1. health and fitness
2. disease
3. cancer

A STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDES ABOUT CERVICAL
CANCER OF WOMEN WHO ATTEND ST. JOHN’S MEDICAL COLLEGE
HOSPITAL. (S.J.M.C.H) OPD, WITH A VIEW TO PREPARE A PAMPHLET.
By
SHINY. M. JOSE (SR. THERESE JOSE)
Dissertation submitted to the
Rajiv Gandhi University Of Health Sciences, Bangalore, Karnataka.
In partial fulfillment
of the requirements for the degree of
MASTER OF SCIENCE IN NURSING
In
OBSTETRIC AND GYNAECOLOGY NURSING
Under the guidance of
SR. SUMA KUTTICKAL MSc (N), BTA.
DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY
COLLEGE OF NURSING
ST. JOHN’S NATIONAL ACADEMY OF
HEALTH SCIENCES
BANGALORE.
YEAR – 2006
I
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
DECLARATION BY THE CANDIDATE
I Shiny. M. Jose (Sr. Therese Jose), hereby declare that this dissertation / thesis
entitled “ A STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDES ABOUT
CERVICAL CANCER OF WOMEN WHO ATTEND ST. JOHN’S MEDICAL
COLLEGE HOSPITAL (S.J.M.C.H) OPD, WITH A VIEW TO PREPARE A
PAMPHLET” is a bonafide and genuine research work carried out by me under the
guidance of SR. SUMA KUTTICKAL MSC (N), ADDETIONAL VICE –
PRINCIPAL AND HEAD OF THE DEPARTMENT OF OBSTETRIC AND
GYNAECOLOGY, ST. JOHN’S COLLEGE OF NURSING, SJNAHS,
BANGALORE.
Reg. No: 04NO052
SIGNATURE OF THE CANDIDATE
Shiny. M. Jose (Sr. Therese Jose)
St. John’s College of Nursing,
St. John’s National Academy of
Health Sciences,
DATE :
Bangalore-560034.
PLACE : Bangalore
II
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation / thesis entitled “A STUDY TO
ASSESS THE KNOWLEDGE AND ATTITUDES ABOUT CERVICAL CANCER
OF WOMEN WHO ATTEND ST. JOHN’S MEDICAL COLLEGE HOSPITAL
(S.J.M.C.H) OPD, WITH A VIEW TO PREPARE A PAMPHLET” is a bonafide
research work done by SHINY. M. JOSE (SR. THERESE JOSE) in partial
fulfillment of the requirement for the degree of MASTER OF SCIENCE IN
NURSING.
SIGNATURE OF THE GUIDE
SR. SUMA KUTTICKAL MSc (N), BTA.
Additional vice principal and H.O.D
Obstetric and Gynecology Nursing,
DATE :
Dept, St. John’s College of Nursing
PLACE : Bangalore
S.J.N.A.H.S, Bangalore – 560034.
III
CERTIFICATE BY THE CO-GUIDE
This is to certify that the dissertation / thesis entitled “A STUDY TO ASSESS THE
KNOWLEDGE AND ATTITUDES ABOUT CERVICAL CANCER OF WOMEN
WHO ATTEND ST. JOHN’S MEDICAL COLLEGE HOSPITAL (S.J.M.C.H)
OPD, WITH A VIEW TO PREPARE A PAMPHLET” is a bonafide research work
done by SHINY. M. JOSE (SR. THERESE JOSE) in partial fulfillment of the
requirement for the degree of MASTER OF SCIENCE IN NURSING.
SIGNATURE OF THE CO-GUIDE
PROF. DR. RITA MHASKAR M.D
H.O.D.OBSTETRIC AND
GYNAECOLOGY
DEPARTMENT,
DATE:
S.J.M.C.H,
PLACE : Bangalore
BANGALORE – 34.
IV
ENDORSEMENT BY THE H.O.D, PRINCIPAL / HEAD OF THE
INSTITUTION
This is to certify that the dissertation entitled “A STUDY TO ASSESS THE
KNOWLEDGE AND ATTITUDES ABOUT CERVICAL CANCER OF WOMEN
WHO ATTEND ST. JOHN’S MEDICAL COLLEGE HOSPITAL (S.J.M.C.H)
OPD, WITH A VIEW TO PREPARE A PAMPHLET”, is a bonafide research
work done by SHINY. M. JOSE (SR. THERESE JOSE) under the guidance of SR.
SUMA KUTTICKAL MSc (N), Additional Vice principal and head of the
department of OBSTETRIC AND GYNAECOLOGY DEPARTMENT, St. John’s
College of nursing, Bangalore.
Seal & Signature of H.O.D (O.B.G.Nursing)
Seal & Signature of the Principal
SR. SUMA KUTTICKAL MSC (N)
PROF. MADONNA BRITTO
St. John’s College of nursing
St. John’s College of Nursing
SJNAHS, Bangalore-34.
SJNAHS, Bangalroe – 34.
DATE :
DATE :
PLACE : BANGALORE
PLACE : BANGALORE
V
COPY RIGHT
DECLARATION BY THE CANDIDATE
I SHINY. M. JOSE (SR. THERESE JOSE) HERE BY DECLARE THAT
THE RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,
SHALL HAVE THE RIGHTS TO PRESERVE, USE AND DISSEMINATE THIS
DISSERTATION / THESIS IN PRINT OR ELECTRONIC FORMAT FOR
ACADEMIC RESEARCH PURPOSE
DATE :
PLACE : BANGALORE
SIGNATURE OF THE CANDIDATE
SHINY M JOSE (SR. THERESE JOSE)
ST. JOHN’S COLLEGE OF NURSING
SJNAHS, BANGALORE – 34.
© Rajiv Gandhi University Of Health Sciences, Karnataka.
VI
ACKNOWLEDGEMENT
God Almighty
“You answered me when I called to you; with your strength you strengthened me.
Complete the work that you have begun.” (Ps. 138-3.8)
With reverence and gratitude; who has been my shepherd and urging drive behind
all my efforts. His unconditional love and Omni presence has been my anchor through
the fluctuating hard moments.
I wish to express my sincere appreciation and deep sense of gratitude to all those
who encouraged and worked with me in completing this task successfully.
Rev. Sr. Suma Kuttickal M.Sc (N) BTA.
The present study has been undertaken and fulfilled under the encouragement,
interest, intellectual guidance, constant support and supervision of my teacher, Rev. Sr.
Suma Kuttickal M.Sc (N) Additional Vice Principal and Head of the department Obstetric
and Gynecology Nursing, St. John’s College of Nursing, Bangalore.
Dr. Rita Mhaskar MD
I am immensely thankful to my co-guide Dr. Rita Mhaskar, Head of the
Department of Obstetric & Gynecology, St. John’s Medical College Hospital, for her
warm presence, critical and constructive comments, valuable suggestions, kind support
and wise guidance in making this study a success.
VII
Mrs. Madonna Britto M. Sc (N)
I am highly obliged to Mrs. Madonna Britto, principal, St.John’s college of
nursing, SJNAHS, Bangalore for her valuable help in providing necessary facilities and
extending support to conduct this study. I also thank her for the constant support,
Motivation, and encouragement through out the course of the study that she has given to
me.
Rev. Dr. Fr. Thomas Kalam Ph.D (UK) Director SJNAHS,
Rev. Fr. M.A Sebastian Assoc. Director SJNAHS
And
Rev. Sr. Ria MSc Nursing Superintendent
I thank Fr. Thomas Kalam, The director & Fr. M.A Sebastian Assoc. director,
and Sr. Ria Nursing Superintendent, SJNAHS, Bangalore, for providing me an
opportunity to undertake this study in this esteemed institution.
Prof. H. Lalitha MSc (N) & Prof. Mildred Rani MSc (N).
I take this opportunity to express my heartfelt gratitude to my M.Sc (N) class
coordinators, St.John’s college of nursing for their expert guidance, inspiration and
constant encouragement in the planning and completion of the study, and also thankful to
the masters of nursing faculty, St. John’s College of nursing who helped with
constructive & valuable suggestions and critics encouraged me to complete this study in a
fruitful manner.
VIII
Mr M.F. Joseph & Mrs. Pennamma Joseph
My dear parents who always wanted me to higher up the knowledge and perform
well and who always strengthened me with their love, affection, comforting words and
valuable prayers. And also extended my thanks to my dear Sisters, Brother and in-laws.
Sr. Thresiamma Pallikrnnel SH
My provincial superior Sr. Thresiamma Pallikrnnel SH and the sisters of my
congregation, I thank them sincerely for the trust and love shown to me and for their
constant encouragement and help extended to me as when ever I needed it.
Dr. Chittaranjan Andrade (MD) Professor department of psychopharmacology
NIMHANS & Mr. A.S Mohammed MSc D.P.I Asst. Professor (Bio statistics) Dept. of
community Health SJNAHS; I remain grateful to them for their expert guidance and
analysis of the data and prompt help as and when required.
Rev. Sr. Anette M.A Ph.D,
It’s my privilege to express my sincere gratitude Sr. Anette M.A. Ph.D for editing
my dissertation in the best way possible.
I am thankful to health personnel of out patient department of St. J.M.C.H, who
extended their support and good will during the data collection period.
I take this chance to place my gratitude to experts who validated the instrument,
for their valuable suggestions, which has enabled me to modify my instrument in a better
way.
IX
My special heartfelt thanks and appreciation to :•
Miss Reena Padmanabhan & Mr. Abi, for their skillful typing and need based
help for me during the entire period of my study.
•
Miss Kavitha & Mrs. Alice who helped for translating the instrument into Tamil
and Kannada.
•
All my study participants who were cooperated to give responses.
•
Mrs. Rajalakshmi & Mrs. Nirmala librarian of CON.
•
Mr. Anandraj, the chief librarian and his team of the Zablocki learning centre for
their help for my literature review.
•
All my classmates, seniors and juniors for their timely support throughout this
study.
•
Miss Vimala, Miss Simy and Miss Labeena (BSc nursing) who were helped me to
re-write the Kannada and Tamil translation and Sr. Sherly, Sr. Jossy & Sr. Lincy to
enter the data into the master sheet.
Thank you ................................................................................
Signature Of The Candidate
Sr .Therese Jose S.H.
DATE:
St. John’s College of Nursing
X
LIST OF ABBREVIATIONS USED
1.
OPD
: Out patient department
2.
S.J.M.C.H : St. John’s Medical College Hospital
3.
HBM
: Health Belief Model
4.
HPV
: Human Papilloma virus
XI
ABSTRACT
BACK GROUND AND OBJECTIVES
Cervical cancer is one of the major life crises for women. This malignancy has
varied causes and risk factors. So all women need more information on the risk factors
and the screening methods about cervical cancer. Adequate knowledge and positive
attitudes of women will help to prevent the disease and promote their health. As health
professionals nurses have a responsibility to improve the knowledge and attitude of
women regarding the killer disease. Thus, the investigator taken up, this study to assess
the knowledge and attitudes about cervical cancer of women and with a view to prepare a
pamphlet.
OBJECTIVES
1. To assess the knowledge of women regarding cervical cancer.
2. To identify attitudes related to cervical cancer
3. To determine the association of knowledge and selected variables such as age,
religion, education, occupation, marital status, family income, betel leaves chewing and
place of residence.
XII
4. To determine the relationship between knowledge and attitudes of women about
cervical cancer.
5. To prepare a pamphlet for women on risk factors and early detection.
METHODS
The study was conducted in a selected hospital in Bangalore. Data were collected
from 322 women who attended out patient department of St. John’s Medical College
Hospital, Bangalore. The research design adopted for the study was descriptive.
Purposive sampling technique was used for the study. Data were obtained with the help
of a structured interview schedule consisting of knowledge and attitudes based
questionnaire regarding cervical cancer and characteristics of the women who were the
subjects of the study.
RESULTS
The data obtained were analysed and interpreted in the light of objectives, using
both descriptive and inferential statistics. Major findings are summarised below :•
The sample consisted of 322 women, out of them 149 (46.7%) were <30 years of
the age where as 75 (23.3%) were 46-60 years of the age.
•
The present study, 13.7% of women have adequate knowledge and 49.9% of
women have favorable attitude towards cervical cancer.
•
In this study, 29.19% women have adequate knowledge on risk factors where as
only 3.4% have adequate knowledge of anatomy and physiology of cervix.
XIII
•
The study findings showed that 53.1% of women had favourable attitude towards
prevention of cervical cancer and 55.3% had favourable attitude towards treatment and
psychosocial impact.
•
The overall mean percentage of knowledge score of women was 24.75% and
mean percentage of attitude score was 58.95%.
•
There is significant association between the knowledge of women and education,
marital status, income and occupation at 0.001 level where as there is no association with
age and chewing of betel leaves at 0.05 level.
•
There is significant association with knowledge, place of residence and religion at
0.01 and 0.05 levels respectively.
•
There is significant correlation between:
Women’s knowledge and attitude of cervical cancer ‘r’ = 0.60**
Knowledge of and attitude towards risk factors, diagnosis and
prevention of cervical cancer, r = 0.28**, 0.57** and 0.48** respectively.
On the basis of the result of the study, a pamphlet was developed on risk factors, early
detection and prevention of cervical cance
XIV
Interpretation and Conclusion
The following conclusions were drawn from the study
1.
Knowledge deficit existed among women regarding risk factors, early detection
and prevention of cervical cancer.
2.
Majority of women have positive attitude towards cervical cancer.
3.
There is significant association between knowledge and religion, education,
occupation, marital status, income; betel leaves chewing and place of residence.
4.
There is significant correlation between knowledge and attitude.
5.
There is no significant correlation between knowledge and age as well as chewing
of betel leaves.
→ Based on this study the investigator proposes the following recommendations.
1.Further studies :
Can be conducted to evaluate the effectiveness of the pamphlet.
May be replicated using a large sample so that findings can be generalized.
Can be conducted with a planned teaching programme and its effectiveness
to be assessed.
2. Similar kind of studies can be done for other categories of women in different
settings.
3.
The similar study can be undertaken with an experimental design.
Key words
Cervical cancer; knowledge; Attitudes; Pamphlet; women
XV
LIST OF CONTENTS
CHAPTER
PAGE
I. INTRODUCTION
1-8
Introduction
1-3
Need for the study
3-8
II. OBJECTIVES
9 - 14
Statement of the problem
9
Objectives
9
Hypothesis
9
Operational Definitions
10 – 11
Conceptual framework
12 - 13
Assumptions
14
Delimitation
14
Projected outcome
14
III.REVIEW OF LITERATURE
15 - 35
Cervical cancer
16 - 17
Knowledge of risk factors and early detection
17 - 20
Knowledge, attitude and practice and cervical cancer
20 - 30
Socio-demographic factors of screening of cervical cancer
31 - 33
Motivations and Barriers to cervical screening
33 – 35
XVI
IV METHODOLOGY
36 - 45
Research approach
36
Research Design
36
Schematic Representation of the study design
37
Setting of the study
38
Population
38
Sample
39
Instrument
•
Development of the tool
•
Description of the tool
•
Validity
•
Suggestions of experts
•
Validation criteria list
•
Reliability
40 - 43
Pilot study report
43
Data collection method
44
Plan for data analysis
45
V RESULT
46 - 68
Objectives and statistics used
46
Section I : Baseline data of women
47 - 53
Section II : To assess the knowledge of women regarding
cervical cancer
53 - 56
XVII
Section III : To identify attitudes of women related to
cervical cancer
57 - 61
Section IV : To determine the association of knowledge and
selected variables such as age, religion, education, occupation,
residence and betel leaves chewing.
62 - 63
Section V : To determine the relationship between knowledge
64 - 68
and attitudes of women about cervical cancer
VI
DISCUSSION
69 - 80
Findings related to baseline variables
71 - 73
Knowledge of women regarding cervical cancer
73 - 75
Attitudes of women towards cervical cancer
75 - 78
Association of knowledge and selected baseline variables
78 - 80
Relationship between knowledge and attitudes of women
regarding cervical cancer.
80
VII CONCLUSIONS
81
VIII SUMMARY
82 - 92
Major findings of the study
84
Implication
86
Recommendation
90
Personal experience
92
IX BIBLIOGRAPHY
93 - 100
X ANNEXURES ( APPENDIX )
XIX
LIST OF TABLES
No
Title
Page
1. Distribution of cervical cancer in percentages and incidence rate
(age adjusted 35-64 years) per 100,000 population
4
2. Distribution of women according to their age of marriage, number
of children, type of family, chewing of betel leaves and diet.
48
3. Distribution of women according to their age, marital status and
Religion
49
4. Distribution of women’s knowledge according to specific content
areas
53
5. Distribution of women’s mean score of knowledge regarding
cervical cancer.
54
6. Distribution of the women’s knowledge regarding risk factors of
cervical cancer.
54
7. Distribution of women’s knowledge regarding signs & symptoms
and diagnosis of the cervical cancer.
55
8. Distribution of the women’s knowledge regarding treatment and
prevention of cervical cancer.
55
9. Distribution of women’s attitude as per areas of cervical cancer.
57
10. Distribution of women’s means score of attitude regarding
cervical cancer.
58
XX
11. Distribution of women’s attitudes regarding risk factors of
cervical cancer.
58
12. Distribution of women’s attitudes about diagnosis of
cervical cancer.
59
13. Distribution of women’s attitudes towards treatment and
psychosocial impact of cervical cancer.
59
14. Distribution of women’s attitudes towards prevention of
cervical cancer.
60
15. Association of knowledge and baseline variables like place of
residence, occupation and income.
62
16. Association of knowledge and baseline variables such as age,
religion, education, chewing of betel leaves, marital status,
place of residence, occupation and income.
63
17. Relationship between knowledge and attitude scores of women
regarding cervical cancer.
