INTRODUCTION:

Adolescence is the phase that comes during the second decade of a human being's life (10-19years). This is a period of rapid growth when young people acquire new capacities and physical changes with many new characteristics that create not only opportunity for their progress but also create problems to their health and well being, if they are not taken care of health. During this period, the growth is accelerated by major physical changes in both boys and girls, (Kimmel PL, 2001)

According to UNICEF (2012), The current population of India estimated to be 1.22billion. India, has the largest population of adolescents (243 million) followed by China (207 million) and United States (44 million).

The report says that around 25 per cent (243 million) of Indians belong to the age group of 11-19 years, 50% of India current population is below age 25 years and 65% below age 35 years. The population of Andhra Pradesh is 84,665,533, out of which 16.5% are of adolescent age group.

Acne referred as a physiological condition. Research has shown that 85% of young people between the ages of 12 and 24 years have acne, and while it is most common in teenagers, acne effects 8% of adults aged 25 to 54 years and 3% of adults aged 35 to 44 years. Acne in young adults may represent continuation of adolescent acne or development of late-onset disease. Prevalence varies greatly across the world, with western modernized civilizations demonstrating much higher rates of acne, whereas some non-industrialized societies report no cases of acne, (Alexa, 2011)

In westernized societies, acne vulgaris is a universal skin disease afflicting 79% - 95% of the adolescent population. In men and women older than 25 years, 40% - 54% have some degree of facial acne, and clinical facial acne persists into middle age in 12% of women and 3% of men. Epidemiological suggests that acne incidence rates are considerably lower in non westernized societies, (Maglione, 2009)

A cross-sectional study was conducted where 409 samples were selected using stratified cluster random sampling from two secondary schools in Muar, involving form 1 to form 5 students in adolescent groups. Students were diagnosed clinically and the severity of facial acne was assessed using global acne grading system. A self reported Cardiff acne disability index was used to assess the quality of life among adolescents who had acne. The prevalence of facial acne among adolescents was 67.5% (n = 276). Facial acne increased with increasing age (p = 0.0001). It was more common in males (71.1%) than females (64.6%), p = 0.165. the males also had a higher prevalence of severe acne (p = 0.0001). the quality of life was affected by the severity of acne, (Hanisah, 2000)

A cross sectional study was conducted on 600 participants by means of a questionnaire, the questionnaire consisted of questions about acne, general health questionnaire and Rosenberg self esteem scale. Five hundred and sixty three questionnaires out of 600 were answered and 550 adolescents who gave permission for examination were evaluated. The study population consisted of 303 girls and 260 boys between the ages 13 and 19, and the mean age was 15.24+/- 1.05 years. Acne prevalence was 63.6% with 29.2% non-inflammatory and 34.4% inflammatory acne, (Jessica, 2002)

Adolescent acne is typically the result of clogged, infected, pilo-sebaceous follicles. Adults may experience fewer comedones and more inflammatory lesions. Normally, sebum travels up the follicle to the skin surface. Hormones may increase sebum production and cause follicular cells to hyper proliferate and block the follicular opening, forming a comedo. Complete follicle blockage results in closed comedones (i.e. “whiteheads”), whereas incomplete blockage results in open comedones (“blackheads”). Comedo formation typically occurs over the course of 2–3 weeks. Acne may manifest in the form of non-inflammatory comedones, superficial inflammatory lesions (papules, pustules), and/or deeper inflammatory lesions (nodules, cysts). Inflammatory lesion formation occurs most commonly when Propionibacterium acnes colonizes the pilo-sebaceous unit, triggering follicular rupture and a neutrophil cascade. Rarely, acne may have nonbacterial causes, (Hoffmann, 2000)

Acne vulgaris is a chronic inflammatory disease of the pilo sebaceous units. It is believed to be the most common disease of the skin. The condition usually starts in adolescence, peaks at the ages of 14 to 19 years and frequently resolves by mid-twenties. Acne vulgaris develops earlier in females than in males, which may reflect the earlier onset of puberty in females. The most severe forms of acne vulgaris occur more frequently in males, but the disease tends to be more persistent in females. Lesion counting are useful in assessing the severity of acne vulgaris. Although very common, the disease can cause significant emotional distress and physical scarring if left untreated. (Baldwin, 2002)

