Chapter-I: Background of the study

o Introduction:
Eat to live and dont live to eat
Digestive system is the food processing system of human body. The whole
digestive system is in the form of a long, hollow, twisted and turned tube, called the
alimentary canal, which starts from the oral cavity and ends at the anus.1
Digestion is the chemical breakdown of large food molecules into smaller
molecules that can be used by cells. The breakdown occurs when certain specific
enzymes are mixed with the food.2 The stomach secretes digestive juices which help
in digestion of food. Digestive juices contain gastric acid (hydrochloric acid) and the
enzyme pepsin. The stomach and the duodenum digest every food item which passes
through them to absorb nutrients from it, the duration and the digestion quality differs
from person to person.3
A peptic ulcer, also known as ulcus pepticum, PUD or peptic ulcer disease, is an
ulcer defined as mucosal erosions equal to or greater than 0.5 cm of an area of the
gastrointestinal tract that is usually acidic and thus extremely painful.4
An ulcer may form in any part of the digestive tract, which is exposed to acid
gastric juice. It is usually found in the stomach (gastric ulcer) and the duodenum
(duodenal ulcer). Peptic ulcers results from hyperacidity in the stomach dietic
indiscretion like over eating, taking of heavy meals or highly spiced foods, coffee,
alcohol, smoking, ingestion of certain drugs particularly aspirin, food poisoning
(campylobacter food poisoning) infections like influenza, septicemia, gout, antiinflammatory drugs, Helicobacter pylori infections.5
More and more people are suffering from digestive disorders these days. Peptic
ulcer is the leading one resulting from poor diets, unhealthy lifestyles and the use of
caffeine, cigarettes and alcohol. Even milder forms of ulcer may endanger a persons
life if the disorder is not appropriately treated. 4
According to the latest WHO data published in April 2011 Peptic Ulcer
Disease Deaths in India reached 108,392 or 1.20% of total deaths. The age adjusted

Death Rate is 12.37 per 100,000 of population ranks India #5 in the world. According
to this study adolescents of the age group16-20yrs are affected by peptic ulcer.6
In the United States there are approximately 100,000 new cases and 4 million
recurrences of peptic ulcer diseases yearly. The one-year point prevalence of Peptic
ulcer diseases in the U.S is about 1.8% of a life time prevalence of 8-14%. Estimated
annual direct costs for Peptic ulcer diseases are $3.3 billion with additional costs of
6.2 billion .Peptic ulcer disease due to H. pylori is unlikely to have its initial
presentation at age 50 years.7
In Western countries H. pylori infects about 20% at age 20, 30% at age 30, 80%
at age 80. Prevalence is higher in third world countries where it is estimated at about
70% of the population, whereas developed countries show a maximum of 40% ratio.8
Approximately 25 millions Indians are suffering from peptic ulcer disease at
some point in their life time. Duodenal ulcers are 5 to 10 times more common than
gastric ulcers. The incidence for duodenal ulcer is 30 to 60 years of age. The male and
female ratio is 3:1. The incidence of gastric ulcer is usually 50years of age and over. It
affect male and female in the ratio of 2:1.each year there are 500,000 to 850,000 new
cases of peptic ulcer disease and more than 1 million ulcer related hospitalizations.9
In Kashmir, The point prevalence of peptic ulcer was 4.72% and the life time
prevalence was 11.22%. The prevalence of peptic ulcer increased with age, with a
peak prevalence of 28.8% in the fifth decade of life. Peptic ulcer was not related to
socio economic status.10
Nowadays youngsters are attracted towards ready to eat food and fried foods, this
attitude among youngsters render their nutritional status to be imbalanced. Hence due
to these causes the rate of peptic ulcer diseases is on the rising stride. Sometimes these
ulcerative diseases tend to take another route i.e they might tend to become malignant.
So youngsters need to eat some natural foods which have got more nutrients and
which is more healthy and nutritious and yields more energy.
Health is wealth with poor health we will lose all wealth .So it is important to
live a healthy life to save and enjoy our wealth.
Assessment of knowledge of adolescents regarding the disease will help the
nursing personnel to plan and carry out health education training programs related to
2

specific disease to enhance their awareness and takes proper precautions to prevent
the occurrence of disease, to reduce the morbidity and mortality rate caused by peptic
ulcer. The literature review has revealed that awareness of peptic ulcer is essential for
preventing it in future life time. Hence the researcher is interested in increasing
awareness of adolescents to prevent the occurrence of peptic ulcer disease.

o Need of the study:

Peptic ulcer is known as a disease due to hurry, worry and curry. Peptic ulcer is a
chronic disorder which producing several signs and symptoms like burning pain,
vomiting, hematemesis etc. Stress, alcohol consumption and poor diet can contribute
to gastritis and which in turn lead to formation of peptic ulcer.
WHO estimated that the annual number of deaths from peptic ulcer was 4,604 in
2005. Peptic ulcer occurs in approximately 10% of the population. Higher incidence
of the peptic ulcer cases were observed among people in between the age of 3060years. Gastric ulcers are more likely to occur the fifth and sixth decades of life.
Duodenal ulcers are more commonly occur during the fourth and fifth decades for
men. In the United States, about 1.6 million people acquire peptic ulcers yearly. Males
and females are affected equally, and incidence increases with age. A higher
percentage of Helicobacter pylori infection occurs in people older than age
50years.Approximately 3.7 million people in USA gets peptic ulcer in their lifetime.11
Sonnenberg A and Everhart J.E (1997) - In United States, Approximately 60%
respondents believed that ulcers were caused by too much stress 17% believed that
eating spicy foods caused ulcers and 27% believed that a bacterial infection caused
ulcers. The belief that stress was the highest among cause persons aged 18-24 years
78% and among persons with annual household incomes of less than $15,000.12
In the United States, about 4 million people have active peptic ulcers and about
350,000 new cases are diagnosed each year. Four times as many duodenal ulcers as
gastric ulcers are diagnosed. Approximately 3,000 deaths per year in the United States
are due to duodenal ulcer and 3,000 to gastric ulcer.13

The lifetime prevalence of Peptic ulcer disease in the UK population is around 10

percent. Approximately 4,500 people in UK and 15,000 in the US die from the
complications of PUD each year. A lifetime prevalence of 13 percent in men and11
percent in women with an average of annual incidence of 1.7 cases per 1,000 people
has been recorded.14
The National Health Survey in Australia estimated that 22 per 1000 people
develop peptic ulcer every year. It was reported that nearly 40,000 duodenal ulcer
patients are admitted to hospital every year in Australia, while more than 4500 people
die from the disease annually.2.7% of female population and 2.8% of male population
self-reported having stomach, duodenal or gastrointestinal ulcers in Australia.15
Gastric ulcers are very common and affects all age group irrespectively. Peptic
ulcer affects 1 in every 10 people. The annual incidence of gastric ulcer varies
approximately 1 case per 1000 population in Japan to 1.5 cases per 1000 population in
Scotland. In the US 2% of general population gets affected with peptic ulcers. The
male to female ratio is 1:1 in US and 18:1 in India. In Denmark, lifetime prevalence
of gastric cancer is 1.2% for men and 0.6% for women.16
El Mouzan and Abdullah.A.M (2004) conducted a study in Saudi Arabia to find
out the prevalence of peptic ulcer among adolescents. The study was conducted
among 500 adolescents and children among the age group 10-18yrs. The results found
that the average age of occurrence was 15yrs and male to female ratio was 7:1.there
was 20 cases of duodenal ulcers and 4 cases of gastric ulcer among a group of 30. It
was concluded that lifestyle factors and stress contributed to rise of peptic ulcer
among adolescents.17
Prevention is always less expensive than cure, the above data shows that there
is an increased prevalence of peptic ulcer, which can lead to complications like
perforation, carcinoma and even death, which can be prevented by simple life style
modifications without spending any amount of money. But the prevention only
requires some concentrated efforts.
Therefore, it is realized that peptic ulcer is a serious problem, leading to
increased morbidity and mortality rates which may be due to lack of awareness of the
public regarding the various risk factors which are causing peptic ulcer. Based on
4

these literatures and work experience, as a researcher, I have decided to take up this
study in view to those belonging to adolescent group derive necessary knowledge
about risk factors and prevention of peptic ulcer and decided to provide the self
instructional module.

o Research problem:
A study to assess the effectiveness of Self Instructional Module (SIM) on knowledge
regarding risk factors and prevention of peptic ulcer among adolescents (10-19yrs) in
selected senior secondary schools of Patiala, Punjab.

o Aim of study:
To assess the effectiveness of Self Instructional Module (SIM) on knowledge
regarding risk factors and prevention of peptic ulcer among adolescents (10-19yrs).

