A Study to Assess the Effectiveness of Guided Imagery Therapy on Postpartum Blues Among Primi Mothers in Selected Hospitals at Coimbatore District

A STUDY TO ASSESS THE EFFECTIVENESS OF GUIDED IMAGERY THERAPY ON POSTPARTUM BLUES AMONG PRIMI MOTHERS IN SELECTED HOSPITALS AT COIMBATORE DISTRICT.

30083222

DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING 2008-2010

CERTIFIED THAT THIS IS THE BONAFIDE WORK DONE

30083222

CHERRAAN’S COLLEGE OF NURSING, COIMBATORE, TAMILNADU.

SUBMITTED IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING TO THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI.

COLLEGE SEAL: Mrs.RANI IRUDAYARAJ. M.Sc(N) Mphil, MBA, PRINCIPAL, CHERRAAN’S COLLEGE OF NURSING COIMBATORE. A STUDY TO ASSESS THE EFFECTIVENESS OF GUIDED IMAGERY THERAPY ON POSTPARTUM BLUES AMONG PRIMI MOTHERS IN SELECTED HOSPITALS AT COIMBATORE DISTRICT.

Approved by the Dissertation Committee on ______

RESEARCH GUIDE…………………………………….. Mrs. Rani Irudayaraj. M.Sc(N) Mphil, MBA, Principal, Cherraans College of Nursing Coimbatore.

CLINICAL GUIDE ……………………………………….. Mrs. Muthukarupayee, M.Sc. (N)., OBG., Vice principal, Cherraan’s College of Nursing, Coimbatore.

MEDICAL EXPERT …………………………………….. Dr.Rajini Sivakumar, M.B.B.S, D.G.O, Obstetrics & Gynaecologists, Alankrita Clinic, Kovai Pudur Pirivu, Coimbatore.

A DISSERTATION SUBMITTED TO THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING MARCH - 2010. ACKNOWLEDGEMENT “ It is God doing marvelous in my eyes” First and the foremost, I extremely thank the lord almighty for his help and blessing on me during my study period. He is the source of the strength and inspiration in every walk of my life and the foundation of knowledge and wisdom. I express my heartfelt thanks to honourable, Mr. K.C.PALANISAMY, B.E. (Agri), Chairman of Cherraan;s Institute of Health Science. I proudly express my deep sense of gratitude and indebtedness to Prof. Mrs.RANI IRUDAYARAJ, M.Sc(N) Mphil, MBA, Principal of Cherraan’s college of Nursing for her excellent suggestions, valuable guidance, constant encouragement throughout this study. I express my gratitude and sincere thanks to my research guide, Prof. MUTHU KARUPAYEE, M.Sc. NSg (OBG)Vice Principal, HOD, Obstetric and Gynaecology nursing, Cherraan’s college of Nursing, for her valuable and patience guidance, kind encouragement, patience correction and valuable suggestion throughout my endeavor. I extend my thanks to Mr. SURESH, M.Sc.(N), co- ordinator, HOD Medical Surgical Nursing, Cherraan’s College of Nursing, Coimbatore, for his guidance, kind encouragement, patience correction and valuable suggestions and motivation throughout the study period. I owe deep grateful and heartful thanks to Mrs. LINDSIE MARY .L.M.Sc. NSg (OBG)., Lecturer, Cherraan’s College of Nursing, Coimbatore, for her valuable guidance, patience correction and valuable suggestions, encouragement, motivation and support throughout my endeavor. I profusely thank my medical guide Dr. Rajini Sivakumar.M.B.B.S, D.G.O Obstetrics & Gynaecology, Alankrita Clinic for the profound interest taken to guide me in my research study. I express my sincere thanks to all the experts for their valuable guidance, suggestion and patience corrections. I express my gratitude and sincere thanks to Prof. Dr.RATHINASWAMY Managing trustee, Sakthi hospital for granting permission to conduct the study in his esteemed institution. I sincerely express my heartful thanks to Dr. ANANDI, Medical officer, Sundakamuthur PHC for granting permission to conduct the study in the PHC. I wish to express my sincere thanks to Bio – Statistician Mr. RAVISHANKAR. Ph.d carrying out statistical analysis of the data. The investigator whishes to thank the respondents from Sundakamuthur and Gandipuram at Coimbatore district who participated in the study willingly and gave full co-operation during data collection. I express my sincere thanks to librarian Mrs.VASANTHI Cherraan’s college of nursing, Coimbatore, and Dr. M.G.R. Medical university, Chennai for their co-operation. My heartfelt gratitude to Mrs. MANJURI RAJESH, M.Sc. NSg. (OBG) Principal incharge SSSIHMS college of nursing, Mrs.SELVARANI.M.Sc.Nsg.(OBG) and Mrs.HEPZIBAH M.Sc.Nsg.(Medsurg)for their guidance, motivation and patience correction and encouragement throughout the study period. I owe much to my friends Mrs. VASUMATHI, M.Sc. NSg (Paed), Ms. MANJU .S.K and Mrs. SUGANTHI for their guidance, support and help throughout the study. A work of commendation is expressed to Mr. MARUTHAMUTHU,M.A.,Mphil. For editing this manuscript. My thanks are extending to the B.Sc. Nsg students 2009 out going batch who helped me to make the audio CD. I express my sincere thanks to Mr.DEVASIGAMANI for his technical assistant . I express my grateful thanks to my lovable mother Mrs. A.SAKUNTHALA and loveable brother Mr. ADITHYAA SANKAR for their constant support, prayer and motivation and evergreen memorable help throughout my life. I dedicate this study to my lovable mother and brother who always wanted me to be in higher position in my life. Above all the investigator owes her success to almighty. ABSTRACT To assess the effectiveness of guided imagery therapy on post partum blues among primi mothers in selected hospital at Coimbatore district, was conducted by 30083222 as a partial fulfillment of requirement for the degree of Master of Science in Nursing at college of nursing, Cherraan’s institute of health science Coimbatore affiliated to the Tamil nadu Dr. M.G.R. Medical university, Chennai. OBJECTIVES 1) To assess the level of post partum blues among primi mothers in experimental group and control group. 2) To assess the effectiveness of guided imagery therapy on post partum blues among the primi mothers in experimental group and control group. 3) To associate the post test post partum blue score with demographic variables in experimental group. 4) To associate the post test post partum blue score with selected demographic variables in control group. HYPOTHESIS

H1 :There will be a significant difference in the levels of post partum blues among primi mothers in experimental group and control group.

H2 : There will be a significant difference in the post test finding on postpartum blues among primi mothers in experimental group and control group.

H3 :There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in experimental group.

H4 : There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in control group. The investigator organized the review of literature under three sections as follows, studies related to post partum blues, studies related to guided imagery therapy, studies related to effectiveness of guided imagery therapy on post partum blues. The conceptual frame work for the study was based on nursing process model. RESEARCH METHODOLOGY The research design used was quasi - experimental design (post test only control group design) sample size was 60 primi mothers. 30 experimental group and 30 control group. The samples were selected by using convenience sampling method. Modified AM I BLUE self rating post partum blues scale was used for data collection, which was a standardized tool and modified by the investigator after the expert suggestion. The data collection tool was validated by five expert, reliability was established by Karl Pearson’s method (r=0.9) the main study was conducted in Sundakamuthur PHC and Sakthi hospital at Coimbatore. The data collected were tabulated, analyzed and interpreted by using micro soft excel-2007. Inferential statistic was used to evaluate the effectiveness of the guided imagery therapy on pregnancy, child birth process and new born care among primi mothers after 36 weeks of pregnancy ( student ‘t’ test, χ2). Student ‘t’ test was adopted to find out the significant difference between experimental group and control group post partum blues score. χ2 is used to assess the association between the experimental group and control group and demographic variables of the primi mothers. RESULTS AND DISCUSSION In the experimental group after the Guided Imagery Therapy majority 25(83.33%) of the primi mothers had mild post partum blues, where as in control group majority 23(76.66%) had moderate blues. In experimental there is no significant relationship between the demographic variables and guided imagery on post partum blues except for age limit at p<0.05 level. In control group there is significant relationship for income, religion and type of marriage at p<0.05 level. CONCLUSION There was significant difference in guided imagery on post partum blues among experimental group of primi mothers. So the guided imagery therapy was independently effective in reducing post partum blues except the age limit in experimental group. So the guided imagery therapy was effective.

TABLE OF CONTENTS S.No. Content Page No. I INTRODUCTION 1-11 Back ground of the study 1 Need for the study 3 Statement of the problem 7 Objectives 7 Hypothesis 7 Operational definition 7 Assumptions 8 Delimitations 8 Conceptual frame work of the study 9 II REVIEW OF LITERATURE 12- 27 1) Studies related to post partum blues 12 2) Studies related to guided imagery 21 3) Studies related to effect of guided imagery on post partum 26 blues. III METHODOLOGY 28-36 Research Approach 28 Research design 28 Variables 31 Setting of the study 31 Population 31 Sample 32 Sample size 32 Sampling criteria 32 Development of tool 33 Description of the tool 33 Scoring 34 Validity of the tool 34 Validating audio CD 34 Try out 34 S.No. Content Page No. III Reliability of the tool 34 Description about guided imagery 35 Data collection procedure 35 Plan for data analysis 36 Ethical issues 36 IV DATA ANALYSIS AND INTERPRETATION 37-54 1) Data on demographic variables of primi postnatal mothers both 38 experimental and control group. 2) Data on levels of post partum blues among primi mothers in 43 experimental and control group. 3) Data on effectiveness of guided imagery therapy on postpartum blues 45 among primi mothers in experimental and control group. 4) Data on association between post partum blues score of primi 47 mothers with their demographic variables in experimental group. 5) Data on association between post partum blues score of primi 51 mothers with their demographic variables in control group. V FINDINGS AND DISCUSSION 55-56 VI SUMMARY, CONCLUSION, IMPLICATIONS, LIMITATIONS AND 57-63 RECOMMENDATIONS Summary of the study 57 Major study findings 59 Conclusion 61 Implications of the study 61 Limitation 62 Recommendations 63 REFERENCES APPENDICES

LIST OF TABLES Table TITLE Page No.

1. Frequency, and percentage distribution of primi mothers in both 38 experimental and control group.

2. Levels of post partum blues of primi mothers in experimental group and 43 control group

3. Mean, Standard deviation and ‘t’ value regarding experimental and 45 control group on post partum blues.

4. Frequency, Percentage distribution and chi-square value of experimental 47 group on post partum blues in association with demographic variables.

5. Frequency, Percentage distribution and chi-square value of control group 51 on post partum blues in association with demographic variables.

LIST OF FIGURES Figure Title Page No. 1. Conceptual frame work 11 2. Research design. 30 3. Levels of post partum blues of primi mothers in experimental group 44 and control group. 4. Mean, Standard deviation and ‘t’ value regarding experimental and 46 control group on post partum blues.

LIST OF APPENDICES Appendix Title A Letter requesting expert’s opinion for content validity. B. Format for content validity. C. Content validity Certificate D. List of Experts E. Letter seeking permission to conduct research study F Letter granting permission for conducting research study G. Tool developed for data collection. H Check list. I Guided imagery on pregnancy, child birth, process and new born care.

INTRODUCTION

CHAPTER I INTRODUCTION “The flute and lute are sweet they say Deaf to baby’s babble’s lay” -Thirukkural “ Feeling fat last nine months but the joy of becoming a mom lasts fore ever” - Nikki Dalton. BACKGROUND OF THE STUDY In a human life each and every minute changes occurs , but in the life of a female there are drastic changes takes place. She will be playing a different role in different situation such as daughter ,wife, mother . According to these roles, there are physiological and psychological changes take place. when she get adjusted with these changes , she won’t have any problems .If she faces any difficulty in this adjustment roles may lead to stress. Same way , when a woman is Pregnant, it brings huge changes in her life. It brings more psychological changes than any other stages of life besides puberty . A woman’s attitude towards pregnancy and delivery depends a great deal on psychological aspects such as the environment in which she resides. Postpartum mental disturbances are not uncommon and should be recognized and treated in time. Mental depression, child abuse, infanticide and even suicide are known to take place with increased incidence in the post partum period. Apart from domestic handling of the depression, mother can strain the family unduly, and there are greater chances of infant neglect. The medical team should be able to recognize three common manifestations. These include post partum blues, post partum depression and post partum psychosis.

All most 30% to 50%of women are varyingly affected. By the 3rd to 5th post partum day these women present with the symptoms of lethargy, irritability, unexplained crying spells and anxiety over their inability to cope with the baby. Psychological

1 adjustments coupled with profound hormonal and metabolic changes possibly trigger the problems. Postpartum blues is an insidious vacuum that crawls in to the brain and pushes the mind out of the way. It is the complete absence of rational thought. It is not possible to roll over in bed because blues steals away whom ever you were, prevents you from seeing who you might some day be and replaces your life with a black hole’(David Karp) Pregnancy and puerperium are highly stressful periods in a woman’s life. The person is threatened by various changes such as physiological changes ,and endocrine changes occurring in ones body , as she is in reorganization of psyche in accordance with the new mother role especially in the first pregnancy. Body image changes and unconscious intra -psychic conflicts related to pregnancy, child birth, and mother hood become activated. It is no wonder that 25% to 50% of the pregnant women develop mild psychological symptoms in the puerperal period. The commonest symptoms are mild depression and irritability termed as the postpartum blues. This stress is to be prevented in the starting stage itself .There are so many techniques available in reliving stress, among these techniques guided imagery therapy has a greater impact on healing the stress during postpartum period among the mothers. Guided imagery therapy is the conscious use of the imagination and the mind to create positive images or a setting in order to bring about the healthful changes In both mind and the body . The belief that the power of imagination can help people to heal has ancient roots. Traditional folk healers known as shamans used guided imagery therapy to treat aliments. In eastern medicine envisioning well-being has always been an important part of the therapeutic process. In Tibetan medicine in particular, creating a mental image of the healing God would improve the patient’s condition and fast recovery. The ancient Greeks including Aristotle and Hippocrates also had their patient to use imagery as a tool for healing process.

It was not in practice until the 1960s, however, those psychologists exploring the emerging field of biofeedback first began to appreciate the powers of the mind on the body. Through biofeedback they could teach patients to slow the heart rate, lower the blood pressure, or open lungs stricken with asthma. Then in the 1970s,O .Carl Simonton, M.D., chief of radiation therapy at Travis Air Force base in Fairfield, and psychotherapist Stephanie Matthews-Simonson, devised a program – today it is known as the Simonton method- that utilized guided imagery therapy to help his cancer patient. Since then a good deal of research in to mind-body connection has appeared in mainstream medical literature. And while many conventional physicians remains skeptical that the mind has an actual physical effect on the reversal of an illness. Guided imagery therapy is now used in many medical inpatient and outpatient programs throughout the world. Further more many holistically oriented psychologists and other counselors routinely employ guided imagery therapy for stress reduction, smoking cessation, weight reduction, immune stimulation, and the relief of both physical and emotional illness. so the researcher is interested to use the guided imagery therapy on prevention of post partum blues among primi mothers because the prevalence rate was more among the primi mothers. The guided imagery therapy will have greater impact on the prevention or reduction of stress and fear of the primi mothers, by giving positive attitude on pregnancy, child birth process, and new born care, and it will change the attitude of the mothers and make the post partum period pleasant and memorable in their life. NEED FOR THE STUDY Pregnancy and child birth are events of great anticipation and glorious moments in a women’s life. But in a few women it could be a stressful event, occasionally severe enough to provoke mental illness such as post partum blues , antenatal and post natal depression is most common in women. It affects not only the patient but also the family and the community.(Scotland 1999)

Postpartum blues is non psychotic that occurs in women shortly after child birth. The rapid drop of the female reproductive hormones after the birth of the baby may deregulate the exquisite integration of neurotransmitters, stress hormones and reproductive hormones leading to the new onset of a psychiatric illness (or) the exacerbation of a previously existing mood disorder. Approximately 80%of all women suffer from the baby blues after giving birth. They may show the first symptoms of feelings of sadness, crying more than usual, over sensitivity, irritability, feeling over whelmed and anxiety. Maternity blues and postpartum depression are common complications of child bearing. However, few studies have shown the relationship between the severity of maternal blues and the risk of postnatal depression. Watanebe M. et. al. (2007) has done a study among Japanese women to show that maternal blues is a useful factor for predicting post partum depression. They took 235 women for their study. They gave the questionnaires before delivery and five days, one month and three months after delivery. They were required to answer the stein’s blues scale and Edinburg postnatal depression scale and other variables. A sequential logistics regression analysis was performed to estimate the association of maternal blues with postpartum depression. The prevalence of post partum depression was 12.8%. a stein’s blue scale of eight or above was significantly associated with postnatal depression. Likelihood ratios (95% CI) for the stein’s blue scale of 0 to 3, 4 to 7, 8 –11 and 12 or more were 0.33 (0.16 – 0.65) and 9.57 (3.41 – 26.86) respectively. These findings suggest that maternity blues is a strong predictor of post partum depression. The higher the blues score, the higher the risk of post partum depression. Adewuya, Adiodum Olugbenga conducted the study in the year 2005 to investigate the prevalence of maternity blues and examine the risk factor involved in a group of Nigerian post partum women. They took 502 post partum women who had a normal vaginal delivery in 5 health centers in these township were assessed with the maternity blues scale daily for the first 10 days post partum. They also filled a structured questionnaire detailing their socio demographic and obstetric histories. The prevalence

