Effect of Nurse-led Education on Parent's Anxiety and Depression on Managing Side Effects of Chemotherapy
Phase: NA
Conditions: Chemotherapy Effect
Sponsor: Nomi Waqas Gul

Registered: www.clincaltrials.gov (NCT03753542) 
 
 
Effect of Nurse-led education on parent’s anxiety, 
depression and stress on managing side effects of 
chemotherapy 
 
 
 
 
 
A RESEARCH THESIS 
Submitted to the Board of Advanced Studies and Research 
Dow University of Health Sciences 
In partial fulfillment of the Requirement 
For the Degree, of 
Master of Science in Nursing (MSN) 
 
 
By 
 
 
NOMI WAQAS GUL 
 
 
 
 
Institute of Nursing (ION) Ojha Campus 
Dow University of Health Sciences 
Karachi, Pakistan 
June 30, 2019 
 
 
 

ii 
 
ACKNOWLEDGEMENTS 
I would like to thanks‘ my ‗ALLAH‘, who helped me in completion of my education and 
research work up. I am especially thankful to Health Department Government of Sindh and 
Principal Sindh Govt Hospital Liaquatabad, Hospital, Karachi, for providing me opportunity for 
higher education. I am also grateful to Vice Chancellor Prof. Dr. Muhammad Saeed Quraishy, 
Dr Kashif Shafique, ORIC DUHS, Mrs. Shehla Naeem Zafar, Director ION DUHS, Dr. Naila 
Baig Ansari, Chairman IRD, Indus Hospital and Mr. Sarfraz Masih , MSN Coordinator DUHS 
who play a leading role in completion. I would like to pay my regard to Mr. Hakim Shah, 
Associate Professor, Institute of Nursing, Dow University of Health Sciences Karachi who 
spend their precious time for me to correct my nursing related errors in synopsis.  
I would also like to pay my special gratitude to Dr. Mehwish Hussain, Ph.D (Statistics), 
Assistant Professor of Biostatistics, Department of Research, Dow University of Health 
Sciences, Karachi who always be the ‗first‘ to motivate, educate and facilitate me toward 
success, she really deserved priceless effort in every step of this research process. 
I would like to do special thanks to Indus Research Department for giving me permission for 
data collection. I am especially thankful to Dr. Shamvil Ashraf, Senior Consultant and Professor 
Pead‘s Oncologist, Department of Pediatric Oncology at Indus hospital, Karachi to facilitate me 
clinically along with their highly qualified and skillful team members, Ms. Rehana Punjwani, 
Head of Department, Mr. Bashir Ahmed, Instructor, and Mr. Muhammad Younas, Supervisor. 
 
____________________ 
 
 
 
 

iii 
 
DECLARATION 
 
I Nomi Waqas Gul S/o Gul Hassan Afridi hereby state that my master‘s project titled                         
―Effect of Nurse-led education on parent’s anxiety, depression and stress on managing side 
effects of chemotherapy‖ is my own work and has not been submitted previously by me for 
taking any degree from Dow University of Health Sciences or anywhere else in the 
country/world. 
At any time if my statement is found to be incorrect even after my Graduate the university has 
the right to withdraw my MSN degree.   
 
NOMI WAQAS GUL 
Student Master of Science in Nursing (MSN) 
Institute of Nursing (ION) Ojha Campus,  
Dow University of Health Sciences, Karachi, Pakistan 
 
Signature_________________________________ 
 
Enrolment No.  12/2015/912 
 
Date: __________________________ 

iv 
 
CERTIFICATE 
This is to certify that the project entitled ―Effect of Nurse-led education on parent’s anxiety, 
depression and stress on managing side effects of chemotherapy‖ submitted by Mr. Nomi 
Waqas Gul to Institute of Nursing (ION) Ojha Campus, Dow University of Health Sciences, 
Karachi, Pakistan for the award of the degree of Master of Science in Nursing (MSN), is a 
bona fide record of the research work carried out by him under my supervision and guidance. 
The content of the project, in full or parts have not been submitted to any other Institute or 
University for the award of any other degree or diploma.   
 
 
RESEARCH SUPERVISOR  
Mr. Hakim Shah 
Associate Professor 
Institute of Nursing 
Dow University of Health Sciences 
Karachi 
 
Date: _____________________ 
 
 

v 
 
CERTIFICATE 
 
This is to certify that the project entitled ―Effect of Nurse-led education on parent’s anxiety, 
depression and stress on managing side effects of chemotherapy‖ submitted by Mr. Nomi 
Waqas Gul to Institute of Nursing (ION) Ojha Campus, Dow University of Health Sciences, 
Karachi, Pakistan for the award of the degree of Master of Science in Nursing (MSN), is a 
bona fide record of the research work carried out by him under my supervision and guidance. 
The content of the project, in full or parts have not been submitted to any other Institute or 
University for the award of any other degree or diploma.   
 
 
 
RESEARCH CO-SUPERVISOR: 
Dr. Mehwish Hussain 
PhD (Statistics),  
Assistant Professor of Biostatistics,  
Department of Research 
Dow University of Health Sciences 
Karachi 
Date: _____________________ 
 
 
 
 
 
 
 
 
 

vi 
 
CERTIFICATE 
 
This is to certify that the project entitled ―Effect of Nurse-led education on parent’s anxiety, 
depression and stress on managing side effects of chemotherapy‖ submitted by Mr. Nomi 
Waqas Gul to Institute of Nursing (ION) Ojha Campus, Dow University of Health Sciences, 
Karachi, Pakistan for the award of the degree of Master of Science in Nursing (MSN), is a 
bona fide record of the research work carried out by him under my supervision and guidance. 
The content of the project, in full or parts have not been submitted to any other Institute or 
University for the award of any other degree or diploma.   
 
 
 
CLINICAL SUPERVISOR 
Dr. Shamvil Ashraf 
Senior Consultant and Professor Pead‘s Oncologist 
Department of Pediatric Oncology at Indus hospital, Karachi  
 
Date: _____________________ 
 
 
 
 
 
 
 
 
 
 

vii 
 
CERTIFICATE 
This is to certify that the project entitled ―Effect of Nurse-led education on parent’s anxiety, 
depression and stress on managing side effects of chemotherapy‖ submitted by Mr. Nomi 
Waqas Gul to Institute of Nursing (ION) Ojha Campus, Dow University of Health Sciences, 
Karachi, Pakistan for the award of the degree of Master of Science in Nursing (MSN), is a 
bona fide record of the research work carried out by him under my supervision and guidance. 
The content of the project, in full or parts have not been submitted to any other Institute or 
University for the award of any other degree or diploma.   
 
 
MSN PROGRAM DIRECTOR 
 
 
 
Prof. Shehla Naeem Zafar,  
Associate Professor 
Institute of Nursing 
Dow University of Health Sciences 
Karachi 
 
Date: _____________________ 
 
 
 
 
 
 
 
 
 

