SYNOPSIS RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES,KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.NAME OF THE MS KANCHAN.D. BHISE CANDIDATE AND 1ST YEAR MSC NURSING, ADDRESS: ST JOHNS COLLEGE OF NURSING, BANGALORE.
2. NAME OF THE INSTITUTION: ST JOHN’S COLLEGE OF NURSING
3. COURSE OF THE STUDY : MSc Nursing 2010
4.DATE OF ADMISSION TO COURSE: 3rd May 2010
5.TITLE OF THE TOPIC: Educating and screening the women for cervical Neoplasm.
-1- 6. BRIEF RESUME OF INTENDED WORK:
6.1 Need for the study:
Cervical cancer is treatable disease if identified at the early stage. Cancer of the cervix is the second most common cancer among women worldwide, with an estimated 529,409 new cases and 274,883 deaths in 2008. About 86% of the cases occur in developing countries, representing 13% of female cancers12.Globally it is estimated that there are 6 million new cancer cases, of which 52% occur in developing countries. The magnitude of the problem of cancer in the Indian sub-continent in terms of sheer number is most alarming. The estimated new cases of cancer in India per year are nearly 6.5 lakhs and at the start of the next millennium estimated to be 8.6 lakhs. The crude incidence of cancer in India is approximately 100 per 100,000 populations. The Cancer in women in the Indian Sub-continent constitutes more than 50% of the total cancer. The most common cancer observed by Indian registries are those related to tobacco usage in males while among females, the most common cancer are those of the Uterine Cervix, Breast and Oral cavity. In Karnataka a state in the southern part of India, it is estimated that annually there are about 35,000 new cases whereas, the prevalent cancer accounts to about 1, 50,000.16
Educating people regarding the disease will help drive away the fears and stigma associated with the disease. Well- illustrated audio-visual educational materials are extremely useful in literate as well as illiterate population.10Efforts to improve awareness of the population have resulted in early detection of and survival from cervical cancer in backward regions of India. Also, where the literacy among women is less than 20% there have been attempts to evaluate the role of improved awareness in the early detection and control of cervical cancer.14
In many developed countries a decline in the incidence and mortality due to cervical cancer has been observed due to cytology screening. Cytology based screening are difficult to organize in India because of issue related to absence of trained manpower, infrastructure, logistics, quality assurance, frequency of screening and cost involved. There are no organised screening programmes for any of the common cancers in the country. Most cancer centres provide only opportunistic screening services. Visual inspection of the cervix after -1- application of the 4-5% acetic acid is a simple inexpensive test that can be provided by trained health care personnel.1 The investigator during her clinical experience has come across a number of cancer patients who were detected in their last stage of cancer. Most of them lacked knowledge about cancer and importance of screening. Women do experience symptoms which remain unaddressed and present it in advanced stages when total cure is extremely difficult or indeed impossible. So, the researcher is stimulated to improve the awareness of the women regarding cervical neoplasm and importance of screening and to screen them for early detection and also diminishing the probability of losing women before they are treated.
6.2 Review of literature:-
Review of literature is a critical summary of research on a topic of interest. In this study review of literature has been organised under the following headings. a) Studies related to importance of knowledge. b) Studies related to importance of screening.
a) Studies related to importance of knowledge:- A descriptive cross sectional study was conducted in Uganda to assess the knowledge, attitude and practices on cervical cancer and screening among the medical workers. In this study, 288 medical workers were interviewed using self-administered questionnaire. In this study, most of the participants were female(69%).Most of the participants knew that cancer was curable if detected at an early stage but knowledge of risk factors for cervical cancer and details of screening activities.6 A Case control survey was done in Chicago to assess the cervical screening knowledge and practices among Korean-American women. A sample of 159 Korean-American women were given a cancer control questionnaire.26% of the respondents never heard of the of the pap smear test. Only 34% of the respondents reported having had a pap smear test for screening. The most frequently cited reason for not having had a pap smear was absence of disease symptom. Result indicate that education and usual sources of health care were significant factors related to having heard of or having had a pap smear test.15 A retrospective case study was conducted in United States to discern HPV knowledge -2- accuracy among women diagnosed with and treated for cervical cancer.Data was collected using self administered questionnaire and medical records.A total of 1174 questionnaire were mailed and 328 women returned the completed forms.About one-third of African- American(32.8%) and white-American(35.2%)women had reported that cervical cancer cannot be prevented.3 An experimental study was conducted to assess the effectiveness of structured teaching guide about cancer cervix on the knowledge and preventive practices among the women and their husbands. A pre-test was given to 30 couples before giving the structured teaching guide and the post-test was given on the 15th and the 30th day after giving the structured teaching guide. The study found that post-test scores were higher than their pre-test score. Also, 85.5% of wives underwent medical examination,79.2%of wives undergone pelvic examination and 36.3% husbands had undergone physical examination.1 A Qualitative study was conducted in 3 districts of Uttar Pradesh to assess the cervical cancer prevention and treatment services. The assessment was designed to evaluate the quality and accessibility of cervical cancer prevention and treatment services and was conducted from March to August 2004. The strategic assessment identified some isolated cervical cancer prevention and treatment services; however, well-coordinated prevention and stage-appropriate treatment services, particularly in the public sector and outside large urban centres, were lacking.9
b)Studies related to importance of screening :- A cross sectional study was conducted in Jabalpur which used Visual inspection of cervix with acetic acid (VIA) in early diagnosis of cervical intraepithelial neoplasia and early cancer of cervix. Of the 750 women screened 122 (16.26) was VIA positive and cytology was positive in 39 (5.2%), 25 were detected by VIA and only 20 cases were detected by pap smear. Two cases were missed by VIA and seven cases were missed by cytology.2 A randomized controlled study was conducted in Maharashtra of 497 rural villages. Women aged 30-59 years were randomized to receive one of the three tests or to a control group. Of the 1000800 invited women 79449 (78.8%) were screened.26755 (33.7%) were screened by Visual inspection of cervix, 25535(32.1%) were screened by cytology and 27159(34.2%) were screened by human papillomavirus testing. From these 932 women were diagnosed with high grade lesions or invasive cancer. The study showed good participation -3- levels and communication methods and delivery strategies aimed at encouraging older, less educated, etc. A prospective study was conducted at Indore. The study included 380 patients referred for colposcopic evaluation for abnormal cervix. Visual inspection of cervix was performed prior to colposcopic examination. Out of 380 patients 100 were found positive on VIA.Out of these 100 patients 75 were found to have abnormal findings on colposcopy. Cervical biopsy was done of these 75 cases and 22 cases revealed as having low grade squamous intra-epithelial lesions,8 as high grade and 7 as pre-clinical invasive cancer and 38 showed no abnormality.8 A prospective study was conducted in Peru where women between 25 and 50 years who visited the centre and were asymptomatic. The women underwent a complete clinical evaluation; including Pap smear and visual inspection by acetic acid.Partcipants with any positive test were referred for colposcopy and biopsy. The results was many women tested positive by visual inspection.10 A prospective study was conducted in New Delhi wherein 400 women were screened using pap smear, visual inspection of the cervix( VIA) and colposcopy.The sensitivity and specificity of each of the screening methods was analyzed. The sensitivity of VIA (96.7%) was much higher than that of pap smear(50%), and almost as high as that of colposcopy(100%).The specificity of VIA (36.4%) was lower than that of pap smear smear(97%) and colposcopy(96.9%).7 A cross sectional study was done in New Delhi,100 women with complains of vaginal discharge, irregular bleeding, post-coital bleeding or unhealthy cervix underwent visual inspection with acetic acid(VIA) and Lugol’s iodine (VILI) by a doctor and a nurse, followed by colposcopy and biopsy.VIA by nurse had a higher sensitivity(100%) versus 87.5%),but lower specificity(53% versus 63%) when compared with the doctor. It was concluded that visual inspection can be performed reliably by trained paramedical workers and doctors and is an effective screening option in low resource setting.11 A survey was done in united states to assess the willingness to participate in cancer screening. The Cancer Screening Questionnaire (CSQ), a 60-item questionnaire, was administered via random-digit-dial telephone interviews to adults in three cities of US. The 1,148 participants in the CSQ study sample consisted of 355 blacks, 311 Puerto Rican, Hispanics, and 482 non-Hispanic whites. Response rates ranged from 45% to 58% by city. -4- Multivariable logistic regression analyses revealed that blacks and Puerto Ricans were often more likely (OR 2.0-3.0) and never less likely than whites to self-report willingness to participate in cancer screenings regardless of who conducted the cancer screening, what one was asked to do in the cancer screening, or what type of cancer was involved (with the exception of skin cancer where blacks, compared with whites, had an OR of 0.5).The findings from this study provide evidence that blacks and Hispanics self-report that they are either as willing or more willing than whites to participate in cancer screening programs.4
6.3 Problem statement:- A study to assess the willingness to avail screening facilities in response to health education about cervical neoplasm among women attendants of inpatients in St John’s Medical College Hospital, Bangalore.
6.4 Objectives of the study:- i) To assess the extent of willingness to avail screening facilities among women attendants following educational programme.
ii) To identify the outcome of the screening test among motivated group.
iii) To determine the association of outcome of screening test with selected demographic variables.
iv) To determine the association of motivated group with the selected demographic variables.
6.5.Operational definition:- Willingness: Ready, eager, or prepared to do something (Oxford Dictionary 2007). In this study, it refers to readiness of the women to undergo a screening test of visual inspection of cervix. Avail: In this study, it refers to take the advantage of the screening facilities provided to women attendants. Screening: In this study, Visual inspection of cervix will be conducted to screen the relatives for early detection of any cervical lesion and if positive followed by colposcopy. -5- Health Education:” Health education is a process that informs, motivates and help people to adopt and maintain healthy practices and lifestyles, advocates environmental changes as needed to facilitate this goal and conducts professional training and research to the same end”.(K.Park) In this study, it refers to the education regarding cervical neoplasm and its prevention. Cervical neoplasm: In this study it refers to the presence of abnormal growth in the neck of the uterus. Attendants: In the study, it refers to the women accompanying the in-patient in the hospital. In-patients: It refers to all the patients admitted in medical, surgical, gynaecology wards of St John’s Medical College Hospital. Demographic variables: In this Study the variables includes age, education status, marital status, occupation, age at marriage, use of contraceptives, use of tobacco, history of sexually transmitted diseases and family history of cancer.
6.6 Assumptions:- 1. Women attendants of the in-patient may undergo the screening programme after attending the education programme. 2. Women attendants may be detected with presence of cervical lesion.
6.7 Delimitation:- The study is limited to relatives of the in-patient admitted to St John’s Medical College Hospital.
6.8 Projected Outcome:- Findings of this study will help to improve the knowledge of the women relatives by education and thereby undergo screening programme organized by the investigator. -6-
Hypothesis:- H1.There will be significant association between outcome of screening score and selected demographic variables at 0.05 level of significance H2.There will be significant association between the motivated group and selected demographic variables.
MATERIAL AND METHOD
7.1 Source of data 7.1.1 Research Design: - Evaluative Study
7.1.2 Setting :- The health education will be conducted in room no 21 of Outpatient department between 2.00 to 4.00pm at St John’s Medical College Hospital Bangalore which is 1200 bedded multispecialty hospital and the screening will be done in the OPD.
7.1.3 Population:- In this study the population comprises of women attendants of in- patient admitted at St John’s Medical College Hospital.
7.2 METHOD OF DATA COLLECTION 7.2.1 Sampling Procedure:- Purposive sampling will be used to select the samples for the study. 7.2.2.Sampling size:- Sample size will be 300 women attendants of the in-patients.
7.2.3 Inclusion criteria and sampling:- i. Women who are attendants of patients admitted in St John’s Medical College Hospital. ii. Women aged 30-64 yrs. iii. Women who are asymptomatic. -7- 7.2.4. Exclusion criteria for sampling:- i. Women who are currently pregnant. ii. Women with previous history of cancer.
7.2.5. Instrument used:- 1. Section I –Performa to elicit demographic variables. Section II- Teaching module of cancer of cervix. 2 .Screening tool of Visual inspection by acetic acid and colposcopy.
7.2.6 Data Collection Method:- Formal permission will be obtained from the Director of St john’s medical college and hospital, the administrator of the hospital, the nursing superintendent and HOD of medical, surgical,urology,nephrology and gynaecology department to collect data.
The subjects who belong to the inclusion criteria will be selected by purposive sampling technique. The selected samples will be called to room no 21 in the outpatient department of St John’s Medical College Hospital .Subjects will be explained about the study and consent to participate in the study will be taken. The subjects will then be given a consent form for willingness to undergo a screening test for cervical cancer. Later, the subjects will be educated about cervical neoplasm. After the education, the subjects will be again asked to fill the consent form for willingness of the screening test. The number of women who have given the consent to undergo screening test will be taken immediately for the screening by the investigator. The screening test will be then carried out by the investigator. The result of the screening test will be consulted with the gynaecology oncologist and then it will be disclosed to the subject by the oncologist. If the result is positive, the subjects will be taken for colposcopy by the oncologist to confirm the screening test .The results obtained will be taken for analysis.
7.2.7 Data analysis plan:-
Descriptive and inferential statistics.
Organization of data in master sheets -8-
Mc Nemars test to assess the willingness to screening test before and after health education. Calculate chi square to determine the association of demographic variables with screening score and baseline variables.
7.3.Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly?
YES
7.4 Has ethical clearance been obtained from your investigation in case of 7.3?
YES. The ethical clearance has been obtained from the scientific and ethical review committee of St John’s National Academy of Health Sciences-Bangalore.
LIST OF REFERENCE:-
1. Maragatham.S, Ratna. P. Effectiveness of structured teaching guide about cancer
cervix, in terms of knowledge and preventive practices. The Nurse.2010 jan-feb
2(1): 11-3
2. Singh KN, More S. Visual inspection of cervix with acetic acid in early diagnosis of
cervical intraepithelial neoplasia and early cancer cervix. J Obstet Gynaecol
India.2010 Jan/Feb 60(1):55-60.
3. Stark A, Gregoire L, Pilarski R, Zarbo A, Gaba A, Lancaster WD. Human
papillomavirus, cervical cancer and women’s knowledge. Cancer detection and
prevention 2008.Feb(32).15-22 -9-
4. Katz RV, Cristina C, Kressin NR, Green L, Wang MQ, Russell SL. Willingness to
participate in cancer screenings:black vs whites vs puerto rican hispanics. Cancer
control 2008.oct 15(4):334-343.
5. Nene B,Kasturi J, Silvina A,Shastri S,Budukh A,Hingmire S,Muwonge R, Malvi
S,Ketayun D. determinants of womens participation in cervical cancer screening
trial,maharashtra,india. Bulletin of the WHO.2007 April 85(4):264-72
6. Mutyaba T, Mmiro FA, Weiderpass E. Knowledge,attitude and practices on cervical
cancer screening among the medical workers of mulago hospital,uganda. BMC
medical education.2006 6(13):6-10
7. Goel A, Gandhi G, batra S, Bambhani S, Zutchi, Sachdeva P. Visual inspection of the
cervix with acetic acid for cervical intraepithelial lesions. International Journal of
Gynaecology and Obstetrics.2004 Sept (88):25-30
8 Bharani B, Phatak S R. Acetic acid visualization of the cervix as an alternative to
colposcopy in evaluation of cervix at risk. J Obstet Gynaecol India 2005.Nov/ Dec
55(6):530-33.
9 Dabash R,Vajpayee J,JacobM,DzubaI,LalN, Bradley J, Prasad LB. A strategic
assessment of cervical cancer prevention and treatment services in 3 districts of uttar
pradesh, india. Reproductive Health.2005.Dec.2(11): 2-11
10 Jeronimo J,Morales O, Horna J, Pariona J, Manrique J, Rubinos J, Takahashi R.
Visual inspection with acetic acid for cervical cancer screening outside of low-
resource settings. Public Health.2005 17(1):1-5 -10-
11 Bhatia N,Mukhopadhyaya A, Joshi S, Kumar A, Kriplani A,Pandey RM,Verma
K.Visual inspection for cervical cancer screening;evaluation by doctor versus
paramedical worker..Indian Journal of Cancer .2004Jan-Feb 41(1):32-36
12. WHO/ICO information centre on hpv and cervical cancer (hpv information centre).
human papillomavirus and related cancers in India. summary report 2010.
13. Dinshaw KA, Shastri SS, Patil SS. Cancer Control programme in india: challenges
for the new millennium. Health Administrator Vol: XVII, Number 1: 10-13.
14. Sankaranarayanan R,Budukh AM, Rajamanickam R. Effective screening programmes
for cervical cancer in low-and middle- income developing countries. Bulletin of the
World Health Organization 2001 79(10):954-961
15. Kim K, Yu.E.S.H, Chen E.H, Kim J, Kaufman M,Purkiss J. Cervical cancer screening
knowledge and practices among korean-american women. Cancer Nursing.1999
22(4):297-302.
16. Incidence of cancer worldwide :http://www.kidwai.kar.nic.ingeneral.htm accessed 10
june 2010
17. Park K. Park’s textbook of preventive and social medicine. 20th ed. Jabalpur;
Banardidas bhanot publishers: 2009.p 760
18. Oxford English mini dictionary.7th ed.New York; oxford university press:2007.p637 -11- 8 Signature of the candidate
9 Remarks of the guide
10 Name and Designation in Block of ( in Block letters) 10.1Guide Sr.Marium .O.J (sr celcy mary) Head of the Department, Obstetrics And Gynaecology, St John’s College Of Nursing
10.2Signature
10.3Co-Guide(if any) Dr.Elizabeth Vallikad, HOD-Gynaecology Oncology, St John’s National Academy of Health Sciences.
10.4.Signature
11 11.1 Head of the Department Sr Marium.O.J (Sr celcy mary), HOD,Obstetrics And Gynaecology, 11.2 Signature St John’s College Of Nursing
12 12.1 Remarks of the Chairman and Principal
12.2 Signature