effectiveness of acupressure in relieving pain and distress

EFFECTIVENESS OF ACUPRESSURE IN RELIEVING PAIN AND DISTRESS

RELATED TO DYSMENORRHEA AMONG ADOLESCENT GIRLS IN

SELECTED SCHOOLS AT KANYAKUMARI DISTRICT.

THESIS

Submitted to

THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY, CHENNAI

for the award of the degree of

DOCTOR OF PHILOSOPHY

IN

NURSING

By

Prof. SANTHI LETHA, M.Sc.N., M.A.(Socio).,

JANUARY 2017

DHARSAN

Placed Image




THESIS

Submitted to

THE TAMILNADUDR.M.G.RMEDICALUNIVERSITY, CHENNAI



IN

NURSING

By

Prof. SANTHI LETHA, M.Sc.(N)., M.A.(Socio).,

Under the Guidance of

Dr.LATHA VENKATESAN, M.Sc (N).,M.Phil., Ph.D (N)., M.B.A.,

PRINCIPAL & Ph.D RESEARCH GUIDE

APOLLO COLLEGE OF NURSING

CHENNAI-600 095

JANUARY 2017

DHARSAN

Placed Image




THESIS

Submitted to




IN

NURSING

By


Guided By

Dr. LATHA VENKATESAN, M.Sc.(N).,M.Phil. (N).,Ph.D.(N)., M.B.A.

PRINCIPAL & Ph.D.RESEARCH GUIDE

APOLLO COLLEGE OF NURSING,

CHENNAI-600 095

JANUARY 2017

DHARSAN

Placed Image

CERTIFICATE - I

This is to certify that the thesis entitled “EFFECTIVENESS OF

ACUPRESSURE IN RELIEVING PAIN AND DISTRESS RELATED TO

DYSMENORRHEA AMONG ADOLESCENT GIRLS IN SELECTED

SCHOOLS AT KANYAKUMARI DISTRICT.” submitted by Prof. SANTHI

LETHA for the award of the degree of Doctor of Philosophy in nursing, is a bonafide

record of research done by her during the period of study, under my supervision and

guidance and that it has not formed the basis for the award of any other Degree,

Diploma, Associateship, Fellowship or other similar title. I also certify that this thesis

is her original independent work. I recommend that this thesis should be placed before

the examiners for their consideration for the award of Ph.D. Degree in Nursing.

Research Guide

Dr. LATHA VENKATESAN, M.Sc(N)., M.Phil., Ph.D.,M.B.A.,

Principal & Ph.D Research Guide

Apollo College of Nursing

Vanagaram to Ambattur Road

Ayanambakkam

Chennai – 600 095

Place :

Date :

CERTIFICATE - II

This is to certify that this thesis work titled “A study to assess the

Effectiveness of Acupressure in relieving pain and distress related to

dysmenorrhea among adolescent girls in selected schools at Kanyakumari

district” of the candidate Prof. Santhi Letha with Registration Number 141320008

for the award of Ph.D in Nursing in the branch of Obstetrics & Gynaecology Nursing.

I personally verified the urkund.com website for the purpose of plagiarism check.

I found that the uploaded thesis file contains from Introduction to Conclusion pages

and result shows 9 % percentage of plagiarism in the thesis.





Ayanambakkam,

Chennai – 600 095

Place :

Date :

DECLARATION

I hereby declare that the thesis entitled “EFFECTIVENESS OF

ACUPRESSURE IN RELIEVING PAIN AND DISTRESS RELATED TO

DYSMENORRHEA AMONG ADOLESCENT GIRLS IN SELECTED

SCHOOLS AT KANYAKUMARI DISTRICT.” is my own work carried out under

the guideship of Dr. LATHA VENKATESAN, M.Sc.(N).,M.Phil(N)., Ph.D(N).,

M.B.A., principal and Research Guide, Apollo College of Nursing , Chennai

which is approved by the Research Committee, The Tamil Nadu Dr. M.G.R

Medical University, Guindy, Chennai.

I further declare that to the best of my knowledge the thesis does not

contain any part of any work which has been submitted for the award of any

degree either in this University or in any other University / Deemed University

without proper citation.

PROF. SANTHI LETHA

RESEARCH SCHOLAR

Place :

Date :

ACKNOWLEDGEMENT

My heartfelt praises to God Almighty for his enriched blessings and abundant

grace and mercy which encircled me through every step of this work and convert this

work into reality and without whom it would not have been possible. I thank him

exceedingly for giving me the required courage from the beginning till the end.

I have been fortunate in having received the cooperation and guidance of

many people in completing this research. I consider it a privilege to acknowledge here

the help and guidance extended by each one of them.

I acknowledge The Tamil Nadu Dr.M.G.R.Medical University.Chennai,for

providing a tremendous change for professional growth and development . I express

my sincere thanks and heartfelt gratitude to the past and present Vice Chancellor,

Registrar and Academic Officer of The Tamil Nadu. Dr. M.G. Medical University,

Guindy Chennai for providing this prospect to pursue my doctoral degree in this

esteemed university and for being the source of support throughout the period of

study.

I am extremely grateful to the management of Sree Mookambika Institute of

Medical Science and hospital, Kulasekharam for the fathomless opportunities they

provide for professional growth and development, in the quest makes a difference in

today’s health care scenario. I am obliged to thank Dr.C.K.Velayudan Nair .M.S.

Chairman, Dr.Rema V.Nair M.D,D.G.O, Director, Trustees

Dr.R.V. Mookambika, M.D,D.M,(Nephrology) and Dr.Vinu Gopinath,M.S,Mch

(Urology) of Sree Mookambika Institute of Medical Science for their encouragement

and for providing me an opportunity to work as a principal in this prestigious

institution which opened the door by starting the first nursing postgraduate programe

in Kanyakumari district for further Nurse Researcher to serve people.

It is my proud privilege to express my heartfelt sincere gratitude to an

enigmatic leader, decisiveness, radiant and vivacious personality, my guide

Dr.Latha Venkatesan M.sc (N), M.Phil, Ph.D (N), M.B.A, Principal Apollo

College of nursing Chennai. Her insightful comments and encouragements innovative

ideas, right direction, brain storming suggestion and affectionate enduring support,

constructive and critical scholarly guidance in each and every step of this study,

which could make the study possible and purposeful, This holds me strong in all

places I flattered and these all kept me working towards the completion of this

successful dissertation. I offer my hearty thanks to her in making my dreams come

true.

I extend my sincere thanks to Mr.J.S.Prasad M.B.A. Administrative officer

of Sree Mookambika Institute of Medical Science for his constant support and help

throughout the study period.

I am grateful to Dr. Suseela M.sc (N), Ph.D (N), Principal, Billroth College of

nursing, Chennai. For her valuable suggestions and support for this dissertation.

I am extremely grateful to Dr. Sujin Herbert BNYS, M.Phil (Psy), M.B.A

(HM), Ph.D (Psy). Assistant Medical Officer, Gov’t Head quarters Hospital,

Padmanabhapuram, for spending his valuable time to train Acupressure therapy.

Unwavering encouragement, invariable help, insisting support and suggestions for

this dissertation,

My grateful thanks to Prof. P.Arumugam, B.Sc: M.P.S; P.G.D.C.A; Professor

of Biostatistics, Sri Muthukumaran Medical College & R I, Chennai, for rendering

support in statistical analysis. The timely corrections and guidance has motivated me

to make this study a reality.

I express my sincere thanks to Mr.S.Siva Kumar and Mr.B.Gopinath

librarians of Apollo College of Nursing Chennai, for extending support during the

study period.

My whole hearted thanks to Dr.Vijayalakshmi , Prof and Head,

Mental Health Nursing, Mrs.Shobana Gangadharan, Prof and Head,

Community Health Nursing, Mrs.Lizy Sonia, Vice Principal, Mrs.Jaslina

Gnanarani, of Apollo College of nursing Chennai, for their motivation,

encouragement and support in successful completion of this research work. I also

extend my thanks to all the faculty members, office Superintendent Mr.R.Kannan,

office and administrative staffs of Apollo College of Nursing for their constant

support and help during the course of study.

I express my sincere thanks to the Ethical Committee of Apollo College of

nursing for their valuable suggestion and approval for the study being conducted.

I extend my sincere thanks to Dr.Suguna, Mrs. Suja, Mrs.Nisha, and all the

faculty members of Sree Mookambika College of nursing for their motivation,

encouragement and immense support given throughout the research work.

I am grateful to Mr.Mohandas M.A,Med the head master of Yettacode

higher secondary school and Sist. Suganthi M.A.Med the head mistress of Ursula’s

higher secondary school – kulasekharam for their extreme permission to conduct the

study successfully.

I take this opportunity to express my gratitude to Mr.Selvaraj,

M.A,Med,Ph.D for the valuable effort in editing this manuscript.

I wish to express my thanks to all participants who enthusiastically

participated and provided the valuable data in this study on Yettacode higher

secondary school, and Ursula’s higher secondary school Kulasekharam at

Kanyakumari district.

My special thanks to all the Subject Experts who spent their valuable time for

validating my tool. Their valuable suggestions and constructive criticism helped me to

complete this study successfully. My sincere thanks to Mr. Sateessh Good Morning

Computers and Darsan offset printers for their co operation in giving technical

support and final shape to the study

I extend my hearty thanks to my beloved parents, husband Mr. Joseph

Prabhu, my son V.S. Joel frank, II yr MBBS and all my family members for their

invaluable sacrifice, support, encouragement and constant prayer during the period of

my thesis work.

A special bouquet of thanks to all my lovable friends who have helped me a

lot to complete the study.

Date: Signature of the candidate

Place: Santhi Letha

ABSTRACT

A study to assess the effectiveness of acupressure in relieving pain and

distress related to dysmenorrhea among adolescent girls in selected schools at

Kanyakumari district. The present study is conducted to make out the impact of

acupressure on primary dysmenorrhea among adolescent girls.

The Objectives of the Study were

1. To assess the level of pain and distress related to dysmenorrhea before and after

acupressure in control and experimental group of adolescent girls.

2. To assess the effectiveness of acupressure in relieving pain and distress related to

dysmenorrhea among control and experimental group of adolescent girls.

3. To determine the level of satisfaction regarding acupressure among experimental

group of adolescent girls

4. To find out the relationship between pain and distress related to dysmenorrhea among

control and experimental group of adolescent girls before and after acupressure.

5. To find out the association between pain and distress related to dysmenorrhea with

selected socio demographic variables among control and experimental group of

adolescent girls.


selected menstrual variables among control and experimental group of adolescent

girls.

Methods

The conceptual framework of the present study was developed based on the

Roy’s adaptation model. The major study variables in the study were pain and distress

related to dysmenorrhea among adolescent girls in various dimensions before and

after the implementation of acupressure therapy. Acupressure therapy is the therapy

which facilitates circulation release muscle tension, and allows eventually flow of

energy. Also it promotes the release of endorphins, which blocks the pain receptor to

the brain. Thus it dilates the cervix and increases the efficiency of contraction.

An acupressure point stimulates various sensory receptors which in turn stimulate

nerves that transmit impulse to the brain. Brain release the body’s natural pain killing

hormones (Neurotransmitters and endorphins). Endorphin plays a vital role in the

functioning of hormonal system. By applying finger pressure, dispatches signal to

spinal cord, mid brain and the pituitary axis, which results in release of substance such

as enkephalin, dynorphin, serotonin, norepinephrine and beta endorphins into blood

stream and cerebrospinal fluid thus alleviating pain.

The data were collected from 260 adolescent girls who were randomly assigned

to control and experimental group. The pre test pain and distress related to

dysmenorrhea was assessed on the first second and third day of menstruation..

The post test 1 and 2 was done following two menstrual cycle after pre test for first

three days of menstruation after acupressure. Acupressure was implemented only for

the experimental group of adolescent girls for first 3 days of menstruation twice a day

for 20 minutes and the level of satisfaction of intervention, were assessed after

administration of acupressure.

The tools used for data collection were socio demographic variables performa,

menstrual variable performa, visual analog scale for pain and modified MMDQ.

Rating scale for the level of satisfaction of intervention .Validity and reliability were

established for the tools developed by the researcher. Pilot study was conducted with

26 adolescent girls.

The main study data were collected from 130 adolescent girls in control group

and 130 adolescent girls in experimental group were analyzed based on the objectives

and hypothesis of the study. The analysis of data was done through an integrated

system of computer programe known as statistical package for social science (SPSS-

20). The major findings of the study were as follows.

Major Findings

SSoocciioo DDeemmooggrraapphhiicc VVaarriiaabblleess ooff AAddoolleesscceenntt GGiirrllss

Majority of the adolescent girls were in the age group of 16-17 yrs

(62.3%, 60.8%), studying in 11th std (63.1%, 60.8%) belongs to Christian religion

(64.6%, 57.7%), living in urban area (50.8%, 54.6%) in joint families (74.6%, 58.5%)

non vegetarians (73.1%, 78.5%) and food craving for sweets (54.6 %,) in control

group and for salt (56.9%) in experimental group of adolescent girls respectively.

Most of the mothers of adolescent girls are educated up to collegiate level

(40.8%, 42.3%) in control and experimental group respectively. mothers’ occupation

al status of adolescent girls as home makers (43.9%) in control group and private

employees (35.4%) in experimental group. family monthly income of half of the

adolescent girls was Rs 20000 to 40000 in control group (50%) and Rs < 20000 in

experimental group (40.7%).

Menstrual Variables of Adolescent Girls

Majority of the adolescent girls have attained their menarche at the age of

10-12 yrs (53.8%, 56.9%), with onset of menstrual pain during menstruation (57.69%,

60.0%),with first line family history of dysmenorrhea (81.5%, 75.4%) and not taking

any treatment for dysmenorrhea (76.9%, 71.5%) in control and experimental group of

adolescent girls respectively.

The frequency of menstrual cycle was 28-35 days (49.2%, 63.1%) in control

and experimental group respectively .The adolescent girls in control and experimental

group had moderate menstrual flow (50.0%, 44.6%) and a majority of the adolescent

girls had 4-6 days of menstrual flow (59.2%, 70.8%) in control and experimental

group respectively.

Pain and Distress related to Dysmenorrhea before Acupressure

In the present study, pre test pain related to dysmenorrhea was severe on first

day (60.0%, 60.8%) in comparison with moderate level of pain on second day

(55.4%,50.0%) and third day (83.8%,85.4%) respectively in both control and

experimental; group of adolescent girls.Pre test distress related to dysmenorrhea was

severe on first day (94.6%,96.2%) in comparison with moderate level of distress

during second day (15.4%,19.2%) and third day (28.58%,20.8%) respectively in both

control and experimental; group of adolescent girls.

Pain Related to Dysmenorrhea among Adolescent Girls before and after

Acupressure

In the current study, pain related to dysmenorrhea on the first day of menstrual

cycle in pre test (60.0%) and post test1 (60.8%) post test 2 (64.6%) remained the same

at severe level of pain among the control group of adolescent girls. Whereas among

the experimental group of adolescent girls in pre test 60.8% had severe level of pain

on the first day and after the intervention of acupressure a majority of them had only

moderate level of pain on the first day of post test 1 (64.7%) and post test 2 (60.8%)

respectively.

The pain related to dysmenorrhea on the second day of menstrual cycle in pre

test (55.4%) and post test 1 (64.6%) and post test 2 (59.2%) remained the same at

moderate level of pain among the control group of adolescent girls. Whereas it can be

observed in table 7 that 48.5% of experimental group of adolescent girls had severe

pain in the pre test done on second day and among the same adolescents after the

intervention of acupressure none of them experienced severe level of pain on second

day in post test 1 and post test 2.They had only mild level of pain on second day in

post test 1 (59.2%) and post test 2 (76.2%).

The pain related to dysmenorrhea on the third day of menstrual cycle in pre

test (83.8%) and post test1 (73.1%) post test 2 (73.1%) remained the same at


noted that 83.8% of experimental group of adolescent girls had moderate pain in the

pre test done on third day and the same adolescents after the intervention of

acupressure none of them experienced severe level of pain on third day in post test 1

and post test 2.They had only mild level of pain on third day in post test 1 (80.0%)

and post test 2 (51.5%) and 47.7% of the adolescents reported no pain in post test 2.

Distress Related to Dysmenorrhea among Adolescent Girls before and after

Acupressure

In the present study shows that the distress related dysmenorrhea on the first

day of menstrual cycle in pre test (94.6%) and post test 1 (87.6%) and post test 2

(88.5%) remained the same at severe level of distress among the control group of

adolescent girls . Whereas it can be observed in table (8) 96.2% of experimental group

of adolescent girls had severe distress in the pre test done on first day and the same

adolescents after the intervention of acupressure none of them experienced severe

level of distress on first day in post test 1 and post test 2.They had moderate and mild

level of distress on first day in post test 1 (75.4%) and post test 2 (70.0%).

The distress related to dysmenorrhea on the second day of menstrual cycle in

pre test (84.6%) and post test1 (81.5%) post test 2 (60.8%) remained the same at

severe level of distress among the control group of adolescent girls. Among the

experimental group majority of the adolescent girls in pre test 80.8% had severe level

of distress on the second day and the same adolescents after the intervention of

acupressure none of them experienced severe level of distress on second day in post

test 1and post test 2. They had only mild level of distress on second day in post test 1

(59.2%) and post test 2 (76.2%) respectively.

In the current study distress related to dysmenorrhea on the third day of

menstrual cycle in pre test (71.5%) and post test1 (50.0%) post test 2 (69.2%)

remained the same at moderate level of distress among the control group of

adolescent girls. Whereas it can be noted that 79.2% of experimental group of

adolescent girls had severe level of distress in the pre test done on third day and the

same adolescents after the intervention of acupressure none of them experienced

severe level of distress on third day in post test 1 and post test 2.They had only mild

level of distress on third day in post test 1 (64.6%) and post test 2 (98.5%).

Level of Satisfaction of Acupressure among Experimental group of Adolescent

girls

All the participants were highly satisfied about acupressure among

experimental group of adolescent girls. None of them were in the category of

dissatisfied and satisfied.

Effectiveness of Acupressure on Pain Related to Dysmenorrhea among

adolescent Girls

In the present study, on the first day of menstruation there was no significant

difference between mean and standard deviation of pre test (M=7.1, SD= 1.7) and

post test 1 (M=7.3, SD=1.2) and post test 2 (M=7.4, SD=1.2) level of pain related to

dysmenorrhea among the control group of adolescent girls (χ2 = 1.290,P>0.05 ).

Whereas the experimental group of adolescent girls there was a significant difference

(χ2=241.179, P<0.001) between the mean, standard deviation of pain related to

dysmenorrhea on first day in pre test (M=7.1, SD=1.7) and post test 1 (M=5.0,

SD=1.5) and post test 2 (M=4.0, SD=1.3). The result can be attributed to the

effectiveness of acupressure upon reducing pain related to dysmenorrhea. Hence the

Null hypothesis Ho1 there will be no significant difference in the effect of

acupressure on pain related to dysmenorrhea was rejected.

In control group on the second day of menstruation there was no significant

difference between pre test (M=6.4, SD=1.6), post test 1 (M=6.2, SD=0.8) and post

test 2 (M=6.3, SD=1.0) level of pain related to dysmenorrhea among adolescents

(χ2=3.211,P.>0.05). Whereas in experimental group there was a significant difference

(χ2=238.381, P<0.001) between the mean and standard deviation of pain related to

dysmenorrhea on second day in the pre test (M=6.4, SD=1.3) post test 1 (M=3.2,

SD=1.4) and post test 2 (M=2.3, SD=1.3) i.e. There was a significant reduction of

pain in post test 1and post test 2, while comparing the pre test in experimental group.

It can be attributed to the effectiveness of acupressure on pain related to

dysmenorrhea. Hence the Null hypothesis Ho1 there will be no significant difference

in the effect of acupressure on pain related to dysmenorrhea was rejected.

In the present study on the third day of menstruation there was significant

difference between the mean and standard deviation of pre test (M=5.2, SD= 1.2) and


dysmenorrhea among the control group of adolescent girls (χ2 = 33.475, P<0.001).

Whereas it can be noted that among the experimental group of adolescent girls there

was a significant difference (χ2=242.540, P<0.001) between the mean, standard

deviation of pain related to dysmenorrhea first day pre test (M=5.3, SD=1.2) and post

test 1 (M=1.6, SD=1.1) and post test 2 (M=0.7, SD=0.8).

There is significant difference between pre test , post test 1 and post test 2

within the groups in control and experimental group of adolescent girls (p<0.001).

Significant reduction of pain even in control group may be due to physiological and

psychological changes of dysmenorrhea on third day of menstruation.

The two groups control and experimental were compared between them in

pre- test, post-test1 and post- test2. According to the Kruskal Wallish test, the

calculated table value was 0.128. In the pre- test both the groups have not differed

statistically significantly (P>0.05). But in Post- test 1 and post test -2, the calculated

values were 174.303 and 195.945 which is higher than the table values, the two

groups were statistically very highly significantly differed between them with the

effect of acupressure (P<0.001). Hence this shows that the acupressure was effective

in reducing menstrual pain among experimental adolescent girls on third day of

menstruation.

Effectiveness of Acupressure on Distress Related to Dysmenorrhea among

Adolescent Girls

In the present study the test in different levels of control group on the first day

of distress. The mean distress score on the pre- test was M= 65.8, SD= 4.4 and post-

test 1 was M = 64.2, SD = 4.3. The mean distress score of post-test 1 and post- test 2

were M = 64.2, SD = 4.3 and M = 63.4, SD = 3.7. The mean distress score of pre-test

through post- test 2 were M = 65.8, SD = 4.4 and M = 63.4, SD = 3.7. The paired “t”

test value of 3.167 (p<0.01), 2.013 (p< 0.05) and 5.706 (p<0.001) were observed

respectively. Hence it is concluded that the level of distress related to dysmenorrhea

among adolescent girls in control group on the first day of menstruation during pre

test, post test 1 and post test 2 was significant at various levels

The effectiveness of acupressure in different levels within experimental group

on the first day distress. The mean distresses score on pre- test to post- test 1 was

M= 66.4, SD = 4.4 and M= 34.6, SD = 6.2, post-test 1 to post test 2 was M = 34.6,

SD = 6.3 and M = 26.3, SD = 5.5 and pre-test to post- test 2 was M= 66.4, SD = 4.4

and M = 26. 3 SD = 5.4. The paired ‘t’ test value of 85.230, 22.522, 97.937 were

significant at (p<0.001). Hence it is concluded that the acupressure is very highly

effective in reducing distress related to dysmenorrhea among adolescent girls.

The three levels of test namely pre-test to post- test1, post- test1 to post- test2

and pre test to post-test2 were compared between the two groups on first day distress.

The difference between the two group’s mean score were M =1.6, SD= 5.8 and

M =31.8, SD = 4.2, M= 0.9, SD = 4.8 and M= 8.3, SD = 4.2, M = 2.5, SD = 4.8 and

M = 40.1, SD = 4.7.The paired ‘t’ test value of 48.696, 13.258, 63.819 were

significant at (p<0.001). Hence it was concluded that the acupressure is found to be

very highly effective in reducing distress related to dysmenorrhea among adolescent

girls. It can be attributed to the effectiveness of acupressure on distress related to



In the current study, the test in different levels of second day distress among

the control group of adolescent girls. The mean distress score on the pre- test was

M= 63.9, SD = 5.0 and post-test 1 was M= 62.0, SD = 4.0. The mean distress score of

Post-test 1 and Post- test 2 were M = 62.0, SD = 4.0 and M = 59.7, SD = 4.3. The

mean distress score of pre-test through post- test 2 were M= 63.9, SD = 5.0 and

M= 59.7, SD= 4.3. The paired‘t’ test values were of 3.538 (p<0.01), 5.401 (p< 0.001)

and 7.943 (p<0.001) respectively. Hence it was concluded that the level of distress

related to dysmenorrhea among adolescent girls in control group on the second day

was significant at various levels.


of adolescents on the second day distress. The mean distress score on Pre- test to Post-

test 1 was M= 64.7, SD = 5.2 and M = 30.5, SD = 6.0, Post-test 1 to Post test 2 was M

= 30.5, SD = 6.0 and M = 23.2, SD = 5.1, Pre-test to Post- test 2 was M= 64.7,

SD = 5.2 and M = 23.2, SD = 5.1. The Paired ‘t’ test value of 85.928, 17.707, 88.948

were significant at (p<0.001). Hence it was concluded that the acupressure is very

highly effective in reducing distress related to dysmenorrhea among adolescence girls.

In the present study the three levels of tests namely Pre-test to Post- test1,

Post- test1 to Post- test2 and Pre test to Post-test2 were compared between the two

groups on second day distress. The difference between the two group’s mean score

were M= 1.9, SD= 6.1 and M =34.2, SD = 4.2, M = 2.3, SD = 4.9 and M= 7.3,

SD = 4.7, M = 4.2, SD = 6.1 and M = 41.5, SD = 5.3.The independent‘t’ test value of

50.565, 8.398, 48.310 were significant at (p<0.001) respectively. Hence it was

concluded that the acupressure is very highly effective in reducing distress related to

dysmenorrhea among adolescence girls. It can be attributed to the effectiveness of

acupressure on distress related to dysmenorrhea. Hence the Null hypothesis Ho1 there

will be no significant difference in the effect of acupressure on pain related to

dysmenorrhea was rejected.

The tests in different levels of control group on the third day distress. The

mean distress score on the Pre- test was M = 62.1, SD = 4.7 and Post-test 1 was

M = 58.6, SD = 4.1. The mean distress score of Post-test 1 and Post- test 2 were

M = 58.6, SD = 4.1 and M = 56.7, SD = 4.2. The mean distress score of Pre-test

through Post- test 2 were M = 62.1, SD = 4.7 and M= 56.7, SD = 4.2. The Paired “t”

test values of 6.040 (p<0.01), 4.517 (p< 0.001) and 10.125(p<0.001). Hence it is

interpreted that the level of distress related to dysmenorrhea among adolescent girls in

control group on the 3rd day was significant at various levels.


on the third day distress. The mean distress score on pre- test to post- test 1 was

M = 63.2, SD = 5.0 and M = 26.1, SD = 5.7, Post-test 1 to Post test 2 was M = 26.1,

SD = 5.7 and M = 19.6, SD = 4.1, Pre-test to Post- test 2 was M = 63.2, SD = 5.0 and

M = 19.6, SD = 4.1. The paired‘t’ test values of 85.527, 18.462, 108.03 were

significant at (p<0.001) respectively. Hence it is concluded that the acupressure is


girls.

In the current study the three levels of test namely Pre-test to Post- test1, Post-

test1 to Post- test2 and Pre test to Post-test2 were compared between the two groups

on third day distress. The difference between the two group’s mean score in Pre test

and Post test 1 were M = 3.4, SD = 6.6 , M = 37.1, SD = 4.9, Post test 1 and Post test

2 were M = 1.9, SD = 4.8, M = 6.5, SD = 4.0, Pre test and Post test 2 were M = 5.4,

SD = 6.1 and M = 43.7, SD = 4.6.The paired ‘t’ test value of 47.252, 8.428, 57.716

were significant at (p<0.001) respectively. The results can be attributed to the

effectiveness of acupressure upon reducing distress related to dysmenorrhea. Hence

the Null hypothesis H01 there will be no significant difference in the effect of

acupressure on distress related to dysmenorrhea was rejected.

Relationship between Pain and Distress Related to Dysmenorrhea among

Adolescent Girls Before and After Acupressure

In the present study there is positive relationship between the pain and distress

related to dysmenorrhea of control and experimental groups of adolescent girls in

different occasions on first day of menstruation. The co-relation among the control

group of adolescents was found to be positive in Pre test ( r = .886) in Post test 1

( r =.807) and Post test 2 ( r = .904). The same finding was seen among experimental

group of adolescents in pre test (r = .894) post test 1 (r = .899) and Post test-2

(r = .866). In all the occasions, the relationships were statistically very highly

significant (P<0.001). i.e. The pain and distress were positively correlated, when the

pain increased distress also increased in both control and experimental groups of

adolescents on the first day of menstruation.

The relationship between the pain and distress related to dysmenorrhea of

control and experimental group of adolescent girls on second day of menstruation.

The correlation was found to be positive in the Pre test (r = .936), Post test 1 (r =.752)

and Post test 2 (r = .821) among the control group of adolescents. In experimental

group also the positive correlation was revealed in Pre test ( r = .901), Post test 1

(r = .891) and Post test-2 (r =.944). In all the occasions, the relationships were

statistically very highly significant (P<0.001).i.e. the menstrual pain and distress were

positively correlated, when the pain increased the distress also increased among the

control and adolescent group of adolescents on the second day of menstruation.

Relationship between the pain and distress related to dysmenorrhea of control

and experimental group adolescent girls on third day of menstruation. The pre test in

control group revealed r = .889, in Post test 1 the r =.819 and in Post test 2 the

r = .893, a positive correlation. The same results was found in experimental group

also wherein the correlation in pre test revealed r = .835, in Post test 1 the r = .946 and

in post test-2 r = .918, a positive correlation. In all the occasions, the relationships

were statistically very highly significant (P<0.001) .i.e. The menstrual pain and

distress were positively correlated, when the pain increased distress also increased

among the control and experimental group of adolescents on the third of

menstruation.

In the present study on all the three days of menstruation, there was a positive

correlation existed between the pre test and post level of menstrual pain and distress at

p <0.001 level among the control and the experimental group of adolescent girls.

Hence the Null hypothesis H02 there will be no significant relationship between

menstrual pain and distress related to dysmenorrhea among the control and

experimental group of adolescent girls in the pre and post test were rejected.

Association Between Pain and Distress Related to Dysmenorrhea and Selected

Socio Demographic Variables of Adolescent Girls.

In the ccuurrrreenntt ssttuuddyy sshhoowwss tthhaatt tthheerree wwaass nnoo ssiiggnniiffiiccaanntt aassssoocciiaattiioonn bbeettwweeeenn

ppaaiinn rreellaatteedd ttoo ddyyssmmeennoorrrrhheeaa aanndd aannyy ooff tthhee ssoocciioo ddeemmooggrraapphhiicc vvaarriiaabblleess ooff ccoonnttrrooll

aanndd eexxppeerriimmeennttaall ggrroouupp ooff aaddoolleesscceenntt ggiirrllss,, ssuucchh aass aaggee .. Educational status of

adolescents (2 = 2.946, 2 = 3.394) , Mothers’ education (2 = 1.560 , 2 = 8.289),

Mothers’ occupation (2 = 0.157 , 2 = 4.232), Religion (2 = 3.026 , 2 = 0.891),

Monthly income (2 = 3.576 , 2 = 1.169), Residence (2 = 0.742 , 2 = 0.600),

Type of family (2 = 0.008 , 2 = 1.934), Dietary habits (2 = 0.136 , 2 = 0.752)

and Food craving patterns (2 = 0.254, 2 = 0.510). The mothers’ education in the

experimental group was associated with pain level in the pre test(2=8.289,P<0.05)

Hence the Null hypothesis H04 there will be no significant association between the

pain and socio demographic variables of control and experimental group of

adolescents was partially rejected.

In the present study finding reveals that there was no significant association

between distress related to dysmenorrhea and any of the socio demographic variables

of control and experimental group of adolescent girls. such as Age, ( 2 = 2.769),

Education (2 = 0.096 , 2 = 2.769), Mothers’ education (2 = 0.645 , 2 = 2.680),

Mothers’ occupation (2 = 0.852, 2 = 3.597), Religion (2 = 6.477, 2 = 0.966) ,

Monthly income (2 = 1.021,2 = 1.385), Residence location (2 = 0.492,

2 = 0.118),Type of family (2 = 1.015, 2 = 1.291),Dietary habits (2 = 0.039,

2 = 0.134) and Food cravings (2 = 0.031,2 = 0.368) among the control and

experimental group of adolescents. Only the adolescents age and religion in the

control group was associated with pre test distress (2 = 5.535, P<0.05), (2 = 6.477,

P<0.05) respectively. Hence the Null hypothesis H05 there will be no significant

association between the distresses related to dysmenorrhea and selected socio

demographic variables of control and experimental group of adolescents was partially

rejected.

Association between Pain and Distress Related to Dysmenorrhea and Selected

Menstrual Variables of Adolescent Girls.

In the current study shows that there was no significant association between

pain related to dysmenorrhea and any of the menstrual variables of control and

experimental group of adolescent girls, such as Age at menarche (2=5.176,2=0.219)

,Frequency of menstrual cycle (2=2.405,2=4.322) Extent of menstrual flow

(2=0.556, 2=0.619),Duration of menstrual flow (2=2.871,2=0.916) onset of

menstrual pain (2=0.125,2=1.626), Family history of dysmenorrhea

(2=0.024,2=2.065) and treatment taken for dysmenorrhea (2=1.385,2=2.309) at

P>0.05 in control and experimental group of adolescents. Hence the Null hypothesis

H06 there will be no significant association between pain related to dysmenorrhea and

selected menstrual variables of control and experimental group of adolescents was

retained.

In the current study reveals that there was no significant association between

distress related to dysmenorrhea and any of the Menstrual variables of control and

experimental group of adolescent girls such as Age at menarche (2=2.005,2=2.808),

Frequency of menstrual cycle (2=0.872,2=5.314),Extent of menstrual flow

(2=1.405,2=1.308), Duration of menstrual flow (2=4.361,2=2.317),Onset of


(2=0.204,2=3.381), Treatment taken for dysmenorrhea (2=3.394,2=1.303) at



selected menstrual variables of control and experimental group of adolescents’ was

retained.

Findings of this study reveals that acupressure is effective and safe form of

therapy for adolescents with primary dysmenorrhea. Single acupoint at sanyinjiao

(SP6) is cost –free and easy to learn .It can be integrated into clinical practice and

health education in order to enhance the quality of life for adolescents with primary

dysmenorrhea. It has clearly emerged with implication for practice.

Recommendation

Adolescent girls may feel shy and embarrassed to discuss aspect of

menstruation like dysmenorrhea consequently leading to ill health. It is believed that

improving adolescents healthy life style and establish physical, mental and social

balance, it is important for them to have a positive attitude towards dysmenorrhea

which girls experience monthly, and to be able to use proactive self management

methods. This study presents preliminary findings that acupressure at the Sanyinjiao

(SP6) acupoint may be an active way to alleviate primary dysmenorrhea among

adolescent girls. The SP6 acupressure protocol used in this study consisted of a simple

set of non – invasive action applied for 20 min and can be integrated in to clinical

practice as an inexpensive and easy- to- learn nursing intervention for adolescent girls

experiencing dysmenorrhea. Further research is merited, especially a randomized trial

replicating the study or research to test a acupressure delivery methods varying in

time interval and duration of treatment.

Conclusion

The findings of the study show that there is a reduction in pain and distress

related to dysmenorrhea among experimental group of adolescent girls, thus proving it

to be effective when compared with control group of adolescent girls. Acupressure as

an alternative therapy is safe, rejuvenating, free from side effects and can be practiced

in their school and home setting. Adolescents in dysmenorrhea showed a positive

attitude towards performing Acupressure, they showed readiness to practice.

TABLE OF CONTENTS

CHAPTER NO. TITLE PAGE NO.

I INTRODUCTION 1-41

Background of the study 1

Significance and Need for the study 14

Statement of the Problem 29

Objectives of the Study 29

Operational Definitions 30

Assumptions 31

Null Hypotheses 32

Delimitations 33

Conceptual Framework applied in this study 33

Summary 41

II REVIEW OF LITERATURE 42-109

Literature reviewed related to the work 42-94

Development of Nursing Evidence Based Protocol 94

Summary 109

III METHODOLOGY 110-127

Research Approach 110

Research Design 110

Variables of the Study 112

Research Setting 113

Population 113

Sample and sample size 114

CHAPTER NO. TITLE PAGE NO.

Criteria for Sample selection 115

Sampling technique 116

Selection and development of study instruments 118

Psychometric properties of the instruments 121

Intervention protocol 121

Pilot Study 124

Data Collection Procedure 124

Plan for data analysis 125

Ethical Considerations 126

Summary 127

IV ANALYSIS AND INTERPRETATION 128-181

Presentation of Data Analysis 130-181

Summary 181

V DISCUSSION 182-220

Summary 220

VI SUMMARY AND RECOMMENDATIONS 221-242

Summary of the study 221

Nursing Implications 237

Recommendations for Future Research & Conclusion 241-242

REFERENCES 243-261

ANNEXURES

LIST OF TABLES

S. NO. TITLE PAGE NO

1. Characteristics of Included Papers in the Literature Review 99

2. Individual Evidence Summary of RCT’s based on effectiveness of

Acupressure upon pain and distress related to dysmenorrhea

102

3. Frequency, Percentage and Chi square values of Socio Demographic

Variables of Control and Experimental Group of Adolescent Girls for

homogeneity

130

4. Frequency, Percentage and Chi square values of Menstrual Variables

of Control and Experimental Group of Adolescent Girls for

homogeneity

135

5. Frequency and Percentage Distribution of Pain Related to

Dysmenorrhea before Acupressure among Control and Experimental

Group of Adolescent Girls on the first, second and third day of

Menstruation

140

6. Frequency and Percentage Distribution of Distress Related to

Dysmenorrhea Before Acupressure among Control and Experimental

Group of Adolescent Girls on the first, second and third day of

Menstruation

141

7. Frequency and Percentage Distribution of Pain related to

Dysmenorrhea Before and After Acupressure among Control and

Experimental Group of Adolescent Girls on the Second Day of

Menstruation

143



Experimental Group of Adolescent Girls on the First Day of

Menstruation.

146



Experimental Group of Adolescent Girls on the Third Day of

Menstruation

149

10. Frequency and Percentage Distribution of Level of Satisfaction of

Acupressure among Experimental Group of Adolescent Girls

150

11. Comparison of Mean, Standard Deviation and Friedman Values of

Pain Related to Dysmenorrhea among Control and Experimental

Group of Adolescent Girls on the First Day of Menstruation.

151

12. Comparison of Mean Standard Deviation and Friedman Values of


Group of Adolescent Girls on the Second day of Menstruation.

153

13. Comparison of Mean Standard Deviation and Friedman Values of


Group of Adolescent Girls on the Third day of Menstruation.

155

14. Comparison of Mean Rank and Kruskal Wallis Values of Pain

Related to Dysmenorrhea between Control and Experimental Group

of Adolescent Girls on the Third day of Menstruation

156

15. Mean, Standard Deviation and paired “t” Values of Distress Related

to Dysmenorrhea among Adolescent Girls in Control Group on the

First Day of Menstruation.

158

16. Mean, Standard Deviation and paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Experimental Group on

the First Day of Menstruation.

159

17. Comparison of Mean Standard Deviation and independent “t” Values

of Distress related to Dysmenorrhea between Control and

Experimental Group of Adolescent Girls on the First Day of

Menstruation

160

18. Mean, Standard Deviation and Paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Control Group on the

Second Day of Menstruation.

162



the Second Day of Menstruation

163

20. Comparison of Mean Standard Deviation, and independent “t” Values

of Distress Related to Dysmenorrhea between Control and

Experimental group of Adolescent Girls on the Second Day of

Menstruation

164


Dysmenorrhea among Adolescent Girls in Control Group on the

Third Day of Menstruation.

166

22. Mean, Standard Deviation and Paired “t” Values of Distress related to


the Third Day of Menstruation

167

23. Comparison of Mean Standard Deviation and Independent “t” Values

of Distress Related to Dysmenorrhea between Control and

Experimental Group of Adolescent Girls on the Third Day of

Menstruation

168

24. Correlation between Pain and Distress related to Dysmenorrhea

among Control and Experimental Group of Adolescent Girls Before

and After Acupressure on the First Day of Menstruation

170

25. Correlation between Pain and Distress Related to Dysmenorrhea


and After Acupressure on the Second Day of Menstruation

171

26. Correlation between Pain and Distress related to Dysmenorrhea


and After Acupressure on the Third Day of Menstruation

172

27. Association between Pain related to Dysmenorrhea and socio

demographic variables of Control and Experimental Group of

Adolescent Girls

173

28. Association between Distress related to Dysmenorrhea and Socio

Demographic Variables of Control and Experimental Group of

Adolescent Girls.

175

29. Association between Pain related to Dysmenorrhea and Menstrual

Variables of Control and Experimental Group of Adolescent Girls

177

30. Association between Distress related to Dysmenorrhea and menstrual

variables of Control and Experimental Group of Adolescent Girls

179

LIST OF FIGURES

S. NO TITLE PAGE NO

1. Conceptual frame work on effect of Acupressure upon pain and

distress related to dysmenorrhea based on Roy’s adaptation model

38

2.

Conceptual frame work on effect of Acupressure upon pain and

distress related to dysmenorrhea based on Roy’s adaptation sub

system- Cognator model

39

3.

Conceptual frame work on effect of Acupressure upon pain and

distress related to dysmenorrhea based on Roy’s adaptation sub

system -Regulator model

40

4. PRISMA Flow Diagram

98

5. Schematic representation of research design

111

6. Schematic representation of research methodology 117

7. Intervention protocol- Administration of acupressure

123

8. Percentage Distribution of Mothers’ Educational status of Control

and Experimental Group of Adolescent Girls

132

9. Percentage Distribution of Mothers’ Occupation of Control and

Experimental Group of Adolescent Girls

133

10.

Percentage Distribution of Family Monthly Income of Control and


134

S. NO TITLE PAGE NO

11. Percentage Distribution of Frequency of Menstrual Cycle of Control


137

12. Percentage Distribution of Extent of Menstrual Flow of Control and


138

13. Percentage Distribution of Duration of Menstrual Flow of Control


139

14. Percentage Distribution of Pain Score Before and After Acupressure

of Control and Experimental Group of Adolescent Girls on the First

Day of Menstruation

142

15. Percentage Distribution of Pain Score Before And After

Acupressure of Control And Experimental Group of Adolescent

Girls On the Third Day of menstruation

145

16. Percentage Distribution of Distress Score Before and After

Acupressure of Control and Experimental Group of Adolescent

Girls on the Second Day of Menstruation

148

17. Comparison of Effectiveness of Acupressure between Control and

Experimental Group of Adolescent girls Pain related to

Dysmenorrhea on the First Day of Menstruation (Repeated

Measures Of ANOVA Plots)

152

S. NO TITLE PAGE NO

18.

Comparison of Effectiveness of Acupressure between Control and

Experimental Group of Adolescent Girls Pain related to

Dysmenorrhea on the Second Day of Menstruation.(Repeated

Measures ANOVA Plots)

154

19.


Experimental Group of Adolescent Girls Pain related to

Dysmenorrhea on the Third Day of Menstruation.(Repeated


157

20.


Experimental Group of Adolescent Girls Distress related to

Dysmenorrhea on the First Day of Menstruation. (Repeated


161

21.


Experimental Group of Adolescent girls Distress related to

Dysmenorrhea on the Second Day of Menstruation.(Repeated


165

22.

Comparison of Effectiveness of Acupressure between the Control

and Experimental Group of Adolescent Girls Distress related to

Dysmenorrhea on the Third Day of Menstruation.(Repeated


169

LIST OF ANNEXURES

S. NO. TITLE

A Provisional Registration Certificate - Ph.D Degree

B Confirmation of Provisional Registration

C Constitution of Doctoral Advisory Committee

D Institutional Ethics Committee Approval Certificate

E Plagiarism check Certificate, Plagiarism Analysis Report by Urkund,

Screenshot of Plagiarism Analysis

F Certificate of English Editing

G Certificate of Acupressure Training

H Letter Granting Permission to Conduct the study from Yettacode Higher

Secodary School

I

Letter Granting Permission to Conduct the study from St Ursula’s Girls Higher

Secodary School Kulasekharam

J Grant of Permission to use the Johns Hopkins Nursing Evidence Based Practice

Models and Tools

K Evidence of Permission to use Standardised MMDQ Questionnaire

L List of experts who Validated the Tool

S. NO. TITLE

M Letter seeking Permission to conduct Research study

N Request for opinions and Suggestions of Experts for Establishing Content

Validity of Research

O Certificate of Validation / Content Validity

P Information Sheets of Adolescent Girls

Q Tools for Data Collection

R Intervention Protocol

S Certificates for Participating/ Presenting in Research / Acupressure Workshop /

Conference

T Thesis related Publications

U Ph.D Synopsis Submission Application Form

V Ph.D Thesis Submission Application Form

W Photos

X Master Coding Sheet

ABBREVIATIONS

1. CAM Complementary Alternative Medicine

2. CIHA Complimentary Integrated Health Approach

3. CMAT Collatoral Meridian Acupressure Therapy

4. DESAPD Department of Economics and Social Affairs of

Population Division

5. EBP Evidence Based Practice

6. HRV Heart Rate Variability

7. IASP International Association for the Study of Pain

8. JHNEBP Johns Hopkins Nursing Evidence Based Practice

9. LH Luteinizing Hormone

10. LBP Low Back Pain

11. NIH National Institute of Health

12. NP Nurse Practitioner

13. NSAID Non Steroidal Anti-Inflammatory Drugs

14. MMDQ Moose Menstrual Distress Questionnaire

15. OAM Office of Alternative Medicine

16. PMS Pre Menstrual Symptoms

17. PGF2 Prostaglandin

18. PD Primary Dysmenorrhea

19. PICO Patient/ Participants / Population, Intervention,

Comparison, Outcome

20. PI (E)

COS

Participants, Interventions (or Exposure), Comparison

groups,

Outcomes, Study designs

21. PRISMA Preferred Reporting Items for Systematic review & Meta

Analyses

22. RCT Randomised Controlled Trial

23. RN Registered Nurse

24. TCM Traditional Chinese Medicine

25. VAS P Visual Analogue Scale for Pain

26. VMDSS Verbal Multi Dimensional Scoring System

27. WHO World Health Organisation

.

1

CHAPTER - 1

INTRODUCTION

Background of the study

“It is the eternal changefulness of life that makes life so beautiful”

- Sigmund Freud

“Adolescent’s- The hope for the future”

Adolescence represents a major potential human resource for the overall

development of a nation. Adolescence is a transition period from childhood to

adulthood and is characterized by a surge in physical, endocrinal, emotional, and

mental growth, along with the pubertal development and sexual maturation. During

puberty, hormonal, psychological, cognitive and physical changes occur

simultaneously, with a change from complete dependence to relative independence.

The stage of adolescence for a girl is a phase of physical and psychological

preparation for safe motherhood. As the direct reproducers of upcoming generations,

the well being of adolescent girls influences not only their own health, but also the

health of the future population. Almost a quarter of India's population comprises of

girls below 20 years.

The term adolescence and young people defined by World Health

Organization on the age group of 10 - 18 and 10 – 24 yrs respectively. Young people

make up over one quarter of the world population. There are 1.2 billion adolescent

and 1.7 billion young people in the world. Today more than half of the world people

2

are aged below 25 yrs about one third are between 10 to 24 yrs of age. Around 243

million of them live in India. 71 million were in Tamil Nadu.

The major physiological change that takes place in adolescent girls is the onset

of menarche. The medium age at which menarche occurs across between 12 and

13 yrs. Menstruation is the periodic and cyclical discharge of blood, mucus and

cellular debris from the uterine mucosa, which occurs due to progesterone withdrawal

after ovulation in non fertile cycles. It occurs in response to changes in the hormonal

production by the ovaries, which themselves are governed by the pituitary and

hypothalamus. Menstruation takes place at approximately 21-35 days interval

between menarche (onset of menstruation) and menopause (cessation of

menstruation), with 2-6 days of flow and an average blood loss of 20-60 ml.

Menstrual cycle is the cycle of change that occurs in the uterus and ovary for

the purpose of sexual reproduction. It is essential for the production of eggs and for

the preparation of the uterus for pregnancy. The menstrual cycle can be described by

the ovarian or uterine cycle. The ovarian cycles describes changes that occur in the

follicles of the ovary whereas the uterine cycles describe changes in the endometrial

lining of the uterus. Both cycles can be divided into three phases. The ovarian cycle

consists of the follicular phase, ovulation, and the luteal phase whereas the uterine

cycle consists of menstruation, proliferative phase, and secretory phase.

Menstrual cycles are counted from the first day of menstrual bleeding,

stimulated by gradually increasing amounts of estrogen in the follicular phase of

blood slow then stop, and the lining of the uterus thickness. Follicles in the ovary

begin developing under the influence of complex interplay of hormones, and after

several days one or occasionally two become dominant (non-dominant follicles

3

atrophy and die). Approximately mid- cycle 24-36 hours after the Luteinizing

Hormone (LH) surges, the dominant follicle releases an ovum or egg in an event

called ovulation.

After ovulation, the egg only lives for 24 hours or less without fertilization,

while the remains of the dominant follicle in the ovary become a corpus luteum, this

body has a primary function of producing large amounts of progesterone. Under the

influence of progesterone, the endometrium (uterine lining) changes to prepare for

potential implantation of an embryo to establish a pregnancy. If implantation does not

occur within approximately two weeks, the corpus luteum will involutes, causing

sharp drops in levels of both progesterone and estrogen. These hormone drops cause

the uterus to shed its lining and egg in a process termed menstruation.

Menstruation disorders are common problem faced by women during their

adolescence that may cause significant anxiety for the women and their family. The

common menstrual disorders for female adolescents are dysmenorrhea, amenorrhea,

abnormal/excessive uterine bleeding and premenstrual syndrome. Dysmenorrhea is

the most common gynaecological condition regardless of age and nationality and that

directly influences a woman’s quality of life.

