1
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY FACULTY OF PUBLIC HEALTH
THE MASTER THESES OF PUBLIC HEALTH
Acne and it’s associations with
psychosocial well-being among adolescents in
Nellore (India)
Amina thazin Khan
Name Surname
(date)
Supervisor
(
dr. Vilma Zaltauskee Name
Surname
(date)
2
Approved by the Council of the Faculty of Public Health
of the Lithuanian University of Health Sciences (LSMU) and the Publishing Commission of the Lithuanian University of Health Sciences
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TABLE OF CONTENTS
1. Preface ...4
2. Summary ...6
Aim and Objectives of the study...6
3. Introduction ...8
3.1. Problem discussion...8
3.2. Psychological effects ...9
4. Literature review...11
3.1. Causes and symptoms of acne...14
3.2. Factors influencing Quality of life...16
5. Methodology ...17
6. Results...19
5.1.
The prevalence of acne among 14-16years of adolescents...19
5.2. The level of emotional, social impairments among adolescents...21
5.3. Association between acne and psychosocial well-being...23
7. Conclusion ...31
8. Practical recommendation...32
9. References...33
4
Preface
---
First and foremost, I would like to seize the moment and express our
appreciation to our supervisor Vilma Zaltauske for her constructive criticism
and encouragement throughout the execution of this thesis.
I would also like to take the occasion to extend my sincere thanks to all of you
participating in the pre-test of my questionnaire. Your critical remarks were of
highest importance for my research. In conclusion, I would like to, once again,
thank you for your support and trust!
Kaunas, June 2018
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LIST OF ABBREVIATIONS
QOL – Quality of life
BDI- Becks Depression Inventory
NCBI- National Center for Biotechnology Information HI - Health Informatics
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SUMMARY
Public health
Acne and it’s associations with psychosocial well-being among adolescents in Nellore (India)
Amina thazin Khan
Scientific Supervisor Dr. Vilma Žaltauskėe
Lithuanian University of Health Sciences, Faculty of Public Health, Department of Preventive Medicine. Kaunas; 2018, p.37.
Aim: The aim of this study was to determine the prevalence of acne and it’s associations
among the level of emotional, social impairments in adolescents of south Nellore district.
Objectives:
1. To assess the prevalence of acne among 14-16years of adolescents. 2. To evaluate the level of emotional, social impairments among adolescents.
3. To analyze association between acne severity and psychosocial well-being among adolescents.
Methods: A cross-sectional study was carried out in 2017 in Nellore city, India. The
participants of the study were 14-16 years old school children. Based on the overall population of middle schools in Nellore, simple random sample method was employed for composing a representative sample and Sample size was 97 students. The data were collected by means of anonymous questionnaires. The self-reported questionnaires (original) were used. Two measures of psychometric evaluation were applied to assess specific psychosocial impairments, which are as follows: Self-made standard Questionnaire and Beck Depression Inventory (BDI). The whole reported questionnaire consisted of 45 questions.
Results: There were 49.5% of males and 50.5% of females in the survey, and the skin of
females was more prone to acne a lot more than males. The mean age of the overall research sample when they got acne for the first time was 14.3 years. The results showed that about 33 % of the survey population was emotionally affected by the onset or presence of acne. And about 5% of the sample agreed that acne was highly bothering. (figure2.1)
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The psychological effect of acne on these teenagers was negative as 52% of the survey sample, was affected by a low self-esteem, which made them to avoid meeting people when they had acne. 43.2% of them were not happy with their looks.
As the results show, that 27.6% of the pupils were suffering from depression. More than half (56.1%) of Nellore adolescents felt sad about their looks and physical appearance. Around 4.1% of overall teens said that they were so sad that they cannot stand it; 3.1% of them felt that their future is hopeless and things cannot improve.
Conclusion: There is a significant impact of acne on psychological symptoms, emotions,
daily and social activities, study/work, and overall health. In conclusion, light must be put on the numbers; teenagers are affected by acne/prevalence of acne among teenagers. As seen in my research more girls were more vulnerable to acne. There were symptoms seen in teenagers of Nellore city, such as low self-esteem, worry about their physical appearance, and to some extent depression. A proper guidance and help is a right of every individual. The impairment of quality of life can be alleviated by appropriate topical acne treatment along with psychosocial support.
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Introduction
Acne is a very common dermatological condition in over 85% of adolescents and frequently continuing in adult and mid-adult life. It is a skin condition characterised by pimples on body especially face due to inflamed or infected sebaceous glands. Uncommonly it can cause reflective psychological disturbance and depression; sometimes it even leads to development of suicidal tendencies. [1]
Major complications of acne are scarring and psychosocial anguish, which persists long after the active lesions have disappeared. Its onset in adolescence may add to the emotional and psychological challenges experienced during this period, and it can lead to the developmental issues of body image, socialization, and sexuality. [2] [3] [4]
Psychological issues such as dissatisfaction with appearance, embarrassment, self-consciousness, lack of self-confidence, and social dysfunction such as avoidance of social interactions with peers and opposite gender. According to researchers, reduced employment opportunities of people affected with acne have been documented.
