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The History And Background Of Suicide Nursing Essay

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Published: 1st Jan 2015 in Nursing

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Suicide is the third leading cause of death among young people; however the incidence of attempted suicide is much more. It has been observed that after puberty, rate of suicide increases with age until it stabilizes in young adulthood. This increase in suicide may be associated with the onset and increase in depressive and other disorders during adolescents as compared to childhood.

Suicide ideation, gestures and attempts are frequently but not always associated with depressive disorders, reports indicate that as many as half of suicidal individuals express suicidal intention to a friend or a relative within 24 hours before enactive suicidal behavior.

It is a time proven fact that all the living organisms on this earth fight for survival and existence. What then makes the man to risk his own life? The tragedy of self – inflicted death has always attracted the attention of the medical as well as the legal fraternity. People who have committed suicide or have been thinking about committing suicide probably feel overwhelmed by their problems. They might not be able to handle that kind of pressure and feel that death would be the only way to escape it.( Alonso J,2008).

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Although suicide was condemned in the Dharmashastras, yet, there is also a chapter on allowed suicides. But the earlier scriptures, of Manu’s and Kautilya’s were against suicide. These sentiments were echoed for ages in India. Even though today, attempted suicide is also a crime in India under the Indian Penal Code system. The neighbouring country Sri Lanka has removed attempted suicide as a punishable offence. In India, even the assisting and abetting suicide is also a punishable offence.

The striking aspect of Indian data is the large variation in different parts of India in relation to attempted/committed suicide. The states and cities with rapid social change are associated with higher suicide rates in the year 2010, such as the states of Tamilnadu (5470) and Andhra Pradesh (5675),Maharashtra (6289), West Bengal (5302).(NCRBI 2007).

Adolescence is a stressful developmental period filled with major changes: body changes, changes in thoughts, and changes in feelings. Strong feelings of stress, confusion, fear, and uncertainty, as well as pressure to succeed, and the ability to think about things in new ways influence a teenager’s problem solving and decision making abilities.

For some teenagers, normal developmental changes, when compounded by other events or changes in their families such as parental divorce or moving to a new community, changes in friendships, difficulties in school, or other losses can be very upsetting and become overwhelming. Problems may appear too difficult or embarrassing to overcome. For some, suicide may seem like a perfect solution.

The adolescent suicide rate has greatly increased in recent years. Suicides in those ages 15 to 24 years once accounted for 5% of all suicides but now it is increased to 14%. This makes suicide the third leading cause of death among adolescents. Suicide rates for males within the age group of 10 – 14 years have tripled, whereas rates for males aged 15 to 19 years have quadrupled. Rates for females have doubled. Males aged 15 to 19 years are nearly 5 times more likely to kill themselves than females in the same age group. Although female adolescents attempt suicide 2 to 3 times more often than their male counterparts. Recorded suicide attempts peak between the ages of 15 and 19years.(WHO 2008).

1.1 NEED FOR STUDY: The numbers of suicides are increasing in India. India accounts for 10% of world’s suicides. According to the latest national crime record bureau report, there are over 1.2 lakh suicides in 2006 and 1.3 lakh in 2007. It also states that Bangalore has the highest rate of suicides in India. Till June 2007 there have been around 900 cases of suicide reported from Bangalore city alone. In 2005, 1,480 persons have committed suicide, while in the year 2006, the number was over 2,000, and among all states, Karnataka stands second after Kerala, followed by Maharashtra and West Bengal (Gururaj G.2008).

According to WHO’s estimation, in the year 2004, approximately one million people died from suicide, and 10 – 20 times more people attempted suicide worldwide. This represents one death every 40 seconds and one attempt every 3 seconds, on average (WHO,2004).

The adolescent suicide rate has greatly increased in recent years. Suicides in those ages 15 to 24 years once accounted for 5% of all suicides but now it is increased to 14%. This makes suicide the third leading cause of death among adolescents. Suicide rates for males within the age group of 10 – 14 years have tripled, whereas rates for males aged 15 to 19 years have quadrupled. Rates for females have doubled. Males aged 15 to 19 years are nearly 5 times more likely to kill themselves than females in the same age group. Although female adolescents attempt suicide 2 to 3 times more often than their male counterparts. Recorded suicide attempts peak between the ages of 15 and 19years

(Marlow,2002).

