Download A study to assess the prevalence of risk factors of cervical cancer

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
H. LALMUANKIMI
1st YEAR M.Sc., NURSING
COMMUNITY HEALTH NURSING
YEAR 2013 - 2015
PADMASHREE INSTITUTE OF NURSING
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
NAME OF THE CANDIDATE AND
ADDRESS
1
2
NAME OF THE INSTITUTE
MS. H. LALMUANKIMI
PADMASHREE INSTITUTE OF
NURSING
BANGALORE
3
COURSE OF STUDY AND SUBJECT
4
DATE OF ADMISSION OF THE COURSE
5
TITLE OF THE TOPIC
1st YEAR M.Sc. NURSING
COMMUNITY HEALTH NURSING
17th July 2013
ASSESSMENT OF THE PREVALENCE
OF RISK FACTORS OF CERVICAL
CANCER AND EFFECTIVENESS OF
LEARNING
PACKAGE
ON
KNOWLEDGE
AND
ATTITUDE
REGARDING THE PREVENTION OF
CERVICAL CANCER AMONG POST
MENOPAUSAL WOMEN IN RURAL
COMMUNITIES.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION:
Cervical cancer is malignancy of the cervix it is one of the most common
cancers affecting women of reproductive age. It may present with vaginal bleeding but is often
only detected in advanced stages, which has made it the focus of intense screening efforts.1
Cervical cancer or cancer of the cervix is the cancer of the entrance to the uterus
(womb). The cervix is the narrow part of the lower uterus, often referred to as the neck of the
womb. Cervical cancer occurs most commonly in women over the age of 30. Cancer of the
cervix is a cancer that begins in the cervix, the part of the womb (or uterus) that opens to the
vagina. The cervix or the neck of the womb, and the womb are both parts of a female
reproductive system. The female reproductive system consists of vagina, womb (uterus), which
includes the cervix, ovaries.
Women have tow ovaries, one either side of the lower abdomen (pelvis). Each
month one of the ovaries produces an egg. Each ovary is connected to the uterus by a tube
called the fallopian tube. In between each menstrual period an egg travels down one of the
fallopian tubes and into the uterus. They alternate - one month may be the left side, and the
next month the right side. When the egg enters the womb its lining thickens in preparation in
case the egg is fertilized by a man's sperm. If fertilization does not occur the thickened lining of
the uterus is shed-a period (menses) occurs. Cervical cancer is a malignant neoplasm arising
from cells originating in the cervix uteri.2
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
(flattened) 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. One of the most common symptoms of cervical cancer is abnormal vaginal
bleeding, but in some cases there may be no obvious symptoms until the cancer has progressed
to an advanced stage. Treatment usually consists of surgery (including local excision) in early
stages, and chemotherapy and/or radiotherapy in more advanced stages of the disease.3
The early stages of cervical cancer may be completely asymptomatic. Vaginal
bleeding, contact bleeding, or (rarely) a vaginal mass may indicate the presence of malignancy.
Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical
cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere.
Symptoms of advanced cervical cancer may includes loss of appetite, weight loss,
fatigue, pelvic pain, back pain, leg pain, and swollen legs, heavy bleeding from the vagina,
bone fractures, and/or (rarely) leakage of urine or faeces from the vagina. Cervical
intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on
examination of cervical biopsies by a pathologist. For premalignant dysplastic changes, the
CIN (cervical intraepithelial neoplasia) grading is used.
The naming and histological classification of cervical carcinoma precursor lesions
has
changed
many
times
over
the
20th
century.
The World
Health
Organization classification system was descriptive of the lesions, naming them mild, moderate
or
severe dysplasia or carcinoma
in
situ (CIS).
The
term, Cervical
Intraepithelial
Neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these
lesions, and to help.