viii 
 
Table of Contents 
ABSTRACT 
 ........................................................................................................................................ xiii 
Background  ........................................................................................................................................ xiii 
Objectives: 
 ........................................................................................................................................ xiii 
Methodology: ........................................................................................................................................ xiii 
Result  
 ........................................................................................................................................ xiii 
Conclusion:  ........................................................................................................................................ xiii 
Keywords: 
 ........................................................................................................................................ xiii 
CHAPTER 1: INTRODUCTION .............................................................................................................. 1 
1.1 
Background ................................................................................................................................. 1 
1.2 
Statement of Problem ................................................................................................................. 3 
1.3 
Rationale of Study ....................................................................................................................... 4 
1.4 
Objectives..................................................................................................................................... 5 
1.5 
Research Question: ..................................................................................................................... 5 
1.6 
Operational Definitions .............................................................................................................. 5 
CHAPTER 2: LITERATURE REVIEW .................................................................................................. 6 
2.1 
International Findings: ............................................................................................................... 6 
2.2 
Regional Finding ......................................................................................................................... 7 
2.3 
Local findings: ............................................................................................................................. 8 
CHAPTER 3: METHODS AND MATERIALS ...................................................................................... 9 
3.1 
Study Design: ............................................................................................................................... 9 
3.2 
Study Setting: .............................................................................................................................. 9 
3.3 
Study Duration: ........................................................................................................................... 9 
3.4 
Study Population:........................................................................................................................ 9 
3.5 
Inclusion criteria: ........................................................................................................................ 9 
3.6 
Exclusion Criteria ....................................................................................................................... 9 
3.7 
Sample Size: ............................................................................................................................... 10 
3.8 
Sampling Technique: ................................................................................................................ 10 
3.9 
Data Collection Procedure: ...................................................................................................... 11 
3.10 
Interventions: ............................................................................................................................ 13 
3.10.1 To Intervention group: ............................................................................................................. 13 
3.10.2 To control Group: ..................................................................................................................... 14 
3.11 
Pilot Study: ................................................................................................................................ 15 
3.12 
Ethical Consideration: .............................................................................................................. 16 
3.13 
Study Variables ......................................................................................................................... 16 
3.13.1 Dependent Variable: ................................................................................................................. 16 
3.13.2 Independent Variable: .............................................................................................................. 17 
3.14 
Statistical analyses: ................................................................................................................... 18 
CHAPTER 4: RESULT ............................................................................................................................ 19 
4.1 
Participant flow:........................................................................................................................ 19 
4.2 
Baseline data: ............................................................................................................................ 21 
4.3 
Depression, Anxiety and Stress over study period:................................................................ 24 
4.3.1 Reliability analysis: ................................................................................................................... 24 
4.3.2 DASS score and level over pre, post and 2 week post time: .................................................. 24 
4.3.3 Changes in depression, anxiety and stress scores over different periods: ........................... 27 
 
 

ix 
 
CHAPTER 5: DISCUSSION ................................................................................................................... 30 
5.2 Limitations ....................................................................................................................................... 33 
5.3 Strength of study: ............................................................................................................................ 34 
5.5 Conclusion: ...................................................................................................................................... 34 
5.6 Recommendation: ........................................................................................................................... 34 
5.7 Harms: 
34 
5.7 Generalizability: .............................................................................................................................. 35 
5.8 Registration ..................................................................................................................................... 35 
5.9 Funding: 35 
5.10 Recommendations for further studies: ....................................................................................... 35 
REFERENCES: ........................................................................................................................................ 36 
Appendix -I:   Socio-demographic and others information ........................................................... 42 
Appendix -II:   DASS-21.................................................................................................................... 42 
Appendix -III:  Multimedia Education ............................................................................................... 42 
Appendix -IV:  Booklet ......................................................................................................................... 42 
Appendix -V:  IRB Approval Letter ................................................................................................ 42 
Appendix -VI:  IRD Approval Letter ............................................................................................... 42 
Appendix -VII  Turnitin Digital Receipt .......................................................................................... 42 
Appendix -VIII Summary of the Similarity Index (Plagiarism) ....................................................... 42 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

x 
 
LIST OF TABLES 
Table 1:  Socio Demographical Features ........................................................................................... 23 
Table 2:  Average scores of Depression, Anxiety and Stress between intervention and control 
group ..................................................................................................................................... 26 
Table 3:  Distribution of depression, anxiety and stress levels between intervention and control 
group over study period ...................................................................................................... 26 
Table 4:  Significant values of depression, anxiety and stress scores .............................................. 28 
Table 5 : Association of Socio demographical features with pre-depression, pre-anxiety and pre-
stress ..................................................................................................................................... 29 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

xi 
 
LIST OF FIGURES 
Figure 1: Participants selection ............................................................................................................. 20 
Figure 2: Depression scores of intervention and control group during study period ....................... 28 
Figure 3: Anxiety scores of intervention and control group during study period ............................ 28 
Figure 4: Stress scores of intervention and control group during study period ............................... 28 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

xii 
 
LIST OF ABBREVIATIONS 
BASR 
 Board of Advanced Studies and Research 
C.I 
 Confidence Interval 
CONSORT 
 Consolidated Standards of Reporting Trials 
DUHS 
 Dow University of Health Sciences 
DASS 
Depression, Anxiety and Stress Scale 
ECT 
 Electroconvulsive Therapy 
IRB 
 Institutional Review Board 
IRD 
 Interactive Research and Development 
MBT 
 Multimedia Booklet and Telephone 
MRI 
 Magnetic Resonance Imaging 
n 
 Number of samples /Participants selected 
NCCN 
National Comprehensive Cancer Network (NCCN)  
NCSS 
 National Council for the Social Studies 
PASS 
Primary Avionics Software System 
NIH 
 National Institutes of Health 
O.R 
 Odd Ratio 
P-Value 
 Probability Value 
QOL 
 Quality of Life 
RCT 
 Randomized control Trial 
RM ANOVA 
Repeated Measure Analyses of Variance 
SPSS 
 Statistical Package for the Social Sciences 
STAI 
 State-Trait Anxiety Inventory 
USA 
 United State of America 
 

xiii 
 
ABSTRACT 
Background: 
A wide range of pediatric cancers are treated by chemotherapy. The adverse effects are usually managed by 
their parents at home. Ineffective coping and lack of knowledge about chemotherapy side effect management 
leads parent‘s psychology disorders. Contemporary research evidence that Nurse-led education, booklet 
providence and follow up about chemotherapy and side effect management, help to decrease parent‘s 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 parent‘s anxiety, depression and stress of children receiving 
chemotherapy for the first time. 
Methodology:  
A randomized control trial was conducted in the department of chemotherapy at Department of Pediatric 
Oncology at Indus hospital, Karachi from September-December 2018 on parents of children below 18 years 
of age undergoing chemotherapy for the first time. Total 100 parents were randomly divided into Intervention 
group (n=50) and Control Group (n=50).  After excluding lost to follow up, the data was analyzed from 77 
sample of parents (41 in intervention group and 36 in control group). The intervention group received 
multimedia education, booklet and weekly tele-nursing follow-up about chemotherapy and side effects 
management. The control group received routine care. Parent‘s anxiety, depression and stress were identified 
by using DASS-21 and repeated measures ANOVA was used to observe changes in outcomes over study 
period.  
Result 
Total 63.4% (n=48) children were under 12 years of age and 64.9% (n=50) children were male. Majority of 
the parents were non-residence of Karachi, labor and low education and income. 66.2% (n=51) children 
diagnosed with leukemia, 63.6% (n=49) children had no pain. At the baseline, depression was found in 84.4% 
(n=56) parents while 67.5% (n=52) parents were anxious and 55.8%(n=43) parents had stress, After the MBT 
intervention, significant reductions were observed in depression and stress (P-Value <0.05) of the parents in 
MBT group. A sharp decline was observed just after one week while at final stage intervention group showed 
higher decrease in depression and stress while anxiety was observed insignificantly different in both groups,  
Conclusion: 
There is a positive effect of nurse-led multimedia education, booklet providence and telephonic follow up 
about chemotherapy and side effects management on parent‘s depression and stress of children receiving 
chemotherapy showing in this study for the first time in Pakistan. For anxiety reduction, other strategies 
should also be incorporated. 
Keywords: 
Nurse-led, Multimedia education, Booklet, telephonic follow-up, chemotherapy, side effects, parents, anxiety, 
depression, children, cancer 

Registered: www.clincaltrials.gov (NCT03753542) 
 
 
CHAPTER 1: INTRODUCTION 
1.1 Background 
Children Cancer in Pakistan: 
Millions of people are affected by cancer worldwide. Cancer  is  one of the major health 
problems in Pakistan [1, 2]. According to W.H.O in male, 61,624 incidence cases, 42,624 
cancer deaths and in female 75,095 incidence cases and 43,188 deaths reported annually 
worldwide. About 8,000 children below 18 years are diagnosed with cancer annually. Most 
children diagnosed in advanced stage [2]. In Pakistan, 31% children have leukemia, 20% have 
Lymphoma, 08 % have  sarcoma, 8 % have  bone tumor, 7% have  brain tumor, 6 % have  
retinoblastoma, 5 % have  Wilms tumor, 4% have  germ cell tumor, 4 % have  neuroblastoma 
and the rest 7 % have other types of cancer [2, 3].Cancer affects families emotionally and 
physically. [4, 5] 
Chemotherapy and side effect: 
Large number of cancer patient face difficulties due to chemotherapy worldwide. If the 
patient was not prepared properly for chemotherapy treatment,, he/she could face problem in 
coping with and managing the side effects of chemotherapy.[6]. Chemotherapy is the common 
method of treatment for cancer management [7]. The common side effects of chemotherapy as 
reported in literature include  diarrhea, nausea and vomiting, hair loss, neuropathy, weight loss, 
dysphagia, oral ulcer, fatigue, dyspnea, constipation, insomnia and cognitive impairment [8-13]. 
It also affects quality of life, economic conditions, emotions and social wellbeing [7, 12-14]. As 
reported  in literature, before starting chemotherapy treatment, the patient should receive written 
information about diagnosis, treatment goal, chemotherapy duration and side effects of drugs, 
and the material should be design at the level of patient knowledge.[15] 
 