1.2 STATEMENT OF PROBLEM:

STRUCTURED TEACHING PROGRAMME ON THE PREVENTIVE MEASURES OF SUICIDAL IDEATION AMONG ADOLESCENTS IN PRIYADARSHINI SCHOOL,PITHAPURAM,ANDHRA PRADESH.

1.3 OBJECTIVES:

1.3.1 To assess the knowledge regarding preventive measures of suicidal ideation among adolescents.

To evaluate the effectiveness of structured teaching programme on Preventive measures of Suicidal ideation among adolescents.

1.3.3 To associate the preventive measures for suicidal ideation among adolescents with the various demographic variables.

1.4 ASSUMPTIONS:

The adolescents are prone for suicidal thoughts.

1.5 HYPOTHESIS:

There will be a significant difference between the preventive measures for suicidal ideation before and after administration of structured teaching programme.

There will be a significant association between the preventive measures for suicidal ideation with various demographic variables

1.6 Operational Definition:

1.6.1 Suicide: is the act of intentionally taking one’s own life in a culturally

no endorsed manner.

1.6.2. Preventive measures: refer to the risk factors, warning signs, suicidal behavior, misconceptions of suicide, how to communicate and monitoring safety needs in the environment.

1.7 Conceptual Framework: Modified general systems theory of learning: General systems theory is useful in breaking process into sequential operations or tasks to ensure goal realization. Purpose, goal or aim is necessary for any process or system. The aim of the study is to increase the knowledge of preventive measures for suicidal ideation.

Input: The first function is the input which is the information, energy or matter that enters the system. For a system to work well the input should concentrate in achieving the purpose of the system. In the present study the information, energy or matter which enters the system is the introduction of structured teaching programme regarding the preventive measures for suicidal ideation. In the present study input is the existing knowledge regarding preventive measures for suicidal ideation.

Throughput: According to the theorist, throughput refers to the process used by the system to convert raw material or energy into products that are usable by the system itself or by the environment. In this active phase, teacher converts the information from structured teaching programme regarding preventive measures for suicidal ideation.

Output: According to theorist, it refers to the product or service which results from the systems through put. Output in this study refers to the end product of the system. This is evidenced by adolescents gaining knowledge regarding the preventive measures for suicidal ideation.

Evaluation: Evaluation is the information about some aspects of data or energy processing that can be used, to evaluate and monitor the system and to guide it to more effective performance. In the present study, evaluation measures the success or failure of output. I t is done by measuring the performance and it is graded as adequate knowledge (>75% scores), moderately adequate knowledge (50%-75% scores) and inadequate knowledge (< 50% scores)

Feedback: The final function is feedback which is the process of communicating what is found in evaluation of the system. It is the information given back to the system to determine whether or not the purpose or end result of the system has been achieved. The final part of feed back communicates what is found in the evaluation and it tells whether the structured teaching programme was effective in enhancing the knowledge of adolescents regarding the preventive measures for suicidal ideation.

1.8 Projected Outcome: Structured teaching program helps to improve the knowledge on preventive measures for suicidal ideation among adolescents.

Fig: 1.1 MODIFIED SYSTEM MODEL TO ASSESS THE KNOWLEDGE OF ADOLESCENTS REGARDING PREVENTIVE MEASURES OF SUICIDAL IDEATION

OUTPUT

THROUGH PUT

INPUT

Assessment of demographic variables of adolescents such as age, sex, family income, religion, parents education.

Pre assessment of knowledge of adolescents regarding preventive measures of suicidal ideation

Post assessment of knowledge of adolescents regarding preventive measures of suicidal ideation

Adequate

Inadequate

Structured teaching Programme on Preventive measures of suicidal ideation

Inadequate

Moderately adequate

REASSESSMENT

CHAPTER II

REVIEW OF LITERATURE

Review of Literature is a key step in research process. Nursing research may be considered as a continuing process in which knowledge gained from earlier studies is an integral part of research in general. In review of literature a researcher analyses existing knowledge before delving into a new study and when making judgement about application of new knowledge in nursing practice. The literature review is an extensive, systematic, and critical review of the most important published scholarly literature on a particular topic.

