Among Multiparous Women in Selected Areas, Tumkur

A STUDY TO “ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE AND ATTITUDE OF CERVICAL CANCER AMONG MULTIPAROUS WOMEN IN SELECTED AREAS, TUMKUR,”

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mrs.VIDYA VIJAYAN

Obstetrics & Gynaecology Nursing

AKSHAYA COLLEGE OF NURSING S. I. T. Main Road, Tumkur. RAJIV GANDHI UNIVERSITY OF HEALTH SECIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate : Mrs VIDYA VIJAYAN

Address : M.Sc., (N) 1st Year, AKSHAYA COLLEGE OF NURSING, S.I.T. MAIN ROAD, TUMKUR

2. Name of the Institution : AKSHAYA COLLEGE OF NURSING, S.I.T. MAIN ROAD, TUMKUR

3. Course of Study & : M.Sc., (N) 1ST Year, Subject Obstetrics & Gynaecology Nursing

4. Date of Admission : 30-10-2009

5. Title of the Topic : A study to “Assess the effectiveness of self instructional module on knowledge and attitude of cervical cancer among multiparous women in selected areas, Tumkur,” 6.INTRODUCTION

Man born in sinful to this world and brought the hand of dread full disease like AIDS and CANCER at the start of third millennium. In the world cancer in all forms is the cause for about 12% of death. WHO report today cancer is the second largest killer in the world. Globally cancer is a major health problem one out of 10 deaths occurs due to cancer. According to WHO out of an estimated total 5.3 Million deaths during 1997 in world, more than 7.1 million are attributed to cancer.1 Cancer- the most dreaded disease refers to all malignant tumors caused by the abnormal growth of a body cell (or) a group of cell. It is today the second largest kills in the world, next only to heart ailments. The tem covers more than 200 diseases. Cancer can spread very rapidly and eventually prove fatal, if not treated properly, and timed. The majority of cancer in age group 50-60 years.2 Indian cancer society. Cancer has emerged as an important health problem in India, more than 1.5 million people suffers from cancer. The number of cancer death by year 2000 was 8 million. In 2006 it may become more than 8 million.3 The cervix is a ring of muscle at the top of the vagina. It is the entrance to the womb. During child birth the cervix expands until it is wide enough to let the baby out. The surface of the cervix facing into the vagina is covered with a type of skin which can become cancerous.4 Carcinoma of the cervix continues to be the most common genital cancer encountered in clinical practice in India (80%).5Cervical cancer is a disease caused by the abnormal growth and division of the cell that make up the cervix, which is narrow and lower end of the uterus.4 Cervical cancer is the second most common cancer of the female reproductive system. It accounts for 6% of all cancer in women; about 12800 cases of cervical cancer will be diagnosed this year. Early-stage cervical cancer and precancerous (tending to become cancerous) cervical conditions are almost 100% curable. The five year relative survivals rates for earliest-stage cervical cancer is 91% cervical cancer death rate fell by 74% between 1955 and 1992 and continues to drop by about 2% a year. 4 In recent years, however, the American, society, the National Cancer Institute, Clinicians, and researchers have placed grates emphasis on primary and secondary prevention of cancer; Primary prevention is concerned with reducing the risk of cancer is healthy people, secondary prevention involves; detection and screening to action early diagnosis and prompt intervention to halt the cancer process. 6 Women need special attention and planning their reproductive health India being an agricultural country has 73.7% if its population in rural areas. Statistics reveals that nearly 25% are below poverty line. A close observation on the social behaviors the society, reveals that most of the women in this category have marriage at very early part of their life, this leads to early age at first coitus continuous assault to cervix by continuous pregnancies and poor sexual hygiene. Which are considered to be the important etiological factor cancer of cervix. Pap smears are tests performed during the pelvic examination by inserting a speculum into the vagina so that the Cervix can be visualized and a sample of cells can be removed from the outer portion of the cervix using a wooden or plastic spatula. A small brush is then used to take a second sample form the inner part of the cervix. These samples are immediately preserved on glass slides and are then microscopically analyzed for the presence of cancerous or precancerous changes. For women who have undergone a hysterectomy with removal of the cervix, the vaginal cuff is visually inspected and the sample is taken from the vaginal cuff. 7 If cancerous or precancerous changes are detected, a cancer diagnosis work-up is required to determine the nature of the cancer and whether it has spread.7 Screening for cervical cancer is the testing of women for precancerous developments even in the absence of any symptoms. The intended outcome of cervical cancer screening is different from that of screening for other types of cancer: the primary goal of cervical cancer screening is not to find cancer, but to find precancerous lesions. The reason for this is that detection and treatment of precancerous cervical lesions (dysplasia) can actually prevent cervical cancer from ever occurring. Additionally, if cervical cancer is detected while in its earliest in situ stage, the likelihood of survival is almost 100 percent with timely and appropriate treatment and follow-up.7 6.1.Need for study

