Rajiv Gandhi University of Health Sciences, Karnataka s53

Rajiv Gandhi University of Health Sciences, Karnataka Curriculum Development Cell CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Registration No. :

Name of the Candidate : KANMANI.V

Address : C/O REV.S.SUBHANANDAN,EAST MISSION COMPOUND,TIRUPATHI

Name of the Institution : Gold Finch College of Nursing,Bangalore

Course of Study and Subject : M.Sc.Nursing in OBG

Date of Admission to Course : 15-06-2009

Title of the Topic : A STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDE ABOUT CERVICAL CANCER OF WOMEN WHO ATTEND MATERNITY HOSPITAL,OPD IN BANGALORE,WITH A VIEW TO PREPARE A BOOK.

Brief resume of the intended work : Attached

Signature of the Student :

Guide Name : JULIE JESTIN. A

Remarks of the guide : SINCE CERVICAL CANCER IS ONE OF THE COMMONLY SEEN PROBLEM AMONG WOMEN UNDER THE AGE OF 50 YEARS STUDIES LLIKE THIS CAN BE ENCOURAGED TO CREATE THE AWARENESS AMONG THEM.

Co-Guide Name :

Signature of the Co-Guide :

HOD Name : JULIE JESTIN. A

Signature of the HOD :

Principal Name :

Principal Mobile No :

Principal E-mail ID :

Remarks of the Principal : THIS STUDY HELPS THE WOMEN WHO VULNARABLE TO CANCER CERVIX TO IMPROVE THEIR KNOWLEDGE REGARDING CANCER CERVIX AND ITS ILL EFFECTS ON HEALTH.

Principal Signature :

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION.

1 NAME OF THE Mrs. V.Kanmani CANDIDATE AND ADDRESS 1st Year M.Sc. Nursing.

Gold Finch College of Nursing.

2 NAME OF THE Gold Finch Colleg of Nursing. INSTITUTION

3 COURSE OF THE 1st Year M.Sc (N) STUDY Obstetrics & Gynaecology

4 DATE OF 31 – 05 - 2009 ADMISSION

5 TITLE OF THE TOPIC.

A Study to assess the knowledge and attitude about cervical cancer of

Women who attend Govt. Maternity hospital , OPD, with a view to prepare

a book.

2 GOLD FINCH COLLEGE OF NURSING – BANGALORE RESEARCH PROPOSAL

TO ASSES THE KNOWLEDGE AND ATTITUDE ABOUT CERVICAL CANCER OF WOMEN WHO ATTNEDED MATERNITY HOSPITAL OPD, BANGALORE.

RESEARCHER KANMANI.V M.Sc(N) FIRST YEAR GOLD FINCH COLLEGE OF NURSING BANGALORE

GUIDER PROF: Mrs.JULIE JESTIN M.sc.(N) PROFESSOR, GOLD FINCH COLLEGE OF NURSING BANGALORE

3 6.BRIEF INTRODUCTION OF THE INTENDED WORK

INTRODUCTION:

Cervical cancer is the second most common cancer in women; worldwide and is one of the leading causes of cancer related to death in women in underdeveloped or developing countries like Somalia and India .It is one of the major public health problems in our country especially in Bangalore. Out of all cervical cancer cases seen in the world 14% occurs in the developed countries and about 86% occur in developing countries. We know that cervical cancer is considered to be a preventable and curable disease, because it can be diagnosed in its pre- cancerous phase and can be controlled. Considering the high incidence of cancer of cervix in our country pap screening becomes mandatory. Pap smear helps to reduce the incidence of cervical cancer significantly. Inadequate knowledge is therefore most of the reason why many patients do not make use of the currently available screening methods. Approximately two third of women who develop cervical cancer have been screened. Race, ethnic background and low income status play a role in incidence, mortality and survival. Survival rates approach 95% if a high quality cytology-screening programme is in place and is used by women.

Nurses and other health care providers, including doctors and health educators should be educate women about the risk factors of cervical cancer and the benefits of early detection with pap test. To do this, health care providers should help women to promote their understanding of cervical cancer screening as a preventive health care measure. Also they should advise their clients who are sexually active to have a Pap smear annually or at regular intervals as indicated. Although health professionals and health educators have limited power to change societal deficiencies or alter the pre-existing socio economic status of individuals, they are able to increase compliance with preventive screening recommendations.