The term dysmenorrhea is derived from the Greek word “dys” meaning

difficult/painful/abnormal “meno” meaning month, and “rrhea’, meaning flow. It is

defined as painful menstruation or difficult menstrual flow. Dysmenorrhea is defined

as difficult menstrual flow or painful menstruation. Dysmenorrhea literally means

painful menstruation. But a realistic and practical definition includes cases of painful

menstruation of sufficient magnitude, so as to incapacitate day to day activities.

(Dutta 2000.)

4

Dysmenorrhea has been classified into primary and secondary. Primary

dysmenorrhea is described as the chronic, cyclic, pelvic, spasmodic pain associated

with menstruation in the absence of identifiable macroscopic pathology. It is typically

known as menstrual cramps of period pain. A true dysmenorrhea is of uterine origin

and directly due to menstruation also be described as spasmodic, intrinsic, essential of

functioning dysmenorrhea. Primary dysmenorrhea thought to affect approximately

one half of all menstruating women. Secondary dysmenorrhea is also called as

organic dysmenorrhea as it is cyclic menstrual pain associated with underlying

macroscopic or anatomic pelvic pathology. The pain of secondary dysmenorrhea

often begins 1-2 weeks prior to menses and persists until a few days after cessation of

bleeding. This condition is most often observed in women aged 30-45 years.

Primary dysmenorrhea can be manifested in two forms, namely spasmodic

and congestive. Spasmodic dysmenorrhea is acute pain which occurs in the first 2 -3

days of menstruation and is often associated with gastro intestinal symptoms. Pain in

this type of dysmenorrhea is confined to the parts of body which are innervated by the

uterine or ovarian nerves. Primary dysmenorrhea thought to affect approximately on

half of all menstruating women, with 10 % of women having symptoms severe

enough to interfere with daily responsibility.

Pain is a feeling of distress and discomfort of varying intensity. It is caused by

stimulation of specialized nerve endings. Pain is the normal predicted physiological

response to an adverse chemical, thermal or mechanical stimuli associated with

surgery, trauma or an acute illness and thus characterized it as sensory response.

Dysmenorrhea pain is located in the supra pubic or lower abdomen and is described

either as sharp, gripping and cramping or a steady dull head ache. It may be

5

accompanied by feelings of pelvic fullness and radiate to the lower back and upper

thighs.

The initial onset of primary dysmenorrhea is usually 6-12 months after

menarche, with the onset of ovulatory cycle. The pain is usually most severe on first

or second day of menstrual flow in more than half of the women, due to highest level

of PGF2 ά in menstrual blood. The pain usually begins a few hours prior to or just

after the onset of a menstrual period and may last as long as 48-72 hours. The pain is

labor like characterized by sharp, fluctuating, supra pubic cramping and may be

accompanied by lumbosacral backache, and radiating to anterior thighs, associated

symptoms are headache, diarrhoea, nausea, vomiting, anxiety ,syncope ,abdominal

bloating, and fatigue.

During severe attack the patient looks pale, sweat, nausea and vomiting are

common. Diarrhoea, rectal and bladder tenesmus may also be present in this

condition. Primary dysmenorrhea is not fatal and causes no organ failure, it may

affect peaceful life and resulting in disability and inefficiency. Complications of

dysmenorrhea include disruption of routine activities like absence from school or

work place, medication use, physical and mental disorder, and Social- Economics and

familial problems.

Distress is the symptoms of dysmenorrhea generally begin with menstruation

although some women will experience symptoms for several hours before the onset of

flow. The experience of menstrual distress is often associated with feelings of control

and helplessness. It includes physical and psychological discomfort. The various

psychological symptoms attributed to menstrual syndrome are sadness, anxiety, anger,

irritability, labile mood, decreased-concentration, suspiciousness, sensitivity,

6

insomnia, anorexia craving for certain foods, social but also occupational functioning

leading to various degrees of maladjustments.

As per the senses Worldwide there are approximately 721 million adolescence

in the age group of 12-17 they represent (12 %) of world population by Dept of

Economics and social affairs population division (DESAPD, 2014). The systematic

review article of 106 researchers on 125249 women, conducted by the World Health

Organization (WHO), reported the prevalence of dysmenorrhea was 17-81 percent.

Globally the prevalence rate has been reported to be as high as 90 % and as

low as 43%, about 15 % of adolescent girls report severe dysmenorrhea and it is

leading cause of recurrent short term school absenteeism. In an Australia study

surveyed 1051 adolescence between 16-18 years and found that 94% experienced

menstrual pain, 96% had pre menstrual symptoms (PMS), and 58% reported clots in

their menstrual blood and 30.5% reported irregular periods. A questionnaire based

study of girls in grade 11 and 12 in Western Australia showed that 80 % suffer from

dysmenorrhea, study of 1000 female students in Hoosten (Texas, US) showed (85%)

had dysmenorrhea.

A recent study of 1546 menstruating Canadian women found that 60 % had

menstrual disorders, severe or moderate pain was 60%, limitation of activities was

reported in 51% and 17% reported absenteeism. A survey was conducted girls aged

12 – 21 yrs in Washington DC. (U.S.) found that premenstrual syndrome (PMS) was

the most prevalent reported menstrual disorders 84.3% followed by dysmenorrhea

65% abnormal cycle length 13.2% and excessive uterine bleeding 8.6 %. A Singapore

study of adolescent girls showed that 83.2% suffered from various degree of

dysmenorrhea.

7

A study of South Korea showed that 43.35% reported bleeding quantity as

large to very large amount, 74.5% complained of dysmenorrhea and 80% complained

of irregular cycles. According to USA based studies 42% of affected adolescents

describe their menstrual pain as severe, 33% as moderate and 25% as mild. Swedish

studies reported average 40-90 % dysmenorrhea in women 19 yrs of age. A Cochrane

systematic review of studies in developing countries reported prevalence of

dysmenorrhea in 25% to 50% adult women. On the other hand, studies from the

developed countries also reported a wide range 60% to 73%.

In India various studies reveal that prevalence of dysmenorrhea varies from

(33- 80%).In Karnataka 6 district total 1648 adolescent students were surveyed, the

incidence of dysmenorrhea was 87.87%.Madhya Pradesh based studies showed

prevalence of dysmenorrhea among adolescent girls 73.80 %. A school based cross

sectional study carried out in Lucknow district, with 640 adolescent girls, the

prevalence of dysmenorrhea found to be 73.9% with 74.4% girls in urban schools and

72.7% girls in rural schools.

A study was conducted in Gwalior which showed that the prevalence of

dysmenorrhea in adolescent girls was 79.67% and 78.96%. They suffered from severe

dysmenorrhea regularly. A study carried out in Kadapa district of Andhra Pradesh

showed a high prevalence of dysmenorrhea 65.02% among adolescent girls. However,

they found that 68.4% and 61.2% were from the urban and rural areas respectively.

The most frequently reported (72.4%) problem during menstruation was dysmenorrhea

as revealed by a study done in Kerala by Nair, Chacko et al . Recently George and

Bhaduri concluded that dysmenorrhea (87.87%) is common problem in India, similar

finding has been reported by Jeya Shree and Jeya lakshmi in Andrapradesh.

8

In Tamil Nadu, the prevalence rates of dysmenorrhea among adolescents were

(50- 83%) (National Journal of Community Medicine, 2011). A cross sectional school

based study was conducted in rural schools of Thiruvallur district, showed that

(72.6%) reported dysmenorrhea (S.R.M, medical college and Research Institute Porur,

2016).A 300 medical student participated cross sectional descriptive study was

concluded that the prevalence of dysmenorrhea was (61%) (S.R.M, medical college,

Kanchepuram, 2011).A structural questionnaire based study of adolescent girls of age

group 14-19 yrs (500) Salem showed (71%) of dysmenorrhea prevalence among

adolescent girls.

The prevalence of primary dysmenorrhea decreases with increasing age,

prevalence is the highest in the 20 to 24 year old age group and decreases

progressively thereafter. They can also result in poor self-esteem, a sense of

dissatisfaction, inadequacy and unhealthy life style. Previous studies have also shown

that women with menstrual disorders have a poor health-related quality of life, a

number of physical psychological and emotional symptoms. Dysmenorrhea has

different detrimental effect on individual and community, for instance, school and

office absenteeism, interference with daily living, limitation of socialization and

higher intake of sedative medication.

Banikarim et al (2010) stated that, dysmenorrhea was the leading cause of

short-term school absenteeism. This is the single greatest cause of absence from

school and work among women of menstruating age. In adolescents, absenteeism

from school work, due to dysmenorrhea ranged from 14% to 51% of girls and

decreased participation in school – related functions ranged from 29% to 50% in

those with severe of dysmenorrhea, 50% missed school. Such absences diminish

9

opportunities for successful educational, psychosocial, and cognitive development

during the critical period of adolescent growth.

Girls on an average miss out (25%) more classes in school compared to boys

due to pain during menses. About 1 in 10 women are unable to perform their normal

routine work for 1-3 days each menstrual cycle due to severe uterine cramping.

Menstrual problems are often the source of anxiety for female adolescents and their

families at large. Sickness, absenteeism was seen on dysmennorhic girls and quality

of life was significantly reduced among them.

The dysmenorrhea is a well known physical complication from dawn of the

years in immemorial. Hippocrates father of medicine hypothesized that stagnation of

menstrual blood secondary to cervical obstruction causes painful menstrual periods.

Soranus of Ephesus advised local application of a bladder filled with hot oil held over

the aching lower abdomen. In Chinese medicine, primary dysmenorrhea is usually

caused by emotional factors, invasion, of 6 exogenous pathogenic factors and

stagnation of Qi and blood; or by retention of blood in the Paogong due to liver

depression and Qi stagnation resulting from emotional upsets.

According to Chinese a healthy menstrual cycle relies on several factors,

including the condition of the blood, the level of energy, and the proper functioning of

the liver and kidneys. If there is heat in the blood or a stagnation of energy resulting

from emotional imbalance and stress, the menstrual flow becomes disrupted, causing

pain and discomfort. Many women also suffer from a condition in which cold affects

the uterus causing severe menstrual cramps and pain. Stress and intense emotions,

especially anger, frustration, and resentment can easily depress the liver. Over time,

10

the stagnation turns into heat, pushing the blood to flow out heavily with clots and

pain.

One of the most common complaints for women that can affect quality of life

is dysmenorrhea. Edward (1863) of Germany outlined his own ideas of menstruation.

He believed that during the cycle increasing pressure was set up in the growing

Graffian follicle. This caused a reflex irritation which sent nerve impulses via the

ovarian nerves to the spinal cord, and this in turn caused pelvic congestion, which led

to painful menstruation.

The etiology of primary dysmenorrhea is increased synthesis and secretion of

prostaglandin F2άincreased vasopressin and oxytocin that subsequently enhance the

secretion of prostaglandin and stimulation of the type “c” pain fibers are postulated to

be the contributing agents.

Hormones are postulated as key influencers for triggering menstrual pain.

Dysmenorrhoeic have higher levels of prostaglandins, leukotrienes, vasopressin

hormone and platelet- activating factor in menstrual fluid. Collectively, these key

elements facilitate pelvic pain associated with arterial vasoconstriction, menorrhagia,

blood clot formation, and increased uterine contractility. Vasopressin is a powerful

muscle-contracting hormone and is shown to contract the uterus 5 times greater in

dysmenorrheics .Increased levels of circulating vasopressin during menstruation

reported in women with primary dysmenorrhea can produce dysrhythmic uterine

contraction that reduce uterine blood flow and causes uterine hypoxia.

Progesterone is the principle trigger of the cascade of events leading to

menstrual cramp. When progesterone levels fall at the end of the secretory phase, pain

ensures as uterine spiral arteries of the endometrium constrict to create ischaemia and

11

necrosis. The release of prostaglandin F2 ά from disintegrating endometrial cells

stimulates free nerve endings, which consequently produce pain. Prostaglandin F2 ά

also increases platelet aggregation which causes blood clots to accompany

dysmenorrhea.

The local action of prostaglandin is threefold. Firstly, they act directly on the

uterine musculature to increase basal intrauterine pressure, as well as the intensity and

frequency of myometrial contractions. Secondly, they cause constriction of uterine

arteries with subsequent tissue ischaemia and pain. Finally, increases the sensitivity of

peripheral pain. The pain of dysmenorrhea is associated with intrauterine resting and

peak pressures. The dysmenorrheic women may have contractions reaching

intrauterine pressure of 200 mmHg vs.100 mmHg for non dysmenorrheic women,

suggesting ischemia in the dysmenorrheic uterus.

Primary dysmenorrhea arises from the release of prostaglandins with menses,

which is secreted during the luteal phase and subsequent menstrual flow. Excessive

release of prostaglandins increases the amplitude and frequency of uterine contraction

and causes vasospasm of the uterine arterioles, resulting in ischemia and cyclical

lower abdominal cramps.

Genetics is related to the development of primary dysmenorrhea. New

exploration of the human genome, at the 22ndchromosome, purports a genetic link

between polymorphisms of enzyme producing and glutathione S-transferase mu with

dysmenorrhea. Cytochrome (P450 2D6) is involved in the degradation of toxins and

synthesis of cholesterol, steroids and other lipids. Glutathione S-transferase mu is a

component of a biological pathway that forms antioxidants. Variant genotype of either

is jointly associated with an increased risk of recurrent of severe dysmenorrhea.

12

Spasmodic dysmenorrhea could be due to the incoordinate muscle action of

the uterus as a whole. This could be explained by an imbalance in autonomic nervous

control of muscle, one in which an overactive sympathetic system leads to hypertonus

of the circular fibers of isthmus and internal os. Emotional and behavior problems

may exacerbate menstrual cycle problem and dysmenorrhea.

Dysmenorrhea is often managed by pharmacological and non pharmacological

measures. Medication is one of the fast relieving techniques used by adolescence

population. The commonly used drugs are NSAID and oral contraceptives. Short and

long term gynecological complication can develop due to usage of this medication. In

order to overcome these complications some special remedies are needed. Nowadays,

non pharmacological remedies are being used to get relief from menstrual pain and

distress. They have no side effects on women in their future. Acupressure is one of

the non pharmacological remedies for dysmenorrhea. Acupressure is an age old

practice which is considered to be a simplest and most effective form of physical

therapy with no side effects.

Acupressure has its roots in ancient Chinese medicine, which views the health

is, the level and flow of energy along the meridians, said to run up and down the body

from head to toe .In Chinese medicine, this vital energy is called qi (pronounced

‘ chee’ and sometimes written ‘ chi’).Imbalances or block-ages in the flow of qi

around the body are said to lead to ill health , so Chinese doctors may treat disease by

regulating the flow of qi. One way in which they do this is by pressing on certain

points on the body where the meridians are said to come close to the skin. Pressing on

these points is believed to strengthen or disperse qi, according to the condition being

treated and the type of pressure used.

13

In Chinese medicine all energy is divided into two complementary aspects: yin

and yang. In simplified terms, yang is active and ‘masculine’ and yin is passive and

‘feminine’. Each meridian is classified as either yin or yang. The Governing Vessel

meridian controls the yang meridians and the Conception Vessel controls the yin

meridians. The meridians are invisible pathways along which energy is said to flow

around the body. Pressing points along them is thought to regulate energy. There are

corresponding meridians and therefore acupressure points on both sides of the body.

It is believed in Chinese medicine that simulation of specific acupressure

points along the meridian lines can release muscular tension, increase circulation and

allow the energy to flow eventually and become balanced. They can as promoting the

release of endorphins, blocking the pain receptors to the brain, dilating the cervix and

increasing the efficiency of contraction. Acupressure points stimulates various sensory

receptors that in turn stimulate nerves that transmit impulses to the brain, the brain

then release the body’s natural pain killing hormones (neurotransmitters and

endorphins). It is estimated that endorphins are 200 times more potent than morphine.

Endorphins also play a vital role in the functioning of the hormonal system. Some

researchers have suggested that manipulating the small myelinated- peripheral nerve

in muscles with finger pressure dispatches signal to spinal cord, mid brain and the

pituitary axis, resulting in release of substance such as enkephalin, dynorphin,

serotonin, norepinephrine, and beta-endorphins, among others into the bloodstream

and cerebrospinal fluid thus alleviating pain.

14

The merit of utilizing acupressure as a nursing intervention has been proposed

in the literature as a non- invasive measure that offers comparable effects to

acupuncture therapy. Acupressure for dysmenorrhea may offer women a

non- invasive, cost-free, and timely way to manage dysmenorrhea on their own,

thereby saving time, cost, and effort. Acupressure massage can be very effective both

as prevention and as a treatment for much health condition ,nursing staffs and students

while educated can practice this upon patients under their care.

Significance and Need for the Study

“Let- My care Remove the pain”

Dr.A.P.J.AbdulKalam

“May I have breath in my nostrils, voice in my

mouth, sight in my eyes, hearing in my ears;

hair that has not turned grey; teeth that are not

discoloured; and much strength in my arms.

May I have power in my thighs, swiftness in my

legs, stead fastness in my feet.

May all my limbs remain unimpaired and my

Soul (athma) ever unconquered.”

- Rigveda

15

WHO (World Health Organization) defines an adolescent as any person

between ages 10 and 19, young people which refers to individuals between 10 and 24.

However adolescence is narrowly equated with puberty and the cycle of physical

changes culminating in reproductive maturity. In other societies adolescence is

understood in broader terms the encompass psychological, social and moral terrain as

well as the strictly physical aspects of maturation. In these societies the term

adolescence typically refers to the period between the ages 12 and 20 is roughly

equivalent to the world teens (WHO, 2014).

Sigma Theta Tau International (2015) estimates one in every two women who

have their period suffer from dysmenorrhea or intense pain and cramping during

menstruation.3 out of 4 women with dysmenorrhea have primary dysmenorrhea. One

in four women with dysmenorrhea has a secondary form caused by an underlying

gynecological condition. It is estimated that 5- 15 % of women with primary

dysmenorrhea suffer from pain that hinders their ability to do everyday task.

Adolescence can be defined biologically, as the physical transition marked by

the onset of puberty and the termination of physical growth; cognitively, as changes in

the ability to think abstractly and multidimensionally, or socially, as a period of

preparation for adult roles. The major physiological change that takes place in

adolescent girls is the onset of menarche, which is often associated with problems of

irregular menstruation, excessive bleeding, and dysmenorrhea; of this dysmenorrhea

is one of the most common problems experienced by numerous adolescent girls. It is

usually starts around the onset of menstruation and may continue for 8 hours to

3 days.

16

Primary dysmenorrhea is defined as painful menses in women with normal

pelvic anatomy, usually begins during adolescence. It is unusual for symptoms to start

within first six months after menarche. Affected women experience sharp, intermittent

spasm of pain usually concentrated in the suprapubic area. Pain may radiate to the

back of the legs or the lower back. Systemic symptoms of nausea, vomiting, diarrhea,

anorexia, and craving for certain foods, fatigue, mild fever and headache or light

headedness are fairly common and occasionally swelling in ankle and knees.

Psychological symptoms are irritability, depression, labile mood, feeling of lack of

control, helplessness, sensitivity, sadness, anxiety, anger, decreased concentration,

suspiciousness, insomnia.

Pain usually develops within hours of the start of the menstruation and peaks

as the flow becomes heavy during the first two days of the cycle and spasmodic or

colicky pain and is worse on 1,2,3 days of menses. Complication of dysmenorrhea

include disruption of routine activities; absent from school or work place; medication

use; physical and mental disorder; and social, economic or familial problems.

Dysmenorrhea constitutes one of the most frequent fertility disorders. In 2007 the

international association for the study of pain estimated that at each menstrual period

approximately (10 % to 15%) of dysmenorrheic women were not able to work for

1 – 3 days International Association for the Study of Pain (IASP 2007). In the United

States, dysmenorrhea causes annual loss nearly 140 million working hours.

Many women experience various premenstrual and menstrual physical ,

emotional and behavioral changes which at times reach such levels of severity that

they may have substantial social impact upon the women herself, her association and

17

her work. In a study findings revealed that out of 40 subjects, (97.5 %) were

experiencing abdominal discomfort as a most common pre menstrual and menstrual

symptom followed by (92.5%) fatigue, (90%) low back pain, decreased interest in

activities and irritability, (80%) generalized aches, restlessness and poor

concentration, (72.5%) anxiety and social withdrawal, (67.5%) loss of appetite and

pain in thighs, (60%) depression, (55%) nausea and forgetfulness, (50%) increased

perspiration, (40%) vomiting.

Chief complaint during menstruation is pain in lower abdomen and may also

be referred to hip, lower back and thighs. The pain usually starts shortly before or

during their menstrual periods peaks after 24 hours and subsides after 3 days

dysmenorrheic pain may be spasmodic in nature along with sharp pelvic cramps at the

start of menstrual flow or congestive with deep dull ache, it is a major cause for

disability in most of the adolescent girls which leads to inability to concentrate on

their work or studies, classes or school absenteeism, inability to perform in their

academic activities like physical training or sports, thus it has a large impact on daily

life activities. Dysmenorrhea has menstrual distress with symptom like pain, water

retention, autonomic reactions, mental distress, impaired concentration, behavior

change and arousal.

Dysmenorrhea can decrease productivity, creativity and work performance

due to serious daily stress, social and economic loss. In a study dysmenorrhea

accounted for 600 million lost work hours and $ 2 billion in lost productivity

annually. Beginning a few hours preceding and immediately after menstruation,

dysmenorrhea typically lasts approximately 48-72 hours and includes symptoms such

18

as lower abdominal cramps, back pain, nausea, vomiting, loss of appetite, fatigue,

and nervousness.

Painful menstruation generally does not occur until ovulatory menstrual cycles

are established. Maturation of the hypothalamic-pituitary-gonadal axis leading to

ovulation occurs at different rates; approximately (18 to 45 %) of teens have

ovulatory cycles two years post menarche, (45 to 70%) by two to four years, and

(80%) by four to five years. Dysmenorrhea occasionally accompanies anovulatory

cycles, especially if heavy bleeding and clots are present. The prevalence of

dysmenorrhea among adolescent females ranges from (60 to 93%). Many adolescents

report limitations on daily activities, such as missing school, sporting events, and

other social activities, because of dysmenorrhea.

The treatment available in the present scenario is not giving enough relief

from dysmenorrhea. The effectiveness of current treatments including oral

contraceptive steroidal anti inflammatory drugs ranging from (64 to 90%) of patient

have intolerable side effects and infertility. These drugs are only temporarily effective

in relieving pain and may induce side effects, dependency and unnecessary medical

costs. Furthermore these drugs need to take repeatedly as their concentration in the

blood decrease over time.

The more powerful the drug, the dangerous their side effects are. The drugs

which were once considered perfectly safe have nowadays proved to be harmful and

even dangerous. Another drawback of modern medical system is that tend to prescribe

separate drug for each ailment or symptoms. Modern medical treatment relies on the

assumption that the human body is composed of separate independent pieces and hot

of an indivisible unit.

19

The traditional therapists of the eastern countries regard the human body on

one indivisible unit or entity (as a whole). In their opinion no individual part of the

human body can remain healthy or unhealthy independent of the other parts. Their

approach is to treat the patient and not the disease. They believe that disease can be

prevented, if the resistance power of the body is strengthened with the help of proper

food, proper life style and proper physical exercise. Illness in fact is not inevitable. It

can be prevented or rapidly cured if resistance power of the body is strong. By

observing the rules of nature one can easily presence the resistance power of his body.

Holistic modalities are becoming increasingly integrated into the main stream

of patient care; National institute of health (NIH) has established an Office of

Alternative Medicine (OAM) for the investigation of holistic modalities -or

complementary and alternative therapies. Manual healing method (Acupressure) is

one of the powerful holistic modality an alternative therapy, In order to provide

quality of patient care nurses to successfully use these modalities in their clinical

practice.

Sohn and cook (2010) surveyed nurse practitioners (NPs) in Missouri and

Oregon to assess their knowledge of complementary and alternative medicine

(CAM).The result of their study revealed that while respondent appeared to embrace

CAM on a large scale a much smaller number actually based that acceptance of

formal education. Total 151 NPs completed the survey, (83%) said they had

recommended CAM to their patient, with (50%) of those referrals being for massage.

In contrast , only (24%) of the study sample noted formal nursing education as the

study sample noted formal nursing education as the source of their knowledge for

recommending CAM , (67%) reported personal experience as a primary source of

20

information, with professional journals, seminars and continuing education as the

source of information .

As the NPs researchers suggested embracing CAM in nursing carries with it a

responsibility not only for its inclusion in formal nursing curriculum, but also an

effort to closely examine the current research literature and to build on that base.

While the nursing profession in the only entity that can address its curriculum needs,

there also exists the other side of the coin responsibility for building the research data

base.

Nursing is an holistic discipline that nurses have demonstrate great enthusiasm

for the technique and modalities associated in the field of complementary and

alternatives, on these technique nurse assist to address the physical, mental emotional

and spiritual dimension of cases. Lenin (1998) conducted a study with 708 nurses.

The findings of the study shows that , majority of them defined their practice in

relation to alternative complementary modalities, most frequently used by these study

responded were acupressure , aroma therapy , bio feedback , humor ,music therapy ,

meditation, relaxation and therapeutic touch etc.

With increasing consumer and professional intent in alternative and

complementary care, registered nurses (RNS) are incorporating alternative

complementary modalities in to their practice. While these modalities give nurses

additional tools to meet client need. Alternative / complementary modalities have

been defined as treatment technique whose goals are to evoke healing, taking in to

account the body mind-spirit connection of every individual.

Nursing theory provides the language concept and world view to reflect on

nursing care and in the use of acupressure modalities. The first case of alternative

21

complementary modalities and nursing theory will be drawn from the modeling and

remodeling theory of Erickson. There are 3 levels of presence defined for nursing

practice, physical presence (being there) psychological presence (being with)

therapeutic presence that fits best with the notion human care.

Holistic Nursing and Complementary Integrative Health Approaches, each

nurse is required to practice in accordance with accepted standards of practice and is

responsible and accountable for his or her nursing judgment, action and competency.

Scope of practice of registered nurse and practical nurse to guide the practice of

registered nurses and licensed to practical nurses who within their practice incorporate

Complementary Integrated Health Approaches (CIHA) to meet such nursing and a

client goal including increased comfort relief of pain, relaxation improved coping

mechanism, reduction of stress and increase sense of well being comprehensive health

promotion and health risk reduction.

Recent research focusing on complementary and alternative intervention for

dysmenorrhea include the use of muscle relaxation therapy, magnetic therapy,

reflexology, acupuncture , heat therapy, aroma therapy, psycho therapy, hypnosis

,nutritional and therapeutic methods have been used to treat primary dysmenorrhea.

Acupressure is a unique science; it is a science as well as art, it is the most ancient and

simplest of the various oriental therapies such as acupressure, acupuncture, shiatsu,

zone therapy and reflexology. Each of these therapies strives to produces healing

effects on the internal organs of the body through well defined points on the body

surface.

Acupressure is a descendent of traditional Chinese manipulative therapy,

which has been considered a legitimate component of Chinese medicine. It also

22

combines traditional Japanese techniques with Western anatomical and physiological

knowledge. Acupressure is a general word for the stimulation of acupoints by means

of pressure, usually using the hands, fingers or thumbs .

Acupressure and treatment system does not regard human body as composed

of two distinct units the emotional or the physical but treats the whole body as one

integrated whole. This principle is fundamental in this kind of treatment. The nerve

ending of all small – big blood vessels and that of the nerves system lie at the base of

the hands and feet. Hence the hands and feet have the control points of the entire

human system which points control which part of the body and how they are to be

linked and identified.

For centuries, in India, China, Japan and other countries, life has been

considered as a bioelectrical phenomenon, that is, our life relies on the bioelectricity

that exists in our body. It is only because of the existence of this energy in our body

that we can move, breathe, digest food or think. We call this bioenergy ‘prana’ or

‘Chetana’. The Chinese call it ‘Chi’. This bioenergy is composed of two kinds of

forces: ‘Yin’ and ‘Yang’. Yin is a negative force while Yang is a positive one.

A person remains in good health if there is co-ordination, harmony and balance

between these two forces. If the balance is disturbed or ‘warped’, that is, if the flow of

one force in the body is greater than the other, illness arises. These forces (bio energy)

flow through definite courses or channels in the body. We shall call these courses

‘meridians’. The Chinese call them ‘Jing’.

It is believed that there are 14 meridians in our body for the flow of

bioelectricity or bioenergy (Chetana). Out of these 14 meridians, 12 meridians are

present in pairs, each on the right side and the left side of the body, while the

23

remaining two are single. One is on the vertically central line on the backside of the

body. The 12 paired meridians comprise of 6 ‘Yin’ meridians and 6 ‘Yang’ meridians.

‘Yin’ meridians start from the toes or from the middle part of the body and go to the

head or to the fingers of the hands. The ‘Yang’ meridians start from the head, the face

or the fingers and go downside or to the middle part of the body.

These meridians which maintain the flow of bioelectricity have connection

with the main organs (or system) of the body. Each meridian has been given the name

of the organ with which it is connected. One end of each meridian lies in the hand, the

leg or the face and the other in one main organ. That is the reason why pressure

applied to a particular point on the leg, affects the remote organ connected with this

point.

Energy, known as “Qi “ in Chinese , is considered to be the motive force of all

life. According to Chinese medical theory, Liver-Qi stagnation causes women’s blood

to stagnate in the uterus, leading to periods of pain. In some cases , stagnant Liver-Qi

may turn into Liver- Fire which ,in turn, may lead to Blood – Heat. Blood – Heat

often combines with Damp-Heat in the uterus. The Sanyinjiao acupoint is located on

the inside of the ankle, four finger- breadths above the ankle bone. This acupoint is

also known internationally as spleen6 (SP6).

The intensity of the flow of bio energy in a particular meridian is not the same

throughout the day. The flow of bio energy in a meridian is maximum only once at a

definite time during twenty-four hours. Twelve hours after that time. the bio energy

flowing in that meridian is the minimum. A particular organ of the body doesn’t have

the smooth flow of blood it becomes sick. This lack of proper blood supply also gives

rise to various nervous disorders which either atrophies the nerves or makes their

24

ending shrink, leading to the coldness or numbness of the affected organ. In certain

cases they also become overheated. Both the conditions signify ailment or disorder of

the limb. By resorting to the acupressure techniques the normal, smooth blood supply

of the affected organ is restored.

Another theory is that some blood vessels develop a sort of crystalline

formation at their end which disturbs the smooth flow of blood. These crystals act as

insulators which slacken the nerve system of the particular organ. Unless these

crystals are removed by applying pressure or puncturing them, the ailment of the part

doesn’t get cured. This theory also endorses the view that various ailments to the body

are the consequence of the faulty or impeded blood supply to the part.

All branches of medicine believes that the whole human body is kept in good

.health by the smooth supply of blood. It is blood which nourishes all parts of the

body and energies them to fight out the foreign material which accentuates the

ailment in the body. By giving pressure at the right point further strength is provided

to that part to get rid of the crystals/foreign matter etc. This pressure removes it and

the smooth flow of blood takes the impurities to various ‘scavengers’ of the body like

kidney/skin etc, to eventually eject it out of the system.

A body sick when many of its centers (reflex point areas) develop

unhomogenious tendencies’ like their becoming unusually hot or cold, extra sensitive

or numb, extremely oily or dry, discoursed or over colored etc. In short, when the

body becomes a conglomeration of various un homogeneous pockets , it disturbs the

nature’s equilibrium in the body leading to various disorders, the well-established

ancient belief, our whole body is made of five elements earth water, fire, sky and air.

The guiding force behind these five elements is our body’s inherent bio-electricity or

25

bio-energy .According to this technique’s fundamental belief when this energy starts

‘leaking’ from certain points, they become sick. By giving pressure on these ‘leaking

holes’ these are plugged to restore the body’s health.

Acupressure physiology is works based on gate control theory. This theory

says the passage of pain impulse to the brain and resultant awareness of pain involve

much more than the simple telephone like circuit running from receptor to cerebral

cortex. It is believed that all pain impulses are controlled, modulated and modified by

means of functional gate. This is located in substantia gelatinosa of the spinal cord.

Under normal conditions this gate is wide open and pain impulses coming into the

spinal by way of posterior nerve roots can get across quite easily. Having passed the

gate they cross to other side of the spinal cord and travel up to spino-thalamic tract to

the thalamus and then to the cerebral cortex. This is how patient “feels” pain.

In acupuncture/Acupressure Analgesia, these pain impulses have to complete

for entry at a gate with a second stream of impulses which have been generated by

needle / pressure stimulation. The lateral impulse is not painful in character. The

Simultaneous appearance of these two streams of impulses cause overcrowding at the

gate and also confusion owing to the disparity in their rates of conduction, the net

result is jamming or closure of the gate, and since the pain impulses are thereby

blocked from proceeding further , the pain threshold is raised and no pain is felt.

While giving acupressure a release of hormone called endorphine. It is a

naturally occurring neuropeptides (having a Chain of 31 amino acids) and like

morphine and other opiates it has a marked propensity for binding on to the “Opiate

receptors” of the pain cell in the brain. Hence like morphine it has powerful analgesic

properties. Acupressure analgesia too can be explained on the basis of the endorphine

26

release. In acupressure analgesia that stimulation of sensory receptor lying in the

muscle result in a message to the brain which stimulates the pituitary gland to release

endorphine which in turn binds with opiate receptors in the pain cells to block the

pain stimuli from, reaching consciousness & awareness.

Acupressure is a technique used in Traditional Chinese Medicine (TCM) that

applies direct finger pressure on specific points of the body in order to alleviate

symptoms or to support various organs or systems of the body. Acupressure helps

dysmenorrhea to relieve symptoms like pain and distress. Acupressure has been

practiced as a healing art for at least 5,000 years. It is the third most popular method

for treating pain and illness in the world. Till 17th century, the western world was

completely unaware of Chinese medicine and acupressure. The recent history of

acupressure reveals that in 1970s World Health Organization after a series of research

declared acupressure medicine highly effective in treating 40 major diseases. This

complete health system has been documented for use in treating over 3000 conditions.

Acupressure uses gentle to firm finger pressure when these acupressure points are

stimulated, they release muscular tension, promote circulation of blood, and enhance

the body’s life force energy to aid healing, relieve pain, detoxify the body, and

strengthens resistance to disease and promote wellness.

Acupressure is the use of touch technique to balance energy channels in the

body or “Qi” energy or cosmic life force, which is called “Qi” in Chinese, moves

inside the body in certain path or channels called meridian, energy flow in these

meridian is in balance. If energy is reduced in one or more meridian body health

would be affected, when acupressure applied to specific sore point along the

meridians at different points for different conditions, this pressure tricks the body into

27

thinking it has been damaged. The body then produced endorphins to relieve distress

in the organs and system corresponding to that acupressure point. While the body is

healing at the point of pain, it produces a healing response ail along the meridian.

Sanyinjiao or the meeting point of spleen, liver and kidney channels is located on

spleen meridians, which is four fingers above the inner ankle behind the posterior

edge of tibia. This point is considered as a selective point in treating women’s

diseases.

Experimental studies on acupressure and acupuncture have demonstrated their

effectiveness in alleviating discomfort through sedative and analgesic effects. Many

studies have shown that acupressure is effective for pain relief in specific sites such as

the SP6 point has been reported to alleviate dysmenorrhea. The SP6 acupoint is the

junction point of the liver, spleen, and kidney meridians, and it is proposed to

strengthen the spleen, resolve and expel dampness, and restore balance to the Yin and

blood, liver, and kidneys.

Chen et al (2015).The effects of acupressure at the Sanyinjiao point (SP6) on

symptoms of primary dysmenorrhea among adolescent girls. Thirty one (87%) of the

35 experimental participants reported that acupressure was helpful, and 33 (94%)

were satisfied with acupressure in terms of its providing pain relief and psychological

support during dysmenorrhea. Another study by Mirbagher et al conducted a

randomized controlled pre and post-test design was employed to verify the effects of

SP6 acupressure on dysmenorrhea. Results shows significant differences were

observed in the scores of dysmenorrhea between the two groups immediately and 3 h

after treatment.

28

Gharlloghi et al studied to determine the effects of acupressure at Sanyinjiao

(SP6) point and diji (SP8) point on pain severity of primary dysmenorrhea and the

associated systemic symptoms. The findings of study indicate that the severity of

dysmenorrhea pain diminished significantly for up to 2 hours following treatment

with acupressure at the SP6 and SP8 points (p<0.001). Furthermore, the severity of

associated systemic symptoms reduced significantly after acupressure at the SP6 and

SP8 points, except for nausea and vomiting.

The Sanyinjiao (SP6) acupoint is commonly used to induce labor and relieve

pain during childbirth and to relive pain after cesarean section Despite renewed

interest in the use of acupressure for dysmenorrhea, few studies have examined the

effects of acupressure on primary dysmenorrhea, hence the investigator motivated for

this present study. Acupoint Sanyinjiao (SP6) was selected for study because it is the

acupoint of choice in gynecology and is easy for women to locate and apply pressure

to without medical assistance

In an attempt to offer comfort, pain control and symptom management, nurses

are increasingly offering acupressure as part of their focus on comprehensive patient

care. According to many research reports acupressure may be regarded as a viable

nursing intervention. From a practical perspective, Acupressure has several distinct

advantages. It is non invasive, free, and relatively easy to learn. Most importantly,

since it depends on neither tools nor product, it is more accessible than medical

techniques, and easily taught to patient to enable them to engage in holistic self

treatment one patient learn the techniques involved, acupressure can be self

administered at home as required, thus reducing the dependence of patients on clinic

29

visits. Thus emphasizing a need for designing acupressure on dysmenorrhea for

adolescent girls.

Statement of the Problem

A study to assess the effectiveness of acupressure in relieving pain and distress

related to dysmenorrhea among adolescent girls in selected schools at Kanyakumari

District

Objectives of the Study

The objectives of the study were as follows






group of adolescent girls.





adolescent girls.



girls.

30

Operational Definitions

An operational definition is a clear concise detailed definition of a measure

Effectiveness

The effectiveness of acupressure in this study refers to significant reduction in

the level of pain and distress related to dysmenorrhea after acupressure as measured

by visual analogue pain scale and modified Moose Menstrual Distress Questionnaire

and determined statistically by the difference in the pre test and post test score.

Acupressure

In this study acupressure is gentle pressure applied in the Sanyinjiao point

(3 cun - superior to the tip of medial maleolus, posterior to medial border of tibia) sp6

situated in the midpoint four fingers above the tip of medial malleolus bone about 20

minutes for three days in two times a day for first three days of menstruation.

Pain

In this study pain refers to the subjective experience of perceived pain by

adolescent girls during first three days of menstruation as measured by Visual

Analogue Scale for Pain (VASP).

Distress

In this study distress means, feeling of physical, psychological and social

discomfort experienced by adolescent girls during menstruation which is measured by

Modified Moos Menstrual Distress Questionnaire (MMMDQ).

31

Dysmenorrhea

In this study dysmenorrhea means Painful menstruation in girls with normal

pelvic anatomy usually begins during adolescents characterized by crampy pelvic pain

and distress at the onset of menses lasting one to three days as measured by Modified

MMDQ and VASP.

Adolescent girls

In this study adolescent girl refers to students studying in schools who have

attained their menarche, aged between 14 and17 years and studying in 9th and 11th

standard.

Satisfaction

It refers to feeling of gratification attained by adolescent girls with acupressure

using satisfaction rating scale developed by the researcher.

Assumptions

The study assumes that

Menstrual pain and distress is common among the adolescents and early adults.

The experience and expression of pain will be unique to each individual.

Acupressure has no side effects.

It enhance immune effect,(Increase white corpusells and Gamma globulins)

Acupressure has Analgesic effect, (Raising pain threshold)

32

Acupressure has Homeostatic / Regulatory effect, (Homeostatic is maintained by

balance activity of sympathetic and parasympathetic divisions of Autonomic Nervous

system and also by endocrine system).

Acupressure increase circulation and energy flow.

It provides strength and resistance to disease.

Acupressure stimulates the brain to release the body’s natural pain killer (Neuro

transmitters and Endorphins).

Null hypotheses

H01 There will be no significant difference in the pain and distress related to

dysmenorrhea before and after acupressure among control and

experimental group of adolescent girls.

H02 There will be no significant relationship between pain and distress

related to dysmenorrhea among control and experimental group of

adolescent girls before and after acupressure

H03 There will be no significant association between the pain related to

dysmenorrhea and their selected socio demographic variables in control

and experimental group of adolescent girls.

H04 There will be no significant association between the distress related to



33


dysmenorrhea and their selected menstrual variables in control and



dysmenorrhea and their selected menstrual variable in control and


Delimitations

The study was delimited to

Only adolescent girls who have primary dysmenorrhea.

Adolescent girls studying in 9th and 11th standard in selected schools at Kanyakumari

District.

Adolescent girls aged between 14 and 17 years.

Only Acupressure as intervention (20 minutes twice a day for 3 days during

menstruation.)

The period of data collection was only 12 months

Conceptual Framework

Based on Collestia Roys’ Adaptation Model

The conceptual framework deals with the interrelated concepts that are

assessable in some rational scheme by virtue of their relevance to a common theme

(Polit and beck, 2013).It is developed from the existing theory and helps in

34

identifying and defining concepts of interest and proposing relationship among them.

The model gives a direction for planning research design, data collection and

interpretation of findings.

The present study aims at describing the adoptive responses to the pain and

distress related to dysmenorrhea by the adolescences girls. Theoretical frame work of

the study is based on the concept of “Roy’s adaptation model”. The core of Roy’s

adaptation model is the belief that a person’s adaptive responses are function of the

incoming stimuli and the adaptive level. The adaptation level is made up of the cooled

effect of three classes of stimuli

Focal stimuli -Which immediately confront the

individual.

Contextual stimuli - This occurs on a result of the focal

stimuli.

Residual stimuli -Those factors that are relevant but

cannot be validated.

Roy further conceptualizes the person on having four modes of adaptation –

Physiological, self concept, and roll function and interdependence relation. These

categories established are valid and useful for nursing assessment.

The conceptual frame work presented in figure 1, 2, 3 explains the application

of Roy’s adaptation model in the care of adolescent girls during dysmenorrhea.

35

Focal stimuli - It is the stimulus most immediately confronting the person and the one

to which the person must make an adoptive response. In this study the focal stimuli is

adolescent girls experiencing pain and distress related to dysmenorrhea every month.

Contextual stimuli - They represent all the other stimuli that contribute to the

behavior caused or precipitated by the focal stimuli. In the study the contextual

stimuli is the socio demographic variable and menstrual variables of adolescent girls.

Residual stimuli - These are the beliefs, attributes and tracts that influence the

person, present situation, mediate and contribute to the effect of focal stimuli. In this

study residual study may be the adolescent student’s attitude and belief about

dysmenorrhea which is not studied by the investigator.

The triggering event result from the interplay of three stimuli, the stimuli and

the triggering event finally end in adaptive or maladaptive responses.

The control process

It consists of regulator and cognator mechanism. The system’s integrity or

wholeness is behaviorally demonstrated when the system is able to meet the goals in

terms of survival, growth, reproduction, mastery and transformation of the system and

the environment. Adoptions include reporting the ability to establish and satisfaction

with dysmenorrheal management.

Regulator

It is a subsystem of coping mechanism which responds automatically through

the neural, chemical and endocrine process.

36

Cognator

It is a sub system of coping mechanism which responds through complex

process of perception, information processing, learning judgment and emotion.

Roy’s models consider the regulator and cognator coping mechanism to be sub

system of the person as an adoptive system. The regulator sub system has the

components of input, internal process and output.

The cognator

Perception- related to the internal process of selective attention, coding and

memory. Learning- is correlated to the process of limitation, reinforcement and

insight. Problem solving and decision making are examples of the internal process

rule out judgment. Emotion- has the process of defense to seek relief, effective

appraisal and attachment.

Adoptive modes

Effectors or adaptive modes are the ways of coping that manifest the regulator

or cognator activity, i.e. physiological self concept, role function and inter-

dependence. In this study adolescence may be manifested as,

Physiologically-The discomfort experienced by the adolescence girls with pain and

distress related to dysmenorrhea.

Self concept- Dysmenorrhea caused by powerlessness, Poor self esteem, sense of

dissatisfaction tension and its effect on negative self concept and their general well

being.

37

Roll function- Unable to attend social activities and academic activities.

Inter dependence- Need of relational integrity, with family support and peer support

to face challengeable moments.

Adoptive responses - Are the responses that promote integrity of the person in terms

of goals of survival, growth and re production. In the study the adoptive responses can

be measured the level of pain and distress related to dysmenorrhea among adolescent

girls before and after implementation of acupressure.

Output:

The behavioral outcome of the adaptive responses or ineffective responses of

the person constitutes the output. In this study the experimental group adolescent girls

after acupressure they had experienced reduction in the pain and distress related to

dysmenorrhea. This was proved in the post test score of the experimental group of

adolescent girls..

38

Fig 1: Conceptual frame work on effect of Acupressure upon pain and distress

related to dysmenorrhea based on Roy’s adaptation model

INPUT CONTROL PROCESS

EFFECT INTERVENTION RESPONSES

Focal Stimuli

Pain and distress related to dysmenorrhea.

Contextual stimuli

Socio demographic variables

Age, Education, Mothers’ education, Occupation, Family income, Type of family, Residence, Religion, Dietary habits, Food craving.)

Menstrual variables

Age at menarche, Duration of menstrual cycle, Extent of flow, Duration of bleeding, onset of pain, Family history, Treatment taken for dysmenorrhea.

Residual stimuli

Attitudes and beliefs ,Lack of knowledge regarding dysmenorrhea management (Not studied)

Regulator

Autonomic reflexes

Psychomotor

responses

Cognator

Perception Learning Judgment and

emotion

(Receives, the internal pain stimuli)

Exhibited in coping mechanism Physical Need for dysmenorrheal

pain and distress management.

Self Concept: Powerless Poor self esteem Anxiety Restricted

Activity Role Function: School Absenteeism Lowed academic

activities Disturbed social

responsibilities / participation of social activities.

Inter dependence: Need for relational

integrity family and peer support.

Good coping skill: Pain and distress

Reduced Enhance self

Satisfaction Healthy life style

Poor Coping skill: Lack of ability

to cope with dysmenorrheal pain and distress

Dissatisfaction with the management

FEED BACK

Adaptive Respons

Ineffective Response

39

EFFECTIVE

RESPONSE

POWER

Psycho

motor

choice of

Response

Selective attention coding and memory

Limitation reinforcement and insight

Problem solving and decision making

Defense to seek relief and effective appraisal and attachment.

EXTERNAL

STIMULAI

Intact path ways

and apparatus

for perceptual /

information

processing.

Learning

Judgement

Emotion

INTERNAL STIMULAI

THE COGNATOR

40

Internal Stimuli

Neural

Chemical

THE REGULATOR

External Stimuli

Causes of Uterine contraction, (Dysmenorrhea)

Neural

Chemical

Intact Pathways to

and from CNS

Spinal cord, brain stem and AutonommicReflexes

Responsiveness of Endocrine Glands

Perception, memory

Effectors

Hormonal output

Psychomotor choice of Response

Autonomic reflex

response

Body Response

Effectors

Fig 3: Conceptual frame work on effect of Acupressure upon pain and distress related

to dysmenorrhea based on Roy’s adaptation – sub system -Regulator model

Memory memory

41

Summary

This chapter 1 has dealt with the introduction which includes background of

the study, significance and need for the study, statement of the problem, objectives of

the study, assumption, conceptual frame work, operational definition, null hypotheses

and delimitations and conceptual framework which included Roys’ adaptation model.

42

CHAPTER - 2

REVIEW OF LITERATURE

A literature review involves the systematic identification, location, scrutiny

and summary of written materials that contain information on a research problem.

(Polit & Beck 2010). A review of literature is a critical analysis of earlier scholarly

work on a chosen topic.

An extensive search of research and non research literature were obtained

through printed and electronic databases for acquaintance with the rationalized

knowledge of selected problem under study search engines such as Pubmed /

Medline, EMBASE, and Cochrane Central Register of Controlled trials for trials /

studies reported in English. Also direct searches of specific journals and backward

searches through reference lists of related publications were done.

Review of literature for the present study aimed to synthesise existing

evidence of studies on various study designs, with a special focus on randomised

controlled trials on the use of pharmacologic and non – pharmacologic interventions

to manage pain and distress related to dysmenorrhea among adolescent population.

The review also focused on effect of acupressure in other conditions..

The review of literature for the present study is organized under the following

headings: Literature reviewed related to the research work and Development of

Nursing Evidence Based Practice Protocol.

43

The Nursing Evidence Based Practice Protocol include Nursing Evidence

Based Practice question development, PRISMA Flow Diagram, Characteristics of

included papers (Study design and Intervention wise) in the present study and

Individual Evidence Summary.

.The literature reviewed related to research work is organized under following

heading.

Prevalence of dysmenorrhea

Non pharmacological modalities and its effects on dysmenorrhea

Acupressure and its effect on different conditions.

