INTRODUCTION:

“The imagination exercises a powerful influence over every act of sense, thought, reason over every day”

-Latin Proverb

Premenstrual syndrome (PMS) refers to symptoms that occur between ovulation and the onset of menstruation. The symptoms include both physical symptoms, such as breast tenderness, back pain, abdominal cramps, headache, and changes in appetite, and psychological symptoms of anxiety, depression, and unrest. Severe forms of this syndrome are referred to as premenstrual dysphoric disorder (PMDD). These symptoms may be related to hormones and emotional disorders. Approximately 75 percent of all menstruating women experience some symptoms that occur before or during menstruation. Premenstrual syndrome encompasses symptoms severe enough to interfere with daily life. The symptoms of this disorder are related to the specific biological characteristics of women's reproductive age that can start from teen years. The symptom’s devastating effect on these crucial years of life can result in a sense of dissatisfaction and inadequacy.¹ Premenstrual symptoms are the cycle changes that a woman perceives as troublesome or problematic which escalate before menstruation, whereas PMS is a diagnostic term used for the cyclic recurrence of psychological and/or physical symptoms within the luteal phase of menstrual cycle. The etiology of the premenstrual experience has progressed from a supposed hormonal imbalance to psychological to a more recent multi-causal origin. Premenstrual symptoms have been associated with perceived stress, whereby perceived stress was the strongest predictor of Premenstrual Syndrome and had a significant positive correlation to all premenstrual symptom group.²

Premenstrual syndrome (PMS) has been conceptualized as a static pathological entity caused by biomedical or psychological factors, with women categorized dichotomouslyas PMS sufferers or non-sufferers on the basis of assessment by standardized instruments However, it has recently been recognized that whist many women experience premenstrual changes in emotion, behaviour, or embodiment, they do not inevitably position these changes as PMS, and do not inevitably experience distress. Equally, it has been argued that PMS exists on a continuum, ranging from minimal to moderate–severe symptom severity, and that women’s distress should be the focus of interest, rather than the categorization of women as having or not having PMS is not the underlying pathology that causes distress, but is the distress itself.³

Women are affected irrespective of socioeconomic status, race, or cultural background, and family clusters are well documented. The causes of the premenstrual syndrome have not been clearly elucidated but have been attributed to hormonal change, neurotransmitters, prostaglandins, diet, drugs, and lifestyle, so causal treatment is difficult. The mechanism of action may also be related to modulation of stress induced prolactin secretion via dopamine, without directly affecting luteinising hormone or follicle stimulating hormone. Binding to opioid receptors, β endorphins, and neuroactive flavonoids may also have a role. The plant has been used traditionally to relieve the symptoms of the premenstrual syndrome, although systematic evaluation of its efficacy is relatively recent.⁴

Imagery had been found to be very effective for the treatment of stress. Imagery is at the center of relaxation techniques designed to release brain chemicals that act as your body's natural brain tranquilizers, lowering blood pressure, heart rate, and anxiety levels. By and large, researchers find that these techniques work. Because imagery relaxes the body, doctors specializing in imagery often recommend it for stress-related conditions such as headaches, chronic pain in the neck and back, high blood pressure, spastic colon, and cramping from premenstrual syndrome. Imagery can also help alter menstrual cycles and relieve symptoms of premenstrual syndrome. In a preliminary study, researchers at Massachusetts General Hospital in Boston found that 12 of 15 women, ages 21 to 40, who used imagery for three months lengthened their monthly menstrual cycles by an average of nearly four days and slashed their perceived levels of premenstrual distress in half. They also reported fewer mood swings.⁵

At the University of South Florida in Tampa, researchers asked 19 men and women, ages 56 to 75, who had chronic bronchitis and emphysema to rate their levels of anxiety, depression, fatigue and discomfort before and after they began using imagery. The researchers concluded that imagery significantly improved the overall quality of these people's lives.⁶

Advocates of imagery contend that the imagination is a potent healer that has long been over looked by practitioners of Western medicine. The power of the mind to influence the body is quite remarkable. Although it isn't always curative, imagery can be helpful in 90 percent of the problems that people bring to the attention of their primary care physicians. At the University of South Florida in Tampa, researchers asked 19 men and women, ages 56 to 75, who had chronic bronchitis and emphysema to rate their levels of anxiety, depression, fatigue and discomfort before and after they began using imagery. The researchers concluded that imagery significantly improved the overall quality of these people's lives.⁶