Acne can negatively influence the intension to participate in sports. Furthermore, anxiety and depression are found to be more prevalent among acne patients than controls. [5][6][7] Even suicidal ideation was found in 6–7% of acne patients. Although acne was earlier considered to be merely a cosmetic affliction, the psychosocial effects of the disease have now been scientifically proven [8][9]
It is considered that patients with moderate-to-severe acne suffer from poor body image, low self-esteem, and experience social separation and constriction of activities. As part of the emotional impact, increased levels of anxiety, anger, depression, and frustration are also observed in patients with acne. Given the fact that acne causes psychological suffering, acne can affect social, vocational, and academic performance of teenagers. [10]
Many people who get acne experience a reduction in self-esteem. Acne can make people feel a range of emotions, including frustration, sadness, and anger. This is well known. However, in this research we will look at the relationship between, particularly, acne and depression, which is a mood disorder that comes with feelings of sadness and a general loss of interest that persists over time. It is thus necessary to reveal those at risk of experiencing a psychological problem and to identify variables predicting this impairment. Acne and depression often occur together, which means they are "correlated," but there is not a clear cause-and-effect relationship.
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This means that acne does not essentially cause depression, or vice versa. However, there is verification that each condition can affect the other: acne may worsen depression, and depression may worsen acne.
People often report that stress, including depression, triggers their acne flares. If depression caused the acne flare, then we would expect that treating the depression would also treat the acne. However, this is not the case. In fact, some acne patients complain that their acne becomes worse when being treated for depression and acne is listed as a possible side effect of some antidepressants.
Depression Sometimes Accompanies Acne: Although acne is a physical disease, it can result in considerable psychological distress and is correlated with depression. The psychological impairments in acne include higher rates of depression, anxiety, anger and suicidal thoughts.” Similarly, the Canadian Dermatology Association stated that acne is correlated with multiple psychological effects, including depression. According to their website, “A Canadian study of nearly 500 patients with acne published in the British Journal of Dermatology found that even having mild acne can bring on feelings of low self-esteem, depression and suicidal thoughts.” [11]
Causes of acne: There are various causes why Acne develops. Apart from rising hormone levels due to puberty, it can be credited to certain other factors like intake of drugs, which contain lithium, barbiturates, and corticosteroids lead to the development of acne. Acne can also be caused due to surplus grease and oil in the scalp, due to cooking oil and use of some cosmetics can actually aggravate the acne problem. Acne problem many times is hereditary also. [12]
Symptoms of acne: The symptoms may differ from person to person but commonly seen symptom are: formation of blackheads, whiteheads, lesions filled with pus and which are very painful and lastly nodules. One may get confused sometimes as symptoms of acne may be like some other skin condition and it is always advised to consult a doctor in this situation.
1.1: Importance of the study: “There is no single disease which causes more psychic trauma, more mal adjustment between parents and children, more general lack of self-confidence and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.” Adolescents are psychologically vulnerable. They are sensitive to modifications in their bodies and appearance.
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Acne commonly affects young people at a time when they are undergoing greatest
psychological, social and physical change. Studies have exposed the burden of acne to reduce adolescents’ quality of life (QoL) and to affect their global self-esteem. Between 30%-50% of adolescents experience psychological difficulties associated with their acne,and although the interface is multifaceted it can be associated with developmental issues of body image, socialization and sexuality. Some patients are severely affected and require more than acne therapy alone. [14]
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Literature review:
Acne is a chronic inflammatory disorder of the skin that most commonly presents during adolescence, a period with psychological instability. Besides experience of impaired functional status and decreased quality of life, it has been recently substantiated the psychological impacts of acne appearance and proved the related negative emotional reactions in the patients. For example, the occurrence of acne substantially augments the massive stress that burdens most girls, particularly the younger in today's demanding society. Depression and anxiety have been recommended more prevalent among patients with acne than among control subjects.
Acne is one of the leading causes for visits to a dermatologist.Although most cases develop in adolescence, with 70%-87% prevalence, it has chances of frequently continuing into adulthood. Acne can affect any age group, and those with post-adolescent acne were increasingly being referred for dermatological care. [13]
1.1:The level of emotional and social impairments among adolescents due to acne:
According to survey conducted by Jeong Eun Do, M.D., Sun-Mi Cho, PhD the quality of life impairment in teenage students could be caused by the presence of acne. From the self-reported questionnaire, high-score self-perceived stress was self-reported by 68 students (13.8%), impairment in interpersonal relationships by 43 students (8.7%), and disturbance in daily life, especially in academic performance, by 32 students (6.4%). [14]
According to the duration of acne, the younger acne began, the more stress students felt regarding the impairments in interpersonal relations and disturbances in daily life. In General self-image, social relationships, and depression were considerable correlated with the subjective grade of severity of acne.
According to the same study girls are likely to experience greater psychological difficulties than boys across a wide range of psychological factors, including self-perceived stress, educational goals, social relations, peer relations, and self-esteem. It is likely that the gender difference observed in this study is due to the different level of cosmetic concern and perception regarding the appearance in relation to gender, thus it may exert differential psychological strain upon girls. [15]
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1.2: Prevalence of acne among adolescent in India:
In review of statistical data of overall onset period of acne in adolescents in India, the peak incidence of acne occurs at the age of 17 years at the earliest. In late adolescents, above the age of 16 years, they move towards young adult roles and appearance is given more importance than at a younger age.
( Figure source: annals of tropical medicine and public health. Self-esteem, cognitive, and behavioural assessment.)