o Objectives:
1. To assess the level of knowledge regarding risk factors and prevention of peptic
ulcer among adolescents (10-19yrs) before and after administration of Self
Instructional Module.
2. To assess the effectiveness of Self Instructional Module on risk factors and
prevention of peptic ulcer among adolescents (10-19yrs).
3. To associate pretest knowledge regarding risk factors and prevention of peptic
ulcer among adolescents (10-19yrs) with their selected sociodemographic
variables.
o Operational definitions:
Assess: It refers to measure the knowledge of adolescents (10-19yrs) regarding
risk factors and prevention of peptic ulcer.
Effectiveness: The extent to which the self instructional module on risk factors
and prevention of peptic ulcer achieve its desired effect in improving the
knowledge of adolescents.
5

 Self instructional module: The structured set of self explanatory instructions

regarding risk factors and prevention of peptic ulcer.
Knowledge: The information possessed by adolescents (10-19yrs) on risk
factors and prevention of peptic ulcer.
Adolescents: It refers to the students (10-19yrs) studying in selected senior
secondary schools of Patiala, Punjab.

o Hypothesis:
H1:

The mean post-test knowledge scores of adolescents regarding risk factors and

prevention of peptic ulcer will be significantly higher than their mean pretest
knowledge scores.
H0:

There will be no significant association between pretest knowledge scores of

adolescents regarding risk factors and prevention of peptic ulcer with their selected
sociodemographic variables.

o Assumptions:
1. Adolescents (10-19yrs) will possess some knowledge regarding risk factors and
prevention of peptic ulcer.
2. Adolescents (10-19yrs) knowledge will increase after the administration of selfinstructional module regarding risk factors and prevention of peptic ulcer.
o Delimitations:
The study is delimitated to adolescents (10-19yrs) in selected senior secondary
schools of Patiala, Punjab.

Chapter-II: Review of Literature

Review of literature is a key step in research process. The typical purpose of
analyzing a review existing literature is to generate research question to identify what
is known and what is unknown about the topic. The major goal of review of literature
is to develop a strong knowledge base to carry out research and non research scholarly
activity. It helps the researcher to be familiar with the existing studies and also
provide basis for methodology, tool for data collection and research design.
The review of literature for the present study has been organized under the following
aspects:

Studies related to risk factors of peptic ulcer.

Studies related to prevention of peptic ulcer.

Studies related to risk factors of peptic ulcer

Pankaja SS et al conducted a comparative study to assess and compare risk factors in

patients with benign gastric ulcer and duodenal ulcer and to correlate the prevalence
of Helicobacter pylori infection in benign peptic ulcer disease in the Department of
surgery, Jawaharlal Institute of post-graduate, India. A total of 30 consecutive
patients with peptic ulcer disease were included in this study after upper
gastrointestinal endoscopy. Overall H.pylori

infection was prevalent in 93.3% of

patients. Patients who took spicy food had a significantly higher rate of H.pylori
infection positivity (p=0.04). It was concluded that the prevalence of H.pylori
infection is similar in duodenal and gastric ulcer and intake of spicy food is a risk
factor for peptic ulcer. 18
Lee KM et al conducted a cohort study in South Korea to evaluate the relationship
between peptic ulcer disease (PUD) and acute pancreatitis. A total of 78 patients with
acute pancreatitis were included in this study. Results revealed that among 78 patients,
41 patients (52.6%) with acute pancreatitis suffered from PUD, but only 13 (31.7%)
patients with PUD were infected by H. pylori. The study concluded that patients with
acute pancreatitis are liable to suffer from PUD. 19
7

Godwin RD et al undertook an epidemiological study to examine relationships

between a range of mental disorders and Peptic ulcer disease among adults. Total
number of 43,098 adults in the age group of 18 were drawn from the National
Epidemiologic Survey on Alcohol and Related Conditions. Results showed
mood / anxiety

disorders

were

associated

with

Peptic

ulcer

that

disease.

