Chapter

-I
INTRODUCTIO
N
 CHAPTER-I
INTRODUCTION

“If we have any chance at prevention, then we women should do something about it”

Cervical cancer is the top cancer observed among women in most East

African and South Asian countries both in terms of incidence and mortality.

In 2008, approximately 530,000 women were diagnosed with invasive

cervical cancer worldwide and 275,000 women died from it. Indeed,

developing countries as a whole experience a disproportionate share of the

disease burden, accounting for 86% of all cervical cancer cases and 88% of

all cervical cancer deaths worldwide (Jemal, 2011). Developing countries

have over 80 per cent of the world’s burden of cancer of the cervix with

India having one fourth of the world’s burden of the disease. Cancer of the

cervix has declined significantly in industrialized countries in the last several

decades mainly due to their implementation of effective population based

prevention programs (WHO, 2002). While cervical cancer rates have

declined markedly in industrialized countries over the past several decades,

the rates have declined at a much slower pace in the developing world and,

for many developing countries, the rates have actually been increasing.

The data from the World Health Organization (WHO) show marked

disparities in cervical cancer incidence and mortality rates across countries

(Ferlay et al, 2008). Cervical cancer, the third most common cancer among

women in the world, was responsible for 275,000 deaths in 2008, 88 per cent

of which occurred in developing countries and 159,800 in Asia. Cervical

1
cancer is generally defined as a disease of disparity. This is due to marked

differences in the incidence and mortality of cervical cancer between the

developed and developing world. According to the Crisis Card, the mortality

rate is the highest in Africa. Australia has the lowest cervical cancer

mortality rate, which is due to the successful rollout of a comprehensive

package of HPV vaccines, treatment and prevention.

Cervical cancer is the 12th most common cancer among women

females in the UK (2010), accounting for around 2% of all new cases of

cancer in females. In 2010, there were 2,851 new cases of cervical cancer in

the UK The crude incidence rate shows that there are around 9 new cervical

cancer cases for every 100,000 females in the UK. According to the

International Agency for Research on Cancer, annually worldwide registered

530,000 new cases of cervical cancer are registered with 275,000 mortalities.

It is also the most common cause of cancer death (266 000 deaths in 2012) in

women worldwide.

Lower cancer survival and higher mortality rates partly result from

higher rates of late-stage cancer diagnosis among women in developing

countries, which are largely due to the lack of effective cervical cancer

screening programs. About 81% of cervical cancer patients in Singapore are

diagnosed at an early, localized stage, compared with only 7% in Chennai,

India, 33% in Costa Rica, 35% in Manila, Philippines, and 53% in Cuba

(Gakidou, 2008). The high rate of early-stage diagnosis in Singapore is

higher than the rate for many industrialized countries, including the United

2
States, where only 52% of invasive cervical cancers in 2008 were diagnosed

at localized stage (Howlader et al, 2008). Detection of cancer at an early

stage may be considered a marker for access to health care and preventive

health services, including cervical cancer screening. Cancer incidence is

generally expressed as Age Adjusted or Age Standardized Incidence Rates

(AAR) per 100,000 persons according to world standard population.

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1.1 Cervical Cancer in India

India has the highest number of deaths from cervical cancer than any

other country. According to a new report, deaths from this preventable

disease will rise unless attitudes of women change. One in every five women

in the world suffering from cervical cancer belongs to India which has the

largest burden of cervical cancer patients in the world. The disease consumes

resources at a staggering rate in the way of medical, non-medical spending

and lost productivity. Although cervical cancer is the most frequent cancer

diagnosed in Indian women, age-adjusted incidence rates vary from 8.8 per

100,000 women to 10.1 per 100,000 women.

In India, each year cervical cancer accounts for 26.7 percent of

worldwide incidence and 72,825 Indian women die due to cervical cancer. It

is a major cause of morbidity and mortality more than 1, 32,000 women are

diagnosed with cervical cancer every year, In fact 200 women are dying

every 24 hours in India due to cervical cancer. In Uttar Pradesh a total of

17367 cases were reported in 2009 and they increased to 18692 in 2012.

After Uttar Pradesh, the number of cases of cervical cancer in 2012 which

has shown an increasing trend is Maharashtra (9892), Bihar (9824), West

Bengal (8396), Andhra Pradesh (7907), Tamil Nadu (7077) and others. In

India, the onus of preventing cervical cancer is on the women themselves.

Therefore, it is the woman’s knowledge level, motivation for screening and

other psychosocial factors that determine her health seeking behavior.

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 India has a disproportionately high burden of cervical cancer (Shanta

et al, 2000). Although its age standardized death rate of 9.5 deaths per

100,000 population is representative of global rates, it accounts for nearly

one-third of global cervical cancer deaths (WHO 2009, GLOBOCAN 2008,

IARC 2009). Cervical cancer is the third largest cause of cancer mortality in

India after cancers of the mouth or pharynx, and esophagus, accounting for

nearly 10% of all cancer related deaths in the country (WHO, 2009). Among

women, it is the leading cause of cancer mortality, accounting for 26% of all

cancer deaths (GLOBOCAN 2008). According to IARC estimates (2010),

mortality from cervical cancer is expected to witness a 79% increase from

74,118 deaths in 2002 to 132,745 deaths by 2025 (National Cancer

Registry Program 2009, WHO 2004).

1.1.1 Economic Burden of Cervical Cancer

Cervical cancer causes loss of productive life both due to early death

as well as prolonged disability (WHO, 2009b). In India, the Years of Life

Lost (YLL) due to cervical cancer were 936 in 2000, being among the

highest in the world, greater than the YYLs caused by any other cancer in

India, and constituting almost 4% of total YYLs due to all causes in India

(Yang et al, 2004). Among women aged 25-64 years, who tend, in India, to

be the sole caretakers of the house & family, and in some cases significant

contributors to the family income, this mortality burden poses a heavy

economic burden on families (Arrossi et al, 2007), as well the country

(National Commission on Macro economics of Health, 2005). Additionally,

5
the high medical costs that are incurred by families due to cervical cancer

(especially since most cases in developing countries are diagnosed at

advanced stages when treatment is costly but prognosis poor), further

impoverish individuals and communities (Bishop et al, 1996).

The cost of secondary care of invasive cervical cancer is another

source of economic burden. According to the National Commission on

Macroeconomics of Health report (2005), the per unit cost of providing

secondary care for cervical cancer at the level of district hospitals is

10,016.04 INR, higher than that of all other chronic conditions with the

exception of cardiovascular diseases. Due to the high number of cervical

cancer cases in the population, India has the highest total cost of secondary

care (100,000 INR per 100,000 populations) relative to all other cancers.

Recognizing the high costs incurred in secondary care of cervical cancer it is

suggested that, prevention through screening and vaccination may be a more

cost-effective option for India. Cancer of the cervix is a common cancer that

afflicts Indian woman - physically, psychologically, socially and financially.

This disease affects not just the woman but also her family and the society. It

is estimated that yearly 1,34,420 Indian women are newly diagnosed with

cancer of the cervix and each year the disease kills an estimated 72,825

Indian women.

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1.2 Cancer

The body is made up of trillions of living cells. Normal body cells

grow, divide into new cells, and die in an orderly fashion. After the person

becomes an adult, most cells divide only to replace worn-out or dying cells

or to repair injuries. Cancer begins when cells in a part of the body start to

grow out of control. There are many kinds of cancer, but they all start

because of out-of-control growth of abnormal cells. Cancer cell growth is

different from normal cell growth. Instead of dying, cancer cells continue to

grow and form new, abnormal cells. Cancer cells can also invade (grow into)

other tissues, something that normal cells cannot do. Growing out of control

and invading other tissues are what makes a cell a cancer cell. Cells become

cancer cells because of damage to DNA. DNA will be in every cell and

directs all its actions. Cancer cells often travel to other parts of the body,

where they begin to grow and form new tumors that replace normal tissue.

This process is called metastasis. It happens when the cancer cells get into

the bloodstream or lymph vessels of our body.

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1.3 Cervical Cancer

Cervical cancer is a disease in which the cells of the cervix become

abnormal and start to grow uncontrollably, forming tumors

The cervix is the lower part of the uterus (womb). It is sometimes

called uterine cervix. The fetus grows in the body of the uterus (upper part).

The cervix connects the body of the uterus to the vagina (Birth canal). The

part of the cervix close to the body of the uterus is called the endo-cervix.

The two main types of cells covering the cervix or squamous cells (on the

exo-cervix). and glandular cells (on the endocervix). These 2 cell types meet

at a place called the transformation zone. Most cervical cancers start in the

transformation zone most cervical cancers begin in the cells lining the cervix.

These cells do not suddenly change into cancer. Instead, the normal cells of

the cervix first gradually develop pre-cancerous changes that turn into

cancer.

There are two main types of cervical cancers: squamous cell

carcinoma and adenocarcinoma. Cancer that develops in the ectocervix is

called squamous cell carcinoma, and around 80-90% of cervical cancer cases

(more than 90% in India) are of this type [WHO/ICO Information Centre on

HPV and Cervical Cancer]. Cancer that develops in the endocervix is called

adenocarcinoma. In addition, a small percentage of cervical cancer cases are

mixed versions of the above two, and are called adenosquamous carcinomas

or mixed carcinomas. There are also some very rare types of cervical cancer,

8
such as small cell carcinoma, neuroendocrine carcinoma etc. (American

Cancer Society). The rest of this discussion will focus on the first two types,

as they constitute the greatest burden, globally as well as in India.

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1.4 Risk Factors for Cervical Cancer

A risk factor is anything that changes the chance of getting a disease

such as cancer. Different cancers have different risk factors. For example,

exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a

risk factor for many cancers. But having a risk factor, or even several, does

not mean that cancer will be affected. Several risk factors increase the chance

of developing cervical cancer. Women without any of these risk factors

rarely develop cervical cancer. Although these risk factors increase the odds

of developing cervical cancer, many women with these risks do not develop

this disease. When a woman develops cervical cancer or pre-cancerous

changes, it may not be possible to say with certainty that a particular risk

factor was the cause. In thinking about risk factors, it helps to focus on those

that can change or avoid (like smoking or human papilloma virus infection),

rather than those that cannot (such as your age and family history).

However, it is still important to know about risk factors that cannot be

changed, because it's even more important for women who have these factors

to get regular Pap tests to detect cervical cancer early.

1.4.1 Human papilloma virus

The main risk factor for the development of cervical cancer is human

papilloma virus (HPV) infection, DNA of which has been found in almost all

cases of invasive cervical cancer (Bosch and de Sanjosé, 2003). HPV is a

sexually transmitted infection, making cervical cancer a chronic disease with

10
an infectious etiology (Alliance for Cervical Cancer Prevention, Cancer

Research UK). At least 50% of sexually active men and women get HPV at

some point in their lives [Centers for Disease Control and Prevention (c)].

Most women with HPV infection will not develop cancer, and the

infection usually resolves spontaneously; however, around 3- 10% of women

with HPV develops persistent infections, and are at high risk of developing

cervical cancer (Monsonego et al, 2004).

HPV is a group of more than 150 related viruses, some of which

cause a type of growth called a papilloma, which are more commonly known

as warts.HPV can infect cells on the surface of the skin, and those lining the

genitals, anus, mouth and throat, but not the blood or internal organs such as

the heart or lungs. HPV can be passed from one person to another during

skin-to-skin contact. One way HPV is spread is through sex, including

vaginal and anal intercourse and even oral sex. Different types of HPVs

cause warts on different parts of the body. Some cause common warts on the

hands and feet; others tend to cause warts on the lips or tongue. Certain types

of HPV may cause warts on or around the female and male genital organs

and in the anal area. These warts may barely be visible or they may be

several inches across. These are known as genital warts or condyloma

acuminatum. Most cases of genital warts are caused by HPV 6 and HPV 11.

They are called low-risk types of HPV because they are seldom linked to

cancer. Other types of HPV are called high-risk types because they are

strongly linked to cancers, including cancer of the cervix, vulva, and vagina

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in women, penile cancer in men, and cancers of the anus, mouth, and throat

in both men and women

Although there are several strains of HPV infection, (most of which

have been found to increase the risk of developing cervical cancer) two

strains: HPV 16 and 18, account for more than 70% of all cervical cancer

cases; five other strains: HPV 31, 33, 35, 45, 52 and 58 account for an

additional 20%. The level of sexual activity of a person will affect the risk of

acquiring HPV infection. Early age of first intercourse, multiple sexual

partners, unprotected sex and sex with uncircumcised men, have been

found to increase the risk of contracting HPV infection (Francheschi et al,

2003; World Health Organisation, 2006; Biswas et al, 1997). For example,

having more than three sexual partners during a woman’s lifetime will

increase the risk of cervical cancer by 94% compared to women with one

lifetime partner. Among men, high lifetime number of sexual partners

[multivariate OR for 2-9 partners relative to none 2.11 (1.17-3.78)] and

recent number of sexual partners [multivariate OR for 2 partners in 3 months

relative to none 2.09 (1.25-3.49)] have been found to increase the risk of

contracting HPV infection, while not having had sex in the past 3 months

[multivariate OR 0.42 (0.22-0.81)] and circumcision [multivariate OR 0.70

(0.52- 0.94)] have been found to have a protective effect (Giuliano et al,

2009).

There are additional factors that increase the risk of developing

cervical cancer after contracting HPV infection. These include smoking, oral

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contraceptive use, high parity, and infection with other sexually transmitted

diseases such as HIV, Herpes, Chlamydia, gonorrhoea, and syphilis (de

González et al, 2004; Plummer et al, 2003; Moreno et al, 2002; International

Collaboration of Epidemiological Studies of Cervical Cancer, 2007; Smith et

al, 2003; Muñoz et al, 2002) González et al, 2004). For example, high parity

(3 births or more) increases the risk of cervical cancer by 51% compared to

women who had not given birth.

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1.4.4 Other factors

The high-risk types include HPV 16, HPV 18, HPV 31, HPV 33, and

HPV 45, as well as some others. There might be no visible signs of infection

with a high-risk HPV until pre-cancerous changes or cancer develops.

1.4.3 Smoking

When someone smokes, they and those around them are exposed to

many cancer-causing chemicals that affect organs other than the lungs. These

harmful substances are absorbed through the lungs and carried in the

bloodstream throughout the body. Women who smoke are about twice as

likely as non-smokers to get cervical cancer. Tobacco by-products have been

found in the cervical mucus of women who smoke. Researchers believe that

these substances damage the DNA of cervix cells and may contribute to the

development of cervical cancer. Smoking also makes the immune system

less effective in fighting HPV infections.

1.4.4 Immune suppression

Human immunodeficiency virus (HIV), the virus that causes AIDS,

damages the immune system and puts women at higher risk for HPV

infections. This might explain why women with AIDS have an increased risk

for cervical cancer. The immune system is important in destroying cancer

cells and slowing their growth and spread. In women with HIV, a cervical

pre-cancer might develop into an invasive cancer faster than it normally

would. Another group of women at risk of cervical cancer are women

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receiving drugs to suppress their immune response, such as those being

treated for an autoimmune disease (in which the immune system sees the

body's own tissues as foreign and attacks them, or those who have had an

organ transplant.

1.4.5 Chlamydia infection

Chlamydia is a relatively common kind of bacteria that can infect the

reproductive system. It is spread by sexual contact. Chlamydia infection can

cause pelvic inflammation, leading to infertility. Some studies have seen a

higher risk of cervical cancer in women whose blood test results show

evidence of past or current chlamydia infection (compared with women who

have normal test results). Women who are infected with chlamydia often

have no symptoms. In fact, they may not know that they are infected at all

unless they are tested for Chlamydia during a pelvic exam.

1.4.6 Diet

Women whose diets don’t include enough fruits and vegetables may

be at increased risk for cervical cancer. Overweight women are more likely

to develop adenocarcinoma of the cervix.

1.4.7 Oral contraceptives (birth control pills)

There is evidence that taking oral contraceptives (OCs) for a long time

increases the risk of cancer of the cervix. Research suggests that the risk of

cervical cancer goes up the longer a woman takes OCs, but the risk goes

back down again after the OCs are stopped. In one study, the risk of cervical
15
cancer was doubled in women who took birth control pills longer than 5

years, but the risk returned to normal 10 years after they were stopped. The

American Cancer Society believes that a woman and her doctor should

discuss whether the benefits of using OCs outweigh the potential risks. A

woman with multiple sexual partners should use condoms to lower her risk

of sexually transmitted illnesses no matter what other form of contraception

she uses.

1.4.8 Intrauterine device use

A recent study found that women who had ever used an intrauterine

device (IUD) had a lower risk of cervical cancer. The effect on risk was seen

even in women who had an IUD for less than a year, and the protective effect

remained after the IUDs were removed. Using an IUD might also lower the

risk of endometrial (uterine) cancer. However, IUDs do have some risks.

Also, a woman with multiple sexual partners should use condoms to lower

her risk of sexually transmitted illnesses no matter what other form of

contraception she uses.

1.4.9 Multiple full-term pregnancies

Women who have had 3 or more full-term pregnancies have an

increased risk of developing cervical cancer. This may be due to the fact that

these women had to have had unprotected intercourse to get pregnant and

thereby they may have had more exposure to HPV. Also, studies have shown

that hormonal changes during pregnancy make women more susceptible to

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HPV infection or cancer growth. Another thought is that pregnant women

might have weaker immune systems, allowing for HPV infection and cancer

growth. Women who were younger than 17 years when they had their first

full-term pregnancy are almost 2 times more likely to get cervical cancer

later in life than women who waited to get pregnant until they were 25 years

or older.

1.4.10 Poverty

Poverty is also a risk factor for cervical cancer. Many low-income

women do not have ready access to adequate health care services, including

Pap tests. This means they may not get screened or treated for cervical pre-

cancers.

1.4.11 Family history of cervical cancer

Some researchers suspect that some instances of this familial tendency

to develop the disease are 2 to 3 times higher than those that are caused by an

inherited condition that makes some women less able to fight off HPV

infection than others. In other instances, women from the same family as a

patient already diagnosed could be more likely to have one or more of the

other non-genetic risk factors.

Other risk factors like a woman's sexual habits and patterns can

increase her risk of developing cervical cancer. Risky sexual practices

include:

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  Having sex at an early age.

 Having multiple sexual partners.

 Having a partner or many partners who are active in high-risk sexual

activities.

1.5 Symptoms of Cervical Cancer

Most women with dysplasia or pre-invasive cancer have no

symptoms. Screening tests, therefore, are very important. When cancer

becomes invasive, unusual bleeding can occur. Bleeding may stop and start

again between regular periods or there may be bleeding after menopause.

Unexpected bleeding can also occur after intercourse or a pelvic exam.

Periods sometimes last longer or are heavier than usual. Increased vaginal

discharge may be noticeable as well. Pelvic pain or pain during sexual

intercourse can occur. These symptoms are not exclusive to cervical cancer.

Sexually transmitted diseases, for instance, can cause similar symptoms.

Most of the time, early cervical cancer has no symptoms. Symptoms

that may occur include:

 Abnormal vaginal bleeding between periods, after intercourse, or after

menopause

 Vaginal discharge that does not stop, and may be pale, watery, pink,

brown, bloody, or foul-smelling

 Periods that become heavier and last longer than usual

Cervical cancer may spread to the bladder, intestines, lungs, and liver.

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Often there are no problems until the cancer is advanced and has spread.

Symptoms of advanced cervical cancer may include:

 Back pain

 Bone pain or fractures

 Fatigue

 Leaking of urine or feces from the vagina

 Leg pain

 Loss of appetite

 Pelvic pain

 Single swollen leg

 Weight loss

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1.6 Diagnosis and Screening

The changes that lead to cervical cancer develop slowly. Screening

tests performed during regular gynecologic examinations can detect early

changes.

1.6.1 Pap smear

Use of the Pap smear has significantly reduced the death rate from

cervical cancer. Many women who have a Pap smear fail to follow-up for

retesting and treatment. Most cases of cervical cancer occur in women who

have not had regular Pap tests.

The procedure
The most accurate test results are obtained 12 - 14 days after

menstruation begins. Women should not douche or have intercourse within

48 hours of the test. Douches and spermicidal creams may clean out

abnormal cells and interfere with the results of a Pap smear. (In general,

douching is not recommended at all.) A Pap smear is usually painless,

although some women may have some discomfort.

 The test is done in a doctor's office. The woman removes her clothes

from the waist down and puts on a medical gown. She lies on her back

on the examination table, bends her knees, and puts her feet in

supports (called stirrups) at the end of the table.

 The doctor inserts a plastic or metal device (called a speculum) into

her vagina to widen it.

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  Using a spatula, brush, or both, the doctor gently scrapes the surface

of the cervix, and sometimes the upper vagina, to gather living cells.

The doctor will also obtain cells from inside the cervical canal. The

scraping is completely painless.

 The cells are preserved, stained for microscopic viewing, and then

analyzed under a microscope by a specialist known as a

cytopathologist.

1.6.2 Reliability and Accuracy

The Pap smear is not a perfectly reliable measure of a woman's risk

for cervical cancer. In general, about 10% of Pap smears have abnormal

results, but only about 0.1% of the women who have these results actually

have cancer. In most cases, abnormal cells are low grade and not likely to

progress to cancer or are due to benign conditions, including natural cell

changes after menopause.

 No test is 100% accurate, and it is possible for the Pap smear to miss

the presence of cancer. However, if abnormal cells are missed on one

test they are likely to be spotted during the next one without a

significant danger.

 New tests and methods have been developed to improve the accuracy

of the Pap smear in detecting cancer cells. For example, there are

several computerized Pap test systems that are used to rescreen the

original smear. These systems are either used to detect abnormal

samples that may have been missed by manual review methods or are

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 used in place of a human cytotechnologist. There is not yet enough

evidence to know whether or not computerized methods are superior

to conventional Pap testing.

 Newer, thin-layer liquid based tests (Thin Prep, Sure Path) use the

original cervical sample, which is rinsed in a special solution to thin

the mucus (rather than dried). The fluid is examined for evidence of

abnormal cells as well as HPV and other early abnormalities. Some,

but not all, studies have found liquid-based Pap tests to be more

accurate than the standard Pap smear.

1.6.3 Current Pap Smear Screening Recommendations

General guidelines for cervical cancer screening recommend:

1.6.3.1 Initial Screening

Women should begin to undergo Pap tests at age 21 regardless of

whether or not they have been sexually active.

1.6.3.2 Women Up to Age 30

Women between the ages 21 - 29 should be screened for cervical

cancer once every 2 years with either a conventional or liquid-based Pap test.

1.6.3.3 Women Age 30 and Over

Women aged 30 and older should be screened for cervical cancer once

every 2 years with either a conventional or liquid-based Pap test. Women in

this age group who have received three consecutive negative (normal)

annual Pap tests may be screened once every three years with either of

these tests. Women who have certain risk factors (HIV-positive, weakened

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immune system, DES exposure, or prior cervical abnormalities) may need to be

screened every year.

1.6.3.4 Elderly Women

Most women can stop cervical cancer screening around age 65 – 70,

as long as they have had three negative (normal) Pap tests within the last 10

years.

1.6.3.5 After a Hysterectomy

Women who have had a total hysterectomy (removal of uterus and

cervix) for non-cancer reasons may choose to discontinue Pap testing.

Women who have had a hysterectomy that preserves the cervix (called a

supra-cervical hysterectomy) should continue with Pap screening.

1.6.4 Colposcopy and Biopsy

The Pap smear shows only the presence of abnormal cells. It is useful

simply as a screening test that identifies women who may have preinvasive

or early cancerous changes. For a definitive diagnosis, the next step is

usually colposcopy, during which the cervix is visualized under low power

magnification. The surgeon takes samples of suspicious cells for biopsies. A

biopsy will determine the stage of the precancerous growth or whether

invasive cancer is present.

1.7 Stages of Cervical cancer

Carcinoma in Situ (Stage 0)

In carcinoma in situ (stage 0), abnormal cells are found in the

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innermost lining of the cervix. These abnormal cells may become cancerous

and spread into nearby normal tissue screened once every three years with

either of these tests. Women who have certain risk factors (HIV-positive,

weakened immune system, DES exposure, or prior cervical abnormalities) may

need to be screened every year.

Elderly Women

Most women can stop cervical cancer screening around age 65 – 70,

as long as they have had three negative (normal) Pap tests within the last 10

years.

After a Hysterectomy

Women who have had a total hysterectomy (removal of uterus and

cervix) for non-cancer reasons may choose to discontinue Pap testing.

Women who have had a hysterectomy that preserves the cervix (called a

supracervical hysterectomy) should continue with Pap screening.

Colposcopy and Biopsy

The Pap smear shows only the presence of abnormal cells. It is useful

simply as a screening test that identifies women who may have preinvasive

or early cancerous changes. For a definitive diagnosis, the next step is

usually colposcopy, during which the cervix is visualized under low power

magnification. The surgeon takes samples of suspicious cells for biopsies. A

biopsy will determine the stage of the precancerous growth or whether

invasive cancer is present.

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Stages of Cervical cancer

Carcinoma in Situ (Stage 0)

In carcinoma in situ (stage 0), abnormal cells are found in the

innermost lining of the cervix. These abnormal cells may become cancerous

and spread into nearby normal tissue.

1.7 Stage I

In stage I, cancer is found in the cervix only. Stage I is divided into

stages IA and IB, based on the amount of cancer that is found.

Stage IA

Stage IA1 and IA2 cervical cancer. A very small amount of cancer

that can only be seen with a microscope is found in the tissues of the cervix.

In stage IA1, the cancer is not more than 3 millimeters deep and not more

than 7 millimeters wide. In stage IA2, the cancer is more than 3 but not more

than 5 millimeters deep, and not more than 7 millimeters wide. A very small

amount of cancer that can only be seen with a microscope is found in the

tissues of the cervix. Stage IA is divided into stages IA1 and IA2, based on

the size of the tumor.

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Stage IB is divided into stages IB1 and IB2

In stage IB1, the cancer can only be seen with a microscope and is

26
more than 5 mm deep or more than 7 mm wide OR the cancer can be seen

without a microscope and is 4 cm or smaller. In stage IB2, the cancer is

larger than 4 cm and can be seen without a microscope.

1.7.2 Stage II

In Stage II of cervical cancer, Cancer will spread beyond the cervix

but not to the pelvic wall or to the lower third of the vagina. Stage II is

divided into stages IIA and IIB, based on how far the cancer has spread. In

stages IIA1 and IIA2, cancer will spread beyond the cervix to the vagina. In

stage IIA1, the tumor can be seen without a microscope and is 4 centimeters

or smaller. In stage IIA2, the tumor can be seen without a microscope and is

larger than 4 centimeters. In stage IIB, cancer has spread beyond the cervix

to the tissues around the uterus.

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  Stage IIA: Cancer will spread beyond the cervix to the upper two

thirds of the vagina but not to tissues around the uterus. Stage IIA is

divided into stages IIA1 and IIA2, based on the size of the tumor.

 In stage IIA1, the tumor can be seen without a microscope and

is 4 centimeters or smaller.

 In stage IIA2, the tumor can be seen without a microscope and

is larger than 4 centimeters.

 Stage IIB: Cancer will spread beyond the cervix to the tissues around

the uterus.

1.7.3 Stage III

In stage III, cancer will spread to the lower third of the vagina, and/or

to the pelvic wall, and/or will cause kidney problems. Stage III is divided

into stages IIIA and IIIB, based on how far the cancer has spread.

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  Stage IIIA:

Cancer will spread to the lower third of the vagina but not to the pelvic
wall.

Stage III B

In Stage IIIB of cervical cancer, Cancer will spread to the pelvic wall;

and/or the tumor will become large enough to block the ureters (the tubes

that connect the kidneys to the bladder). The picture shows the ureter on the

right blocked by the cancer. This blockage can cause the kidney to enlarge or

stop working.

29
1.7.4 Stage IV

In stage IV, cancer will spread to the bladder, rectum, or other parts of

the body. Stage IV is divided into stages IVA and IVB, based on where the

cancer is found.

Stage IVA

 Stage IVA cervical cancer. Cancer has spread to nearby organs, such

as the bladder or rectum.

Stage IVB

In Stage IVB of cervical cancer, Cancer will spread to parts of the

body away from the cervix, such as the liver, intestines, lungs, or bones.

30
1.8 Treatment for cervical cancer by stage

The stage of a cervical cancer is the most important factor in choosing

treatment. However, other factors that affect this decision include the exact

location of the cancer within the cervix, the type of cancer (squamous cell or

adenocarcinoma), age, overall physical condition, and whether the patient

wants to have children.

Stage 0 (carcinoma in situ)

Treatment options for squamous cell carcinoma in situ are the same as

for other pre-cancers (dysplasia or cervical intraepithelial neoplasia [CIN]).

Options include cryosurgery, laser surgery, loop electrosurgical excision

procedure (LEEP/LEETZ), and cold knife conization.

For adenocarcinoma in situ, hysterectomy is usually recommended.

For women who wish to have children, treatment with a cone biopsy may be

31
an option. The cone specimen must have no cancer cells at the edges, and

the patient must be closely watched. After the woman has finished having

children, a hysterectomy is recommended.

A simple hysterectomy is also an option for treatment of squamous

cell carcinoma in situ, and might be done if it returns after other treatments.

All cases of Carcinoma in situ (CIS) can be cured with appropriate treatment.

However, pre- cancerous changes can recur (come back) in the cervix or

vagina, so it is very important for the doctor to watch the patient closely.

This includes follow-up with regular Pap tests and in some instances with

colposcopy.

Stage IA is divided into stage IA1 and stage IA2

Stage IA1: For this stage there are3 options

 To beable to have children, first the cancer is removed with a cone

biopsy, and then the patient will be watched closely to see if the

cancer comes back.

 If cone biopsy doesn't remove all of the cancer ((or) if the family size

is completed), then the uterus will be removed (hysterectomy).

 If the cancer has invaded the blood vessels or lymph vessels, it might

need a radical hysterectomy along with removal of the pelvic lymph

nodes. For women who still want to be able to have children, a radical

trachelectomy can be done instead of the radical hysterectomy.

32
Stage IA2: There are 3 treatment options

 Radical hysterectomy along with removal of lymph nodes in the pelvis

 Brachytherapy with or without external beam radiation therapy to the

pelvis.

 Radical trachelectomy with removal of pelvic lymph nodes can be

done if; patient still needs to be able to have children.

 If cancer is found in any pelvic lymph nodes during surgery, some of

the lymph nodes that lie along the aorta (the large artery in the

abdomen) may be removed as well. Any tissue removed at surgery

will be examined in the laboratory to see if the cancer has spread

further than expected. If the cancer has spread to the tissues next to the

uterus (called the parametria) or to any lymph nodes, radiation therapy

is usually recommended. Often chemotherapy will be given with the

radiation therapy. If the pathology report says that the tumor had

positive margins, this means that some cancer cells might have been

left behind. This is also treated with pelvic radiation (given with

cisplatin chemotherapy). The doctor may advise brachytherapy, as

well.

Stage IB is divided into stage IB1 and stage IB2

Stage IB1: There are 3 options available:

 The standard treatment is a radical hysterectomy with removal of

lymph nodes in the pelvis. Some lymph nodes from higher up in the

33
 abdomen (called para- aortic lymph nodes) are also removed to see if

the cancer has spread there. If cancer cells are found in the edges of

the tissues removed (positive margins) or if cancer cells are found in

lymph nodes during this operation, radiation therapy may be given,

possibly with chemotherapy, after surgery.

 The second treatment option is radiation with both brachytherapy and

external beam radiation therapy.

 Radical trachelectomy with removal of pelvic (and some para-aortic)

lymph nodes is an option if the patient still wants to be able to have

children

Stage IB2: There are 3 options available

 The standard treatment is the combination of chemotherapy with

cisplatin and radiation therapy to the pelvis plus brachytherapy.

 Another choice is radical hysterectomy with removal of pelvic (and

some para-aortic) lymph nodes. If cancer cells are found in the lymph

nodes removed, or in the margins, radiation therapy may be given,

possibly with chemotherapy, after surgery.

 Some doctors advise radiation given with chemotherapy (first option)

followed by a hysterectomy.

Stage II is divided into stage IIA and stage IIB

Stage IIA: Treatment for this stage depends on the size of the tumor.

34
 One choice for treatment is brachytherapy and external radiation

therapy. This is most often recommended if the tumor is larger than 4

cm (about 1½ inches). Chemotherapy with cisplatin will be given

along with the radiation.

 Some experts recommend removing the uterus after the radiation

therapy is done.

 If the cancer is not larger than 4 cm, it may be treated with a radical

hysterectomy and removal of lymph nodes in the pelvis (and some in

the para- aortic area). If the tissue removed at surgery shows cancer

cells in the margins or cancer in the lymph nodes, radiation treatment

to the pelvis will be given with chemotherapy. Brachytherapy may be

given as well.

 Stage IIB

 Combined internal and external radiation therapy is the usual

treatment. The radiation is given with the chemotherapy drug

cisplatin. Sometimes other chemo drugs may be given along with

cisplatin.

 Stage III and IVA

 Combined internal and external radiation therapy given with cisplatin

is the recommended treatment. If cancer has spread to the lymph

nodes (especially those in the upper part of the abdomen) it can be a

sign that the cancer has spread to other areas in the body. Some
35
 experts recommend checking the lymph nodes for cancer before

giving radiation. One way to do this is by surgery. Another way is to

do a CT or MRI scan to see how big the lymph nodes are. Lymph

nodes that are bigger than usual are more likely to have cancer. Those

lymph nodes can be biopsied to see if they contain cancer. If lymph

nodes in the upper part of the abdomen (the para-aortic lymph nodes)

are cancerous, doctors may want to do other tests to see if the cancer

has spread to other parts of the body.

 Stage IVB

 At this stage, the cancer has spread out of the pelvis to other areas of

the body. Stage IVB cervical cancer is not usually considered curable.

Treatment options include radiation therapy to relieve the symptoms

of cancer that has spread to the areas near the cervix or to distant sites

(such as the lungs or bone). Chemo is often recommended.

Recurrent cervical cancer

Cancer that comes backs after treatment is called recurrent cancer.

Cancer can come back locally (in the pelvic organs near the cervix) or come

back in distant areas (spread through the lymphatic system and/or the

bloodstream to organs such as the lungs or bone).

If the cancer has recurred in the pelvis only, extensive surgery (by

pelvic exenterating) may be an option for some patients. This operation may

successfully treat 40% to 50% of patients. Sometimes radiation or

36
chemotherapy may be used for palliative treatment (treatment to relieve

symptoms but not expected to cure). If cancer has recurred in a distant area,

chemo or radiation therapy may be used to treat and relieve specific

symptoms. Sometimes chemo can improve quality of life of the patients, and

other times it can diminish it and the patients have to discuss this with the

doctors. Fifteen percent to 25% of patients may respond at least temporarily

to chemo.

New treatments that may benefit patients with distant recurrence of

cervical cancer are being evaluated in clinical trials.

1.9 Prevention of Cervical Cancer

Since the most common form of cervical cancer starts with pre-

cancerous changes, there are 2 ways to stop this disease from developing.

One way is to find and treat pre-cancers before they become true cancers,

and the other is to prevent the pre- cancers in the first place.

1.9.1 Avoiding Exposure to Human Papilloma Virus

Since HPV is the main cause of cervical cancer and pre-cancer,

avoiding exposure to HPV could help prevent this disease. HPV is passed

from one person to another during skin-to-skin contact with an infected area

of the body. Although HPV can be spread during sex – including vaginal

intercourse, anal intercourse, and oral sex − sex doesn't have to occur for the

infection to spread. All that is needed is skin- to-skin contact with an area of

the body infected with HPV. This means that the virus can be spread through

37
genital-to-genital contact (without intercourse). It is even possible for a

genital infection to spread through hand-to-genital contact.

Also, HPV infection seems to be able to be spread from one part of the

body to another. This means that an infection may start in the cervix and then

spread to the vagina and vulva. It can be very hard not to be exposed to HPV.

It may be possible to prevent genital HPV infection by not allowing others to

have contact with the anal or genital area, but even then there might be other

ways to become infected that aren’t yet clear. In women, HPV infections

occur mainly in younger women and are less common in women older than

30.

Certain types of sexual behavior increase a woman's risk of getting

HPV infection, such as having sex at an early age and having many sexual

partners. Women who have had many sexual partners are more likely to get

infected with HPV, but a woman who has had only one sexual partner can

still get infected. Waiting to have sex until you are older can help you avoid

HPV. It also helps to limit the number of sexual partners and to avoid having

sex with someone who has had many other sexual partners. Although the

virus most often spreads between a man and a woman, HPV infection and

cervical cancer are also seen in women who have only had sex with other

women. Remember that someone can have HPV for years and still have no

symptoms − it does not always cause warts or other problems. Someone can

have the virus and pass it on without knowing it. Still, since all that is needed

to pass HPV from one person to another is skin-to-skin contact with an area

38
of the body infected with HPV, even never having sex doesn’t guarantee that

one will not get infected. It might be possible to prevent anal and genital

HPV infection by never allowing another person to have contact with those

areas of body.