2.1 Literatures related to Suicide risk factors

2.2 Literatures related to Prevention of suicidal ideation

2.1 Literatures related to Suicide risk factors

A case – control study was conducted to identify and quantify risk factors for completed suicides in Bangalore, India. The study was conducted with the families of 269 completed suicides and 269 living controls within the broader population of the city using psychological autopsy methods. The results showed that, the significant risk factors for completed suicides were the presence of previous suicidal attempt in self [odds ratio (OR) = 42.62], interpersonal conflicts and marital disharmony with spouse [OR = 27.98], alcoholism [OR = 23.38], presence of mental illness [OR = 11.07], sudden economic bankruptcy [OR =7.1], domestic violence [OR = 6.82], and unemployment [OR = 6.15]. Individuals completing suicides did not have a positive outlook towards life, problem solving approaches and coping skills. The study concluded that, the intervention strategies should include prioritized macro and micro level efforts aimed at individual, family and society. (Gururaj G 2007)

A study conducted involving 1205 adolescent students of two schools from New Delhi reported, one year suicidal ideation was 11.7%. they also found that physical abuse by parents, feelings neglected by parents, history of running away from school, history of suicide by a friend and death wish were found to be associated with non-fatal suicidal behavior. (Siddhartha and Jena,2006).

A study conducted on bullying and risk of suicidal behaviour among adolescents in New York. Total 2341 adolescents aged 13-19 years who were enrolled in grades 9 through 12 in suburban school was selected for study. Researchers used Beck Depression Inventory to assess depression and suicide Ideation Questionnaire. Suicide attempt history included any attempt, regardless extend of injury. With regard bullying behaviour, students were asked how often they had been bullied or had bullied others in and out of school during the past 4 weeks. “Being bullied” was defined as having the student say or do unpleasant thing or being teased repeatedly in a way the person does not like. Result shows about 20% student reported that they were victims of bullying in school and about 10% reported that they were victims of bullying outside the school. With regard to bullying behavior, about 25% students reported that they bullied other students in school and 15% reported that they were bullied others outside school .The risk of depression, suicidal ideation and suicidal attempt was significantly higher for students who were considered either a victim or a bully compared with students who were not. The more frequent the bullying behaviour the greater risk of depression, suicidal ideation or suicidal attempt. (Wagnar KD,2007).

A study conducted on rates and factors associated with suicide in Kaniymbadi block, Tamil Nadu, South India. The setting for the study was a comprehensive community health programme in a development block in rural South India. The main outcome measure was death by suicide diagnosed by detailed verbal autopsy and census and birth and death data to identify population base. Result shows the average suicide rate was 92.1 per 1,00.000. The ratio of male to female suicide was 1:0.66. The age specific suicide rate for women showed two peaks: 15-24 year and over 65 years of age. Hanging (49%) and poisoning with organo-phosphorus compound (40.5%) were commonest method of suicide. Acute or chronic stress was elicited for nearly all subjects. More men suffered from chronic stress while more women had acute precipitating events (x2= 4.58; p<0.04). People less than 44 age had more acute precipitating events before death while older subjects reported more chronic stress (x2=17.38;p<0.001). Conclusion of study is there is need for sentinel centers in India and in developing countries to monitor trends and to develop innovative strategies to reduce death by suicide (Prasad J, Abraham VJ and Minz S, Joseph A, 2006).

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A study conducted on risk factors for completed suicide in Banglore, India. A case control study conducted with families of 269 completed suicides and 269 living control within the broader population of city, using psychological autopsy method. Result shows that several factor in the areas of family, marriage, education, occupation, general health, mental health and absence of protective factors contribute significantly for suicides .The significance factor were presence of previous suicidal attempt in self (odds ratio OR = 42.62), interpersonal conflicts and marital disharmony with spouse (O =27.98), alcoholism in self (OR=23.38), presence of mental illness (OR=11.07), sudden economic bankruptcy (OR=7.1), domestic violence (OR=6.82) and unemployment(OR= 6.15). Individual completing suicide did not have a positive outlook towards life, problem solving approaches and coping scale (Gururaj G and Isaac MK, 2007).

A study was conducted on psychosocial risk factors associated with suicide attempts among psychiatric inpatient and this study examine how suicide attempts and violent behavior associated with various psychosocial problems. This study included 216 inpatient who had physically assaulted another patient and a comparison group of 81 inpatient who had not assaulted any one. The result was suicide attempts were associated with a history of head trauma harsh parental discipline and parental psychopathology (Menhem.I and Krakowski, 2004).