4 of maternity blues was 31.3% and the symptoms peaked at the 5th post partum. The predictors of maternity blues includes significant mood change during the pregnancy (OR 3.17, 95%) past admission during pregnancy (OR 3.21, 95%) female baby (OR 2.82, 95% ) and single mothers ( OR 3.35, 95%).The prevalence and the significant risk factors for maternity blues seen to differ across culture. Obstetricians and midwives have to consider this in strategies for prevention and management of post partum depression in new mothers in this environment. All the studies said that the severe psychological problems that occurs during the post partum period is mainly due to maternal (or) post partum blues. The post partum blues is the main cause to post partum depression and psychosis. If the post partum blues is identified earlier and treated properly the severe complications of post partum psychosis and depression can be prevented. There are several treatments are available to treat the post partum blues. They are medication, psychotherapy, counseling, and group treatment and support strategies, estrogen replacement therapy, hormone replacement therapy, guided imagery therapy depending on the women’s need treatment can be adopted. In this, treatments are given after the symptoms appear but “prevention is better than the cure” preventive measures can be taken to prevent the post partum blues in the antenatal period it self by giving counseling, psychotherapy, guided imagery therapy and developing the positive attitude. Among all these measures the guided imagery therapy has more impact on the post partum blues. Guided imagery therapy is a cognitive – behavioral technique in which a client is guided in imaging a relating scene (or) series of experiences. Guided imagery therapy is a form of self hypnosis that has been associated with positive stimulation of the immune system. Positive suggestion is used to help release a negative self image, to assist in creating and achieving goals, and as a natural way to relieve physical, mental and emotional stress-related illnesses such as high blood pressure and insomnia. Numerous clinical observations suggest that an individual, visualizing an imagined scene reacts as though it were actually occurring. There fore “ induced”

5 images can have a profound effect on behavior. The usefulness of guided imagery therapy techniques have been shown to be effective in helping individuals learn or modify behavior such as Learning to relax, Changing (or) controlling their negative emotion in response to a particular situation, event (loss of a job), or belief, Preparing themselves for changes they are likely to have to deal with in the future (children leaving home, parent moving). Rees BL (2006), conducted a studies, in using relaxation with guided imagery therapy to assist primipara in achieving maternal role attainment by means of promoting reducing anxiety and depression, fear and to increase self-esteem. There by promoting maternal role attainment and expected infant behavior during the post partum period. Although relaxation with guided imagery therapy (RGI) has been used clinically in many situations because of RGI has been effective in altering the responses of adult and children in diverse settings. It is inferred that RGI could be effectively used in helping primiparas adapt to the pressure of parenthood. So the researcher is very interested to take this topic because the post partum blues occurs due to inadequate knowledge on delivery and by giving the positive reinforcement on child birth process, new born care during the antenatal period will have some effect on postpartum blues after the 36 weeks, we can bring the positive attitude regarding post natal period there by we can prevent the post partum blues and other post partum psychological problems, which is expected during the post partum period. So the researcher is interested to do the study on post partum blues among primi postnatal mothers. By giving a guided imagery therapy during antenatal period, the researcher is interested to develop the positive attitude towards the pregnancy, child birth process and new born care based on various literatures.

STATEMENT OF THE PROBLEM A study to assess the effectiveness of guided imagery therapy on postpartum blues among primi mothers in selected hospitals at Coimbatore district. OBJECTIVES 1) To assess the level of post partum blues among primi mothers in experimental group and control group. 2) To assess the effectiveness of guided imagery therapy on postpartum blues among the primi mothers in experimental group and control group. 3) To associate the post test post partum blue score with the demographic variables among primi mothers in experimental group. 4) To associate the post test post partum blue score with the demographic variables among primi mothers in control group. HYPOTHESIS

H1 :There will be a significant difference in the levels of post partum blues among primi mothers in experimental group and control group.

H2 : There will be a significant difference in the post test finding on postpartum blues among primi mothers in experimental group and control group.

H3 :There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in experimental group.

H4 : There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in control group. OPERATIONAL DEFINITION 1) EFFECTIVENESS It is an outcome of guided imagery therapy on post partum blues. 2) GUIDED IMAGERY THERAPY It is an imagery talk played through audio and developing a positive thinking about the pregnancy, child birth process and new born care.

3) POST PARTUM BLUES It is a slight mood change takes place after the 4 days of post partum period. 4) PRIMI MOTHER A woman who is pregnant for the first time in the gestational age of 36 weeks, effect will be seen in post partum period. ASSUMPTION 1) The primi mother may experience post partum blues after the 4th day of delivery. 2) There may be a positive effect by guided imagery therapy on post partum blues. DELIMITATIONS 1) Study was delimited to the primi mothers who are from Sundakamutur PHC, and Sakthi hospital at Coimbatore. 2) The samples were selected by convenience sampling technique.

CONCEPTUAL FRAME WORK The present study was aimed at helping the primi mothers to develop positive attitude towards pregnancy, delivery, postnatal period and new born care to prevent post partum psychological problems. The conceptual frame work of the present study was based on nursing process model. It was an organized systematic approach to clients clinical problems. In the course of delivering patient care, nurses collect relevant information, make assessments and diagnose and develop plans for nursing actions, initiate interventions and evaluate the effects of these interventions. The process incorporates general and specific critical thinking competencies in a manner that focuses on a particular client’s unique needs. The format for nursing process is unique to the discipline of nursing and provides a common language and process for nurses to “ think through” client’s clinical problems (ANA 2003). ASSESSMENT Gathering the subjective and objective data were the basic foundation of nursing assessment. It includes, gathering, classifying, categorizing and analyzing the information about primi mothers. In this study demographic variables of primi mothers after 36 weeks, the variables are age, education, religion, income, type of family, food habits, any family history of mental illness, history of any other medical complication during pregnancy, living area, support of the family members, marriage type, occupations were assessed through the questionnaire. PLANNING Assessment and analysis of client data helps in formulating nursing diagnosis, which also forms the basis for planning nursing care. Through the planning the nurse determines what needs to be accomplished and in which is the priority needs that have to be met and how it should be done. In this study planning was regarding guided imagery therapy on post partum blues, to develop positive attitude regarding pregnancy, child birth process and New born care.

IMPLEMENTATION Implementation of the nursing intervention is the next step to planning in nursing process. In this study Implementation referred to playing guided imagery therapy audio cassette on positive attitude towards the pregnancy, child birth process and New born care. It was played for 15min once a day for one month period before delivery. EVALUATION The last stage of the nursing process involves the evaluation for degree to which the behavioral out comes were accomplished (or) how for the goals developed at the planning stage have been met. In this study evaluation involved the post test to analyze the effectiveness of guided imagery therapy through modified Am I blue self rating postpartum blues scale score ranges from mild 0-45, moderate 46-80, severer 81-135 among primi mothers after practicing the guided imagery therapy on post partum blues for 4 weeks.

Assessment Primi Mothers after 36 weeks of Pregnancy Back Ground Factors :- Age ,Religion, Education, Occupation, family type, income, food habits, history of pervious mental illness, any other medical complication during pregnancy, living area, Support of the family members. Marriage type

Evaluation Post test was conducted on 4th postnatal day. And the Planning effectiveness of guided Nursing Process Intervention :- Guided imagery therapy was imagery therapy on analyzed through modified. Positive attitude AM. I BLUE SCALE score towards pregnancy, ranges from mild 0-45, child birth process and moderate 46-80, severe 81- New born care. 135. Setting :- Sundakamuthur PHC

Implementation and Sakthi Hospital at Coimbatore. Playing Audio on Guided imagery therapy after the 36 wks of pregnancy, Regarding pregnancy, Child Birth

process and New born care daily 15 minutes for one month.

Fig – 1 : CONCEPTUAL FRAME WORK BASED ON NURSING PROCESS MODEL

REVIEW OF LITERATURE

CHAPTER – II REVIEW OF LITERATURE The review of the literature is an extensive systematic scrutinization of potential sources of previous study and work. This process helps in identification and selection of problem, back ground of the study, formation of the tool, choosing the methodology, formulating hypothesis. Based on the review of literature investigator developed a conceptual frame work for the study. The review of studies gave the ideas for the study of assessing maternal attitude during the post partum period. PART – I Related literatures to the present study was divided into the following sections. Section – A Literature related to post partum blues. Section – B Literature related to Guided imagery therapy. Section – C Literature related to effect of guided imagery therapy on post partum blues. Section – A Literature related to post partum blues. Mrs. S. Rajamani Victor et. al (2008) conducted a study on effectiveness of prophylactic information on maternal adjustment in term of post natal blues, among the post natal mothers admitted at Government Rajaji hospital, Madurai. The target population of the study was post natal mothers, and the sample consisted of 60 post natal mothers, 30 for experimental group and 30 for control group. The tool used for the study was “ Am I blue” developed by Skillman, NJ. Johnson and Johnson consumer products. It consisted of 30 items to assess the post natal blues. Majority 29(93.7%) of the post natal mothers in the experimental group had mild baby blues and 1(3.3%) had moderate blues. Where as a larger percentage 16 ( 53.3%) of the post natal mothers in the control group had moderate baby blue, 11(36.7%) of the post natal mothers had

12 severe blues in the control group and 3(10%) of the post natal mothers had mild blues. The post natal mothers had encountered difficulties with regard to the physiological factors (Appetite, fatigue, and insomnia) during their immediate post partum period. However the post natal mothers in the control group (2.80, 2.77 and 2.90 respectively) had heightened experiences when compare to their counter parts in the experimental group (1.60, 1.60 and 1.65 respectively). The post natal mothers more than 25 years of age had experienced the greatest “ baby blue feeling” followed by the post natal mothers whose infant weighted between 2 – 3 kg (12.200) and those post natal mothers who had a normal vaginal delivery (11.79). Reck . C. et. al (2008), conducted a study on maternity blues as a pre doctor of DSM – Iv depression and anxiety disorders in the first three months post partum. They took 853 women for their study and they assessed the maternity blues, after the 2nd week of delivery in a community, using a telephone interview and the patient health questionnaire – depression. Depression and anxiety disorders were diagnosed according to DSM – IV criteria. Over the first 3 months following delivery. 2 stage screening procedure was applied. In a first stage, the patient health questionnaires depression, the Edinburgh Depression Scale, and two anxiety – Screening Instruments were employed. The estimated prevalence rate of maternity blues among German women was 55.2%, they found a significant association between maternity blues and post partum depression (odds ration – 3.8) and between maternity blues and anxiety disorders (odds ration – 3.9) Finally they came to a conclusion that women with maternity blues should be carefully observed in the first week post partum with the aim of identifying those at risk of developing post partum depression/ anxiety disorders and providing treatment at an early stage of the disorder. Heidrich .et. al (2008) conducted a study on The relationship between non- bound steroid hormone levels in plasma and the occurrence of postpartum mood changes was investigated in 26 newly delivered mothers throughout the first 5 days postpartum. Studies with saliva samples had reported higher concentrations of 17 beta- estradiol and progesterone on the days of symptoms in women experiencing

13 postpartum blues. As there had been a controversy as to how far saliva concentrations reflect free hormone levels in plasma, free hormone levels of 17 beta-estradiol and progesterone were determined in plasma using ultrafiltration. No significant difference concerning free hormone levels could be found between women with and without postpartum blues. Scand J Varing sci (2008) conducted a comparative study of different instruments to measure blues and to predict depressive symptoms of first 2 months post partum among new mothers and fathers. The aim of the study was to investigate ‘blues’ during the first week. Post partum in new mothers and fathers and to compare different instruments for measuring blues as well as their ability to predict depressive symptoms at 2 months. Parents were informed while at the maternity clinic about the study and asked to independently answer the questions for 5 days during the first week on the blues questionnaire, a VAS questionnaire and on the Edinburgh postnatal depression scale (EPDS) at 1 week and 2 months of the parents who initially agreed to participate in the study 171(38%) of the mothers and 133 (31%) of the fathers returned all questionnaires completely filled-out after the first month. The results showed that mothers experienced more blues than fathers. The blues questionnaire and the VAS sub scale depressed mood. Identified more women as having blues (64% and 52%) respectively during the first week over the EPDS (34%). N. Denis. et. al (2008), conducted a study to investigate the contribution of psychological and obstetrical factors in the intensity of post partum blues. 148 women participated in the study and completed questionnaires 3 days after delivery. A questionnaire was built to collect information on psychosocial and obstetrical factors. The maternity blues (Kennerley and Gath, 1989) was used to assess post partum blues. Psychological factors were measured with the maternal self-report inventory (Shea er Tronick, 1988). The perceived stress scale (Cohen, Kamarch et Mermelstein, 1983) and the Sarason’s social support questionnaire (1983). The intensity of postpartum blues by entering psychosocial factors, history of depression, obstetrical factors and psychological and relational factors. Significant predictors (Maternal self-esteem, marital

14 status, previous psychotherapeutic treatment, previous antidepressant treatment) were entered in a multiple analysis predicting the intensity of postpartum blues. This model accounted for 31% of the variance in the intensity of postpartum blues (F(4.143) = 17.9; p<0.001). Maternal self-esteem (beta = -0.37; p<0.001). marital situation beta= - 0.16; p=0.02) were significant predictors. Previous anti depressant treatment (beta= 0.13; p=0.05) was almost a significant predictor. Yolanta D. Booker & Sonia L. White, et . al (2007) conducted a study to assess the relationship between socio demographic factors and postpartum blue among a sample of newly delivered mothers in broward county, florida. This was a descriptive-co relational study to explore the relationship between postpartum depressive symptomatology and socio-demographic variables of newly delivered mothers in Broward County, Florida. The available literature suggests that postpartum blues is a fairly common experience found to correlate with biological, environmental, and socio demographic factors. Substance abuse and previous psychiatric disorder history also have been found to correlate with postpartum blues. Roy's Adaptation Model (1984) was the theoretical framework underpinning the study. The Beck Depression Inventory measured depression among a convenience sample of 27 predominantly married, young, White, non-Hispanic women who were four to eight weeks postpartum. The data revealed no significant correlations among perceptions of inadequate support among women with unplanned pregnancies (r=.4332, r=.024), and women with previous births (r=.6366, p=.008). Single mothers were also more likely to use alcohol in the postpartum period (r=.4183, p=.030). These findings suggest additional research remains necessary area and that nurses must conduct in depth assessment of the psychosocial needs and resources of postpartum women. Gonodakis F. et. al (2007) conducted a study to investigate the prevalence, time course and symptomatology of maternity blues in the Greek urban, and relation of maternity blues with certain clinical and socio demographic factors. They took 402 women, they were recruited during the first day after delivery each women completed the Kennerley’s blues questionnaire on a daily basis for the first 3 days of puerperium.

Clinical and socio demographic data were obtained through questionnaires and personal interview in that 179 (44.5%) women experienced severe maternity blues during the 1st 3 days after delivery. Delivery by caesarian section (p=0.006) stressful events during pregnancy (p=0.02) depressive feelings the last month prior to delivery (p=0.002), anxiety on the day of delivery (p=0.001) and hypochondriasis (p=0.001) were the factors that were found to relate significantly to maternity blues. Chabrol H. et . al (2007), conducted a study to evaluate the effect of providing information on postpartum blues during pregnancy on the intensity of the blues. Their sample size is 37 women on the third trimester of pregnancy and were randomly assigned to one of three groups. The 1st group received a short text book of information. The second group received the text which was regard and discussed and 3rd group was the control group. All the participants completed the Edinburgh postnatal depression scale (EPDS) questionnaire during the period 3 to 5 days of postpartum. They found that providing information on postpartum blues during the 3rd trimester of pregnancy may reduce the intensity of the depressive dimension of the blues symptomatology. Glowary et . al (2007) conducted a study to investigate the prevalence time course and symptomatology of maternity blues in a Greek urban during the first 3 days after delivery. They recruited 402 women during the first day after delivery and data was collected on a daily basis for the first 3 days of postpartum. 179 (44.5%) women experienced severe maternity blues during the first 3 days after delivery. Delivery by Caesarian section (p=0.006), stressful events during pregnancy (p=0.02), depressive feelings the last month prior to delivery (p=0.002), anxiety on the day of delivery (p=0.001) and hypochondriasis (p=0.001) were the factors that were found to relate significantly to maternity blues. The women’s emotional condition prior and after delivery, delivery via caesarotomy, as well as tears concerning somatic health had strong impact on the occurrence maternity blues.