“There is a reason behind everything in nature”. (Aristotle) Cancer of cervix has been recognized as a health problem in India. It is considered as one of the main cause of mortality among women ranking next of breast cancer.5 According to Indian Council of Medical research 22 lakhs of people in our country are suffering from cancer. Every year another 5 lakh people are added to it nearly 75% of people are found to have advanced stage of cancer at the time of diagnosis 90% of all cancer are curable it diagnosed at an early stage.9 National cancer for health statistics found cancer is the second leading cause of death. Each year more than 1.25 million people are diagnosed with cancer in the United States search year more than half a million people die form this disease.3 According to the population based in India, cancer is registry in Chennai for the year 1996 from Adyar cancer Institute showed that 27.8% of female cancers were of cervix and in Jawaharlal Nehru Institute of Post graduate Medical Education and Research (JIMPER) pondichery the annual gynecology out patient attendance was 59093 out of which 525 were suffering from cancer of cervix during 1998. Vidya and Anil have stated in their study that 90% of the invasive cancer cervix occurs in multiparrous women. Dutta el,al. observed that 48.9% and 33.7% of their subject selected for case control studies related cancer of cervix were having more than 3 children. Thus these is a significant association between increased parity and occurrence of cervical dysplasia [P<0.05]10 Each year over 4000 women united states die from cervical cancer 13000 new cases are diagnosed carcinoma of the cervix in USA is 10/100000 and in UK 15/100000 per annum and also each year ,over 40,000 women are found to have CIN2 or CIN3, almost all of them are successfully treated. However over 3,000 new case of cervical cancer diagnosed each year in the UK and 11,000 in the USA. Cervical screening started in 1964 the effects have been quite clear. The death rate from this cancer has fallen by two thirds since than it has been estimated that over a 10- year period, cervical screening has saved the live of 8,000 women in the UK. 4 Between 60% and 80% of women newly diagnosed with cervical cancer have not had a pap test within five year some of these women have never had Pap test.11 Pap smear test and pelvic examination yearly for women who are (or) have been sexually active (or) who have reached age 18. 12 After three consecutive normal smear Pap test less than often at the discretion of physician. Alter women to the 3-earliers of cervical cancer control by the following. 12 “Early detection” “Early diagnosis” “Early treatment” The increased use of the Pap test is mostly responsible for the decrease in the number of cervical cancer. This simple highly effective screening procedure can detect precancerous conditions of the cervix and more than 90% of all cervical cancers. The fact that thousands of women die each year of a disease that can be prevented (or) cured reflects widespread failure to have Pap test as often as experts recommended. 10 By acquiring the knowledge and skills necessary to educate the community about cancer risk, nurses in all settings play key role in cancer prevention. Assisting patients to avoid known carcinogens is one way to reduce the risk for cancer. Another way involves adopting dietary and various lifestyle changes that epidemiologic and laboratory studies show influence the risk for cancer. Nurses can use their teaching and counseling skills to facilitate patient participation in cancer prevention programme to health full life styles.6 Public awareness about health promoting behaviors can be increased in a variety of way. Health education and health maintenance programs are separated by community organization such as churches, senior citizen groups and parent teachers association. If caught in the early stages cervical cancer is almost 100% curable. Hence the investigator felt a need to give a structured teaching programme about cancer of cervix. 6 In India, a large proportion of female population is vulnerable to cervical neoplasia. Carcinoma of cervix is predominantly epidermoid cancer. An abnormal change in the appearance of cervical cells occurs up to 15 years before the cancer develops and treatment at this stage can prevent it13. The multiparous women acquire the knowledge through self study or the setting given by health provide. Self instructional module related to knowledge and attitude regarding cervical cancer among multiparous women will refresh their concepts of the disease, Awareness , prevention and control of disease.