1.9.2 Condoms

Condoms (" rubbers") provide some protection against HPV but don't

completely prevent infection. Men who use condoms are less likely to be

infected with HPV and to pass it on to their female partners. One study found

that when condoms are used correctly every time sex occurs they can lower

the HPV infection rate by about 70%. One reason that condoms cannot

protect completely is because they don't cover every possible HPV-infected

area of the body, such as skin of the genital or anal area. Still, condoms

provide some protection against HPV, and also protect against HIV and

some other sexually transmitted diseases. Condoms (when used by the male

partner) also seem to help the HPV infection and cervical pre- cancers go

away faster.

1.9.3 HPV Vaccine

Vaccines have been developed that can protect women from HPV

infections. So far, a vaccine that protects against HPV types 6, 11, 16 and 18

(Gardasil) and one that protects against types 16 and 18 (Cervarix) have been

studied and approved for use. Both vaccines require a series of 3 injections

over a 6-month period.

39
 Side effects are usually mild. The most common one is short-term

redness, swelling, and soreness at the injection site. Rarely, a young woman

will faint shortly after the vaccine injection. In clinical trials, both vaccines

prevented pre-cancers and cancers of the cervix caused by HPV types 16 and

18. Gardasil also prevented anal, vaginal, and vulvar cancers caused by those

HPV types, as well as genital warts caused by HPV types 6 and 11. Cervarix

also provides some protection against infection and pre-cancers of the cervix

caused by high-risk HPV types other than HPV 16 and 18. It has also been

shown to prevent anal infection with HPV types 16 and 18. Both vaccines

only work to prevent HPV infection − they will not treat an infection that is

already there. That is why, to be most effective, the HPV vaccine should be

given before a person becomes exposed to HPV (such as through sexual

activity).

1.9.4 Avoiding smoking

Avoiding smoking is another important way to reduce the risk of

cervical pre- cancer and cancer.

1.9.5 HPV and men

For men, the 2 main factors influencing the risk of genital HPV

infection are circumcision and the number of sexual partners. Men who are

circumcised (have had the foreskin of the penis removed) have a lower

chance of becoming and staying infected with HPV. Men who have not been

circumcised are more likely to be infected with HPV and pass it on to their

40
partners. The reasons for this are unclear. It may be that after circumcision

the skin on the glands (of the penis) goes through changes that make it more

resistant to HPV infection. Another theory is that the surface of the foreskin

(which is removed by circumcision) is more easily infected by HPV. Still,

circumcision does not completely protect against HPV infection − men who

are circumcised can still get HPV and pass it on to their partners.

The risk of being infected with HPV is also strongly linked to having

many sexual partners (over a man's lifetime).

1.10 Cervical cancer prevention and treatment strategies in India

Non-communicable diseases including cancer are emerging as major

public health problems in India. These diseases are lifestyle related, have a

long latent period and need specialized infrastructure and human resources

for treatment Cancer of the uterine cervix is still the most common cancer

among women in India. Improvements in living standards and access to

health care have reduced the rate of occurrence of cervical cancer in certain

States like Kerala. However, the changing sexual behavior in young adults

might lead to another wave of cervical cancers. Early age at first intercourse,

multiple sexual partners, poor sexual hygiene, repeated child birth etc are

some of the reproductive risk factors for cervical cancer. Improvements in

the living standards of women have resulted in a reduction in the incidence

of cervical cancer. Regular cervical cytology examination (Pap smear) by all

women who have initiated sexual activity can prevent the occurrence of

cervical cancer. This has been successfully achieved in many European

41
countries. However, there are many limitations for cytology based cervical

cancer screening in India. These are various levels of health care delivery and

health infrastructure in the states in India and it is possible that there are

certain areas in which screening programs could be initiated. The system for

screening, with facilities for call back and proper referral, is very important,

irrespective of the screening strategy.

India is the one of the few developing countries that has formulated a

National Cancer Control Program. The program envisages control of tobacco

related cancers; early diagnosis and treatment of uterine cervical cancer; and

distribution of therapy services, pain relief and palliative care through

augmentation of health infrastructure. Suggested surrogate outcome

measures include change in tobacco use, 'Knowledge, Attitude,

Practice'(KAP) pattern, compliance to screening programs, changes in

referral practices and shift in stage distribution.

1.10.1 Primary prevention and screening programs

Primary prevention is the most cost effective prevention program as it

aims at reducing the incidence of cancer by risk factor modification. Fifty

percent of all cancers are considered to be related to the dietary practices and

the importance of a healthy diet rich in green and yellow vegetables and

fruits has to be highlighted. Cancer of the uterine cervix can be controlled to

a certain extent by practicing genital hygiene and safe sexual practices.

Cervical cytology (pap smear) screening programs were found to be

successful in reducing cervical cancer incidence and women in the age group

42
35 to 64 years should undergo regular pap smear screening. Given the

limitations in large scale population based screening programs, India can

consider primary prevention of cervical cancer by promoting genital hygiene

and sexual behavior. States that have achieved a high level of health care

delivery can consider starting organized screening programs. The primary

target should be to offer once a life time screening for all women at the age

of 40 years. Government and private health care providers can join in this

effort and offer these services.

Measures identified and propagated for cancer control in the

developed countries may not be applicable the Indian context. The answers

have to be found through methods which are feasible and evaluable in the

Indian context. Cancer prevention needs to be considered as part of the Non

Communicable Diseases prevention program as it will make it more effective

and feasible. The risk factors, Alcohol, Tobacco, Bad Diet and Physical

inactivity are risk factors for most of the Non Communicable Diseases and

have to be approached together as lifestyle modification.

1.10.2 Cancer detection & prevention clinics

Late stage at presentation is the main reason for the poor survival from

cancer in India. The late presentation is mainly due to the lack of diagnostic

facilities at the peripheral levels. District hospitals in India should have the

services of specialists and provide reasonable services. These hospitals can

have a 'Cancer Detection and Prevention Clinic’, which will provide diagnostic

services and minimal treatment. The diagnostic services set up in the hospital
43
can also be of use to all the patients who attend this hospital. Cost recovery

may be attempted from the beginning and an experience in Kerala has

demonstrated that such services are feasible and sustainable. The services as

well as the program provides a good range of services and the cytology

services helped to diagnose cancers at an early stage. Provision of Palliative

Care services has also been accepted by the community. Existing staff of the

hospital can be trained to provide the services. Regional Cancer Centers can

set up cancer detection and prevention centers in District hospitals.

1.10.3 Treatment facilities

A multidisciplinary approach to cancer treatment is essential and this

has to be made available at all Regional Cancer Centers. The services of a

trained surgeon and a Clinical Oncologist are needed to plan the most

appropriate treatment. Radiotherapy services are still the mainstay of

treatment given the large proportion of advanced epithelial cancers in India.

Given the long waiting lists and the distance that patients have to travel to

reach treatment facilities, optimal strategies have to be identified. Patients for

palliative treatment and curative treatment need to be identified at the

beginning of the treatment plan and palliation may be achieved with the

minimum time. An essential drug list has to be prepared for cancer

chemotherapy and chemotherapy services for common cancers have to be

made available in all centers. Advanced facilities for high intensity

chemotherapy for leukemia and other cancers where chemotherapy is the

mainstay of treatment, need to be provided at the Regional Cancer Centers.

44
 Surgical Oncology training has to be provided to General Surgeons

during their training as well as to those in practice as majority of the cancer

is likely to present themselves to a surgeon in the first instance.

India‘s National cancer control program emphasizes the importance of

early detection and treatment. But the country has no organized screening

program, and many Indian women lack awareness about the disease and

access to prevention and treatment facilities.

1.11 Innovative research on Cervical Cancer

1.11.1 Sentinel lymph node biopsy

During surgery for cervical cancer, lymph nodes in the pelvis may be

removed to check for cancer spread. Instead of removing many lymph nodes,

a technique called sentinel lymph node biopsy can be used to target just the

few lymph nodes most likely to contain cancer. In this technique a blue dye

containing a radioactive tracer is injected into the cancer and allowed to

drain into lymph nodes. Then, during surgery, the lymph nodes that contain

radiation and the blue dye can be identified and removed. These are the

lymph nodes most likely to contain cancer if it had spread. If these lymph

nodes don’t contain cancer, the other lymph nodes don’t need to be removed.

Removing fewer lymph nodes may lower the risk of later problems.

1.11.2 Targeted therapy

As researchers have learned more about the gene changes in cells that

cause cancer, they have been able to develop newer drugs that specifically
45
target these changes. These targeted drugs work differently from standard

chemotherapy drugs. They often have different (and less severe) side effects.

These drugs may be used alone or with more traditional chemotherapy.

1.11.3 Hyperthermia

Some research indicates that adding hyperthermia to radiation may

help keep the cancer from coming back and help patients live longer.

Hyperthermia is a treatment that raises the temperature in the area where the

tumor is, most often by using radiofrequency antennae placed around the

patient.

1.11.4 Other clinical trials

Many clinical trials are testing new chemotherapy drugs, new ways of

giving radiation therapy, and new combinations of surgery and radiation

therapy or chemotherapy. In 2009, the Federal Advisory Committee on

Immunization Practices (ACIP) published updated recommendations for

HPV vaccination in girls and young women. It recommended that females

aged 11 to 12 be routinely vaccinated with the full series of 3 shots. Females

as young as age 9 may also receive the HPV vaccine at the discretion of their

doctors. Women aged 13 to 26 who have not yet been vaccinated get "catch-

up" vaccinations. Either vaccine may be used to prevent cervical cancers and

pre-cancers. However, the ACIP recommends using Gardasil to prevent

genital warts as well as cervical cancers and pre-cancers. These vaccines

have been tested in women over 26, and do seem to be effective in producing

46
an immune reaction to the HPV types in the vaccine and also reduce cervical

cancers and pre- cancers in those vaccinated. But the overall benefit in this

age group was small, and so they have not been approved.

1.12 Structured teaching program

Structured teaching program is an intervention philosophy developed

by the University of North Carolina. Structured teaching is an approach to

instruct the persons/people. It allows for implementation of a variety of

instructional methods (e.g., visual support strategies, Picture Exchange

Communication System - PECS, sensory integration strategies, etc.).

Structured teaching is based upon an understanding of the unique features

and characteristics Structured teaching describes the conditions under which

a person should be taught rather than "where" or "what" (i.e., "learning how

to learn"). Structured teaching is a system for organizing their environments,

developing appropriate activities, and helping people to understand what is

expected of them.

Structured teaching utilizes visual cues which help women focus on

the relevant information which can, at times, be difficult for the person .It

teaching addresses challenging behaviors in a proactive manner by creating

appropriate and meaningful environments that reduce the stress, anxiety and

frustration which may be experienced by women. Modified behavior may

occur. Hence in the present study effectiveness of STP has been adopted to

analyze the knowledge levels of women about cervical cancer.

47
1.13 Significance of the Study

In India a large number of female populations are vulnerable to

cervical cancer, since the recognized risk factors for cancer of cervix like

illiteracy, low socio- economic status, early marriage, multiparty, first child

birth at early age, poor genital hygiene and genital infections are widely

prevalent in this population. However, the risk of development of cervical

cancer is due to the life style of the individual, social customs and personal

hygiene. The present study tries to analyze the socio-economic and health

practices relating to knowledge of cancer of cervix among married women.

However, there are few studies which focused on the practices for prevention

of the cervical cancer among women. The present study focuses on

knowledge of cervical cancer, female reproductive system; symptoms and

the barriers to access the health services and preventive health practices of

women through structured teaching program.

In India Cervical cancer is a major health problem among women.

One of the reasons may be lack of means for early detection which forces

women to often access the health services when the disease is at an advanced

stage. There are limited resources for ensuring the health care services and a

stunted health care system which does not have the capacity to offer

treatment for more advanced cases of cervical cancer such as radiation

combined with chemotherapy. In addition to that, referral to higher

recognized institutions for specialized care is difficult due to huge travel and

treatment costs. Hence, knowing about the barriers to health services and

48
interventions to improve the survival due to cervical cancer are needed.

There are certain studies relating to knowledge levels, barriers and

preventive modes on cervical cancer in the Indian context. However to fill

the gap, this study tries to focus on effective structured teaching program on

cervical cancer among women as many women are not aware of the severity

of the disease. Hence knowledge of cervical cancer through structured

teaching program can make them understand and improve their decision

making in health checkups.

The health problems of women are varied and they are related to the

customs and beliefs, which they follow according to norms of a particular

society. In order to reach the women on cervical cancer perspectives, there is

a need to implement inclusive specialized policies and programs by the

policy makers. An awareness programs on primary prevention can bring

change in their life style, social customs and hygiene practices. So the

studies, to promote preventive behavior and to prevent cancer of the cervix

by detecting it at an early stage through screening are helpful in ever

bringing the policies and programs on reproductive health and also to get the

support of the family in screening .

There is a need to educate women on the importance of cervical

cancer screening and of responsibilities for their own reproductive health

matters as it is a critical element in fighting against cervical cancer. So,

community based studies focusing on the importance of educating the

women, especially, those in rural areas, are significantly important.

49
 Hence, an attempt has been made to study to assess the knowledge

regarding cervical cancer among the women between the age group of 20-60

years in Dunera, Pathankot, Punjab.

1.14 Chapterization of Thesis

The thesis is constructed into seven chapters-

The first chapter deals with introduction about the cervical cancer,

its prevalence rate in developed and developing countries. Definition of

Cervical cancer, risk factors, symptoms, screening, treatment and its

prevention.

The second chapter presents the Review of the Literature. Survey of

literature is based on various articles published in the leading journals,

unpublished and published books and theses submitted for presentations and

news paper and reports.

The third chapter focuses on the methodology and field work

adopted in the study. Methodology chapter includes Research design concepts,

variables of the study, hypothesis and limitations of the study, description of

the setting, Sample and sampling technique, development and description of

the tool, pilot study and data collection.

The fourth chapter deals with socio demographic variables which

include; age, education, age at marriage, number of children, habits and other

variables of the sample population.

50
 The fifth chapter focuses on effectiveness of the structured teaching

program on the knowledge about cervical cancer. It also discusses

association between socio economic & demographic factors on the various

issues concerning knowledge of cervical cancer.

The sixth chapter focused on Logistic Regression Analysis of the

data. It is used for predicting the outcome of dependent variables based on

independent variables.

The seventh chapter focused on summary and Conclusions drawn

from the findings. Suggestions with suitable implications to make policies in

view of the cervical cancer are also added.

51
Chapter-II

REVIEW OF LITERATURE

52
 CHAPTER-II
REVIEW OF LITERATURE

Researchers generally undertake a literature search to familiarize themselves

with a knowledge base. A review of related literature is an integral

component of any scientific approach. It involves the systematic

identification, location, scrutinizing and summary of written materials that

contain information on the research problem under study (Polit and Hungle,

2002).

A review of literature helps to assess what is already known, what is still

unknown and untested to justify the need for its replication and to throw

some light on the feasibility of the study and problems that may be

encountered.

For the present research the investigator carried out extensive review of

literature from the published, unpublished scholarly articles and internet

search to broaden the understanding and insight in to the selected problem

under study. The review of literature is a broad overview of studies, which

are organized and arranged under the following headings.

 Studies Related To Prevalence / Epidemiology of Cervical Cancer

 Studies Related to Causes and Risk Factors of cervical cancer

 Studies Related to Signs and Symptoms of Cervical Caner

 Studies related to cervical cancer screening and diagnosis

 Studies related to barriers and benefits of cervical cancer screening

 Studies related to cervical cancer treatment

 Studies related to cervical cancer prevention

42
 Studies related to awareness of cervical cancer

 Studies related to Structured teaching program ( STP)

43
2.1 Prevalence / Epidemiology of Cervical Cancer

Gopal (2012) conducted a study on examined disparities in cervical cancer

mortality rates among US women in metropolitan and non-metropolitan

areas from 1950 through 2007. During the last five decades, women in non-

metropolitan areas had significantly higher cervical cancer mortality than

those in metropolitan areas. Disparities persisted against a backdrop of

consistently declining mortality rates. Throughout 1969–2007, both white

and black women in non-metropolitan areas maintained significantly higher

cervical cancer mortality rates than their metropolitan counterparts. Among

black women, cervical cancer mortality declined at a faster pace in

metropolitan than in non-metropolitan areas. In both metropolitan and non-

metropolitan areas, black women had twice the mortality rate of white

women. Survival rates were significantly lower in non-metropolitan areas,

particularly among rural black women. The 5-year survival rate for black

women diagnosed with cervical cancer was 50.8% in non-metropolitan areas,

compared with 60.2% for black women and 71.0% for white women in

metropolitan areas.

Gopal et al., (2012) conducted a study on Global Inequalities in

Cervical Cancer Incidence. The mortality rates varied widely, with many

African countries such as Guinea, Zambia, Comoros, Tanzania, and Malawi

having at least 10-to-20- fold higher rates than several West Asian, Middle

East, and European countries, including Iran, Saudi Arabia, Syria, Egypt, and

Switzerland. HDI, GII, poverty rate, health expenditure per capita,

44
urbanization, and literacy rate were all significantly related to cervical cancer

incidence and mortality, with HDI and poverty rate each explaining >52% of

the global variance in mortality. Both incidence and mortality rates increased

in relation to lower human development and higher gender inequality levels.

A 0.2 unit increase in HDI was associated with a 20% decrease in cervical

cancer risk and a 33% decrease in cervical cancer mortality risk. The risk of

a cervical cancer diagnosis increased by 24% and of cervical cancer death by

42% for a 0.2 unit increase in GII. Higher health expenditure levels were

independently associated with decreased incidence and mortality risks.

Ali et al., (2012), the global burden of cervical cancer is

disproportionately high among the developing countries where 85 per cent of

the estimated 493, 000 new cases and 273, 000 deaths occur worldwide.

There are several dimensions of the problem. Cervical cancer is a problem

where people are poor, where the socio- economic status of the women is

low and sometimes specific ethnicity also posses additional risk to the

women to develop cervical cancer. Human papillomavirus infection is a main

risk factor for the cervical cancer however there are some other factors which

increase the risk. Among them some are number of sexual partners, age of

first sexual intercourse, infection of sexually transmitted diseases, use of

hormonal contraceptives, parity, age, smoking, food and diet. Apart from

these factors, some other issues, such as policy on cancer, capacity of health

system, socio-economic and cultural factors and awareness among the

women are also associated with the cervical cancer related morbidity and

45
mortality across the developing countries. There some interventions which

give promising results in terms of reducing cervical cancer related morbidity

and mortality. Among them visual inspection of cervix with acetic acid

followed by treatment is one such effective method.

Lei et al., (2011) conducted a study on cervical cancer data of 11

cancer registries during 1988-2002 in China. The age and urban/rural

differences and trend of cervical cancer incidence and mortality showed that

during 1988-2002, a total of 6007 incidence cases and 3749 mortality cases

of cervical cancer were reported in the 11 cancer registries. The incidence

crude rate of cervical cancer was 3.80/100,000 and the world age adjusted

rate was 2.78/100,000. In the same period, the mortality crude rate was

2.37/100,000 and the world age adjusted rate was 1.66/100,000. Declined

incidence and mortality trends were observed during this period in urban as

well as in rural areas. When calculating the rates by age group, we found that

the declining trends were only for older women and increasing trends for

younger women, especially for women in the rural areas.

Ronco et al., (2010) study on human papillomavirus (HPV)-based

screening for cervical tudy of the four randomized trials to investigate these

outcomes. 176 464 women aged 20—64 years were randomly assigned to

HPV-based (experimental arm) or cytology-based (control arm) screening in

Sweden (Swede screen), the Netherlands (POBASCAM), England

(ARTISTIC), and Italy (NTCC). These women for a median of 6-5 years (1

214 415 person-years) were followed and identified 107 invasive cervical

46
carcinomas by linkage with screening, pathology, and cancer registries, by

masked review of histological specimens, or from reports. Cumulative and

study- adjusted rate ratios (experimental vs control) were calculated for

incidence of invasive cervical carcinoma. The rate ratio for invasive cervical

carcinoma among all women from recruitment to end of follow-up was 0.60

(95% CI 0.40-0.89), with no heterogeneity between studies (p=0.52).

Detection of invasive cervical carcinoma was similar between screening

methods during the first 2-5 years of follow-up (0.79, 0.46- 1.36).

Bruni et al., (2010) conducted a study on meta-analysis was

performed of studies published between 1995 and 2009 that used polymerase

chain reaction or Hybrid Capture 2 for HPV detection in women with normal

cytological findings. The analysis included 194 studies comprising 1,016,719

women with normal cytological findings. The estimated global HPV

prevalence was 11.7% (95% confidence interval, 11.6%–11.7%). Sub-

Saharan Africa (24.0%), Eastern Europe (21.4%), and Latin America

(16.1%) showed the highest prevalence. Age-specific HPV distribution

presented with a first peak at younger ages (<25 years) and, in the Americas

and Africa, a rebound at older ages (45 years). Among the women with type-

specific HPV data (n= 215,568), the 5 most common types worldwide were

HPV-16 (3.2%), HPV- 18 (1.4%), HPV-52 (0.9%), HPV-31 (0.8%), and

HPV-58 (0.7%).

Sofia et al., (2008) conducted a study on we analyzed data from

national databases to obtain mortality trends and regional variations using a

47
Poisson regression model based on location (urban-rural). During 1995-2005

a total of 48,761 cervical cancer (CC) deaths were reported in Mexico

(1995=4 280 deaths/year; 2005=4 620 deaths/year). On average, 12 women

died every 24 hours, with 0.76% yearly annual growth in CC deaths. Women

living in rural areas had 3.07 higher CC mortality risks compared to women

with urban residence. Comparison of state CC mortality rates (reference =

Mexico City) found higher risk in states with lower socio-economic

development (Chiapas, relative risk [RR]=10.99; Nayarit, RR=10.5).

Predominantly rural states had higher CC mortality rates compared to

Mexico City (lowest rural population).

Carmen (2008) conducted a study and observed a significant decline

in the incidence and mortality rates of cervical cancer in the United States

since the introduction of the Pap test. Unfortunately, a reduction in the

burden of cervical cancer is not equal across all ethnic and racial groups;

significant disparities exist. Disparities are reflected not only in mortality and

incidence rates, but also in screening rates.

Asmaa Haseeb Hwaid (2013) conducted a cross sectional study

about study 198 women, the age range was (17-60) years present results

show that the women demonstrated poor levels of knowledge about HPV and

cervical cancer, 106(53.54%) of them had heard about HPV, while, only

73(36.87%), 60(30.30%) knew that the cervical cancer and genital warts

caused by HPV respectively. This study showed that the participants had

very limited knowledge about pap smear, only 57(28.79%) knew that pap

48
smear is the test to detect abnormal cervical cells, the results show highest

level of knowledge and awareness about HPV, cervical cancer was among

health care workers group, participants who live in urban and married with

statistically significant difference (P<0.05), (P<0.01). Geetha Mani et al.,

(2012) conducted a descriptive, cross-sectional study conducted among 100

women attending a rural health centre, in Kancheepuram district, Tamil

Nadu between May and July 2012, using a semi-structured schedule. Among

the 100 participants, 74% were aware of the term cervical cancer. This

awareness was positively associated with higher levels of education,

socioeconomic status and occupational status (p< 0.05). Awareness about

symptoms (29.7%), risk factors (1.35%), Pap smear (14.9%), other screening

methods (13.5%) and treatment (4%) was low. None of the participants were

aware of human papilloma virus (HPV) vaccine and none had undergone

screening or immunization.

Habib Hasan Farooqui et al (2012) conducted a study to know the

most prevalent types of human papillomavirus in cervical cancer in India are

HPV 16 and HPV 18, found in 60.7 per cent and 16 per cent of cases

respectively. A comprehensive strategy with a judicious mix of interventions

on health promotion, specific protection (vaccination), early diagnosis

(screening), and treatment should be instituted to prevent and control

cervical cancer in India. Proponents of vaccination and screening argue for

enhanced investments on these interventions based on their relative cost-

effectiveness. For policymakers, the major concerns about these

interventions remain affordability and cost to government. Herein we try to

49
review comprehensively the evidence on prevention and control

interventions and to recommend appropriate policies to guide public health

decision-making.

2.2 Causes and Risk Factors of Cervical Cancer

Lia (2010) conducted a cross-sectional survey of risk factors for

cervical cancer in 1991 in one city and 12 villages in the province. A marked

decline in cervical cancer mortality rates was observed from 1970 to 1992 and

in successive birth cohorts from 1892 to 1927, and rates remained relatively

constant in subsequent birth cohorts through that of 1952. The percentages

of women with selected risk factors were lower in younger women (30–54

years) than in older women (55–69 years) in both cities and rural areas.

Biswas et al (2012) used a case-control design to a total of 268

subjects, comprising 134 women with invasive cervical cancer as cases and

134 control women were studied. A multiple logistic regression model was

used to analyses the data. In a multiple logistic regression model, independent

effects were observed for early age at first coitus, showing maximum risk in

women who reported their first intercourse at < 12 years of age, compared to

that of women at > or = 18 years (odds ratio [OR] = 3.5. 95% confidence

interval [CI]: 1.1-10.9). Increased risk was also seen for women who had

extramarital sex relationships (OR = 5.5, 95% CI: 1.5-19.5).

Austoker, (2011) conducted a study on women at National cancer

Institute of the NIM dealing with cervix cancer the exciting development of

50
vaccines for human papilloma virus (HPV). Both target HPV 16 and HPV 18

C account for about 70% of cases of cervical cancer. The merck vaccine also

target HPV 6 and HPVII account for about 90% of external genital warts.

M. Burd., (2010) studies the association between certain oncogenic

(high- risk) strains of HPV and cervical cancer. Although HPV is essential to

the transformation of cervical epithelial cells, it is not sufficient, and a variety

of cofactors and molecular events influence whether cervical cancer will

develop. Early detection and treatment of precancerous lesions can prevent

progression to cervical cancer. Identification of precancerous lesions has been

primarily by cytological screening of cervical cells. Cellular abnormalities,

however, may be missed or may not be sufficiently distinct, and a portion of

patients with borderline or mildly dyskaryotic cytomorphology will have

higher-grade disease identified by subsequent colposcopy and biopsy.

Sensitive and specific molecular techniques that detect HPV DNA and

distinguish high-risk HPV types from low-risk HPV types have been

introduced as an adjunct to cytology.

Gatune JW and Nyamongo (2005) conducted an ethnographic study

of cervical cancer among women in rural Kenya with question is there is a folk

causal model? One hundred and sixty women (mean age 37.9 years) who

sought various health care’s interviewed using a semi-structured

questionnaire. In addition, three focus group discussions (25 participants) were

held, five factors obtained from a group of 41 women respondents. All women

were aged between 20 and 50 years. About 40 percent knew about cervical

51
cancer, although many still lack factual information. A history of sexually

transmitted diseases (61.5%), multiple sexual partners (51.2%), and

contraceptive use (33%) were identified as risk factors.

Noureddine Chaouki, (2010), conducted A hospital-based case-control

study was. The study included 214 cases of invasive cervical cancer and 203

controls. A structured questionnaire was used to investigate known and

suspected risk factors for cervical cancer. In multivariate adjusted or HPV-

stratified analyses, in addition to the strong effect of HPV, other risk factors

identified were sexual intercourse with multiple partners before the age of 20

and low socio-economic status. Use of oral contraceptives for 5 or more years

and high parity were also found to be related to cervical cancer.

Huang, et al., (2010) conducted a study to evaluate the association

between HPV and cervical cancer in Chinese women, among the women who

lived in Shanghai, People's Republic of China. Biopsies from 40 women,

diagnosed with either squamous-cell carcinoma (n = 35) or adenocarcinoma (n

= 5) were tested for HPV DNA by PCR. The HPV types present in tumors

were determined either by hybridization of PCR products with HPV type-

specific probes or by PCR-based sequencing. A total of 35 of the 40 cervical

cancer specimens (87.5%) contained HPV DNA. In this population of Chinese

women with cervical cancer, HPV 52 and 58 were as prevalent as the “high-

risk” (for cervical cancer) viruses HPVs 16 and 18.

Bosch et al., (2009) conducted an Epidemiologic studies and showed

that the association of genital human papillomavirus (HPV) with cervical

52
cancer is strong, independent of other risk factors, and it is consistent in

several countries. There are more than 20 different cancer-associated HPV

types, More than 1000 specimens from sequential patients with invasive

cervical cancer were collected and stored frozen at 32 hospitals in 22

countries. Slides from all patients were submitted for central histologist

review to confirm the diagnosis and to assess histologist characteristics. A

generalized linear Poisson model was fitted to the data on viral type and

geographic region to assess geographic heterogeneity. HPV DNA was

detected in 93% of the tumors, with no significant variation in HPV

positivity among countries. HPV 16 was present in 50% of the specimens,

HPV 18 in 14%, HPV 45 in 8%, and HPV 31 in 5%. HPV 16 was the

predominant type in all countries except Indonesia, where HPV 18 was more

common.

Harry et al., (2009) conducted a study on Multi factorial Etiology of

Cervical Cancer, human papillomaviruses (HPV), especially HPV-16 and

HPV-18, play at least a major if not a necessary role in the etiology of

cervical cancer. However, many investigators acknowledge that HPV is not

sufficient to induce cervical cancer and that a multi factorial etiology is

likely. HPV can be found in a growing proportion of patients with cervical

cancer, approaching 100%, but is not yet found in every patient with disease.

Other factors, such as herpes simplex virus type 2 infections, cigarette

smoking, vaginal douching, nutrition, and use of oral contraceptives; have

been proposed as contributing factors.

53
 Angela et al., (2009) Conducted study among 16 573 women with

cervical cancer and 35 509 without cervical cancer were reanalyzed

centrally. Relative risks of cervical cancer were estimated by conditional

logistic regression, stratifying by study, age, and number of sexual partners,

age at first intercourse, parity, smoking, and screening. Among current users

of oral contraceptives the risk of invasive cervical cancer increased with

increasing duration of use (relative risk for 5 or more years' use versus never

use, 1•90 [95% CI 1.69—2.13]). The risk declined after use ceased, and by

10 or more years had returned to that of never users. A similar pattern of risk

was seen both for invasive and in-situ cancer, and in women who tested

positive for high- risk human papillomavirus. Relative risk did not vary

substantially between women with different characteristics.

Moreira ED et al., (2006) conducted a cross-sectional study on

“Assessment of knowledge and attitude of young uninsured women toward

human Papilloma virus vaccination and clinical trials”, Brazil. The sample

consisted of 204 women aged 16 to 23 years, attending a public outpatient

gynecological clinic. A questionnaire was administered by in person

interview. Data on knowledge and attitudes towards HPV vaccination was

collected. Overall, 72 percent of the respondents would enroll in a HPV

vaccine trail, despite the fact that 69percent of women were ignorant of what

HPV may cause, and only 10percent acknowledged that HPV might ledad to

cervical cancer. The need of a placebo arm(31%) and three vaccinations

injections (25%) were the trial design characteristics most cited for deterring

participation. Factors promoting participation were “Careful/detailed

54
consultations by the same physician” (92%), “access to more information on

women’s health” (84%), and “Office visits on time” (79%); whereas “clinic

too far from home” (36%) , “fear of adverse events”(29%), and

“Gynecologic examination discomfort (25%) were the most commonly

reported reasons for not enrolling in a trial. Being sexually active, more than

three lifetime sexual partners and perception of high risk for cervical cancer

were predictors of participation in a HPV vaccine trial urban, young

populating. Thus, when planning HPV vaccine trial. Knowledge of HPV

infection and cervical cancer was low in this urban, young population. Thus

when planning HPV vaccine trials, it was important to “consider implementing

educational programs to provide knowledge of the benefits of preventive

vaccine and information on the etiology of and risk factors for cervical

cancer.

Apple et al., (2006) conducted a study to find the association between

tobacco smoking and cervical cancer, The International Collaboration of

Epidemiological Studies of Cervical Cancer has brought together and

combined individual data on 13,541 women with and 23,017 women

without cervical carcinoma, from 23 epidemiological studies. Relative risks

(RRs) and 95% confidence intervals (CIs) of carcinoma of the cervix in

relation to tobacco smoking were calculated with stratification by study, age,

sexual partners, age at first intercourse, oral contraceptive use and parity.

Current smokers had a significantly increased risk of squamous cell

carcinoma of the cervix compared to never smokers (RR = 1.60 (95% CI:

1.48-1.73), p<0.001). There was increased risk for past smokers also, though
55
to a lesser extent (RR = 1.12 (1.01-1.25). In current smokers, the RR of

squamous cell carcinoma increased with increasing number of cigarettes

smoked per day and also with younger age at starting smoking (p<0.001 for

each trend), but not with duration of smoking (p- trend = 0.3). Eight of the

studies had tested women for cervical HPV-DNA, and in analyses restricted

to women who tested positive, there was a significantly increased risk in

current compared to never smokers for squamous cell carcinoma (RR = 1.95

(1.43-2.65).

Xavier castellsague and Nubia Munoz, (2003) conducted large

prospective and retrospective cohort studies on cofactors in Human

popilloma virus carcinogenesis, role of parity oral contraceptives and

tobacco smoking. Among middle-aged women in which several markers of

HPV exposure are used and HPV persistence is documented it would b e

valuable to study the role of these and other cofactors in HPV

carcinogenesis, multiparous women who are smokers, and women on long-

term oral contraceptive pills use may need close surveillance for cytologic

abnormalities and HPV infections than women in the general population.

Chichareon et al., (1998) conducted a hospital-based, case-control

study of invasive cervical cancer to investigate risk in relation to HPV

infection and its epidemiologic cofactors in Hat-Yai, Thailand. A total of 338

patients with squamous cell carcinoma, 39 patients with adenocarcinoma,

and 261 control subjects were included in the study and were interviewed to

obtain information with regard to cervical cancer risk factors, HPV DNA

56
was detected in 95% of patients with squamous cell carcinoma, 90% of those

with adenocarcinomacarcinoma, and 16% of control subjects. For patients

with squamous cell carcinoma, the most common types of HPV found were

type 16 (60% of the positives), type 18 (18%), type 58 (3%), type 52 (3%),

and type 31 (2%). For patients with adenocarcinoma, the most common

HPV types found were type 18 (60% of the positives), type 16 (37%), and

type 45 (3%).

Ravikiran et al., (2013) conducted a cross-sectional study among 345

village women of age group 15 years and above using systematic random

sampling technique by a predesigned and a pretested questionnaire. Data was

analyzed using SPSS version 17 for windows. The risk factors of carcinoma

cervix like multiple sexual partners, smoking tobacco and prolonged use of

Oral Contraceptive Pills (OCPs) for a period of 5 or more years for family

planning were known to majority of the rural women. Misconceptions about

carcinoma cervix like screening for carcinoma cervix, Intra Uterine Devices

(IUDs) usage, Use of tampons and herbs was seen in a maximum proportion

of the village women.

Sing, et al., (2012), conducted a Epidemiological Study of Various

Risk Factors For Carcinoma Cervix of 813 women at the outpatient

department (OPD), smears of the women who were suspected for carcinoma

on clinical examination were confirmed by the cyto pathological

investigations and were found to be the cases of SIL (Squamous Intraepithelial

Lesion) (90; 11.68%) and carcinoma cervix (4; 0.51%). The compatibility

57
between histology and cytology was 100% in the 3 cases of the 4 cases of

frank carcinoma cervix diagnosed on cytology. Study revealed greater age,

higher parity, early marriage, poor educational status, rural habitation,

sexually transmitted infections (mainly HPV; Human Papilloma Virus),

clinical lesions of the cervix and ethnic groups variation as the predominant

factors in the path of cervical carcinogenesis.

Jissa V Thulaseedharan (2012) conducted a study on Socio

demographic and reproductive potential risk factors for cervical cancer were

studied using the data from a cohort of 30,958 women who constituted the

unscreened control group in a randomized screening trial in Dindigul district,

Tamilnadu, India. The analysis was accomplished with the Cox proportional

hazard regression model. Women of increasing age (HR=2.4; 95% CI: 1.6,

3.8 in 50-59 vs 30-39), having many pregnancies (HR=7.1; 1.0, 52 in 4+ vs

0) and no education (HR=0.6; 0.2, 0.7 in high vs. none) were found to be at

significantly increased risk of cervical cancer. This cohort study gives very

strong evidence to say that education is the fundamental factor among the

socio demographic and reproductive determinants of cervical cancer in low

resource settings.

Singh (2012) conducted a prospective analysis of a total number of

813 women, those underwent gynecological examination from May-August,

2010 at the from outpatient department (OPD), of Obstetrics and

Gynecology, JA Groups of Hospitals, Gwalior for cervical pap smears, taken

as a part of their routine check-up. Smears of the women who were suspected

58
for carcinoma on clinical examination were confirmed by the

cytopathological investigations and were found to be the cases of SIL

(Squamous Intraepithelial Lesion) (90; 11.68%) and carcinoma cervix (4;

0.51%). The compatibility between histology and cytology was 100% in the

3 cases of the 4 cases of frank carcinoma cervix diagnosed on cytology.

Study revealed greater age, higher parity, early marriage, poor educational

status, rural habitation, sexually transmitted infections (mainly HPV; Human

Papilloma Virus), clinical lesions of the cervix and ethnic group’s variation

as the predominant factors in the path of cervical carcinogenesis.

2.3 Signs and Symptoms of Cervical Caner

Nwozor et al ., (2014) conducted a study on awareness of cervical

cancer screening and uptake among women in Onitsha, Anambra State,

Nigeria. Data were collected using close-ended structured questionnaires.