Acupressure and its effect on pain and distress related to dysmenorrhea

Prevalence of Dysmenorrhea

Ravi, Sha, Palani, Edward and Sathyasekaran (2016) carried out a cross

sectional school based study at Department of Community medicine, Sree

Ramachandra Medical University, Chennai, Tamil Nadu. Adolescent girls who

attained menarche at least 1 year before the data collection period were selected using

a simple random sampling method. Total of 350 participants were participated in the

study. A structured questionnaire was used for the data collection. The main outcome

measured in this study was the prevalence of menstrual problems, namely

dysmenorrhea, menorrhagia, and irregular menstrual cycles. The mean age of the

study participants was 14.74 years. The mean age at menarche was 12.4 years. In this

study, 87.7% of the girls suffered from a menstrual problem. Overall, dysmenorrhea

44

prevalent was 72.6% and menorrhagia and irregular menstrual cycles were present

among 45.7% and 31.7% of the participants respectively.

A cross sectional study was conducted by Priya, Ratnam, Shanker (2016)

among 500 adolescent girls the age group of 14-19 years who had attained menarche.

The student’s data were collected by personal interviews by using a pre tested

structured questionnaire. The questionnaire comprised of age, socio economic status,

educational status, menorrheal age, menstrual pattern, premenstrual symptoms (PMS),

dysmenorrhea, impact of menstrual disorders on school attendance, consultation for

menstrual problems and the hygienic practices followed during the time of

menstruation The mean age of menarche was 12.67 years. (62.2%) of the adolescent

girls had pre-menstrual symptoms. Among the various menstrual symptoms the most

common were abdominal pain (94.6%), cramps (82.2%) and backache (77.8%).

dysmenorrhea (65%) was the most common one followed by oligomenorrhoea (16%)

and menorrhagia (11%). Only 41.6% of them had the habit of using sanitary pads and

majority had said that the average pad/cloth (51.4%) used on those days were only 2

and 905 of the girls did not had the habit of cleaning the genitals with soap and water.

In West Bengal an observational study was conducted with 875 students by

Subhraboat (2016) to determine the problem related to menstrual cycle. Pre designed

questionnaire and verbal multidimensional scoring system were used to collect the

data from study samples. The study findings shows that prevalence of dysmenorrhea

was 76% among there 16.9% reported severe dysmenorrhea 43.31% as moderate and

24.9% were mild, 85% have PMS, (P<0.05) it shows statistically significant the study

concluded dysmenorrhea is a major problem leading to college / class absenteeism.

45

Kharaghani and Damghanian (2016) conducted a Meta analysis to estimate

the overall prevalence of dysmenorrhea in Iran. Meta analysis was done by a random

– effects model. Twenty five eligible students were assessed among 9,677

participants. The study results revealed 6,748 had experience primary dysmenorrhea

and 280 had secondary dysmenorrhea. The overall prevalence rate of primary

dysmenorrhea was 0.71 (95% CI = 0.67, 0.77) and secondary dysmenorrhea was 0.18

(95% CI = 0.03, 0.32). The study concluded that primary dysmenorrhea is one of the

most common problems in Iran and only few studies reported secondary

dysmenorrhea. Also, the study suggested further evidence base data is needed to

estimate the exact estimation of prevalence of dysmenorrhea in Iran.

Most females exhibit some degree of pain and distress during menstrual

period, which can create impact on their daily activities, and disappoint their

efficiency and provide distress at home and even at their work place. A prospective

interventional study prepared for the adolescent girls is to evaluate the prevalence and

pattern of dysmenorrhea and to observe the menstrual hygiene practices among 232

female students in a technical graduate college to improve their quality of life. The

data was collected by general assessment form, questionnaires regarding menstrual

characteristics and dysmenorrhea severity. The study concluded prevalence of

dysmenorrhea was formed to be 81.7% and there was an association between

dysmenorrhea and consumption, exercise, breakfast, menstrual bleeding duration

day’s menstrual cycle irregularity and family history of dysmenorrhea ( Atlun and

Jyothi, 2016)

The prevalence of dysmenorrhea is high in adolescent women with estimates

ranging from 20 to 90% depending on the measurement method used about 15% of

46

adolescence girls report severe dysmenorrhea and it is the leading cause of recurrent

short term school absenteeism in adolescent girls in the United States. A longitudinal

study of a representative Cohort of Swedish woman found a prevalence of

dysmenorrhea of 90% in women 19 years of age and 67 % in women 24 years of

age. Ten percentage of the 24 years old reported pain that interfered with daily

function most adolescents self medications with over the counter medicines and few

consult a physician about dysmenorrhea. (Mahbbobeh kafaei et al, 2016).

A cross- sectional study was conducted by Moolraj Kural (2015) department

of Obstetrics and Gynecology, Index Medical College Madhya Pradesh, India, for a

period of 3 months. The study was performed on a total of 310 girls aged between 18

and 25 yrs. A questionnaire regarding details of menstrual cycle was filled up by the

participants. The study was estimated that prevalence of dysmenorrhea various from

20% to 95%.

A systematic review in different countries was carried out by Sanctis,

Soliman, Elsedfy and Soliman (2015) to analysis the epidemiology of dysmenorrhea

and its effect on public health. The data were identified from pub med, Embase and

Google based on the keywords, dysmenorrhea, adolescents and epidemiology which

is published from 2010 to Aug 2015. 50 students were scrutinized. The study

findings shows, the prevalence of dysmenorrhea varied from (34%) Egypt to (94%)

Oman, Korea (0.9%) reported very severe pain to Bangladesh (59.8%). About 50% of

students (53.7% - 47.4%) reported a family history of dysmenorrhea. Incidence of

dysmenorrhea was 0.97 times, lower as age increased (P< 0.006). The study

concluded, the main gynecological complaint of adolescents is dysmenorrhea. It is

one of the leading causes of absenteeism from school and work.

47

An observational cross sectional study was conducted by Sharma, Sahayaraj,

Sujatha, Rehman, Abirami, Khan, Aditya and Ajantha (2014) to investigate the

burden of dysmenorrhea and menorrhagia, at Saveetha University adolescent girls

who had attained menarche in the age of 17-20 yrs, total 252 adolescent girls were

participated. The study findings raveled the median age of menarche was 13-14 yrs.

Regular menstrual cycle were apparent in 77.4% of young adults. Menstrual cycle

duration was more than 7 days in 13.9% of individuals. Although 70.4% of girls

experienced dysmenorrhea only 3.6% of girls experienced dysmenorrhea only 3.6%

used pharmacotherapy due to the fear of side effect.

A cross sectional study was conducted by Yasir, Kant, and Dar (2014) to

evaluate the prevalence of dysmenorrhea, its impact and management strategies

among 356 females aged between 18- 25 years at Mohiuddin Islamic University in

Pakistan. The tool used to collect the data were structured questionnaire, visual

analogue pain scale. The study reported 56.1% had dysmenorrhea 25% reported being

absent to college due to pain, 65% reported difficult to concentrate, 64% had less

involvement in social activities 58% had mood disturbances,56% reported mood

disturbences,43% were using house hold remedies for dysmenorrhea, 66% were using

analgesics and 4% sought medical advice for pain. The study conducted that

dysmenorrhea is a very common problem. More over it affects academic performance

and limiting daily activities requiring appropriate intervention.

Sinha, Srivastava, Sachan and Singh (2014). A school based cross-sectional

study to identify the menstrual pattern and the prevalence of dysmenorrhea among

school going adolescent girls in Lucknow district of Uttar Pradesh, India. A total of

640 Adolescent girls were recruted in the study. Data was collected by using

48

structured questionnaire and Visual Analogue Pain Scale. The findings highlights

overall prevalence of dysmenorrhea was found to be 73.9% with 74.4% girls in urban

schools and 72.7% girls in rural schools. The mean age at menarche was 12.87 years

(S.D±1.45). In urban area it was 12.69 years (SD±1.37) and 13.22 years (SD±1.56) in

rural areas.

The prospective observational study was conducted among 435 higher

secondary girls between the age group of 12 and 16 years in rural area of Amravati

district of Maharashtra by Rahman, Aditya (2015). The aim of the study was to

assess the menstrual pattern & problems. The samples were required by purposive

sampling technique. Data was collected by structured questionnaire. The study finding

shows 17.9%, adolescent girls reported premenstrual syndrome, 81.3% girls had

abdominal pain during menstruation followed by 28.5% cramp, 11% were

uncomfortable , 11% had backache ,2.5% had depressed , 3.4% girls were did not

have any symptoms during menses . The study concluded that menstruation is an

important milestone for adolescent girls and menstrual problem are common among

adolescent girls.

A cross sectional study was investigated by Chauhan and Kodnari ( 2014)

among adolescent girls between the age group of 14-19 years in Vadora City , Gujarat

India. Samples 91000 were collected by using oral questionnaire. The study finding

shows that the prevalence of dysmenorrhea 75%, school absenteeism 65% decreased

school performance 56%, prevalence of associated menstrual symptoms 57% lower

adnominal pain 42% and emotional instability 46%. The study concluded that

dysmenorrhea is common among adolescent girls. Health education on issues, related

to reproductive health should be incorporated with school curriculum.

49

Wasnik, Dhumale and Javarkar (2014) conducted a prospective

observational study to assess the menstrual pattern and problems among 435

adolescent girls of Amravati district, Maharashtra, India. Purposive sampling

technique was used to recruit the study samples. Data were collected by using pre

determined questionnaire. The study findings revealed that the 17.9% reported pre

menstrual syndrome, 81.3% girls had abnormal pain, 28.5% had abdominal cramp,

11% were uncomfortable, 11% had backache and 2.5% had depression. The study

concluded that dysmenorrhea was the commonest problem among the adolescent also

it suggested health educational activities among the adolescent girls for effective

management of menstrual problem.

A cross sectional study was conducted to evaluate the menstrual

characteristics and prevalence of dysmenorrhea among 133 female students aged

between 17 and 23 years in Suraj, western India. The data was collected by general

assessment form, menstrual characteristics and dysmenorrhea questionnaire, visual

analogue scale and verbal multidimensional scoring system (VMMS). The study

findings revealed that prevalence of dysmenorrhea was (71.2%), (n = 89) mild 58

(65.17%), moderate 19 (21.35%) and severe 12 (13.48%). The study concluded that

dysmenorrhea is a very common problem among girls and affects their academic

performance. It can be better managed by mental preparation and by appropriate

change in life style (Selvisha , Makwana and Sha, 2014).

A descriptive survey was conducted to assess the prevalence of dysmenorrhea

among 233 adolescent girls of Udupi district, Karnataka, India by George, Sangeetha

and Shetty (2013). The tools used for the study were baseline performa,

Dysmenorrhea questionnaire and numerical pain scale. The study findings revealed

50

that the prevalence of dysmenorrhea was 1246 (62.70%), 28 (12%) had mild pain,

77(33%) had moderate pain and 41 (17.6%) had severe pain during menstruation,

tiredness 110 (75.34%), back pain 106(72.60%) and irritability 97(66.43%).The study

conducted that dysmenorrhea as a very common problem among adolescent girls and

the study indicates the need for appropriate intervention through life style changes.

A recent study (2012) done among students of nine, PGIMER, Chandigarh,

Showed the prevalence of dysmenorrhea was 87.5%. It decreases productivity,

creativity, and work performance due to serious daily stress & a common cause of

absenteeism in students. The common strategy used is over the counter drugs but

these drugs have many adverse effects. Moreover, it is a social stigma for the girls

who wish to get medical treatment for dysmenorrhea. So, there is a need to adopt risk

free approach or non-medicinal treatment which the girls can use in their

homes/hostel.

Grandi., Ferrari and Eagnacci (2012) conducted a cross – sectional

analytical study to determine the prevalence of dysmenorrhea and associated factors

among 408 young women in Italy. The tool used for this study was self assessment

questionnaire. The study findings revealed that menstrual pain was reported by

(84.1%) of women higher prevalence among smokers (P = 0.031) and lower

prevalence among hormonal contraceptive users (p = 0.015). The study concluded

that at least one in four women experiences distressing menstrual pain characterized

by a need for medication and absenteeism from study or social activities.

An exploratory study conducted by Kiran, Sandozi, Chakraborty,

Meherban and Ran (2012) for the prevalence, severity and treatment of

dysmenorrhea in medical and nursing students. A total of 401 students from SRM

51

University, 97 students from Vaidehi Institute of Medical Sciences and Research

Center, Bangalore respectively were enrolled in this study. In Chennai 306 students

gave a history of dysmenorrhea giving prevalence of (76.3%). (57.1%) had severe and

19.20% had mild dysmenorrhea. All the students enrolled in Bangalore presented with

a history of dysmenorrhea, 73.19 % with severe and 26.80% mild dysmenorrhea

.Allopathic treatment was taken by 33 and (37.11%), homemade remedies by 6.20 and

(2.06%) and ayurvedic medicines by 0.98 and (1.03%) by Chennai and Bangalore

students respectively. Homeopathic treatment was taken by 2.28% students in

Chennai alone.

A cross sectional study was conducted from Jan 2011 to May 2011 among 183

Adolescent girls (14-19years) in Schools and colleges of Kadapa town in Andhra

Pradesh to estimate the prevalence of dysmenorrhea among adolescent girls (14-

19yrs) and also to study the various symptoms of dysmenorrhea and its impact on

quality of life of adolescent girls. Out of 183 adolescent girls, 119 (65%) are

dysmenorrhea, (68.4%) and (61.2%) are from the urban and rural areas respectively.

Out of 81 adolescent girls with family history of dysmenorrhea 60 (74.1%) adolescent

girls have dysmenorrhea. Sickness absenteeism is seen among 47.9% dysmennorhic

girls. Quality of life is significantly reduced among dysmennorhic girls. Almost

73.1% of rural girls rely on self help technique to manage the dysmenorrhea as

compare to urban girls 55.2 %.The study concluded that the dysmenorrhea is a very

common problem among adolescent girls and it affects their quality of life. It can be

better managed by mental preparation and life style modification like regular physical

exercise and with assurance to the urban girls. (Keembhar, Reddy, Sujana, Reddy

and Bhargavi , 2011).

52

Rodrigues et al (2011) carried out a study to determine the prevalence of

dysmenorrhea, limitations in daily living and health care use due to menstrual pain.

Data were obtained by a 24 item anonymous questionnaire. One hundred and seventy

two (62.8) subjects experienced menstrual pain. of these, 65.7 reported limitations in

their daily activities due to dysmenorrhea. The prevalence of limitations in daily

living was influenced by the presence of additional symptoms (r = 0.331; p < 0.001),

pain intensity (r = 0.281; p < 0.027). The most commonly mentioned limitation was

anxiety/ depression (42.5). Fourteen of the subjects reported missing school or work

due to dysmenorrhea.

The prevalence of dysmenorrhea, menstrual syndrome and its severity were

assessed among female medical students. A cross-sectional descriptive design was

adopted on 300 female medical students, all participants were given a questionnaire to

complete; questions were related to menstruation elucidating variations in menstrual

patterns, history of dysmenorrhea and pre-menstrual syndrome and its severity and

absenteeism from college/class; to detect the severity of dysmenorrhea the verbal

multidimensional scoring system, participants were given 20 minutes to complete

the questionnaire. The prevalence of dysmenorrhea was (51%) and that of pre-

menstrual syndrome was (67%) of students with dysmenorrhea reported limitation of

daily activities. Findings of the study shows, dysmenorrhea and PMS is highly

prevalent among female medical students, it is related to college/class absenteeism.

Maximum participants do not seek medical advice and self treatment. (Leksmi,

Saraswathi, Saravanan and Ramachandran 2011).

Agarwal and Agarwal (2010) conducted s study to find out the prevalence of

dysmenorrhea severity and its associated symptoms among adolescent girls. The

53

prevalence of dysmenorrhea in adolescent girls was found to be 79.67%. Most of

them, (37.96%) suffered regularly from dysmenorrhea severity. The three most

common symptoms present on both days they have lethargy and tiredness (first),

depression (second) and inability to concentrate in work (third) whereas the ranking

of these symptoms on the day after the stoppage of menstruation showed depression

as the first common symptoms.

Harlow (2010). A descriptive study was conducted among 26 high schools located

in Erzurum, Northeastern Turkey. A total of 1951 single female adolescents, aged 13

to 18 years, were selected for this study. The prevalence of dysmenorrhea was high

among female adolescents (68.1-72.2%). Pain mostly lasted for one to three days

(56.6%), followed by less than 1 day (23.5%) and more than 4 days (14.9%),

respectively. Several symptoms were observed including sweating, appetite loss,

headache, distraction, nausea/vomiting, dizziness, diarrhoea, and fainting. School

performance was negatively affected by dysmenorrhea. Findings of this research

suggested that dysmenorrhea prevalence was high among female adolescents. The

duration and intensity of pain adversely affected school and social attitudes towards

their families and friends.

Ortiz (2010) carried out a study to evaluate the prevalence, impact and treatment of

primary dysmenorrhea among 1539 Mexican University students of various

department. Data were collected by using multiple choice questionnaires which

consists of presence, severity, symptoms, treatment and limitations caused by

dysmenorrhea. The study findings revealed 64 % of the women experienced

dysmenorrhea. Dysmenorrhea was more prevalent among nutrition and psychology

students than among medicine, pharmacy and dentistry students (p < 0.05).

54

Dysmenorrhea was mild in (36.1 %) of women, moderate in (43.8 %) and severe in

(20.1%). Nursing students reported an intensity of pain that was significantly higher

than medicine and dentistry students (p < 0.05). Medicine (29.9 %) consulted a

physician and (61.7%) practiced self medication. The study concluded that the

prevalence of dysmenorrhea among Mexican university students were high and the

pain is not completely relieved despite the use of medication. It is necessary to

improve the therapeutic option for dysmenorrhea and to minimize the impact of

dysmenorrhea on social, economic and school activities.

Comparative cross sectional study was conducted by Kameswararao, Avasarala,

Saibharghavi and Panchangam (2008) to assess the epidemiological profiles,

perceptions, socio economic losses, and quality-of-life losses and management of

dysmenorrhea in different settings for effective management. The study conducted

with (101 girls in urban areas and 79 girls in rural areas) in the district of Karimnagar.

The prevalence of dysmenorrhea is (54%), (53% girls in urban areas and 56% girls in

rural areas). Sickness absenteeism (28% - 48%), socio economic losses, and

perceived quality of life losses are more prevalent among girls in urban areas than

girls in rural areas.

Singh (2008) investigated a cross sectional descriptive study to evaluate the

menstrual problem specially dysmenorrhea and its severity in female medical students

its effect on their regular activities. 107 female medical students, all participants were

given a questionnaire to complete. The questions were related to menstruation

elucidating variations in menstrual patterns, history of dysmenorrhea and its severity,

premenstrual symptoms and absenteeism from college and /or class. To detect the

severity of dysmenorrhea they used the verbal multi-dimensional scoring system,

55

participants were given 20 minutes to complete the questionnaire. The age of subjects

at menarche was with a range of 10-15 years. The prevalence of dysmenorrhea was

73.83%, approximately 4.67% of dysmennorhic subjects had severe dysmenorrhea.

The average duration between two periods and the duration of menstrual flow were

28.34 days and 4.5 days respectively. Among female medical students who reported

dysmenorrhea, 31.67% and 8.68% were frequently missing colleges & classes

respectively.

Most females experience some degree of pain and discomfort during menstrual

period, which can impact on their daily activities, and disturb their productivity at

home or at their workplace. During menstruation, they should consult a doctor and

take medications to relieve their pain and other relevant symptoms of dysmenorrhea.

Vomiting, diarrhea, headache, weakness and fainting. At least (50%) of women

experience this problem during their reproductive years. The results of recent studies

showed nearly 10% of females with dysmenorrhea experienced an absence rate of 1 to

3 days per month from work or were unable to perform their regular/daily tasks due to

severe pain.

Klein and Litt [2006] was conducted an epidemiology study on adolescent

population (aged 12-17) reported a prevalence of dysmenorrhea of 59.7%. Among

them, 12% described it as severe, 37% as moderate and 49% as mild. Dysmenorrhea

causes 14% of patients to miss school frequently. Black adolescents were absent from

school more frequently 23.6% than whites 12.3%.

Hinohara (2006) investigated an epidemiology of dysmenorrhea in Japanese

women of menstrual age. Among 823 enrolled participants (age range, 18-51 years),

dysmenorrhea (mean duration 1.75 days: range 1-5 days) was reported in (15.8 %)

56

during the 1 – month study period. Common associated symptoms included headache

(10.77%), back pain (6.92%) and fatigue (5.38%). No participants with dysmenorrhea

visited a physician, while (51.5%) of the women used self medication and (7.7%)

used alternative medicine. This study shows the dysmenorrhea is significantly

associated with younger age and employment status.

Linda (2005) studied the prevalence, determinants, impacts, and treatment

practices of dysmenorrhea, 664 female students in secondary schools in urban and

rural areas were studied. Data was collected through a self-administered

questionnaire. About (75%) of the students experienced dysmenorrhea (mild 55.3%,

moderate 30.0%, and severe 14.8%). Most did not seek medical advice although

(34.7%) treated themselves. Fatigue, headache, backache and dizziness were the

commonest associated symptoms. No limitation of activities was reported by

(47.4%) of student with dysmenorrhea, but this was significantly more reported by

students with severe dysmenorrhea.

Babnkarim (2005) conducted a study to determine the prevalence of

dysmenorrhea among Hispanic female adolescents. A total of 706 female adolescents

participated among (85%) reported dysmenorrhea, of these (38%) reported missing

school due to dysmenorrhea during the 3 months prior to the survey and (33%)

reported missing individual classes. This study results shows menstrual pain was

significantly associated with school absenteeism and decreased academic performance

(p<0.01).

A cross-sectional, descriptive study was conducted by Blessing ,omalaso

,Adegbite, and Seriki (2005) to assess the knowledge of menstruation and primary

dysmenorrhea and the severity of pain they experienced during an episode of primary

57

dysmenorrhea and determine the management strategies. Dysmenorrhea is a problem

that girls and women face and often manage themselves with or without support from

health professionals among adolescents with dysmenorrhea. 150 students were

participated in this study by convenient sampling technique. In Nigeria..The tool were

used for the study was Face Pain Scale. The study findings highlighted . (58%) of

respondents reported pain between face 4 and face 10 on the Faces Pain Scale and the

majority used inappropriate methods to manage primary dysmenorrhea. School nurses

are able to assist adolescents and their mothers in proper management of primary

dysmenorrhea.

Lee (2004) investigated the incidence of dysmenorrhea and difference of

dysmenorrhea according to the general characteristics, life style, and menstrual

pattern in women community college students. Prevalence rate of dysmenorrhea was

(81. 9%). Among women who had dysmenorrhea, (46%) of them had family history

of dysmenorrhea, 47% of them had experienced the dysmenorrhea monthly, (89.2%)

of them had experienced dysmenorrhea on the first second day, (38.5%) of them

responded that the most painful region was low abdomen, (61.5%) of them responded

that they used analgesics to soothe dysmenorrhea and (42.6%) of them responded

digestive system related symptoms during menstrual period.

A descriptive – correlational study by Hillen (2004) explored the prevalence

of dysmenorrhea among senior high school girls in perth, Australia, its impact on

school, sporting, and school activities, student’s management strategies and their

knowledge of available treatment. The reported prevalence of dysmenorrhea among

these girls was (80%). (53 %) of these girls with dysmenorrhea reported that is limited

their activities, (37%) said that dysmenorrhea affected their school activities. The

58

most common medication used by those reporting dysmenorrhea was simple

analgesics (53%) followed by non- steroidal anti- inflammatory drugs (42%). Health

education measures are needed in the area to prevent unnecessary suffering and

interruption to school routine.

Pedron and Nuevo (2004) conducted a study to find the incidence of

dysmenorrhea and associated symptoms in women aged 12-24 years .A menstrual

symptom questionnaire was administered to 1066 women students from Mexico City.

The prevalence of dysmenorrhea was (52.1%) for the group <15 years of age, (63.8%)

for women between 15-19 years and (52.3%) for women between 20-24 years. The

frequency of absenteeism as a result of dysmenorrheal group < 15 years was (4.3 %),

(9.3 %) for the group 15-19 years and (19.8%) for the group 20-24 years. The most

symptoms associated with dysmenorrhea were nervousness, depression, irritability

and sleeplessness.

An explorative survey was conducted by Agarwal and Agarwal. (2003) to

study the prevalence and severity of dysmenorrhea in pre University College at

Gwalior. Nine hundred and seventy adolescence girls between the age of 15 and 20

years participated in the study. The multistage of cluster sampling technique were

used to recruit the sample. A visual analogue scale was used for measuring the pain

intensity. The study findings shows majority of the adolescent girl under study had

experienced dysmenorrhea (71.96%). (33.95) experienced dysmenorrhea every

month and (16.90%) experienced it is most of the month and it is statistically highly

significant (p < 0.001). The study concluded dysmenorrhea is a very common

problem among adolescent girls and they experience a number of physical and

emotional symptoms associated with dysmenorrhea.

59

Non - Pharmacological Modalities and its effect on Dysmenorrhea

A quasi experimental study was conducted by Mayi,Ponmathi and

Sivakumar (2016) at Chennai to compare the effectiveness between aerobic and

stretching exercise programs on pain and menstrual symptom with primary

dysmenorrhea among 100 samples between the age group of 16 and 26 years.

Samples were randomly assigned to group a (50) and group b (50). Data were

collected by using moos menstrual Distress Questionnaire and numerical pain rating

scale. The study findings revealed that there was no statistical significant difference in

pain intensity and menstrual symptoms between two groups, but group had better

clinical outcome with Moos Menstrual Questionnaire. The study concluded that there

is no significant difference between aerobic verses stretching exercise programe for

pain and menstrual symptoms with primary dysmenorrhea

Shanmugam, ,Susila and kalaimathi (2016) investigated a pre experimental

study to assess the effectiveness of hot application on dysmenorrhea among 30

adolescence girls in Billroth college of nursing at Chennai, Tamil Nadu. Samples

were recruited by purposive sampling technique. Data were collected by using Visual

Analogue Scale. The study findings shows there was a significant reduction in level

of dysmenorrhea among adolescence girls after hot application (p<0.05).

Kashefi et al (2014) carried out a study to compare the effect of ginger, Zinc

Sulphate and placebo on the severity of primary dysmenorrhea among 150 high

school students. The participants were divided into three groups. The first group

received ginger capsules, the second group received placebo capsules for 4 days. The

severity of pain was assessed by visual analogue scale. The study findings showed

that the severity of pain was significant different between , before and after the

60

intervention in both the ginger and the Zinc Sulphate groups (p<0.001) compared with

placebo receiving group, participants receiving ginger and Zinc Sulphate reported

more alleviation of pain during the intervention (p<0.05). Ginger and Zinc Sulphate

had similar positive effects on the improved of primary dysmenorrhea pain in young

women.

Effect of aromatherapy massage on a group of nursing students studied Tyseer

(2013). A randomized blind clinical trial of cross over design was used. In the first

treatment phase group 1 (n=48) received aromatherapy abdominal massage for seven

days prior to the menstruation using the essential oils ( Linnamon, clove, rose and

lavender in a base of almond oil) group 2 (n=47) received the same intervention but

with placebo oil (almond oil). In the second treatment phase, the two groups switched

to alternative regimen. Level and duration of pain and the amount of menstrual

bleeding were evaluated at the base line and after each treatment phase. The study

results suggest that the level and duration of menstrual pain and the amount of

menstrual bleeding were significantly lower in the aromatherapy group than in

placebo group.

Usha Nag (2013) to analysis the effect of Yoga and meditation as alternative

therapy for primary dysmenorrhea in young students and its outcome on school

absenteeism. 113 Medical students, Unmarried girls from Siddhartha Medical College

with primary dysmenorrhea were randomly assigned to the study (n=60) and control

group (n=53). Semi structured questionnaire and the numerical pain rating scale were

administered on all the participants at base line and after three months. The study

group was practiced Yoga and pryanayama and meditation. The study findings

showed that a significant (p<0.0001) reduction in the perceived pain after Yoga

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intervention in study group (83.33%), reported complete pain relief. No reduction of

pain was found in the control group. After Yoga intervention, absenteeism dropped

,daily activity was improved in study group.

Halder (2012) conducted a study to examine the comparative efficacy of

progressive muscle relaxation and the oral intake of ginger on symptoms of

dysmenorrhea among nursing students of Pune, Maharashtra. The study students

(n=75) were divided in three groups, two experimental and one control, Ginger

powder I gm per dose was administered twice a day with warm water after meal and

the second experimental group was practiced muscle relaxation technique during the

first three days of their menstruation. Main outcome measures were the severity of

selected symptoms of dysmenorrhea. The daily symptom calendar and 5- point. Likert

scale was used to assess the severity of selected symptoms of dysmenorrhea. Main

outcome measures were the severity of selected symptoms of dysmenorrhea. It was

concluded that in treating symptoms of dysmenorrhea, ginger powder has efficacy

superior than the progressive muscle relaxation.

A prospective randomized cross over study was investigated by Amina and

Neimer (2012) the effect of aromatherapy abdominal massage on reducing primary

dysmenorrhea among 100 nursing students at Mansoura University. The samples were

randomly assigned to two groups. Data were collected by using VAS-pain Scale. The

study findings revealed that the level and duration of menstrual pain and the amount

of menstrual bleeding were significantly lower in the aroma group than in the placebo

group (p<0.001).The study concluded that the aroma therapy can be a best non

pharmacological pain relief measure for girls suffering from dysmenorrhea or

excessive menstrual bleeding.

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A quasi experimental study to investigate the effect of Aromatherapy massage

on dysmenorrhea among 438 nursing students in Turkish. Subjects were allotted by

random sampling technique. The tool used to assess the level of menstrual pain was

visual analogue scale. The study findings revealed that the lavender massage was

found to decrease the level of pain perception during menstruation at a statistically

significant rate. The study concluded the aromatherapy massage was effective non

pharmacological measures in reducing dysmenorrhea. (Apay, Arslan,and Akpinar,

2012)

An experimental study was conducted by Mahvash, Alijani, Kohandel and

Mehdi (2012) to examine the effect of physical activity on primary dysmenorrhea

among 50 female students of Islamic Azad University at Iran. Samples were recruited

by random technique to the experimental (N=25) and control (N=25) group. The tool

used for this study was MC Gill’s questionnaire. The study findings revealed that

performing a regular physical activity significantly reduced type of drug consumed (p

< 0.08), number of drug used (p <0.01), volume of bleeding (p < 0.02), rate of

bleeding (p < 0.05), length of menstrual pain (p < 0.01), and intensity of pain (p <

0.01, p < 0.05). The study concluded Participating the detrimental effect of primary

dysmenorrhea symptoms in young females.

Rakhshaee (2011) studied a randomized clinical trial design to determine the

effectiveness of Yoga among 92 adolescents with primary dysmenorrhea. The

samples were randomly assigned to an experimental group (n=50) and a control group

(n=42). The data were collected by using questionnaire of menstrual characteristics

and visual Analogue scale for pain. The study findings revealed that there was a

significant difference in the pain intensity and pain duration in the experimental group

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(p<0.05). The study concluded that practicing Yoga reduced the severity and duration

of primary dysmenorrhea. Yoga is one of the safest and effective treatments for

primary dysmenorrhea.

A prospective randomized cross – over study to investigate the effect of aroma

therapy by Tyseer. Zoub, Amina ,Nemer, Hany and Baraka (2011) to evaluate the

abdominal massage on primary dysmenorrhea among 100 Nursing students at

Mansoura University. The samples were randomly assigned to two groups. Group 1

received aromatherapy abdominal massage where as group 2 received same

intervention with placebo oil (almond). The data were collected by using VAS- pain

scale. The study findings revealed that the level and duration of menstrual pain and

the amount of menstrual bleeding were significantly lower in the aromatherapy group

than in the placebo group. The study concluded that the aromatherapy can be a best

non- pharmacological pain relief measure for girls suffering from dysmenorrhea or

excessive menstrual bleeding.

Consuming a mixture of dried mint leaves and honey is an excellent cure for

menses problems. It is found to be very effective for relieving painful cramps during

menstrual time. Curing dysmenorrhea is another advantage of using this herbal

mixture. Apart from relieving menstrual problems, use of mint leaves and honey also

helps in preventing headaches, curing acne and reducing free radical mechanism.

Drinking vegetable juice is a safe remedial measure for alleviating the risk of

menstrual problems (Latha 2011).

A quasi experimental study was conducted by Shaji (2010) to find out the

effectiveness of structured teaching programe & fish oil on dysmenorrhea and its

control measures among adolescent girls in Chennai. Sample size is 800 were selected

64

by simple random technique. The data collection tool used for the study were semi

structured questionnaire, & Modified Moos Menstrual Distress Questionnaire

(MMDQ). The study finding shows that more than half of the girls 51.1% had

experienced pain only one day, 51.5% had menstrual flow for four to five days 64.1%

had the positive family history of dysmenorrhea. Study revealed that both the

intervention together was found to be very effective in reducing the severity of

dysmenorrhea of adolescent girls than STP alone.

Anandhi (2010) was carried out a study to assess the effect of mint extract on

dysmenorrhea and associated symptoms among 16 physical education students.

Subjects were assigned by simple random technique. The study group was selected

for the intervention of mint extract of 5ml daily two times for three days. The tool

used for the study was Visual Analogue Pain Scale and Menstrual Distress

Questionnaire. The findings shows a considerable reduction in dysmenorrhea and

associated symptoms in the study group (P<0.01) levels.

A Meta analysis reviewed the efficacy and safety of herbal and dietary

therapies for dysmenorrhea. The review article has been taken from the electronic

searcher of the Cochrane. Menstrual disorder and sub fertility group. RCT, CCTR,

MEDLINE, EMBASE, CINHAL, Bio extracts. Quality assessment and data

extraction were performed by two reviewers. The study findings revealed that vitamin

B1 shown to be an effective for dysmenorrhea if taken 100mg daily. The study

concluded that there is insufficient evidence to recommend the use of any of the other

herbal and dietary therapies considered in this review for the treatment of primary and

secondary dysmenorrhea. (Procter and Murphy, 2010).

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A study was conducted to assess the effectiveness of ginger rhizome powder

to manage dysmenorrhea among selected hostel students, Coimbatore. Experimental

design, post test control group was adopted in this study.18 dysmenorrhea students

were selected for the study. The samples were randomly assigned to experimental n=9

and the control group n=9 respectively. The level of menstrual pain was assessed by

numerical pain intensity scale. Oral administration of ginger rhizome powder 250mg

four times a day, up to three days starting from first day of menstruation were given to

experiment group. Results showed that independent t test is used to test the significant

in mean difference among two groups post test scores. The calculated t value is 3.074,

thus the calculated value is greater than the table value at 0.05(2.353) level of

significance at 3 degrees of freedom. There is significant evidence of oral ginger

rhizome powder helps in lowering the level of pain in dysmenorrhea. Deepa.R.

(2010)

Abbaspour, Rostami and Najar (2008) conducted a randomized clinical trial

study to determine the effects of exercise on primary dysmenorrhea among 150 high

school girl students in Masged Solaymen city. Samples were randomly assigned to

exercise and non- exercise groups. The study findings revealed that the intensity of

the pain in the exercise group determine declined from 8.59 to 4.63 (p<0.01). The

average of using sedative tablets also decreased from 1.13 to 0.35 (p<0.01). The study

concluded that the exercise can decrease the duration and severity of dysmenorrhea

among high school girls.

Claudia, Rein and Wiillich (2007) conducted a randomized controlled trial

plus non-randomized clinical design to investigate the effectiveness of acupuncture

for dysmenorrhea among 649 women in Germany. The data were collected by using

66

numerical rating scale for pain. The interventions were provided for consecutive

three months. The study findings revealed that after 3 months, the average pain

intensity was lower in the acupuncture compared to the control group 3.1 (95 %, CI

2.7; 3.6) vs 5.4 (4.9; 5.9), difference -2.3(-2.9;-1.6) p<0.001. The study concluded that

the acupuncture group had better improvements in pain and quality of life as

compared to other remedies. It is found to be cost effective within usual thresholds.

Han et al (2006) conducted a study to explore the effect of aromatherapy on

menstrual cramps and symptoms of dysmenorrhea. Subjects were allotted by random

sampling technique in three groups. Aromatherapy was applied topically to the

experimental group in the form of an abdominal massage using two drops of rose in

5cc of almond oil. The menstrual cramps were significantly lowered in the

aromatherapy group than in the other two groups at both post test time. The findings

suggest that aromatherapy using topically applied lavender, clary sage and rose is

effective in decreasing the severity of menstrual cramps.

Kalpana, Rajeswari, Nalini and Varghese, (2004) conducted a quasi and

pre test control group to assess the effectiveness of fenugreek on menstrual distress in

Chennai among adolescent girls between the age group of 19 and 22 yrs. Samples

(60) were conveniently recruited to experimental group (30) and control group (30).

The data was collected using Moos Menstrual Distress Questionnaire. The study

findings revealed that there was a significant difference count between pre test and

post test on menstrual distress (P <0.001). The study concluded that fenugreek seed

are effective in decreasing the severity of menstrual distress among adolescent girls

with dysmenorrhea.

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Acupressure and its effect on different conditions

Nam, Hyancha, Sohyune and Sok (2015) carried out a randomized

controlled trial to examine the effect of auricular acupressure therapy on primary

dysmenorrhea among 91 female high school students in South Korea. Sample were

randomly assigned to experimental group (n=45) and control group (n=46). The data

were collected using menstrual distress questionnaire and visual analogue scale. The

study findings raveled that there were significant difference on abdominal pain

(t=24.594, p<0.001) between two groups. The study concluded that auricular

acupressure therapy was an effective intervention for alleviating menstrual distress

and primary dysmenorrhea for adolescent girls.

Acupressure and its effect on sleep quality in menopausal women

A double blind randomized clinical trial by Abedian Z,Eskandari L ,Abidi H

and Ebrahim Zadeh (2015) to assess the effect of acupressure on sleep quality in

menopausal women was performed on 120 qualified menopausal women at the age of

41-65 years. Their sleep quality was measured according to the Pittsburgh Sleep

Quality Index (PSQI). Participants were randomly assigned to an acupressure group

(n=37), a sham acupressure group (n=36) and a control group (n=32) by two time

randomized method (systematic and simple randomized). These interventions were

carried out for four consecutive weeks. The participants in the acupressure and sham

acupressure groups learned to carry out the acupressure technique as a self-care at

home with simultaneous massage techniques that were to be performed 2 hours before

sleep, whereas only conversation was used in the control group. The results indicated

significant differences in total PSQI scores among the three groups (P<0.001).

Tukey’s test revealed that there were significant differences between the acupressure

68

group and the control group (P<0.001), the acupressure group and sham acupressure

group (P<0.001), and the sham acupressure and the control group (P<0.001).

Acupressure and its effect on nausea and vomiting for post hysterectomy

A randomized double blind controlled trial was conducted by Hseu, Tsai and

Lee (2012) to evaluate the effect of P-6 acupressure on prevention of nausea and

vomiting after epidural morphine for post hysterectomy pain relief among 60 samples

at Taiwan. Samples were randomly assigned to the experimental group and placebo

group. The study findings revealed that the incidence of nausea and vomiting was

significantly decreased from (43% and 27%) in the placebo group. (3% and 0%) in

the acupressure group (p<0.05). The study concluded that the prophylactic use of

acupressure can significantly reduce incidence of nausea and vomiting after epidural

morphine for post hysterectomy pain relief.

Acupressure and its effect on quality of sleep in hemodialysis patient

Raei, Vatani and Kazemi (2011) conducted a study to research the effect of

Acupressure on quality of sleep in hemodialysis patients. A randomized clinical trial;

conducted at Razi hospital on a sample of 62 hemodialysis patients who had

complains from sleep disorders. The sample were randomized into experimental and

control groups. The experimental group received acupressure 3 times per week while

undergoing dialysis for 4 weeks. Control group only received unit routine care.

Quality of life was measured using Pittsburgh Sleep Quality Index (PSQI) before and

after intervention. In order to record the pattern of quality of sleep the sleep log were

used.. Findings on quality of life showed statistically significant differences between

experimental and control groups based on PSQI. Domain of subjective quality of life

(p = 0.042), time needed to falling sleep (p = 0.007), sleep duration (p = 0.017),

69

habitual sleep efficiency (p = 0.001), sleep disorders (p = 0.024), daily performance

disorders (p = 0.002) and overall score (p = 0.001) were improved in experimental

group compared to control group. Moreover, sleep log demonstrated the decrease in

nighttime waking and increase in quality of sleep that started from the first week of

intervention and continued up to one week after intervention.

Acupressure and its effect on pain after active phase of labour

A single blind randomized clinical trial study to evaluate the effect of

sanyinjiao point (SP6) acupressure, on the duration and pain of the active phase of

labor among 120 nulliparas women who were at the beginning of active face of labor

(3 to 4 cm dilatation of cervix plus proper uterine contraction). Samples were

randomly assigned to case group (n=60), received acupressure at SP6 point, for 30

minutes during contraction and control group (n=60), simply a touch at this point Data

were collected by visual analogue scale. The study findings revealed that the severity

of pain in the case group was less than in the control group (p=0.003). The amount of

necessary oxytocin in the case group was less than the control group (p=0.003). The

study concluded that acupressure at Sanyinjiao point (SP6) reduced the duration and

severity of pain during active phase of labor. (Kashnain and Shahali, 2010).

A case report describes the observation of relief from painful dysmenorrhea

and its associated symptoms in a female patient having primary dysmenorrhea after

collateral meridian acupressure therapy (CMAT) treatment by Ta- Liang Chen

(2009) Samples previously had taken oral analgesic pills to alleviate her symptoms

during the menstrual period. The observation period was 6 months. Collateral

meridian acupressure therapy was performed once on the second day of both the first

(partial treatment) and fourth (complete treatment) menstrual period. Pain was

70

resolved immediately after partial CMAT treatment during the first menstrual period,

but the pain recurred 20 minutes later. Satisfactory results were obtained during the

fourth menstrual period after complete CMAT treatment, which were also carried

over to the next session (fifth menstrual period). In addition, no oral analgesics were

necessary after treatment. However, the symptoms of dysmenorrhea recurred 2

months after treatment (sixth menstrual period).This case report indicates that CMAT

treatment may be effective in relieving the associated symptoms of dysmenorrhea.

The carryover effect might suggest that there is a potential to produce a long- lasting

effect on dysmenorrhea.

Study related to acupressure and its effect on stage 3 and 4 pancreatic cancer pain

Barrie and Cassileth (2009) carried out a study to assess the effectiveness of

acupuncture and acupressure in treating patients who have moderate or severe pain

associated with stage III or stage IV pancreatic cancer. Patients receive acupuncture

treatment comprising 20 minutes of needle insertion into the arms and abdomen after

each acupuncture treatment. The acupuncturist applies/reapplies acupressure devices

by inserting 2-6 smaller needles into the abdomen and taping tiny metal balls to 3

points in each ear. Patients are caregivers are instructed to administer acupressure by

pressing on the ear point (metal balls) for 1-2 minutes per point and moving the semi

– permanent abdominal needles in small circular movements with the fingers, at a rate

of 2-3 cycles per second, for 1-2 minutes per point. Analgesic medication use is

assessed on approximately day’s 1-3 and 15-17. The result shows that both

acupressure and acupuncture both are effective in reducing pain.

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Acupressure and its effect on chronic low back pain

Zhu and Polus (2009) conducted a controlled trial on acupressure for chronic

low back pain in Betta Health Medical Center. Twenty- nine volunteers with chronic

low back pain were randomly recruited into two groups. Both groups received two

phases of treatment with a washout period between the two phases. Group A (14

volunteers) received the Chinese medicine acupressure in the first phase and sham

acupressure in the second. Group B (15 volunteers) received sham in the first and real

in the second. Comparison of subjective and objective measures between the two

groups was made at different periods, including baseline, after each phase of

treatment, after washout, and after the 16th week follow-up. Both the real and sham

treatments significantly reduced subjective pain, without significant differences

between groups for most subjective measures.

Acupressure and its effect on labor outcome among primi parturient mothers

Mohanal and Judie (2008) adopted non equivalent control group pre test and

post test design were used to evaluate the effectiveness of acupressure on labor

outcome among primi parturient mothers in maternity centre Chennai. Fifty primi

parturient mothers who have fulfilled the inclusion criteria were selected using non

probability purposive sampling technique. In the experimental group acupressure was

applied on the SP6 meridian point in the leg. The level of labor pain was obtained

using a modified combined numerical categorical scale. Analysis revealed that the

mothers in the experimental group showed a highly significant decrease in the level of

labor pain and duration of labor following the SP6 acupressure at P<0.001.

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Acupressure and its effect on pregnancy related to nausea and vomiting

Zong (2008) examined the role that acupressure can play in easing pregnancy

related nausea and vomiting. A group of 26 women were asked to wear an

“acupressure band” for 3 days. The (wrist) band applied pressure to the p (6)

acupressure point – which is indicated for stomachaches, vomiting and a whole host

of unrelated symptoms. A separate group of women also wore an acupressure

wristband, but did not have therapeutic pressure applied to the p (6) point. The group

that wore the wristband (applying pressure to the p (6) point) found an improvement

in the control / or alleviation of “morning sickness” symptoms.

Suh-Hwa Maa et al (2004) was reviewed a prospective randomized pilot

study that involved eight weeks of treatment at Chang Gung memorial hospital. 41

patients with chronic obstructive asthma where enrolled. Patients were randomly

assigned to receive (n=21) acupressure and standard care, 20 patients received

standard care alone, self administration of acupressure was performed daily for 8

weeks and 6 minute walking. The tool used for data collection were dysmenorrhea

visual analogue scale, the modified Borg Scale, St. Georges’ respiratory questionnaire

and the Bronchitis emphysema symptom check list where used at the beginning and

end of the 8 weeks treatment. The study findings showed the total average 18.5 fold

improvement (95%) confidence interval CI 1.54- 211.48 p=0.02. The improvement

of the acupressure subject was 6.57- fold (95%) confidence interval CI 0.98- 44.00 p=

0.05. Patients clinically stable, chronic obstructive asthma experienced clinically

significant improvements in quality of life.

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Acupressure and its effect on post caesarean pain and anxiety

An experimental study was conducted Chen, chang, ching and Hsu (2005)

to examine the effectiveness of acupressure for controlling post cesarean section

symptom among 104 women in Taiwan. Samples were recruited to experimental

group and control group by convenience sampling technique. The data were collected

by using Rhodes index of nausea and vomiting. Visual Analogue scale for Anxiety,

state –Trait anxiety inventory, visual analog scale for pain. The study findings

revealed that experimental group had significantly lower anxiety and pain perception

of cesarean section than the control group. The study concluded that acupressure

treatment aids to promote the comfort of women decreasing cesarean delivery.

An Acupressure Device [Relief Brief] for managing Symptoms of

Dysmenorrhea by Diana Taylor, Miaskowski and Kohn. (2004) studied the safety

and effectiveness of an acupressure garment (the Relief Brief) in decreasing the pain

and symptom distress associated with dysmenorrhea. A randomized clinical trial

applied a 2 (Relief Brief use or control group) x 3 (baseline and two treatment

measurement occasions) mixed factorial design. Sixty- one (61) women with

moderately severe primary dysmenorrhea were randomly assigned to the standard

treatment control group or the Relief Brief acupressure device group after one

pretreatment menses, with 58 women reporting the effect on their pain during two

post treatment menstrual cycles. The Relief Brief is a cotton Lycra panty brief with a

fixed number of lower abdominal and lower back latex foam acupads that provide

pressure to dysmenorrhea – relieving Chinese acupressure points. The result shows an

acupressure device is an effective and safe nonpharmacologic strategy for the

treatment of primary dysmenorrhea.

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A non equivalent control group pretest-post test study was conducted by

Chang, Park, Cho and Lee (2004) to explain difference of cesarean section rates

according to Sanyinjiao (SP6) acupressure for women in labor among 209 samples at

Korea. Samples were assigned to one of three group SP6 acupressure (n=86), SP6

(n=47) and control group (n=76). The study findings revealed that, there was a

significant difference among groups (p=0.049). Cesarean section rates were

significantly difference between SP6 acupressure and non SP6 acupressure group (p=

0.035). The study concluded that SP6 acupressure was effective in decreasing the

cesarean section rate hence it could be applied as an effective nursing intervention.

Lee et al (2004) conducted a study to evaluate the effects of SP-6 acupressure

on labor and delivery time women admitted in labor room, samples were recruited

by purposive sampling technique. Study findings revealed that there were significant

differences between the group in subjective labor pain scores at all time points

following intervention (p=0.012). The total labor time (3cm dilatation to delivery)

was significantly shorter in the SP-6 acupressure intervention group than in the

control (p= 0.006). The study proved that acupressure was effective for decreasing

labor pain and shortening the length of delivery time.

Tsay.et al (2003) assessed the effectiveness of acupoints massage for patients

with end stage of renal disease and experiencing sleep disturbances and diminished

quality of life. Study findings concluded sleep log data shows that the acupressure

group significantly decreased wake time and experienced an improved quality of

sleep at night over the control group. Medical outcome study short form 36 data also

documented that acupressure group patient’s significantly improved quality of life.

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Study related to acupressure and its effect on post operative vomiting

A double blinded randomized placebo- controlled trial was conducted by

Bochlee, Mitterschiffthaler and Schlager (2002) to investigate the effectiveness of

Korean hand acupressure is preventing post- operative vomiting among 80 women at

Australia, samples were randomly assigned to experimental group (n=40) and placebo

group (n=40). The study findings revealed that Korean hand acupressure of the

acupuncture point K-Ka is an effective method for reducing post- operative nausea

and vomiting after minor gynecological laparoscopic surgery. The study concluded

that Korean hand acupressure has antiemetic effect is preventing post operative

vomiting.