67
18. Relationship between knowledge and attitude scores of women
regarding diagnosis, risk factors and prevention of cervical cancer
XXI
68
LIST OF FIGURES
No
Title
Page
1. Health belief model (Rosenstoch’s (1974) and Becker and
Maiman’s (1975)
13
2. Schematic representation of research design.
37
3. Distribution of women according to their education
50
4. Distribution of women according to their occupation.
51
5. Distribution of women based on their place of residence.
51
6. Distribution of women according to their monthly family income.
52
7. Distribution of women’s knowledge according to the mean
percentage of different areas of cervical cancer.
56
8. Distribution of women’s attitude according to the mean percentage
of specific areas of cervical cancer.
61
9. Relationship between knowledge and attitude of women regarding
cervical cancer.
65
10. Mean percentage distribution of women’s knowledge and attitudes
under specific content area.
66
XXII
LIST OF ANNEXURES
No
Title
1.
Letter seeking permission to conduct the study
2.
Letter requesting consent to validate research tool
3.
Acceptance form for tool validation
4.
Letter requesting opinion and suggestions of experts for
content validity of the research tool
5.
List of Experts Address
6.
Evaluation criteria check list
7.
Certificate of validation
8.
Structured interview schedule on cervical cancer
9.
Kannada translation of the tool
10.
Tamil translation of the tool
11.
Pamphlet on cervical cancer
XXIII
CHAPTER I
INTRODUCTION
“ Growth in knowledge can not be separated from growth in being, for both growth
and self that grows are basically a whole”.
(Earl, V, P. et.al 1963)
Knowledge is virtue and power, therefore the more learned a person is, the
more educated he/she is. Health is our wealth, which can be protected by powerful
weapons like knowledge and positive health behaviour can be gained through life
experiences, mass media and other educational materials.
Cervical cancer is the second most common cancer in women; worldwide and
is one of the leading causes of cancer related to death in women in underdeveloped
or developing countries like Somalia and India. It is one of the major public health
problems in our country especially in Bangalore (Indian Express Sep 9. 2005). Out2
of all cervical cancer cases seen in the world 14% occurs in the developed countries
and about 86% occur in developing countries. We know that cervical cancer is
considered to be a preventable and curable disease, because it can be diagnosed in its
pre-cancerous phase and can be controlled. Considering the high incidence of cancer
of cervix in our country pap screening becomes mandatory. Pap smear helps to
reduce the incidence of cervical caner significantly. Inadequate knowledge is
therefore most of the reason why many patients do not make use of the currently
available screening methods. Approximately10 two thirds of women who develop
1
cervical cancer have never been screened. Race, ethnic background and low-income
status play a role in incidence, mortality and survival. Survival rates approach 95% if
a high quality cytology-screening programme is in place and is used by women.
Nurses and other health care providers, including doctors and health
educators should be educate women about the risk factors of cervical cancer and the
benefits of early detection with Pap test. To do this, health care providers should help
women to promote their understanding of cervical cancer screening as a preventive
health care measure. Also they should advise their clients who are sexually active to
have a pap smear annually or at regular intervals as indicated. Although health
professionals and health educators have limited power to change societal deficiencies
or alter the pre-existing socio economic status of individuals, they are able to
increase compliance with preventive screening recommendations.
Cancers of reproductive system take a heavy toll on women’s lives. Health
teaching by nurses can maximize, change to reduce this toll. Encouraging women to
practice healthy behaviour is challenging because change is always difficult. Many
of the preventive behaviour, which helps to decrease the incidence of cervical
cancer, also help to prevent other diseases in women. It may be also possible for
nurses to use preventive knowledge for behaviour modifications. The investigator
realised, that nurses as educators and exemplar can become agents of change. Nurses
are the largest group of health professionals can help it through their clinical practice
2
and verbal advice or informational materials like pamphlet. Early detection and
prevention of cervical cancer will continue to rise in the hierarchy of health care.
NEED FOR THE STUDY
The adoption of “Health for All” by government of India implies a
commitment to promote and encourage the individual citizens, to achieve a higher
quality of life. The world health organization (WHO) estimates that the 5.8 billionworld population of today will swell by nearly 80 million, per year, to total 8 billion
by the year 2025. Average life expectancy in the year 2025 will be 73 years, having
risen from 65 years in 1995. But non-communicable diseases are expected to grow in
developing countries into this millennium, because the adoption of western life style.
Of course, cancer will continue to hold its place as one of the leading causes of
death, worldwide. The risk of cancer will continue to rise in developing countries
even until 2025.57
Cervical cancer has become challenging and life threatening problem in
industrially developed and developing countries. It is one of the most common
leading causes of death in the aging population of women. This may be due to
increasing number of carcinogens, poor life style patterns and unskilled diagnoses.
Screening is expected to continue to make cervical cancer less of a threat in
developing countries. The highest rates are in Latin America, Africa and South East
Asia including India, where risk of cervical cancer is the highest.57 Six Indian
registries (five urban and one rural) have shown that cancer of uterine cervix is the
3
commonest in all, except Bombay.12According to Indian Council of Medical
Research (ICMR 1981-2001), cervical cancer rate is as follows:19,20
Table I: Distribution of cervical cancer in percentages and incidence rate (age
adjusted 35-64yrs) per 100.000 populations.
Sl. No
Place
Cervical Cancer
%
21.5 %
Incidence rate per 100,000
Population
26.4
1
Bangalore
2
Barshi
50.7 %
26.2
3
Bhopal
23.9 %
24.3
4
Chennai
26.9 %
43.5
5
Bhopal
23.9 %
24.3
6
Delhi
19.9 %
30.1
7
Mumbai
15.2 %
19.4
The above-mentioned table shows that, in women, cervical cancer occupies a
high percentage among all other cancers. The same way cervical cancer has affected
a big number of women in the age group of 35-64 years per 100,000 population.
In Ujjain district (M.P) a study was done about cancer screening showed that,
women had knowledge regarding cancer in different levels, urban slum women had
44%, urban women 62.6%, rural women had only 18.1%. Cervical cancer is
considered preventable and survival rate is 47%, more over it has been shown that
unscreened women carry a 10 times higher risk of invasive cancer than screened
4
women.3 Out of all cervical cancer cases seen the world 14% occurs in the developed
countries and about 86% occurs in developing countries.2 In Alkapuri, a study was
conducted for the awareness of cancer screening among educated women. Sixty
percentages knew that cancer was curable if detected early and 10% knew of Pap
test, while 5% had undergone it. Pap smear is to reduce the incidence of cervical
cancer significantly.4
In Orissa, one hundred patients who suffered from invasive carcinoma of the
cervix and who underwent surgical treatment cases were analysed for the
epidemiological risk factors. Early menarche, early marriage and early frequent
coital activity were influencing the risk of cancer cervix. Early first pregnancy and
multiple pregnancies also contributed to the risk. Poor socio - economic status and
rural habitat were associated with the majority of the patients. In a developing
country like ours, counselling against early marriage, social motivation for delayed
first pregnancy and first child birth, promotion of barrier contraception should be
emphasized because hardly anything can be done about socio-economic status.
Identification of the population at risk and early detection of the disease and
education of the people should be aimed at.8
Cervical cancer is the most common cancer among Indian women due to
prevalence of several risk factors in our community. A population based study report
revealed (Vadodara) that, the women who were (2688) attending the camp were
married belonged to the poor socio-economic class, were illiterate and their age
5
varied from 18 to 72years. These women had some reproductive tract infections or
discomforts their average age being 36years. Poor genital hygiene (60.9%) and age
at marriage below 18years (58.5%) were the most common risk factors, followed by
age at first childbirth below 18years (39%), multiparity (32.9%) and family history
of cervical cancer 9.8%. Out of 154 health workers, only 12.5% knew of Pap smear
test is for cervical cancer screening. Women’s perceptions of cervical cancer and
cervical screening services might affect their health seeking behaviour.46
World wide, approximately 500,000 cases of cervical cancer are diagnosed
each year. Routine screening has decreased the incidence of invasive cervical cancer
in the United States, where approximately 13,700 cases of invasive cervical cancer
and 65,000 cases of cervical carcinoma in site (localized cancer) are diagnosed
yearly.1 Invasive cervical cancer is more common in middle aged and older, in
women of poor socio economic status, who are less likely to receive regular
screening and early treatment. There is also a high rate of incidence among
developing countries. Among African Americans, the death rate from cervical cancer
is more than twice the national average. Hispanics and Indian American also have
death rates above the average.62
Most women who develop cervical cancer tend to have one or more
identifiable factors that increase their risk for the disease. It is uncommon but not
impossible for women to develop cervical cancer without any of these risk factors.
Some risk factors can be changed (smoking and diet) where as others cannot be
6
changed (age and race). The American Cancer Society (2003) suggests that focusing
on the risk factors can prevent cervical cancer. Though some symptoms can indicate
cervical cancer, there are often no symptoms associated with early stages of the
disease. Therefore, all women should receive yearly pap smears once they reach at
the age of 18 or become sexually active, which ever occurs earlier. After three
negative pap smears in three consecutive years, Pap smears may be performed less
often at the discretion of the patient’s physician.62
In the 1960’s the average age of the women diagnosed with malignancy of
cervix was 50. Over the next three decades, the average age during which women
developed cervical cancer declined to 35. At the same time, the number of younger
women with cervical neo-plasia has increased.1 In 1981, one fifth of the deaths from
cervical cancer occurred in women under age of 50years, six years later 28% of
women those who died with cervical cancer was under the age of 50 years. Pap
smear testing is a policy for western women.1
In the gynaecologic ward of St. John’s Medical College Hospital
approximately 200 (10%) cervical cancer patients were admitted within (2003-2004)
one year. According to the investigator’s observation, majority of the patients were
not aware of the risk factors, signs and symptoms, detection methods and treatment
of the condition. In this hospital no study has been done till date for improving the
knowledge of women regarding cervical cancer and its risk factors, early detection
methods and prevention. The gynaecological department lecturers also encouraged
7
the investigator to take up this study, hence the investigator is keen to identify
existing knowledge of women regarding risk factors, screening methods, prevention,
signs and symptoms and treatment, with the aim to develop an informational
pamphlet which will be useful for women, for healthy living.
Nurses are in a position to provide information such as: prenatal care
contraceptive practice, immunization and well baby clinic because they are in
contact with women in a variety of settings. Any of these times is ideal to discuss
with the women the need for routine gynaecological care and screening. Nurses can
educate the public through health education, open conversations, mass media and
learning materials. Though India is in a developing stage, technological advancement
is poor in rural areas. Thus investigator identified learning materials can be of use to
educate the women to improve their knowledge regarding cervical cancer.
8
CHAPTER II
OBJECTIVES
STATEMENT OF THE PROBLEM
A study to assess the knowledge and attitudes about cervical cancer of
women who attend St. John’s Medical college hospital, (S.J.M.C.H) OPD, with a
view to prepare a pamphlet.
OBJECTIVES
1. To assess the knowledge of women regarding cervical cancer.
2. To identify attitudes related to cervical cancer.
3. To determine the association of knowledge and selected variables such as
age, marital status, religion, education, occupation, income; betel leaves
chewing and habitation.
4. To determine the relationship between knowledge and attitudes of women
about cervical cancer.
5. To prepare a pamphlet for women on risk factors and early detection.
HYPOTHESIS
There will be a significant relationship between knowledge and attitudes of
women about cervical cancer.
9
OPERATIONAL DEFINITIONS
1. Knowledge:- It refers to women’s awareness regarding cervical cancer, risk
factors and pap smear testing as measured by scores obtained according to
the response to the items on the structured questionnaire.
2. Women :- It refers to female, 18-60 years of age group who attend any OPD
in St. John’s Medical College Hospital, Bangalore.
3. Attitudes :- Refers to scores obtained by women as measured by their
response to items on a Likert’s scale, in which they expressed their views
about cervical cancer.
4. Baseline variables :- It refers to age, marital status, education, occupation,
income, betel leaves chewing, religion and place of residence.
5. Pamphlet:- It refers to systematically arranged written materials providing
information on risk factors, early detection methods, signs and symptoms,
prevention and treatment of cervical cancer.
CONCEPTUAL FRAME WORK
The conceptual framework is the most liberating and dynamic idea for
the practice of nursing. Polit and Beck (2004) stated, conceptual model (conceptual
frame work), inter related concepts or abstractions assembled together in a rational
scheme by virtue of their relevance to a common theme.
The study is based on Health Belief model, by Rosenstoch (1974)
Becker and Maiman (1975). According to Health Belief Model, the essence of
10
healthy behaviour focuses on preventing or detecting disease in a symptomatic stage.
This model explains the relationship between a person’s belief and behaviour and
assumes that attitudes and beliefs play an important role in health behaviours. It also
emphasizes the need for an individual to believe that the benefits of the preventive
action in reducing susceptibility to disease and its severity. The potential negative
aspects of a particular health action may act as impediments to undertaking the
recommended behaviour. People are not likely to take heath action unless they
believe that they are susceptible to disease, the disease would have serious effects on
their lives or are aware of certain actions that can be taken and believe that these
action may reduce their likelihood of bring down the incidence rate or reduce the
severity of illness.
The Health Belief Model based on the three factors:
1. Individual’s perceptions that can be :
•
Perceived susceptibility
•
Perceived seriousness of the disease
2. Modifying factors
3. Likelihood of action
The first component of the model involves the individual’s perception of
susceptibility to illness. The women need to recognize the importance of screening of
cervical cancer and its prevention. The second component of the individual’s
perception is the seriousness of the disease. This perception in this study can be
11
influenced and modified by demographic variables such as age, religion, education,
occupation, marital status, family income, diet pattern, habits and place of residence.
According to Health Belief Model, modifying variables that can help to
explain variations in participant’s knowledge and attitudes about cervical cancer. The
modifying factors also help to perceive the susceptibility, seriousness and threat that
can lead to action. When cues to action are known, the likelihood of action increases.
The cues to action in present study were mass media campaigns, newspaper or
magazine articles, education materials, reminder from medical professionals, advice
from trust worthy persons and family members. Thus development and distribution
of a pamphlet contribute to women some amount of knowledge about cervical
cancer.
The third component, the likelihood that a person will take preventive action
results from the person’s knowledge and attitude of the benefits and barriers of
taking action. In this study, the women can modify their behaviours or life style
pattern, can have increased adherence to medical facilities and can avail of screening
tests.
The Health Belief Model serves as a basis for this study. The perceived threat
and possibility of actions will leads to awareness of cervical cancer and acceptance
of the need of pap smear test. There is weighing of the perceived benefits of
preventive action and barriers to action. If benefits are more, there is an inclination to
positive action, women are ready to modify the health behaviour and will lead to the
better health of women.
12
13
ASSUMPTION
Women possess some knowledge regarding cervical cancer.
DELIMITATION
The study results would be generalized to women who are attending
St. John’s Medical College Hospital.
PROJECTED OUT COME.
The study will help to educate the women about cervical cancer by providing
learning materials, which consists of risk factors, early detection methods, signs and
symptoms, prevention and treatment of cervical cancer. It may help them to change
their life style patterns and protect their health. Not only health promotion and
protection but also can reduce the death rate of women by cervical cancer. They can
make use of it to educate their neighbors and relatives about this life threatening
disease.
14
CHAPTER III
REVIEW OF LITERATURE
“Review of literature provides a basis for future investigations, justifies the
application, throws light on the feasibility of the study and constraints of data
collection, relates the findings from one study to another with the hope to establish a
comprehensive body of scientific knowledge in professional discipline from which
valid and pertinent theories may be developed”.
[Faye Abdellah and E. Levine 1981]
This chapter deals with review of literature, which is an essential step in the
development of a research project. It helps to develop an insight in to the area of
investigation and directs the researcher to develop a plan.
In this study, literature review has been organized under five headings.
1. Cervical cancer
2. Knowledge of risk factors and early detection
3. Knowledge, attitude and practice of cervical cancer screening
4. Socio demographic factors to cervical cancer screening
5. Motivations and Barriers to cervical screening
15
I
CERVICAL CANCER
Cervical cancer develops in the lining of the cervix, the lower part of the
uterus (womb) that enters the vagina (birth canal). This condition usually develops
over a time. Normal cervical cells may gradually undergo changes, to become precancerous and cancerous.
The causes of cervical cancer are unknown, but some of the risk factors are
known, which are human papilloma virus and human immunodeficiency virus,
cigarettes smoking, age, multiple sexual partners, history of not having pap tests,
diethyl-strilbestrol (DES), weakened immune system, poor nutrition (Vit A, C, E &
folic acid) race and ethnicity, low socio economic status, oral contraceptive pills,
poor genital hygiene, obesity, early age of marriage and many children and sexually
transmitted diseases and male factors like the use of tobacco and alcohol.
Early cervical cancer is often asymptomatic (does not produce symptoms). In
women, who receive regular screening, the first sign of the disease is usually an
abnormal Pap smear test result. Symptoms that may occur include the following.
Abnormal vaginal bleeding (eg. Spotting after intercourse, bleeding between
menstrual periods, increased menstrual bleeding)
Abnormal (yellow, odorous) vaginal discharge
Low back pain
Painful sexual intercourse (dyspareunia)
16
Painful urination (dysuria)
Anaemia
Weight loss
Cervical cancer that spread to other organs may cause constipation, blood in
the urine, abnormal opening in the cervix (fistula) and ureteral obstruction (blockage
in the tube which carries urine from the kidney to the bladder).8,12,22,46,62
II KNOWLEDGE OF RISK FACTORS AND EARLY DETECTION OF
CERVICAL CANCER
A study was conducted in Canada, to assess the knowledge of Pap smear and
risk factors for cervical cancer among 528 Chinese immigrant women. Findings
revealed that, the average summary score of knowledge about risk factors was 5.2/10
(52%) and knowledge level was significantly associated with the women’s
educational level and the gender of the doctor providing routine care. Among them
74% received a pap test and 56% reported having received it within last two years.