In the study conducted by Saravanan Dharshana, Awnish Kumar Singh, Shruti Sharma, Surapaneni Krishna Mohan, and Ashish Joshi, as seen in the figure above, Participants with severe acne had higher levels of emotional and social impairments. The longer the acne persisted, the more stress the students felt. The degree of stress and extent of self-image impairment were related to individual severity more than objective grading. [16]
Site of acne: Acne commonly involves the face. It affects the appearance of the individual, which makes it more worrisome than acne at other sites. The same study observed facial acne (99.3%) to be the commonest in our study and there was no noteworthy association with the Quality of life, either alone or with facial and truncal acne together. This may be due to the mild nature of acne the patients had.
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1.3: Acne in India by gender over a Lifetime:
In review of articles related to gender based acne, Acne was more widespread and severe in
boys than girls. According to survey conducted by Belliappa Pemmanda Raju, Umashankar Nagaraju, females were more commonly affected than males (ratio of 1.5:1). However, male students were found to have more moderately severe acne compared to female students. The findings are consistent with previous studies done in other countries. Males tend to have more severe acne compared to females because they have oilier complexion and their androgen levels are higher. [17]
As of now, the rising occurrence of acne vulgaris in late adolescence is a global issue; however, it is unidentified whether this increase is a result of higher prevalence of the Western diet, earlier onset of puberty, genetic drift, or a by-product of unfamiliar environmental factors. [17]
Girls and boys with acne have lower self-attitude, more feelings of uselessness, and fewer feelings of pride, lower self-worth and lower body satisfaction than those without acne. In a regression model for body mass index and depressive symptoms, acne explains considerable lower self-attitude in boys and poor self-worth in girls.
Adolescent girls may be more vulnerable than boys to the negative psychological effects of acne. Many Studies have reported occurrence of acne in 28-61% of school children in the age group of 10-12 years; about 79-95% in the age group of 16-18 years; and even in children in the age group of 4-7 years. [17]
There is a strong association between incidence of acne and depression, anger, poor self-esteem, suicidal ideation, mental health problems and social impairments among adolescents. In Australia, acne was observed in 27.7% of students' aged between 10-12. In countries like Belgium and China, prevalence in adolescents is high that is about 90%, while in England it is approximately 50%. [18]
Certain patients are intended as “High risk” because of increased probability for psychosocial and functional impairment or self/other injurious behaviour independent of their acne severity. [18]
According to Vowels and Yang a special attention needs to be taken when assessing girls with acne, as girls often have poorer mental health in this age group regardless of their acne status, which is in agreement with existing evidence that they are at greater risk of developing emotional disorder post puberty. [19]
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Another report noted higher anxiety among girls with acne when compared to boys with acne, a finding that was not related to acne severity. The study concluded that girls were more vulnerable to negative psychological effect of acne than boys. It has also been observed that girls with acne account for depression as twice as male with acne.
Girls are more concerned about the appearance of their condition and feel they are more noticeable to others than men, they also feel they are more discomfited, more self-conscious and have more negative body image than men. This can be attributed on what we know about social pressure to have clear skin in women in western cultures, which is stronger and more prevalent than in men as stated by Hassan et al. [19]
Physician’s assumptions about the effects of a skin condition are often imprecise. The psychological effect of acne is unique for each patient. Patients should be asked how much their acne bothers them, regardless of how severe it appears to physicians. Acne in adolescence can have an effect on self-image and assertiveness, factors important in forming friendships and dating. Although we often observe adolescents as being more influenced by the psychosocial effects of acne, older patients are more bothered by the appearance of acne and consequently report a more substantial effect on their lives. Because the face is so important to body image, young men with rigorous scarring acne are at particular risk of depression and suicide. [19]
1.4: Behaviour pattern:
Acne often leads to considerable psychological and physical morbidity. Unlike most other dermatologic diseases that may be restricted to areas covered by clothing, acne is often visible on the face heightening issues of body image and socialization. Therefore, it is not surprising that a susceptible personality with facial acne may develop considerable psychosocial disability. Many acne patients have problems with self-image and interpersonal relationships. Effects are aggravated by teasing or taunting, other’s analysis and the feeling of being on display. Often, awkwardness is a prominent response in acne patients, as it is easier for them to articulate than dysphoria, depression and anxiety. They usually experience social anxiety and general evading of activities that bring attention to their condition.
These feelings often relate to fear of having their faces scrutinized by others and the societal idea of ideal skin makes appearance the most important factor. Adolescents with acne feel uncomfortable and avoid eye contact, grow their hair long to cover the face and girls often use makeup to reduce the appearance of acne lesions. Studies have shown that acne can considerable impact dress choice in adolescents with acne.
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More than a cosmetic irritation, acne can produce anxiety, depression, and other psychological problems that affect patients’ lives in ways comparable to life-threatening or disabling diseases. Given the fact that acne causes psychological suffering, acne can affect social, vocational, and academic performance of teenagers.