Nagata M.Ando.T et .al (2006) conducted a study maternity blues and attachment to children in mothers of full term normal infants. It is a survey study so called “maternity blues” refers to a transitional depressive state developing about 3 days after delivery and lasting perhaps 2 weeks with mild insomnia, fatigue, and tearfulness, reports from Japan city rates 4 to 50 percent of mothers. This state is distinct from post partum depression, which usually develops 4 to 6 weeks after delivery and is a pathological condition. This questionnaires survey directed at 417 women’s giving birth at a single hospital was conducted to estimate the frequency of maternity blues and relate it to maternal attachment to the new born infant. The questionnaire consisted of the sung self rating depression scale & a measure of maternal attachment and anxiety regarding children termed the post partum maternal attachment scale. This measure is based on words and phrases encountered during counseling of mothers whose infants were admitted to neo intensive care. The mother whose average age was 30 tilled out the questionnaire 3 to 25 days post partum, the average interval being about 5 days. A positive sung score was obtained in two, thirds of the cases. C Henshaw, et . al (2006) Postnatal blues a risk factor for postnatal depression postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors

17 each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised. Ann Josefsson et . al (2006), Prevalence of blues symptoms in late pregnancy and postpartum. Postnatal blues refers to a non-psychotic depressive episode that begins in or extends into the postpartum period. The aims of this study were to examine the prevalence of blues symptoms in a pregnant and later postnatal population, to determine the natural course of these symptoms and whether there is an association between antenatal and postnatal blues symptomatology. a longitudinal study with a total population of 1,558 consecutively registered pregnant women in the southeast region of Sweden. Presence of blues symptoms was measured with the Edinburgh Postnatal Depression Scale on four occasions namely in gestational week 35–36, in the maternity ward, 6–8 weeks and 6 months postpartum.. The prevalence of depressive symptoms during late pregnancy was 17%; in the maternity ward 18%; 6–8 weeks postnatally 13%; and 6 months postnatally, 13%. A correlation between antenatal and postnatal depressive symptoms was found (r=0.50, p<0.0001).Conclusion. Detection of women at risk for developing postnatal depressive symptoms can be done during late pregnancy. Antenatal care clinics constitute a natural and useful environment for recognition of women with depressive symptoms. Cindy-Lee Dennis, (2005) conducted a study on to assess the effect of psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care on the risk of postnatal blues. The primary or secondary aim was a reduction in the risk of postnatal blues. The pregnant women new mothers less than six weeks postpartum are selected as a sample. Eligible studies were abstracted, assessed for methodological quality, and pooled with relative risk for categorical data and weighted mean difference for continuous data. The 7697 women were included for the study, although there was no overall statistically significant effect

18 on the prevention of postnatal blues in the meta-analysis of all types of interventions (15 trials, n= 7697; relative risk 0.81,95% confidence interval 0.65 to 1.02), these results suggest a potential reduction in postnatal blues. The only intervention to have a clear preventive effect was intensive postpartum support provided by a health professional (0.68, 0.55 to 0.84). Identifying women "at risk" assisted in the prevention of postnatal depression (0.67, 0.51 to 0.89). Interventions with only a postnatal component were more beneficial (0.76, 0.58 to 0.98) than interventions that incorporated an antenatal component. In addition, individually based interventions were more effective (0.76, 0.59 to 1.00)than group based interventions (1.03, 0.65 to 1.63). Diverse psychosocial or psychological interventions do not significantly reduce the number of women who develop postnatal depression. The most promising intervention is the provision of intensive, professionally based postpartum support. L. Fossey et. al (2005) conducted a study on Postpartum blues: a clinical syndrome and predictor of postnatal depression towards, postnatal depression before postpartum discharge from the hospital. Studying a population of 186 women who had just given birth and using two tools, the self-administered questionnaires designed by Pitt and by Cox, we found a relationship between postpartum blues, evaluated with Pitt's tool on the 3rd day after delivery, and postnatal depression, evaluated 8 months later. We thus show that the postpartum blues, evaluated with Pitt's tool, especially when severe, is predictive of the subsequent development of postnatal depression. Dallas.E et. al (2005) study to demonstrate the possibility of a link between the intensity of the baby blues & some specific factors like maternal self esteem, maternal child care stress & social background. 95 mothers were studied after the 3rd day following birth & 6 week of post birth. The intensity of the baby blues was explained by the type of pregnancy (p=0.002) a low maternal self esteem (p=0.025) high level of the baby (p=0.074) on the whole baby blue seem to be a physiological process where by the intensity is influenced by psychological factors. Regave C.J (2005) on influence of prophylactic information on the frequency of baby blues. It is an prospective randomized study. First group was given oral & written

19 information about baby blues and other group as not both the groups were evaluated by using Edinburgh post partum depression scale in 3 days after delivery them 6 weeks & 3 months of post partum period. 169 mothers were included in this study the result obtained was only 12(15%) of the information group experienced a baby blues in control group 25(29%)(p=0.027). the percentage of score above 11 in the EPDS around birth was 8.5% vs. 9.3% in the information vs. control group. 6 weeks after birth the percentages were 7.5 vs 7.1 & 12 weeks after birth they were 7.3% vs 8.0% women considering themselves as depressive by self evaluation 3 month post partum. Only a few sought help from a specialist 7 or 13 in information vs 4 of 14 in control group. So the oral & written information about baby blues given post partum is be an effective instrument to lower its frequency.

Murata A. Nadaoka et. al (1998) conducted a study on prevalence and back ground factors of maternity blues. It was a longitudinal study there about 111 women where taken as a sample and conducted the study on women who received obstetric care at Yamagata university hospital from November 1994 to 1995 august. Cases of maternity blues were found using Am I blue self-rating maternity blues scale. Mother child relationship in the women’s childhood were assessed using the parental bonding instrument of the 111 women. 17 (15.3%) developed maternity blues during the 1st postpartum month. The PBI revealed that these depressed women appeared to be cared for less sufficiently in their own childhood than the non- depressed women. As revealed in interviews, they also seemed to receive less support from their families during pregnancy. These findings suggest that maternity blues may be related to insufficient maternal care in childhood, as well as to poor family support during pregnancy.

Section – B Literatures related to Guided imagery therapy. Marc H. Kalmanson, (2007) conducted a study on the effect of guided imagery on pain perception in adult with chronic pain. Recent Studies describe the use of guided imagery as a valid, reliable and cost effective adjunct in the treatment of pain which, this Study has undertaken to demonstrate the effectiveness of guided imagery in the treatment of chronic pain. When untreated, chronic pain negatively impacts upon quality of life, self image, job performance, and interpersonal relationships. Data were collected from a convenience sample of 30 adult clients from 18 to 70 years of age from an outpatient treatment facility in Broward County Florida comprising. Statistical analysis was performed using descriptive and co relational statistics in this quasi-experimental prospective study. Lisa K. Mannix. MP, (2007) has conducted a study on to determine the effect of adjuvant guided imagery on patients with chronic tension-type headache. One hundred twenty-nine patients with chronic tension-type headache completed the Headache Disability Inventory and the Medical Outcomes at their initial visit to a specialty headache center and again 1 month after the visit. In addition to individualized headache therapy, patients listened to a guided imagery audiocassette tape daily for the month. One hundred thirty-one control subjects received individualized therapy without guided imagery. Controls and the patients who listened to the guided imagery tape improved in headache frequency, headache severity, patient global assessment, quality of life, and disability caused by headache. More guided imagery patients (21.7%) than controls (7.6%) reported that their headaches were much better (P.004). The guided imagery patients had significantly more improvement than the controls in three of the SF-36 domains: bodily pain (95% CI; guided imagery patients 11.0, controls 0.2), vitality (95% CI; guided imagery patients 10.9, controls I.7), and mental health (95% CI; guided imagery patients 7.8, controls 0.4). So guided imagery is an effective adjunct therapy for the management of chronic tension-type headache.

Troesch LM, Rodehayer, (2006) conducted a study on influence of guided imagery on chemotherapy-related nausea and vomiting. The purpose of this study was to determine if the addition of guided imagery to a standard antiemetic regimen decreased nausea, vomiting, and retching occurrence and distress in patients receiving cisplatin-based chemotherapy. A convenience sample of patients (N = 28) was selected from an oncologist's patient population and randomized into two groups. Both groups received the same standard antiemetic regimen, while the experimental group additionally used a chemotherapy-specific guided-imagery audiotape. The Rhodes Index of Nausea and Vomiting Form 2 was used to measure the nausea and vomiting experience. Findings revealed no statistically significant difference in this measurement between the two groups when measured at five different times during chemotherapy administration. The Chemotherapy Experience Survey was used to evaluate the participants' overall perceptions of the chemotherapy experience. The guided-imagery group expressed a significantly more positive experience (p = 0.0001) with chemotherapy. These findings have definite implications for developing effective nursing interventions to promote patient involvement in self-care practices and to increase patient coping abilities during symptom occurrence. James et . al (2006) conducted a study to determine whether guided imagery in the preoperative period could improve the outcome of colorectal surgery patients. We conducted a prospective, randomized trial of patients undergoing their first elective colorectal surgery at a tertiary care center. Patients were randomly assigned into one of two groups. Group 1 received standard preoperative care, and Group 2 listened to a guided imagery tape three days preoperatively; a music-only tape during induction, during surgery, and postoperatively in the recovery room; a guided imagery tape during each of the first six postoperative days. Both groups had postoperative patient- controlled analgesia. All patients rated their levels of pain and anxiety daily, on a linear analog scale of 0 to 100. Total narcotic consumption, time to first bowel movement, length of stay, and number of patients with complications were also recorded. Groups were similar in age and gender distribution, diagnoses, and surgery performed. Median

22 baseline anxiety score was 75 in both groups. Before surgery, anxiety increased in the control group but decreased in the guided imagery group (median change, 30; P < 0.001). Postoperatively, median increase in the worst pain score was 72.5 for the control group and 42.5 for the imagery group (P <0.001). Least pain was also significantly different (P <0.001), with a median increase of 30 for controls and 12.5 for the imagery group. Total opioid requirements were significantly lower in the imagery group, with a median of 185 mg vs.326 mg in the control group (P <0.001). Time to first bowel movement was significantly less in the imagery group (median, 58 hours) than in the control group (median, 92 hours; P <0.001). The number of patients experiencing postoperative complications (nausea, vomiting, pruritus, or ileus) did not differ in the two groups. Guided imagery significantly reduces postoperative anxiety, pain, and narcotic requirements of colorectal surgery and increases patient satisfaction. Guided imagery is a simple and low-cost adjunct in the care of patients undergoing elective colorectal surgery. Rees BL. (2006), using relaxation with guided imagery therapy to assist primiparas in achieving maternal role attainment to reduce anxiety and depression and to increase self-esteem during the post partum period. The mothers were given a relaxation with guided imagery therapy with new mothers. The relaxation with guided imagery therapy has been effective in altering the responses of adults and children in diverse settings. It is inferred that relaxation with guided imagery therapy can be effectively used in helping primi paras adapt to the pressure of parenthood. Hilary A. Tindle, MD, MPH et .al (2006) conducted a study on Guided Imagery for Smoking Cessation in Adults: A Randomized Pilot Trial, This pilot study describes a randomized controlled trial of an audio CD—based interactive guided imagery program for smoking cessation for adults versus a wait-listed control. Feasibility, process measures, and biochemically validated abstinence were assessed at end of treatment (6 weeks) and 12 weeks, as well as at 52 weeks for intervention participants. Fifty-nine percent of intervention participants attended four of six guided imagery sessions, and 94% found the technique helpful for smoking cessation. Intervention participants had

23 greater readiness to quit (Readiness to Quit Ladder, 8.3 vs. 7.2, p < .05) and lower state anxiety (Spielberger Index, 32 vs. 38, p < .05) at end of treatment than the control group. Abstinence rates in the intervention versus control groups were 36% versus 18% (p = .43) at 6 weeks and 30% versus 12% (p = .40) at 12 weeks, respectively. At 1 year, 24% of intervention participants remained abstinent. A guided imagery program for smoking cessation was feasible, perceived to be helpful, improved intermediate measures, and resulted in a trend toward smoking cessation. Geden, elizabeth A. Phd, RN, (2006) conducted a study on Effects of Music and Imagery On Physiologic and Self-Report Of Analogued Labor Pain Two studies were conducted to examine the effects of music on analogued labor pain using volunteer nulliparous subjects who were randomly assigned to treatment groups (n = 10 per group). Assessments of the treatments were made in a 1-hour session involving twenty 80-second exposures to a laboratory pain stimulus patterned to resemble labor contractions. In the first experiment, it was hypothesized that subjects listening to easy- listening music would report lower pain ratings and cardiovascular responses than subjects listening to rock music, self-selected music, or a dissertation (placebo- attention) and subjects in a no-treatment control group. No significant group effects were found; significant time effects were found for heart rate, systolic and diastolic blood pressure. Subjects spontaneously reported using imagery as a pain reduction technique. In the second study a combination of music and imagery was examined by randomly assigning subjects to one of five groups: self-generated imagery with music (SIM), guided imagery with music (GIM), self-generated imagery without music (SI), guided imagery without music (GI), or no-treatment control. Again, no significant group effects were obtained. Significant time effects were obtained for heart rate, systolic and diastolic blood pressure. Limbert, Sally A Phd.R.N. (2006) conducted a study on postoperative course of children. The purpose of this study was to examine the effect hypnosis/guided imagery on the postoperative course of pediatric surgical patients 52 children (matched for sex, age, and diagnosis) were randomly assigned to an experimental or control

24 group. The experimental group was taught guided imagery by the investigator practice of the imagery technique included suggestions for a favorable postoperative course significantly lower postoperative pain ratings and shorter hospital says occurred for children in the experimental group. State anxiety was decreased for the guided imagery group and increased postoperatively for the control group. This study demonstrates the positive effectives of hypnosis/guided imagery for the pediatric surgical patient. Antall Gloria (2005) conducted a study the use of guided imagery to manage pain in a elderly orthopedic population. Who has undergone joint replacement surgery study used a two group experimental repeated measures design. A sample of 13 patients age 55 years and older were recruited the control group received usual care and a music audio tape. The experimental group received usual care and a guide imagery audio tape intervention. Trends in this study demonstrated positive out comes for pain relief decreased anxiety and decreased length of stay complementary therapy holds the promise of increasing positive out come further research is needed to validate these findings with a larger postoperative samples and in other populations as well. Kolcaba K, Fox C. (2005) conducted a study on the effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. It is an experimental longitudinal, study two urban radiation oncology departments. It is an experimental longitudinal study, samples were selected as random sampling technique 53 women were selected 26 in the experimental group, 27 in the control group. The women with stage I or II breast cancer about to begin radiation therapy. The experimental group was to listen to a guided imagery audiotape once a day for the duration of the study. The Radiation Therapy Comfort Questionnaire was self- administered at three time points: prior to the introduction of intervention and the beginning of radiation therapy (Time 1), three weeks later (Time 2), and three weeks after completing radiation therapy (Time3). The State Anxiety Inventory was administered at Time 1 only. Guided imagery is an effective intervention for enhancing comfort of women undergoing radiation therapy for early stage breast cancer. The intervention was especially salient in the first three weeks of therapy.

Cynthiya et. al (2005), Conducted a study on use of Guided Imagery for the Treatment of Recurrent Abdominal Pain in Children. Few effective therapies are available for children with recurrent abdominal pain (RAP). Ten children with RAP were enrolled in the study after evaluation by a pediatric gastroenterologist. They were trained in relaxation and guided imagery during 4 weekly 50-minute sessions. Pain diaries were completed at 0, 1, and 2 months. Children and parents also completed psychological questionnaires at enrollment. Although refractory to conventional treatment by their physician and pediatric gastroenterologist, the children experienced a 67% decrease in pain during the therapy (chi-square for trend, p<0.001). No baseline psychological characteristics impacted the response to therapy. The use of relaxation along with guided imagery is an effective and safe treatment for childhood RAP. Barbara L.Rees, (2005) conducted a study on effectiveness of Guided imagery therapy on anxiety depression, and self esteem in primiparas. They took 60 samples as convenient and gave a relaxation through guided imagery therapy in primiparas during the 1st 4 weeks of postpartum period. The results showed that the experimental group had less anxiety and depression and greater self – esteem than did the control group at the end of the period. Positive correlation were obtained between anxiety and depression, negative correlation between self-esteem and anxiety and depression all findings were significant at the 0.05 level. Section – C Literature related to effect of guided imagery on post partum blues. Cindy-Lee E Dennis, RN, (2006) conducted a study on to determine the current state of scientific knowledge concerning the prevention of postpartum psychological problem (PPD) from a non-biological perspective . Twenty-nine studies that met criteria were examined. These included studies evaluating interpersonal psychotherapy, cognitive-behavioural therapy, psychological debriefing, antenatal classes, intrapartum support, supportive interactions, continuity of care, antenatal identification and notification, early postpartum follow-up, flexible postpartum care, educational strategies, and relaxation with guided imagery. While this review demonstrates that no specific

26 approach can be strongly recommended for clinical practice, many explicit research implications have been highlighted. To further post partum blues, depression, psychosis as a public health problem, it is critical to include ethnically and socioeconomically diverse women in research efforts examining the differences among depression symptoms, intervention response rates, and health service use.

