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MSc Nursing 2010


3rd May 2010


Educating and screening
the women for cervical



6.1 Need for the study:
Cervical cancer is treatable disease if identified at the early stage. Cancer of the
cervix is the second most common cancer among women worldwide, with an estimated
529,409 new cases and 274,883 deaths in 2008. About 86% of the cases occur in developing
countries, representing 13% of female cancers12.Globally it is estimated that there are 6
million new cancer cases, of which 52% occur in developing countries. The magnitude of the
problem of cancer in the Indian sub-continent in terms of sheer number is most alarming. The
estimated new cases of cancer in India per year are nearly 6.5 lakhs and at the start of the next
millennium estimated to be 8.6 lakhs. The crude incidence of cancer in India is approximately
100 per 100,000 populations. The Cancer in women in the Indian Sub-continent constitutes
more than 50% of the total cancer. The most common cancer observed by Indian registries
are those related to tobacco usage in males while among females, the most common cancer
are those of the Uterine Cervix, Breast and Oral cavity. In Karnataka a state in the southern
part of India, it is estimated that annually there are about 35,000 new cases whereas, the
prevalent cancer accounts to about 1, 50,000.16
Educating people regarding the disease will help drive away the fears and stigma
associated with the disease. Well- illustrated audio-visual educational materials are extremely
useful in literate as well as illiterate population. 10Efforts to improve awareness of the
population have resulted in early detection of and survival from cervical cancer in backward
regions of India. Also, where the literacy among women is less than 20% there have been
attempts to evaluate the role of improved awareness in the early detection and control of
cervical cancer.14
In many developed countries a decline in the incidence and mortality due to cervical
cancer has been observed due to cytology screening. Cytology based screening are difficult to
organize in India because of issue related to absence of trained manpower, infrastructure,
logistics, quality assurance, frequency of screening and cost involved. There are no organised
screening programmes for any of the common cancers in the country. Most cancer centres
provide only opportunistic screening services. Visual inspection of the cervix after

-1application of the 4-5% acetic acid is a simple inexpensive test that can be provided by
trained health care personnel.1
The investigator during her clinical experience has come across a number of cancer
patients who were detected in their last stage of cancer. Most of them lacked knowledge
about cancer and importance of screening. Women do experience symptoms which remain
unaddressed and present it in advanced stages when total cure is extremely difficult or indeed
impossible. So, the researcher is stimulated to improve the awareness of the women regarding
cervical neoplasm and importance of screening and to screen them for early detection and
also diminishing the probability of losing women before they are treated.

6.2 Review of literature:Review of literature is a critical summary of research on a topic of interest. In this
study review of literature has been organised under the following headings.
a) Studies related to importance of knowledge.
b) Studies related to importance of screening.
a) Studies related to importance of knowledge:A descriptive cross sectional study was conducted in Uganda to assess the knowledge,
attitude and practices on cervical cancer and screening among the medical workers. In this
study, 288 medical workers were interviewed using self-administered questionnaire. In this
study, most of the participants were female(69%).Most of the participants knew that cancer
was curable if detected at an early stage but knowledge of risk factors for cervical cancer and
details of screening activities.6
A Case control survey was done in Chicago to assess the cervical screening knowledge
and practices among Korean-American women. A sample of 159 Korean-American women
were given a cancer control questionnaire.26% of the respondents never heard of the of the
pap smear test. Only 34% of the respondents reported having had a pap smear test for
screening. The most frequently cited reason for not having had a pap smear was absence of
disease symptom. Result indicate that education and usual sources of health care were
significant factors related to having heard of or having had a pap smear test.15
A retrospective case study was conducted in United States to discern HPV knowledge