Severe acne may lead to scarring and disfigurement, aggravating the already present psychosocial aspects of this condition. [20]
Suicidal ideation was found to be around 6-7% in acne patients. Some studies have shown that there are gender differences in the effect of psychological trauma on acne patients. Psychological co morbidities in acne are most likely greater than usually assumed. Therefore, emotional problems due to acne should be taken seriously and included in the treatment plan. [20]
Adolescence is an important period for emotional and psychosocial development and considerable changes happen to self-consciousness. Low self-esteem in adolescence has been concurrent with delinquency, aggression, antisocial behavior, poor physical and emotional health, and lower financial success in adulthood compared to individuals with high self-esteem. According to survey done by Schroeder RE, Kaplan SG, Feldman SR Patient perception of disease severity was found to be the most important and universal indicator of low self-esteem. Acne treatment was associated with improvement in self-esteem. Early and aggressive treatment can have a positive impact on self-esteem in adolescents with acne, and it is important to consider a patient’s insight of his/her disease severity when selecting a treat-ment routine. The high association between acne and psychosocial problems in adolescents indicates that it is urgency to assess patients for low self-esteem and depression prior to treatment. [21]
Acne commonly affects young people at a time when they are undergoing maximum psychological, social, and physical modification. Using the abundant available rating scales for quantifying quality of life (QoL) in patients with acne, studies have shown that the burden of acne diminishes adolescents’ QoL and affects their global self-esteem. Many people with acne experience problems with self-image and interpersonal relationships. Teasing or taunting and evasion by others are two important factors in the relationship between acne and embarrassment and self-consciousness. That also creates feeling of dishonour and also leads to harm to self-esteem and self-image. [21]
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There is a significant correlation between acne and quality of life. This assessment is important to know the impact of acne on quality of life to detect those who are at increased risk of negatively affected. The impact of acne on quality of life is becoming more common among young adults due to the social and occupational functioning and worsens as age advances. In middle adolescence, peer relationships become more prominent. In late adolescence, over 16 years old, adolescents make more important life decisions and move towards young adult roles. In these ages, appearance is important, so acne causes more problems in comparison to early adolescence where the family is still the key and appearance does not seem to affect their life. However, the relationship between adolescent acne and emotional distress, as well as the relationship between the onset of acne and quality of life are poorly understood and quite controversial.
The evaluation of impact of acne on the QoL is essential, to detect those patients who are at increased risk of being negatively affected to treat them in a more integrated method. Hence, it is important for health professionals to add in QoL measurements when managing acne patients to provide better and suitable care. More effort for health education in general and selective patient education in particular is required to improve patients’ knowledge about acne and its modalities of treatment and to give confidence to take up early medical consultation behavior and improve patient obedience to treatment. Considering psychological effect, it appears to be high, as it has been proved in other cultures and needs always to be measured and addressed early in the route of patient management. [22]
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Methodology:
A cross-sectional study was carried out in 2017 in Nellore city, India. The participants of the study were 14-16 years old school children. Based on the overall population of middle schools in Nellore, simple random sample method was employed for composing a representative sample and Sample size was 97 students, conforming to inclusion and exclusion criteria after obtaining permission from school trust as well as bio ethics committee.
Throughout the study were distributed 100 questionnaires, of which 97 completed. The response rate was 96 percent. Students suffering from medical disorders or on drugs likely to interfere with assessment of acne were excluded from the study.
The data were collected by means of anonymous questionnaires. The self-reported questionnaires (original) were used. A detailed history pertaining to the following parameters like demographic data, presenting illness, personal history/factors aggravating acne, presence of medical/surgical diseases, family, and mainly psychological assessment associated with acne was elicited. and a subjective acne severity rate. Questionnaire consisted of around 15-20 questions.
QoL pertaining to psychological assessment was measured using a combination of original self-made and acne-specific (beck inventory) questionnaires.
Two measures of psychometric evaluation were applied to assess specific psychosocial impairments, which are as follows:
Self-made standard Questionnaire. Beck Depression Inventory (BDI) Beck's Depression Inventory
This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire. The questions are partly taken from beck inventory and some question irrelevant to study are excluded.
The whole reported questionnaire consisted of 45 questions.
Statistical analysis: Statistical data analysis was performed by using SPSS/15.0 for data accumulation and analysis. Data was analysed by descriptive statistics with frequency distribution, chi-square (χ2) test calculation, and correlation by mean values. Correlations were considered to be statistical significant when the p-value were < 0.05.
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Pilot study
Before conducting the main study, I have tested the questionnaire on a group of ten students with various backgrounds. The test group was selected based on a convenience approach and primarily consisted of my own family members (children and teens). Based on the remarks of the test group and my supervisor the original questionnaire was modified and reconstructed. After testing and reconstructing the questionnaire the actual data collection was performed at Rainbow school on the 5th of July 2017 between 10 am and 5 pm. The students were assembled in an auditorium for easy hand out of questionnaires. Primarily we approached and hand-delivered questionnaires to students sitting by themselves. The reason for this was to avoid the direct influence respondents could have on each other if answering the questions and statements together. While the respondents were answering the questionnaire, I moved away for a while in order to avoid pressuring them, receiving hasty responses and further disturbing them with our presence. But, I was present in the room for queries and doubts. I had explained each question in detail prior to the survey.
Strict privacy was maintained throughout the process of data collection, entry and analysis. All efforts were made in this study to fulfil the ethical considerations in accordance with the ‘Ethical principles for medical research involving human subjects’ of Helsinki Declaration. The response rate was 96 percent.
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Results and discussion:
1.1: The prevalence of acne among 14-16years of adolescents.
Relation between daily routine habits and acne:
Distribution of children by gender was equal. There were 49.5% of males and 50.5% of females in the survey, and the skin of females was more prone to acne a lot more than males. The mean age of the overall research sample when they got acne for the first time was 14.3 years.
Table 1.1: age group of survey sample.