NEED FOR THE STUDY:

Recent studies show that as many as 80% of American women have premenstrual syndrome at some time during the average 400 menstrual cycles occurring between menarche and menopause, or the time between when the menstrual period start at puberty and when it ceases after menopause. Although there is no therapeutic "cure" for premenstrual syndrome, the good news is that there are significant, new advancements in understanding and managing it--break-through that mean improvements in the quality of life for literally millions of women. Though there is no doubt that women suffer from premenstrual syndrome, many endure the discomfort and pain in silence or complain only to family and friends because they do not realize that anything can be done to help them. Not so, but the way premenstrual syndrome is managed depends on identifying specific challenges, when they occur and how severe they are. It is important for a woman to take charge of understanding her premenstrual syndrome patterns and learning about what's happening within her body. Only then can she realistically evaluate their effects on her life and make informed decisions about management.⁶

Recent research has suggested that the construction of premenstrual change as PMS is an ongoing process of negotiation, associated with the mode of appraisal and coping adopted by women in the context of relationships (Ussher, 2002). For example, in a qualitative study of women who reported moderate–severe premenstrual distress, PMS was characterized by expressions of over-sensitivity, irritation, or anger within family relationships, particularly in situations where there were overwhelming demands from partner or children (Ussher, 2003) This pathologization is associated with hegemonic constructions of femininity which dictate that ‘good’ women are eternally calm, in control, and self-sacrificing in relationships (O’Grady, 2005), and there productive body is positioned as the site of the ‘monstrous feminine’ (see Ussher,2006). Transgressions from gendered ideals are thus blamed on the body, and the interpersonal or political problems that are associated with women’s premenstrual distress are disavowed (Chrisler and Caplan, 2002).⁷

Imagery can also help alter menstrual cycles and relieve symptoms of premenstrual syndrome. In a preliminary study, researchers at Massachusetts General Hospital in Boston found that 12 of 15 women, ages 21 to 40, who used imagery for three months lengthened their monthly menstrual cycles by an average of nearly four days and slashed their perceived levels of premenstrual distress in half. They also reported fewer mood swings using guided imagery to reduce the severity of Premenstrual syndrome and menstrual pain can lead to increased comfort and decreased absenteeism, without the cost and potential undesirable side effects of some medications.⁵

The research conducted on the effects of regular, moderate exercise on mood states and menstrual cycle symptoms. A group of female regular exercisers (N = 97), and a second group of female nonexercisers (N = 159), completed the Menstrual Distress Questionnaire (MDQ) and the Differential Emotions Scale (DES-IV) premenstrually, menstrually and intermenstrually. Multivariate analyses of covariance (MANCOVAs) revealed significant effects for exercise on negative mood states and physical symptoms, and significant effects on all measures across menstrual cycle phase. The regular exercisers obtained significantly lower scores on impaired concentration, negative effect, behaviour change and pain. No differences were found between groups on positive affect and other physical symptoms.⁸

Clinically significant premenstrual syndrome occurs in 20% of girls. It is important for a girl to take charge of understanding her premenstrual syndrome patterns and learning about what's happening within her body. Only then she can realistically evaluate their effects on her life and make informed decisions about management. Hence the researcher felt the need to find the prevalence of PMS by guided imagery technique among the adolescence girls.

OBJECTIVES:

1. To assess the level of premenstrual syndrome among the first year B.Sc. nursing students.

2. To evaluate the effectiveness of guided imagery technique in alleviating premenstrual syndrome among the first year B.Sc. nursing students.

3. To find out the association between the level of premenstrual syndrome with selected demographic variables such as age in years, age at menarche, religion, dietary habits, cycling period, remedial measures used in PMS, family history of PMS.

MATERIAL AND METHODS:

Research approach:

The research approach adopted for this study is quantitative approach.

Research design:

The research design selected for this study belongs to the pre experimental design with one group pre and post test design.

Variables:

Independent variable:

In the present study the independent variable refers to the guided imagery technique for alleviating premenstrual syndrome.

Dependent variable:

In this study the dependent variable is the premenstrual syndrome among the first year B.Sc. nursing students.