-2accuracy among women diagnosed with and treated for cervical cancer.Data was collected
using self administered questionnaire and medical records.A total of 1174 questionnaire
were mailed and 328 women returned the completed forms.About one-third of AfricanAmerican(32.8%) and white-American(35.2%)women had reported that cervical cancer
cannot be prevented.3
An experimental study was conducted to assess the effectiveness of structured
teaching guide about cancer cervix on the knowledge and preventive practices among the
women and their husbands. A pre-test was given to 30 couples before giving the structured
teaching guide and the post-test was given on the 15th and the 30th day after giving the
structured teaching guide. The study found that post-test scores were higher than their pre-test
score. Also, 85.5% of wives underwent medical examination,79.2%of wives undergone
pelvic examination and 36.3% husbands had undergone physical examination.1
A Qualitative study was conducted in 3 districts of Uttar Pradesh to assess the cervical
cancer prevention and treatment services. The assessment was designed to evaluate the
quality and accessibility of cervical cancer prevention and treatment services and was
conducted from March to August 2004. The strategic assessment identified some isolated
cervical cancer prevention and treatment services; however, well-coordinated prevention and
stage-appropriate treatment services, particularly in the public sector and outside large urban
centres, were lacking.9
b)Studies related to importance of screening:A cross sectional study was conducted in Jabalpur which used Visual inspection of
cervix with acetic acid (VIA) in early diagnosis of cervical intraepithelial neoplasia and early
cancer of cervix. Of the 750 women screened 122 (16.26) was VIA positive and cytology was
positive in 39 (5.2%), 25 were detected by VIA and only 20 cases were detected by pap
smear. Two cases were missed by VIA and seven cases were missed by cytology. 2
A randomized controlled study was conducted in Maharashtra of 497 rural villages.
Women aged 30-59 years were randomized to receive one of the three tests or to a control
group. Of the 1000800 invited women 79449 (78.8%) were screened.26755 (33.7%) were
screened by Visual inspection of cervix, 25535(32.1%) were screened by cytology and
27159(34.2%) were screened by human papillomavirus testing. From these 932 women were
diagnosed with high grade lesions or invasive cancer. The study showed good participation

-3levels and communication methods and delivery strategies aimed at encouraging older, less
educated, etc.
A prospective study was conducted at Indore. The study included 380 patients
referred for colposcopic evaluation for abnormal cervix. Visual inspection of cervix was
performed prior to colposcopic examination. Out of 380 patients 100 were found positive on
VIA.Out of these 100 patients 75 were found to have abnormal findings on colposcopy.
Cervical biopsy was done of these 75 cases and 22 cases revealed as having low grade
squamous intra-epithelial lesions,8 as high grade and 7 as pre-clinical invasive cancer and 38
showed no abnormality.8
A prospective study was conducted in Peru where women between 25 and 50 years
who visited the centre and were asymptomatic. The women underwent a complete clinical
evaluation; including Pap smear and visual inspection by acetic acid.Partcipants with any
positive test were referred for colposcopy and biopsy. The results was many women tested
positive by visual inspection.10
A prospective study was conducted in New Delhi wherein 400 women were screened
using pap smear, visual inspection of the cervix( VIA) and colposcopy.The sensitivity and
specificity of each of the screening methods was analyzed. The sensitivity of VIA (96.7%)
was much higher than that of pap smear(50%), and almost as high as that of
colposcopy(100%).The specificity of VIA (36.4%) was lower than that of pap smear
smear(97%) and colposcopy(96.9%).7
A cross sectional study was done in New Delhi,100 women with complains of vaginal
discharge, irregular bleeding, post-coital bleeding or unhealthy cervix underwent visual
inspection with acetic acid(VIA) and Lugols iodine (VILI) by a doctor and a nurse, followed
by colposcopy and biopsy.VIA by nurse had a higher sensitivity(100%) versus 87.5%),but
lower specificity(53% versus 63%) when compared with the doctor. It was concluded that
visual inspection can be performed reliably by trained paramedical workers and doctors and
is an effective screening option in low resource setting.11
A survey was done in united states to assess the willingness to participate in cancer
screening. The Cancer Screening Questionnaire (CSQ), a 60-item questionnaire, was
administered via random-digit-dial telephone interviews to adults in three cities of US. The
1,148 participants in the CSQ study sample consisted of 355 blacks, 311 Puerto Rican,
Hispanics, and 482 non-Hispanic whites. Response rates ranged from 45% to 58% by city.

-4Multivariable logistic regression analyses revealed that blacks and Puerto Ricans were often
more likely (OR 2.0-3.0) and never less likely than whites to self-report willingness to
participate in cancer screenings regardless of who conducted the cancer screening, what one
was asked to do in the cancer screening, or what type of cancer was involved (with the
exception of skin cancer where blacks, compared with whites, had an OR of 0.5).The findings
from this study provide evidence that blacks and Hispanics self-report that they are either as
willing or more willing than whites to participate in cancer screening programs.4

6.3 Problem statement:A study to assess the willingness to avail screening facilities in response to health
education about cervical neoplasm among women attendants of inpatients in St Johns
Medical College Hospital, Bangalore.

6.4 Objectives of the study:i)

To assess the extent of willingness to avail screening facilities among women

attendants following educational programme.


To identify the outcome of the screening test among motivated group.


To determine the association of outcome of screening test with selected

demographic variables.


To determine the association of motivated group with the selected demographic


6.5.Operational definition:

Willingness: Ready, eager, or prepared to do something (Oxford Dictionary 2007).

In this study, it refers to readiness of the women to undergo a screening test of
visual inspection of cervix.

Avail: In this study, it refers to take the advantage of the screening facilities provided to
women attendants.