Age Percentage valid 14 70.4 15 27.6 16 1.0 Total 99.0 missing 1.0 Total 100
The percentage of boys prone to acne was 29.8%, whereas 57.1% girls were prone to acne. (Table 1.2) This can be explained by the general habits of both sexes, for example 29.2% of boys washed their face twice daily, whereas only 24.5% of girls washed their face twice daily. The results showed that about 60.4% of boys were using different face towel, but only 40.8% girls were using separate towel for the face.
Table 1.2: correlation between gender and incidence of acne. Incidence of acne Girls Boys Yes 57.1% 29.8% No 42.9% 70.2% Total 100% 100%
There was also a habit of intake of junk food leading to disrupt nutritional imbalance between the gender, about 53.1% of girls consumed junk food at least once a week, whereas only 29.2% of boys did the same.
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Figure 1.1: skin type of the survey sample in percentages.
The skin type was also taken into account here, although there was statistically significant difference in skin types there was a noticeable difference seen between the gender in terms of oily skin which is more prone to acne, more girls had oily skin type than boys. The general duration of acne stayed around 2-4 days overall in majority of cases analysed for both the gender. Again, here the differences between both age and sex were not statistically significant.
About 70.8% of females did not take treatment at the time of onset of acne for the first time. (figure 1.2) Only 29.2% females treated themselves. Whereas males were more particular in treating themselves at the onset of acne for the first time, only 57.8% were negligent and 42.2% took treatment (figure 1.3). These results interpreted quite a contrast results as predicted. Often boys are negligent about their looks, and usually don’t treat themselves for dermatological issues.[16] But in my research sample, females were more negligent.
17.3 27.4 11.6 41.8 0 5 10 15 20 25 30 35 40 45 overall sample
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Figure 1.2: correlation between frequency of treatment taken at onset of acne for the first time and gender
1.2: The level of emotional, social impairments among adolescents.
The results showed that about 33 % of the survey population was emotionally affected by the onset or presence of acne. And about 5% of the sample agreed that acne was highly bothering. (figure2.1)
Figure 2.1: correlation between level of emotional impairment among adolescents and age group 14-16 (in percentages).
male female *p<0.05 – z test, comparing males and females.
The psychological effect of acne on these teenagers was negative as 52% of the survey sample, was affected by a low self-esteem, which made them to avoid meeting people when they had acne. 43.2% of them were not happy with their looks.
42.2 29.2 57.8 70.8 0 10 20 30 40 50 60 70 80 male female treated not treated 2 20 14 12 1 15 26 7 0 5 10 15 20 25 30
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In particular, considering the gender 63.3% females were affected by low self-esteem. (Table 2.1)As the acne was not localised in many of the cases, according to the survey, females had to cover their body more than males to hide the acne as well as the scars.
The students aged 16 years old felt negative about their acne scars and had a low self-esteem. In case of those aged about 15 years, 37% had a bothering psychological condition. Whereas those aged 14 years were more concerned about presence of acne, about 58% were emotionally affected. The results showed that 10.9% of males and 16.3% of females isolated themselves socially when they suffered from acne. (Table2.1)
Table 2.1: Correlation between gender and social isolation.
Avoid meeting people while suffering from acne.
Boys
Girls
Yes
10.9 16.3No
89.1 83.7 Total 100% 100%The analysis was done also on the social life of the school children. In country like India much of social activities were allowed only for boys, but as Nellore is a modern and culturally developed city, both males and females were provide with equal opportunities. In this case the pupil were asked about their social life which includes regular outing, meeting friends or family relatives, school picnics, etc., and the response options were divided into good, fair, poor. (figure 2.3) [20]
Those who had regular outdoor activities, meetings, and social activities were considered as good. Those who visited their relatives or friends less often or those who had less social interactions were considered as fair.
In addition, those who were not at all socially active were considered as poor. According to the survey, about 69.4% of overall survey population were socially active, 28.6% were less active and 1% was socially isolated.
23 Figure 2.3: analysis of current state of mind
1.3: Association between acne severity and psychosocial well-being among
adolescents.
Acne can have deep social and psychological effects. These are not necessarily related to its clinical severity. Even mild acne can be significantly depressing. Acne can affect people of all ages but it predominantly occurs during the teenage years. [21] This objective was the main reason I chose this survey. To analyse this factor along with general questionnaire was picked up the Beck‘s depression scale. The scale questions were explained prior to the survey. They were made clear to the pupils and were advised to answer in relation to acne and their physical appearance.
Table 3.1: frequency of occurrence of psychological indices when suffering from acne.
Psychological indices
Percentage
Worry
29.6
Loneliness
30.6
Depression
27.6
Anger
11.2
Missing system
1.0
Total
100
Our main concern that is depression falls among the major point of discussion. As the results show, that 27.6% of the pupils were suffering from depression(Table 3.1). However, as investigated, depression was stated as just mild, and there was no noticeable severe depression among the population. The effects of acne were bothering as the pupils were depressed with the same reason as well.
62.5 77.6 35.4 22.4 2.1 0 0 20 40 60 80 100 male female good fair poor
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As shown in the figure 3.1 it is clear that the difference or level of emotional impairment or depression and other psychosocial illnesses were not statistically significant in genders. Some amount of difference can be seen in the column of loneliness, more girls than boys feel lonely when they suffer from acne that is 38.8%.
Figure 3.1: the analysis of psychosocial indices among gender.
The study result showed that more than half (56.1%) of Nellore adolescents felt sad about their looks and physical appearance. Around 4.1% of overall teens said that they were so sad that they cannot stand it; 3.1% of them felt that their future is hopeless and things cannot improve.
