working place

Agriculture 17 32.7% < Rs.3000 11 11.0% Rs.3000 -4000 18 18.0% Rs.4000 -5000 30 30.0%

Income

>Rs.5000 41 41.0% Rural 56 56.0% Urban 25 25.0%

Domicile

Sub urban 19 19.0% Hindu 66 66.0% Christian 24 24.0%

Religion

Muslim 10 10.0%

54

SECTION I: B

Table 4: The personal information of suicide attempters from the pre-

designed Proforma

Personal information of

suicide attempters from

pre- designed Proforma

No. of

persons %

Marital status

Single 22 22.0%

Married 78 78.0% Type of marriage

Arranged marriage 53 67.9%

Love marriage 15 19.2%

Love cum arranged 10 12.8%

Age at marriage

< 20 yrs 34 43.6%

20 -25 yrs 37 47.4% > 25 yrs 7 9.0% Family type Nuclear

family 56 56.0%

Joint family Extended family

32 12

32.0% 12.0%

Family history of suicidal attempt

Present Absent Do not know

35 56 9

35.0% 56.0% 9.0%

No. Of suicide attempt

1st attempt 2nd attempt >2nd attempt

52 42 6

52.0% 42% 6%

Among the samples higher proportion 78% of them were married ,

among them 67.9% of them married by arranged marriage, only 9% of them

were married after 25 years of age and more than half of them 56% were

living in nuclear family. About 35% of the samples had the familial history of

suicidal attempt. Nearly half of them 52% attempted suicide for the first

time

55

FIG 5: PERSONAL HABITS OF THE SUICIDE ATTEMPTERS

Among the suicide attempters 39% of them had the habit of smoking and alcohol consumption

56

SECTION II

Table 5: LEVEL OF CRISIS (LIFE CHANGE EVENTS)

H

Higher proportion of the samples 67% of them had

experienced high level of crisis in their life before the suicidal

attempt

score No. of persons %

Low 0 0.0%

Mild 15 15.0%

Moderate 18 18.0%

High 67 67.0%

Total 100 100%

57

FIG 6: ANALYSIS OF RISK FACTORS ASSOCIATED WITH ATTEMPTED SUICIDE AMONG SUICIDE ATTEMPTERS

Among suicide attempters higher proportion 72% of them considered stressors from home and family as the major

factor for suicidal attempt

58

SECTION III

FIG 7: MENTAL WELL BEING OF THE SUICIDE ATTEMPTERS

More than half of the suicide attempters 56% were not mentally healthy

59

SECTION IV

Table 6: CORRELATION BETWEEN LEVEL OF RISK FACTOR AND MENTAL HEALTH STATUS

MENTAL HEALTH STATUS

Mentally

healthy

Moderately mentally

healthy

Mentally

unhealthy

n % n % n % n

Pearson chi

square test

Mild 2 13.3% 8 53.3% 5 33.3% 15

Moderate 2 11.1% 6 33.3% 10 55.6% 18

High 0 00.0% 26 38.8% 41 61.2% 67

Leve

l of

risk

fac

tor

Total 4 40 56 100

χ2=10.81

P=0.02*

DF=4

significant

* significant at P<0.05 ** highly significant at P<0.01 *** Very high significant at P<0.001

As the crisis level increases the mental well being of the samples decreases. So, level of risk factors and

mental health were significantly associated.

60

SECTION V

TABLE 7: ASSOCIATION BETWEEN TYPE OF FAMILY AND MENTAL

HEALTH

WEMWBS

Mentally

healthy

Moderately

mentally

healthy

Mentally

unhealthy

Family Type

n % n % n %

n

Pearson

chi square

test

1

Nuclear

family

1 1.8% 25 44.6% 30 53.6% 56

2

Joint

family

2 6.3% 14 43.8% 16 50.0% 32

3

Extended

family

1 8.3% 1 8.3% 10 83.3% 12

χ2=5.54

P=0.04

DF=4,

significant

* significant at P≤0.05 ** highly significant at P≤0.01 *** very high significant at P≤0.001

More than half of the samples 53.6% living in nuclear family was

mentally unhealthy thus; samples from the nuclear family were at high risk

in attempting suicide.

61

FIG 8: ASSOCIATION BETWEEN LEVEL OF RISK FACTORS AND AGE OF

SUICIDE ATTEMPTERS

Younger age group were at high risk for suicidal attempt

62

FIG:9 ASSOCIATION BETWEEN LEVEL OF RISK FACTORS AND OCCUPATION STATUS OF SUICIDE

ATTEMPTED

Unemployed samples were at high risk for stressful events and suicidal attempt

63

FIG 10 ASSOCIATION BETWEEN OCCUPATION STATUS AND MENTAL HELATH STATUS

Majority of the unemployed samples 68.8% were mentally unhealthy than the employed samples

64

FIG 11 ASSOCIATION BETWEEN MARITAL STATUS AND LEVEL OF RISK FACTORS

Unmarried samples were at high risk for suicide were compared with married samples