Setting of the study:

The study was conducted in Anuradha College of nursing and Columbia College of nursing at Bangalore. The selected setting was provided the required samples adequately, feasibility and accessibility of the sample.

Population:

The target population for the study was first year B. Sc nursing students those who are present in the selected colleges of Bangalore.

Sampling technique:

Purpoive sampling technique was used.

Sample size:

60 first year B. Sc nursing students those who fulfilled the inclusion and exclusion criteria.

Sampling Criteria:

Inclusion criteria: First year B.Sc. nursing students,

· Who are studying in first year

· Who are in the age between 18 to 21

· Who are willing to take part in the study

· Who are suffering from premenstrual syndrome

Exclusion criteria:

First year B.Sc. nursing students,

· Who are not willing to take part in the study

· Who do not suffer from premenstrual syndrome

· Who do not study in first year

Method of data Collection:

The investigator met all the students and gave brief introduction of self and the nature of the study, rapport was established with the students. Consent to participate in the study was obtained from the students.

Phase-I: - With prior informed consent, pre-test was conducted through structured premenstrual syndrome assessment scale.

Phase-II: - The investigator provided guided imagery technique to the samples.

Phase-III: - After 21 days, post test was conducted to the samples.

All the subjects were very co-operative and investigator expressed her gratitude for, their co-operation. Data collected was processed every day. Missed out information was identified and immediately next day it was rectified.

Development of the tool:

Steps in Construction of the Tool:

The following steps were carried out in preparing the tool:

· Related literature was reviewed in preparing of tool.

· Preparation of blue print

· Guidance and construction of the subject experts were taken for construction of tool.

Review of Literature:

Related literature review like books, journals, articles, periodicals, published research studies were reviewed and used for the development of the tool.

Description of the Tool:

The tool consists of 2 parts.

Part 1: Consist of demographic data such as age in years, age at menarche, religion, dietary habits, cycling period, remedial measures used in PMS, family history of PMS.

Part 2: It consists of structured premenstrual syndrome assessment scale with 25 items. Each item has 5 responses with one response answer on perception of symptoms among the students with premenstrual syndrome. The 25 items were subdivided as physiological, emotional and behavioral symptoms of premenstrual syndrome. Based on the percentage of scores the levels of premenstrual syndrome were graded in five categories. They are “no symptoms”, “mild”, “moderate”, “severe” and “extreme”.

Table-1: actual score of premenstrual symptoms

Sr. No.	Level of symptoms	Actual score
1	No symptoms	1-25
2	Mild	26-50
3	Moderate	51-75
4	Severe	76-100
5	Extreme	101-125

Guidance and construction of the subject experts were taken for construction of tool:

Experts in the field of obstetrics and gynecology consulted for developing an appropriate tool.

Development of the guided imagery technique:

A first draft of guided imagery technique developed, keeping in mind the objectives, literature review and the opinion of experts the guided imagery technique was 100% agreement regarding content and images by all experts except minor modifications.

Description of the guided imagery technique:

The images are recorded on the DVD with pleasant music. The images recorded are waterfalls, rain, beach waves, breeze, birds flying, peaceful natural scene, rolling hills, sunset, snow, and darkness begins in to light.

Content Validity of the Tool:

The structured questionnaire so prepared was given to experts for content validity who were requested to render their opinion about the relevance of the items of the study. Out of this 5 experts were opted from obstetrical and gynecological nursing, two gynecologists, and one Biostatistician the total was modified as per the recommendation of the experts.

Reliability of the Tool:

The reliability r = 0.87

Feasibility:

The language of the tool was found to be clear and all the items in the tool were clearly understood by the subject without ambiguity. Hence the tool was found to be feasible and practicable for the study.

Translation of the tool:

After establishing content validity the tool was translated by language experts in English.

Pilot Study:

To find out the practicability and feasibility of the tool a pilot study was conducted at Sri Shanthini College of nursing in Laggere situated at Bangalore in the month of October 2012. The permission was obtained from the principal and students who met the inclusion criteria were selected by using purposive sampling. The investigator given self-introduction, explained the purpose of study and the written consent was obtained from the subjects and assuring them to maintain the confidentiality of the information provided. The pilot study was conducted with 6 first year B. Sc nursing students. The mean post test scores 85.7 %was higher than the mean pre-test scores 39.3% with t- value 13.07 being significant at 0.05 level. The findings of the data indicate that this study is feasible.