Two third of the respondents (76.5%) were positive about their achievements, and felt they are not a failure. A very less number replied that they felt like a failure. They were also positive about their level of work satisfaction out of things they do in daily life. They were not guilty about their overall life experience, which includes both emotional and physical state.
An amount of depression or stress was seen among students who had a bad QoL, but in terms of overall assessment there was 6% of hate feeling found from the research among 14 years age group, but there was no such feeling seen among 15-16 years old students. In terms of gender, 10% of females were feeling dissatisfaction and hatred towards oneself, and 2.1% of males hated themselves.
Comparatively there was no significant difference seen among males. Although these numbers match, feeling of hatred differed between the sexes. Only a 2% of males had observed this feeling.
29.2 22.9 33.3 14.6 30.6 38.8 22.4 8.2 0 5 10 15 20 25 30 35 40 45
worry loneliness deppresion anger male female
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Figure 3.3 correlation between disappointment and disgust in oneself and gender
I DONT FEEL DISAPPOINTED IN MYSELF I AM DISAPPOINTED IN MYSELF I AM DISGUSTED WITH MYSELF I HATE MYSELF Total Male 52.7 51.5 33.3 16.7 49.5 Female 47.3 48.5 66.7 83.3 50.5 Total 100 100 100 100 100
To the contrast, half of the respondents replied a positive feeling of confidence in oneself. 49.5% of students felt they are not worse than anybody.
This question also had the critical factor, wherein overall 5.1% blamed themselves for everything bad that happened to them.
As we all know crying lets the inner sorrow of a person out and then leaving with a feeling of relief, but crying every often or more is also a sign of weakness and depression. There are many factors which lead to crying, but here we are discussing crying of students because of physical unattractiveness or a sense of ugliness in them. A stage where, you cannot cry even though you want to was considered as deep sorrow or depression. Two third of the respondents were strong emotionally and did not cry any more than usual. 11.5% were facing this state where they couldn’t cry even if they wanted to.
Those aged 16 years 100% were emotionally strong when compared to 14-15 years old. Those aged 14 years about 13.2% were emotionally weak than anyone else. Gender differences were comparatively significant, as both males and females showed equal results. Males were slightly stronger emotionally when compared to females in this research.
When people hide a sad feeling for a longer time, a sense of irritation grows within themselves. The same results were shown in the survey as, half of the survey respondents were slightly more irritated than before. The reason to this can be the negligence of the issue for a longer time. [23]
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Figure 3.4: level of irritation in 14-16 years old school children
When suffering from physical condition like acne especially facial one, teenagers start to avoid meeting people to stay away from unwanted attention towards their flaw. [23] My results also reported the same, about one third(33.6%) of respondents avoided meeting people when they suffered from acne, among which females were leading the criteria. Overall 6.2% of both males and female respondents totally lost interest in meeting people.
Table 3.5: frequency of psychological indices among survey population. Psychological
indices
n
Percentage (%)
I feel I look good 58 59.2
I worried that I may look bad
30 30.6
I feel that I will look unattractive
6 6.1
I believe that I look ugly
4 4.1
Total 100 100
The major reason for this behaviour was, the feeling of unattractiveness of oneself, 4.2% of overall respondents believed that they look ugly, and the same number believed that they
38.8 50.5 3.1 6.1 0 10 20 30 40 50 60 I am not irritated Iam slightly more irritated I am annoyed all the time
I feel irritated all the time
27
have developed permanent changes in their appearance, which made them look unattractive. Again, even in these criteria females were more perceived towards this feeling.
About 6.2% of girls believed that they look ugly, and the same percent felt they are permanently unattractive because their acne had already left scars. 2.0% boys felt they look ugly. In a gross analysis of age group, those aged 14 years, 4.4% felt that they look ugly.
My research shows that about half of the respondents (50%) were able to focus on studies normally like completing assignments on time, attentiveness in class etc., rest 33.7% felt it took extra effort for them to do a task, and about 15.3% replied that they have to push themselves very hard to do anything. Analysis of data of children focus in studies by age groups revealed that 14-15 years old were more vulnerable to lack of focus in this manner. Table 3.6: correlation between gender and effort taken to work.
Boys
Girls
I can work about as well as before
56.2% 44.9%
It takes an extra effort to get started at doing something
37.5% 30.6%
I have to push myself very hard to do anything
6.3% 24.5%
Total 100% 100%
The analysis of data reveals a significant difference, more females are facing a problem in doing things in a normal manner (Table3.6). These results were statistically significant with a value of p=0.04 chi square >0.05.
Only 6.2% of males had to push themselves to do anything, whereas 24.5% of females faced a lack of focus in work and had to push themselves hard to do a task.
Not just work or studies but sleep of these students was also an important aspect of this research.
Lack of sleep, improper sleep was some of the common problems faced by the respondents. To the content, more than half of the survey population were able to sleep well as usual.
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However, a slight difference was seen among 31.6% of students. 5.2% of students replied that they wake up several hours early and face difficulty going back to sleep. There was no statistically significant difference among genders as both males and females responded on the same level of percentage. Those aged 16 years slept well as usual by 100%. Age group of 14-15 years had sleep issues.