Women with the highest knowledge were more likely to have received Pap test. The
average knowledge level was low about risk factors of cervical cancer.13
Another study was carried out in London to determine the belief about risk
factors of cervical cancer among 1940 women by face-to-face interview. Knowledge
has been found to be poor, although there was evidence of public awareness of a link
between sexual activity and the risk of cervical cancer. The most common single
17
response was ‘don’t know’ 88%, 41% mentioned factors relating to sex, but only
14% were aware of a link with sexual transmission, 1% named Hpv. Women who
were more educated had better knowledge of the established risk factors.14 Another
one more study was done to assess the level and accuracy of public understanding of
human papillma virus (Hpv) in the United Kingdom. Finding showed that,
questionnaire were completed by 1032 women, of whom 30% had heard of Hpv.
Even among those who had heard of Hpv, knowledge was generally poor and less
than 50% were aware of the link with cervical cancer. There was also confusion
about whether condom or oral contraceptives could protect against Hpv infection.15
A study was done in Nottingham to identify the women’s knowledge of
cervical cancer and human papillomer virus. It was found that almost 80% of the
respondents thought cervical cancer was a leading cause of cancer death amongst
women. Most subjects consistently over-estimated the incidence of cervical cancer,
consistent with the social amplification hypothesis. The majority accurately
identified the major risk factors, although family history was emphasized to a degree
unwarranted by epidemiological evidence. Subjects knowledge of the screening
programme was accurate in some respects but not in others.16 Another study was
conducted on the knowledge of risk factors of cervical cancer, pap smear testing
along with socio economic characteristics among Chinese immigrants in the USA.
The overall estimated response was 64% and the co-operation rate was 72%. The
majority of women could not recognize the importance of risk factors of cervical
cancer, but less than 50% of women recognized most of the risk factors. Factors
18
independently associated with knowledge of cervical cancer risk factors included
marital status, employment and education. Respondents with the highest knowledge
had greater odds of ever receiving a pap smear compared with to those women who
had the minimum knowledge.17
Australia, another study was conducted to know the human papilloma virus
infection and risk factors of cervical cancer. Report showed that human papilloma
virus (Hpv) is now known to be a risk factor of cervical cancer. This study examined
women’s knowledge of cervical screening, dysplasia and Hpv. Among the 400
women who received Pap test knowledge of early detection of cervical cancer and
screening methods were good. However, risk factors for cervical cancer were not
well known. Awareness and knowledge of Hpv were very limited. Past experience of
an abnormal smear result and colposcopy was significantly associated with good
knowledge of cervical screening, but not with knowledge of Hpv.18 A cross-sectional
descriptive study was carried out on 722 women to compare smokers & non smokers
perceptions of risk factors of cervical cancer and attitudes towards cervical
screening. Report showed that, smokers perceived their relative risk of heart disease
to be greater than that of non-smokers but they did not perceive their risks of cervical
cancer to be greater. Smokers held less positive attitudes towards cervical screening
than non-smokers.21
The study ,which was done Kerala in India, to determine the risk factors of
cervical cancer among cervical cancer women (3450). The mean age was 39.5 years,
19
68% of women under the age of 50 years, had been sterilized and 15 women were
unmarried. Out of all women 33% of the women had vaginal discharge and 16% had
low back pain. The risk factors found were increasing age, increasing parity;
illiteracy and poor sexual hygiene.22 A study was done (Orrissa) to determine the risk
factors in invasive carcinoma of cervix. The findings showed that, the mean age of
the patient was 46.2 + 8.05 years. Their mean age of menarche was 13.44 + 0.97
years. The mean age of marriage and coitarche was 16.15 + 1.17 and first pregnancy
was as low as 18.13 + 1.48 years. Hindus were 98%, multiparity 93% (more than
three children). Below poverty line 55% and rural habitation 64% and oral
contraceptive pills users were 10%.
III KNOWLEDGE, ATTITUDE AND PRACTICE OF CERVICAL CANCER
SCREENING
The knowledge, attitude and practice level of female primary care physicians
(98) regarding cervical screening where studied through questionnaire. The research
report showed that only 40% have ever performed a pap smear. Thus various training
methods and programmes on cervical screening are currently being developed based
on the results of the study.23 Again the knowledge, attitude and practice status of
women (112) were studied in the USA. The results suggested that knowledge of
screening guideline was low for all participants, especially regarding cervical cancer
screening. Although supervisors held positive cancer attitude, participation in
preventive cancer screening was low, which is indicative of the need for more
effective cancer prevention communication processes.24 The study described the
20
belief, attitude and personal characteristics influencing the cervical cancer screening
status of women in USA. The study findings showed that 69% had a Pap test and
56% had a test in the last year. Eighty percentages of women were sexually active
and of these, 63% were using birth control measures. Respondents understood the
seriousness of cervical cancer; their susceptibility to cervical cancer and the benefits
of Pap tesing, however, only 61% agreed that most young women whom they know
have pap tests. The perception that the test would be painful and not knowing where
to go for the test were negatively associated with ever having a pap test.25
A study conducted on knowledge and practice about cervical cancer and Pap
smear test in Kenya. The report showed that 51% of respondents were aware of
cervical cancer while 32% knew about Pap smear testing. There was no significant
difference in knowledge between cervical cancer and non-cancer patients. Health
care providers were the primary source of information about Pap test 87%, 22% of
all patients had Pap smear test in the past. Patient’s awareness of cervical cancer
were not likely to have a Pap smear test in the past. The level of knowledge was low
among non-cancerous patients. There is need to increase the level of knowledge and
awareness about cervical cancer screening and for women to increase the uptake of
currently available hospital screening facilities.2.6 The knowledge, belief, health care
behaviour and attitudes towards cervical cancer and cervical screening was studied in
Hong Kong on 98 female domestic helpers, their age being between 24-45 years. The
findings revealed that the majority of women had previously heard about cervical
smear 78%, 53% reported never having taken cervical smear. The women who had a
21
prior cervical smear had significantly more knowledge about cervical smear and
cervical cancer than those who never had a cervical smear.27
The study which was conducted to examine the knowledge and perception of
cervical cancer and screening on 30 women, selected from all income group from the
USA. The findings showed that the knowledge of cervical cancer and Pap smear test
was inadequate among women with low income. Among them 44% had opportunity
to Pap test and 40% had never had Pap smear test. Pap smear utilization was also
limited among low-income women. Major barriers to Pap smear screening included
inadequate knowledge about Pap smear testing, provider’s negative attitudes and
limited access to doctors. Health education and health policy is important and nurse’s
involvement is also essential.28
Another study was performed Tanzania to determine the level of knowledge
of basic symptoms of cancer of the cervix among women and to determine causes of
late presentation with advanced disease among cancer patients. The study findings
showed that knowledge of basic symptoms of cancer of the cervix, attitudes and
reasons for late presentation among female patients and controls were low. More
than 90% patients were advanced disease. The majority of patients, 50.6% and
controls, 23.6% were illiterate and 21.3% of patients and 33.7% of controls had
incomplete primary education. Both groups had 47.23% and 56.7% respectively no
routine gynaecological examination.29
22
The awareness of cervical cancer and breast cancer was assessed among 70
urban and 70 rural women, age between 21-59 years, with structured interview
questionnaire. Almost 20% women had not heard of these cancers and more than
50% were unaware of the test for cervical cancer and breast cancer. General lower
awareness levels of older and rural women were also significantly more inclined to
abnormal cervical smear.
32
A population-based survey was conducted in Rivas to
obtain baseline information to design a community based intervention programme
about cervical cancer. Screening on men (612) and women (634) respectively.
Results showed that, inadequate screening status included low education level,
exclusive level of public health facilities and lack of knowledge about prevention
and symptoms of cervical cancer. Negligence, absence of medical problems, fear,
lack of knowledge and economic reasons were the main reasons given for not being
screened. Reluctance to be screened in the future was related to lack of knowledge of
disease, inadequate screening status, older age and low education level.33
A population-based study was conducted about knowledge and attitudes of
Pap smear screening programme of 400 women, aged between 20-59 years in
Sweden. The results showed that 95% of respondents had a registered pap smear in
the pathology database. Women’s knowledge and cancers were age-dependent, 95%
stated that they knew the purpose of screening but only 62% could indicate which
type of cancer the screening actually examined.34 A study was done to measure the
young women’s attitude about communication with providers regarding pap smear.
The report expressed, knowledge of the pap smear and Hpv, intention to return for
23
follow up pap smears, positive attitudes about pap follow up were significantly
associated with good communication. 35
A population-based study was done in Sweden to investigate the attitudes of
cervical cancer screening, among non Pap smear attenders 430 and Pap smear
attenders 514. The reports were non-attendance that was negatively associated with
perceived severity of cervical cancer compared to other malignancies (95%), but
positively associated with time consuming and economical barriers.36 A study was
done in Texas, to examine knowledge, attitude and screening behaviour about breast
and cervical cancer on 2239 women aged 40 and older. The result showed that
knowledge was significantly related to age, education income, language, preference
and recent screening history. Over all attitudes were not predictive of mammography
and Pap smear screening behaviour. Knowledge of pap smear was 41% to 55.6%
among different Hispanic population.37
In Italy, a study was carried out to assess the knowledge, attitudes and
behaviour regarding breast and cervical cancer screening of female teachers with
questionnaire. The response rate was 65%. Only about 30% (mammography) 50%
(Pap smear) had undergone test according to the recommended time interval. Pap
smear in previous three years was significantly more likely in women in their forties,
with a higher family income and in those who had been examined by a physician in
the previous year.38 The knowledge, behaviour and beliefs of cervical cancer
screening were assessed among (96) adult women by face to face interview in New
24
Orleans. The findings were, three fourth (75%) of the women interviewed could not
correctly explain what a pap test is used for and few were aware that is most
commonly occurring cancer in females. Most of them believed that their risk of
cervical cancer was low, less than 50% reported ever having had a pap test and cited
not having a gynecologist, cost and fear of the test as reasons for not ever having had
the test done.39 A study was conducted in USA, assess knowledge of cervical cancer
screening among 154 female students completed a questionnaire. Report showed that
90% knew that a pap test screened for pre-cancerous and cancerous lesions of the
cervix. More than 50% of the students, however, thought that the test also screened
for other forms of gynaecologic cancer and for a variety of sexually transmitted
diseases. Approximately 50% of the respondents were unfamiliar with proper
preparation for the test and majority did not know about specific risk factors for
cervical cancer.40
A literature search identified women’s attitudes, knowledge and behavior of
factors influencing women’s participation in the cervical screening, their
psychological reaction to the receipt of an abnormal cervical smear result and
experience of colposcopy. Reasons of non participation included administrative
failures, availability of a female screener, inconvenient clinic trines, lack of
awareness of the test and benefits, considering oneself not to be at risk of developing
cervical cancer and fear of embarrassment, pain or the detection of cancer. Many
women believed that the test aims to detected existing cervical cancer.41
25
In England, a cross sectional survey was done on 650 women aged between
15 to 78 years, who were randomly selected and administered questionnaire to know
the attitudes and awareness of cervical smear test. The study reveled that 80% of
these women had at least one pap smear and 71.5% reported regular smears every 35 years, 37.4% women who attended regular health check-up, compared with 23%
who did not make regular visits for screening, 60% considered the test ‘No
problems’. Women who regarded it as ‘embarrassing, painful or troublesome’ were
significantly younger than those who did not. Seventy percentages perceived cervical
cancer to be a common disease and there was good awareness of the association
between this cancer and both smoking and number of sexual partner, 91.7% believed
cervical cancer could be treated if detected early enough. Knowledge levels were
greater among younger women and those who obtained regular smears.42
Another study was done to assess the knowledge of women (187) regarding
cervical cancer and cervical screening in Scotland. Results showed that, there was a
lack of knowledge with regard to both the screening itself and the possible causes of
cervical cancer. Those over 37 saw the main causes as higher sexual activity among
those aged below 37 and smoking and virus. The majority of women showed
preference for a female professional to take the smear. The main reasons cited for
non-compliance were the fear and dislike of the test itself.56
A study was conducted to assess the knowledge and attitudes of cervical
cancer on 254 women who attended OPD section of university college hospital,
26
Nigeria. The findings showed that, women aged 20 to 65 years attended general
OPD, response rate was 100%, 90% had heard of cancer at one time, while only 15%
had heard of cervical cancer. The media 38% and peers 36% were the major sources
of information, 36.8% had no knowledge while 40% had poor knowledge and 23.2%
had moderate knowledge regarding cervical cancer.43 A randomized clinical trail was
done in Austria to determine the efficiency of three interventions regarding
knowledge and satisfaction of women about cervical screening. It was to increase
patient’s knowledge of cervical screening and satisfaction with preventive health
care. At pre-test women had a low level of knowledge, which increased significantly
at post-test. The knowledge score were slightly higher in women who received
information supported by graphic or video colposcopy than in women who received
information without teaching aids. Visual aids were effective and increasing
satisfaction. 44
Another study was done to assess the knowledge and fears of Pap smear
among 299 women, aged between 25-54 years, who were attending primary health
care. Most (87%) of these women had not had a pap test in three years. Only 28%
knew that the test is used to detect cervical cancer, 58% knew the test was related to
reproductive health but did not have a clear idea of its purposes, 14% knew nothing
of the test or gave completely incorrect information about the test.45 A study was
conducted to determine the knowledge and practice of 159 women about cervical
screening, aged between 40-69years. Report showed that 26% women never heard of
Pap smear test, only 34% respondents reported having had a Pap smear test for
27
screening. Most of them said reasons for not having had a Pap smear test, because
there were no symptoms of diseases. Results indicates that education and usual
sources of care were significant factors related to having heard have or having had a
Pap smear test.9
A study was done to evaluate the use of anganwadi workers in the cancerscreening programme. By this aim, conducted a camp with the help of anganwadi
workers (154), result showed that (2864 women) cervical cancer was most common
cancer among Indian women due to the prevalence of sexual risk factors in our
community. The study showed that all the women attending the camp were married
100%, belonged to the poor socio economic class, were illiterates and their age
varied from 18 to 72 years, average being 36 years. Poor genital hygiene 60.9% and
age at marriage less than 18 years 58.5%, were the most common risk factors
followed by the age at first child birth less than 18 years 39%, multiparity 32.9% and
family history of cancer 9.8%.46 Another study was carried out to identify the male
factors, which contribute to cervical cancer. Samples were husbands of patients with
histopathologically diagnosed cervical cancer were interviewed and examined group
A. Results showed, 76% of husbands consumed tobacco and 46.3% consumed
alcohol. Level of education was lower and incidence of multiple sexual partners was
higher. Group B consisted of husbands, whose wives had no cervical cancer. Result
showed that 51.9% consumed tobacco and 18.5% consumed alcohol and 29.6%
circumcised but group A only 12.7%.47
28
Another study was done about knowledge of cancer and antenatal well being
of women and attitudes and practice in rural, urban and urban slum with 260 women,
result showed that 62.6% of women aware of cancer in urban areas as compared to
44% and 18.1% in slums and rural areas respectively, the rural areas need more
attention for cancer awareness.3 A study was carried out to determine the level of
awareness about menopause and cancer screening among educated women (342).
The findings reveled that 60% know that cancer was curable if detected early and
10% knew of Pap test while 5% had undergone it. 4
The knowledge about cervical cancer and cervical screening was assessed
among Hong Kong women (467) with confidential questionnaire. Evidence suggests
that women’s knowledge about cervical cancer and preventive strategies are
significant to their screening practices. Out of 467 women, 135 women had attended
screening, with those who were married with children significantly more likely to
attend. Although there was no significant difference found between the overall level
of knowledge of attenders and non-attenders. Individual items such as women’s
knowledge of risk factors were significant. The further need for education of
prevention and regular screening was demonstrated. 5 A study was done to determine
the older women’s attitudes to cervical screening and cervical cancer. The study
findings showed that their emotional, cognitive, socio-economic and ego integrity
barriers to regular cervical screening. Nurses have a major role in disease prevention
and education for healthy older women.10
29
A study was conducted in Ibadan, to determine the knowledge, attitude and
practice related to prevention of cervical cancer among (205) female health workers.
The study report showed that, doctors had high level of knowledge, surprisingly
inadequate among nurses, predictable poor among hospital maids. However, 93.2%
of respondents have never had Pap smear performed. The poor utilization of the test
was independent of respondent’s profession, marital status and hospital. Therefore,
there is a need to intensify campaign towards prevention of cervical cancer even
among health workers. 30
Another study was carried out on 600 women to assess the attitudes towards
cervical cancer screening and cervical cancer. The study findings showed that, 74%
of women had never had a smear before, however, 64% agreed that it is important,
34.5% of women did not know significance of a positive cervical smear, 77% of
women were not aware of causes of cervical cancer. Finally when asked who would
they like to take their cervical smear test, a clear preference was stated for a female
doctors or a female nurse. These findings provide a useful background for
developing strategies to increase the uptake of cervical smears among women. It also
emphasize the need to educate and promote awareness of women regarding risk
factors of cervical cancer and to the need for screening programmes.31
30
IV
SOCIO DEMOGRAPHIC FACTORS ASSOCIATION TO CERVICAL
SCREENING
A study was done to assess the socio-cultural influences of women’s
attendance for cervical cancer screening. The findings were, women indicate, that the
social factors of cost, educational base, knowledge of risk, the social value of early
detection and cultural issues such as modification and embarrassment contributed to
screening attendance. The doctors perceived a cultural tendency towards fatalism as
well as seeing the gender, interpersonal and inter professional skills of practioners to
be important in influencing level of women’s shyness and discomfort.48
Another study was conducted to assess the knowledge of cervical cancer
screening and utilization of screening facilities among women from low, middle and
upper social background. The report showed that the majority of patients from lower
socio-economic circumstances with multiple risk factors were not aware of cervical
screening or facilities available for this purpose. However, in spite of knowledge of
cervical screening and availability of such services, the majority of women (87%)
from higher social and educational background did not undergo cervical screening.
