A STUDY TO ASSESS THE EFFIECTIVENESS OF TWO EDUCATIONAL METHODS ON THE KNOWLEDGE & ATTITUDE OF ELDERLY WOMEN REGARDING THE AWARENESS OF CANCER CERVIX IN SELECTED AREAS AT BENGALURU.

M.Sc. Nursing Dissertation Protocol submitted to

RajivGandhiUniversity of Health Sciences, Bangalore, Karnataka.

By

Mrs. PARAMESWARI .T

M.Sc. NURSING 1st Year

2011-2013

Under the Guidance of

Head Of the Department,

Obstetrics and Gynaecology Nursing,

National College of Nursing,

Gandhadakaval, Hegganahalli Cross,

Vishwaneedam Post, Magadi Road,

Bangalore – 91.

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME & ADDRESS OF THE CANDIDATE / MRS. PARAMESWARI .T
M.SC. NURSING 1ST YEAR
NATIONAL COLLEGE OF NURSING,
SRIGANDHADAKAVAL,
HEGGANAHALLI CROSS,
VISHWANEEDAM POST, MAGADI ROAD,
BANGALORE – 91.
2. / NAME OF THE INSTITUTION / NATIONAL COLLEGE OF NURSING,
GANDHADAKAVAL,
HEGGANAHALLI CROSS,
VISHWANEEDAM POST, MAGADI ROAD,
BANGALORE – 91
3. / COURSE AND SUBJECT OF STUDY / M.Sc. NURSING
OBSTETRICS AND GYNAECOLOGY NURSING
4 / DATE OF ADMISSION TO THE COURSE
5 / TITLE OF THE RESEARCH:
“A STUDY TO ASSESS THE EFFIECTIVENESS OF TWO EDUCATIONAL METHODS ON THE KNOWLEDGE & ATTITUDE OF ELDERLY WOMEN REGARDING THE AWARENESS OF CANCER CERVIX IN SELECTED AREAS AT BENGALURU.”

6.0BREIF RESUME OF THE INTENDED WORK

INTRODUCTION:

Cervical cancer is the most common cause of death among women in developing countries despite the fact the cervical cancer is preventable.

According to World Health Organisation, the incidence rate for cancer cervix is increasing every year. It is estimated with approximately 471,000 new cases diagnosed with cervical cancer worldwide in the year 2010. It’s sobering to thing that a woman dies of cervical cancer every 2 minute.

The American cancer Society estimated that 12,280 women were diagnosed as cervical cancer & mortality rate is 4,210in the year 2010. Central & South America, the Caribbean, Sub-Saharan Africa, parts of Oceania & parts of Asia have the highest incidence rates over 30 per 1,00,000 women. In Canada2 per 100,000 deaths in women occur because of cervical cancer (National Cancer Institute of Canada, 2008).

In developing countries, it is the second most common cancer in women & accounts up to 300,000 annual deaths (Kitchener, The Lancet 1999). In India, every year 132,082 women are diagnosed as Cancer cervix & 74,118 die from the disease in the year 2010. The growing risk of cervical cancer in women in India is 2.4% compare to 1.3% for the world. The major reason for the highest incidence rate of cervical cancer in the developing countries is due to the lack of awareness about cervical cancer among the elderly women. 80% of the cases occur in low income women. More than 99% of cervical cancer cases are related to infection with Human Papilloma Virus (HPV) an oncogenic virus and is a sexually transmitted disease (STD) which is mostly asymptomatic.

The screening programs were implemented in developing countries since the early 1980’s, yet have failed to reduce the mortality rates. The WHO in 2002 estimated that only 5 % of women in developing countries are screened appropriately.

Cancer cervix represents approximately 40 % of all cancer cases in women, stated by (Rajeswari 1992) in her study in TATAMemorialHospital, Mumbai.Cancer cervix is easily accessible for physical examination & amenable to early diagnosis. The cure rate is also high if they all treated at early stages of I & II. But unfortunately, the patients present themselves to medical facilities when the disease is far advanced & not amenable to treatment. This is the crux of the problem.