Table 3.7: sleep disturbances among age groups 14-16 years. 14 years 15 years 16 years
I can sleep as
well as usual 55.1 63.0 100 I don’t sleep as
well as I used to 33.3 29.6 0 I wake up 1-2
hours earlier than usual and find it hard to get back to sleep
5.8 3.7 0
I wake up several hours earlier and cannot get back to sleep
5.8 3.7 0
Total 100 100 100
There is also an effect on physical strength of the students in terms of daily routine. Tiredness is a result of stress and depression, which comes from acne. More than half of the respondents (56.1%) are physically fit, and do not get tired than usual. Only a 4% of respondents felt too tired to do anything overall. The gender differences were not statistically significant. Males and females felt the same energy levels comparatively.
Along with tiredness, the students also felt a sense of decrease in appetite. About 31.6% of students felt their appetite was not good as it used to be. 11.3% of respondents replied their appetite is worse and they don’t feel hungry most of the times. Same as the above quotient, the gender differences were not statistically significant. Those aged 16 years had a normal appetite. Age group 14-15 years old replied that their appetite was affected. 18.5% agreed that their appetite was affected (Table 3.8).
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Table 3.8: correlation between age and level of tiredness.
14 years
15 years
16 years
My appetite is no worse than usual 50.7 59.3 100 My appetite is not good as it used to be 36.2 22.2 0 My appetite is much worse now 8.7 18.5 0 I have no appetite at all anymore 4.4 0 0 Total 100 100 100
There were no statistically significant differences seen in age factor and this scale. The reason can be small sample size of age group 16, or overall shortage of respondents.
About 86.7% of the students replied that they have not lost much weight lately. Only 1% had lost more than 10 pounds of weight. Again, in this case females are slightly more leading the race, as 12.5% replied that they have lost more than 5 pounds of weight lately.
The concept of weight loss was analysed or accessed by having a check on annual health reports of the school. The school conducts regular weight check-up twice a year.
Height, weight, BMI, general health issues were regularly checked and noted by the school authorities. The pupils were made aware of the values of the weight component in pounds. 1 pound= 0.45kgs approximately.
Figure 3.9: Analysis of weight loss since half a year.
0 20 40 60 80 100 i havent lost much weight i have lost more than 5 pounds i have lost more than 10 pounds male female
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Becks ideology of measuring depression was not just emotional wellbeing but also about physical problems related to diseases. Some of them are pains, aches, upset stomach or constipation. There is a close relationship between emotional stress, constipation and acne. Someone with an acne personality is highly reactive and prone to bouts of anxiety and depression. [25]
As it turns out, gut bacteria are able to affect all aspects of the acne personality. Directly and indirectly, beneficial gut bacteria influence:
• Systemic, all-over inflammation • Levels of oxidative stress
• Levels of mood-regulating neurotransmitters [26]
Low levels of good gut bacteria or constipation can have an impact on skin too which leads to acne. Therefore, we analysed this aspect in my research.
The results showed that about 29.6% of students were suffering from constipation, and physical aches, which they were worried about. There were other nutritional factors as well but my research topic made me be relevant. Age and gender factors were not found statistically significant. As the results were almost same for both aspects.
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Conclusion:
1. There is a significant impact of acne on psychological symptoms, emotions, daily and social activities, study/work, and overall health. In conclusion, light must be put on the numbers, teenagers are affected by acne/prevalence of acne among teenagers. As seen in my research more girls were more vulnerable to acne. About 70% of incidence of acne for the first time occurred at the age of 14 years. In addition, this age is more vulnerable to psychological indices related to acne as we discussed earlier in the survey.
2. There were symptoms seen in teenagers of Nellore city, such as low self-esteem, worry about their physical appearance, and to some extent depression. Around 33% of teenagers, felt upset and emotionally distressed when they suffered from acne, and about 5% were depressed about the mark acne had left on their appearance. This has led these 5% of depressed teens to socially isolate themselves and avoid meeting people.
3. As there is a decent association between acne and psychological issues among teenagers in Nellore city, both schools and parents/guardians should provide proper counselling. The more severe the acne was, the deeper they had psychological worries. About 4% of teenagers felt the severity of acne they had had led them to believe that this problem will never solve and it will worsen over time, and 3 % had left hope on acne scars to fade which has led to permanent scar on their mental wellbeing.
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Practical recommendations
Monitor: Measures should be taken to decrease these numbers in both girls as well as boys. Dermatological checkups should be included in general checkups in schools. Along with gender, age factor should also be considered to have an even look on this matter.
Education/awareness: Severity of acne not only should be assessed exclusively on the physical grade of acne alone, but also should include its psychological effect on QoL and state of mind of teenagers. Education of dermatologists and general practitioners alike, about the psychosocial impairments of acne can help in identifying cases with acne related depression and QoL issues. There is a need for incorporation of psychological intervention in the management of acne vulgaris, for improvement in the QoL and psychological wellbeing in such cases.
Community: The impairment of quality of life can be alleviated by appropriate topical acne treatment along with psychosocial support. Setting up supportive groups could also be of immense help for these patients. Family involvement can also help the patient to come out of any such distress. A proper guidance and help is a right of every individual.
33
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2. Kulthanan K, Jiamton S, Araya M. Clinical characteristics and quality of life of seborrheic dermatitis patients in a tropical country. Indian Journal of Dermatology. 2015;60(5):519.
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Patients. Dermatology and Psychosomatics / Dermatologie und Psychosomatik. 2000;1(2):62-65.
10. Khan r, khan s, gul s, kanwal s, samin a, ahmed a. pre-diabetes; prevalence in students of ayub medical college, abbottabad. the professional medical journal.