The effects of acupressure using new combination of acupoints, and Ibuprofen

on the severity of primary dysmenorrhea (PD) were conducted by Pouresmail and

Ibrahimzadeh (2002) 216 female high school students, aged between 14 to 18 years,

were randomly selected and divided into three groups. Each group underwent

different treatment techniques: acupressure, Ibuprofen and sham acupressure as a

placebo. The results indicated that the three therapeutic techniques were significantly

effective in reducing the pain. However the therapeutic efficacies of acupressure and

Ibuprofen were similar with no significant difference, and were significantly better

than the placebo. Thus acupressure, with no complications, is recommended as an

alternative and also a better choice in the decrease of the severity of primary

dysmenorrhea.

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Acupressure and its effect on primary dysmenorrhea

Christina,Saha,Sharma, Bano ,Gaur and Malviya (2016) conducted a cross

over clinical trial study in Bhampur, Bhopal, Madhya Pradesh, 60 adolescent girls

were selected by purposive sampling technique , one group pre test ,post test design

was adopted ,SP6 (Sanyinjiao or spleen 6 point) acupressure was given 20 minutes

each leg continuously three days, two times a day during menstruation. The pre test

mean score was 6-18 and post test mean score was 1.88. The calculated’ value was

7.4 which was very much higher than the table value p> 0.05. This shows that there

was very highly significant difference pre test and post test. There was no significant

association found between the pain score with selected socio demographic variables.

Peyman, Jufari Marjun and Khajeh (2016.) studied the effect of

acupressure at the Sanyinjiao (SP6) point on primary dysmenorrhea. 86 adolescent

students. were participated, The study group received Sanyinjiao point acupressure

while control group received Sham acupressure. The severities of dysmenorrhea were

assessed the following time periods 1,2 and 3 hours prior to the intervention..The

acupressure caused decline in the severity of dysmenorrhea immediately after

intervention in both groups during the first menstrual cycle, although there difference

was not significant (p>0.05). In addition decrease pain the same cycle, the severity of

the dysmenorrhea decreased more in study groups rather than control group at 1,2 and

3 hours after intervention (p<0.05), during the second menstrual cycle acupressure

made dysmenorrhea reduced in both study and control group, however the decline

was more salient among participant of the study groups at all the stages after the

intervention (p<0.05).

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Cha (2016) was examined the effect of auricular acupressure on primary

dysmenorrhea among female high school students. A randomized controlled trial was

employed. The study sample consisted of 91 female high school students, 45

participants in the experimental group and 46 in the control group. Auricular

acupressure performed three days of menstruation during extreme dysmenorrhea.

Tools used for the data collection were Visual Analogue Pain scale and Menstrual

Distress Questionnaire. Study findings revealed there were significant difference on

abdominal pain (t = 24.594, p < 0.001) back pain (t = 225.661, P < 0.001) and primary

dysmenorrhea (t = 32.087, p < 0.01) between the two groups. Auricular acupressure

therapy decrease abdominal pain, back pain and primary dysmenorrhea of female high

school students.

Abaraogu, Lgwe, Ochoigu (2016) systematically reviewed and Meta-

analyzed the effectiveness of SP6 (Sanyinjiao) acupressure for the relief of primary

dysmenorrhea symptoms as well as patients experience of this intervention, searched

six relevant databases and gray literature for publications dated up to march 2016.

The search yielded 72 potential studies, six of these studies contributing a total of 461

participants were included in this review. The primary outcome was pain intensity.

Studies with significant homogeneity were pooled for Meta analysis. The Cochrane

criteria demonstrated that the included studies were generally of low quality with a

high risk ,SP6 acupressure delivered by trained personal significantly decrease pain

intensity immediately after intervention ( effect size = 0.718, cl = - 0.951 to 0.585

P=0.000) and pain relief remained up to 3 hrs after intervention (effect size = 0.979

cl = - 1.296 to 0.662 p = 0.000 ). However patient administered intervention required

multiple monthly cycles to effect pain reduction. Sp6 acupressure appears to be

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effective when delivered by trained personal for some primary dysmenorrhea

symptoms.

A Systematic Review and Critique of Randomized controlled trials comparing

true acupressure with sham interventions was studied by Jung-Yu Tan, Suem,

Wang, Molassiotis (2015) thirteen electronic databases were adopted to locate

relevant studies from July 3, 2014., eight Chinese journals on complementary and

alternative medicine were manually searched to locate eligible articles.

Methodological quality of the included studies was evaluated using the risk of bias

assessment tool developed by the Cochrane. Descriptive analysis was used to

summarize the therapeutic outcomes. Sixty-six studies with 7265 participants were

included. Six types of sham acupressure approaches were identified and “non-

acupoint” stimulation was the most frequently utilized sham point while an

acupressure device was the most commonly used approach for administering sham

treatments. Acupressure therapy was a beneficial approach in managing a variety of

health problems and the therapeutic effect was found to be more effective in the true

acupressure groups than that in the sham comparative groups. No clear association

could be identified between different sham acupressure modalities and the reported

treatment outcomes.

A randomizes controlled trial study was conducted by Mohammed, Salim

and Al- Agamy (2015) to investigate the effect of Femi- band acupressure on primary

dysmenorrhea. 150students who were randomly divided into two groups. The study

group consisted 75 students who applied the Femi- band acupressure to both the legs

three times daily for first three days of menstruation with application to each leg for

one minute. The control group consisted 75 students who applied a placebo band three

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times daily for first three days of menstruation to each leg for one minute. The tools

were used for data collection VAS Femi- band follow up chart and satisfaction Likert

Scale. The result showed in the intervention group the severity of the pain reduced

from 8.27 to 9.92 following intervention ,the severity of the pain reduced after using

Femi band (immediate 30 min , 1 hr , 2 hr ) at first and second month in the

intervention group. When the severity of the pain was analyzed at each time period

significant difference were observed (30 min ,1 hr , 2 hr) after applying the band at

1,2 and 3 month

Elakkiya (2015) conducted a true experimental study to assess the

effectiveness of acupressure SP6 on dysmenorrhea among 60 adolescence girls at

Chrompet, Chennai. Study samples were recruited using lottery method in

experimental group (n=30) and control group (n=30). Data were collected using

Visual Analogue Pain Scale. The study findings concluded that there was a

statistically significant difference in between experimental and control group

(p<0.001). The Study concluded that acupressure therapy was effective in reducing

dysmenorrhea among adolescence girls.

A randomized controlled trial design to examine the effect of auricular

acupressure therapy on primary dysmenorrhea studied by Hyancha, Sohyune and

Sok (2015) among 91 female high school students in South Korea. Sample were

randomly assigned to experimental group (n=45) and control group (n=46). The data

were collected using menstrual distress questionnaire and visual analogue scale. The

study findings revealed that there were significant difference on abdominal pain

(t=24.594, p<0.001) between two groups. The study concluded that auricular

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acupressure therapy was an effective intervention for alleviating menstrual distress

and primary dysmenorrhea for adolescent girls.

Amarajith Singh (2014) conducted a crossover clinical trial study to assess

the effects of acupressure at Sanyinjiao (SP6) point and Diji (SP8) point on pain

severity of primary dysmenorrhea and the associated systemic symptoms. 50 females

aged 18-30 years old who met the study criteria and were under the care of Sarpole

Zahab Health Care Centre were selected subjects were randomly assigned to one of

two groups and evaluated during three menstrual cycles, pain severity was evaluated

using the Mc Gill pain scale and associated systemic symptoms using a verbal

multidimensional scoring system. The findings of the study indicates that the pain

diminishes significantly for up to 2 hours following treatment with acupressure at the

SP6 and SP8 points (p<0.001). Furthermore the severity of associated systemic

symptoms reduced significantly after acupressure at the SP6 and SP8 points, except

for nausea and vomiting comparison of the severity of systemic symptoms with

acupressure at the SP6 and SP8 points revealed no significant difference except for

severity of fatigued, which was reduced significantly further with SP6 point compared

to SP8 point (p=0.004).Acupressure at the SP6 and SP8 points can reduce pain

severity of dysmenorrhea for up to 2 hours after application and these points may be

used to alleviate the severity of systemic symptoms accompanying dysmenorrhea

A pre experimental study to assess the effectiveness of acupressure SP6 on

dysmenorrhea among nursing students in PGIMER, Chandigarh, was conducted by

Sharma, Rana and Singh (2014) total 78 study samples were enrolled by

enumeration sampling technique. The study samples received acupressure for 20

minutes at SP6 point. Dysmenorrhea was assessed by Numerical Pain rating Scale,

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Modified Menstrual distress questionnaire. The result revealed there was significant

reduction in severity of dysmenorrhea (p<0.001).The study concluded acupressure is

an effective way in reducing dysmenorrhea.

Afshar (2014) conducted a study to compare the maximum pain intensity

(MPI) and duration of primary dysmenorrhea after acupressure on third liver (LIV3)

and placebo points. Students who were suffering from primary dysmenorrhea were

studied for the menstrual cycle intensity and duration of dysmenorrhea was assessed.

Student with pain score ≥ 4 according to visual analogue for MPI were selected.

Randomized block allocation was performed based on pain intensity with 1:1

allocation ratio. Students applied acupressure themselves on LIV 3 or placebo points

in the second and third cycles, only on first day of menstruation beginning of the

bleeding. Acupressure was performed 4 times intermittently, ( 2 minutes pressure

followed by 2 minutes rest) twice on each leg and 16 minutes in total. The findings of

the study revealed there was significant reduction in pain intensity during

menstruation in each group but decrease in duration of primary dysmenorrhea was not

significant.

An experimental study was conducted by Chen,Wang,Chiu,Mei (2014) to

examine the effects of acupressure on menstrual distress and low back pain (LBP) in

dysmenorrheic young adult women and 129 female students who had been

experiencing dysmenorrhea with LBP during menstruation and who scored more than

4 points on the visual analog scale for pain, were randomly assigned to an

experimental group and a control group. The experimental group received acupressure

massage three times a week for 30 minutes on the acupoints 81 (SP6), ciliao (BL32),

and tai chong (Liver 3) acupoints. The control group (received only a manual of

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menstrual health education without acupressure intervention. Data were collected at

five time points: at baseline, 30 minutes, and 4, 8, and 12 months after the

intervention. During the 12-month follow-up, the experimental group had

significantly lower menstrual distress and LBP scores than the control group. Among

65 participants in the experimental group, 53 (82%) reported a moderate to high levels

of menstrual distress, 51 (78%) reported moderate to high levels of LBP relief, and 49

(75%) reported moderate to high levels of satisfaction with acupressure.

Nasibe Teacher Education College was selected for a clinical trial study

conducted by Asghari (2013) 194 eligible student teachers were included for the

study. In the first cycle, severity and duration of pain were assessed. Then the

participants were randomly assigned to an experimental or control group. In the

second, third and fourth cycles, 3-7 days before menstruation, acupressure was

applied at liv 3 and placebo points for 20 minutes per day. With the onset of

menstruation, the severity and duration of dysmenorrhea was determined for the three

cycles. Data were analyzed through chi-square test, Mann- Whitney test, Friedman

test and independent t test. There was no significant difference in severity of pain

between two groups in the first cycle (P = 0.40) but there was a significant difference

in severity of pain between two groups in the second (P<0.05), third (P<0.01) and

fourth cycles (P<0.01). In the fourth cycle, the median severity of dysmenorrhea was

6 in the two groups. In the fourth cycle, it was 4 in intervention group and, 6 in the

control group. There was no significant difference in duration of pain between two

groups in the first (P=0.81) and the second cycle (P = 0.09), but there was a

significant difference in severity of pain between the two groups in the third (P<0.05)

and the fourth cycles (P<0.001). Duration of pain decreased significantly in

intervention group, compared to control group.

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Systematic review of randomized clinical trials of acupressure therapy for

primary dysmenorrhea studied by Hui-ru Jiang et al (2013) to evaluate the efficacy

of acupressure in the treatment of primary dysmenorrhea based on randomized

controlled trials (RCTs) searched MEDLINE, the Chinese Biomedical Database

(CBM0,and the Cochrane Central Register of Controlled Trials (CENTRAL)

databases from inception until march 2012. Statistical analysis was performed with

Rev Man 5.1 software. Eight RCTs were identified from the retrieved 224 relevant

records. Acupressure improved pain measured with VAS (- 1.41 cm 95% CI

[- 1.61, - 1.21], SF- MPQ at the 3 – month follow-up (WMD – 2.33,95% CI

[-4.11,- 0.54] ) and 6- month follow-up (WMD – 4.67, 95% CI [- 7.30, - 2.04] ) , and

MDQ at the 3- month follow-up (WMD- 2.31,95% CI [- 3.74, - 0.87] ) and 6-month

follow-up (WMD – 4.67,95% CI [ - 7.30, - 2.04] ) . All trials did not report adverse

events.

Ling yeh, Hang , Hsinga and Hsia (2013) conducted a single – blind

placebo – controlled design study to evaluate the effect of auricular acupressure of

menstrual pain and distress among 113 adolescent with dysmenorrhea. Samples were

recruited and assigned to the experimental and control group by a coin toss

techniques. The tools used for data collection procedure are visual analogue scale,

short form MC Gill pain questionnaire (SF-MPG) and menstrual distress

questionnaire (MDQ). (The experimental group received auricular acupressure where

as control group received sham acupoints without the effect of dysmenorrhea). The

study findings raveled that the auricular dysmenorrhea was effective treating

dysmenorrhea (P< 0.05).

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An experimental study was conducted by Wong , Lai and Tse (2013) to

evaluate the effects of Sanyinjiao (Sp6) acupressure in reducing the pain level and

menstrual distress among 40 samples with dysmenorrhea. The samples were

randomly assigned to experimental group (n= 19) and the control group n (21). Data

were collected using in the pain Visual Analogue Scale (PVAS). Short form MC Gill

pain questionnaire (SF- MPQ) and short form Menstrual Distress Questionnaire

(SF.MDG). The study findings revealed there was a statistically significant decrease

in pain score for PVAS (P= 0.003) and SF – MPQ (P= 0.02). SF-MDQ (P=0.024).

The study concluded that SP6 acupressure has an immediate pain- relieving effect for

dysmenorrhea.

Chen, Hung, Faan (2012) systematically reviewed the effectiveness of

acupressure on relieving pain in various setting, articles used the databases of

MEDLINE, Pubmed, and cumulative index to nursing and Allied Health Literature

( CINAHAL) was performed using the search terms of “ acupressure” and “pain”

studies during which acupressure was applied as an intervention and assessed for its

effectiveness on relieving pain were selected . The studies selected were those

published from January 1, 1996 to December 31, 2011 that met the inclusion and

exclusion criteria. The participants included patients with dysmenorrhea, labor pain,

low back pain, chronic headache, and other treatment pains. The oxford 2011 Levels

of Evidence was used to appraise the literature. Fifteen studies were extracted for

reducing dysmenorrhea. (Menstrual distress), labor pain, low back pain, chromic

headache and other treatment pain. These papers were further reviewed for their study

design, Adequacy of randomization concealment of allocation, blinding of

participants, intervention and outcome measurement. Acupressure has been shown to

be effective for reliving a variety pains in different populations. The reviews begin to

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establish credible evidence base for the use of acupressure in pain relief. The

implication for health care provided would be incorporating acupressure into their

practice as an alternative therapy to facilitate who suffer from pain.

The effect of acupressure at third liver point on the anxiety level in patients

with primary dysmenorrhea. A clinical trial was conducted in parallel in the control

and treatment groups for three menstrual periods at the dormitory of Kashan

University of Medical Sciences between March and June by Atrian (2012). Students

with pain score equal to or greater than 4 were selected and divided into groups based

on severity of pain using a randomized block design with the allocation ratio of 1:1.

Acupressure was applied in two acupoints including third Liver point (Liv3) and

placebo points. Spielberg anxiety questionnaire was completed before and after

intervention. Randomization, subjects, and data analyzer were blinded to the analysis.

Chi- square tests, t- test, Mann- Whitney, paired sample t- test, and univariate analysis

of variance were used for statistical analysis. P values < 0.05 were considered

statistically significant.

A crossover clinical trial study was conducted by Gharloghi, Torkzahrani,

Akbarzadeh, and Hesmat. (2012) to assess the effect of acupressure on severity of

primary dysmenorrhea with 50 females aged 18-30 years old who met the study

criteria and were under the care of Sarpolezahab Health Center were selected.

Subjects were randomly assigned to two groups and evaluated during three menstrual

cycles. The tool used to assess the pain severity using the Mc Gill pain scale and

associated systemic symptoms using a verbal multidimensional scoring system. The

findings of our study indicate that the severity of dysmenorrhea pain diminishes

significantly for up to 2 hours following treatment with acupressure at the SP6 and

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SP8 points (P < 0.001). Furthermore, the severity of associated systemic symptoms

reduced significantly after acupressure at the SP6 and SP8 points, except for nausea

and vomiting. Comparison of the severity of systemic symptoms with acupressure at

the SP6 and SP8 points significantly further with SP6 point compared to Sp8 point

(P = 0.004).

The evidence for shiatsu a systematic review of shiatsu and acupressure.

Rotrins, Lorence, Liao (2011). Acupressure and shiatsu clinical trial were identified

using the 86cup term acupressure EB Review AMED, BNI, CINAHL: EMBASE,

MEDLINE science direct black well synergy. Theses and ZETOC references of

articles were checked inclusion criteria were shiatsu or acupressure administered

manually published after January 1990. Two reviewer performed independent study

selection and evaluation of study design and reporting using standardized checklist,

(Consort, Trend, casp, searchers identified 1714 publications. Final inclusions were 9

Shiatsu and 71 acupressure studies. A quarter were graded (highest quality) Shiatsu

studies comprised RCT three controlled studies investigating mental and physical

health issues. Acupressure studies included 2 meta analysis, 6 systematic reviews and

39 RCTS, strongest evidence was for pain particularly dysmenorrhea, low back pain

and labor post operative nausea. Additionally evidence found improvement in

institutionalized elderly persons.

A clustered randomized control trial with two parallel arms design was studied

by Alizaeh, Charandabi, Nashtaei, Kamali and Majlesi (2011) to determine the

effect of acupressure at the Sanyinjiao (SP6) on severity of menstrual symptoms

(primary dysmenorrhea) and the duration of resting time, as well as the number of

ibuprofen conception was assessed with 72 eligible student residing in dormitories of

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public university of Tabriz, Iran. Menstrual symptoms questionnaire and VAS used to

collect the data from 36 participants who suffered from each type of dysmenorrhea

were enrolled from the four dormitories. The dormitories were randomly assigned into

interventional and control group. First cycle no intervention carried out, the next two

cycles the experimental group subject received acupressure 20 min at the time of pain.

Both group were allowed to consume ibuprofen, when needed. During the three

cycles the participants recorded and reported menstrual symptoms severity, duration

of resting time and number of ibuprofen used. The result revealed the severity of

menstrual symptoms and duration of resting time in the second and third cycle were

significantly reduced than control group.

Torkzahrani, Zadeh, Hashmat, Gharloghi (2011) a crossover clinical trial

150 females who suffered from dysmenorrhea wished to participate. The data were

collected using Mc Gill pain scale and verbal multidimensional scale for evaluation of

systemic symptoms. After assessment participants allocation two group (A, B)

subjects were taught acupressure technique by the researcher. Participants were

instructed on the correct methods of locating either the SP6 or SP8 point applying

pressure 20 min. The procedures were applied once per day during first 3 days of the

menstruation period.. The findings indicates that the severity of dysmenorrhea

diminished significantly immediately 30 min, 1 hr and 2hrs after application of

acupressure at the point was SP6 and SP8 points. In addition mean (SD) pain severity

in the group using SP8 point was (6.4 ± 1.09) prior to acupressure which diminished

to (4.4 ± 0.99) immediately after acupressure. (4.08 ± 1.01) 30 min after acupressure,

(3.17±0.96) 1 hr after acupressure and (2.03±0.94) 2 hrs later. The reduction in the

pain severity were significant for all intervals and at both SP6 and SP8 points revealed

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that for all intervals, acupressure at the SP8 point reduced pain severity significantly

more than the SP6 point (P<0.001).

A study was conducted by Ajorpaz, Hajbaghery (2011) to evaluate the effect

of acupressure on primary dysmenorrhea , A randomized controlled pre and post test

design was employed to verify the effects of SP6 acupressure on dysmenorrhea , Total

30 young college female student with primary dysmenorrhea were randomly allocated

to intervention (n=15) groups. The intervention group received SP6 acupressure

during menstrual cycle and the control group received light touch on SP6 acupoint

using visual Analogue scale, the severity of the dysmenorrhea was assessed prior and

immediately, 30 min, 1, 2 and 3 h following treatment. Data were analyzed using X 2,

t- test and statistical test significant differences were observed in the scores of

dysmenorrhea between the two groups immediately after 3.5 ± 1.42 vs. 5.06 ± 1.43,

P= 0.004 and also 3 h after treatment ( 1.66 ± 1.98 vs. 4.80 ± 1.37 , P = 0.0004.

Acupressure on the SP6, meridian can be an effective non invasive nursing

intervention for alleviating primary dysmenorrhea and its effects last for 3 h post

treatment.

Archana (2011) was carried out a study to examine the changes in heart rate

variability in dysmenorrhea by assessing sympathetic and parasympathetic activity

and to find out the effect of acupressure therapy in alleviating the symptoms of

dysmenorrhea. In this study they have used heart rate variability (HRV) as a sensitive

marker of autonomic activity. HRV and intensity of pain was assessed before and

after acupressure therapy in dysmenorrhea by using Visual analog scale. The result

shows that acupressure therapy has been effective in regulating the autonomic

89

alterations and it has significantly reduced the dysmenorrhoeic pain as observed from

the visual analog scores.

Karthika (2011) conducted a quasi experimental study to assess the

effectiveness of acupressure in reducing menstrual pain among 60 adolescent girls

with primary dysmenorrhea in Bangalore., India. Samples were conveniently recruited

to experimental group (n = 30) and control group n (30). Data were collected using

Visual Analogue Pain scale, menstrual discomfort rating scale, acupressure opinion

questionnaire. The study findings highlights that the pre test pain perception among

control and experimental group and the computed value of t= 1.033 is less than the

table value (2.326) which is statistically not significant the post test pain perception

among experimental and control group and computed value of “ t “ after half an hour

,one hour, one and half an hour and two hour is 1.033 , 2.797,4.306,4.504,4.504 is

more than the table value (2.326) which is statistically significant at 0.01 level. This

establishes the acupressure application SP6 point is effective in reducing pain

perception among the experimental group than the control group .

A randomised controlled trial by Kashefi , Ziayadlou, Jafari (2010) to

evaluate the effect of acupressure at the Sanyinjiao (SP6) point on primary

dysmenorrhea, 86 students participated in the study and the study group received

acupressure at Sanyinjiao point (SP6), while the control; group received sham

acupressure. The severity of dysmenorrhea was assessing prior to the intervention 30

min 1, 2 and 3 hrs following the intervention. The findings reveals the acupressure

caused decline in the severity of dysmenorrhea immediately after intervention in both

groups during their first menstrual cycle, although, there difference was not

significant (P>0.005) in addition, during the same cycle the severity of the

90

dysmenorrhea decrease more in study group rather than control group at 30 min, 1,2

and 3 hrs after intervention (P< 0.05).During the second menstrual cycle , acupressure

made dysmenorrhea reduce in both study and control group. However the decline was

more salient among participants of the study group at all stage after the intervention

(P<0.05).

An experimental study was undertaken by Elif and Ayranci (2010) to assess

the effectiveness of acupressure on primary dysmenorrhea. Total 172 university

students with dysmenorrhea were randomly divided into two groups. One group

received an acupressure treatment at the Tai Chong point on the foot and the other

received acupressure at a sham point. Each treatment lasted for 20 minutes. The

subjects were asked to perform the acupressure treatment for three to seven days

before their next two menstrual cycles. Subjects who received acupressure at the Tai

Chong stated that they were not affected by symptoms went from (23% to 55 %). At

the other end of the scale, 14 subjects reported the most severe symptoms at the

beginning of the study. By the end of the study, none of them reported having the

most severe symptoms.

Misbagher, Mohsen and Fatemeh (2010) conducted an experimental study

to examine the effectiveness of acupressure among 50 Iranian Medical Sciences

students. All the dysmenorrhea students were randomly allocated to intervention and

control groups. The intervention group received SP6 acupressure during menstrual

cycle and the control group received light touch on the SP6 acupoint. Using Visual

Analogue Pain scale the severity of dysmenorrhea has assessed prior to and

immediately, 30 min, 1, 2 and 3 hours following treatment. Results shows that

acupressure on the SP6 meredian can be an effective non-invasive nursing

91

intervention for alleviating primary dysmenorrhea and its effects last for 3 hours post

treatment.

Moatler and Adesina (2009) was conducted a study to evaluate the effect of

SP6 acupressure on primary dysmenorrhea. 58 college-aged women participated in

this experimental study, half of the women were subjected to a course of acupressure

to a specific point, known as the “SP6 acupoint”. The other half was used as a

“control” group, to provide a comparison to the acupressure treatment group. The

treatment group received acupressure within 8 hours of menstruation. The researchers

measured the symptoms relating to dysmenorrhea before the acupressure was applied,

30 minutes afterward and also at the 1, 2 and 3 hour mark following the

administration of acupressure. The researchers found that there was a significant

reduction in the severity of symptoms immediately after treatment. The effect

appeared to last for up to 2 hours after the treatment.

An experimental study was conducted by Wong, Jojo (2008) with forty

subjects from Nursing School of local university and assigned in to the acupressure

groups and control group. The acupressure group received 20 minutes Acupressure on

SP6 acupoint while the control group only received 20 minutes rest the researcher

used pain visual analogue scale and short form MDQ pain questionnaire, and for the

experimental group only the acupressure assessment form were used for data

collection right before the intervention and in the first three days of subjects menstrual

cycle from the first second months after the intervention. The result showed that there

was statistically significant decrease of pain score of pain visual analogue scale MG

Gill pain questionnaire immediately after 20 minutes of SP6 but not for the menstrual

distress score no significant difference were in blood pressure and heart rate,

92

significant reduction of pain and menstrual distress were noted in the post three

months. The findings of the research showed the acupressure applied to the SP6

acupoint can be an effective non invasive nursing intervention for the alleviation of

primary dysmenorrhea also showed that acupressure can be adopted as a self help

measure in relieving primary dysmenorrhea for adolescent girls.

A systematic review by Cho and Hwang (2008) assess the effectiveness of

acupressure for the symptomatic treatment of primary dysmenorrhea from

randomized controlled trials (RCTs) Electronic databases including English, Korean,

Japanese and Chinese databases were systematically searched for RCTs investigating

acupressure for primary dysmenorrhea up to July 2008 with no language restrictions.

The methodological qualities of eligible studies were assessed using the criteria

described in the Assessing risk of bias of the Cochrane Handbook edited by Higgins

and Atman. Four RCTs comprising a total of 458 participants were systematically

reviewed. Only one of the included trials described adequate methods of

randomization. All trials did not have clear descriptions of that of their method of

allocation concealment. Two studies reported significant improvements in the severity

of pain for acupressure compared with sham acupressure on non- acupoints.

Acupressure reduced the pain and anxiety typical of dysmenorrhea in a Taiwan study.

The US study using an acupressure device reported that the reduction of menstrual

pain was significantly better in worst menstrual pain. One study investigated adverse

events and reported that there was no adverse event in acupressure treatment.

Alaettin, Mustafa (2007) carried out a study to monitor the effect of

acupressure at the Sanyinjiao point on primary dysmenorrhea among 86 adolescence

girls at Iran .Samples were randomly assigned to experimental group received

93

acupressure at SP6 point and control group received sham acupressure. Data were

collected by visual analogue pain scale and severity of dysmenorrhea was assessed at

the following time periods; prior to the intervention, 30 minutes, 1, 2 and 3 hr

following the intervention. The study findings raveled that acupressure made

dysmenorrhea reduce in both study and control group, however the SP6 point was

more salient among participants of the study group at all stages after the intervention

(p<0.05). The study concluded that acupressure at SP6 and intervention for improving


. Chen, Chung-and Chen (2004) conducted an experimental study to assess

the effects of acupressure at the Sanyinjiao point on primary dysmenorrhea among 69

adolescent girls attending a technical college in Taiwan. The data were collected by

Visual Analogue Scale for pain, short form MC Gill pain questionnaire, menstrual

distress questionnaire and acupressure assessment form and Visual Analogue Scale

for anxiety, participants were randomly assigned to experimental group n(35) and

control group n (34). The study findings revealed that the initial session reduced the

pain and anxiety typical of dysmenorrhea. In the self treatment follow up session,

acupressure at Sanyinjiao significantly reduced menstrual pain but not anxiety. Thirty

– one (84%) of the thirty five experimental participants reported that acupressure was

helpful, and thirty three ( 94% ) were satisfied with acupressure in terms of its

providing pain relief and psychological support during dysmenorrhea.

A quasi experimental study was conducted. Rashma and Al- Bulushi (2004)

to verify the effects of SP6 acupressure on skin temperature and dysmenorrhea.

Young college women with primary dysmenorrhea were recruited from classrooms at

two universities in Korea and 58 eligible participants were allotted to either a SP6

94

acupressure group or placebo group that received light touch on the SP6. The

experimental group received acupressure treatment within the first 8 h of

menstruation, and severity of dysmenorrhea and skin temperature changes in the

Zhongwan (CV2) and Qugu (CV12) 94acupoints were assessed prior to and 30 min,

1,2,and 3 h following treatment. There was a significant difference in severity of

dysmenorrhea between the two groups immediately after (F= 18.50, P= 0.000) and

for up to 2 h ( F= 8.04, P=0.032)post treatment . Skin temperature was significantly

elevated at 30 min after acupressure at the suprapubic CV2 acupoint in the

experimental group compared to the control group. Temperature elevation was also

noted at the epigastric CV12 acupoint post treatment but group differences were not

significant, indicating that SP6 acupressure relieves dysmenorrhea primarily by

temperature elevation in the CV2 pathway.

Development of Nursing Evidence-Based Practice Protocol

For the development of evidence based practice guideline, an extensive

systematic review was carried out by the researcher. The electronic data bases and

various hand search strategies were adopted for the systematic review. The search

engines included were Pubmed Central, Google Scholar, Science Direct, Cochraine

Library and Proquest. All the studies identified through this search were subjected to

quality check by using Johns Hopkins evidence Practice Model. The researcher

obtained permission from Johns Hopkins University (https://www.ijhn-education.org)

to use the Johns Hopkins Nursing Evidence Based Practice (JHN EBP) model and

tools. (Annexure J)

95

The Protocol includes the following aspects in this study:

1. Nursing Evidence Based Practice Question Development


3. Characteristics of included papers (Study design wise and Intervention wise)

4. Individual Evidence Summary

1. Nursing Evidence Based Practice Question Development

What is the problem and why is it important?

This research focuses on pain and distress related to dysmenorrhea

experienced by the adolescent girls. This research work was undertaken by the

investigator to seek evidence as every adolescent girls subjectively have been facing

one or the other dysmenorrheal symptoms.

What is the current practice?

At present, developed countries widely use pharmacological measures,

(NSAID) to manage the dysmenorrhea problems. The traditional practice in India

among adolescent girls to accept the hormonal changes and symptoms during

menstruation as a part of their developments, and they used some home remedies.

Like developed countries the adolescent girls in India too undergo stress, modification

in lifestyle, family, absenteeism in school, college, work place and work pressure.

This makes them slowly move from conventional practices to modern medicine for

speedy relief. It is seen that more and more adolescent girls experience dysmenorrheal

symptoms in varying degrees and seek the help of gynecologists.

96

What is the focus of the problem?

The focus of the problem is both of clinical and educational concern.

Dysmenorrheal symptoms are subjective and it differs from individuals. Those not

able to manage visits the consultant, they are compared to above the water line of the

Iceberg. Not all of them with dysmenorrheal symptoms consult the physician or

express their difficulty. Hence it is assumed that majority of them stay unidentified in

the community i.e., below the waterline of the Iceberg. This majority ought to focus

through educational / non pharmacological interventions.

How was the problem identified?

The problem was identified by the researcher when adolescent girls constantly

reported of ill health suggestive of pain and distress related to primary dysmenorrhea.

What is the scope of the problem?

In this research work the problem initially looks at the individual

dysmenorrhea problems later shifting the scope on to the whole mass of adolescent

girls with pain and distress related to dysmenorrhea to generalise the evidence.

What are the PICO Components?

P - Population / Patient. Here it is the adolescent girls experiencing pain and distress

related to dysmenorrhea during menstruation

I – Intervention. Here Acupressure is the intervention planned.

C – Comparison. A comparison group is also identified who follows regular practices

/ routines without the given intervention.

O – Outcome – The expected outcome is reduction of pain and distress related to

dysmenorrhea and is based on acupressure as an intervention measured using Visual

97

Analogue Scale for Pain and Modified Moose Menstrual Distress questionnaire thus

increasing level of satisfaction on the Intervention and enhancing Quality of Life.


PRISMA (Preferred Reporting Items for Systematic Reviews and

Meta – Analyses) is an evidence based minimum set of items aimed at helping

authors to report a wide array of systematic reviews and meta-analyses that assess the

benefits and harms of a health care intervention. PRISMA focuses on ways in which

authors can ensure a transparent and complete reporting of this type of research.

The two important components of PRISMA are The PRSMA checklist and

The PRISMA flow diagram. In this research work, the researcher used the PRISMA

flow diagram to depict the flow of information through the different phases of

systematic review.

In this research work, PRISMA helped the author mainly focus and improve

the reporting of systematic review of randomised controlled trials. It is further used as

a basis for reporting reviews of other types of researches like cross sectional, cohort,

case – control studies. Total records collected for the systematic review include 97,

out of which 77 were identified through database search and 20 were identified

through other searches. Duplicate records were excluded at this stage were 12. The

remaining records after undergoing screening for abstract and methodology were 85.

Among these 85, 55 were excluded based on the exclusion criteria. The remaining 30

full text articles were assessed for eligibility, out of which 24 full text articles were

excluded with reasons. Hence there were 6 studies included for qualitative synthesis /

metasynthesis.

98

3. PRISMA Flow Diagram depicting the different phases of Systematic Review

Fig 4. PRISMA Flow Diagram

Records identified through

database searching

(n =77)

Additional records identified

through other sources

(n = 20)

Total records collected

(n= 97)

Records screened (85)

(Title / Abstract + Methodology

Screening)

Records excluded,

according to exclusion

criteria (n = 55)

Full –text articles assessed for

eligibility (n=30)

Studies included in qualitative

synthesis (n = 06)

Full-text articles

excluded, with reasons

(n=24)

Scr

een

ing

Eli

gib

ilit

y In

clu

ded

Duplicate records

excluded (n = 12)

Iden

tifi

cati

on

99

4. Characteristics of Included Papers in the Literature Review

Table1: Characteristics of included papers

I

Study design

Number (%)

of Articles,

N=85

%

Systematic Reviews

Meta Analysis

Critical trials

Randomized controlled trials

Randomized clinical trials

Non-randomized pre test-post test/ Evaluative

studies

Evaluation of Cohort study

Cohort (Prospective)

Cohort (Retrospective)

Prospective cross sectional studies

Randomized control pre and post test studies

Randomized double blind and control studies

Randomized controlled prospective clinical

studies

Non- randomized controlled trials

Prospective randomized cross over studies

Randomized single blind studies

Cross over clinical trials

Cross sectional analytical studies

Cross sectional survey studies

Cross sectional descriptive studies

Non equivalent controlled groups pre and post test

studies

Comparative cross sectional studies

Observational cross sectional study

Case control studies

9

3

4

13

4

2

1

1

1

2

2

2

4

2

2

2

5

2

6

2

2

2

2

2

10.59

3.51

4.68

15.21

4.68

2.34

1.17

1.17

1.17

2.34

2.34

2.34

4.68

2.34

2.34

2.34

5.85

2.34

7.05

2.34

2.34

2.34

2.34

2.34

100

Experimental studies

Quasi experimental studies

Pre experimental study

4

2

2

4.68

2.34

2.34

II

Intervention

Number

of Articles,

N=53

%

Acupressure

Aerobic and stretching exercise

Ginger and Zinc sulphate

Hot Application

Aroma Therapy

Yoga

Muscle Relaxation

Physical Activity

Acupuncture

Fish oil and structured teaching programme

Mint leaves

Mint Extract

Herbal and dietary therapy

Exercise

Ginger rhizome powder

Fenugreek

Relaxation

31

1

1

1

3

2

1

1

4

1

1

1

1

1

1

1

1

58.49

1.88

1.88

1.88

5.64

3.76

1.88

1.88

7.52

1.88

1.88

1.88

1.88

1.88

1.88

1.88

1.88

101

The included papers were classified based on the study design and based on

the interventions. Based on the study design, there were totally 85 papers, there were

13 (15.21%) randomized controlled trials. 9 (10.59%) systemic reviews. 3(3.51%)

Meta analysis. The remaining were Randomized clinical trials, Non-randomized pre

test-post test/ Evaluative studies, Evaluation of Cohort study, Cohort

(Prospective),Cohort (Retrospective),Prospective cross sectional studies Randomized

control pre and post test studies, Randomized single blind studies ,Cross over clinical

trials, Cross sectional analytical studies ,Cross sectional survey studies ,Cross

sectional descriptive studies, Comparative cross sectional studies , Observational

cross sectional studies, Case control studies , Experimental studies Quasi

experimental studies and Pre experimental studies.

Based on the intervention there were totally 53 articles for primary

dysmenorrhea. Among them 31 (58.49%) were acupressure as intervention.4 (7.52%)

were acupuncture as intervention. 3(5.64%) were aroma therapy as intervention.

2 (3.76%) were yoga as intervention. The other intervention were Acupressure

,Aerobic and stretching exercise, Ginger and Zinc sulphate, Hot Application, Muscle

Relaxation, Physical Activity, Fish oil and structured teaching programme, Mint

leaves, Mint Extract , Herbal and dietary therapy Exercise, Ginger rhizome powder,

Fenugreek and Relaxation.

102

EBP Question: Is Acupressure as an Intervention effective in treating pain and distress related to dysmenorrhea

Table.2 Individual Evidence Summary of RCT’s based on effectiveness of Acupressure upon pain and distress related to

dysmenorrhea

Article No

Author & Date

Title / Objective

Evidence Type

Sample, Sample Size, Setting and

tool used

Study findings that help answerthe EBP

Question

Evidence Level & Quality

1 Nam

Hyun

Cha

(2016)

Title- Auricular

acupressure therapy

on primary

dysmenorrhea

Objective- To

examine the effect

of auricular

acupressure therapy

on primary

dysmenorrhea

Randomised

Controlled

Trial (RCT)

Sample- Female high

school students on primary

Dysmenorrhea.

Sample size- 46 high

school students.

Tool used – Visual

analogue scale , Menstrual

distress questionnaire.

Study findings revealed there were

significant difference on abdominal pain

(t = 24.594, p < 0.001) back pain ( t =

225.661, P < 0.001) and primary

dysmenorrhea (t = 32.087 , p < 0.01)

between the two groups. Auricular

acupressure therapy decrease abdominal

pain, back pain and primary

dysmenorrhea of female high school

students.

Level 1

103

Article No

Author & Date

Title / Objective

Evidence Type


tool used

Study findings that help answer the EBP Question


2 Mohammed.

Salim.Al;-

Agamy

(2015),

Title

Femi- band

acupressure

reduction of

dysmenorrhea

pain

Objectives- to

investigate the

effect of using

Femi band

acupressure on

primary

dysmenorrhea

Randomised

Controlled

Trial (RCT)

Sample-Adolescent

students

Sample size -

150.adolescent students.

Tool - Visual analog

scale (VAS) Femi band

follow up chart and

satisfaction likert scale

The result showed in the intervention

group the severity of the pain reduced

from 8.27 to 9.92 following intervention

,the severity of the pain reduced after

using Femi band (immediate 30 min , 1

hr , 2 hr ) at first and second month in the

intervention group. When the severity of

the pain was analyzed at each time period

significant difference were observed (30

min ,1 hr , 2 hr) after applying the band

at 1,2 and 3 month

Level I

104

Articl No

Author & Date

Title / Objective

Evidence Type


tool used



3 Gharloghi,

Torkzahrani,

Akbarzadeh

and Heshmat

(2015)

Title

Acupressure at

Sanyinjiao

(SP6) point

and Digi (SP8)

point

Objectives- to

evaluate the

effect of

acupressure at

SP6 and

SP8point on

pain severity of

primary

dysmenorrhea

and associated

symptoms

Randomised

Controlled

Trial (RCT)

Sample- females aged 18

to 30 yrs

Sample size- 42 females

aged 18 to 30 yrs.

Tool used Mc Gill pain

scale, verbal multi

dimensional scoring

system

Findings of the study showed the severity

of dysmenorrhea pain diminishes

significantly for up to 2 hrs following

treatment with acupressure at the SP6

and SP8 points (p, 0.001).The severity of

associated systemic symptoms reduced

significantly after acupressure at the SP6

and SP8 point except for nausea and

vomiting. Comparison of the severity of

systemic symptoms with acupressure at

SP6 and Sp8 points revealed no

significant difference except for severity

of fatigue, which was reduce

significantly further with SP6 point

compared to Sp8 point ( p =0.004)

Level I

105

Article No

Author & Date

Title / Objective

Evidence Type


tool used



4 Mahboobeh,

Kafaeiatrain

et al (2014)

Title

Acupressure

on third liver

(L1V3) and

placebo points.

Reduce

dysmenorrhea

and improve

the quality of

life

Objectives- to

compare the

maximum pain

intensity (MPI)

and duration of

primary

dysmenorrhea

(PD)

Randomised

Controlled

Trial (RCT)

Sample-adolescent

students

sample size -59.,

Tool used Visual

analogue scale for

maximum pain intensity

(MPI)

The study findings highlighted in LIV3

group 27 and in control group 32

students were analyzed. Maximum pain

intensity (MPI) in each group decreased

after intervention but decrease in

duration of primary dysmenorrhea was

not significant. There were not

significant differences between groups

based ordinal regression test for

maximum pin intensity (MPI) and

duration of dysmenorrhea (p>0.05)

Level I

106

Article No

Author & Date

Title / Objective

Evidence Type


tool used

Study findings that help answer the EBP

Question


5

Alizaeh ,

Charandabi,

Neshtaei,

Kamali and

Majlesi

(2011)

Title -

Sanyinjiao

SP6,

acupressure

reduction of

menstrual pain

and menstrual

symptoms

Objectives- to

investigated

the effect of

SP6

acupressure on

severity of

menstrual pain

and symptoms

duration of

resting time ,

Number of

ibuprofen

conception

Randomised

Controlled

Trial (RCT)

Sample-Primary

dysmenorrhea students,

sample size- 72

adolescent students.

Tool - menstrual

symptoms

questionnaire and

visual analogue pain

scale

The result showed the severity of the

menstrual symptoms and duration of

resting times and conception of ibuprofen

was reduced in the second and third cycle

of menstruation in experimental group

than control group.

Level I

107

Article No

Author & Date

Title / Objective

Evidence Type


tool used

Study findings That helpanswer the EBP

Question


6 Ajorpaz,

Hajbaghery

and

Mosaebi

(2011)

Title

To evaluate the

effect of

acupressure on

primary

dysmenorrhea

pain reduction

assessed prior

to menstruation

Immediately 30

minutes. 1,2

and 3 hrs

following

treatment

Randomised

Controlled

Trial (RCT)

Sample-Adolescent

college girls. sample

size- 30, adolescent

college girls.

Tool - visual analogue

scale and symptoms

questionnaire used

Study findings revealed significant

differences were observed in the scores

of dysmenorrhea between control and

experimental groups immediately after

(3.50 ± 1.42 vs 5.06 ± 1.43,p=0.004) and

also 3 hours after treatment (1.66 ± 1.95

vs 4.80 ± 1.37 p = 0.000). acupressure on

the SP6 meridian can be effective non

invasive nursing intervention for

alleviating primary dysmenorrhea and its

effects last for 3 hrs post treatment

Level I

© The Johns Hopkins Hospital / Johns Hopkins University.

108

Synthesis of Evidence

There were six evidences on the topic, found appropriate for Individual

Evidence Summary and they were tabulated. All of the Evidences belonged to Level 1

which is coming under Evidence type, Randomised Controlled Trial.

Recommendations

The Strength of overall Evidence suggests that Acupressure is proven to be

effective for managing pain and distress related to dysmenorrhea. Acupressure at SP6

and SP8 point effective to the severity of associated systemic symptoms like

abdominal pain and back pain reduced significantly in the study conducted by

Gharloghi, Torkzahrani, Akbarzadh and Heshmat. 2015. A study by Nam Hyuncha

2016 showed that a specific point of auricular acupressure might be effective in

reducing abdominal pain and back pain as well as improving quality of life among

adolescent girls. (Maboobeh et al 2014) in their study stated that acupressure is

effective in reducing pain intensity during menstruation and duration of primary

dysmenorrhea and improving the quality of life. Ajorpaz , Hajbaghery and Mosaebi

2011 conducted a randomized control trial to investigate the effect of acupressure on

primary dysmenorrhea among adolescent girls , results suggest that acupressure

reduce pain and distress related to dysmenorrhea and promote positive physical and

psychological changes in adolescent girls and may be applied as a complementary

therapy towards population.

109

Hence Acupressure an alternative therapy is safe, free from untoward effects,

could definitely be a choice for reducing pain and distress related to dysmenorrhea

and promoting quality of life. The consistent practice of it is suggestive of having an

impact even on psychosocial domain of dysmenorrheal symptoms thus enhancing

quality of life and well being. The types of evidences, their level and their findings

selected in this study helped the researcher to proceed in the completion of the work.

Summary

This chapter has dealt with the review of published research literature related

to the problem stated. It has helped the researcher understand the impact of the

problem under study. It has also enabled the investigator to design the study, develop

the tool, plan for data collection procedure and analyse the collected data. This

chapter has also dealt with Nursing evidence Based Practice Protocol which include

NEBP question development, PRISMA flow diagram, the characteristics of included

papers with regard to study design and interventions and Individual Evidence

Summary of qualitative synthesis.

110

CHAPTER - III

RESEARCH METHODOLOGY

The present study aimed at determining the effectiveness of acupressure upon

pain and distress related to dysmenorrhea among adolescent girls and to find out how

well acupressure as an intervention works.This chapter describes the aspects like

research approach , research design, variables of study, research setting, population ,

samples and samples size , sample selection criteria , sampling technique , data

collection instruments , intervention , content validity, reliability of the tool ,ethical

consideration, pilot study, data collection procedure and data analysis procedure.

Research Approach

To accomplish the objective of this study. Quantitative experimental approach

was considered most appropriate. The experimental research approach was selected

for the present study as the study involved Acupressure as intervention for adolescent

girls.

Research Design

According to Polit and Beck (2010) a research design is the overall plan for

addressing a research question, including specification for enhancing the study

integrity.

The controlled experiment is considered to be the gold standard for yielding

reliable evidence about the cause and effect. Hence the Randomized Controlled Trial

(RCT) a full experimental design to test a treatment involving random assignment to

treatment group and control group was selected for the present study to determine the

111

effect of acupressure upon pain and distress related to dysmenorrhea among

adolescent girls.

A true experimental research design with comparison group is portrayed

diagrammatically as follows:

RE O1 X1 O2 X2 O3

RC O1 - O2 - O3

Fig. 5 Schematic representation of Research Design

R –Random Assignment of the Adolescent girls to both the groups

C – Control group

E- Experimental group

O1 - Pre test assessment of Pain and Distress related to Dysmenorrhea.

X1, .X2 - Administration of Acupressure as an Intervention

O2, -O3 – Post test assessment for pain and distress related to dysmenorrhea.

112

Variables

Variables under Study

A variable is defined as anything that has a quantity or quality that varies. The

dependent variable is the variable a researcher is interested in and independent

variable is a variable believed to affect the dependent variable.

Independent Variable

The independent variable of the present study is administration of acupressure

to the adolescent girls with pain and distress related to dysmenorrhea. In this research

acupressure is the variable that the researcher will manipulate to see if it makes the

dependent variables change.

In this study independent variable acupressure is gentle pressure applied in the

Sanyinjiao point (3 cun - superior to the tip of medial malleolus, posterior to medial

border of tibia) sp6 situated in the midpoint, four fingers above the tip of medial

malleolus bone about 20 minutes, twice a day for first three days of menstruation.

Dependant Variables

Pain related to dysmenorrhea as measured by Visual Analogue Pain Scale,

distress related to dysmenorrhea as measured by modified MMDQ Satisfaction level

assessed using rating scale.

Attribute Variables

A variable that is a characteristic or trait of a subject which therefore,

researchers cannot manipulate but can only measure. The present study includes the

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socio demographic and menstrual variable as attribute variables which were measured

by the researcher influence on pain and distress related to dysmenorrhea of the

adolescent girls.