450 questionnaires, based on completeness were analyzed. Percentages were

calculated and expressed in simple descriptive statistics. Results showed that

the awareness of cervical cancer screening was 160 (35.56%), while 8

(1.78%) had done the test. The reasons for not doing the test were: cost 70

(15.84%), lack of facility 70 (15.84%), lack of awareness 228 (51.58%),

distance 13 (2.94%), do not think it is necessary 52 (11.76%), no reason 9

(2.04%). Majority of the respondents were traders 120 (26.67%) and

students 119 (26.44%). 133 (29.56%) had secondary education, while 284

(63.11%) had tertiary education.

Gyenwali et al., (2014) conducted a cross-sectional descriptive study

59
conducted in two tertiary cancer hospitals of Nepal. Face to face interview

and medical records review were carried out among 110 cervical cancer

patients. Total diagnostic delay was categorized into component delays:

patient delay, health care providers delay, referral delay and diagnostic

waiting time. Total 110 patients recruited in the study represented 40 districts

from all three ecological regions of the country. Median total diagnostic

delay was 157 days with more than three fourth (77.3%) of the patients

having longer total diagnostic delay of >90 days. Out of the total diagnostic

delay, median patient delay, median health care provider delay, median

referral delay and median diagnostic waiting time were 68.5 days, 40 days, 5

days and 9 days respectively. Majority of the patients had experienced longer

delay of each type except referral delay. Fifty seven percent of the patients

had experienced longer patient delay of >60 days, 90% had suffered longer

health care provider delay of >1 week, 31.8% had longer referral delay of

>1 week and 66.2% had waited >1 week at diagnostic center for final

diagnosis. Variation in each type of delay was observed among women with

different attributes and in context of health care service delivery.

Raychaudhur et al., (2012) Conducted study on community-based

cross- sectional study. Among 133 women in a rural area (Kawakhali) and 88

women in an urban slum (Shaktigarh) using predesigned semi-structured

questionnaires. The respondents were informed of the causes (including

HPV), signs and symptoms, prevention of cervical cancer and treatment, and

the procedure of the Pap test and HPV vaccination. The prevalence of risk

factors like multiparty, early age of marriage, use of cloth during

60
menstruation, use of condom and OCP, early age of first intercourse was

37.2%, 82%, 83.3%, 5.4%, 15.8% and 65.6% respectively. Awareness about

the cause, signs and symptoms, prevention of cervical cancer, Pap test and

HPV vaccination was 3.6%, 6.3%, 3.6%, 9.5% and 14.5% respectively. Chi-

square testing revealed that in the study population, significant differential at

5% exists between rural and urban residents with respect to number of

children, use of cloth/sanitary napkins, family history of cancer and

awareness regarding causes of cervical cancer.

Eleanor et al., (2012) conducted a study to explore factors that

contribute to delay in seeking early diagnosis and treatment of cervical

cancer among women in Malawi. In-depth interviews were conducted using

a semi-structured interview guide on a purposive sample of 24 women who

were diagnosed of cervical cancer at the gynaecological wards of Zomba and

Queen Elizabeth Central Hospitals in Malawi between July and September,

2011. The individual factors included; limited knowledge on symptoms and

signs and limited financial resources. The health facilities factors included;

limited accessibility and unavailability of cancer screening facilities in the

health centers. Results show that there is a need to strengthen the screening

of cervical cancer among women in the country. In addition, there is a need

to create community awareness on the signs and symptoms of cervical cancer

and the merits of seeking early diagnosis and treatment.

Schalkwyk, et al., (2008) conducted a qualitative study in 2007, using

semi- structured interviews with 15 women with advanced cervical cancer, to

61
understand the routes they followed from first signs and symptoms of disease

to receiving treatment. The willingness of the women to be diagnosed was a

positive finding of the study. The women did seek treatment, often more than

once. The average number of months from first contact with a health care

professional until diagnosis was 17.3, ranging from 11.8 months for urban

participants to 28.4 months for rural participants, and three to seven months

from diagnosis to referral for treatment. Lack of knowledge and awareness

among health care professionals resulted in a low suspicion of cancer and

misdiagnosis. A national cervical cancer strategy, including health education

and re- training of health professionals, should be made a priority.

2.4 Cervical Cancer Screening and Diagnosis

Castanon et al., (2014) conducted a study on 1,341 women at age 65–

83 years can were randomly selected from population registers. Depended on

the age mix of women because of the weakening association with time since

last screen: OR = 0.11, 95% CI 0.08–0.14 at 2.5 to 7.5 y since last screen;

OR = 0.27, 95% CI 0.20– 0.36 at 12.5 to 17.5 y since last screen. Screening

at least every 5.5 y between the ages 50 and 64 y was associated with a 75%

lower risk of cervical cancer between the ages 65 and 79 y (OR = 0.25, 95%

CI 0.21–0.30), and the attributable risk was such that in the absence of

screening, cervical cancer rates in women aged 65+ would have been 2.4

(95% CI 2.1–2.7) times higher. In women aged 80–83 y the association was

weaker (OR = 0.49, 95% CI 0.28–0.83) than in those aged 65–69 y (OR =

0.12, 95% CI 0.09–0.17).

62
 Change et al., (2013) conducted a study on Chinese women

experienced Pap testing The women were invited to partake in the focus

groups from having participated in a large-scale quantitative study.

Participants were all first-generation immigrants and their average age was

53-years-old. We used content analyses to analyze transcripts and extract

themes. The women heavily endorsed traditional Chinese medicine

philosophy, conceptualizing physical health holistically, and valuing

preventative measures over screening and interceptive measures. Pap testing

was described as qualitatively different from other screening procedures,

such that women assigned a sexually charged meaning to Pap testing, often

discussing it in relation to sexual activity and promiscuity.

Hazra et al., (2013) conducted a study among 300 females, 63.4%

(190/300) were aged between 40 and 59 years. Nearly, 70.7% were illiterate

and 52.6% had monthly family income between Rs. 2,000 and 5,000.

Majority was married and 72.7% had parity between 1 and 3 and 58.7% had

early marriages. Unaided visual examination of the women showed 62.7% of

them had visible growth and 48.7% of them had bleeding erosions. Visible

growths along with bleeding erosions were present in 11.3% cases. Histo

pathological examination of cervical biopsy specimens revealed mild,

moderate and severe dysplasia in 14, 22 and 36 cases, respectively. A total of

212 patients had invasive squamous cell carcinoma. Only 16 patients had

normal histopathology findings. Nearly, 56.61% had Stage II disease; among

them 27 had Stage IIa and 33 had Stage IIb disease, 26 patients had Stage I

disease. Stage IIIa and IIIb have been found in 50 and 12 cases respectively.
63
Four cases had cancer extending to urinary bladder and rectum (Stage IVa).

Ugwu, et al., (2013), Questionnaires were administered 177 female

health- care workers selected systematically from the University of Nigeria

The awareness of screening for cervical cancer (91%) was significantly

higher than that of the HPV vaccine (62.7%) [odds ratio (OR): 0.17; 95%

confidence interval (CI): 0.09-0.30]. However, the acceptability rate of the

HPV vaccine (91.0%) was significantly higher than that of cervical screening

(71.4%) (OR: 4.04;95% CI: 1.94-8.42)]. Only 25 (14.1%) of the health-care

workers had done cervical screening, but 30 (49.2%) of the 61respondents

with adolescent daughters had immunized their daughters with the HPV

vaccine.

Muhamed et al., (2013) conducted a study to explore the knowledge

and awareness about cervical cancer among Iraqi women living in Malaysia.

A self- administrated Arabic version questionnaire distributed among 142

Iraqi women in Malaysia. One hundred and eight participants ranging in age

from 18 to 61 years (Mean = 36.1) returned the completed questionnaire. A

lack of knowledge on cervical cancer and the Pap smear test was found

among the respondents. Many women did not have a clear understanding of

the meaning of an abnormal cervical smear and the need for the early

detection of cervical cancer. These findings emphasize the need to educate

and promote awareness among immigrant Iraqi women in Malaysia to risk

factors for cervical cancer and to the need and the purpose of Pap smear

screening.

64
 Begum et al., (2013) conducted a study with a quasi-experimental

design. Women aged between 18 to 49 years and their husbands were

randomly selected for the survey. Pre and post intervention survey was

conducted to see the impact of intervention on creating awareness and

utilization of Pap smear services. Multilevel intervention program was

adopted to achieve the objectives. The results showed a significant increase

in awareness about cervical cancer among couples was observed from pre

(5.5%) to post (97.7%) intervention survey. About 32.2% women were found

to be infected with HPV.

Swaddiwudhipong et al., (2012) conducted a study to evaluate the

effect of the program on changes in knowledge and use of screening by

comparing the results of three interview surveys of women, 18-65 years old,

in villages selected by systematic sampling for each survey; first in 1991

(before the operation of the program), secondly in 1994 (one year after the

first screening campaign), and last in 1997 (one year after the second

campaign). This report also compares data on Pap smears taken by the

mobile unit with other existing screening services in the study area. A total

of 1603, 1369, and 1576 women respectively, participated in each survey.

The proportion of women reported knowing of the Pap smear test increased

from 20.8% in 1991 to 57.3% in 1994 and to 75.5% in 1997. The proportion

of women who had ever had a Pap smear increased from 19.9% in 1991 to

58.1% in 1994 and to 70.1% by 1997. Screening by the mobile unit

accounted for 85.2% of all cervical intraepithelial neoplasia (CIN) III and all

invasive cancers identified among the Pap smears taken by screening

65
services in the area between 1992 and 1996. The rate of CIN III was

3.5/1000 smears in this screening program, which was 5.2 and 2.0 times

higher than the rates in the maternal and child health/family planning clinic

and the annual one-week mass screening campaign respectively.

Rathodome et al., (2011) conducted a study on large cluster-

randomized, controlled trial of a single round of HPV testing, cytology

testing or visual inspection with acetic acid - with appropriate treatment for

those confirmed positive - as interventions to decrease mortality from

cervical cancer. The control arm did not receive any screening or treatment.

Several issues are brought up through the approval and conduct of this trial,

which was carried out among high-risk women in rural Maharashtra, India.

Specifically, this trial offers an opportunity to further discussion around

clinical equipoise, identification of primary endpoints, observation of null

effects, and the informed consent process, within the context of a low-

income setting. Such discourse may shed light on the necessity and manner

of examining a biomedical intervention in low-income settings, when the

intervention is already considered efficacious in high-income settings.

D Moon et al., (2011) conducted a study on 4651 women using VIA

in Zambézia Province. VIA was judged positive for squamous intraepithelial

lesions in 8% (n=380) of the women (9% if age ≥30 years (n=3154) and 7%

if age <30 years (n=1497); p=0.02). Of the 380 VIA-positive women, 4%

(n=16) had lesions (0.3% of 4651 total screened) requiring referral to

Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were

66
seen at the hospital, but records were inadequate to judge outcomes. Of

women screened, 2714 (58%) either had knowledge of their cervical cancer

prevention.

Catherine et al., (2011) conducted a study on a cross-sectional self-

administered questionnaire in 5 parts with 46 items regarding cervical cancer

etiology and prevention was addressed to healthcare workers in six hospitals

of Yaoundé, Cameroon. Eight hundred and fifty questionnaires were

distributed, 401 collected. Data were analyzed with SPSS version 16.0. Chi-

square tests were used and P-values < 0.05 were considered significant.

Mean age of respondents was 38 years (range 20- 71 years). Most

participants were aware that cervical cancer is a major public health concern

(86%), were able to identify the most important etiological factors (58%) and

believed that screening may prevent cervical cancer (90%) and may be

performed by Pap test (84%). However, less than half considered VIA or

HPV tests screening tests (38 and 47%, respectively). Knowledge about

cancer etiology and screening was lowest among nurse/midwives.

Sheona et al., (2011) conducted a study on 300 women aged 30 to 65

years who lived and/or worked in this community. Descriptive data and

multivariate modeling were used to identify the predictors of the women's

willingness to collect their own cervical samples. More than 80% of the 300

participants were willing to collect their own samples. In multivariate

modeling, factors positively associated with this willingness were agreement

to let outreach workers deliver the necessary swab at their homes (adjusted

67
odds ratio [AOR], 4.10; 95% confidence interval [CI], 1.83– 9.18) and

willingness to undergo a pelvic examination if the sample was abnormal

(AOR, 3.91; 95% CI,1.03–14.90). Factors negatively associated were

embarrassment at collecting the sample at home where they lacked privacy

(AOR, 0.09; 95% CI, 0.03–0.29) and concern of not collecting the sample

properly (AOR, 0.1; 95% CI, 0.05–0.3).

Ibrahim, (2011) conducted a cross-sectional prospective study of 100

asymptomatic women. The patients underwent a complete gynecological

examination and filled in a questionnaire on risk factors and feasibility and

acceptability. They were screened for cervical cancer by application of 3%–

5% VIA. Women with a positive test were referred for colposcopy and

treatment. Sixteen percent of screened women were tested positive.

Statistically significant associations were observed between being positive

with VIA test and the following variables: uterine cervix laceration (odds

ratio [OR] 18.6; 95% confidence interval [CI]: 4.64–74.8), assisted vaginal

delivery (OR 13.2; 95% CI: 2.95–54.9), parity (OR 5.78; 95% CI: 1.41–

23.7), female genital mutilation (OR 4.78; 95% CI: 1.13–20.1), and

episiotomy (OR 5.25; 95% CI: 1.15–23.8).

Hounsagaard et al., (2010) conducted a study focus-group interviews

with and 2 individual interviews with Greenlandic-speaking women. The

analysis involved a phenomenological-hermeneutic approach with 3 levels of

analysis: naive reading, structural analysis and critical interpretation. These

revealed that women were unprepared for screening results showing cervical

68
cell changes, since they had no symptoms. When diagnosed, participants

believed that they had early-stage cancer, leading to feelings of vulnerability

and an increased need to care for themselves. Later on, an understanding of

HPV as the basis for diagnosis and the realization that disease might not be

accompanied by symptoms developed. The outcome for participants was a

life experience, which they used to encourage others to participate in

screening and to suggest ways that information about screening and HPV

might reach a wider Greenlandic population.

Wyshak, G. (2010) Studies have shown that human papilloma virus

(HPV) infection is responsible for more than 90% of the cases of invasive

cervical cancer worldwide, and it is related to 80% of pre-cancerous changes

in the cervix. There is a vaccine that helps prevent cervical cancer and other

conditions caused by certain types of Human Papillomavirus (HPV). The best

time to get vaccinated is before you come in contact with the HPV virus.

Cervical cancer can be prevented by identifying pre-cancerous lesions early

using repeated paponicolaou smear screening and treating these lesions before

they progress to cancer. In the United States, the introduction of the

paponicolaou smear has been responsible for a 90% decrease in deaths from

cervical cancer. In Australia, 85%of the women who die of cervical cancer

have not had regular paponicolaou smears and about 50% of them have never

had a paponicolaou smear at all.

Sasieni, et al., (2009) conducted a Population based case-control study

on 4012 women aged 20-69 with invasive cancer diagnosed in participating

69
centre’s and two controls per case individually matched on age and area of

residence. cervical cancer at ages 25-29 (odds ratio 1.11, 95% confidence

interval 0.83 to 1.50). Screening was associated with a 60% reduction of

cancers in women aged 40, increasing to 80% at age 64. Screening was

particularly effective in preventing advanced stage cancers. Cervical screening

in women aged 20-24 has little or no impact on rates of invasive cervical

cancer up to age 30.

Mues, et al., (2008), systematically reviewed all studies examining

socio-cultural factors influencing cervical cancer screening among immigrant

and ethnic minorities, fatalistic attitudes, a lack of knowledge about cervical

cancer, fear of Pap smears threatening one's virginity, as well as beliefs that a

Pap smear is unnecessary unless one is ill. Beliefs unique to specific cultural

groups included: as childbirth, menses, sex, and stress were considered to play

a role in one's susceptibility to cancer. African Americans identified

administrative processes in establishing health care as barriers.

Ezem (2007) conducted a cross sectional study in which self

administered questionnaires returned by eight hundred and forty six

respondents were analyzed using simple percentages. The level of awareness

of cervical screening was 52.8 %( 447), while 7.1 %( 60) had ever done the

test. The major sources of information about cervical smear were hospital

/health facilities (31.3%) and friends (30.9%).The most common reasons given

for not doing the test were lack of awareness 390(46.1%),no need for it 106(

12.5%) and fear of a bad result 98(11.6%).

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 Castellsague, et al., (2002) conducted a study on 1913 couples enrolled

in one of seven case–control studies of cervical carcinoma in situ and cervical

cancer in five countries. Circumcision status was self-reported, and the

accuracy of the data was confirmed by physical examination at three study

sites. The presence or absence of penile HPV DNA was assessed by a

polymerase-chain-reaction assay in 1520 men and yielded a valid result in the

case of 1139 men (74.9 percent). Penile HPV was detected in 166 of the 847

uncircumcised men (19.6 percent) and in 16 of the 292 circumcised men (5.5

percent). After adjustment for age at first intercourse, lifetime number of

sexual partners, and other potential confounders, circumcised men were less

likely than uncircumcised men to have HPV infection (odds ratio, 0.37; 95

percent confidence interval, 0.16 to 0.85). Monogamous women whose male

partners had six or more sexual partners and were circumcised had a lower

risk of cervical cancer than women whose partners were uncircumcised

(adjusted odds ratio, 0.42; 95 percent confidence interval, 0.23 to 0.79).

Smita et al., (2013) a carried out cross sectional community based

study 415 women, of them 263(63.4%) had one or more symptoms of

reproductive tract infections. On examination, 69(35%) had cervicitis

and30(15.2%) pelvic inflammatory disease, 39(19.8%) bacterial vaginosis and

candidiasis in 61(31%). Cervical erosion was present in 147(74.6%) women.

On Pap smear, 20(10.2%) women had ASCUS (Atypical squamous cells of

undetermined significance). Only 2(1%) women found HIV positive. No

woman was found VDRL reactive.

71
 Sankaranarayanan et al., (2013) conducted a study on a cluster

randomized controlled trial in south India. Women aged 30-59 years in 113

clusters in Dindigul District were randomized to VIA screening by nurses (57

clusters, 48,225 eligible women) and to a control group (56 clusters, 30,167

women). 30,577 (63.4%) eligible women participated in screening. Younger,

educated, married, multi parous, low- income women and those who have had

tubal sterilization had a higher compliance with screening. Of the 2069 women

diagnosed with CIN and invasive cancer, 1498 (72.4%) received treatment.

Young women, those who practiced contraception and women with high-grade

precursor lesions and invasive cancers were more likely to comply with

treatment.

Aswathy et al., (2012) conducted a cross-sectional study in Vypin

Block of Ernakulam District, Kerala, India where four of the seven Panchayats

were randomly chosen. Households were selected by systematic random

sampling taking every second house in the tenth ward of the Panchayat till at

least 200 women were interviewed. Thus, 809 women were interviewed from

four Panchayats. Mean age of the study population was 34.5 + 9.23 yr. Three

fourths of the population (74.2%) knew that cervical cancer could be detected

early by a screening test. Majority of respondents (89.2%) did not know any

risk factor for cervical cancer. Of the 809 women studied, only 6.9 per cent

had undergone screening. One third of the population were desirous of

undergoing screening test but had not done it due to various factors. These

factors related to knowledge (51.4%) such as no symptoms, not being aware of

Pap test, not necessary, etc. This was followed by resource factors (15.1%)
72
like no time, no money, etc. and psychosocial factors (10.2%) included lack of

interest, fear of procedure, etc. Independent predictors for doing Pap test

included age >35, having knowledge of screening for cervical cancer and Pap

test (P<0.05).

Singh et al., (2012) conducted a study on through an in-depth

questionnaire used in Obstetrics and Gynecology OPD, Gwalior, India on a

total of 813 women with a modal average age of 35.51 ± 10.64 years. We

found a large amount of lack in awareness and perception in Indian women.

Surprisingly all women presented were married. Only 9.59% of women had

ever heard of cervical cancer, mostly belonging to upper socioeconomic group

with only 11.62% underwent at least one cervical screening in their life time.

None of them reported exact purpose of the Pap test. Male partner were the

sole decision maker of the family in 47.20% women. 73.65% of the

respondents were using clothes instead of tampons or sanitary pads during

menstruation.

Shetty (2011) conducted a community based cross-sectional study

among 30- 65 years old married women in the field practice area of a tertiary

health care center. A pre-designed questionnaire was administered to collect

information on socio- demographic and reproductive characteristics from 316

women. They were tested for the presence of pre-malignant lesions of the

cervix using Pap smear and VILI as screening tools. The VILI test was

positive among 24 (7.6%) women and positivity was found to be more in the

age group of 50 years and above, and among women from low socio-

73
economic status. But the observed variations were statistically insignificant.

None of the Pap smears showed any epithelial cellular abnormalities.

Elizabeth et al., (2011) conducted a study on Cervical cancer is a

common disorder worldwide. Screening and treatment paradigms in highly

developed countries have dramatically decreased disease prevalence and the

implementation of preventive vaccination against high risk human

papillomavirus (HPV) subtypes should decrease prevalence even further.

Promising advances are also being made toward the development of a

therapeutic vaccine for cervical neoplasia. Under-resourced countries suffer

from an inability to implement many of the approaches to prevention and

diagnosis that have proved successful in countries with adequate resources.

Several protocols are presently being developed that are low cost and require

minimal training and infrastructure that may allow low-resource areas to

begin to improve the early diagnosis of low and moderate grade cervical

neoplasia.

Pragya Sharma (2011) conducted a community based cervical cancer

screening programmed among women of Delhi using camp approach,

Maulana Azad Medical college ,cross section studies were carried out infield

practice areas .The awareness campus were organized ,majority 98.7% of the

women attending the camp were in reproductive age group 15-44 years and

illiterate .A significant association between high parity and cervical cancer

had been reported.

Chankapa et al., (2011) conducted a study on Nine hundred and

74
sixty-eight adult women in the age group 15−60 years by simple random

sampling technique in a population based descriptive cross-sectional study in

a cervical cancer screening camp in a primary health center at the East

Sikkim. Main outcome measures were the extent and correlates of cervical

cancer without any interventions.. Information on socio- demographic and

reproductive variables was collected by interview method using this

questionnaire. Out of 968 women in the study population, overwhelming

majority 921 (95.15%) had no overt or pre-cancerous cervical lesion. Only

47 were found to have changes in their cervical epithelium. None of these 47

women was proved dyskaryotic on cytopathological screening of the cervical

smear.

Rengaswamy et al., (2009) conducted a study on in this cluster-

randomized trial, 52 clusters of villages, with a total of 131,746 healthy

women between the ages of 30 and 59 years, were randomly assigned to

four groups of 13 clusters each. The groups were randomly assigned to

undergo screening by HPV testing (34,126 women), cytological testing

(32,058), or VIA (34,074) or to receive standard care (31,488, control

group). Women who had positive results on screening underwent colposcopy

and directed biopsies, and those with cervical precancerous lesions or cancer

received appropriate treatment. In the HPV-testing group, cervical cancer

was diagnosed in 127 subjects (of whom 39 had stage II or higher), as

compared with 118 subjects (of whom 82 had advanced disease) in the

control group (hazard ratio for the detection of advanced cancer in the HPV-

testing group, 0.47; 95% confidence interval [CI], 0.32 to 0.69). There were
75
34 deaths from cancer in the HPV-testing group, as compared with 64 in the

control group (hazard ratio, 0.52; 95% CI, 0.33 to 0.83).

Eleanor Chadza et al ( 2012) conducted a semi-structured interview

guide on a purposive sample of 24 women who were diagnosed of cervical

cancer at the gynecological wards of Zomba and Queen Elizabeth Central

Hospitals in Malawi between July and September, 2011. Results show that

there is a need to strengthen the screening of cervical cancer among women

in the country. In addition, there is a need to create community awareness on

the signs and symptoms of cervical cancer and the merits of seeking early

diagnosis and treatment.

Chukwuemeka Anthony Iyoke et al (2013) Cervical cancer accounts

for over 60% of the gynaecological cancer burden in developing countries

despite being preventable by current technologies. This is due to the absence

of effective nationally organized screening programs in most developing

countries. Institution of such programs, therefore, has the potential to

dramatically reduce gynecological cancer burden in these countries.

Subsidized human papilloma virus (HPV) vaccine and HPV typing as well as

cheap screening techniques such as visual inspection aided with acetic acid

hold the key to effective prevention of cervical cancer in these countries.

This is because a significant proportion of patients in developing countries

are unable to access and avail themselves of the few available preventive,

diagnostic and treatment services because of poverty. Although, advocacy

and the political will to invest in the development of human resources and

76
healthcare infrastructure appear critical to gynaecological cancer control and

reducing the burden of disease in many developing countries, the proposition

assumes that resources are truly available for this investment.

Aruna Nigam et al., (2014) conducted a study to know role of human

papilloma virus (HPV) in the genesis of cervical carcinoma is well

documented. The HPV 16 and 18 are found to be most commonly associated

with invasive cervical carcinoma. The advent of cervical carcinoma vaccine

has advanced the hopes that eradication of cervical carcinoma might be

possible in future. The scenario of prevention of cervical carcinoma is

completely different in developed and developing countries. The

implementation of the vaccination as a routine in India is still controversial.

Here we have tried to critically analyze these issues in Indian context.

However it is clear that cervical cancer vaccine is not an immediate panacea

and cannot replace the cervical cancer screening which is mandatory in

Indian context.

2.5 Barriers and Benefits of Cervical Cancer Screening

Jia et al., (2013) conducted a cross-sectional survey of women

conducted to determine their knowledge about cervical cancer and screening,

demographic characteristics and the barriers to screening. Women who were

willing to undergo screenings had higher knowledge levels. “Anxious feeling

once the disease was diagnosed” (47.6%), “No symptoms/discomfort”

(34.1%) and “Do not know the benefits of cervical cancer screening”

(13.4%) were the top three reasons for refusing cervical cancer screening.

77
Women who were younger than 45 years old or who had lower incomes,

positive family histories of cancer, secondary or higher levels of education,

higher levels of knowledge and fewer barriers to screening were more

willing to participate in cervical cancer screenings than women without these

characteristics.

Williams et al., (2013), conducted a Semi-structured interviews with

49 Ghanaian women with cancer and 171 Ghanaian women who did not

have cancer. The quantitative analysis indicated that cancer patients were not

more likely to have greater knowledge of cancer signs and symptoms than

women without cancer. Analysis of the qualitative data revealed several

psychological barriers to cervical cancer screening including, common myths

about cervical cancer, misconceptions about cervical cancer screening, the

lack of spousal support for screening, cultural taboos regarding the gender of

healthcare providers, and the stigmatization of women with cervical cancer.

Garbanati, et al., (2013) conducted study on ninety-seven women of

Mexican origin participated in 12 focus groups exploring barriers to

screening. All participants knew what a Pap test was and most knew its

purpose. More acculturated participants understood the link between HPV

and cervical cancer. More recent immigrants did not. Most frequently

mentioned barriers were lack of time and concern over missing work. Lower

income and less acculturated women were less likely to be aware of

free/low-cost clinics. Older and less acculturated participants held more

fatalistic beliefs, were more embarrassed about getting a Pap test, were more

78
fearful of being perceived as sexually promiscuous, and were more fearful of

receiving disapproval from their husbands.

Julinawati et al., (2013) conducted a study perceived barrier constructs

within the aforementioned model in order to understand reasons that might

contribute to the consistency of Pap smear uptake. Previous use of HBM has

shown that the main cause underpinning in affecting change is to alter

behavior (Webb and Sheeran, 2006). While use of HBM has made a positive

influence on behavioral change by way of ‘cues to action’ element in its

construct, the cues to action effect could be as good or as bad as the

receivers’ perception (Rosenstock et al., 1994). It appears that HBM does not

work when it comes to non-health behavior prediction (GALVIN KT, 1992)

through a comprehensive literature review was carried out to identify,

analyze, synthesize and evaluate the best-published information scholars,

researchers and practitioners published in this subject area (Fink, 2009).

Watkins et al., (2012) conducted a study using direct interviews to

learn about factors that may influence cervical cancer screening among rural

Mexican women. We interviewed 97 rural women between the ages of 16

and 66 were interviewed and found that 52% had not received a Pap smear

within the last 2 years (of that group, 62% had never received a Pap smear).

In our sample, the most frequent reason for not obtaining a Pap smear was

anxiety regarding physical privacy (50%). Less frequent reasons were lack of

knowledge (18%) and difficulty accessing health care (14%). Women who

had delivered children were significantly more likely to have received a Pap

79
smear (71%) than women who had no children (10%), P < 0.05. The

responses of many women suggest that compliance with cervical cancer

screening would be enhanced by addressing cultural beliefs, encouraging

conversations about women's health issues, and increasing the number of

female health care providers.

Fort et al., (2011) study was to know how women in rural Malawi

make health-seeking decisions regarding cervical cancer screening using

qualitative research methods. This study found that the primary cue to action

for cervical cancer screening was symptoms of cervical cancer. Major

barriers to seeking preventative screening included low knowledge levels,

low perceived susceptibility and low perceived benefits from the service.

Study participants did not view cervical cancer screening as critical health

care. Interviews suggested that use of the service could increase if women

are recruited while visiting the hospital for a different service.

Were et al., (2011) conducted a Cross-sectional questionnaire survey

involving a consecutive sample of 219 consenting women about perceptions

on cervical cancer risk, barriers to screening and previous screening. Out 219

women interviewed, 12.3% of participants had screened before. Women of

over 30 years were more likely to have screened before (p=0.012). While

22.8% felt that they were at risk of the cervical cancer, 65% of all

participants, nevertheless, wished to be screened. Perception of being at risk

was significantly associated with a felt need for screening (p=0.002), an

association that persisted only for women reporting multiple lifetime sex

80
partners (p=0.005). Fear of abnormal results and lack of finances were the

commonest barriers to screening reported by 22.4% and 11.4% of

respondents, respectively.

Banda et al., (2009) conducted a quantitative design among196

women from the population of women aged 18 and over in two Reproductive

Health clinics, a structured questionnaire was used to collect data. The

questionnaire was translated from English into the local Chichewa language

so that respondents were interviewed and responded in a language that they

were able to comprehend.. The study revealed that the main barrier to CCS

was that women lack knowledge and information about cervical cancer and

there is a lack of publicity about CCS services. Lack of knowledge was

found in relation to - risk factors, prevention of, detection of and benefits of

cervical cancer screening with a greater knowledge deficit being found in the

rural women.

Eduardo, et al., (2009) conducted a qualitative study to know barriers

to use of the detection program from the point of view of actual and potential

program users. Four focus groups were organized in standard conditions in

Mexico City (urban, developed) and in the southern state of Oaxaca (rural,

economically disadvantaged area). Participants were either women with at

least one previous Papanicolaou (Pap) test or women who had never had the

test. Barriers to Pap test use included (1) lack of knowledge about cervical-

uterine cancer etiology, (2) not knowing that the Pap test exists, (3) the

conception that cancer is an inevitably fatal disease, (4) problems in

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doctor/medical institution-patient relationships, (5) giving priority to unmet

needs related to extreme poverty, (6) opposition by the male sexual partner,

(7) rejection of the pelvic examination, (8) long waits for sample collection

and receiving results, and (9) perceived high costs for care. To increase

coverage of the early detection program for cervical-uterine cancer in

Mexico, the needs, perceptions, and beliefs of women and their partners must

be taken into account when developing policy and planning, given the role

these factors play in the decision-making process that leads to their

participation or nonparticipation in this program.

2.6 Cervical Cancer Treatment

Anas Gamal et al., (2014) Conducted a study 355 patients with

histologically confirmed ICC were recruited at the Departments of

Gynaecology and Radiotherapy at Kenyatta National Hospital (KNH).

Structured questionnaires were completed recording socio-demographics,

tumour response and overall survival following treatment with combinations

of external beam radiation (EBRT), brachytherapy and adjuvant

chemotherapy. Of the 355 patients, 42% (146) were lost to follow-up while

18% (64) died during the two year period. 80.5% of patients presented with

advanced stage IIB disease or above, with only 6.7% of patients receiving

optimal combined EBRT, brachytherapy and adjuvant chemotherapy. Kaplan

Meier survival curves projected two year survival at <20%.

Basel, (2013) conducted a study on women who received Avastin plus

chemotherapy compared to those who received chemotherapy alone

82
(HR=0.71, p=0.0035). Women who received Avastin plus chemotherapy

lived a median of 3.7 months longer compared to those who received

chemotherapy alone; the median overall survival (OS) was 17 months with

Avastin plus chemotherapy compared to 13.3 for chemotherapy alone. No

new safety signals related to Avastin were observed and overall safety was

consistent with that seen in previous pivotal studies of Avastin across

different tumour types.

Maranga et al., (2013) conducted study on between 2008 and 2010,

355 patients with histologically confirmed ICC were recruited at the

Departments of Gynaecology and Radiotherapy at Kenyatta National

Hospital (KNH). Structured questionnaires were completed recording socio-

demographics, tumour response and overall survival following treatment

with combinations of external beam radiation (EBRT), brachytherapy and

adjuvant chemotherapy. Of the 355 patients, 42% (146) were lost to follow-

up while 18% (64) died during the two year period. 80.5% of patients

presented with advanced stage IIB disease or above, with only 6.7% of

patients receiving optimal combined EBRT, brachytherapy and adjuvant

chemotherapy. Kaplan Meier survival curves projected two year survival at

<20%.

Chai et al., (2013) conducted a study on Medical records of FIGO

stage IIB cervical cancer patients treated between July 2008 and December

2011 were retrospectively reviewed. A total of 148 patients underwent

radical hysterectomy with pelvic lymph node dissection followed by

83
adjuvant radiotherapy (surgery-based group). These patients were compared

with 290 patients that received radical radiotherapy alone (RT-based group).

Recurrence rates, progression-free survival (PFS), overall survival (OS),

local control rates, and treatment-related complications were compared for

these two groups. Similar rates of recurrence (16.89% vs. 12.41%, p = 0.200),

PFS (log-rank, p = 0.211), OS (log-rank, p = 0.347), and local control rates (log-

rank, p = 0.668) were observed for the surgery-based group and the RT-based

group, respectively.

Vasilevska et al., (2012 ) conducted a systematic review and meta-

analysis on identified 35 studies published in 1969–2008. In findings,

indigenous populations did not have an elevated risk of cervical dysplasia or

carcinoma in situ relative to non- indigenous populations, but had elevated

risks of invasive cervical cancer (pooled RR=1.72) and cervical cancer-

related mortality (pooled RR=3.45). There was a log- linear relationship

between relative risk and disease stage. In conclusion, the indigenous women

have a markedly higher risk of cervical cancer morbidity and mortality than

non-indigenous women, but no increased risk of early-stage disease,

suggesting that structural, social, or individual barriers to screening, rather

than baseline risk factors, are influencing poor health outcomes.

Khaemba et. al., (2012) conducted a descriptive non-intervention

study on 211 patients with an initial diagnosis of cancer of the cervix

between January 2010 and June 2011were followed up for five years

respectively. Total 108 (51.18%) patients were confirmed dead within that

84
period, 15 (7.11%) were still alive and 88 (41.70%) were lost to follow up.

The patients’ median age was 46 years. The probability of surviving beyond

five years was estimated at 0.198. The cumulative proportion surviving at the

end of the study interval was 0.67 at stage I, 0.36 at stage II, 0.15 at stage III

and 0 at stage IV. The age of patients, stage at diagnosis and level of

education significantly affects the survival. As is the trend in developing

countries most of the patients were diagnosed at advanced stages. Only 15

(7.11) had an initial diagnosis at stage I. In this study survival is poor

compared to results from other developing countries such as Uganda.

Sidath et al., (2011) conducted a study on clinical staging has

inherent deficiencies in evaluating several parameters that are critical for

treatment planning. It is now widely accepted that cross-sectional imaging,

and in particular MRI, has an important role to play in the staging of these

tumors. MRI is an excellent modality for depicting invasive cervical cancer:

it can provide objective measurement of tumor size and provides a high

negative predictive value for parametrial invasion and stage IVA disease.

MRI and positron emission tomography (PET)/computed tomography (CT)

play key roles in identifying recurrent disease. PET/CT is also useful in

detecting nodal and distant metastases and in radiotherapy planning.

Diffusion- weighted MRI is an emerging imaging technique that is currently

being evaluated for the detection of primary and recurrent disease and in the

assessment of treatment response.

2.7 Cervical Cancer Prevention

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 Wright et al., (2014) conducted a descriptive cross-sectional study on

317 consecutively recruited consenting participants at a medical outreach

using a pretested, interviewer-administered, semi structured questionnaire.

Data analysis was done using statistical package for social sciences version

19. Tests of significance were performed using 95% confidence interval with

level of significance The majority of respondents were within 30–49 years of

age (46.7%) and female (62.1%) and 70.3% had secondary level education

and above. About 37.2% of respondents had heard about cervical cancer with

84.5% of the participants willing to attend a cervical cancer health education

program. Among the female respondents, 4.1% had received the HPV

vaccine, while 5.1% had undergone a Pap test.