Data Collection Procedure:

Formal permission was obtained from the concerned authority to conduct the study. The study was conducted during the month of November 2012 in Anuradha College of Nursing and Columbia College of Nursing, Bangalore. Samples were selected in accordance with laid down criteria’s consent was obtained from the students.

Pre test (O1):

Data collection is the gathering of information from the sampling units. The investigator collected data from 60 samples in Anuradha College of Nursing and Columbia College of Nursing, Bangalore. The need for the study and the objectives were explained to the students and confidentiality was assured. An average of 10 students was administered with the tool per day and approximately 20 minutes were spent for collecting the data from each sample.

Administration of Guided Imagery Technique:

After pre-testing, 20 minutes guided imagery technique was shown to the subjects for 3 weeks.

Post test (O2):

Post test was conducted on 21^th day to find out the effectiveness of guided imagery technique in alleviation of premenstrual syndrome. Each subject took about 20 minutes to complete the post-test. All the participants co-operated well with the investigator in both pre-test and post-test. The data collection process was terminated by thanking the subjects.

ETHICAL CONSIDERATION:

· Permission was obtained from the concerned authority.

· Written informed consent was obtained from all participants of the study after explaining the purpose and other details.

· The subjects were asked to maintain confidentiality of the data obtained

· The subjects were informed that their participation was voluntary, had the freedom to drop out training program at any

Plan of Data analysis:

The collected data was analyzed by using the descriptive and inferential statistics to evaluate the effectiveness of guided imagery technique in alleviation of premenstrual syndrome among first year B.Sc. nursing students. The sample characteristics described by using the descriptive statistics such as mean, SD and percentage. The effectiveness of guided imagery technique was analyzed by using paired ‘t’ test and chi-square test was used to describe association of sociodemographic variables with post test score.

RESULT AND DISCUSSION:

Presentation of data:

The analyzed data has been organized and presented in the following sections:

Section-1: Description of selected demographic variables of the first year B.Sc. nursing students.

Table-2 shows that 70% samples were distributed in 18-19 years, 21.67% were distributed in the 19-20 years, 8.33% distributed in 20-21 years. 20% of samples were distributed below 13years, 58.33% were distributed in 14-16 years, 21. 66% were distributed above 16 years. Maximum respondents were Christians 55%, only 5% were Muslims and Hindus being 40%. 90% respondents were belongs to non vegetarian and 10% were belongs to vegetarian. 66.67% respondents were in the 28 days of period, 26.67% were in the 29-30 days of period, 6.67% were more than 30 days of period. 75% respondents were using oral analgesic, 10% were using dietary intervention and 15% were using fluid therapy. 31.67% respondents were belongs to first line relatives, 25% were belongs to second line relatives and 43.3% were not oriented.

Table – 2: Classification of Respondents by Demographic Characteristics n=60

S. No	Demographic variables	Number	%
1	Age
	a. 18-19 years	42	70
	b. 19-20 years	13	21.667
	c. 20--21 years	5	8.3333
2	Age at Menarche
	a. < 13years	12	20
	b. 14--16 years	35	58.333
	c. > 16 years	13	21.667
3	Religion
	a. Hindu	24	40.0
	b. Christian	33	55.0
	c. Muslim	3	5.0
4	Dietary habits
	a. Vegetarian	6	10.0
	b. Non vegetarian	54	90.0
5	Cycling period
	a. 28 days	40	66.67
	b. 29--30 days	16	26.67
	c. More than 30 days	4	6.67
6	Remedial measures used for premenstrual syndrome
	a. Oral analgesic	45	75.00
	b. Dietary intervention	6	10.00
	c. Fluid therapy	9	15
7	Family history of premenstrual syndrome
	a. First line relatives	19	31.67
	b. Second line relatives	15	25.00
	c. Not oriented	26	43.33
	TOTAL	60	100

Graph-1 shows that the percentage, in the pre-test, Level of physiological symptoms Mean is 55.4, SD 5.83 and Mean percentage 79.1%, Level of emotional symptoms Mean is 19, SD 5.21 and Mean percentage 76%, Level of behavioral symptoms Mean is 21.4, SD 4.89 and Mean percentage 71.3%, Over all pre test level Mean is 95.8, SD 6.79 and Mean percentage 76.6%.