36.7% patient had a screening test performed at some time in past, only 27.3% of
patients, reported having had a pap test. Among women from higher socio-economic
groups, the level of education was better and knowledge of the Pap test was not aged
dependent. 49
31
Another study was done on older low-income women (923) about
knowledge, behaviours and fear of cervical & breast cancer. The results were, the
knowledge and attitudes about cancer varied with age, education, type of health
insurance, English speaking ability and place of birth. Women 65 years of age and
older had least knowledge of cancer detection methods and screening. Women who
did not speak English, did not know the signs and symptoms of cancer, risk factors
and screening guidelines.50 A study was conducted in urban colposcopy clinics about
knowledge of cervical cancer screening on 144 women. Results were compared with
those of 42 patients attending a health maintenance organization for the same
procedure. Less than 50% of clinic patients correctly identified the nature of a pap
smear or reasons for their referral, but 84% knew that pap smear were indicated
annually; study found out educational level to be the only significant predictor of this
knowledge.5
A study was conducted in U.S. about relationship between income and
education to cervical cancer on women. Report showed that women in high poverty
census tracts were 20% more likely to be diagnosed with later stage disease than
women in census tracts with low poverty levels. Survival, 31% lower in patients with
late state disease from census tracts with high poverty levels compared to low
poverty census tracts. American women cervical cancer incidence and mortality rates
increased as the level of poverty increased and education level decreased for the total
population.6 A study found out about socio-demographic predictors of adherence to
annual cervical cancer screening in minority women. Report showed, the Pap test is
32
an effective screening mechanism for reducing mortality and morbidity from cervical
cancer. Black women found adherent to annual Pap smear testing were slightly less
than black non-adherers and more income women.11
V
MOTIVATIONS AND BARRIERS TO CERVICAL SCREENING
A study was conducted to identify the barriers to cervical screening, about
factors that may influence screening. Among 97 rural women the aged between 1666 years and found that 52% had not received a pap smear within the last two years,
42% had never received a pap smear. The most frequent reason for not obtaining a
pap smear was anxiety regarding physical privacy (50%), lack of knowledge (18%)
and difficulty accessing health care (14%) women who had delivered children were
significantly more likely to have received a pap smear (71%), P<0.05. The responses
of many women suggests that compliance will cervical cancer screening would be
enhanced by addressing cultural beliefs, encouraging conversation about women’s
health issues and increasing the number of female health care providers.52 An article
explores the negative attitudes some women have towards the cervical screening
programme. These attitudes could ultimately prevent them from participating in the
programme. The negative experiences of women who receive a positive result are
also explored. Women’s negative attitudes towards cervical screening can largely be
countered by improving their under standing of the process and diagnosis of cervical
cancer. Women who received a positive smear should be offered support to reduce
their anxiety.53
33
A population-based study was done to find out reasons for women who did
not want to find out reasons for cervical cancer on 430 non-attenders and 514
attenders of Pap smear. Report showed, non attendance was positively associated
with non use of oral contraceptive pills, seeing different gynaecologists, seeing
physicians very often, frequent use of condom, living in rural or semi rural areas and
not knowing the screening test. Socio economic status and time was not their nonattendance.54 Another study was done to identify knowledge, barriers and motivators
related to cervical cancer screening with 102 women. Findings revealed that there
was misinformation and lack of knowledge about cervical cancer. The women
therefore confused about the causative factors and preventive strategies related to
cervical cancer. The major structural barriers were economic and time factors along
with language problems. The main psychological barriers were fear, fatalism,
confusion thinking and denial.7 The barriers to women’s use of cervical screening
services were identified with 20 women. The study found a high level of awareness
of a local cervical screening programme. The specific barriers determined were
social problems, embarrassment, belief in the sacred nature of human sexuality, an
anxiety about lack of confidentiality within small community groups and perceived
relationship between cervical smear and sexual activity.55
34
SUMMARY :
The investigator after reviewing the literature felt that knowledge and
attitudes of women about cervical cancer should be improved, especially in
developing countries like India. Public education and good communication may
improve the knowledge level women regarding cervical cancer. As a part of public
health education, investigator has decided to develop an informational pamphlet,
which will help the women to improve their knowledge on cervical cancer,
awareness and also their screening behaviours. Hence, such studies repeated in
various categories of women and settings will help to generate better findings and
arrive at more conclusive findings.
35
CHAPTER IV
METHODOLOGY
This chapter describes the methodology adapted by the investigator to study
the knowledge and attitudes of women about cervical cancer. It includes the
description of research approach, research design, schematic representation of the
study, setting of the study, population, sample, instrument, pilot study report, data
collection method and plan for data analysis.
RESEARCH APPROACH
The research approach adopted for this study was a non-experimental
approach, which depends on the purpose of the study.
REASEARCH DESIGN
The research design is the plan for the study, providing the overall framework
for collecting the data. Polit and Beck (2004) stated that in the second major phase of
a quantitative research project, researchers make decision about the methods and
procedures to be used to address the research questionand plan for the actual
collection of data. The research design helps the researcher in the selection of the
subjects for interviewing the womenand determines the type of analysis to be used to
interpret the data. The selection of research design depends upon the purpose of the
study. This study was initiated to assess the knowledge and attitudes of women (1860 yrs) regarding cervical cancer. The research design used for this study was
descriptive which was selected since it aided in attaining first hand information and
enhanced obtaining accurate and meaningful data.
36
37
SETTING OF THE STUDY
The setting of the study refers to the area where the study is conducted. The
setting of this study was in out patient department of St. John’s Medical College
Hospital; Bangalore is a tertiary care Hospital and a teaching institution. The out
patient departments are staffed with efficient and skilled doctors, nurses, paramedical
staff, nursing students and auxiliary nurses.
On an average every day 60-200 women (patients and attendents) visit each
out patient department (OPD) and will they undergo routine examinations and
laboratory investigations and other procedures for the better health care as per they
need. The investigator selected 18 units of the out patient departments to draw the
samples, according to the inclusion and exclusion criteria. The consultation timings
are 9 am – 1 pm and 4 pm – 6 pm every day. In each OPD an average five senior
consultants are available during morning hours and two will be available in the
evening time. There are adequate physical facilities for patient care and consultation
in each section.
POPULATION
Population refers to the aggregation of cases that meet a designated set of
criteria. The purpose of defining population for a research project arises from the
requirement, specific to the group to which the results of a study can be applied. In
this study population refers to all women who belong to the age group of 18-60
years, who attend any OPD of St. John’s Medical College Hospital, Bangalore.
38
SAMPLE
A sample is a small portion of a population, selected to assess the knowledge and
attitudes of women and to analyse it. The process of sampling makes it possible to
draw valid inferences or generalization. The sample in this study is comprised of the
women who are in the age group of 18-60 yrs attend any OPD of S.J.M.C.H.
Sampling technique: The technique used in this study was purposivesampling method, which was done from 18 units of the OPD of St. John’s
Medical College Hospital, Bangalore.
Sample size: To assess the knowledge and attitudes of women about cervical
cancer 322 women were selected for this study.
Criteria for selection of sample :
→ Inclusion criteria:
-
Women who are between the age group of 18-60 years.
-
Women who attend any units of the OPD of S.J.M.C.H. Bangalore.
→ Exclusion criteria
Women who are:
-
Diagnosed to have any cancer
-
With mental illness
-
Critically ill
-
In need of emergency care
-
Attending psychiatry and oncology OPD
39
INSTRUMENT
The actual collection of data normally proceeds according to preestablished plan to minimize confusion, delays and mistakes. The researcher’s plan
typically specified procedures for the actual collection of data. The instrument
selected in a research should as far as possible be the vehicle that would best help to
collect client data for drawing conclusions pertinent to the study.
Based on the objectives and the conceptual framework of the study, the
following were developed in order to generate the data.
Section I : Performa for baseline data of women
Section II: Cervical cancer knowledge questionnaire
Section III: Performa for cervical cancer attitude questionnaire (4 point
attitude scale)
→ Development of the tool
The instrument was developed based on review of literature on related
studies, textbooks, Internet support, interviews some women to get their opinions,
preparation of blue print and discussion with experts.
→ Description of the tool
•
Section I : Performa of baseline variables of women
It consists of 12 items including the participants: age, religion, education,
occupation, marital status, age of marriage, number of children, family income
40
per month, type of family, place of residence, habits (smoking, alcoholism, drug
abuse, tobacco use, betel leaves chewing) and diet.
•
Section II : Cervical cancer knowledge questionnaire
It includes 20 objective type of multiple-choice items, which
deals with anatomy and physiology of cervix (2 items), risk factors (7 items),
signs & symptoms and diagnosis (7 items) treatment and prevention (4 items) of
cervical cancer. Each item has one correct response and was given the score of
one, each according to the predetermined key.
•
Section III : Performa for cervical cancer attitude questionnaire (4 point
scale)
The structured attitude questionnaire consists of 20 items. On diagnosis (5
items), risk factors (5 items), prevention (5 items) and treatment & psychosocial
impact (5 items). Items were rated as strongly disagree (0 score) disagree (1
score), undecided (2 score) agree (3 score) and strongly agree (4 score). This is
for all the positive statements and the scoring is reversed for all the negative
statements. There are an equal number of positive and negative statements. Total
number of items, 20.
→ Validity
Nine experts established the content validity of the tool. They comprised
of eight nursing experts from obstetric and gynaecologic field and one gynaecologist.
41
•
Suggestions given by the experts:
1. To omit the repetition of items from knowledge questionnaire.
2. Two items were to be modified (items No 7 & 8) in attitude questionnaire.
3. To include treatment part in knowledge questionnaire.
4. Grading of attitude scale according to the score.
→ Validation criteria list
A validation criteria list also was sent to the experts. It was completed by
each of the experts for content validation. The analysis of evaluation criteria list
completed by the experts is presented below in percentages below: Baseline data
All the characteristics necessary for the study are included – 100%
Clarity of items – 100%
Knowledge questionnaire
Covers the entire content – 88.8%
Questions are arranged in sequence – 78%
Questions are arranged in logical order 88.8%
Language is simple and easy to follow – 88.8%
All items necessary to achieve the objectives of the study are included –
88.8%
Attitude scale
Relevancy of the items – 100%
42
Statements are arranged in sequence – 88.8%
Covers the entire content – 88.8%
Statements are simple and easy to follow – 78%
All statements necessary to achieve the objectives of the study – 100%
Modifications were made on the basis of suggestions and comments given by
experts.
→ Reliability:
The reliability of the tool was checked after validation and modifications,
done from 11-07-05 to 17-7-05 in obstetric ward of St. John’s Medical College
Hospital, Bangalore. According to inclusion and exclusion criteria, five women were
selected and interviewed. After six days, the investigator administered a retest to
check the reliability: The investigator changed the study setting for checking
reliability from the OPD to the ward. Because, it was not possible to do re-test in the
OPD setup. After one week same subjects do not come to the same setting.
The reliability of the tool was established using test-retest method for
stability and split-half method for internal consistency. The value was obtained r =
0.921 and 0.917 respectively.
PILOT STUDY REPORT
Pilot study was conducted in the same setting (OPD) between 01-08-05 to
06-08-05 on 32 women who attended the out patient department of S.J.M.C.H;
43
belonging to the age group of 18-60 years. It was done to check the feasibility
practicability, the use of instruments, whether any modifications were to be done
before actual implementation of the study and to determine the method of statistical
analysis.
The findings of the pilot study revealed that, by using the structured interview
schedule, an average of 35-60 minutes were taken per women. Around 6-8 women
were interviewed per day. Purposive sampling technique was used to select the
participants. The study was found to be feasible and practicable.
After pilot study, some modifications were done on the tool such as : Item No.19 from knowledge questionnaire was replaced.
In baseline data, ‘type of diet’ was added.
Habit, income and education items were modified.
DATA COLLECTION METHOD
A formal permission was obtained from the Administrator of St. John’s
Medical College Hospital, Bangalore with regard to the study. A total of 322 women
who attended the 18 units of the outpatient department were selected through
purposive sampling technique for the study. The investigator first introduced her self
to the participant and obtained verbal consent for the study. If the woman was not
willing to participate, the next woman who met the inclusion criteria was selected for
the study. From each units of the OPD, an average of
8-10
women were
interviewed per day. Total 322 samples were collected for the present study.
44
PLAN FOR DATA ANALYSIS
The data obtained was analysed in terms of the objectives of the study using
descriptive and inferential statistics. The plan of data analysis was developed : First organize the data on master sheet.
Frequency, percentage mean and standard deviation would be used for the
analysis of baseline variables of women.
Objective I :- Mean range percentages and standard deviation would be used
to determine the level of knowledge.
Objective 2 :- Mean, mean, percentages and standard deviation would be
used to determine the level of attitudes about cervical cancer.
Objectives 3 :- To find out the association of knowledge and baseline
variables, Chi-square test would be computed.
Objectives 4 :- To find out relationship between knowledge and attitudes,
Pearson’s product-moment correlation method would be used.
SUMMARY
This chapter dealt with the methodology undertaken for the study, it includes
research approach, research design, schematic representation of the study, setting of
the study, population, sample, instrument, pilot study report, data collection method
and plan for data analysis.
45
CHAPTER V
RESULTS
OBJECTIVES AND STATISTICS USED
This chapter deals with the analysis and interpretation of data. This data was
collected from 322 women between 18-60 years of age. The purpose of the study
was to assess the knowledge and attitudes towards cervical cancer of women through
structured interview schedule. The baseline data also was collected which is relevant
to the present study to analyse and interpret the knowledge and attitudes of women.
This chapter is divided into five sections according to the objectives and various
statistical methods are used for appropriate and accurate results. In each section,
findings were presented in attractive and précise manner in different forms such as
tables, pie charts, graph and bar diagrams.
The analysis and interpretation of data are presented as follows :Section I
: Baseline data of women.
Section II
: To assess the knowledge of women regarding cervical cancer.
Section III
: To identify attitudes of women related to cervical cancer.
Section IV
: To determine the association of knowledge and selected variables
such as
age, religion, education, occupation, marital status, income,
place of residence and betel leaves chewing.
Section V
: To determine the relationship between knowledge and attitudes of
women about cervical cancer.
46
The data was analysed with different types of statistical methods, which were used
according to the objectives.
1. The descriptive statistics were computed to analyses the base line variables. These
included range, mean and standard deviation, frequency and percentages for baseline
variables.
2. The inferential statistical analysis, which includes Chi-square test to determine the
association of knowledge with selected baseline variables.
3. Correlations were obtained to test the strength of the relationship between two
quantitative variables, by using the Pearson’s product moment correlations
coefficient.
r=
1/n ∑ (xy) – x y
(S.D of x) (S.D of y)
47
SECTION I
Description of baseline variables of women
Table 2 : Distribution of women according to age of marriage, number of
children, type of family, betel leaves chewing and diet.
N = 322
Sl. No
Variables
Age of marriage
2
3
4
5
Number of children :
0
1
2
3
4
>4
Types of family :
Nuclear
Joint
Extended
Habit :
Betel leaves chewing
Diet :
Vegetarian
Non vegetarian
yes
no
No
%
284
88.2
53
65
82
56
34
32
16.5
20.2
25.5
17.4
10.6
9.9
261
54
7
20
302
81.1
16.8
2.2
6.2
93.8
33
284
10.2
89.8
Mean
18.7
S.D
4.6
The above table shows that the mean age of marriage was 18.7 with 4.6 S.D.
Majority of women 82 (25.5%) had two children, where as 53 (16.5%) had no
children because less than one year of married life. Majority 261 (81.1%) of women
were belonging to nuclear family and 302 (93.8%) had no bad habits of chewing
betel leaves. Majority of them 284 (89.4%) were non-vegetarians.
48
Table 3 : Distribution of women according to their marital status and religion.
N = 322
Sl No
1
2
3
Variables
Age :
< 30 yrs
30-45yrs
46-60yes
Marital status
Unmarried
Married
Religion
Hindu
Muslims
Christian
No
%
149
98
75
46.2
30.4
23.4
38
284
11.8
88.2
244
19
59
75.8
5.9
18.3
The above table shows that, out of 322 women 149 (46.2%) were belonging
to < 30 years of age whereas only 75 (23.4%) come under the age group of 4660years. Most of the women 284 (88.2%) were married and 244 (57.8%) belong to
Hindu religion.
49
Figure 3 : Distribution of women according to their education
The above figure depicts that the education status of women was high.
Majority of women 104 (32.3%) had high school education whereas 68 (21.1%)
were illiterate. While 60 (18.6%) had primary education, 38 (11.8%) had higher
secondary, 36 (11.2%) had graduation and 22 (5%) had post graduation. Over all
78.9% of women had different educational background.
50
Figure 4: Distribution of women according to their occupation.
Occupation of women
23.90%
11.20%
Unskilled
Semiskilled
Skilled
64.90%
This pie diagram shows that majority of women 209 (64.9%) come under
semi skilled (House wife) where as 36 (11.2%) belonged to skilled category.
Figure 5: Distribution of women based on their place of residence.
Place of residence of women
47.50%
Urban
Rural
52.50%
According to the data presented in the pie chart, majority of women 169
(52.5%) were living in rural areas and 153 (47.5%) were living in urban areas.
51
Figure 6: Distribution of women according to their monthly family income.
Monthly family income
60%46.3%
50%_
40%-
31.7%
22%
30%20%10%0
< 1000 Rs
1001-5000Rs
5001-10,000/above
The data presented in the above mentioned bar diagram, shows that most of
the women 149 (46.3%) belong to Rs.1001 – 5000 income group. whereas 102
(31.7%) come under < Rs.1000 and 71 (22%) belong to Rs.5001-10,000/above
categories.