Joshi, et al., (2013) conducted a descriptive study was designed in

order to access the knowledge, attitude and belief of rural women based in

rural setup of B. G. Nagara. A sample size of 1000 women attending

Gynaecology OPD between 25- 55 years was targeted. Simple random

sampling technique was adapted for the sample collection. Pre tested

questionnaire were used for data collection. The study, albeit small and

simple has thrown out a gamut of realizations related to the complete lack of

knowledge and awareness not only regarding cervical Cancer but also other

aspects of women's health among the populations.

Frazer (2013) conducted a study on Cervical Cancer Prevention in the

21st Century, Vaccines that prevent infection with two of the commonest

human papillomaviruses associated with cervical cancer are available, and

86
point of care tests for high risk human papillomavirus infection in cervical

samples are likely to be available within the next year. Mapping of genetic

polymorphisms predisposing to persistent HPV infection and cervical cancer

is underway. However, strategies will likely be adopted that involve

vaccination as the primary preventative measure, and detection of persisting

high risk HPV infection as the first line secondary measure, perhaps with

particular focus of secondary screening on women at increased genetic risk.

Cassidy, et al., (2012) reviewed the predictors of knowledge about

human papillomavirus (HPV), HPV vaccine, and factors related to HPV

vaccine uptake and report a quality assurance project that evaluated HPV

vaccine uptake and three-dose completion rates. The setting was a small

private urban pediatric practice. Chart review was used to describe HPV

vaccine uptake and dose completion rates in 2007. The convenience sample

included 189 girls aged 12 to 21 years with HPV vaccine uptake. During

2007, 153 girls aged 12 to 17 years and 42 girls aged 18 to 21 years were

seen at well-child care visits. HPV vaccine uptake was 72% (n = 110) for the

younger group and 79% (n = 33) for the older group. There was no

significant difference in HPV vaccine uptake by group. One quarter (24%, n

= 46) received the HPV vaccine dose at an episodic visit. The dose

completion rate was 64% (n = 120).

Farooq et al., (2012) conducted a study prevalent types of human

papillomavirus in cervical cancer in India are HPV 16 and HPV 18, found in

60.7 per cent and 16 per cent of cases respectively. A comprehensive

87
strategy with a judicious mix of interventions on health promotion, specific

protection (vaccination), early diagnosis (screening), and treatment should be

instituted to prevent and control cervical cancer in India. Proponents of

vaccination and screening argue for enhanced investments on these

interventions based on their relative cost-effectiveness. For policymakers, the

major concerns about these interventions remain affordability and cost to

government.

Kobetz, et al., (2011) conducted a study on Women in Haiti and

throughout the Haitian Diaspora shoulder a disproportionate burden of

cervical cancer morbidity and mortality. The widespread Human

Papillomavirus (HPV) vaccination holds promise for helping to attenuate this

disparity. However, previous research has not fully examined Haitian

women’s perceptions of, and barriers to, HPV vaccination, which is

essential for informing future intervention. The current paper aims to fill this

gap. As part of ongoing Community-Based Participatory Research (CBPR)

efforts, we conducted a series of focus groups with Haitian immigrant women

in Little Haiti, the predominantly Haitian neighborhood in Miami, Florida,

U.S. Focus group questions assessed women’s knowledge and beliefs about

cervical cancer and HPV, their opinions of vaccines in general, their

knowledge and exceptions of the HPV vaccine specifically and health

communications preferences for cervical cancer prevention. Results: Among

the participants who had heard of HPV, many held misconceptions about

virus transmission and did not understand the role of HPV in the

development of cervical cancer. Virtually all participants expressed support

88
for vaccines in general as beneficial for health. Some women had heard of

the HPV vaccine, primarily as the result of a contemporary popular media

campaign promoting the Gardasil® vaccine.

Nagan et al., (2011) conducted a study to provide evidence-based

recommendations for health professionals, to develop a comprehensive

cervical cancer program for a clinic, a community, or a country. Ensuring

access to healthcare is the responsibility of all societies, and the Asia

Oceania Research Organization in Genital Infections and Neoplasia

(AOGIN) is committed to working collaboratively with governments and

health professionals to facilitate prevention programs, to protect girls and

women from cervical cancer, a disease that globally affects 500,000 and kills

nearly 300,000 women annually, just over half of whom are in the Asia

Oceania region. We share the vision that a comprehensive program of

vaccination, screening, and treatment should be made accessible to all girls

and women in the world.

Nour, (2009), conducted a study on cervical cancer kills 260,000

women annually, and nearly 85% of these deaths occur in developing

nations, where it is the leading cause of cancer deaths in women. Disparities

of health and poverty play a large role in this high mortality rate. Whereas

routine Papanicolaou and human papillomavirus (HPV) testing has

dramatically reduced cervical cancer deaths in Western nations, without

proper infrastructure, facilities, and medical training, the rates of cervical

cancer in developing nations will remain high. Studies on HPV DNA testing

89
and the low-technology method of “screen and treat” are promising. In

addition, reducing the cost and increasing the availability of HPV vaccines in

developing nations brings hope and promise to the next generation of

women.

Ayinde and Omigbodun (2005) conducted a study on Knowledge,

attitude and practices related to prevention of cancer of the cervix among

female health workers in Ibadan. A 20-item questionnaire containing items

on characteristics and knowledge of respondents on aetiology and prevention

of cervical cancer was administered to a total of 205 female doctors, nurses

and hospital maids in these hospitals within Ibadan metropolis. Knowledge

about the condition was high among doctors, surprisingly inadequate among

nurses and predictably poor among hospital maids (possibly due to lack of

formal paramedical training). However, 93.2 percent of respondents had

never had Pap smear performed. The poor utilization of the test was

independent of respondent’s profession, marital status or hospital. Therefore,

the study felt that there is a need t intensify campaign towards prevention of

cervical cancer even among health workers

According international agency (2010) the study was conducted to

determine the prevalence of human papilloma virus among females in the

United States. The National Health and Nutrition Examination Survey uses a

representative sample of the US non-institutionalized civilian population.

Females aged 14 to 59 years who were interviewed at home and examined

in a mobile examination center and provided a self collected vaginal swab

90
specimen. Swabs were analyzed for human papilloma virus and sexual

behavior information was obtained from all participants. The result of overall

human papilloma virus was 26.8% among US females aged 14 to 59 years.

Human papilloma virus prevalence was 24.5% among females aged 14 to 19

years, 44.8% between 20 to 24 years, 27.4% between 25 to 29 years, 27.5%

in 30 to 39 years, 25.2% in 40 to 49 years, and 19.6% in 50 to 59 years.

Satiya (2009), conducted a survey that cervical cancer is one of the

most common among women worldwide .Its mortality exemplifies health in

low and middle income countries and in low socio economic groups within

the countries. About 80% of global cervical cancer cases in low and middle

income countries. The prevention of cervical cancer is on the women

themselves. Therefore it is the women knowledge level, motivation for

screening and psychological factors that determine her health seeking

behavior .In India, most of studies have either addressed compliance rate

attendees of the specially arranged screening programs or have been done in

hospital setting.

Kathleen et al., (2014) conducted a study on preventing cervical

cancer , it is one of the leading causes of cancer and cancer-related deaths

among women worldwide. More than 85% of cases and deaths occur in the

developing world where the availability of effective screening is limited. In

this issue of the journal, Pierce and colleagues describe a novel technique

using a high-resolution micro endoscope to diagnose cervical dysplasia. This

perspective reviews the limitations of existing cervical cancer screening

91
methods currently in use in low-resource settings and the potential for

imaging to contribute to cervical cancer prevention in the developing world.

Dabash et al., (2013) conducted a systematic assessment included a

review of the available literature, observations of services, collection of

hospital statistics and the conduct of qualitative research (in-depth interviews

and focus group discussions) to assess the perspectives of women, providers,

policy makers and community members. There were gaps in provider

knowledge and practices, potentially attributable to limited provider training

and professional development opportunities. In the absence of a state policy

on cervical cancer, screening of asymptomatic women was practically

absent, except in the military sector. Cytology-based cancer screening tests

(i.e. pap smears) were often used to help diagnose women with symptoms of

reproductive tract infections but not routinely screen asymptomatic women.

Access to appropriate treatment of precancerous lesions was limited and

often inappropriately managed by hysterectomy in many urban centers.

Cancer treatment facilities were well equipped but mostly inaccessible for

women in need. Finally, policy makers, community members and clients

were mostly unaware about cervical cancer and its preventable nature,

although with information, expressed a strong interest in having services

available to women in their communities.

2.8 Awareness on Cervical Cancer

Omotara et al., (2013) conducted a study a cross sectional descriptive

study was conducted among 1600 rural women aged 15-55 years (randomly
92
selected from 28 villages) who were interviewed using a structured

questionnaire between April and June, 2010. The majority (82.2%) were

married before the age of 20 years and 19.3% before 15 years, 40% in

polygamous union, 22.6% have had 2 or more sexual partners, 71.3% were

primi and grand multiparous, 7.5% have had previous treatment for STIs and

10.1% were on various types of contraceptive. 454 (28.4%) have heard of Ca

cervix, 358 (22.4%) knew the location of the cervix. 2.3% had Pap smear test

of which 72.6% were within 2 years. The majority (89.9%) will avail

themselves for screening.

Hong et al., (2013) conducted a study on 200 women’s longitudinal

evaluative study on 70.8% of the participants ever heard of cervical cancer,

and as few as 22.1% and 13.3% ever heard of HPV and HPV vaccine,

respectively. The mean score on a 7-item knowledge scale was 2.2 (SD = 2.4).

Less than 10% of FSW perceived any risk of cervical cancer, and only 15.3%

ever had a Pap smear. About 40.8% of FSW would accept HPV vaccine if it

is free, and 21.8% would accept it even with a charge. Multivariate

regression suggested that women with better knowledge of cervical cancer

were more likely to have a Pap smear (aOR = 1.35); women who had tested for

HIV were 11 times more likely to have a Pap smear, and women who had

worked longer in commercial sex (aOR = 1.01) and had regular health check-

ups (aOR = 1.95) were more likely to accept HPV vaccine.

Hwaid (2013) conducted a cross sectional study in Diyala, Iraq. This

study included 198 women, the mean age was (27.29 ± 9.63) years, the age

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range was (17- 60) years, the participants were divided into two groups,

group I, (students group) includes (99) female college students who studies

in Diyala university, group II, (health care workers group), includes (99)

female physicians and nurses who worked in AL-Batol Maternity and

Children Teaching Hospital. Data was collected using questionnaire that was

adopted from previous studies. All data were statistically analysis. The

present results showed that the women demonstrated poor levels of

knowledge about HPV and cervical cancer, 106(53.54%) of them had heard

about HPV, while, only 73(36.87%), 60(30.30%) knew that the cervical

cancer and genital warts caused by HPV respectively. This study showed that

the participants had very limited knowledge about pap smear, only

57(28.79%) knew that pap smear is the test to detect abnormal cervical cells,

the results show highest level of knowledge and awareness about HPV,

cervical cancer was among health care workers group, participants who live

in urban and married with statistically significant difference (P<0.05),

(P<0.01).

Abiodun, et al., (2013) study was an insight into women’s

understanding of cervical cancer risk factors, symptomatology, prevention

and screening. Quantitative Data was collected using questionnaires

administered to 2000 women (aged 20 to 64 years) who were selected by

multi-stage sampling technique across the 20 local government areas in

Ogun State, Nigeria. The study showed that the awareness of cervical cancer

and screening was very low (6.5% and 4.8% respectively). The knowledge

about cervical and screening was very poor. Only 2.3% of the women could
94
identify a virus as the cause of cervical cancer while 4.1% identified cervical

screening as a way to prevent cervical cancer. 97.7% and 97.9% had no or

poor knowledge of risk factors and knowledge of symptoms of cervical

cancer. 90.5% identified lack of awareness as the barrier to uptake of

cervical screening. 1.4% of the women have had cervical screening done. In

order to step up the campaign for the control of cervical cancer in Nigeria, it

is therefore very important to concentrate much of the effort on creation of

awareness and enhancing the knowledge of women about cervical cancer and

screening. Keywords: cervical cancer, cervical screening, barriers.

Hoque (2013) conducted a cross-sectional study among 180 full time

final year undergraduate female university students A multistage sampling

technique was used to select the sample and self administered questionnaire

was used to collect the information. Statistical Analysis Used: Chi-square

test and logistic regression were used to find association and the significant

predictor for doing Pap smear test. Over half (53.3%) of the participants had

heard about cervical cancer and its detection method. More than half (60%)

and over a third (37.8%) of the participants knew about human papilloma

virus (HPV) and multiple sexual partner respectively as risk factors for

cervical cancer. More than half (55.3%) indicated that they were not aware if

cervical cancer can be prevented. Majority (76.7%) knew that Papanicolau's

(Pap) smear test is used for detection or prevention of cervical cancer.

Among those who were sexually active and knew about Pap smear test

79.3% did not do the test mainly because of personal factors such as fear of

the procedure, or were not ill.

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 Eze et al., (2012) A questionnaire-based descriptive cross-sectional

study. Structured questionnaires were administered to female attendees to the

antenatal and gynecological clinics of a secondary hospital in the outskirts of

Afikpo, Southeast Nigeria over a six-month period (1st July to 31st December

2007). Data analysis was by SPSS. Five hundred questionnaires were given

out. Three hundred and sixty were correctly filled (72%) and analyzed. The

mean age of respondents was 36.2 years, 25.0% had tertiary education and

40.3% were self employed. All the respondents were sexually active. There

were high incidences of premarital sex, multiple sexual partners and

abnormal vaginal discharge and low condom use. Awareness of cervical

cancer (37.5%), its preventable nature (31.9%), cervical screening (25%) and

screening centers (20.8%) were generally low and screening uptake (0.6%)

was abysmally low. Lack of awareness, non-availability of screening centers

locally, cost and time were the main reasons adduced by respondents for not

being screened. Overall, 62.5% of all the respondents indicated willingness

to be screened.

Mail, et al., (2012) study in Nairobi, Kenya showed that only 14% of

the 409 women (67% HIV-positive; median age 29 years) had ever had a Pap

smear prior to study enrollment and very few women had ever heard of HPV

(18%). Although most women knew that Pap smears detect cervical cancer

(69%), very few knew that routine Pap screening is the main way to prevent

ICC (18%). Most women reported a high level of cultural acceptability for

Pap smear screening and a low level of physical discomfort during Pap smear

collection. In addition, over 80% of women reported that they would feel
96
comfortable using a self-sampling device (82%) and would prefer at- home

sample collection (84%). Nearly all women (94%) reported willingness to be

vaccinated to prevent cervical cancer if offered at no or low cost.

Balogun et al., (2012) conducted a study on Cervical cancer is the

commonest gynaecological cancer in Nigeria and women of low socio-

economic status are at high risk of this condition. A study was conducted on

the awareness of cervical cancer, attitude towards the disease and screening

practice of major risk factors for cervical cancer among the women.

Multistage sampling was used to select 240 women who were interviewed

with a structured questionnaire and data collected was analyzed with Epi-

info version 3.5.1 statistical software. Only 10 (4.2%) women in this study

were aware of cervical cancer and none of them believed they were at risk of

developing the disease. Most (73.3%) were willing to undergo a cervical

cancer screening test Age, education and previous history of vaginal

examination were positively associated with willingness to undergo

screening (p < 0.05).

Quet, et al., (2012) conducted a study on 320 women aged 25 to 65,

living. Controls were 320 women matched for age and place of

residenceCases had a greater number of sexual partners and used condoms

more often than controls. Only 36.6% of women had consulted a

gynecologist (47.5% among cases and 25.6% among controls, p < 0.001) and

3.9% had benefited from at least one Pap smear screening (5.6% cases and

2.2% controls, p = 0.02). The average knowledge score was 3.5 on a 0 to 13

97
scale, significantly higher in cases than in controls (p < 0.0001). Despite

having a lower education level and economic status,

McCarey et al., (2011) conducted a cross-sectional self-administered

questionnaire in 5 parts with 46 items regarding cervical cancer etiology and

prevention was addressed to women’s in six hospitals of Yaoundé,

Cameroon. Eight hundred and fifty questionnaires were distributed, 401

collected. Data were analyzed with SPSS version 16.0. Chi-square tests were

used and P-values < 0.05 were considered significant. However, less than

half considered VIA or HPV tests screening tests (38 and 47%, respectively).

Knowledge about cancer etiology and screening was lowest among women’s

.Knowledge of cervical cancer and prevention by screening showed several

gaps and important misconceptions regarding screening methods.

Kobetz et al., (2011) conducted a study on Women in Haiti and

throughout the Haitian Diaspora shoulder a disproportionate burden of

cervical cancer morbidity and mortality. As part of ongoing Community-

Based Participatory Research (CBPR) efforts, we conducted a series of focus

groups with Haitian immigrant women in Little Haiti, the predominantly

Haitian neighborhood in Miami, Florida, U.S. Focus group questions

assessed women’s knowledge and beliefs about cervical cancer and HPV,

their opinions of vaccines in general, their knowledge and perceptions of the

HPV vaccine specifically and health communications preferences for

cervical cancer prevention. Virtually all participants expressed support for

vaccines in general as beneficial for health.

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 Muhamed et al., (2010) conducted a study to explore the knowledge

and awareness about cervical cancer among Iraqi women living in Malaysia.

A self- administrated Arabic version questionnaire distributed among 142

Iraqi women in Malaysia. One hundred and eight participants ranging in age

from 18 to 61 years (Mean = 36.1) returned the completed questionnaire. A

lack of knowledge on cervical cancer and the Pap smear test was found

among the respondents. Many women did not have a clear understanding of

the meaning of an abnormal cervical smear and the need for the early

detection of cervical cancer. These findings emphasize the need to educate

and promote awareness among immigrant Iraqi women in Malaysia to risk

factors for cervical cancer and to the need and the purpose of Pap smear

screening.

Voltraki et al., (2010) the sample-studied consisted of 100 adult

women attended in outpatient settings. The data were collected by the

completion of a questionnaire referring to the knowledge of the women

regarding the prevention of the cervical cancer, and the Pap test. Statistical

analysis was conducted using the Statistical Package for Social Sciences 13.0

and the methods used were X2 test along with Yates’ correction for 2x2

tables. 81% of the participants belonged to the group of 20-45 years old.

Regarding the demographic characteristics, 53% of the sample- studied were

High School graduates, 59.2% were not employed, and 71% lived in urban

areas. Regarding the perception of women towards the disease, 63.2%

considered it common, 17.3% very common, whereas 19.4% responded it

was rare or very rare. 64.3% of the participants reported the doctor as the
99
main source of information, 15.3% the family and 20.4% reported other

sources of information. Regarding the frequency of having the Pap test, 79%

had conducted it at least once in their life. 71.3% had the test in the last 1-3

years, whereas 28.7% within the last year. In regard to the precise

knowledge for the purpose of the test, 23.6% reported the prevention of the

cancer, 19.1% the prevention of the cancer of the genitals, 55.1% the cervical

cancer and 2.2% reported other reasons. Single women knew to a smaller

extent what the Pap test was compared to married, divorced or widowed with

statistical significant difference, p= 0.000. Regarding the place of residence,

women living in urban area knew better what the test was, with statistical

significant difference compared to the village residents, p=0.000. In terms of

the causes for not having conducted the test, 40% reported negligence, 25%

lack of information and 35% reported other reasons as the main causes for

not having the test.

Abotchie, et al., (2009) A cross sectional survey among college

women in a university in Ghana elicited information about

sociodemographics, knowledge and beliefs and acceptability of cervical

cancer screening, screening history, and sexual history. Bivariate analyses

were conducted to identify factors associated with screening. 140 females

were recruited; the age range was 20-35 years. The prior pap screening rate

was 12.0%; Women were unaware of local screening initiatives and only

7.9% were aware of the link between HPV and cervical cancer. The most

prevalent barriers were lack of awareness that the purpose of pap screening is

to diagnose cancer, concerns about what others may think, and lack of
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information about how to obtain screening services. Although women

perceived the benefits of screening, only about half perceived themselves to

be at risk. Women received few screening cues. Three barriers were

negatively associated with screening in bivariate analyses: lack of belief that

cervical screening diagnoses cancer, belief that pap test is painful and belief

that the test will take away virginity.

Waller et al., (2006) in his study focused on women attending a well

woman clinic were asked to complete a questionnaire assessing HPV

awareness and specific knowledge about the virus. Questionnaires were

completed by 1032 women, of whom 30% had heard of HPV. Older women,

non-smokers, and those with a history of candida, genital warts, or an

abnormal smear result were more likely to have heard of HPV. Even among

those who had heard of HPV, knowledge was generally poor, and fewer than

half were aware of the link with cervical cancer. There was also confusion

about whether condoms or oral contraceptives could protect against HPV

infection.

Neilson et al., (2008) conducted a study on assessment of women’s

knowledge of cervical screening and cervical cancer women’s knowledge of

screening, 187 women in a general practitioner practice in Lothian, Scotland

were targeted by questionnaire. As with other studies in this field 50% of

those contacted were ineligible for a variety of reasons. Seventy-two women

completed the questionnaire, providing a mix of qualitative and quantitative

data. Although the majority of women felt the invitation to attend screening

101
was clear and easy to understand, there was a lack of knowledge with regard

to both the screening itself and the possible causes of cervical cancer. The

main ‘causes’ were seen as higher sexual activity among those aged under 37

and smoking and a virus by those over 37. The majority of women showed

preference for a female professional to take the smear. Practical problems of

time and venue were not considered insurmountable. The main reasons cited

for non-compliance were the fear and dislike of the test itself.

Morton, (2001) conducted a study on the study was conducted in

Malaysian women aged 21-29 years and who have never had a paponicolaou

smear, to explore their knowledge and awareness of prevention of cervical

cancer and it’s screening. A qualitative study was undertaken using face-to-

face in-depth interviews. The study found that a lack of knowledge on

cervical cancer and the paponicolaou smear among women. Many women

did not have a clear understanding of the meaning of an abnormal cervical

smear and need for the early detection of cervical cancer. After interview

the women got accurate information about cervical cancer and the purpose of

paponicolaou smear screening.

Mani et al., (2014) conducted a descriptive, cross-sectional study

among 100 women attending a rural health centre, in Kancheepuram district,

Tamil Nadu between May and July 2012, using a semi-structured schedule.

Among the 100 participants, 74% were aware of the term cervical cancer.

This awareness was positively associated with higher levels of education,

socioeconomic status and occupational status (p< 0.05). Awareness about

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symptoms (29.7%), risk factors (1.35%), Pap smear (14.9%), other screening

methods (13.5%) and treatment (4%) was low. None of the participants were

aware of human papilloma virus (HPV) vaccine and none had undergone

screening or immunisation with HPV.

Prutt et al., (2005) conducted a study on knowledge of cervical

dysplasia and human papilloma virus among women seen in a colposcopyh

clinic, in USA. Demographic factors, Knowledge, and psychological distress

were assessed in structured interviews with 175 women before, during, and

after colposcopy. Respondents had low knowledge sores before and after

colposcopy: however, their overall knowledge improved slightly (P=0.013)

following the exam. When responses were examined by question,

respondents demonstrated a significant increase of correct answers to only

one question: Does dysplasia, or precancerous cells on the cervix, always

goes away without treatment? Pre-exam knowledge was positively

associated with educational level and was lower among Hipanics and

patients recruited at the clinic. Post-exam knowledge was positively Associated

with pre-exam knowledge and educational level. Routine clinical education

during colposcopy can improve patients understanding of cervical cancer;

however, the low level of knowledge that persisted after colposcopy was a

cause for Ralston et al., (2003) conducted a community-based survey on

knowledge of cervical cancer risk factors among Chinese immigrants in

Seattle, U.S.A They assessed knowledge of cervical cancer risk factors and

history of Pap smear testing along with socioeconomic and acculturation

characteristics. The study sample included 472 women. Most cervical cancer
103
risk factors were recognized by less than half of the participants. Factors

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

to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1, 5.8).

Finding suggests a need for increased recognition of cervical cancer risk

factors among Chinese American immigrants. Culturally and linguistically

appropriate educational interventions for cervical cancer risk factors should

be developed, implemented and evaluated.

Kidanto et al., (2002) conducted a hospital based cross-sectional

study on cancer of the cervix: knowledge and attitude of female patients

admitted at Muhimbili National Hospital; Dares Salaam, Tanzania. Eighty

nine cervical cancer patients and 178 controls were interviewed between

August 1999 and January 2000. At Muhimbili National Hospital most

patients are admitted in very advanced stages of the disease (stage IIb

andIV). Using a structured questionnaire, knowledge of basic symptoms of

cancer of the cervix, attitude and reasons for late presentation among female

patients admitted at Muhimbilli National Hospital gynecological ward were

studied. concern. The mean age of cases was 48.8 years and the mean parity

was 6.7 years compared to that of control group, which were 45 years and

mean parity of 6.6 respectively, mean age in years at marriage was lower for

cases 17.5 than controls 18.8 Majority of cases (50.6%) and controls

(23.6%) were illiterate, and 21.3 percent of cases and 33.7 percent of

controls had incomplete primary education. Majority of both cases (47.23%)

104
and controls (56.7%) had no routine gynecological examination and they do

not find it necessary. More than 90 percent of the cases were in advanced

stages of the disease (sage IIb-IV). Both cases and controls had low

knowledge of basic symptoms of cancer of the cervix and as a result most of

those who happen to have problems reported late with advanced disease.

Pitts and Clarke (2002) conducted a study on Human papilloma

virus infection and risks of cervical cancer; what do women know? The

entire female work force of a medium-sized UK university received a

questionnaire concerning knowledge of cervical screening, treatment for

abnormalities and HPV. Four hundred women returned completed

questionnaires. Knowledge of early cervical cancer detection and screening

methods was good. However, risk factors for cervical cancer were not well

known. Awareness and knowledge of HPV was 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. It was essential to Improve women’s understanding of

this area in the context of plans to include screening for HPV in the UK’s

national cervical screening program.

Wellensiek et al., (2002) conducted a study on knowledge of cervical

cancer screening and use of cervical screening facilities among women from

various socioeconomic backgrounds in Durban, Kwazulu Natal, South Africa

The study was carried out among women from different socioeconomic

circumstances (low, middle, and upper social/financial backgrounds). The

105
assessment was performed by means of a questionnaire. 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 the availability

of such services, the majority of women (87%) from higher social and

educational backgrounds did not undergo cervical screening. Most patients

resided within a 12 kilometer radius of a facility that either provided or could

potentially provide screening. Although some patients 36.7 percent had a

screening test performed at some time in the past, only 27.3 percent of

patients reported having had a pap test. This was due to failure on the part of

the healthcare giver to disseminate information of the patient regarding the

reason and value of cervical screening.

Dell et al., (2002) conducted a study on knowledge about Human-

Papilloma virus among adolescents, USA. They administered written surveys

to 523 inner-city high school students in Toronto, Canada, that asked about

HPV, other sexually transmitted diseases (STDs) and papanicolaou testing.

They also asked them to report doctor or clinic visits and whether they

received sexual health information at those visits. The predictor variables

used in analysis were gender and sexual experience. Eighty-seven percent of

our population had not heard of HPV. Only 39 percent of sexually

experienced adolescent women knew who should get a papanicolaou test.

Sexually experienced and inexperienced adolescents failed to identify

correctly their STD risk. Both genders showed greater knowledge about

human immunodeficiency virus (HIV) than other diseases. Among

106
adolescent women, 85 percent had visited a doctor or clinic within the past

year, but only 29 percent had talked about sexual health. Knowledge of HPV

infected and cervical cancer screening was low in this urban adolescent

population. Improved efforts are needed for prevention of HPV infection and

HPV-related cervical changes.

2.9 Structured teaching program on cervical cancer

Latifa et al., (2013) conducted a self –control intervention study

among125 women their ages ranged from 16 to 54 years. The studied

population was chosen for being women as well as for being a part of the

corner stone of the community which is in need for such education and

knowledge. The study was conducting from the first of October (2011) to

end of January (2012) among women in the four MCH centers of Tanta city.

In the baseline interview all the women received an interview questionnaire

for the pre-test and post test. It included personal data about women, cervical

cancer, screening and vaccine assessment tool, and perception of women

toward cervical cancer by applying Health belief Model (HBM), Intervention

implemented through a health education program, for four weeks duration

followed by a post-test. It shows that more half of the women was aged 26-

35 years and lived in urban areas. There was a significant improvement post

intervention in all items of knowledge regarding cervical cancer. There was

also a significant improvement post intervention in all items regarding

(seriousness, susceptibility of disease, benefits of early detection,

vaccination, total perception towards cervical cancer respectively), except

107
the barriers which faced them.

Utoo et al., (2013) conducted a study a cross-sectional study using

interviewer administered questionnaires to women attending the outpatient

gynecological clinic at the Benue State University Teaching Hospital,

average age and parity of respondents was 35±11.2 years and 2.4±2.3

respectively. Most 48.3% were civil servants, Married 89.0% and had post-

secondary education (64.5%). About 65% were aware of cancer of the

cervix. Fifty one percent were aware of cervical cancer screening. Main

source of information was through the mass media (35.5%). Among the

'aware' group for screening services, only 13.6% had utilized the services

(X2=12.2, p=0.0004, OR=3.7). Overall, only 7% of the study population

have ever screened for the disease. Education significantly affected

awareness for both cancer of the cervix (p=0.0001) and screening services

(P=0.0002).

Urrutia et al., (2013) conducted a cross sectional study on the Beliefs

About Cervical Cancer and Pap Test among the women .The purpose of this

study was to develop and validate a questionnaire to examine women's

beliefs about cervical cancer and the Pap smear test .The sample included

333 women recruited from a women's healthcare center in Santiago, Chile. It

was concluded that questionnaire will have important implications on

research, education, and administration across disciplines and Nursing

curricula and healthcare providers must stress the importance and reinforce

the importance of prevention of cervical cancer and regular Pap test

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screenings.

Birhanu et al., (2012) study on Health seeking behavior for cervical

cancer Focus group discussions were conducted with men, women, and

community leaders in the rural settings of Jimma Zone southwest Ethiopia

and in the capital city, Addis Ababa. Data were captured using voice

recorders, and field notes were transcribed verbatim from the local languages

into English language. Key categories and thematic frameworks were identified

using the health belief model as a framework, and presented in narratives

using the respondents own words as an illustration. Participants had very low

awareness of cervical cancer. However, once the symptoms were explained,

participants had a high perception of the severity of the disease. The etiology

of cervical cancer was thought to be due to breaching social taboos or

undertaking unacceptable behaviors. As a result, the perceived benefits of

modern treatment were very low, and various barriers to seeking any type of

treatment were identified, including limited awareness and access to

appropriate health services. Women with cervical cancer were excluded from

society and received poor emotional support.

Wagstaff, (2012) A study was conducted among 300 women in rural

area, concluded that in the pre teaching phase, a majority of woman lacked

knowledge regarding prevention of cervical cancer, In the post teaching

phase the woman have gained knowledge and basic skills for prevention of

cervical cancer.

Shepherd, et al., (2010) conducted a study o interventions to promote

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sexual risk reduction behaviors amongst women in order to reduce

transmission of human papillomavirus (HPV), Studies were included in the

review if they evaluated educational interventions targeting women only and

measured the impact on either a behavioral outcome such as condom use for

sexual intercourse, partner reduction or abstinence, educational interventions

targeting socially and economically disadvantaged women in which

information provision is complemented by sexual negotiation skill

development can encourage at least short-term sexual risk reduction

behavior. This effect has the potential to reduce the transmission of HPV and

thus possibly reduce the incidence of cervical carcinoma.

Wyshak, (2010) conducted study stated that cervical cancer is one of

the most preventable malignant tumor and 90% of cases can be identified

and treated in its early stages in a simple outpatient procedure using health

education about prevention of Cervical cancer is one of the most preventable

dieses through vaccines, paponicolaou test (smear), use of barrier

contraceptives and male circumcision. The other measures include avoid

getting infected with human papilloma virus (HPV) and certain vitamins

protect benefits against cervical cancer.

Shepherd et al., (2010) A systematic review was conducted to

determine the effectiveness of health education interventions to promote

sexual risk reduction behaviors amongst women in order to reduce

transmission of human papillomavirus (HPV), a leading agent in the

development of cervical cancer. A comprehensive search was conducted to

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identify relevant studies. Studies were included in the review if they

evaluated educational interventions targeting women only and measured the

impact on either a behavioral outcome such as condom use for sexual

intercourse, partner reduction or abstinence, or a clinical outcome such as

incidence of a STD. Thirty studies met the inclusion criteria for the review;

all had the primary aim of preventing HIV and other STDs rather than

cervical cancer. Ten of the 30 studies were considered to provide the

strongest evidence for a causal relationship between the intervention and the

change in outcomes measured. Each of these 10 most rigorous studies

showed a statistically significant positive effect on sexual risk reduction,

typically with increased use of condoms for vaginal intercourse. This

positive effect was generally sustained up to 3 months after intervention.

Rebecca et al., (2007), conducted a study on the effectiveness radio

broadcasts was assessed using across-sectional design (control groups n =

124, n = 243; intervention group n = 233). A pre-/post-test design was used

to evaluate the nurses’ training program (n = 32). A subset of nurses (n = 16)

was retested two years later. Evaluation included t tests, chi-square and

Fisher exact analyses. The radio broadcast increased the proportion of

women who were familiar with the term “cervical cancer,” who could

identify means of preventing cervical cancer, and who understood the

purpose of the Pap smear. In addition, older and under-screened women were

successfully recruited for screening via radio. The nurses’ program improved

understanding of the correct use of the Pap smear, the age-related risk of

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dysplasia, and the proper triage of abnormal results. The nurses retained a

significant amount of knowledge two years after this training.

Mock et al., (2007) a study on conducted a media-based education.

Lay health workers met with the combined intervention group twice over 3

to 4 months to promote Papanicolaou (Pap) testing. The questionnaires were

sued to measure changes in awareness, knowledge, and Pap testing. Testing

increased among women in both the combined intervention (65.8% to

81.8%; P<.001) and media-only (70.1% to 75.5%; P<.001) groups, but

significantly more in the combined intervention group (P=.001). Among

women never previously screened, significantly more women in the

combined intervention group (46.0%) than in the media-only group (27.1%)

obtained tests (P<.001). Significantly more women in the combined

intervention group obtained their first Pap test or obtained one after an

interval of more than 1 year (became up-to-date; 45.7% to 67.3%,

respectively; P<.001) than did those in the media-only group (50.9% to

55.7%, respectively; P=.035).

Manivannan (2014) conducted study on Impact of different health

educational modalities in screening for cervical cancer in selected areas of

Chennai, India”. The focus of primary prevention has been health education

and we need to stress on this using various means to motivate women

undergo pap smear test. The survey technique was used to collect the

baseline information and for issuing the pamphlets and quasi experimental

design was used for conducting the second part of the study. Betty

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Newman’s’ systems theory was used for conceptualization of the study.

Husbands found to be unaware of the reproductive tract related sickness

symptoms. Health educating only husbands could get 5 times more the

response than motivating only wives. Educating couples get 10 times more

the response than motivating only wives. Reinforced teaching has better

success rates.

Indra, (2013) has studied on 520 women under the age group of 35-

55years knowledge of the women was assessed by giving pre test followed

by teaching intervention (N=520). First phase was conducted as one group

pre and post test only design. Experimental approach of repeated measures

design was used in the II phase of the study. Setting of the study was selected

villages in Puducherry covered by Villianur Health Center and Community

Health Centre, Mannadipet and Thirubhuvani. Participants. Educational

intervention was given in the form of structured teaching and its impact was

tested by giving post test within a week. The health seeking behavior of the

women was identified by their acceptance for screening (N = 204) The health

seeking behavior of women of subjecting themselves for cervical cancer

screening is increased by creating awareness by imparting educational

intervention.

Suneetha et al., (2011) conducted a study on with a Quasi-

experimental research design pretest-posttest was used. The study was

conducted by using multistage sampling. The data was collected through a

Structured Interview schedule using demographic perform, structured

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knowledge questionnaire ,Majority of married women 84% in urban area,

76% in rural had moderate knowledge. The pretest attitude score for all the

married women 100% in urban, 92% in rural was favorable. The study

showed that there was significant improvement between pretest and posttest

knowledge.

Kriti, (2011) conducted a 490 women of reproductive age group were

interviewed using a structured questionnaire to assess their knowledge of

Cervical cancer. Basic data regarding awareness, risk factors, screening

techniques and preventive measures were included in the questionnaire. The

data has been analyzed using SPSS - 20 software simultaneously women

were told about the effectiveness of preventive strategies, benefits to the

entire family and were motivated to get screened for the cervical cancer.

Results A total of 490 females of the age group 20-45 years were

interviewed. Of them, only 19% reported that they "had ever heard about

cervical cancer". Of those who had heard of ca cervix, only 9% considered

foul smelling discharge, post coital bleeding &amp; irregular vaginal

bleeding could be symptoms of Carcinoma Cervix. Though 3% thought

smoking, alcohol &amp; STDs including HIV could be associated with

cervical cancer, other risk factors like 'sexual intercourse before 18yrs of

age', 'having multiple sex partners', 'multiple parity', 'poor personal hygiene',

'first delivery before 20 yrs of age' were recognized by only 1.4%, 0.8%,

1.6%, 2.4% and 1% respectively. The term 'Pap test' &amp; 'HPV' had been

heard by 0.40% and 0% of the women respectively. Only 0.20% of the

114
women interviewed were aware of vaccines available against cervical cancer.

