Proforma for Registration of Subject for Dissertation s4

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Miss. LENY.L I YEAR M.Sc NURSING OBSTETRICS AND GYNAECOLOGY NURSING YEAR 2010-2012

PADMASHREE COLLEGE OF NURSING GURUKRUPA LAYOUT, NAGARBHAVI BANGALORE-5600072

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

1 BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE MS.LENY.L I YEAR M.Sc NURSING AND ADDRESS PADMASHREE COLLEGE OF NURSING,GURUKRUPA LAYOUT,NAGARBHAVI, BANGALORE- 560072. 2. NAME OF THE INSTITUTE Padmashree College of Nursing, Bangalore.

3. COURSE OF THE STUDY AND I Year M.Sc Nursing SUBJECT Obstetrics and Gynaecology Nursing 4. DATE OF ADMISSION TO THE 03/05 /2010 COURSE 5. TITLE OF THE STUDY A Study To Assess The Knowledge And Attitude Regarding Prevention Of Cervical Cancer Among Mothers Of Adolescent Girls In Selected Urban And Rural Communities, Bangalore.

6. BRIEF RESUME OF THE INTENDED WORK

2 6.1 INTRODUCTION

“ First love is a vaccination which saves a man from catching the complaint ” HONORE DE BALZAC

Cancer can be defined as any malignant growth or tumor caused by abnormal and uncontrolled cell division; it may spread to other parts of the body through the lymphatic system or the blood stream. Cancer can affect any part of the body, Once a person get cervical cancer it cannot be prevented so the best way of saving the person from catching the complaint is to vaccinate against cervical cancer.1

Cancer is a class of diseases in which a cell, or group of cells display uncontrolled growth Cancers are primarily an environmental disease with 90- 95% of cases due to lifestyle and environmental factors and 5-10% due to genetics. Common environmental factors leading to cancer death include diet (30-35%),infections (15-20%), radiation, stress, lack of physical activity, environmental pollutants.2

Cancers can occur in any part of the female reproductive system, the vulva, vagina, cervix, uterus, fallopian tubes, or ovaries. These cancers are called gynecologic cancers. Gynecologic cancers can directly invade nearby tissues and organs or spread through the lymphatic vessels and lymph nodes or bloodstream to distant parts of the body.3

The cervix is the narrow portion of the uterus where it joins with the top of the vagina. Most cervical cancers are squamous cell carcinomas, arising in the squamous epithelial cells that line the cervix adenocarcinoma, arising in glandular epithelial cells is the second most common type. Very rarely, cancer can arise in other types of cells in the cervix.4

3 The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus infection, smoking, chlamydia infection, stress and stress-related disorders, dietary factors, hormonal contraception, multiple pregnancies, exposure to the hormonal drug diethylstilbestrol and a family history of cervical cancer.

Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. It may present with vaginal bleeding, but symptoms may be absent until the cancer is in its advanced stages. Treatment consists of surgery in early stages and chemotherapy radiotherapy in advanced stages of the disease.4

Cancer of cervix is the second most common cancer in women worldwide, and is the cause of cancer related death in women in under developed countries. 80% of the new cervical cancer causes occur in developing countries, like India , which reports approximately one fourth of the worlds cases of cancer each year.

Cervical cancer is caused by Human Papillomavirus. More than 150 type of Human Paoillomavirus are acknowledged to exist, of these, 15 are classified as high risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 & 82) three are probable high risk (26, 53 &66) and 12 are ;low risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81 & 14) but even those may cause cancer. Type 16 and 18 are responsible for 70% of cervical cancer.

The early stages of cervical cancer may be completely asymptomatic. Vaginal bleeding, contact bleeding or a vaginal mass may indicate the presence of malignancy. Also moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer.

The widespread introduction of the papanicoloau test , or pap smear for cervical cancer screening has been credited with reducing the incidence and mortality of cervical cancer in developing countries. Abnormal pap smear may

4 suggest the presence of cervical intraepithelial neoplasia before a cancer has developed, allowing examination and a possible preventive treatment.

According to American National Cancer Institute “widespread vaccination has the potential to reduce cervical cancer death around the world by as much as two-third, if all women were to take the vaccine and if protection turn to be life-term, the vaccine can reduce the need for medical care, pap test, thus helping to reduce health care cost and anxiety related to abnormal pap test and follow up protection”.

The primary preventive measures for cervical cancer is vaccination. Gardasil and Cervarix are preventive vaccine and do not treat Human Papillomavirus infection or cervical cancer. They are recommended for women who have not been exposed to Human Papillomavirus. Gardasil show the prevention of cervical dysplasia for the HPV strain such as type 16, 18, 6 & 11 and the effect last for more than 6 yrs after vaccination, Gardasil is up to 98% effective. Cervarix act against type 16 & 18 and effect last for four years.

Human Papillomavirus vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The vaccines have been shown to be effective for at least 4 to 6 years, and it is believed they will be effective for longer, however the duration of effectiveness and whether a booster will be needed is unknown.4

6.2 NEED FOR THE STURY

The diversity in cancer incidence among different regions and populations, and different ethnic and age groups has been well documented. This phenomenon has been extensively used, among others, to formulate hypotheses to support relationships between cancer risk on the one hand, and genetic background as well as life-style and behavior on other hand. Examples

5 of such relationships are the higher cancer incidence rates in densely inhabited, urbanized areas when compared to less populated, non-metropolitan areas.

In urban areas, cancer of the cervix account for over 40% of cancer while in rural areas it account for 60% of cancer, due to low income status, they fail to carry out check-up.

Globaly cervical cancer is the fifth most deadly cancer , second most common cancer.470,000 new cases are diagnosed per year. Mortality rate is 233,000 death per year. In India 1.30 lakh women are diagnosed per year. 47,000 die of cervical cancer per year. Incidence is 17.1 women per 100,000 population.5

The barrier which prevent people from screening against cervical cancer in Urban and rural areas within counties are the, the view that cancer is a death sentence, and the stigmatization of people with cancer, inadequate knowledge regarding cervical cancer. Barriers to screening also included cost, lack of insurance, transportation problems, fear, embarrassment, and privacy issues. These findings highlight the important role of geography, social environment, and culture on health behaviors and health outcomes.6

Since cancer mortality rates are slightly higher in the urban centers , and since the typical diets of rural and urban populations within each country are generally identical, this points towards two causative factors; the quality of nutrition, and environmental contaminants. Since the difference in the cancer rate between rural and urban populations is very small, environmental factors appear to play a only small role. This leaves the quality of the food of these populations as the chief and major cause of the huge differences in cancer mortality rates. The Indian authorities are, however, well aware that the incidence of cancer is dramatically lower in rural areas .7

A study was conducted on acceptance of Human Papillomavirus vaccination among parents of daughters. 75% of sample reported that they like

6 to vaccinate daughters before 13 yrs. Hispanic parents were more likely to accept than non- Hispanic. African- American and Asian- American were less likely, the reason for non-accepting parents were concern about effect on sexual behavior, specific Human Papillomavirus vaccine concerns, moral concerns about sexual behavior, general vaccine concern and denial to need.8

A study on mothers attitude towards preventing cervical cancer through Human Papillomavirus vaccination. Most mothers were favor of protecting their daughters from cervical cancer, some mothers were worried about increase in risky sexual behavior, mothers were concerned about discussing the vaccine with young girls and preferred to wait until they were older. Mothers had reservations, particularly about vaccinating girls younger than 10 yrs.9

A study was conducted by Purnima Madhivanana on Attitudes toward Human Papillomavirus vaccination among parents of adolescent girls. The study found that while parents have limited knowledge about Human Papillomavirus or cervical cancer, most are still highly accepting an Human Pappilomavirus vaccine. In addition, high acceptability levels appear to reflect positive attitudes toward the government universal immunization program in general, rather than to the Human Papillomavirus vaccine in particular. The results highlight the need for additional education and health promotion regarding Human Papillomavirus and cervical cancer prevention in India.10

Several religious and conservative groups opposed the concern of making Human Papillomavirus vaccination mandatory for pre-adolescent girls, asserting that making the vaccine mandatory is a violation of parental right, also it leads to early sexual activity, giving a sense of immunity to sexually transmitted diseases. Many organizations disagree with the argument that the vaccine increases sexual activity among teens. Dr. Christine Peterson, director of the University Of Virginia’s Gynecology clinic said “The presence of seat belt in cars doesn’t cause people to drive less safely. The presence of a vaccine

7 in a persons body doesn’t cause them to engage in risk- taking behavior they would not otherwise engage in”.

Mother is the person responsible for the health of the children. The adolescent age is a period of stress and anxiety due to the hormonal changes and body changes, the adolescents will be dependent on their parents, so the preventive measures that the adolescent girls adopt against specific diseases depend on their mothers knowledge and attitude.

Through the personal experience of the researcher during the clinical posting in Holy Cross Hospital, researcher found that most of the women were unaware and had inadequate knowledge regarding prevention of cervical cancer. They were seeking information from their health care providers. The target group for Human Papillomavirus vaccination are girls and women between 9 to 26yrs, Since the vaccination of adolescent girls depend not only on their knowledge, but also the knowledge and attitude of their mothers. Hence the researcher felt the need to assess the knowledge and attitude of the mothers of adolescent girls regarding prevention of cervical cancer.

6.3 STATEMENT OF THE PROBLEM A study to assess the knowledge and attitude regarding prevention of cervical cancer among mothers of adolescent girls in selected urban and rural communities, Bangalore.

6.4 OBJECTIVES 1. To assess the knowledge of mothers in rural and urban areas. 2. To assess the level of attitude of mothers in rural and urban areas. 3. To correlate the knowledge and level of attitude of rural and urban mothers. 4. To associate the knowledge and level of attitude between rural and urban mothers with their selected demographic variables.

8 6.5 OPERATIONAL DEFINITION Knowledge : Refers to the awareness and understanding of mothers of adolescent girls in urban and rural areas regarding prevention of cervical cancer.

Attitude : Refers to the view expressed by mothers of adolescent girls regarding the prevention of cervical cancer.

Prevention : Refers to the measures taken by mothers by vaccinating there adolescent girls to protect against cervical cancer.

Cervical Cancer : Refers to the malignant neoplasm of the cervical area. Human papillomavirus is the important factor in the development of cervical cancer.

Mothers : Refers to women who have female children between the age group of 13 – 19 yrs and residing in rural and urban community. Adolescent Girls : Refers to female children between the age group of 13 -19 yrs and residing in rural and urban community.

6.6 ASSUMPTIONS 1. The mothers may have inadequate knowledge regarding prevention of cervical cancer. 2. The mothers attitude may vary depending on the existing knowledge on prevention of cervical cancer.

9 6.7 RESEARCH HYPOTHYSIS

H1 : There will be significant correlation between knowledge and attitude among mothers about prevention of cervical cancer.

H2: There will be significant association between knowledge and attitude with their selected demographic variables.

6.8 REVIEW OF LITERATURE Review of literature is a key step in research process . Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. One of the most satisfying aspect of the literature review is the contribution it make to the new knowledge.11

The literature review is sectioned under the following headings:

1) Literature related to knowledge regarding Cervical cancer .

2) Literature related to knowledge regarding Prevention of cervical cancer.

3) Literature related to attitude regarding prevention of cervical cancer.

1) Literature related to knowledge regarding Cervical cancer A study on women's knowledge regarding Human Papillomavirus infection, cervical cancer and Human Papillomavirus vaccines. The study was conducted in women in the age group of 18-30 yrs, the sample size was 90, the setting was Australia. Most respondents (89%) had heard of HPV, 79% of respondents stated that the most common resource they would use to obtain further information is their general practitioner. The study reveals the need for further education regarding HPV infection and the potential long-term complications such as cervical cancer.12

A study on Knowledge and Practice Regarding Breast and Cervical Cancer Among Females. The study was conducted in women of the age group 30-35yrs, two wards of each panchayats were selected in the study, the study

10 was conducted in Northern part of Kerala. About 30% opined that early coitus and early childbirth leads to cervical cancer. 50% of the study group knew that multiple sexual partners are a cause for the occurrence of cervical cancer. The study reveals the need of more health education programs in the community so that it is possible to make attitudinal changes among the women and thus will reduce the load of the disease and increase the life span of individuals.13

A study on Knowledge about cancer screening among medical students and residents. The study was conducted in medical students attending either private or public medical school and internal medicine residents, the sample size was 451, the study was conducted in Mexico City. There was no difference in the knowledge regarding cervical cancer . The study reveals that, Knowledge of screening guidelines is suboptimal among medical students and residents especially regarding cervical and colon cancer, Further educational efforts should be targeted to educational and training programs in this country.14

A study on Utility of Cytological Screening in Cervical Cancer The data was derived from the routine cervical cytological studies carried out in 29,321 women attending Gynecology OPD of Queen Mary’s Hospital, Lucknow. Incidence of carcinoma cervix was found to be 0.5% (167 cases). The halving of the total observation period revealed remarkable decline in detection rate of carcinoma cervix from 1.1% in the initial 15 years to 0.4% in the next half of the study. Cervical cytology was also found effective in detecting malignant smears in 12 women with apparently healthy cervix. The study revels that the utility of cytological screening in curtailing the menace of cervical carcinoma under low resource settings.15

2) Literature related to knowledge regarding prevention of cervical cancer.

A study on knowledge and attitude about Human Papilomavirus and Human Papillomavirus vaccines among women in metropolitan and rural areas of China. A population based survey, which was embedded in a cervical cancer

11 screening project; the result was that only 15.0% of women reported to have ever heard of HPV, this knowledge differs by rural(9.3%) and metropolitan areas (21.6%). Most (84.6%) participant were willing to be vaccinated if HPV vaccine is available to them. The study reveals the potential barriers and success of introducing HPV vaccine to China.16

A study on Knowledge and Awareness about Cervical Cancer and Its Prevention amongst Interns and Nursing Staff. The samples were selected from tertiary care hospitals, the sample size was 400. The study was conducted in Karachi, Pakistan. In the study, 1.8% did not know cervical cancer as a disease. Only 23.3% of the respondents were aware that cervical cancer is the most common cause of gynecological cancers and 26% knew it is second in rank in mortality. Seventy-eight percent were aware that infection is the most common cause of cervical cancer, of these 62% said that virus is the cause and 61% of the respondents knew that the virus is Human Papillomavirus. The study reveals that majority of working health professionals are not adequately equipped with knowledge concerning cervical cancer.17

A systematic review on factors influencing familial decision making regarding Human Papillomavirus vaccination, the purpose of the study is to summarize the research regarding HPV vaccination uptake among families with adolescent, preadolescent daughters. The study reveals that physical recommendations, perception of belief of peer and others, history of childhood immunization and communication with adolescents regarding sexual topics appears to influence HPV vaccination outcome.18

A formative research on informing adolescence about Human Papillomavirus vaccination, the study was to evaluate HPV and cervical cancer prevention for school children who will be provided HPV vaccination in UK. The main outcome measures were the number of children allowed by parents to view the childrens knowledge. The study reveals that the message were acceptable to parents and largely understood by adolescents.19

12 3) Literature related to attitude regarding prevention of cervical cancer

A study on attitude towards Human Papillomavirus immunization of Italian mothers of adolescent girls and potential role of health professionals in the immunization program. The study was conducted in mothers of adolescent girls, the sample size was 807 mothers, the study was conducted in Rome, Italy. To know the willingness of the mothers of adolescent girls about Human Papillomavirus and Human Papillomavirus vaccination, to immunize their daughters, 54% mothers reported to have ever heard about Human Papillomavirus, 84% were willing to immunize their daughters. Pediatricians most frequently provided information on Human Papillomavirus vaccine (31%). The study reveals that Acceptance of Human Papillomavirus immunization was high and not associated with knowledge of Human Papillomavirus.20

A study on acceptability of human papillomavirus trial vaccine among mothers of adolescents, A survey was carried out in a random sample in women between the age of 15 – 49 yrs, the sample size was 880 women, the setting was Cuernavaca, Mexico. Only 1.9% said that the risk factor was infection with Human Papillomavirus, 84.2% were aware of the usefulness of vaccine and 83.6% of women said that they would allow there daughters to participate in trial to evaluate the effectiveness of Human Papillomavirus vaccine that help to prevent cervical cancer. The study reveals the importance of educating mothers of these individuals, knowledge of the benefits of a preventive vaccine as well as the etiology and risk factors of cervical cancer should be emphasized.21

A descriptive study on Human Papillomavirus vaccine acceptability in rural southern Area, the study was conducted in 146 women in Southern rural areas ofUnited States, 62% respondents were African-American. Most respondents intended to vaccinate adolescent daughters against Human Papillomavirus, older African-American women reported lower vaccination

13 intentions, higher intention to vaccinate adolescent against Human Papillomavirus were associated with knowledge about HPV. Women reported higher intentions to get the Human Papillomavirus vaccine for an adolescent daughter than for themselves. The study reveals that the acceptability of Human Papillomavirus vaccination was based on the knowledge of the mothers.22

A descriptive study on Human Papillomavirus vaccine and cervical cancer screening acceptability among adults. Adults were invited to participate in a telephone survey, a sample size of 500 adults, in the region of Quebc City,Canada. 471 adults answered the questions, the mean age was 45yrs, 67% were female, 65% had college or university degree, 86% of women had undergone pap smear test in their life, 55% in the last year and 15 % 1-3 yrs ago. 87% agreed that Human Papillomavirus vaccine could prevent cervical cancer. 73% the vaccine had to be administered before the onset of sexual activity, 80 % recommended vaccination to their daughters and nieces. The study reveals that most of the adults have positive attitude towards Human Pappilomavirus Vaccine.23

A descriptive study on attitude towards HPV vaccination among parents of adolescent girls, the population was parents of adolescent girls, the sample size was 120 parents, the study was conducted in Mysore, India. The study reveals that while parents have limited knowledge about HPV and cervical cancer, most are highly accepting Human Papillomavirus vaccine. High acceptability levels reflect positive attitude towards Human Papilloma Virus vaccination.24

A study on mothers attitude towards preventing cervical cancer through human papillomavirus vaccination. The study was conducted on mothers with daughters age 8-14 yrs, 24 mothers of girls took part in four focus groups, the study was conducted in London. The study reveals that most mothers were favour of protecting their daughters from cervical cancer, some mothers were

14 worried about increase in risky sexual behavior. Mothers had reservations, particularly aboyt vaccinating girls younger than 10 yrs.25

A descriptive study on Human Papillomavirus vaccination more likely if mothers approve, the study was conducted in college students, a sample of 972 female undergraduates of the large Midwestern University. An anonymous questionnaire assessed the undergraduate’s sexual – risk behavior, knowledge on Human Papillomavirus, perception of Human Papillomavirus risks, communication from their mothers about sex related topics. 65% of women reported being sexually active, 49% reported having received at least the first of the three short Human Papillomavirus vaccine series. The study reveals that the unvaccinated femals were interested in future vaccination if they thought their mother will allow.26

15 7 MATERIALS AND METHODS

7.1Source of data:

The data will be collected from mothers of adolescent girls of selected rural and urban communities, Bangalore.

7.2 Method of data collection i. Research design Non-experimental descriptive design.

ii. Research variables Study variable: Knowledge and attitude of mothers of adolescent girls regarding prevention of cervical cancer.

Extraneous variable: Age of mother, age of adolescent girls, religion, education, occupation, type of family, income of family, previous source of information.

iii. Settings:

The study will be conducted in selected rural and urban communities, Bangalore.

iv. Population: Mothers of adolescent girls of the age group 13-19yrs of selected rural and urban communities, Bangalore

v. Sample: All the Mothers of adolescent girls who fulfill the inclusion criteria shall be considered as sample and sample size is 120.