Screening: In this study, Visual inspection of cervix will be conducted to screen

the relatives for early detection of any cervical lesion and if positive followed by


Health Education: Health education is a process that informs, motivates and help
people to adopt and maintain healthy practices and lifestyles, advocates environmental
changes as needed to facilitate this goal and conducts professional training and research
to the same end.(K.Park)
In this study, it refers to the education regarding cervical neoplasm and its

Cervical neoplasm:

In this study it refers to the presence of abnormal growth in the

neck of the uterus.

Attendants: In the study, it refers to the women accompanying the in-patient in the

In-patients: It refers to all the patients admitted in medical, surgical, gynaecology wards
of St Johns Medical College Hospital.

Demographic variables: In this Study the variables includes age, education status,
marital status, occupation, age at marriage, use of contraceptives, use of tobacco, history
of sexually transmitted diseases and family history of cancer.

6.6 Assumptions:1. Women attendants of the in-patient may undergo the screening programme after
attending the education programme.
2. Women attendants may be detected with presence of cervical lesion.

6.7 Delimitation:The study is limited to relatives of the in-patient admitted to St Johns

Medical College Hospital.

6.8 Projected Outcome:Findings of this study will help to improve the knowledge of the women relatives
by education and thereby undergo screening programme organized by the investigator.


Hypothesis:H1.There will be significant association between outcome of screening score and selected
demographic variables at 0.05 level of significance
H2.There will be significant association between the motivated group and selected
demographic variables.


7.1 Source of data
7.1.1 Research Design: - Evaluative Study
7.1.2 Setting:The health education will be conducted in room no 21 of Outpatient department
between 2.00 to 4.00pm at St Johns Medical College Hospital Bangalore which is 1200
bedded multispecialty hospital and the screening will be done in the OPD.

7.1.3 Population:In this study the population comprises of women attendants of in- patient admitted at
St Johns Medical College Hospital.


7.2.1 Sampling Procedure:Purposive sampling will be used to select the samples for the study.

7.2.2.Sampling size:Sample size will be 300 women attendants of the in-patients.

7.2.3 Inclusion criteria and sampling:i. Women who are attendants of patients admitted in St Johns Medical College Hospital.
ii. Women aged 30-64 yrs.
iii. Women who are asymptomatic.


7.2.4. Exclusion criteria for sampling:i.

Women who are currently pregnant.


Women with previous history of cancer.

7.2.5. Instrument used:1. Section I Performa to elicit demographic variables.

Section II- Teaching module of cancer of cervix.
2 .Screening tool of Visual inspection by acetic acid and colposcopy.

7.2.6 Data Collection Method:Formal permission will be obtained from the Director of St johns medical college and
hospital, the administrator of the hospital, the nursing superintendent and HOD of medical,
surgical,urology,nephrology and gynaecology department to collect data.
The subjects who belong to the inclusion criteria will be selected by purposive
sampling technique. The selected samples will be called to room no 21 in the outpatient
department of St Johns Medical College Hospital .Subjects will be explained about the study
and consent to participate in the study will be taken. The subjects will then be given a consent
form for willingness to undergo a screening test for cervical cancer. Later, the subjects will
be educated about cervical neoplasm. After the education, the subjects will be again asked to
fill the consent form for willingness of the screening test. The number of women who have
given the consent to undergo screening test will be taken immediately for the screening by
the investigator. The screening test will be then carried out by the investigator. The result of
the screening test will be consulted with the gynaecology oncologist and then it will be
disclosed to the subject by the oncologist. If the result is positive, the subjects will be taken
for colposcopy by the oncologist to confirm the screening test .The results obtained will be
taken for analysis.

7.2.7 Data analysis plan:Descriptive and inferential statistics.

Organization of data in master sheets


Mc Nemars test to assess the willingness to screening test before and after health

Calculate chi square to determine the association of demographic variables with screening
score and baseline variables.

7.3.Does the study require any investigation or intervention to be

conducted on patients or other humans or animals? If so please describe

7.4 Has ethical clearance been obtained from your investigation in case of
YES. The ethical clearance has been obtained from the scientific and ethical review
committee of St Johns National Academy of Health Sciences-Bangalore.

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Signature of the candidate

Remarks of the guide


Name and Designation in Block

of ( in Block letters)

Sr.Marium .O.J (sr celcy mary)

Head of the Department,
Obstetrics And Gynaecology,
St Johns College Of Nursing


10.3Co-Guide(if any)

Dr.Elizabeth Vallikad,
HOD-Gynaecology Oncology,
St Johns National Academy of Health Sciences.



11.1 Head of the Department

11.2 Signature


Sr Marium.O.J (Sr celcy mary),

HOD,Obstetrics And Gynaecology,
St Johns College Of Nursing

12.1 Remarks of the Chairman and Principal

12.2 Signature