Swamy, (2010) conducted a study on an evaluative study was

conducted to determine effectiveness of a teaching program on knowledge

about cancer prevention and early detection of cancer among 200 women,

Udupi Taluk, Karnataka State. The instruments used for the study were

demographic questionnaire and knowledge questionnaire. The results found

that the pretest score was 43.75% and posttest score was 79.15%. This

clearly indicated the effectiveness of structured teaching program.

Nicola Sharon Grabam et al., (2008) conducted a study onthe study

was conducted to assess the prevalence of cervical cancer among 100 women

selected by convenient random sampling at Rani Annanagar Village,

Chennai. Screening women for cervical characteristics was done by Visual

Inspection of cervix with Acetic Acid. The result was found that most of the

women 29% had infection of the cervix, 5% benign conditions, with

precancerous lesions on cervix 5%, severe anemia 6% and ectopy of cervix

12%. It indicates screening has helped in early identification of precancerous

lesions and other cervical characteristics.

Jajamohanraj et al., (2008) conducted a study on the study was

conducted to assess the effectiveness of structured teaching program on

knowledge of women regarding early detection and prevention of cervical

cancer at Family welfare centre and hospital through experimental design,

among women between the age group of 35to55 years. The pre-test results

showed that out of 60 women in overall knowledge on cancer cervix

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41(68%) had inadequate knowledge 19(32%) moderate, and no one of them

had adequate knowledge. The post-test result showed that, the knowledge of

the women had increased through structured teaching program, compared

with the pre-test knowledge. In post-test 51(55%) had adequate knowledge

and 9(15%) moderate adequate knowledge regarding cancer cervix this data

proved that the knowledge of the women had been markedly improved after

structured teaching program. As there is a dearth of literature on the cervical

cancer especially in Indian context, it is a significant that this study bridge

the gap by providing effective teaching program on cervical cancer to

increase the knowledge levels among women. It will in turn help to develop

appropriate policies and new innovative approaches to address and prevent

the cervical cancer among women.

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Chapter-iii

METHODOLOGY

117
 CHAPTER-III

RESEARCH METHODOLOGY

Research methodology is a way to systematically solve the research

problem. It may be understood as a science of studying how research is done

scientifically. The various steps that are adopted by a researcher are studied

along with the logic behind them. It is necessary for the researcher to know not

only the research methods/techniques but also the methodology. Researchers not

only need to know how to develop certain indices or tests, how to calculate the

mean, the mode, the median or the standard deviation or chi-square, how to

apply particular research techniques, but they also need to know which of these

methods or techniques are relevant and which are not, and what would they

mean and indicate and why.

Researchers also need to understand the assumptions underlying various

techniques and they need to know the criteria by which they can decide that

certain techniques and procedures will be applicable to certain problems and

others will not. All this means that it is necessary for the researcher to design the

methodology for the problem as it may differ from problem to problem. The

scope of research methodology is wider than that of research methods. Thus,

research methodology includes not only research methods but also the logic

behind the methods used in the context of the research study and explains why

the particular method or technique has been used and why the others are not

used. So that research results are capable of being evaluated either by the

researcher himself or by others.

105
 The importance of research methodology is that different research

methods are compatible with different situations, and therefore it is important to

know which method is best suitable for use with a particular hypothesis or

question. In fact, if an unsuitable research method is used; it could render the

research useless. Research methods are a mix of concepts and ideas utilized to

determine through neutral observation and analysis the truth of a situation.

This chapter presents the methodology of the study. It describes the study

design, the settings and the site selection .It also describes the target population,

the sample size as well as the sampling procedure. The inclusion and exclusion

criteria were explained followed by a brief description of the development of

tool, content validity, and reliability, pilot study procedure for data collection

process and data analysis.

3.1 Research design

A quasi experimental research design is selected for the study

SCEHEMATIC REPRESENTATION OF PRE & POST- TEST

DESIGN

PRE TEST INTERVENTION POST TEST

Structured teaching
Knowledge test Knowledge test
program

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 Knowledge on cervical
Knowledge on cervical
cancer among married
cancer among married
women by administering STP on knowledge about
women by administering
Study structured interview cervical cancer among married
structured interview
group schedule on the women
schedule on the
1sr day
14th day

O1 X O2

O1= Pre-assessment, knowledge of cervical cancer

X= Intervention– Structured teaching program on knowledge about cervical cancer

by using charts, flash cards and exhibits.

O2=Post assessment knowledge of cervical cancer among married women.

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 3.2 Variables of the study

Independent variable

A presumed “cause “is referred to as an independent variable. All the

socio, economic, demographic and cultural variables are the independent

variables in this study.

Dependent Variable

A presumed ‘effect’ is referred to as a dependent variable. Knowledge of

cervical cancer among married women is the dependent variable in the study.

3.3 Operational Definition of Terms

Assess- To determine or evaluate

Effectiveness

The outcome of structured teaching identified with the help of structured

questionnaire given to married women before and after structured teaching.

Structured teaching program (STP)

A Systematic organized planned intervention of knowledge of cervical

cancer given to married women.

Married women

Married women between the ages of 20 to 59 years are the respondents of the study.

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Cervical screening

For the purpose of this study cervical screening relates to early detection

of pre-cancer lesions through a Papanicolausmear (Pap). A Papanicolautestisa

screening tool used to detect cervical abnormalities. Mucus and cells are

collected from the ecto-cervix and endo-cervix, by scraping and then fixed onto a

glass slide and sent to the Cytopathology laboratory for assessment

Awareness

Awareness is described as appreciation, familiarity, knowledge,

observation or understanding (Oxford Concise English Dictionary 1995). For

this study awareness meant “being familiar and also knowledgeable about

cervical cancer and cervical cancer smear screening.” It also relates to the

experience and perceptions influencing the uptake of cervical screening services.

Cervix

The cervix is the lower part or neck of the uterus forming the opening to

the vagina. It is divided into 2 parts, namely the endo-cervix, internal part and

ecto- cervix, the outer part that is next to the vagina (Pocket Medical Dictionary,

2003: 57).

Cervical cancer

Cervical cancer relates to the actual neoplasma cancerous cell changes in

the cervix commonly referred to as carcinoma in situ (cancerous growth

localized) and invasive cancer (cancer spreads to nearby organs).

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Perceived susceptibility

Refers to the views of the participants regarding their risk of having cervical

cancer.

Perceived severity

Refers to a subjective assessment of how serious cervical cancer is

viewed by these women

Perceived benefits

Viewed as the gain that, by undergoing cervical cancer screening, will

result in like early detection of cervical cancer, delay progression of cervical

cancer and subsequently leading to decrease in mortality due to cervical cancer.

Perceived barriers

Refers to obstacles that prevent those eligible for cervical cancer

screening from participating in the available cervical cancer screening programs.

3.4 Objectives

General objective

 To assess the effectiveness of structured teaching program on the knowledge

of cervical cancer among married women.

Specific objective

 To determine the women’s knowledge on preventive health practices of

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 cervical cancer before and after teaching program.

 To determine the women’s perceived severity of cervical cancer by

collecting pre-test and post-test knowledge.

 To find association between socio demographic variables and knowledge on

preventive practices of women through pre-test & post test.

 To describe the association between socio demographic variables &

perceived susceptibility and severity of cervical cancer.

 To study socio demographic variable and perceived benefits from and

barriers to seeking cervical cancer screening before & after the STP

3.5 Hypotheses

 There will be significant difference between knowledge levels of the women

regarding cervical cancer before and after STP (structured teaching program).

 Structured teaching program can have significant effect on knowledge

regarding preventive practices about cervical cancer.

 The more the exposure to structured teaching, the greater will be the

awareness among women about cervical cancer

 The lesser the knowledge the lesser will be the screening.

 The lesser the knowledge of preventive practices, the higher will be the risk

of cervical cancer.

 The more the knowledge through STP of cervical cancer the higher will be

the early detection of symptoms.

 The lesser the education the poorer will be preventive practices of cervical
cancer.

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3.6 Conceptual framework

Conceptualization refers to the process of developing and refining

abstract ideas (Polit and Hunger, 2002). The conceptual framework is to clarify

the concepts used in the study and to propose relationship between concepts if

also provides .meaning within which to interpret the research findings

(Fawcett,1989).Research studies are based on a theoretical (or) conceptual

framework that facilitates visualizing the problem and places the variables in a

logical context (Talbot,1995).

This study aims at evaluating the effectiveness of the structured teaching

program on knowledge about cervical cancer among married women. The

effectiveness in terms of adequate knowledge gain, change in their lifestyles,

develop more positive attitude towards cervical cancer prevention and use

preventive measures as screening for early detection of cervical cancer . Since

cervical cancer is preventable and completely curable if it is diagnosed early, it

requires initiation and motivation for preventive and control measures. Hence, in

this study, Rosenstock’s and Becker’s Health Belief model is used. The Health

Belief model is intended to predict whether an individual is likely to participate

in disease prevention and Health promotion activities. The Health Belief Model

includes specific health beliefs such as individual perceptions about

susceptibility, seriousness and threat of disease, modifying factors and variables

likely to affect initiating action .The model has been used in explaining

preventive measures such as compliance with primary and secondary preventive

112
health practice for cervical cancer.

In the study perceived susceptibility is the non compliance with

preventive measures by women, such as poor education, poor hygiene, early age

marriage, high parity, multiple sex partners, prolonged use of oral

contraceptives, lack of awareness about screening measures etc., which may

make the individual susceptible to high risk. The perceived the serious

consequences of the cervical cancer, such as spreading of cervical cancer to

bladder, intestine, lungs, liver etc., According to Becker (1977), perceived

susceptibility and perceived seriousness combine to determine the total perceived

threat of cervical cancer, whether the cervical cancer cause death or not.

These perceptions facilitate women to make decisions on the risk/benefit

analysis for compliance with preventive measures.

The factors that modify women’s perceptions include socio-demographic

variables, knowledge about cervical cancer and cues to action such as structured

teaching program on knowledge about cervical cancer that includes causes , risk

factors,stages,clinicalmanifestations,diagnosis,treatmentandpreventionof cervical

cancer.

The third component is the likelihood of women’s taking recommended

preventive health action which depends on the perceived benefits minus the

perceived barriers to the action.

In this study the perceived benefit is compliance with the preventive

health practices such as prevention and early diagnosis of cervical cancer.

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Further it aids in complete cure if it is diagnosed at an early stage. There are

certain triggering agents of actions like structured teaching program to enhance

the awareness, which will aid in developing more positive attitudes towards

cervical cancer prevention, leading to adoption of preventive measures such as

screening for early detection of cervical cancer. In the presence of right cues,

married women can overcome the barriers and are likely to take the

recommended preventive health actions to prevent and control cervical cancer.

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 CONCEPTUAL FRAME WORK

ROSENSTOCK’S AND BECKER’S HEALTH BELIEF MODEL (1977)

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTIONS

PERCEIVEDBENEFITSOFPREVENTIVE HEALTH ACTION

PRETEST Adequate knowledge on cervical cancer
PerceivedSusceptibilitytoCervical Cancer Change their lifestyles
o o o o o o o o o Develop more positive attitude towards cervical cancer prevention
Demographic variables (Age, Religion, Education, Occupation, Parity, Member of Children, Income, Family Type, Family History, etc.,)
Low socioAssessment
economics ofstatus Poor Education Use preventive health measures as screening for early detection of cervic
o knowledge on cervical cancer
Poor Hygiene
Early age at marriage High Parity
Multiples ex partners
Prolonged use of oral contraceptives STDs
Lack of awareness about screening Perceived seriousness of cervical cancer
Cervical cancer spreads to bladder, intestine, lungs, liver etc.
Perceived threat of cervical cancer
Cervical cancer leads to death CUESTOACTION
Structuredteachingprogramon knowledge about Cervical Cancer PERCEIVED BARRIERS TO PREVENTIVE HEALTH ACTION
Anatomyphysiologyoffemale reproductive system Inadequate knowledge on cervical cancer
Causes and risk factors
Signs and symptoms
Diagnosis
Treatment
Prevention
o

POSTTEST
Assessment of knowledge on Cervical Cancer.

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3.7 Study Area

The present research investigation is under taken in the village Dunera,

District Pathankot in the state of Punjab.

Profile of Punjab

Punjab is in northwestern India and has a total area of 50,362 square

kilometres (19,445 sq mi). Punjab is bordered by Pakistan's Punjab province on

the west, Jammu and Kashmir on the north, Himachal Pradesh on the northeast

and Haryana and Rajasthan on the south.[9] Most of Punjab lies in a fertile,

alluvial plain with perennial rivers and an extensive irrigation canal system . A

belt of undulating hills extends along the northeastern part of the state at the foot

of the Himalayas. Its average elevation is 300 metres (980 ft) above sea level,

with a range from 180 metres (590 ft) in the southwest to more than 500 metres
116
(1,600 ft) around the northeast border. The southwest of the state is semi-arid,

eventually merging into the Thar Desert. Of the five Punjab rivers, three—Sutlej,

Beas and Ravi—flow through the Indian state. The Sutlej and Ravi define parts

of the international border with Pakistan.

The soil characteristics are influenced to a limited extent by the

topography, vegetation and parent rock. The variation in soil profile

characteristics are much more pronounced because of the regional climatic

differences. Punjab is divided into three distinct regions on the basis of soil

types: southwestern, central, and eastern. Punjab falls under seismic zones II, III,

and IV. Zone II is considered a low-damage risk zone; zone III is considered a

moderate-damage risk zone; and zone IV is considered a high-damage risk zone.

Punjab is a state in India situated in the northwestern section of the

country. It is bordered on the north by Jammu and Kashmir union territory, on

the northeast by Himachal Pradesh state, on the south and southeast by Haryana

state, on the southwest by Rajasthan state, and on the west by Pakistan. When

most of Punjab’s literacy rate, largely Hindi-speaking districts, were divided to

form the new state of Haryana on November 1, 1966, Punjab took on its current

form. Chandigarh is the joint capital of Punjab and Haryana and is located within

the Chandigarh union territory. Let’s look at the sex ratio of Punjab, the literacy

rate, and the census of Punjab.

According to the Census of Punjab 2011, the Population of Punjab was

27,704,234. These include males 14,634,819 & females 13,069,417. The overall
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literacy rate of Punjab was recorded at 75%.

Punjab’s most populated district – The most populated district in the state

is Ludhiana, with an estimated population of 3,498,739 (2011). It is also

Punjab’s largest district in terms of land.

The city with the most people – Ludhiana, is the district’s administrative

centre and the state’s largest city. As of 2021, the city has a population of over

17.79 lakh people.

Punjabi Population by Religion – In the Punjab state, Sikhism, or the Sikh

religion, is practiced by most of the population. Sikhs make up more than 60 per

cent of the state’s entire population. Hindus are the second-largest religious

group, accounting for 34% of the population.

In Punjab, Islamists account for 2% of the population. The rest of the

state’s population comprises Christians, Jains, and people of other faiths.

Punjab’s Population of 31,623,274 people and is home to the bulk of Sikhism

adherents in India.

According to the Census of Punjab 2021, the population of Punjab is

made up of 57.69 per cent Sikhs, 38.49 percent Hindus, 1.93 percent Muslims,

and 1.26 percent Christians.

In Punjab, Islamists account for 2% of the population. The rest of the

state’s population comprises Christians, Jains, and people of other faiths. Punjab

has a population of 31,623,274 people and is home to the bulk of Sikhism

adherents in India.

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 Population growth in Punjab is below average compared to other

populated states of India. Its population was estimated to be 30,045,949 in the

year 2017. The culturally rich state of Punjab adds around 3.5 lakh people to its

population every year. With recent urbanization witnessed in many cities in

Punjab, the Urban population is growing rapidly in comparison with the rural

population. The Census of Punjab 2021 in 2014 was 28,884,179. With a growth

rate of 1.4% (yearly) in population, the total number of people living in Punjab in

2013 was 28,485,384. The total number of people living in Punjab was estimated

to be 28,092,095 in 2012.

Literacy rate in Punjab has seen upward trend and is 75.84 percent as per

latest population census. Of that, male literacy stands at 80.44 percent while

female literacy is at 70.73 percent.

Punjab grew out of the settlements along the five rivers, which served as

an important route to the Near East as early as the ancient Indus Valley

civilization, dating back to 3000 BCE, followed by migrations of the Indo-Aryan

peoples. Agriculture has been the chief economic feature of the Punjab and

formed the foundation of Punjabi culture. The Punjab emerged as an important

agricultural region, especially following the Green Revolution during the mid-

1960s to the mid-1970s, and has been described as the "breadbasket of both India

and Pakistan.

The historical region of Punjab produces a relatively high proportion of

the food output from India and Pakistan. The region has been used for extensive

wheat farming. In addition, rice, cotton, sugarcane, fruit, and vegetables are also

119
grown.

The agricultural output of the Punjab region in Pakistan contributes

significantly to Pakistan's GDP. Both Indian and Pakistani Punjab is considered

to have the best infrastructure of their respective countries. The Indian state of

Punjab is currently the 16th richest state or the eighth richest large state of India.

Pakistani Punjab produces 68% of Pakistan's food grain production. It’s share of

Pakistan's GDP has historically ranged from 51.8% to 54.7%.

Called "The Granary of India" or "The Bread Basket of India", Indian

Punjab produces 1% of the world's rice, 2% of its wheat, and 2% of its cotton. In

2001, it was recorded that farmers made up 39% of Indian Punjab's workforce. In

the Punjab region of Pakistan, 42.3% of the labor force is engaged in the

agriculture sector.

Alternatively, Punjab is also adding to the economy with the increase in

employment of Punjab youth in the private sector. Government schemes such as

'Ghar Ghar Rozgar and Karobar Mission' have brought enhanced employability

in the private sector. As of October 2019, more than 32,000 youths have been

placed in different jobs and 12,000 have been skill-trained.

The state of Punjab is divided into five administrative divisions:


Faridkot


Ferozpur


Jalandhar


Patiala

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
Rupnagar

3.8 Area of study Pathankot District

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Profile of Pathankot (Dunera) District

For the present study Pathankot district (Dunera) is chosen as the study area.

Pathankot is a small city of Punjab at Latitude 32° 16′ 40″ N (southern

limit) to 32° 21′ 21″ N (northern limit) and Longitude 75° 31′ 15″ E (western

limit) to 75° 46′ 56″ E (eastern limit)., officially declared as district on 27 July,

2011 by Government of Punjab. In past, it was a Tehsil of the District

Gurdaspur. It is a meeting point of the three northern states Punjab, Himachal

Pradesh and Jammu and Kashmir. Due to its ideal location, Pathankot serves as a

travel hub for the three northerly states. It is the last city in Punjab on the

national highway that connects Jammu and Kashmir with the rest of India.

Situated in the picturesque foothills of Kangra and Dalhousie, with the river

Chakki flowing close by, the city is often used as a rest-stop before heading into

the mountains of Jammu and Kashmir, Dalhousie, Chamba, Kangra,

Dharamshala, Mcleodganj, Jwalaji, Chintpurni and deep into the Himalayas.

Pathankot also serves as education hub for the nearby areas of Jammu &

Kashmir and Himachal. Many students basically from rural areas of these states

come to study here.

Pathankot is a city and the district headquarters of the Pathankot

district in Punjab, India. Pathankot is the 6th most populous city of Punjab,

after Ludhiana, Amritsar, Jalandhar, Patiala and Bathinda. Its local government

is a municipal corporation.

The current estimate population of Pathankot city in 2024 is 209,000 ,

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while Pathankot metro population is estimated at 226,000 . The last census was

conducted in 2011 and the schedule census for Pathankot city in 2021 was

postponed due to Covid. The current estimates of Pathankot city are based on

past growth rate. Once govt conducts census for Pathankot city, we will update

the same here in 2024. As per provisional reports of Census India, population of

Pathankot in 2011 is 148,937. Although Pathankot city has population of

148,937; its urban / metropolitan population is 160,509.

In education section, total literates in Pathankot city are 118,533 of which

63,958 are males while 54,575 are females. Average literacy rate of Pathankot

city is 87.99 percent of which male and female literacy was 91.05 and 84.65

percent. The sex ratio of Pathankot city is 907 per 1000 males. Child sex ratio of

girls is 807 per 1000 boys.

Total no. of Slums in Pathankot city & it’s Out Growth numbers 7,430 in

which population of 37,069 resides. This is around 23.72% of total population of

Pathankot city & its outgrowth which is 156,306.

Hinduism is majority religion in Pathankot city with 88.89 % followers.

Sikhism is second most popular religion in Pathankot city with 8.05 % following

it. In Pathankot city, Islam is followed by 0.38 %, Jainism by 0.01 %, Christinity

by 8.05 % and Buddhism by 0.02 %. Around 0.01 % stated 'Other Religion',

approximately 0.91 % stated 'No Particular Religion'.

Pathankot is an ancient city and has historical significance. It was ruled

by many rulers. Till 1781, Pathankot was ruled by a Muslim descendant of Raja

Sayed Khan of Nupur State. From the end of 17 th century, this region was the

part of the princely state – Nurpur and was ruled by the Rajputs. Nurpur state
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was established by Rana Bhet, a Taur Rajput of Delhi, who is well-known as

Jatpal. Jatpal established his dynasty at Pathankot and took the control of whole

country in the foot of the hills. In the end of 17th century, he shifted his capital to

Nurpur. In the great epic, Mahabharata, Pathankot is noted as Audumbar and in

the ancient book of Ain-i-Akbari, it was noted as ‘Pargana Headquarter’.

According to Sikh history, it is believed that, Pathankot was established by the

first Sikh Guru – Guru Nanak Dev Ji. During the Medieval period, when the

Ghilzai tribe of Pathan in Afghanistan came into power – the Pathan tribes of

Afghanistan – Marwat, khattak, yusufzai and other Pathans moved to India. They

settled in the places like Pathankot and Hoshiarpur. Hence the city got its name

as Pathankot. According to the famous historian – Cunnigham the name of

Pathankot originated from the word ‘Pathan’. Rajput Rulers – During 17-18th

century this region was ruled by Rajput rulers. Pathankot is world famous for its

Military station – Mammon Cantt. It is the biggest Military base in Asia.

State limits in ancient times, Nurpur state in ancient times included

Pathankot, Shahpur and Kandi and a large tract on the plains, in addition to the

whole of the present Nurpur Tahsil, except the tappa of Gango. A small tract to

the west of the Ravi, called Lakhanpur, now in Jammu, was also within the state

in later times. (District Gazetteer, Kangra District 1924-1925) The state was

bounded on the north by Chamba, on the east by Kangra and Gular, on the south

by the Punjab plains, and on the west by the Ravi. The original capital and

nucleus was Pathankot, of which the name in Mughal times was Paithan, an

abbreviation of Pratishthana, meaning, “the firmly established place.” (History of

Punjab Hill States – J Hutchison and J. PH. Vogel) Sir A. Cunningham was at
124
first inclined to regard it as “a genuine Hindu word derived from pathan,

meaning ‘road’ as if intended to describe the first meeting of the roads which

there takes place” This derivation, however, he afterwards abandoned in favour

of Pratishthana, of which the abbreviated name, Paithan, is found both in the

Aini-i-Akbari and Badshahnamah. “I can find no trace of the name in the

historians of Alexander, but the quotations which I have given from

Varahamihira and the Puranas show that the name was well known before the

Muhammdan invasions. (Ancient India – Rapson)

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 3.9 Sample and Sampling Frame

In the present research multi stage random sampling technique is used to

collect the data

In the first stage of study from the Pathankot district four mandals are

selected, they are Pathankot, Sujanpur, Gharota and Bamial.

In the second stage, from each mandal 5 villages are selected

constituting 20 villages are randomly selected from all the four mandals .The

villages selected are Abadgarh, Bhoa, Dunera, Gharota Kalan and Najo Chak

villages from Pathankot mandal, Nuagarh, Patanapur, Ratanapur, Sujanpur,

Gauradeipur villages from Sujanpur Mandal, Kanwan, Jalampur, Hayati Chak,

Haibo and Danour villages from Gharota mandal and Bhakhari, Chak Amir,

Dostpur, Janial and Samrala villages from Bamial mandal.

In the third stage from each village, 25 married rural women are selected

by simple random sampling technique to collect the data. Like that, from 20

villages 500 married women are selected. The information is collected from all

the 500 women using the interview schedule without any STP.

For the structured teaching program, 250 married rural women from

above mandals and from same villages are selected. From each village, 10-13 are

selected through lottery method by preparing the slips with names of married

rural women (who are the respondents of the pre-test study).

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 3.10 Criteria for sample selection

Inclusive criteria

 Married women in the age group of 18-60 years.

 Married women who are willing to participate in the study.

 Married women who are able to understand Punjabi.

Exclusive Criteria

 Unmarried women are excluded from the study.

 Married women below 18 years are excluded from the study.

 Married women with mental illness.

 Married women above 60 years of age.

3.11 Pilot study

A pilot study is carried out prior to the main study to find out the

feasibility of the study. 50 rural married women are interviewed from Dunera,

Pathankot district. Certain questions are modified and edited taking into

consideration local language and information required for research. After

finalizing the interview schedule the researcher herself conducted the interviews

with the respondents.

3.12 Period

The data was collected from October 2024 to November 2024.

3.13 Data Collection

The data is collected by using interview schedule. Same schedule is used

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for pre-test and post test to collect data by the researcher.

The data collection comprised three phases

Pre-intervention phase

This phase involved the collection of cross sectional base line

information using questionnaire consisting of multiple choice, open and closed

ended questions. The study instrument is divided into sections comprising socio-

economic and demographic data, knowledge of cervical cancer, anatomy &

physiology of female reproductive system, severity of cervical cancer,

symptoms, diagnosis and treatment, benefits of cervical cancer screening,

barriers, and preventive health practices.

Intervention phase

This phase includes health education and communication through the use

of audiovisual aids like teaching aids and lectures consisting of various issues on

cervical cancer, charts on female reproductive system and short-films on cervical

cancer. Intervention phase also include sex habiting the cards on risk factors,

symptoms, importance of screening and preventive practices with regards to

cervical cancer prepared in Telugu language. Each session took around two

hours. The women were also informed that the post test will be conducted after

two weeks.

Post-Intervention phase - is carried out with 250 members after two weeks of

the intervention phase and the researcher provided sufficient time for collecting

the interventional effect information on cervical cancer by using the same

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instrument in both the preliminary survey and the post assessment.

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3.14 Tools of data collection

Data is collected using a researcher administered structured interview

schedule (see appendix). This instrument comprises seven sections that looked at

the socio demographic characteristics, knowledge about cervical cancer,

knowledge of anatomy and physiology of female reproductive system,

knowledge of susceptibility to cervical cancer, knowledge of symptoms of

cervical cancer, knowledge of diagnosis and treatment for cervical cancer,

knowledge concerning preventive health practices of women for cancer of

cervix.

3.15 Structured teaching program

The Structured teaching program consists of Anatomy and physiology of

female reproductive system, definition, causes, risk factors, stages, clinical

features, warning signs, diagnosis, treatment and prevention of cervical cancer.

3.16 Content validity

The content validity of tool is obtained from medical experts. The content

validly of the tool and structured teaching are given to experts along with

objectives. They are experts from the field of obstetrics and gynecology,

preventive medicine and experts from oncology. The experts were permitted to

give their opinions and suggestions regarding ‘adequacy’ and ‘appropriateness’

of the study. After obtaining suggestions from the experts, necessary

modifications are made in the tool andin structured teaching programme.

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3.17 Reliability of the tool

The reliability of the tool is established by using the data collected from

the married women who are residing at Pathankot mandal rural areas of

Pathankot district. The reliability is established by test-retest method by using

Karl Pearson’s correlation co-efficient. The obtained reliability of r=0.99,

indicated that the tool is highly reliable.

3.18 Data Analysis

After the collection of data it is processed in computer through the use of

Statistical Package for Social Science (SPSS) to make the analysis easy and

clear. Through the analysis, frequency tables are drawn and some tables are cross

tabulated to find out the difference between post test and pre test. To find the

significance & association, chi square tests, t – tests and Logistic regression

analyses are carried out.

3.19 Limitations of the study

 The study is limited to married women in the age group of 20–59 years.

 The study is limited to those residing in one district i.e., in Pathankot district of

Punjab.

 The structured teaching program is limited to the knowledge about cervical

cancer.

 Due to the limited time period, STP was given only once.

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 Assembling the women for STP has become difficult for the researcher.

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Chapter-IV
RESULTS
AND
DISC US ON
(Socio economic and SI
demographic Factors

133
 CHAPTER-IV
RESULTS AND DISCUSSION

SOCIO ECONOMIC AND DEMOGRAPHIC FACTORS

4.1 Socio-Economic and Demographic Factors

Socio-economic demographic variables play a vital role in shaping the

state of health. The health status of women is influenced by several socio-

demographic variables such as educational status, marital pattern, occupation

and so on. Socio- demographic factors are as important as physical health

variables in affecting a person's ability to function normally in their everyday

life. Research indicates that socio demographic variables are the key factors

in determining the quality of life of women. Inequities in wealth and quality

of life, low socio economic conditions among women and its correlates, such

as poverty, lower education, and poor health ultimately affect our society as

a whole. Women's health in India can be examined in terms of multiple

indicators, which vary by geography and socioeconomic standing. To

adequately improve the health of women in India multiple dimensions of

wellbeing must be analyzed. Health is an important factor that contributes to

human wellbeing and economic growth. Currently, women in India face a

multitude of health problems, which ultimately affect the aggregate

economy’s output.

In this section an attempt has been made to describe the socio

economic- demographic characteristics of the respondents. The socio-economic

134
and demographic variables of the selected married women are coded and

analyzed.

4.2 Age

It is a fact of life that health declines with age. For the women

delaying the age of cervical screening increases the risk of cervical cancer.

Table No. 4.1: Percentage distribution of Respondents by their age

Age group Number Percentage

20-29 117 23.40
30-39 216 43.20
40-49 74 14.80
50-59 93 18.60
Total 500 100.0

The data presented in table no. 4.1 reveals that more than two fifths of

the respondents (43.20 percentage) were in the age group of 30-39 years as

against less than a quarter (23.40 percentage) of the respondents in the age

group of 20-29 years. Less than one fifths (18.6 percentage) of the

respondents were in the age group of 50- 59 years followed by only a minor

proportion (15.0 percentage) in the age group of 40-49 years.

It can be observed from the above data majority of respondents were

in between the ages of 30-39 years. This can be because this age group is the

highest peak period of child bearing age of women, describing them as being

sexually active, more likely to have exposure to HPV and to develop pre-

cancerous lesions. Traditionally the assumption has been that this age group

accesses the healthcare system more often in order to receive contraception

135
and pregnancy care.

Table No. 4.2: Percentage distribution of Respondents Husbands by their

age

Age group Number Percentage

21-29 152 30.40

30-39 171 34.20

40-49 94 18.80

50-59 67 13.4

60-69 16 3.20
TOTAL 500 100.0

The above data reveals that slightly more than one third of the

respondents (34.2 percentage) husband’s age group was in between 30-39

years (Table No.4.2) followed by less than one third of the respondents (30.4

percentage) of husband’s age was in between 21-29 years. Less than one

fifths (18.8 percentage) of the respondents husbands age is between 40-49

years, 13.4 percent of husbands age group was in between 50-59 years and

very fewer proportion (3.2 percentage) of respondents husbands age was in

between 60-69 years.

4.3 Age at Puberty

Normally the age of puberty is between 10-11years of age but can be

as early as 8 years or as late as 13 years. As soon as breasts begin to develop,

girls begin to grow much more rapidly (this is why girls are often taller than

boys at 11-12 years of age). It is at this time there is a need to educate girls

menstrual hygiene practices to prevent and maintain healthy life style.

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Table No. 4.3: Percentage distribution of Respondents by their age at
Puberty

Age group Number Percentage

11-12 160 32.00

13-14 320 64.00

15-16 20 3.20
Total 500 100.0

More than two thirds of the respondents (64.0 percentage) puberty age

was in between 13-14 years followed by, one third of respondents (32.0

percentage) between by 11-13 years (Table No.4.3) and only a minor

proportion (3.2 percentage) of the respondents age at puberty was in between

15-16 years.

4.4 Age at Marriage

Marriage is a universal institution. Entering into marriage relationship

is intended to meet sexual and reproductive needs. In Indian society in

general people prefer early age at marriage, it may affect health status of

women. The studies have found that early married girls have many

disadvantages related to health, social, and economic spheres, hampering

their ability to negotiate their reproductive health.

Table No. 4.4: Percentage distribution of Respondents by their Age at

Marriage

Age group Number Percentage

15-18 277 55.4

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 19-22 179 35.8

23-26 11 2.20

27-30 17 3.40

31-34 16 32.20

Total 500 100.0

The data presented in table 4.4 reveals that more than half of the

respondents (55.4 percentage) were married between the age of 15-18 years

followed by more than one third of the respondents (35.8 percentage)

between the age of 19-22 years and a very minor proportion (3.40

percentage) were married between the age of 27-30 years, 31-34 year (3.2

percent) and 23-26 years (2.20 percent). On the whole an over whelming

proportion of the respondents were married by 22 years of age.

Age at marriage is considered as a proxy measure of age at first sexual

intercourse, but it did not come out as an independent risk factor for cervical

cancer. Recently a pooled analysis of case control studies on cervical cancer

from eight developing countries provide convincing evidence for the risk

associated with early age at first sexual intercourse (Mukherjee et al., 1994).

Moreover, age at first sexual intercourse, age at marriage and age at first

pregnancy were highly interrelated in developing countries, where mostly

there is a very short latency period between age at marriage and age at first

pregnancy (Louie et al., 2009).

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4.5 Number of Children

Number of children in the family is a complex area with many factors

combining to influence children’s health and development. A child's health

and wellbeing depends on what happens to them as individuals, as part of a

family, as members of communities and within society as a whole. More

number of children may affect health of mother followed by child’s health.

Table No. 4.5: Percentage distribution of Respondents by the number of

Children

Number of Children Number Percentage

No children 33 6.6

One child 95 19.0

2 children 168 33.6

3 children 130 26.0

4 children 60 12.0

Above 5 children 14 2.8

Total 500 100.0

One third of the respondents (33.6 percent) had two children (Table

No.4.5) followed by one fourth of respondents (26.0 percent) with 3 children.

Nearly one fifth (19.0 percent) of the respondents had one child, and 12.0

percent of respondents with 4 children, 5 children and above (2.8 percent)

and 6.6 percent of the respondents does not have children.

Supporting the literature, having four or more children can be a

predominant factor for cervical cancer. The results from a case control study
139
in Chennai showed that high parity (>4 vs. ≤ 2 births) was associated with

invasive cervical cancer (OR=7.3)

4.6 Number of Pregnancies

Number of in pregnancies refers to the number of pregnancies women

got, no matter the pregnancies were completed or not. if the women become

more times pregnant it may cause health problem and also risk of developing

cervical cancer.

Table No. 4.6: Percentage distribution of Respondents by Number of

pregnancies

Number of Children Number Percentage

Ist pregnancy 99 19.8

IInd pregnancy 165 33.0

IIIrd pregnancy 138 27.6

IVth pregnancy 82 16.4

Above V 16 3.2

Total 500 100.0

One third (33.0 percent) respondents had IInd pregnancy, followed by

more than one fourth of the respondents (27.6 percent) with IIIrd pregnancy

(Table No.4.6). One fifths (19.8 percent) had Ist pregnancy, only 16.4 percent

of the respondents were with IVth pregnancy and a minor proportion (3.2

percent) with above Vth.

Birth interval or the rapidity of multiple pregnancies also has an

independent influence on the risk for cervical cancer (Mukherjee et al.,

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1994). The pregnancy induced cervical changes may predispose to malignant

transformation, and multiparty may increase the risk of cervical cancer by

maintaining the transformation zone on the ecto-cervical region for several

years ,resulting direct exposure to HPV and other cofactors (Hinkula et al.,

2004).

4.7 Family

Family related health problems fall into two categories: physical and

mental illnesses or syndromes. There are several types of illnesses in both

categories that are genetically inherited, often passed down strictly through

either the maternal or paternal side of the family genealogy.

Table No. 4.7: Percentage distribution of Respondents by Type of

Family

Age group Number Percentage

Nuclear 342 68.4

Joint 157 31.4

Extended 1 0.2

Total 500 100.0

In the present table two third of the respondents (68.4 percent) were in

nuclear families as against one third of the respondents (31.4 percent) in joint

families followed by a very minor proportion 0.2 percent in extended

families (Table No.4.7).

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4.8 Education

Education has been universally acknowledged as one of the single

most powerful factor of socio economic development that helps in the

maintenance of health.

Education is the fundamental factor among the socio demographic and

reproductive determinants of cervical cancer in low resource settings. Public

awareness through education and improvements in living standards can play

an important role in reducing the high incidence of cervical cancer in India.

Table No. 4.8. Percentage distribution of Respondents by their

Education

Respondents Number Percentage

Illiterates 278 55.6

Primary education 167 33.4

Secondary education 55 11.0

Total 500 100.0

More than half of the respondents (55.6 percent) were illiterates

(Table No.4.8) as against one third of the respondents (33.4 percent) had

primary education followed by only 11.0 percent of the respondents with

secondary education.