Women need special attention & planning in their reproductive health. India being an agricultural country has 73.7 % of its population in rural areas. Statistics reveal that nearly 25& are below poverty line. In this, most of the women have their marriage at very early age. This leads to early age of First Coitus, continuous assault to cervix by continuous pregnancies & poor sexual hygiene, which are considered to be the important etiological factors for Cancer cervix.

Cervical cancer most often develops in women after the age of 40 & the incidence is highest among women in their 50’s & 60’s (Miller, International Journal of Cancer 2000). The prevalence of cervical cancer has been recognized as a health problem in India. It is considered as one of the main cause of mortality among women in the reproductive age group ranking next to breast cancer.

Due to slow progress & the availability of effective screening test, prevention & early detection is possible. The primary prevention is focused on reducing infection by encouraging the use of barrier contraceptives, especially condoms. No other form of cancer better documents the remarkable effects of early cancer diagnosis & curative therapy on the mortality rate than cancer of the cervix.

The easy accessibility of cervix to inspection palpation & application of cytologic & tissue sampling procedures have led to screening programs for early detection & treatment of the disease. More than 80 out of every 100 women can be cured if treated at the precancerous stage.

This study is mainly done to focus on the determination of the knowledge & attitude of elderly women of reproductive age group regarding cancer cervix and to give them health education on cancer cervix for early health seeking behavior & to motivate them for early screening.

6.1NEED FOR THE STUDY:

The cervical cancer shows changes in the epidemiological pattern with a shift of incidence toward the younger age group. Due to this reason, cervical cancer ranks foremost among the health problems of women in the socially reproductive age group. The uterine cervix is the commonest site of malignancy among females in India, especially among the multiparous and women from socially background groups.

Awareness of women in rural areas regarding the cervical cancer is less. By educating them, their attitude can be changed and knowledge can be improved. Linder Michie (1993) suggest that population based health education campaigns can create awareness amongthe rural population regarding cervical cancer and its prevention through early detection.

Women in rural areas refuse to attend the gynecological clinics because of socio economic factors, fear of blood collection, internal check-ups & spiritual myths.

During our community visit to Bengaluru areas, the investigations found that mothers do not have any idea about cancer cervix which is the major problem of women at reproductive age group which in turn progress to advanced stage resulting in death. So we realized that the knowledge of mother needs to be increased and awareness to be brought among the mother regarding prevention, early detection and treatment of cancer cervix. So the investigator has decided to do a research on this topic and also to impart health education program so that the knowledge and attitude of elderly women regarding cancer cervix can be changed.

6.2REVIEW OF LITERATURE:

The research literature review is a written summary of the state of existing knowledge on the research problem. An attempt has been made to bring out the available literature, which was helpful in focusing the widen perspective of the study.

Review of literature comprises of two parts viz.,

Part 1 – Literature related to information on Cancer cervix.

Part 2 – Literature related to this Study.

PART 1 – LITERATURE RELATED TO INFORMATION ON CANCER CERVIX

The Cervix is the lower part of the Uterus. The uterus is divided into three parts. The upper part or body of the uterus, isthmus and Cervix. The cervix connects the uterus to the vagina. The part of the cervix close to the uterus is called endo - cervix and the part next to vagina is ecto - cervix. The vaginal portion of the cervix is covered by a non-Keratinizing squamous epithelium. These epithelial cells are replaced every 4 – 5 days and the process may be accelerated by administration of oestrogen.

Cervical cancer is the cancer in the lining of the cervix. Cervical cancer does not form suddenly, gradual changes takes place from a normal cervix to pre-cancerous to cancer. These changes usually take several years, but sometimes it can happen in less than a year. For some women pre-cancerous stage may resolve without any treatment. If these pre cancers are treated, cancer can be prevented. The cervix uteri can be examined, palpated, scraped, cultured and biopsied perhaps more than any other area in the female body. These lead to extensive screening program for early detection and treatment of the disease thereby contributing remarkable lowering of mortality from cervical cancer. The easy access to cervix has also lead to the evolution of the skillful application of radiation technique to this cancer, resulting in the best overall cure rate for any malignancy in human body.

