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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
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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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101
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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