 

2 
 
 
Anxiety, Depression & Stress:  
The prevalence of anxiety is high among cancer patient due to unawareness about 
chemotherapy‘s side effect. 47% of cancer patient undergoing  chemotherapy have  anxiety due 
to  chemotherapy [16]. The power to control disease can be lost because of anxiety [17]. Side 
effect of chemotherapy management required self-care and this capability of patient  can be 
effected due to depression.[18]. Anxiety and depression had an association with cancer, 
chemotherapy related fatigue, lack of education about chemotherapy side effect management 
and long term exposure of children in hospital [4, 11, 19-21]. Cancer treatment requires nursing 
intervention to reduce anxiety and depression [4, 22]. Anxiety leads to delay chemotherapy 
treatment and prognoses [11, 23].  
 
Evidences of Multimedia education to reduce Anxiety and depression: 
This is the main responsibility of oncology nurse to educate patient about the 
management of side effect of chemotherapy but most patient received only written material 
instead of proper education regarding management of chemotherapy side effects  [11, 18, 24-
26]. The recommended practice to reduce anxiety of patient is to educate the patient about the 
side effects of chemotherapy. The patients should be educated both for short term management 
and long-term management. Education about side effects of chemotherapy  helps the patient in   
decreasing their  anxiety[27, 28]. 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.[23, 29-45]. 
Nursing intervention through education helps to reduce anxiety and stress [8, 9, 19, 20], after 
chemotherapy, promote side effect management, decrease complications and increase 
psychological wellbeing. [11, 15, 16, 46]. Many resource materials are available on internet for 

3 
 
patient education on cancer about chemotherapy and its side effects, and to enhance the 
psychosocial health of cancer patients. These resources can be utilized as a part of continuous 
nursing education [11, 16].   
Anxiety and depression in Pakistan: 
Anxiety and depression are common psychological disorders in Pakistan due to lack of 
resources and proper infrastructure for mental health services [4]. 
Aim of the study: 
The aim of this study is to determine the effects of nurse led chemotherapy education on 
parent‘s anxiety and depression, as parents have the key role in caring their children cancer. 
This study helped to examine the effects of psycho-education about chemotherapy and its side 
effect management on parent‘s anxiety, depression and stress at Department of Pediatric 
Oncology at Indus hospital, Karachi Pakistan. 
1.2 Statement of Problem 
The prevalence of cancer among children has been projected drastically since last decades in 
Pakistan [1, 2]. Children cannot look after themselves. Parents are the primary caregiver of 
children [5, 21, 47]. If they initially feel anxiety and depression, it is difficult for them to 
manage chemotherapy and side effects [5, 11, 15, 47-49]. Education about chemotherapy has 
been neglected due to heavy workload and other responsibilities of duty nurses [11, 15, 50]. 
More than 50% of individual newly diagnosed with cancer have  unknown anxiety related to 
chemotherapy and their side effect [51]. As per literature, those who do not receive 
chemotherapy education prior to treatment face difficulties in later life [6]. The side effects of 
chemotherapy, like vomiting, nausea, loss of appetite and fatigue were managed through self-
care [52].  After an intensive literature review it was found that no study has been conducted in 
Pakistan focusing on effect of nurse-led multimedia education and telephonic follow up on 
chemotherapy side effects management for parent‘s anxiety and depression.  

4 
 
 
1.3 Rationale of Study 
Pediatric cancer is the leading cause of children mortality and morbidity in Pakistan. 
More than 8,000 children under 18 years of age are diagnosed with cancer in a year. Cancer 
treatment are managed by the parents,  usually by the  mothers of children [5, 21]. Evidences 
showed lack of knowledge about chemotherapy and dissatisfaction of the information about 
what they had received leads to uncertainty, apprehension and delay continuation with 
chemotherapy treatment [4, 11, 15, 52]. Many organizations have developed booklet for 
patient‘s education about chemotherapy and side effect management. They have also provided 
online resources. The patient read the information using their own efforts [11, 16, 29-37]. 
Multimedia education and Tele-nursing follow up are reported as cost effective method to 
reduce family anxiety in many countries [11, 23, 25, 26, 29-46, 51, 53, 54]. Parent‘s anxiety and 
depression lead to poor management of cancer treatment for their child. Literature reveals that 
Nurse led psycho-education through multimedia education and telephonic follow up was found 
cost effective method to reduce anxiety and depression related to treatment process. According 
to a senior oncologist in Pakistan, parents are anxious not only about chemotherapy side-effect 
but also about the disease itself [2]. Most parents have the same knowledge of side effects of 
chemotherapy as they experienced with friend‘s relatives who had undergone to course 
treatment. Secondly, side effect was mentioned at first counseling session by primarily 
oncologist.  
 
 

5 
 
1.4 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, 
depression and stress of children receiving chemotherapy for the first time 
 
1.5 Research Question:  
Are there effects of nurse-led multimedia education, booklet providence and telephonic 
follow up about chemotherapy and side effects management on parent‘s anxiety, depression and 
stress of children receiving chemotherapy for the first time? 
 
1.6 Operational Definitions 
Depression: The score greater than 9 under DASS-21 scale Criteria 
Anxiety: The Score Greater than 7 under DASS-21 scale Criteria 
Stress: The Score Greater than 14 under DASS-21 scale Criteria 
  
 
 
 
 
 
 
 
 
 
 

6 
 
CHAPTER 2: LITERATURE REVIEW 
2.1 International Findings: 
European literature reported that 20 minutes of video education was more effective than 
verbal and written education [55]. A randomized control trial was done by Williams and 
Schreier (2005), 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. More number of patient (n=16) in control group reported anxiety as 
compared to experimental group (n=10) significantly (p=0.001) [26] Similar results were found 
from the study of Malone (2007) that education helps to reduce anxiety.[25] Another study 
mentioned that familiarity with environment of chemotherapy was necessary as it has also an 
impact on anxiety [11, 56].  Almost 50% cases diagnosed with cancer reported the symptoms of 
anxiety [51]. According to NCCN guideline, the anxiety management related to chemotherapy 
and side effect management was the primary responsibility of oncology team including 
oncology nurse [16]. Study from USA mentioned that the caregiver of children diagnosed with 
cancer had 44% greater stress as compared to 24% parents of healthy children [47]. Another 
study mentioned that 98% participant were satisfied with chemotherapy educational experience, 
all study participants found educational environment as supportive and 81% felt that quality of 
life could be improved through education [46].  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 was 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 was effective for chemotherapy education [11]. 
In another study 84% patient reported that educational class was a help to reduce anxiety and 
64.7% participant disagree for education in group [25]. A randomized control trial was 

7 
 
conducted in Greenville and concluded that 23% participant in control group reported anxiety 
after 1 month of treatment as compared to 14% in interventional group [26]. Written 
information before chemotherapy should be provided to patient, the information should include 
chemotherapy and side effect, future plan, and follow-up [15]. Many studies had mentioned that 
that psycho-education was effective to reduce anxiety during chemotherapy management [28, 
51, 56, 57]. 
2.2 Regional Finding 
A study from Korea mentioned 38% (n=342) caregiver of children bearing cancer had 
anxiety, with 5 % of them had severe anxiety.  82% (n=737) caregiver had depression, and 16% 
abode severe depression of cancer patient. The predicted anxiety level of family caregiver was 
9.22 times higher with poor Quality of life (QOL), for burdensomeness 3.44 times higher for 
degree of disturbance and 2.12 times higher for financial concerns. There are many evidences of 
nursing intervention effect on anxiety and depression other than chemotherapy side effect 
management.  A study from Turkey mentioned the effect of  multimedia nursing education for 
cardiac care on anxiety and depression score from 6.1±0.7 and 5.4 ± 0.6 reduced to 1.9 ± 0.2 
and 1.9 ± 0.3 [37]. In Iran effect of nurse led telephonic follow on anxiety and depression for 
hemodialysis patients was studied [42] Other studies provided evidences of family anxiety 
reduction in cardiac care [23, 29, 34, 38],  during electroconvulsive therapy [33], elderly care 
[22] and for laparoscopic cholecystectomy [41].. Another study from Korea also mentioned the 
effect of nursing intervention on anxiety during laparoscopy hysterectomy [58]. A study from 
Azerbaijan mentioned positive effect of nursing intervention on anxiety during endoscopy [53] 
and from Egypt mentioned positive effect of nursing intervention on anxiety during MRI 
procedures [32]. Studies from China also mentioned the effect of nursing intervention on 
anxiety level for peptic ulcer [44], breast cancer [40], tooth extraction [43] and laparotomy [39].  