Research Setting

The study was conducted St Ursula’s Higher secondary school Kulasekharam,

which was started in the year 1963. They are taught both in the matriculation and

state syllabi, in the 9th standard there are 5 divisions with students around 230 and

in the 11th standard 8 groups comprising a total strength of 340 . They are all come

from nearby places, the important factor of the school is, it is run by Reverent sisters

of a convent. It is Girl’s school that caters to the important of welfare of the female

community, the weaker students are detected in the beginning and imparted morning

and evening special classes.

The second school used for data collection was yettacode Higher Secondary

School; it was started in the year 1970. There are 5 divisions in the 9th standard total

220 students are studying. It is a co- educational school, classes are conducted both in

the state and matriculation syllabi, in the 11th standard there are 8 groups and has a

total students of 320 , students of the school belongs to the surrounding area . Here

also morning and evening special classes are conducted.

Population

Population is a well-defined collection of individuals or objects known to have

similar characteristics. All individual or objects within a certain population usually

have a common, binding characteristics or unit.

114

Target population

Target population refers to the entire group of individuals or objects to which

researcher are interested in generalizing the conclusion. The target population usually

has varying characteristics and it is also known as the theoretical population. In this

study target population comprises of adolescent girls having dysmenorrhea studying

9th and 11thstandard.

Accessible population

It is the population in research to which the researchers can apply their

conclusion. This population is a subset of the target population and is also known as

the study population. The accessible populations in the study refers to the adolescent

girls having dysmenorrhea studying 9th and 11th standard at St Ursula’s Higher

secondary school Kulasekharam and Yettacode Higher secondary school Attoor

during the time of data collection period.

Sample

A sample is a subset of a population that is used to represent the entire group

as a whole. The participants of the study were the adolescent girls who fulfill the

inclusion criteria and are studying St Ursula’s Higher secondary school and Yettacode

Higher secondary school Attoor. The samples were selected through sampling

process.

Sample Size

The sample size of the present study was 260: 130 in control group and 130 in

experimental group. The required samples were calculated for each scale and finally

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the averages of all have been taken into account for the main study. The sample size

calculations were done for the intervention variables namely pain and distress. The

pre and post-1 test was taken in calculation. The pre and post -1 test mean pains were

7.2 and 6.6 with combined standard deviation of 1.4. The online before and after

sample size calculator was used with the following statistics. The α and β levels were

0.05 and 0.10. The calculated sample size was 115 with power of 0.90. Similarly, the

mean distress of pre and post-1 tests was 68.8 and 66.1 with combined SD 7.2. The

calculated sample size was 150. By taking the averages of the above two means was

132.5. The rounding of the sample size was 130. An equal number of samples sizes

130 were assigned to control group. The power of the study (1- β) was 0.90 or 90%.

Criteria for Sample Selection

The sample selection was based on the following inclusion and exclusion

criteria

Inclusion criteria

Adolescence girls who are:

Between 14 and 17 years of age group

Studying in 9th and 11th standard

Having primary dysmenorrhea

Having regular menstrual cycle

Having moderate to severe dysmenorrhea symptom as per the VASP and MMDQ

symptom scale.

Willing to participate

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Exclusion Criteria

Adolescence girls

who are have secondary dysmenorrhea

Under medical treatment for dysmenorrhea

Practicing yoga and exercise or any other complimentary therapy.

Unwilling to participation the study.

With irregular menstrual cycle.

Sampling Technique

Sampling is the process of selecting a portion of the population to represent

the entire population (Polit 2008). In the present study, the investigator used random

sampling technique (lottery method). Researcher has selected this technique as it was

believed that representative sample can be obtained by using a sound judgment.

Simple random sampling is a method of selecting (n) units from a population of size

N such that every possible sample has an equal chance of being drawn.

The investigator created a sampling frame by enumerating all members of a

population i.e. adolescent girls, who were having moderate to severe dysmenorrhea

(N = 390).The investigator allotted numbers to all members in a serial order i.e. from

1 to 390. Numbers were written on pieces of paper and put all these pieces of papers

in to a box. Drawn a piece of paper one by one after shaking the box until 260piece of

papers, these 260 samples consider as a study sample. Based on these criteria 260

adolescent girls were selected 130 assigned to control group and 130 in experimental

group.

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DESIGN

True Experimental research design with comparison group Times series Repeated measures

Study Setting : Yettacode Higher Secondary School and St. Ursula’s Higher Secondary School.

Acupressure Group

Random Sampling based on Inclusion

criteria

Sample Size 130

Pre Test - I

Acupressure

Acupressure

Non Acupressure Group

Random Sampling based on Inclusion

criteria

Sample Size 130

Pre Test - I

No Acupressure

No Acupressure

Data Analysis

Pre test

Socio demographic and menstrual

variables VASP Modified MMDQ

Post test 1 VASP

Modified MMDQ

Post test 2

VASP

Modified MMDQ

Fig. 6 : Schematic Representation of e Research Methodology

118

Selection and Development of Study Instruments

Treece and Treece (1996) states that the instruments selected in a research

should be the best tool to obtain data for drawing conclusions pertinent to the study.

The following instruments were selected for use in the present study were :

Socio demographic variable Proforma

It was developed by the researcher to assess the socio demographic variables

of adolescent girls such as Age, Education, Mothers’ education, Mothers’ occupation,

Family monthly income, Residence, Religion, Dietary habits and Food cravings. The

information was collected by interviewing the participants. No scores were provided.

Only coding was done

Menstrual Variable Proforma

A performa was developed by researcher to identify the menstrual variables

such as Age at menarche, Frequency of menstrual cycle, Extent of menstrual flow,

Duration of menstrual flow, Onset of menstrual pain, Family history of dysmenorrhea

Socio demographic variables proforma

Menstrual variables proforma

Visual Analogue scale for pain to assess the pain related to

dysmenorrhea

Modified Moos Menstrual distress questionnaire to assess the

distress related dysmenorrhea

Rating scale on level of satisfaction regarding acupressure

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and Treatment taken for dysmenorrhea. The researcher filled in the details by

interviewing the participants. No scores were provided. Only coding was done.

Visual Analogue Pain Scale

The Visual Analogue scale for pain (VASP) was used to assess the intensity of

pain. It consisted of a 10- cm horizontal scale with the descriptors ‘no pain’ on the left

and ‘worst possible pain’ on the right. Participants were asked to place a mark on the

10-cm line at a point that correspondent to the level of pain intensity they felt. The

distance in centimeters from the low end of the VASP to the participant’s mark was

used as a numerical index of the severity of pain. The visual analogue scale was

explained to the adolescent girls and they are asked to mark the response before and

after acupressure. The score was divided into three quartiles 1 to 3- mild, 4 to 6 –

moderate, and 7 to 10 – severe.

Modified Moos Menstrual Distress questionnaire

The moose menstrual distress questionnaire (Moose, 1968) was developed for

assessing the menstrual distress of adolescent girls it comprises 8 components (44

items) which include Pain, Concentration , Behavioral change, Autonomic reaction ,

Water retention , Negative effect , Arousal and Control. In the present study modified

MMDQ was used by the researcher, which comprises of 6 components (30 items)

which includes Pain, Concentration, Behavioral changes, Autonomic reaction, Water

retention, Negative effect. This helps to identify various menstrual distresses before

and after acupressure.

It is designed in the form of rating scale. The maximum score was 90. The

symptoms is graded from 0 to 3: 0 (no symptoms): 1 (symptoms exist only mildly and

120

do not interfere with routine activities): 2 (symptoms exist moderately and interfere

with routine activities but are not debilitating) and 3 (symptoms exist severely and are

completely debilitating). The instrument was self administered by the participants.

They were asked to mark their symptoms experienced during their first three days of

menstrual period before and after acupressure. Scoring interpretation < 30 - mild level

of distress. 30 to 60 - moderate level of distress. Above 60 - Severe level of distress

Rating Scale to Assess the Level of Satisfaction of Intervention in adolescent girls

Level of satisfaction of administration of acupressure.It consists of 16 items. It

is rated on a three point rating scale ranging from 1 to 3. The items were rated

according to the satisfaction of the samples on the part of the researcher,

administration of acupressure, method of administration, benefits and effectiveness &

continuity. Each section has 4 items.

Scoring key:

Highly satisfied - 3

Satisfied - 2

Dissatisfied - 1

Score interpretation:

16- 24 - Inadequate satisfaction

25- 36 - Moderate satisfaction

37-48 - Adequate satisfaction

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Psychometric properties of the instruments

Validity

Content validity refers to how accurately an assessment or measurement tool

taps into various aspects of the specific construct in question. Validity of the tool was

established with a guide and nine experts .The prepared instruments along with the

objectives, blue print and criteria evaluation was submitted to nine experts. The

experts were consulted from various fields like nursing, medicine, naturopathy

statistics and were mentioned in the annexure. The tool was found adequate and minor

suggestions given by them were incorporated.

Reliability

Reliability is concerned with how consistently and accurately the instrument

technique measured the concept of interest (Burns & Grove 1999). In this study all the

tools were pre tested. The reliability coefficient of the symptom reaction to adolescent

girl’s inventory was computed by using Cronbach’s alpha method and it was 0.87 and

the reliability coefficient of visual analogue scale for pain was computed by using

Kappa method and it was 0.92.The reliability of rating scale to assess the satisfaction

of intervention were computed by using Cronbach’s alpha method and it was 0.804.

Intervention Protocol

Acupressure:

A pressure applied to the Sanyinjiao point (3 cun - superior to the tip of medial

maleolus, posterior to medial border of tibia) sp6 situated in the midpoint, four fingers

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above the tip of medial malleolus bone about 20 minutes (intermittent) twice a day for

first three days of menstruation..

Acupressure procedure

Explain the procedure to the adolescent girls to win the confidence and co operation

Bladder should be emptied prior to the intervention

Adolescent girls with moderate and sever dysmenorrhea were informed to sit in a

comfortable position with legs elevated, leg elevated in a supine position on a foam

bed

Encourage to relax their mind and body

Pressure points were identified by pointing four fingers above the tip of medial

malleolus bone and posterior border of the medial aspect of the tibia in lower leg.

Pressure was applied for 20 minutes twice a day with a duration of 10 minutes in each

leg for first three days of menstruation

Apply deep pressure slightly behind the bone (tibia)

Massage the area for 20 minutes intermittently as far as pain is tolerable ( Pain

threshold )

Press the specified point with thumb finger in a clock wise circular fashion

Pressure should be applied both the legs for 20 minutes

123

The point is located in the medial side of the leg.

Point is located four finger space above the ankle in the depression under the bone

(tibia).

Fig.7 : Administration of Acupressure

124

Pilot Study

Polit and Beck (2010) is a small scale version done in preparation for the

original research work. The purpose is to find out the feasibility and practicality of the

main study.

A Pilot study was conducted among 26 samples, 13 each in control and

experimental group who met the inclusion criteria. The study was feasible to conduct.

Tools were found to be relevant and feasible to use. There were no confusion,

duplication or ambiguity in any questions or tools. The overall study was found to be

feasible. Therefore this pilot study confirmed that it is feasible to conduct this study

on a larger sample.

Data Collection Procedure

The data were collected from adolescent girls between June 2015 and July

2016. The researcher obtained the formal permission from the headmasters of

Yettacode Higher Secondary School Attoor and St Ursula’s Higher Secondary School

Kulasekharam. Verbal and written consent was obtained from the adolescent girls

indicating the voluntary participation. 260 adolescent girls who were having moderate

to severe dysmenorrhea were randomly (lottery) assigned into control and

experimental group. Based on the adolescent girls menstruation date, the researcher

separated the girls in control and experimental group for each day of data collection

procedure. There was no attrition.

Data about Background variables was collected before pre test, using socio

demographic Performa and menstrual performa. The researcher has conducted pre test

during menstruation to assess the pain and distress related to dysmenorrhea for the

125

first three days of menstruation (1st day, 2nd day and 3rd day) by using Visual

Analogue Scale for pain and Modified Moos Menstrual Distress Questionnaire for

distress to the control group and experimental group. After pre test, the subsequent

two menstrual cycle post test 1 and 2 was conducted. Acupressure was provided to

the Sanyinjiao point (SP6) ( 3 cun - superior to the tip of medial malleolus, posterior

to medial border of tibia) situated in the midpoint, four fingers above the tip of medial

malleolus bone about 20 minutes (both legs) for the first three days of menstruation

twice a day to the experimental group., post test was conducted after acupressure for

first three days of menstruation with a same tool in the experimental group, without

acupressure post test was conducted in the control group for first three days of

menstruation with the same tool. Twenty minutes after acupressure adolescents in the

experimental group were asked to evaluate their satisfaction with the helpfulness of

acupressure.

Before conducting the study the investigator got qualified with acupressure

training on dysmenorrhea (SP6), which enabled her to implement the therapy for

adolescent girls.

Plan for data Analysis

The data collected was transferred into master code sheet and entered in

statistical package for social studies (SPSS-20), IBM .The collected data was

organized and analyzed according to the objectives and hypothesis of the study,

Descriptive statistics (frequency, percentage.) were planned to be used to calculated

the socio demographic variable and menstrual variable also the level of pain and

distress related to dysmenorrhea on the 1st ,2nd, and 3rd day before and after

acupressure pre test and post test 1and 2.

126

The effectiveness of acupressure on pain related to dysmenorrhea between the

groups was planned to be Mean and standard deviation and Friedman test. Distress

related to dysmenorrhea on (1st ,2nd and 3rd day),pre test, post 1 and post 2 was

planned to by paired ‘t’ test (within the group) independent ‘t’ test (between group)

repeated measures of ANOVA were planned to conformed this result. Spearman’s

rank correlation coefficient was planned to be used for finding the correlation between

pain and distress related to dysmenorrhea before and after intervention on the 1st ,2nd

and 3rd day of menstruation. The chi square analysis was planned to be used to find

out the association between the pre test pain and distress related to dysmenorrhea and

their selected socio demographic and menstrual variables.

Ethical considerations

Ethics are the norms or standards for conduct that distinguish between right

and wrong. They help to determine the difference between acceptable and

unacceptable behaviors. Research proposal approved by the dissertation committee

and institutional review board and ethical clearance board from The Tamil Nadu

Dr. MGR. Medical University and Apollo College of Nursing Chennai. It is consulted

and works as per ICH-GCP, ICMR and revised Y guidelines under the ICMR.

It reviewed and discussed the project proposal document at the meeting held on 28th

October 2014. It has 6 members including pharmacologist, project executive, assistant

professor, medical superintendent, blood bank officer and lawyer.

127

Formal permission was obtained from the concerned school authorities. The

verbal and written consent of each student was obtained before starting the data

collection. Clear explanation of the study purpose, type of data required, participation

and the right to withdraw from the study at any point of time and full privacy was

assured. Assurance was given to the adolescent girls that anonymity of each

individual would be maintained.

Summary

This chapter deals with the research methodology of the study. It included

research approach, research design, variables, research setting, population, sampling

process, description of the tool, content validity and reliability of the tools, pilot

study, data collection procedure, plan for data analysis and ethical considerations.The

next chapter deals with the statistical analysis of data and the interpretation of results.

128

CHAPTER - IV

ANALYSIS AND INTERPRETATION

The research data need to be processed and analyzed in some systematic

fashion, so that trends and pattern of relationship can be detected. In this chapter the

data collected from 130 adolescent girls in the control group and 130 adolescent girls

in the experimental group to determine the effect of acupressure on dysmenorrhea is

presented. The data were analyzed according to objectives and hypotheses of the

study. Analyses of the data were done after transferring all the data into a master data

sheet. It was done through an integrated system of computer program known as

statistical package for social science (SPSS-20).

Statistical analysis and interpretations:

The study subjects namely control and experimental groups of adolescent girls

were described and matched for homogeneity in respect of their socio demographic

and menstrual variables. The effectiveness of acupressure in experimental subjects

were analyzed in terms of descriptive statistics and interpreted by students paired “t”

test. The interpretations were confirmed by the statistical model Repeated measures of

ANOVA since the variables were measured three times. The pain scale is an ordinal

scale. Because of that, instead of repeated measures of ANOVA the Friedman test

was applied. The Friedman test is similar to repeated measures of ANOVA. The

interpretations between the groups were done by independent “t” test. Since the pain

scale is an ordinal scale, the interpretations between the groups were done by Kruskal

Wallis (KW) test. Similarly the control group subjects were analyzed and interpreted

accordingly. The relationship between pain and distress of dysmenorrhea were

analyzed and interpreted by Spearman’s rank correlation since the pain measurement

129

was in ordinal scale. The associations between pain and distress with demographic

and clinical characteristics of both groups were done by χ2 (Chi-square test). The

above statistical procedures have been undertaken with the help of the statistical

package namely IBM SPSS Statistics-20. The P-values less than or equal to 0.05

(P≤0.05) were considered as statistically significant.

Organization of the study findings:

The substantive summary of the data analysed is organised under the

following headings.

Description of socio demographic and menstrual variables

Description of pain and distress related to dysmenorrhea on the day wise assessment

before intervention

Description of pain and distress related to dysmenorrhea on the daywise assessment

before and after intervention

Effectiveness of acupressure on pain and distress related to dysmenorrhea

Frequency and Percentage distribution of level of satisfaction of acupressure

Relationship between pain and distress related to dysmenorrhea before and after

acupressure

Association between pain and distress related to dysmenorrhea with socio

demographic and menstrual variables

130

Table.3 Frequency, Percentage and Chi square values of Socio Demographic Variables

of Control and Experimental Group of Adolescent Girls for homogeneity

Demographic

variables

Category Control group

n=(130)

Experimental

group

n =(130)

χ2

df

P value

Sig

f % f %

Age (years) 14-15 49 37.7 51 39.2 χ2=0.065

df=1

P>0.05

16-17 81 62.3 79 60.8

Adolescents’

educational

status

9th Std 48 36.9 51 39.2 χ2=0.702

df=1

P>0.05

11th Std 82 63.1 79 60.8

Religion Hindu 37 28.5 40 30.8 χ2=2.126

df=2

P>0.05

Christian 84 64.6 75 57.7

Muslim 9 6.9 15 11.5

Residence Urban 66 50.8 71 54.6 χ2=0.385

df=1

P>0.05

Rural 64 49.2 59 45.4

Type of

family

Nuclear 33 25.4 54 41.5 χ2=7.618

df=1

P<0.01

Joint 97 74.6 76 58.5

Dietary

habits

Vegetarian 35 26.9 28 21.5 χ2=1.027

df=1

P>0.05

Non- Veg. 95 73.1 102 78.5

Food craving Salt 59 45.4 74 56.9 χ2=3.463

df=1

P>0.05

Sweet 71 54.6 56 43.1

131

It can be observed from the above Table. 3 that majority of the adolescent girls

were in the age group of 16-17 yrs (62.3%, 60.8%), studying in 11th std (63.1%,

60.8%) belongs to Christian religion (64.6%, 57.7%), living in urban area (50.8%,

54.6%) in joint families (74.6%, 58.5%) non vegetarians (73.1%, 78.5%) and food

craving for sweets (54.6 %,) in control group and for salt (56.9%) in experimental

group of adolescent girls respectively.

Fig.8 shows that most of the mothers of adolescent girls are educated up to

collegiate level (40.8%, 42.3%) in control and experimental group respectively.

Fig.9 illustrates mothers’ occupational status of adolescent girls as home

makers (43.9%) in control group and private employees (35.4%) in experimental

group.

Fig.10 depicts that family monthly income of half of the adolescent girls was

Rs 20000 to 40000 in control group (50%) and Rs < 20000 in experimental group

(40.7%).

The data in table.3 and figures 8, 9 and 10 reflect that the control and

experimental groups are homogeneous in respect of their demographic variables. The

two groups were homogeneous groups except type of family. Since the two groups

did not show statistically significant difference (P>0.05). The significantly differed

groups such as type of families did not play any effect in the study since they are not

physiological variables. Hence the control and experimental groups of adolescent girls

were comparable.

132

Fig. 8 Percentage Distribution of Mothers’ Educational status of Control and Experimental Groups of Adolescent Girls

0

5

10

15

20

25

30

35

40

45

50

Illiterate School College Professional

8.5

31.5

40.8

19.2

5.4

40 42.3

12.3

Control Group

Experimental Group

2=4.203

P>0.05

133

Fig. 9 Percentage Distribution of Mothers’ Occupational status of Control and Experimental Groups of Adolescent Girls

0

5

10

15

20

25

30

35

40

45

Cooli Private Govt Home Maker

4.6

31.5

20

43.9

6.9

35.4

24.6

33.1

Control Group

Experimental Group

2=3.468

P>0.05

134

Fig. 10 Percentage Distribution of Family Monthly Income of Control and Experimental Groups of Adolescent Girls

24.6

50

25.4

40.7 38.5

20.8

0

10

20

30

40

50

60

<20000 20000-40000 40000+

Control Group

Experimental Group

2=2.126

P>0.05

135

Table. 4 Frequency, Percentage and Chi square values of Menstrual Variables of

Control and Experimental Group of Adolescent Girls for homogeneity

Menstrual

variables Category

Control group

(n=130)

Experimental

group

(n =130) χ2

df

P value

sig f % f %

Age at

Menarche

(years)

10-12 70 53.8 74 56.9 χ2=0.648

df=2

P>0.05

13-14 55 42.3 53 40.8

15-16 5 3.8 3 2.3

Onset of

Menstrual

Pain

Prior to

menstrua

tion

55 42.31 52 40.0 χ2=0.385

df=1 P>0.05

During

menstruation 75 57.69 78 60.0

Family

History of

dysmenorrhea

1st line

relatives 106 81.5 98 75.4

χ2=1.457

df=1 P>0.05

2nd line

relatives 24 18.5 32 24.6

Treatment

taken for

dysmenorrhea

Nothing 100 76.9 93 71.5

χ2=1.178

df=3 P>0.05

Rest 14 10.8 19 14.6

Medical 11 8.5 13 10.0

Herbal 5 3.8 5 3.8

The data presented in Table .4.shows that a majority of the adolescent girls

have attained their menarche at the age of 10-12 yrs (53.8%, 56.9%), with onset of

menstrual pain during menstruation (57.69%, 60.0%),with first line family history of

dysmenorrhea (81.5%, 75.4%) and not taking any treatment for dysmenorrhea

(76.9%, 71.5%) in control and experimental group of adolescent girls respectively.

136

It can also be noted the frequency of menstrual cycle was 28-35 days (49.2%,

63.1%) in control and experimental group respectively (Fig.11).

Fig.12. depicted that the adolescent girls in control and experimental group

had moderate menstrual flow (50.0%, 44.6%) respectively.

A majority of the adolescent girls had 4-6 days of menstrual flow (59.2%,

70.8%) in control and experimental group respectively as per the data presented in

fig.13.

The above table 4 and figures 11, 12 and 13 depicts the matching and

description of control and experimental groups. The two groups did not differ

significantly in respect of their menstrual variables (P>0.05). Hence the two groups

were comparable groups and homogenous.

137

Fig.11. Percentage Distribution of Frequency of Menstrual Cycle of Control and Experimental Groups of Adolescent Girls

0

10

20

30

40

50

60

70

<28 28-35 35-45 45+

11.5

49.2

34.6

4.6

10

63.1

35.4

0

Control Group

Experimental Group

2= 7.357

P>0.05

138

Fig. 12.Percentage Distribution of Extent of Menstrual Flow of Control and Experimental Group of Adolescent Girls

0

5

10

15

20

25

30

35

40

45

50

Heavy Moderate Light

37.7

50

12.3

40.8

44.6

14.6

control Group

ExperimentalGroup

2= 0.812

P>0.05

139

Fig. 13.Percentage Distribution of Duration of Menstrual Flow of Control and Experimental Group of Adolescent Girls

0

10

20

30

40

50

60

70

80

90

100

1-3 4-6 7-9

17.7

59.2

23.1

11.5

70.8

17.7

Control Group

Experimental Group

2=3.940

P>0.05

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Table.5 Frequency and Percentage Distribution of Pain Related to

Dysmenorrhea before Acupressure among Control and Experimental Group of

Adolescent Girls on the first, second and third day of Menstruation.

Pain

Control group (n=130) Experimental group (n=130)

Pre test Pre test

First day Second

day Third day First day

Second

day Third day

f % f % f % f % f % f %

No 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0

Mild 0 0.0 2 1.5 8 6.2 0 0.0 2 1.5 7 5.4

Moderate 52 40.0 72 55.4 109 83.8 51 39.2 65 50.0 111 85.4

Severe 78 60.0 56 43.1 13 10.0 79 60.8 63 48.5 12 9.2

Total 130 100 130 100 130 100 130 100 130 100 130 100

The data in table 5 shows that in pre test the pain related to dysmenorrhea was

severe on first day (60.0%,60.8%) in comparison with moderate level of pain on

second day (55.4%,50.0%) and third day (83.8%,85.4%) respectively in both control

and experimental; group of adolescent girls.

141

Table.6 Frequency and Percentage Distribution of Distress Related to

Dysmenorrhea Before Acupressure among Control and Experimental Group of

Adolescent Girls on the first, second and third day of Menstruation.

Distress


Pre test Pre test

First day Second

day Third day First day

Second

day Third day

f % f % f % f % f % f %

No 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0

Mild 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0

Moderate 7 5.4 20 15.4 37 28.5 5 3.8 25 19.2 27 20.8

Severe 123 94.6 110 84.6 93 71.5 125 96.2 105 80.8 103 79.2

Total 130 100 130 100 130 100 130 100 130 100 130 100

It can be inferred from Table 6 that in pre test the distress related to

dysmenorrhea was severe on first day (94.6%,96.2%) in comparison with moderate

level of distress during second day (15.4%,19.2%) and third day (28.58%,20.8%)

respectively in both control and experimental; group of adolescent girls.

It can be noted the pain related to dysmenorrhea on the first day of menstrual

cycle in pre test (60.0%) and post test1 (60.8%) post test 2 (64.6%) remained the same

at severe level of pain among the control group of adolescent girls.

Whereas among the experimental group of adolescent girls in pre test 60.8%

had severe level of pain on the first day and after the intervention of acupressure a

majority of them had only moderate level of pain on the first day of post test 1

(64.7%) and post test 2 (60.8%) respectively ( fig. 14)

142

Fig.14 Percentage Distribution of Pain Score Before and After Acupressure of Control and Experimental Group of Adolescent

Girls on the First Day of Menstruation

0 0 0 0

14.6

36.2 40 39.2

35.4 39.2

64.7

60.8 60 60.8

64.6 60.8

20.7

3

0

10

20

30

40

50

60

70

80

90

100

110

Control Pre Control Post 1 Control Post 2 Experi Pre Experi Post 1 Experi Post 2

Severe

Moder

Mild

143

Table. 7 Frequency and Percentage Distribution of Pain related to

Dysmenorrhea Before and After Acupressure among Control and Experimental

Group of Adolescent Girls on the Second Day of Menstruation.

Pain

Control Group (n=130) Experimental Group (n=130)

Pre test Post test-1 Post test-2 Pre test Post test-1 Post test-2

f % f % f % f % f % f %

No 0 0.0 0 0.0 0 0.0 0 0.0 1 0.8 11 8.5

Mild 2 1.5 0 0.0 0 0.0 2 1.5 77 59.2 99 76.2

Moderate 72 55.4 84 64.6 77 59.2 65 50.0 52 40.0 20 15.3

Severe 56 43.1 46 35.4 53 40.8 63 48.5 0 0.0 0 0.0

Total 130 100 130 100 130 100 130 100 130 100 130 100

The data presented in table 7 shows that the pain related to dysmenorrhea on

the second day of menstrual cycle in pre test (55.4%) and post test 1 (64.6%) and post

test 2 (59.2%) remained the same at moderate level of pain among the control group

of adolescent girls .

Whereas it can be observed in table 7 that 48.5% of experimental group of

adolescent girls had severe pain in the pre test done on second day and among the

same adolescents after the intervention of acupressure none of them experienced

severe level of pain on second day in post test 1 and post test 2.They had only mild

level of pain on second day in post test 1 (59.2%) and post test 2 (76.2%).

144

Fig 15 illustrates the pain related to dysmenorrhea on the third day of


remained the same at moderate level of pain among the control group of adolescent

girls.

Whereas it can be noted that 83.8% of experimental group of adolescent girls

had moderate pain in the pre test done on third day and the same adolescents after the

intervention of acupressure none of them experienced severe level of pain on third

day in post test 1 and post test 2.They had only mild level of pain on third day in post

test 1 (80.0%) and post test 2 (51.5%) and 47.7% of the adolescents reported no pain

in post test 2.

145

Fig.15 Percentage Distribution of Pain Score Before And After Acupressure of Control And Experimental Group of Adolescent

Girls on the Third Day of menstruation

0 0

12.3

47.7

6.2

25.4 22.3

5.4

80

51.5

83.8

73.1 73.1

85.4

7.7 0.8

10 1.5 4.6 9.2

0

10

20

30

40

50

60

70

80

90

100


Severe

Moder

Mild

No

146

Table. 8 Frequency and Percentage Distribution of Distress Related to


Group of Adolescent Girls on the First Day of Menstruation.

Distress


Pre test Post test-1 Post test-2 Pre test Post test-1 Post test-2

f % f % f % f % f % f %

No 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0

Mild 0 0.0 0 0.0 0 0.0 0 0.0 32 24.6 91 70.0

Moderate 7 5.4 16 12.3 15 11.5 5 3.8 98 75.4 39 30.0

Severe 123 94.6 114 87.6 115 88.5 125 96.2 0 0.0 0 0.0

Total 130 100 130 100 130 100 130 100 130 100 130 100

The data presented in table 8 depicts that the distress related dysmenorrhea on

the first day of menstrual cycle in pre test (94.6%) and post test 1 (87.6%) and post

test 2 (88.5%) remained the same at severe level of distress among the control group

of adolescent girls .

Whereas it can be observed in table (8) 96.2% of experimental group of

adolescent girls had severe distress in the pre test done on first day and the same




147

It can also be noted the distress related to dysmenorrhea on the second day of


remained the same at severe level of distress among the control group of adolescent

girls. Fig 16

Among the experimental group majority of the adolescent girls in pre test

80.8% had severe level of distress on the second day and the same adolescents after

the intervention of acupressure none of them experienced severe level of distress on

second day in post test 1and post test 2. They had only mild level of distress on

second day in post test 1 (59.2%) and post test 2 (76.2%) respectively as per the data

illustrated in fig 16

148

Fig. 16 Percentage Distribution of Distress Score Before and After Acupressure of Control and Experimental Group of

Adolescent Girls on the Second Day of Menstruation

0 0 0 0

43.8

86.2

15.4 18.5

39.2

19.2

56.2

13.8

84.6 81.5

60.8

80.8

0 0

0

10

20

30

40

50

60

70

80

90

100

110


Severe

Moder

Mild

149

Table. 9 Frequency and Percentage Distribution of Distress Related to


Group of Adolescent Girls on the Third Day of Menstruation.

Distress


Pre test Post-1 test Post-2 test Pre test Post-1 test Post-2 test

f % f % f % f % f % f %

No 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0

Mild 0 0.0 0 0.0 0 0.0 0 0.0 84 64.6 128 98.5

Moderate 37 28.5 65 50.0 90 69.2 27 20.8 46 35.4 2 1.5

Severe 93 71.5 65 50.0 40 30.8 103 79.2 0 0.0 0 0.0

Total 130 100 130 100 130 100 130 100 130 100 130 100

It can be elicited from table 9 that the distress related to dysmenorrhea on the

third day of menstrual cycle in pre test (71.5%) and post test1 (50.0%) post test 2

(69.2%) remained the same at moderate level of distress among the control group of

adolescent girls.

Whereas it can be noted that 79.2% of experimental group of adolescent girls

had severe level of distress in the pre test done on third day and the same adolescents

after the intervention of acupressure none of them experienced severe level of distress

on third day in post test 1 and post test 2.They had only mild level of distress on third

day in post test 1 (64.6%) and post test 2 (98.5%).

150

Table. 10 Frequency and Percentage Distribution of Level of Satisfaction of

Acupressure among Experimental Group of Adolescent Girls

Level of satisfaction

Score

Experimental Group (n=130)

f %

Dissatisfied 16-24 0 0

Satisfied 25-36 0 0

Highly satisfied 37-48 130 100

The data in above table 10 depicts that all the participants were highly

satisfied about acupressure among experimental group of adolescent girls. None of

them were in the category of dissatisfied and satisfied

151

Table. 11 Comparison of Mean, Standard Deviation and Friedman Values of

Pain Related to Dysmenorrhea among Control and Experimental Group of

Adolescent Girls on the First Day of Menstruation.

Group Pre-test Post test-1 Post test-2 χ2

(Friedman)

df Sig

Mean SD Mean SD Mean SD

Control

(n=130)

7.1 1.7 7.3 1.2 7.4 1.2 1.290 2 P>0.05

Experimental

(n=130)

7.1 1.7 5.0 1.5 4.0 1.3 241.179 2 P<0.001

The data in table 11 reveals that on the first day of menstruation there was no

significant difference between mean and standard deviation of pre test (M=7.1,

SD= 1.7) and post test 1 (M=7.3, SD=1.2) and post test 2 (M=7.4, SD=1.2) level of

pain related to dysmenorrhea among the control group of adolescent girls

( χ2 = 1.290,P>0.05 ).

Whereas it can be noted that among the experimental group of adolescent girls

there was a significant difference (χ2=241.179, P<0.001) between the mean, standard

deviation of pain related to dysmenorrhea on first day in pre test (M=7.1, SD=1.7) and

post test 1 (M=5.0, SD=1.5) and post test 2 (M=4.0, SD=1.3). The result can be

attributed to the effectiveness of acupressure upon reducing pain related to



152

Pre test Post test-1 Post test-2

Fig-17 Comparison of Effectiveness of Acupressure between Control and

Experimental Group of Adolescent girls Pain related to Dysmenorrhea on the

First Day of Menstruation (Repeated Measures of ANOVA Plots)

The repeated measure of ANOVA illustrated in fig17 indicates the pain on

first day of menstruation among the control and experimental group of adolescent

girls and decrease in pain among the experimental group of adolescents in post test 1

and Post test 2 can be noted.

153

Table. 12 Comparison of Mean Standard Deviation and Friedman Values of Pain

Related to Dysmenorrhea among Control and Experimental Group of

Adolescent Girls on the Second day of Menstruation.

Groups Pre-test Post-1 Test Post-2 Test

χ2

(Friedman) df Sig


Control

(n=130) 6.4 1.6 6.2 0.8 6.3 1.0 3.211 2 P>0.05

Experimental

(n=130) 6.4 1.3 3.2 1.4 2.3 1.3 238.381 2 P<0.001

The data in the table 12 shows that in control group on second day of

menstruation there was no significant difference between pre test (M=6.4, SD=1.6),


dysmenorrhea among adolescents (χ2=3.211,P.>0.05)

Whereas in experimental group there was a significant difference (χ2=238.381,

P<0.001) between the mean and standard deviation of pain related to dysmenorrhea

on second day in the pre test (M=6.4, SD=1.3) post test 1 (M=3.2, SD=1.4) and post

test 2 (M=2.3, SD=1.3) i.e. There was a significant reduction of pain in post test 1and

post test 2, while comparing the pre test in experimental group. It can be attributed to

the effectiveness of acupressure upon reducing pain related to dysmenorrhea. Hence

the Null hypothesis Ho1 there will be no significant difference in the effect of


154



Experimental Group of Adolescent Girls Pain related to Dysmenorrhea on the

Second Day of Menstruation.(Repeated Measures ANOVA Plots)

The repeated measures of ANOVA illustrated in fig 18 indicates the pain on

second day of menstruation among the control and experimental group of adolescent


and post test 2 can be noted .

155

Table. 13 Comparison of Mean Standard Deviation and Friedman Values of

Pain Related to Dysmenorrhea among Control and Experimental Group of

Adolescent Girls on the Third day of Menstruation.

Group Pre-test Post- Test 1 Post- Test 2 χ2

(Friedman) df Sig


Control

(n=130) 5.2 1.2 4.4 1.0 4.5 1.2 33.475 2 P<0.001

Experiment

(n=130) 5.3 1.1 1.6 1.1 0.7 0.8 242.540 2 P<0.001

The data presented in the above table 13 reveals that on the third day of

menstruation there was significant difference between the mean and standard

deviation of pre test (M=5.2, SD= 1.2) and post test 1 (M=4.4, SD=1.0) and post test

2 (M=4.5, SD=1.2) level of pain related to dysmenorrhea among the control group of

adolescent girls (χ2 = 33.475, P<0.001).

Whereas it can be noted that among the experimental group of adolescent girls

there was a significant difference (χ2=242.540, P<0.001) between the mean, standard

deviation of pain related to dysmenorrhea first day pre test (M=5.3, SD=1.2) and post

test 1 (M=1.6, SD=1.1) and post test 2 (M=0.7, SD=0.8).

The table 13 reveals that there is significant difference between pre test , post

test 1 and post test 2 within the groups in control and experimental group of

adolescent girls (p<0.001). Significant reduction of pain even in control group may be

due to physiological and psychological changes of dysmenorrhea on third day of

menstruation.

156

Table. 14 Comparison of Mean Rank and Kruskal Wallis Values of Pain Related

to Dysmenorrhea between Control and Experimental Group of Adolescent Girls

on the Third day of Menstruation

Tests

Control Experimental χ2

(K W) df Sig.

n Mean Rank n Mean Rank

Pre test 130 128.90 130 132.10 0.128 1 P>0.05

Post-1

test 130 188.78 130 72.22 174.303 1 P<0.001

Post-2

test 130 194.84 130 66.16 195.945 1 P<0.001

The data in table- 14 shows, the two groups control and experimental were

compared between them in pre- test, post-test1 and post- test2. According to the

Kruskal Wallish test, the calculated table value was 0.128. In the pre- test both the

groups have not differed statistically significantly (P>0.05). But in Post- test 1 and

post test -2, the calculated values were 174.303 and 195.945 which is higher than the

table values, the two groups were statistically very highly significantly differed

between them with the effect of acupressure (P<0.001). Hence this shows that the

acupressure was effective in reducing menstrual pain among experimental adolescent

girls on third day of menstruation.

157


Fig.19 Comparison of Effectiveness of Acupressure between Control and

Experimental Group of Adolescent Girls Pain related to Dysmenorrhea on the

Third Day of Menstruation.(Repeated Measures ANOVA Plots)

The repeated measure of ANOVA illustrated in fig 19 indicates the pain on

third day of menstruation among the control and experimental group of adolescent


and post test 2 can be noted.

158

Table 15. Mean, Standard Deviation and paired “t” Values of Distress Related to

Dysmenorrhea among Adolescent Girls in Control Group on the First Day of

Menstruation..

N=130

Tests/

Levels

Level-1 Level-2 Improved Paired

“t”

value

df P value Mean SD Mean SD Mean SD

Pre –

Post-1 65.8 4.4 64.2 4.3 1.6 5.8 3.167 129 P<0.01

Post-1-

Post-2 64.2 4.3 63.4 3.7 0.9 4.8 2.043 129 P<0.05

Pre-

Post-2 65.8 4.4 63.4 3.7 2.5 4.8 5.706 129 P<0.001

The table 15 depicts the test in different levels of control group on the first day




through post- test 2 were M = 65.8, SD = 4.4 and M = 63.4, SD = 3.7. The paired‘t’




test, post test 1 and post test 2 was significant at various levels.

159

Table 16. Mean, Standard Deviation and paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Experimental Group on the First Day

of Menstruation.

N=130

Tests/Levels


“t”

values

df P value

Sig. Mean SD Mean SD Mean SD

Pre & Post-1 66.4 4.4 34.6 6.2 31.8 4.2 85.230 129 P<0.001

Post-1&

Post-2 34.6 6.3 26.3 5.5 8.3 4.2 22.522 129 P<0.001

Pre& Post-2 66.4 4.4 26.3 5.4 40.1 4.7 97.937 129 P<0.001

The data in table 16 depicts the effectiveness of acupressure in different levels

within experimental group on the first day distress. The mean distresses score on pre-

test to post- test 1 was M= 66.4, SD = 4.4 and M= 34.6, SD = 6.2, post-test 1 to post

test 2 was M = 34.6, SD = 6.3 and M = 26.3, SD = 5.5 and pre-test to post- test 2 was

M= 66.4, SD = 4.4 and M = 26. 3 SD = 5.4. The paired ‘t’ test value of 85.230,

22.522, 97.937 were significant at (p<0.001). Hence it is concluded that the

acupressure is very highly effective in reducing distress related to dysmenorrhea

among adolescent girls.

160

Table 17. Comparison of Mean Standard Deviation and independent “t” Values

of Distress related to Dysmenorrhea between Control and Experimental Group

of Adolescent Girls on the First Day of Menstruation

N=260

Tests

Control Experimental Difference

b/w means

Independent

“t” value df Sig

Mean SD Mean SD

Pre &

Post-1 1.6 5.8 31.8 4.2 30.2 48.696 258 P<0.001

Post-1&

Post-2 0.9 4.8 8.3 4.2 7.4 13.258 258 P<0.001

Pre &

Post-2 2.5 4.8 40.1 4.7 37.6 63.819 258 P<0.001

The data observed from table 17 reveals the three levels of test namely pre-test

to post- test1, post- test1 to post- test2 and pre test to post-test2 were compared

between the two groups on first day distress. The difference between the two group’s

mean score were M =1.6, SD= 5.8 and M =31.8, SD = 4.2, M= 0.9, SD = 4.8 and

M= 8.3, SD = 4.2, M = 2.5, SD = 4.8 and M = 40.1, SD = 4.7.The paired ‘t’ test value

of 48.696, 13.258, 63.819 were significant at (p<0.001). Hence it was concluded that

the acupressure is found to be very highly effective in reducing distress related to

dysmenorrhea among adolescent girls.The results can be attributed to the

effectiveness of acupressure upon reducing distress related to dysmenorrhea. Hence

the Null hypothesis H01 there will be no significant difference in the effect of


161

Pre test Post test 1 Post test 2


Experimental Group of Adolescent Girls Distress related to Dysmenorrhea on

the First Day of Menstruation. (Repeated Measures ANOVA Plots)

The repeated measures of ANOVA showed in fig 20- indicates the distress on

first day of menstruation among the control and experimental group of adolescent

girls and the decrease in distress related to dysmenorrhea among the experimental

group of adolescents in post test 1 and Post test 2 can be noted.

162

Table 18. Mean, Standard Deviation and Paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Control Group on the Second Day of

Menstruation.

N=130

Tests/Levels


“t”

value

df P value

Sig Mean SD Mean SD Mean SD

Pre –Post-1 63.9 5.0 62.0 4.0 1.9 6.1 3.538 129 P<0.01

Post-1-Post-2 62.0 4.0 59.7 4.3 2.3 4.9 5.401 129 P<0.001

Pre-Post-2 63.9 5.0 59.7 4.3 4.2 6.1 7.943 129 P<0.001

The table 18 shows the test in different levels of second day distress among

the control group of adolescent girls. The mean distress score on the pre- test was

M= 63.9, SD = 5.0 and post-test 1 was M= 62.0, SD = 4.0. The mean distress score of

Post-test 1 and Post- test 2 were M = 62.0, SD = 4.0 and M = 59.7, SD = 4.3. The

mean distress score of pre-test through post- test 2 were M= 63.9, SD = 5.0 and

M= 59.7, SD= 4.3. The paired‘t’ test values were of 3.538 (p<0.01), 5.401 (p< 0.001)

and 7.943 (p<0.001) respectively. Hence it was concluded that the level of distress

related to dysmenorrhea among adolescent girls in control group on the second day

was significant at various levels.

163

Table. 19 Mean, Standard Deviation and paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Experimental Group on the Second

Day of Menstruation

N=130

Tests/Levels


“t”

value

df P value


Pre –Post-1 64.7 5.2 30.5 6.0 34.2 4.5 85.928 129 P<0.001

Post-1-Post-2 30.5 6.0 23.2 5.1 7.3 4.7 17.707 129 P<0.001

Pre-Post-2 64.7 5.2 23.2 5.1 41.5 5.3 88.948 129 P<0.001

The data in table 19 shows the effectiveness of acupressure in different levels

within experimental group of adolescents on the second day distress. The mean

distress score on Pre- test to Post- test 1 was M= 64.7, SD = 5.2 and M = 30.5,

SD = 6.0, Post-test 1 to Post test 2 was M = 30.5, SD = 6.0 and M = 23.2, SD = 5.1,

Pre-test to Post- test 2 was M= 64.7, SD = 5.2 and M = 23.2, SD = 5.1. The Paired ‘t’

test value of 85.928, 17.707, 88.948 were significant at (p<0.001). Hence it was

concluded that the acupressure is very highly effective in reducing distress related to

dysmenorrhea among adolescence girls.

164

Table 20. Comparison of Mean Standard Deviation, and independent “t “Values

of Distress Related to Dysmenorrhea between Control and Experimental of

Adolescent Girls on the Second Day of Menstruation

N=260

Tests


b/w means

Independen

t “t” value df

P value

Sig Mean SD Mean SD

Pre &

Post-1 1.9 6.1 34.2 4.2 32.3 50.565 258 P<0.001

Post-1-

Post-2 2.3 4.9 7.3 4.7 5.0 8.398 258 P<0.001

Pre-

Post-2 4.2 6.1 41.5 5.3 37.3 48.310 258 P<0.001

The data from table 20 shows that, the three levels of tests namely Pre-test to

Post- test1, Post- test1 to Post- test2 and Pre test to Post-test2 were compared between

the two groups on second day distress. The difference between the two group’s mean

score were M= 1.9, SD= 6.1 and M =34.2, SD = 4.2, M = 2.3, SD = 4.9 and M= 7.3,

SD = 4.7, M = 4.2, SD = 6.1 and M = 41.5, SD = 5.3.The independent‘t’ test value of

50.565, 8.398, 48.310 were significant at (p<0.001) respectively. The results can be

attributed to the effectiveness of acupressure upon reducing distress related to

dysmenorrhea. Hence the Null hypothesis H01 there will be no significant difference

in the effect of acupressure on distress related to dysmenorrhea was rejected.

165

Pre test-1 Post test-1 Post test-2

Fig.21. Comparison of Effectiveness of Acupressure between Control and

Experimental Group of Adolescent girls Distress related to Dysmenorrhea on

the Second Day of Menstruation.(Repeated Measures ANOVA Plots)

The repeated measures of ANOVA in fig no 21 indicates the distress on

second day of menstruation among the control and experimental group of adolescent


group of adolescents in Post test 1 and Post test 2 can be noted

166

Table. 21 Mean, Standard Deviation and paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Control Group on the Third Day of

Menstruation.

N=130

Tests/

Levels


“t” value df P value Sig.


Pre –

Post-1 62.1 4.7 58.6 4.1 3.4 6.6 6.040 129 P<0.001

Post-1-

Post-2 58.6 4.1 56.7 4.2 1.9 4.8 4.517 129 P<0.001

Pre-

Post-2 62.1 4.7 56.7 4.2 5.4 6.1 10.125 129 P<0.001

The data presented in Table 21 shows the tests in different levels of control

group on the third day distress. The mean distress score on the Pre- test was M = 62.1,

SD = 4.7 and Post-test 1 was M = 58.6, SD = 4.1. The mean distress score of Post-test

1 and Post- test 2 were M = 58.6, SD = 4.1 and M = 56.7, SD = 4.2. The mean distress

score of Pre-test through Post- test 2 were M = 62.1, SD = 4.7 and M= 56.7, SD = 4.2.

The Paired “t” test values of 6.040 (p<0.01), 4.517 (p< 0.001) and 10.125(p<0.001).

Hence it is interpreted that the level of distress related to dysmenorrhea among

adolescent girls in control group on the 3rd day was significant at various levels.

167

Table. 22 Mean, Standard Deviation and Paired “t” Values of Distress related to

Dysmenorrhea among Adolescent Girls in Experimental Group on the Third

Day of Menstruation

N=130

Tests/

Levels


“t” value df

P value


Pre –

Post-1 63.2 5.0 26.1 5.7 37.1 4.9 85.527 169 P<0.001

Post-1-

Post- 2 26.1 5.7 19.6 4.1 6.5 4.0 18.462 169 P<0.001

Pre-

Post-2 63.2 5.0 19.6 4.1 43.7 4.6 108.03 169

P<0.001

The data in Table 22 reveals the effectiveness of acupressure in different

levels within experimental group on the third day distress. The mean distress score on

pre- test to post- test 1 was M = 63.2, SD = 5.0 and M = 26.1, SD = 5.7, Post-test 1 to

Post test 2 was M = 26.1, SD = 5.7 and M = 19.6, SD = 4.1, Pre-test to Post- test 2

was M = 63.2, SD = 5.0 and M = 19.6, SD = 4.1. The paired‘t’ test values of 85.527,

18.462, 108.03 were significant at (p<0.001) respectively. Hence it is concluded that

the acupressure is very highly effective in reducing distress related to dysmenorrhea

among adolescent girls.