Section -2: Analysis and interpretation of pre -test and post- test score of level of premenstrual syndrome of first year B.Sc. nursing students.

Pre test level on Premenstrual Syndrome:

Graph .1: Classification of Respondents Aspect wise Mean% of Pre test on Premenstrual syndrome

Graph 2: Classification of Respondents on Pre and Post test level on premenstrual syndrome

TABLE – 5: Association between Demographic variables and Post test level of Premenstrual Syndrome n=60

S. No	Demographic Variables	No	%	Level of premenstrural syndrome				Chi square
				≤ Median (36)		< Median (24)
				No	%	No	%
1	Age
	a. 18--19 years	42	70.00	26	61.9	16	38.1	0.9
	b. 19--20 years	13	21.67	8	61.5	5	38.5	df 2
	c. 20--21 years	5	8.33	2	40.0	3	60.0	N.S
2	Age at Menarche
	a. < 13years	12	20.00	10	83.3	2	16.7	7.24
	b. 14--16 years	35	58.33	16	45.7	19	54.3	df 2
	c. > 16 years	13	21.67	10	76.9	3	23.1	S
3	Religion
	a. Hindu	24	40.00	12	50.0	12	50.0	1.67
	b. Christian	33	55.00	22	66.7	11	33.3	df 2
	c. Muslim	3	5.00	2	66.7	1	33.3	N.S
4	Dietary habits
	a. Vegetarian	6	10.00	2	33.3	4	66.7	1.97
	b. Non vegetarian	54	90.00	34	63.0	20	37.0	df 1 N.S
5	Cycling period
	a. 28 days	40	66.67	19	47.5	21	52.5	8.02
	b. 28--30 days	16	26.67	14	87.5	2	12.5	df 2
	c. More than 30 days	4	6.67	3	75.0	1	25.0	S
6	Remedial measures used for premenstrual syndrome
	a. Oral analgesic	45	75.00	26	57.8	19	42.2	0.38
	b. Dietary intervention	6	10.00	4	66.7	2	33.3	df 2
	c. Fluid therapy	9	15.00	6	66.7	3	33.3	N.S
7	Family history of premenstrual syndrome
	a. First line relatives	19	31.67	14	73.7	5	26.3	9
	b. Second line relatives	15	25.00	12	80.0	3	20.0	df 2
	c. Not oriented	26	43.33	10	38.5	16	61.5	S

Table- 5 shows that the association between the level of premenstrual syndrome and socio demographic variable. The chi-square value shows that there is no significance association between age in years, religion, remedial measures used in premenstrual syndrome.

CONCLUSION:

The study concluded that maximum number of students (70%) were from the age group of 18-19 years. The data shows that (58.3%) of students atttained menarche at the age of 14-16 years. (55) of them belonged to the religion of christian. Majority of them belongs to the non vegetarian (90%) and (66.6%) of students had a cycling period of 28 days. About (75%) of the students were using the oral analgesic as a remedial measures for premenstrual syndrome. The majority of the students (43.3%) were belongs to the non oriental family history of premenstrual syndrome.

The study also concluded that 53.3% were had moderate symptoms during pre test but during post test 8.3% of the students had moderate symptoms and 20% of students had only mild symptoms of premenstrual syndrome.

IMPLICATIONS OF THE STUDY:

The finding of the study has implication in nursing education, nursing practice, nursing administration and nursing research.

Nursing Education:

1. Specialized training course on alleviation of premenstrual syndrome among the students is a comprehensive individualized approach.

2. Students of midwifery should be given an opportunity to teach about the guided imagery technique in clinical setting.

3. Schools of nursing should consider the inclusion of women-centered care curriculam at both the undergraduate and graduate levels.

4. Midwife educators should incorporate the findings into premenstrual syndrome education classes to help the students to develop realistic and positive expectations.

Nursing Practice:

1. Nursing professionals working in hospital and community to educate the adolescent girls regarding guided imagery in premenstrual syndrome.

2. Nursing personnel need to be equipped with appropriate measures to alleviate the premenstrual syndrome.

3. It is important to explore and discover the wishes and feelings of women in their care so that realistic expectations can be promoted and then hopefully fulfilled.