There are two main types of cervical cancer, squamous cell carcinoma and adenocarcinoma. About 85% to 90% of cervical cancers are squamous cell carcinomas which begin from the ecto-cervix. The remaining 10% to 15% are adenocarcinomas which develop from the mucous producing gland cells of the endo-cervix. Rarely cervical cancers have futures of both squamous cell carcinomas & adenocarcinomas. They are called adenosquamous carcinomas or mixed carcinomas.

Cervical pre-cancer does not exhibit any signs and symptoms. A woman usually develops symptoms when the cancer has become invasive. Discharge from the vagina which includes blood spots or light bleeding, bleeding following intercourse and pain during intercourse may indicate cervical cancer. However all of these signs and symptoms can be caused by conditions other than cancer. Ignoring symptoms may allow the cancer to progress to a more advanced stage and lower the chance for effective treatment. It is better not to wait for symptoms to appear, but to have regular pap test.

Invasive squamous carcinoma of the cervix results from the progression of pre-invasive pre-cursor lesions called Cervical Intra-epithelial Neoplasia (CIN) or Dysplasia. CIN is histologically graded into mild dysplasia (CIN 1), moderate dysplasia (CIN 2) or severe dysplasia ( CIN 3). Not all of these lesions progress to invasive cancer, many mild and moderate lesions regress. In one study 50% of women with cancer stage I progress to stage III, 28% either progress to stage II or remained in stage I for nine years. The more severe the grade of dysplasia, the shorter is the time span for the development of carcinoma insitu. Carcinoma insitu (CIN/3) is clearly a precursor of invasive carcinoma.

As clinical course is highly nonspecific periodic papanicalaou smears should be performed on all women, after they become sexually active.

Diagnosis can be done by taking smear and thorough complete personal and family medical history, a complete physical examination, cystoscopy, proctoscopy, examination of the pelvis, colposcopy, endocervical curettage, cautery, cone biopsy, ultrasound, visual inspection with acetic acid, etc. are some diagnostic methods.

Staging is a process of collecting, organizing and describing information about the extent of the cancer such as the size of the tumor, low deeply the tumor has invaded tissues at the site of origin, the extend on any invasion into surrounding organs and the presence of metastasis to lymph nodes or distant organs. Cancer cervix is most frequently staged using the FIGO (International Federation of Gynecology & Obstetrics) system of staging. This system classified the disease in stages 0 to IV. Unlike the staging system for some other cancers, it is based on clinical staging rather than surgical staging.

Stage 0: The tumor is carcinoma insitu, which means that the cancer is found only in the layer of cells lining the cervix and it has not invaded deeper tissue of cervix.

Stage I: The cancer has spread from the lining of cervix into the deeper connective tissue of the cervix. However it is still confined within the uterus.

Stage IA: This is the earliest form of stage I. There is a very small amount of cancer which is visible only under a microscope.

Stage IA 1: The area of invasion is less than 3 mm deep and less than 7 mm wide.

Stage IA 2: The area of invasion is between 3 mm and 5 mm deep, less than 7 mm wide.

Stage 1B: This stage includes cancer that can be seen without a microscope. It also includes cancers seen only with a microscope that have spread deeper than 5 mm into connective tissue of the cervix or are wider than 7 mm.

Stage IB 1: A stage IB cancer that is no larger than 4 cm.

Stage IB 2: A stage IB cancer that is larger than 4 cm.

Stage II: The cancer has spread beyond the cervix to nearby areas, but is still inside the pelvic area.

Stage II A: Cancer has spread beyond the cervix to the upper part of the vagina. The cancer does not involve the lower third of the vagina.