There are two main types of cervical cancer Ectocervix - flat cells – squamous
cell cervical cancer. The ectocervix is the portion of the cervix that projects into the vagina,
also known and the portio vaginalis. It is about 3 cm long and 2.5 cm wide. There are flat cells
on the outer surface of the ectocervix. These fish scale-like cells can become cancerous,
leading to squamous cell cervical cancer.
Endocervix - glandular cells - adenocarcinoma of the cervix. The endocervix is the
inside of the cervix. There are glandular cells lining the endocervix; these cells produce mucus.
These glandular cells can become cancerous, leading to adenocarcinoma of the cervix.
Adenocarcinoma - any cancer that develops in the lining or inner surface of an organs.
The most common symptoms are: Bleeding between periods, bleeding after sexual intercourse,
bleeding in post-menopausal women, discomfort during sexual intercourse, smelly vaginal
discharge, vaginal discharge tinged with blood, pelvic pain.4
There are some risk factors which are known to increase the risk of developing
cervical cancer. These risk factors includes human papilloma virus infection is a sexually
transmitted virus. There are over 100 different types of HPVs - 15 types can cause cervical
cancer; probably 99% of them. In addition there are a number of types which can cause genital
warts. It is estimated that HPV types 16 and 18 cause about 70% of cases cervical cancer while
HPV types 6 and 11 cause 90% of genital warts. Other HPV types can cause cervical intraepithelial neoplasia (CIN) - the growth of abnormal cells on the surface of the cervix.5
Many sexual partners, becoming sexually active early, cervical cancer-causing HPV
types are nearly always transmitted as a result of sexual contact with an infected individual.
Women who have had many sexual partners generally have a higher risk of becoming infected
with HPV, which raises their risk of developing cervical cancer. There is also a link between
becoming sexually active at a young age and a higher risk of cervical cancer.6
Smoking increases the risk of developing many cancers, including cervical cancer.
Weakened immune system People with weakened immune systems, such as those with
HIV/AIDS, or transplant recipients taking immunosuppressive medications have a higher risk
of developing cervical cancer. Certain genetic factors of scientists at Albert Einstein College of
Medicine of Yeshiva University found that women with certain gene variations appear to be
protected against cervical cancer.
Long-term mental stress a woman who experiences high levels of stress over a
sustained period may be undermining her ability to fight off HPV and be at increased risk of
developing cervical cancer it can cause, scientists at the Fox Chase Cancer Center reported.
Giving birth at a very young age of women who gave birth before the age of 17 are
significantly more likely to develop cervical cancer compared to women who had their first
baby when they were aged 25 or over.
Several pregnancies in women who have had at least three children in separate
pregnancies are more likely to develop cervical cancer compared to women who never had
children. Long-term use of the contraceptive pill slightly raises a woman's risk. Other sexually
transmitted diseases (STD): Women who become infected with chlamydia, gonorrhea,
or syphilis have a higher risk of developing cervical cancer. Scientists at the Medical
University of South Carolina found that HPV infections last longer if Chlamydia also is
present.7
Socio-economic status studies in several countries have revealed that women in
deprived areas have significantly higher rates of cervical cancer, compared to women who live
in other areas. Studies have also found higher rates in women of working age in manual jobs,
compared to women in non-manual jobs. The most likely reason is a difference in the
proportion of women who have regular screening.