8 
 
2.3 Local findings: 
A study from Rawalpindi revealed  that 10%-25% participant reported anxiety and 
depression during chemotherapy and 16% had anxiety and 27% had depression [4]. Myeloid 
leukemia was commonly diagnosed in younger age but mostly reported in chronic phase [59]. A 
study from Lahore mentioned that 56% parents had depression, higher in mothers specially 
those who were low educated and had poor socio-economic class [5]. A study from Karachi 
mentioned caregiver stress related to cancer patients, 17% mild, 34% moderate and 49 % had 
severe stress. It was also concluded that caregiver stress for cancer patient had significant 
association with caregiver age, relationship with child, female gender and longer duration of 
care [49].  A study was conducted in Karachi to identify the psychological need of parents of 
children disposed with cancer and found that correct and adequate information through 
education is necessary for parents [60]. 
 
We fail to find study both regional and locally focusing this concept. 
 
 
 
 
 
 
 
 
 

9 
 
CHAPTER 3: METHODS AND MATERIALS 
3.1 Study Design: 
Randomized control trial (RCT) 
3.2 Study Setting: 
Department of Pediatric Oncology at Indus hospital, Karachi 
3.3 Study Duration: 
September 2018 to December 2018 
3.4 Study Population:  
The populations of interest were parents along with their children receiving 
chemotherapy treatment for the first time. 
 
3.5 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 
3.6 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.   
 

10 
 
3.7 Sample Size: 
 
By using NCSS PASS v.11 repeated measure analyses of variance (RMANOVA), at 80% 
power, and 95% confidence interval., RMANOVA of STAI Anxiety score for interventional 
group at Pre-Intervention means 42.01 (SD=12.96), Post intervention means 37.27 (SD=13.47) 
and 2 weeks post intervention means 38.40 (SD=10.55)  [11], The sample size calculated was 
30 samples per group. After adjusting error in non-response of data collection 50 samples were 
drawn from each group. Total 100 caregivers along with their children was recruit in this study. 
 
3.8 Sampling Technique: 
Samples were randomly drawn by using block randomization list. This allocation was 
based on computer generated random allocation with randomly selected size of block i.e. 
number of patients on a given day. The participation of each parent in each session was based 
on the given generated numbers. For example, if on a given day block of parents was 
recommended by the consultant to the researcher then based on generated block random 
number; parents were allocated to either intervention arm or control arm. The same procedure 
was repeated on other day until the sample size in each group was completed. This sampling 
technique was referred as stratified random sampling. 
 
 
 
 
 
 

11 
 
3.9 Data Collection Procedure: 
1. Approval: Being a part of academic research, approvals were taken from scientific 
committee, institutional review board (IRB) and Board of Advanced Studies and Research 
(BASR) of Dow University of Health sciences, Karachi. Then ethical review committee of 
Research Department, Indus hospital Karachi was obtained where the study participants 
were approached.  
2. Multimedia Room arrangement: A room was arranged for multimedia chemotherapy 
education. 
3. Approach to target population: The target population was approached through Pediatrics 
oncology registration counter. A help was also taken from the primary adviser to 
acknowledge each newly advised chemotherapy children along with their parents to 
Multimedia education room.  
4. Parent selection: In the multimedia room, consent was taken from the parents and they 
were selected according to the above-mentioned inclusion and exclusion criteria. 
5. Randomization: The parents were allocated to Intervention group and Control group per 
the generated random number as mentioned in sampling technique defined in section 3.8.  
6. Socio-demographic and others information: The socio-demographics and others 
information were collected as given in Annexure -1. 
7. Pre-Intervention Anxiety, Depression and stress: Parent's anxiety, depression and stress 
levels were assessed by using DASS-21 (Urdu version) as mentioned in Annexure –II. 
8. Post-intervention Anxiety, Depression and stress: After two weeks the anxiety, 
depression and stress levels were again assessed by using DASS-21 after multimedia 
education of ―Pre-intervention anxiety and depression‖ identification. The data were 
collected during next appointment/mail/Telephonic follow up. The main objective of post 
intervention was to measure the mean difference of DASS score against Pre-intervention. 

12 
 
9. 2-week Post-Intervention Anxiety, Depression and stress: The parent  anxiety, 
depression and stress were again assessed after two weeks of ‗post intervention anxiety 
depression‖ identification. The technique of data collection was same as mentioned under 
Pre and post intervention. The main objective of two-week post intervention was to 
measure the mean difference DASS score against Post-intervention 
10. Anxiety, depression and stress mean difference: Finally, mean differences in the anxiety 
and depression level of parents in both Intervention Group and Control group were 
measured. 
11. Recruitment: The parents were recruited in the study from September 2018 to November 
2018 and follow up were continued from October 2018 to December 2018. After the 
completion of follow up to 5th December 2018 the trail was ended due to the completion of 
target sample sized (N=100) of parents and follow up schedule.  
 
 
 
 
 
 
 
 
 
 

13 
 
3.10 
Interventions: 
After an intensive literature review [11, 18, 24-29, 37-39, 42, 44, 46, 52, 54, 55, 58, 61, 62] 
following intervention strategy was develop in consultation with expert Pediatric 
Oncologist detail as mentioned below.  
3.10.1 To Intervention group: 
Before chemotherapy: 
1. Multimedia Education: The Intervention group received 60 minutes of PowerPoint 
multimedia education in Urdu language about chemotherapy, its side effect and 
nutritional guide. The copy of PowerPoint presentation is given in Annexure –III. It 
was ensured that well explained and comfortable friendly environment was provided to 
the parents. 
2. Booklet providence: A booklet "Chemotherapy and you" in Urdu translation were 
provided to the parents focusing on the detailed information about chemotherapy and its 
side effects management. The copy of the booklet is enclosed in Annexure –VI. 
After chemotherapy:  
Follow up were done, during follow up side effect appear in their child were determined 
and the parents were re-educated as per their appearance. There were 18 side effect of 
chemotherapy in booklet and it was not necessary that all would appear, e.g. example 
after chemotherapy the child may develop vomiting and diarrhea, but other 16 side 
effect may remain silent or appear later. 
 
 
 
 
 

14 
 
 
3. Tele-Nursing follow-up:  
3.1 The parents were provided opportunity to call from 9:00 a.m. to 5:00 p.m., in any week day 
to ask question related to chemotherapy and its side effect management according to booklet. 
The education was again provided according to the booklet. If any information asked by 
parents was not related to the booklet, they were referred to their primary consultant.  
3.2 Each parent was called by the researcher on weekly basis according to following schedule, 
day of education (day 0) to 7th, 14th, 21st and 28th day. The content of telephonic conversation 
majorly focused on (i) list of problem related to chemotherapy side effect and (ii) 
Management techniques according to the booklet. The approximate duration of call was 15 
minutes depending upon the problems identified by the parents. 
3.10.2 To control Group:  
Before chemotherapy:  
They were recruited in the study and were informed about the day of data collection for 
post-analysis. 
After Chemotherapy:  
Control group followed routine care. During routine care parent verbally educated by the 
physician and nurses about Chemotherapy and Side effect Management. 
 