Cancer of reproductive system takes a heavy toll on women’s lives. Health teaching by nurses can maximize, change to reduce this toll. Encouraging women to practice healthy behavior is challenging because change is always difficult. Many of the preventive behavior, which helps to decrease the incidence of cervical cancer, also help to prevent other

4 diseases in women. It may be also possible for nurses to use preventive knowledge for behavior modifications. The investigator realized that nurses as educators and exemplar can become agents of change. Nurses are the largest group of health professionals can help it through their clinical practice and verbal advice or informational material like pamphlets. Early detection and prevention of cervical cancer will continue to rise in the hierarchy of health care.

6.1 NEED FOR THE STUDY:

Cervical cancer has become challenging and life threatening problem in industrial developed and developing countries. It is one of the most common leading causes of death in the aging population of women. This be due to increasing number of carcinogens, poor life style patterns and unskilled diagnoses. Screening is expected to continue to make cervical cancer less of a threat in developing countries. The highest rates are in Latin America, Africa and South East Asia including India, where risk of cervical cancer is the highest. Six Indian registries (five Urban and one rural) have shown the cancer of uterine cervix is the commonest in all, except Bombay.

In Ujjain district (MP) a study was done about cancer screening showed that, woman had knowledge regarding cancer indifferent levels, urban slum woman had 44%, urban woman 62.6%, rural woman had only 18.1%. Cervical cancer is consider preventable and survival rate is 47%, more over it has been shown that screened woman carried a 10 times a higher risk of invasive cancer than screened woman

In Orisa, 100 patient patients who suffered from invasive carcinoma of the cervix and who underwent surgical treatment cases were analyzed for the epidemiological risk factors. Early menarche, early marriage and early frequent coital activity were influencing the risk of cancer cervix. Early first pregnancy and multiple pregnancies are also contributed to the risk. Poor socio economic status and rural habitat were associated with the majority of the patients. In a developing country like ours, counseling against early marriage, social motivation for delayed pregnancy and first child birth, promotion of barrier contraception should be emphasized because hardly anything can be done above socio economic status.

5 Cervical cancer is the most common cancer among Indian woman due to prevalence of several risk factors in our communities. A population based study repot reveal that, the woman who were (2688) attending the camp were married belonged to the poor socio economic class were illiterate and their age varied from 18 to 72 years. These women had some reproductive tract infections or discomforts their average age being 36 years. Poor genital hygiene (60.9%) and age at marriage below 18 years (58.5%) were the most common risk factors, followed by age at first child birth below 18 years (39%), multiparity (32.9%) and family history of cervical cancer 9.8%. Out of 154 health workers, only 12.5 % knew of Pap smear test is for cervical cancer screening.

World wide approximately 500,000cases of cervical cancer are diagnosed each year. Routine screening has decreased the incidence of invasive cervical cancer in the United States, where approximately 13,700 cases of invasive cervical cancers and 65,000 cases of cervical carcinoma in site are diagnosed yearly. Invasive cervical cancer is more common in middle aged and older, in women of poor socioeconomic status, who are less likely to receive regular screening and early treatment. There is also a high rate of incidence among developing countries. Among African Americans, the death rate from cervical cancer is more than twice the national average. Hispanics and Indian American also have death rates above the average.

Most women who develop cervical cancer tend to have one or more identifiable factors that increase their risk for the disease. It is uncommon but not impossible for woman to develop cervical cancer without any of these risk factors. Some risk factors can be changed (smoking and diet) where as others cannot be changed (age and race). The American cancer society 2003 suggests that focusing on the risk factors can prevent cervical cancer. Though some symptoms can indicate cervical cancer, there are often no symptoms are associated with early stages of the disease. Therefore all women should receive yearly pap smears once they reach at the age of 18 are become sexually active, which ever occurs earlier. After 3 negative pa smears in three consecutive years, pap smears may be performed less often at the discretion of the patient’s physician.

In the 1960’s the average age of the women diagnosed with malignancy of cervix was 50. Over the next three decades, the average age is during which women developed cervical

6 cancer declined to 35. At the same time, the number of younger women with cervical neo- plasia has increased. In 1981, one fifth of the deaths from cervical cancer occurred in women under age of age of 50 years, 6 years later 28% Of women those who died with cervical cancer was under the age of 50 years. Pap smear testing is a policy for western women.