METHODOLOGY

CHAPTER III RESEARCH METHODOLOGY Research methodology is a way to systematically solve the research problem. It is a science of studying how research is done scientifically. Methodology is a significant part of the research under which the researcher is able to project a blue print of the research undertaken. This chapter includes research design, variable, setting, population, sample size, sampling technique, development of tool, data collection procedure, plan for data analysis and ethical consideration. The problem stated in this study was “ A pre experimental study to assess the effectiveness of guided imagery therapy on post partum blues among primi mothers in Coimbatore district. RESEARCH APPROACH The research approach used for this study was an evaluative approach, without random selection of sample by manipulating the variables to assess the effectiveness of guided imagery therapy on post partum blues. RESEARCH DESIGN The term research design refers to the plan of a scientific investigation. Research design helps the researcher in the selection of the subject, Identification of variables, their manipulation, control, observations to be made and types of statistical analysis to interpret the data. Considering all the above factors and the availability of time for data collection the researcher had selected the quasi-experimental design, ie the post test only control group design. It is a relatively straight forward research design in which there is a treatment group with a control group. All the subjects of experimental group receives the treatment and post test was given. The control group has been given post test without any treatment. After the collection of data, they were analyzed for difference. In this study an experimental group of primi mothers after 36 weeks was receiving the guided imagery therapy on post partum blues and post test was

28 conducted. For control group primi mothers post test was conducted without intervention using modified AM I Blue self rating post partum blue scale.

The diagrammatic representation of research design is given below,

Group pretest Treatment Post test

Experimental - Х O1

Control - - O2

Key:

O1 - post test to assess the post partum blues among primi mothers after the guided imagery therapy in experimental group.

O2 - post test to assess the post partum blues among primi mothers in control group. Х – Manipulation (guided imagery therapy for one month after 36 weeks of gestation.)

TARGET POPULATION Primi mothers after 36 weeks of pregnancy

ACCESSIBLE POPULATION Primi mothers after 36 weeks of pregnancy from selected hospitals at Coimbatore district.

DEMOGRAPHIC VARIABLES SAMPLING Age, religion, SAMPLE AND SAMPLE TECHNIQUE education SIZE Convenient Sampling Technique ,occupation, 60 primi mothers family type, income, food habit, family history of EXPERIMENTAL pervious mental CONTROL GROUP GROUP illness, any other 30 primi mothers 30 primi mothers medical complication during INTERVENTION pregnancy, Guided imagery living area, therapy on post support of the partum blues. family members, type of marriage. Post Test DATA COLLECTION Modified Am I ANALYSIS AND INTERPRETATION OF DATA blue self rating Descriptive and Inferential Analysis scale.

CRITERIAN MEASURES Findings postpartum blues score

Report / Thesis

Fig 2 :- SCHEMATIC PRESENTATION OF RESEARCH DESIGN

VARIABLES

The three categories of variables discussed in the present study were, Independent Variable : Guided imagery therapy. Dependent Variable : Post partum blues Associate Variable : Age, education, religion, occupation, income Family type, food habit, family history of pervious mental illness, any other medical complication during pregnancy, living area, support of the family members, type of marriage.

SETTING OF THE STUDY Research setting is the specific place where data collection is to be made. The selection of setting was done on the basis of feasibility of conducting the study, availability of subjects and permission from the concerned authorities. The study was conducted in Sundakamuthur PHC, and Sakthi hospital at Coimbatore district. POPULATION Polit and Hunger (2004), referred population as the entire set of individuals(or)subjects having common characteristics sometimes referred to as universe. Population may be of two types-target population, accessible population. In this study two populations were described. TARGET POPULATION It refers to the population that the researcher wish to make a generalization. In this research the target population was the primi mother after 36 weeks of pregnancy. ACCESSIBLE POPULATION It refers to the aggregate of cases which conforms the design to the researcher as the pool of subjects(or)objects. In this research the accessible population is the primi mothers after 36 weeks of pregnancy in Sundakamuthur PHC and Sakthi hospital at Coimbatore.

SAMPLE Sample consist of the primi mothers in the selected population to participate in this research study. In this study the samples were primi mothers after 36 weeks of pregnancy, those who are coming to a regular antenatal checkup and delivery at Sundakamuthur PHC and Sakthi hospital Gandhipuram at Coimbatore district. SAMPLE SIZE The sample size for the present study was arbitrarily decided to be 60 primi mothers . The sample size was determined based on the type of study variables being studied, the statistical significance required and availability of sample and feasibility of conducting the study. SAMPLING TECHNIQUE The purpose of using a sampling technique is to increase representativeness and to decrease bias and sampling error. In this study convenience sampling technique was used to select subjects as they fulfilled the inclusive criteria. SAMPLING CRITERIA In sampling criteria the researcher specifies the characteristics of the population under the study by detailing the inclusive and exclusive criteria. Inclusive criteria are characteristics that each sample elements must posses to be included in the sample . exclusion criteria are characteristics that confound or contaminate the results of the study, therefore such participants are excluded from the study. INCLUSION CRITERIA 1. Primi mothers who were after the 36 weeks of pregnancy, and those who are coming for regular antenatal checkup and delivery at Sundakamuthur PHC and Sakthi hospital. 2. Primi mothers who were willing to participate. 3. Primi mothers who could speak in Tamil.

EXCLUSION CRITERIA 1) Primi mothers those who were having obstetrical and medical problems during pregnancy and delivery. 2) Primi mothers those who were not having hearing ability. 3) Primi mothers those who were not present at the time of data collection. DEVELOPMENT OF TOOL An instrument in research refers to the tool (or) equipment used for collecting data. The investigator used AM I Blue self rating post partum blue scale to assess the level of post partum blues among primi mothers. The investigator modified the tool after the extensive review of literature and consulting with the experts. The average time taken to complete the questionnaire was 20 minutes. DESCRIPTION OF THE TOOL The study tool consists of 2 sections SECTION 1 – Demographic variables of primi mothers. SECTION 2 – Modified AM I Blue self rating postpartum Blues Scale. SECTION 1 : Demographic Variables The questionnaire consists of 12 items seeking general information about primi mother’s like , age, education, religion, occupation, family type ,income, food habit, family history of pervious mental illness, any other medical complication during pregnancy, living area, support of the family members, and type of marriage. It was a self administered questionnaire . Instructions were given to the primi mothers for using the questionnaire. SECTION 2 : Modified Am I Blue self rating postpartum blues scale. It consist of 45 items to assess the postpartum blues among the primi mothers. Modified Am I blue self rating postpartum blues scale was used to assess the primi postnatal mothers. Instructions were given to them for the usage of self rating postpartum blues scale. The responses were ranged from ‘Nil’ to ‘severe.’

SCORING The questionnaire had 45 items. Postpartum blues were measured in terms of modified Am I blue self rating postpartum blues scale the score was Nil:- 0, Mild:-1, moderate:-2, and severe:-3, the maximum score was 135. VALIDITY OF THE TOOL In the present study, five experts including one clinical obstetrician, three nursing experts and one psychologist were validated the entire section of the tools. The experts were requested to check for the relevance, sequence and adequacy of the content in the tool. Based on the recommendation, few items were modified. Items with 100% agreement were included in the study. The tool was drafted in English and translated into Tamil and retranslated in to English. So the language validity was satisfied. VALIDITY OF THE AUDIO CD Audio CD was validated by five experts including one obstetrician ,three nursing experts and one psychologist, After making appropriate modifications the content was finalized. the audio program was pretested with the 5 primi mothers, the average time taken to listen the guided imagery therapy was around 15 minutes. It was found to be understandable and clear. TRYOUT The guided imagery therapy audio CD was pretested with the 5 primi mothers. The primi mothers chosen were similar in characteristics to those of the population under study. The tool was administered to 5 primi mothers and checked for the feasibility and appropriateness. The items were found clear and understandable by the subjects. RELIABILITY OF THE TOOL The reliability of the tool for the present study was established by interrater method among 5 primi mothers. Reliability was computed using Karl Pearson’s correlation co-efficient r=0.9. The tool was found to be reliable.

DESCRIPTION OF GUIDED IMAGERY THERAPY Guided imagery was defined by Bresler and Rossman, co-founders of the academy for guided imagery. Guided imagery therapy as a “range techniques from simple visualization and direct imagery – based suggestion through metaphor and story telling” (2003). It is a form of self-hypnosis that has been associated with positive stimulation of the immune system. Positive suggestion is used to help release a negative self – image, to assist in creating and achieving goals and as a natural way to relieve physical, mental and emotional stress. The usefulness of guided imagery technique are: It makes the persons to learn to relax, changing on controlling their negative emotions in response to a particular situation, even (loss of a job) (or) belief, preparing themselves for changes they are likely to have to deal with in the future (children leaving home, parent moving)…… Through this guided imagery is currently understood to be mainly an “alternative” (or) complementary therapeutic technique. It is a series of relaxation events and positive reinforcement about pregnancy, child birth process, and new born care as described in an audio CD. DATA COLLECTION PROCEDURE The present study was conducted in Sundakamuthur PHC and Sakthi hospital, at Coimbatore. The data was collected for 4 weeks from 1st Aug to 30th Aug 2009. Prior permission from the authorities were sought and obtained. Individual informed consent was taken from the study samples orally. The study samples were selected by convenient sampling method based on sample selection criteria. All the primi mothers from the selected PHC and Sakthi hospital were screened. In that 60 eligible primi mothers were selected, who satisfied the selection criteria were recruited in the experimental group and control group anticipating attrition. The objectives and purpose of the study was explained and assured that the confidentiality would be maintained.

Guided imagery therapy was played to the primi mothers of the experimental group with the help of audio CD. Each participant was advised to hear the audio CD once a day, daily for 4 weeks and it was directed by the researcher regularly with the help of check list. Post test was conducted after the 4th day delivery of post partum period for the experimental group. The effective samples were 30 primi mothers who have participated in the post test in experimental group and in control group only post test was conducted for 30 primi mothers. The tools were checked for their completeness. PLAN FOR DATA ANALYSIS The investigator has edited the tool, coded the data and entered the data into excel sheet. Statistical analysis was done by SPSS packages version 10. The level of significance, 0.05 was used to reject the null hypothesis. The data were analyzed as follows 1. Demographic variables were analyzed using frequency and percentage distribution. 2. Effectiveness of guided imagery therapy was evaluated by unpaired ‘t’ test. 3. Association between post test findings and demographic variables of experimental group were analyzed by using chi – square. 4. Association between post test findings and demographic variables of control group were analyzed by using chi – square. ETHICAL CONSIDERATIONS The study objectives, intervention and data collection procedures were approved by the research and the ethical committee of the institution. Informed consent was obtained from the individual primi mothers in oral form. The primi mothers had the freedom to leave the study at their will without assigning any reason. Explanation regarding the purpose of giving guided imagery therapy was explained to the primi mothers involved in this study. Thus the ethical issues were ensured in the study.

ANALYSIS AND INTERPRETATION

CHAPTER-IV DATA ANALYSIS AND INTERPRETATION Polit (2004) states that statistical analysis is a method of rendering quantitative information and elicit meaningful and intelligible form of research data, analysis and interpretation of data of this study. The aim of the study is to develop the positive attitude among the primi mothers by giving a guided imagery therapy on pregnancy, child birth process, and new born care. Data collected from 60 primi mothers, in which 30 experimental group and 30 control group. Collected data were tabulated , analyzed and interpreted to understand the impact of guided imagery therapy on post partum blues among primi mothers. OBJECTIVES 1) To assess the level of post partum blues among the primi mothers in experimental and control group. 2)To assess the effectiveness of guided therapy on postpartum blues among the primi mothers in experimental group and control group. 3) To associate the post test post partum blues score with the demographic variables among primi mothers in experimental group . 4) To associate the post test post partum blues score with the demographic variables among primi mothers in control group. The collected data were edited , tabulated ,analyzed, interpreted and the findings were presented in the form of tables and diagrams under the following section. SECTION I : Data on demographic variables of primi postnatal mothers both experimental and control group. SECTION II : Data on levels of post partum blues among primi mothers in experimental group and control group. SECTION-III: Data on Association between the level of postpartum blues of primi mothers with the demographic variables in the experimental group and control group.

SECTION I

DATA ON DEMOGRAPHIC VARIABLES OF PRIMI POSTNATAL MOTHERS OF BOTH EXPERIMENTAL GROUP AND CONTROL GROUP.

Table I Reveals that the frequency percentage distribution and 2value of primi mothers regarding the demographic variables Experimental Control S.No Demographic Variables Group Group 2 F % F % 1. Age

16 to 20 yrs 12 40 13 43.33 2=0.14 21 to 25 yrs 12 40 12 40 p=7.82 26 to 30 yrs 5 16.66 4 13.33 NS 31 yrs and above 1 3.33 1 3.33 2. Religion

Hindu 19 63.33 19 63.33 2=3.6 Christian 6 20 2 6.66 p=7.82 Muslim 3 10 7 23.33 NS Others 2 6.66 2 6.66 3. Education

Primary education 9 30 16 53.33 2=3.78 Secondary education 10 33.33 9 30 p=7.82 Undergraduate 6 20 3 10 NS Post graduate and above 5 16.66 2 6.66 4. Occupation Housewife 15 50 15 50

Coolie 3 10 9 30 Not Business 8 30 4 13.33 applicable Government employee 3 10 2 6.66 Others 1 3.33 0 0 5. Family type Nuclear family 23 76.66 17 56.66 2=2.9 Joint family 6 20 10 33.33 p=5.99 Extended family 1 3.33 3 10 NS 6. Income Rs. 3000 to 5000 14 46.66 24 80 Not Rs. 6000 to 10000 11 36.66 4 13.33 applicable Rs. 11000 to 15000 5 16.66 2 6.66 Rs. 16000 and above 0 0 0 0

Experimental Control S.No Demographic Variables Group Group 2 F % F % 7. Food habit Vegetarian 7 23.33 9 30 2=5.3 Non vegetarian 5 16.66 10 33.33 p=5.99 Both 18 60 11 36.66 NS 8. Family history of previous mental

illness Not Yes - - - - applicable No 30 100 30 100 9. Any other medical complication during

pregnancy Not Yes - - - - applicable No 30 100 30 100 10. Living area 2=3.89 Rural 20 66.66 18 60 p=3.84 Urban 10 33.33 12 40 11. Support of the family members Husband 8 26.66 14 46.66 Mother & Father 4 13.33 5 16.66 Sisters & Brothers 1 3.33 1 3.33 2=3.72 Both a & b 16 53.33 9 30 p=9.49 Mother-in-law & Father- in- 1 3.33 1 3.33 law 12. Type of marriage 2=1.14 Arranged marriage 21 70 17 56.66 p=3.84 Love marriage 9 30 13 43.33

Among the experimental group regarding age majority 12(40%) of the primi mothers were equally distributed between the age group of 16 to 20 yrs and 21 to 25 yrs, and the least 1(3.33%) of primi mothers were in the age group of 31 yrs and above. Among control group regarding age majority 13(43.33%) of the primi mothers belong to the age group of 16 to 20 yrs and the least 1(3.33%) of primi mothers belong to the age group of 31 yrs and above. The obtained 2 value 0.14 , was not significant at 0.05 level.

Among the experimental group regarding religion majority 19(63.33%) of the primi mothers were belonged to Hindu religion, and the least 2(6.66%) of primi mothers were from other religion. Among the control group regarding religion majority 19(63.33%) of the primi mothers belonged to Hindu religion, and the least 2(6.66%) of primi mothers were equally distributed between Christian and other religion. Obtained2 value 3.6 , was not significant at 0.05 level. Among the experimental group regarding education majority 10(33.33%) of the primi mothers had secondary education, and the least 5(16.66%) of primi mothers had post graduate education. Among the control group regarding education majority 15(50%) of the primi mothers had primary education, and the least 2(6.66%) of primi mothers had post graduate educations. obtained2 value 3.78 , was not significant at 0.05 level. Among experimental group regarding occupation majority 15(50%) of the primi mothers were house wives, and the least 1(3.33%) of primi mothers were from other occupation. Among control group regarding occupation majority 15(50%) of the primi mothers were house wives, and the least 2(6.66%) of primi mothers were government employees . Among experimental group regarding family type majority 23(76.66%) of the primi mothers belonged to nuclear family, and the least 1(3.33%) of primi mothers belonged to extended family. Among control group regarding family type majority 17(56.66%) of the primi mothers belonged to nuclear family, and the least 3(10%) of primi mothers belonged to extended family.  Obtained 2 value 2.9, was not significant at 0.05 level. Among experimental group regarding income majority 14(46.66%) of the primi mothers belonged to the income of Rs.3000 to 5000, and the least 5(16.66%) belonged to the income of Rs.11,000 to 15,000.