6.2 NEED FOR THE STUDY:
Cancer of the cervix is the second most common cancer in women worldwide, with
about 500,000 new cases and 250,000 deaths each year. Almost 80% of cases occur in lowincome countries. New technological developments offer the potential to tackle cervical cancer
in a more comprehensive way and build a healthier future for girls and women. Comprehensive
cervical cancer prevention and control - a healthier future for girls and women is a new WHO
guidance note for senior policy makers and programme managers.8
Incidence and mortality — globally, cervical cancer accounted for an estimated
530,000 new cancer cases worldwide and for 275,000 deaths in 2008. Eighty-six percent of
new cervical cancer cases will be seen in developing countries. Worldwide, the mortality rate
from cervical cancer is 52 percent. Global incidence and mortality rates depend upon the
presence of screening programs for cervical precancer and cancer and of human papilloma
virus vaccination, which are most likely to be available in developed countries. Due to these
interventions, there has been a 75 percent decrease in the incidence and mortality of cervical
cancer over the past 50 years in developed countries.9
In developed countries, cervical cancer was the tenth most common type of cancer in
women (9.0 per 100,000 women) and ranked below the top ten causes of cancer mortality (3.2
per 100,000). In contrast, in developing countries it was the second most common type of
cancer (17.8 per 100,000) and cause of cancer deaths (9.8 per 100,000) among women. On the
continent of Africa and in Central America, cervical cancer is the number one cause of cancerrelated mortality among women. 10
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 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.
In the United States, it is estimated that 12,340 cases of invasive cervical cancer will
be diagnosed and that 4,030 women will die of the disease. These rates had been improving
steadily. However, from 2005 to 2009, rates were stable in women younger than 50 years and
decreased by 3.0% per year in women aged 50 years and older. From 2005 to 2009, mortality
rates were stable among women of all ages. This improvement has been attributed largely to
screening with the Papanicolaou (Pap) test.11
About 12,000 women will be diagnosed with cervical cancer, and about 22,000 with
ovarian cancer. A well-woman exam is the number one way for both cervical and ovarian
cancer to be caught early, but many women choose to skip their yearly exam. Doctor Omar
Perez says this leads to women getting a late diagnosis. Ovarian cancer develops in the tissue of
one or both of the ovaries and there's no screening test to detect it.12
It can only be caught during a pelvic exam. So women should know the
symptoms."Pelvic pressure, pelvic pain, increase in the diameter of the abdominal area,
because of the mass, some of the ovarian cancers can grow 20 to 30 centimeters." Unlike
ovarian cancer, cervical cancer can be detected through a yearly pap smear. It’s not as
aggressive, and can almost always be caught early if you see your doctor regularly. The cases
of cervical cancer are actually on the decline due to the introduction of the HPV vaccine, which
prevents the disease that leads to cervical cancer.
There has been a regular campaign against cervical cancer 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 cancer mostly affects middle-aged women (between 45-55 years),
especially those from the lower economic status who fail to carry out regular health check-ups
due to financial inadequacy. In urban areas, cancer as per the information from the cancer
registry in Barshi.13
Globally cervical cancer was the 5th most common cause of cancer death among
women in the world, and had 489,000 new cases, an age-standardized incidence rate (global) of
16 per 100,000 women in 2002, 1-year prevalence of 381,033, and 5-year prevalence of 1.41
million in 2002, 268,000 deaths (3.6% out of 7.4 million cancer deaths), 9 age-standardized
deaths per 100,000 in 2002, 3,719,000 DALYs (disability adjusted life-years)
In India cervical cancer was the third largest cause of cancer mortality in India, and
age-standardized incidence rate of 30.7 per 100,000 women in 2002, 1-year prevalence of
101,583, and 5-year prevalence of 370,243 in 2000, 72,600 deaths (nearly 10% out of 729,600
cancer deaths), 6.5 deaths per 100,000, 9.5 age-standardized deaths per 100,00 987,000
DALYs, 88 DALYs per 100,000, 113 age-adjusted DALYs per 100,000(WHO, 2009b;
GLOBOCAN 2002 database, IARC).14
Distribution
prevalence
and
incidence
of
Cervical
Cancer
in
India.
Prevalence/Incidence of Cervical Cancer- As of 2002, the 1 year prevalence of cervical
cancer in India was 101,583, and the 5 year prevalence was 370,243, accounting for
approximately 26% of global prevalence, and 83% of total prevalence in South Central Asia
(GLOBACAN 2002 database, IARC). In India, the age-adjusted incidence of cervical cancer
(30.7 per 100,000 women, 132,082 incident cases) is the highest relative to that of all other
types of cancer, and is higher than the average for the South Central Asia
region(GLOBACAN 2002 database, IARC 2009). By 2025, the number of new cervical
cancer cases in India is projected to increase to 226,084 [WHO/ICO Information Centre on
HPV and Cervical Cancer].
