Rajiv Gandhi University of Health Sciences s4

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms. Divya 1 year M.sc Nursing Mental Health Nursing 2012-2014

Rajiv Gandhi College of nursing Bangalore.

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

1 1 Name of the candidate and Ms.Divya address I year M.Sc.(N) Rajiv Gandhi College Of Nursing Bangalore

2 Name of the Institution Rajiv Gandhi College Of Nursing

3 course of the study and M.Sc.(N) subject Psychiatric nursing

4 Date of admission to course 16-06-12

5 Title of the topic Adescriptive study to assess the level of depression and coping skills among the clientsdiagnosed with cancer in selected hospitals at Bangalore with a view to develop an information booklet.

6. BRIEF RESUME OF INTENTED WORK INTRODUCTION The difference between the impossible and the possible lies in a man’s determination

"Don't count the days, make the days count." -Muhammad Ali

Cancer is the second biggest cause of death in India, growing at 11 per cent annually. There are 2.5 million cancer cases and four lakh deaths a year in India. In 2011, six lakh new cancer cases were diagnosed; that figure has now risen to eight

2 lakh. Smoking one to seven cigarettes daily doubles the cancer risk. One in five Indian men dies between age 30 and 69 due to tobacco-related cancers.1

In India, around 5,55,000 people died of cancer in 2010, according to estimates published in The Lancet today. Tobacco-related cancers represented around 42% of male and 18% of female cancer deaths. In men, two of the most common fatal cancers were oral (including lip and pharynx) and lung. Cervical, stomach and breast cancers accounted for 41% of cancer deaths in women in rural and urban areas. Thus, interventions such as tobacco control, human papilloma virus (HPV) vaccination, cervical cancer screening alongside early detection and treatment of oral and breast cancer can have a substantial impact in India in averting future cancer deaths. 2 According to Baider L, Bengel J, there is a universal that everyone has the right to adequate standard of physical and mental well-being. Biological process or seen as contributing factors to individual variation in health and wellbeing. Most patients experience some level of distress however only a small percentage receives help. Distress is on unpleasant emotional, psychological, social or spiritual experience that interferes with the patient ability to cope up with cancer treatment. Patients may experience a range of feeling from normal sadness and fear to deep depression, anxiety, panic or isolation. Distress may become disabling at the time of diagnosis, during cancer treatment, at the end of the long course of treatment, when the cancer returns or when beginning palliative care. Patients who experiencing moderate to severe distress may require a referral to mental health professionals such a psychiatric nurse, psychologist, psychiatrist, social worker or pastoral counsellor3. Psycho social distress exists on a continuum ranging from normal adjustment issues to adjustment disorders to a level of severe mental disorder (e.g. major depressive disorder). Depression can occur when a person feels that he/she does not have the resources to manage or control the cancer. Depression experienced by a patient who have the same diagnosis and are undergoing the same treatment may be different from others. A doctor or nurse or health professional can help the patient adjust to the treatment schedule help the patient to cope with the treatment. Major depressive disorders or generalized anxiety disorders were estimated in 16 % of the cancer patient by Karger S and Basel AG. Only these patients were referred to the psycho oncology unit, hence the psychological distress of many

3 patients was not considered during their hospitals stay. In the multiple regression analysis, independent predictors of depression were female gender, experience of disturbance in family and social life due to illness, nausea, vomiting and perception of being in a poor state of health. The author concluded that the psycho oncology team should focus on helping doctors and nurses to identify the patient’s psychological problems dealing with them4. According to Chaturvedi SK the psychological and emotional problems occur frequently during the advanced and terminal stages of cancer need to be appropriately detected and managed. Patient during terminal phases report numerous fear and often experience anxiety and depression with gender difference for ascertain cancer. Psychiatric patient with additional psychiatric diagnosis significantly more often reported concern for physical health, sadness, anxiety, future, work or occupation and being slow down, rather than the cancer pain, interpersonal relationship and marital emotional distress due to the concern needs to be alleviated in order to improve the overall quality of life and help the patient to cope with cancer and often distressing symptoms5.

The number of cancer care visits in the emergency department for evaluation and treatment has been steadily increasing.At an emergency department of a hospital, during a period of over six months, starting on April 1st, 2011 to October 31st of the same year. There were 1,051 oncologic visits during this period, with the age ranging from 19 to 89 years. The greater demand for care was sought by patients with urological, breast, upper and lower gastrointestinal tract and lung cancer. The three major complaints of the consultations were pain, respiratory and gastrointestinal symptoms.6

NEED FOR THE STUDY

Cancer can affect people of all ages, and a few types of cancer are more common in children, the risk of developing cancer generally increases with age. In 2007, cancer caused about 13% of all human deaths worldwide (7.9 million). Rates are rising as more people live to an old age and as mass lifestyle changes occur in the developing world7.