6.2.REVIEW OF LITERATURE One of the major functions of a literature review is to ascertain what is already known in relation to a problem of interest. According to Polit and Beck, review of literature is a written summary of the state of existing knowledge on a research problem. A review of literature involves systematic identification, location, securitization and summary of written materials that contain information of a research problem. Knowledge: The study was conducted on knowledge of cervical cancer and parity as a risk factor for cervical cancer. The study included 230 cases of cancer cervix and equal number of controls, matched for age. The study identified significance of multiparty, as a risk factor for cancer cervix. Estimates of attributable risk proportion (ARP) and population attributable risk proportion (PARP) endorsed etiological and preventable role of multiparrity in the out come of cervical cancer, respectively. 14 The study was conducted on knowledge of cervical cancer among Vietnams Cambodian women. Seventy -one percent (95%[CI] 54% to 85%] )of women in the study did not know what cervical cancer, another 74% were unable to identify a cervical cancer prevention strategy. 15 A study was conducted to describe knowledge of cervical cancer among Vietnamese women, Exploratory, descriptive design was used. Non probability sample of 96 adults Vietnamese migrant’s women taken as a sample. The finding was three fourth of the women interviewed could not correctly explain about cervical cancer pap test. They reported the numbers of Vietnam’s women who adhere to knowledge of cervical cancer and screening guidelines are low. 16 A study was reported to examine women’s knowledge of cervical cancer. The entire female work force of a medium-sized U.K. University received a questionnaire containing knowledge of cervical screening treatment for abnormalities and HPV. Four Hundred women returned completed questionnaires knowledge of cervical cancer was good but risk factors for cervical cancer were not well known. Awareness and knowledge of HPV was very limited. It is essential to improve women’s knowledge of cervical cancer and risk factors. 17

Knowledge and Screening The study was Conducted on knowledge of cervical cancer and screening behaviors of Vietnamese and Cambodian women. They conducted interviews among which seventy- one percent (95% confidence interval [CI], 54-85%) of women in the study did not know what cancer was and 74% were unable to identify a cancer prevention strategy. Cancer education programs need to identify the patient’s knowledge about cancer, elicit and respectfully address beliefs about causality and prevention, and ensure that health information is provided in a language understandable to the patients. 18 A study was conducted on knowledge and screening of cervical cancer among Hispanic women, who were diagnosed with cervical cancer in this study. They used case comparison study design and data from a survey Hispanic cervical cancer (n=58) survivors were analyzed by bivariate analysis. Knowledge of screening guidelines was low for all participants, especially regarding cervical cancer screening. Participation in prevention cancer screening was low indicating the need for more effective cancer prevention communication process. This study finding is that Hispanic cancer survivors need culturally sensitive cancer prevention education and associated communication processes that acknowledges difference among the varying Hispanic subgroups.19 A study was conducted regarding cervical cancer screening beliefs among Hispanic women. The study examined among Hispanic women aged 35-45 years old. 69% reported ever having had a pap test and 56% reported had test in the past year. Eight percent reported that they were sexually active and of those 63% reported using birth control. The study found suboptimal rates if screening for cervical cancer in a sample of Hispanic women residing along the U.S- Mexico border.20