 
 
 
 
 
 

15 
 
3.11 Pilot Study: 
Content Validity of Booklet “Chemotherapy and you” 
The pilot study was conducted to ensure the ‗content validity‘ of educational material 
―Chemotherapy and You’, as it was adopted through international Guideline of NIH: National 
Cancer Institute, so that applicability of educational guideline at Department of Pediatric 
Oncology at Indus hospital, Karachi need to be ensured.  Though, minor changes were 
determined in the education materials during pilot study which were later incorporated under the 
supervision of expert reviewers in educational material according to educational need of parents 
and study setting. 
Training of Principal Investigator for Multimedia education and telephonic Follow up: 
 
During Pilot Study, researcher was also observed and guided by the most senior expert 
educationist already working in education department from ‗Department of Pediatric Oncology 
Indus hospital Karachi‖, on how to educate the Parents on multimedia education and Telephonic 
Follow up. After ensured that, researcher is capable to educate Parents, preceded to final study. 
It was also ensure that no additional information other than booklet ―Chemotherapy and you‖ 
will be given. If parents will asked any question other than booklet, will be refer to primary 
consultant. 
 
Reliability of DASS-21 Scale: 
Although DASS-21 Scale is a reliable tool and has an evidence of its usage in Pakistani 
context. But in order to ensure its local applicability, total 10 samples (10% of sample size of 
original study) were taken and it was found a 88.7% reliable. From control group, it shows 
92.5% reliability and from intervention group it shows 67.4% reliability.  

16 
 
3.12 Ethical Consideration: 
The research study got approvals from the scientific and ethical bodies as defined in 
section 3.9. Furthermore, signed consent was obtained from the selected participants after 
briefing the information about study. They were told that their relevant personal informed like 
names of child and parents, their phone number would only be used for telephonic follow up 
with parents and would be kept confidential within investigators of the study. 
  
3.13 Study Variables 
3.13.1 Dependent Variable: 
Depression (D) anxiety (A) and stress (S) were outcome variables. [63]. They were 
identified by using DASS-21 Scale. The use of DASS-21 scale was evident in different research 
studies from Pakistan [62, 64-67]. There were 21 questions in this scale equally divided into 
three parts having seven questions for Depression, Anxiety and stress respectively. Each 
question had four level of measurement 0, 1, 2 and 3, represent past week experiences. 0 means 
not applicable to person, 1 means applicable to some degree or sometime, 2 means applicable to 
considerable degree or good part of time, 3 means applicable to person very much or most of 
the time. Each question was separated for Stress(s), Anxiety (a) and Depression (d). The 
questions focusing the concept (1) (s) hard to wind down, (2)(a) dryness of mouth, (3)(d) 
experience of positive feeling, (4)(a)breathing difficulty, (5)(d) difficulty in initiation of work,  
(6)(s) overreaction according to situation, (7)(a) experience of trembling in hand, (8)(s) use of 
excessive nervous energy, (9)(a) worriedness about panic situation, (10)(d)noting to look 
forward, (11)(s) getting agitated, (12)(s) difficulty in relaxation, (13)(d)feeling of downhearted 
and blue, (14)(s) lack of tolerance, (15)(a) feeling of panic, (16)(d)lack of enthusiasm, 
(17)(d)lack of worthiness as a person, (18)(s) feeling of somewhat sensitive, (19)(a) palpitation 
and increase of heart beat, (20)(a) feeling of scary and (21)(d) feeling of meaningless life. The 

17 
 
cut-off scoring for (1) Depression was Normal (0-9), Mild (10-13), Moderate (14-20), severe 
(21-27) and extreme Severe (28+), (2) Anxiety was Normal (0-7), Mild (8-9), Moderate (10-14), 
severe (15-19) and extreme Severe (20+)and (3) Stress was Normal (0-14), Mild (15-18), 
Moderate (19-25), severe (26-33) and extreme Severe (34+). For further categorical analysis, 
the depression, anxiety and stress were dichotomized into ―No‖ and ―Yes‖ where ―Yes‖ 
category was generated while combining the statuses of ―mild‖, ―moderate‖, ―severe‖ and 
―extremely severe‖. The Scores on DASS-21 scale was multiplied by 2 to get the final score. 
3.13.2 Independent Variable:  
 
 
 
The independent variable was mentioned as socio-demographics and other 
information in Annexure-I. It included (1) Sectioned (A), Personal information focusing Child 
Age, Child gender, Primary Care taker area of residence, (2) Section (B), Socioeconomic and 
educational status of Childs caretaker focusing Occupation, Level of education, Employment 
status, Income per month and Treatment Expenses. (3) Section C, Cancer Information focusing 
Diagnoses, Type of cancer, Stage of cancer, treatment being sought, Duration of Chemotherapy, 
Date of diagnoses, Duration of diagnoses, Family History of cancer and Number of cancer 
patients in the family of the patient other than this case. (4) Section (D), Pain scale focusing 
Pain felt by the child at that moment and (5) Section (E), General information related to Anxiety 
and depression focusing, Caregivers awareness of whether he or she was anxious and 
depressed? Did caregivers taken any treatment sought for his anxiety and depression? Whether 
any health professional advices the Caregivers? and Do caregiver had smoking habits? 
 
 
 
 

18 
 
3.14 Statistical analyses: 
 
The data were analyzed by using SPSS version 21. The patient identification was omitted 
from analyses. The reliability measures were made using Cronbach‘s alpha. Descriptive 
analyses were performed for all the variables. Mean and standard deviation were computed for 
continuous variable such as DASS score, age etc. Frequency and percentages were computed 
for categorical variable such as DASS categories, gender and other socio-demographic 
variables. As the outcome variable were collected over three periods of time. One-way repeated 
measurement of ANOVA (RM ANOVA) was used for comparing the mean DASS scores over 
28 periods of time. The post hoc test applied for each time of measurement and the differences 
were identified between pre-intervention (day 0), Post intervention (day 14) and 2 weeks after 
post intervention (day 28).  
 
 

19 
 
CHAPTER 4: RESULT 
4.1 Participant flow: 
Consolidated Standards of Reporting Trials (COSORT) guidelines were used for 
organization of methods and results of the study [68].  Total 113 children were admitted in 
Department of Pediatric Oncology at Indus hospital, Karachi from September 2018 to 
November 2018.  Out of 113, 13 parents along with their children were excluded for not 
meeting inclusion criteria i.e. non-confirmation of cancer diagnosis, no need for Chemotherapy 
and refused to participate in study.  Thus, 100 parents were randomly allocated to intervention 
group and Control group with equal number of allocations in each group respectively.  
Out of 50 parents in intervention group 4.5% (n=9) were lost during follow up, due to death 
(n=2) of the children and no response (n =7) from parents. In intervention group 4 children were 
lost in 1st week, 2 were lost in 2nd week, 2 were lost in 3rd week and 1 was lost in 4th week of 
follow up. On the other hand, 50 parents along with their children who were randomly allocated 
to control group as routine care, 3 children died, and 11 participants did not respond afterward. 
Total 6 were lost in 1st week, 4 were lost in 2nd week, 2 were lost in 3rd week and 2 were lost 
in 4th week of follow up in control group. It was further identified that lost to follow-up due to 
death and non-response was somewhat more in control groups as compared to intervention 
group. The detail is mentioned in Figure 1 
 

20 
 
  
 
Figure 1: Participants selection 
 
 
 
 
 
 
 

21 
 
4.2 Baseline data: 
Personal information:  
Total 31.2% (n=24) children were under 2-4 year of age, 23.4% (n=18) were under 5-7 
years, 31.2 % (n=24) were also under 8-12 year of age and 14.3% (n=11) children were under 
13-18 years of age group. Female to male ratio was 1:1.85. Majority (88.3%) of primary 
caregiver of studied children were any one of the parents. Most of them belonged to non-local 
area, other than Karachi territory.  
 
Socioeconomic and educational status of Childs care taker:  
Total 54.4% (n=42) children‘s father were labors, 22.1% (n=17) were shopkeepers and 
23.4%(n=18) had other occupations. Total 28.6 % (n=22) participate of them were found 
uneducated, 42.9% (n=33) were educated at School level, while 28.6% (n=22) were educated at 
higher level. Most of the father‘s worked on daily Wages, Total 37.7% (n=29) Primary care 
taker income had less than 10, 000 incomes per month and 62.3% (n=48) had more than 10,000 
incomes per month.  
 