A study conducted on psychosocial stressors may be strongly associated with suicide attempts; the aim of the study was to clarify the importance of psychosocial stressors in suicidal behavior and 250 suicide attempts seen at general hospital emergence room. Acute and chronic life events were assessed with the St. Paul Ramsey life experience scale Holmes and Rahes social adjustment scale respectively, life long adverse experience were also assessed. The logistic regression with dependent variable included psychosocial stressor (Odds ratio (OR)=33.6) And other interpersonal conflicts (OR =10.5) modification of life habits (OR = 14.6) & adult physical abuse (OR = 7.1) confounding factors with significant ORS were cluster B traits (OR = 21.2) and finally this study mainly a replication of prior knowledge of psychosocial stressors.( Enrique Baca-Garcia, and Claudia.P.Parra,2007).

A cross-sectional study of 342 adolescents aged 10-19 years from 19 schools. Multivariate analysis showed that a history of self-violence, violent thoughts toward others, mental health diagnoses other than depression, and a history of sexual abuse were positively associated with suicide attempt. Sexual abuse, mental health diagnoses other than depression, self-violence, and ease of access to lethal substances/weapons were positively associated with suicide ideation and found a relatively high prevalence of suicide ideation and suicide attempts among adolescents living in Western Jamaica. An accurate understanding of the prevailing risk factors for suicide attempts will promote a more sympathetic approach to victims and facilitate prevention efforts.( Rudatsikira E,2010).

A cross-sectional school survey of 4,500 adolescent students based on a structured questionnaire. Data were collected using the supervised self-administered questionnaire (modified version of the Youth Risk Behavior Surveillance in the Malaysian National Language, Bahasa Malaysia). Seven percent (312 of 4,454) of the adolescent students had seriously considered attempting suicide. Among the adolescents, 4.6% had attempted suicide at least once during the 12 months preceding the survey. Female adolescents were more likely to put their suicidal thoughts into suicidal action than were male adolescents. Malay and Indian people are more likely than the Chinese to respond, “Felt sad and hopeless.” However, Malay adolescents had the lowest rate of attempted suicide. Based on multiple logistic regression, factors significantly related to urban adolescents’ suicide behavior are “Felt sad or hopeless,” “Number of days felt unsafe to go to school,” “Riding with a driver who had been drinking alcohol,” “Physical fight,” and “Number of days absent from school.” In comparison, factors relating to rural adolescents’ suicide behavior are “Felt sad or hopeless,” “Physical fight,” “Physical fight resulting in injury,” and “Drive a vehicle after drinking alcohol.” Adolescent suicide behavior should be viewed as a serious problem. Measures can be taken to prevent suicide by looking at the factors significantly linked to suicidal behavior among adolescents. Steps can then be taken to identify adolescents who have serious suicidal ideation so that intervention can be taken to reduce the suicidal rate.( Chen PC and Lee LK,2005).

A comparative study conducted at Slovenia in 2006 to compare coping styles among adolescents with and without deliberate self-harm concluded that suicidal ideation was associated with higher scores on emotional coping and lower scores on rational and detachment coping styles. Deliberate self-harm was associated with significantly higher scores on avoidance coping strategies and identified a need for improving coping strategies among deliberate self harm adolescents(Marusic A, Goodwin RD,2006).

A study conducted on the associations between peer and parental relationships and suicidal behaviour in early adolescents. Method used statistics Canada’s National Longitudinal Survey of Children Youth as the dataset. This cross sectional sample included 1049 girls and 1041 age 12 to 13 years. Answers obtained through self- report questionnaires that included measures of peer relationships, parental nurturance, and parental rejection, suicidal ideation and attempts. Result shows that among early adolescent boys and girls, depression, poor peer relationships, decrease parental nurturance and increase parental rejection wear all significantly associated with suicidal ideation and attempt.( Sarah A and Laurence YK, 2006).

2.2 Literatures related to Prevention of suicidal ideation

An experimental study was conducted to evaluate the effectiveness of a school – based suicide awareness intervention among adolescents in Louisville, Kentucky. A self – report questionnaire was used to collect data. A Solomon four – groups design was used to assess the efficacy of suicide intervention classes. The results revealed that, the experimental groups as compared with control groups showed significant gains in relevant knowledge about suicidal peers and significantly more positive attitudes toward help seeking and intervening with troubled peers. (Kalafat J.,2006).