168

Table. 23 Comparison of Mean Standard Deviation and Independent “t” Values

of Distress Related to Dysmenorrhea between Control and Experimental Group

of Adolescent Girls on the Third Day of Menstruation

N=260

Tests


b/w means

Independent

“t”

value

df P value

Sig Mean SD Mean SD

Pre-

Post-1 3.4 6.6 37.1 4.9 33.7 47.252 258 P<0.001

Post-1-

Post-2 1.9 4.8 6.5 4.0 4.6 8.428 258 P<0.001

Pre-

Post-2 5.4 6.1 43.7 4.6 38.3 57.716 258 P<0.001

The data observed from table 23 the three levels of test namely Pre-test to

Post- test1, Post- test1 to Post- test2 and Pre test to Post-test2 were compared between

the two groups on third day distress. The difference between the two group’s mean

score in Pre test and Post test 1 were M = 3.4, SD = 6.6 , M = 37.1, SD = 4.9, Post test

1 and Post test 2 were M = 1.9, SD = 4.8, M = 6.5, SD = 4.0, Pre test and Post test 2

were M = 5.4, SD = 6.1 and M = 43.7, SD = 4.6.The paired ‘t’ test value of 47.252,

8.428, 57.716 were significant at (p<0.001) respectively. The results can be attributed

to the effectiveness of acupressure upon reducing distress related to dysmenorrhea.

Hence the Null hypothesis H01 there will be no significant difference in the effect of


169

Pre test -1 Post test-1 Post test-2

Fig. 22 Comparison of Effectiveness of Acupressure between the Control and

Experimental Group of Adolescent Girls Distress related to Dysmenorrhea on

the Third Day of Menstruation.(Repeated Measures ANOVA Plots)

The repeated measures of ANOVA shows in fig 22 indicates the distress on

third day of menstruation among the control and experimental group of adolescent


group of adolescents in Post test 1 and Post test 2 can be noted.

170

Table 24. Correlation between Pain and Distress related to Dysmenorrhea

among Control and Experimental Group of Adolescent Girls Before and After

Acupressure on the First Day of Menstruation

Groups Variables Tests rs Significant r2 Determination

%

Control

(n=130)

Pain and

distress

Pre 1 0.886 P<0.001 0.785 78.5

Post-1 0.807 P<0.001 0.651 65.1

Post-2 0.904 P<0.001 0.817 81.7

Experi-

mental

(n=130)

Pain and

distress

Pre 1 0.894 P<0.001 0.799 79.9

Post-1 0.899 P<0.001 0.808 80.8

Post-2 0.866 P<0.001 0.750 75.0

Table 24 shows the relationship between the pain and distress related to

dysmenorrhea of control and experimental groups of adolescent girls in different

occasions on first day of menstruation. The co-relation among the control group of

adolescents was found to be positive in Pre test ( r = .886) in Post test 1( r =.807) and

Post test 2 ( r = .904). The same finding was seen among experimental group of

adolescents in pre test (r = .894) post test 1 (r = .899) and Post test-2 (r = .866). In all

the occasions, the relationships were statistically very highly significant (P<0.001).

i.e. The pain and distress were positively correlated, when the pain increased distress

also increased in both control and experimental groups of adolescents on the first day

of menstruation.

171

Table 25. Correlation between Pain and Distress Related to Dysmenorrhea


Acupressure on the Second Day of Menstruation


%

Control

n=130)

Pain and

distress

Pre 1 0.936 P<0.001 0.876 87.6

Post-1 0.752 P<0.001 0.566 56.6

Post-2 0.821 P<0.001 0.674 67.4

Experi –

mental

(n=130)

Pain and

distress

Pre 1 0.901 P<0.001 0.812 81.2

Post-1 0.891 P<0.001 0.794 79.4

Post-2 0.944 P<0.001 0.891 89.1

The data presented in Table. 25 depicts the relationship between the pain and

distress related to dysmenorrhea of control and experimental group of adolescent girls

on second day of menstruation. The correlation was found to be positive in the Pre

test (r = .936), Post test 1 (r =.752) and Post test 2 (r = .821) among the control group

of adolescents.

In experimental group also the positive correlation was revealed in Pre test

(r = .901), Post test 1(r = .891) and Post test-2 (r =.944). In all the occasions , the

relationships were statistically very highly significant (P<0.001).i.e. the menstrual

pain and distress were positively correlated, when the pain increased the distress also

increased among the control and adolescent group of adolescents on the second day of

menstruation.

172

Table. 26 Correlation between Pain and Distress related to Dysmenorrhea


Acupressure on the Third Day of Menstruation


%

Control

(n=130)

Pain and

distress

Pre 0.889 P<0.001 0.790 79.0

Post-1 0.819 P<0.001 0.671 67.1

Post-2 0.893 P<0.001 0.797 79.7

Experi-

Mental

(n-130)

Pain and

distress

Pre 0.835 P<0.001 0.697 69.7

Post-1 0.946 P<0.001 0.895 89.5

Post-2 0.918 P<0.001 0.843 84.3

The above table 26 shows the relationship between the pain and distress

related to dysmenorrhea of control and experimental group adolescent girls on 3rd day

of menstruation. The pre test in control group revealed r = .889, in Post test 1 the

r =.819 and in Post test 2 the r = .893, a positive correlation. The same results was

found in experimental group also wherein the correlation in pre test revealed r = .835,

in Post test 1 the r = .946 and in post test-2 r = .918, a positive correlation. In all the

occasions, the relationships were statistically very highly significant (P<0.001)

.i.e...The menstrual pain and distress were positively correlated, when the pain

increased distress also increased among the control and experimental group of

adolescents on the third of menstruation.

On all the three days of menstruation, there was a positive correlation existed

between the pre test and post level of menstrual pain and distress at p <0.001 level

among the control and the experimental group of adolescent girls. Hence the Null

hypothesis H02 there will be no significant relationship between menstrual pain and

distress related to dysmenorrhea among the control and experimental group of

adolescent girls in the pre and post test were rejected.

173

Table 27. Association between Pain related to Dysmenorrhea and socio

demographic variables of Control and Experimental Group of Adolescent Girls


Control Group (n=130) Experimental group (n=130)

Moderate

Severe Total Test

statistics Moderate Severe Total

Test statistics

Age of adolescents in yrs 14-15

17

32

49

χ2=2.254 df=1

P>0.05

15

36

51

χ2=3.394 df=1

P>0.05 16-17 39 42 81 36 43 79 Total 56 74 130 51 79 130 Adolescents’ educational status 9th Std

16

32

48

χ2=2.946 df=1

P>0.05

15

36

51

χ2=3.394 df=1

P>0.05 11th std 40 42 82 36 43 79

Total 56 74 130 51 79 130

Mothers’ Educational status illiterate

5

6

11

χ2=1.560 df=3

P>0.05

0

7

7

χ2=8.289 df=3

P<0.05

School 19 22 41 17 35 52

College 24 29 53 25 30 55

Professional 8 17 25 9 7 16

Total 56 74 130 38 92 130

Mothers’ occupational status Cooli

3

3

6

χ2=0.157 df=3

P>0.05

3

6

9

χ2=4.232

df=3 P>0.05

Private 18 23 41 14 32 46 Govt. 11 15 26 12 20 32 Home maker 24 33 57 22 21 43 Total 56 74 130 51 79 130 Religion Hindu

13

24

37 χ2=3.026

df=2 P>0.05

14

26

40 χ2=0.891

df=2 P>0.05

Christian 37 7 84 32 43 75 Muslim 6 3 9 5 10 15 Total 56 74 130 38 79 130 Family monthly income <20000

17

15

32

χ2=3.576 df=2

P>0.05

20

33

53

χ2=1.169 df=2

P>0.05 20000- 40000 29 36 65 18 32 50 >40000 10 23 33 13 14 27 Total 56 74 130 51 79 130

Contd…

174

Residence Urban

26 40 66 χ2=0.742 df=1

P>0.05

30 41 71 χ2=0.600 df=1

P>0.05 Rural 30 34 64 21 38 59 Total 56 74 130 51 79 130 Type of family Nuclear

14

19 33 χ2=0.008

df=1 P>0.05

25 29 54 χ2=1.934 df=1

P>0.05 Joint 42 55 97 26 50 76 Total 6 74 130 51 79 130 Dietary habits Vegetarian

16

19 35 χ2=0.136

df=1 P>0.05

9

19 28

χ2=0.752 df=1

P>0.05 Non-Veg 40 55 95 42 60 102 Total 56 74 130 51 79 130 Food craving Salt 24

35 59

χ2=0.254 df=1

P>0.05

31

43 74

χ2=0.510 df=1

P>0.05 Sweet 32 39 71 20 36 56 Total 56 74 130 51 92 130

The data presented in the above table 27 shows that there was no significant

association between pain related to dysmenorrhea and any of the socio demographic

variables of control and experimental group of adolescent girls, such as age

2=2.254, 2= 3.394,), Educational status of adolescents (2 = 2.946, 2 = 3.394), (

Mothers’ education (2 = 1.560 , 2 = 8.289), Mothers’ occupation (2 = 0.157,

2 = 4.232), Religion (2 = 3.026 , 2 = 0.891), Monthly income (2 = 3.576,

2 = 1.169), Residence (2 = 0.742 , 2 = 0.600), Type of family (2 = 0.008,

2 = 1.934), Dietary habits (2 = 0.136 , 2 = 0.752) and Food craving patterns

(2 = 0.254, 2 = 0.510). The mothers’ education in the experimental group was

associated with pain level in the pre test(2=8.289,P<0.05) Hence the Null hypothesis

H04 there will be no significant association between the pain and socio demographic

variables of control and experimental group of adolescents was partially rejected.

Contd…

175

Table 28. Association between Distress related to Dysmenorrhea and Socio

Demographic Variables of Control and Experimental Group of Adolescent Girls.



<Median Media+ Total Test

statistics Median

Media+

Total Test

statistics

Age of adolescents in yrs 14-15

18

31

49

χ2=5.535 df=1

P<0.05

17

34

51

χ2=2.769

df=1 P>0.05 16-17 47 34 81 38 31 79

Total 65 65 130 55 75 130 Adolescents’ educational status 9th Std

17

31

48

χ2=0.096 df=1

P>0.05

17

34

51

χ2=2.769 df=1

P>0.05 11th std 48 34 82 38 31 79 Total 65 65 130 55 75 130 Mothers’ educational status, Illiterate

5

6

11

χ2=0.645 df=3

P>0.05

1

6

7

χ2=2.680 df=3

P>0.05

School 21 30 41 22 30 52 College 28 31 53 24 31 55 Professional 11 8 25 8 8 16 Total 65 65 130 55 75 130 Mothers’ occupational status Cooli

3

3

6

χ2=0.852 df=3

P>0.05

3

6

9

χ2=3.597 df=3

P>0.05

Private 22 19 41 15 31 46 Govt. 11 15 26 16 16 32 Homemaker 29 28 57 21 22 43 Total 65 65 130 55 75 130 Religion Hindu 13 34 37

χ2=6.477 df=2

P<0.05

19 21 40 χ2=0.966

df=2 P>0.05

Christian 45 39 84 31 44 75 Muslim 7 2 5 10 15 Total 65 65 130 55 75 130 Family monthly income <20000

17

15

32

χ2=1.021 df=2

P>0.05

24

29

53

χ2=1.385 df=2

P>0.05 20000-40000 34 31 65 18 32 50 >40000 14 19 33 13 14 27 Total 65 65 130 55 75 130

Residence Urban

31

35

66 χ2=0.492

df=1 P>0.05

31

40

71

χ2=0.118 df=1 P>0.0

Rural 34 30 64 24 35 59 Total 65 65 130 55 75 130

Contd…

176

Type of family

Nuclear

14

19

33

χ2=1.015

df=1

P>0.05

26

29

54

χ2=1.291

df=1 P>0.05

Joint 51 46 97 29 40 76

Total 65 65 130 55 69 130

Dietary habit Vegetarian

18

17

35 χ2=0.039

df=1 P>0.0

11

17

28 χ2=0.134

df=1 P>0.05

Non-Vegetarian 47 48 95 44 58 102

Total 65 65 130 55 75 130

Food craving Salt

30

29

59

χ2=0.031 df=1

P>0.05

32

41

74

χ2=0.368 df=1

P>0.05 Sweet 35 36 71 22 34 56

Total 65 65 130 55 75 130

The above table 28 reveals that there was no significant association between

the distress related to dysmenorrhea and any of the socio demographic variables of

control and experimental group of adolescent girls., such as Age, ( 2 = 2.769),


Mothers’ occupation (2 = 0.852, 2 = 3.597), Religion (2 = 6.477, 2 = 0.966) ,

Monthly income (2 = 1.021,2 = 1.385), Residence location (2 = 0.492 ,







demographic variables was partially rejected.

Contd…

177

Table29. Association between Pain related to Dysmenorrhea and Menstrual

Variables of Control and Experimental Group of Adolescent Girls

Menstrual variables


Moderate Severe Total Test

statistics Moderate Severe Total

Test Statistics

Age at menarche (years) 10-12

24

46

70 χ2=5.176

df=2 P>0.05

28

46

74 χ2 =0.219

df=2 P>0.05

13-14 30 25 55 22 31 53

15-16 2 3 5 1 2 3

Total 56 74 130 51 79 130

Frequency of Menstrual cycle (days) <28

4

11

15

χ2=2.405 df=2

P>0.05

3

10

13

χ2 =4.322 df=2

P>0.05

28-36 27 37 27 10 76

36+ 25 26 21 49 41

Total 56 74 51 79 130

Extent of menstrual flow Heavy

20

29

χ2=0.556 df=2

P>0.05

20

33

53

χ2 =0.619 df=2

P>0.05

Moderate 30 35 22 36 58

Light 6 10 9 10 19

Total 56 74 51 79 130

Duration of menstrual flow 1-3

10

13

χ2=2.871 df=2

P>0.05

6

9

15

χ2 =0.916 df=2

P>0.05

4-6 37 40 34 58 92

7-9 9 21 11 12 23

Total 56 74 51 79 130

Con

Contd…

Contd…

178

Onset of menstrual pain Prior to menstruation

27

38

χ2=0.125

df=1 P>0.05

20

40 60

χ2 =1.626 df=1

P>0.05

During menstruation

29 36 31 39 70

Total 56 74 51 79 130

Family history of dysmenorrhea 1st line relatives

46

60 χ2=0.024

df=1 P>0.05

35

63

98 χ2 =2.065

df=1 P>0.05

2nd line relatives

10 14 16 16 32

Total 56 74 51 79 130

Treatment taken for dysmenorrhea Nothing

43 57

χ2=1.385 df=1

P>0.05

30 58 93

χ2 =2.309 df=1

P>0.05

Rest 7 7 10 9 19

Medical 5 6 5 8 13

Herbal 1 4 1 4 5

Total 56 74 51 79 130

The above table 29 shows that there was no significant association between



,Frequency of menstrual cycle (2=2.405,2=4.322) Extent of menstrual

flow(2=0.556, 2=0.619),Duration of menstrual flow (2=2.871,2=0.916) onset of





selected menstrual variables among control and experimental group of adolescents

was retained.

Contd…

179

Table 30. Association between Distress related to Dysmenorrhea and menstrual

variables of Control and Experimental Group of Adolescent Girls

Menstrual

variables


<Med* Med+ Total Results <Med Med+ Total Results

Age at Menarche (Years) 10-12

31

39

70 χ2=2.005

df=2 P>0.05

30

44

74

χ2=2.808 df=2 P>0.05

13-14 31 24 55 25 28 53 15-16 3 2 5 0 3 3 Total 65 65 130 55 75 130

Frequency of menstrual cycle (days)<28

7

8

15 χ2=0.872

df=2 P>0.05

6

7

13

χ2=5.314 df=2 P>0.05

28-35 30 34 64 26 50 76 36-45 28 23 51 23 18 41 Total 65 65 130 55 75 130 Extent of menstrual flow Heavy

24

25

49 χ2=1.405

df=2 P>0.05

22

31

53

χ2=1.308 df=2 P>0.05

Moderate 35 30 65 24 34 58 Light 6 10 16 9 10 19 Total 65 65 130 55 75 130 Duration of menstrual flow (days) 1-3

13

10

23 χ2=4.361

df=2 P>0.05

6

9

15

χ2=2.317 df=2 P>0.05

4-6 42 35 77 36 56 92 7-9 10 20 30 13 10 23 Total 65 65 130 55 75 130 Onset of menstrual pain Prior to menstruation

31

34 65 χ2=0.27

df1 P>0.05

25

35

60

χ2=0.019 df=1 P>0.05

During menstruation

34 31 65 30 40 70

Total 65 65 130 55 75 130 Family history of dysmenorrhea First line relatives

52

54 106

χ2=0.204 df=1

P>0.05

37

61

98

χ2=3.381 df=1 P>0.05

Second line relatives

13 11 24 18 14 32

Total 65 65 130 55 75 130

180

Treatment taken for dysmenorrhea Nothing

48

52

100

χ2=3.394 df=3

P>0.05

39

54

93

χ2=1.303 df=3 P>0.05

Rest 9 5 14 9 10 19

Medicine 7 4 11 6 7 13

Herbal 1 4 5 1 4 5

Total 65 65 130 55 75 130

The above table 30 reveals that there was no significant association

between Pre test distress and any of the Menstrual variables of control and

experimental group of adolescent girls,such as Age at menarche (2=2.005,2=2.808),

Frequency of menstrual cycle (2=0.872,2=5.314),Extent of menstrual flow

(2=1.405,2=1.308), Duration of menstrual flow (2=4.361,2=2.317),Onset of


(2=0.204,2=3.381), Treatment taken for dysmenorrhea (2=3.394,2=1.303) at



selected menstrual variables among the control and experimental group of

adolescents’ was retained.

Contd…

181

Summary

This chapter explained the analysis of the data using descriptive and

inferential statistics which clearly revealed the effectiveness of acupressure in

reducing pain and distress related to dysmenorrhea among adolescent girls. The

succeeding chapter will discuss the findings of the study with supportive studies for

better clarity.

182

CHAPTER - V

DISCUSSION

The aim of this study was to assess the effectiveness of acupressure in

relieving pain and distress related to dysmenorrhea among adolescent girls in

selected schools at Kanyakumari district. The results of the research interpreted in the

preceding chapter are discussed in this chapter in detail. The key focus here is to

throw light on the changes seen in the Acupressure group in terms of dependent

variables. The analysis revealed the statistical significance of the effectiveness of

acupressure administered as an intervention. The impact of Acupressure was the

benefit to the dysmenorrhea symtoms thus enhancing quality of life in the adolescent

girls

This chapter presents the discussion of the obtained result based on the stated

objectives and hypotheses of the study.

Objectives of the study:

The objectives of the study were as follows





183


group of adolescent girls





adolescent girls.



girls.

Null hypotheses

H01 There will be no significant difference in the pain and distress related to

dysmenorrhea before and after acupressure among control and


H02 There will be no significant relationship between pain and distress

related to dysmenorrhea among control and experimental group of

adolescent girls before and after acupressure




184





dysmenorrhea and their selected menstrual variables in control and



dysmenorrhea and their selected menstrual variable in control and


Keeping this objectives of the study in view, the results are discuss under the

following headings

Assessment of Socio Demographic Characteristics of the Adolescent Girls

Distribution of samples according to the demographic variables described that

majority of the samples were in the age group of 16-17 years i.e. (62.3%) in the

control and (60.8%) in the experimental group. This also shows that the maximum

numbers of adolescent girls are from 11th standard (63.1%) in the control group and

60.8 % in the experimental group). This is because the strength of the 11th standard is

more when compared to the 9th grade and so that the researcher was able to get more

samples within the age group of 16-17 years for the study. It was also proved that

during the early menstruations after menarche, the cycles are usually anovulatory with

the less chance of dysmenorrhea. However, ovulation and dysmenorrhea happens only

185

after 1 to 2 years after menarche and thereby supported our study for the better

outcome.

A prevalence study of dysmenorrhea in female resident age 14 to 19 years

reported that dysmenorrhea about (52%). The prevalence rate is reduced with

increasing age. The pain has been found to decrease with advancing age (Shafeeq

,Rahman and Renuka , 2013). This was also supported by Baidya, Debnath& Das

(2014). They studied reproductive health problems among adolescent girls in Tripura

found that nearly majority of their respondents were between the age group of 16-17

years. Correspondingly, another retrospective case control study conducted by Gagua,

Tkeshelashvili & Gagua (2012) to assess the prevalence of primary dysmenorrhea

among adolescent population in two groups stated that their mean age of the girls

were 16 and 17 respectively. However, a descriptive study conducted to assess

dysmenorrhea among adolescents by Mathew, Varghese, Shaju, Joseph &Tamrakar

(2015) contradicts that there is a significant association between age and the level of

dysmenorrhea.

Majority of the subjects mothers’ were graduates i.e. (40.8%) in control group

and (42.3%) in experimental group. This showed that the literacy level is high in the

area where the researcher conducted the study and also influences the study positively

where highly educated mothers can be motivated to educate their daughters about the

general physiology, positive coping strategies, techniques of acupressure and other

non- pharmacological measures of management of pain and distress related to

dysmenorrhea. In a cross sectional study conducted by Habibi, Huang, Gan,

Zulida&Safavi (2015) to assess the prevalence of primary dysmenorrhea and factors

associated with its intensity among undergraduate students, less number of years of

education among the mothers were found to be significantly associated with higher

186

intensity of dysmenorrhea. Whereas the study conducted by Chen Lu (2010) on

Dysmenorrhea and related factors among adolescent girls in Taiwan says that there is

no association between mothers' education and dysmenorrhea. The very similar result

was also obtained in the study conducted by Mathew, Varghese, Shaju, Joseph

&Tamrakar (2015) on Dysmenorrhea among adolescent girls in Mangalore. They

revealed that maternal education has no significant association with dysmenorrhea.

When mothers’ occupation is taken into consideration, about (43.9%) belongs

to the control group are home makers and (35.4%) in the experimental group are

private employees. Even though women’s occupation is given with due importance,

most of the women work until they get married and they become home makers after

marriage or work in a nearby private organizations with an only aim to give maximum

time to their family. The study was conducted in a setting where there is a strong

feeling that the life of the children will be spoiled if both their parents are working

and so women prefer to stay at home to take care of their children.

Another prevalence study of dysmenorrhea among females aged between 14 to

19 years reported that among those with dysmenorrhea, (52%) of them are students,

(42%) of them are working and (30%) of them are home makers, reported that their

ability to perform work was affected Wensaicheong et al (1998). Social and

psychological factors highly influence on the symptoms of dysmenorrhea. Also

women with high femininity traits and home makers with no career, ambition and

external exposure also have reported severe dysmenorrhea than others. As income,

education and age increases, the severity of dysmenorrhea decreases (Brown et al,

1994).

187

In a cross sectional study conducted by Quraishi et al. (2015) among 707

adolescent girls in the Sangli District of Maharashtra to study the association between

Menstrual disorder and mental health, majority (612) of the participants’ mothers

were home makers. To contrast this, a cross sectional study conducted by Habibi et al.

(2014) to assess the prevalence if primary dysmenorrhea among 311 students aged

between 18 – 27 in Iran, reported that about 232 mothers of their participants were

home makers.

Majority of the girls in the control group (64.6%) and experimental group

(57.7%) were Christians. This may be due to the study background selected, moreover

Christians have their own mental makeup to cope with pain and sufferings if adequate

counseling and education is given. Likewise, the study conducted by Baidya,

Debnath& Das (2014) on reproductive health problems among rural adolescent girls

in Tripura says that all the respondents included in their study were Hindus. In the

same contrary, the majority of the participants were Muslims in a descriptive study

conducted to assess dysmenorrhea among adolescents in Mangalore by Mathew,

Varghese, Shaju, Joseph &Tamrakar (2015). They also stated that there is no

association between religion and dysmenorrhea.

When monthly income is taken into consideration, the income of about half of

the adolescent girls in the control group (50%) was between Rs. 20000 – Rs. 40000/-

and about (40.7%) of the adolescent girls in the experimental group have their income

below Rs.20000 per, month. This is because of the reality that the researcher has

conducted the study among people hailing from middle class socioeconomic status.

Similarly a study conducted by Geetha et al. (2016) to assess the prevalence of

dysmenorrhea and its correlation in India stated that more than half of their

188

participants fall under middle socio economic status with their income ranging

between 25000 – 40000 respectively. Whereas, a descriptive study conducted by

Mathew, Varghese, Shaju, Joseph &Tamrakar (2015) to assess dysmenorrhea among

adolescents in Mangalore states that there is no significant association between family

income and dysmenorrhea. Comparably, a retrospective case control study conducted

by Gagua, Tkeshelashvili& Gagua (2012) to assess the prevalence of primary

dysmenorrhea among adolescent population depicts that the prevalence of

dysmenorrhea is dependent on family income. Their study conveys that dysmenorrhea

is high among adolescents with medium income. The findings differ from one study

to the other, suggesting the necessity of further studies to clarify this aspect.

Many of them in the control group (50.8%) and experimental group (54.6%)

were living in the urban area.The menstrual disorder in adolescent girls from urban

population revealed that the dysmenorrhea is the most common disorder (56.3%).

(Skierska 2000). A study carried out in Kadapa district of Andhra Pradesh, they found

that (68.4%) were from the urban area. The outcome is also supported by a cross

sectional study conducted to assess the prevalence of dysmenorrhea among adolescent

girls and its impact on Quality of life in Kadapa District by Kumbhar, Reddy,

Sujana,Bargavi&Balkrisna (2011), where the majority of the adolescent girls are from

the urban areas. Likewise, in a cross sectional study conducted by Habibi, Huang,

Gan, Zulida & Safavi (2015) to assess the prevalence of primary dysmenorrhea and

factors associated with its intensity among undergraduate students, the widely held

respondents were from urban area. However, they concluded that urban residential

status is significantly contributing to the intensity of primary dysmenorrhea among

adolescent girls which need to be studied in detail.

189

Majority of the adolescent girls in both the control and experimental group

(74.6% & 58.5%) were hailing from joint family system. This is because the setting

selected for the study was the area where families are given due importance and joint

family system will be preferred to the greater extent. Joint family system teaches

adjustment and grows the human as a healthy social being. It also teaches coping and

adjustment strategies which gives maximum support to the present study. In a cross

sectional study conducted by Omidvar et al. (2015) among 100 health females to

assess the prevalence, impact and management of primary dysmenorrhea and

menstrual symptoms in India reported that around (87.5%) of the participants were

living under nuclear family system which is the contradictory scenario to the present

study. Whereas in a descriptive survey conducted by George et al. (2014) to assess the

characteristics and symptoms of dysmenorrhea among adolescent girls in Karnataka

reported that about one- third of the participants were from joint family.

With regard to food habits, about (73.1%) of the adolescent girls in the control

group and (78.3%) of them in the experimental group are non-vegetarians. This is

because people from Kanyakumari District usually give much preference to fish in

their diet which is a non-vegetarian food. In a study where cross over design is used to

assess the relationship between diets, sex hormone binding globulin, dysmenorrhea

and premenstrual symptoms by Barnard. (2000) reported that taking low fat

vegetarian diet was found to have significant reductions in menstrual pain duration,

pain intensity and duration of pre menstrual symptoms. In the same contrary, a

descriptive survey conducted by George. (2014) to study dysmenorrhea among

adolescent girls stated that among 233 adolescent participants, nearly 167 of them

were taking mixed diet (non-vegetarian food). This is quite common as adolescents

always prefer non-vegetarian and fast food. `

190

In the control group about (54.6 %) of the adolescent girls were craving for

sweets and about (56.9%) of them in the experimental group were craving for salt.

This is one of the major manifestations of Premenstrual syndrome. The study finding

is supported by a randomized double blinded placebo controlled parallel group study

conducted by Schulenburg (2000), stated that one of the major diagnostic criteria for

the pre-menstrual syndrome is the change in eating habits (craving to eat sweets/salt).

It is very clear that craving to eat sweets/salt is one of the associated factors in the

menstrual cycle. Supportively, a cross sectional study conducted by Omidvar et al.

(2015) to assess the association between menstrual symptoms and dysmenorrhea

stated that their participants have reported craving to eat something during their

premenstrual period, which adds volume to the present study finding.

Assessment of the Menstrual Variables in both the control and experimental

group of Adolescent Girls

In the present study, many of the girls 53.8% in control group and 56.9% in

experimental group attained menarche at the age between 10-12 years. This statistics

support the concept that the age at menarche among girls have reduced. The main

etiological factor may be the dietary factors, sedentary lifestyle, lack of exercises etc.

This finding is also supported by a cross sectional study conducted by Sinha,

Srivastava, Sachan& Singh (2016) to assess menstrual pattern and prevalence of

dysmenorrhea among adolescents in Uttar Pradesh, states that the mean age at

menarche in their study was 12 which was almost similar to the present study.

Similarly, one of the studies conducted by Gulzar, Khan, Abbas & Arif (2015) to

assess the prevalence, perceptions and effects of dysmenorrhea among adolescents in

Pakistan also reported that majority of their respondents’ attained menarche at the age

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of 11-13 respectively. This shows that the average age to attain menarche has been

reduced not only in India but also in other countries. At present, the median age at

menarche is noted to be between 12 and 13 years. The major contributing factors for

severe dysmenorrhea are early menarche, heavy menstrual flow, long menstrual

periods and family history of severe dysmenorrhea. Adolescent girls tend to have a

higher prevalence of primary dysmenorrhea, a cross sectional study was conducted

by Ravi (2016) in a rural school of Thiruvallur District, findings revealed mean age at

menarche was 12.4 years, and overall dysmenorrhea prevalence (72.6%),another

study also supported this findings Senthil Priya ( 2016). Cross sectional study was

undertaken among 500 adolescent girls in the age group of 14 – 19 years, study

findings shows mean age of menarche was 12.67 years (62.2%).

In the control group 59.2% adolescent girls and 70.8% adolescent girls in the

experimental group had the duration of menstrual flow for 4-5 days and the frequency

of menstrual cycle of adolescent girls in the control group (49.2%) and experimental

group (63.1%) was found to be between 28-35 days. Similarly, a study conducted by

Geetha et al. (2016) to assess the prevalence of dysmenorrhea and its correlates

among free living adults of Chittur District, India reported that among the 752

participants, (88%) of them have their cycles between 28 – 35 days which adds

volume to the study. Likewise, a descriptive study conducted to assess dysmenorrhea

among adolescent girls in Mangalore by Mathew; Varghese et al. (2015) also reported

that maximum number of adolescent girls had 3-4 days of menses with the cycle of

28-30 which is almost similar to the result obtained by the present study.

With regard to the extent of menstrual flow, among the 260 adolescent girls,

65 and 58 of them in the control and experimental group have reported that they used

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to experience moderate menstrual flow. The finding of the present study was

supported by a cross sectional study conducted by Baidya (2010) to assess the

reproductive health problems among rural adolescent girls in west Tripura, stated that

among the 200 participants around 177 of them opened up that they used to have

moderate/average menstrual flow. Usually women will experience moderate flow

unless until bleeding disorders or other pathological conditions are diagnosed which

augments heavy flow. To contradict this finding, a study conducted by Omidvar and

Begum (2012) to assess the characteristics and determinants of primary dysmenorrhea

among young adults shows that among the 500 healthy participants, about 50% of

them had a heavy menstrual flow

About (57.69%) of adolescent in the control group have their onset of

menstrual pain on the day before menstruation whereas in the experimental group

about (60.0%) of them have perceived pain on the day of menstruation. Similar study

was reported by Anjali Patil et al (2015). The average age of menarche was ranging

from 9 to 19 years in which majority of the participants (97.6%) fall between 10 and

17years of age. About (61.5%) of the respondents opened up that the pain usually

occur during the 1st,2nd, 3rd day of menses and only 5% reported pain prior to

menstrual cycle ,(14.2 %) have experienced pain on either day 2 and day3. Among the

310 participants, the average duration of menstrual cycle was 28 to 35 days, which is

almost considered as normal. Very small number (1.5%) had > 35 days of cycle

length and 11.8% used to have their cycles between 22 and 27 days. Majority of the

participants (73.9%) reported 4-5 days of bleeding duration, (7.7%) reported less than

3 days and in (18.4%) participants, the duration was more than 5 and it can reach up

to 7 days. Regarding the duration of pain, almost one third of the girls (37%) have felt

pain for the duration of 24hrs, (39.8%) have experienced pain for 2 days, followed

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with (15.4%) stated that their pain duration will be for 3 days and only 5.4% girls

have reported 4 days of continuous menstrual pain and (2.3%) reported pain even

after cessation of menses.

Regarding the family history of menstrual pain, (81.5%) in the control group

and (75.4%) in the experimental group had first line history of menstrual pain. A cross

sectional study conducted by Habibi, Huang et al. (2015) to assess the prevalence of

primary dysmenorrhea and its associated factors accounted that more than half of the

participants reported history of dysmenorrhea in their family members (mother, sister

or both). This is also supported by a suggestion given in the study conducted by

Gagua, Tkeshelashvili & Gague (2012) to assess prevalence of primary dysmenorrhea

among adolescent population states that if there is no underlying gynecological

pathology is noticed, prediction of family history of dysmenorrhea could be an

important risk factor.

A familial tendency towards severe symptoms has been noted in several

studies. It is reported that the pain history of mothers and daughters have a strong

correlation on pain ratings which is sometimes attributed to a “modeling effect” where

the daughters learn from their mothers on what to expect from menus and how to

prepare themselves. (Arshiya Sultana et al – 2013).A systematic review in different

countries was conducted by Sanetis Soliman (2015) about (50%) of the students

reported family history of dysmenorrhea .A similar study reported by Lee (2004) ,

(46% ) of adolescent girls had family history of dysmenorrhea ,(89.2%) of them had

experienced to dysmenorrhea on the first and second day .

Most of them did not take any treatment for dysmenorrhea (i.e. 76.9% in

control group and 71.5% in experimental group). The outcome is supported by an

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observational cross-study conducted by Sharma, Sagayaraj et.al (2014) to assess the

prevalence of dysmenorrhea among college students described that in the midst of the

maximum number of students experienced dysmenorrhea, only (3%) of them used

pharmacotherapy due to the fear of complications. To contradict this finding, another

descriptive study conducted by Mathew, Varghese et al. (2015) to assess

dysmenorrhea among adolescent girls in Mangalore states that maximum numbers of

participant have used pharmacotherapy and the most commonly used medicine was

Paracetamol.

Both control and experimental group did not differ statistically in terms of

demographical variables and menstrual variables. Hence both groups are

homogeneous and comparable.

Assessment of Pain Related to Dysmenorrhea of Adolescent Girls before

Acupressure on the First, Second and Third Day of Menstruation

In the present study, the Pre test pain related to dysmenorrhea was severe on

first day (60.0%, 60.8%) in comparison with moderate level of pain on second day

(55.4%, 50.0%) and third day (83.8%, 85.4%) respectively in both control and

experimental; group of adolescent girls.

Fogel says “The menstrual pain may be located in the supra pubic or lower

abdominal area which is described sharp, gripping and cramping that may be

associated with dull headache and the feeling of pelvic fullness and radiate to lower

back and upper things”. Similarly, spasmodic dysmenorrhea is an acute pain which

occurs in the first day of menstruation (SedighehKamali 2013). Pain during

menstruation is mainly confined to the parts of body which are innervated by the

uterine and ovarian nerves.

195

According to Katz and Melzack, pain is a personal and subjective experience

that can only be felt by the sufferer. Primary or essential dysmenorrhea is a painful

syndrome which proceeds with in few hours and accompany during the menstrual

flow which may be seen in more or less in all the adolescents (Labriola 2006).

A similar study performed by Kartika (2011) found that (40%) of the control

group subjects have experienced dreadful to horrible menstrual pain whereas, (36%)

had uncomfortable pain. Similarly in the experimental group, (53.3%) had dreadful to

horrible pain and (26%) had uncomfortable pain. Another study reported by Nashtaei

(2012) states that about (74%) of their study subjects had severe pain and (56%) of

them have felt moderate pain. In the same contrary, a cross sectional study conducted

by Habibi et al (2014) to assess the prevalence of primary dysmenorrhea and the

associated factors among undergraduate students reported that among the 277

respondents, 84 of them have reported mind pain, 101 have experienced moderate

pain and 92 of them have recounted severe pain respectively. Various other studies

also have assessed this menstrual variable and the results are in accordance with the

present study.

The study findings was congruent with Erzurum (2002) Turkey, total 1951

adolescent students age 13 – 18 yrs, revealed that pain mostly lasted for 1 – 3 days

(56.6%) and more than 4 days( 23.5%) , similar study George , Sangeetha and Shetty

(2013) a descriptive survey with 233 adolescent girls in Udupi District revealed (12%)

had mild pain (77.33%) moderate pain (17.6%) had severe pain , (75.34%) had back

pain and 66.43% had irritability during menstruation

196

Assessment of Distress Related to Dysmenorrhea of Adolescent Girls before

Acupressure on the First, Second and Third Day of Menstruation

The current study that the level of pre test distress related to dysmenorrhea

during menstruation was severe on first day (94.6%, 96.2%) in comparison with

moderate level of distress during second day (15.4%, 19.2%) and third day (28.58%,

20.8%) respectively in both control and experimental; group of adolescent girls.

Pain is not just from physical disorder but also from combination of

physiological, pathological, emotional, psychological, cognitive, environmental and

social practices. Some of the psychological factors such as high emotional

disturbance, psychological symptoms during menstruation are reported by (96%) of

teenagers and late teenagers. It is also reported that menstrual distress are causing

school or college absenteeism in 14-51% of teenagers and it is highly interfering with

activities of daily life.

Distress is the symptom of dysmenorrhea generally begins with menstruation.

The experience of menstrual distress often associated with feeling of control and

helplessness. It often causes physical, psychological and social discomfort,

Carol (2008).

Similar findings are reported following studies conducted in Asia and New

Zealand showed that approximately (75% to 95%) of women experience menstrual

distress symptoms (Proctor & Farquhar, 2006; Wong & Khoo, 2009) and that

moderate to severe dysmenorrhea constitutes from (42% to 73%) of the cases

(Omidvar & Begum, 2011;Pembe & Ndolele, 2011; Rahma & Anbarin, 2011). When

experiencing menstrual distress, between (58% and 90%) of young adult women

197

choose bed rest rather than proactive methods and treatments (Rahma & Anbarin,

2011; Wong & Khoo, 2009).

Menstrual distress caused by primary dysmenorrhea involves emotional and

physical symptoms that occur before and during menstruation, including back and

waist pain, autonomic responses, and water retention (Moos, 2010; Omidvar &

Begum, 2011; Wong & Khoo, 2009). The five most common symptoms are lower

abdominal pain, fatigue, low back pain (LBP) during menstruation, abdominal

bloating, and swelling of the breasts (Chen & Chen, 2005; Omidvar & Begum, 2011).

LBP during menstruation is reported by (33% to 56%) of the women (Chen & Chen,

2005; Omidvar & Begum, 2011; Pembe & Ndolele, 2011) and is the third most

common menstrual distress symptom.

The present study findings were congruent with the results obtained by

Karthika (2011), who conducted a study to assess the level of dysmenorrhea, where

the investigator found that out of 60 subjects in a control group, (55%) had severe

discomfort and (46%) had moderate discomfort. Similarly in an experimental group,

(56%) have reported severe and (42%) had moderate level of menstrual discomfort.

A very similar study reported by Suresh, Kumbhar (2011) states that majority

of the dysmennorhic girls have felt disgusting. Among them, (81.5%) have felt

irritability, (70.6%) have experienced emotional instability, (44.5%) of loss of interest

in regular work, (61.3%) of disturbed sleep, (55.5%) of reduced appetite and (52.1%)

of other symptoms during menstrual period. A very similar study finding was reported

by Sharmar, &Rana (2014) states that (60.3%) had moderate and (58%) have

experienced severe menstrual distress.

198

In a study conducted by Ortiz among 1539 students of Mexican University,

the author concluded that dysmenorrhea was mild in (36.1%),moderate in (43.8%

)and severe in (20.1%) of the subjects. Maitri shah et al, found that (18%, 40 %) and

(42%) of students had mild, moderate and severe dysmenorrhea respectively. This

indicates that dysmenorrhea is still an important public health problem which is

causing a negative impact on health, social environment, work and psychological

wellbeing.

Assessment of pain related to dysmenorrhea before and after acupressure in

control and experimental group of adolescent girls on the first, second and third

day of menstruation.

In the current study , the pain related to dysmenorrhea on the first day of


remained the same at severe level of pain among the control group of adolescent girls.

Whereas among the experimental group of adolescent girls in pre test 60.8% had

severe level of pain on the first day and after the intervention of acupressure a



According to Katz and Melzack “pain is a personal and subjective experience

that can only felt by the sufferer. Primary or essential dysmenorrhea is a painful

syndrome which proceeds by few hours of accompany is the menstrual flow present

above all in adolescent labriola (2002).A similar study was found that in control group

40% had the menstrual pain range between dreadful to horrible pain , experimental

group 53.3% had dreadful to horrible pain 26% had uncomfortable pain (Kartika

2011).

199

Findings were similar in a study conducted by Christina et al (2016) the 20

minutes acupressure shows that there was a very high significant difference in the

pain score of pre test and post test. There was no significant association found

between pain score with selected socio demographic variables.

The pain related to dysmenorrhea on the second day of menstrual cycle in pre

test (55.4%) and post test 1 (64.6%) and post test 2 (59.2%) remained the same at







A similar study reported by Kiran B,Akila L, Jamunarani R (2012) stated that

in the total of 401 students from Chennai SRM University and 97 students from

Vydehi Institute of Medical Sciences and Research Centre Bangalore, around 306

students from Chennai had dysmenorrhea, given a prevalence rate of (76.3%) to the

study. Among them, (57%) had severe and (19.20%) had mild dysmenorrhea.

Likewise, (73.19%) had severe and (26.80%) had mild dysmenorrhea among the

participants from Bangalore. The rate of allopathic treatment taken by both the

Chennai and Bangalore students were (33% and 37.11%). About (6.20% and 2.06%)

of the participants used to follow homemade remedies and ayurvedic medicines by

(0.98% and 1.03%) of the respondents respectively.

Similar conclusion made by Wong and Jojo (2008), administration of 20

minutes acupressure on the SP6 acupressure point for continuous three months first

200

three days of menstrual cycle. The result shows that there were statistically significant

decrease of pain score of pain visual analogue scale and Mc Gill pain questionnaire

Pain related to dysmenorrhea on the third day of menstrual cycle in pre test

(83.8%) and post test1 (73.1%) post test 2 (73.1%) remained the same at moderate

level of pain among the control group of adolescent girls. Whereas it can be noted that

83.8% of experimental group of adolescent girls had moderate pain in the pre test

done on third day and the same adolescents after the intervention of acupressure none

of them experienced severe level of pain on third day in post test 1 and post test

2.They had only mild level of pain on third day in post test 1 (80.0%) and post test 2

(51.5%) and 47.7% of the adolescents reported no pain in post test 2.

The present study accordance with the Selvisha, Mekwana and Sha (2014)

cross sectional study was conducted 250 student aged 17 – 23 yrs. The study findings

reveled the prevalence of dysmenorrhea was (71.2%) mild (65.17%) moderate and

(21.35%) severe. Similar to the present study Elakkiya (2015) was reported (50%) of

the adolescent girls had severe pain 47% had moderate pain in control and

experimental group.

Dysmenorrhea was reported in (84.2%) of the girls and around (34.2%) of

girls experienced severe pain, (36.6%) have felt moderate pain and (29%) had mild

pain. In total, about (53.7%) of the girls had a family history of dysmenorrhea in a

study conducted by MoolRajkural et al 2015 to assess the dysmenorrhea among

adolescents.

Another study conducted by Agarwal and Agarwal (2010) to assess the

prevalence of dysmenorrhea among adolescent girl found that (79.6%) of the girls

have experienced severe dysmenorrhea and (37.96%) of them have suffered regularly

201

from the severity of dysmenorrhea. Another study conducted by RafiaBano et al

(2013) reported that the prevalence of dysmenorrhea is 100% in their study.

Assessment of distress related to dysmenorrhea before and after acupressure in

control and experimental group of adolescent girls on the first ,second and third

day of menstruation.

In the present study , distress related dysmenorrhea on the first day of

menstrual cycle in pre test (94.6%) and post test 1 (87.6%) and post test 2 (88.5%)


girls . Whereas it can be observed in table (8) 96.2% of experimental group of





In the study of Sohrabi et al., mean pain duration in the first and second

months after implementation of acupressure was significantly lower than ibuprofen

users. Similarly in Gilan, Bostani et al. compared the effects of acupressure and

vitamin E and found lower mean pain duration during the first and second cycles after

acupressure. The results of both of these studies are in accordance with the findings of

present study.

The distress related to dysmenorrhea on the second day of menstrual cycle in

pre test (84.6%) and post test1 (81.5%) post test 2 (60.8%) remained the same at

severe level of distress among the control group of adolescent girls. Among the

experimental group majority of the adolescent girls in pre test 80.8% had severe level

of distress on the second day and the same adolescents after the intervention of

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acupressure none of them experienced severe level of distress on second day in post

test 1and post test 2. They had only mild level of distress on second day in post test 1


Distress related to dysmenorrhea on the third day of menstrual cycle in pre


moderate level of distress among the control group of adolescent girls. Whereas it can

be noted that 79.2% of experimental group of adolescent girls had severe level of

distress in the pre test done on third day and the same adolescents after the

intervention of acupressure none of them experienced severe level of distress on third

day in post test 1 and post test 2.They had only mild level of distress on third day in


The study finding was congruent with Kartika (2011) who conducted the study

to assess the level of dysmenorrhea with 60 adolescent girls. The study concluded

(55%, 46%) and (56%, 42%) had severe and moderate level of discomfort in control

and experimental group. A similar study was reported by Suresh Kambhar (2011)

majority of the dysmenorrheic girls are experiencing (81.5%) irritability, (70.6%)

emotional instability, (44.5%) loss of interest in regular work, (61.3%) disturbed sleep

and (55.5%) had reduced appitite.

Similar study was conducted Gharloghi (2010). 50 adolescent girls randomly

assigned two groups. Acupressure was applied once per day during first three days of

the menstruation. The study findings concluded the intervention groups (SP6) points

alleviate menstrual pain and distress.

203

The above findings were in accordance to the study conducted Smith et al in

(2011) concluded that acupressure and acupuncture are more efficient in relieving

systemic symptoms compared with medical therapy and traditional herbal medicines.

Assessment of the effect of Acupressure in relieving pain related to

dysmenorrhea in control and experimental group of adolescent girls on the first

,second and third day of menstruation

In the present study, on the first day of menstruation there was no significant



dysmenorrhea among the control group of adolescent girls (χ2 = 1.290,P>0.05 ).






Null Hypothesis Ho1 there will be no significant effect of acupressure on pain related

to dysmenorrhea was rejected.

Kothari (2013). In Acupuncture/Acupressure Analgesia, these pain impulses

have to complete for entry at a gate with a second stream of impulses which have

been generated by needle / pressure stimulation. The lateral impulse is not painful in

character. The Simultaneous appearance of these two streams of impulses cause

overcrowding at the gate and also confusion owing to the disparity in their rates of

conduction, the net result is jamming or closure of the gate, and since the pain

204

impulses are thereby blocked from proceeding further , the pain threshold is raised

and no pain is felt.

Sohrabi et al, also reported that the pain severity in a group during the first and

second month after treatment with acupressure was significantly lower than in a group

treated with ibuprofen. Similarly, in the study conducted by Jun et al in Korea, it was

reported that there was a significant difference in the severity of dysmenorrhea

between the two groups intervention group (acupressure at the SP6 point) and control

group (placing the thumb on SP6 point slowly with no pressure for 20 minutes)

immediately after the treatment and two hours after it.









It can be attributed to the effectiveness of acupressure upon reducing pain related to

dysmenorrhea. Hence the Null Hypothesis Ho1 there will be no significant effect of


In Taiwan, Chen et al found that acupressure at the Sanyinjiao SP6 point has

reduced the pain and stress resulted from the dysmenorrhea during the first session of

pressure by the researcher. In the next cycle, participants applied acupressure

themselves and could significantly reduce the pain resulted from menstruation.

205

On the third day of menstruation there was significant difference between the

mean and standard deviation of pre test (M=5.2, SD= 1.2) and post test 1 (M=4.4,

SD=1.0) and post test 2 (M=4.5, SD=1.2) level of pain related to dysmenorrhea

among the control group of adolescent girls (χ2 = 33.475, P<0.001). Whereas it can be

noted that among the experimental group of adolescent girls there was a significant

difference (χ2=242.540, P<0.001) between the mean, standard deviation of pain

related to dysmenorrhea first day pre test (M=5.3, SD=1.2) and post test 1 (M=1.6,

SD=1.1) and post test 2 (M=0.7, SD=0.8).













menstruation.

Similar study reported by Wong.c.et al reported that acupressure has a long

term and accumulative effect in relieving primary dysmenorrhea. Another study

conducted by Gharlloghi.s.et al to determine the effect of acupressure at Sanyinjiao

206

SP6 point on pain severity of primary dysmenorrhea and the associated systemic

symptom indicates that the severity of dysmenorrhea diminished significantly for up

to 2 hours following treatment.

These findings were also supported by Unsal et al who compared the

effectiveness of acupressure, fish oil capsule and ibuprofen on the severity of primary

dysmenorrhea reported that (85%) of the participants in an acupressure group were

satisfied by this method than anything else for the relief.

Acupressure in fact refers to the touch for balancing human body‘s energy

flow. The analgesic effect of acupressure can be due to the release of endorphin and

glucorticoids that can block pain gates. This method leads to the release of various

neurotransmitters, which thereby cut the nervous signals transferred by the nervous

system.