Cancer Information:  
Leukemia (blood cancer) was found to be the commonest cancer among the children 
(66.2%) and 33.8 % had other cancers. Nearly, 90.0 % caregiver had no history of cancer in 
their family. While 9.1% (n=7) had an active history of cancer in their family.  
 
 
 
 
 

22 
 
Pain scale (Visual analog scale):  
When asked about the pain felt by the children, majority (n=49) children responded that 
they were not feeling any pain at that moment. Those who felt pain, was due to the invasive 
procedure of bone marrow biopsy. Minority complaints about pain were due to abdominal 
distention and nodules formations. 
Factor associated with Anxiety and depression:  
Nearly, 42.9% parents had smoking habits, while 57.1 % did not have smoking habit. 
The baseline data of parents along with their child are shown in Table 1. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

23 
 
Table 1:  
Socio Demographical Features 
 
Total 
Intervention 
Control 
 
Chi-Square 
P-Value 
Section A: Personal information 
n=77 (100%) 
n=41 (100%) 
n=36 (100%) 
1. Child Age: 
- 
- 
- 
 
 2-4years 
 
24(31.2) 
13(31.7) 
11(30.6) 
0.98 
 5-7years 
 
18(23.4) 
10(24.4) 
8(22.2) 
 8-12 years 
 
24(31.2) 
12(29.3) 
12(33.3) 
 13-18 years 
 
11(14.3) 
6(14.6) 
5(13.9) 
2. Child Gender:  
 
 
 
 
 
Male 
50(64.9) 
24(58.5) 
26(72.2) 
0.20 
 
Female 
27(35.1) 
17(41.5) 
10(27.8) 
3. Primary Care Giver: 
 
 
 
 
 
Mother/Father 
68(88.3) 
38(92.7) 
30(83.3) 
0.20 
 
Other 
9 (11.7) 
3 (7.3) 
6 (16.7) 
4. Residency/Locality: 
 
 
 
 
 
Local 
28(36.4) 
17(41.5) 
11(30.6) 
0.32 
 
Non- Local 
49(63.6) 
24(58.5) 
25(69.4) 
Section B: Socioeconomic and 
educational status of Childs care taker 
N=77 (100%) 
Intervention 
n=41 (100%) 
Control 
n=36 (100%) 
Chi-Square 
P-Value 
5. Occupation 
 
 
 
 
Labor 
42(54.4) 
24(58.5) 
18(50) 
0.74 
Shopkeeper 
17(22.1) 
8(19.5) 
9(25) 
Other 
18(23.4) 
9(22) 
9(25) 
6. Level of education  
 
 
 
 
Uneducated 
22(28.6) 
11(26.8) 
11(30.6) 
0.80 
School Education  
33(42.9) 
17(41.5) 
16(44.4) 
Higher Education 
22(28.6) 
13(31.7) 
9(25) 
7. Employment status  
 
 
 
 
Daily Wages 
49(63.6) 
28(68.3) 
21(58.3) 
0.36 
Monthly Salary 
28(36.4) 
13(31.7) 
15(41.7) 
8. Income per month (Rupees) 
 
 
 
 
less than 10,000  
29(37.7) 
12(29.3) 
17(47.2) 
0.10 
More than 10,000 
48(62.3) 
29(70.7) 
19(52.8) 
Section C: Cancer Information 
N=77 (100%) 
Intervention 
n=41 (100%) 
Control 
n=36 (100%) 
Chi-Square 
P-Value 
9. Diagnoses 
 
 
 
 
Leukemia 
51(66.2) 
28(68.3) 
23(63.9) 
0.58 
Others 
26(33.8) 
13(31.7) 
13(36.1) 
10. Family History of cancer 
 
 
 
 
No 
70(90.9) 
34(82.9) 
33(91.7) 
0.25 
Yes 
7(9.1) 
7(17.1) 
3(8.3) 
Section D: Pain scale (Visual analog 
scale) 
N=77 (100%) 
Intervention 
n=41 (100%) 
Control 
n=36 (100%) 
Chi-Square 
P-Value 
11. Pain felt by the child 
 
 
 
 
No 
49(63.6) 
23(56.1) 
26(72.2) 
0.14 
Yes 
28(36.4) 
18(43.9) 
10(27.8) 
Section E: Factor associated with 
Anxiety and depression 
N=77 (100%) 
Intervention 
n=41 (100%) 
Control 
n=36 (100%) 
Chi-Square 
P-Value 
12. Do parent have smoking habits? 
 
 
 
 
No 
44(57.1) 
21(51.2) 
23(63.9) 
0.26 
Yes 
33(42.9) 
20(48.8) 
13(36.1) 

24 
 
4.3 Depression, Anxiety and Stress over study period: 
4.3.1 
Reliability analysis: 
The Cronbach‘s alpha values of overall DASS measures were 75%, 85.1% and 85.3% at 
pre, post and 2-week post intervention period respectively. Among the control, their respective 
values were 79%, 84.9% and 83.5% while from intervention group, these were 69.4%, 81.1% 
and 78.2% at pre, post and 2-week post intervention respectively. From these values of 
Cronbach‘s alpha, it was perceived that consistency among the responses from the participants 
while responded to the questionnaire showed very good reliability. 
 
4.3.2 
DASS score and level over pre, post and 2 week post time: 
The descriptive statistics of depression, anxiety and stress scores are given in table 2 
while distribution of depression, anxiety and stress levels between intervention and control 
group over study periods are mentioned in table 3. 
Depression: 
At the baseline depression score was 15.82 ± 6.6, while 15.6% had no depression and 
most of the parents 84.4% (n=65) had depression. One week after the depression score was 
reduced to 7.97 ± 5.15, in which 62.3% had no depression, while 37.7% (n=29) had depression. 
The average ‗two-week post-depression‘ score was reduced to 4.26 ± 4.36, in which 85.7% had 
no Depression, while 14.3% (n=11) had depression. The percentage of depression in 
intervention group was reduced from baseline to 22% and 2.4% among intervention group at 
post and 2-week post intervention while it respectively retained to 55.6% and 27.8% in control 
group. 
 
 
 

25 
 
 
Anxiety: 
The average ‗pre-anxiety‘ score was 11.35 ± 6.72, in which nearly one out of three 
(n=25) had no anxiety, while 67.5% (n=52) had Anxiety. The average ‗post-anxiety’ score was 
5.32 ± 4.5, in which about three-quarter (n= 56) had no anxiety, while 27.3% (n=21) had 
anxiety. The average ‗two-week post‘ anxiety score was 4.26 ± 4.36, in which 83.1% (n=64) 
had no anxiety and 16.9% (n=13) had anxiety. The anxiety level reduced to 14.6% to 4.9% in 
intervention group in post and 2 week post stages respectively though, 41.7% and 30.6% of 
parents in control group remained anxious in post and 2 week post stages. 
 
Stress: 
The average ‗pre-stress score‘ was 16.65 ± 6.15, in which 44.2% (n=34) had no Stress, 
while 55.8% (n=43) had stress. The average ‗post-stress score‘ was 8.88 ± 5.77, in which 87% 
(n= 67) had no stress, while 13% (n=10) had stress. The average ‗two-week post stress‘ score 
was 4.73 ± 4.64, in which 96.1% (n=74) had no stress and 3.9% (n=3) had stress. There was 
steep declined in stress level in intervention group that no parent was in stressed at 2 week after 
intervention. However, 8.3% of parents in control group still had stress level at final stage of the 
study.  
 
