Effect of Nurse-led Education on Parent's Anxiety and Depression on Managing Side Effects of Chemotherapy
Effect of Nurse-led Education on Parent's Anxiety and Depression on Managing Side Effects of Chemotherapy
ABSTRACT

 Background:

 Today, a wide range of pediatric cancers is treated by chemotherapy. More than 21 side
 effects of chemotherapy have been identified. Among those nausea; vomiting, infection and
 anemia are most common. The adverse effects are normally managed by the parents at home.
 Ineffective coping and lack of knowledge about chemotherapy side effect management leads
 parents stress. Contemporary research evidence that Nurse-led education, booklet providence
 and follow up about chemotherapy and side effect management, help to decrease parents anxiety
 and depression.

 Objectives:

 To measure the effect of nurse-led multimedia education, booklet providence and telephonic
 follow up about chemotherapy and side effects management on parents anxiety and depression of
 children receiving chemotherapy for the first time.

 Methodology:

 A randomized control trial will be conducted in the department of chemotherapy at Indus
 Children Cancer Hospital Karachi from March 2018 to August 2018 on parents of children below
 18 years of age undergoing chemotherapy for the first time. Total 100 parents will be
 randomly divided into Intervention group (n=50) and Control Group (n=50). The Intervention
 group will received multimedia education, booklet and weekly tele-nursing follow-up about
 chemotherapy and side effects management. The Control group will receive routine care.
 Parent's anxiety and depression will be identified by using DASS-21 and generalized
 estimating estimation will be used to analyzed the data.

 Keywords:

 Nurse-led, Multimedia education, Booklet, telephonic follow-up, chemotherapy, side effects,
 parents, anxiety, depression, children, cancer
INTRODUCTION Background Children Cancer in Pakistan: Millions of people are affected by
 cancer worldwide. Cancer is one of the major health problems in Pakistan . About 8,000
 children below 18 year were diagnosed with cancer annually. Most children diagnosed in
 advance stage . In Pakistan 31% children had leukemia, 20% had Lymphoma, 08 % had sarcoma, 8
 % had bone tumor, 7% had brain tumor, 6 % had retinoblastoma, 5 % had wilms tumor, 4% had
 germ cell tumor, 4 % had neuroblastoma and the other had 7 % .Cancer affects family
 emotionally and physically.

 Chemotherapy and side effect: Millions of people are also facing difficulties due to
 chemotherapy worldwide. If the patient will not prepare for chemotherapy treatment properly
 he/she can face problem in future .Chemotherapy is the common method of treatment. The common
 side effects of chemotherapy are diarrhea, nausea and vomiting, hair loss, neuropathy, weight
 loss, dysphagia, oral ulcer, fatigue, dyspnea, constipation, insomnia and cognitive
 impairment, also affects quality of life, economic conditions, emotions and social wellbeing.
 Before starting chemotherapy treatment the patient should receive written information about
 diagnoses, treatment goal, chemotherapy duration, side effects of drugs, the material should
 design at the level of patient knowledge.

 Cancer vs anxiety depression: The anxiety is due to unawareness about chemotherapy side
 effect. 47% victims of patient have anxiety due to cancer . The power to control disease can
 be lost due to anxiety .Side effect of chemotherapy management required self-care and it is
 can be effect due to depression. Anxiety and depression has an association with cancer,
 chemotherapy related fatigue, lack of education about chemotherapy side effect management and
 long term exposure of children in hospital . Cancer treatment required nursing intervention
 to reduce anxiety and depression . Anxiety leads to delay chemotherapy treatment and
 prognoses.

 Evidences of Multimedia education to reduce Anxiety and depression: It is the main
 responsibility of Oncology nurse to educate patient about the management of side effect of
 chemotherapy but mostly patient received written material only. The recommended practice to
 reduce anxiety of patient is to educate about side effect of chemotherapy. The patient should
 be education both for short term management and long-term management. Education about side
 effect helps to decrease anxiety. The effect of multimedia education to reduce anxiety is
 evident in mammography, MRI, ECT, cardiac surgeries, gynecological laparotomy, laparoscopic
 cystectomy, hemodialysis, teeth removal and peptic ulcer disease. Nursing intervention
 through education helps to reduce anxiety and stress , after chemotherapy, promote side
 effect management, decrease complications and increase psychological wellbeing. Many resource
 centers for patient education on cancer are available on internet about chemotherapy and side
 effect to increase the psychosocial health. The resources can be utilized as a part of
 continuous nursing education.

 Anxiety and depression in Pakistan: Anxiety and depression is more common in Pakistan due to
 lack of infrastructure for mental health services.

 Aim of the study: The main aim of this study is to find the effect of nurse let chemotherapy
 education on parent's anxiety as in children case parents are the key role for securing among
 children cancer. The study will help to examine the effect of psycho-education about
 chemotherapy and side effect management on parent's anxiety and depression at Indus children
 cancer Hospital, Karachi Pakistan.