Acne vulgaris is often referred to as a physiological condition. Research has shown that 85% of young people between the ages of 12 and 24 years have acne, and while it is most common in teenagers, acne affects 8% of adults aged 25 to 34 years and 3% of adults aged 35 to 44 years. Acne in young adults may represent continuation of adolescent acne or development of late-onset disease. Acne is more common in girls than boys during adolescence, but the incidence is higher in women during adulthood. Nodulocystic acne has an increased prevalence in white people compared to black people. Prevalence varies greatly across the world, with Western modernised civilisations demonstrating much higher rates of acne, whereas some non-industrialised societies report no cases of acne. Acne vulgaris affects 40 to 50 million people annually in the US,(Gurklis, 2005)

Adolescent acne is a common, chronic and self-limiting skin disease that is associated with physical and psychological morbidity in up to 90 percent of adolescents and young adults. In Western countries, acne affects all ages, but its maximum prevalence peaks at 16-18 years when 75-98 percent of this age group is affected. Acne is more common in girls, both overall and below the age 12 years, (Catherine Berk, 2006)

In pediatric populations, the prevalence of acne increases with age. In 10- to 12-year-old children, 28% to 61% of the population has clinically diagnosed acne, whereas 79% to 95% of 16- to 18-year-old adolescents are affected.Even a significant percentage of children (aged 4-7 years) are diagnosed with acne. Thus in the Western world, acne is a skin disease affecting primarily adolescents but also a significant portion of adults older than 25 years, (Cunliffe and Gould, 2006)

Nobody is completely sure what causes acne. Experts believe the primary cause is a rise in androgen levels – androgen levels rise when a human becomes an adolescent. Rising of androgen levels make the oil glands under your skin grow; the enlarged gland produces more oil. Excessive sebum causes bacteria to grow, (Walton, 2005)

Several factors contribute to the development of acne. The problem is the abnormal development of cells inside the hair follicle, leading to the formation of a plug or blackhead. Some of the causes of acne are hormonal, genetic, psychological, infectious and diet. The hormonal activity such as menstrual cycles and puberty, may contribute to the formation of acne. Stress has the connection in developing of acne, high glycemic diet is associated with worsening acne. There is a positive association between the consumption of milk and a greater rate and severity of acne, (Bechelli, 2008)

Mud, which contains organic and mineral ingredients, has been used in the treatment of several degenerative diseases. It has been proposed that beneficial effects of mud are not only related to its local thermal effects, but also to its chemical components. The chemical analysis of mud does not only reveal hydrophilic organic substances, such as humic, fulmic, and ulmic acids, but also organic substances composed of fatty acids, (Rajiv Rastogi, 2010)

Mud packs and mud baths are best and popular forms of mud therapy. Mud therapy is very simple and cost effective and efficacious treatment in naturopathy. The mud used for treatment should be clean and taken from 122 to 153cm depth from the surface of the ground. It should be free from contamination of stones pieces and chemical manures. Before using it should be powdered and sieved from stones, grass and other impurities. Mud dilutes the toxic substances of body and ultimately eliminates them from the body, (Petrecia, 2000)

NEED FOR THE STUDY:

Nearly 85% of all teenagers will suffer from acne outbreak between the ages of 12 and 24. Additionally, 25% of those will develop deep permanent scarring as a result of their acne and 25% of adults suffer from active acne, 60 million Americans are currently experiencing active acne, 20 million Americans are likely to suffer from acne scars and at most and only 11% of acne suffers ever seek treatment. (The American Dermatologists association, 2000)

Smith, (2009), Conducted a study to evaluate the effects of mud pack therapy on acne for the age group of 14 – 24 years. The study included 23 patients who were diagnosed as having acne vulgaris according to Global acne grading system criteria and had complaints lasting for more than three months, All the patients had mild to moderate acne severity. Twelve patients (10males, 13females; mean age of 14 – 24 years) received mud pack therapy on acne and applied for 30 minutes daily for a total of 12 weekdays. The study revealed that mud pack therapy is a cosmetic and cost effective treatment for patients with acne.

Application of mud packs for 20min on face and washed gently with cold water, which helps in improving the skin complexion and removes acne. It also opens the skin pores which in turn facilitates the elimination process. Mud application on face helps in elimination of dark circles around the eyes, (Suarez, 2002)

70 to 90% of teen never sought medical advice for their acne in response to embarrassment and ignorance so the researcher felt mud therapy can be the best choice of treatment for effective enough to treat acne.

STATEMENT OF PROBLEM:

“Effectiveness of mud therapy on acne vulgaris among adolescent girls at selected schools, Nandigama, Andhra Pradesh, India”

Objectives

1. To compare the effectiveness of mud therapy on acne vulgaris among adolescent girls in control and experimental group before and after mud therapy.