 An estimated 12.7 million new cancer cases were diagnosed worldwide in 2008.

4  Lung, female breast, colorectal and stomach cancers were the most commonly diagnosed cancers, accounting for more than 40% of all cases.

 Worldwide, an estimated 7.6 million deaths from cancer occurred in 2008.

 Lung, stomach, liver, colorectal and female breast cancers were the most common causes, accounting for more than half of all cancer deaths.

In India the most common site of cancer in men is respiratory tract cancer and in women is cervical cancer. Among Indian women, cancer of cervix and breast account for nearly 60% of all cancers.7 Across the globe 30% of patients have different type of cancer which are terminally ill with palliative management. More over the level of depression experienced by these patients varies in magnitude. The controversy and emotional liability put cancer patient in a devastating state of helplessness and hopelessness in life. The primary family members and peers also face and undergo emotional instability7. Cancer screening involves efforts to detect cancer after it has formed, but before any noticeable symptoms appear. This may involve physical examination, blood or urine tests, or medical imaging. Cancer screening is currently not possible for many types of cancers, and even when tests are available, they may not be recommended for everyone. Universal screening or mass screening involves screening everyone.Selective screening identifies people who are known to be at higher risk of developing cancer, such as people with a family history of cancer7. Cancer is a curable disease but the stigma associated with disease is dreadful and people go through degree of stress and lead to depression. Patients need to be counselled and taught about various relaxation techniques to relax them from distress and depression. Hence the researcher felt there is a need for the patients about relaxation techniques and help to compact their livelihood to cope and live with cancer.

6.2. REVIEW OF LITERATURE Review of literature is a systematic identification, location, scrutiny, and summary of written materials that contain information on research problem.8 Review literature is categorised based on the following headings  General information about cancer.

5  Literature related level of depression among cancer patients  Literature related coping skills among cancer patients General information about cancer

Cancer known medically as a malignant neoplasm, is a broad group of various diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the body through the lymphatic system or bloodstream. There are over 200 different known cancers that afflict humans.

Many things are known to increase the risk of cancer, including tobacco use, certain infections, radiation, lack of physical activity, obesity, and environmental pollutants. These can directly damage genes or combine with existing genetic faults within cells to cause the disease. Approximately five to ten percent of cancers are entirely hereditary.9

Cancers are primarily an environmental disease with 90–95% of cases attributed to environmental factors and 5–10% due to genetics. Common environmental factors that contribute to cancer death include tobacco (25–30%), diet and obesity (30–35%), infections (15–20%), radiation (both ionizing and non- ionizing, up to 10%), stress, lack of physical activity, and environmental pollutants.Up to 10% of invasive cancers are related to radiation exposure, including both ionizing radiation and non-ionizing radiation. Additionally, the vast majority of non-invasive cancers are non-melanoma skin cancers caused by non-ionizing ultraviolet radiation.Sources of ionizing radiation include medical imaging, and radon gas.9

Cancer prevention is defined as active measures to decrease the risk of cancer. The vast majority of cancer cases are due to environmental risk factors, and many, but not all, of these environmental factors are controllable lifestyle choices. Thus, cancer is considered a largely preventable disease. Greater than 30% of cancer deaths could be prevented by avoiding risk factors including: tobacco, overweight / obesity, an insufficient diet, physical inactivity, alcohol, sexually transmitted infections, and air pollution. The primary dietary factors that increase risk are obesity and alcohol consumption; Consumption of coffee is associated with a reduced risk of liver

6 cancer. Dietary recommendations for cancer prevention typically include an emphasis on vegetables, fruit, whole grains, and fish, and an avoidance of red meat, animal fats and refined carbohydrates.10

Coping with Cancer: Supportive and Palliative Care Managing Physical Effects : Manage the physical symptoms of cancer and the side effects from chemotherapy, radiation, and other treatments. Learn how to maintain proper nutrition during treatment.

Managing Emotional Effects : Manage depression, anxiety, and other emotional effects, and learn how to support people with cancer.

For Caregivers, Family, and Friends : Information to help caregivers cope while caring for a loved one with cancer; help someone with cancer cope with the illness.

About Children with Cancer : Information for parents about children with cancer, as well as guides to help children and teens cope when a family member has cancer.