 Literature Review

 International Findings:

 European study found that 20 minutes of video education is more effective with verbal and
 written education . A randomize control trial was done by Williams and Schreier (2005), on
 RCT(N=71), the experimental group (n-38) received audiotaped 20 minutes of education on
 management of fatigue, sleep disturbance and anxiety along with standard care and the control
 group (n=33) received verbal instruction and written material. The anxiety level was measured
 at 1 month and 2 months. Larger number of patient (n=16) in control group reported anxiety as
 compared to experimental group (n=10) significantly (p=0.001). Similar result were found from
 the study of Malone (2007) that education helps to reduce anxiety. Another study mentioned
 that familiarity with environment of chemotherapy is necessary as it also impact on anxiety.
 Almost 50% cases diagnosed with cancer reported the symptoms of anxiety. According to NCCN
 guideline, the anxiety management related to chemotherapy and side effect management is the
 primary responsibility of oncology team including oncology nurse . Study from USA mentioned
 that, the caregiver of children diagnosed with cancer have 44% greater stress as compared to
 24% parents of healthy children . Another study mentioned that 98% participant were satisfied
 with chemotherapy educational experience, 100 % participants mentioned that educational
 environment is supportive, 81% feel that quality of life can be improved through education .
 Another study mentioned, 87.6% participant were satisfied with chemotherapy education, 87.5 %
 agree that it helps to reduce anxiety, 93.3% participant felt that it will be effective if
 given first time before chemotherapy, 86.6% participant was satisfied for 30 minutes of
 education timing before chemotherapy treatment. 85.7% participant report that quite room
 environment is effective for chemotherapy education .In another study mentioned that, 84%
 patient report that educational class was help to reduce anxiety and 64.7% participant
 disagree for education in group . A randomize control trail was conducted in Greenville and
 founded that 23% participant in control group report anxiety after 1 month of treatment as
 compared to 14% in interventional group significantly . Written information before
 chemotherapy should be provided to patient, the information should include chemotherapy and
 side effect, future plan, and follow-up . Many studies had mentioned that that
 psycho-education is effective to reduce anxiety during chemotherapy management.

 Local findings:

 A study from Rawalpindi reported that 10-25% participant reported anxiety and depression
 during chemotherapy and 16% have anxiety and 27% have depression . Another study mentioned
 that myeloid leukemia is commonly diagnosed in younger age but mostly reported in chronic
 phase . A study from Lahore mentioned that 56% parents have depression, higher in mothers
 specially those who are low educated and had poor socio-economical class. A study from
 Karachi mentioned caregiver stress related to cancer patient s, 17% mild, 34% moderate and 49
 % severe stress. It was also conclude that caregiver stress for cancer patient had
 significant association with caregiver age, relationship with child , female gender and
 longer duration of care.

 Statement of Problem Children cannot look after themselves. Parents are the primary caregiver
 of children. If they initially feel anxiety and depression, it will be difficult for them to
 manage chemotherapy and side effects. Education about chemotherapy is neglected due to heavy
 workload and other responsibilities. More than 50% of individual newly diagnosed with cancer
 have unknown anxiety related to chemotherapy and their side effect . Those who do not receive
 chemotherapy education prior to treatment face difficulties in later life . The side effects
 of chemotherapy like vomiting, nausea, loss of appetite and fatigue were managed through
 self-care . After an intensive literature review it was found that no study was conducted in
 Pakistan focusing effect of nurse-led multimedia education and telephonic follow up, on
 chemotherapy side effects management for parent's anxiety and depression.

 Rationale of Study Pediatric cancer is the leading cause of children mortality and morbidity
 in Pakistan. More than 8,000 children under 18 year of age were diagnosed with cancer in a
 year. Cancer treatment were managed by the parents specially mother. Evidences showed lack of
 knowledge about chemotherapy and dissatisfaction of the information about what they have
 received, leads uncertainty, apprehension and delay continuation with chemotherapy treatment.
 Many organization developed booklet for patient education about chemotherapy and side effect
 management. They also have provided online resources. The patient read information at their
 own efforts. Multimedia education and Tele- nursing follow up was found cost effective method
 to reduce family anxiety in many countries . Parent's anxiety and depression leads poor
 management of cancer treatment for their child. Literature evidence that Nurse led
 psycho-education through multimedia education telephonic follows up is cost effective method
 to reduce anxiety and depression related to treatment process. According to senior oncologist
 Pakistan, Parents are anxious not only about Chemo side-effect but also about disease itself.
 Most parents have same knowledge of side effects of chemotherapy because of their experiences
 with friend's relatives who have undergo to course treatment. Secondly, side effect is
 mentioned at first counseling session by primarily oncologist.

 Objectives To measure the effect of nurse-led multimedia education, booklet providence and
 telephonic follow up about chemotherapy and side effects management on parent's anxiety and
 depression of children receiving chemotherapy for the first time.

 Operational Definitions Nurse-Led: Any intervention given by the nurses under professional
 guidelines. Multimedia education: Education given by using PowerPoint presentation or by
 using multimedia projector.

 Telephonic Follow up: The continuation of educational process by using Tele-communication.

 Chemotherapy side effect: The adverse effects of chemotherapy other than therapeutic effect.

 Parent's anxiety and depression: Feelings of concern, uneasiness, nervousness and sadness of
 parents related to child, diagnosed with cancer and undergoing for chemotherapy first time.
Inclusion Criteria:

 1. Parents along with their children younger than 18 years of age

 2. Parents along with their children newly diagnosed with cancer in last three weeks

 3. Parents along with their children schedule to receive first time chemotherapy in the
 outpatient department

 Exclusion Criteria:

 1. Parents along with their children refused to participate

 2. Parents along with their children already receiving interventions like multimedia
 education, booklet providence and telephonic follow up for chemotherapy and side
 effect management

 3. Parents taking medicine for their anxiety and depression. (e.g. Anxiolytics/
 Antidepressant)

 4. Parents showing uneasiness and discomfort during educational session.