The findings of this study indicate the possible physiological mechanism of

acupressure, such as decreasing pain through activation of an endogenous opioid

system and release of specific neuropeptides and restoring health of the body by

balancing the energy.

Assessment of the effect of Acupressure in relieving distress related to

dysmenorrhea in control and experimental group of adolescent girls on the first,

second and third day of menstruation

The test in different levels of control group on the first day of distress. The

mean distress score on the pre- test was M= 65.8, SD= 4.4 and post-test 1 was

M = 64.2, SD = 4.3. The mean distress score of post-test 1 and post- test 2 were

M = 64.2, SD = 4.3 and M = 63.4, SD = 3.7. The mean distress score of pre-test

207

through post- test 2 were M = 65.8, SD = 4.4 and M = 63.4, SD = 3.7. The paired ‘t’

















significant at (p<0.001). Hence it was concluded that the acupressure is found to be


girls.

The present study findings was congruent with Wong et al (2010) also

determined the effectiveness of acupressure by conducting randomized control trial in

which acupressure at SP6 was given twice a day for first three days of the menstrual

cycle and findings showed statistically significant decrease in pain score using Visual

208

Analogue Scale (p-0.00.) and SF-MPQ (p= 0.02) immediately after the 20 min of SP6

acupressure during the initial intervention session. Following self- care periods,

Participants were taught to perform the technique for them to do twice days from the

first to third days of their menstrual cycle, 3 months subsequent to the first session.

Findings showed significant reduction of PVAS (p=0.008). Short form – McGill pain

questionnaire (p=0.012),and short form- Menstrual Distress Questionnaire (p=0.024)

scores was noted in the third month of post – intervention. Wong et al reported that

acupressure has a long term and accumulative effect in relieving primary

dysmenorrhea.

The test in different levels of second day distress among the control group of

adolescent girls. The mean distress score on the pre- test was M= 63.9, SD = 5.0 and

post-test 1 was M= 62.0, SD = 4.0. The mean distress score of Post-test 1 and Post-

test 2 were M = 62.0, SD = 4.0 and M = 59.7, SD = 4.3. The mean distress score of

pre-test through post- test 2 were M= 63.9, SD = 5.0 and M= 59.7, SD= 4.3. The

paired ‘t’ test values were of 3.538 (p<0.01), 5.401 (p< 0.001) and 7.943 (p<0.001)

respectively. Hence it was concluded that the level of distress related to dysmenorrhea

among adolescent girls in control group on the second day was significant at various

levels.



test 1 was M= 64.7, SD = 5.2 and M = 30.5, SD = 6.0, Post-test 1 to Post test 2 was

M = 30.5, SD = 6.0 and M = 23.2, SD = 5.1, Pre-test to Post- test 2 was M= 64.7,


209



The three levels of tests namely Pre-test to Post- test1, Post- test1 to Post-

test2 and Pre test to Post-test2 were compared between the two groups on second day

distress. The difference between the two group’s mean score were M= 1.9, SD= 6.1

and M =34.2, SD = 4.2, M = 2.3, SD = 4.9 and M= 7.3, SD = 4.7, M = 4.2, SD = 6.1

and M = 41.5, SD = 5.3.The independent‘t’ test value of 50.565, 8.398, 48.310 were

significant at (p<0.001) respectively. Hence it was concluded that the acupressure to

be very highly effective in reducing distress related to dysmenorrhea among

adolescence girls.

A similar study reported by Gharloghi et al (2012) comparing the acupressure

at SP6 and SP8 point in which results showed that the severity of dysmenorrhea

diminishes significantly for up to 2 hours following intervention and in the present

study only one group receiving acupressure at Sp6 point was studied and that has

shown similar result but with 3 days of repeated intervention for two months depicts

longer effects.









210





M = 19.6, SD = 4.1. The paired ‘t’ test values of 85.527, 18.462, 108.03 were



girls.

The three levels of test namely Pre-test to Post- test1, Post- test1 to Post- test2

and Pre test to Post-test2 were compared between the two groups on third day

distress. The difference between the two group’s mean score in Pre test and Post test 1

were M = 3.4, SD = 6.6 , M = 37.1, SD = 4.9, Post test 1 and Post test 2 were

M = 1.9, SD = 4.8, M = 6.5, SD = 4.0, Pre test and Post test 2 were M = 5.4, SD = 6.1

and M = 43.7, SD = 4.6.The paired ‘t’ test value of 47.252, 8.428, 57.716 were

significant at (p<0.001) respectively. The results can be attributed to the effectiveness

of acupressure upon reducing distress related to dysmenorrhea. Hence the H01 stating

that there will be no significant difference in the effect of acupressure on distress

related to dysmenorrhea was rejected.

The finding shows that in all occasions (1st, 2nd and 3rd day) menstrual pain and

distress was reduced by acupressure. The calculated value is higher than the table

value. hence the acupressure is found to be highly statistically significant (p<0.001).

Hence the Null hypothesis H01 there will be no significant different in the effect of

acupressure in relieving pain and distress related to dysmenorrhea among adolescent

girls was rejected.

211

A randomized control trial conducted by Chen and Chen (2010), determined

that acupressure is effective in reducing severity of dysmenorrhea when it was given

for 20 minutes on SP6 point. On the same lines, the present study was undertaken in

which acupressure was given for 20 minutes, two times a day for three days and long

term effect was assessed ( 1st,2nd and 3rd day of menstruation)

In the present study, acupressure was provided within the first three days of

menstruation and results showed statistically significant reduction in severity of

dysmenorrhea. These findings were in accordance with the study conducted by Chang

et al (2010), in which study subjects received acupressure treatment within the first 8

hours of menstruation and similar results were obtained i.e., significant reduction in

severity of dysmenorrhea.

Similar study was conducted by Mirbagher.et al (2011) comparing acupressure

at two different points i.e. light touch at SP6 for 20 minutes in control group and

acupressure at Sp6 in experimental group. There were significant differences in VAS

scores between the control and experimental groups immediately. In present study

after 1st ,2nd and 3rd days of intervention, reduction in the pain score was noticed at 3

days time intervals. Results of both the studies are comparable. Findings of this study

clearly indicates that 20 minutes of acupressure is an effective complementary means

for reducing dysmenorrhea without expecting any side effects of drugs. The same

report was concluded Smith et al (2011) that acupressure is efficient in relieving

systemic symptoms compared with medical therapy.

Based on the findings of the present study, it was concluded that the study

group had significant reduction in the severity of dysmenorrhea after giving

intervention. So the null hypothesis was rejected and alternate hypothesis was

212

accepted i.e. acupressure is effective in reducing dysmenorrhea. Acupressure can be

used as a convenient self-care method i.e. free of cost, no complications and easy to

learn nursing intervention to reduce the dysmenorrhea. The findings of the study can

be used as a guideline for further research on the effect of acupressure using

combination of different points. However, further studies of efficacy as well as

effectiveness are needed to determine the clinical applicability of acupressure for

dysmenorrhea. Further investigations are necessary to replicate the beneficial findings

of acupressure in a large population and to better elucidate physiologic mechanism

underlying pain relief.

Assessment of correlation between pain and distress related to dysmenorrhea in

control and experimental group of adolescent girls before and after acupressure

on the first ,second and third day of menstruation.

In the current study relationship between the pain and distress related to









of menstruation.

Favorable results were observed in a study conducted by Immanuel Thomas

and Girija Narayanan (2006) say that “Premenstrual distress is used to refer to

213

symptoms of distress associated with menstruation, which may be experienced during

the period immediately before, during, or immediately after the menstrual process”. A

study conducted by them to assess the psycho social correlates of premenstrual

distress reported that the menstrual distress has definite biological, psychological and

social determinants. Thereby the finding revealed that one who lives with

maladjustments and stressful life events are more prone to get higher degree of

menstrual distress with pain. Thus it is very clear that as distress increases, pain also

increases.

The relationship between the pain and distress related to dysmenonorrhea of








control and adolescent group of adolescents on the second day of menstruation.

Similar study was conducted by Cindy Davis (2014) to assess the

premenstrual distress among Caucasian, African-American and Chinese Women

stated that in the study conducted all the women experience premenstrual distress

symptoms differently in terms of prevalence, nature of symptoms and the treatment

modalities available. He also reported that Chinese women in their study have

reported lesser pain and distress than others. Even though the study supports ethnicity,

it is very clear that as the pain is low distress will also be less. The author also stated

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that occurrence of symptoms and the severity varies from one person to the other.

Some may report mild menstrual distress with pain and the other may experience

moderate to severe symptoms associated with depression, absenteeism and impaired

activities of daily living and quality of life.

Relationship between the pain and distress related to dysmenorrhea of control

and experimental group adolescent girls on third day of menstruation. The pre test in

control group revealed r = .889, in Post test 1 the r =.819 and in Post test 2 the

r = .893, a positive correlation. The same results was found in experimental group

also wherein the correlation in pre test revealed r = .835, in Post test 1 the r = .946 and

in post test-2 r = .918, a positive correlation. In all the occasions, the relationships

were statistically very highly significant (P<0.001) .i.e. The menstrual pain and

distress were positively correlated, when the pain increased distress also increased

among the control and experimental group of adolescents on the third of

menstruation.







Relationship between pain and distress among both the groups of adolescent

girls on the first day shows the relationship between both pain and distress of the girls

in the pre, post test 1 and post test 2 correspondingly. In all the tests conducted, the

relationships were statistically very highly significant. This shows that both pain and

215

distress were positively correlated and illustrates that as the pain increases, distress

also increases. Similarly on the second and third day, the relationship was also

statistically very highly significant and depicts that as the pain increases, distress also

increases correspondingly.

Primary dysmenorrhea is the most common physiological change that teenage

girls and women under the age group of 25 years face periodically Chen et al (2014).

It is very evident that the author concluded in their study that approximately about 75

– 95% of women experience menstrual distress and its associated symptoms. The

menstrual distress associated with dysmenorrhea often involves emotional and

physiological symptoms such as back/waist pain, water retention, and lower

abdominal pain, abdominal bloating, selling of the breast tissues and fatigue. This

shows that menstrual distress will not stand alone. However, it will be accompanied

with menstrual pain too.

Association of pre test pain related to dysmenorrhea with socio demographic

variables of control and experimental group of adolescent girls.

In the present study, none of the socio demographic variables showed

significant association with their pre test pain related to dysmenorrhea among control

and experimental group of adolescent girls. There was no statistically significant

association between the adolescent age and pain related to dysmenorrhea (P> 0.05).

This shows that pain perception does not depend on the age. Throughout the age the

menstrual pain perception is same. But our response to the pain perception depends on

the individual’s roles and responsibilities.

There was a statistically significant association at (p<0.05) between Mothers’

Education and pain related to dysmenorrhea in the experimental group. It is a known

216

fact that mothers’ education will not affect pain perception of their children. This

association may be because the mothers who are educated may know the physiology

behind the menstrual cycle and they might have prepared their children to cope up

with the menstrual pain.

There won’t be any association between the religion and pain among the girls

is a known fact. This was supported by the present study that there was no statistically

significant association between religion and pain. Income does not influence the pain

level. There was no statistically significant association between pain and monthly

income. The area where the adolescents live does not reduce or increase the pain

level. In the present study also there was no statistically significant association

between residence and pain, also the other variables such as type of family, dietary

habit and food craving did not show statistically significant association ( P > 0.05).

Hence the null hypothesis H03 is partially rejected.

The above findings are in accordance with the study conducted by Karthika.

S, Lecturer, NIMS College, Jaipur Rajasthan (2011), to identify the association

between demographic variables and menstrual pain perception. She describes that

there is no association between the participants’ age, religion, type of family, monthly

income, food habits, age at menarche, and mother’s education status with pain

perception of the subjects in both the control and the experimental group.

In the same context, the study conducted by Kamali et al in Tabriz to assess

dysmenorrhea among adolescent population also shows that there is no significant

association between dysmenorrhea with that of the selected socio-demographic

variables such as age, family history, family income, dietary habits, parental

education among the study groups.

217

Association of pre test distress related to dysmenorrhea with socio demographic

variables of control and experimental group of adolescent girls.

In the current study none of the socio demographic variables showed

significant association with their pre test distress related to dysmenorrhea in control


There was significant association at p < 0.05 between adolescent age and pre

test distress related to dysmenorrhea in control group, also had a association with

religion and pre test distress related to dysmenorrhea in the control group

respectively. However there was no significant association between other socio

demographical variables such as education ,mothers ‘education ,mothers’ occupation,

family monthly income, residence , type of a family , food habit , food craving, and

pre test distress related to dysmenorrhea. Hence the null hypothesisH04 is partially

rejected.

To contradict this finding, another descriptive study conducted by Mathew,

Varghese et al. (2015) to assess Dysmenorrhea among adolescent girls in selected

schools at Mangalore concluded that there is a significant association between the

level of dysmenorrhea and the selected variables such as age, educational status, and

age at menarche. In the same contrary, Habibi et al (2014) conducted a cross sectional

study to assess the prevalence of primary dysmenorrhea and factors associated with its

intensity among undergraduate students reported that there is a strong significant

relationship between family histories of dysmenorrhea, age, residential status,

bleeding intensity, mothers’ years’ of formal education with the severity of

218

dysmenorrhea. This shows that extended study is required to bridge the gap between

such associations.

Association of pre test pain related to dysmenorrhea with menstrual variables of

control and experimental group of adolescent girls.

In the present study shows that there was no significant association between pre

test pain related to dysmenorrhea of adolescent girls in control and experimental

group and any of the menstrual variables such as age at menarche ,frequency of

menstrual cycle, extent of menstrual flow duration of menstrual flow, onset of pain ,

family history of dysmenorrhea and treatment taken for dysmenorrhea (P>0.05).

Hence the null hypothesis H05 is retained.

Favorable results were observed in a study conducted by Chauhan, Kodnani

(2015) there was no statistical significant association between dysmenorrhea and the

following menstrual variables, length of menstrual cycle, amount of flow and age at

menarche P > 0.05.

The findings are contradicted by a cross sectional study by Kumbhar et al

(2011), on 500 healthy female aged 18 to 28 yrs in Mysore. Among the factors

studied amount of menstrual flow, length of menstrual flow and family history of

dysmenorrhea exhibited positive association.

Association of pre test distress related to dysmenorrhea with menstrual variables

of control and experimental group of adolescent girls.


pre test distress related to dysmenorrhea of adolescent girls in control and

experimental group and any of the menstrual variables such as age at menarche,

219

frequency of menstrual cycle, extent of menstrual flow, duration of menstrual flow,

pain during menstrual cycle, family history of dysmenorrhea and treatment taken for

dysmenorrhea. Hence the null hypothesis H06 is retained.

Similar study findings were reported by Valiani et al who conducted a study

among female students of Isfahan University found that there is no significant

association between dysmenorrhea with the clinical variables such as age at

menarche, duration of menstrual flow, extent of menstrual flow, frequency of

menstrual cycle and family history of dysmenorrhea.

Determination of level of satisfaction

The present study showed all the adolescent girls in the acupressure group

were highly satisfied with Acupressure as a complementary therapy. This high level

satisfaction may have been caused due to impact of acupressure.

This effect of acupressure seems to be due to its benefits on the nervous

system, musculo- skeletal system, immune system, circulatory system. Acupressure

had a positive effect on relieving pain, balancing body energy, good health, increase

circulation and enables deep relaxation. Acupressure therapy strengthens resistance to

disease and promotes wellness. Self care application and pressure points formulas for

specific conditions such as chronic fatigue, fibromyalgia, chronic muscular pain,

mental stress, addiction recovery, learning disorders, trauma and emotional

imbalances.

220

SUMMARY

Considering the objectives, hypothesis and study findings, this discussion

chapter dealt on the effectiveness of acupressure on pain and distress related to

dysmenorrhea. The forth coming chapter gives a brief report of the summary of major

findings, conclusions, nursing implications, limitations and recommendations. Thus

this chapter highlights the findings in a view of hypotheses and compared the findings

with other similar published studies conducted in the past in nursing and various

health disciplines.

.




THESIS

Submitted to




IN

NURSING

By

Prof. SANTHI LETHA, M.Sc.N., M.A.(Socio).,

JANUARY 2017

DHARSAN

Placed Image




THESIS

Submitted to

THE TAMILNADUDR.M.G.RMEDICALUNIVERSITY, CHENNAI



IN

NURSING

By


Under the Guidance of

Dr.LATHA VENKATESAN, M.Sc (N).,M.Phil., Ph.D (N)., M.B.A.,

PRINCIPAL & Ph.D RESEARCH GUIDE

APOLLO COLLEGE OF NURSING

CHENNAI-600 095

JANUARY 2017

DHARSAN

Placed Image

221

CHAPTER - VI

SUMMARY, IMPLICATIONS, RECOMMENDATIONS AND CONCLUSION

Menstruation is a normal physiological phenomenon for females indicating

her capability for procreation. It is the normal process that indicates the sexual health

of the women in response to various physical, psychological and endocrinal functions.

However it is often associated with some degree of sufferings and embracement.

Primary dysmenorrhea is a form of painful menstruation that begins at 6 to 12 months

after menarche till menopause without any underlying gynecological issue. (Adegbite,

Omolaso, Seriki & Akpabio, 2016).

Dysmenorrhea affects half of all female adolescents today and represents the

leading cause of periodic school / college absenteeism. Dysmenorrhea can decrease

productivity, creativity and work performance due to serious daily stress and social

and economic loss. The quality of life during dysmenorrhea is comparatively poor

among dysmenorrhea girls loss of physical activity and work satisfaction, personal

relationship confidence and concentration of work also suffers.

The effectiveness of current treatments including oral contraceptive steroidal

and inflammatory drugs may induce intolerable side effects, infertility, dependency

and unnecessary medical costs.The present study explores the non pharmacological

way of managing dysmenorrhea. Acupressure is one such therapy. Administration of

acupressure during menstruation to reduce pain and distress related to dysmenorrhea.

Acupressure utilised in this study to manage dysmenorrhea in a non invasive effective

manner which is available free of cost and free of side effects.

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This chapter presents the major findings of the study, conclusions drawn and

implications of the study, limitations encountered and the recommendations for the

future research. The present study was intended to find the effectiveness of


girls in selected schools at Kanyakumari district. The research work was conducted in

partial fulfillment of the requirements for the award of doctor of philosophy in

nursing under The Tamil Nadu Dr.M.G.R Medical University Chennai.

The objectives of the study were:






group of adolescent girls.





adolescent girls.



girls.

The conceptual frame work of the study was developed based on the Roy’s

adoption model. The major study variables in the study were pain and distress related

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to dysmenorrhea of adolescent girls before and after implementation of acupressure.

Acupressure is a complementary and alternative medicine. (A light firm pressure is

applied on acupressure point SP6). Hypotheses were formulated. The level of

significance selected was (p<0.05).

The data were collected from 260 moderate and severe levels of dysmenorrhea

among adolescent girls studying in 9th and 11th standards were selected for the study.

Sample size was calculated based on power analysis and samples were equally

randomly assigned to experimental group (n=130) and control group (n=130). Pre test

was conducted to the control and experimental group during the first three days of

menstruation and the post test 1 and 2 was conducted following two menstrual cycle

after pre test, post test was conducted after acupressure first three days of

menstruation in the experimental group (Acupressure administered 20 minutes, twice

a day for three days over the Sanyinjiao point, four fingers above the tip of medial

malleolus) Similarly, the post test was also conducted in the control group without

acupressure.

The tools used for the data collection procedure were demographic variable

Performa, menstrual variable Performa visual analogue pain scale, and Modified

moose menstrual distress questionnaire. (MMDQ), and a rating scale level of

satisfaction of intervention of acupressure validity and reliability were established,

pilot study was conducted on 26 adolescent girls.

The main study was conducted among 260 adolescent girls, 130 in control and

130 in experimental group were analyzed according to the objectives and hypothesis

224

of the study. The analysis of data was done through an integrated system of computer

programe known as statistical package for social sciences (SPSS 20.0). The major

findings of the study were as follows.

Major Findings

Socio Demographic Variables of Adolescent Girls

Majority of the adolescent girls were in the age group of 16-17 yrs

(62.3%, 60.8%), studying in 11th std (63.1%, 60.8%) belongs to Christian religion

(64.6%, 57.7%), living in urban area (50.8%, 54.6%) in joint families (74.6%, 58.5%)

non vegetarians (73.1%, 78.5%) and food craving for sweets (54.6 %,) in control

group and for salt (56.9%) in experimental group of adolescent girls respectively.

Most of the mothers of adolescent girls are educated up to collegiate level

(40.8%, 42.3%) in control and experimental group respectively. mothers’

occupational status of adolescent girls as home makers (43.9%) in control group and

private employees (35.4%) in experimental group. family monthly income of half of

the adolescent girls was Rs 20000 to 40000 in control group (50%) and Rs < 20000 in

experimental group (40.7%).

Menstrual Variables of Adolescent Girls

Majority of the adolescent girls have attained their menarche at the age of 10-

12 yrs (53.8%, 56.9%), with onset of menstrual pain during menstruation (57.69%,

60.0%),with first line family history of dysmenorrhea (81.5%, 75.4%) and not taking

any treatment for dysmenorrhea (76.9%, 71.5%) in control and experimental group of

adolescent girls respectively.

225

The frequency of menstrual cycle was 28-35 days (49.2%, 63.1%) in control

and experimental group respectively .The adolescent girls in control and experimental

group had moderate menstrual flow (50.0%, 44.6%) and a majority of the adolescent

girls had 4-6 days of menstrual flow (59.2%, 70.8%) in control and experimental

group respectively.

Pain and Distress related to Dysmenorrhea before Acupressure

In the present study, pre test pain related to dysmenorrhea was severe on first

day (60.0%, 60.8%) in comparison with moderate level of pain on second day

(55.4%,50.0%) and third day (83.8%,85.4%) respectively in both control and

experimental; group of adolescent girls.Pre test distress related to dysmenorrhea was

severe on first day (94.6%,96.2%) in comparison with moderate level of distress

during second day (15.4%,19.2%) and third day (28.58%,20.8%) respectively in both

control and experimental; group of adolescent girls.

Pain Related to Dysmenorrhea among Adolescent Girls before and after

Acupressure

In the current study, the pain related to dysmenorrhea on the first day of


remained the same at severe level of pain among the control group of adolescent girls.

Whereas among the experimental group of adolescent girls in pre test 60.8% had

severe level of pain on the first day and after the intervention of acupressure a



226

Pain related to dysmenorrhea on the second day of menstrual cycle in pre test

(55.4%) and post test 1 (64.6%) and post test 2 (59.2%) remained the same at







The pain related to dysmenorrhea on the third day of menstrual cycle in pre



noted that 83.8% of experimental group of adolescent girls had moderate pain in the

pre test done on third day and the same adolescents after the intervention of

acupressure none of them experienced severe level of pain on third day in post test 1

and post test 2.They had only mild level of pain on third day in post test 1 (80.0%)

and post test 2 (51.5%) and 47.7% of the adolescents reported no pain in post test 2.

Distress Related to Dysmenorrhea among Adolescent Girls before and after

Acupressure

In the present study, the distress related dysmenorrhea on the first day of

menstrual cycle in pre test (94.6%) and post test 1 (87.6%) and post test 2 (88.5%)


girls . Whereas it can be observed in table 8 that 96.2% of experimental group of



227



Distress related to dysmenorrhea on the second day of menstrual cycle in pre

test (84.6%) and post test1 (81.5%) post test 2 (60.8%) remained the same at severe

level of distress among the control group of adolescent girls. Among the experimental

group majority of the adolescent girls in pre test 80.8% had severe level of distress on

the second day and the same adolescents after the intervention of acupressure none of

them experienced severe level of distress on second day in post test 1and post test 2.

They had only mild level of distress on second day in post test 1 (59.2%) and post test

2 (76.2%) respectively.

The distress related to dysmenorrhea on the third day of menstrual cycle in pre


moderate level of distress among the control group of adolescent girls. Whereas it can

be noted that 79.2% of experimental group of adolescent girls had severe level of

distress in the pre test done on third day and the same adolescents after the

intervention of acupressure none of them experienced severe level of distress on third

day in post test 1 and post test 2.They had only mild level of distress on third day in


Level of Satisfaction of Acupressure among Experimental group of Adolescent

girls

All the participants were highly satisfied about acupressure among

experimental group of adolescent girls. None of them were in the category of

dissatisfied and satisfied.

228

Effectiveness of Acupressure on Pain Related to Dysmenorrhea among

adolescent Girls

In the current study ,on the first day of menstruation there was no significant



dysmenorrhea among the control group of adolescent girls (χ2 = 1.290, P>0.05).






Null hypothesis Ho1 there will be no significant difference in the effect of










It can be attributed to the effectiveness of acupressure upon reducing pain related to

dysmenorrhea. Hence the Null hypothesis Ho1 there will be no significant differtence


229

On the third day of menstruation there was significant difference between the

mean and standard deviation of pre test (M=5.2, SD= 1.2) and post test 1 (M=4.4,

SD=1.0) and post test 2 (M=4.5, SD=1.2) level of pain related to dysmenorrhea

among the control group of adolescent girls (χ2 = 33.475, P<0.001). Whereas it can be

noted that among the experimental group of adolescent girls there was a significant

difference (χ2=242.540, P<0.001) between the mean, standard deviation of pain

related to dysmenorrhea first day pre test (M=5.3, SD=1.2) and post test 1 (M=1.6,

SD=1.1) and post test 2 (M=0.7, SD=0.8).













menstruation.

230

Effectiveness of Acupressure on Distress Related to Dysmenorrhea among

Adolescent Girls

In the present study, the test in different levels of control group on the first day




through post- test 2 were M = 65.8, SD = 4.4 and M = 63.4, SD = 3.7. The paired ‘t’


















231

of acupressure upon reducing distress related to dysmenorrhea. Hence the Null

hypothesis H01 there will be no significant difference in the effect of acupressure on

distress related to dysmenorrhea was rejected.

The test in different levels of second day distress among the control group of

adolescent girls. The mean distress score on the pre- test was M= 63.9, SD = 5.0 and

post-test 1 was M= 62.0, SD = 4.0. The mean distress score of Post-test 1 and

Post- test 2 were M = 62.0, SD = 4.0 and M = 59.7, SD = 4.3. The mean distress

score of pre-test through post- test 2 were M= 63.9, SD = 5.0 and M= 59.7, SD= 4.3.

The paired ‘t’ test values were of 3.538 (p<0.01), 5.401 (p< 0.001) and 7.943

(p<0.001) respectively. Hence it was concluded that the level of distress related to

dysmenorrhea among adolescent girls in control group on the second day was

significant at various levels.



test 1 was M= 64.7, SD = 5.2 and M = 30.5, SD = 6.0, Post-test 1 to Post test 2 was

M = 30.5, SD = 6.0 and M = 23.2, SD = 5.1, Pre-test to Post- test 2 was M= 64.7,




The three levels of tests namely Pre-test to Post- test1, Post- test1 to Post-

test2 and Pre test to Post-test2 were compared between the two groups on second day

distress. The difference between the two group’s mean score were M= 1.9, SD= 6.1

and M =34.2, SD = 4.2, M = 2.3, SD = 4.9 and M= 7.3, SD = 4.7, M = 4.2, SD = 6.1

and M = 41.5, SD = 5.3.The independent‘t’ test value of 50.565, 8.398, 48.310 were

232

significant at (p<0.001) respectively. Hence it was concluded that the acupressure is

to be very highly effective in reducing distress related to dysmenorrhea among

adolescence girls.













M = 19.6, SD = 4.1. The paired‘t’ test values of 85.527, 18.462, 108.03 were



girls.

The three levels of test namely Pre-test to Post- test1, Post- test1 to Post- test2

and Pre test to Post-test2 were compared between the two groups on third day

distress. The difference between the two group’s mean score in Pre test and Post test 1

were M = 3.4, SD = 6.6 , M = 37.1, SD = 4.9, Post test 1 and Post test 2 were

M = 1.9, SD = 4.8, M = 6.5, SD = 4.0, Pre test and Post test 2 were M = 5.4, SD = 6.1

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and M = 43.7, SD = 4.6.The paired ‘t’ test value of 47.252, 8.428, 57.716 were


of acupressure upon reducing distress related to dysmenorrhea. Hence the Null

hypothesis H01 there will be no significant difference in the effect of acupressure on

distress related to dysmenorrhea was rejected.

The finding shows that in all occasions (1st, 2nd and 3rd day) menstrual pain and

distress was reduced by acupressure. The calculated value is higher than the table

value. Hence the acupressure is found to be highly statistically significant (p<0.001).

Hence the Null hypothesis H01 there will be no significant difference in the effect of


girls was rejected.

Relationship between Pain and Distress Related to Dysmenorrhea of Adolescent

Girls Before and After Acupressure

In the present study, the relationship between the pain and distress related to









of menstruation.

234









control and experimental group of adolescents on the second day of menstruation.


control and experimental group adolescent girls on third day of menstruation. The pre

test in control group revealed r = .889, in Post test 1 the r =.819 and in Post test 2 the

r=.893, a positive correlation. The same results was found in experimental group also

wherein the correlation in pre test revealed r = .835, in Post test 1 the r = .946 and in

post test-2 r = .918, a positive correlation. In all the occasions, the relationships were

statistically very highly significant (P<0.001) .i.e. The menstrual pain and distress

were positively correlated, when the pain increased distress also increased among the

control and experimental group of adolescents on the third day of menstruation.







235


Socio Demographic Variables of Adolescent Girls.


pain related to dysmenorrhea and any of the socio demographic variables of control

Educational status of and experimental group of adolescent girls, such as age .

adolescents (2 = 2.946, 2 = 3.394) , Mothers’ education (2 = 1.560 , 2 = 8.289),

Mothers’ occupation (2 = 0.157 , 2 = 4.232), Religion (2 = 3.026 , 2 = 0.891),

Monthly income (2 = 3.576 , 2 = 1.169), Residence (2 = 0.742 , 2 = 0.600),

Type of family (2 = 0.008 ,

2 = 1.934), Dietary habits (2

= 0.136 , 2 = 0.752)

and Food craving patterns (2 = 0.254, 2 = 0.510). The mothers’ education in the

experimental group was associated with pain level in the pre test (2=8.289, P<0.05)

Hence the null hypothesis H04 there will be no significant association between the

pain and socio demographic variables of control and experimental group of

adolescents was partially rejected.

The present study reveals that there was no significant association between

distress related to dysmenorrhea and any of the socio demographic variables of

control and experimental group of adolescent girls, such as Age, ( 2 = 2.769),


Mothers’ occupation (2 = 0.852,

2 = 3.597), Religion (2

= 6.477, 2 = 0.966) ,

Monthly income (2 = 1.021,

2 = 1.385), Residence location (2

= 0.492 ,



236





demographic variables was partially rejected.


Menstrual Variables of Adolescent Girls.

In the present study shows that there was no significant association between



,Frequency of menstrual cycle (2=2.405,2=4.322) Extent of menstrual

flow(2=0.556, 2=0.619),Duration of menstrual flow (2=2.871,2=0.916) onset of





selected menstrual variables among control and experimental group of adolescents

was retained.

The present study shows that there was no significant association between Pre

test distress related to dysmenorrhea and any of the Menstrual variables of control

and experimental groupof adolescent girls, such as Age at menarche

(2=2.005,2=2.808), Frequency of menstrual cycle (2=0.872,2=5.314),Extent of

menstrual flow (2=1.405,2=1.308), Duration of menstrual flow (2=4.361,

237

2=2.317),Onset of menstrual pain (2=0.277,2=0.019), Family history of

dysmenorrhea (2=0.204,2=3.381), Treatment taken for dysmenorrhea

(2=3.394,2=1.303) at P>0.05 in control and experimental group of adolescents.

Hence the Null hypothesis H07 there will be no significant association between

distress related to dysmenorrhea and selected menstrual variables among the control

and experimental group of adolescents’ was retained.

Treatment Outcome

The present study reveals Acupressure is an effective, simple, non

pharmacological measure to reduce dysmenorrhea. The study can create awareness

regarding menstrual pain and distress management among adolescent girls, school

teachers and parents. Acupressure is an effective and safe form of therapy for

adolescents with primary dysmenorrhea, it is a practical method which can be done

anywhere and anytime by women themselves. Single point acupressure at Sanyinjiao

(SP6) is cost free and easy to learn. It can be integrated in to clinical practice and

health education in order to enhance the quality of life for adolescent with primary

dysmenorrhea

IMPLICATIONS

Nursing Practice

The findings of this study enlighten the fact that acupressure can be used to

reduce the level of pain and distress related to dysmenorrhea for girls who are

suffering from dysmenorrhea. Acupressure is a safe and better modality which brings

238

a higher level of satisfaction for student with dysmenorrhea. Health promotion is a

vital function of the nurse and nurse can use this therapy at three levels of prevention

(i.e. Primary, secondary, tertiary).

Acupressure as a complementary alternative medicines as proved to have great

scope in its application in a wide variety of clinical and community scenarios –

muscular and joint pain , insomnia , asthma , stress , lack of concentration , labor

pain , arthritis. Nurses come across plenty of opportunities to explore the benefits of

Acupressure on patient and to teach acupressure for those in the community, thus

facilitating them to attain holistic health and an enhanced quality of life.

Acupressure has implications for comprehensive nursing practice.

Demonstrating the efficacy of acupressure and promoting a clinical application of a

culturally based nursing intervention. Nurse can learn the energy pathway or body

meridian and apply pressure over particular points along the pathways to treat certain

gynecological disorders. Acupressure can be made to practice as a routine nursing

care. Many simple easy acupressure techniques can be taught to clients for primary

prevention. This intervention could bring benefits to students with dysmenorrhea who

are on pharmacological therapy. Acupressure can be practiced by nurses for

dysmenorrhea in the institutional level since it has no side effects. It helps to reduce

analgesics required.

Independent Acupressure Practice

The nurse can get educated to implement various complementary alternative

therapies for patients including acupressure therapy and can implement it to the

patient independently. They can also conduct short term and long term courses to

other nurses and health care team members and trained them to develop expertise in

239

acupressure therapy implementation. Acupressure education will aid nurses to be

confident, stress free in their work settings helping them provide competent care.

Education and training will help nurses practice acupressure independently.

Nursing Education

Nurses could learn and integrate the knowledge of acupressure in the clinical

care settings. The subject knowledge on primary dysmenorrhea among adolescent is

negligible for nurses as nursing curriculum does not emphasise on primary

dysmenorrhea (adolescent health) in the under graduate curriculum. Continuing

nursing educations cells in different institutions can start focusing on adolescent girls

and their health issues through creating awareness to teachers and students on various

dysmenorrhea symptom rating scale and questionnaires. It is essential also to conduct

CNE on various pharmacological and non pharmacological interventions for

dysmenorrhea including complementary and alternative medicine. Nursing education

must emphasise primary care approach focusing on preventive care. Students could be

motivated to conduct mass awareness programmes, rallies and street plays to create

awareness to adolescent girls.

Alternative and complementary therapies can be integrated as an adjuvant on

the existing therapies in the nursing curriculum. Nursing personal’s need to be

equipped with knowledge and practice an application of acupressure therapy for any

kind of pain. The study can motivate student nurses to explore new strategies for

effective relief of dysmenorrhea. This finding can be utilized to organize in service

education or continuing education so that nurses to provide and strengthen evidence

based nursing practice.

240

Nursing Administration

Nurse leaders and nurse administrators should encourage the staff and student

to actively practice acupressure in various disease conditions. Nurse administrator can

formulate the policy to implement acupressure therapy in the routine care. It can be

practiced with minimum explanation and minimum preparation of students and

environmental. Nurse administrator can arrange in-service education programe and

continuing education programe for directing and motivating staff towards acupressure

therapy. Nursing manager should establish the policies or protocols that involve

acupressure therapy as a standard of care for patients in wards.

Nurse leaders and nurse administrators should encourage the use of evidence –

based complementary therapies as alternative nursing intervention in patient care.

Nurses should take initiative in coloborating with policy makers to create national

policies for utilising acupressure technique in dysmenorrhea among adolescent girls.

Nursing Research

More researches could be designed on primary dysmenorrhea health related

aspects and strategies to overcome them have to be experimented. Evidence-based

practice in nursing could be done by implementing systematic reviews and Meta

analyses following guidelines / tools from institutions like Oxford / Johns Hopkins

College of Evidence Based Medicine. Acupressure as alternative therapy is safe and

cost effective. Therefore, more researches have to be planned, conducted and

published. Complementary and Alternative therapies could be experimented for

primary dysmenorrhea and their impact can be assessed. More Randomised

Controlled Trials could be initiated as they serve as the Gold Standard of all the other

research methods.

241

The nursing implication of the study lies in the scope for expanding the quality

of nursing service. In this area of evidenced based practice, publication of these will

take nursing to a new horizon. Present study finding can be effectively utilized by

emerging researches. The findings of this study help to expand professional

knowledge upon which further researches can be conducted. Research in the nursing

field can initiate evidence based nursing practice.

Recommendations

A similar study could be done with large sample for the generalization of the findings.

A comparative study may be done between effectiveness of acupressure and other

pharmacological methods.

A similar study could be replicated in different settings.

An experimental study to assess the effectiveness of acupressure on dysmenorrhea

could be done for a longer duration.

A comparative study could be carried out between acupressure and other alternative

complementary therapy on dysmenorrhea.

The effectiveness of acupressure therapy in reducing pain and anxiety in patient

suffering from any other illness could be studied.

A correlative study on dysmenorrhea symptom experience and quality of life among

adolescent girls could be designed.

A meta analysis could be done on the effectiveness of acupressure on dysmenorrhea

Another systematic review could be done on complementary alternative therapies on


242

A multicentric trial could be planned to know the dysmenorrhea symptom experience

on adolescent girls in selected countries

A comparative study could be planned to evaluate the effectiveness of acupressure on

dysmenorrhea in different acupoints

Conclusion

The findings of this study show that there was a highly significant reduction in

the level of pain and distress related to dysmenorrhea among adolescent girls after the

application of acupressure when compared with control group. Thus acupressure

played an important role in reducing pain and distress related to dysmenorrhea.

Acupressure as an alternative therapy is safe, free from side effects and can be

practiced in their own home settings. Adolescent girls in primary dysmenorrhea

showed a positive attitude towards performing acupressure, they showed readiness to

practice.

243

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ANNEXURE - A

PROVISIONAL REGISTRATION CERTIFICATE – Ph.D DEGREE

ANNEXURE - B

CONFIRMATION OF PROVISIONAL REGISTRATION

ANNEXURE - C

CONSTITUTION OF DOCTORAL ADVISORY COMMITTEE

ANNEXURE – D

INSTITUTIONAL ETHICS COMMITTEE APPROVAL CERTIFICATE

ANNEXURE – E

CERTIFICATE OF PLAGIARISM CHECK

This is to certify that this thesis work titled “A study to assess the

Effectiveness of Acupressure in Relieving pain and Distress related to

Dysmenorrhea Among Adolescent girls in selected Schools at Kanyakumari

District” of the candidate Prof. Santhi Letha with Registration Number 141320008

for the award of Ph.D in Nursing in the branch of Obstetrics & Gynaecology Nursing . I

personally verified the urkund.com website for the purpose of plagiarism check. I found

that the uploaded thesis file contains from Introduction to Conclusion pages and result

shows 9 % percentage of plagiarism in the thesis.





Ayanambakkam,

Chennai – 600 095

ANNEXURE – F

CERTIFICATE FOR ENGLISH EDITING

ANNEXURE – G

CERTIFICATE OF ACUPRESSURE TRAINING

ANNEXURE – H

LETTER GRANTING PERMISSION TO CONDUCT THE STUDY FROM YETTACODE HIGHER SECODARY SCHOOL

ANNEXURE – I

LETTER GRANTING PERMISSION TO CONDUCT THE STUDY FROM

St URSULA’S GIRLS HIGHER SECODARY SCHOOL KULASEKHARAM

ANNEXURE – K

EVIDENCE OF PERMISSION TO USE STANDARDISED MMDQ

QUESTIONNAIRE

shanthi latha <[email protected]> RE: Menstrual Distress Questionnaire 1 message Rudolf H. Moos <[email protected]> Sat, Apr 1, 2017 at 5:35 AM To: shanthi latha <[email protected]> Shanthi Latha, Thank you for your interest in the Menstrual Distress Questionnaire (MDQ). I would be happy to have you use the MDQ in your work. For your information, the Menstrual Distress Questionnaire (MDQ) and 4th Edition of the MDQ Manual are published by Mind Garden, 855 Oak Grove Ave, Suite #215, Menlo Park, CA 94025; (Phone 650-322-6300; FAX 650-322-6398; email is [email protected].) The overall Mind Garden website address is www.mindgarden.com. You can access the MDQ Manual at www.mindgarden.com/products/mdq.htm. I hope this information is helpful. Good luck with your research. Rudolf Moos, Ph.D., Professor Emeritus Department of Psychiatry and Behavioral Sciences Stanford University School of Medicine Palo Alto, California -----Original Message----- From: shanthi latha [mailto:[email protected]] Sent: Friday, March 31, 2017 4:07 AM To: Rudolf H. Moos <[email protected]> Subject: Tool request Dear Sir, I am Mrs. Santhi Letha, Principal, Sree Mookambika College of Nursing, Kulasekharam,K.k. dist, Tamil Nadu, India. I am undergoing Ph.D program in OBG Nursing at TamilNadu Dr.M.G.R. Medical University Chennai, TamilNadu. I have been selected MMDQ tool for my Ph.D study. I kindly request you to grant permission to use your tool. Thanking you Shanthi Latha

ANNEXURE – L

LIST OF EXPERTS WHO VALIDATED THE TOOL

1. Dr.Rema Devi,

Director,

Sree Mookambika Institute of

Medical Science,

Kulasekharam

Dr. Sujin Herbert, BNYS,Ph.D (Psy)

Assistant medical officer,

Govt head quarters,

Padmanapapuram,

Kanyakunmari.Dt.

2. Dr.Latha Venkatesan

Principal


Ayanambakkam

Chennai 600095

Prof. P. Arumugam, B. Sc; M.A; M.P.S;

P.G.D.C.A;

Professor of Biostatistics,

Sri Muthukumaran Medical College

& R I, Chennai- 600 069

Dr.Vijaya Lakshmi,

Principal,

Vignesh College of Nursing,

Thiruvannamali

Dr.Diana,

Vice Principal,

C.S.I.College of Nursing ,

Neyoor,K.K.dist.

Dr.Suseela,

Principal,

Bilroth College of Nursing,

Maduaravoyal, ,

Chennai.

Dr.Neelakshi,

Professor,

Sri. Ramachandra College of

Nursing, Porur, Chennai.

Dr. Suguna ,

Professor,

Sree Mookambika college of

Nursing ,

Kulasekharam,

Kanniyakumari District.

Dr. Saraswathy, Professor ,& H.O.D,

Obstetrics and Gynaecology,

Sree Mookambika Institute of Medical

Science,

Kulasekharam.

ANNEXURE – M

Letter seeking permission to conduct research study

To

Respected Sir / Madam

Sub: Letter for Seeking Permission to conduct data Collection regarding:

This is to kindly inform you that, I am Mrs. Santhi Letha Principal of

Sree Mookambika College of Nursing, Kulasekharam. I would like to conduct data

collection in Ph.D research study which is to be submitted to the Tamil Nadu Dr.M.G.R.

Medical University, Chennai. “A study to assess the effect of Acupressure in

relieving pain and distress related to dysmenorrhea among adolescent girls in

selected school at Kanyakumari District”.

I need your esteemed help and co-operation as I am interested in

conducting the study in your institutions. In this regard I request you to extent possible

guidance and support for successful completion of data collection.

Thanking You

Date Yours sincerely

Place Santhi Letha

ANNEXURE - N

REQUEST FOR OPINIONS AND SUGGESTIONS OF EXPERTS FOR ESTABLISHING

CONTENT VALIDITY OF RESEARCH

From

Mrs.V.Santhi Letha ,Msc,(N)

Principal,

Sree mookambika college of nursing, Kulasekharam.

To

Dr.Latha venkatesan M.Sc (N), M.phil, Ph.D,(N).

Principal,

Apollo College of nursing, Chennai.

Respected sir/madam,

Sub: Requisition to expert opinion and suggestion for the content validity of the research tools.

I, Mrs. Shanthi letha v.Msc (N), PhD candidate Apollo College of Nursing , Chennai has

selected the topic mentioned below for the research project to be submitted to The Tamil Nadu

Dr.M.G.R. Medical University, Chennai.

Topic: “A study to assess the effectiveness of Acupressure in relieving pain and

distress related to dysmenorrhea among adolescent girls in selected schools at

Kanyakumari district”

With regards may I kindly request you to validate my tool for its appropriateness and

relevancy and content of moos menstrual distress questionnaire, visual analogue pain scale, level

of satisfaction, content of demographic variable and menstrual variable give your expert opinion

for necessary modification. I would highly obliged and remain thankful for your great help if

you could validate and sent it as soon as possible.

Thanking you,

Place: Kulasekharam Yours sincerely,

Date: V.Santhi Letha

Encl : (1) Background, Need for the study, Statement of problem, Objectives of Study.

(2) Criteria Check list of evaluation of tool and content

(3) Tool for collection of data

(4) Acupressure content

(5) Certificate of Validation

Criteria Checklist for Evaluation of Tool Requesting Suggestion and Opinion from the Experts

Dear Madam / Sir,

I kindly request you to go through the tool and place a tick mark () in the columns given against each question and give your

comments on the items you disagree/ partially agree / to be deleted which will help in modification of tool.

Socio demographic variable Proforma

Contents

Relevant Organized Measurable Remarks

Agree Partially agree Disagree Agree Partially agree Disagree Agree Partially agree Disagree

Age in years

.Education

.Mothers education

.Mother’s occupation

Monthly family income

Religion

Type of family

Residence

Dietary habit

Food craving


Contents

Relevant Organized Measurable

Remarks Agree Partially agree Disagree Agree Partially agree Disagree Agree Partially agree Disagree

Age at menarche

Frequency of menstrual cycle

Extent of menstrual flow

Duration of menstrual flow

Onset of menstrual pain

Family history of dysmenorrhea

Treatment taken for

dysmenorrhea

Modified Moose Menstrual Dstress Questionnaire (MMDQ)

Contents



1.Pain

2.Concentration

3.Behavioral change

4.Autonomic reaction

5.Water retention

6.Negative effect

Visual Analog Scale for Pain (VASP)

Contents



Visual Analog

Pain Scale (VASP)

Interventions (Acupressure)

Contents



Acupressure

(procedure)

General Comments

Place: Signature of the Experts

Date: Name and Designation

BLUE PRINT

Modified Moose Menstrual Distress Questionnaire (MNMDQ)

S.No Item grouping Item no Total No. of items Percentage

1. Pain 1.1 - 1.6 6 18%

2. Concentration 2.1 - 2.4 4 16%

3. Behavioral change 3.1 - 3.5 5 18%

4. Autonomic reactions 4.1 - 4.3 3 12%

5. Water retention 5.1 - 5.4 4 16%

6. Negative affect 6.1 - 6.8 8 20%

Total 30 100%

BLUE PRINT

RATING SCALE TO ASSESS THE LEVEL OF INTERVENTION, SATISFACTION OF ACUPRESSURE IN ADOLESCENT

GIRLS

S. No. Item grouping Item No. Total No. of items Percentage

1. Researcher 1-4 4 25%

2. Procedure of acupressure 5-8 4 25%

3. Benefits of acupressure 9-12 4 25%

4. Effectiveness & Continuity 13-16 4 25%

Total 16 100%

CONTENT VALIDITY INDEX OF TOOL

Dear Sir / Madam,

I request you to kindly examine the research tool and give your valuable opinion and

suggestions on the developed tools. Please enter the items of each tool in the

appropriate column on the basis of relevance. Your valuable opinion and kind suggestion

will be highly appreciated.

S.No

Tool

Completely meets the Criteria- Relevant

Meets the Criteria to

some extent / Requires

Modification

Does not meet the

Criteria – Not

Relevant

Remarks

I Socio Demographic

variable Proforma

II Menstrual variable

performa

II Visual Analogue Pain

Scale

IV Modified Moose

Menstrual Distress

Questionnaire

(MMMDQ)

V Level of Satisfaction

Rating Scale

VI Intervention Protocol

EVALUATION CRITERIA CHECKLIST FOR VALIDATION

Instruction:

The expert is requested to go through the following criteria for evaluation. Three

columns are given for responses and a column for remarks. Kindly please tick mark () in

the appropriate columns and give remarks.

Column I – meets the criteria.

Column II- partially meets the criteria.

Column III- does not meets the criteria.

S.NO CRITERIA I II III REMARKS

1 Content

Logical

Sequence

Adequacy

Relevance

2 Language

Appropriate

Clarity

Simplicity

3 Practicability

Easy to score

Precise

Utility

4 Scoring

Adequacy

Clarity

Simplicity

Any other suggestion: Signature:

Name:

Address: Designation:

ANNEXURE - O

CERTIFICATE OF VALIDATION / CONTENT VALIDITY

This is to certify that the research tool and intervention protocol constructed

by Mrs. Shanthi letha currently pursuing her part – time Ph.D programe at Apollo

College of Nursing, Chennai under The Tamil Nadu Dr. M.G.R. Medical University,

Guindy,Chennai for the research study to “Assess the Effectiveness of Acupressure

in Relieving Pain and Distress Related to Dysmenorrhea among Adolescent Girls

in Selected School at Kanyakumari District” are found to be valid to the best of my

knowledge.