Operational Definitions

Mud Therapy

Refers to application of refined and purified mud (red soil/black soil) which is taken from 3-4 feet depth from the surface of the ground.

Steps in mud therapy for an individual:

Step 1: Clean the face with tap water

Step 2: Take 5 tablespoons of mud powder in a bowl, and 15 ml of water

Step 2: Make a paste of mud with water

Step 3: The thickness of the paste should be ½ inch

Step 4: Apply mud paste to the face for 45minutes.

Step 5: After 45minutes wash the face with tap water.

Note: This is to be applied once a day for 30days.

Acne vulgaris

Refers to multiple lesions such as whiteheads, blackheads, papules, pustules and nodules which are seen in the face and is assessed by using Global Assessment Acne Rating Scale.

Adolescent girls

Adolescent girls with acne aged between 12 – 17 years

Hypotheses

H₁: There is a significant effectiveness of mud therapy on acne vulgaris among adolescent girls in experimental group than control group.

Delimitation

This study was delimited to,

Ø Assess the effectiveness of mud therapy

Ø Identify changes in acne vulgaris

Ø Adolescent girls

Ø At Zilla Parishad High School, Nandigama, Andhra Pradesh

Ø At Mahatma Gandhi High school, Nandigama, Andhra Pradesh

RESEARCH METHODOLOGY:

Research Design:

Quasi experimental design where one group pre and posttest with control group design was selected to evaluate the effectiveness of mud therapy on acne vulgaris among adolescent girls.

Setting of the study

1. The setting for experimental group was Zilla Parishad High School, Nandigama at Andhra Pradesh.

2. The setting for control group was Mahatma Gandhi High School, Nandigama, at Andhra Pradesh.

Variables

Independent Variable - Mud therapy

Dependent Variable - Acne vulgaris.

Population - Adolescent girls with acne vulgaris present during the period of data collection.

Sample - Adolescent girls with acne vulgaris who are studying in Zilla Parishad High School and Mahatma Gandhi High School, Nandigama, at Andhra Pradesh.

Sample Size - The total sample size was 30 adolescent girls, out of which 15 were control group and 15 were experimental group.

Sampling Technique

Convenient sampling technique was used to select adolescent girls with acne vulgaris are during the period of data collection.

SAMPLING CRITERIA

Inclusion Criteria

Adolescent girls with

1. Age between 12 – 17 years.

2. Non-inflammatory lesions and Inflammatory lesions with papules, pustules and nodulo-cystic lesions present in the face

3. Who are residing in hostel

4. Who have given consent to participate in this study

5. Who are present during the period of data collection

Exclusion Criteria

Adolescent girls with

1. Severe skin infections

2. Contagious skin disease

3. Allergies of mud

4. Those who are using pharmacological treatment

DEVELOPMENT OF THE TOOL

This consists of Global acne assessment scale, which was given by American Academy of Dermatology in March 1990. This tool is useful to assess the acne vulgaris, which consist of 0-5 score.

DATA ANALYSIS AND INTERPRETATION

Table.1. Frequency and percentage distribution of the control group pre and posttest scores of adolescent girls with acne vulgaris. (N₁ = 15)

Level of lesions	Control Group
	Pretest scores		Posttest scores
	F	Percentage (%)	F	Percentage (%)
No lesions	-	-	-	-
Non-inflammatory lesions	9	60	10	67
Inflammatory lesions	6	40	5	33

Frequency and percentage distribution of control group pretest and posttest scores of adolescent girls with acne vulgaris depicts that, in pretest 60% of them had non-inflammatory level of lesion and 40% of them had inflammatory lesion, whereas in posttest 67%of them had non-inflammatory lesion, and 33% of them had inflammatory lesions of acne vulgaris. It seems that without intervention there is no obvious change in the level of lesions among adolescent girls with acne vulgaris.

Table-.4. Paired ‘t’test and Unpaired ‘t’test experimental and control group

Adolescent girls	“t” test				Level of significant
	Paired ‘t’ test value		Unpaired ‘t’test value
	CV	TV	CV	TV
Control group	1.14	2.145			P > 0.05 Not significant
Experimental group	6.65	2.145	5.5	2.05	P < 0.05 significant
Control group and experimental group posttest	-	-			P < 0.05 significant

Table.5. Comparison of mean, SD, and mean percentage of control group and experimental group

Adolescent girls	Maximum scores	Pretest scores			Posttest scores			Difference in mean %
Adolescent girls	Maximum scores	Mean	SD	Mean %	Mean	SD	Mean %	Difference in mean %
Control group	5	3.2	0.7	64	3.2	0.7	64	0
Experimental group	5	2.8	1.06	56	2.1	0.8	42	14
Difference in mean percentage of control and experimental group post test scores - 22

Fig.4. Cone diagram shows the mean percentage of acne vulgaris among adolescent girls in control group and experimental group.