Studies by Lockwood-Rayermann (2004, p. 355) and Lee (2000) have

reported that the level of education is a contributing factor to a woman‘s

ability to understand the importance of healthcare, the diagnosis of cervical

142
cancer and the benefits of screening. Generally, the better educated a woman

is, the healthier she is likely to be. The better the education, the more likely

the women is to adopt healthy behaviors and healthy lifestyles .However,

Breitkopf, Pearson and Breitkopf (2005) advised health care providers to

exercise caution when using reported education level as a guideline for

educating and communicating the clients about cancer screening, as many

clients have low reading levels. Health care providers should use effective

educational techniques which tailor information to populations with low

literacy like the use of pictures and videos as well as clarifying with clients

what particular words mean to them.

Table No. 4.9: Percentage distribution of Respondents Husbands by

their Education

Husbands Education Number Percentage

Illiterates 253 50.60

Primary education 172 34.40

Secondary education 61 14.0

College education 14 2.8

Total 500 100.0

Half of the respondent’s husbands (50.6 percent) were illiterates

followed by one third of respondent’s husbands (34.4 percent) with primary

education (Table.4.9) and only 14.0 percent of the respondents husbands had

secondary education and very fewer proportion (2.8 percent) of them had

college education.

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4.9 Occupation

Occupation is an indicator of the status or class of a person. It is one of the

important socio-economic variables.

Table No. 4.10: Percentage distribution of Respondents by their

occupation

Occupation Number Percentage

Cooli 296 59.2

House wife 153 30.6

Petty Trade 51 10.2

Total 500 100.0

Nearly three fifths of the women (59.2 percent) were coolie / daily

laborers (Table No.4.10) as against less than one third (30.6 percent) were

house wives and only 10.2 percent of the respondents were in petty trade like

selling fruits, vegetables and milk.

Lockwood-Rayermann (2004, p. 355)’s study have found that

economic circumstances (environmental resources) are vitally important

factors in the health promotion of any community. Employment is expected

to provide a source of income to the individual as well as an opportunity for

access to the employer providing insurance coverage at either minimal or no

expense to the employee (Gosschalk and Carrozza, 2009).

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 Occupation, type of house and family income were the measures to

assess the economic status of the women who participated in this study and

those are interrelated. Manual workers were mainly the laborers working in

the agricultural sector and housewives/others included those women who

were taking care of their family and doing house works or working in public

or private sectors.

Table No. 4.11: Percentage distribution of Husbands by their

occupation

Occupation Number Percentage

Agriculture 245 49.0

Cooli 145 29.0

Migrated 110 22.0

Total 500 100.0

Half of the respondents husbands (49.0 percent) were in agricultural

occupation (Table No.4.11) whereas more than a quarter (29.0 percent) of

the husbands were cooli / daily laborers and more than one fifths (22.0

percent) of the respondents husbands migrated to kuwait for occupation.

4.10 Income

The income health relationship occupies a central place in the domain

of research on factors influencing household decision making in health care

services.

Table No. 4.12: Percentage distribution of Respondents by their family

income per month

Income (Rs.) Number Percentage

1000-5000 341 68.2

145
 6000-10000 95 19.0

11000-15000 50 10.0

16000-20000 14 2.8

Total 500 100.0

More than two third of the (68.2 percent) respondents monthly family

income was in between is Rs.1000-5000 (Table No.4.12) followed by one

fifths (19.0 percent) of the respondents had monthly family income between

Rs.6000-10000. Only 10.0 percent of the respondent’s family monthly

income was in between Rs.11000-15000, a very minor proportion 2.80

percent of the respondent’s monthly family income was in between

Rs.16000-20000.

4.11 Abortions

Abortions are categorized as safe or unsafe using World Health

Organization definitions. WHO defines unsafe abortion as a procedure meant

to terminate an unintended pregnancy that is performed by individuals

without the necessary skills, or in an environment that does not confirm to

the minimum medical standards, or both this practices makes women to

become ill health.

Table No. 4.13: Percentage distribution of Respondents by their

Abortions

Abortions Number Percentage

Spontaneous abortions 40 60.6

Induced abortions by doctor 7 10.6

Induced abortions by self 19 28.8

Total 66 100.0
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 Among those who had abortions less than two thirds of respondents

(60.6%) (Table No.4.13) had spontaneous abortions followed by a more than

quarter (28.8%) had induced abortions by self using traditional practices and

only 10.6% of the respondents had induced abortions by doctor.

4.12 Religion

Religion is usually asked in order to ensure whether patients have the

appropriate religious attention if required. However it is also important in

considering the medical needs and preventive health practices based on their

cultural acceptance.

Table No. 4.14: Percentage distribution of Respondents by their

Religion

Religion Number Percentage

Hindu 319 63.80

Muslim 145 29.0

Christian 36 7.2

Total 500 100.0

Nearly two third of the respondents (63.8 percent) belonged to Hindu

religion followed by more than quarter (29.0 percent) were Muslims and

only 7.2 percent of respondents were Christians (Table No.4.14).

Dunn et al. (2005)’s study found that churches have a strong social

influence in their communities as they can facilitate access to information of

cancer screening to the lay communities. As they exist in practically every

147
community and have the ability to influence the hardest to reach populations,

church members have the potential to receive life saving messages and to

disseminate health information to others in the community who do not attend

a particular faith community. The oral culture of inseminating health

information is vital in decreasing the morbidity and mortality of rural

community.

4.13 Habits

Un-healthy habits can often damage our health. They can make the

person feel unwell. They can have long-term effects on their physical

condition. If the person wants to live a long and healthy life, there may be

some unhealthy habits that he / she need to overcome to maintain good

health.

Table No. 4.15: Percentage distribution of Respondents by their habits

Habits Number Percentage

Yes 195 39.0

No 305 61.0

Total 500 100.0

Three fifths of the respondents (61.0 percent) do not had any habits as

against the remaining two fifths (39.0 percent) had habits like chewing betal

leaves and tobacco (Table No.4.15).Pan chewing with or without tobacco

was common among manual workers and low educated women in the

community.

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To sum up

In the present study majority of women were within 20-39 years of

age groups. The mean age of puberty was in between 13-14 years. More than

half of the respondents were married before the legal age at marriages of 18

years. Majority of the respondents had 2 to 3 children and with II & III

pregnancies. Nuclear families were predominantly observed in the sample

population. More than half of the women are illiterates followed by primary

education. The same pattern has also been observed in their husband’s

educational level. Nearly two three fifths of the women are daily laborers.

Hindus were more in the sample population. Two fifths of the women had

habits like chewing betel levels and tobacco chewing.

149
Chapter-V

Effectiveness of structured
Teaching program

150
 CHAPTER-V

EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAM

After reviewing literature the structured teaching manual has been

prepared in the local language with pictorial outline and verbal explanation

through structured teaching program on Anatomy & physiology of female

reproductive system, causes, risk factors, stages, clinical features, screening,

diagnosis, treatment to improve awareness of the women on cervical cancer.

5.1 Awareness Of Cervical Cancer

Awareness regarding cervical cancer and its prevention is quite low

amongst Indian women. It is necessary to make Indian women aware of cervical

cancer, so that they can have knowledge regarding cervical cancer and its

prevention. Hence it may lead to increase of health-seeking behavior in women.

Table No. 5.1: Percentage Distribution of Respondents by their

Awareness of Cervical Cancer

Awareness on Cervical Pretest (250) Posttest (250)

Cancer

No 67.6(169) 10.0(25)

Yes 32.4(81) 90.0(225)

In pretest only one third of the respondents (32.4 percent) were aware of cervical

cancer as against two thirds who were not aware (67.6 percent) whereas after the STP in

post test an over whelming proportion (90.0 percent) were aware of cervical cancer as

138
against a minor proportion (10.0 percent).

139
5.2 Source of Awareness of Cervical Cancer

Table No. 5.2: Percentage distribution of Respondents by their source

of awareness

Sources of Awareness Pretest (250) Posttest (250)

Not aware 67.6 (169) 8.0 (20)

Relatives/Friends 4.0 (10) 4.0 (10)

Gynecologist 2.4 (6) 8.8 (22)

Mass media 6.8 (17) 2.8 (7)

Family Physician 3.2 (8) 2.8 (7)

ANM 16 (40) 2 (5)

Teaching module 0 (0.0%) 71.6 (179)

Before the STP two thirds of the respondents (67.6 percent) were not

aware and among the respondents who were aware for more than one tenth of the

respondents (16.0 percent) Axillaries Nurse midwife was the major source of

awareness followed by less than one tenth of the respondents (6.8 percent) mass

media , Relatives / friends (4.0 percent), family physician (3.2 percent) and for

only 2.4 percent of the respondents gynecologist was the source of awareness.

On the other hand in post test for more than two thirds of the respondents (71.6

percent) teaching module has been the major source of awareness, followed by

less than one tenth of the respondents (8.8 percent). Gynecologist was the source

of awareness, for only 4 percent of the respondents relatives/friends were the

source of awareness. For a minor proportion of the respondents (2.8 percent)

mass media was the source of awareness and for only 2.8% of the respondents

family physician was the source of awareness about cervical cancer.

140
5.3 Knowledge of the Anatomy & Physiology

Cancer of the cervix is also called cervical cancer, begins in the cells

lining the cervix. These cells do not suddenly change into cancer. Instead, the

normal cells of the cervix first slowly change into pre-cancer cells that can then

turn into cancer.

Table No. 5.3: Percentage distribution of Respondents by their knowledge

of the meaning of cervical cancer

Pretest (250) Posttest (250)

Meaning of Cervical Cancer

An abnormal growth of cells in breast 46.0 (115) 12.4 (31)

An abnormal growth in cervix 12.8 (32) 75.6 (189)

An abnormal growth of cells in stomach 41.2 (103) 12.0 (30)

In pretest more than two fifth respondents (46.0percent) stated that

abnormal growth of cells in breast was cervical cancer followed by a lesser

proportion of the respondents (41.2%) for whom cancer cervix was an abnormal

growth of cells in stomach and only more than one tenth of the respondents (12.8

per cent) correctly stated that abnormal growth in cervix as cervical cancer

(Table No.5.3). Whereas in post test majority of the respondents (75.6 per)

correctly stated abnormal growth of cells in cervix as cervical cancer. Still more

than one tenth of the respondents each(12.4 per cent) stated abnormal growth of

cells in breast as cervical cancer and abnormal growth of cells in stomach as

cervical cancer (12.0 percent).

141
5.3.1 Awareness about uterus and its structure

The uterus is shaped like an upside-down pear, with a thick lining and

muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a

blastocyte, or fertilized egg, to implant and grow. It also allows the inner lining

of the uterus to build up until a fertilized egg is implanted, or it is sloughed off

during menses

Table No.5.4 Percentage distribution of Respondents by their

Awareness about uterus

Pretest (250) Posttest (250)

Awareness on Uterus

No 26.8 (67) 2.0 (5)

Yes 73.2 (183) 98 (245)

In pre test nearly three fourth of the respondents (73.2 per cent) know

about uterus and one fourth of the respondents (26.8 per cent) do not know about

uterus (Table No. 5.4). On other hand in post test an overwhelming proportion of

the respondents (98.0 per cent) know about uterus and still 2.0 percent of the

respondents do not know about uterus.

Table No.5.5: Percentage distribution of Respondents by their

knowledge of uterus as an organ/ part of the body

Pretest (250) Posttest (250)

Meaning

Not known 26.8 (67) 2.0 (5)

Part of female reproductive

52.4 (131) 94.4 (236)
system

142
 Part of male reproductive system 9.2 (23) 1.2 (3)

Organ of male & female

11.6 (29) 2.4 (6)
reproductive system

In pretest more than half of the respondents (52.4 per cent) correctly

stated uterus as a part of female reproductive system as against more than one

tenth of the respondents (11.6percent) uterus as a part of both male & female

reproductive system and only 9.2 per cent of the respondents (9.2 per cent) stated

uterus as a part of male reproductive system (Table No. 5.5). Where as in post

test an over whelming proportion of the respondents (94.4 per cent) correctly

stated uterus as an organ of female reproductive system as against a minor

proportion (2.4 per cent) of the respondents uterus as an organ of male and

female reproductive system followed by 1.2 percent of the respondents stated

uterus an organ of male reproductive system.

Table No. 5.6: Percentage distribution of Respondents by their knowledge

about parts of uterus

Pretest (250) Posttest (250)

Parts of Uterus

Not known 26.8 (67) 2.0 (5)

Fallopian tubes, ampullas and Ovaries 30.8 (77) 10.4 (26)

Fundus, body and cervix 24.4 (61) 79.6 (199)

Colon, rectum and Anus 18.0 (45) 8.0 (20)

In pretest less than one third of the (30.8 per cent) respondents stated

fallopian tubes, ampullas and ovaries were the part of uterus followed by one

fourth (24.4 per cent) of the respondents stated fundus, body and cervix were the

143
parts of uterus and less than one fifth (18.0 percent) of the respondents stated

colon, rectum and anus were the parts of uterus (Table5.6). Whereas in post test

more than three fourths of the respondents (79.6 per cent) correctly stated

fundus, body and cervix were the parts of uterus, as against one tenth of the

respondents (10.4 percent) stated fallopian tubes, ampullas and ovaries were the

parts of uterus and only8per cent of the respondents still stated colon, rectum and

anus as the parts of uterus.

5.3.2 Knowledge of the Cervix and its Importance

The cervix is the lower, narrow end of the uterus. The cervix connects the

vagina (the birth canal) to the upper part of the uterus. The uterus (or womb) is

where a baby grows when a woman is pregnant.

Table No. 5.7: Percentage distribution of Respondents by their

knowledge of location of cervix

Knowledge on the location of Pretest (250) Posttest

Cervix (250)

No 86.0 (215) 4.0 (10)

Yes 14.0 (35) 96.0 (240)

In pre-test only one tenth (14.0 percent) of the respondents knew the

location of cervix as against a major proportion of the (86.0 per cent)

respondents do not know about the location of cervix (Table No. 5.7).On other

hand in post test an over whelming proportion (96.0 per cent) of the respondents

were aware of the location of cervix and only 4.0 per cent of the respondents do

not about the location.

144
Table No. 5.8: Percentage distribution of Respondents by their knowledge
about the exact location of cervix

Pretest (250) Posttest (250)

Location of Cervix

Not known 86.0 (215) 4.0 (10)

Beside the Ovary & Fallopian tubes 8.8 (22) 3.6 (9)

Behind the Uterus & Bladder 1.6% (4) 4.4 (11)

Between the Uterus & Vagina 3.6 (9) 88.0 (220)

Among this who know about the location of cervix in pre-test less than

one tenth (8.8 percent) of the respondents stated cervix was located besides the

ovary and fallopian tubes, only a minor proportion of the (3.6 percent)

respondents correctly stated cervix was located between the uterus and vagina

and 1.6 per cent of the respondents stated cervix was located behind the uterus

and bladder (Table No. 5.8) where as in post test a major proportion of the

respondents (88.0 per cent) correctly stated that cervix was located between the

uterus and vagina, still a minor proportion (4.4percent) stated cervix was located

behind the uterus and bladder and 3.6 percent of the respondents stated uterus

was located beside the ovary and fallopian tubes.

Table No. 5.9: Percentage distribution of Respondents by their

knowledge on the importance of cervix

Pretest (250) Posttest (250)

Importance of Cervix

Not known 86.0 (215) 4.0 (10)

Dilates during defection 5.6 (14) 4.8 (12)

145
 Expands during urination 4.8 (12) 10.0 (25)

Dilates during child birth 2.8 (7) 79.6 (199)

During Menstruation 0.8 (2) 1.6 (4)

Among those who responded on the importance of cervix in pretest only

2.8 percent of the respondents correctly stated cervix will be dilated during child

birth and only 0.8% of the respondent stated cervix dilated during menstruation

followed by minor proportion of the respondents (5.6 percent) stated cervix will

be dilated during defecation and relatively a lesser proportion (4.8 percent) of the

respondents stated cervix expands during urination, (Table No. 5.9). On other

hand in post-test majority of the respondents (79.6%) correctly stated cervix will

be dilated during child birth followed by one tenth of the respondents (10.0 per

cent) stated cervix will be dilated during urination, still a minor proportion of the

respondents (4.8 percent) stated cervix will be dilated during defecation and only

1.6 of the respondents stated cervix will be dilated during menstruation.

146
5.4 Knowledge a perceived severity of cervical cancer

Table No. 5.10: Percentage distribution of Respondents by their

knowledge on severity of cervical cancer

Knowledge on the Severity of Pretest (250) Posttest (250)

Cervical Cancer

No 67.6 (169) 6.4 (16)

Yes 32.4 (81) 93.6 (234)

In pre-test one third of the respondents (32.4 percent) know about the

severity of cervical cancer and two thirds of the respondents (67.6 percent) do

not know about the severity of cervical cancer (Table 5.10). Whereas in post test

an over whelming proportion of the respondents (93.6 percent) know about the

severity of cervical cancer and still 6.4 percent of the respondents do not know

about severity of cervical cancer.

147
148
 Table No.5.11: Percentage distribution of Respondents Response to
statements on perceived severity to cervical cancer

Perceived Not known Disagree Not Sure Agree

severity Pre Post Pre Post Pre Post Pre Post

Cervical 'Cancer
67.6 6.4 14.4 14.8 12.8 5.2 5.2 73.6
makes women’s
life difficulty (169) (16) (36) (37) (32) (13) (13) (184)

Cervica lcancer not

67.6 6.4 8.8 76.4 7.2 3.6 16.4 13.6
serious like other
cancer (169) (16) (22) (191) (18) (9) (41) (34)

Cervical Cancer is 67.6 6.4 8.8 75.6 6.0 5.2 17.6 12.8
easily cured (169) (16) (22) (189) (15) (13) (4) (32)

Cervical cancer
67.6 6.4 13.2 13.6 12.0 4.8 7.2 75.2
can result
infertility (169) (16) (33) (34) (30) (12) (18) (188)

Death from
67.6 6.4 10.4 76.8 6.8 6.0 15.2 10.8
Cervical Cancer
is rare (169) (16) (26) (192) (17) (15) (38) (27)

In pretest only a minor proportion (5.2 percent) of the respondents agreed

that cervical cancer makes women’s life difficult as against nearly three fourth

(73.6 percent) agreed the statement in post test. Less than one tenth (8.8 percent)

of the respondents have disagreed cervical cancer was not serious like other

cancer in pre-test where as in post test 76.4 percent disagreed. In pretest only 8.8

percent of respondents have disagreed cervical cancer is easily cured as against

75.6 percent disagreed in post test. Less than one tenth (7.2 percent) of the

respondents agreed that cervical cancer can result infertility in pretest where as

75.2 percent in post test agreed with this. In pre-test only one tenth (10.4 percent)

of the respondents disagreed that death from cervical cancer was rare as against

149
more than three fourth (76.8 percent) in post test (Table 5.11).

On the whole in pretest nearly two thirds do not know about the perceived

severity of cervical cancer whereas after the structure teaching program three

fourth of the respondents were aware of perceived severity of cervical cancer.

5.5 Knowledge on Causative Organism

Table No.5.12: Percentage distribution of Respondents by their knowledge on

organism involved in the causation of cervical cancer

Knowledge on organism which Pretest Posttest

causes Cervical Cancer (250) (250)

No 94.4 (236) 10.8 (27)

Yes 5.6 (14) 89.2 (223)

In pre-test only a minor proportion (5.6%) of the respondents have idea

about the organism involved in the causation of cervical cancer and an over

whelming proportion (94.4 percent) of the respondents do not know about the

organism involved in the causation of cervical cancer where as in post test a

major proportion of the respondents (89.2 percent) know about the organism

involved in the causation of cervical cancer and still one tenth of the respondents

(10.8 percent) do not know about the organism involved in causation of cervical

cancer (Table No. 5.12)

150
 Table No. 5.13: Percentage distribution of Respondents by their
knowledge of the name of the organism causing cervical
cancer

Pretest (250) Posttest (250)

Name of the Organism

Not known 94.4 (236) 10.8 (27)

Human Immune Virus 3.6 (9) 4.0 (10)

Human Papilloma Virus 0.4 (1) 82.4 (206)

Hepatitis Virus 1.6 (4) 2.8 (7)

In pretest a minor proportion (3.6 percent) of the respondents stated

Human Immune Virus as the organism that cause cervical cancer, only 1.6

percent of the respondents stated hepatitis virus was the cause for cervical cancer

and only0.4 percent of the respondents correctly stated human papilloma virus

was the organism causing cervical cancer (Table No. 5.13).On the other hand in

post test a major proportion of the respondents (82.4 percent) correctly stated

human papiloma virus as the organism causing cervical cancer, only a minor

proportion 4.0 percent of the respondents stated human immune virus and still

2.8 percent of the respondents stated hepatitis virus was the causative organism

of cervical cancer.

HPV is the primary cause of cervical cancer. Virtually everyone will

contract HPV in their lifetime, with many never knowing they were a carrier of
151
the virus. For some, the virus causes no adverse health effects, but for others, it

leads to genital warts, dysplasia, and cancer.

Table No. 5.14: Percentage distribution of Respondents by awareness of

spread of Human papilloma virus

Knowledge on the Spread of Pretest (250) Posttest (250)

Papilloma Virus

No 94.4(236) 15.2(38)

Yes 5.6(14) 84.8(212)

In pretest only 5.6 percent of the respondents know that Human

Papilloma Virus will spread and an over whelming proportion (94.4 percent) of

the respondents do not know about the spread of human papilloma virus (Table

No. 5.14). On other hand in post-test majority of the respondents (84.8 percent)

know that Human Papilloma virus will be spread and still more than one tenth

(15.2%) of the respondents do not know that Human Papilloma virus will spread

Human papillomavirus (HPV), a sexually transmitted disease is the primary

causal agent of cervical cancer. Sexual activity is the main cause for HPV

transmission. Approximately 40 identified HPV genotypes infect the genital

tract. The risk of infection was reported to be markedly increased in women

having more than one partner.

152
 Table No. 5.15: Percentage distribution of Respondents knowledge of
route of spread of Human Papilloma Virus

Pretest (250) Posttest (250)

Mode of spread

Not known 94.4 (236) 15.2 (38)

Sexual contact 0.8 (2) 80.4 (201)

Sharing of Food 1.2 (3) 1.6 (4)

Sharing of Bathrooms 1.6 (4) 1.2 (3)

Sharing of things 2.0 (5) 1.6 (4)

As it has been already stated an overwhelming (94.4 percent) of the

respondents stated they doesn’t know about the spread of Human Papilloma

virus in pretest. Among those who know the spread of virus. a minor proportion

of the respondents stated human papilloma virus will be spread by sharing of

things (28.0 percent), of Bathroom (1.6 percent), sharing food (1.2 percent) and

only 0.8 percent of the respondents correctly stated Human papilloma virus will

be spread through sexual contacts (Table No.5.15). On the other hand in post test

a major proportion of the respondents (80.4 percent) correctly knew that human

papilloma virus will spread through sexual contacts. Only 1.6 percent of the

respondents each stated by sharing of things and food.A minor proportions (1.2

percent) of the respondents stated human papilloma virus will be spread by

sharing of bath room.

153
 Table No.5.16: Percentage distribution of Respondents by their
awareness of detection of cervical cancer at an early
stage

Detection of Cervical cancer at an early Pretest (250) Posttest (250)

stage

No 70.8 (177) 4.4 (11)

Yes 29.2 (73) 95.6 (239)

In pretest more than one quarter respondents (29.2 percent) know that

cervical cancer can be noticed at an early stage and more than two thirds of the

respondents (70.8 percent) do not know that cervical cancer can be detected at an

early stage (Table No. 5.16). On the other hand in post test an over whelming

proportion of the respondents were aware that cervical cancer can be detected at

an early stage and 4.4 percent of the respondents do not know that cervical

cancer can be noticed at an early stage.

5.6 Knowledge of Susceptibility to Cervical Cancer

Researchers have identified several risk factors associated with cervical

cancer. A cervical cancer risk factor is something that increases the likelihood of

developing the disease. However it is not a guarantee that cervical cancer will

develop if risk factors are present. Some risk factors can be avoided such a

sexual behavior and smoking, but some risk factors cannot be controlled. The

Risk factors like genetics and age, cannot be controlled however the other risk

factors like early age at marriage, coitus before the age of 18 years, multiple

sexual partner, delivery of the first baby before the age of 20 years, multiparty

154
with poor birth spacing between pregnancies, poor personal hygiene and women

with STD, HIV infection, herpes simplex virus and human papilloma virus.

(HPV) (16, 18, 31, 33) infection can be avoided.

Table No.5.17: Percentage distribution of Respondents by their

knowledge of susceptibility to cervical cancer

Awareness on the susceptibility of Pretest (250) Posttest (250)

cervical cancer

No 62 (155) 6.8 (17)

Yes 38 (95) 93.2 (233)

In pretest more than one third of the respondents (38.0 percent) were of

susceptibility to cervical cancer and the remaining two thirds (62.0 percent) were

not aware of susceptibility to cervical cancer (Table No. 5.17). Whereas in post

test an over whelming proportion of the respondents (93.2 percent) were aware

about susceptibility to cervical cancer and only 6.8 percent of the respondents

were not aware of susceptibility to cervical cancer even after the STP.

155
156
 Table No.5.18: Percentage distribution of Respondents Response to
statements of perceived susceptibility to cervical cancer

Perceived Not known Disagree Not Sure Agree

susceptibility Pre Post Pre Post Pre Post Pre Post

Greater risk in
women with 62.0 6.8 9.6 9.2 20.4 5.6 8.0 78.4
multiple sexual (155) (17) (24) (23) (51) (14) (20) (196)
partners

Greater risk in
62.0 6.8 10.0 11.2 18.8 1.6 9.2 80.4
HIV Positive
women (155) (17) (25) (28) (47) (4) (23) (201)

Prolonged use 62.0 6.8 8.0 11.6 20.8 4.4 9.2 77.2
of oral pills (155) (17) (20) (29) (52) (11) (23) (193)

Increased
62.0 6.8 8.0 13.2 19.6 3.6 10.4 76.4
susceptibility with
parity (155) (17) (20) (33) (49) (9) (26) (191)

Poor genital 62.0 6.8 19.2 9.6 8.0 2.8 10.8 80.8
hygiene (155) (17) (48) (24) (20) (7) (27) (202)

Early age at first 62.0 6.8 18.8 8.4 11.2 7.2 8.0 77.6
coitus (155) (17) (47) (21) (28) (18) (20) (194)

62.0 6.8 17.2 14.8 13.2 3.2 7.6 75.2

Smoking
(155) (17) (43) (37) (33) (8) (19) (188)

Risk in older
women than 62.0 6.8 15.2 14.4 9.2 5.2 13.6 73.6
younger women (155) (17) (38) (36) (23) (13) (34) (184)

Risk in all
62.0 6.8 22.4 8.4 8.0 7.6 7.6 77.2
women of child
bearing age (155) (17) (56) (21) (20) (19) (19) (193)

Occurs only
62.0 6.8 11.6 73.6 7.6 12 18.8 7.6
above the age
of 50 years (155) (17) (29) (184) (19) (30) (47) (19)

157
 In pretest only less than one tenth of the (8.0 percent) respondents agreed

that the risk of cervical cancer will be greater among the women with multiple

sexual partners whereas in post test more than three fourth (78.4 percent) agreed

with this. A minor proportion of 9.2 percent of the respondents in pre-test agreed

cervical cancer was greater risk to the HIV positive women as against a major

proportion of 80.4 percent in post test. Only less than one tenth (9.2 percent) of

the respondents in pretest agreed prolonged use of oral pills will leads to cervical

cancer whereas in post-test 77.2 percent agreed the same. One tenth of the

respondents (10.4 percent) agreed that cervical cancer susceptibility can be

increased with parity as against 76.4 percent in post-test. More than one tenth

(10.8 percent) of the respondents agreed that poor genital hygiene will increase

the chances of cervical cancer in pre-test as against an over whelming proportion

(80.8 percent) in post test. Less than one tenth (8.0 percent) of the respondent in

pre-test agreed increased susceptibility with early age at first coitus as against

more than three fourths (77.6 percent) in post test. Only a minor proportion (7.6

percent) of the respondents agreed increased susceptibility to cervical cancer

with smoking in pre-test as against 75.2 percent in post-test. More than one tenth

(13.6 percent) of the respondents in pre-test agreed that risk of cervical cancer

will be more in older women than younger women as against 73.6 percent in post

test. A minor proportion (7.6 percent) of the respondents in pretest agreed

cervical cancer can occur to all women of child bearing age as against three

fourths (77.2 percent) in post test. In pre-test one tenth (11.6 percent) of the

respondents disagreed cervical cancer will occur to the women above the age 50

years as against 73.6 percent in post test (Table 5.18).

158
 On the whole in pre test for all the statement nearly two thirds do not

know about the perceived susceptibility to cervical cancer, whereas in post-test

for all the statements except that cervical cancer will occur to only above the age

of 50 years of age more than three fourths agreed on all the statements of

perceived susceptibility to cervical cancer.

5.7 Knowledge of Temporary Contraceptive Methods

Birth control is a regimen of one or more actions, devices, or medications

followedinordertodeliberatelypreventorreducethelikelihoodofawoman becoming

pregnant. Methods and intentions typically termed birth control may be

considered a pivotal ingredient to family planning. Methods of birth control (e.g.

the pill, IUDs, implants, patches, injections, vaginal ring and some others) which

may prevent the implantation of an embryo if fertilization occurs are medically

considered to be contraception. But prolong use of birth control methods leads to

have effect on women’s health .Condoms are helpful in protecting the cervix,

and research shows that condom use can promote clearance of the virus.

Table No.5.19: Percentage distribution of Respondents by their

awareness of temporary contraceptive methods

Awareness on temporary Pretest (250) Posttest (250)

contraceptive methods

No 57.2(143) 14.4(36)

Yes 42.8(107) 85.6(214)

In pretest more than two fifths of the respondents (42.8%) were aware of

temporary contraceptives and the remaining more than half of the respondents

159
(57.2 percent) do not know about temporary contraceptive methods (Table No.

5.19).On the other hand in post-test a major proportion of the respondent s(85.6

percent) were aware of temporary contraceptives methods and still more than

one tenth of the (14.4percent) respondents do not know about temporary

contraceptive methods.

Table No.5.20: Percentage distribution of Respondents by their

knowledge of type of temporary contraceptive
methods

Pretest (250) Posttest (250)

Mention the type of methods

Not known 57.2 (143) 14.4 (36)

Vaginal Jelly 3.6 (9) 10.0 (25)

Copper-T 26.8 (67) 56 (140)

Oral Pills 7.6 (19) 14 (35)

Others (Condom, other lubes) 4.8 (12) 5.6 (14)

In pre-test only one quarter (26.8 percent) of the respondents know about

copper T. Less than one tenth (7.6 percent) know that oral pill as one method of

contraception, 4.8 percent of the respondents know about condoms as a method

of contraceptionandonly3.6percentoftherespondentsstatedvaginaljellyasthe

method of temporary contraception (Table No. 5.20).On other hand in post test

more than half of the respondents (56.0 percent) know that Copper-T as

temporary contraceptive method, followed by more than one tenth (14.0 percent)

oral pills, one tenth of respondents (10.0 percent) vaginal jellies and only 5.6

percent of the respondents condom as methods of temporary contraception.

160
 There is evidence that long-term oral contraceptive use (5 years or longer)

increases the risk of cervical cancer. Use of oral contraceptives may also mean

that women are less likely to use condoms when having sex, thus increasing the

chance of getting HPV.

Table No.5.21: Percentage distribution of Respondents by their awareness on

prolongeduseoftemporarybirthcontrolmethodscanleadtocervicalcancer

Prolonged use of birth control Pretest (250) Posttest

measures lead to cervical cancer (250)

No 70.8 (177) 11.2 (28)

Yes 29.2 (73) 88.8 (222)

In pretest more than one fourth of the respondents (29.2 percent) were

aware that prolong use of temporary birth control method will lead to cervical

cancer and less than two third of the (70.8 percent) respondents do not know that

prolong use of temporary birth control methods can lead to cervical cancer

(Table No. 5.21). On the other hand in post test an over whelming proportion of

the respondents (88.8 percent) were aware that prolong use temporary

contraception will lead to cervical cancer and the remaining more than one tenth

of the (11.2 percent) respondents were not aware that prolong use of temporary

contraception can lead to cervical cancer

161
Table No.5.22: Percentage distribution of Respondents by their knowledge
on the type temporary birth control methods that can lead to cervical
cancer

Birth control method lead to Pretest (250) Posttest (250)

cervical cancer

Not known 70.8(177) 11.2(28)

Vaginal Jelly 10.4(26) 3.2(8)

Copper-T 5.6(14) 7.2(18)

Oral Pills 9.2(23) 76.8(192)

Others (Condom, other lubes) 4(10) 1.6(4)

In pretest more than one tenth (10.4 percent) of the respondents stated

prolong use of vaginal jellies will lead to cervical cancer, as against only less

than one tenth (9.2 percent) of the respondents correctly stated prolong use of

oral pills will lead to cervical cancer. A minor proportion (5.6percent) of the

respondents stated prolong use of copper T and Prolong use of condom (4.0

percent) can lead to cervical cancer (Table No. 5.22). On the other hand in post

test more than two thirds of the (76.8 percent) respondents correctly stated

prolong use of oral pills will lead to cervical cancer followed by a minor

proportion of the respondents (7.2 percent) stated prolong use of copper T and

vaginal jellies (3.2 percent) will lead to cervical cancer Still 1.6 percent of the

respondent stated prolong use of condom will lead to cervical cancer.

162
5.8 Knowledge on Symptoms of Cervical Cancer

Cervical cancer symptoms vary from woman to woman. Some women

will experience no symptoms, while others may have severe cervical cancer

symptoms. Advanced cervical cancer may have symptoms like abnormal vaginal

bleeding, increased vaginal discharge, pelvic pain, or pain during sex.

Table No.5.23: Percentage distribution of Respondents by their knowledge

on the symptoms of cervical cancer

Knowledge on the Symptoms of Pretest (250) Posttest (250)

cervical cancer

No 67.2 (168) 9.2 (23)

Yes 32.8 (82) 90.8 (227)

In pretest on third of the respondents (32.8 percent) are aware of

symptoms of cervical cancer as against more than two thirds of the respondents
(67.2 percent) who are not aware of symptoms (Table No. 5.23). Where as in
post test an over whelming proportion (90.8 percent) aware about symptoms of
cervical cancers against less than one tenth (9.2 percent) of the respondents not
aware of symptoms of cervical cancer.

163
164
 Table No.5.24: Percentage distribution of Respondents by their perceived on
symptoms of cervical cancer

Perceived Not known Disagree Not Sure Agree

symptoms Pre Post Pre Post Pre Post Pre Post

Abnormal
67.2 9.2 17.6 14.4 4.8 3.2 10.4 73.2
vaginal discharge
(168) (23) (44) (36) (12) (8) (26) (183)

Vaginal 67.2 9.2 17.2 10.8 6.0 2.8 9.6 77.2

bleeding (168) (23) (43) (27) (15) (7) (24) (193)

Post-coital 67.2 9.2 19.6 8.0 5.6 2.4 7.6 80.4

bleeding (168) (23) (49) (20) (14) (6) (19) (201)

Bleeding after 67.2 9.2 17.6 13.2 4.0 2.8 11.2 74.8
menopause (168) (23) (44) (33) (10) (7) (28) (187)

In pretest more than one tenth (10.6 percent) of the respondents agreed

that abnormal vaginal discharge was a symptom of cervical cancers against 73.2

percent of the respondents in post test. Less than one tenth (9.6 percent) of the

respondents in pre-test had agreed that abnormal vaginal bleeding was a

symptom of cervical cancer as against 77.2 percent in post-test. A minor

proportion (7.6 percent) of the respondents agreed that post coital bleeding was a

symptom of cervical cancer in pretest as against 80.4 percent in post test. In pre

test more than one tenth of the (11.2 percent) respondents agreed that bleeding

after menopause was a symptom of cervical cancer as against three fourths of the

respondents (74.8 percent) in post test (Table5.24).

The above table clearly shows that two thirds of the respondents were not

aware of the symptoms of cervical cancer in pre-test, whereas after the STP,
165
three fourth of the respondents perceived symptoms of cervical cancer.

5.9 Knowledge on Screening, Diagnoses and Treatment

Cervical cancer is a complex disease that is diagnosed through a series of

medical tests and exams. The Pap smear is a highly effective screening tool for

cervical cancer. It is recommended that virtually all women should have a

regular Pap smear to check for any abnormal cervical changes.

Table No.5.25: Percentage distribution of Respondents by their

knowledge on cervical cancer screening

Pretest (250) Posttest (250)

Knowledge on the screening

No 72.8 (182) 10.0 (25)

Yes 27.2 (68) 90.0 (225)

In pre-test one fourth of the respondents (27.2 percent) know about the

screening of cervical cancer and remaining three fourth (72.8 percent) does not

know about the screening. However after the STP, in post-test an overwhelming

proportions of the respondents (90.0 percent) know about the screening for

cervical cancer and still 10.0 percent of the respondents does not know about the

screening for cervical cancer (Table No. 5.25).

