A Study to Assess the Effectiveness of Nurse Led Interventions on Anxiety and Depression among Head and Neck Cancer Patients Admitted in Pravara Rural Hospital, Loni (Bk)

Ms. Melisa Leo Fernandes

Clinical Instructor, Institute of Nursing Education and Training, Gokhale Education Society, Krushi Nagar, Nashik. Maharashtra, India-422005

*Corresponding Author Email: leomanju31@yahoo.com

ABSTRACT:

Background: Many of the cancer patients receiving cancer treatment does have variety of health problems and were found to be psychologically disturbed. Nurses play an important role in reducing the impact of physical and psychological problems / symptoms and improve the quality of life.

Objectives : A study was 1)To assess the Anxiety and Depression of head and neck cancer patients 2)To determine the effectiveness of Nurse Led Interventions on Anxiety and Depression of head and neck cancer patients and 3)To compare the Anxiety and Depression with their selected socio demographic variables.

Materials and Methods: Thirty head and neck cancer patients in the age group of above 18 years who were admitted in Pravara Rural hospital were studied. They were assessed for the level of anxiety and depression on the first day of admission followed by implementation of Nurse led Interventions like education, reinforcement (educative material like Pamphlets) and care (mouth care, oral care, breathing exercises, counseling and spiritual care) from admission to discharge. The post test was carried on the time of follow up visit. The data was analyzed with descriptive and inferential statistics wherever required.

Results:It was noted that after the Nurse led intervention the level of anxiety and depression was significantly reduced from moderate to mild level.. There was a significant association was found between depression and the socio demographic variables like occupation, treatment of cancer and compliance with treatment. A positive relationship existed between the study variables like anxiety and depression.

Conclusion:The study outcome revealed that the nurse led intervention was found to be effective in reducing anxiety, and depression of head and neck cancer patients. It should be emphasized that nurse led intervention should be practiced and used routinely for the head and neck cancer patients to have better outcome of cancer treatment.

KEYWORDS: Effectiveness Anxiety, Depression, Nurse Led Intervention and Head and neck cancer patients

INTRODUCTION:

WHO (2012) estimated that in worldwide there were 14.1 million new cancer cases, 8.2 million cancer deaths and 32.6 million people living with cancer(within 5 years of diagnosis) The overall age standardized cancer incidence rate is almost 25% higher in men than in women¹. National Cancer Control Programme (2008)statistics revealed that there are 2 to 2.5 million cancer patients at any given point of time with about 0.7 million new cases coming every year and nearly half die every year in India. Two-third of the new cancers are presented in advance and incurable stage at the time of diagnosis. More than 60% of these affected patients are in the prime of their life between the ages of 35 and 65 years. The causes of head and neck cancers are predominantly life-style –related: Tobacco, Areca nut, alcohol, poor diet, viral infections and pollution are all important etiological factors.²

The researchers emphasized that a diagnosis of head and neck cancer, like any other cancer diagnosis, is often accompanied by much fear and uncertainty. In addition, patients with head and neck cancer face difficulties in eating, chewing, drinking, breathing, speaking as well as changes in appearance.³ Alongside it is very stressful event for the patients and their families. The Head and Neck cancer patients experiences physical symptoms, side effects from treatment, symptoms distress and psychological distress. Patients also experience uncertainty about the effectiveness of an unfamiliar treatment, their ability to manage daily living, and long –term effects of the disease and treatment. Researchers have found higher prevalence of depression and depressive symptoms prior, during and at the completion of cancer treatment⁴

The nurses can influence head and neck cancer treatment through emphasis on symptom management, tobacco and alcohol cessation, and on patient and family education and care co-ordination. As a health care professional, nurses play an important role in reducing the impact of physical and psychological problems / symptoms and improve the quality of life. The nursing intervention like oral care, back care, breathing exercises, counseling and spiritual care proved to have significant role in the reduction of severity of symptoms and improvement of health status. Thus the researcher was interested to develop nurse led intervention with the focus of education, care and reinforcement; and to determine the effectiveness of Nurse led intervention on head and neck cancer patients.

MATERIALS AND METHODS:

The Quasi - experimental study, pretest – post test design without control group approach was used. The present study was conducted in 30 Head and Neck cancer patients who are admitted in oncology ward of Pravara Rural Hospital, Loni (BK).The patients who are above 18 years of age, able to follow and practice Nurse Led Interventions and willing to participate were included in the study.. However those who are acutely ill and unable to respond and having other types of cancer were excluded. Approval by ethical committee of Pravara Institute of Medical Sciences was obtained and the informed consent was obtained from the subjects. The subjects were selected by non probability; purposive sampling method. A structured interview schedule (for evaluation of anxiety, depression and quality of life) was prepared in three sections to collect data. Section A includes socio – demographic data and clinical characteristics of head and neck cancer patients, Section B Hospital Anxiety and Depression Scale, to assess the anxiety and depression of head and neck cancer patients, which includes the 14 items out of which 7 items were to assess the anxiety and other 7 items to assess the level of depression. Each item has four alternatives like not at all, rarely, sometimes and always with the score of 0,1,2,3 respectively. The maximum obtainable score was 21.