65

FIG 12 ASSOCIATION BETWEEN WORKING HOURS AND LEVEL OF RISK FACTORS

Samples worked for longer hours were at high risk for suicidal attempt

66

FIG 13 ASSOCIATION BETWEEN PROBLEMS AND LEVEL OF MENTAL HEALTH STATUS

Samples with family and financial problems were mentally unhealthy when compared with the samples

with out those problems

67

FIG 14 ASSOCIATION BETWEEN MARITAL STATUS AND LEVEL OF MENTAL HEALTH

Marital status was significantly associated with their level of mental well being. Unmarried samples were

mentally unhealthy when compared with the samples married samples

68

FIG 15 ASSOCIATION BETWEEN WORKING HOURS AND LEVEL OF MENTAL HEALTH

Samples worked for long hours of duration were at higher risk for suicidal attempt

69

CHAPTER V

DISCUSSION

This chapter deals with detailed description of the study findings

gathered from the statistical analysis. Suicide is becoming one of the

leading causes of death in all countries. The unfortunate thing is its

causes and risk factors still not unfolded. The data gathered from the

suicide attempters reveal various factors contributing for the attempt,

the data are statistically analysed and findings are discussed under the

objectives formulated by the researcher.

The first objective of this study is to describe about the socio-

demographic variables of the suicide attempters

Higher proportion of the samples participated in this study were

between the age group of 31-40 yrs, about 65% of the study samples

were males, when comparing their marital status into account majority

of the samples 78% were married, only 9% of them were married after 25

years of age and more than half of them 56% were living in nuclear

family and only 9% of the samples were graduates and 47% of the

samples had high school education in this about 52% that is nearly half

of the samples only were employed, about 41% of the samples monthly

income was more than 5000 rupees. Majority of the study samples 66%

were Hindu and 56% of the samples were from rural area

When taking the details of pre-designed Proforma higher

proportion for the samples 39% of them had both the habits of

alcoholism and smoking. Higher proportion of the samples 52% had no

significant history of suicide in their family

70

The second objective of this study is to identify the risk factors

associated with attempted suicide among suicide attempters

The risk factors were analysed using Miller and Rahe recent life

change unit scale. When studying each domain in separate heading the

samples were at least risk for suicidal attempt due to health, minimal of

them considered troubles of work as the precipitating factor for the

suicidal attempt, but majority of the samples 72% considered problems

related to home and family as the major factor for their attempt, and the

second major dimension of risk was social and personal problems

The study conducted by Klein J et al 2008, with the primary

objective of determining the factors contributing to suicide by Semi-

structured interview schedule for the patients between the age group of

18 -70 selected from the primary care setting, supports the present study

by concluding that factors contributing to suicide were complex and

majority of the factors were stress , hopelessness, family conflicts, recent

major life change event.

The study conducted by Aravind Pillai (2009) in Goa among

young people to estimate the prevalence and risk factors for suicidal

behavior also supports this study. They concluded that Premarital sex,

independent decision making, physical abuse and alcohol use as the

major independent risk factor for suicidal behavior and violence and

psychological distress as the dependent risk factors for suicidal attempts.

This study supports both the second and the third objective of this

study. Firstly, the marital status, alcohol use were identified as the risk

factor in both the studies. Secondly, psychological distress was also

identified as the risk factor for suicidal attempt

71

The third objective of this study is to assess the mental health

status of the suicide attempters

The mental health of an individual is the major component in

perceiving an event as a stressor. The mental well being of the suicide

attempters was analysed using The Warwick-Edinburgh Mental Well-

being Scale. Only 4% of the suicide attempters participated in this study

mentally healthy, less than half of the samples were moderately mentally

healthy, more than half of the samples 56% were mentally unhealthy.

The mental health is very important for any individual to handle

situations during crisis when the mental health is devastated, no

individual can overcome even a mild crisis. The mental health described

here is definitely not an illness or a disorder as it is one of the component

of health.

The study conducted by Henrikenson MM et al (2007) among

suicide attempters at certain parts of America disclosed that 59% of the

samples participated in the study were mentally unhealthy and 39% of

them consulted psychologists at least once, before six months from the

suicidal attempt. This study supports the researchers report as nearly

half of the attempters 56% were not mentally unhealthy.

The fourth objective is to correlate the risk factors of attempted

suicide and mental health status of suicide attempters

The risk factors and the mental health status of the suicidal

attempters were significantly correlated with each other. As the crisis

level increases, the mental well being of the samples decreases.

Whenever an individual in a crisis the mental health of them gets

distorted eventually the coping mechanism fails. In this study 61% of

them showed good negative correlation to risk factor and mental health

72

status. So the mental health status of the suicide attempters is inversely

proportional to the risk factor.

The fifth objective is to associate the risk factors of attempted

suicide and mental health of suicide attempters with selected

demographic variables

When associating the risk factor with the demographic variables

80.6% of the samples belonging to the age group of 21-30 yrs were at

high risk than the samples between the age group of 31-40 yrs 66.1%

and only 38.5% of the samples participated between the age group were

at high risk for suicidal attempt. The finding is people from younger

group were at high risk for suicidal attempt

When associating the occupational status with the risk factors

nearly 75% of the unemployed samples participated in this study were at

very high risk with high level of crisis. So unemployment was identified

as one of the major risk factor for suicidal attempt. In the same way

68.87% of the unemployed samples participated in this study were

mentally unhealthy.