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12. Simpson N. Effect of Isotretinoin on the Quality of Life of Patients with Acne. PharmacoEconomics. 1994;6(2):108-113.
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Hamilton, New Zealand; Dr John Collier MBChB MRCPsych FRANZCP, Psychiatrist and Psychotherapist, Hamilton, New Zealand, 1999.
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36 ANNEXURES
Annex 1: Questionnaire
BASIC DATA: NAME: AGE: SEX: ADDRESS: EMAIL: HEIGHT: BIRTHDAY: WEIGHT: Routine:1. How many times do you use soap/face wash in a day?
a) once b) twice a day c) 2-3 times a day d) more than 4 times 2. Describe your bowel movements?
a) Once daily b) 2times a day c) once in 2-3days d) need laxatives 3. Nature of bowel:
a) Soft b) medium c) hard 4. How often do you bath?
a) Daily b) daily twice c) once in 2 days d) once in 2-3 days 5. Do you use a separate towel for your face?
a) Yes b) no 6. Do you use others towel?
a) Yes b) no
7. How often do you eat junk food?
a) Daily b) weekly c) weekly twice d) rarely 8. Do you have any past medical history? a) yes b)no
Skin:
9. What is your skin type?
a) Dry b) oil c) normal d) sensitive
10. Is your skin type a combination of both oily and dry?
11. If yes, specify? ... 12. What is your skin complexion?
Light fair wheatish brown black
37 a)yes b)no
14. Do you cover your face when you go out? a)yes b)no
15. Is your skin prone to acne a lot? a)yes b)no
16. At what age did you get acne for the first time?
a) Before 10yrs b)10-15yrs c)15-20yrs d)after 20yrs 17. Is your acne localized?
a)yes b)no
18. How often do you use cosmetics? A) Daily b)occasionally c)rarely 19. Any cosmetic allergies? If yes
specify?... 20. What is the duration of your acne?
a)1-2 days b)2-4 days c)most of the time?
21. Did you start any treatment at the outburst of acne for the first time or you were negligent at that time?
22. How much does your acne bother you?
a)Highly bothering b)bothering c)not much d)never 23. Does your acne affect your self esteem or you don’t care?
Psychiatric assessment
24. Are you happy with your looks? Yes not much no
25. Do you avoid meeting people when you suffer from acne?
Yes no
26. What is your present state of mind? Good fair poor 27. How is your social life?
Good fair poor
28. Do you often experience any of the following?
Worry loneliness depression anger fear /panic irritation.
38 29. 1 I do not feel sad.
2 I feel sad
3 I am sad all the time and I can't snap out of it. 4 I am so sad and unhappy that I can't stand it.
30. 1 I am not particularly discouraged about the future. 2 I feel discouraged about the future.
3 I feel I have nothing to look forward to.
4 I feel the future is hopeless and that things cannot improve.
31. 1 I do not feel like a failure.
2 I feel I have failed more than the average person.
3 As I look back on my life, all I can see is a lot of failures. 4 I feel I am a complete failure as a person.
32. 1 I get as much satisfaction out of things as I used to. 2 I don't enjoy things the way I used to.
3 I don't get real satisfaction out of anything anymore. 4 I am dissatisfied or bored with everything.
33. 1 I don't feel particularly guilty 2 I feel guilty a good part of the time. 3 I feel quite guilty most of the time. 4 I feel guilty all of the time.
34. 1 I don't feel disappointed in myself. 2 I am disappointed in myself. 3 I am disgusted with myself. 4 I hate myself.
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2 I am critical of myself for my weaknesses or mistakes. 3 I blame myself all the time for my faults.
4 I blame myself for everything bad that happens.
36. 1 I don't cry any more than usual. 2 I cry more now than I used to. 3 I cry all the time now.
4 I used to be able to cry, but now I can't cry even though I want to.
37. 1 I am no more irritated by things than I ever was. 2 I am slightly more irritated now than usual.
3 I am quite annoyed or irritated a good deal of the time. 4 I feel irritated all the time.
38. 1 I have not lost interest in other people.
2 I am less interested in other people than I used to be. 3 I have lost most of my interest in other people. 4 I have lost all of my interest in other people.
39. 1 I don't feel that I look any worse than I used to. 2 I am worried that I am looking bad or unattractive.
3 I feel there are permanent changes in my appearance that make me look unattractive 4 I believe that I look ugly.
40. 1 I can work about as well as before.
2 It takes an extra effort to get started at doing something. 3 I have to push myself very hard to do anything.
4 I can't do any work at all.
40 2 I don't sleep as well as I used to.
3 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 4 I wake up several hours earlier than I used to and cannot get back to sleep.
42. 1 I don't get more tired than usual. 2 I get tired more easily than I used to. 3 I get tired from doing almost anything. 4 I am too tired to do anything.
43. 1 My appetite is no worse than usual. 2 My appetite is not as good as it used to be. 3 My appetite is much worse now.
4 I have no appetite at all anymore.
44. 1 I haven't lost much weight, if any, lately. 2 I have lost more than five pounds. 3 I have lost more than ten pounds. 4 I have lost more than fifteen pounds.
45. 1 I am no more worried about my health than usual.
2 I am worried about physical problems like aches, pains, upset stomach, or constipation.
3 I am very worried about physical problems and it's hard to think of much else. 4 I am so worried about my physical problems that I cannot think of anything else.