Specifically, generalized anxiety disorder (GAD) (Odds ratio (OR) = 3.43) was
most associated with peptic ulcer disease, followed by panic disorder (OR = 3.11),
Dysthymia (OR = 3.59), and bipolar disorder (OR = 2.91). It was concluded that
mood /anxiety disorders are associated with increased rates of Peptic ulcer disease;
nicotine and alcohol dependence seems to play a substantial role in explaining the link
with Peptic ulcer disease. 20
Aro P et al conducted a study in Kalix Hospital, Sweden to explore the prevalence,
symptomatology and risk factor for peptic ulcer in a general adult population. A
random sampling was done. The prevalence of peptic ulcer was 4.1% (20 gastric
ulcers and 21 duodenal ulcers). The results have shown that eight subjects with
duodenal ulcer (38%) lacked evidence of current Helicobacter pylori infection.
Smoking, aspirin use, and obesity were risk factors for gastric ulcer; smoking, lowdose (160 mg) aspirin use, and Helicobacter pylori infection were risk factors for
duodenal ulcer. 21
Kanbay M et al undertook a study to determine the relationship between H. pylori
and ABO/Rhesus blood groups, age, gender, and smoking. Blood samples were tested
for H.pylori antibodies, and ABO/Rhesus blood group antigen typing was performed.
Prevalence of all blood groups were O (29.2%), A(38.2%), B(17.8%), and
AB(14.8%). Patients in blood groups A and O were more prone to H. pylori infection
than were patients in other blood groups (P<0.05), and patients in the AB blood group
were less prone to H. pylori infection compared with patients in other blood groups
(P<0.05). The results demonstrates that H. pylori infection can be related to ABO
blood group, age, gender and smoking. 22
Mitani K et al carried out a prospective study among 52 patients with H. pylori
infection and 34 patients without H. pylori infection. The results shows that Gastric
ulcers developed in 8 (15%) of 52 patients with H. pylori infection, but not in patients
8

without H. pylori

infection. It was concluded that Helicobacter pylori infection

increases the risk for development of gastric ulcers and gastric ulcers developed
through the progression of H. pylori-associated gastric mucosal atrophy. 23
Stevanovic D and Ivanisevic V carried out a comparative study to evaluate the risk
factors among 2 group of patients. First group consisted of Patients with acute gastric
or duodenal

bleeding peptic ulcer, the second group consisted of patients without

peptic ulcer bleeding. In both groups the anterior wall of the duodenum is the most
Common localization. In this group of patients there was a high percentage of
penetrating ulcers (62.5%) with active arterial bleeding. The presence of Helicobacter
pylori infection is statistically significant higher in the group of patients with bleeding
peptic ulcers. It was concluded that age of patient, localization of ulcer, diameter and
Helicobacter pylori infection are very important and well known risk factors for the
development of bleeding peptic ulcer. 24
Jain A et al conducted a study to evaluate the association of various risk factors such
as smoking, alcohol, NSAIDs, inadequate dietary intake of fibers and consumption of
spicy foods with chronic duodenal ulcer in Maulana Azad Medical College, New
Delhi. A total of 16 consecutive patients with endoscopically proven duodenal ulcer
(DU) constituted the test group while 160 subjects with non-ulcer dyspepsia (NUD)
were recruited as controls. Results shows that there were significantly greater number
of smokers (80%) and alcoholics (58%) in the male population of duodenal ulcer
group as compared to the controls (49% smokers & 15% alcoholics). Similar trend
was seen in relation to history of chronic exposure to NSAIDs (29% in duodenal
ulcer & 11% in non-ulcer dyspepsia) and inadequate intake of fiber in diet (66% and
39% respectively). It was concluded that in North Indian subjects, alcohol
consumption, smoking, inadequate intake of fiber in diet and use of NSAIDs are the
risk factors associated with duodenal ulcer disease. 25
Svanes C et al undertook a study to assess the role of smoking in ulcer perforation.
Sample consists of total of 168 consecutive patients with gastroduodenal ulcer
perforation and 4469 control subjects from a population based health survey. The
results shows that Current smoking increases the risk for ulcer perforation 10-fold in
the age group 1574 years (OR 9.7, 95% CI 5.9 to 15.8) and there was a highly
9

significant dose-response relationship (p<0.001). It was concluded that smoking is a

causal factor for ulcer perforation and accounts for a major part of ulcer perforations
in the population aged less than 75 years. 26