Nurses are in position to provide information such as: prenatal care contraceptive practice immunization and well baby clinic because they are in contact with women in a variety of settings. Any of these times is ideal to discuss with the women the need for routine gynecological care and screening. Nurse can educate the public through health education, open conversations, mass media and learning materials. Though India is in developing stage, technological advancement is poor in rural areas. Thus investigator identified learning materials can be of use to educate the women to improve their knowledge regarding cervical knowledge. 6.2REVIEW OF LITERATURE

1. CERVICAL CANCER

Cervical cancer develops in the lining of the cervix, the lower part of the uterus that enters the vagina. This condition usually develops over a time. Normal cervical cells may gradually undergo changes, to become pre-cancerous and cancerous.

The causes of cervical cancer are unknown , but some of risk factors are know, which are human papilloma virus and human immuno deficiency virus , cigarettes smoking, age, multiple sexual partners, history of not having pap tests, diethyl-strilbestrol(DES), weakened immune system, poor nutrition(vit A,C ,E ,&Folic acid) race and ethnicity, low socioeconomic status, oral contraceptive pills, poor genital hygiene , obesity, early age of marriage, many children, and sexually transmitted diseases and male factors like the use of tobacco and alcohol.

7 Early cervical cancer is often asymptomatic. In women ,who receive regular screening, the first sign of the disease is usually an abnormal pap smear test result. Symptoms that may occur include the following.

 Abnormal vaginal bleeding(e.g.: spotting after intercourse , bleeding between

menstrual periods, increased menstrual bleeding)

 Abnormal (yellow, odors) vaginal discharge.

 Low back pain.

 Painful sexual intercourse.

 Painful urination.

 Anemia

 Weight loss

Cervical cancer that spread to other organs may cause constipation, blood in the urine, abnormal opening in the cervix (fistula) and urethral obstruction (blockage in the tube which carries urine from the kidney to the bladder).

II. KNOWLEDGE OF RISK FACTORS AND EARLY DETECTION OF CERVICAL CANCER

A study was conducted in Canada, to assess the knowledge of pap smear and risk factors for cervical cancer among 528 Chinese immigrant women. Findings revealed that, the average summary score of knowledge about risk factors was 5. (52%) knowledge level was significantly associated with the women’s educational level and the gender of the doctor providing routine care. Among them 74% received a pap test and 56% reported having received it with in last 2 years. Women with the highest knowledge were more likely to have received Pap test. The average knowledge level was low about risk factors of cervical cancer.

8 Another study was carried out in London to determine the belief about risk factors of cervical cancer among 1940 women by face –to –face interview. Knowledge has been found to be poor, although there was evidence of public awareness of a link between sexual activity and the risk of cervical cancer. the most common single response was ‘don’t know’ 88%, 41% mentioned factors relating to sex, but only 14% were aware of a link with sexual transmission, 1% named Hpv. Women who were more educated had better know of the established risk factors. Another one more study was done to asses the level and accuracy of public understanding of human papillma virus (Hpv) in the United Kingdom. Finding showed that, questionnaire were completed by 1032 women, of whom 30% had heard of Hpv. Even among those who had heard of Hpv, knowledge was generally poor and less than 50% were aware of the link with cervical cancer. There was also confusion about whether condom or oral contraceptives could protect against Hpv infection

A study was done in Nottingham to identify the women’s knowledge of cervical cancer and human papillomer virus. It was found that almost 80% of the respondents thought cervical cancer was a leading cancer death amongst women. Most subjects consistently over- estimated the incidence of cervical cancer, consistent with the social amplification hypothesis. The majority accurately identified the major risk factors, although family history was emphasized to a degree unwarranted by epidemiological evidence. Subjects knowledge of the screening programme was accurate in some respects but not in others. Another study was conducted on the knowledge of risk factors of cervical cancer, Pap smear testing along with socio economic characteristics among Chinese immigrants in the USA. The overall estimated response was 64% and the co-operation rate was 72%. The majority of women could not recognize the importance of risk factors of cervical cancer, but less than 50% of women recognized most of the risk factors. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment and education. Respondents with the highest knowledge had greater odds of ever receiving a pap smear compared with to those women who had the minimum knowledge.

9 III. KNOWLEDGE, ATTITUDE AND PRACTICE OF CERVICAL CANCER SERVICING.

The knowledge, attitude and practice level of female primary care physicians (98) regarding cervical screening where studied through questionnaire. The research report showed that only 40% have ever performed a pap smear. Thus various training methods and programmes on cervical screening are currently being developed based on the results of the study. Again the knowledge, attitude and practice status of women (112) were studied in the USA. The results suggested that knowledge of screening guideline was low for all participants, especially regarding cervical cancer screening. Although supervisors held positive cancer attitude, participation in preventive cancer screening was low, this is indicative of the need for more effective cancer prevention communication processes. The study described the belief, attitude and personal characteristics influencing the cervical cancer screening status of women in USA. The study findings showed that 69% had a Pap test and 56% had a test in the last year. Eighty percentages of women were sexually active and of these, 63% were using birth control measures. Respondents understood the seriousness of cervical cancer; their susceptibility to cervical cancer and the benefits of Pap tests. The preparation that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test.