16 vi. Criteria for sample selection:

Inclusion criteria: The study includes  Mothers who can read and write English or kannada.  Mothers of adolescent girls of the age grour 13-19yrs.

Exclusion criteria:

The study excludes  Mothers who are not willing to participate in the study.  Mothers of adolescent girls who are vaccinated against human pappiloma virus.  Mothers of adolescent girls with cervical cancer.

vii.Sampling technique

 Non probability convenient sampling.

viii. Tool for data collection:

The tool consists of the following sections:

Section A: Demographic data of mothers of adolescent girls such as age of mother, age of the adolescent girl, religion, education, occupation, type of family, income of family, previous source of information.

Section B: A self administered Structured questionnaire to assess the knowledge of mothers regarding prevention of cervical cancer .

Section C: 3 point Likert scale to assess the level of attitude of the mothers of adolescent girls regarding prevention of cervical cancer.

17 ix. Method of data collection: Phase 1: The investigator will administer the self administered questionnaire to assess the knowledge of mothers of adolescent girls regarding prevention of cervical cancer.

Phase 2: The investigator will administer Likert scale to assess the level of attitude of mothers of adolescent girls regarding prevention of cervical cancer.

Phase 3: Based on the study findings, the investigator will prepare an informational pamphlet on prevention of cervical cancer that will be distributed to the mothers of adolescent girls.

Duration of the study : 4 Weeks.

x. Plan for data analysis The data collected will be analyzed by using descriptive and inferential statistics.

Descriptive statistics: Frequency, percentage distribution, mean, median and standard deviation will be used to analyze the knowledge and level attitude of mothers of adolescent girls of selected rural and urban communities, Bangalore.

Inferential statistics: Paired ‘t’ test will be used to compare the knowledge level of attitude, chi-square test will be used to associate knowledge and attitude of mothers of adolescent girls with the selected demographic variables.

xi. Projected Outcome After the study, the investigator will come to know the knowledge and level of attitude of mothers regarding prevention of cervical cancer. Based on the study findings the investigator will prepare an

18 informational pamphlet regarding prevention of cervical cancer that will be distributed to the mothers of adolescent girls.

7.3 Does The Study Requires Any Investigation Or Intervention To The Patient Or Other Human Beings Or Animals?

 Yes, the study requires some investigations from the subjects and no active manipulation is involved in the study.  Privacy and confidentiality of data will be maintained.

7.4 Has Ethical Clearance Obtained From Your Institution?

 Yes, permission will be obtained from the institution and concerned authorities before data collection.  Informed consent will be obtained from the mothers of adolescent girls.

19 8. REFERENCES

1. Definition for cancer. Avalible from wordnetweb.princeton.edu/perl/ webwn

2. Jimmy Wales. Avaliable from wikipedia.org/wiki/Cancer .

3. Cancers of the female reproductive system. Avalible from www.merckmanuals.com/home.html.

4. Jimmy Wales. Avaliable from wikipedia.org/wiki/Cervical_cancer.

5. Incidence of cervical cancer. Avalible from www.medindia .net/patients/patentinfo/cervical cancer-incidence.htm.

6. Mira L, Katz.Avalible from qhr.sagepub.com/content/full.pdf.

7. M L Katz. Avalible from qhr.sagepub.com/content/full.pdf.

8. Constantine N A and Jerman P, acceptance of human papillomavirus vaccination among Californian parents of daughters. J Adolesc Health,2007 Feb;40(2):108-15.

9. Jo Waller, Laura A.V. Marlow and Jane Wardle. Mothers' Attitudes towards Preventing Cervical Cancer through Human Papillomavirus Vaccination. cebp.aacrjournals.org/content/abstract.

10. Purnima Madhivanan, Karl Krupp, M.N. Yashodha, Laura Marlow and Jeffrey D. Klausner, Arthur L. Reingold. Attitudes toward HPV vaccination among parents of adolescents girls in Mysore, India. www.sfcityclinic.org/providers/AttitudesHPV.