Nursing Administration:

Nurse administrator should plan in service education program for nurses to enhance their knowledge. For this, she should include all research findings in teaching program and conduct continuing education program periodically. Nurse administrators are in the key position to organize, implement and evaluate staff education programs which will in turn help to raise the standards.

Nursing Research:

Research in nursing about various aspects of premenstrual syndrome is a mile stone in the methodology aspects. Trained nurses enhance the adaptation to the technological advancement and creative, critical thinking skills. This will increase thirst for the evidence based practice and effective utilization research approaches.

SUGGESTIONS:

The nurse midwives should consider the potential, psychological, emotional aspects of adolescent girls. Adequate assessment of the level of premenstrual syndrome will help to prevent discomfort among the girls.

RECOMMENDATIONS:

1. The Study can be replicated on large sample and their findings can be generalized to large group

2. A comparative study can be done with guided imagery and alternative therapies.

3. The study can be done in a large setting

4. A longitudinal study to find out the guided imagery for long lasting therapeutic effect on PMS can be taken up.

5. A similar study can be done in a true experimental study.

LIMITATION:

Health is the wealth. In this study limited to the students those who are in the selected setting .Generalization is limited selected sample. An Increase sample size and duration of the study would be an overall measure to assess the effectiveness of guided imagery technique.

SUMMARY:

The chapter has brought out the various implications and also has provided the suggestion and recommendation for future studies. Evidence based approach in the premenstrual syndrome is an important area to promote healthy life style and practices in day to day life.

REFERENCE:

1. Hunfeld JA et al. Chronic pain and its impact on quality of life in adolescents and their families. Journal of Pediatric Psychology.26; 2001:145-153.

2. Hulstein, Pamela Lou. Premenstrual Symptoms and Academic Stress in Emerging Adulthood Women. A review: Available from: http://arizona.openrepository.com/arizona/bitstream/10150/196113/1/azu_etd_10308_sip1_m.pdf

3. Janet Perz, Journal of reproductive and infant psychology.24 (4); 2006:289–303.

4. Annamma Jacob, a Comprehensive Textbook of Midwifery. Jaypee brothers Medical publishers Ltd, New Delhi.2008.

5. Guided Imagery or visualization. A review: Available from: http://www.holisticonline.com/guided-imagery.htm

6. Guided Imagery or visualization. A review: Available from: http://www.successwaves.com/articles-breakthrough-nlp-business-coaching/visualization-guided-imagery-breakthrough-business-coaching-01.html

7. Jane M Usshe, Women’s experience of premenstrual syndrome. Journal of Reproductive and Infant Psychology 24(4); 2006: 101-105

8. Aganoff JA, Boyle GJ, Aerobic exercise, mood states and menstrual cycle symptoms, 1994 Apr;38(3):183-92. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8027958

9. Ziba Taghizadeh, Shirmohammadi, Arbabi, The effect of premenstrual syndrome on quality of life in adolescent girls. Iranian J psychiatry.3(3); 2008:105

Received on 20.12.2016 Modified on 01.02.2017

Asian J. Nur. Edu. and Research.2017; 7(3): 399-406.

DOI: 10.5958/2349-2996.2017.00080.5

Aspects wise knowledge	Pre test			Post test			Enhancement
Aspects wise knowledge	Mean	SD	Mean%	Mean	SD	Mean%	Mean	SD	Mean%
Physiological symptoms	55.4	5.83	79.14	39	3.4	55.71	16.4	3.8	23.4
Emotional symptoms	19	5.21	73.80	14	3.11	56.00	5	2.85	20.0
Behavioural symptoms	21.4	4.89	69.00	16	2.89	53.33	5.4	2.15	18.0
Overall	95.8	6.79	75.64	69	4.12	55.20	26.8	4.15	21.4

Aspects wise knowledge	Enhancement			Paired 't' test
Aspects wise knowledge	Mean	SD	Mean%	Paired 't' test
Physiological symptoms	16.4	3.8	23.4	33.4**
Emotional symptoms	5	2.85	20.0	23.6**
Behavioural symptoms	5.4	2.15	18.0	19.5**
Overall	26.8	4.15	21.4	50**
**Significant at P<0.01 level df 59, t cal = 2.66