Date Signature:

Place

Name: & Designation:

Seal:

:

ANNEXURE - P

INFORMATION SHEETS OF ADOLESCENT GIRLS

You are invited to take part in this research study. It is important that you understand

several general principles that apply to all who take part in this study

i. Taking part in this study is entirely voluntary

ii. You may or may not benefit from taking part in this study, but the benefits will

Out weigh the risks.

iii. You may withdraw from this study at any point of time.

iv. The confidentiality of the details provided would be maintained.

v. The nature of the study, the risks and benefits are discussed.

vi. You are requested to discuss and clarify any doubts you have about this study.

Nature of the study:

This is an experimental study to assess the effect of Acupressure upon pain

and distress related to dysmenorrhea like Pain, Concentration, Behavioral change,

Autonomic reactions, and Negative effect. The information gathered and the tests

done will help the researcher to administer the Acupressure therapy which control the

pain and distress related to dysmenorrhea and provide ease and relief.

INFORMED CONSENT

I have been informed about the procedures of the study as stated in the

information. I have understood that I have the right to refuse my consent or withdraw

it any time during the course of the study without adversely affecting my therapy.

I am aware that by subjecting to this data collection, I will have to give more time for

assessments by the researcher. I understand that the information gathered will be kept

confidential and will be used only for the study purpose.

I, ------------------------------------------------------------------ , the undersigned, give my

consent to be a participant of this study programme.

Signature of the Subject Signature of the Researcher

(Name and Address)

Standard and Division

ANNEXURE – Q

TOOLS FOR DATA COLLECTION

Socio Demographic Variable Proforma

Purpose:

This proforma is used to measure the demographic variable such as age,

education, religion, education, parent’s education, parent’s occupation, family

monthly income, type of family, area of residence and dietary pattern.

Instructions:

The researcher will collect the information by interviewing the participants

and places a tick mark against the appropriate options.

Instruction to participants

Please answer the following questions

Please be frank and free in answering the following. This will be used only for

research purposes. The collected information will be kept confidential.

Sample No Date…………

Address

1. Age

1:1 14 -15 ( )

1: 2 16-17 ( )

2. Education

2:1 9th std ( )

2:2 11th std ( )

4. Mother’s Education

4:1 Illiterate ( )

4:2 School Education ( )

4:3 college Education

4:4 Professional ( )

( )

6. Mother’s Occupation

6:1 Coolie ( )

6:2 Private Employee ( )

6:3 Government Employee ( )

6:4 Home maker ( )

7. Religion

7:1 Hindu ( )

7:2 Christian ( )

7:3 Muslim ( )

8. Parent’s monthly income

8:1 <20000 Rs ( )

8:2 20000 Rs to 40000 Rs ( )

8:3 > 40000 RS ( )

9. Area of Residence

9:1 Urban ( )

9:2 Rural ( )

10. Type of Family

10:1 Neuclear ( )

10:2 Joint ( )

11. Dietary Habits

11: 1 Vegetarian ( )

11:2 Non Vegetarian ( )

12. Food cravings

12.1 Salt ( )

12.2 Sweet ( )


Purpose

This proforma is used to measure the clinical variables such as Age at

menarche, Years since menarche, Nature of Menstrual cycle, Duration of menstrual

cycle, Extent of menstrual flow, Duration of menstrual flow, Duration of pain, Family

history of dysmenorrhea.

Instructions

The researcher will collect information by interviewing the participants

according to the response a tick mark will be placed against the appropriate options.

Please be frank and free in answering the following. This will be used only for

research purposes.

1: Age at Menarche

1:1 10 - 12 ( )

1:2 13– 14 yrs ( )

1:3 15-16 ( )

2. Frequency of Menstrual cycle

2:1 < 28 days ( )

2: 2 28- 35 days ( )

2:3 36- 45 days ( )

2:4 > 45 days ( )

3. Extent of menstrual flow

3:1 Heavy ( )

3:2 Moderate ( )

3:3 light ( )

4. Duration of Menstrual flow

4:1 1- 3 days ( )

4:2 4- 6 days ( )

4:3 7- 9 days ( )

5. Onset of menstrual pain

5:1 Prior to menstruation ( )

5:2 During menstruation ( )

6. Family history of Dysmenorrhea

6:1 First line Relative ( Mother / sister ) ( )

6:2 Second line Relative ( cousin ) ( )

7. Treatment taken for Dysmenorrhea

7:1 Nothing ( )

7:2 Rests ( )

7:3 Medical ( )

7:4 Herbal ( )

MODIFIED MOOSE MENSTRUAL DISTRESS QUESTIONNAIRE (M M M D Q)

Purpose:

The Rating scale on Modified moose menstrual distress questionnaire MMDQ is used to assess the level of distress related to

dysmenorrhea among adolescent girls.

Instructions:

There are thirty items given below under five headings (Pain, concentration, behavioural change, autonomic reaction, water

retention and negative effect) Responses extent from none to severe. The researcher will conduct the interview and the response will be

recorded .Please be frank in answering the following questions. Your answer will be kept confidential. Anonymity will be maintained

Sl.No Signs and symptoms Before Acupressure After Acupressure None Mild Moderate Sever None Mild Moderate Sever

1. PAIN

1.1. Muscular stiffness

1.2. Headache

1.3. Cramps

1.4. Backache

1.5. Fatigue

1.6. General aches and pains

2. CONCENTRATION

2.1. Insomnia

2.2. Forgetfulness

2.3. Confusion

2.4 Difficulty concentration

3. BEHAVIORAL

CHANGE

3.1. Lowered school or work

performance

3.2. Take naps;stay in bed

3.3. Stay at home

3.4. Avoid social activities

3.5. Decreased efficiency

4. AUTONOMIC

REACTIONS

4.1. Dizziness, faintness

4.2. Nausea, vomiting

4.3. Hot flashes

5. WATER

RETENTION

5.1. Weight gain

5.2. Skin disorders

5.3.. Painful breasts

6. NEGATIVE AFFECT

6.1. Crying

6.2. Loneliness

6.3. Anxiety

6.4. Restlessness

5.4 Swelling

6.5. Irritability

6.6. Mood swing

6.7. Depression

6.8. Tension

Scoring keys:

None ( No Symptoms) - 0

Mild (Symptoms Exist only mildly-do not interfere routine activities) - 1

Moderate (Symptoms Exist moderately-interfere with routine activities) - 2

Severe (Completely debilitating ) - 3


Mild distress - 1 - 29

Moderate distress - 30 – 60

Severe distress - 61 – 90

RATING SCALE ON LEVEL OF SATISFACTION REGARDING ACUPRESSURE

Purpose

This rating scale is designed to assess the level of satisfaction of adolescent girls with dysmenorrhea regarding Acupressure and

this will be assessed by the researcher after Acupressure intervention.

Instructions

There are sixteen items given below. Responses extent from highly satisfied to dissatisfied. Describe your satisfaction regarding

acupressure. Please be frank in answering the following questions. Your answer will be kept confidential.

Sample No: Date:

Address

S. No. Items Highly satisfied 3

Satisfied 2

Dissatisfied 1

Researcher

1. Explanation for the reason of the treatment

2. Researcher’s approach towards you

3. Time spent by the researcher with you

4. Clarifications given by the researcher on doubts regarding the treatment

Procedure of acupressure

5. Preparation of client

6. Duration of treatment

7. Frequency of treatment

8. No of session administered

Benefit of acupressure

9. Improving energy flow

10. Enhance body immunity

11. Releasing natural pain killers

12. No side effect

Effectiveness & Continuity

13. Benefits of the treatment

14. Ability to continue treatment without being

setback financially

15. Comfort after taking the acupressure

16. The ability to disseminate this information to

others

Scoring key:

Highly satisfied - 3

Satisfied - 2

Dissatisfied - 1


Inadequate satisfaction - 16-24

Moderate satisfaction - 25-36

Adequate satisfaction - 37-48

ANNEXURE – R

INTERVENTION PROTOCOL

ACUPRESSURE FOR DYSMENORRHEA

Introduction

Traditional Chinese medicine it is believed that simulation of specific

acupressure points along the meridian lines can release muscular tension, increase

circulation and allow the energy to flow eventually and become balanced. They can

be viewed as promoting the release of endorphins, blocking the pain receptors to the

brain, dilating the cervix and increasing the efficiency of contraction.

Acupressure points stimulates various sensory receptors that in turn stimulate

nerves that transmit impulses to the brain, the brain then release the body’s natural

pain killing hormones ( neurotransmitters and endorphins). It is estimated that

endorphins are 200 times more potent than morphine. Endorphins also play a vital

part in the functioning of the hormonal system. Some researcher have suggested that

manipulating the small Myelinated peripheral nerve in muscles with finger pressure

dispatches signal to spinal cord, mid brain and the pituitary axis, resulting in release

of substance such as enkephalin, dynorphin, serotonin, norepin ephrine,and beta-

endorphins, among others into the bloodstream and cerebrospinal fluid thus

alleviating pain.

Acupressure (SP6):

A pressure applied to the Sanyinjiao point (3 cun - superior to the tip of medial

maleolus, posterior to medial border of tibia) 20 minutes (intermittently) first three

days of menstruation twice a day

Benefits of acupressure

Relieving pain

Balancing the body

Enhancing immune effect

Maintaining good health

Analgesic effect (Raising pain threshold)

The healing touch of acupressure reduces tension and increases circulation

Release body’s natural pain killers

Strengthens resistance to disease to disease and promotes wellness ( Neuro

transmitters and endorphins )

Homeostatic / Regulatory effect, (Homeostatic is maintained by balance activity of

sympathetic and parasympathetic divisions of Autonomic Nervous system and also by

endocrine system).

Procedure (Sanyinjiao, SP6 )

Explained the procedure to the client win the confidence and co operation.

Provide calm and quiet environment

The point is located in the medial side of the leg.

Point is located four finger space above the ankle in the depression under the bone

(tibia).

Bladder should be emptied prior to the intervention

Provide comfortable position

Then the pressure point will be identified

Adolescent girls were informed to sit in a comfortable position with legs elevated .

Encourage to relax their mind and body

Pressure points were identified by pointing four fingers above the medial malleolus

bone and posterior border of the medial aspect of the tibia in lower leg. Pressure was

applied for 20 minutes to twice a day with a duration of 10 minutes in each leg for

three days of menstruation

Apply deep pressure slightly behind the bone (tibia)

Massage the area for 20 minutes (intermittently) as far as pain is tolerable ( Pain

threshold )

Press the specified point with thumb finger in a clock wise circular fashion

How to apply pressure to acupressure points

Use finger pressure directly on the point; penetrating pressure approximately three

minutes is ideal. Each point will feel somewhat different when you press it: some

points feel tense, while others are often sore or ache when pressed. How much

pressure to apply to any point depends on how fit you are. A general guideline to

follow is that the pressure should be firm enough so that it “hurts good” – in other

words, something between pleasant, firm pressure and outright pain.

Cautions to consider

Apply finger pressure in a slow, rhythmic manner to enable the layers of tissue and

the internal organs to respond. Never press any area in an abrupt, forceful, or jarring

way.

Use the abdominal points cautiously, especially if you are ill. Avoid the abdominal

area entirely if you have a life- threatening disease, especially intestinal cancer,

tuberculosis, serious cardiac conditions, and leukemia. Avoid the abdominal area

during pregnancy as well.

Pregnancy – special care should be taken during pregnancy.

Lymph areas, such as the groin, the area of the throat just below the ears, and the

outer breast near the armpits, are very sensitive. These areas should be touched only

lightly and not pressed.

Burns & infections: Do not work directly on a serious burn , an ulcerous condition,

or an infection: for these conditions, medical care alone is indicated.

Scars and injuries: Do not work directly on a recently formed scar. During the first

month after an injury or operation, do not apply pressure directly on the affected site.

However, gentle continuous holding a few inches away from the periphery of the

injury will stimulate the area and help it heal.

After an acupressure session, your body heat is lowered: thus your resistance to cold

is also lower. Because the tensions have been released, your body’s vital energies are

concentrating inward to maximize healings. Your body will be more vulnerable, so be

sure to wear extra clothing and keep warm when you finish an acupressure routine.

Contraindications

Patients with life – threatening disease and serious medical problems should always

consult their doctor before using acupressure or other alternative therapies. It is

important for the novice to use caution in any medical emergency situation, such as a

stroke or heart attack, or for any serious medical condition, such as arteriosclerosis or

an illness caused by bacteria. Nor is acupressure an appropriate sole treatment for

cancer, contagious skin diseases, or sexually transmitted disease.

ANNEXTURE – S

CERTIFICATES FOR PARTICIPATING/ PRESENTING IN RESEARCH /

ACUPRESSURE WORKSHOP / CONFERENCE

ANNEXURE – U

Ph.D SYNOPSIS SUBMISSION APPLICATION FORM

ANNEXURE – V

Ph.D THESIS SUBMISSION APPLICATION FORM

ANNEXURE – W

PHOTOS

APPENDIX - X ‐

MASTER CODING SHEET SOCIO DEMOGRAPHIC VARIABLES MENSTRUAL VARIABLES PRE TEST AND POST TEST ASSESSMENT OF PAIN AND DISTRESS

Group

Sl.No

Age

Education

Mot.Edu

n

Mot.Occup

n

religion

Fam.M

on.In

c

Reside

nce

Ty. O

f Fam

i

Diet Habi

Food

Cravi

Age@

Men

a

freq

.Men

a

Men

s.Flow

Flow

Dura

Men

s Pain

Fam Histo

Dysm

en Tmt

Pre PainD1

PreP

ain D2

Pre Pain D3

Po1 Pain D1

PO1 Pain D2

Po1 Pain D3

PO2 Pain D1

PO2 Pain D2

PO2 Pain D3

Pre dist D1

Pre distr D

2

Pre distr D

3

Po1 distr D

1

PO1 distr D

2

Po1 distr D

3

PO2 distr D

1

PO2 distr D

2

PO2 distr D

3

1 1 1 1 2 2 2 2 2 2 2 2 1 2 1 2 1 1 1 9 8 6 7 5 3 4 3 1 71 70 69 31 28 31 26 24 221 2 1 1 2 2 2 2 2 2 2 2 2 2 1 2 1 1 1 8 7 5 6 4 3 3 2 1 69 69 67 38 32 31 20 20 221 3 1 1 1 3 2 1 2 2 2 2 1 2 1 2 1 1 1 9 8 6 7 3 2 4 1 0 71 70 68 31 27 28 25 17 181 4 1 1 3 3 2 2 2 2 2 1 2 2 2 2 1 1 1 7 6 6 5 3 2 3 2 1 66 64 62 34 34 28 21 21 211 5 1 1 2 2 2 2 1 2 2 1 1 1 3 1 1 1 2 8 8 6 5 3 1 3 2 0 68 72 70 36 28 20 22 20 161 6 1 1 2 3 1 1 1 2 2 1 1 1 2 2 1 1 1 7 6 5 4 2 1 2 1 0 65 62 60 30 26 24 20 20 181 7 1 1 2 3 1 1 1 2 2 1 1 2 2 2 1 1 4 9 7 5 7 4 3 6 3 2 71 69 68 44 40 32 38 26 251 8 1 1 1 4 2 2 2 2 1 2 1 2 2 1 2 2 1 7 7 7 5 3 2 4 2 1 69 66 65 37 31 30 25 20 211 9 1 1 2 2 2 1 2 1 1 2 1 2 3 1 2 1 1 7 7 5 5 4 2 5 4 2 67 64 62 36 37 30 30 29 241 10 1 1 2 2 2 3 2 1 1 2 1 2 3 2 2 1 4 10 8 6 7 2 6 3 2 73 71 69 44 36 30 31 30 301 11 1 1 3 3 1 3 1 1 2 2 2 2 1 2 2 2 1 4 6 5 4 2 1 4 2 1 60 60 60 29 24 20 20 21 201 12 1 1 2 3 1 2 1 2 2 1 1 2 1 2 1 1 1 9 7 6 6 4 3 5 3 1 71 68 65 38 35 32 30 25 221 13 1 1 2 4 2 1 1 1 2 1 1 2 2 2 2 1 1 10 9 7 7 4 2 6 3 1 66 73 70 43 36 30 32 25 211 14 1 1 3 2 2 2 1 1 2 2 1 2 2 2 2 1 3 7 7 5 5 3 1 5 4 1 68 67 62 36 30 25 24 24 201 15 1 1 4 2 1 2 1 2 2 2 1 2 2 2 2 1 1 7 6 5 4 2 1 3 2 1 68 64 63 29 25 23 21 20 201 16 1 1 3 2 1 2 2 2 2 2 1 1 1 2 1 1 2 9 7 5 7 4 2 3 3 1 73 69 68 41 35 29 22 25 211 17 1 1 1 1 1 1 2 2 2 1 1 1 2 2 2 1 1 7 7 6 5 3 1 4 2 0 65 69 68 36 30 24 26 22 181 18 1 1 3 3 1 3 1 2 1 2 2 2 2 2 1 1 4 10 8 6 6 4 2 5 3 1 66 70 68 39 35 30 30 25 211 19 1 1 3 4 3 3 2 1 2 1 1 2 1 2 1 2 3 9 8 6 6 4 1 6 3 0 71 70 69 39 36 23 32 26 181 20 1 1 2 4 2 2 2 1 1 2 1 3 2 2 1 2 2 6 6 5 5 3 1 4 2 0 65 62 61 36 31 25 27 22 171 21 1 1 3 2 2 2 2 1 1 2 1 3 3 2 1 1 1 6 5 4 5 5 4 4 3 1 63 60 60 38 36 38 33 25 241 22 1 1 1 1 2 1 2 1 1 1 2 3 2 2 2 1 1 10 8 6 7 5 4 7 5 4 66 72 70 45 40 34 39 31 311 23 1 1 2 2 3 3 2 2 2 1 1 2 2 3 1 1 2 9 7 6 6 4 3 4 3 0 73 69 68 39 36 34 32 24 191 24 1 1 4 3 2 3 2 2 1 1 1 3 2 3 1 1 3 6 6 5 4 2 0 3 2 0 62 57 57 30 26 20 21 21 151 25 1 1 4 4 2 3 2 2 1 2 1 3 2 2 1 1 1 4 5 4 3 1 1 2 1 1 60 59 57 28 22 24 20 20 201 26 1 1 3 4 2 2 1 2 2 1 1 2 1 2 1 1 4 6 5 3 5 3 1 4 2 0 68 60 55 38 32 27 25 20 161 27 1 1 3 3 1 2 1 2 2 2 1 2 2 2 1 1 1 6 7 6 4 3 1 3 2 0 68 70 69 33 32 27 21 20 151 28 1 1 2 3 1 2 1 1 2 2 2 2 2 2 1 1 1 4 4 3 2 1 0 2 0 0 59 57 54 36 22 20 19 16 141 29 1 1 2 3 2 1 2 1 1 2 1 2 1 2 1 1 1 9 8 7 7 5 3 6 5 2 72 70 70 41 38 31 32 32 261 30 1 1 2 3 2 3 2 2 1 2 1 3 2 2 1 1 1 7 7 6 4 3 1 3 2 1 62 65 65 29 30 21 24 22 201 31 1 1 2 4 1 3 2 2 2 1 1 3 2 2 2 2 3 7 7 6 4 3 2 3 2 1 68 67 65 30 30 30 24 23 211 32 1 1 1 1 2 3 1 2 2 2 1 2 1 3 1 2 1 9 7 6 6 5 3 5 4 2 71 67 66 40 36 34 30 31 291 33 1 1 3 4 2 3 1 2 1 1 2 2 1 1 1 1 1 6 5 5 4 2 0 3 1 0 62 59 56 30 25 18 23 20 141 34 1 1 4 4 3 2 2 2 2 2 1 2 1 2 1 1 1 7 6 6 5 3 2 5 3 1 66 63 63 36 30 30 30 25 211 35 1 1 4 2 1 2 2 1 2 1 1 2 1 2 1 1 1 8 8 6 7 5 4 6 4 3 69 71 68 43 39 35 34 30 291 36 1 1 2 3 3 2 2 2 2 1 1 3 2 2 2 1 1 10 7 7 7 4 3 6 3 1 73 70 71 44 36 32 38 36 221 37 1 1 1 3 2 1 2 2 2 1 2 2 1 2 2 1 1 10 9 7 8 6 4 7 5 3 74 74 72 49 41 36 34 32 241 38 1 1 2 2 2 3 1 2 1 1 2 2 1 3 2 2 1 7 6 4 5 4 2 4 3 1 68 70 60 34 34 28 25 24 201 39 1 1 3 2 2 2 1 1 1 1 2 2 1 2 2 1 2 4 5 4 3 2 0 2 0 0 60 59 58 25 24 18 19 14 101 40 1 1 3 2 2 1 1 1 1 1 2 1 2 2 1 2 1 6 5 4 4 2 1 3 1 0 62 59 57 32 26 27 21 17 151 41 1 1 4 3 1 2 1 1 1 1 2 1 2 1 1 1 3 8 7 6 6 4 2 4 2 1 69 69 66 39 35 30 28 22 211 42 1 1 4 3 1 1 2 2 2 1 1 2 3 1 2 1 1 6 5 5 4 2 1 4 2 0 61 59 60 30 25 24 26 21 171 43 1 1 3 3 1 3 2 2 2 1 1 2 2 2 2 1 1 10 8 6 8 6 4 5 2 1 66 70 68 48 41 35 30 22 241 44 1 1 3 2 2 2 2 2 2 2 1 2 2 2 1 2 1 5 4 4 3 1 0 3 0 0 60 57 60 26 20 18 23 15 141 45 1 1 3 2 2 1 1 1 2 1 1 1 2 1 1 1 1 7 6 5 4 2 1 3 0 0 66 63 62 34 27 24 23 17 171 46 1 1 3 3 2 2 1 1 1 2 1 1 1 1 1 1 1 9 7 6 7 6 3 4 2 0 72 69 66 46 45 40 38 23 191 47 1 1 3 3 1 2 2 1 1 2 2 2 1 3 2 1 4 7 7 6 5 3 1 5 3 0 65 69 68 37 32 27 30 27 181 48 1 1 3 2 3 1 2 2 2 1 1 2 1 2 2 1 1 9 9 8 7 5 4 5 2 0 71 73 72 41 38 35 30 22 191 49 1 1 3 4 2 3 1 2 2 1 1 2 1 2 1 2 1 6 6 5 3 3 1 3 3 0 61 63 62 27 30 24 24 27 181 50 1 1 3 2 2 3 1 2 2 2 1 2 3 2 2 2 3 4 3 3 2 1 0 2 1 0 58 55 53 23 20 18 20 20 151 51 1 1 2 2 1 1 2 2 2 1 1 2 2 1 1 2 1 9 8 7 7 5 4 2 0 0 71 70 70 42 38 35 30 17 191 52 2 2 2 3 2 2 2 2 2 1 2 2 2 3 1 1 1 6 5 5 4 3 1 4 3 0 62 60 62 30 30 22 28 24 161 53 2 2 2 3 2 2 1 2 1 1 2 2 2 2 2 2 1 7 7 6 3 2 1 3 2 0 67 64 62 28 25 20 22 21 181 54 2 2 2 1 1 2 1 2 1 2 3 2 2 2 2 1 1 8 7 5 6 4 2 2 0 0 68 70 66 40 37 30 19 16 181 55 2 2 2 1 2 2 1 1 1 2 2 1 1 2 1 2 2 7 7 6 5 3 1 5 3 1 69 69 68 38 31 25 24 24 20

1 56 2 2 3 2 2 1 1 1 1 1 2 1 1 2 1 1 3 10 8 6 8 6 5 4 2 0 74 72 69 49 42 40 32 21 191 57 2 2 2 3 1 1 1 1 2 1 2 3 1 1 2 1 1 6 6 5 4 3 1 4 3 1 63 57 57 33 31 27 27 26 201 58 2 2 2 2 3 1 1 2 2 1 2 3 1 2 2 1 1 6 5 5 4 3 1 3 2 0 65 59 59 28 28 20 20 20 161 59 2 2 3 2 2 1 1 2 2 1 1 2 1 3 1 1 1 7 7 5 4 3 1 3 2 1 65 69 62 29 29 21 21 21 201 60 2 2 2 3 2 1 1 2 2 1 2 2 1 3 1 1 1 9 8 8 7 5 3 6 4 2 71 70 72 42 39 31 33 29 251 61 2 2 2 3 2 1 1 2 2 1 3 2 1 3 1 1 1 7 7 6 6 4 3 6 4 2 69 65 64 39 36 33 34 30 271 62 2 2 2 3 1 1 1 1 2 1 2 1 2 3 1 1 2 4 5 4 3 1 0 3 1 0 60 59 59 27 20 20 20 18 141 63 2 2 3 4 2 1 1 1 2 1 1 3 2 3 2 1 1 6 6 5 4 3 1 4 3 0 65 63 61 30 30 23 25 24 151 64 2 2 2 4 2 2 1 2 2 1 1 2 3 2 2 2 1 7 8 6 5 4 1 4 3 1 69 70 69 34 32 21 25 24 201 65 2 2 3 4 2 1 1 1 2 1 1 2 1 2 2 1 3 6 6 5 6 3 1 5 3 0 64 60 60 38 29 21 30 25 171 66 2 2 3 4 2 2 2 1 2 1 1 3 3 2 2 1 1 5 5 4 3 1 0 2 1 0 60 59 55 25 20 13 20 19 141 67 2 2 2 2 2 1 2 1 2 2 1 2 3 2 2 1 1 8 7 6 6 5 3 6 4 2 74 67 66 38 36 34 38 30 251 68 2 2 2 2 2 1 1 2 2 2 1 2 2 2 2 1 1 9 7 7 7 5 3 7 5 2 70 67 65 42 38 31 39 39 261 69 2 2 2 2 2 1 2 1 1 2 1 2 2 2 2 1 1 6 5 5 4 2 0 3 2 0 63 60 63 32 26 20 21 21 111 70 2 2 2 4 1 2 2 1 2 1 1 2 2 3 2 1 1 6 6 5 4 3 1 4 3 0 69 65 64 31 30 24 27 24 161 71 2 2 3 4 3 2 1 1 2 1 2 2 2 2 2 1 1 5 5 3 3 1 0 2 1 0 60 60 55 25 20 18 20 18 141 72 2 2 3 4 3 2 1 1 2 2 2 3 2 2 2 2 1 8 7 6 6 5 3 6 5 2 69 69 68 38 28 32 31 31 291 73 2 2 2 4 1 3 2 1 2 2 2 3 2 2 1 2 1 7 7 5 5 4 1 4 2 1 65 69 67 34 34 21 24 20 201 74 2 2 2 4 2 3 2 2 2 1 1 3 2 2 1 2 1 9 6 6 7 5 4 6 4 2 71 56 56 31 28 34 30 29 291 75 2 2 2 3 2 3 1 2 1 1 1 2 2 3 1 1 1 7 6 5 6 4 1 4 3 2 69 62 60 39 36 22 25 24 241 76 2 2 3 2 2 3 1 2 1 2 1 2 2 2 2 1 3 6 6 5 4 3 2 4 2 0 62 64 64 32 30 30 26 22 181 77 2 2 3 3 1 1 1 1 2 2 1 3 1 2 2 1 3 5 5 4 3 1 0 2 0 0 60 60 60 27 22 20 20 17 141 78 2 2 2 2 3 2 2 2 2 1 1 3 1 2 2 1 1 6 5 4 4 2 1 4 2 0 64 57 56 30 26 24 27 22 171 79 2 2 2 2 3 2 2 1 2 1 1 2 2 2 2 1 1 9 9 7 7 5 3 6 5 2 71 72 70 44 40 34 35 34 261 80 2 2 2 3 3 2 1 2 2 1 1 3 2 3 2 2 1 6 4 4 4 2 1 4 2 0 63 56 55 29 25 21 24 21 171 81 2 2 3 2 1 1 1 1 2 2 1 2 3 2 1 1 1 9 6 6 6 4 2 5 4 1 70 64 64 38 38 28 30 30 211 82 2 2 3 4 1 1 1 1 2 2 2 3 3 3 1 1 3 7 7 6 5 3 1 4 3 1 69 70 70 34 28 22 20 25 201 83 2 2 2 4 2 1 1 1 2 2 2 2 1 2 2 1 1 10 8 6 7 6 3 6 5 2 73 72 70 42 41 32 34 33 291 84 2 2 4 4 2 1 2 1 2 1 1 2 1 2 2 2 1 5 5 4 3 1 1 3 2 0 60 60 60 27 20 24 24 21 171 85 2 2 4 4 1 2 2 2 2 1 2 2 2 3 2 2 1 6 6 6 4 2 1 4 2 0 64 60 64 30 26 25 29 23 171 86 2 2 2 4 1 2 1 2 2 1 2 2 3 3 1 2 1 7 7 6 4 3 1 4 2 1 65 69 67 40 30 24 29 28 201 87 2 2 2 2 2 2 1 2 2 2 1 3 1 3 2 1 1 7 5 4 5 3 1 4 3 1 65 59 59 36 31 26 29 28 201 88 2 2 2 2 2 2 1 2 2 2 2 3 1 2 2 1 1 8 8 6 6 4 2 4 3 1 74 70 69 40 37 29 29 28 221 89 2 2 3 2 1 1 2 2 2 1 2 3 2 2 2 1 2 9 7 5 7 5 2 6 4 1 71 68 68 44 40 30 36 30 211 90 2 2 3 3 2 1 1 2 2 1 2 3 1 2 1 1 2 6 6 5 4 2 1 4 1 1 63 64 63 30 25 22 28 19 201 91 2 2 3 4 2 1 1 2 2 1 2 2 2 2 2 1 2 7 7 4 4 3 2 3 2 0 68 70 60 29 28 29 21 20 181 92 2 2 3 4 2 2 2 2 1 1 1 3 2 2 2 1 1 8 6 6 6 4 1 4 2 1 69 64 64 38 34 21 24 20 201 93 2 2 4 2 2 2 2 2 1 1 2 3 1 2 1 1 1 7 7 6 5 3 2 4 2 0 69 64 64 34 28 29 24 20 181 94 2 2 4 2 1 3 1 1 2 1 2 1 1 2 1 2 1 6 5 5 4 2 1 4 1 1 64 60 62 29 23 20 26 18 201 95 2 2 4 2 1 3 2 1 2 1 2 2 1 2 2 2 1 7 6 4 4 3 1 4 2 1 68 70 60 29 29 21 27 22 201 96 2 2 4 1 1 3 2 2 2 1 2 2 2 2 2 2 2 5 4 4 3 1 0 2 0 0 60 57 55 26 20 18 20 17 151 97 2 2 3 2 2 2 1 2 2 2 1 2 1 2 2 1 2 7 6 6 4 2 1 4 1 0 68 70 68 30 25 22 28 20 181 98 2 2 4 2 2 2 2 2 2 2 1 3 2 2 1 1 2 10 8 6 7 5 3 4 3 1 73 72 70 39 32 31 26 27 221 99 2 2 3 2 3 1 2 1 2 2 1 3 1 2 2 1 1 8 6 5 6 4 2 3 1 0 69 64 64 38 35 29 20 18 181 100 2 2 3 1 1 1 1 2 2 2 1 3 1 2 2 1 1 6 6 5 4 3 1 3 2 0 62 65 64 29 27 20 20 21 151 101 2 2 3 4 2 3 1 1 2 2 1 3 1 2 2 1 1 6 7 6 4 2 1 4 2 0 69 64 62 29 24 20 24 21 151 102 2 2 3 4 2 3 1 1 1 2 2 2 2 2 2 1 1 8 5 4 5 3 1 5 2 1 69 59 58 34 28 21 19 21 201 103 2 2 2 2 2 2 1 1 2 2 2 3 2 2 2 1 1 6 5 4 4 2 1 4 1 0 66 60 59 28 23 20 24 18 161 104 2 2 2 2 2 2 2 2 2 1 2 2 1 2 1 1 1 9 7 6 6 5 3 5 4 2 71 67 65 38 28 31 29 29 251 105 2 2 2 3 1 2 2 1 2 1 2 3 1 2 1 1 1 7 7 6 5 3 2 4 2 1 62 65 64 34 30 30 25 20 201 106 2 2 3 4 1 2 2 1 2 2 1 2 1 2 1 1 1 9 8 7 7 5 4 6 4 1 71 70 70 43 39 35 32 30 231 107 2 2 1 2 3 2 1 2 2 1 1 3 1 3 1 1 1 10 7 6 7 5 3 5 3 1 73 70 69 41 38 31 29 28 221 108 2 2 3 2 2 3 1 2 2 1 1 3 2 3 1 1 1 6 6 5 4 2 1 2 1 0 63 56 63 30 25 21 18 18 151 109 2 2 3 1 2 3 1 2 2 1 3 2 1 2 2 1 1 6 6 5 4 3 1 2 1 0 68 70 64 29 30 21 19 18 171 110 2 2 2 2 2 2 2 2 2 2 1 2 1 2 2 1 1 4 4 4 3 1 0 3 1 0 59 55 53 25 20 16 20 18 141 111 2 2 4 2 1 2 1 1 2 1 2 2 3 2 2 2 2 4 5 4 3 2 1 3 1 0 60 59 58 25 24 21 22 18 171 112 2 2 2 4 1 2 2 1 2 2 2 2 3 2 1 1 2 6 6 5 4 2 1 3 2 1 61 60 60 29 25 20 20 20 201 113 2 2 2 4 2 3 1 1 2 1 1 2 1 2 2 2 1 4 3 2 1 1 0 1 0 0 57 54 52 20 20 18 18 14 121 114 2 2 4 4 2 1 2 2 2 1 2 2 3 3 2 1 2 6 5 6 4 2 1 3 2 0 68 60 60 33 26 24 21 20 161 115 2 2 3 4 2 1 1 2 2 2 2 3 2 2 2 1 1 6 5 4 4 3 1 4 3 0 62 60 60 30 30 25 29 28 171 116 2 2 3 2 1 1 2 1 2 1 2 2 2 2 2 1 1 8 7 5 6 5 2 5 3 1 69 69 64 42 40 30 30 28 211 117 2 2 3 2 2 1 1 2 2 1 1 2 2 1 2 1 1 9 7 5 7 5 3 7 4 2 71 68 62 46 40 34 42 37 29

1 118 2 2 3 1 1 1 2 2 2 2 2 2 3 1 2 1 1 7 7 7 6 4 2 5 3 1 68 68 65 40 37 30 30 27 221 119 2 2 3 3 1 1 1 1 2 1 1 1 2 2 1 1 1 7 6 6 4 3 1 4 3 1 65 60 65 34 30 26 29 27 201 120 2 2 3 3 2 1 2 1 2 2 1 3 2 1 2 1 2 6 6 5 4 2 1 4 1 1 61 62 60 34 26 26 29 20 201 121 2 2 3 4 2 1 1 1 2 2 1 3 1 2 2 1 2 7 5 3 6 5 2 4 3 1 68 59 52 40 36 30 29 29 221 122 2 2 2 4 2 1 2 2 2 2 1 2 1 1 1 1 1 6 6 5 4 3 1 2 1 0 60 60 60 34 32 27 20 20 181 123 2 2 2 4 2 1 1 2 2 2 2 2 1 2 2 1 3 7 7 6 5 3 2 4 1 0 62 65 64 36 30 30 29 20 191 124 2 2 2 4 2 1 2 2 2 1 2 3 2 3 2 2 1 4 4 3 2 0 0 2 0 0 59 56 53 31 28 16 20 17 151 125 2 2 3 4 2 1 1 2 2 1 2 3 3 3 1 1 1 5 5 4 3 1 0 2 1 0 60 60 60 26 20 17 20 20 151 126 2 2 3 4 2 1 1 2 2 1 2 3 3 2 2 2 1 10 8 6 7 4 2 6 3 1 73 72 70 41 32 28 36 35 211 127 2 2 3 4 3 1 1 2 2 2 2 2 2 2 2 1 1 9 8 6 4 2 1 3 1 0 72 70 68 29 24 20 22 18 181 128 2 2 2 4 3 1 1 1 2 2 2 3 1 1 2 2 2 4 5 4 3 3 1 3 0 0 60 60 59 25 28 21 22 16 171 129 2 2 3 4 1 1 1 2 2 1 2 3 2 2 1 2 3 7 6 5 6 5 2 6 2 1 68 63 61 38 28 29 31 20 201 130 2 2 3 4 2 1 2 1 2 1 1 2 3 2 1 2 1 6 6 4 4 3 1 3 2 1 62 63 58 30 29 21 20 20 202 1 2 2 3 4 2 1 1 2 2 2 2 3 2 2 2 1 1 7 6 4 6 6 3 8 7 6 74 62 60 61 60 51 66 63 602 2 1 1 2 2 2 2 1 2 2 1 1 2 2 2 1 1 1 9 8 5 8 7 5 9 8 6 70 66 60 64 64 60 68 67 622 3 1 1 3 2 1 2 1 2 2 1 1 2 2 2 1 1 1 9 9 5 7 6 5 6 7 5 74 74 73 60 60 60 62 63 602 4 1 1 3 3 2 2 1 2 1 2 2 2 2 2 1 1 1 7 6 4 6 7 3 6 6 4 66 64 64 60 64 53 62 60 552 5 1 1 3 2 2 2 1 2 1 2 1 2 2 2 1 1 1 5 4 4 9 6 5 8 7 6 60 57 54 70 68 60 63 61 612 6 1 1 3 4 2 2 1 2 1 2 2 2 3 2 1 1 1 6 5 4 8 7 5 6 6 4 64 60 58 69 69 63 59 57 562 7 1 1 3 2 1 2 2 2 1 2 1 2 2 2 1 2 1 10 9 7 9 7 5 9 7 5 72 74 73 70 65 61 70 63 602 8 1 1 4 2 1 2 2 1 2 2 1 3 1 2 1 2 1 9 8 6 8 7 6 10 8 6 71 69 64 66 65 64 66 68 652 9 1 1 1 1 1 1 2 2 2 1 2 3 1 2 1 2 2 6 5 4 6 8 5 8 7 7 64 60 59 62 70 69 64 62 642 10 1 1 1 2 2 3 2 1 1 1 1 3 1 1 1 1 2 10 9 8 6 5 7 6 6 3 66 74 74 59 56 56 62 57 532 11 1 1 4 2 2 2 1 1 1 2 2 3 1 1 1 2 2 10 9 8 8 6 2 6 6 6 66 74 74 68 62 49 56 59 602 12 1 1 3 2 2 2 1 1 2 1 2 3 1 2 1 1 1 7 6 5 6 7 4 8 7 6 66 62 60 63 65 59 63 61 602 13 1 1 3 2 1 2 1 2 2 1 1 3 1 2 2 2 1 6 5 4 6 8 5 6 6 5 63 60 56 58 57 56 60 55 592 14 1 1 4 2 2 1 1 2 2 1 2 3 1 2 2 1 1 4 4 2 6 5 5 6 6 4 59 58 56 58 56 60 61 57 572 15 1 1 4 3 1 2 2 2 2 2 1 3 3 3 1 2 1 7 7 6 8 7 4 8 7 6 66 66 63 68 66 59 64 61 602 16 1 1 4 3 2 3 2 2 2 2 1 3 3 3 1 1 1 8 7 5 7 6 6 9 8 7 69 67 67 64 62 60 68 66 642 17 1 1 4 3 1 3 2 2 2 1 1 1 3 3 1 2 4 9 8 7 7 8 6 9 8 7 74 71 67 64 64 65 69 67 622 18 1 1 4 3 1 3 2 2 2 1 2 1 2 3 2 1 3 8 8 5 8 7 5 7 6 5 67 68 67 68 68 63 62 60 602 19 1 1 4 4 1 2 2 1 2 2 1 2 1 2 2 1 3 5 4 4 8 7 3 8 6 4 61 59 56 68 68 59 66 57 532 20 1 1 2 4 3 2 2 1 1 2 1 2 1 2 1 1 1 9 8 6 7 6 5 6 7 6 71 70 68 63 62 62 62 60 612 21 1 1 1 4 2 2 2 1 1 2 2 2 1 2 1 1 1 10 9 6 7 6 3 6 5 5 72 64 64 63 61 51 60 55 522 22 1 1 2 4 2 2 2 2 1 2 1 2 2 2 2 1 1 6 6 5 6 5 3 6 6 4 64 64 61 62 57 57 60 60 562 23 1 1 2 1 2 3 1 2 2 2 1 3 2 2 2 1 1 8 8 6 8 4 2 7 5 3 67 68 63 65 64 50 50 55 492 24 1 1 3 3 2 3 1 2 2 1 2 3 2 2 2 1 1 10 9 8 9 6 3 8 7 5 72 74 72 69 68 50 63 61 582 25 1 1 3 3 2 3 2 2 2 1 2 2 2 2 2 1 1 5 4 3 10 6 3 8 6 3 60 59 56 71 69 53 63 57 502 26 1 1 3 2 3 2 2 2 1 2 1 2 2 2 2 1 3 6 5 5 9 6 4 9 8 6 62 59 59 69 65 53 68 65 602 27 1 1 3 2 2 2 1 2 1 2 1 2 2 2 1 1 3 8 6 6 8 7 4 8 7 6 64 62 62 64 64 57 65 63 612 28 1 1 2 2 1 2 1 2 2 2 1 2 1 1 1 1 4 8 7 6 6 6 5 9 6 5 69 64 62 62 60 61 70 60 602 29 1 1 2 2 2 1 1 2 2 2 1 1 1 1 1 1 1 6 6 5 6 7 3 8 7 3 63 62 60 58 65 57 66 62 502 30 1 1 1 1 1 3 1 2 2 2 1 2 1 1 1 1 1 9 6 6 7 6 6 8 7 6 70 64 62 63 61 64 65 62 552 31 1 1 1 1 2 1 1 2 2 1 1 2 1 2 2 1 1 9 9 6 8 6 5 7 6 5 71 64 64 67 60 61 62 60 602 32 1 1 4 4 1 1 1 2 1 2 1 1 1 2 2 2 1 8 8 6 6 6 4 6 5 4 68 69 65 63 62 59 60 52 502 33 1 1 3 4 2 1 1 2 1 2 1 1 1 2 1 2 1 9 8 7 6 7 5 8 7 6 71 70 68 70 67 62 66 65 622 34 1 1 4 4 3 3 1 1 2 1 1 1 2 2 1 1 1 6 6 5 6 6 5 8 8 6 64 61 60 58 62 56 65 60 622 35 1 1 4 1 3 1 1 1 2 2 1 2 2 2 1 2 1 4 3 4 9 8 5 9 8 5 58 54 53 70 70 68 68 66 602 36 1 1 3 1 2 2 1 1 1 2 2 2 2 2 1 1 1 5 4 4 8 5 3 8 7 4 60 55 57 66 56 57 64 62 552 37 1 1 4 4 2 2 1 1 1 2 1 2 2 1 2 1 1 9 8 7 8 7 3 9 9 6 70 72 72 65 65 51 68 69 602 38 1 1 2 4 2 3 1 2 1 1 1 2 3 3 2 1 2 7 7 6 6 6 6 6 6 5 66 66 62 63 62 64 61 59 602 39 1 1 3 4 2 2 1 2 2 1 1 3 2 2 2 1 2 6 5 4 6 7 5 6 6 4 62 60 57 64 68 63 60 60 572 40 1 1 3 4 2 1 1 1 2 1 1 2 2 3 1 1 2 8 7 6 8 5 4 8 7 5 69 67 65 69 57 59 66 63 592 41 1 1 3 2 2 1 1 1 2 2 1 2 2 2 1 1 2 6 6 5 8 7 5 9 7 4 63 61 60 68 67 61 68 62 572 42 1 1 3 4 1 1 1 2 2 2 1 2 2 3 1 1 1 8 6 6 10 7 5 10 8 5 67 64 64 71 67 63 70 65 612 43 1 1 2 2 1 3 1 2 2 2 1 2 3 2 1 1 1 10 9 6 7 6 6 6 6 3 66 64 61 63 62 65 62 59 532 44 1 1 2 2 2 2 1 1 2 2 1 3 1 2 1 1 1 8 6 6 6 5 4 8 7 5 69 64 62 59 57 59 64 60 582 45 1 1 2 2 2 1 1 2 2 2 2 3 1 2 2 1 1 9 8 6 7 6 4 6 6 4 71 70 68 63 60 57 61 60 552 46 1 1 2 2 2 2 2 2 2 2 1 3 2 2 2 1 1 8 8 6 6 6 3 6 5 4 69 71 69 62 60 51 60 55 532 47 1 1 3 4 2 2 2 2 2 2 1 4 2 1 2 1 1 10 9 6 8 7 4 8 7 5 74 64 62 65 65 57 65 62 592 48 1 1 3 4 2 2 2 2 2 2 1 4 2 1 2 1 1 7 7 6 6 6 5 6 6 3 66 67 63 62 60 60 62 60 522 49 1 1 1 4 1 2 1 2 2 2 1 4 2 1 1 1 1 6 5 4 8 7 3 7 6 4 63 60 58 64 64 55 62 58 54

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2 2 2 2 2 1 1 2 2 2 3 2 1 1 6 6 5 6 5 3 6 5 3 64 62 60 53 54 49 57 51 492 87 2 2 2 2 3 3 2 2 2 2 3 3 3 3 2 1 3 6 5 4 6 6 3 6 6 4 64 60 59 60 59 50 61 59 532 88 2 2 2 4 2 3 1 2 2 2 2 3 3 3 1 2 1 8 7 6 6 6 5 6 6 4 69 64 60 60 58 59 59 59 572 89 2 2 2 4 2 3 1 2 2 1 1 2 2 2 1 1 1 8 5 4 6 5 5 6 5 3 65 60 57 56 56 60 72 68 552 90 2 2 3 3 2 3 1 2 2 2 1 3 2 2 1 1 1 5 4 4 8 7 3 7 6 5 60 54 57 65 65 57 60 60 592 91 2 2 3 3 2 3 1 2 2 1 2 2 1 2 2 1 1 7 6 4 6 6 5 8 6 6 66 62 60 61 60 60 63 58 552 92 2 2 3 2 2 3 1 2 2 1 3 1 2 2 2 1 1 8 6 6 6 6 6 6 5 4 65 62 62 61 60 64 61 53 582 93 2 2 3 2 2 3 2 2 2 1 2 3 2 2 2 1 4 6 5 5 8 7 5 8 7 5 63 60 60 67 65 60 66 63 592 94 2 2 4 4 2 3 2 2 2 1 2 3 1 3 2 1 1 8 7 6 8 6 4 8 7 5 65 70 62 68 62 57 66 64 592 95 2 2 4 4 1 2 2 2 2 1 2 3 3 3 2 1 1 8 8 6 9 5 5 9 5 4 69 71 66 69 50 60 68 64 572 96 2 2 4 4 1 2 1 2 2 1 3 2 1 1 1 1 1 5 5 5 8 5 3 6 6 5 60 60 60 64 54 52 62 59 582 97 2 2 4 4 1 2 1 2 1 1 2 2 2 1 1 1 1 6 6 5 8 6 3 8 7 5 64 62 60 65 60 55 64 61 582 98 2 2 2 2 1 3 1 1 1 1 1 2 1 2 1 1 1 7 7 6 9 6 4 7 6 4 66 66 63 70 62 59 62 58 542 99 2 2 1 4 1 3 2 1 2 2 1 2 2 2 1 1 1 4 4 3 6 5 3 6 5 3 59 55 53 66 57 59 60 54 502 100 2 2 3 4 2 3 2 2 2 2 1 3 2 2 2 2 1 5 4 4 6 6 5 6 5 3 60 55 58 63 62 61 60 55 522 101 2 2 4 4 2 3 1 2 2 1 1 3 2 2 1 2 2 8 7 6 6 6 4 6 6 4 65 64 62 62 60 57 63 60 542 102 2 2 2 3 2 2 1 1 2 1 2 2 1 2 1 1 2 6 6 5 8 7 5 7 5 3 61 60 59 66 65 60 60 50 512 103 2 2 2 3 1 2 1 2 2 1 2 1 1 1 1 1 3 6 5 4 9 6 5 8 7 4 62 60 57 69 68 60 63 61 572 104 2 2 1 4 1 2 1 1 2 1 2 2 1 1 1 1 3 8 7 6 9 6 4 10 6 3 69 64 62 70 62 59 68 60 502 105 2 2 3 4 2 3 2 1 2 2 2 2 3 3 2 1 3 10 8 6 10 7 5 7 5 3 66 69 68 71 64 60 62 59 522 106 2 2 3 3 2 1 2 2 2 2 1 2 1 3 2 1 3 8 6 5 6 6 5 8 5 3 69 64 61 58 60 61 65 54 522 107 2 2 3 2 2 1 2 2 2 2 2 3 2 2 2 1 3 6 5 4 6 5 3 6 6 4 64 60 59 55 50 53 60 60 612 108 2 2 3 2 2 1 2 2 1 2 1 3 2 2 2 1 1 9 9 6 8 7 3 5 5 4 71 72 69 65 65 51 56 55 532 109 2 2 2 3 2 3 2 2 1 2 1 3 2 2 2 1 1 6 6 5 8 6 3 8 7 4 64 64 61 65 60 50 66 64 532 110 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