Cervical cancer is the leading cancer among women in terms of incidence rates in
2 out of the 12 Population Based Cancer Registries (PBCRs) in India, and has the second
highest incidence rate after breast cancer in the rest of the PBCRs. The age-adjusted incidence
is highest in Chennai, a metropolitan city in the south, and lowest in Thiruvanathapuram, the
capital of Kerala (National Cancer Registry Programme and World Health Organisation). 15
There is a high incidence belt in the north eastern districts of Tamil Nadu, as well as in
two districts in the North-Eastern region of the country. The prevalence and burden of cervical
cancer is much higher among women of low SES, as well as among rural women in India
(Vallikad, 2006; Kurkue, and Yeole, 2006). The primary reason given for this is lack of access
to screening and health services, and lack of awareness of the risk factors of cervical cancer.
HPV infection and precancerous lesions go unnoticed and develop into full blown cancer
before women realize they need to go for medical help (Kaku et al, 2008). Moreover, due to
difficulties of access and affordability, compliance to, and follow up of, treatment is much
worse for women of low SES, leading to further morbidity and mortality from the disease.16
The above instances provoked the researcher to undergo a study on cervical
cancer. Also, the researcher during community postings has observed the rural mothers with
inadequate information on cervical cancer. As cervical cancer alarming increases in the rural
area, there becomes a need for awareness on Prevention of Cervical Cancer among post
menopausal women. Thus the researcher decided to undergo a study on creating awareness
regarding Prevention of Cervical Cancer among Post menopausal women in the rural areas.
6.3 STATEMENT OF THE PROBLEM:
A study to assess the prevalence of risk factors of cervical cancer and effectiveness of
learning package on knowledge and attitude regarding prevention of cervical cancer among
post menopausal women in rural communities.
6.4 OBJECTIVES
1.
To assess the prevalence of risk factors of cervical cancer among post
menopausal women in rural communities
2.
To assess the pre-test knowledge and attitude regarding prevention of cervical
cancer among post-menopausal women in rural communities.
3.
To assess the post-test knowledge and attitude regarding prevention of cervical
cancer among post menopausal women.
4.
To compare the pre-test and post test level of knowledge and attitude
regarding the prevention of cervical cancer among post menopausal women.
5. To correlate knowledge and attitude regarding prevention of cervical cancer
among post menopausal women.
6.
To associate the prevalence of risk factors and knowledge and attitude
regarding the prevention of cervical cancer among post menopausal women with their selected
demographic variables.
6.5 OPERATIONAL DEFINITIONS
1. Prevalence of Risk factors:
It refers to the occurrence of risk factors for cervical cancer such as age, early age of
pregnancy, low economic status, frequent child birth, smoking, multiple sexual partner, early
sexual intercourse (less than 16 years), sexually transmitted disease, which is elicited through
check list.
2.
Effectiveness
In this study, it refers to improvement in knowledge and attitude regarding prevention
of cervical cancer among post menopausal women after administration of learning package.
3.
Learning package
It refers to information, education and communication in the aspects of
prevention of cervical cancer administered to post menopausal women prepared by the
investigator. In this study learning package includes teaching and communication for the post
menopausal women for duration of 45 minutes regarding risk factors, sign and symptoms,
diagnosis and prevention of cervical cancer using flash cards and pamphlets.
4.
Knowledge
It refers to the level of understanding regarding the prevention of cervical cancer
among post menopausal women which is elicited through structured questionnaire.
5.
Attitude:
In this study, it refers to the opinion and belief regarding the prevention of cervical
cancer among post menopausal women, which is elicited by Likert scale.