The study of Allement z 2009 ,a retrospective study at South

Delhi with the primary objective to determine the factors contributing to

suicide risk.769 suicide attempters were selected by convenient sampling

technique, from the psychiatric department. The samples were assessed

using suicide lethality and intent scales. They concluded that

unemployment, bank mortage, marital conflicts and impulsive behavior

as the major factors for suicide risk. The results also proved that

unemployment and financial crisis were the risk factors for the male

suicide attempters and marital conflicts and family problem were the risk

factors for the female suicide attempters.

73

This study supports the findings of the present study where

unemployment played the major role as the risk factor for the suicidal

attempt. People irrespective of their gender they become even more

stressed when there are unemployed. This is one of the social issue

where in many people all over India commit suicide because of

unemployment. The reasons for it vary according the states and

individual issues. When a man/ woman is unemployed their level of

stress increases due to increased needs, demand, role expectation and

social guilt. The researcher identified unemployment as the major risk

factor for suicidal attempt

Accounting the mental health 5.8% of the employed were mentally

healthy and only 2.1% of the unemployed were mentally healthy. Both

the risk factor and mental health status of the unemployed was

significantly associated with the unemployment. Unmarried samples

were at risk when compared with the married samples. Marital status

was significantly associated with the risk factor with the P value of 0.04.

A Cross-national study on prevalence and risk factors for suicidal

ideation, plans and attempts conducted by Matthew K 2007, regarding

suicidal behaviors and socio-demographic and risk factors. The results

showed that cross-national lifetime prevalence of suicidal ideation, plans,

and attempts is 9.2%, 60% of transitions from ideation to plan and

attempt occur within the first year after ideation onset. The risk factors

included being male, younger, less educated, and unmarried and impulse

control disorders in low- and middle-income countries. This study also

supports the researcher findings in this study, when people are young

there are very impulsive in handling situations. Young age pre disposes

them to many unanswered questions in the society. The next factor is

being single i.e., unmarried persons are more prone for the suicidal

attempt, this may be because of lack of support from the family, in this

74

study also more than 70% of the samples perceived lack of support in

that above 40% of them consider their supportive persons as friends and

not family members. So, supportive services need to be improved for

vulnerable groups.

Leventhal T 2009 conducted a study to determine whether living

in poor neighborhood is associated with suicidal thoughts. Totally 2776

participants were selected and using Canadian census suicidal behavior

and risk factors were self reported. The results showed suicidal thoughts

were about twice as high in poor than in the non poor neighbors. He

conclude that there is greater risk of suicide thought and attempt among

the people in poor neighborhood

This study support the findings of the researcher, majority of the

samples from the lower socio economic group were mentally unhealthy

and being mentally unfit is also one of the risk factor for attempting

suicide

Samples from the nuclear family significantly associated with the

mental health i.e samples from nuclear family were mentally unhealthy

when compared to samples from joint family and extended family. 64.5%

of the samples with problems were mentally unhealthy in that only

1.60% of them were mentally healthy. When associating the marital

status with mental well being 77.3% of the unmarried samples were

mentally unhealthy, Marital status was significantly associated with their

level of mental well being with the P value of 0.05

In this study the researcher has identified the risk factors of

attempted suicide as younger age, unemployment, unmarried persons,

living in nuclear family, habits of smoking and alcoholism, stressors

from home and family.

75

CHAPTER-VI

SUMMARY AND CONCLUSION

6.1. SUMMARY

According to the World Health Organization, suicide is the world’s

13th leading cause of death. It is estimated that over 100,000 people die

by suicide in India every year. India alone contributes to more than 10%

of suicides in the world. The suicide rate in India has been increasing

steadily and has reached 10.5 (per 100,000 of population) in 2006

registering a 67% increase over the value of 1980.

A suicidal person may not ask for help, but that does not mean

that help isn’t wanted. Most people who commit suicide doesn’t want to

die they just want to stop hurting. Suicide prevention starts with

recognizing the warning signs and taking them seriously. In this study

the researcher took this opportunity in identifying the risk factors for

attempted. The non fatal outcome of suicidal attempt is called attempted

suicide. Though the factors contributing for suicidal attempt are vivid,

the researcher has taken all the steps in identifying the risk factors for

suicidal attempt with the help of the available samples.

76

The research approach used in this study was non – interventional

study, retrospective descriptive study design was the research design

used. 100 suicide attempters from Poison Control Training and Research

centre and medical wards at RGGGH were conveniently selected for this

study. The tools used for this study were socio-demographic schedule,

pre designed Proforma to collect the details regarding the samples

personal information, Miller and Rahe recent life change questionnaire

for collecting details regarding stressful events, The Warwick-Edinburgh

Mental Well-being Scale to assess the mental well being of the samples.

The tool was also tested for the content validity and reliability prior

to the study. Subsequently, a pilot study was conducted and it was

found that, the tool was feasible and practicable. The data collection

period was from 16/12/2010 to 15/01/2011. Suicide attempters’

fulfilling the selection criteria were selected and was interviewed between

9am to 5pm. Informed consent was obtained from all the samples. About

3 -5 patients were interviewed each day for about 30 -40 minutes.The

data collected were analyzed using mean, Pearson correlation method

and association by chi- square method. The collected data were entered

in a master sheet and computerized and analyzed and interpreted in

terms of the objectives using descriptive and inferential statistics.The

data was tabulated under tables and figures and detailed discussion was

executed with suitable literature reviews

6.2. Major findings of the study

Among the study subjects (56%) were from the age group of

31 – 40 yrs.