Among control group regarding income majority 24(80%) of the primi mothers belonged to the income of Rs. 3000 to 5000, and the least 2(6.66%) had the income of Rs.11,000 to 15,000. Among experimental group regarding food habit majority 18(60%) of the primi mothers were taking both vegetarian and non vegetarian, and the least 5(16.66%) of primi mothers were taking only non vegetarian. Among control group regarding food habit majority 11(36.66%) of the primi mothers were taking both vegetarian and non vegetarian, and the least 9(30%) of primi mothers were taking only vegetarian. Obtained2 value is 5.34 , was not significant at 0.05 level. None of them had family history previous of mental illness in both experimental and control group of primi postnatal mothers. None of them had any other medical complication during pregnancy in both experimental and control group of primi postnatal mothers. Among experimental group regarding living area majority 20(66.66%) of the primi mothers were living in the rural area, and the least 10(33.33%) of primi mothers were from urban area. Among control group regarding living area majority 18(60.%) of the primi mothers were from rural area, and the least 12(40%) of primi mothers where from urban area. Obtained2 value 3.89 , was significant at 0.05 level. Among experimental group regarding support of the family members majority 16 (53.33%) of the primi mothers had both husband & mother and father support and, the least 1(3.33%) of primi mothers were equally distributed on sisters & brothers and mother in law & father law’s support . Among control group regarding support of the family members majority 14 (46.66%) of the primi mothers had husband support, and the least 1(3.33%) of primi mothers were equally distributed on sisters & brothers and mother in law & father law’s support . obtained 2 value 3.72, was not significant at 0.05 level.

Among the experimental group regarding type of marriage majority 21(70%) of the primi mothers had arranged marriage, and the least 9(30%) of primi mothers had love marriage. Among control group regarding type of marriage majority 17(56.66%) of the primi mothers had got arranged marriage, and the least 13(43.33%) of primi mothers had love marriage. obtained 2 value 1.14 , was not significant at 0.05 level. It was inferred that in experimental group majority of the primi mothers were in the age group of 16 to 20yrs and 21 to 25 yrs, they belonged to Hindu religion, had secondary education, and working as a house wives, living in a nuclear family, and their income was between Rs. 3000 to 5000/ month, they preferred to take both vegetarian and non vegetarian , and did not have any family history of previous mental illness, and any medical complication during the period of pregnancy, most of them were living in rural area, and got support from husband and her mother and father and they had arranged marriage. In control group majority of the primi mothers were in the age group of 16 to 20yrs, they belonged to Hindu religion, and had a primary education, and working as a house wives, living in a nuclear family, their income was between Rs. 3000 to 5000/ month, and they preferred to take both vegetarian and non vegetarian , and none of them had family history of previous mental illness, and other medical complication during the period of pregnancy and they were living in rural area, had support from husband and her mother and father and they had arranged marriage.

SECTION-II DATA ON LEVELS OF POSTPARTUM BLUES OF PRIMI MOTHERS IN EXPERIMENTAL GROUP AND CONTROL GROUP. Table -2

Mild Blues Moderate Blues Severe Blues Group (1-45) (46-80) (81-135) F % F % F % Experimental 25 83.33 5 16.66 0 0 group Control group 2 6.66 23 76.66 5 16.66

Figure 3 reveals that in expeimental group majority 25(83.33%) of the primi mothers had mild postpartum blues, and least 5(16.66%) had moderate post partum blues after guided imagery therapy. Among control group majority 23(76.66%) of the primi mothers had moderate post partum blues, where as 5(16.66%) had severe post partum blues, and the least 2(6.66%) had mild post partum blues. It was inferred that majority from experimental group had mild blues, and in control group majority had moderate blues.so the guided imagery was effective in reducing postpartum blues among primi mothers.

83.33% 90 76.66% P 80 e 70 r 60 c Experimental Group 50 e Control Group n 40 16.66% t 30 16.66% a 20 6.66% g 0.00% 10 e 0 Mild Blues Moderate Blues Severe Blues

FIG – 3 : Percentage Distribution of Post Partum Blues

SECTION-III: DATA ON EFFECTIVENESS OF GUIDED IMAGERY THERAPY ON POSTPARTUM BLUES AMONG PRIMI MOTHERS IN EXPERIMENTAL GROUP AND CONTROL GROUP. For the purpose of the study following null hypotheses was stated.

H01 :There will be no significant difference in postpartum blues score after the guided imagery therapy among primi mothers in experimental and control group. TABLE- 3 Mean, Standard deviation and ‘t’ value regarding experimental and control group on post partum blues

N=60 Group Mean S.D ‘t’ value

Experimental 12.93 20.51 12.51 Control 66.13 10.46 (P > 0.05) (sig) *Significant

Table 3 revealed that primi mothers of experimental group post test mean (12.93) was less than that of the control group post test mean (66.13). The obtained

‘t’ value ( 12.51) was significant at 0.05 level. Hence the null hypothesis H01 was rejected . It was inferred that, the guided imagery therapy was highly effective in reducing post partum blues.

66.13

70 Experimental Group 60 Control Group 50 40 ‘t’ value 12.51 20.51 30 12.93 10.46 20 10 0 Mean S.D.

Fig – 4 : Mean Standard Deviation of Post Partum Blues.

SECTION VI : DATA ON ASSOCIATION BETWEEN POSTPARTUM BLUE SCORE OF PRIMI MOTHERS WITH THEIR DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP. TABLE-4 Frequency, percentage distribution and 2 value of experimental group on post partum blues in association with their demographic variable.

Post partum blues score Demographic variable 1-45 46-80 81-135 2 F % F % F %

Age 16 to 20yrs 10 33.33 2 6.66 - - 2 21 to 25yrs 11 36.66 1 3.33 - -  =17.57* p=12.59 26 to 30yrs 4 13.33 1 3.33 - - 31 yrs and above - - 1 3.33 - - Religion Hindu 17 56.66 2 6.66 - - 2 = 2.023 Christian 5 16.66 1 3.33 - - P = 12.59 Muslim 2 6.66 1 3.33 - - N.S Others 1 3.33 1 3.33 - - Education Primary education 7 23.33 2 6.66 - - 2 Secondary education 9 30 1 3.33 - -  = 0.419 P = 12.59 Undergraduate 5 16.66 1 3.33 - - NS Post graduate and 4 13.33 1 3.33 - - above Occupation House wife 14 46.66 1 3.33 - - Coolie 2 6.66 1 3.33 - - 2 = 7.092 Business 7 23.33 1 3.33 - - P = 15.51 Govt employee 1 3.33 2 6.66 - - N.S others 1 3.33 - - - -

Family type 2 Nuclear family 14 46.66 3 10 - -  =0.925 P = 12.59 Joint family 9 30 1 3.33 - - N.S Extended family 2 6.66 1 3.33 - -

Post partum blues score Demographic variable 1-45 46-80 81- 2 135 F % F % F % Income Rs 3000 to 5000 12 40 2 6.66 - - 2 = Rs6000to10,000 10 3.33 1 3.33 - - 1.215 Rs 11,000 to 15,000 3 10 2 6.66 - - P = 12.59 Rs 16,000 and above ------N.S

Food habit 2 = Vegetarian 5 16.66 2 6.66 - - 1.146 Non vegetarian 4 13.33 1 3.33 - - P = 9.49 Both 16 53.33 2 6.66 - - NS Family history of pervious mental illness Yes 2 = 0 No ------25 83.33 5 16.66 - - Any other medical illness during pregnancy 2 = 0 Yes ------No 25 83.33 5 16.66 - - Living area 2 = Rural 17 56.66 3 10 - - 0.055 Urban 8 26.66 2 6.66 - - P = 3.84 NS Support of the family members Husband 6 20 2 6.66 - - Mother &Father 3 10 1 3.33- - - 2 =7.185 Sisters& Brothers 1 3.33 - - - - P = 15.51 Both A&B 15 50 1 3.33 - - N.S Mother in law & Father in law - - 1 3.33 - -

Type of marriage 2 =3.048 Arranged marriage 19 63.33 2 6.66 - - P = 5.99 Love marriage 6 20 3 10 - - N.S *Significant NS – Not Significant

Table : 4 Regarding age majority of the primi mothers 11(36.66) between 21 to 25 years had mild post partum blues and least 1(3.3%) were equally distributed between 16 to 20 years and 26 to 30 years and 31 years and above had moderate post partum blues. The 2value 17.57 was significant at 0.05 level. Regarding religion majority, Hindu 17(56.66%) had mild post partum blues and least 1(3.33%) equally distributed between Christian, Muslim, and other religion had mild and moderate blues. The 2 value 2.023 was not significant at 0.05 level. Regarding education majority secondary education 9(30%) of the primi mothers had mild blues, least 1(3.33%) equally distributed between, secondary, under graduate, post graduate education had mild and moderate post partum blues. The 2 value 0.419 was not significant at 0.05 level. Regarding occupation majority 14(46.66%) primi mothers were house wives, had mild post partum blues, least 1(3.33%) equally distributed to house wives, coolie, business, government employee and other occupation had mild and moderate post partum blues. The 2 value 7.092 was not significant at 0.05 level. Regarding family type, majority 14(46.66) primi mothers living in nuclear family had post partum blues, and least 1(3.3%) were equally distributed to joint family extended family had mild post partum blues. The 2 value 0.925 was not significant at 0.05 level. Regarding income, majority 12(40%) between Rs. 3000 to 5000 income group primi mothers had mild post partum blues, least 1(3.3%) had moderate blues in the income group of Rs. 6000 to 10000. The 2 value 1.215 was not significant at 0.05 level. In regard to family history of mental illness, majority 25(83.33%) of the primi mothers had mild blues, least 5(16.66%) had moderate blues. The 2 is not applicable.

In regard to any other medical complication during pregnancy, majority 25(83.33%) of the primi mothers had mild blue, least 5(16.66%) had moderate blues. The 2 was not applicable. In regard to living area, majority 17(56.66%) had mild post partum blues, least 2(6.66%) had moderate post partum blues, the 2value 0.055 was not significant. In regard to support of the family members , majority 15(50%) had post partum blues. They were supported by both husband, mother and father, least 1(3.33%) equally distributed to mother and father, sister and brothers, both A & B, and mother- in- law and father-in-law supported primi mothers had mild and moderate post partum blues. The 2 value 7.185 was not significant. In regard to type of marriage, majority 19(63.33%) of the primi mothers had arranged marriage and they had mild post partum blues, least 2(6.66%) of the primi mothers had arranged marriage and they had moderate blues. The 2 value 3.048 was not significant at 0.05 level. It was inferred that there was a significant association between the age and post partum blues, and there was no association with other demographic variables like education, occupation, family type, income, food habit, family history of previous mental illness, any other medical illness during pregnancy, living area, support of the family member, type of marriage. So the guided imagery therapy was independently effective in reducing post partum blues except age limit.

SECTION VI : DATA ON ASSOCIATION BETWEEN POSTPARTUM BLUES SCORE OF PRIMI MOTHERS WITH THEIR DEMOGRAPHIC VARIABLES IN CONTROL GROUP. TABLE-5 Frequency, percentage distribution and 2 value of control group on post partum blues in association with their demographic variable

Demographic variable Post partum blues score 2 1-45 46-80 81-135 F % F % F % Age 16 to 20yrs 1 3.33 10 33.33 2 6.66 21 to 25yrs 1 3.33 9 30 2 6.66 2=0.8491 26 to 30yrs - - 3 10 1 3.33 p=12.59 31 yrs and - - 1 3.33 - - NS above Religion 2 Hindu 1 3.33 16 53.33 2 6.66  = 24.018* Christian - - 2 6.66 - - P = 12.59 Muslim 1 3.33 4 13.33 2 6.66 S Others - - 1 3.33 1 3.33 Education Primary 1 3.33 14 56.66 1 3.33 2 Secondary - - 7 23.33 2 6.66  = 7.134 P = 12.59 Undergraduate 1 3.33 1 3.33 1 3.33 NS Post graduate - - 1 3.33 1 3.33 and above Occupation House wife 2 6.66 12 40 1 3.33 Coolie - - 8 26.66 1 3.33 2 = 6.83 Business - - 2 6.66 2 6.66 P = 15.51 Govt employee - - 1 3.33 1 3.33 N.S others ------

Family type 2 Nuclear family 1 3.33 18 60 4 13.33  =1.457 P = 9.49 Joint family 1 3.33 4 13.33 1 3.33 N.S Extended family - - 1 3.33 - -

Post partum blues score Demographic variable 2 1-45 46-80 81-135 F % F % F % Income Rs 3000 to 5000 - - 21 70 3 10 2 = Rs6000to10,000 2 6.66 1 3.33 1 3.33 13.821* Rs 11,000 to 15,000 - - 1 3.33 1 3.33 P = 12.59 Rs 16,000 and above ------S

Food habit Vegetarian 1 3.33 6 20 2 6.66 2 = 3.445 Non vegetarian 1 3.33 8 26.66 1 3.33 P = 9.49 Both - - 9 30 2 6.66 NS

Family history of pervious mental illness 2 = 0 Yes ------No 2 6.66 23 76.66 5 16.66 Any other medical illness during pregnancy 2 = 0 Yes ------No 2 6.66 23 76.66 5 16.66 Living area 2 = 4.4 Rural 1 3.33 15 50 2 6.66 P = 5.99 Urban 1 3.33 8 26.66 3 10 NS Support of the family members 1 3.33 12 40 1 3.33 Husband 1 3.33 2 6.66 2 6.66 2 Mother &Father - - - - 1 3.33  =10.33 P = 15.51 Sisters& Brothers - - 8 26.66 1 3.33 N.S Both A&B - - 1 3.33 - - Mother in law & Father in law Type of marriage 2 =10.41* Arranged marriage 1 3.33 14 46.66 2 6.66 P = 5.99 Love marriage 1 3.33 9 30 3 10 S *Significant NS – Not Significant

TABLE 5:- In regard to age majority of the 10(33.33%) of the primi mothers between 16 to 20 years had moderate post partum blues, least 1(3.33%) equally distributed between 16 to 20 years, 21 to 25 years, 26 to 30 years and 31 years and above had mild, moderate and severe post partum blues. The 2 value 0.8491 was not significant at 0.05 level. In regard to religion, majority 16(53.33%) primi mothers belonged to Hindu religion had moderate blues, least 1(3.33%) equally distributed between Hindu, Muslim, other religion had mild, moderate and severe blues. The 2 value 24.018 was significant at 0.05 level. In regard to education, majority 14(56.66%) primi mothers had primary education, had moderate blues, least 1(3.33%) equally distributed between primary, undergraduate and post graduate and above had mild, moderate and severe blues. The

2 value = 7.134 was not significant at 0.05 level. In regard to occupation, majority 12(40%) of the primi mothers were house wives, had moderate blues, least 1(3.33%) equally distributed between house wives, coolies and government employees, primi mothers had moderate and severe post partum blues. The 2 values 6.83 was not significant at 0.05 level. In regard to family type, majority 18(60%) of the primi mothers living in nuclear family, had moderate blues, least 1(3.33%) equally distributed between nuclear family, joint family and extended family, had mild, moderate and severe post partum blues. The

2 value 1.457 was not significant at 0.05 level. In regard to income , majority 21(70%) of the primi mothers monthly income Rs. 3000 to 5000, had moderate post partum blues, least 1(3.33%) equally distributed between Rs. 6000 to 10000 and 11000 to 15000, had moderate and severe blues. The

2 value 13.821 was significant at 0.05 level. In regard to food habit, majority 9(30%) of the primi mothers were taking both vegetarian and non-vegetarian had moderate blues, least 1(3.33%) equally distributed between vegetarian and non-vegetarian had mild and severe blues.

Regarding family history of previous mental illness, majority 23(76.66%) had moderate blues, least 2(6.66%) had severe and mild blues. The 2 is not applicable. Regarding living area, majority 15(50%) of the primi mothers living in rural area, had moderate post partum blues, least 1(3.33%) equally distributed between rural and urban area were had mild and moderate post partum blues. The 2 value 4.4 was not significant at 0.05 level. Regarding support of the family members, majority 12(40%) of the primi mothers was supported by the husband, and had moderate post partum blues, least 1(3.33%) equally distributed between husband, mother and father, mother-in-law and father-in- law, brother and sister supports, had mild, moderate and severe blues. The 2 value 10.33 was not significant at 0.05 level. Regarding type of marriage, majority 14(46.66%) of the primi mothers were had arranged marriage and they had moderate blues, least 1(3.33%) equally distributed between arranged marriage and love marriage, had mild post partum blues. The 2 value 10.41 was significant at 0.05 level. It was inferred that there was a significant association between the religion, income, and type of marriage with post partum blues, and there was no association with other demographic variables like age, education, religion, occupation, family type, food habit, family history of previous mental illness and other medical illness during pregnancy, living area, support of the family members with post partum blues. So the guided imagery therapy was independently effective in reducing post partum blues except the religion, income and type of marriage.