6.
Post menopausal women:
Women who are in the age group of 45-55 years, and attained menopause.
6.6 ASSUMPTIONS
1.
Cervical cancer is mostly prevalent among post menopausal women in rural
communities.
2.
The post menopausal women may have inadequate knowledge and
unfavorable attitude regarding the prevention of cervical cancer.
3.
The learning package may improve the knowledge and attitude on prevention
of cervical cancer among post menopausal women.
6.7 RESEARCH HYPOTHESES
H1: There will be a significant difference between the mean pre test and post test
knowledge and attitude scores regarding prevention of cervical cancer among post menopausal
women.
H2: There will be a significant correlation between knowledge and attitude regarding
the prevention of cervical cancer among post menopausal women.
H3: There will be a significant association between knowledge and attitude regarding
the prevention of cervical cancer among post menopausal women with their demographic
variables.
6.8 REVIEW OF LITERATURE:
A retrospective study of 108 cases of cervical cancer above 30 years of age was
conducted to determine the prevalence of cervical cancer in rural teaching hospital and to know
the stage of the disease at the time of diagnosis and treatment of cervical cancer. The results
revealed that, out of the 108 women undergoing cervical biopsy, 101 (93.51%) had squamous
cell carcinoma, 6 (5.55%) had adenocarcinoma & 1 (0.92%) had adeno-squamous carcinoma.
As almost all patients (92.57%) with cervical cancer were in advanced stage. High prevalence
of advanced cervical cancer indicates very poor cervical cancer screening program in this area.
Public education, effective cervical cancer screening strategies using PAP smear, visual
inspection with acetic acid & cervical tissue sampling whenever required will reduce the
prevalence of advanced cervical cancer. 17
A study was conducted on effectiveness of educational package about cancer on
the attitude and knowledge of married women. Married women 84% in urban area, 76% in
rural had moderate knowledge. The pre test score for all the married women 100% in urban
92% in rural was favorable. The study showed that there was significant association between
knowledge on cancer cervix, attitude in urban, rural and selected demographic variables. The
study conducted that educational package is more effective in urban than rural area in
improving the knowledge.18
A World Health Organization (WHO) findings revealed that every year, around
1,32,082 women across the globe are diagnosed with cervical cancer and over 74,000 die from
this disease. Almost 2.4% of Indian women aged between 0 and 64 years are at risk of cervical
cancer compared to 1.3% women worldwide. January 18-24 is earmarked as cervical cancer
prevention week. 19
A community-based cervical cancer screening program among women of Delhi using
camp approach cervical cancer is the commonest malignancy among women in developing
countries. To find out number of cervical cancer cases among patients reporting to a general
health care camp through screening program and study the prevalence of perceived morbidity
and its confirmation. Cross-sectional study among women attending cancer awareness
camps. A total of 435 women attending cancer awareness camps were screened for carcinoma
cervix. Pap smears of all the symptomatic patients were collected and cytological diagnosis
was confirmed by a pathologist. The perceived gynecological morbidity was observed to be
59.8%. The smear of the women who were suspected of carcinoma on clinical examination was
confirmed to be the cases of carcinoma-in-situ (7.8%) and high-grade neoplasia (2.9%) on
laboratory investigations. 20
A
descriptive
correlation
study
was
carried
out
on
65
consecutive cervical cancer survivors in three different oncology centers related to Shahid
Beheshti University of Medical Sciences, Tehran. The QOL was evaluated using three
different standard questionnaires: 1) EORTC QLQ-C30 for patients with malignant tumors;
2) EORTC QLQ-CX24 for cervical cancer patients; and 3) SSQ for assessing the social
support. The data was obtained by telephone interviews. Cervical cancer survivors stated a
good QOL. However, its score was negatively associated with symptoms including short
breathing, lack of appetite, nausea and vomiting, sleep disorders, peripheral neuropathy, and
menopausal symptoms. Also, there was a positive association between QOL and economic
conditions as well as QOL and social functioning.21
A
study
was
conducted
on
changes
demographics
in
the cervical
cancer population. The SEER database 9 registries from 1973 to 2008 were queried to
perform a retrospective cohort study of women with invasive cervical cancer. Estimated
annual percent change (EAPC) in incidence rates and 95% confidence intervals (CI) over the
entire study period were compared according to age, stage, race, and cell type (squamous
[SCC] and adenocarcinoma [ACA]). The odds of a newly diagnosed cervical cancer patient
having advanced disease are 10% higher, being less than age 50 are 37% higher, and being
Asian or Pacific Islander are 68% higher in the second time period as compared to the first.