52
SECTION II
Description of knowledge of women regarding cervical cancer (Objective 1)
The knowledge of women regarding cervical cancer was assessed by 20
items of structured questionnaire. Each correct answer was given a score of one.
According to the content of cervical cancer knowledge of women, was classified in
to four categories.
•
Anatomy & physiology of cervix
•
Risk factors of cervical cancer
•
Signs, symptoms and diagnosis
•
Treatment and prevention
Table 4 : Distribution of women’s knowledge according to specific content area.
N = 322
Sl. No
Area
Adequate
No
%
Inadequate
No
%
1
Anatomy & physiology
11
3.4
311
96.58
2
Risk factors
94
29.19
288
70.8
3
Sign & symptoms and
diagnosis
Treatment and prevention
36
11.18
286
88.8
66
20.4
256
79.5
4
The above table shows that the knowledge of women regarding risk factors
was significantly high 94 (29.1%) compared their knowledge of anatomy and
physiology of cervix 11 (3.4%).
53
Table 5 : Distribution of women’s mean score of knowledge regarding cervical
cancer.
Max. Score Range
Knowledge
20
Mean
Score
4.95
0-18
Mean %
S.D
24.75
4.54
Key :
Adequate - > 50%
Inadequate - < 50%
The above table shows that the mean percentage of women regarding
knowledge of cervical cancer was 4.95 (24.75).
Table 6 : Distribution of the women’s knowledge regarding risk factors of
cervical cancer.
S.L
N = 322
ITMES
No
%
Married and many children
Use oral contraceptive pills
Poor genital hygiene and infection
Low socio-economic status
Multiple sexual partners, early age of marriage
and family history
Male partner’s – tobacco use, alcoholism & poor
genital hygiene
Average age of development of cervical cancer
120
34
34
120
53
37.2
10.5
10.5
37.2
16.4
152
47.2
83
25.7
Risk factors :1
2
3
4
5
6
7
The above-mentioned table shows that 47.2% of women responded correctly
regarding ‘tobacco use, alcoholism and poor genital hygiene’ of male partner where
as only 10.5% of women responded correctly about oral contraceptive pills and
infections.
54
Table 7 : Distribution of women’s knowledge regarding signs & symptoms and
diagnosis of the cervical cancer.
N = 322
Sl. No
ITEMS
No
%
1
Irregular vaginal bleeding and excessive whitish
discharge
First observer of symptoms
Early detection lead to cure of disease
Pap smear test is screening method
Cervical biopsy is another detection method
Pap smear helps to early detection of cervical cancer
Pap smear is necessary for reproductive and
menopausal women
149
46.2
72
55
27
77
39
33
22.3
17
8.3
23.9
12.1
10.2
2
3
4
5
6
7
The above table shows that 46.2% of women responded correctly ‘irregular
vaginal bleeding and excessive whitish discharge’ are the signs and symptoms of
cervical cancer whereas only 8.3% responded correctly about pap smear is the test
which is used for the screening of cervical cancer.
Table 8: Distribution of women’s knowledge regarding treatment and
prevention of cervical cancer.
N = 322
Sl. No
ITEMS
No
%
1
2
3
4
Removal of uterus and radiotherapy
Education of women as one of the preventive strategy
Avoidance of multiple sexual partner
Personal hygiene and birth control
121
120
63
88
37.5
37.2
19.5
27.3
The above table shows that 37.5% of women answered correctly about
removal of uterus and radiotherapy as the treatment of cervical cancer, while 37.2%
correctly responded about education of women as one of the strategies is of
prevention of cervical cancer whereas only 19.5% of women knew about avoidance
of multiple sexual partnesr.
55
Figure 7: Distribution of women’s knowledge according to the mean percentage
of different areas of cervical cancer.
35
%
30
%
25
%
20
%
15
%
10
%5%
0%
30.85%
30.50%
20.14%
8%
Anatomy &
physiology
Risk factors
Signs &
symptoms
Treatment &
Prevention
The above figure presents that the mean percentage of knowledge regarding
anatomy & physiology is 8%, signs & symptoms and diagnosis is 20.14%, treatment
and prevention is 30.5% and risk factors is 30.85%. The findings show that they have
some knowledge regarding cervical cancer but they need to improve their knowledge
regarding cervical cancer to prevent it. The knowledge score of percentage about
treatment, prevention and risk factors is significantly high compared to their
knowledge of anatomy and physiology of cervix.
56
SECTION III
Description of attitudes of women towards cervical cancer (objectives 2)
This section deals with the findings regarding the attitudes of women towards
cervical cancer. The score of attitude questionnaire (Likert’’ Scale) was analysed
using descriptive statistics. Attitudes of women were classified in to four categories.
•
Risk factors
•
Diagnosis (screening methods)
•
Treatment and psycho-social impact
•
Prevention.
Table 9 : Distribution of women’s attitude towards cervical cancer.
N = 332
Favourable
Unfavourable
Sl. No
Area
No
%
No
%
1
2
3
Risk factors
Diagnosis
Treatment & Psychosocial
impact
Prevention
156
160
178
48.44
49.68
55.3
166
162
144
51.5
50.3
44.7
171
53.1
151
46.8
4
The above table depicts the attitude of women towards treatment and psychosocial impact of cervical cancer 178 (55.3%) and the risk factors of cervical cancer
156 (48.44%).
57
Table 10 : Distribution of women’s means score of attitude regarding cervical
cancer.
Max. Score Range
Attitude
80
Mean
Score
47.1
27-78
Mean %
S.D
58.8%
5.2
Key :
Favourable - >50%
Unfavourable - < 50%
Table 11 : Distribution of women’s attitudes regarding risk factors of cervical
cancer.
N = 322
S. No
1
2
3
4
5
Items
There is no risk of infection after cervical
screening
Sex without using a condom is a risk factor
Unhealthy life style patterns can influence the
risk of cervical cancer.
A diet, rich in vitamins and folic acid is the
cause of cervical cancer.
Cervical cancer will affect only women from
low socio-economic classes.
No
%
64
19.9
102
31.7
172
53.4
92
28.5
112
34.8
The data depicted in the above table, shows that 53.4% of women agreed that
unhealthy life style pattern can increase the risk of cervical cancer where as only
19.9% of women disagree that ‘there is no risk of infection, after cervical screening’.
These findings show that they had positive attitudes towards the risk factors of
cervical cancer, still much more to improve.
58
Table 12 : Distribution of women’s attitudes about diagnosis of cervical cancer.
N = 322
S. No
1
2
3
4
5
Items
Cervical cancer is curable if detected early
A pap smear test can help to reduce the
incidence of cervical cancer
Cervical screening is unnecessary after
menopause
A pap smear is necessary only in elderly
women
A pap smear test is very expensive and painful
No
%
197
114
61.1%
35.4%
57
17.7%
65
20.1%
36
11.1%
The above-mentioned table shows that 61.1% of women agreed that ‘cervical
cancer is curable if detected early. Only 11.1% of women disagreed that ‘a pap
smear test is very expensive and painful’. It reveals that women were not aware of
Pap smear test and its cost.
Table 13 : Distribution of women’s attitudes towards treatment and psychosocial impact of cervical cancer.
S. No
1
2
3
4
5
N = 322
Items
Cervical cancer is one of the health problems in
women
Poor health will have impact on self image
Prevention of cervical cancer is better than
treatment
Cervical cancer disrupts the whole family and
affects the relationship between husband & wife
Cervical cancer, even if untreated, is not a life
threatening disease
No
185
%
57.4
107
156
33.2
48.4
114
35.4
96
29.8
The above table shows that 57.4% of women agreed that ‘cervical cancer is
one of the health problems in women. Only 29.8% of women disagreed that ‘cervical
cancer, even if untreated, is not a life threatening disease. It shows women were not
much aware of its threat.
59
Table 14 : Distribution of women’s attitudes towards prevention of cervical
cancer.
S. No
N = 322
Items
No
%
1
Educated women do not get cervical cancer
70
21.7
2
Early marriage and child birth can prevent
cervical cancer
Women’s education is one of the best methods
for prevention of cervical cancer
Women should be prevented from taking up
any employment in order to prevent cervical
cancer
Mass media and education can improve the
knowledge of women regarding cervical
cancer
73
22.7
146
45.3
93
28.9
160
49.7
3
4
5
This table depicts that 49.7% women agreed that ‘mass media and education
can improve the knowledge of women regarding cervical cancer. Only 21.7%
disagreed that ‘educated women do not get cervical cancer’. These findings draw the
conclusion that women have to improve their attitude towards prevention of cervical
cancer.
60
Figure 8 : Distribution of women’s attitude according to the mean percentage of
specific areas of knowledge of cervical cancer.
70%60%
60%-
60%
59.5%
56.5%
50%40%30%20%10%0
Risk
Factors
Diagnosis
Treatment
& Psycho-social
impact
Prevention
The above figure presents that the mean percentage of attitude regarding risk
factors 60%, signs and symptoms and diagnosis 56.5%, treatment and psychosocial
impact 60% and prevention 59.5% of cervical cancer.
61
SECTION IV
Association of knowledge and selected variable (objective 3)
This section mainly deals with the findings of association of knowledge
regarding cervical cancer and selected baseline variables like age, religion,
education, occupation, marital status, income and place of residence. It was analysed
with Chi-square test.
Table 15 : Association of knowledge and baseline variables such as occupation,
place of residence and income.
N = 322
S. No
1
2
3
Baseline
variables
Place of
residence :
Rural
Urban
Occupation :
Unskilled
Semiskilled
Skilled
Income :
< 1000 Rs
1001-5000Rs
5001-10,000
/ above
Adequate %
Inadequate %
Test
of
significance
91.1
80.4
χ2=7.69
df=1
P<0.01
7.69 75
13.24 180
31.42 24
92.3
86.76
68.58
χ2=31.9
df=2
P<0.001
5.88 96
13.42 129
26.76 52
94.12
86.58
73.24
χ2=15.2
df=2
P<0.001
15
30
8.9
19.6
5
29
11
6
20
19
154
123
The above table shows that there is significant association of knowledge and
occupation, income at 0.001 levels whereas place of residence at 0.01 level.
62
Table 16 : Association of knowledge and baseline variables such as age, religion,
education, chewing of betel leaves and marital status.
N = 322
S. No
1
2
3
4
5
Baseline
variables
Age:
< 30 years
30-45years
46-60years
Religion :
Hindu
Muslim
Christian
Education :
Illiterate
Primary
Secondary
Graduate
Chewing of
betel leaves :
No
Yes
Marital
status :
Married
Unmarried
Adequate %
Inadequate %
Test
of
significance
22
17
6
14.76 127
17.35 81
8
69
85.24
82.65
92
χ2=3.23
df=2
P>0.05
26
5
14
10.75 216
26.3 14
22.95 47
89.25
73.7
77.05
χ2=6.3
df=2
P<0.05
0
1
18
26
0
1.6
7.4
50
100
98.4
92.6
50
χ2=32.00
df=3
P<0.001
44
1
12
33
14.6
5
31.6
13
68
59
124
26
258
19
26
251
85.4
95
χ2=1.436
df=1
P>0.05
68.4
87
χ2=11.19
df=1
P<0.001
The above table shows that there is a significant association of knowledge
and education, marital status at 0.001 levels whereas there is no association between
knowledge and age as well as chewing of betel leaves.
63
SECTION V
Relationship between knowledge and attitudes of women regarding cervical
cancer (objectives 4)
This section deals with the analysis of data, in order to find the attitudes and
to test the significance of the coefficient of correlation between the knowledge scores
and attitudes in different aspects of cervical cancer.
Pearson’s product moment coefficient of correlation was selected and ‘r’
values are computed between knowledge scores and attitudes scores of women
regarding cervical cancer in different areas.
64
Figure 9: Relationship between knowledge and attitude of women regarding
cervical cancer
Knowledge
80%-
Attitude
76.3%
76.3%
Knowledge
70%Attitude
60%50.1%
50%40%-
35.75%
30%20%-
13.7%
13.4%
13.7%
10%-
0.6%
0
Adequate
& favourable
Inadequate Adequate
Inadequate
& favourable & unfavourable & unfavourable
The above figure shows that 13.7% women had adequate knowledge and
13.4% had favourable attitudes where as 76.3% had inadequate knowledge and
50.1% had unfavourable attitudes regarding cervical cancer.
65
Figure 10 : Mean percentage distribution of women’s knowledge and attitudes
under specific content area.
70%
60%
60%
60%
56.50%
50%
40%
30%
Attitude
30.85%
20%
30.50%
Knowledge
20.14%
10%
0%
Risk factors
Diagnosis
Prevention
The above figure shows that the highest mean percentage knowledge score
was in the area of risk factors 30.85% and least mean percentage knowledge score
was in the area of diagnosis 20.14%. It also shows the highest mean percentage of
attitudes score of women was in the areas of risk factors and prevention 60% and
lowest mean percentage of attitude score was in the area of diagnosis 56.5% and
women’s knowledge level is low compared to attitudes towards cervical cancer.
66
Table 17 : Relationship between
knowledge and attitude scores of women
regarding cervical cancer.
N = 322
S. No
Areas
1
Knowledge
Max.
Possible
Score
20
2
Attitude
80
Range
Mean Mean
of score
%
S.D
0-18
4.95
24.75
4.54
27-78
47.1
58.87
5.2
‘P’
value
r=0.607
df 320
* 0.01, * * 0.001.
The data presented in the above table shows that the correlation between
knowledge scores and attitude scores were 0.607, which is significant at 0.001 levels.
This indicates that there was moderate positive correlation between overall
knowledge and attitude scores about cervical cancer.
67
Table 18 : Relationship between knowledge and attitude scores of women
regarding diagnosis, risk factors and prevention of cervical cancer
N = 322
S.N
Content
area
Knowledge
Range Mean S.D
Range
Attitude
Mean S.D
1
Diagnosis
0-7
1.41
1.57
5-20
12
3.0
2
Risk factors
0-7
2.16
1.96
5-20
12
3.14
3
Prevention
0-4
1.22
1.33
5-20
11-9
3.4
‘r’
value
0.572
df=320
0.28
df=320
0.47
df=320
** 0.001
The data presented in above-mentioned table shows that the correlation between
knowledge and attitude scores of diagnosis, risk factors and prevention were 0.572,
0.28 and 0.47 which were significant at 0.001 level.
Summary :
The dissertation has achieved after analyzing the data; the knowledge
and attitude of women regarding cervical cancer have to be improved. In this chapter
mainly analysed the baseline variables of women, their knowledge and attitudes of
women regarding cervical cancer, association of knowledge with selected baseline
variables and relationship between total knowledge and attitude scores, as well as,
the different areas of knowledge and attitude scores. These analyses were done with
different statistical methods, which were appropriate for each section.
68
CHAPTER VI
DISCUSSION
“Prevention is better than cure” (WHO)
Cancer, the killer disease be prevented, is the achievement of the medical
advancement today.
The purpose of the present study was to assess the knowledge and attitudes of
women regarding cervical cancer, between 18-60 years of age. To achieve the aims
of the study the conceptual framework used was Health Belief Model (HBM). The
modifying factors from the conceptual framework showed that the women differed in
their baseline variables. The present study was done in the 18 units of the out patient
department of SJMCH, Bangalore. A total number of 322 women were selected
according to the inclusion and exclusion criteria, which was previously mentioned,
for the study. The method used to select the samples was Purposive sampling
technique and these women were interviewed through structural interview schedule.
The discussion will therefore be made under the following headings :
Findings related to :
•
Baseline variables of participants.
•
Knowledge of women regarding cervical cancer.
•
Attitudes of women towards cervical cancer.
•
Association of knowledge and selected baseline variables.
•
Relationship between knowledge and attitudes of women regarding cervical
cancer.
69
In conceptual framework (Health Belief Model) modifying factors are
important in the present study. It was represented by the baseline variables and
socio-psychological variables such as age, religion, education, occupation, marital
status, number of children, age of marriage, type of family, monthly family income,
place of residence, habits and diet patterns. All these were assumed to affect the
level of knowledge and attitudes of women. Cues to action were presumed to be
advices received from educational materials, mass media, advices from medical
professionals or others, newspaper and magazine articles. Previous studies13,14,46 have
found that the level of knowledge of women regarding cervical cancer was
inadequate. The present study also found that majority of women had some of
knowledge pertaining to cervical cancer. Thus, according to HBM, there is need to
educate and promote awareness of women regarding cervical cancer to developing
positive attitudes and healthy lifestyle and regular screening,.
So the investigator planned to prepare an educational material as a
pamphlet to make them more aware of cervical cancer and protect their lives from
the killer disease.
70
FINDINGS RELATED TO BASELINE VARIABLES
The investigator decided to compare the findings related to baseline
variables with other studies, so as to know if similar results were obtained.
A total of 322 women were studied, among them 149 (46.23%)
belong to the age group of <30 years; whereas 75 (23.3%) belonged to 46-60 years
of age group. The age group of subjects varied from 18-60 years. A previous study5
on women regarding knowledge of cervical cancer revealed that the women had
adequate knowledge risk of cervical cancer, the age group of 20-60 years. It shows
that present study findings are similar to other studies and proved that this age group
of women is the standard category of women to assess the knowledge and attitudes
regarding cervical cancer, to prevent the disease. Most of the women 244(75.8%)
belonged to Hindu religion, whereas Christians were 59(18.3%) and Muslims were
19(5.9%). Educational status of women varied from illiterate to post-graduate level.
Out of 322 women 104(32.3%) had high school education, whereas 68(21%) were
illiterates and 16(5%) were postgraduates. The mean education was 7.9yrs with 5.3
S.D. The similar findings were seen in previous study.64 which shows that 43.7%
had high school education whereas 20.8% had elementary education. Majority of
women (78.9%) had basic education.