 

26 
 
Table 2:  
Average scores of Depression, Anxiety and Stress between intervention and control 
group  
 
Dependent Variable 
Total 
n=77   
(Mean ± SD) 
Intervention 
n=41  
(Mean ± SD) 
Control 
n=36  
(Mean ± SD) 
DEPRESSION 
Pre-Depression 
15.82 ± 6.6 
15.41 ± 5.97 
16.28 ± 7.32 
Post-Depression 
7.97 ± 5.15 
6.44 ± 3.94 
9.72 ± 5.82 
Two- Week Post Depression 
4.26 ± 4.36 
2.63 ± 2.98 
6.11 ± 4.94 
ANXIETY 
Pre-Anxiety 
11.35 ± 6.72 
11.9 ± 6.51 
10.72 ± 7 
Post-Anxiety 
5.32 ± 4.5 
4.2 ± 3.43 
6.61 ± 5.23 
Two- Week Post Anxiety 
2.98 ± 3.23 
1.75 ± 2.33 
4.27 ± 3.61 
STRESS 
Pre-Stress 
16.65 ± 6.15 
16.63 ± 5.96 
16.67 ± 6.45 
Post-Stress 
8.88 ± 5.77 
7.02 ± 4.59 
11 ± 6.3 
Two- Week Post Stress 
4.73 ± 4.64 
2.88 ± 3.1 
6.83 ± 5.22 
 
 
Table 3:  
Distribution of depression, anxiety and stress levels between intervention and 
control group over study period 
Dependent Variable 
Yes/No 
Total 
(n=77) 
n(%) 
Intervention  
(n=41) 
n(%) 
Control 
(n=36) 
n(%)  
DEPRESSION 
Pre-Depression 
0= No 
12(15.6) 
6(14.6) 
6(16.7) 
1= Yes 
65(84.4) 
35(85.4) 
30(83.3) 
Post-Depression 
0= No 
48(62.3) 
32(78) 
16(44.4) 
1= Yes 
29(37.7) 
9(22) 
20(55.6) 
Two- Week Post Depression 
0= No 
66(85.7) 
40(97.6) 
26(72.2) 
1= Yes 
11(14.3) 
1(2.4) 
10(27.8) 
ANXIETY 
Pre-Anxiety 
0= No 
25(32.5) 
11(26.8) 
14(38.9) 
1= Yes 
52(67.5) 
30(73.2) 
22(61.1) 
Post-Anxiety 
0= No 
56(72.7) 
35(85.4) 
21(58.3) 
1= Yes 
21(27.3) 
6(14.6) 
15(41.7) 
Two- Week Post Anxiety 
0= No 
64(83.1) 
39(95.1) 
25(69.4) 
1= Yes 
13(16.9) 
2(4.9) 
11(30.6) 
STRESS 
Pre-Stress 
0= No 
34(44.2) 
19(46.3) 
15(41.7) 
1= Yes 
43(55.8) 
22(53.7) 
21(58.3) 
Post-Stress 
0= No 
67(87) 
40(97.6) 
27(75) 
1= Yes 
10(13) 
1(2.4) 
9(25) 
Two- Week Post Stress 
0= No 
74(96.1) 
41(100) 
33(91.7) 
1= Yes 
3(3.9) 
0(0) 
3(8.3) 
 
 

27 
 
4.3.3 
Changes in depression, anxiety and stress scores over different periods: 
Table 4 depicted significance values from RM-ANOVA and further post-hoc analyses. 
Profile plots mentioned as figure 2-4 displayed changes of mean scores of depression, anxiety 
and stress at baseline, post and 2-week post intervention. 
Depression: The average depression between intervention and control group was 
significantly different (P=0.012) over study period (P<0.0001). Post-hoc analysis revealed that a 
reduction of 7.76 unit decrease in depression score from baseline to post intervention while it 
significantly reduced to 11.47 unit after 2 weeks of the study. 
Anxiety:  The anxiety level did not show any significant difference between intervention 
and control group (P=0.172) though both groups displayed concurrently significantly decline in 
anxiety level at pre, post and 2 week post study period (P<0.0001). Post-hoc analysis also 
discovered that a reduction of 5.90-unit reduction in Anxiety score from the reference line after 
intervention and significantly reduced to 8.29 unit after 2 weeks of the study. 
Stress: The reduction in stress level depicted similar panorama as it was observed in 
depression score. Post-hoc analysis further exposed a decrease of 7.67-unit reduction in stress 
score from the baseline line after MBT intervention and significantly reduced to 11.79 units 
after 2 weeks of the study. 
 
 

28 
 
Table 4:  
Significant values of depression, anxiety and stress scores 
Dependent 
Variables 
Significance value 
between study 
groups 
Significance value over 
time 
Post Hoc Analysis  
P-Value with Mean differences 
Pre   
& 
Post 
Pre  
& 
2week Post 
Post 
 & 
2week Post 
Depression 
0.012 
<0.0001 
<0.0001 
Dif. (7.76) 
<0.0001 
Dif. (11.47) 
<0.0001 
Dif. (3.70) 
Anxiety 
0.172 
<0.0001 
<0.0001 
Dif. (5.90) 
<0.0001 
Dif. (8.29) 
<0.0001 
Dif. (2.38) 
Stress 
0.012 
<0.0001 
<0.0001 
Dif. (7.63) 
<0.0001 
Dif. (11.79) 
<0.0001 
Dif. (4.15) 
 
Figure 2: Depression scores of intervention and control 
group during study period 
Figure 3: Anxiety scores of intervention and control 
group during study period 
 
 
 
 
Figure 4: Stress scores of intervention and control group during study period 
 
 

29 
 
Table 5 : Association of Socio demographical features with pre-depression, pre-anxiety 
and pre-stress 
 
socio demographical 
features  
Pre-Depression 
Chi-Square 
P-Value 
Pre-Anxiety  
Chi-Square 
P-Value 
Pre-Stress  
Chi-Square 
P-Value 
1. 
Child Age 
0.58 
*0.031 
0.18 
2. 
Child Gender 
0.42 
0.15 
0.35 
3. 
Primary Care Giver 
0.69 
0.41 
0.46 
4. 
Residency/Locality 
0.67 
0.58 
0.10 
5. 
Occupation 
*0.017 
0.25 
0.20 
6. 
Level of education  
0.13 
0.25 
0.15 
7. 
Employment status  
0.28 
0.96 
0.76 
8. 
Income per month (Rupees) 
0.32 
0.07 
0.92 
9. 
Diagnoses 
0.97 
0.77 
0.81 
10. Family History of cancer 
*0.02 
0.20 
0.77 
11. Pain felt by the child 
0.12 
0.11 
0.51 
12. Do parent have smoking 
habits? 
0.92 
0.88 
0.50 
 
Significant Association (P-Value <0.05) 
 
 
The significant association has been identified between child age and pre-anxiety 
of parents, Occupation and pre-depression of parents and family history of cancer and pre-
depression of parents. It is further identified that there is significantly 4 times more likely to 
have no Anxiety at the time of admission (pre-anxiety), if the child age is < 4 year as compared 
to the child age > 4 years [OR=4.1, 95%CI(1.0-16.2),P-Value=.042] Moreover, found that there 
is significantly 20% less likely to have no depression at the time of admission (pre-depression), 
if Family history has cancer as compared to no history of cancer patient in family [OR=0.20 , 
95%CI(.047-.880),P-Value=.033]. No association was found with other variable. 
Since, almost all variables produced insignificant effect on the outcome variables at 
three stages of observations. Therefore, these variables were not proceeded for multivariable 
analysis. 
 
 
 
 
 
 

30 
 
CHAPTER 5: DISCUSSION 
Parents are the primary care giver of the children. If parents will be in anxiety, so it will 
be difficult for them to manage side effect of chemotherapy. The main purpose of this study was 
to measure the impact of multimedia education, booklet providence and telephonic follow-up on 
parent‘s anxiety, depression and stress. As far as we know, the study is first of its kind that was 
conducted in Karachi Pakistan focusing this concept. We found significant reduction in 
depression and stress because of MBT intervention while anxiety was not significantly different 
between study groups. 
Epidemiology of Pediatric cancer: 
Large number of people are affected with cancer worldwide, leading major health 
problem of Pakistan [1, 2]. Approximately 8,000 children under 18 years of age are being 
diagnosed on yearly basis. In our study it was found that highest proprtion of patients were 
diagnosed with Leukemia (blood cancer) followed by Lymphoma (cancer of lymph gland), 
Similarly, one of the study from Pakistan also reported that Leukemia and Lymphoma were 
higher among children [2, 3]. The prevalence of leukemia is similarly higher in this study. 
Depression Anxiety and Stress among parents: 
In this study it was found that 84.4% parents had depression, 67.50% parents had 
anxiety and 55.50% parents had stress below normal range at baseline.  The reason of 
mentioned in the literature that anxiety in parents was due to unawareness about chemotherapy 
side effect, lack of knowledge about disease, lack of knowledge above side effect management 
[4, 11, 16, 17, 19-21]. The findings are similar to this study, as mostly parents were unaware 
about the disease and management.  
 