A study was conducted to assess the efficacy of a school – based prevention programme for reducing suicide potential among high – risk youth in Washington, USA. A sample of 105 subjects at suicide risk participated in a three group, repeated – measures, intervention study. Participants in (1) an assessment plus 1 – semester experimental programme, (2) an assessment plus 2- semester experimental programme, and (3) an assessment – only group were compared, using data from pre – intervention, 5 month, and 10 – month follow – up assessments. The results suggested that, all groups showed decreased suicide risk behaviours, depression, hopelessness, stress, and anger; all groups also reported increased self- esteem and network social support. Increased personal control was observed only in the experimental groups, and not in the assessment – only control group. The potential efficacy of the experimental school – based prevention programme was demonstrated. The study concluded that, the necessary and sufficient strategies for suicide prevention have to be adopted. (Eggert LL, 2004).

A study was conducted to assess the impact of a suicide prevention programme for adolescents on suicidal tendencies, hopelessness, ego identity, and coping ability in Israel. 393 adolescents from six schools participated in the study. The subjects were randomly divided into experimental (n = 215) and control (n= 178) groups. The experimental groups took part in seven weekly 2 – hour meetings. In this pre-test – post-test design, the students completed questionnaires of suicidal tendencies, hopelessness, ego identity, and coping ability before and after the programme. The statistical analysis showed that the experimental groups were superior to the controls, with at least some of the dependent measures pointing out the effectiveness of the programme ( Orbach I, 2003).

An experimental study was conducted to evaluate the effectiveness of the Signs of Suicide (SOS) prevention programme in Farmington, USA. 2,100 students in 5 high schools were randomly assigned to intervention and control groups. Self administered questionnaire were completed by students in both groups approximately 3 months after programme implementation. The results revealed that, significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide were observed among students in the intervention group than control group. The study concluded that, SOS is the first school – based suicide prevention programme to demonstrate significant reductions in self reported suicide attempts (Eggert LL and Thompson EA,2007).

A study was conducted on the effectiveness of school based psycho-educational programme in suicide prevention in adolescents. Sample collected from 172 high school students in the 16-18 age group include 108 girls and 64 boys. Method used a structured self-report questionnaire. The results show that the programme had no effect on coping styles and level of hopelessness. However positive effect on knowledge could be identified an interaction effect of the programme with gender on attitude was also found. A negative impact of programme could not be found. Findings from study suggest that psycho-educational programs in schools may influence knowledge about suicide and attitudes towards suicidal persons but may not affect the use of coping styles or levels of hopelessness (Gwendolyn P and Kees VH,2006).

A study was conducted on the evaluation of the signs of suicide prevention program where data was collected from 4133 students in 9 schools. Method used self administered questionnaires completed by students in both groups approximately 3 month after the program implementation. Result shows significantly lower rates of suicide attempts and greater knowledge and more adaptive attitude about depression and suicide were observed in intervention group.( Robert H and Asetine J,2007).

A study was conducted on to develop and evaluate the effectiveness of an Informational Booklet on cancer risk factors among college students, nurses and doctors at university of Delhi. The objectives of the study was (1) to prepare an informational booklet on cancer risk factors (2) to assess the knowledge before and after the administration of informational booklet on cancer risk factors and (3) to determine the acceptability and utility of an informational booklet by college students, nurses and doctors. The one group pre-test post-test pre experimental research design adopted Convenient sampling method was used to select sample size 30. The data collection instruments used were (I) a structured knowledge questionnaire to assess the knowledge of students and (2) two structured opinionnaires were used to gather opinion regarding acceptability and utility of the booklet from college students, doctors and nurses. The results shown that information booklet is effective in increasing the knowledge of the college students as evident from ‘t’ (29) = 52.44 higher significant. Doctors and nurses were higher and close to the maximum possible acceptability and utility scores. The study concluded that the informational booklet was acceptable and useful for findings cancer risk factors ( Bairwa KS,2002).