DISCUSSION

CHAPTER – V FINDINGS AND DISCUSSION The aim of the present study was to assess the effectiveness of guided imagery therapy on post partum blues among primi mothers after 36 weeks of gestation at Coimbatore. The study was conducted by evaluative approach and research design was quasi - experimental design, which is experimental in nature. The primi mothers after 36 weeks of gestation were selected for the study. The sample size was 60 primi mothers after 36 weeks of gestation. The response was analyzed through descriptive (mean, frequency, percentage and standard deviation) and inferential (chi – square student ‘t’ test) statistics. The reliability of the tool was established through interrater method and co-efficient correlation score of post partum blues was (0.9). the tool was found to be reliable. Discussion on the findings was arranged based on the objectives of the study. The results of the study were discussed according to the findings of the study. Findings – 1 :- Findings on the level of post partum blues among primi mothers in experimental group and control group. Post test score of post partum blues in experimental group were mild blues 25(83.33%), moderate blues 5(16.667%) and there was no severe blues observed. Post test score of post partum blues in control group were mild 2(6.66%), moderate 23(76.66%) and severe blues 5(16.66%). Mrs. S, Rajamani victor et. Al, (2007) reported a similar findings about reduction of post partum blues by giving prophylactic information on maternal adjustment in Rajaji hospital Madurai. Findings 2 :- Findings on the effectiveness of guided imagery therapy in experimental group and control group of primi mothers. There was a significant difference in post partum blues among primi mothers in experimental group and control group after the guided imagery therapy ‘t’ = 12.93 (p<0.05).

Findings 3 :- Findings on the association between post test post partum blues score with demographic variables of primi mothers in experimental group.

The obtained 2 value of the demographic variables are as follows age 2 =

17.57*, religion 2 = 2.023, education 2 = 0.419, occupation 2 = 7.092, family type

2 = 0.925, income 2 = 1.215, food habit 2 = 1.146, family history of previous mental illness 2 = not applicable, any other medical complication during pregnancy 2

= not applicable, living area 2 = 0.055, support of the family members 2 = 7.185, type of marriage 2 = 3.048, shows no significant difference (p>0.05) in post partum blues score in relation to back ground factors, except age limit of the primi mothers. So the guided imagery therapy was independently effective in reducing post partum blues except the age limit. Findings 4 :- Findings on the association between the post test post partum blues score with demographic variables of primi mothers in control group.

The obtained 2 value of the demographic variables are follows age 2 =

0.8491, religion 2 = 24.018*, education 2 = 7.134, occupation 2 = 6.83, family type

2 = 1.457, income 2 = 13.821*, food habit 2 = 3.445, family history of previous mental illness 2 = not applicable, any other medical complication during pregnancy 2

= not applicable, support of the family members 2 = 10.33, type of marriage 2 = 10.41*, shows no significant association (p>0.05) in post partum blues score in relation to demographic variables, except religion, income and type of marriage. This has an influence over the post partum blues among primi mothers in control group. So the guided imagery therapy was independently effective in reducing post partum blues except religion, income and marriage type.

SUMMARY, FINDINGS, CONCLUSION, IMPLICATION AND RECOMMENDATION

CHAPTER – VI SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS This chapter deals with summary, findings, discussion, implication, limitation, conclusion and recommendation. The essence of any research project is based on study findings, limitations, interpretation of the research results and recommendation that incorporate the study implication. It also gives meaning to the results obtained in the study. SUMMARY The prime aim of the study was to assess the effectiveness of Guided Imagery therapy on post partum blues among primi mothers after 36 weeks of gestation. The objectives of the study were: 1) To assess the level of post partum blues among primi mothers. 2) To assess the effectiveness of guided imagery therapy on post partum blues among primi mothers in experimental and control group. 3) To associate the post test post partum blues score with demographic variables among primi mothers in experimental group. 4) To associate the post test post partum blues score with demographic variables among primi mothers in control group. The study attempt to examine the following research hypothesis.

H1 :There will be a significant difference in the levels of post partum blues among primi mothers in experimental group and control group.

H2 : There will be a significant difference in the post test finding on postpartum blues among primi mothers in experimental group and control group.

H3 :There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in experimental group.

H4 : There will be a significant association between the post test findings on post partum blues with the demographic variables among primi mothers in control group. A review of literature helped the investigator to develop the conceptual frame work, tool and development of audio CD on guided imagery therapy. Literature review was done for the present study and presented in the following headings. Studies related to post partum blues, studies related to guided imagery therapy, studies related to effect of guided imagery therapy on post partum blues. The conceptual frame work adopted for the present study was based on the nursing process model. This model helped the investigator to assess the effectiveness of guided imagery therapy on post partum blues among the primi mothers after the application of guided imagery therapy. The research approach adopted for this study was evaluative in nature. The present study is a pre experimental design (post test only control group design). In this study Independent variable was guided imagery dependent variable was post partum blues among primi mothers. Associate variables for this study were age, education, religion, occupation, income, family type, food habit, history of previous mental illness, any other medical complication during pregnancy, living area, support of the family members, marriage type. The tool which was used for the study is modified “AM I BLUE” self rating post partum blue scale. The content validity of the tool was established by 5 experts. The tool was found reliable and feasible. The reliability of the tool was established by interrater method, Karl pearson’s correlation co-efficient was found high (r=0.9). Three nursing experts, one psychologist, and one clinical obstetrician had validated the audio. After making appropriate modifications the content was finalized. The audio programme was pretested with 5 primi mothers. The average time taken to listen the guided imagery therapy to develop positive attitude regarding pregnancy, child birth process, and new born care was around 15 minutes.

The main study was conducted in Sundakkamuthur PHC and Sakthi hospital Gandhipuram, Coimbatore. The data was collected for a period of four weeks from August 1st to August 30th 2009. Prior permission from the authorities was sought and obtained. Individual informed consent was taken from the study samples orally. The study samples were selected by convenient sampling method based on sample selection criteria. All selected primi mothers were screened for the completion of 36 weeks of pregnancy, and with out any other medical complication during pregnancy 60 eligible primi mothers who satisfied the selection criteria were recruited in that 30 have been selected for control group and 30 have been recruited for experimental group. The objectives and purpose of the study were explained and confidentiality was assured post partum blues were assessed and data were collected using modified AM I BLUE? Self rating post partum blue scale. The effective samples who participated in the post test were 30 in experimental group and 30 in control group. Gathered data were analyzed and interpreted in terms of objectives using Micro soft excel -2007. FINDINGS The major findings of the study were classified under the following heading, based on the objectives of the study. Objective 1 :- To assess the level of post partum blues among primi mothers in experimental group and control group. Post test score of post partum blues in experimental group was mild blues 25 (83.33%), moderate blues 5(16.6%). There was no severe blues found in the primi mothers of experimental group after the guided imagery therapy. Post test score of level of post partum blues in control group was mild blues 3(6.66%), moderate blues 23(76.66%) severe blues 5(16.66%).

Objective 2 :- To assess the effectiveness of guided imagery therapy on post partum blues among the primi mothers in experimental group and control group. Post test mean of post partum blues in experimental group was less 12.93(SD=20.51). Post test mean of post partum blues score in control group was 66.13 (SD=10.46). There was a significant difference in post partum blues score in experimental group and control group after the guided imagery therapy among primi mothers ‘t’ = 12.51 (p<0.05). Objective 3 :- To associate the post test post partum blues score with the demographic variables in the experimental group. There was significant association between the age and post partum blues of primi mothers in experimental group (p<0.05). There was no significant association between demographic variables like religion, education, family type, income, food habit, history of previous illness, any other medical complication during pregnancy, living area, support of the family members, type of the marriage and post partum blues (p>0.05). So the guided imagery therapy was independently effective in reducing post partum blues except the age limit. Objective 4:- To associate the post test post partum blue score with demographic variables in control group. There was a significant association between demographic variables like religion, income, and type of marriage and post partum blues among primi mothers in control group (p<0.05). There was no significant association between demographic variables like education, occupation, family type, food habit, history of previous mental illness, any other medical complication during pregnancy, living area, support of the family members and post partum blues (p>0.05).

CONCLUSION The guided imagery therapy was effective in the reduction of post partum blues among primi mothers. Majority 25(83.33%) of the mothers in experimental group fall on mild blues after the guided imagery therapy, where as majority 23(76.66%) of the mothers in control group fall on moderate post partum blues. Therefore guided imagery therapy on pregnancy, child birth process and new born care have developed the positive attitude and helped the mother to adjust the maternal role as a parent. So guided imagery therapy should be used as supportive therapy for post partum blues among primi mothers. IMPLICATIONS The result of the study proved that guided imagery therapy to develop positive attitude on pregnancy, child birth process and, new born care, had a significant effect in prevention of post partum blues among primi mothers. The findings of the study has the following implications in nursing practice and nursing research. Nursing practice 1) Nurses have a responsibility to reduce the post partum blues among mothers. 2) Guided imagery therapy can be used as a part of nursing intervention in child birth education and also it is cost effectiveness. 3) Pre-recorded guided imagery therapy audio CD (or) video CD can be used to develop the positive attitude on pregnancy, child birth process and new born care. Nursing research 1) The study will be a valuable reference for future researchers. 2) The findings of the study would help to expand the scientific body of professional knowledge upon which further research can be conducted. 3) Guided imagery therapy may be studied more scientifically and used as a specific nursing intervention for all type of patients.

Nursing education 1) There is a need for collaboration of the nursing and health department with other department like the education department, to ensure that regular health sessions are organized for the antenatal mothers. 2) The nursing curriculum should be community oriented and it should focus on psychological and emotional aspect of the antenatal mothers. 3) There should be regular child birth classes to be arranged by the female health workers to develop positive attitude among mothers. 4) The midwives and other health care personnel should be educated about guided imagery therapy. Nursing administration 1) Nurse administrator should take initiative, in organizing continuing education program for nurses on guided imagery therapy. 2) Appropriate teaching- learning materials need to be prepared and made available for nurses on guided imagery therapy. 3) Helping in early identification of emotional and psychological disturbances of the primi mothers by providing proper tools and aids. 4) Child birth education can be provided by peripheral level health workers and train them on the challenge of the health. 5) Arrange the other alternative therapy and give training to the health workers and make them to put into practice. LIMITATIONS 1) The study was limited to the primi mothers who came for the delivery to the Sundakamuthur PHC and Sakthi hospital. 2) The study was limited to primi mothers after 36 weeks of gestation. 3) The study had no pre test to prove the effectiveness of guided imagery therapy. 4) The samples were selected by non-random method limiting the generalized ability. 5) The intervention was given only for 4 weeks.

RECOMMENDATION 1) A similar study can be replicated on a large scale and for a longer period from second trimester onwards. 2) Maternal adjustment scale can be used for this study. 3) This study can be conducted by combining with other alternative therapy. 4) Comparative study can be conducted to identify the mother’s blues and father’s blues.

BIBLIOGRAPHY AND REFERENCES

REFERENCES BOOKS 1. Bennet V.R et.al (2003), “ Myles Text Book for Midwives”, 14th edition, Edinburgh Churchil livinston. 2. Bobak M.I et. al (1987), “Essential of Maternity Nursing”, edition, St. Louis C.V. Mosby publication, Sydney. 3. Broom, Novak (1995), “Maternal and Child Health Nuraing”, 8th edition, Mosby publication, Sydney. 4. Chenoy.R (1987), “Clinical Obstetrics and Gynaecology”, London, Addison Wesly publication. 5. David M.L Phips (2004), “Obstetrics and Gynaecology,” Arnold international student edition. 6. Dawn C.S (2000), “Text Book of Obstetrics and Gynaecology,” Calcutta. Dawn book house. 7. Dutta D.C (2004), “Text Book of Obstetrics,” 6th edition, New central book agency (p) Ltd, Calcutta. 8. Daftary. N, Shirish, Chakravarthi Sudip, (2005), “Manual of Obstetrics,” 2nd edition, Elsevier Indian Pvt. Lts, New Delhi. 9. Evans .T Arthur (2007), “Manual of Obstetrics,” 7th edition, Lippincott publication, New Delhi. 10. Enise Polit, Hungler .P, (1999), “Nursing Research Principles and Methods,” 1st edition, Philadelphia, Lippincott company. 11. Hooper and Iron Bar (1991), “Self Instruction in Mental Health Nursing,” 2nd edition, Bailliere Tindall publication, Sydney. 12. Jacob Annamma (2008), “A Comprehensive Text Book of Midwifery,” 2nd edition, Jaypee brothers medical publication. 13. Leifer (2005), “Maternity Nursing,” 9th edition, Elsevier Saunders publication. 14. Laraia. T. Michele, Stuart W. Gail (2001), “Principles and Practice of Psychiatric Nursing,” 7th edition, Harcourt (India) Private limited, New Delhi. 15. Menon’s and Mudaliar (2007), “Clinical Obsteetrics,” 10th edition, Orient longman Pvt. Ltd, Chennai. 16. Nitaj Ahuja (1995), “A short Text Book of Psychiatry,” 3rd edition, Jaypee brothers publication, New Delhi. 17. Pilliteri Adele (1999), “Maternal and Child Health Nursing,” 12th edition, J.B. Lippincott company, Philadelphia. 18. Paderbidri v. Elaa Anand (2006), “Text Book of Obstetrics,” B.I. Publication Pvt, Ltd, New Delhi. 19. Reeder .J. Martin.L (1997), “Maternity Nursing”, 18th edition, Lippincott publication, New York. 20. Ricy Scott Susan (2007), “Essentials of Maternity New born and Women’s Health Nursing,” 1st edition, Lippincott publication, New York. 21. Sundar Rao P.S.S Richard J (1997), “An Introduction to Biostatistics, A Manual for Students in Health Science,” 3rd edition, Prentice Hall of India Pvt. Ltd.

JOURNAL REFERANCE 1) Anitha. C. Rao (2009), Postnatal depression among Mothers, “Nightingale nursing times,” vol-5, No-3, p: 51-53. 2) Ann Josefssom et.al. (2006), Prevalance of blues symptoms in late oregnancy and post partum, Amirican journal of Medical Association, vol-11, No-3, p: 543-544. 3) Boudou M. et.al (2007), Association between the intensity of child birth pain and intensity of post partum blues, “Journal of Encephale,” vol-33, No-5, p:805-810. 4) Beeber. L (2003), The pinks and the blues symptoms of chronic depression in mothers during their children’s first year, “American Journal of Nursing,” vol-102, No-11, p:91- 98. 5) Chabrol. H (2007), “Prevention of post partum blues, “Journal of Gynaecology and obstetric fertility,” vol-35, No-12, p: 1242-1244. 6) Cindy-lee Dennis (2005), Psychosocial and psychological intervention for prevention of post natal blues, “British medical journal,” vol-335, No-15. 7) Denis et.al (2008), Role of some psychological and obstetrical factors in the intensity of post partum blues, “Journal of Encephale,” vol – 34, No – 2, p: 179 – 182. 8) Edhbor .M. (2008), Comparisons of different instruments to measure blues and to predict depression symptom of new mothers and father, “Scand journal of caring science,” vol – 22, No – 2, p: 186 – 195. 9) Faisal – Cury .A. et.al (2008), Maternity blues prevalence and risk factors, “Journal of psychology,” vol – 11, No – 2, p : 593 – 599. 10) Ferber S.G (2004), The nature of tooch in mothers experiencing maternity blues, “Journal of early human development,” vol – 79, No- 1, p : 65 – 67. 11) Fooladi .M. (2006), Therapeutic tear and post partum blues, “Journal of holistic nursing practice,” vol – 20, No – 4, p :204 – 211. 12) Glory. D Suramanjary (2009), Post natal depression among mothers, “Nightingale nursing times,” vol – 5, No – 3, p : 51 – 53. 13) Gutteridge. K (2006), Safety delivery from the baby blues, “Nursing times,” vol – 96, No – 1, p : 52. 14) Holary A. Tindle et.al (2006), Guided imagery for smoking cessation in adults, “Journal of complementary health practice,” vol – 11, No – 3. 15) Jitendra Nagpal, Puerperal Psychoses are more frequent in primiparour women, those who have suffered previous major psychiatric illness. Those with a family history of mental illness, and probably in unmarried mothers. “Obs & Gynae,” Vol-II, No-3, March -1993, Page No: 149-151. 16) Kato .N. et. al (2008), Maternity blues as predictor of post partum depression among Japanese women, “Journal of psychosomatic obstetrics and gynecology,” vol – 29, No – 3, p :206 – 212. 17) Mamta. Sood and A.K. Sood (2003), Depression in pregnancy and post partum period, “Indian journal of psychiatry,” vol – 45, No – 3, p : 1. 18) Nagai. Y. et.al (2000), Maternity blues and attachment to children in mothers of full term normal infants, “Journal of acta psychiatry scand,” vol – 101, No – 3, p : 209 – 217. 19) Rees BL (2000), Using relaxation with guided imagery to assist primi paras in achieving maternal role attainment, “Journal of holic nursing,” vol – 10, No – 2, p :197 – 182. 20) Reck. C et. al (2009), Maternity blues as a predictor of DSM.IV depression and anxiety disorders in the 1st 3 months of post partum, “Journal of affective disorder,” vol-113, No -2, p: 77-87. 21) Rajamani Victor. S. et.al (2008), Effectiveness of prophylactic information on maternal adjustment in terms of post natal blues, among the post nata; mothers, “Nightingale nursing times,” Vol 31 , No - 4 , p : 58 .