Finding Healthcare Services : Tips for choosing a doctor or a treatment facility, healthcare options, assistance at home, and hospice care.

Financial, Insurance, and Legal Information : Information about getting financial help, insurance coverage, and support organizations.

Survivorship - Living With and Beyond Cancer : Life and health after a cancer diagnosis and once treatment is over.

Preparing for the End of Life : Information for patients, their families, and friends about grief and bereavement, hospice care, and end-of-life planning.

Supportive and Palliative Care Clinical Trials : Clinical trials to help people cope with symptoms and side effects of cancer.10

Literature related level of depression among cancer patients A observational study conducted on psychological distress in couples facing colorectal cancer within 6 months after surgery. In addition, correspondence in Treatment1, respondents were to asked to indicate how they felt during the week prior to surgery. At T2 and T3, respondents reported their feelings during the preceding week. Psychological distress was measured using the 20-item Centre for Epidemiologic studies Depression Scale (CES-D) in 137 couples. Concerning the week prior to surgery, females reported more distress being a patient, whereas males

7 reported more distress being a spouse. At 3 and 6 months following surgery, increased level of distress continued to exist in female where as males distress return to normal. The study demonstrated a considerable impact on the cancer diagnosis of both male and female patients and their spouse before and 3 months after surgery. 6 months after surgery females more vulnerable to depression11. A descriptive study demonstrated that approximately one fifth of women reported moderated to severe level of depression and more than half reported high stress responses to cancer and their treatment. There was also evidence to suggest that younger patients, patients with more advanced or recurrent disease, and patients who had more recently been diagnosed with ovarian cancer experienced greater psychological distress. These findings indicate that psychological distress and high stress responses to cancer are prevalent among women with ovarian cancer, suggesting they should be carefully evaluated to determine whether treatment for those symptoms is warranted12. An exploratory descriptive study was conducted by Neville. K to investigate the psychological distress and depression among the middle and late adolescents recently diagnosed with cancer. Respondents consisted of 40 males and 20 females who are diagnosed with a malignancy within the past 100 days and received the outpatient treatment. Brief symptom inventory was used to collect data. Among the various disease groups adolescents with leukaemia experienced the greatest psychological distress and moderate depression.13 A descriptive survey was conducted on quality of life and depression among cause patients who recently diagnosed with cancer in Oslo. 131 heterogeneous group of cancer patients were selected by purposive method and power’s quality of life index and beck depression inventory was used to assess the data. The study results showed that quality of life is adequate and moderate depression was observed among the newly diagnosed patients14. A descriptive co-relational study on depression among Cancer patients of head and neck undergoing radiation treatment in Brisbane, Australia. Functional assessment of cancer therapy, hospital anxiety and depression scale was used to collect data from 58 patients. The study results revealed that functional symptoms level and depression was high among the cancer of head and neck who undergoing radiation therapy15.

8 A comparative study was conducted to assess the level of disaster among male and female who diagnosed as cancer and admitted in selected hospital at Bangalore. 50 males and 50 females were selected by convenience sampling method. The study reveals that psychological distress was more common in female subjects, experienced more distress when composed to male subjects16. A descriptive study conducted on quality of life among cancer patients who all are undergoing chemotherapy in a selected hospital. 178 cancer patients receiving chemotherapy was selected and data was collected using quality of life index analogue scale. The study revealed that majority of the patients has poor quality of life and more psychological distress17. A study conducted to assess the psychological distress of cancer patients in a disease-specific manner as well as the demographic and medical variables that have an impact on the distress. Psychological distress was assessed with the Questionnaire on Stress in Cancer Patients revised version, which has been developed and psychometrically evaluated in Germany. It consists of items about 23 cancer-specific stress situations, which have to be answered in terms of relevance and amount of distress. A heterogeneous sample of 1721 cancer in- and outpatients was assessed. For the total group, the most important distress is the fear of disease progression. The most distressed diagnostic subgroups are patients with soft tissue tumors and breast cancer patients. There are no global (general) stress factors, as the relevant demographic and medical 'risk factors' varied between the diagnostic subgroups.18

A study conducted to identified the needs of terminal cancer patients, investigated the factors associated with unmet needs, and assessed psychological and symptom distress associated with unsolved needs. Ninety-four patients were randomly selected from 324 patients admitted for palliative care in 13 Italian centers. Two self-administered questionnaires were administered to all the patients. The most frequent unmet needs were symptom control (62.8%), occupational functioning (62.1%), and emotional support (51.7%). The less frequently reported needs were those related to personal care (14.6%), financial support (14.1%), and emotional closeness (13.8%). Low functional state was significantly associated with a high proportion of patients with unmet needs of personal care, information, communication, occupational functioning, and emotional closeness. Patients with unmet needs showed significantly higher psychological and symptom distress for

