INTRODUCTION :

“Snow and adolescence are the only problems that disappear if you ignore them long enough”.

Earl Wilson

The blossoming of adolescence in each generation is as fascinating a sight as the unfolding offspring each year predictable and repetitive. Adolescents belong to vital age group, not only because they are the entrant population to parenthood but also because they are in the threshold between childhood and adulthood. As they attempt to cross this stage they face various physiological, psychological and developmental changes.

According to UNICEF (2011), In India about 243 millions (20%) of adolescents are in the age group of 10 – 19 years in total population. Adolescents today represent a significant proportion of the world population and they constitute 18% of the world population.

The period of adolescence for a girl is a period of physical and psychological preparation for safe motherhood. As they are direct reproducers of future generations, the health of adolescent girls influences not only their own health, but also the health of the future population.

The first menstrual period is called menarche. It usually starts between the ages 11 and 14. Though the menstruation is normal, some women experience dilemma during their monthly periods. The most commonly experienced problem by the women is cramping pain during menstruation, known as Dysmenorrhea. Cramping pain is experienced by most of the women, out of which 50% experience some form of pain like low back pain, abdominal pain, etc., and 10% of them face severe symptoms which necessitating time off from work or school. It is the common cause of sickness absenteeism (13 to 51%) from classes by students’ community.

Dysmenorrhea is defined as pain or discomfort (cramps) during or just before a menstrual period. Two types of dysmenorrhea are primary and secondary dysmenorrhea. When the menstrual cycle begins prostaglandins are released by the endometrial cells as they are shed from the uterine lining causing the uterine muscles to contract. If excessive prostaglandin is present, the normal contraction response can become strong and painful spasm. Uterine muscles deprive for oxygen and cause cramps. (D.C.Dutta, 2006)

NEED FOR THE STUDY:

Lowdermilk (2004) had highlighted that the dysmenorrhea is a common gynecological problem in women in all ages. Most adolescence experience dysmenorrhea in the first 3 years after menarche. Young adult women ageing 17 to 24 years are most likely to report painful menstruation. Of them 50% to 80% report some level of discomfort while 10% to 18% complained severe dysmenorrhea. It has been estimated that up to 10% of women have severe pain which interfere with their normal functioning for 1-3 days a month.

Primary dysmenorrhea has a biochemical basis and arises from the release of prostaglandin (PG) with menstruation. During the luteal phase and subsequent menstrual flow PGF2 alpha increases and amplitude to the increase frequency of uterine contractions and causes vasospasm of the uterine arterioles , resulting in ischemia and cyclic lower abdominal cramps.

The degree of discomfort is related to the duration of menstrual flow but not to cycle length.

Systemic responses to PGF2 alpha include back ache, sweats and gastrointestinal symptoms. Pain begins at the onset of the menstrual flow and lasts for 12 to 48 hours.

Although primary dysmenorrhea is not normal, it is not caused by underlying pathologic disorders; rather it is the occurrence of a physiologic alteration.

Banikarim et al (2007) had found that the overall prevalence of dysmenorrhea in high school population was 79.2%. It was determined that the prevalence of dysmenorrhea among adolescents has impact on academic performance, school attendance, sports, social activities and its management. Among 706 participants who had a menstruation in the previous 3 months, 85% reported dysmenorrhea. Out of that 38% reported missing school due to dysmenorrhea, 33% reported missing individual classes. Further, the study also revealed that the activities affected by dysmenorrhea include class concentration (59%), sports (51.1%) and homework (35%).

Although it is not life-threatening, dysmenorrhea can be debilitating and psychologically taxing for many women. Some choose to self-medication at home and never seek medical attention for their pain.

Pharmacotherapy can be used to treat dysmenorrhea. Taking pain medicine can help but only temporarily. It simply masks the pain instead of addressing the root of the cause. Using NSAID drugs as first-line treatment but it has limitation because of adverse reactions such as gastrointestinal side effects, immunohaemolytic anaemia and nephrotoxicity. Overdose is accompanied by central nervous system toxicity and convulsions which mandates the selection of alternative therapeutic modalities.

Relaxation and hatha yoga therapy used successfully to decrease menstrual discomfort (Lowdermilk et.al.). And Medical Online had recommended that yoga is relieving menstrual pain.

Dr. Hema.S (2003) had highlighted that yoga balances the function of organs. The organs are stimulated if it is under working. It is suppressed if it is overworking. No other exercise does this. Mind is calmed in yoga. It does not occur in other systems.

Usha and Madhavi (2013) had analyzed the effect of yoga and meditation as alternative therapy for primary dysmenorrhea in young students and its outcome on school absenteeism. The study group was subjected to do yoga, pranayama and meditation for three months. The findings observed a significant (p<0.0001) reduction in the perceived pain after yoga intervention in study group. 83.33% of the study group reported complete pain relief and 11.66% reported mild pain. No reduction of pain was found in the control group. After yoga intervention, absenteeism dropped to 10.3% and improvement in daily activity was observed in study group.

Hence the investigator preferred to undertake this study in a rural setting and also she came across during her clinical and teaching experience students were absent for college and clinical area every month because of dysmenorrhea.

So the investigator interested to take this study and teach yoga to the school students which is one of the alternative therapies for management of primary dysmenorrhea and see the effectiveness on dysmenorrhea.

Though yoga is one of the alternative therapies to treat primary dysmenorrhea there are limited research studies done in this area. So investigator took one step ahead and selected this topic.

AIM:

The aim of this study was to teach yoga to the adolescent girls which is one of the alternative therapies for managing primary dysmenorrhea and analyse the effectiveness of yoga on primary dysmenorrhea.

STATEMENT OF THE PROBLEM:

Effectiveness of Yoga on primary dysmenorrhea among adolescent girls at selected schools in Kallakurichi Taluk, Villupuram District.

OBJECTIVES:

1. To assess the pain level during menstruation before and after yoga training programme among adolescent girls in Experimental group and Control group.

2. To assess the associated factors with primary dysmenorrhea before and after yoga training programme among adolescent girls in Experimental group and Control group.

3. To find out the effectiveness of yoga training programme on primary dysmenorrhea among adolescent girls by comparing Experimental and Control groups.

4. To analyse the association between dysmenorrhea pain mean posttest value and demographic variables and menstrual pattern variables among adolescent girls in Experimental group.

5. To analyse the association between associated factors of dysmenorrhea mean posttest value and demographic variables and menstrual pattern variables among adolescent girls in Experimental group.

HYPOTHESIS:

1. H₁ There was a significant difference before and after yoga training programme on Primary Dysmenorrhea among adolescent girls.

2. H₂ There was a significant association between the dysmenorrhea pain and associated factors mean posttest value with selected demographic variables and menstrual pattern variables among adolescent girls.

METHODOLOGY:

Research Approach--Evaluative Approach

Research Design--Quasi- experimental Research Design

Setting of the Study--Selected Schools at Kallakurichi Taluk

Variables under the study:

Independent Variable:

Yoga Training Prorgramme

Dependent Variable:

Dysmenorrhea pain and associated factors of dysmenorrhea

Sample:

Adolescent girls with primary dysmenorrhea who were in age group of 14 – 17 years studying in 9^th to 12^th standard in selected schools at Kallakurichi Taluk.

Sample size:

· 300 adolescent girls with primary dysmenorrhea.

· 150 in experimental group and 150 in control group.

Sampling technique:

Simple Random Sampling Technique

Criteria for sample selection:

Inclusion Criteria:

1. All adolescent girls, aged between 14 – 17 years.

2. Adolescent girls who were having primary dysmenorrhea.

3. Adolescent girls who were having dysmenorrhea pain score moderate and above (4 and above).

4. Adolescent girls who were available during data collection.

5. Adolescent girls who agreed not to use analgesics and oral contraceptives throughout the yoga training period for primary dysmenorrhea.

Exclusion Criteria:

1. Adolescent girls who were not willing to participate in yoga training programme.

2. Adolescent girls who were having irregular cycle.

3. Adolescent girls who had surgery within last 6 months.

4. Adolescent girls who were having congenital disorders like heart defects, muscular and bone defects.

5. Adolescent girls who were taking medications and other form of treatments (like Homeo and Siddha) for primary dysmenorrhea.

Description of the instrument:

The tool consists of 3 parts, they are

Part: 1

Part 1 consists of 2 sections.

• Section A consisted of demographic variables like age, religion, education, age at menarche, mother’s educational status, father’s educational status, type of employment, family income and type of family.

• Section B consisted of menstrual pattern variables like height, weight, body mass index, years after menarche and onset of pain after menarche, onset of pain during menstruation, pain lasts during menstruation, menstruation frequency, number of days menstrual flow and family history of dysmenorrhea.

Part: 2

Numeric pain intensity scale to assess the dysmenorrhea pain level. Scale is having 11points (0 -10) to indicate pain.

Part: 3

Likert 4 points scale used to assess the associated factors of primary dysmenorrhea. The scale consisted of 3 factors like physical factors, psychological factors and educational factors.

Analysis and Interpretation:

Prevalence rate of Primary Dysmenorrhea at selected schools

Distribution of Level of Pain during Menstruation before and after Yoga Training programme among Adolescent Girls for Study Group:

Level of Pain Score	Pretest		Posttest
Level of Pain Score	No.	%	No.	%
No Pain (0)	0	0.0	107	71.3
Mild Pain (1 – 3)	0	0.0	43	28.7
Moderate Pain (4 – 6)	107	71.3	0	0.0
Severe Pain (7 – 9)	38	25.3	0	0.0
Worst Possible Pain (10)	5	3.3	0	0.0
Total	150	100.0	150	100.0

Associated factors of Primary Dysmenorrhea before and after Yoga Training among Adolescent Girls for Study Group

Comparison of Effectiveness of Yoga Training Program on Pain between Study and Control Groups among Adolescent Girls

Effective Score

Study Group

Mean difference score (%)

Control Group Mean difference score (%)

Independent ‘t’ test and P value

Mean

58.3

-3.9

t = 44.858

P < 0.001

Significant

Standard Deviation

13.3

10.5

DISCUSSION AND SUMMARY:

Regarding Hypothesis:

H₁-There was a significant difference before and after yoga training programme on Primary Dysmenorrhea among adolescent girls. Study findings showed that there was a reduction of pain and associated factors of dysmenorrhea score during post-test. Hence hypothesis 1 was accepted.