Net Reference 1. www.indiaparenting.com/pregnancy/data 2. www.healthyplace.com/depression 3. www.childbirthsolutions.com 4. www.ayustveda.com/..../baby.blues 5. www.pregnancy.org/article/postpartumblues 6. www.marchofdimes.com 7. www.babyblues.com 8. www.imdb.com/titlet 9. www.remedies4.com 10. www.pregnancytoday.com 11. www.alternativedepressiontherapy.com 12. www.ehow.com

APPENDICES

APPENDIX – A Letter seeking permission for content validity.

REQUISTION FOR CONTENT VALIDITY

From, A.PONMALAR, M.SC (N) II YEAR, Cherraan’s college of Nursing, Coimbatore.

To,

Through, The principal, Cherraan’s college of Nursing, Coimbatore.

Respected Madam, Sud: Requisition for expert opinion and suggestion for content validity of the tool. I am a student of M.SC Nursing II year of Cherraan’s college of Nursing, coimbatore affiliated to the Dr.M.G.R Medical University, Chennai, as partial fulfillment of M.SC Nursing Programme, conducting a study on “EFFECTIVENESS OF GUIDED IMAGERY ON POSTPARTUM BLUES AMONG PRIMI MOTHERS IN SELECTED HOSPITALS AT COIMBATORE.” Here with I am sending the developed tool for content validity and for your expert opinion and possible suggestion. It will be very kind of you to return the same to the undersigned at the earliest possible. Thanking you, Yours faithfully, Date : Place: Coimbatore. (A.PONMALAR)

APPENDIX – B FORMAT FOR CONTENT VALIDITY

Name of the expert :

Address :

Total Content for the tool : Adequate/ Inadequate kindly validate each tool and tick ( )wherever applicable.

Strongly Need S.No. No. of Tool/Section Agree Remarks Agree Modification

Signature of the expert with date

APPENDIX – C

CONTENT VALIDITY CERTIFICATE

I Here by certify that I have validated the Tool of 30083222 M.SC(N) II year who is under taking “ A STUDY TO ASSESS THE EFFECTIVENESS OF GUIDED IMAGERY ON POST PARTUM BLUES AMONG PRIMI MOTHERS IN SELECTED HOSPITALS AT COIMBATORE.”

Place: Signature of the expert Date :

Designation

APPENDIX – D LIST OF EXPERTS

1) Dr. Mrs. Suceela, Principal, Billroth college of Nursing, Chennai.

2) Dr. Jeeva Ilango, M.B.B.S., DGO., Government hospital, Arakkonam.

3) Miss. Girija, Clinical Psychologist, K.G.College of Nursing, Coimbatore.

4) Mrs. Manjuri, A.E, Principal Incharge, SSSIHMS- College of Nursing, Bangalore.

5) Mrs. Illayarani, Asst. Professor, - OBG department, Meenakshi college of Nursing.

APPENDIX – E Letter seeking permission to conduct research study.

APPENDIX - F

Letter Granting Permission to Conduct Research Study

APPENDIX - G SECTION I

CODE NO:

DEMOGRAPHIC DATA

Tick ( ) the appropriate answer. 1) Age a) 16 to 20 yrs ( ) b) 21 to25 yrs ( ) c) 26to 30 yrs ( ) d) 31yrs and above ( )

2)Religion a) Hindu ( ) b) Christian ( ) c) Muslim ( ) d) others. ( )

3)Education a) Primary education ( ) b) secondary education ( ) c) under graduate ( ) d) Post graduate and above ( )

4)Occupation a) House wife ( ) b) Cooli ( ) c) Business ( ) d) Government employee ( ) f) Other______( )

5)Family type a) Nuclear family ( ) b) Joint family ( ) c) Extended family ( )

6) Income a) 3000 to 5000 ( ) b) 6000 to 10,000 ( ) c) 11,000 to 15,000 ( ) d) 16 ,000 and above ( )

7)Food habit a) vegetarian ( ) b) non vegetarian ( ) c) Both ( )

8)History of pervious mental illness a) Yes ( ) b) No ( )

9)Any other medical complication during pregnancy a) Yes ( ) b) No ( )

10)living area a) Rural ( ) b) Urban ( )

11)Support of the family members a) Husband ( ) b) Father & Mother ( ) c) Brothers & Sisters ( ) d) Both a & b ( ) e) Mother-in-law & Father-in-law ( ) f) Brother-in-laws & Sister-in-laws ( )

12)Type of marriage a) Arranged marriage ( ) b) Love marriage. ( )

SECTION II

MODIFIED AM I BLUE SELF RATING SCALE

S.NO. SCALE 0 1 2 3 1 Unexplained anger 2 Unusual Anxiety 3 Periods of very strong fear 4 I have Shortness of breath 5 I feel my heart beats Rapidly 6 I feel Increased Appetite that dose not seen normal 7 I feel Decreased Appetite that dose not seen normal 8 I feel I have Weight gain that does not seen normal 9 I feel I have Weight loss that does not seen normal 10 I have Strong feeling of that I need to get away from particular situation. 11 I Need more time for your own interests 12 I have Problems in a relationship with a family members and close friend etc. 13 I have Crying Spells (or) feel like it. 14 I have Less interest in your personal appearance. 15 I have Less motivation 16 I feel I have Less energy and interest in accomplishing the goals 17 Depression 18 I feel Fatigue – feeling tired (or) Exhausted 19 I feel holding my baby might injure (or) brake him / her. 20 I feel I Loss my sense of humor 21 I am Feeling Nervous always. 22 I am Feeling tense simply. 23 I am Feeling of guilt 24 I am Feeling of panic 25 I Feel I am alone (or) lonely; without the support of others 26 I am Feeling no love, (or) not enough love, to my baby . 27 I am Feeling forgetful, distracted always.

S.NO. SCALE 0 1 2 3 28 Absent – minded having trouble concentrating 29 I feel Frustrated. 30 I am feeling Hopeless 31 I have trouble sleeping at night. 32 I am Feeling irritable even a simple matter. 33 I have Bad-tempered. 34 I have Loss of sexual desire and/or pleasure in sex 35 I feel Loss of self – respect. 36 I have Loss of confidence feeling to do anything right. 37 I am Feeling confused. 38 I have the Feeling of uncertain. 39 I feel my Mood swings always. 40 I feel my moods and emotions are change in all the time. 41 I feels I have Obsessive thoughts – ideas (or) feelings you can’t stop from repeating in your mind. 42 I am having Frightening thoughts –( thoughts (or) images that scare you (or) that you can’t control) 43 Thought of suicide. 44 I am Feeling sad always. 45 I am Feeling unhappy always.

SCORING 0 = Not there at all 1 = Mild 2 = Moderate 3 = Severe 1-45 : Mild Blues This will probably pass, but pay attention to feelings and needs. 46 –80 : Moderate Blues You may want to ask for help from a close friend (or) family, members (or) ask the advice of your health care provider 81 – 135 : Severe Blues You could be depressed, see your health care provider for a check-up and advice as soon as possible. APPENDIX - H Check list to ensure the hearing of Audio CD on guided imagery therapy.

INSTRUCTION : Kindly place a tick ( ) mark after hearing Guided Imagery Therapy.

Starting Day : ______Finishing Day : ______

Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Time

Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Days 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Time

APPENDIX - I GIUDED IMAGERY THERAPY

Welcome! Women are holding a holy place in this world. According to famous poet Bharathiyar, to born as a female you have to do penance. It’s all because of motherhood, which can give only by a female. If you need to consider you as a women, you must give birth to a child. Because for a women, ‘delivery’ means a way to ‘born again’ in this world. Nothing is equal than motherhood. The word ‘Mother’ is a symbol for love, trust and care. Only a mother can provide the real love to a child, no one can love a child like mother. Now, you are also going to be a mother for a baby…………! Are you listening to me! Now you can have a comfortable position by sitting or lying position? Wherever you are lying down, turn left side. Do you know why I am insisting you to be in this position. When you are in the left side during lying down position, your baby in the womb will receive good blood supply. Do you understand? Are you listening to me! Close your eyes slowly. Have you closed your eyes? Take breath slowly. Repeat it for 3 times. Are you following me? Right now your mind and body become like a soaring bird. You may feel like flying in the sky! Now you are in a calm and quiet environment. You are in the end stage of pregnancy within one month, your baby in the womb will come out to this beautiful world. This baby will provide happiness to you and your family. How much you might have suffered for last 9 months. Never think all those events. Because those events will bring prosperity to you and your family. I am saying to you, “that you are the luckiest person in this world”! Because you are going to receive precious position called ‘Motherhood’. You might have seen the glowing face of your family, the day when you confirmed and conveyed the message that you are pregnant. I hope you can see those faces infront of you right now. You are entering to a new world now; which you will find relaxation, happiness and peace in your mind. Please keep your hands over your abdomen slowly! Did you keep your hand? You can feel the presence of your baby in your hand. Now your baby is moving with lot of ambitions inside your womb. Slowly it is opening the eyes and looking at you with expectations. Extending the hands and touching you with a finger lovingly. Its floating over the amniotic fluid with lot of love. Can you take a deep breath now. Whenever you are singing, even though it is slow in pitch, your baby can hear and it is listening carefully. See, your baby is kicking on you; indicates feel very happy inside. Your baby feel love and care inside the womb. Whenever you feel hungry, your baby also will feel that. When you awake, your baby also open its eyes when you take rest, look at your abdomen and try to speak and sing. By that time your baby also will respond to you. Do you know how it is, by giving kicking to your abdomen. Can you feel that thrilling kick. You might have undergone a family are many at the end of the second trimester called “Bangling Hands’. Isn’t it? It is to keep your baby happy and energetic. Now you may be experiencing the movement that is gifting by your baby. It is a nice experience, that you can’t express by words. Whenever you are thinking of ‘Motherhood’, I can see the glow on your face. Do you know how many women are not gifted by this happiness? You might have understood how lucky you are. I repeat, you are the luckiest person in this world. If you need to get happiness in life you have to face sorrow, and pain. Then only you can enjoy that happiness. Likewise the motherhood and pregnancy is! Do you have any idea how will be the labour pain? I will say, at first, the labour pain starts from down and radiate towards up in the abdomen. Then it move towards the hip. At first the pain may be very little and as times exceeds, it become severe. But don’t worry. Why should you have to fear? You are a creator, designer and provider for a new life. How happiest situation is ……….. all these pain will be till your baby comes out from the womb. After delivery when you hear the first cry of your baby you will take your baby and give lots of sweet kisses. You are kissing your baby now. Isn’t it? This is motherhood. An another important thing, what baby it may be, it will give prosperity, happiness and blessings. Are you listening to me? Now your baby is in your hands. You are enjoying its beauty. You are touching its sweet little fingers, rose like face and apple like cheeks. Isn’t it? This will offer an amazing happiness for your mind. When your baby laughs at you, you are receiving all the happiness in this world. How much pain it gives also, your baby’s smile will make you to suppress everything. Now you can hear the laugh of your baby. Are you hearing? Eventhough your baby cries due to hungry, if it is in midnight also it may disturb your sleep, but you will get up, feed and make sleep. This is mother’s love. Now you will hear the cry of your baby. Did you hear? Only a mother can identify why a baby cries. Whether it is due to hungry or for something else. This is mother’s care. Everyday your baby will grow up and you can feel the drastic changes day by day. This is crawling, changing patterns of cry, laughing like sounds of pearls, walking with much difficulties and so on. Can you hear the talking of your baby. Did you? Now you will hear laugh of your baby. Did you hear. You should not miss all these golden opportunities. You are waiting for this precious occasion. I can understand you. This moment is a dream of you and your family. All your dreams are going to become true. You an your family is expecting for your baby. All the best wishes from me. I congratulate you. Your baby is dedicating a poem for you.

Mom! Moon may fails Infront of your beauty Sun may hide Mom! In your loving look Everest may become like a valley Mom! Infront of your patience Burning valeances become shill In your love. Lightening may fail Mom, because of you I am going to flourish And I’ll spread fragrance every where And make you proud of everyone. You where the way for me in this world. I am bowing my head Infront of you !!!! my dear mother!

Now take a deep breath, repeat for 3 times. Are you following me? Open your eyes slowly. I am thinking you for listening me with patience. Thanking you.

khw;wpaikf;fgl;l Ra kjpg;gp;;l;L kfg;NgWf;Fg; gpd; Vw;gLk; kd cisr;ry; msTNfhy;

t.vz; fzf;fPL 0 1 2 3

1. Njitapy;yhky; mbf;fb Nfhgk; Vw;gLfpwJ. 2. Njitapy;yhj ftiy Vw;gLfpwJ. 3 Ntz;lhj gak; cz;lhfpwJ. 4 Or;R jpzwy; vw;gLfpwJ. 5 ,Uja Jbg;G mjpfkhf cs;sJ. 6 grp mjpfkhf Vw;gLfpwJ 7 grp ,y;iy. 8 tof;fj;jpw;F khwhf cly; vil mjpfhpj;jy;. 9 tof;fj;jpw;F khwhf cly; vil Fiwjy;. 10. gpbthjkhf xU ,lj;ij tpl;L ntspNaWjy;. 11 vd;Dila tpUg;gq;fis mila ePz;l Neuk; Njitg;ghLfpwJ. 12 FLk;gj;jpy; cs;s kw;w cwtpdh;fSlDk; ed;gHfSlDk; xj;J Nghf Kbatpy;iy. 13 Vdf;F mbf;fb mOif tUfpwJ. 14 jd;id moF gLj;jp nfhs;tjpYk; Rj;jkhf itj;J nfhs;tjpYk; mf;fiw FiwT. 15 Cf;fk; ,y;iy. 16 Ntiy nra;tjpy; MHtKk; rf;jpAk; ,y;iy. 17 kd mOj;jk; Vw;gLfpwJ. 18 mbf;fb Nrh;T(m) mrjp Vw;gLfpwJ. 19 Vdf;Fk; vd; Foe;ijf;Fk; jPq;F Vw;gLk; Vd;W gakhf cs;sJ. 20 eifr;Rit czHT Fiwthf cs;sJ. 21 Vg;nghOJk; eLf;fkhf czHfpNwd;. 22 Vg;nghOJk; rq;flkhf czHfpNwd;. 23 Fw;w czHthf cs;sJ. 24 fhuzkpy;yhky; Fog;gkhf cs;sJ. 25 jdpikapy; tplg;gl;lJ Nghd;w czHT Vw;gLfpwJ. 26 Foe;ijapd; kpJ ghrk; Fiwthf cs;sJ. 27 rpwpa Ntiyfis nra;tjpy; $l kwjp kw;Wk; ftdf;FiwT Vw;gLfpwJ. 28 KbT vLg;gjpy; kdk; jLkhw;wk; Vw;gLfpwJ. 29 Vkhw;wkhf czHfpNwd;. 30 jplkhd ek;gpf;if ,y;iy. 31 Jhf;fkpd;ik 32 Vspjpy; vhpr;ry; Vw;gLfpwJ. 33 mLj;jthplk; kpfTk; Nfhgkhf NgRjy; 34 clYwT nfhs;tjpy; tpUg;gkpy;iy. 35 Rakhpahijp ,y;iy vd;gJ Nghd;w czHT Vw;gLfpwJ. 36 jd;dk;gpf;ifaw;w czHT Vw;gLfpwJ.

t.vz; fzf;fPL 0 1 2 3

37 vg;nghOJk; Fog;gkhf cs;sJ. 38 vjpYk; re;Njfkhf cs;sJ. 39 kdk; xU epiyapy; ,y;iy. 40 vg;nghOJk; cq;fSil vz;zj;jpYk; czHr;rpapYk; khw;wq;fs; Vw;gl;Lnfhz;Nl ,Uf;fpwJ. 41 xNu khjphpahd vz;zq;fSk; fUj;Jf;fSk; jpUk;g jpUk;g vd; epidtpw;F tUfpwJ 42 gaKWj;Jk; vz;zq;fs; kw;Wk; cUtq;fs; kdjpy; Njhd;WfpwJ. 43 jw;nfhiy vz;zk; kdjpy; Vw;gLfpwJ. 44 vg;nghOJk; tUj;jkhf czu;fpNwd;. 45 vg;nghOJk; re;Njh#kw;w epiyia czh;fpNwd;.

kjpg;gpL:

0: xd;Wk; ,y;iy

1: Fiwthd

2: kpjkhd

3: jpPtpukhd

0 - 45 kpff; Fiwthd kd cisr;ry;

46 - 80 Fiwthd kd cisr;ry;

81 - 135 mjpfkhd kd cisr;ry;

thpir vz;: gFjp m fpo; nfhLf;fg;gl;Ls;s thf;fpaj;jpy; rhpahd tpilia Njh;e;njLf;f:

1. taJ (m) 20 ypUe;J25 taJ tiu. ( ) (M) 26 ypUe;J 30 taJ tiu. ( ) (,) 31 ypUe;J taJ tiu. ( ) (<) 35 tajw;F Nky;. ( )

2. kjk; (m) ,e;J ( ) (M) %];yp;;k; ( ) (,) fpwp];bad; ( ) (<) kw;wit ( )

3. fy;tpj; jFjp (m) Muk;gf;fy;tp ( ) (M) eLepif;fy;tp ( ) (,) gl;lglg;G ( ) (<) gl;la glg;G ( ) (c) kw;wit. ( )

4. Ntiy (m) tPl;L Ntiy ( ) (M) $yp Ntiy ( ) (,) jdpahH Jiw ( ) (<) muR Ntiy ( ) (c); kw;wit ( )

5. FLk;gk; (m) jdp FLk;gk; ( ) (M)p $l;Lf;FLk;gk; ( ) (,) nghpa FLk;gk; ( )

6. t&khdk; (m) 3000 yp&e;J 5000 ( ) (M); 6000 yp&e;J 10;000 ( ) (,) 11000 yp&e;J 15000 ( ) (<) 16000 Nky; ( )

7. czT Kiw (m) irtk; ( ) (M) mirtk; ( ) (,) ,uz;Lk; ( )

8. FLk;gj;jpy; ahUf;fhtJ kdepiy ghjpg;G Vw;gl;Ls;sjh (m) Mk; ( ); (M) ,y;iy ( )

9. fw;g fhyj;jpy; VjhtJ cly;epiy NfhsWfs; cs;sjh (m) ,hj;j mOj;jk; ( ) (M) rh;f;fih Neha; ( ) (,) ,&ja Neha; ( ) (<) kw;wit ( )

10. trpf;Fkplk; (m) fphhkk; ( ) (M) efHGwk;. ( ) (,) Gw efH gFjp. ( ) (<) Fbir tho; gFjp. ( )

11.cq;fs; FLk;gj;jpy; cq;fSf;F mjuthf cs;stHfs; (m) fztH ( ) (M) mk;kh mg;gh. ( ) (,) rNfhju rNfhjupfs; ( ) (<) khkdhH khkpahH; ( ) (c) fzthpd; rNfhju rNfhjupfs; ( )

12. jpUkzk; (m) nghpath;fshs; epr;rapf;fg;gl;l jpUkzk;. ( ) (M) fhjy; jpUkzk;. ( )

tzf;fk;!

vd;Dila ngaH M.nghd;kyH ehd; ,uz;lhk; Mz;L vk;.v];]p KJfiy gl;lg;gbg;G gbf;fpNwd; vdJ fy;tp jFjpapd; xU gFjpahf ,e;j rpwpa Ma;tpid Nkw;nfhs;fpNwd;.

,e;j cyfj;jpy; kpfTk; GdpjkhdJ ngz;ik jhd; vg;gbdh ghujpahh; $l nrhy;ypUf;fpwhu; . ‘khjuha; gpwg;gjw;Nf ey;y khjtk; nra;jpl ntz;Lkk;kh’. ,Jf;F vd;d mh;j;jk; njhpAkh ngz;zha; gpwg;gjw;f;F ey;y jtk; nra;jpUf;f Ntz;Lk;. Vd; mg;gb nrhd;dhh;fs; vd;why; jha;ik itj;Jjhd;;;. xU ngz; vg;nghKJ KOik milfpwhs; vd;why; mts; jha;ik epiyia milAk;NghJ jhd;;;. Vd; vd;why; xt;nthU ngz;Zf;Fk; gpurtk; vd;gJ kWgpwg;G vd;W nrhy;thu;fs;.

,e;j cyfj;jpy; jha;ikf;F epfuhf NtW vJTk; fpilahJ. jha; vd;w nrhy;Yf;F md;G> ghpT> ghrk;> gw;W mutizg;G ,d;Dk; vt;tsNth nrhy;yyhk;. ,e;j cyfj;jpy; jha; ghrj;ij NtW ahuhYk; nfhLf;f KbahJ. ,g;g ePq;fSk; me;j jha;ik epiyia milag; NghwPq;f. ehd; nrhy;wj Nfl;Ll;L ,Uf;fPq;fsh> ,g;g ePq;f cq;fSf;F trjpah ,Uf;fp;w khjphp cl;fhh;e;Jf;Fq;f ,y;Nydh gLj;Jf;Fq;f gLj;jpl;bq;fsh!

ePq;f mg;gb gLf;Fk; NghJ vg;nghKJk; cq;f ,lJ Gwkhf jpUk;gp gLj;Jf;Fq;f gLj;jpl;bfsh?

Vd; mg;gb gLf;FDKd;D nrhy;Nwd; njhpAkh> mg;Nghjhd; cq;f Foe;ijf;F Njitahd msT ,uj;j Xl;lk; fpilf;Fk;. ,g;Ngh GhpAjh ehd; Vd; mg;gb nrhd;NdD. ehd; nrhy;wj Nfl;Ll;L ,Uf;fPq;fsh?

,g;Ngh ePq;f cq;f fz;fis nkJth %bf;Nfhq;f> %bl;Bq;fsh! nky;ykh %r;R ,Oj;J tpLq;f ,Nj khjphp Kd;W Kiw nra;q;f…….. nrQ;rpl;bq;fsh!

,g;Ngh cq;f kdRk; clk;Gk; Nyrh ,Uf;Fk;> ePq;f gwf;fpwkhjphp czu;tPq;f>,g;g cq;fis Rw;wp mikjpahd #o;epiy ,Uf;F> ePq;f ,g;Ngh KO jha;ik epiyapy; ,Uf;fPq;f.

,d;Dk; xU khjj;jpy; cq;f Foe;ij ,e;j ntspTyfj;ij ghHf;f tuNghFJ.

mJ cq;fisAk; cq;f FLk;gj;ijAk; re;Njh#j;jpy; kpjf;f itf;Fk;.

,e;j 9 khjkh cq;fSf;F vt;tsNth f#;lk; Vw;gl;bUf;Fk;. mij gw;wpnay;yhk; ePq;f epidf;f khl;bq;f> Vd;dh me;j f#;lk; cq;fSf;Fk; cq;f FLk;gj;jpw;f;Fk; kfpo;r;rpia jug;NghFJ.

ehd; cq;fSf;F xU tp#ak; nrhy;Nwd;> ePq;f jhd; ,e;j cyfj;jpNyNa kpfTk; mjp#;lrhyp.

Vd;dh ePq;f jha;ikq;fpw cd;djkhd epiyia milag; NghwPq;f> vg;gb nrhy;Nwdh Kjypy; ePq;f fUTw;wpUf;fPq;fD nrhd;dJNk cq;f FLk;gj;jpy; cs;s vy;yhNuhl Kfj;jpYk; re;Njhrj;ij ghHg;gPq;f.

,g;g cq;fSf;F me;j re;Njhrkhd Kfq;fs; njhpAk;.

,g;g ePq;f xU GJ cyfj;Jf;Fs;s NghwPq;f> me;j cyfk; cq;fSf;F mikjpiaAk; kfpo;r;rpiaAk; jUk;.

,g;g cq;f iffis nkJth cq;f tapj;J Nky itq;f> tr;rpl;bq;fsh? nkJth jltpg; ghUq;f>

,g;g cq;f Foe;ijNahl ];ghprj;ij ePq;f czHtPq;f>,g;g cq;f Foe;ij cq;fis cijf;FJ. mJ nky;y fz;z jpwe;J ghHf;FJ> mNjhl iffis ePl;b xU tpuyhy njhLJ.

xU ePz;l Vf;f ngU%r;R tpLJ> ePq;f nky;ykh ghLw ghl;l $l mJ Nfl;L nuhk;g re;Njh#gLJ.

,g;g cq;f ghg;gh cq;fis cijf;FJy;y> mJ ,g;g nuhk;g re;Njh#kh ,Uf;F.

cq;f Foe;ij cq;f tapw;wpy; re;Njh#khTk; ghJfhg;ghfTk; ,Uf;F.

cq;fSf;F grpf;fpwg;g> cq;f Foe;ijf;Fk; grpf;Fk;.

ePq;f Kopr;rpl;bUf;Fk;NghJ> cq;f Foe;ijAk; Kopr;rpl;bUf;Fk;;> Xa;thf ,Uf;Fk;NghJ cq;f tapw;iw ghHj;J NgRq;f> ghLq;f> mg;Ngh cq;f Foe;ijAk; cq;f $l NgRk; vg;gb njhpAkh? mJ cq;fis cijf;fpwJ %ykh>

,g;g cq;fs cq;f Foe;ij cijf;Fjh?

cq;fSf;F tisfhg;G nra;thq;f> nrQ;rhq;f jhNd me;j tisay; rj;jk; cq;f Foe;ijia cw;rhfkhfTk;> re;Njh#khfTk; itf;Fk;. ,g;g ePq;f cq;f Foe;ijNahl mirTfis czHtPq;f> ,J xU ,dpikahd mDgtk; cq;fSf;F.

,e;j mDgtj;ij cq;fshy; thHj;ijfshy; nrhy;yNt KbahJ.

,e;j jha;ikia epidf;fpwg;gNt cq;f kdRy mstpy;yhj re;Njh#k; guTuj cq;f Kfj;Jy vd;dhy ghHf;f KbAJ.

,e;j cyfj;Jy vj;jidNah ngz;fs; ,e;j re;Njh#k; fpilf;fhk Vq;Fwhq;f mJ njhpAkh cq;fSf;F. ,g;g cq;fSf;F GhpQ;rpUf;FNk ePq;f vt;tsT nghpa ghf;fparhypd;D! kWgbAk; ehd; nrhy;Nwd; ePq;f jhd; ,e;j cyfj;jpNyNa nuhk;g>nuhk;g ghf;fparhyp!

tho;f;ifapy; ve;jnthU re;Njh#j;ij milaDd;dhYk; mJf;F rpy f#;lq;fs;>Ntjidfs; ,Uf;f jhd; nra;Ak;.

mg;gjhd; me;j re;Njh#j;ij ek;khy KOikah mDgtpf;f KbAk;; mJNghyjhd; jha;ik vd;gJk; Foe;ij gpwg;G vd;gJk;.

cq;fSf;F gpurt typ vg;gb ,Uf;Fd;D njhpAkh? ehd; cq;fSf;F nrhy;Nwd;> Kjy;y cq;fSf;F gpurt typ vLf;Fk; NghJ mJ cq;fNsl mbtapw;wpy; njhlq;fp Nky; tapw;Wf;F guTk; mg;Gwkh mJ cq;fNshl ,Lg;G gFjpf;F guTk;;. Kjy;y typ Nyrhjhd; ,Uf;Fk; Neuk; Nghf Nghf typ mjpfkhFk;.

mJf;fhf ePq;f gag;gl $lhJ> Vd; gag;glDk;! ePq;f xU capu cUthf;fp mJf;F cUtk; nfhLj;J mJf;F capiuAk; nfhLf;f NghwPq;f vt;tsT re;Njhrkhd tprak;.. ,e;j typnay;yhk; cq;f Foe;ij fUg;igia tpl;L ntspNa tUk; tiu jhd;. Foe;ij gpwe;jJk; mjNdhl Kjy; mOif rj;jj;j Nfl;l clNdNa…

cq;fNshl me;j typ f#;lk; vy;yhj;ijAk; kwe;Jl;L clNd cq;f Foe;ijia ms;sp mizr;R Kj;jk; nfhLg;gPq;f. nfhLj;Jl;bq;fsh……

,Jjhd; jhad;G > jha;ikNahl kfj;Jtk;.

,d;ndhU Kf;fpakhd tprak; ve;j Foe;ijahdhYk;;> me;j GJtuT cq;f FLk;gj;Jy>kfpo;r;rpiaAk;> I];thpaj;ijAk; nfhz;L tUk;. ehd; nrhy;wj Nfl;Ll;L ,Uf;fPq;fsh?

,g;g cq;f Foe;ij cq;f ify ,Uf;F mNjhl mof ePq;f urpf;fpwPq;f me;j NuhIh G{ Kfj;ijAk;> me;j Mg;gps; Nghd;w fd;dj;ijAk; ePq;f njhl;L ghHfpwPq;f… njhl;L ghHj;Jl;bq;fsh……….

,J cq;f kdRy nrhy;y Kbahj> ,d;gkhd czh;it nfhLf;FJy;y …

cq;f Foe;ij cq;fs ghHj;J rphpf;Fk; NghJ> cyfj;Jy ,Uf;fpw mj;jid ,d;gq;fisAk; czHtPq;f…

vt;tsNth f#;lj;Njhl ,Ue;jhYk; me;j rphpg;ig ghHj;jTlNd vy;yhf#;lj;ijAk; kwf;f itr;rpLk;.

,g;g cq;f Foe;ijNahl rphpg;G cq;fSf;F Nfl;Fk;…………. Nfl;Ll;bq;fsh? cq;f Foe;ij grpf;fhf eL ,uj;jphpapy; mKk;NghJ mJ cq;f Àf;fj;Jf;F ,ilAwh ,Ue;jh $l ePq;f vOe;J ghy; nfhLj;J Àq;f itg;gPq;f…….

,J jhd; jha;ghrk; vd;gJ

,g;g cq;f Foe;ijNahl mOif rj;jk; cq;fSf;F Nfl;Fk;……..

Nfl;Bq;fsh?

xU jha;f;F kl;Lk; jhd; njhpAk; Foe;ij grpf;F mOjh >Ntw vJf;fhf mOjh vd;W.

,j xU jhahy kl;Lk; jhd; GhpQ;Rf;f KbAk;> ,J jhd; jhad;GD nrhy;wJ.

Xt;nthU ehSk; cq;f Foe;ijNahl cly; kw;Wk; kdryTs Vw;gLfpw tsHr;rpia ePq;f ghHj;J ,urpg;gPq;f…….

mjhtJ cq;f Foe;ij jto;e;J NghwJ> mNjhl nry;ykhd mOif> Kj;Jf;fs; rpjWtJ Nghd;w rphpg;G> mJ jj;jp jj;jp elg;gJ ,J vy;yhk; jhd;; .

,g;g cq;fSf;F cq;f Foe;ijNahl koiy Ngr;R Nfl;Fjh………..

Nfl;Ll;Bq;fsh ?

,g;g cq;f Foe;ijNahl rphpg;G rj;jk; Nfl;Fjh……………. Nfl;Ll;Bq;fsh ?

,e;j kfpo;r;rpahd jUzj;ij ePq;f jtwtplNt $lhJ. ePq;f me;j jUzj;Jf;fhf fhj;Jf;fpl;L ,Uf;fpwPq;fD vdf;F ey;yh GhpAJ.

me;j jUzk; cq;fNshlJk; cq;f FLk;gj;Njhl fdTk; $l jhd; me;j fdT $ba tpiuTy epidthf NghFJ. ePq;fSk; cq;f FLk;gKk; cq;f Foe;ijNahl tUiff;fhf fhj;Jl;L ,Uf;fPq;fd;D vdf;F njhpAk;;. mjw;fhf vd;Dila tho;j;Jf;fs; cq;fs; jha;ikf;F vd;Dila ,jak; fdpe;j ey;tho;j;Jf;fs;. cq;f Foe;ij cq;fSf;fhf xU ftpij nrhy;YJ>

“ mk;kh! re;jpuDk; Njhw;Wg; NghFk; mk;kh! cd; Kf mofpy;! #hpaDk; xsp ,oe;J NghFk; mk;kh! cd; md;G ghHitapy; vtnu];l;; kiyAk; rpW JUk;ghFk; mk;kh! cd;nghWik rpayj;jpd; Kd; vhp kiyAk;; FspHe;J NghFk; mk;kh! cd;ghr kioapy; kpd;dy;fs; $l Njhw;WNghFk;mk;kh! cd; ,ikfs; Kb jpwe;jhy; mk;kh! cd;dhy; kyug;NghFk; kyH ehd; kzk; gug;gp cdf;F ngUik NrHg;Ngd; vd;id kyHtpf;f ,Uf;Fk; md;Gj;jhNa cdf;F Nfhb tzf;fq;fs;.

,g;g nkJth nghpa Kr;R vLj;J tpLq;f> mNj khjphp Kd;W Kiw nra;q;f…….. nrQ;rpl;Bq;fsh ?

,g;g nkJthf cq;f fz;fis jpwq;f> mikjpah Nfl;ljw;f;F ed;wp…. tzf;fk;;.