Stage II B: Cancer has spread to the tissue next to the cervix, called the parametrical tissue.

Stage III: Cancer has spread to the lower part of the vagina or the pelvic wall. The cancer may be blocking the ureters.

Stage III A: The cancer has spread to the lower third of the vagina, but not to the pelvic wall.

Stage III B: The cancer extends to the pelvic wall and / or blocks urine flow to the bladder.

Stage IV: This is the most advanced stage of cervical cancer. This cancer has spread to the other parts of the body.

Stage IV A: The cancer has spread to the bladder or rectum, which are organs close to the cervix.

Stage IV B: The cancer has spread to distant organs beyond the pelvic area such as the lungs.

Cancer cervix can be managed by following therapies:- electro cautery, cryotherapy, laser therapy, surgery etc.

PART II – LITERATURE RELATED TO THIS STUDY

A study was conducted regarding HPV screening for cervical cancer in rural India. 52 villages with a total number of 131,746 healthy women between the ages of 30 to 59 years were selected. Of the 34126 women in the HPV- testing group, 2812 had positive results. Of the 32058 women in cytologic testing group, 1787 had positive result. Of the 34074 women in the VIA group, 3733 had positive result. More than 88 % of subjects with positive results underwent colposcopy.7

A study was conducted on cancer risk and diet in India. A review of studies on diet and cancers of the cervix and endometrium have provided equivocal results. The study suggested that a diet high in carotenoids, vegetables and fruits may reduce the risk of cervical cancer. High intake of vitamin C & D reduces the occurrences of cervical cancer. 8

A study regarding knowledge and attitude of general outpatient attendants in Nigeria to cervical cancer among women between the ages of 20 to 65 years was made. A total number of 254 women were randomly selected from general outpatient clinic at a tertiary hospital in Nigeria and were given a structured questionnaire. Only 15 % had heard of cancer cervix. The author concluded that knowledge of cervical cancer is poor and that there is a need to educate women about cervical cancer and its prevention.21

A study is designed by World Health organization (WHO) to provide comprehensive practical advice to healthcare providers at all levels of the health care system on how to prevent, detect early, treat and palliate cervical cancer.9

A study is conducted on alternative cancer cervix screening approaches in low-resource settings. On the basis of new data and the results of earlier research conducted in 20 African, Asian and Latin-American countries, Alliance for Cervical Cancer Prevention (ACCP) partners summarized, share findings and recommendations for effective cervical cancer screening and treatment programs in low-resource settings.10

A study was conducted among the medical workers regarding their knowledge, attitudes and practices on cervical cancer at Mulago Hospitals, Uganda. 310 medical workers invited, out of which 288 (92%) participated. Out of this, 93% conceded cervical cancer as a public health problem and 83% have knowledge about pap smear and 81% had never been screened.11

An article reviewed various studies on the screening methods for cervical cancer in India during 1995 to 2005 with emphasis on screening by pap smear and visual inspection method.12

A study in Nigeria compared the efficacy of visual inspection of the cervix using acetic acid(VIA) with this pap smear method. The sensitivity of VIA was 100%, while that of pap smear was 85.7%. VIA is proposed as a credible alternative to pap smear in resource – challenged settings.13

A study showed that the incidence of cervical intra-epithelial Neoplasia is 4 to 5 times higher among HIV infected than HIV negative women & girls. HIV infected women are at higher risk for cervical cancer than are HIV negative women.14

In India, Goel examined 400 women between the ages of 30 to 34 attending the gynaec outpatient clinic in New Delhi. The doctors performed PAP cytology, VIA & colposcopy on all 400 women. VIA had a sensitivity of 96.7% much higher than that of a Pap smear, which they found to be a mere 50%.15

A study to access the two effective vaccines against Human Papylloma virus (HPV), the necessary cause of cervical cancer, has introduced a fresh lease of life to the cervical cancer control strategy. The current high cost of the vaccines is a major impediment to implement a vaccine – based primary prevention approach. 16