Thus educating materials like pamphlet
distribution may be helpful to make them more aware of cervical cancer.
71
Regarding occupation, majority of women 142 (64.9%) belong to the
category of semi-skilled and 36(11.2%) belong to skilled category. So as a means of
educating women regarding cervical cancer, written materials may help them to read
and impart their knowledge to others about cervical cancer. Out of 322 women 284
(88.2%) were married and 82 (25.5%) had two children each. Similar findings were
seen in previous study5 68% were married, but 53% had no children.
It is
contradicting to the present study. The present study revealed that their mean age of
marriage was 18.7 years with 4.6 S.D. Somewhat similar findings were seen in
previous study8, their mean age of marriage was 16.15 yrs with 1.7 S.D. The
findings show that early age of marriage and childbirth is one of the risk factors of
cervical cancer. Educating the women regarding the risk factors and increasing the
age of marriage and first childbirth are important aspects of prevention of cervical
cancer.
The economic status of the women was categorized into three. It
was found that 149 (46.3%) come under middle category whereas only 71(22%)
come under upper category and 102 (31.7%) were placed in lower category.
The
previous study4 findings showed that 65% women come under middle category
(Rs.1000-5000) and 4.8% come under upper category whereas 30.9% lower
category. Majority of women belonged to middle class family. So education may
positively affect their health and other dimensions of life. Out of them 169 (52.5%)
were living in rural area and 153 (47.5%) in urban areas. Previous study8 showed
that 64% women were living in rural areas. 74.6% Indians live in rural areas and
24.4% in urban areas. It shows the importance of concentrating on rural health
72
regarding health care facilities and distribution of resources. Healthy people are the
wealth of the country. Of the 322 women, 288 (89.8%) were non vegetarian in the
present study.
FINDINGS RELATED TO KNOWLEDGE OF WOMEN REGARDING
CERVICAL CANCER
The first objective of this study was to assess the knowledge of women
regarding cervical cancer. Women those who have got above 50% was considered in
this study as adequate knowledge and less 50% considered as inadequate knowledge.
The findings revealed that the 45 (13.7%) women had adequate knowledge. Among
322 women, 73(23%) had not heard about cervical cancer. The previous study14
(conducted in London) findings showed that 38% women gave single response ‘I
don’t know about cervical cancer. Overall knowledge has been found to be poor. It
shows that both is developed and developing countries there is a need to educate the
women regarding cervical cancer. Yet another study10 revealed that most of the
women did not know of cancer of the cervix.
Knowledge about risk factors of cancer of cervix, the present study found
that 94 (29.15%) women had adequate knowledge. Among 7 items of risk factors
alcoholism and tobacco use of male partner scored the highest 152 (47.2%). The
other six factors scored : multiparity 120 (37.2%), poor genital hygiene and oral
contraceptives 34 (10.5%), Low Socio economic status 122 (37.8%), multiple sexual
partners, early age of marriage and family history 53 (16.4%). These findings show
73
that there is lack of knowledge about cervical cancer to prevent the disease. A
previous study46 revealed that 47.3% of women were recognized with the risk factors
of multiple sexual partner, 32.8% history of genital infections and HPV where as
only 17.1% and 13.15% knew about the relatedness of multiple child birth & early
age of marriage, 26.3% had a family history of the said disease. Another study5
contradicting the present study findings, showed the response rate as : multiple
sexual partners 86%, genital infections 77%, age factor 73%, early age of sex 58%,
oral contraceptive pills 57%, lack of regular screening 42%, sex without condom
21%. Comparing with present study finding, there was higher response rate to the
previous study. In this study, 44% were graduates. It concludes that education may
improve the knowledge of women regarding cervical cancer. It was surprising to
know that 86% of the women answered multiple sexual partners as the risk of
cervical cancer.
The knowledge about signs and symptoms and diagnosis of cervical cancer:
36 (11.18%) women had adequate knowledge. Most of the women could not give
correct response. The study finding revealed that 149 (42.2%) recognized irregular
vaginal bleeding and excessive whitish discharge is one of the symptoms of cervical
cancer. The previous study46 report revealed that the similar findings, symptoms of
leucorrhoea 32.9%, post coital bleeding 11.8% and post menopausal bleeding 40.1%.
These findings show that, they have some knowledge, but still there is a need to
improve the knowledge of women regarding symptoms of cervical cancer. The
present study the investigator realized that only 8.3% women knew of the pap smear
74
test as a means of diagnosing cervical cancer. Similar findings showed in previous
studies,4,46 10% women knew about pap test while 5% had undergone itand 12.6%
women heard of pap smear test for cervical cancer screening. In the present study 77
(23.9%) knew that cervical biopsy is also a method of detection. Out of 322 women,
only 33 (10.2%) understood Pap smear test is necessary for reproductive and
menopausal women and 39(12.1%) agreed that it would help in early detection of
cervical cancer.
Regarding knowledge about treatment and prevention of cervical cancer, the
present study revealed that 66 (20.4%) of women had adequate knowledge. Among
322 subjects 121 (37.5%) knew that the removal of the uterus and cervixand
radiotherapy are the treatments for cervical cancer. Pertaining to preventive methods
120 (37.2%) recognized women’s education is one of the best methods for
prevention of cervical cancer. They knew that avoidance of multiple sexual partners
63(19.5%) and personal hygiene & birth control 88(27.5%) were another preventive
strategies for prevention of cervical cancer. Surprisingly the previous study61 findings
on the knowledge about prevention of cancer of cervix, is only 1%.
FINDINGS
RELATED
TO
ATTITUDES
OF
WOMEN
TOWARDS
CERVICAL CANCER
The second objective of the present study was to determine the attitudes of
women toward cervical cancer. The attitudes said to be favourable if the score is
above 50% and unfavourable if the score is less than 50%.The present study showed
75
that 158 (49.1%) women had favourable attitudes. The previous study25 findings
revealed that the respondents (61%) understood the seriousness of cervical cancer,
their susceptibility to cervical cancerand its benefits of pap testing. Another study31
report also supporting the present results, 64% agreed that cervical screening is
important for prevention of cervical cancer.
These findings provide a useful
background for developing strategies to increase the uptake of cervical cancer
prevention among women. It also emphasizes the need to educate and promote
awareness of women regarding cervical cancer.
The present study findings reported about attitudes of risk factors of women
156 (48.44%) had favourable attitudes. Review of literature identified previous
studies
31,32
findings regarding attitudes about risk factors, 77% of women were not
aware of the causes of cervical cancerand 20% had not heard of this cancer and
almost more than 50% were unaware of the test for cervical cancer. Generally lower
awareness level was found. Regarding diagnostic measure, the present study findings
revealed that the women 160 (49.68%) had favourable attitudes. A previous study34
conducted on attitudes towards Pap smear screening, 62% indicated that Pap smear
test will screen the cervical cancer and reduce its threats. Another study26 findings
showed that 51% of respondents were aware of cervical cancer while 32% knew
about Pap smear testing. These findings show, there is need to increase the level of
awareness about cervical screening and women need to increase the uptake of the
currently available hospital screening facilities.
76
According to present scenario, health promotion and prevention of diseases
are the important aspect of health care delivery system. The findings of the present
study revealed 171 (53.1%) women had favourable attitudes regarding prevention of
cervical cancer. It shows that women have positive attitudes regarding prevention of
cervical cancer and they may take up initiatives to protect their life from cervical
cancer. Most of the participants (64%) agreed that women’s education is one of the
best methods for prevention, where as 71.9% agreed that mass media can improve
the knowledge of cervical cancer.
Each ones health will be improved by comprehensive care so the present
study findings showed that the overall 178 (55.7%) women had favourable attitudes
regarding treatment and psychosocial impact of cervical cancer. It concludes women
have positive attitudes about their health and social status and also their relationship
with partner and family members. So they may have inclination to protect their
health from the killer disease. Though they have positive attitudes regarding cervical
cancer, only 10.55% women accepted Pap smear test is not expensive and not
painful, where as 89.45% were not sure whether it is expensive or painful. It shows
that there is a need to educate about Pap smear test and its expense in term of
prevention of cervical cancer.
The previous study25 findings showed that they
perceived the test as painful and many women did not know where to go for the test.
77
FINDINGS RELATED TO ASSOCIATION OF KNOWLEDGE AND
SELECTED BASELINE VARIABLES
The Health Belief Model considered that knowledge is also influenced by
baseline variables. In this study, the third objective was to determine the association
between selected baseline variables like age, religion, education, occupation,
residence, marital status betel leaves chewing and income taken into consideration
with total knowledge score. Using Chi-square test did these associations.
The study findings revealed that there was no significant association with
knowledge and age variable (P > 0.05). Review of literature identified32,37 knowledge
was significantly related to age. Generally lower awareness levels were found in
older women. Yet another study34 findings showed, knowledge of women was age
dependent, 95% stated that they knew the purpose of screening but only 62%
understood which type of cancer is screened by pap test.
In India, compared to men, women are less educated. Some religions
concentrate more on education. The present study findings showed that there was
significant association between religion and knowledge score (χ2 = 6.3), it was
significant at 0.05 level. There was a previous study8 conducted on 100 cervical
cancer patients to find out the risk factors of cervical cancer. Among 100 patients 98
patients belonged to Hindu religion. Education helps people to take measures to
prevent any threat to their health. The present study findings concluded that there
was significant
association between
education and knowledge score (χ2 = 32),
78
significant at p<0.001 level.
The previous studies17,29,33,37 findings, showed that
knowledge of risk factors of cervical cancer are independently associated with
education. It shows education and knowledge of cervical cancer mean less number
of cervical cancer patients. The study report showed that there is a significant
association with occupation and knowledge score (χ2 =31.9) at P<0.001 levels. The
previous study17 findings showed that there was a significant association between
knowledge and employment.
The findings of the study showed that there was significant association of
knowledge score and marital status (χ2 =11.19) P<0.001.
The previous study17
results also support the present study results. The present result showed unmarried
women had more knowledge than married women. The study report drawn a picture,
of significant association of knowledge score and income (χ2 =15.2) at P<0.001
level. The previous studies37,38 conducted on knowledge and attitudes of women
regarding cervical cancer, showed that knowledge was significantly related to
income. Another study6 supporting the relationship between income and education
regarding cervical cancer showed that women in high poverty level were 20% more
likely to be diagnosed with later stage of disease than women in low poverty level.
Most of the Indians are living in rural areas. The present study result showed
that there is an association with place of residence and knowledge score (χ2 = 7.69) at
P<0.01 levels. The previous studies3,32 showed that there was significant association
of knowledge and place of residence with regard to cervical cancer screening: urban
79
women had 62.6%, urban slum 44% and rural 18.1%. So this report showed that
rural women had low level of knowledge about cervical cancer to urban women.
FINDINGS RELATED TO RELATIONSHIP BETWEEN KNOWLEDGE
AND ATTITUDE SCORES OF WOMEN REGARDING CERVICAL
CANCER.
The investigator, in the present study attempted to determine the correlation
between knowledge and attitude scores of women regarding cervical cancer. A
significant positive correlation was found in total scores and also each area of
content. The overall knowledge score and attitude scores were (r=0.607) significant
at 0.001 levels. The correlation of different areas also was significant at 0.001, that
is the relation ship between risk factors, prevention and diagnosis (r=0.28, 0.47 &
0.57) respectively according to Pearson’s coefficient product moment method.
SUMMARY
The above-mentioned discussion reveals that the women suffer from lack of
knowledge regarding cervical cancer and screening practices. This calls for the need
for health education of the general population regarding the topic. So the nursing
service and education departments can plan and organize teaching programmes for
women’s health promotion, protection and early detection of pathological changes
related to cervical cancer.
80
CHAPTER VII
CONCLUSION
The descriptive study was done on women’s knowledge and attitudes of
cervical cancer that were attended the out patient department of St. John’s Medical
College Hospital, OPD. It was assessed by structured interview schedule. Its findings
indicate that most of the women do not have sufficient knowledge and attitudes
about cervical cancer. Women need to know that the test screens for cervical cancer
and its risk factors and also preventive strategies.
Findings reveled that most of the women need more information on the risk
factors and screening methods for cervical cancer. Women who become sexually
active need to know that pap smear is their best insurance against cervical cancer.
Although women do believe that cancer is a serious disease, they do not perceive
cervical cancer as incurable. The majority of women knew that cervical cancer was
treatable if diagnosed early.
Based on the findings of present study the following conclusions were drawn.
•
The majority of women have (76.3%) inadequate knowledge regarding
cervical cancer.
•
Most of the women (49.1%) have favourable attitudes towards cervical
cancer.
•
There is association with knowledge and education, occupation, income,
marital status, religion, betel leaves chewing and place of residence.
•
There was positive correlation between knowledge and attitudes regarding
cervical cancer.
81
CHAPTER VIII
SUMMARY
Cervical cancer is cured if detected early.
But primary treatment is
prevention. Stressing the need for continuing education in the field of oncology is
important is a developing country like India. Workshops, mass media programmes
and educational materials are very important for increasing awareness of cervical
cancer. Public awareness and education are a must for the control of cervical cancer.
Rural areas are more prone to fall victims of this cancer, because poor socioeconomic status, lack of education and poor hygiene. The role of contraceptives is
no longer protective. The treatment of cancer is a costly affair. In India treatment
facility is a far cry from what we need.
Governmental and non-governmental
organizations should take up this challenge and work to answer this need of the
society. So the present study has taken this into consideration and has prepared a
pamphlet for public education.
Objectives were :
1.
To assess the knowledge of women regarding cervical cancer.
2.
To identify attitudes related to cervical cancer
3.
To determine the association of knowledge and selected variables such as
age, marital status, religion, education, occupation, income, betel leaves
chewing and place of residence.
4.
To determine the relationship between knowledge and attitudes of women
about cervical cancer.
5.
To prepare a pamphlet for women on risk factors and early detection
82
CONCEPTUAL FRAMEWORK/MODEL
The study made use of the Health Belief Model by Rosen Stock Becker and
Marimans, 1975.
The model focuses on the individual’s perception modifying
factors and likelihood of action. The study was limited to women who are attending
any of the out patient department of St.John’s Medical College Hospital, Bangalore.
The descriptive approach was utilized to achieve the overall purpose of the study.
The sample was drawn using Purposive Sampling technique and selection was based
on the inclusion and exclusion criteria established.
The data collection instrument consists of a structured interview schedule,
which included three sections. They are :
Section I – Items were used to collect baseline data of subjects.
Section II – Knowledge items of cervical cancer containing multiple-choice
objective type questions regarding Anatomy & Physiology of cervix, risk factors,
signs & symptoms, diagnosis and treatment & prevention.
Section III – Attitude questionnaire of 20 items, each item measured on four points
scale (Likert scale) depending on whether women strongly agree,
agree, undecided disagree and strongly disagree, the score was 4,3,2,1and 0
respectively.
Content validity of the tool was established based on expert’s suggestions and
judgments. Reliability testing of the instrument was done before the pilot study.
83
The reliability of questionnaire was 0.917 and it was found reliable (used test-retest
and split half method). Final data was drawn from 322 samples from 18 OPD of
SJMCH. The data was collected from OPDs on 29th August to 8th October 2005.
The collected data was analysed using descriptive and inferential statistics, the
results of which were interpreted for the benefits of the women.
FINDINGS RELATED TO SUBJECTS CHARACTERISTICS
-
The samples consisted of 322 women. About 149 (46.7%) of women were in
the age group of < 30 years where as 75 (23.3%) were 46-60 years. Most of them
were Hindus 244 (75.8%), about 104 (32.3%) of women had high school education
and 209 (64.9%) were semiskilled workers. Most of the women 284 (88.2%) were
married and 82 (25.5%) have two children. About 149 (46.3%) of women belong to
the category of Rs 1001 – 5000 monthly family income and 169 (52.5%) were living
in rural area. Majority of the women 281 (81.1%) come under nuclear family and
302 (93.8%) had no habits of chewing betel leaves. Out of 322 women 289 (89.8%)
were non-vegetarians.
MAJOR FINDINGS OF THE STUDY
-
The overall, 13.7% of women have adequate knowledge regarding cervical
cancer.
-
In this study, 49.1% of women have favourable attitude towards cervical
cancer.
84
-
There is significant association between knowledge and selected variables
life religion (χ2-11.19), place of residence (χ2-7.69) occupation (χ2-31.9) and
income (χ2-15.2).
-
Findings revealed that the women have adequate knowledge with respect to
specific content area like anatomy and physiology 3.4%, risk factors 29.19%,
signs and symptoms and diagnosis 11.18% and 20.4% on prevention.
-
The results of the study showed that the women have favourable attitude
towards cervical cancer with respect of different areas like risk factors
48.4%, diagnosis and signs and symptoms 49.68%, treatment and
psychosocial impact 55.3% and prevention 53.1%.
-
The overall mean percentage knowledge score was obtained in the area of
anatomy and physiology 8%, risk factors 30.8%, diagnosis and signs and
symptoms 20.1%and 30.5% on prevention.
-
The over all mean percentage score of attitude towards cervical cancer in
different areas like risk factors 60%, diagnosis 56.6%, treatment and
psychosocial impact 60% and prevention 59.5%.
-
There is a significant relationship between knowledge and attitudes scores at
0.001 levels.
-
There is no significant association with age and chewing of betel leave, χ23.23 and 1.436 respectively.
85
IMPLICATIONS
“Our deepest fear is not that we are inadequate, but that we are powerful
beyond measure. It is our light, not our darkness, that must frighten us” (Nelson
Mandela). His powerful words should stimulate us as professional nurse. We can
make differences, thus these study findings will help us to think and implement
several possible practical things in the field of Nursing practice, Nursing education,
Nursing Research, Nursing Administration and Public / General education
NURSING PRACTICE
All these challenges lie ahead. As we are in this new millennium, as nurses,
we can move forward from the past we can learn from our rich experiences,
respecting differences and adapting our message to ensure that what we teach is
heard and implemented. At present we can be agent of change. In the future, we can
accept the challenges of our profession and those in our care, accepting our role as
leadersand educators. We can dedicate our selves and create an exciting future by
accepting the challenges of today.