Pre test was conducted on i.e. the day of admission before implementation of nurse led intervention. The selected intervention for the present study was the Nurse led intervention which includes.

1) Education: information on Heads and neck cancer

2) Care: which includes a) Oral care every 8 hourly b) Back care every 12 hourly c) Breathing Exercises (Deep Breathing and Pursed Lip Breathing) every 4 hourly d) Counseling once a day and e) Spiritual care – prayer two times a day.

3) Reinforcement: Educative material like pamphlets on a) Head and Neck cancer, b) Radiation therapy and its side effects management and c) Chemotherapy and its side effects management. The Nurse led intervention was implemented to the cancer patients under study based on the predetermined frequency of care by the nurse researcher. Post test was carried out on the follow up visit (average 15 days after) to Department of radiotherapy and oncology of Pravara rural hospital. It was carried out with same structured interview schedule. The collected data was organized, tabulated and analyzed by using descriptive and inferential statistics.

RESULTS:

Findings related to Socio demographic characteristics:

One third (33%) of patients under study was belonged to the age group of 35 - 45 years and 56 - 65years, majority 67% were males, (70%) of patients were literates, highest percentage (43%) of the patients had Agricultural work (farmers), more than half (53%) of them had monthly income less than Rs. 3000, most (90%) of them were married and most (93%) of patients were Hindus.

Findings related to clinical characteristics:

Higher percentage (47%) of patients under study had stage II cancer, highest (40%) of patients had cancer Buccal mucosa, three fourth (73%) of patients had more than six months duration of cancer, significant percentage (33%) of patients had metastasis, highest percentage (73%) had received combined therapy and half (53%) of patients had combination of habits like smoking, use of pan, supari, and drinking.

Findings related to anxiety, depression of head and neck cancer patients:

Distribution of mean, SD, and mean percentage of pre and post test anxiety, depression and quality of life of head and neck cancer patients shows that, in post test the mean score for anxiety was(8.83 ± 1.85) which is (42.04%) of the total score wherein the pretest score for the same was (10.5 ± 2.87) which is (50%) of the total score with the effectiveness of 7.96%.In relation to the depression, the post test mean score was (8.90± 1.84) which is 42.38% of total score wherein the pre test score for the same was (10.2 ±3.40) which is 48.57% of the total score with the effectiveness of 6.19%. The facts interprets that the nurse led intervention was effective in reducing the anxiety and depression among the cancer patients. (t= 2.04 , P ≤ 0.05). (Table1)

(Table 2)Findings revealed that there was a significant association was found between the depression and the demographic variables like occupation, treatment of cancer and compliance with treatment.

Table 2: Association between the anxiety and depression of head and neck cancer patients with their selected demographic variables

SN	Variables	Anxiety	Depression
1	Age	0.02	0.71
2	Sex	0.03	0.22
3	Education	0.01	1.57
4	Occupation	1.30	6.51*
5	Type of family	1.31	0.55
6	Monthly income	0.94	0.69
7	Stage of cancer	1.35	1.02
8	Site of cancer	0.21	0.75
9	Duration of cancer	1.13	0.96
10	History of metastasis	1.42	1.67
11	Treatment of cancer	2.75	4.29*
12	Compliance with treatment	0.13	3.92*

(df-1) Table Value 3.84 P ≤ 0.05 level * Significant

Findings related to relationship between anxiety and depression: The calculated co efficient of co relation test values revealed that among the selected study variables the anxiety and depression had moderately positive correlation (r = + 0.31) which indicates the anxiety had influence in the development of depression.

DISCUSSION:

The world’s population continues to grow and age, the burden of cancer worldwide will inevitably further increase, an estimated 8.20 million people died from cancer across the world. the Head and Neck cancer patients experiences physical symptoms, side effects from treatment, symptoms distress and psychological distress. Patients also experience uncertainty about the effectiveness of an unfamiliar treatment, their ability to manage daily living, and long –term effects of the disease and treatment.⁵ The study findings revealed that highest percentage (33%) of patients under study were in the age group of 35-45 years and 56-65 years respectively. It was consistent with the study conducted by Kulkarni MA (2013) who also noted that maximum number of oral cancers among males (25%) were above the age of 55 years.⁶

The results showed that highest percentage (73%) had compliance with cancer treatment while the remaining (27%) did not had the regular compliance with the treatment. Which is congruent with a study carried out by by Mohanti BK, Nachiappan P, Pandey RM, Sharma A, Bahadur S and Thakar A(2006) that (56%) of patients complied with the prescribed treatments.⁷Half (53%) of cancer patients under study had the habit of smoking, use of pan, supari and drinking.(Fig No.15) Ruback MJ, Galbiatti AL, Arantes LM, Marucci GH, Russo A and Ruiz-Cintra T et.al (2011) also noted that (54%) of cancer patients were smokers and alcohol abusers.⁸