H₂-There was a significant association between the mean posttest dysmenorrhea score with selected demographic variables and menstrual pattern variables among adolescent girls. The results showed that weight and number of days of menstrual flow had a significant association. Hence hypothesis 2 was accepted.

MAJOR FINDINGS OF THE STUDY:

1. In posttest 71.3% of girls had no pain, 28.7% had mild pain during menstruation and none of them had moderate, severe and worst possible pain in experimental group.

2. Among 150, 107 adolescent girls had never and 43 girls mild level of associated factors of dysmenorrhea after yoga training programme among adolescent girls in experimental group.

3. In posttest dysmenorrhea pain independent ‘t’ value was 38.125 and this was statistically significant at p< 0.001 level between two groups.

4. The dysmenorrhea pain paired ‘t’ test value was 53.588 and had significant difference at the level of P<0.001 in experimental group after the intervention.

5. The associated factors of dysmenorrhea overall paired ‘t’ test value was 51.520 and it was highly significant at P<0.001 level in experimental group.

6. In Study group there was a significant association between pain with the menstrual pattern variable - weight at P<0.05 level in posttest.

7. Study group had a significant association between associated factors of dysmenorrhea with the menstrual pattern variable - number of days of menstrual flow at P<0.01 level in posttest.

NURSING IMPLICATIONS:

Nursing Practice, Education, Administration and Research:

· Nurses can render information through education in simple ways to enhance the adolescents’ knowledge regarding alternative therapies.

· The school health nurses can play a major role in increasing knowledge about dysmenorrhea, associated factors of primary dysmenorrhea and its controlling measures.

· Nursing administrators can formulate policies, which will include all nursing staff to be actively participated in Continuous Nursing Education (CNE) programmes to update their knowledge on current modalities in treating primary dysmenorrhea especially on complementary and alternative therapies in hospitals and community.

· The school health nurse administrator should initiate to carryout periodical survey on the prevalence of primary dysmenorrhea management among the adolescent girls to take preventive measures.

· Adolescent health camps can be conducted in schools and community to find out various menstrual problems and it may create awareness regarding that.

· It can also be used for the future reference as review of literature and this study can be replicated in several areas.

· Nurses can practice evidence based research to disseminate the findings.

LIMITATIONS:

1. The investigator had no control on extraneous variables like diet habits, exam stress and absenteeism, etc.

2. Cultural belief restricted some participants to enroll in the study.

3. As parents are not having enough knowledge on alternative therapies, some of them did not give consent initially to participate in the study.

4. Study findings were limited generalization as it was conducted in selected schools.

5. Most of the schools did not give permission due to public exam, so schools were selected purposively.

RECOMMENDATIONS:

1. This study can also be replicated in different cultural groups, urban areas and larger samples in different settings.

2. A similar study can be conducted as a video assisted teaching program with adequate follow up.

3. A comparative study could be conducted to assess the effectiveness of conventional medicine and the yogasanas on dysmenorrhea.

4. A similar study could be carried out for other menstrual problems like irregular cycle and excessive flow, etc.

5. There are limited studies on effect of yoga on primary dysmenorrhea. So more studies could be replicated.

6. In rural areas most of the schools did not appoint school health nurse. The government should appoint and urge all the private schools to appoint school health nurse. So that the young girls get guidance for their reproductive health problems.

CONCLUSION:

The study findings concluded that yoga was effective in reduction of pain and associated factors of dysmenorrhea. It also improved the physical and mental health of adolescents and enabled them to do normal activity without any disruptions. Furthermore, it was observed that decreased the school absenteeism and improved concentration in studies. As well as it may prevent the possibility of getting secondary dysmenorrhoea, teaching yoga to young girls in schools could be most effective ,most efficient, and most time-saving method.

REFERENCES:

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Received on 06.07.2014 Modified on 10.08.2014

Int. J. Nur. Edu. and Research 2(3): July- Sept. 2014; Page 231-236

Dysmenorrhea factors	Effective Score
	Study Group		Control Group		Independent ‘t’ test and P - value
	Mean difference	S.D.	Mean difference	S.D.	Independent ‘t’ test and P - value
Physical factors	43.15	15.34	-2.89	7.24	t = 33.225, P < 0.001 Significant
Psychological factors	58.89	15.94	-0.76	5.26	t = 43.528, P < 0.001 Significant
Educational factors	52.44	21.45	-1.11	8.78	t = 28.302, P < 0.001 Significant
Overall	51.86	12.33	-1.66	5.13	t = 49.362, P < 0.001 Significant