Higher proportion of the samples (65% )of them were males

Majority of the study subject (78.0%) were married.

Among the study subjects (47.0%) were educated up to high

school level.

77

Among the study subjects (41.0%) were earning more than

5000 rupees/ month.

More than half of the study subjects (56%) were from rural

community.

Among the study subjects nearly (39%) had the habit of both

smoking and alcoholism

There was a negative correlation between the risk factors

and mental health of the suicide attempters

Among the study subjects nearly (67%) of them had high

level of crisis

People at younger age group were at higher risk for suicidal

attempt

More than half of the study samples (56%) were mentally

unhealthy

There was significant association between unemployment

and risk factors

There was significant association between the younger age

and risk factors

There was significant association between unemployment

and the mental health status

6.3. CONCLUSION

The present study has identified the various risk factors for

suicidal attempt they were younger age group, unemployment,

unmarried people, nuclear family and stressful life events including

problems in home and family. The identified factors are generalisable

because of the increased sample size.

6.4. IMPLICATIONS OF THE STUDY

The investigator had drawn the following implications from the

study, which is important concern in the field of nursing research

78

Nursing Practice

Nurses trained in stress management and crisis intervention

techniques are very essential in minimizing the loss due to suicide.

Clients admitted either for an illness or for rehabilitation or during the

convalescence period needs to be observed effectively. So, imparting

knowledge regarding suicide is very much essential

Nursing Administration

The role of nurse administrator in suicide is many. She must

encourage his subordinates in conducting various studies on suicide.

She must also organize journal presentation, seminar, discussion

sessions, continuing education programs and visits to suicide prevention

centre

Nursing Education:

Crisis intervention is one of the primary responsibilities of the

psychiatric nurses. Educating them regarding the behaviors of suicidal

client, techniques of counseling in handling suicidal client is very much

essential in making them wise for handling all critical situations.

Nursing Research

Many studies can be conducted in the field of nursing research

Research studies can be conducted in early identification of

suicidal tendencies by conducting longitudinal studies among

high risk group

Research studies can be conducted on various therapies for

suicidal ideation and prevention.

Comparative research studies can be conducted in identifying the

relationship between personality traits and suicidal ideation

79

This study will motivate the future researchers for conducting

various studies based on suicide prevention strategies

6.5. RECOMMENDATIONS

Psychiatric nurses should be appointed in all schools and colleges

for early prevention and management of suicidal tendency

Many hot lines can be served for suicide prevention programs

Counseling sessions, group therapy, and behavior modification

programmes can be conducted for suicide attempters to prevent

further attempt

Suicide prevention programmes can be conducted in schools,

colleges and in all health care institutions

Suicide prevention modules can be developed for each age group to

act appropriately

6.6. SUGGESTIONS FOR FUTURE RESEARCH:

The researcher takes this opportunity in suggesting future

recommendation for this type of study

Similar studies can be conducted with sample replica in various

settings including both government and private organizations

Similar studies can be conducted for identifying the prevalence of

suicidal tendencies

Similar studies can be conducted with preventive strategic

measures for people during crisis situation.

Similar studies can be conducted among high risk and vulnerable

groups

The risk factors can be compared with different age groups and

areas after specific period of time

6.7. LIMITATION OF THE STUDY

80

Details regarding supportive services were not discussed

The details regarding pre/extra marital relationship was not

sufficient

The study was limited only with the suicide attempters, if the

supportive persons were included still more information regarding

the risk factors could be identified.

81

BIBLIOGRAPHY

BOOK REFERENCE

1. Agrawal,K.N. (2005). Pediatrics and neonatology. India: Modern Publishers.pp.155 –

210.

2. Angela Gillis.,&Winston Jackson. (2002). Research for nurses – methods and

interpretation. Philadelphia: F.A. Davis company. pp. 450-466.

3. Annamma Jacob. (2008). A comprehensive textbook of Midwifery .India: Jaypee brothers

.pp.487 – 529.

4. Basavanthappa,B.T. (2003). Nursing Education. New Delhi: Jaypee brothers medical

publishers .pp. 37.

5. Beth Richardson. (2006). Pediatric Nurse practitioners. Missouri: Mosby .pp.21 – 27.

6. Carol, C. Manacenee.(2004).Understanding nursing research –reading and using

research in practice. Philadelphia: Lippincott William and wilkins.pp. 114-119.

7. Carole kenner, & Jacqulaine, M. MC Grath .(2004). Development care of newborns &

infants: A guide for health professionals. USA: mosby. pp. 15- 41.

8. Colleen,P. Andreoni., & Beverly klin Khammur. (2000). Pediatric emergency nursing

.Piladelphia: W.B.Saunders company .pp. 44 – 45.

9. Dawn, C.S. (2004) .Textbook of obstetrics and neonatology. India: Dawn books.pp. 285 –

290.

10. Donald ,M.,&Mc. Burney .(2003). Research method. Australia: Thomason Asia

publisher.pp. 169-182.