Unpaired ‘t’ test was calculated to analyze the effectiveness between experimental and control group posttest scores on mud therapy among adolescent girls. Unpaired ‘t’ test value was 5.5, when compared to table value 2.05 is high. It seems that there is significant effectiveness between mud therapy on acne vulgaris among adolescent girls.

Comparison of mean, SD, and mean percentage of control group pre and post test scores reveals that, the overall mean percentage of pretest was 64% whereas in posttest it was 64% revealing a difference of 0%. It depicts that without mud therapy there were no changes in lesions on acne vulgaris among adolescent girls.

Comparison of mean, SD, and mean percentage of experimental group pre and post test scores reveals that, the overall mean percentage of score for pretest was 56%, whereas in posttest it was 42% revealing a difference of 14%. It depicts that mud therapy on acne vulgaris was effective among adolescent girls.

Comparison of mean, SD, mean percentage of post test scores of both control and experimental groups depicts that, the overall mean percentage of score in control group was 64%, whereas in experimental group it was 42% revealing a difference of 22%. It depicts that the mud therapy on acne vulgaris was effective among adolescent girls.

SUMMARY:

¨ Paired ‘t’ test value was 1.14, (P > 0.05, Not significant) in control group whereas in experimental group was 6.65, (P < 0.05, significant)

¨ Mean Pre test score was 3.2 ± 0.7, which is 64% in control group whereas in experimental group was 2.8 ± 1.06, which is 56%.

¨ Mean Post test score was 3.2 ± 0.7, which is 64% in control group whereas in experimental group was 2.1 ± 0.8, which is 42%.

¨ The unpaired ‘t’ test value was 5.5, (P < 0.05, significant) and the mean difference was 22%

CONCLUSION:

From the findings of the study it can be concluded that,

v There was moderate effectiveness of mud therapy on acne vulgaris among adolescent girls in experimental group than control group.

NURSING IMPLICATIONS:

Nursing Services

1. The nursing personnel working in hospital can reinforce the health benefits of mud therapy.

2. Mud therapy can be used by nursing persons

3. Mud therapy can be used for hormone induced acne vulgaris for patient with Poly cystic ovarian disease

4. Nurse can recommend mud therapy for patient with oily skin

Nursing Education

1. Nurse educator should educate the students regarding mud therapy and its implementation.

2. Nurse educator should educate the Nursing personnel about the mud therapy among adolescents with acne vulgaris and find out the effectiveness.

3. Nurse educator should provide health education regarding the usage and benefits of mud therapy in community area.

Nursing Administration

1. Nurse administrator can organize an in-service program on mud therapy and its uses in various health aspects.

2. Nurse administrator can support the Nurses for conducting research on acne vulgaris.

Nursing Research

Ø This study may be issued for further references.

Ø Further large scale study can be done as replication to standardize the mud therapy on acne vulgaris.

RECOMMENDATIONS:

Based on the findings of the study the following recommendations have been made for the study.

· A large scale study can be conducted with large samples to generalize the findings

· A similar study can be conducted in both the gender

· A similar study can be conducted to test the effectiveness of mud therapy on all vulnerable groups

· A similar study can be compared with other alternative therapies like laser, homeopathy, ayurveda

· A similar study can be conducted in various settings like community and industrial area

· A study can be conducted with true experimental research design

· Effectiveness of mud therapy can be tested in constipation, headache due to tension, osteoarthritis, gynaecological conditions (inflammatory and menstrual disorders).

REFERENCES:

1. www.ncbi.nlm.nih.gov/pubmed

2. www.Urbanchildinstitute.org

3. www.nichd.nih.org

4. www.medscape.com

5. www.ncbi.nim.nih.org

6. www.nursingcenter.com

7. www.alternativetherapies.com

8. www.youtube.com

9. www.Content.Karger.Com/Produkte

10. www.nichd.nih.gov/cochrane_data

Received on 11.09.2014 Modified on 24.09.2014

Int. J. Nur. Edu. and Research 3(1): Jan.-March, 2015; Page 13-19

DOI: