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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFOMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
MS.SABITHA.K.RAJ
1
2
NAME OF THE
CANDIDATE AND
ADDRESS
NAME OF THE
INSTITUTION
NAVANEETHAM COLLEGE OF
NURSING
NO;132/1, 5th CROSS,
HORAMAVU
BANASWADI , BANGALORE
NAVANEETHAM COLLEGE OF
NURSING
NO;132/1, 5th CROSS,
HORAMAVU
BANASWADI , BANGALORE
M.SC.NURSING 1 YEAR
3
COURSE OF STUDY AND
SUBJECT
OBSTETRICS AND
GYNAECOLOGICAL NURSING
4
DATE OF ADMISSION TO
THE COURSE
03-06-2009
5
TITLE OF THE TOPIC
“A STUDY TO EVALUATE THE
EFFECTIVENESS OF PLANNED
TEACHING PROGRAMME ON
CERVICAL CANCER
SCREENING AMONG ELDERLY
WOMEN IN SELECTED AREAS.
BANGALORE.”
1
BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
With the
changes in the lifestyles and demographic profiles of developing
countries, non-communicable diseases are emerging to be an important health problem.
cervical cancer is a disease that can be prevented through both primary prevention
and early detection using screening techniques (1) .
Cervical cancer is the third most common cancer worldwide, and 80% of cases occur
in the developing world. It is the leading cause of death from cancer among women in
developing countries, where it causes about 190,000 deaths each year. Approximately
471,000 new cases diagnosed each year. It’s sobering to think that a woman dies of cervical
cancer approximately every 2 minutes. Every year cervical cancer is diagnosed in about
500,000 women globally and is responsible for more than 280,000 deaths annually. There is a
wide variation in the incidence of cervical cancer across the globe. In the west, early
detection through regular screening has aided to significantly control the prevalence of this
disease, thereby, lowering its incidence. In the last 50 years in the United States, the Pap
smear tests have reduced the deaths related to cervical cancer by three-quarters. At one time
cervical cancer was one of the most dreaded cancer and the leading causes of of death in
women in the US but now it is the eighth most common cancer there. 80% of the new
cervical cancer cases occur in developing countries, like India, which reports approximately
one
fourth
of
the
world's
cases
of
cervical
cancer
each
year.
2
There has been a regular campaign against cervical canal for 30 years in India, but this
has had little impact on the morbidity and mortality from the disease, with India ranking
fourth worldwide. The number of deaths due to cervical cancer is estimated to rise to 79,000
by the year 2010. The cancer mostly affects middle- aged women (between 40 and 55 years),
especially those from the lower economic status who fail to carry out regular health checkups due to financial inadequacy (22).
According to Chittaranjan Cancer Institute in Kolkata India, approximately 14%
of the 6,000 new cases reported annually in Kolkata are cervical cancer. It is
important to investigate women’s screening practices. Currently, there are no national
guidelines in India for recommended cervical cancer screening or screening intervals.
Pap tests are performed predominantly for diagnosis in the presence of problematic
symptoms such as abnormal vaginal bleeding. Continued progress and education about
screening may allow for earlier detection and higher cure rates (2).
However in 1992,the world health organization(WHO) outlined screening
recommendation for women living in low resource settings, stating that every women
be screened at least once over their life time at the age of 40years with priority
placed
on
women
ages
35-55
who
should
be
screened
every
5years.
Women in developing countries should be educated for utilizing the health care
system. Early
case
detection, methodology
through
educational
and
awareness
programme will reduce incidence and mortality from cervical cancer (3).
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6.1
NEED FOR THE STUDY
Cancer of the cervix is the most common cancer among women in India, constituting
between one-sixth to one-half of all female cancers with an age-adjusted incidence rate
ranging from 19.4 to 43.5 per 100,000 in the registries under the National Cancer Registry
Programme (NCRP) (Annual Reports, NCRP, ICMR). It has been estimated that 100,000
new cases of cancer of the cervix occur in India every year, and 70% or more of these are
Stage III or higher at diagnosis. Survival analysis was carried out in 2121 patients diagnosed
during 1982-89 in the population of Bangalore, India. The observed 5 year survival was
34.4% and the relative survival 38.3%. Clinical stage at presentation was the single most
important variable in predicting survival. The 5 year observed survival for stage I disease was
63.3%, for stage II 44.0%, for stage III 30.3% and for stage IV 5.7% (22).
Attitudes toward cervical cancer and participation in early detection and screening
services are well known to be profoundly affected by cultural beliefs and norms. In this
qualitative study explored the attitudes and sociocultural beliefs on cervical cancer screening
among in depth interview elderly
women who have never had a Papanicolaou (Pap)
smear. Respondents generally showed a lack of knowledge about cervical cancer screening
using Pap smear, and the need for early detection for cervical cancer. Many believed the Pap
smear was a diagnostic test for cervical cancer, and since they had no symptoms, they did not
go for Pap screening. Other main reasons for not doing the screening included lack of
awareness of Pap smear indications and benefits, perceived low susceptibility to cervical
cancer, and embarrassment. Other reasons for not being screened were related to fear of pain,
misconceptions about cervical cancer, fatalistic attitude, and undervaluation of own health
needs versus those of the family. Women need to be educated about the benefits of cervical
4
cancer screening. Health education, counseling, outreach programs, and community-based
interventions are needed to improve the uptake of pap smear (4).
Proportionally, India has the highest mortality from cervical cancer in the world. A
study conducted on 299 women from a gynecology clinic in Kolkata, India who completed a
questionnaire assessing demographic information; health care history; Pap test utilization;
and knowledge, beliefs, and attitudes about cervical cancer and screening. A total of 10%
had received a Pap test at least once. Most women reported “limited” to “no” knowledge of
cervical cancer (84%) and the Pap test (95%). Age (P < .013) and perceived knowledge of a
Pap test (P < 0.001) were significant predictors of first-time screening. . Findings suggest a
need to increase cervical cancer awareness in the community and to develop communitybased screening programs (5).
A long-term community-based intervention study to improve screening rates and
reduce the stage of disease at diagnosis, a cervical cancer screening canvass of a
defined population of poor, inner-city Baltimore residents was conducted between 1987 and
1989. A total of 4089 at-risk women were interviewed (81.3% response), of whom 95.5%
reported ever having a Pap test, and 28% gave histories of inadequate recent screening.
Reporting never having received a Pap test was associated with age, infrequent contact with
the medical care system, and no recall of being advised how often to obtain Pap tests. Race
was not a significant predictor. Logistic regression analysis yielded two important factors—no
recent physician visit or recall of periodicity recommendation. For current screening
adequacy, age, medical care encounters and recall of physician advice were significant in
bivariate analysis as well as in multivariate analysis: no racial differences were seen. The
results demonstrate the key role played by primary health care providers and the power
of physician advice in reinforcing the need to maintain routine screening examinations (6).
5
Negative attitude some women have towards the cervical screening programme these attitude
could ultimately prevent them from participating in the programme. Women negative attitude
towards cervical screening can largely encountered by improving their understanding of
process and diagnosis o cervical cancer (7).
Hence the investigator felt that these studies help the elderly women to enhance their
knowledge regarding cervical screening, if they receive advance and adequate information to
lead a better life.
6.2
REVIEW OF LITERATURE
“A literature review is a critical summary of the research on a topic of interest, often
prepared to put a research problem in contest.
Review of literature for the present study has been organized under the following
headings.
(a)
Studies related to knowledge on cervical cancer screening.
(b)
Studies related to effectiveness of cervical cancer screening among elderly
women
(a.) Studies related to knowledge on cervical cancer screening
Mona al sairafi, Farida a mohammad (2009) conducted a study with 300 married women,
randomly selected according to the socio-demographic characteristics, to know the
knowledge attitude and practice related to cervical cancer screening .A structured
knowledge questionnaire were adopted and complete information were selected from
281(93.7%), the knowledge about the cervical screening was adequate 147(52.3%),
while 86 (30.6%) adequate towards the test and only 67(23.8%) had an adequate
practice.The level ofeducation was the only significant factor independently associated with
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inadequate knowledge and attitude towards the screening test. This results states that well
designed health education programme on cervical cancer and benefits would increase
the knowledge regarding cervical cancer screening(8).
Eunicee E Lee, et.al ; (2008), a telephone survey was conducted with age marital
status, income, knowledge of early detection, methods for cervical cancer and perceived
beliefs about benefits of and barriers to receiving pap tests. The outcome of women
ever having a pap test and having had one in the proceeding 3 years. Variables
uniquely related to ever having the test were education, fluency in English, and the
employment. Having had the test during the proceeding 3 years were having a usual
source of care and regular health checkups. Different intervention were suggested, who
have never had a pap smear and for those who have not had one in the preceding three years.
The main intervention strategies is to increase knowledge, perceived benefits and to
decrease perceived barriers to receiving pap test.(9)
Wellensiek N Moodley M, ( 2002),conducted a questionnaire method study among
women from different socio-economic circumstances. Majority of them from low
socio-economic background and are not aware of cervical cancer screening.87% women
from
higher socio-economic background
and did
not
undergo
cervical
cancer
screening.36.7% had had a screening test performed at some time in the past , only 27.3%
reported having had a pap test, due to the failure on the part of health care givers to
disseminate
information regarding the reason and value of cervical screening .Among
women from the higher socio ecomic groups, the level of education was better and
knowledge of pap test was not age dependent Finally the socio-economic and educational
circumstances should be improved only when the health care giver provide adequate
information and women have to take initiative to avail themselves of such screening.(10)
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Twinn s,et.al;(2002), conducted a preliminary pilot study consisting of two phase
descriptive design using qualitative and quantitative methods of data collection to
investigate the level of knowledge about cervical cancer and screening . Total sample of
467 women, 242(52%) responded to a confidential questionnaire 18 of whom, aged
between 30 and 54 years volunteered to participate in a semi structured interview.
Total of 135(57%) women had attended screening, with those who were married with
children significantly more likely to attend. Although there is no significant difference
between the overall level of knowledge of attendees and non-attendees, individual items
such as women’s knowledge of risk factors were significant.The need for further knowledge
about the preventive nature of cervical screening and regular screening was demonstrated .
The implications of these fining to womens attendee pattern fo screening are considered ,
particularly the need for culturally sensitive health promotion and intervention strategies(11)
Lee . M . C (2000),The Health Belief Model(HBM) Provided the theoretical basis
qualitative study to improve the knowledge regarding cervical cancer screening and to
identify the major barriers . With 8 focus group (n=102) using 11 questions. Economic
and time factors along with language problems are the major structural barriers. The
main psycho social barriers were fear, denial, and Confucian thinking. Participants
stated that medical advice and education would influence them to undergo paptest.
Recommendations were made to reduce certain barriers and to increase motivation and
knowledge on cervical cancer screening(12).
Kim . K, et.al; (1999), conducted a study among 159 elderly women based upon
1987 cancer control supplement questionnaire to collect data. 26% of the respondents
never heard of cervical cancer screening, only 34% having had a pap smear test for
cervical cancer screening. The results indicate that Education and usual sources of health
care were significant factors related to having heard or having had a screening test.
8
The findings from this study have important implications for health practitioners and
policy makers to improve the knowledge on cervical cancer screening(13).
(b). A study related to the effectiveness of cervical cancer screening among elderly
women.
Tota j , franco E L (2009), conducted population based case control study, with
the cases identified from centers across the UK and using data from the NHS
database. Screening elderly women (aged 35-60 years) was shown to reduce cervical
cancer risk by approximately 60-80%.This study suggests that the screening age can
be safely raised to 25years without causing harm(14).
Anne
kathryn
goodman,et.al;(2008), Determining the relative
effectiveness of
different cervical cancer screening intervals is reducing the incidence and mortality of
cervical cancer is limited by the need to rely in observational data, in the absence of
randomized trials. The International Agency for research on cancer (IARC) modeled the
effectiveness
of
different
screening
intervals
using
data
from
large
screening
programmes in 8 countries. Protection from cervical cancer remain high for at least 3 years
after the last negative cervical cytology screen and was substantial up to 10 years. The
findings shows that estimated reduction in cumulative incidence of invasive cervical
cancer among women aged 35-58 fall minimally when the screening interval was
unscreened from 1 year (93.5% reduction) to 2 years (92.5%), to 3 years (90.8%) (15).
Sankaranarayanan.R, et.al; (2007),A study conducted with randomized controlled
trial to evaluate the efficacy and effectiveness of cervical cancer screening among the
elderly women.100,800 women aged 35- 55 years according to socio- demographic
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characteristics. Of the 932 women diagnosed with invasive cancer, 85.3% (795) received
treatment. Women with higher levels of education, who had had fewer pregnancy and those
who were married where more likely to comply with the treatment. This shows that
communication method and delivery strategies aimed at encouraging older ,less educated
women who have less contact with reproductive services are needed to further increase
screening uptake. There is no differences in rates of screening and good participation
levels can be achieved.(16)
Lynne Gaffikin,et.al;(2005), Computer based models used to assess the screening
strategies
to
estimate
age
specific
incidence, mortality rate of cancer
and
the
effectiveness of cancer screening for and treatment of pre- cancerous lesions. Screening
women in their life time at the age of 35 years with 1 or 2 visit. Screening strategy
involving visual inspection of the cervix with acetic acid reduce the life time risk of
cancer approximately 25-36%.Relative cancer risk declined by an additional 40% with
2 screenings (at 35 and 40 years of age(17).
Z.Philips et.al; 2005 Data were obtained from a questionnaire survey of randomly
selected women eligible for screening .The majority of women in the sample overestimated
the current incidence of cervical cancer. With respect to the screening process 78.3% believe
that the smear abnormality rate is higher than it actually is , and only 7.6% correctly
appreciate that the abnormality rate is highest at younger ages. With respect to performance
16.3% believe that the smear test to be completely accurate, and more than half over
estimated the likely number of cancer cases prevented by screening. While certain cervical
risk factors were correctly assigned by the majority of women , undue emphasis was place in
genetic influence , while the respondents possess by HPV infections where unfamiliar to
almost half of the sample. The study states that women typically possess only a partial picture
10
of risk factor and over estimate both the incidence of cervical cancer and efficacy of
screening (18).
Insinga r p,et,al;(2004), Observational cohort study was conducted from among
44,493 routine cervical smears, results were normal for 94.5%,with abnormal diagnosis
of a typical squamous cells(3.3%),a typical glandular cells (0.2%), low grade intra
epithelial lesions (1.2%), high grade squamous intra epithelial lesion (0.3%), and
inadequate (0.5%).Overall 5% of routinely screened women were found to have an
abnormal cervical smear with an annual incidence of cervical intraepithelial neoplasia
acroo all female enrollers of 2.7/1000 (19).
Taylor V M,et,al;(1999),the PRECEDE MODEL was used in
cervical cancer
screening participation. The overall survey response was 72%.413 women completed
the questionnaire, women who believe in karma were less likely to have ever been
screened than those who did not. The study findings indicate that culturally specific
approaches might be effective in modifying the cervical cancer screening (20).
HODGE
F.S,et.al;(1998),conducted knowledge and attitude of cervical cancer
screening among Indian American. Eight Indian clinics centers, 4 urban and 4 rural were
selected randomly to intervention and control sites (n=414) Educational approach used to
cancer screening recommendations. Pre and post questionnaire were administered and data
analyzed. The study results that statistical difference in post intervention knowledge
levels between the women from the intervention and control centers. This study has
shown the effectiveness of a culturally appropriate approach and methodology for
teaching about recommended preventive health techniques for cancer control(21).
11
6.3
STATEMENT OF THE PROBLEM
“A study to evaluate the effectiveness of planned teaching programme on
cervical cancer screening among elderly women in selected areas at Bangalore.”
6.4
OBJECTIVES OF THE STUDY :
1. To assess the existing knowledge on cervical cancer screening among elderly
women.
2. To assess the effectiveness of planned teaching programme on cervical cancer
screening by post test.
3. To associate the findings with selected demographic variables.
6.5. HYPOTHESIS:
H1
:
There is a significant increase in the level of knowledge after post
test.
H2
:
There is a significant association between the
Knowledge level and with selected demographic variables.
6.6
OPERATIONAL DEFINITIONS :
1.
Cervical cancer
: It is a malignant neoplasm of the cervix uteri
or cervical area.
2.
Screening
:
Screening is looking for cancer before a
person has any symptoms.
12
3.
Effect iveness
: It refers to the interventions measured in terms of
numerical scores
4.
Planned teaching programme ; It is an act of teaching a group.
5.
Elderly Women
6.7
ASSUMPTIONS :
: 35-55 years of age.
1.
Elderly women need cervical cancer screening.
2.
The investigator assumes that this planned teaching programme will improve
the knowledge among elderly women regarding cervical cancer screening.
6.8 DELIMITATIONS:
1. The study is limited to elderly women only.
2. The effectiveness of the cervical cancer screening is measured by
pre-test and post-test knowledge scores.