CHAPTER – III

MATERIALS AND METHODS

Research design provides the glue that holds the research project together. A design is used to structure the research, to show how all of the major parts of the research project. This study was designed to find out effectiveness of structured teaching programme in promoting knowledge on preventive measures of suicidal ideation among adolescents. This study was conducted by adopting following steps of research process as research design, setting, population and sampling, criteria for selection of samples, instruments and tools for data collection and methods of data analysis. Pilot study was conducted and changes were incorporated.

3.1 Research Design:The study was based on one group pre test and post test design. Pre test knowledge on preventive measures of suicidal ideation among adolescents was assessed before providing education programme. Education regarding what is suicide, risk factors,misconceptions and facts, preventive measures of suicide was delivered through lecture cum discussion method by using LCD, blackboard. After a period of 5 to 7 days of education, the knowledge on preventive measures of suicidal ideation among adolescent was reassessed. The paired ‘t’ test was used to compare the pre test score and post test score and assosciation was used to find among variables.

3.2 Setting of the Study: The study was conducted in Priyadarshini High school Pithapuram, Andhra Pradesh.

3.3 Population: The population of this study consisted of adolescents in the 9th standard.

3.3.1 Sample size: Size was determined by purposive sampling. All adolescents in the 9th standard were taken for the study 50 students.

3.4 Criteria for selection of sample:

Inclusion criteria:

Adolescents in the class of 9th standard

Variables of the study:

3.5.1 Independent variable: The independent variable in this study is structured teaching programme on preventive measures of suicidal ideation.

3.5.2 Dependent variable: The dependent variable in this study is knowledge level gained by adolescent.

3.6 Instruments and tools for data collection: A questionnaire was prepared to assess the knowledge of adolescents towards preventive measures of suicidal ideation . A structured questionnaire was developed based on literature, journal, text book. The questionnaire has two aspects demographic data and questionnaire on preventive measures of suicidal ideation.

Section A: The demographic data includes sample number, age, sex, number of siblings, religion, family profile.

Section B: This section consists of 25 questions, for each question 4 options were given in that only one is correct, students have to tick any one of the 4 options. For each question one mark was awarded, maximum mark obtained was 25. It was mandatory that all the 25 questions should be responded by the student.

Scoring:

Adequate : >75%

Moderately adequate: 50 -75%

Inadequate : <50%

3.7 Reliability and validity of instruments and tools for data collection: The tool was prepared with the help of literature, research and subject guides. The reliability and validity was tested through pilot study. Additions and modifications suggested by experts were included in the tool.

3.8 Data Collection Procedure: Data collection was done in the month of July; data was collected through self administered questionnaire. After assessment education was delivered through lecture cum discussion using LCD, charts, black board. Doubts were clarified at the end of teaching. The reassessment was done after 5 to 7 days from the day the education started.

3.9 Method of Data Analysis and Interpretation: Frequency distribution tables were formulated for all baseline information. Frequencies were tabulated to understand the knowledge on preventive measures of suicidal ideation. The distribution pattern was depicted through appropriate graphical methods. Results were inferred through statistical techniques likes paired ‘t’ test and association was used among variables.

3.9.1 Paired ‘t’ test: This formula was adopted to find out the significant difference between pretest and post test score, of adolescents to understand the knowledge on preventive measures of suicidal ideation.

= Mean difference between pretest and post test score.

d = Difference between pretest score and post test score.

SD = Standard deviation of the pretest score and post test score.

= number of samples.

3.10 Report of Pilot Study: Pilot study was conducted in Priyadarshini School, Pithapuram,Andhra Pradesh. For the Pilot Study 16 Students were taken from 9th standard. The questionnaire was given to the students for the assessment of knowledge on Prevention Of suicidal ideation, after Pre-test it was found that only 2 students had adequate knowledge, 13 had moderately adequate knowledge,1 had in adequate knowledge. After structured teaching programme, the result of the Post test is as follows, 8 students had adequate knowledge, 8 students had moderately adequate knowledge. None of them had inadequate knowledge.

3.11. Changes Brought After pilot Study: After the pilot study changes were made in the questionnaire.

CHAPTER -IV

DATA ANALYSIS AND INTERPRETATION

Data analysis is the process of analyzing the data in such a way that the research questions can be answered (Hungler and Polit, 2004). This chapter deals with analysis and interpretation of data collected from students of Priyadarshini high school in Pithapuram, A.P. Students’ knowledge on preventive measures of suicidal ideation w

 

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