Table No. 5.26: Percentage distribution of Respondents by their

knowledge on the test for cervical cancer screening

Pretest (250) Posttest (250)

State the screening test

Not Known 72.8 (182) 10.0 (25)

166
 Hemoglobin test 19.2 (48) 8.0 (20)
Pap-smear 0.4 (1) 78.0 (195)
Sputum test 2.8 (7) 2.4 (6)
Glucose test 4.8 (12) 1.6 (4)

In pretest less than one fifths (19.2 percent) of the respondents stated

Hemoglobin testing should be done for cervical cancer screening followed by a

minor proportion (4.8 percent) stated Glucose test, 2.8 percent of the respondents

stated sputum test will be done for cervical cancer screening and only 0.4 percent

of the respondents correctly stated pap smear was the screening test for cervical

cancer (Table No. 5.26).On the other hand in post test more than two thirds

(78.0) of the respondents correctly stated pap smear was the screening test for

cervical cancer as against less than one tenth of the (8.0 percent) respondents

stated Hemoglobin test. A minor proportion of respondents stated sputum test

(2.4 percent) as the screening test and remaining 1.6 percent of the respondents

stated glucose test as the screening test for cervical cancer.

Table No.5.27: Percentage distribution of Respondents by their

practice of cervical cancer screening

Undergone for cervical Pretest (250) Posttest (250)

screening test

No 99.6(249) 68.8(172)
Yes 0.4(1) 31.2(78)

In pretest only 0.4 percent of the respondents had undergone for cervical screening and an

over whelming proportion of the respondents have not undergone for screening of cervical

cancer (Table No. 5.27). On the other hand in post test one third of the respondents (31.2%)

167
had undergone for cervical cancer screening and remaining two thirds (68.8 percent) did not

go for the screening of cervical cancer.

168
 Table No.5.28: Percentage distribution of Respondents by their sources
for screening test

Source motivation for Cervical Pretest Posttest

screening test (250) (250)

Not screening 99.6 (249) 68.8 (172)

Friends 0.0 (0) 1.6 (4)

Family members 0.0 (0) 1.2 (3)

Health workers/ANM 0.4 (1) 3.6 (9)

Teaching module 0.0 (0) 24.8 (62)

In pretest only 0.4% of the respondents had undergone for cervical cancer

screening by motivation of Health worker/ ANM (Table No. 5.28).On the other

hand in post test more than one fourth of the respondents (24.8 percent) have

under gone screening after the structured teaching program followed by minor

proportion (3.6 percent) of the respondents by the motivation of Health worker/

ANM, friends (1.6 percent) and remaining 1.2 percent of the respondents

undergone screening by the motivation of family members.

Table No.5.29: Percentage distribution of Respondents by their

awareness on having pap test for every two years

Undergone for pap test for every Pretest (250) Posttest (250)
two years

No 94.8 (237) 14.4 (36)

Yes 5.2 (13) 85.6 (214)

In pretest only 5.2 percent of the respondents agreed that healthy adult

women should undergo pap test for every two years and an over whelming
169
proportion (94.8 percent) did not agreed (Table No. 5.29). On the other hand in

post-test an over whelming proportion agreed every adult women should go for

pap test for every two years as against the remaining one tenth of the (14.4

percent) respondents still not agreed that every women should have pap test for

every two years.

Table No.5.30: Percentage distribution of Respondents by their knowledge

on the benefits of cervical cancer screening

Knowledge on the benefits of cervical Pretest Posttest

cancer screening (250) (250)

No 74.4 (186) 11.2 (28)

Yes 25.6 (64) 88.8 (222)

In pre-test only more than quarters (25.6 percent) of the respondents know

about the benefits of cervical cancer screening and the remaining (74.4 percent)

did not know-about the benefits of cervical cancer. However after the STP in

post test an over whelming proportion (88.80 percent) were aware about the

benefits of cervical cancer and only minor proportion (11.20 percent) still does

not know about the benefits of cervical cancer screening (Table No.5.30)

170
171
 Table No.5.31: Percentage distribution of Respondents by their response to
statements on perceived benefits of cervical cancer screening

Not known Disagree Not Sure Agree

Perceived benefits
Pre Post Pre Post Pre Post Pre Post
Screening important
to be done so 74.4 11.2 10.8 10.0 4.8 5.2 10.0 73.6
women will know if (186) (28) (27) (25) (12) (13) (25) (184)
she is
healthy
Screening can find
74.4 11.2 10.4 11.2 6.0 7.2 9.2 70.4
changes, before they
(186) (28) (26) (28) (15) (18) (23) (176)
become cancer
Easily curable when 74.4 11.2 10.0 12.8 4.8 4.4 10.8 71.6
found early (186) (28) (25) (32) (12) (11) (27) (179)
Cervical cancer
74.4 11.2 8.4 75.6 4.8 5.6 12.4 7.6
Improves chances of
(186) (28) (21) (189) (12) (14) (31) (19)
pregnancy infertile
Cervical cancer
screening decreases 74.4 11.2 6.8 72.0 6.0 6.8 12.8 10.0
the chances of (186) (28) (17) (180) (15) (17) (32) (25)
abortions

In pre-test only one tenth (10.0 percent) of the respondents agreed that

screening was important to know whether she is healthy as against 73.6 percent

in post-test. A minor proportion (9.2 percent) of the women agreed screening can

find the changes before they became cancer in pre-test as against 70.4 percent in

post-test. In pre-test one tenth of the respondents (10.8 percent) agreed that if

found early it can be cured easily as against 71.6 percent in post test. Less than

one tenth of the respondents (8.4 percent) in pre test disagreed that cervical

cancer screening can improve chances of pregnancy in infertile woman as

against two thirds (75.6percent) in post test. Only a minor proportion (6.8

percent) of the respondents disagreed in pre-test that cervical cancer screening

decreases the chances of abortion as against 72.0 percent in post test (Table5.31).
172
 From the above table it is clear that after the structured teaching program

three fourths of the respondents were perceived the benefits of screening for

cervical cancer.

Table No.5.32: Percentage distribution of Respondents by Barriers to

cervical cancer screening

Pretest (250) Posttest (250)

Barriers for screening

No 94.4 (236) 29.6 (74)

Yes 5.6 (14) 70.4 (176)

In pretest only a minor proportion (5.6 percent) of the respondents stated

that they had barriers for cervical cancer screening and remaining 94.4 percent of

the respondents did not have any barriers for cervical cancer screening (Table

No. 5.34). On the other hand in post test 70.4 percent of the respondents had

barriers for cervical cancer screening and remaining 29.6 percent of the

respondents did not have any barriers for cervical cancer screening (Table 5.32).

In this study the reasons for not getting the screening test done in spite of

a desire to do so were mainly lack of awareness, no symptoms or disease, do not

know where to go, no one is doing it and never thought of it. Lacks of

knowledge about the disease, absence of the concept of preventive behavior

appear to be important factors. Reported obstacles to screening included not

knowing where to obtain a Pap test; the test is painful, anxiety about results and

cost. Some other determinants included being scared of the tests, feeling shy.

The present study these factors were categorized as psychosocial factors. These

included lack of interest, pain, fear of pain and embarrassment. Fear of

discomfort and embarrassment were most important barriers for women, some

respondents could not specify a reason and some did not answer for the desire to
173
go for Pap test.

174
175
 Table No.5.33: Percentage distribution of Respondents and
response to statement on perceived barriers to cervical
cancer screening

Not known Disagree Not Sure Agree

Perceived benefits
Pre Post Pre Post Pre Post Pre Post

94.4 29.6 3.2 14.4 1.2 5.6 1.2 50.4

Embarrassing
(236) (74) (8) (36) (3) (14) (3) (126)

Cervical cancer screening is 94.4 29.6 2.0 51.6 1.2 4.4 2.4 14.4
painful (236) (74) (5) (129) (3) (11) (6) (36)

Screening suggests one in having sex 94.4 29.6 2.8 54.8 1.6 5.6 1.2 10.0
(236) (74) (7) (137) (4) (14) (3) (25)

Screening makes one worry 94.4 29.6 2.0 50.4 1.2 5.2 2.4 14.8
(236) (74) (5) (126) (3) (13) (6) (37)

Screening takes away virginity 94.4 29.6 2.4 54.4 1.6 4.8 1.6 11.2
(236) (74) (6) (136) (4) (12) (4) (28)

Not knowing where screening is 94.4 29.6 2.4 16.0 2.0 7.2 1.2 47.2
done (236) (74) (6) (40) (5) (18) (3) (118)

Only mothers needs to do 94.4 29.6 2.0 51.6 2.0 6.4 1.6 12.4
screening (236) (74) (5) (129) (5) (16) (4) (31)

Partner resisting cervical cancer 94.4 29.6 3.2 14.8 0.8 6.0 1.6 49.6
screening
(236) (74) (8) (37) (2) (15) (4) (124)
Lack of female screeners in health
facilities contributes for not doing 94.4 29.6 2.8 12.0 1.2 7.2 1.6 51.2
(236) (74) (7) (30) (3) (18) (4) (128)

Attitudes of health workers

discourages cervical cancer 94.4 29.6 2.4 14.0 2.4 8.4 0.8 48.0
screening (236) (74) (6) (35) (6) (21) (2) (120)

Lack of convenient time is a

barrier to routine cervical cancer 94.4 29.6 2.0 13.2 2.4 9.6 1.2 47.6
screening (236) (74) (5) (33) (6) (24) (3) (119)

Lack of information also a barrier to 94.4 29.6 2.4 11.2 1.6 9.2 1.6 50.0
cervical cancer screening
(236) (74) (6) (28) (4) (23) (4) (125)

176
 In pretest only a very minor proportion (1.2 percent) of the respondents

perceived that they feel embraced to go for screening as against 50.4 percent of

the respondents in post test. Only 2.0 percent of the respondents in pretest

disagreed that cervical cancer screening was painful as against 51.6 percent in

post-test. In pre-test 2.8 percent of the respondents disagreed screening should be

done by women who are involved in sexual life as against 54.8 percent in post

test. Only 2 percent of the respondents in pre-test disagreed that cervical

screening, makes one worried as against 50.4 percent in post-test. A minor

proportion (1.2 percent) of the respondents in pre-test agreed that they do not

know where screening will be done as against 47.2 percent in post test. Only 2.0

percent of the respondents in pretest disagreed that only mothers should go for

screening as against 51.6 percent in post test. A minor proportion of 1.6 percent

of the respondents pre test perceived resistance from their partners as a barrier

for cervical cancer screening as against 49.6 percent is post test. In pretest only

1.6 percent of the respondents agreed that lack of female screening staff is health

facilities as barrier for not undergoing screening as against 51.2 percent in post

test. Only 0.8 percent of the respondents in pre-test agreed attitude of health

workers discouraged them for not screening as against 48.0 percent in post test.

A minor proportion (1.2 percent) of the respondents in pretest perceived lack of

convenient time as a barrier to cervical cancer screening as against 47.6 percent

in post-test. In pre-test only 1.6 percent of the respondents perceived that lack of

information as a barrier to cervical cancer screening as against 50.0 percent in

post-test. The above table shows that an over whelming proportion of the

respondents in pretest were not able to perceive the barriers to cervical cancer
177
screening (Table 5.33).However after the STP more than half of the respondents

were able to perceive the barriers for screening of cervical cancer.

The treatments methods commonly used to treat cervical cancer are

surgery, chemotherapy, and radiation therapy. Sometimes they are used alone,

and others times they are used in conjunction with one another. The treatment

method(s) are chosen depend on several factors like type of cervical cancer,

stage of the disease, general health of the patient.

Table No.5.34: Percentage distribution Respondents by their knowledge

of the treatment available for cervical cancer

Pretest Posttest
Treatment for Cervical cancer
(250) (250)

No 65.2 (163) 10.8 (27)

Yes 34.8 (87) 89.2 (223)

In pretest one third (34.8 percent) of the respondents know about the

treatment available, for cervical cancer as against two thirds doesn’t know about

the treatment (Table No. 5.34). However in post-test an over whelming

proportion of the respondents (89.2 percent) know about the treatment available

for cervical cancer as against more than one tenth of the (10.80 percent)

respondents still doesn’t know about the treatment available for cervical cancer.

178
 Table No.5.35: Percentage distribution of Respondents by their
awareness of modes of treatment available for cervical
cancer

Pretest (250) Posttest

Mode of treatment
(250)
Not known 65.2(163) 10.8(27)
Oral Drugs 17.2(43) 0.8(2)
Surgery 8.4(21) 5.6(14)
Radiation 4.0(10) 5.2(13)
Surgery &radiation 5.2(13) 77.6(194)

In pretest more than one tenth (17.2 percent) stated only drugs as the

treatment available for cervical cancer, followed by surgery (8.4 percent). A

minor proportion (5.2 percent) stated both surgery and radiation as mode of

treatments available for cervical cancer and only 4.0 percent respondents stated

radiation as the only mode of treatment for cervical cancer(Table

No.5.35).Where as in post test more than two thirds of the (77.6 percent)

respondents stated surgery and radiation were the modes of treatment, followed

by surgery (5.6 percents) as only mode of treatment for cervical cancer. A minor

proportion (5.2 percent) of the respondents stated radiation as the mode of the

treatment available for cervical cancer and still 0.8 percent of the respondents

stated oral drugs was the mode of treatment for cervical cancer.

5.10 Knowledge of Preventive Practices

Cervical cancer prevention should be a top priority for all women.

Women can take several simple steps to reduce their risk of developing cervical

cancer. Small lifestyle adjustments combined with medical care go a long way in

preventing cervical cancer. As prophylactic and therapeutic HPV vaccines are

179
still under development, and evidence shows that other primary prevention

measures are not useful, secondary prevention, in the form of screening and

treatment of precancerous lesions continues to be the most effective way to

reduce the incidence of cervical cancer at the present time. A vaccine to prevent

cervical cancer is now available. The vaccines called Gardasil and Cervarix, cost

around 10000 Rs for 3 shots, can prevent infection against the two types of

human papilloma virus responsible for most cervical cancer cases.

Table No.5.36: Percentage distribution of Respondents by their awareness of

the name of cervical cancer vaccine

Pretest (250) Posttest (250)

Awareness on Vaccine

BCG 33.6 (84) 8.4 (21)

DPT 58.4 (146) 17.2 (43)

GARDASIL 0.4 (1) 66.8 (167)

Polio 7.6 (19) 7.6 (19)

In pretest more than half of the (58.4 percent) respondents stated DPT

vaccine will prevent cervical cancer followed by one third of the (33.6 percent)

respondents stated BCG vaccines will prevent cervical cancer. Less than one

tenth of the (7.6 percent) respondent stated polio vaccine and only 0.4 percent of

the respondents correctly stated Gardasil vaccine will prevent cervical cancer

(Table No.5.36).Whereas in post test two thirds of the respondents (66.8 percent)

correctly stated Gardasil vaccine will prevent the cervical cancer as against 17.2

percent DPT vaccine, BCG vaccine (8.4 percent) still remaining 7.6 percent of

the respondents stated polio vaccine will prevent cervical cancer. Human

180
papilloma virus vaccination is recommended for 9 and to 26 years.

Table No.5.37: Percentage distribution of Respondents by their awareness of

the ideal age group for cervical cancer

Pretest (250) Posttest (250)

Age for Vaccine

Don’t know 56.0(140) 5.6(14)

09-26years 4.0(10) 83.6(209)

26-44years 33.2(83) 3.6(9)

45+ 6.8(17) 7.2(18)

In pretest more than half (56.0 percent) of the respondents do not know

about the ideal age group for cervical cancer vaccine, where as one third of the

respondents (33.2 percent) stated 26-44 years age as ideal age for cervical cancer

vaccine, a minor proportion 6.8 percent of the respondents stated above 45 years

age as the ideal age and only 4.0 percent of the respondents correctly stated

between 9-26 years as the ideal age for Vaccine (Table No.5.37).Where as in

post test a major proportion of the respondents (83.6 percent) correctly stated

between 9-26 years was the ideal age to give cervical cancer vaccine followed by

less than one tenth (7.2 percent) of the respondents stated above 45 years and

only 3.6 percent of the respondents stated 26- 44 years age as ideal age for the

vaccination cervical cancer.

5.11 Menstrual and Sexual Hygiene

Most of the population used home-made sanitary napkins made of cotton

cloth which was reused after washing and reusing home-made sanitary napkins is

181
a risk factor for cervical cancer.

Table No.5.38: Percentage distribution of Respondents by their awareness

of the cloth during menstruation

Pretest (250) Posttest (250)

Use of old cloth during menstruation

No 62.0(155) 70.8(177)

Yes 38.0(95) 29.2(73)

In pretest more than one third (36.4 percent) of the respondents used cloth

during menstruations and the remaining two thirds of the respondents (62.0

percent) did not old cloth to absorb menstrual fluid.(Table 5.38).Where as in post

test more than one fourth (29.2 percent) of the respondents used old cloth to

absorb menstrual blood and remaining less than two thirds of the respondents

(70.8 percent) did not used old cloth to absorb menstrual fluid and they opted

sanitary pads.

Table No. 5.39: Percentage distribution of Respondents by their practice on

frequency of changing Pad / Napkin

Frequency to change Pre test Post test

the Pads/Napkins (250sample) (250sample)
2to4hrs 5.6(14) 7.6(19)
4to6hrs 36.0(90) 66.4(166)
6+ 58.4(146) 26(65)

In pre-test more than half of the (58.4 percent) respondents changed pad/

napkin for every six hours followed by more than one third of the respondents

(36.0 percent) between 4 to 6 hrs and remaining only 5.6 percent of the

182
respondents changed napkin/pad in between 2 to 4 hrs (Table No. 5.39), whereas

in post-test more than half of the respondents (66.4 percent) changed napkin/pad

in between 4 to 6 hours. More than one fourth (26.0 percent) of the respondents

changed napkin / pad for 6 hours and above only 7.6 percent of the respondents

changed for every 2 to 4hours.

Table No.5.40: Percentage distribution of Respondents by their habit of

cleaning private parts during menstruation.

Cleaning private parts during Pretest (250) Posttest (250)

menstruation

No 66.8 (167) 18.4 (46)

Yes 33.2 (83) 81.6 (204)

Two Thirds (66.8 percent) of the respondents were not cleaning private

parts during menstruation and the remaining one third of the respondents

(33.2percent) were cleaning private during menstruation in the table (Table

5.40). Whereas in post- test a major proportion of the respondents (81.6 percent)

were cleaning private parts during menstruation however still less than one fifth

(18.4 percent) of the respondents were not cleaning private parts during

menstruation.

183
Table No.5.41: Percentage distribution of Respondents by their habit of
washing private parts before / after the changing pads /
napkins.

washing private parts before/after the Pretest Posttest

changing pads/napkins (250) (250)

No 63.6(159) 29.2(73)

Yes 36.4(91) 70.8(177)

In pretest nearly two thirds (63.6 percent) of the respondents were not

having habit of cleaning private before and after the changing pads / napkin and

remaining more than one third of the (36.4 percent) respondents had the habit of

cleaning private parts before / after the changing pads / napkins (Table No.5.41),

on the other hand, in post test more than two thirds (70.8 percent) of the

respondents had the habit of cleaning private parts before / after the changing

pads / napkin and less than one third (29.2 percent) of the respondents were not

having habit of washing private parts before / after the changing pads / napkin.

Table No.5.42: Percentage distribution of Respondents by their habit of

washing private parts after urination.

washing private parts after urination Pretest Posttest

(250) (250)

No 62.8 (157) 14 (35)

Yes 37.2 (93) 86 (215)

184
 In pretest more than three fifth of respondents (62.8 percent) were not

cleaning private parts after urination and remaining more than one third of the

(37.2 percent) respondents were cleaning private parts after urination (Table

5.42) where as in post-test an overwhelming proportion (86.0 percent) of the

respondents were cleaning private parts after urination (Table 5.33) and the

remaining 14 percent of the respondent were not cleaning private parts after

urination.

Table No.5.43: Percentage distribution of Respondents by their habit of

cleaning private parts before sexual intercourse

Cleaning Private parts before sexual Pretest Posttest

intercourse (250) (250)

No 94.8 (237) 54 (135)

Yes 5.2 (13) 46 (115)

In pretest an over whelming proportion of the respondents (94.8 percent)

were not cleaning private parts before sexual intercourse, and only a minor

proportion (5.2 percent) of the respondents were cleaning private parts before

sexual intercourse (Table No. 5.43) whereas after the STP more than half of the

respondents (54.0 percent) were cleaning private parts before sexual intercourse.

Table No.5.44: Percentage distribution of Respondents by their habit of

cleaning private parts after sexual intercourse

Cleaning private parts after sexual Pretest Posttest

intercourse (250sample) (250sample)

No 92.8 (232) 57.6 (144)

185
 Yes 7.2 (18) 42.4 (106)

An over whelming proportion of the respondents (92.8 percent) were not

cleaning private parts after sexual intercourse and only 7.2 percent of the

respondents were cleaning before the structured teaching program (Table

5.44).On the other hand in post test more than half of the (57.6 percent)

respondent had cleaned private parts after sexual intercourse and still more than

two fifth of the (42.4 percent) respondents were not cleaning private parts after

sexual intercourse.

5.12 IN TAKE OF NURTIENTS

Table No.5.45: Percentage distribution of the Respondents by their

habit of eating vegetables

Pretest Posttest
Eating vegetables daily
(250) (250)

No 62.0 (155) 41.6 (104)

Yes 38.0 (95) 58.4 (146)

In pretest three fifth (62.0) of respondents were not eating vegetables

daily and remaining more than one third (38.0 percent) respondents were eating

vegetables daily(Table5.45)whereas in post-test more than half (58.4 percent) of

the respondents were eating vegetables daily and still two fifths (41.6 percent) of

the respondent were not eating vegetables daily.

186
 Table No.5.46: Percentage distribution of the Respondents by their
habit of eating fruits

Pre Post (n=250)

Eating fruits daily
(n=250)
No 96.4 (241) 9.2 (23)
Yes 3.6 (9) 90.8 (227)

In pretest only a minor proportion of 3.4 percent of were eating fruits

daily as against an over whelming proportion of the (96.4 percent) of the

respondents were not eating fruits daily (Table 5.46). On the other hand in post-

test a major proportion of the (90.8 percent) respondents were eating fruits daily

and 9.2 percent of the respondents were not eating fruits daily.

5.13. Overall knowledge on cervical cancer

Table No. 5.47: Percentage distribution of the Respondents by their overall

knowledge of cervical cancer

Pretest (250) Posttest (250)

Knowledge of respondents

Overall knowledge on cervical cancer 21.2 (53) 72.8 (182)

The data presented in (Table No.5.47) shows the comparison of

knowledge among married women on cervical cancer in pretest and post test. In

pre test less than one fourth of the respondents (21.2 percent) had adequate

knowledge as against nearly three fourth (72.8 percent) of the respondents had

187
adequate knowledge on cervical cancer after STP .This clearly shows that

structured teaching program had influenced the knowledge levels of the

respondents.

The present study findings shows that in pre-test only one third of the

respondents were aware of cervical cancer as against in post test an over

whelming proportion are aware of cervical cancer. In pre test for more than one

tenth of the respondents Axillaries Nurse midwife was the major source of

awareness On the other hand in post test for more than two third of the

respondents teaching module was the major source of awareness. In pre-test only

one tenth of the respondents correctly stated that abnormal growth in cervix was

cervical cancer whereas in post-test majority of the respondents correctly stated

abnormal growth of cells in cervix was cervical cancer. Only a minor proportion

of the respondents correctly stated cervix was located between the uterus and

vagina .In post test a major proportion of the respondents correctly stated cervix

was located between the uterus and vagina. In pre- test one third of the

respondents know about the severity of cervical cancer whereas in post test an

over whelming proportion of the respondents knows about the severity of

cervical cancer. In pre-test only a minor proportion of the respondents stated

Human Immune Virus that causes organism causing cervical cancer, On the

other hand in post test a major proportion of the respondents correctly stated

human papiloma virus waste cause for cervical cancer, In pre-test more than one

third of the respondents were aware of susceptibility to cervical cancer Where as

in post an test an over whelming proportion of the respondents are aware about

susceptibility to cervical cancer. In pre- test one third of the respondents were
188
aware of symptoms of cervical cancer whereas in post test an over whelming

proportion were aware about symptoms of cervical cancer In pre-test one fourth

of the respondents know about the screening methods of cervical cancer

However after the STP, in post-test an over whelming proportions of the

respondents know about the screening methods of cervical cancer only 0.4

percent of the respondents correctly stated pap smear is the screening test for

cervical cancer. On the other hand in post-test more than two thirds of the

respondents correctly stated Paps smear was the screening test for cervical

cancer. In pre-test only more than a quarter of the respondents know the benefits

of cervical cancer screening, however after the STP an over whelming

proportion were aware about the benefits of cervical cancer screening. In pre-test

one third of the respondents know about the treatments available, However in

post-test an over whelming proportion of the respondents know about the

treatment available for cervical cancer. In pre-test only 0.4 percent of the

respondents correctly stated Gardasil vaccine will prevent cervical cancer.

Whereas in post-test two thirds of the respondents correctly stated

Gardasilvaccinewillpreventthecervicalcancer.OnthewholeInpretestlessthan

onefourthoftherespondentshadadequateknowledgeasagainstnearlythreefourth of

the respondents had adequate knowledge on cervical cancer after STP .This

clearly shows that structured teaching program had influenced the knowledge

levels of the respondents.

189
5.14 Knowledge on Cervical Cancer of Respondents- ‘F’ test

The data presented in (Table No.5.48) shows the comparison of

knowledge among married women on cervical cancer in pre-test and post-test.

The maximum mean score of 5.7240 and standard deviation 4.46403 has been

obtained for anatomy and physiology of female reproductive system in pretest

and in the post test, mean scores has been increased to 5 folds, i.e., 27.1240 and

standard deviation was 4.78332. The F value 7.275 which was statistically

significant at 0.01 levels clearly shows that structured teaching had an impact on

knowledge of married women.

The knowledge on susceptibility to cervical cancer showed score of the

mean as 7.4680 and standard deviation 10.05212 in pre test and in the post test

mean score has increased to 26.1920 and standard deviation 8.97627 with the f

value 3.124 and p value 0.009 was statistically significant at 0.01 level which

clearly shows the impact of structure teaching program on married women. A

mean score 2.6200 and standard deviation 4.23359 has been obtained for signs

and symptoms of cervical cancer in pre test and an increase in the mean score of

10.7640 and SD 4.12606 has been obtained in post test. The f value 3.034 and p

value was 0.05 was statistically significant at 5 percent level which clearly

showed the impact of structured teaching on the knowledge married women.

190
 For the diagnosis and treatment of cervical cancer the mean score 7.0210

and SD 8.08414 in pre-test, whereas in post-test the mean value 40.3400 and SD

17.67467.The f value 1.330 was statistically not significant. For the knowledge

on perceived benefits of cervical cancer screening, the mean score 2.4480 and

SD 4.25296 was obtained in pre test whereas in post test mean value 11.9960

and S.D 4.80670 has been obtained. The f value 10.001 and p value is 0.000

which was statistically significantat1 percent level. This clearly showed the

impact of structured teaching on knowledge on married women perceived

benefits of cervical cancer screening. Knowledge on barriers of cervical cancer

showed a mean value of 1.2720 and S.D 5.26163 in pre test, where as in post test

the mean value has increased to 21.3800 the f value 1.173 and which was found

to be not significant .Knowledge on preventive practices of cervical cancer has

showed as mean value of 0.3095 in pre test where as in post test mean value is

3.1560. It has been observed to be statistically significant at 1 percent level

which clearly showed that structured teaching had an impact on knowledge of

married women.

191
 Table No.5.48: Pre Test and Post Test Knowledge of Cervical Cancer
among the Respondents – ‘F’ test

Knowledge Pre test n=250 Post test n=250 P

S. No. F value
variable Mean SD Mean SD value

Knowledge of
anatomy &
physiology of
1. 5.7240 4.46403 27.1240 4.78332 7.27** 0.000
female
reproductive
system

Knowledge of
susceptibility to
2. 7.4680 10.05212 26.1920 8.97627 3.124** 0.009
cervical cancer

Knowledge of
3. symptoms of 2.6200 4.23359 10.7640 4.12606 3.034* 0.011
cervical cancer

Knowledge of
4. diagnosis 7.0120 8.08414 40.3400 17.67467 1.330 0.252
&treatment

Knowledge of
5. 2.4480 4.25256 11.9960 4.80670 10.001** 0.000
perceived

Knowledge of
perceived
6. barriers of 1.2720 5.26163 21.3800 14.90652 1.173 0.310
cervical cancer
screening

Knowledge of
7. preventive 0.3095 0.56258 3.1560 0.80390 4.651* 0.010
practices

Overall
8. knowledge of 23.1000 15.61413 80.4520 24.54223 1.929 0.040
cervical cancer

Note: P< 0.01 → 1 % level significant

P < 0.05 → 5% level

192
 On the whole overall knowledge of cervical cancer among married

women showed a mean value 23.1000 and SD 15.61413 in pre-test, where as in

post test mean value has increased to 80.4520 the S.D. 24.54223. The f value

1.929 and p value 0.040, which was statistically significant at 5% level. This

clearly shows that structure teaching program on the whole had no impact on the

knowledge of married women.

Socio–demographic factors & knowledge about cervical cancer

5.15 Socio- demographic characteristics and knowledge on anatomy

and physiology of female reproductive system

The below (Table No.5.49) shows the relation between socio-

demographic characteristics like age, age at marriage, number of children,

education, occupation and in come with level of knowledge on anatomy and

physiology of female reproductive system of cervical cancer.

193
 Table No. 5.49. Distribution of Respondents by socio-demographic
characteristics and level of knowledge on anatomy and physiology of
female reproductive system

Socio Demographic Pre-test(250) Posttest(250)

Variable Low Moderate High Low Moderate High
Age
34.6 28.8 36.5 23.0 26.9 50.1
20-29
(18) (15) (19) (12) (14) (26)
54.1 26.2 19.7 32.8 31.1 36.0
30-39
(66) (32) (24) (40) (38) (44)
38.2 50.0 11.7 23.5 32.4 54.1
40-49
(13) (17) (4) (3) (11) (17)
31.0 19.0 50.0 11.9 35.7 52.4
50-59
(13) (8) (21) (5) (15) (22)
44.0 28.8 27.2 26.4 31.2 48.4
Total
(110) (72) (68) (65) (78) (109)
*P<0.05,Significantat5%level
Age at marriage
40.3 31.9 27.8 25.7 35.4 38.9
15-18
(58) (46) (40) (37) (51) (56)
48.8 24.4 26.7 31.7 26.7 52.5
19-22
(42) (21) (23) (22) (23) (43)
25.0 37.5 37.5 25.0 12.5 62.5
23-26
(2) (3) (3) (2) (1) (5)
40.0 20.0 40.0 20.0 20.0 60.0
27-30
(2) (1) (2) (1) (1) (3)
85.7 14.3 0.0 14.3 28.6 57.1
31-34
(6) (1) (0) (1) (2) (4)
44.0 28.8 27.2 31.2 31.2 42.4
Total
(110) (72) (68) (78) (78) (106)
*P<0.05,Significantat5%level
Education
41.0 29.9 29.1 26.9 31.3 41.8
Illiterates
(55) (40) (39) (36) (42) (56)
48.3 31.0 20.7 18.4 31.0 50.6
Primary
(42) (27) (18) (16) (27) (44)
44.8 17.2 37.9 31.0 20.7 48.3
Secondary
(13) (5) (11) (9) (6) (14)
44.0 28.8 27.2 23.4 30.0 50.6
Total
(110) (72) (68) (61) (75) (15)
**P<0.01, Significant at 1 % level

194
No. Of Children
65.2 17.4 17.4 21.7 26.1 52.2
No Children
(15) (4) (4) (5) (6) (12)
34.7 38.8 26.5 32.4 34.7 42.9
Single Child
(17) (19) (13) (11) (17) (21)
40.0 30.6 29.4 34.1 22.4 43.5
Two children
(34) (26) (25) (29) (19) (37)
49.1 22.8 28.1 18.8 35.1 48.1
Three children
(28) (13) (16) (10) (20) (27)
50.0 21.4 28.6 26.6 28.6 42.9
Four children
(14) (6) (8) (8) (9) (12)
25.0 28.8 27.2 29.6 26.4 44.0
Five and above
(2) (72) (68) (74) (67) (110)
44.0 28.0 27.2 29.6 26.4 44.0
Total
(110) (72) (68) (74) (67) (110)
*P<0.05, Significant at 5 % level
Occupation
44.3 30.2 25.5 26.2 28.9 45.0
Cooli
(66) (45) (38) (39) (43) (67)
48.1 28.6 23.4 35.1 23.4 41.6
Housewife
(37) (22) (18) (27) (8) (32)
29.2 20.8 50.0 29.2 20.8 50.0
Petty trade
(7) (5) (12) (7) (5) (12)
44.0 28.8 27.2 28.2 26.4 52.4
Total
(110) (72) (68) (73) (66) (11)
**P<0.01, Significant at 1 % level
Income
41.4 32.5 26.0 29.0 29.0 42.0
Rs.1000-5000
(70) (55) (44) (49) (49) (71)
45.5 20.5 34.1 22.7 36.4 40.9
Rs.6000-10000
(20) (9) (15) (10) (16) (18)
51.6 19.4 29.0 16.1 35.5 48.4
Rs.11000-15000
(16) (6) (9) (5) (11) (15)
66.7 33.3 0.0 33.3 33.3 33.2
Rs.16000-20000
(4) (2) (0) (2) (2) (2)
44.0 28.8 27.2 26.4 31.2 42.4
Total
(110) (72) (68) (66) (78) (106)
**P<0.01, Significant at 1 % level

195
 The relation between age and level of knowledge of anatomy &

physiology of female reproductive system shows that in pretest one third of the

respondents (34.6 percent) in the age group of 20-29 years had low knowledge

whereas half of the respondents (50.1 percent) had high knowledge on anatomy

& physiology after STP. In pretest more than half (54.1 percent) respondents

between the ages 30-39 years had low knowledge where as two fifths (40.1

percent) of the respondents had high knowledge on Anatomy & Physiology after

STP. Half of the respondents (50.17 percent) in the age 40-49 had moderate

knowledge in pretest and less than one fourth (23.5 percent) of the respondents

had low knowledge in post test. Less than one third (31.0 percent) of the

respondents in pretest in the age 50-59 years had low knowledge whereas more

than half of the respondents (52.4 percent) had high knowledge on Anatomy &

Physiology of female reproductive system after STP.

The association between age at marriage and level of knowledge of

Anatomy & physiology of female reproductive system revealed that in pre-test

less than one third (31.9 percent) married in between 15-18 years had moderate

knowledge and only one fourth of the respondents (25.7 percent) had low

knowledge in post test. Less than half (48.8 percent) of the respondents married

in between 19-22 years had low knowledge in pre-test whereas more than half of

the respondents (52.5percent) had high knowledge on Anatomy & physiology in

post test. In pretest one fourth of the respondents (25.0 percent) married in

between 22-26 years had low knowledge whereas less than two thirds (62.5

percent) of the respondents had high knowledge on Anatomy & physiology in

196
post test. Two fifths of the respondents (40.0 percent) married in between 27-30

years had low knowledge in pretest whereas less than two thirds of the

respondents (62.5 percent) had high knowledge on Anatomy & physiology in

post-test. In pre-test a major proportion of the respondents (85.7 percent) married

between 31-34 years of age had low knowledge and more than half (57.1

percent) of the respondents had high knowledge in post test.

The relation between education and level of knowledge of Anatomy &

physiology of female reproductive system shows that two fifths (41.0 percent) of

the illiterates in pretest had low knowledge and a similar proportion of the

respondents (41.8 percent) had high knowledge on Anatomy & Physiology after

STP. In pre-test less than one third (31.0 percent) of the respondents with

primary education had moderate knowledge and only 18.4 percent of the

respondents had low knowledge after STP. Less than half (44.8 percent) of the

respondents with secondary education in pretest had low knowledge whereas a

similar proportion (48.2 percent) of the respondents had high knowledge on

Anatomy & Physiology of female reproductive system in post test.

The association between number of children and knowledge of Anatomy

& physiology of female reproductive system shows that in pretest less than two

thirds (65.2 percent) respondents with no children as against more than half of

the respondents had high knowledge on Anatomy & Physiology after STP. More

than one third of the respondents (38.8 percent) having single child had moderate

knowledge in pre-test and only less than one fourth (22.4 percent) of the

respondents had low knowledge after STP. In pre-test two fifths of the

197
respondents (40.0 percent) having two children had low knowledge as against a

similar proportion of the respondents (43.5 percent) had high knowledge on

anatomy & physiology of the STP. Half of the respondents (50.0 percent) with

four children had low knowledge in pre-test whereas more than two fifths (42.9

percent) of the respondents had high knowledge after STP. Half of the

respondents (50.0 percent) with five children and above had moderate

knowledge in pre-test and only one fourth of the respondents (25.0 percent) had

low knowledge on anatomy & physiology of female reproductive system in post

test.

The relation between occupation and level of knowledge of Anatomy &

physiology of female reproductive system shows that in pretest less than one

third of the (30.2 percent) the coolie/daily laborers had moderate knowledge

whereas more than two fifths (45.0 percent) of the women had high knowledge

after STP. In pretest less than half of the (48.1 percent) house wives had low

knowledge as against two fifths (41.6 percent) had high knowledge after STP.