11. Dorothy,R.marlow., & Barbara,A. Redding .(2006). Textbook of pediatric nursing. India:

Saunders .pp. 345- 500.

12. Emily slone M.C. Kinne. (2005) .Maternal child nursing .Missouri: Elsevier .pp. 78 – 89.

82

13. Gerald, B.Merenstein., & Sandra, L. Gardner .(1998). Handbook of neonatal intensive

care .Missouri : Mosby .pp. 76,743.

14. Geri Lobiondo – wood., & Tuddith ,Haber .(2006). Nursing research method and critical

appraisal for evidence – based practice. Missouri: Mosby .pp. 317-335.

15. Ghai, O.P. et al. (2003).Text book of paediatrics. India: Mehta Publishers .pp. 130 – 138.

16. James., & Fain Reading. (2004).Understanding & applying nursing

research.Philadelphia: F.A.Davis company. pp. 143-164.

17. Kadar Parahoo. (2006).Nursing Research Principles, process and issues.New York:

Palgrave Macmillan.pp. 55-65.

18. Marie, Jaffe. (1998) .Pediatric nursing care plans. Africa: Delmar .pp. 433 – 439.

19. Marilyn, J.Hockenberry.,& David Wilson. (2009). Essentials of pediatric Nursing. India:

mosby. pp.173 – 175.

20. Meharban Singh. (2004). Care of newborn .India :Sagar publication.pp. 1-65.

21. Nancy, L.Herban Hill., & Linda M.Sullivan. (2004). Management Guidelines for nurse

practitioners .Philadelphia. F.A.Davis company .pp. 16.

22. Nancy burns. & Susan K. Grove. (2007). Understanding nursing research. Missouri:

Saunders .pp. 339-396.

23. Nancy,T. Hatfield. (2003) .Introductory pediatric Nursing. Philadelphia: Lippincott

williams & wilkins .pp.107 -122.

24. Nicki, L.Potts., & Barbara,L .Mandleco. (2002) .pediatric nursing: Caring for children

and their families. Australia : Delmar .pp. 165 – 180

25. Panda, U.N. (1997) .Review of pediatrics. India: Jaypee brothers .pp.35 – 55.

26. Parthasarathy, A. (2010) .IAP textbook of pediatrics. India: Jaypee borthers.pp. 65 -70.

27. Parul Dutta .(2009). Pediatric Nursing. India: Jaypee brothers .pp. 109 -112.

83

28. Polit. F.,& Charyl Tatano back .(2004). Nursing research principles and methods. New

Delhi: Lippincott Williams and Wilkins .pp. 317-444.

29. Rose Marie. (2009). Foundations of nursing research.New Delhi: Pearson

education.pp.210-261.

30. Sachdev, H.P.S. et al. (2004) .Principles of pediatric and neonatal emergencies. India:

Jaypee brothers .pp. 8- 12.

31. Sally huband., & Ethel Trigg. (2002). Practices in children’s nursing: Guidelines for

hospital & Community. Edinburgh: Churchill livingstone .pp. 132 – 139.

32. Susan Rowen, James. (2002) .Nursing care of children: Principle & practice.

Pennsylvania: W.B.Saunder company .pp. 97 – 116.

33. Susan Scott Ricci. (2007). Essential of maternity, newborn and women’s health nursing

.Philadelphia: Lippincott Williams & Wilkins. pp.639 – 645.

34. Suraj Gupte .(2000). The short text book of pediatrics. India: Jaypee brothers .pp. 15- 25.

35. Suraj Gupte. (2004). Recent advance in pediatrics. India: Jaypee brothers.pp. 360 – 368.

36. Tambulwadkar, R.S. (2005) .Pediatric Nursing. India: Vora medical publication .pp.49 –

70.

37. Tom Lissauer & Graham clayden .(2001). Illustrated textbook of pediatrics. Edinburgh:

Mosby .pp. 119 – 135.

38. Viswanathan.J., & Desai,A.B.(2006) .Textbook of pediatrics .India: orient longman .pp.

165 – 220.

JOURNAL REFERENCE

1. Bergh, A.M., et al. (2005).Measuring implementation progress in kangaroo mother care.

A care of pediatrics. 94(8). 1102 – 1108.

2. Bergh, A.M., & Pattinson, R.C. (2003) .Development of a conceptual tool for the

implementation of Kangaroo mother care. A care of pediatrics. 92(6). 709 – 714.

84

3. Bergman,N.J., et al .(2004) .Randomized controlled trial of skin to skin contact from

birth versus conventional incubator for physiologic stabilization in 1200 to 2199 gram

newborns.A care of pediatrics. 93(6) 779 – 785.

4. Bergaman.N.,et al. (2003) ..Fourth international workshop on kangaroo mother care.

Journal on Tropical pediatrics .49(5). 311 - 322.

5. Burkhammer, M.D., et al. (2004) .Grief, anxiety, still birth, and perinatal problems.

Journal on obstetrics gynecology neonatal nurses. 33(6) .774 – 782.

6. Charpark. N., et al .(2005) “Kangaroo mother care : 25 years after. A care of pediatrics.

94(5). 514- 522.

7. Chwo M.J., et al. (2002) .A randomized controlled trial of early kangaroo care for

preterm infants: effects on temperature, weight, behaviour and acuity. Journal of Nursing

Research, 10(2). 129-142.