Understanding the implications of these evolving population characteristics may facilitate
planning targeted studies and interventions for cervical cancer prevention, screening and
treatment in the future.22
A cohort of post-menopausal women study was conducted to examine the value
of screening for high-risk HPV in post-menopausal women. The prevalence of HPV16 in
CIN2+ lesions (29%, 95% CI 22-37%) in post-menopausal women was less than half of
previous estimates in pre-menopausal women from this population. Most histological CIN2+
lesions in post-menopausal women are not recognized by a single Pap smear. The study
concluded
that
a
large
fraction
of
pre-invasive cervical
cancer cases
in
post-
menopausal women result from infections by HPV types not included in the present vaccine
formulas.23
A systematic review was conducted to determine the effectiveness of health
education interventions to promote sexual risk reduction behaviours amongst women in order
to reduce transmission of human papillomavirus (HPV), a leading agent in the development
of cervical cancer. Thirty studies met the inclusion criteria for the review; all had the primary
aim of preventing HIV and other STDs rather than cervical cancer. Ten of the 30 studies were
considered to provide the strongest evidence for a causal relationship between the
intervention and the change in outcomes measured. This study concluded that educational
interventions targeting socially and economically disadvantaged women in which information
provision is complemented by sexual negotiation skill development can encourage at least
short-term sexual risk reduction behaviour. 24
A study was conducted on current status of knowledge, attitude and practice
(KAP) and screening for cervical cancer in countries at different levels of development by
Department of Community Medicine, North Bengal Medical College, Susrutanagar,
Darjeeling, Wsest Bengal, India. Analyses have shown significant differences exist in terms
of screening and HPV testing facilities among high income and low to middle income
countries. In addition, acute lack of awareness and knowledge among the concerned
population is particularly noted in rural areas of the low income countries. A detailed review
of Indian case studies revealed that early age of marriage and childbirth, multiparity, poor
personal hygiene and low socio-economic status among others are the principal risk factors
for this disease. This review concluded that a two pronged strategy involving strong
government and NGO action is necessary to minimize the occurrence of cervical
cancer especially in low and medium income countries.25
A cross-sectional study was conducted on current knowledge and practice of
cervical cancer screening among women in a rural population of Ernakulam District
Kerala, India where four of the seven Panchayats were randomly chosen. Households were
selected by systematic random sampling taking every second house in the tenth ward of the
Panchayat till at least 200 women were interviewed. The result of the study revealed that,
mean age of the study population was 34.5 + 9.23 yr. Three fourths of the population (74.2%)
knew that cervical cancer could be detected early by a screening test. Majority of respondents
(89.2%) did not know any risk factor for cervical cancer. Of the 809 women studied, only 6.9
per cent had undergone screening. One third of the population was desirous of undergoing
screening test but had not done it due to various factors.26
A prospective cohort study was conducted to determine the risk factors for
cervical cancer in rural setting in South India. The aim of this study was to quantify the effect
of risk factors related to cervical cancer. Socio demographic and reproductive potential risk
factors for cervical cancer were studied using the data from a cohort of 30,958 women who
constituted the unscreened control group in a randomised screening trial in Dindigul district,
Tamilnadu, India. This cohort study gives very strong evidence to say that education is the
fundamental factor among the socio demographic and reproductive determinants of cervical
cancer in low resource settings. Public awareness through education and improvements in
living standards can play an important role in reducing the high incidence of cervical
cancer in India. These findings further stress the importance of formulating public health