A study conducted on knowledge and practice about cervical cancer and Pap smear test in Kenya. The report showed that 51% of respondents wee aware of cervical cancer while 32% knew about Pap smear testing. There was no significant difference in knowledge between cervical cancer and non-cancer patients. Health care providers were the primary source of information about Pap test 87%, 22% of all patients had Pap smear test in the past. Patient’s awareness of cervical cancer was not likely to have a Pap smear test in the past. The level of knowledge was low among non-cancerous patients. There is need to increase the level of knowledge and awareness about cervical cancer screening and for women to increase the uptake of currently available hospital screening facilities. The knowledge, belief, health care behavior and attitudes towards cervical cancer and cervical screening was studied in Hong Kong on 98 female domestic helpers, their age being between 24 - 45 years. The findings revealed that the majority of women had previously heard about cervical smear 78%, 53% reported never having

10 taken cervical smear. The women who had a prior cervical smear had significantly more knowledge about cervical smear and cervical cancer than those who never had a cervical smear.

The study which was conducted to examine the knowledge and perception of cervical cancer and screening on 30 women, selected from all income groups from the USA. The findings showed that the knowledge of cervical cancer and Pap smear test was inadequate among women with low income. Among them 44% had opportunity to Pap test and 40% had never had Pap smear test. Pap smear utilization was also limited among low-income women. Major barriers to Pap smear screening included inadequate knowledge about Pap smear testing, provider’s negative attitudes and limited access to doctors. Health education and health policy is important and nurse’s involvement is also essential.

IV. SOCIO DEMOGRAPHIC FACTORS ASSOCIATION TO CERVICAL SCREENING

A study was done to assess the socio-cultural influences of women’s attendance for cervical cancer screening. The findings were, women indicate, that the social factors of cost, educational base, knowledge of risk, the social value of early detection and cultural issues such as modification and embarrassment contributed to screening attendance. The doctors perceived a cultural tendency towards fatalism as well as seeing the gender, interpersonal and inter professional skills of practioners to be important in influencing level of women’s shyness and discomfort.

Another study was conducted to assess the knowledge of cervical cancer screening and utilization of screening facilities among women from low, middle and upper social background. The report showed that the majority of patients from lower socio-economic circumstances with multiple risk factors were not aware of cervical screening or facilities available for this purpose. However, in spite of knowledge of cervical screening and availability of such services, the

11 majority of women (87%) from higher social and educational background did not undergo cervical screening. 36.7% patient had a screening test performed at some time in past, only 27.3% of patients, reported having has a Pap test. Among women from higher socio-economic groups, the level of education was better and knowledge of the Pap test was not aged dependent.

V. MOTIVATIONS AND BARRIERS TO CERVICAL SCREENING.

A study was conducted to identify the barriers to cervical screening, about factors that may influence screening. Among 97 rural women the aged between 16-66 years and found that 52% had not received a pap smear within the last two years, 42% had never received a pap smear. The most frequent reason for not obtaining a Pap smear was anxiety regarding physical privacy (50%), lack of knowledge (18%) and difficulty accessing health care (14%) women who had delivered children were significantly more likely to have received a Pap smear (71%), P<0.05. The responses of many women suggests that compliance will cervical cancer screening would be enhanced by addressing cultural beliefs, encouraging conversation about women’s health issues and increasing the number of female health care providers. An article explores the negative attitudes some women have towards the cervical screening programme. These attitudes could ultimately prevent them from participating in the programme. The native experiences of women who receive a positive result are also explored. Women’s negative attitudes towards cervical screening can largely be countered by improving their understanding of the process and diagnosis of cervical cancer. Women who received a positive smear should be offered support to reduce their anxiety.