8. Dodd, V.L. (2005) .Implication of Kangaroo care for growth and development in preterm

infants. Journal of obstetrics gynecology neonatal nurses. 34(2). 218 – 232.

9. Dzukou, T., et al. (2004). Kangaroo mother care: review on the current attitudes, their

interests and their limits. A research on pediatrics. 11(9) 1095 – 1100.

10. Elliott, D. (2002). Kangaroo care .Journal on maternal child nurses .27(6). 357.

11. Feldman,R., et al .(2003). Skin to skin contact accelerates autonomic and

neurobehavioural maturation in preterm infants. Development medical child neurology.

45(4). 274 - 281.

12. Feldman,R., et al.(2002) .Comparison of skin to skin and traditional care :parenting out

comes and preterm infant development .Journal on pediatrics. 110(1) .16- 26.

13. Feldman.R.,et al. (2002). Kangaroo care promotes self regulation in infants sleep wake

cyclicity , arousal modulation and sustained exploration. Developmental psychology.

38(2). 194 – 207.

85

14. Ferber,S.G., & Makhoul .I.R. (2004). The effect of kangaroo care shortly after birth on

the neuro behavioural responses of the term newborn.Journal on pediatrics .113(4). 853 –

865.

15. Fohe, K., et al. (2000). Skin to skin contact improves you exchange in infants. Journal of

perinatology. 20(5). 311 - 315.

16. Furaln, C.E., et al. (2003) .Perception of parents in experiencing the kangaroo mother

method. Developmental psychology. 11(4).113-116.

17. Ibe, O.E., (2004) .A comparison of kangaroo mother care and conventional incubator

care for thermal regulation of infants. A Journal on tropical pediatrics. 24(3). 245 – 251.

18. Johnson , A.N. (2005) .Kangaroo holding beyond the NICU. Pediatric Nurses. 31(1). 53

– 56.

19. kadam,S., et al. (2005). Feasibility of kangaroo mother care in Mumbai.Indian Journal of

pediatrics .72(1) .35 – 38.

20. kambarami, R.A., et al .(2002) .Care giver’s perception and experiences of kangaroo care

in a developing country. Tropical doctors. 32(3). 131 – 133.

21. Karl heinzbrisch., et al. (2005) .Attachment quality in low birth weight infants in relation

to maternal attachments and neurological development .5(14). 311 – 331.

22. Knobel, R., et al. (2010). Thermoregulation and heat loss prevention after birth.

Advanced neonatal care .14(5).

23. Kristen, G.F., et al. (2001). Kangaroo mother care in the nursery. Pediatrics clinical

North America. 48(2). 443- 452.

24. Lai, H.L., et al. (2005). Randomized controlled trail of kangaroo care on maternal state

anxiety and infants responses. International Journal for nursing students. 5(5). 455 –

466.

25. Lin, et al. (2007). As low birth weight babies grow. Demography. 44(2). 335 – 343.

86

26. Ludington - Hoe, S.M. & Swinth, J.Y. (2009). Kangaroo mother care during

phototherapy. Neonatal network .20(5). 41- 48.

27. Ludington - Hoe, S.M., (2004) .Randomized controlled trial of kangaroo care: cardio

respiratory and thermal effects on healthy infants. Neonatal net work. 23(3). 39- 48.

28. Ludington - Hoe, S.M,, et al. (1994). Kangaroo care: research results, and practice

implications and guidelines. Neonatal network .13(1). 19- 27.

29. Mangels dorf., et al .(2006). Attachment security in low birth weight infants.

Developmental psychology .32(5). 914 – 920.

30. Margetts, B.M., et al (2002) .Persistence of Low birth weight. Journal of

epidemiological community health. 2(56). 684 – 687.

31. Mehler,K., et al. (2010) .Mothers seeking their low birth weight infants with in 3 hour

after birth are more likely to establish a secure attachment behaviuour. online journal.

32. Monsur,E .,et al. (2005). Morbidity and mortality of low birth weight infants in Egypt.

Egyptian Journal of pediatircs .11(4).

33. Motah hareh Golestan, M.D., et al. (2008). Neonatal mortality of low birth weight infants

in Yazd. Iranian Journal of reproductive medicine 6(4) .205 – 208.

34. Ohgi, S., et al. (2002) .Comparison of kangaroo care and standard care :behavioural

organization , development and temperament in healthy, low birth weight infants .

Journal of perinatology. 22(5).374 – 379.

35. Parmar, V.R., et al. (2010).Experience of Kangaroo mother care.Journal of pediatrics

.27(4). 230 – 232.

36. Pattinson, R.C., et al. (2005). Implementation of kangaroo mother care: A randomized

trial of two outreach strategies. Journal of pediatrics .949(7).924 - 927

37. Quasem, I. et al (2003). Adaptation of Kangaroo mother care for community based

application. Journal on perinatology .23(8) .646 – 651.

87

38. Roller, C.G. (2005) .Getting to know you:mothers experience of kangaroo care. Journal

on obstetrics gynecology neonatal nurse. 34(2). 210 – 217.