 
 

31 
 
MBT as Nursing Intervention to reduce Anxiety Depression and stress:  
In our study randomized control trial was done in which intervention group received 
multimedia education on chemotherapy and side effect management along with routine care and 
the control group received verbal instruction as routine care of hospital. The anxiety level was 
measure at 2-week differences up to 1 month and found that large no of parents reported anxiety 
in control group after 1 month as compared to experimental group. Similarly study was 
conducted by Williams and Schreier (2005) and reported larger number of patient in control 
group reported anxiety as compared to experimental group significantly. [26].  Another Malone 
(2007) and mentioned that education help in reduction of anxiety  [25]. In our study it was 
found that parent who came at Department of Pediatric Oncology at Indus hospital, Karachi 
have the considerably highest pre-scores of anxiety, depression and stress.  
Susan Swanson, 2008 mentioned that almost 50% cases diagnosed with cancer reported 
the symptoms of anxiety [51]. Similar in this study we have reported slightly higher Prevalence 
possibly due to study setting differences. Study from USA mentioned that, the caregiver of 
children diagnosed with cancer had 44% greater stress as compared to 24% parents of healthy 
children [47] According to National Comprehensive Cancer Network (NCCN) guideline, 
anxiety management related to chemotherapy and side effect management was the primary 
responsibility of oncology team including oncology nurse [16]. Similarly, the responsibility was 
assigned to physician, nurses and other paramedics. In our study it was found that almost 68% 
parents had anxiety and 84% caregiver had depression. Similarly, a study from Korea 
mentioned lower percentage that 38% caregiver had anxiety and 82% caregiver had depression 
[48]. In our study the effect of multimedia nursing education about chemotherapy and side 
effect management imparted significant reduction in anxiety (i.e. from 11.35 ± 6.72 which 
reduced to 2.98 ± 3.23) in 1 month and in depression score (i.e. from 15.82 ± 6.6 reduce to 4.26 
± 4.36) in 1 month. This is similar to a study from Turkey that mentioned the significant 

32 
 
reduction of  multimedia nursing education for cardiac care on anxiety and depression score 
from 6.1±0.7 and 5.4 ± 0.6 reduce to 1.9 ± 0.2 and 1.9 ± 0.3 respectively [37]. In Iran significant 
effect of nurse led telephonic follow on anxiety and depression for hemodialysis patients were 
reported [42], evidences of family anxiety reduction in cardiac care [23, 29, 34, 38],  during 
electroconvulsive therapy [33], elderly care [22] , laparoscopic cholecystectomy [41], 
laparoscopy hysterectomy [58], endoscopy [53] MRI procedures [32], peptic ulcer [44], breast 
cancer [40], tooth extraction [43]and laparotomy [39] correspondingly supported the procedure 
for multimedia education and telephonic follow up. In this study we found that 30 minutes of 
education about chemotherapy and side effect management was enough for education to 
parents. In a European study they recommended 20 minutes of multimedia education [55].  
We consider ourselves successful to report that our study focused on effect of nursing 
led education on chemotherapy and side effect management on parent‘s anxiety depression of 
children undergoing chemotherapy for the first time at local level in Pakistan. In literature we 
failed to find any study focusing this concept. Our study from Karachi reported 2 time higher 
parental anxiety and depression as compared to a study from Rawalpindi reported that 10-25% 
participant reported anxiety and depression during chemotherapy and 16% had anxiety and 27% 
had depression [4]. A study from Lahore mentioned that 56% parents had depression, higher in 
mothers specially those who were low educated and had poor socio-economical class. Another 
study mentioned that myeloid leukemia was commonly diagnosed in younger age but mostly 
reported in chronic phase [5, 59].  A study from Karachi mentioned caregiver stress related to 
cancer patients, 17% mild, 34% moderate and 49 % severe stress, mentioned that caregiver 
stress for cancer patient had significant association with caregiver age, relationship with child , 
female gender and longer duration of care [49]. The findings from our study showed that 
implementing MBT intervention would help to reduce depression, anxiety and stress in our 
setup. 

33 
 
This procedure adopted in this study was supported by the literatures that written 
material about chemotherapy side effect management is the responsibility of oncology nurses 
[11, 18, 24-26]. The main content of our education focused chemotherapy and side effect 
management. In literature it was further mentioned that education related to side effect 
management reduces anxiety of the patient [8, 9, 11, 15, 16, 19, 20, 27, 28, 46]. Using 
multimedia education for the reduction of anxiety was also found in mammography, MRI, ECT, 
cardiac surgeries, gynecological laparotomy, laparoscopic cystectomy, hemodialysis, teeth 
removal and peptic ulcer disease.[23, 29-45]. Anxiety and depression were more common due 
to lack of infrastructure in Pakistan [4]. Therefore, strategies like MBT intervention should be 
derived to reduce such psychological disorders in Pakistan especially among cancer patients and 
their caregivers. 
 
5.2 Limitations 
Few caveats should be taken while generalizing findings of the study. First, the study 
was conducted in a single center; therefore, results would be different if such psychological 
disorders persist in parents of cancer children in other clinical or community setups. Further 
effect of parents‘ age and gender could not be found out in our study. 
The MBT intervention alone could not help in reducing anxiety significantly. The reason 
would be most of the participants were anxious about finding a suitable residence in the city 
during treatment period for which researcher could not help. Also, this element was not 
addressed in the study questionnaire so that the reason would be confounded to determine sole 
effect of MBT intervention on anxiety too. 
 

34 
 
5.3 Strength of study: 
There are certain strengths to report about this study. First, the study was of its first kind 
to report major psychological disorders among caregiver of cancer children in Pakistan.  
The novel internationally adapted MBT intervention showed noteworthy decline which added 
the strength that the intervention is replicable to reduce depression, anxiety and stress among 
target population. The higher reliability scores also strengthened the confidence in using the 
MBT intervention for the same. 
Furthermore, despite having loss to follow-up, we retained more than desired sample 
size in both groups which yielded good power of the study. 
 
5.5 Conclusion: 
There is a positive effect of nurse-led multimedia education, booklet providence and 
telephonic follow up about chemotherapy and side effects management on parent‘s depression 
and stress of children receiving chemotherapy showing in this study for the first time in 
Pakistan. For anxiety reduction, other strategies should also be incorporated. 
 
5.6 Recommendation: 
Nurse-led multimedia education, booklet providence and telephonic follow up about 
chemotherapy and side effects management can be recommended as supportive care to reduce 
parent‘s depression and stress of children receiving chemotherapy for the first time. 
 
5.7 Harms: 
As no invasive procedure was done on parents along with their children and intervention 
is based on education guideline under NIH, hence did not cause any harm to the participant.  
 

35 
 
5.7 Generalizability: 
As the sample was drown through randomized block design so it can be generalizable to 
caretakers of cancer children from similar setup.  
 
5.8 Registration 
This Study is registered at ClinicalTrials.gov by Identifier NCT03753542, 
 
5.9 Funding: 
It was a self-funded academic research project. 
 
5.10 Recommendations for further studies: 
Nurse-led multimedia education, booklet providence and telephonic follow up about 
chemotherapy and side effects management can be recommended as supportive care to reduce 
parent‘s anxiety, depression and stress of children receiving chemotherapy for the first time. 
Though, further researches are needed to measure effect of MBT intervention based on parents‘ 
responses, their psychological aspects, age, gender, recovery of child and result association with 
public and private sector healthcare setting. 
 
 
 

36 
 
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42 
 
 
ANNEXURES 
 
The following annexures were enclosed with this document. 
Appendix -I:   Socio-demographic and others information 
Appendix -II:   DASS-21 
Appendix -III:  Multimedia Education 
Appendix -IV:  Booklet 
Appendix -V:  IRB Approval Letter 
Appendix -VI:  IRD Approval Letter 
Appendix -VII  Turnitin Digital Receipt 
Appendix -VIII Summary of the Similarity Index (Plagiarism)