Awareness and Prevention A study was conducted on awareness if cervical cancer – a case control study on north Indian population. The present case control study on married women with cervical cancer and controls ( 100 each) revealed the association of age at marriage, socioeconomic status and parity with cervical cancer but young age at marriage (rr 3.79) and low socioeconomic status (rr-3.81) emerged as independent predictor of disease status.21 The study was conducted to assess the number of women taking part in the secondary prevention of cervical cancer. The results of four cervical prevention surveys on representative samples of polish women aged over 35 years were compared 58% of women have awareness of cytological test. 12% of women have yearly visits of cytological test, cytological test done during last three year by 7%. The lowest level of awareness and the lowest frequency of using prevention service were declared among women aged over 60, represented the lowest education level. It is important to continue educational work and intervention measure concerning cervical cancer prevention.22 A Study was done on knowledge regarding cervical cancer screening and prevention. The study design followed cohort study (n=529) results low health literacy (<9th grade) was found among 40% of participants minority women were know about pap test (9% vs 21%;P<.0.3) and were significantly more likely to have low literacy level compared with white women (46% vs 15%; p<0.05) literacy was the only factor independently associated with knowledge related to cervical cancer screening and prevention. Finding improved awareness, development of screening, and prevention regarding cervical cancer.23 6.3.Statement of the problem

A study to “Assess the effectiveness of self instructional module on knowledge and attitude of cervical cancer among multiparous women in selected areas, Tumkur,”

6.4.OBJECTIVES

 To assess the knowledge about cervical cancer among multiparous women.

 To assess the pre test knowledge about cervical cancer amnong multiparous women.

 To assess the pre test attitude about cervical cancer among multiparous women.

 To evaluate the effectiveness of self instructional module on knowledge and attitude

of cervical cancer among multiparous women.

 To compare mean scores of pre test and post test knowledge and attitude of

multiparous women regarding cervical cancer.

 To assess the association between knowledge and attitude of multiparous women

regarding cervical cancer with selected demographic variables such as age, sex,

income, marital status, education and religion etc.

6.5.Operational definitions

Assess: It is the organized systematic and continues process of collecting data from a multiparous women regarding cancer of cervix.

Effectiveness: Before to determining the extent to which instructional module has brought the result intended is measured in terms of significant knowledge gain in the posttest.

Self Instructional Module (SIM)

It refers to a self contained, self sufficient unit of instruction, designed to be managed by the participants or users rather than by an instructor. It contains information’s regarding the meaning of cancer of cervix, predisposing factors, signs and symptoms, misconception, importance of early screening, complications and preventive measure of cancer cervix. .

Knowledge: Refers to the facts information and skills that multiparous possess regarding the meaning of cancer of cervix, predisposing factors, signs and symptoms, misconception, importance of early screening, complications and preventive measure of cancer cervix.

Attitude: Refers to the word of opinion of women in relation to cancer of cervix and their interest in seeking early medical advice and follow up.

Multiparous women: women who had give birth to two (or) more children age between 35-55 years.

Cervical cancer: Cancer of uterine cervix

Assumption

1. Multiparous women may have deficit of knowledge and attitude regarding cervical

cancer.

2. Self instruction module will enhance the knowledge and attitude regarding cervical

cancer among multiparous women.

Research hypothesis

There is a significant difference between before and after the self instructional module on knowledge and attitude of cervical cancer among multiparous women.

7. MATERIALS AND METHODS

7.1SOURCES OF DATA

Research approach : The experimental approach is used for the study

Research design : Quasi experimental ,one group pre-test and post –test design

Setting of the study : selected rural area of Tumkur

Sample size: 60 subjects Sampling technique : purposive sampling

Sampling criteria

Inclusion criteria

 who are having two (or) more than two children

 who are in between the age group of 35-55 years

 permanent resident of the village

 who knows Kannada and English

 who are willing to participate in the study

Exclusion criteria

 Who have not given birth to less than two children

 Who are not with in the age group of 35-55 years

 Temporary residents of the village.

 Who are not willing to participate

 who does not know Kannada and English

7.2METHODS OF DATA COLLECTION

Tools for data collection :

Tool 1- Part A : Proforma for collecting demographic data

Part B : Structured questionnaire to assess the knowledge

and attitude scale for assessing cervical cancer

Tool 2- : Self instructional module on cervical cancer

Method of data analysis and interpretation: Pre and post test scores of knowledge will be analyzed through the following technique.

Descriptive statistics: Mean, standard deviation, range and mean score percentage will be used to quantify the level of knowledge before and after SIM.