policies aimed at increasing awareness and implementation of cervical cancer screening
programmes.27
A
Population-based study describing
the
association
between
education
and cancer incidence has not yet been reported from India. Information on the educational
attainment of 4417 cancer cases aged 14 years and above, diagnosed during 2003-2006 in
Dindigul
district,
Tamil
Nadu, India,
was
obtained
from
the
Dindigul
Ambilikkai Cancer Registry, which registers invasive cancer cases by active methods from
102 data sources. The study revealed that the men and women with no education had higher
overall cancer incidence rates compared to the educated population. The risk of cervix,
mouth, esophagus, stomach and lung cancers were inversely associated with higher levels of
education whereas a high incidence of breast cancer was observed with increasing
educational levels. With more and more women in rural India becoming educated, one could
foresee breast cancer becoming more frequent even in rural areas of India in future.28
A community-based cross-sectional study was conducted in brothel-based sex
workers of West Bengal, Eastern India, to determine their oncogenic human papillomavirus
(HPV) status and the presence of pre-cancerous lesions. A total of 229 sex workers from
three districts of West Bengal participated in the study. All the study participants were
interviewed with the aid of a pre-tested questionnaire to determine their socio demographics,
risk behaviour and risk perceptions after obtaining informed verbal consent. This study
concluded that young sex workers are particularly vulnerable to high-risk HPV, similar to
human immunodeficiency virus (HIV). The observation of older sex workers relatively free
from HPV supports the view of acquired immunity against HPV, which needs to be studied
in-depth further. 29
A Community-based cross-sectional study was conducted to determine the
prevalence and make a comparative analysis of the socio-demographic and behavioural risk
factors of cervical cancer and knowledge, attitude and practice between rural and urban in
India. A survey was conducted among 133 women in a rural area (Kawakhali) and 88 women
in an urban slum (Shaktigarh) using predesigned semi-structured questionnaires. The
respondents were informed of the causes (including HPV), signs and symptoms, prevention
of cervical cancer and treatment, and the procedure of the PAP test and HPV vaccination.
The result revealed that, a large number of risk factors was present in both areas, the
prevalence being higher in the rural areas. The level of awareness and role of education
appears to be insignificant determinants in rural compared to urban areas. This pilot study
needs to be followed up by large scale programmes to re-orient awareness campaigns,
especially in rural areas.30
The study was to establish the prevalence of cervical cancer in a rural ethnically
Muslim community in the state of Jammu and Kashmir in India. A community based
screening for cancer cervix was conducted on married women aged 20-65 years. Of the 270
subjects, the majority were married before 19 years of age (81.1%) and 42.5% delivered their
first child within 1-2 years. Multi parity was seen to the tune of 51.3 %. There was no
evidence of cervical dysplasia or cancer cervix among the screened population. The study
revealed that, the presence of risk factors of high parity, early age of marriage and early
childbirth after marriage, absence of cervical dysplasia and malignancy emphasizes the fact
that socio-cultural factors, like absence of promiscuity and male circumcision, play an
important role in the low prevalence of cancer cervix.31
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
The data will be collected from the post menopausal women of Sullikere rural areas,
Bangalore.
7.2 METHODS OF COLLECTION OF DATA.
i.
Research design
Quasi experimental one group pretest –posttest design.
PRE TEST (O1)


Assess the pre test
INTERVENTION (X)

Learning package
POST TEST (O2)

Assess the post test
knowledge regarding
regarding the
knowledge regarding
the prevention of
prevention of cervical
the prevention of
cervical cancer
cancer using
cervical cancer
through structured
pamphlets and flash
through Likert scale.
questionaire.
cards for duration of
Assess the pre test
45 minutes.