As we nurse professionals, leaders and educators, must emphasize those
activities, which promote the health of women and protect them from different
diseases as well as improve their health behaviours.
The knowledge deficit in
various areas of cervical cancer in women indicated the need of organizing health
education programme in different levels; it may be through mass media, public
awareness programme, educating material or medical professional advices. It can be
86
conducted in community or hospital settings. Correct knowledge and attitudes are to
be combined together and influence their cervical cancer awareness in a positive
sense of life.
The health teaching is an essential part of nursing practice. It should be
planned systematically and scientifically, based on the needs of the society or target
group. This will help us to make the message of communication more appropriate
and adequate for them and enhance their self-care ability and protection of health.
The teaching programme should not only be in pamphlet form but also
through self-instructional modules, planned teaching conferences, workshops, mass
media, newspapers etc. The nursing service can have a cervical cancer education
cell with a group of adequately prepared nurses, for developing education materials
for women, families and communities. This will help the nursing profession move
towards the goal of providing holistic and comprehensive care to women and achieve
health for all by 2010 A.D.
NURSING EDUCATION
Nursing is a dynamic, therapeutic and educative process in meeting the health
needs of the society. The purpose of nursing education is to prepare a person who
can fulfill the role, functions and responsibilities of professional nurse within the
society, assisting the individual or family to achieve their potential for self-direction.
So nursing curriculum should provide opportunities to the students to plan and
87
implement education programme for women on cervical cancer, which will be
according to the present actual needs of the society in different settings. This is
possible if the curriculum adds more concentration on target groups of women
regarding reproductive health and education, well integrated with other subjects.
Holistic and comprehensive care approach to the sick or well should be focused
during the training period of the students.
Nursing personnel are working in various settings of health care and the
faculty should be given in-service education to update their knowledge and skill in
identifying health needs of the society and present health problems. They should be
given special concern to plan and administer the education programme to the
identified actual and potential problems of the women. This will help to empower
the women and protect their life in a healthy way.
NURSING RESEARCH
Further research on women’s knowledge of cervical cancer is essential to
make them more aware of this present health problem. Women should be motivated
to adopt preventive strategies with regard to cancer of the cervix as in the present
scenario of lifestyle related diseases. Another improvement in research findings may
ensure if recruitment sides provided access to women who take part in routine
gynaecological screening. There is need to conduct further study in India in the field
of cervical cancer and women’s reproductive health. In Western countries, a lot of
researches had done to identify the cervical cancer and related problems in different
88
setting. The severity of the health problems, needs and nature is changing in India
day-by-day. Thus research programme will help to give a national awareness to
women’s reproductive health education programme.
NURSING ADMINISTRATION
Nurses are change agents, so there should be provision for them to devote
time for giving education to women. And it is needed to encourage and motivate
nurses to develop educational material for target group teaching.
Necessary
administrative support should be provided to arrange ‘cervical cancer’ health
education programme in any setting as required. Cost effective and cost benefited
health education materials are to be prepared. This will be more effective and
improve women’s healthy life style practices. The nursing administration should
have enough budgets for public education regarding cervical cancer and it should be
conducted for various categories of women as per their level of knowledge and
awareness.
GENERAL / PUBLIC EDUCATION
The literature review, present study findings and investigator’s personal
experiences revealed the importance of public education regarding cervical cancer.
There is great need to include the risk factors and screening tests about cervical
cancer, as part of mass education, which will be useful in creating awareness among
the general public. Nurse and mass media have a vital role in educating the public
through different health awareness programme or health advices.
89
LIMITATIONS
The limitations recognized in the study are :
-
The investigator-developed tools used for data collection, as no standardized
and appropriate tool could be located; so, the limitations involved in the use
of constructed tools.
-
The tool used for eliciting the knowledge and attitudes of women regarding
cervical cancer is in the form of structured interview schedule.
This
restricted free responses of the women.
-
Study findings cannot be broadly generalised, since it is limited to samples
selected from out patient department of St.John’s Medical College Hospital,
Bangalore, only.
-
The women were selected from age group of 18-60 years, so the findings can
be generalised only to that age group of women
RECOMMENDATIONS
On the basis of study findings and the suggestion of the study participants the
following recommendations were drawn :
1. Similar study may be replicated using a large sample so that findings can be
generalized.
2. Similar study can be conducted with a planned teaching programme and its
effectiveness is to be assessed.
90
3. Similar kind of studies can be conducted for other categories of women in
different settings.
4. Similar study can be carried out to ascertain the knowledge, attitude and
practices of cervical cancer among patients, college students, rural women,
urban slum women etc.
5. The similar study can be undertaken with an experimental design.
6. A study can be carried out to determine the cost-effectiveness of cervical
cancer education programme planned, in terms of its preparation,
implementation and evaluation.
7. Further study can be conducted to evaluate the effectiveness of the pamphlet.
SUGGESTIONS FROM THE STUDY PARTICIPANTS
-
Women’s health education programme should be conducted regularly in the
teaching institution like hospital, colleges and schools.
-
Health related educational programme is to be conducted by medical
professional and it should be culturally oriented.
-
Mass media should be effectively utilized for conducting programme on
women’s health awareness.
91
PERSONAL EXPERIENCE
Majority of women whether urban or rural have to get education
regarding cervical cancer to improve their health related behaviours.
Even educated women also have knowledge deficit regarding cervical
cancer.
Rural women were more ignorant regarding cervical cancer.
Majority of women did not know the position of the cervix.
Investigator has good experience in the fields of research and finding the
facts about knowledge and attitudes of women in cervical cancer.
92
BIBLIOGRAPHY
1. Jacquelyn Reid. Women’s knowledge of Pap smear, risk factors for cervical
cancerand cervical cancer. JOGNN. 2001; 30 : 299-304.
2. Seung Jo Kim. Role of colposcopy and cervicography in the screening
management of pre-cancerous lesions and early invasive cancer of uterine
cervix. The journal of obstetric & gynaecology of India. 2000; 50:139.
3. Mahadik kalpana V, Deshpande Kirti R. Survey of women for knowledge of
cancer, antenatal well-being attitudes and practice in rural, urban and urban
slum area of district MP. Journal of obstetric & gynaecology of India. 2003;
53:363-366.
4. Desai Monali. Awareness about menopause and cancer screening among
educated women. Journal of obstetric and gynaecology of India. 2003;
53:271-273.
5. Sheila Twinn, Hoirogd E. Women’s knowledge about cervical cancer and
cervical screening practices. Cancer nursing. 2002; 25:377-384.
6. Dr. Gopal K. Singh and his colleagues. Low income and education increases
risk for cervical cancer. Health news [Serial online] 2004 July; 1 (1) :
[screens]. Available from http://www.nccc-online. Org/news 072604.asp.
Assessed July 26, 2004.
7. Miok.C.Lee. Knowledge, barriers and motivators related to cervical cancer
screening among Korean-American women. Cancer nursing. 2000; 23:168175.
93
8. Jita Mohanty, Badal K. Mohanty. Risk factors in invasive carcinoma of
cervix. Journal of obstetric and gynaecology. 1990; 22:10-14.
9. Katherine kim, Elena S.H, Jackying. Cervical screening knowledge and
practices among korean-American women. Cancer nursing. 1999; 22: 297302.
10. Ann Eyres White. Older women’s attitudes to cervical screening and cervical
cancer: a New Zealand experience. Journal of Advanced Nursing. 1995;
21:659-666.
11. Kathleen Jennings, Deirdre Lowrence. Socio-Demographic predictors of
adherence to annual cervical cancer screening in minority women. Cancer
nursing. 2000; 23:350-357.
12. Dr. V.L. Bhargava. Cancer in women. Health for the millions. 1999; 6:28-29.
13. Hislop Ter, Teh C, Lai A, Raiston JD, Shu J, Taylor VM. Pap screening and
knowledge of risk factors for cervical cancer in chinese women. Ethn Health.
2004; 9:267-81. (Abstract)
14. Waller J.Macuffery. Beliefs about the risk factors for cervical cancer in
British population sample. Preventive Medicine. 2004; 38: 745-53.
15. Waller J, Macaffery K, Furrest S. Awareness of human papilloma virus
among women attending a well woman clinic. Sex Trans Infect. 2003; 79:
320-22.
94
16. Philips Z, Johnsons, Avis M. why ness D k. Human papiloma virus and the
value of screening young women’s knowledge of cervical cancer. Health
education Research. 2003; 18:318-28.
17. Ralston JD, Taylor VM. Knowledge of cervical cancer risk factors among
chinese immigrants in seattle. Journal of Community Health. 2003; 28 : 4157.
18. Pitts M, Clarke T. Human papillomavirus infections and risk factors of
cervical cancer; what do women know? Health Education Research. 2002; 17
: 706-14.
19. National cancer Registery programme. Indian Council of Medical Research.
New Delhi. 1981-2001. 18-19.
20. Alphonsa (Sr. Rubeena). A study to evaluate the effects of planned teaching
programme on the knowledge of college girls regarding breast cancer and
breast self examination and ability to perform breast self examination in
selected college of Kerala. Unpublished master in science dissertation,
Rajkumar Amritaur College of Nursing. University of Delhi. 1992.
21. Martean TM, Hankins M, Collins B. Perception of risk of cervical cancer and
attitudes towards cervical screening a comparison of smokers and nonsmokers. Family Practitioner. 2003; 20 : 93-94.
22. Varghese C, Amma NS, Chitrathara K. Risk factors for cervical dysplasia.
Bulletin of world Health organization. 1999; 77 :
95
23. Badrinath P, Ghazal – Aswad S. A study of knowledge, attitude and practice
of cervical screening among female primary care physicians in the United
Arab Emirates. Health Care Women Int. 2004; 25: 663-670.
24. A Paricio – Ting F., Ramirez Ag. Breast and cervical cancer knowledge,
attitudesand screening practices of Hispanic women diagnosed with cancer.
Journal of cancer education.2003; 18:230-236.
25. Byrel TL,peterson SK,chavez R. Cervical cancer screening beliefs among
young Hispanic women. Preventive Medicine.2004; 38:192-197.
26. Gichangi P,Esdambale B,Temmerman M. Knowledge and practice about
cervical cancer and pap smear testing among patients at Kenyatta National
Hospital. International Journal of Gynaecological cancer. 2003, 13:827-33.
27. Holroyd FA, Twinn SF. Knolwedge, beliefs and attitudes towards cervical
cancer and cervical screening. Women Health. 2003, 38:69-82.
28. Mc Farland DM. Cervical cancer and pap smear screening in Botswanna;
knowledge and perceptions. Int. Nurs. Rev. 2003; 50: 167-75.
29. Kindanto HL, Moshiro C, Kilewo CD. Cancer of the cervix: knowledge and
attitudes of female patients admitted at Mulimbilli National Hospital. East.
Afr. Med. J. 2002; 79: 467-75.
30. Ayinde OA, Omigbodun AO. Knowledge, attitude and practice related to
prevention of cancer of the cervix among female health workers in Ibadan.
Journal of Obstetric & Gynaecology. 2003; 23:59-62.
31. Maaitam, Barakat M. Jordanian women’s attitudes towards cervical screening
and cervical cancer. Journal of Obstetric and Gynaecology. 2002; 22:421-22.
96
32. Pillay AI. Rural and urban South African women’s awareness of cancers of
the breast and cervix. Ethn Health. 2002; 7:103-14.
33. Claeys P, Gonzalez C, Temmerman M. Determinanats of cervical cancer
screening in a poor area : results of a population-based survey in Rivas. Trop
Med Int Health. 2002; 7: 935-41.
34. Idestrom M, Milsom Tandersson-Ellstrom A. knowledge and attitudes about
the pap smear screening programe: a population-based study of women aged
20=59 years. Acta Obstet Gynecol Scand. 2002; 81: 962-967.
35. Kahn JA, Emans SJ, Goodman F. measurement of young women’s attitudes
about communication with providers regarding papamicelaou smear. Journal
of Adolescent Health. 2001; 29 : 344-351.
36. Eaker S, Adami HO, Sparen P. attitudes to screening for cervical cancer : a
population-based study in sweden. Cancer causes control. 2001; 12: 519528.
37. Ramirez AG, Suarez L, Chalela P. Hispanic women’s breast and cervical
cancer knowledge, attitude and screening behaviour. American Journal of
Health Promotion. 2000; 14 : 292-300.
38. Pavia M, Ricciardi G, Angelillo JF. Breast and cervical cancer screening :
knowledge attitudeand behaviour among school teachers in Italy. Eur J
Epidemiol. 1999; 15 : 307-311.
97
39. Schulmeister L, Lifsey DS. Cervical cancer screening knowledge, behaviour
and beliefs of vietnamese women. Oncology nursing Forum. 1999; 26 87987.
40. Hasenyager C. knowledge of cervical cancer screening among women
attending a university health centre. Journal of American College Health.
1999 ; 47 : 221-224.
41. Fylan F. Screening for cervical cancer: a review of women’s attitudes,
knowledge and behaviour. Br. J. Gen pract. 1998; 48 1509-1514.
42. Yu ck, Rymer J. women’s attitudes and awareness of smear testing and
cervical cancer. Br. J Fam Plann. 1998; 23 : 127-133.
43. Ajayi Jo, Adewole JF, knowledge and attitudes of general out patient
attendants in Nigeria to cervical cancer. Genl Afr J. Med. 1998; 44: 41-43.
44. Greimel ER, Gappermayer-Locker E, Huber HP. Increasing women’s
knowledge and satisfaction with cervical cancer screening. J Psychosom
Obstet Gynacol 1997; 18 : 273-279.
45. Lamadrid Alvasez S. knowledge and fears among chilean women with regard
to the papanicolaou test. Bull Pan Am Health organization. 1996; 30: 354361.
46. Monali Desai. An assessment of community Based cancer screening program
Among Indian women using the Anganwadi workers. Journal of obstetric
and gynaecology of India. 2004; 54: 483-487.
98
47. Desai Monali. Male factors in cancer cervix. Journal of obstetric and
gynaecology of India. 2004; 54 : 583-585.
48. Holroyd E, Twinn S, Adab P. Socio-cultural influence on Chinese women’s
attendance for cervical screening. Journal of Advanced nursing. 2004; 46:
42-52.
49. Wellensiek N, Moodley M, Moodley J, NK wanyana N. knowledge of
cervical
cancer
screening
facilities
among
women
from
various
socioeconomic background in Durban. Int. J gynecol cancer. 2002; 12 : 376382.
50. Suarez L, Roche RA, Nichols D, Simpson DM, knowledge, behaviour
behaviorand fears concerning breast and cervical cancer among older lowincome mexican- American women. Am J prev Med. 1997; 13 : 137-142.
51. Massad LS, Meyer P, Hobbs J. knowledge of cervical cancer screening
among women attending urban colposcopy clinics. Cancer Detect prevention.
1997; 21 : 103-109.
52. Watkint MM, gabalic, winkleby M, Goana E, Lebaron S, Barriers to cervical
cancer screening in rural Mexico. Int. J Gynecol cancer. 2002; 12 : 475-479.
53. Baileff A. cervical screeening : Patients negative attitudes and experiences.
Nurs Stand. 2000; 14 : 35-37.
54. Eaker S, Adami HO, Sparen P. Reasons women do not attend screening for
cervical cancer: a population – based study in Sweden. Preventive Medicine:
2001; 32: 482-491.
99
55. Jameson A, Sligo F, Comric M. Barriers to pacific women’s use of cervical
screening services. Aust N 7 J Public Health. 1999; 23 : 89-92.
56. Neilson A, Jones RX. Women’s lay knowledge of cervical cancer / cervical
screening accounting for non-attendance at cervical screening clinic. Journal
of Advanced Nursing. 1998; 28: 571-575.
57. Behbakht K, Lynch A, Teals, Degeest K, Massad S. Social and cultural
barriers to papanicolaou test screening in an urban population. Obstetric and
gynaecology. 2004; 104 : 1355-1361.
58. L. White Helton. Vital signs at the millennium. Cancer Nursing. 1999; 22 :
12-15.
59. Morriers. Cervical intraepithelial neoplasia and cervical cancer. Obstetric and
gynaecology clinics of North America 2002; 29 : 358 – 373.
60. N.M.Lonky. Cervical cancer risk factors. Obstetric and gynaecology clinics
of North America. 2002; 29 : 820-842.
61. Greeda Selva Rani. Effectiveness of planned teaching programme on cervical
cancer in rural community, unpublished master in science dissertation.
C.M.C. Vellore. 1998.
62. Lynn A, Richards. An inpatients cervical cancer-screening programme to
reach under served women. JOGNN. 2000; 29 : 465-472.
63. Jondavid Pollock. Risk factors for cervical cancer. A article available from
http//www.nccc-online.2003.
64. Potter P & Perry A. Fundamentals of nursing. Ed-6. Missouri Mosby. 2005;
91-92.
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Figure 1 : HEALTH BELIEF MODEL (Rosenstoch’s 1974 and Becker & Maimans – 1974)
INDIVIDUALS PERCEPTION
MODIFYING FACTORS
• Baseline Variables
Age, marital status, type of family, number of
children, diet, age of marriage, and habits.
• Socio psychological variables
Education, occupation, income and residence.
Perceived threat of cervical cancer.
Perceived
susceptibility to
cervical cancer.
Perceived seriousness
of cervical cancer.
Cues to action
- Educational materials mass media, advice
from medical professionals for others and
news paper or magazine articles
13
13
LIKELIHOOD OF ACTION
Perception regarding the
benefits of healthy lifestyle and
regular screening
minus
Perception regarding barriers to
healthy life style and screening
(assessment of knowledge and
attitudes)
Likelihood of developing
positive attitudes and healthy
lifestyle practices and regular
screening.