Inferential statistics: Paired t-test will be use to examine the effectiveness of SIM by comparing the pre- test and posttest score.

Chi-square test will be worked out to determine the association of socio-demographic factors of people with pre-test knowledge.

Duration of the study : 6 weeks

7.3.Does the study require any investigation or intervention to be conducted on the patients or other human beings or animals? If so please describe briefly.

7.4. Has ethical clearance been obtained from your institution in case of the above?

Yes enclosed in the end 8. References 1. Cancer .1997:http://www.WHO.com. 10/05/06. 2. Joy kuttappan.cancer. Herald of Health May 2005;vo96:No.5. 13-14 3. Cervical cancer. National Cancer Health Statistics. 1998;http//www.cancernet.nci.nigh.gov 26/06/06 4. Cervical cancer.2006; http://www.aicr.org.uk/cervical cancer FA.stm 10.7.2006 5. D.C.Dutta.Text Book of Gynaecology. Fourth edition. Calcutta (India); New Publisher(P)ltd, 2005. 6. Smeltzer C. Suzanne, Bare G. Brenda. Brunner and Suddarth’s. Text book of Medical surgical Nursing. Philaedselphia : Lippincott; 1999. 7. Cervical cancer.2006;.http// www.ncci.org.an. .15.07.2006 8. Ruth mccorkle, Marcia Grant, Marillyn Frank- Stromborg, Susan. B. Barid. A comprehensive Text book of Cancer Nursing. 2th edition , Philadelpia; W.B.saunder company, 1996. 9. Cervical cancer. Indian Council of Medical Research 1995;http//www.goole.com.10/08/07 10. Vidya and Anil.Cervical Cancer. India 1997 11. Cervical cancer. May 2002;http//www.Health.M.D.com.20/06/06 12. Ms.A.Purnungla Aier .Cancer. Nightingale Nursing Times of India. July-2007; vol 1.17-18 13. Ram Sharma Mehta. Oncology Nursing. First edition. Delhi (India); Jaypee Brothers (P) LTD, 2007. 14. Gawande V, Wahab SN, zodpey SP, Vasudeo ND. Knowledge of cervical cancer and parity as a risk factor for cervical cancer. Indian Journal Medical Science. 1998 April;52(4):147-50. 15. Phipps E, Cohen MH, Sorn R, Braitman LE. Cancer knowledge among Vietnamese and Cambodian women. Health care women Int.199 March-April 20(2): 195-207. 16. Schulmeister L, Lifsey DS. Knowledge of cervical cancer among women. Oncology Nurs Forum. 1999 June; 26(5): 879-87. 17. Pitts M, Clarket T. Women’s knowledge of cervical cancer. Health education Research. 2002 December; 17(6): 706-14. 18. Phipps E, Cohen MH, Sorn R, Braitman LE. Cancer knowledge and screening behaviours. Health Care Women Int.1999 March-April;20(2):195-207. 19. Apricio-Ting F, Ramirez AG. Knowledge and screening practices of cervical cancer. Journal Cancer Educ.2003 Winter;18(4):230-6. 20. Byrd TL, Peterson SK, Chavez R, Heckert A. Cervical screening belief among women. Preventive Medicine. 2004 Feb;38(2):192-7. 21. Capalash N, Sobti RL. Epidemiology of cervical cancer- a cause control study on north Indian population. Indian Journal cancer.1999 Jun-Dec;36 (2-4):179-85 22. Jokiel M, Bielska-Lasota M, Kraszewska E. cervical cancer prevention and awareness. Przegl Epidemiol. 2001; 55(3): 323-30. 23. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garicia P. Cervical cancer prevention knowledge. American Journal Obstet Gynecol. 2002 May;186(5):938- 43. 9. Signature of Candidate

10. Remarks of the Guide

11. NAME AND DESIGNATION OF:

11.1 Guide

11.2 Signature

11.3 Co Guide (if any)

11. 4. Signature

11. 5 Head of the Department:

11. 6 Signature

12. REMARKS OF THE PRINCIPAL

12.1 Signature