Studies related to prevention of peptic ulcer

Bandyopadhyay U et al carried out a study was conducted to investigate whether

Neem bark extract have any antisecretory and antiulcer effects. For this purpose, a
group of patients suffering from acid-related problems and gastroduodenal ulcers
were orally treated with the aqueous extract of Neem bark. The lyophilised powder of
the extract when administered for 10 days at the dose of 30 mg twice daily caused a
significant (p < 0.002) decrease (77%) in gastric acid secretion. The bark extract when
taken at the dose of 3060 mg twice daily for 10 weeks almost completely healed the
duodenal ulcers monitored by barium meal X-ray or by endoscopy. One case of
esophageal ulcer (gastroesophageal reflux disease) and one case of gastric ulcer also
healed completely when treated at the dose of 30 mg twice daily for 6 weeks. The
results revealed that Neem bark extract has therapeutic potential for controlling and
prevention of gastric hypersecretion and gastroesophageal and gastroduodenal
ulcers.27
Misciagna G et al conducted a study to explore the role of diet in causation,
treatment and prevention of duodenal ulcer recurrence. Results revealed that soluble
fibre from fruit and vegetables seem to be protective against duodenal ulcer and
refined sugars a risk factors. The role of fibre in the treatment and prevention of
occurrence of duodenal ulcer is uncertain, as is that of essential fatty acids. 28
Harvard school of public health conducted a cohort study to determine the
preventive measures for occurrence of peptic ulcer. The study found that clients
consuming high fiber diet reduced the risk for developing duodenal ulcer. Food
sources of soluble fibres such as oats, legumes, barley and certain fruits and
vegetables were found to be protective and reduced the risk by 60%. Also adolescents
consuming vit.A rich diet had chances of decreased rate for occurrence of peptic
ulcers by 54%. The study also concluded that avoidance of alcohol, coffee reduces the
occurrence of peptic ulcer. 29
Welsh JD undertook a study on diet therapy of peptic ulcer. There were 74 teaching,
10

65 teaching/private, 46 private, 120 Veterans Administration, and 21 miscellaneous

hospitals. A bland diet was the most commonly used diet for peptic ulcer disease in
250 (77%) of the hospitals. 72% used a bland I(or) II. Milk was given routinely or
usually in 55% of the 326 hospitals. Results showed that dietitian in one half of the
hospitals instructed their patients on a bland diet where as the remaining dietitian
instructed their patients on a regular (or) modified regular diet. 30

Chapter-III: Methodology
o Research Approach:
Quasi-experimental study approach will be adopted in present study.
o Research design:
One group pretest-post test design
Group

Pre test (O1)

Intervention(X)

Post test (O2)

Adolescents (10-

Assessment of

Administration of

Assessment of

19yrs) studying in knowledge

self instructional

knowledge

selected senior

module regarding

regarding risk

secondary schools factors and

risk factors and

factors and

of Patiala,

prevention of

prevention of

prevention of

Punjab.

peptic ulcer among peptic ulcer among

peptic ulcer among

adolescents (10-

adolescents (10-

adolescents (10-

19yrs) on 1st day.

19yrs).

19yrs) after 7 days.

regarding risk

o Research setting:
The study will be conducted in selected senior secondary schools of Patiala,
Punjab.
o Target population:
Adolescents (10-19yrs) studying in selected senior secondary schools of Patiala,
Punjab.
11

o Sample size:
Total sample of the study will consists of 60 adolescents studying in selected
senior secondary schools of Patiala, Punjab.
o Sample technique:
Simple random sampling
o Sampling criteria:
Inclusion criteria
1. Adolescents who are available at the time of data collection.
2. Adolescents who are willing to participate in the study.
o Selection and development of tool:
A structured Knowledge questionnaire will be used as a tool for the present study.
Tool will be selected after reviewing the related literature and after the consultation
with the expert.
o Description of tool:
Tools for data collection are divided into following categories:
Part I: Items on demographic variables will be listed under sociodemographic data.
Part II: Items on knowledge regarding risk factors and prevention of peptic ulcer will
be listed under structured knowledge questionnaires.
o Validity of the tool:
The content validity of the tool will be established in consultation with the
expert.

o Reliability of the tool:

Split half method, Karl Pearsons coefficient of correlation.
12

o Pilot study and try out:

It will be calculated on 10 percent of total sample.
o Data collection procedure:

Formal permission will be obtained from school authorities.

The investigator introduces self and purpose of the study.

Consent will be taken from the selected samples.

Pre test will be conducted on adolescents (10-19yrs).

Self Instructional Module (SIM) will be administered to adolescents (1019yrs).

Conduction of post test after 1 week.

o Ethical consideration:
Ethical clearance will be obtained from Institutional Ethical Committee (IEC)
and the permission will be obtained from the selected senior secondary schools for
data collection.
Anonymity and confidentiality of the study participants will be maintained.
o Plan for data analysis:
The data obtained will be analyzed in terms of terms of the objective of the
study using descriptive and inferential statistics.
Descriptive statistics:
To describe demographic variable by percentage, mean, mode, median and
standard deviation.
Inferential statistics:
1. Paired t test to find significance of difference between the pre test and post test
mean knowledge score of adolescents (10-19yrs) on risk factors and prevention of
peptic ulcer.

13

2. Chi square test to determine the association between the knowledge regarding risk
factors and prevention of peptic ulcer among adolescents ( 10-19yrs) with selected
demographic variables.

14

FIGURE:

SCHEMATIC

PRESENTATION

METHODOLOGY

15

OF

RESEARCH