9 most needs. This study provides some suggestions about the concerns that should be carefully considered during the late stage of cancer.19

Literature related coping skills among cancer patients A descriptive study conducted on gender differences in social and psychological adjustment among cancer patients. The social adjustment and psychological distress of 49 patients (34 women and 15 men) undergoing active medical care (chemotherapy and radiation) were assessed. Socio-demographic and medical parameters were also examined to account for differences in adjustment. Three questionnaires were used: A personal information questionnaire; a Psychosocial Adjustment to Illness Scale (PAIS-SR) (Derogatis& Lopez, 1983); and a psychological distress one (BSI) (Derogatis& Spencer, 1982). The result revealed that there were significant differences found between men and women patients in several dimensions of the social adjustment, psychological distress and medical variables. Possible explanations, recommendations for further research and clinical intervention are suggested20. A study conducted by Taniguch K, Akeche T a total of 272 men and 252 women with cancer participated in the study of the impact of being married and the presence of spousal support on psychological distress and coping with cancer. A structured interview was conducted. Multivariate analysis was conducted revealed that unmarried man had significantly higher level of psychological distress and lower levels of fighting spirit than married man. These study finding suggest that being married may play an important role in reducing psychological distress and enhancing fighting spirit of man with cancer and that being unmarried may be a risk factor for psychological distress and lower fighting spirit for men with cancer21.

6.3 STATEMENT OF THE PROBLEM A descriptive study to assess the level of depression and coping skills among the clients diagnosed with cancer in selected hospitals at Bangalore with a view to develop an information booklet . 6.4 OBJECTIVES OF THE STUDY The objectives of the study are  To assess the level of depression among the clients diagnosed with cancer.

10  To assess the coping skills among the clients diagnosed with cancer.  To find out the association between the level of depression among the clients diagnosed with cancer with their selected demographic variables.  To develop an information booklet to cope up with cancer.

6.5 HYPOTHESIS

H1 : There will be significant difference in the level of depression and coping skills among the clients diagnosed with cancer.

H2 : There will be significant association between the level of depression among the clients diagnosed with cancer with their selected demographic variables.

6.6 OPERATIONAL DEFINITIONS Assess: It refers to the process used to identify the level of depression among the clients diagnosed with cancer by administering questionnaire. Depression: It refers to a state of sad mood and loss of interest in activities as assessed by modified Becks Depression Inventory. Coping skills:Refers to the skills used by the cancer patients in order to cope up with depression as a result of cancer. Clients with cancer: Patients who had suffer from cancer and undergoing Radiation and chemotherapy in selected hospitals. Information Booklet: It is a booklet which contains structured information about various coping skills and helps to cope up with depression pertaining to cancer.

6.7 ASSUMPTIONS  The researcher assumes that there will be a marked level of depression experienced by clients who are diagnosed with cancer.  Coping skills in regard to depression may vary between clients.  Level of depression will vary between male and female.  There will be some relationship between depression and duration of treatment and type of cancer.  Information booklet will improve the coping skills of the cancer clients.

6.8 DELIMITATIONS

11 The study is delimited to  clients diagnosed with cancer from a selected hospitals at bangalore.  a duration of study is 4-6 weeks.  clients between the age group of 20-60 years.

7. MATERIALS AND METHODS: 7.1. SOURCE OF DATA: Data will be collectedfrom cancerpatients in selected hospitals atBangalore. 7.2 METHOD OF DATA COLLECTION TOOL: Research Approach : Non Experimental Survey Approach Research design : Non Experimental descriptive research design Sampling technique : Non Probability Convenient sampling technique Sample size : 60clients diagnosed with cancer. Setting of the study : Selected hospitals at Bangalore. 7.2.1 SAMPLING CRITERIA: INCLUSION CRITERIA: The study includes clients  between the age group of 20-60 years.  whoare attending selected hospitals at Bangalore.  able to communicate in English and Kannada.  who are willing to participate inthe study.  who are available at the time of data collection. EXCLUSION CRITERIA: The study excludes the participants  who are seriously ill during the data collection time.  Who undergoing alternative therapies for cancer.  Who are not willing to participate

7.2.2 DATA COLLECTION TOOL: A structured questionnaire will be prepared by the investigator to assess the level of depression and coping skills among the clients diagnosed with cancer of selected hospitals. The Tool consists of