11. BT Basavanthappa . Nursing Research.2nded.New Delhi: Jitendar P Vij;2007.

20 12. Michelle Giles and Suzanne Garland. A study of women's knowledge regarding human papillomavirus infection, cervical cancer and humanpapilloma virus vaccination. ANZJOG;2006 Aug;46(4):311-315.

13. Sreedharan J, Muttappillymyalil J,Haran J C and Divakaran B. Knowledge and Practice Regarding Breast and Cervical Cancer Among Females in northern part of Kerala. Epidemology; 2006 Nov;17(6):532.

14. C. Villarreal-Garza, A. R. Villa, M. Perfecto-Arroyo and L. Garcia- Aceituno, M Rojas-Flores, Leon-Rodriguez. Knowledge about cancer screening among college students and residents. J Clin Oncol;2009;27(15):1541.

15. Misra JS and Pandey S. Utility of Cytological Screening in Cervical Cancer Control Under Low Resource Settings. Journal of cytology;2007 ;21(1):30-32.

16. Jing Li, Lian-Kun Li, Jun-Fei Ma, Li-Hui Wei, Mayinuer Niyazi, Chang-Qing Li et al. Knowledge and attitudes about human papillomavirus (HPV) and HPV vaccines among women living in metropolitan and rural regions of China. Vaccine;2009 Feb;27(8):121o- 1215.

17. Syed Faizan Ali, Samia Ayub, Nauman Fazal Manzoor, Sidra Azim, Muneeza Afif, Nida Akhtar et al. Knowledge and awareness about cervical cancer and its prevention among interns and staff nurses. Journal pone;2009 Jun;5(6)11059-001.

18. Healther L Gamble, James L Klosky, Gilbert R Parra and Mary E Randolph. Factors influencing familial decision making regarding human papillomavirus vaccination. Journal Of Peadiatric Psychology,2010 Dec;35(7):704-715.

21 19. Vallely LA, Roberts SA, Kitchener HC and Brabin L. Informing adolescence about human papillomavirus vaccination. Vaccine; 2008 Apr;26(18):2203-2210.

20. Tozzi AF, Raval L, Pandolfi E, Marino MG and Ugazio AG. Attitude towards HPV immunization of Italian mothers of adolescent girls and potential role of health professionals in the immunization programme;Journal Womens Health,2008 May17(4):539-548.

21. Lazcano Ponce E, Arillo Santillan, E,Salmeron, J,Hernandez Avila, Munoz and Munoz N. Acceptability of a human papillomavirus trial vaccine among mothers of adolescents in Cuernavaco, Mexico. Archives Of Medical Research; 2001 May- Jun;32(3):243-247.

22. Fazekas, Brewer NT and Smith JS. HPV vaccine acceptability in a rural southern area .Vaccine;2009 Aug;27(38):5203-5208.

23. Sauvageau C, Duval B, Gilca V, Lavoie and Quakki M. Human Papilloma Virus vaccine and cervical cancer screening acceptability among adults in Quebec, Canada.Public Health, 2007 Oct;25(7):304.

24. Madhivanan P, Krupp K, Yashodha MN, Marlow L, Klausner JD and Reingold AL. Attitude towards HPV vaccination among parents of adolescent girls in Mysore, India pubmed/19596420.

25. Jo Waller, Laura A.V.Marlow and Jane Wardle. Mothers attitude towards preventing cervical cancer through human papillomavirus vaccination. Cancer Epidermiol Biomarkers Prev,2006;15(7):1257- 1261.

26. Gerrard and Megan Roberts. HPV vaccination more likely if mothers approve. Vaccine,2009 Apr;27(19):2625-2629.

22 9. Signature of the candidate :

10. Remarks of the guide :The study is researchable and relevant. It has implication in nursing in prevention of cervical cancer among adolescent girls by educating their mothers.

11. Name and designation :

11.1 Guide : Miss. Subhashini G

11.2 Signature :

11.3 Co guide (if any) : Mrs.Dhanalakshmi

11.4 Signature :

11.5 Head of the department : Miss. Subhashini G

11.6 Signature :

12.1 Remarks of the principal : This study is relevant, feasible and appropriate 23 for the specialty chosen.

12.2 Signature :