3. The duration of the study is delimited to 30 days.
6.9
PROJECTED OUTCOMES
1.
The findings of the study will reveal the effectiveness of the cervical cancer
screening among elderly women.
2.
The intervention designed for this study will remain as a protocol that could be
practiced by the elderly women and to improve the knowledge on cervical
cancer screening.
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7.
MATERIALS AND METHODS
7.1
SOURCE OF DATA
:
Elderly women, who all are in
selected areas.
7.2.1 Criteria for selection of sample
Research method
: Quasi experimental method
Experimental design
: One group pre-test post-test design
Sampling technique
: Stratified random sampling technique
Sample size
:50 elderly women
Setting of study
:Study will be conducted in selected areas, Bangalore.
SAMPLING CRITERIA
INCLUSION CRITERIA :
1.
Elderly women between the ages of 35-55 years.
2.
Elderly women who are able to interact in Kannada or English.
3.
Elderly women who are available during the period of study.
EXCLUSION CRITERIA :
1.
Elderly women who are not willing to participate in the study.
2.
Elderly women who are not physically and mentally healthy.
3.
Elderly women who cannot understand the languages -English or
Kannada.
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7.2.2 DATA COLLECTION TOOL;
A prior formal permission will be obtained from the elderly women for conducting
the study.
The purpose of the study will be explained and consents of the participants will be
obtained to involve in the study.
The investigator will administer structured knowledge questionnaire in the pre- test
then educated about the cervical cancer screening and conduct post- test after 7 days
using the same tool.
The proposed study duration is of 30 days.
METHOD OF DATA ANALYSIS
The investigator will obtain data by using descriptive and inferential statistics and the
plan of data analysis will be as follows:
Organize the data in a master sheet computer.
Mean and standard deviation, frequencies and percentage for the data analysis of the
background of the data.
Paired “t” test will be used to test the significant difference in the pre-test and posttest knowledge scores.
Chi-square test to determine the association.
15
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS ?
Yes, the study requires specific interventions to be conducted on the cervical cancer
screening among elderly women .
7.4
HAS ETHICAL CLEARANCE BEEN OBTAINED?
YES, informed consent will be obtained from the institution, authorities, privacy;
confidentiality and anonymity will be guarded. Scientific objectivity of the study will
be maintained with honesty and impartiality.
16
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2. Health category, April 24 (2009), 15:19.
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4. Wong LP.et.al; International journal of behavioral medicine; 2008; volume 15; issue 4;
pages 289-292.
5.Trica.s et.al: Journal of cancer education; 2008 October; volume 23; issue 4; pages
253- 259
6.Abdullahi.et.al ; Public health ; 2009 October 26;
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8.Mona.Al .Sairafi.et.al international journal of Kuwait university, health science center;
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9.Eunicee E Lee.et.al Western journal of nursing research; 2008; volume 13; issue8; pages
960-974.
10.Wellen siek.N.Moodley M; Internal journal gynecological cancer. 2002 July-August;
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12.Lee M C ; cancer nursing ;2000 June ; volume 23; Issue 3; pages 168-175
13.Kim K YUSS. et.al; cancer nursing; 1999 August; volume 22; issue 4; pages 297-302.
14.Tota.j,Franco EL; Western Health(lond engl);2009 November; Volume 5;Issue 6; Pages
613-616.
15.AnneKathryn Goodman, MD.et.al; Br.Med.J(clin.Res ed)1986;293;569;January 2008
16.Sankaranarayanan.R.et.al;Bulletin World Health Organization; 2007 April; Volume
85;Issue 4;Pages 264-272.
17.Lynne Gaffikin,The New England Journal of Medicine. Volume 17, 2005;Pages 2158-
17
18.Z Philips .et.al;International journal of Gynecological cancer 2009 volume;15, issue:4,
pages-639 to 649
19.Insinga.R.P,et.al;American Journal Of Obstetrics and Gynaecology;July-2004;Volume
191;Issue 1;Pages-1799-1804.
20.Taylor.V.M,et.al;Cancer Epidemeology Biomarkers; 1999 June ;Volume 8;Issue 6;Pages
541-546.
21.Hodge.F.S, Knowledge and attitude behavior among Indian American
Women1998;Volume 83;No;8;Pages 1799-1804.
22.www.pubmed.com
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