12 Section-A: Demographic data Section–B: Modified Beck’s Depression Inventory to assess the level of depression. Section-C: Checklist to assess the coping skills of cancer patients. 7.2.3 DATA ANALYSIS METHOD: Data will be analysed by using descriptive (mean, standard deviation) and inferential statistics. Frequency and percentage distribution will be used to analyse demographic variables. Mean and standard deviation will be used to assess the level of depression among the clients diagnosed with cancer of selected hospitals. A Chi- square test(X2) will be done to find out the association between the level of depression and their selected demographic variables.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? Yes. A structured questionnaire will be used to assess the level of depression and coping skills among the clients diagnosed with cancer of selected hospitals. No other physical or laboratory procedures will be conducted or done on the samples. 7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED? Yes,  A written permission from the concerned administrative authority will be obtained.  Consent will be obtained from the participants.  Confidentiality and anonymity will be maintained. 8. LIST OF REFERRENCES:

1. http://indiafacts.in/health/cancer-deaths-in-india/

2. http://www.iarc.fr/en/media-centre/pr/2012/pdfs/pr210_E.pdf

3. Baider L, Bengel J. Cancer and the spouse: gender-related differences in dealing with health care and illness. Critical Review on Oncology &hematology 2001; Nov.40(2):115-123.

13 4. Corr CA, Adam M Journal of social work and health care 2003;Sep.41(2):37- 47 5. Chatruvedi SK. Illness related distress Journal of Oncology 2002 Mar 23(2):256-60. 6. Karger S, Basel. Psychological distress in cancer patients: Journal of Oncology. 2004; Nov 57(4): 297-302. 7. http://www.ncbi.nlm.nih.gov/pubmed/23301648 8. Polit, Hungler. Nursing Research and Methodology 5th edition. 2007; 79-81. 9. www.en.wikipedia/cancer/ici. 10.www.en.wikipedia/cancer.html 11.Mathew BA, Role and gender differences in cancer related distress. Oncology Nurses Forum. 2003 May-Jun 30(3):493-498. 12.Tunista j, Ranchov AV. Psychological distress in couples dealing with colorectal cancer. British Journal of Health Psychology 2004 Nov 9(4); 465- 470. 13.Herschbach P, Henrich P. Psychological problems of cancer patients. British Journal of cancer. 2004; Aug 2(3); 504-511. 14.Neville .K. Psychological distress in adolescents with cancer. Journal of Paediatric Nurses 2003; Aug 11(4); 243-251. 15.Manne SL &Warshall D. Prevelance and predictors of psychological distress among women with ovarian cancer. Journal of Clinical Oncology. 2004 Mar 22 (5); 919-926. 16.Rose .P, Yater P Quality of life experienced by patients receiving radiation treatment for cancer of head and neck. Cancer Nursing 2001; 24(4): 255-263. 17.Rusoten T, Mount, Henested BR. Quality of life in newly diagnosed cancer patients. Journal of Advanced Nursing 2004;29(2): 490-498. 18.Peleg-Oren N, Sherer M. Effect of gender on the social and psychological adjustment of cancer patients. Journal of Social Work Health Care. 2003;37(3):17-34. 19. Gabriella Morasso, Psychological and Symptom Distress In Terminal Cancer Patients with Met and Unmet Needs. Journal of Pain and Symptom Management Volume 17, Issue 6 , Pages 402-409, June

14 20.Du Hamel K, Glassman. Intrusion, avoidance, and psychological distress among individuals with cancer. Journal of Psychosomatic Medicine. 2008; Jul-Aug63(4):658-67. 21.Henrich G. Gender aspects in cancer patients' distress and adjustment. Journal of Oncology. 2006;38(6):747-55. 22.Taniguchi K, Akeche T. Lack of marital support and poor psychological responses in male cancer patients. Journal of supportive care in cancer. 2003. Sep 11(9); 604-610.

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE The topic of the study is mandatory as the psychosocial aspect of cancer patient are not considered in many hospitals. 11 NAME AND DESIGNATION 11.1 GUIDE Mrs. Kavitha Poorna. M

11.2 SIGNATURE 11.3 CO- GUIDE

11.4 SIGNATURE

15 11.5 HEAD OF THE Mrs. Kavitha Poorna. M DEPARTMENT

11.6 SIGNATURE 12 12.1REMARKS OF THE Cancer patient under gone PRINCIPAL depression hence the study is essential for conduct. 12.1 SIGNATURE