A population-based study was done to find out reasons for women who did not want to find out reasons for cervical cancer on 430 non-attenders and 514 at tenders of Pap smear. Report showed, non attendance was positively associated with non use of oral contraceptive pills, seeing different gynecologists, seeing physicians very often, frequent use of condom, living in rural or semi rural areas and not knowing the screening test. Socio economic status and time was not their nonattendance. Another study was done to identify knowledge, barriers and motivators related to cervical cancer screening with 102 women. Findings revealed that there was misinformation and lack of knowledge about cervical cancer. The women therefore confused about the causative factors and preventive strategies related to cervical cancer. The major structural barriers were economic and time factors along with language problems. The

12 main psychological barriers were fear, fatalism, confusion thinking and denial. The barriers to women’s use of cervical screening services were identified with in 20 women. The study found a high level of awareness of a local cervical screening programme. The specific barriers determined were social problems, embarrassment, belief in the sacred nature of human sexuality, an anxiety about lack of confidentiality within small community groups and perceived relationship between cervical smear and sexual activity.

6.3STATEMENT OF THE PROBLEM

A STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDE ABOUT CERVICAL CANCER OF WOMEN WHO ATTEND METARNITY HOSPITAL , OPD,WITH A VIEW TO PREPARE A BOOK.

6.4 OBJECTIVES

1 .To assess the knowledge of women regarding cervical cancer.

2. To identify attitude related to cervical cancer.

3. To determine the association of knowledge and selected variable such

as age, marital status ,religion , education , income :betel leaves

chewing and habitation.

4. To determine the relationship between knowledge and attitudes of

women about cervical cancer.

5 .To prepare a pamphlet for women on risk factors and early detection.

6.5 HYPOTHESIS:

There will be a significant relationship between knowledge and attitudes of women about cervical cancer.

13 6.6 OPERATIONAL DEFINITIONS:

1. Knowledge:- It refers to women’s awareness regarding cervical cancer, risk factors and

Pap smear testing as measured by scores obtained according to the response to the items

on the structured questionnaire

2. Women:- It refers to female,18-60 years of age group who attend any OPD.

3. Attitudes:-It refers to scores obtained by women as measured by their response to items

on a Likerts Scale, in which they expressed their views about cervical cancer.

4. Baseline variables:- It refers to age, marital status, education ,occupation ,income ,betel leaves chewing, religion and place of residence.

6.7 ASSUMPTION:

Women possess some knowledge regarding cervical cancer.

6.8 DELIMITATIONS:

The study results would be generalized to women who are attending meternity hospital in Karnataka.

6.9 PROJECTED OUTCOME:

The study will help to educate the women about cervical cancer by providing learning materials ,which consists of risk factors ,early detection methods,signs and symptoms ,prevention and treatment of cervical cancer. It may help them to change their life style patterns and protect their health.

7. MATERIALS AND METHODS OF STUDY:

7.1 SOURCE OF DATA :

The data will be collected from women’s who are attended in OPD, and admitted in ward of Maternity Hospital in Bangalore.

14 7.1.1 RESEARCH DESIGN AND APPROACH:

RESEARCH DESIGN :

This study was a Non-Experimental, The research design used for this study was descriptive, which was selected since it aided in attaining first hand information and enhanced obtained accurate and meaningful data.

RESEARCH APPROACH : An evaluative research approach is used to the study.

7.1.2 SETTING :The study will be conducted at a selected hospital at Bangalore.

7.1.3 POPULATION:

In this study population refers to all women who belong to the age group or 16 to 60 years, Who attend any OPD of Maternity Hospital, Bangalore.

7.2 METHOD OF DATA COLLECTION:

A total of 50 women who attended the units of the outpatient department were selected through purposive sampling technique for the study. The investigator first introduced her self to the participant and obtained verbal consent for the study . If the woman was not willing participate , the next woman who met the inclusion criteria was selected for the study.

7.2.1 SAMPLING PROCEDURE :

A sample is a small portion of a population, selected to assess the knowledge and attitudes of women and to analyse it. The process of sampling makes it possible to draw valid inferences or generalization. The sample in this study is comprised of the women who are in the age group of 40 – 60 years attend any OPD of Maternity Hospital.

7.2.2 VERIABLES UNDER STUDY :

Independent Variable:

Knowledge and attitude of women with age group 40 – 60 Years.

Dependent Variable:

Cervical Cancer.

15 7.2.3 Sample size:

To assess the knowledge and attitudes of women about cervical cancer 50 women were selected for this study.

7.2.4 DURATION OF STUDY: 4 Weeks

7.2.5 INCLUSIVE CRITERIA FOR SAMPLING:

 Women who are between the age group of 40 to 60 years.  Women who attend any unit of the OPD of government Maternity Hospital, Bangalore.