39. Roudbari, M., et al. (2007) .Prevalence risk factors of low birth weight infants .Journal of

pediatrics. 13(4). 205 – 208.

40. Sachdeva. (2009). Study factors affecting birth weight .Journal of global pharmacy

technology. 9(5).

41. Sell, Elsa, J.M.D., et al. (2008) .Outcome of low birth weight infants in neonatal

behaviour. Journal of developmental & behavioural pediatrics.

42. Sontheimer, D., et al. (2004) .Kangaroo transport instead of incubator transport.

Pediatrics journal .113(4) .920 – 923.

43. Toma , T.S (2003) .Kangaroo mother care:The role of health care services and family

networks in a successful program. Journal on pediatrics .19(2). 233 – 242.

NET REFERENCE

1. www.ajpmonline.org

2. www.altavista.com

3. www.1drc.a.home.com

4. www.google.com

5. www.medscape.com

6. www.nature.com

7. www.oxfordjournals.com

8. www.pubmed.com

88

9. www.springerlink.com

10. www.wikipedia.com

11. www.yahoo.com

Appendix-A

Data collection tool

Sample no: Section-A

Part I: Demographic profile

1) Name of the child

2) Age of the neonate

a) 1/365 days

b) 2 /365 days

c) 3/365 days

d) Above 3 /365 days

3) Sex of the neonate

a) Male

b) Female

4) Birth weight of the neonate

a) 1.5-2 kg

89

b) 2-2.5 kg

5) Birth order

a) First

b) Second

c) Third

d) More than three

6) Educational status

a) Illiterate

b) Primary

c) Secondary

d) Collegiate

7) Monthly income of the family

a) Below Rs1000/month

b) Rs1001-3000/month

c) Rs3001-5000/month

d) Above Rs 5001/month

8) Religion

a) Hindu

b) Muslim

c) Christian

9) Residence

a) Rural

b) Urban

10) Type of family

a) Nuclear

b) Joint

Section-B: Observation checklist

90

Part I: Physiological response observation checklist

1) Temperature

a) Below 96.6◦F/above 98.6◦F

b) 96.6-97.6◦F

c) 97.8-98.6◦F

2) Heart rate

a) Below 100/min or above 140/min

b) 100-120/min

c) 121-140/min

3)Respiration

a) Below 20/min or above 40/min

b) 20-30/min

c) 31-40/min

4) Oxygen Saturation

a) Below 96%

b) 96-98%

c) Above 98%

5) Skin colour

a) Completely Blue

b) Body pink, extremities blue

c) Completely pink

Part II: Behavioural response observation checklist

1) Moro reflex

a) absent

b) weak

c) normal

2) Grasping reflex

a) absent

b) weak

c) normal

91

3) Rooting reflex

a) absent

b) weak

c) normal

4) Muscle tone

a) Poor

b) Average

c) Good

5) Ability of attention

a) in attention

b) delayed attention

c) immediate attention

6) Cuddliness

a) resist

b) passively resist

c) actively resist

7) Posture

a) flaccid

b) some flexion

c) fully flexed

8) Consolability

a) not consolable

b) picking up and holding

c) voice and face

9) Cry to stimuli

a) no cry

b) weak cry

c) strong cry

10) Sleep

92

a) drowsy

b) light sleep

c) deep sleep

Part III: Psycho social observation checklist

Attachment of the neonate

1) Whether the neonate is stop crying when holding by the mother?

2) Whether the neonate is grasping the mother?

3) Whether the neonate is alert and stops movement in the presence of mother’s voice?

4) Whether the neonate is physically rest and sleep in the presence of mother?

5) Whether the neonate is smiling by seeing the face of the mother?

Attachment of the mother:

6) Does the mother talk with the neonate?

7) Does the mother maintain eye contact with the neonate?

8) Whether the mother is providing the basic care to the neonate?

9) Whether the mother is demonstrating any type of affection to the neonate such as

similing,stroking,kissing or rocking?

10) Whether the mother is holding the neonate is in such a way that the neonate in close contact

with the mother?

Appendix-B

93

SCORING AND GRADING PROCEDURE

a) Physiological response

Score Key: In a particular question, if the observation is ‘a’ given score 1, if the

observation is ‘b’ given score 2 and if the observation is ‘c’ given score 3.

Grading:

Above 12 - Good physiological response

8-11 - Average physiological response

Below 8 - Poor physiological response

b) Behavioural response

Score Key: In a particular question, if the observation is ‘a’ given score 1, if the

observation is ‘b’ given score 2 and if the observation is ‘c’ given score 3.

Grading:

Above 24 - Good behavioural response

15-24 - Average behavioural response

Below 15 - Poor behavioural response

c) Psycho social response

Score Key: In a particular question, if the observation is present given score ‘2’and if the

observation is absent given score ‘1’.

94

Grading:

Above 16 - Good psycho social response

12-16 - Average psycho social response

Below 12 - Poor psycho social response

Appendix-C

ASSESSMENT PROCEDURE

a) Physiological response

1) Temperature

Assessed by placing the thermometer in the axilla for 2 full minutes.

2) Heart rate

Obtained by taking an apical pulse for one full minute with stethoscope.

95

3) Respiratory rate

Place the hand over the chest and count the inspirations for one full minute.

4) Oxygen saturation

Measured by using pulse oxymeter.