Assess the post test
attitude regarding the
attitude regarding the
prevention of cervical
prevention of cervical
cancer through Likert
cancer through Likert
scale.
scale.
ii.
Variables
Dependent variables:
Knowledge and attitude regarding the prevention of cervical cancer among post
menopausal women.
Independent variables:
Learning package on knowledge and attitude regarding the prevention of cervical cancer.
iii.
Setting
The study will be conducted at selected rural communities under Sulekere PHC
Bangalore.
iv.
Population
The population for the study will be all the post menopausal women of Sulekere, rural
communities, Bangalore.
v.
Sample
The post menopausal women who fulfill the inclusion criteria will be the samples for the
study and the sample size will be 60.
Criteria for sample selection
Inclusion criteria:
The study includes the post menopausal women.
1. Between 45-55 years of age.
2. Who are willing to participate in the study.
3. Who are able to understand Kannada or English
Exclusion criteria:
The study excludes the post menopausal women
1. Who have visual and hearing problem.
2. The post menopausal women who are not available at the time of study.
vi.
Sampling technique
Simple random sampling technique
vii.
Tool for data collection
The tool consists of the following sections:
Section A:
Demographic data which gives base line information of the post menopausal women
such as age , marital status, religion , educational status, income, habits, family history.
Section B:
Check list to assess the Prevalence of risk factors of cervical cancer among post
menopausal women.
Section C:
Structured questionnaire to assess the knowledge of post menopausal women regarding
the prevention of cervical cancer.
Section D:
Likert scale to assess the attitude of post menopausal menopausal women regarding the
prevention of Cervical Cancer.
viii.
Methods of data collection
After obtaining the official permission from the Medical officer, Sulekere rural PHC
and informed consent from the samples, the investigator will personally collect the baseline
demographic data. After which the data will be collected in the following four phases.
Phase I: Assess the prevalence of risk factors of cervical cancer among post menopausal
women.
Phase II: Assess the existing knowledge and attitude regarding the prevention of cervical
cancer among post menopausal women with the help of structured questionnaire and likert
scale.
Phase III: Learning package will be given to the post menopausal women through the
distribution of pamphlets, teaching regarding the prevention of cervical cancer with the help
of A.V Aids to the post menopausal women in the rural communities, for duration of 45
minutes.
Phase IV: After a period of one week posttest knowledge and attitude will be assessed
within the same group using same structured questionnaire and likert scale.
Duration of data collection: 4-6 weeks
ix.
Plan for data analysis
The data collected will be analyzed by using descriptive and inferential statics.
Descriptive statistics

Frequency, percentage distribution, mean and standard deviation will be used to
analyze the knowledge and attitude regarding the prevention of cervical cancer among
post menopausal women.

Correlation coefficient will be used to analyze the correlation between knowledge and
attitude regarding the prevalence of risk factors and prevention of cervical cancer
among post menopausal women.
Inferential statistics

Paired’ test will be used to compare the pre-test and post-test knowledge of post
menopausal women.

Chi square test will be used to analyze the association between knowledge and attitude
on prevention of cervical cancer among post menopausal women with their selected
Demographic variables.
x.
Projected outcome
The study will improve the knowledge and attitude of post menopausal women
regarding prevention of cervical cancer. This could help to create awareness and help to
reduce the prevalence of risk factors of cervical cancer among post menopausal women.
7.3 Does the study require any investigation or interventions to be conducted on
patients or other human?
Yes, learning package will be administered for the post menopausal women regarding
the prevalence of risk factors and prevention of cervical cancer in selected rural communities
of Bangalore.
7.4 Has ethical clearance obtained from your Institution?
Ethical clearance will be obtained from concerned authorities and informed consent
will be obtained from the samples. Confidentiality and privacy of data will be maintained.
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