Development of pamphlet about
cervical cancer and Pap smear test.
Figure 2 : SCHEMATIC REPRESENTATION OF RESEARCH DESIGN
Setting out patient department of S.J.M.C.H.
Population
Sample
Instrument
Data
Collection
Women 1860yrs of age
* 322 women
attending any of
the OPDs.
* Purposive
sampling
technique
Structured
interview
schedule
* Baseline
variables
Performa
* Knowledge
questionnaire
*Attitude
(4points)
questionnaire
37
Interview to the
women 1860years
Out Come
Assess the
knowledge and
attitude of
women
regarding
cervical cancer
and
development of
a pamphlet
Uterus and cervix
Womb
Cervix is the lower part of the uterus
1 cervical cancer
Cervical cancer is the growth
from the inside lining of the
cervix . This is the most
common cancerous tumour
of the female genital tract.
Target group ;36-45 years of
the age.
Fallopian Tube
3 Diagnosis
[a] Cervical smear /Papsmear test: The material
is taken from the cervix which is collected
using spatuala made of wood or plastic
whole of the mouth of the cervix has to be
scrapped to obtain good surface cells or
material for screening.
Ovary
Cervix
2 Signs and symptoms
[a] Bleeding :
(*) Bleeding after sex.
(*) Bleeding after menopaus.
(*) Irregular menses.
(*) Anaemia because of bleeding.
(*) Increased menstrual bleeding.
[b] Discharge:
(*) Excessive vaginal whitish discharge .
(*) Blood stained or offensive vaginal
discharge
[c] Ulcers of the cervix
[d] Low back pain
[e] weight loss
[f] painful sex
[g] painful urination
[h] Constipation /diarrhoea
[I] Blood in the urine
[b] Cervical Biopsy: Small bit of cervix send
for examination.
[c] Visualization of the cervix with low power
microscope to detect pre cancerous
abnormalities of the cervix.
4 Prevention.
[a] Avoid
(*) Early age of
marriage.
(*)More number
of children.
(*)More vaginal
deliveries.
(*)Early age of
first sex.
(*)Early age of first
child birth.
(*)Multiple partners.
(*)Increased intake
of fat and obesity.
(*)Oral contraceptive
pills.
(*)Smoking.
(*)Alcoholism.
[B] Precautions
(*)Treatment of veneral disease.
(*)Nutritional status.
(*)Socio-economic status
(*)Education.
(*)Personal and genital hygiene.
(*)Frequent check up.
(*)Use of condom during sex .
5 Treatment
(*) Cervical cancer is a slow progressing
cancer, early detection and treatment
may help to cure the disease.
(*) Primary management is removal of
uterus and cervix, followed by
radiotherapy or chemotherapy as per
need of the patient .
Guide
Sr. Suma Kuttickal Msc (N) BTA
H.O .D of OBG Nursing
St.John's College of Nursing
Bangalore 34 .
Co Guide
Dr.Rita Mhaskar MD
H.O.D of OBG
St. John's Medical College Hospital
Bangalore- 34
“Health
is
Wealth”
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St ness i
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Prepared by :
Shiny . M..Jose [Sr. Therese Jose]
MSc[N] ,2004 [B ]
St.John's College of Nursing ,Bangalore -34.
[Partial fulfillment of Master of Science in Nursing ]
What you want to know
about cervical cancer
ANNEXURE – 2
LETTER REQUESTING CONSENT TO VALIDATE RESEARCH TOOL
From,
Shiny M Jose (Sr. Therese Jose)
Ist Year Msc Nursing
St. John’s College of Nursing
Bangalore – 560034.
To,
Through
The Principal, College of Nursing,
SJNAHS, Bangalore – 34.
Subject: Letter requesting consent to validate research tool.
Respected Sir/ Madam,
I, Shiny M Jose (Sr. Therese Jose), Ist year M.Sc., Nursing student of Obstetrics
and Gynaecological nursing specialty at St. John’s College of Nursing. Kindly request
you to give consent to validate my tool.
Topic:
A study to assess the knowledge and attitudes about cervical cancer of women
who attend St. John’s Medical College Hospital (S.J.M.C.H) OPD, with a view to prepare
a pamphlet.
I would be highly obliged if you kindly give your acceptance and valuable
suggestions. A self addressed envelope and acceptance form are enclosed here with for
your perusal.
Thanking you,
Place: Bangalore
Date:
Yours sincerely,
Shiny M. Jose (Sr. Theresa Jose)
ANNEXURE – 3
ACCEPTANCE FORM FOR TOOL VALIDATION
Name:
Designation:
Name of the College:
Statement of acceptance or non-acceptance.
I give my acceptance/ non-acceptance to validate the tool.
TOPIC:
A study to assess the knowledge and attitudes about cervical cancer of women
who attend St. John’s Medical College Hospital (S.J.M.C.H) OPD, with a view to prepare
a pamphlet.
Date:
Signature
ANNEXURE – 4
LETTER REQUESTING OPINION AND SUGGESTIONS OF EXPERTS FOR
CONSENT VALIDITY OF THE RESEARCH TOOL
From,
Shiny M. Jose (Sr. Therese Jose)
Ist year, Msc Nursing
St. John’s College of Nursing
Bangalore – 560034.
To,
Respected Sir/ Madam,
Subject: Requesting opinion and suggestions of experts for establishing content validity
of the research tool.
I am a postgraduate student in nursing and St. John’s College of Nursing. I have
selected the below mentioned topic for research study to be submitted to Rajiv Gandhi
University of Health Sciences, Bangalore, in partial fulfillment of master of nursing
degree.
TOPIC:
A study to assess the knowledge and attitudes about cervical cancer of women
who attend St. John’s Medical College Hospital (S.J.M.C.H) OPD, with a view to prepare
a pamphlet.
Objectives:
1. To assess the knowledge of women regarding cervical cancer.
2. To determine the association of knowledge and selected variables.
3. To identify attitudes related to cervical cancer.
4. To determine the relationship between knowledge and attitudes of women about
cervical cancer.
5. To prepare a pamphlet for women on risk factors and early detection.
Here with I am enclosing
1. Blue print
2. Tool (Interview schedule and Likert’s scale)
3. Validation criteria
The tool consists of structured interview schedule and Likert’s scale.
May I request you to kindly to through the consent of the tool based on the
blueprint for accuracy, appropriateness and relevancy and give your expert and
valuable suggestions.
Please do the needful.
Thanking you.
Place: Bangalore
Yours sincerely,
Date:
Shiny M. Jose (Sr. Therese Jose)
ANNEXURE - 5
EXPERTS ADDRESS
1) Sr. Philomin, Principal
Carithas College of Nursing,
Thellakom P.O
Kottayam, Kerala.
2) Dr. Mrs. Kasthuri, Principal
Govt. College of Nursing
Fort, Bangalore-560002.
3) Sr. Lordhanna Korah,
Sidhya sadan, Lourd’s College of nursing
Kerkkanand P.O
Cochin, Kerala.
4) Dr. Mrs. Sumathi Kumar swami
Depty Director of Nursing
Chennai – 600010.
5) Dr. Sheela M.D
St. John’s Medical College Hospital,
OBG Dept.
Bangalore – 34.
6) Mrs. Ancy Mathew
Govt. College of Nursing
Kottayam-683008.
7) Mrs. Alameelu Raman, Principal
Omyal Achi College of Nursing
King Cross Road, Sathyamurthi Nagar
Avadi, Chennai-3.
8) Mrs. Ester, Professor
K.G. College of Nursing
Coimbatoor
Tamil Nadu.
9) Mrs. Thilakavathy, Prof.
College of Nursing
Oxford, Bangalore.
ANNEXURE – 6
EVALUATION CRITERIA CHECK LIST
Kindly go through the evaluation criteria for a validation of the tool. There are
two columns given for your responses and a column for remarks, kindly place a tick [ √ ]
in the appropriate column and give your remarks in the remark column whenever
appropriate.
I request you to kindly give me your valuable suggestions to the content of the
tool. Please give your expert comments on the items you think should be modified or
deleted in respective tool.
SL.NO.
CRITERIA
YES
1
BASELINE DATA
1.1
All the characteristics necessary
for the study are included
1.2
Clarity of items used
2
QUESTIONNAIRE
21.
Covers the entire content on
prevalence risk factors, early
detection features and treatment
of cervical cancer
2.2
Questions
sequence
2.3
Questions are arranged in a
logical order
2.4
Language is simple and easy to
follow
2.5
All item necessary to achieve
are
arranged
in
NO
REMARKS
the objectives of the study are
included
Any other suggestions :
3
ATTITUDE SCALE (Likerfit
scale)
3.1
Relevancy of the items
3.2
Statements
sequence
3.3
Covers the entire content
3.4
Statements are simple and easy
to follow
3.5
All statements necessary to
achieve the objectives of the
study
are
arranged
in
Any other suggestions :
Any other suggestion (S) about the tool in general.
Thanking you,
Yours sincerely,
SHINY M. JOSE (Sr. Therese Jose)
ANNEXURE - 7
CERTIFICATE OF VALIDATION
This is to certify that the tool for baseline data, structured interview schedule for
knowledge assessment, attitude scale (Likert’s scale) to check the attitude of women,
constructed by Shiny M. Jose (Sr. Therese Jose), first year Master of Science in nursing
programme at St. John’s College of Nursing, Bangalore, to be used in her study titled
“Assess the knowledge and attitude about cervical cancer of women who attend St.
John’s Medical College Hospital (SJMCH) OPD, with a view to prepare a pamphlet” has
been validated by me.
Sign :
Name :
Designation :
Date :
ANNEXURE - 8
STRUCTURED INTERVIEW SCHEDULE ON CERVICAL CANCER:
The interviewer introduces her self and explains the purpose of the study. She
will then ask questions listed in the schedule using one-to-one techniques. She places a
tick mark () in the box provided against the item as per the responses given by the
participants.
For data collection the following tool, consisting of three parts, was constructed.
•
Section I: deals with baseline variables.
•
Section II: deals with knowledge related to cervical cancer.
•
Section III: deals with attitudes related to cervical cancer.
Section I
Description of the baseline variables.
Code No:
1) Age of the participant
2) Religion
2.1 Hindu
2.2 Muslim
2.3 Christian
2.4 Other (Specify)
3) Education of the participant
3.1 Illiterate
3.2 Primary
3.3 Secondary
3.4 College degree
3.5 Professional
4) Occupation of the participant
4.1 Unskilled
4.2 Semi skilled
4.3 Skilled
5) Marital status
5.1 Unmarried
5.2 Married
6) Age of marriage
6.1 16-20 years
6.2 21-25 years
6.3 26-30 years
6.4 Above 30 years
7) Number of Children
7.1
0
7.2
1
7.3
2
7.4
3
7.5
≥4
8) Family income per month
8.1 >1000 Rs.
8.2 1001-5000 Rs.
8.3 5001 – 10,000/above
9) Type of family
9.1 Nuclear family
9.2 Joint family
9.3 Extended family
10) Place of residence
10.1Urban
10.2Rural
11) Habits
11.1Smoking
11.2Alcoholism
11.3Drug Abuse
11.4Tobacco chewing
11.5Betel leaves chewing
12) Diet
12.1 Vegetarian
12.2 Non-Vegetarian
SECTION II
Instructions:
The Interviewer will ask questions listed in the schedule using a one-to-one
technique, she place a tick mark () in the box provided against the item as per the
responses given by the participants. Each item has only one correct answer. Each correct
answer carries one score. Total score = 20.
Eg. What are the parts of female reproductive system
1.1 Womb, Ovaries, Vagina and fallopian tubes
1.2 Abdomen & Interstine
1.3 Kidney & Liver
1.4 Spleen & Pancreas
Anatomy and Physiology of cervix:
1) Cervix is
1.1 The lower part of uterus
1.2 Upper part of uterus
1.3 Center of the uterus
1.4 Lower part of ovary
2) What is the function of cervix during pregnancy
2.1 Prevent bleeding
2.2 Prevent urinary tract infections
2.3 Prevent ascending infections from vagina
2.4 Prevent frequency of urination
Causes and risk factors:
3) On an average, the age at which women develop cervical cancer is:
3.1 15 – 25 years
3.2 26 – 35 years
3.3 36 – 45 years
3.4 Above 45 years
4) A women is more likely to develop cervical cancer if she has
4.1 Married and has many children
4.2 Not married
4.3 Had a hysterectomy
4.4 Married after the age 30
5) Which of the following contraceptive methods has the highest risk factor for cervical
cancer?
5.1 Tubectomy
5.2 Condom use
5.3 Oral contraceptive pills
5.4 Copper –T
6) Which of the following includes risk factors for cervical cancer?
6.1 Poor iron intake and anemia
6.2 Poor dental hygiene and infection
6.3 Poor genital hygiene and infections
6.4 Lack of rest and sleep
7) Cervical cancer is more seen in
7.1 Middle class and educated people
7.2 Low socio-economic class
7.3 Government employees
7.4 Nuclear families.
8) Which statement is not related to cervical cancer?
8.1 Multiple sexual partners
8.2 Family history of cervical cancer
8.3 Early age of marriage and more number of children
8.4 Infertility ( Lack of ability to reproduce)
9) Risk factors of cervical cancer which are associated with the male partner are:
9.1 Poor genital hygiene, alcoholism and tobacco use
9.2 Use of condoms and circumcision
9.3 High education and obesity
9.4 Diabetes and heart diseases
Signs and symptoms & Diagnosis:
10) Early signs and symptoms of cervical cancer
10.1Fever & cough
10.2Lump in the breast and nipple discharge
10.3Profuse sweating and tiredness
10.4Irregular vaginal bleeding and excessive whitish vaginal discharge.
11) The early signs and symptoms of cervical cancer can be detected by
11.1Doctor
11.2Nurse
11.3Woman herself
11.4Husband
12) Early detection of cervical cancer can help to
12.1Prevent cervical cancer
12.2Cure the disease
12.3Avoid treatment
12.4Avoid surgery
13) The diagnostic technique involved in early detection of cervical cancer is:
13.1Mammography
13.2Vaginal examination
13.3Pap smear test
13.4Fine needle aspiration
14) Which is the test appropriate for the detection of cervical cancer
14.1X-ray of the pelvis
14.2Blood test
14.3Electro cardiogram (ECG)
14.4Cervical biopsy
15) A Regular pap smear test will help to the:
15.1Early detection of cervical cancer
15.2Early detection of ovarian cancer
15.3Early detection of breast cancer
15.4Early detection of lung cancer
16) A Pap smear test is necessary for
16.1All female
16.2Only women in the reproductive age group
16.3Only menopausal women
16.4 Reproductive and menopausal women
Treatment & Prevention:
17) The management of cervical cancer is by:
17.1Removal of uterus and radiotherapy
17.2CT. scan
17.3Blood testing
17.4Blood transfusion
18) Primary prevention of cervical cancer involves
18.1Improving hospital facilities
18.2Increasing number of doctors and nurses
18.3Educating the people about risk factors of cervical cancer
18.4Availability of drugs
19) Which statement is related to prevention of cervical cancer?
19.1Avoidance of multiple sexual partners
19.2Avoidance of non vegetarian food
19.3Avoidance of any treatment
19.4Avoidance of social interactions
20) Cervical cancer can be prevented by
20.1Multiple childbirth
20.2Increased intake of alcohol
20.3Early age of marriage
20.4Personal hygiene and birth control
SECTION III
Attitude statements regarding cervical cancer:
Instructions:
A Likert’s scale is prepared by the investigator to assess the attitude of women
regarding cervical cancer.
The Interviewer reads each statement and requests participants to give their
opinion about it. A tick mark () is placed against the item in the appropriate column as
per the response given by the participants.
It is a ‘5’ point scale when the points are –
1) Strongly agree (SA) 4 marks
2) Agree (A) 3 marks
3) Undecided (UD) 2 marks
4) Disagree (D) 1 marks
5) Strongly disagree (SD) 0 mark
This is for all the positive statements and the scoring is reversed for all negative
statements. There is an equal number of positive and negative statements. Total number
of items is20.
0
Sl. No.
Statements
SD
1
Cervical cancer is curable if detected early.
2
Cervical cancer is one of the health problems
in women
3
A Pap smear test can help to reduce the
incidence of cervical cancer.
4
Cervical
screening
is
unnecessary
after
menopause
5
A Pap smear is necessary only in elderly
women.
6
There is no risk of infection after cervical
screening.
7
Cervical cancer disrupts the whole family and
affects the relationship between husband and
wife.
8
Poor health will have impact on self image
9
Sex without using a condom is a risk factor
10
A Pap smear test is very expensive and painful
1
D
2
UD
3
A
4
SA
11
Educated women do not get cervical cancer.
12
Early marriage and childbirth can prevent
cervical cancer.
13
Women’s education is one of the best methods
for prevention of cervical cancer.
14
Prevention of cervical cancer is better than
treatment in terms of expense.
15
Women should be prevented from taking up
any employment in order to prevent cervical
cancer.
16
Cervical cancer, even if untreated, is not a life
threatening disease.
17
Unhealthy life style patterns can influence the
risk of cervical cancer.
18
Mass media and education can improve the
knowledge of women regarding cervical
cancer.
19
A Diet rich in vitamins and folic acid is the
cause of cervical cancer.
20
Cervical cancer will affect only women from
low socio-economic classes.
ANSWER KEY
1 – 1.1
11-11.3
2-1.3
12-12.2
3-3.3
13-13.3
4.4.1
14-4
5.5.3
15-15.1
6-6.3
16-16.4
7-7.2
17-17.1
8-8.4
18-18.3
9-9.1
19-19.1
10-10.4
20-20.4