5) Skin colour

Examine the whole body and observe the colour of the skin.

b) Behavioural response

1) Moro reflex

Elicit the moro reflex by placing the newborn on his back. Support the upper body

weight of the supine newborn by the arms using a lifting motion without lifting the

newborn off the surface. Then release the arms suddenly. The newborn will throw the

arms outward and flex the knees, arms then return to the chest. The fingers also

spread to form a C.

2) Grasping reflex

Elicit the grasping reflex by placing a finger on the newborn’s open palm. The

newborn’s hand will close around the finger.

3) Rooting reflex

Elicit the rooting reflex by stroking the newborn’s cheek. The newborn will turn

toward the side that was stroked and begin to make sucking movements with his

mouth.

4) Muscle tone

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Support the newborn with one hand under the chest. Observe how the neck

muscles hold the head. The neck extensors should be able to hold the head in line

briefly. Also there should only be slight head lag when pulling the newborn from a

supine position to a sitting tone.

5) Ability of Attention

Newborn’s attention to auditory stimuli demonstrated by their movement of head

and eyes to focus on the stimulus.

6) Cuddliness

Cuddliness is assessed by the degree to which the newborn molds and nestles into

the contour of the care giver’s body.

7) Posture

How does the newborn hold his or her extremities in relation to the trunk.

8) Consoloability:

Consoloability is how newborn’s are able to change from the crying state to an

active alert, quite alert, drowsy or sleep state by using any of the behaviour such as

picking up and holding ,voice and face etc.

9) Cry to stimuli

A painful stimuli (Pinching) is provided to the newborn and the characteristics

of cry is assessed.

10) Sleep

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Assessed the state of sleep as drowsy that is eye open and active body

movement, light sleep that is closed eyes and slight muscular twitching of the body

and deep that is closed eyes and no movement.

Appendix-D

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98

Appendix-E

KANGAROO MOTHER CARE PROCEDURE

Low birth weight babies can be protected by providing kangaroo mother care

Baby should be dressed with cap and nappy only.

Ask the mother to wash their hands and sit comfortably in the bed.

The baby should be placed on the mother’s bare chest between the breasts in an upright

position.

The head should be turned to one side and in a slightly extended position

Support the baby’s bottom with a binder

Keeping the baby inside the mother should wear their shirt/top garments.

The mother can sleep with the baby in kangaroo position in a reclined or semi recumbent

position by using several pillows (15-30 °degrees from bed)

99

KANGAROO MOTHER CARE PROCEDURE

Kangaroo mother care procedure while sitting.

100

Kangaroo mother care procedure while sleeping

Appendix-F

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102

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Appendix-G LETTER REQUESTING PERMISSION TO CONDUCT THE STUDY

From R.Semmalar M.Sc (Nursing) II Year Student, College of Nursing, Madurai Medical College, Madurai-20 To The Professor and Head of the Department, Department of Pediatric Medicine,

Govt. Rajaji Hospital, Madurai-20

Through: The Principal, College of Nursing, MMC, Madurai.

Respected Sir,

SUB: M.Sc (Nursing) – Dissertation- Data collection- Permission requesting- Reg.

--------- As part of curriculum requirement for post graduation in nursing, I wish to do dissertation on the topic “A STUDY TO ASSESS THE EFFECTIVENESS OF KANGAROO MOTHER CARE ON RESPONSES AMONG LOWBIRTH WEIGHT NEONATES IN POSTNATALWARD OF GOVT RAJAJI HOSPITAL, MADURAI”. Hence I kindly request you to permit me to collect data from pediatric surgical and post operative wards for my above said dissertation.

103

Thanking you,

Madurai Yours faithfully,

19.10.2010

(R.SEMMALAR)

Appendix-H LETTER SEEKING PERMISSION FOR CONTENT VALIDITY OF TOOL From

R.Semmalar, M.Sc (N) II year, College of Nursing, Madurai Medical College, Madurai-20.

To Through,The proper channel

Respected Madam/Sir, Sub: Requesting opinion and suggestion of experts for content validity of tool for my dissertation topic “Effectiveness of Kangaroo mother care among low birth weight neonates”

I am a final year Master degree nursing student in the college of nursing, Madurai medical college, Madurai. In partial fulfillment of Master degree in nursing, I have selected the topic for the research project to submit to the Tamil nadu Dr.MGR Medical university, Chennai. I request you to kindly validate the tool and give your expert opinion for necessary modifications and also I would be very grateful if you could refine the problem statement and the objectives. Enclosure

Statement of the problem Objectives Hypotheses Research tool

1. Demographic profile 2. Observation checklists

Thanking you, Date: Your sincerely, Place: Madurai. (Name)

CONTENT VALIDITY CERTIFICATE

104

TO WHOMSOEVER IT MAY CONCERN

This is to certify that the tool developed for data collection by R.Semmalar on the thesis

entitled “A STUDY TO ASSESS THE EFFECTIVENESS OF KANGAROO MOTHER

CARE ON RESPONSES AMONG LOWBIRTH WEIGHT NEONATES IN

POSTNATALWARD OF GOVT RAJAJI HOSPITAL, MADURAI” is relevant valid and

fulfill the study objectives.

Date: Signature

Seal