7.2.6 EXCLUSIVE CRITERIA FOR SAMPLING:

Women who are:

 Diagnosed to any cancer.  With Mental illness.  Critically ill.  In need of emergency case.  Attending psychiatry and oncology OPD

7.2.7 INSTRUMENT INTENDED TO BE USED:

Planned questionnaire will be used to assess the knowledge of cervical cancer among women. It has two sections: Demographic data Questionnaire

7.2.8 METHOD OF DATA COLLECTION:

A total of 50 women who attended the units of the outpatient department were selected through purposive sampling technique for the study. The investigator first introduced her self to the participant and obtained verbal consent for the study . If the woman was not willing participate , the next woman who met the inclusion criteria was selected for the study.

7.2.9 LIMITATIONS: The study is limited to : - those who are willing to participate . - those who are able to understand English ,kannada and Hindi - women who are attending Matarnity Hospital in Bangalore.

16 7.2.10 PILOT STUDY:

Pilot Study is planed with 10% population.

7.2.11 PLAN FOR ANALYSIS:

The data obtained was analyzed in terms of the objectives of the study using descriptive and inferential statistics.

7.2.12 DESCRIPTIVE STATISTICS:

Appropriate statistical measures will be used with the consultation of statistician.

7.2.13 INFERENTAL STATISTICS:

Appropriate statistical measures will be used with the consultation of statistician.

7.2.14 DOES STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON : YES: Assessment of effects of cervical cancer will be done for women by providing informational booklet.

7.2.15 HAS ETHICAL CLEARANCE OBTAINED:

Yes, It is already obtained from the authority.

17 8. BIBLIOGRAPHY

1. Jacquelyn Reid. Women’s knowledge of Pap smear, risk factors for cervical cancer and

cervical cancer. JOGNN. 2001 ; 30 : 299 – 304.

2. Seung Jo Kim. Role of colposcopy and cervicography in the screening management of pre-cancerous lesions and early invasive cancer of uterine cervix. The journal of obsttric & gynaecology of India. 2000; 50:139.

3. Mahadik kalpana V, Deshpande Kirti R. Survey of women for knowledge of cancer, antenatal well-being attitudes and practice in rural, urban and urban slum area of district MP. Journal of obstetric & gynaecology of India. 2003; 53:271-273.

4. Desai Monali. Awareness about menopause and cancer screening among educated women. Journal of obstetric and gynaecology of India. 2003; 53;271-273.

5. Sheila Twinn, Hoirogd E. Women’s knowledge about cervical cancer and cervical screening practives. Cancer nursing. 2002 ; 25:377-384.

6. Dr. Gopal K. Singh and his colleagues. Low income and educated increases risk for cervical cancer. Health news [ Serial online ] 2004 July; 1 (1) : [screens]. Available from http://www.ncc-online.org/news 072604.asp. Assessed July 26,2004.

7. Miok. C.Lee. Knowledge, barriers and motivators related to cervical cancer screening among Korean-American women. Cancer nursing. 2000; 23:168-175.

8. Jita Mohanty, Badal K.Mohanty . Risk factors in invasive carcinoma of cervix. Journal of obstetric and gynaecology. 1990; 22:10-14.

9. Katherine kim. Elena S.H. Jackying. Cervical screening knowledge and practices among Korean-American women. Cancer nursing. 1999; 22:297-302.

10. Ann Eyres White. Older women’s attitudes to cervical screening and cervical cancer : a New

18 9. SIGNATURE OF THE CANDIDATE 10. REMARKS OF THE GUIDE

SINCE CERVICAL CANCER IS ONE OF THE COMMONLY SEEN PROBLEM AMONG WOMEN UNDER THE AGE OF 50 YEARS STUDIES LIKE THIS CAN BE ENCOURAGED TO CREATE THE AWARENESS AMONG THEM.

11. NAME & DESIGNATION OF Mrs. JULIE JESTIN. A , ASSOCIATE GUIDE PROFESSOR.

12. SIGNATURE 13. CO-GUIDE 14. SIGNATURE 15. HEAD OF THE Mrs. JULIE JESTIN. A , ASSOCIATE DEPARTMENT PROFESSOR. 16. SIGNATURE

17. REMARKS OF THE THIS STUDY HELPS THE WOMEN WHO PRINCIPAL ARE VULNERABLE TO CANCER CERVIX TO IMPROVE THEIR KNOWLEDGE REGARDING CANCER CERVIX & ITS ILL EFFECTS ON HEALTH 18. SIGNATURE