The Study findings noted that the cancer patients under study had moderate level of anxiety (10.5 ± 2.87) and mild depression (10.2 ±3.40) .These findings was consistent with the study carried out by Karabulutlu EY, Bilici M. Cayir K, Tekin SB and Kantarci R (2010) that cancer patients experience moderate level of anxiety⁹, further in relation to depression, Polikandrioti M, Evaggelou E, Zerva S, Zerdila M. Koukoularis D and Kyritsi E (2008) findings that depression is the common symptom in cancer patients, 21.5% mild, 10.2% moderate and 0.6% severe depression.¹⁰

The study findings revealed that comparison of level of pre and post test anxiety of head and neck cancer patients showed that after the nurse led intervention i.e. in post test higher percentage (57%) had mild anxiety and only (20%) had moderate anxiety .It was evident that the nurse led intervention was effective in reducing the anxiety among the cancer patients. It was consistent with the study carried out by Jones RB, Pearson J, Cawset AJ, Bental D, Barrett A and White J et al (2006) who also found that after the nurse led intervention at three months follow up, 45% of cancer patients had improved anxiety scores.¹¹

In relation to depression, after the nurse led intervention i.e. in post test higher percentage (70%) had mild depression and only (17%) had moderate depression. It was credited that the nurse led intervention was effective in reducing the level of depression among the cancer patients. It was well supported by Ftanou M and Mitchael N (2014) that individual interventions were more effective in reducing symptoms of depression in patients with cancer.¹²

It was proved that the problem chosen for the study was common and has greater significance in the medical and nursing practice. As emphasized through the study findings practicing the nurse led intervention reduce the anxiety and depression of head and neck cancer patients.

CONCLUSION:

The cancer patients suffer with physical and psychological problems which had significant impact in the QOL aspects. It was noted that in the present study also that cancer patients had anxiety, depression and poor QOL. The nurse led intervention like was shown impact in reducing the anxiety, depression and improving the QOL aspects significantly. It was well accepted the patients and cost effective intervention.

ACKNOWLEDGEMENT:

The author express sincere thanks to the Pravara Institute of Medical Sciences (DU), the Medical Superintendent, HOD of Department of Radiation therapy and Oncology of Pravara Rural Hospital, Loni (BK), the Principal ,college of nursing, Guide Dr. T. Sivabalan and the Head and Neck cancer patients for their kind co-operation and support.

REFERENCES:

1. World Health Organization 2012 available from URL:http://www.who.int/cancer/en/index.html

2. National Cancer Control Programme 2008 available from URL:http://www.who.int/cancer/en/

3. Semple CJ, Sullivan K, Dunwoody L, Kernohan G, Psychosocial interventions for patients with head and neck cancer , Oral cancer foundation, Part II, 2004 ;27(0):434 - 441.

4. Horney D, Smith H, McGurk M, Weinman J, Herold J and Altman K et.al. Association between quality of life, coping styles, optimism, and anxiety and depression in pretreatment patients with head and neck cancer, Head and Neck (2011)33,65-71

5. World Health Report 2012 available from URL:www.who.int/entity/mediacentre/factsheets/fs297/en/ - 36k

6. Kulkarni MR, Head and neck cancer burden in India, International journal of head and neck surgery, 2013;4(1):29-35

7. Mohanti BK, Nachiappan P, Pandey RM, Sharma A, Bahadur S and Thakar A. Analysis of 2167 head and neck cancer patients management, treatment compliance and outcomes from a regional cancer centre, Delhi, India 2006;available from URL:ordjournals.org/content/2004/32/57/T4.expansion.html

8. Ruback MJ, Galbiatti AL, Arantes LM, Marucci GH, Russo A and Ruiz-Cintra T et.al. Clinical and epidemiological characteristics of patients in the head and neck surgery Department of a University Hospital.2011

9. Karabulutlu EY, Bilici M. Cayir K, Tekin SB and Kantarci R. Coping, anxiety and depression in Turkish patients with cancer, European journal of General medicine,2010;7(3):296-302

10. Polikandrioti M, Evaggelou E, Zerva S, Zerdila M. Koukoularis D and Kyritsi E. Evaluation of depression in patients undergoing chemotherapy, Health Science Journal,2008: 2(3).162-172

11. Jones RB, Pearson J, Cawset AJ, Bental D, Barrett A and White J et. al. Effect of different forms of information produced for cancer patients on their use of the information, social support and anxiety: Randamised trial .BMJ.2006.332:942-948

12. Ftanou M and Mitchael N .Clinical practice guidelines for the treatment of lung cancer. Cancer council.2014 available from URL: http://wiki.cancer.org.au/australia/Guidelines:Lung_cancer.

Received on 20.07.2015 Modified on 16.08.2015

Int. J. Nur. Edu. and Research 3(4): Oct.-Dec., 2015; Page 378-381

DOI: 10.5958/2454-2660.2015.00027.7

SN	Area	Pre test			Post test			Difference in mean (%)	‘t’ value
SN	Area	Mean	SD	Mean%	Mean	SD	Mean%	Difference in mean (%)	‘t’ value
1	Anxiety	10.5	2.87	50.00	8.83	1.85	42.04	7.96	8.3*
2	Depression	10.2	3.40	48.57	8.90	1.84	42.38	6.19	3.75*