More than one fourth (29.2 percent) respondents in petty trade had low

knowledge in pretest whereas half of the respondents (50.0 percent) had high

knowledge on Anatomy & Physiology of female reproductive system in post

test.

The association between income and level of knowledge of Anatomy &

Physiology of female reproductive system shows that in pre-test less than one

third (32.5 percent) of the respondents monthly family income in between

Rs.1000-5000 had moderate knowledge whereas 42.5 percent of the respondents

198
had high knowledge on anatomy & physiology after STP. Less than half of the

respondents (45.5 percent) monthly family income in between Rs.6000-10000

had low knowledge as against two fifths (40.9 percent) had high knowledge on

Anatomy & Physiology in post test. In pre-test less than one fifth of the

respondents (19.9 percent) with monthly family income Rs.11000-15000 had

moderate knowledge as against only 16.1 percent of the respondents had low

knowledge after STP. None of the respondents (0.0 percent) having monthly

income 16000-20000 in pre-test had high knowledge as against one third of the

respondents (33.2 percent) had moderate knowledge on Anatomy & Physiology

of female reproductive system in post test.

On the whole the knowledge of the respondents of Anatomy and

Physiology of female reproductive system increased with all the variables after

the STP. In all the age groups the respondents’ knowledge increased to high

levels. However higher knowledge has been observed among those married in

between 23-26 years as against lesser in 50-59 years of age. The same increased

trend has been observed among the respondents with primary education, with

three children, coolie/daily laboursand with income levels between Rs 11000-

15000. However, education, occupation and income of the women have been

observed to be statistically significant at 1% level and Age, age at marriage and

numbers of children were observed to be statistically significant at 5% level

199
5.16 Socio- demographic characteristics and knowledge of

susceptibility to cervical cancer

The below (Table No.5.50) shows the association between socio-

demographic characteristics like age, age at marriage, number of children,

education, occupation and income with level of knowledge on susceptibility to

cervical cancer.

200
Table No.5.50: Distribution of Respondents by socio-demographic
characteristics by level of knowledge on susceptibility to
cervical cancer

Socio Demographic Pre-test(250) Posttest(250)

variable Low Moderate High Low Moderate High
Age
67.3 15.4 17.3 15.4 19.2 65.4
20-29
(35) (8) (9) (8) (10) (34)
65.6 18.0 16.4 19.7 28.7 51.6
30-39
(80) (22) (20) (24) (35) (63)
50.0 17.6 32.4 11.8 20.6 67.6
40-49
(17) (6) (11) (4) (11) (23)
54.8 28.6 16.7 16.7 26.2 57.1
50-59
(23) (12) (47) (7) (11) (24)
62.0 19.2 18.8 17.2 25.2 57.6
Total
(155) (48) (47) (43) (63) (144)
**P<0.01, Significant at 1% level
Age at marriage
61.1 18.1 20.8 13.2 25.0 61.8
15-18
(88) (26) (30) (19) (36) (89)
64.0 20.9 15.1 23.3 24.4 52.3
19-22
(55) (18) (13) (20) (21) (45)
62.5 12.5 25.0 0.0 25.0 75.0
23-26
(5) (1) (2) (0) (2) (6)
80.0 0.0 20.0 20.0 40.0 40.0
27-30
(4) (0) (1) (1) (2) (2)
42.9 42.9 143 28.6 28.6 42.9
31-34
(3) (48) (47) (2) (2) (3)
62.0 19.2 18.8 25.2 17.2 57.6
Total
(155) (48) (47) (63) (42) (14)
**P<0.01, Significant at 1% level
Education
59.7 20.1 20.1 16.4 24.6 59.0
Illiterates
(80) (27) (27) (22) (33) (79)
64.4 19.5 16.1 20.7 26.4 52.9
Primary
(56) (17) (14) (18) (23) (46)
65.5 13.8 20.7 10.3 24.1 65.9
Secondary
(19) (4) (6) (3) (7) (19)
62.0 19.2 18.8 17.2 25.2 57.6
Total
(155) (48) (47) (43) (63) (144)

201
*P<0.05, Significant at 5% level
No. of Children
65.2 17.4 17.4 13.0 13.0 73.9
No Children
(15) (4) (4) (3) (3) (17)
63.3 18.4 18.4 10.2 22.4 67.3
Single Child
(31) (9) (9) (5) (11) (33)

54.1 18.8 27.1 17.6 29.4 52.9

Two children
(46) (16) (23) (15) (25) (45)

68.4 21.2 10.5 15.8 33.3 50.9

Three children
(39) (12) (6) (9) (19) (29)
64.3 21.4 14.3 7.1 39.3 53.6
Four children
(18) (6) (4) (2) (11) (15)
75.0 12.5 12.5 37.5 0.0 62.5
Five and above
(6) (1) (1) (3) (0) (5)
62.0 19.2 18.8 26.0 2.0 72.0
Total
(155) (48) (47) (65) (5) (180)
**P<0.01, Significant at 1% level
Occupation
65.1 18.8 16.1 18.8 24.2 57.0
Cooli
(97) (28) (24) (28) (36) (85)
55.8 20.8 23.4 15.6 23.4 61.0
Housewife
(43) (16) (18) (12) (18) (47)
62.5 16.7 20.8 12.5 37.5 50.0
Petty trade
(15) (4) (5) (3) (9) (12)
62.0 19.2 18.8 17.2 25.21 57.6
Total
(155) (48) (47) (43) (63) (144)
*P<0.05, Significant at 5% level
Income
62.1 19.5 18.3 17.8 27.2 55.0
Rs.1000-5000
(105) (33) (31) (30) (46) (93)
65.9 15.9 18.2 15.9 27.3 56.8
Rs.6000-10000
(29) (17) (8) (7) (12) (25)
54.8 25.8 19.4 16.1 12.9 71.0
Rs.11000-15000
(17) (8) (8) (5) (4) (22)
66.7 0.0 33.3 16.7 16.7 66.7
Rs.16000-20000
(4) (0) (2) (1) (1) (4)
62.0 19.2 18.8 17.2 25.2 57.6
Total
(155) (48) (47) (43) (63) (144)
*P<0.05, Significant at 5% level

202
 Association between age and level of knowledge on susceptibility to

cervical cancer shows that in pretest two thirds of the (67.3 percent) respondents

in the age group of 20-29 years had low knowledge as against a similar

proportion (65.4) of the respondents with high knowledge on susceptibility to

cervical cancer after STP. In pretest only 18.0 percent of the respondents in the

age 30-39 years had moderate knowledge where as in post test half (51.6

percent) of the respondents had high knowledge on susceptibility .In pretest half

of the respondent (50.00) in the age 40-49 years had low knowledge where as in

post test two thirds (67.6 percent) of the respondents had high knowledge on

susceptibility. More than one fourth (28.6 percent) of the respondents in the age

50-59 years in pre-test had moderate knowledge as against only 16.7 percent of

the respondents had low knowledge in post test.

The relation between age at marriage and level of knowledge on

susceptibility to cervical cancer shows that in pretest less than two thirds (61.1

percent) of the respondents married between the age of 15-18 years had low

knowledge as against a similar proportion (61.8 percent) of the respondents had

high knowledge to susceptibility after STP. In pre-test less than one fourth (20.9

percent) of the respondents married in between the age of 19-22 years had

moderate knowledge whereas more than half (52.3 percent) of the respondents

had high knowledge on susceptibility in post test. In pre-test only 12.5 percent of

the respondents married in betweentheagegroup23-26 years had moderate

knowledge as against none of the (0.0 percent) respondents had low knowledge

after STP. In pretest none of the respondents (0.0 percent) married in between

203
the age group 27-30 years had moderate knowledge as against 40.0 percent of

the respondents had moderate knowledge on susceptibility in post-test. In pre-

test less than half (42.9 percent) of the respondents married in between the age

group 31-34 years had low knowledge as against less than half of the

respondents (42.9 percent) had high knowledge on susceptibility after STP.

The relation between number of children and level of knowledge on

susceptibilitytocervicalcancerpresentedinthe(Table5.50)revealsthatinpretest two

thirds of the respondents (65.2 percent) without children had low knowledge as

against less than three fourth (73.9 percent) of the respondents had high

knowledge on susceptibility after STP. In pretest less than one fourth (18.4

percent) of the respondents with single child had moderate knowledge whereas

two thirds (67.3 percent) had high knowledge on susceptibility in post-test. In

pre-test less than one fifth (18.8 percent) of the respondents having two children

had moderate knowledge and half of the respondents (52.9 percent) had high

knowledge on susceptibility after STP. In pretest more than two thirds (68.4

percent) of the respondents with three children had low knowledge as against

more than half (50.9 percent) of the respondents had high knowledge on

susceptibility after STP. In pretest less than one fourth (21.4 percent) of the

respondents with four children had moderate knowledge as against only 7.1

percent of the respondents had low knowledge on susceptibility after STP. In

pretest three fourth of the (75.0 percent) respondents having five and above

children had low knowledge, where as 62.5 percent had high knowledge on

susceptibility in post test.

204
 Association between education and level of knowledge on susceptibility

of cervical cancer presented in table shows that in pretest more than half of the

illiterate respondents (59.7 percent) had low knowledge as against a similar

proportion (59.0 percent) had high knowledge on susceptibility after STP. In pre-

test less than two thirds (64.4 percent) of the respondents with primary education

had low knowledge as against more than half (52.9 percent) of the respondents

had high knowledge on susceptibility after STP. In pretest more than one tenth

(13.8 percent) of the respondents with secondary education had moderate

knowledge and whereas two thirds (65.9 percent) of the respondents had high

knowledge on susceptibility in post-test.

The data on the relation between occupation and level of knowledge on

susceptibility to cervical cancer presented shows that in pre-test two thirds (65.1

percent) of the daily laborers/coolie had low knowledge as against more than

half of the (57.0 percent) respondents had high knowledge on susceptibility after

STP. In pre-test less than one fourth of the (20.8 percent) house wives had

moderate knowledge as against only 15.6 percent of the respondents with low

knowledge on susceptibility after STP. In pretest less than two thirds (62.5

percent) of the respondents in petty trade had low knowledge as against half of

the respondents (50.0 percent) with high knowledge on susceptibility after STP.

The association between income and level of knowledge on susceptibility

of cervical cancer shows that in pretest less than two thirds (62.1 percent) of the

respondents monthly family income of between Rs. 1000-5000 had low

knowledge as against more than half of the (55.0 percent) respondents had high
205
knowledge on susceptibility after STP. In pretest two thirds of the (65.9 percent)

respondents with a monthly family income between Rs. 6000-10000 had low

knowledge as against more than half (56.8 percent) of the respondents had high

knowledge on susceptibility after STP. One fourth of the respondents (25.8

percent) monthly family income in between Rs.11,000 to 15,000 in pretest had

moderate knowledge and only 16.1 percent of the respondents had a low

knowledge on susceptibility in post test. In pretest none of the respondents

(0.0percent) with monthly family income in between 15000-20000 had moderate

knowledge as against two thirds of (66.7 percent) of the respondents had high

knowledge on susceptibility after STP.

On the whole the socio demographic variables have been found to have an

effect on the level of knowledge on susceptibility to cervical cancer screening.

The knowledge of the respondents on the susceptibility to cervical cancer

screening has been increased in the post test after the STP program for all the

variables. Age, age at marriage and number of children, were found to have

significance of 1% level on the knowledge of the respondents on susceptibility to

cervical cancer screening. Education, occupation and income have been observed

to be significant of 5% level with the knowledge of the respondents to

susceptibility of cervical cancer screening.

5.17 Socio-demographic characteristics and knowledge of symptoms

of cervical cancer

The below (Table No.5.51) shows the association between socio-

demographic characteristics like age, age at marriage, number of children,

206
education, occupation and income with level of knowledge on symptoms of

cervical cancer.

207
Table No.5.51: Distribution of Respondents by socio-demographic
characteristics and level of knowledge of symptoms of cervical
cancer screening

Socio Demographic Pre-test(250) Posttest(250)

variable Low Moderate High Low Moderate High
Age
57.7 25.0 17.3 5.8 17.3 76.9
20-29
(30) (13) (9) (3) (9) (40)
68.9 14.8 16.4 1.6 28.7 69.7
30-39
(84) (18) (20) (2) (35) (85)
50.0 29.4 20.6 0.0 23.5 76.5
40-49
(17) (10) (7) (0) (8) (26)
88.1 7.1 4.8 0.0 31.0 69.0
50-59
(37) (3) (2) (0) (13) (29)
67.2 17.6 15.2 2.0 26.0 72.0
Total
(168) (44) (38) (5) (65) (180)
**P<0.01, Significant at 1% level
Age at marriage
66.7 16.7 16.7 1.4 27.1 71.5
15-18
(96) (24) (24) (2) (39) (103)
65.1 19.8 15.1 2.3 22.1 75.6
19-22
(56) (17) (13) (2) (19) (65)
50.0 37.5 12.5 12.5 25.0 62.5
23-26
(4) (3) (1) (1) (2) (5)
100.0 0.0 0.0 0.0 60.0 40.0
27-30
(5) (0) (0) (0) (3) (2)
100.0 0.0 0.0 0.0 28.6 71.4
31-34
(71) (0) (0) (0) (2) (5)
67.2 17.6 15.2 2.0 26.0 72.0
Total
(168) (44) (38) (5) (65) (180)
*P<0.05, Significant at 5% level
Education
67.2 16.4 16.4 0.7 24.6 74.6
Illiterates
(90) (22) (22) (1) (33) (100)
70.1 18.4 11.5 4.6 24.1 71.3
Primary
(61) (16) (10) (4) (21) (62)
58.6 20.7 20.7 0.0 37.9 62.1
Secondary
(17) (6) (6) (0) (11) (18)
67.2 2.0 72.0
Total 17.6(44) 15.2(38) 26.0(65)
(168) (5) (180)

208
*P<0.05, Significant at 5% level
No. of Children
87.0 4.3 8.7 0.0 30.4 69.6
No Children
(20) (1) (2) (0) (7) (16)
67.3 22.4 10.2 0.0 22.4 77.6
Single Child
(33) (11) (5) (0) (11) (38)
63.5 16.5 20.0 2.4 17.6 80.0
Two children
(54) (14) (17) (2) (15) (68)
68.4 19.3 12.3 1.8 28.1 70.2
Three children
(39) (11) (7) (1) (16) (40)
57.1 21.4 21.4 7.1 53.5 39.3
Four children
(16) (6) (1) (2) (15) (11)
75.0 12.5 12.5 0.0 12.5 87.5
Five and above
(6) (1) (1) (0) (1) (7)
67.2 17.6 15.2 2.0 26.0 72.0
Total
(168) (44) (38) (5) (65) (180)
*P<0.05, Significant at 5% level
Occupation
71.8 14.8 13.4 0.7 28.2 71.1
Cooli
(107) (22) (20) (1) (42) (106)
62.3 22.1 15.6 5.2 23.4 71.4
Housewife
(48) (17) (12) (4) (18) (55)
54.2 20.8 25.0 0.0 20.8 79.2
Petty business
(13) (5) (6) (0) (5) (19)
67.2 17.6 15.2 2.0 26.0 72.0
Total
(168) (44) (38) (5) (65) (180)
**P<0.01, Significant at 1% level
Income
68.0 18.3 13.6 1.8 31.4 66.9
Rs.1000-5000
(155) (31) (23) (3) (53) (113)
63.6 11.4 25.0 0.0 11.4 88.6
Rs.6000-10000
(28) (5) (11) (0) (5) (39)
64.5 22.6 12.9 6.5 19.4 74.2
Rs.11000-15000
(20) (7) (4) (2) (6) (23)
16.7 33.3 50.0 0.0 16.7 83.3
Rs.16000-20000
(1) (2) (3) (0) (1) (5)
34.8 38.8 26.4 2.0 72.0
Total 26.0(65)
(87) (97) (66) (5) (180)
*P<0.05, Significant at 5% level

209
 The association between age and level of knowledge of symptoms of

cervical cancer shows that in pretest more than half of the respondents (57.70) in

the age 20-29 years had low knowledge whereas more than three fourths (76.9

percent) of the respondents had high knowledge after STP. Only 14.8 percent of

the respondents in the age 30-39 years had moderate knowledge in pretest, where

as two thirds of the respondents (69.7) percent had high knowledge in post-test.

In pre-test half of the (50.0 percent) respondents in the age 40-49 years had low

knowledge and none had low knowledge after STP. In pretest a major proportion

of the (88.1 percent) respondentsintheage50-59 years had low knowledge as

against more than two thirds of the respondents (69.0 percent) had high

knowledge on symptoms after STP.

The association between age at marriage and level of knowledge of

symptoms of cervical cancer reveals that in pretest two thirds of the (66.7

percent) respondents married between the age of 15-18 years had low knowledge

whereas less than three fourth (71.5 percent) of the respondents had high

knowledge on symptoms after STP. One fifth of the (19.8 percentage)

respondents married between the age of 19-22 years had moderate knowledge in

pre-test whereas in post-test two thirds (75.6 percent)of the respondents had high

knowledge on symptoms. In pretest half of the respondents (50.0) married

between the age of 23-26 years had low knowledge whereas less than two thirds

(62.5 percent) of the respondents had high knowledge on symptoms in post test.

None of the respondents (0.0 percentage) married between the age of 27-30 years

in pre-test had low knowledge whereas less than two thirds (60.0 percent) had

210
high knowledge on symptoms after STP. In pre-test all respondents (100.00

percentage) married between the age of 31-34 years had low knowledge whereas

less than three fourth (71.4 percent) of the respondents had high knowledge after

STP.

The association between education and level of knowledge of symptoms

of cervical cancer presented here shows that in pre-test more than two thirds

(67.29) of the illiterate respondents had low knowledge whereas three fourth

(74.0 percent) of the respondents had high knowledge on symptoms after STP. In

pre-test more than one fifth (18.4 percent) of the respondents with primary

education had moderate knowledge whereas in post-test 71.3 percent of the

respondents had high knowledge on symptoms. More than half (58.6 percent) of

the respondents with secondary education in pretest had low knowledge whereas

none of the respondents (0.0 percent) had low knowledge on symptoms in post

test.

The association between number of children and level of knowledge of

symptoms of cervical cancer in pretest reveals that an over whelming proportion

(87.0 percent) of the respondents without children had low knowledge as against

more than two thirds (69.6 percent) of the respondents had high knowledge on

symptoms after STP. In pre-test more than one fifth (22.40 percent) of the

respondents with single child had moderate knowledge whereas two thirds (77.6

percent) of the respondents had high knowledge on symptoms after STP. Less

than two thirds (63.5 percentage) of the respondents with two children in pretest

had low knowledge whereas a major proportion of the respondents (80.0 percent)

211
had high knowledge on symptoms in post test. In pretest only 19.3 percent of the

respondents having 3 children had moderate knowledge whereas 70.2 percent of

the respondents had high knowledge on symptoms after STP. More than one fifth

of the respondents (21.4 percent) with four children had moderate knowledge in

pretest where as in post test only more than half (53.5percent) of the respondents

had low knowledge on symptoms. Three fourth of the respondents (75.0) with 5

children and above had moderate knowledge before the STP whereas a major

proportion of the respondents (87.5 percent) had high knowledge on symptoms

of cervical cancer after STP.

The association between occupation and level of knowledge on symptoms

of cervical cancer shows that in pre-test only 14.8 percent of the coolie/daily

laborers had moderate knowledge whereas only 71.1 percent of the respondents

had high knowledge on symptoms after STP. In pretest less than two thirds (62.3

percent) of house wives had low knowledge whereas less than three fourth (71.1

percent) of the respondents had high knowledge after STP. In pretest more than

half of the (54.2 percent) respondents in petty trade had low knowledge whereas

more than three fourth (79.2 percent) of the respondents had high knowledge on

symptoms of cervical cancer after STP.

The association between Income and level of knowledge on symptoms of

cervical cancer shows that in pretest more than two thirds (68.0 percent) of the

respondents monthly family income in between Rs. 1000-5000 had low

knowledge however two thirds (66.91) of the respondents had high knowledge

on symptoms after STP. Only 11.4 percent of the respondents monthly family

212
income in between Rs. 6000-10000 had moderate knowledge in pretest and

whereas none of the respondents (0.0 percent) had low knowledge on symptoms

after STP. In pretest less than two thirds (64.5 percent) of the respondents

monthly family income in between Rs.11000 -15000 had low knowledge

whereas three fourth of the respondents (74.2 percent) had high knowledge on

symptoms after STP. In pre test only one third of the respondents (33.3 percent)

monthly family income in between 16000-20000 had moderate knowledge

whereas 83.3 percent of the respondents had high knowledge on symptoms of

cervical cancer in post test.

To summarize, effective structured teaching program had an impact on

the knowledge on symptoms of cervical cancer. In all the age groups the

knowledge of the respondents has increased to high in post-test. Age &

occupation of the respondents has been statistically significant at 1% level with

the knowledge only symptoms of cervical cancer. The increase in the knowledge

levels were also observed with the differences in age at marriage and education

of the respondents. Ages at marriage, education, income and number of children

have been statistically significant at 5% level with the knowledge on symptoms

of cervical cancer. Women with three & four children had high knowledge than

the children with no children and single child. More number of respondents

in petty business acquired high knowledge after the STP. Respondents of all

income levels had high knowledge in post test.

213
5.18 Socio- demographic characteristics by knowledge of diagnosis

and treatment

The below (Table No.5.52)shows the association between socio-

demographic characteristics like age, age at marriage, number of children,

education, occupation and income with level of knowledge on diagnosis and

treatment of cervical cancer.

214
Table No.5.52: Distribution of Respondents by socio-demographic
characteristics and knowledge diagnosis and treatment

Socio Demographic Pre-test(250) Posttest(250)

variable Low Moderate High Low Moderate High
Age
36.5 46.2 17.3 25.0 28.8 46.2
20-29
(19) (24) (9) (13) (15) (24)
38.5 31.1 30.3 27.9 28.8 50.4
30-39
(47) (38) (37) (34) (28) (50)
35.3 50.0 14.7 29.4 20.6 50.0
40-49
(12) (17) (5) (10) (7) (17)
21.4 42.9 35.7 14.3 35.7 50.0
50-59
(9) (18) (15) (6) (15) (21)
34.8 38.88 26.4 25.2 26.4 48.4
Total
(87) (97) (66) (63) (65) (122)
*P<0.05, Significant at 5% level
Age at marriage
31.9 43.8 24.3 24.4 27.1 50.5
15-18
(46) (63) (35) (36) (39) (69)
38.4 33.7 27.9 22.7 25.6 50.7
19-22
(33) (29) (24) (21) (22) (43)
25.0 25.0 50.0 0.0 12.5 87.5
23-26
(2) (2) (4) (0) (1) (7)
40.0 20.0 40.0 20.0 20.0 60.0
27-30
(2) (1) (2) (1) (1) (3)
57.1 28.6 14.3 14.3 42.9 42.9
31-34
(4) (2) (1) (1) (3) (3)
34.8 38.8 26.4 25.2 26.4 48.4
Total
(87) (97) (66) (60) (66) (123)
*P<0.05, Significant at 5% level
Education
29.9 47.8 22.4 20.1 27.6 52.2
Illiterates
(40) (64) (30) (27) (37) (70)
46.0 24.1 29.9 23.0 32.2 44.8
Primary
(40) (21) (26) (20) (28) (39)
24.1 41.4 34.5 37.9 20.7 51.4
Secondary
(7) (12) (10) (6) (6) (7)
Total 34.8 38.8 26.4 23.4 25.2 58.9
(87) (97) (66) (61) (63) (126)
**P<0.01, Significant at 1% level

215
No. of Children
30.4 26.1 43.5 26.1 30.4 43.5
No Children
(7) (6) (10) (6) (7) (10)
38.8 38.8 22.4 20.4 26.5 53.1
Single Child
(19) (19) (11) (10) (13) (28)
29.4 52.9 17.6 22.4 27.1 50.6
Two children
(25) (45) (15) (19) (23) (43)
35.1 33.3 31.6 28.1 26.3 45.6
Three children
(20) (19) (18) (16) (15) (26)
42.9 25.0 32.1 32.1 17.9 50.0
Four children
(12) (7) (9) (9) (5) (14)
50.0 12.5 37.5 0.0 62.5 37.5
Five and above
(4) (1) (3) (0) (5) (3)
34.8 38.8 26.4 25.2 48.4 26.4
Total
(87) (97) (66) (63) (121) (66)
*P<0.05, Significant at 5% level
Occupation
37.6 35.6 26.8 22.8 26.8 50.3
Cooli
(56) (53) (40) (34) (40) (75)
31.2 42.9 26.0 33.8 26.0 40.3
Housewife
(24) (33) (20) (26) (20) (31)
29.2 45.8 25.0 12.5 25.0 62.5
Petty trade
(7) (11) (6) (3) (6) (15)
34.8 38.8 26.4 25.2 26.4 48.4
Total
(87) (97) (66) (63) (66) (121)
**P<0.01, Significant at 1% level
Income
35.5 37.9 26.6 26.6 29.0 44.4
Rs.1000-5000
(60) (64) (45) (45) (49) (75)

36.4 36.4 27.3 22.7 13.6 63.6

Rs.6000-10000
(16) (16) (12) (10) (6) (28)
32.3 48.4 19.4 19.4 32.3 48.4
Rs.11000-15000
(10) (15) (6) (6) (10) (15)
16.7 33.3 50.0 13.3 16.7 60.0
Rs.16000-20000
(1) (2) (3) (1) (1) (4)
34.8 38.8 26.4 25.2 26.4 48.4
Total
(87) (97) (66) (63) (66) (121)
*P<0.05, Significant at 5% level

216
 The relation between age and level of knowledge on diagnosis and

treatment of cervical cancer reveals that in pre-test less than half of the (46.2

percent) respondents in the age 20-29 years had moderate knowledge as against a

similar proportion (46.2 percent) of the respondents had high knowledge on

diagnosis & treatment after STP. More than one third (38.5 percent) of the

respondents in the age 30-39 years had low knowledge in pretest whereas less

half of the respondents (50.4 percent) had high knowledge on diagnosis &

treatment after STP. In pre-test half of the respondents (50.0 percent) in the age

40-49 years had moderate knowledge and a similar proportion (50.0 percent) of

the respondents had high knowledge on diagnosis& treatment in post test. One

fifth of the (21.4 percent) respondents in the age 50-59 years had low knowledge

in pre-test whereas half of the (50.0 percent) respondents had high knowledge

diagnosis and treatment of cervical cancer after STP.

The association between age at marriage and level of knowledge on

diagnosis and treatment of cervical cancer shows that in pre-test less than one

third (31.9 percent) of the respondents married between the age of 15-18 years

had low knowledge as against half of the respondents (50.5 percent) had high

knowledge on diagnosis & treatment after STP. One third of the respondents

(33.7) married between the age of 19-22 years had moderate knowledge before

the STP and whereas half of (50.7 percent) of the respondents had high

knowledge on diagnosis& treatment after STP. In pretest one fourth of the (25.0

percent) respondents married between the ages of 23-26 years had low

knowledge whereas a major proportion of the respondents (87.5) had high

217
knowledge on diagnosis & treatment in post-test. Less than half of the (40.0

percent) respondents married between the age of 27-30 years had low knowledge

age before the STP whereas less than two thirds (60.0percent) of the respondents

had high knowledge on diagnosis & treatment after STP.

In pre-test more than one fourth of the (28.6 percent) respondents married

between the age of 31-34 years had moderate knowledge and whereas 42.9

percent of the respondents each had moderate and high knowledge on diagnosis

and treatment of cervical cancer after STP.

The relation education and level of knowledge on diagnosis and treatment

of cervical cancer shows that in pre test more than one fourth (29.0 percent) of

the illiterates had low knowledge whereas more than half of the respondents

(52.2 percent) had high knowledge eon diagnosis & treatment after STP. Less

than half of the respondents (46.0 percent) having primary education had low

knowledge in pretest and in post test only less than half (44.8 percent) of the

respondents had high knowledge on diagnosis & treatment after STP. In pretest

less than one fourth (24.1 percent) of the respondents with secondary education

had low knowledge whereas more than half (51.4 percent) respondents had high

knowledge on diagnosis &treatment in post test.

The association between number of children and level of knowledge on

diagnosis and treatment shows that in pretest less than one third (30.4 percent) of

the respondents with no child had low knowledge as against two fifths (43.5

percent) had high knowledge on diagnosis & treatment after STP. In pretest more

than one third(38.8 percent) with single child had low knowledge whereas more
218
than half (53.1 percent) of the respondents had high knowledge on diagnosis &

treatment after STP. In pre-test more than half (52.9 percent) of the respondents

having two children had moderate knowledge and half (50.6 percent) of the

respondents had high knowledge on diagnosis & treatment after STP. One third

of the respondents (33.3 percent) having three children had moderate knowledge

in pre-test and whereas 45.6 percent (28.1 percent) of the respondents had high

knowledge on diagnosis & treatment in post test .In pretest two fifths of the

respondents (42.9 percent) with four children had low knowledge whereas half

of the (50.0 percent) respondents had high knowledge on diagnosis & treatment

after STP.12.5 percent of the respondents have with children and above had

moderate knowledge before the STP whereas none of the respondents

(0.0percent) had low knowledge on diagnosis and treatment of cervical cancer in

post test.

The relation between occupation and level of knowledge on diagnosis and

treatment of cervical cancer presented in table revels that in pre-test more than

one third (37.6 percent) of the coolie/daily laborer had low knowledge whereas

half of the respondents (50.3 percent) had high knowledge on diagnosis &

treatment after STP. Two fifths (42.9 percent) of the housewife’s had moderate

knowledge in pre-test and 40.3 percent of the respondents had high knowledge

on diagnosis & treatment in post-test. In pre-test more than two fifths of the

respondents (45.8 percent) in petty trade had moderate knowledge and less than

two thirds (62.5 percent) percent of the respondents had high knowledge on

diagnosis & treatment after STP.

219
 The association between income and level of knowledge on diagnosis and

treatment of cervical cancer shows that in pretest one third (37.9 percent) of the

respondents with a monthly family income in between Rs.1000-5000 had

moderate knowledge whereas 44.4 percent of the respondents had high

knowledge on diagnosis & treatment after STP. More than one third (36.4

percent) of the respondents monthly family income in between Rs.6000-10000

had low knowledge in pretest whereas less than two thirds of the (63.6 percent)

respondents had high knowledge on diagnosis & treatment after STP. In pre-test

only 16.5 percent of the respondent monthly family income in between 16000-

20000 had low knowledge whereas more than half of (60.0 percent) of

respondents had high knowledge on diagnosis & treatment after STP.

The knowledge of respondents on diagnosis and treatment of the

respondents increased after the post test with all the socio demographic variables

analyzed. The respondents level of knowledge increased with age. Women in

younger ages had higher level of knowledge on diagnosis and treatment after the

STP. Respondents with more number of children had high knowledge on

diagnosis and treatment after the STP. The same pattern has also been observed

with occupation and income of the respondents. However, education and

occupation were observed to be statistically significant at 1% level and age, age

at marriage, number of children and income were observed to be significant at

5% level with the knowledge on diagnosis &treatment of cervical cancer.

220
5.19 Socio- demographic characteristics and perceived benefits of

cervical cancer screening

The below (Table No.5.53) shows the relation between socio-

demographic characteristics like age, age at marriage, number of children,

education, occupation and income with level of knowledge on perceived benefits

of cervical cancer screening.

221
Table No.5.53: Distribution of Respondents by socio-demographic
characteristics and perceived benefits of cervical cancer
screening

Pre-test(250) Posttest(250)
Socio Demographic
variable No
Low Moderate High Low Moderate High
benefit
Age
76.9 15.4 5.8 1.9 7.7 26.9 65.4
20-29
(40) (8) (3) (1) (4) (14) (34)
70.5 13.1 4.1 12.3 6.6 41.0 52.5
30-39
(86) (16) (5) (15) (8) (50) (64)
97.1 2.9 0.0 0.0 17.6 29.4 52.9
40-49
(33) (1) (0) (0) (6) (10) (18)
64.3 9.5 7.1 19.0 11.9 23.8 64.0
50-59
(27) (4) (3) (8) (5) (10) (27)
74.4 11.6 4.4 9.6 9.2 33.6 57.2
Total
(186) (29) (11) (24) (23) (84) (143)
**P<0.01, Significant at 1% level
Age at marriage
78.5 11.1 2.8 7.6 4.9 38.9 56.3
15-18
(113) (16) (4) (11) (7) (56) (81)
69.8 12.8 4.7 12.8 16.3 23.3 60.5
19-22
(60) (11) (4) (11) (14) (20) (52)
50.0 12.5 37.5 0.0 25.0 25.0 50.0
23-26
(4) (1) (3) (0) (2) (2) (4)
60.0 0.0 0.0 40.0 0.0 20.0 80.0
27-30
(3) (0) (0) (2) (0) (1) (4)
85.7 14.3 0.0 0.0 0.0 28.6 71.45
31-34
(65) (1) (0) (0) (0) (2) (5)
74.4 11.6 9.6 9.2 57.2
Total 4.4(11) 31.6(81)
(186) (29) (24) (23) (146)
**P<0.01, Significant at 1% level
Education
75.4 14.2 3.7 6.7 11.2 34.3 54.5
Illiterates
(101) (19) (5) (9) (15) (46) (73)
73.6 4.6 5.7 16.1 4.9 29.9 65.2
Primary
(64) (4) (5) (14) (5) (26) (55)
72.4 20.7 3.4 3.4 6.9 41.4 51.7
Secondary
(21) (6) (1) (1) (2) (12) (15)
74.4 11.6 4.4 9.6 9.9 33.6 54.2
Total
(186) (29) (11) (24) (22) (84) (144)

222
*P<0.05, Significant at 5% level
No. of Children
52.2 21.7 4.3 21.7 4.3 21.7 73.9
NoChildren
(12) (5) (1) (5) (1) (5) (17)
81.6 6.1 0.0 12.2 8.2 36.7 55.1
SingleChild
(40) (3) (0) (6) (4) (18) (27)
77.6 16.5 3.5 2.4 16.5 32.9 50.6
Twochildren
(66) (14) (3) (2) (4) (28) (43)
73.7 7.0 8.8 10.5 1.8 28.1 70.2
Threechildren
(42) (4) (5) (6) (1) (16) (40)
75.0 3.6 7.1 14.3 4.1 56.6 48.3
Fourchildren
(21) (1) (2) (4) (1) (15) (17)
62.5 25.0 0.0 12.5 12.5 25.0 64.5
Fiveandabove
(5) (2) (0) (1) (1) (2) (6)
74.4 11.6 4.4 9.6 9.2 33.6 57.2
Total
(186) (29) (11) (24) (23) (84) (143)
**P<0.01,Significantat1%level
Occupation
71.8 12.1 3.4 12.8 10.1 28.2 61.7
Cooli
(107) (18) (5) (19) (15) (42) (92)
76.6 9.1 7.8 6.5 5.8 41.6 52.6
Housewife
(59) (7) (6) (5) (5) (32) (44)
83.3 16.7 0.0 0.0 8.3 41.7 50.0
Pettytrade
(20) (4) (0) (0) (2) (10) (12)
74.4 11.6 4.4 9.6 9.2 33.6 57.2
Total
(186) (29) (11) (24) (23) (84) (147)
**P<0.01,Significantat1%level
Income
75.1 8.3 5.3 11.2 8.9 34.3 56.8
Rs.1000-5000
(127) (14) (9) (19) (15) (58) (96)
72.7 18.2 2.3 6.8 9.1 34.1 56.8
Rs.6000-10000
(32) (8) (1) (3) (4) (15) (25)
77.4 16.1 3.2 3.2 9.7 25.8 64.5
Rs.11000-15000
(24) (5) (1) (1) (3) (8) (20)
50.0 33.3 0.0 16.7 16.7 33.3 50.0
Rs.16000-20000
(3) (2) (0) (1) (1) (2) (3)
74.4 11.6 4.4 9.6 9.2 33.6 57.2
Total
(186) (29) (11) (24) (23) (83) (146)
*P<0.05,Significantat5%level

223
 The relation between age and perceived benefits of cervical cancer

screening shows that in pre test an over whelming proportion of the 40-49 years

of the age, followed by three fourth (76.9 percent) in 20-29 years of age and 30-

39 years of age (70.5 percent) as against two thirds (64.3 percent) felt there were

no benefits in going for screening of cervical cancer. However in post-test none

of the respondents stated no benefits and all the respondents stated low, high or

medium.

In pretest only 15.4percent of the respondents in 20-29 years of age

perceived low benefits of cervical cancer whereas two thirds of the respondents

(65.4 percent) perceived high benefits of cervical cancer screening after STP.

13.1 percent of the respondentsbetween30-39 years of age perceived moderate

benefits of cervical cancer screening in pre-test and whereas half of the

respondents (52.5percent) perceived high benefits of screening in post-test. None

of the respondents (0.0 percent) in 40-49 years of age perceived moderate

benefits of screening before the STP and 52.9 percent of the respondents

perceived high benefits of screening after STP. In pre test two thirds (64.3

percent) of the respondents in 50-59 years of age had perceived low benefits of

screening and a similar proportion of (64.9 percent) respondents perceived high

benefits of cervical cancer screening in post test.

The relation between age at marriage and perceived benefits of cervical

cancer screening in pre-test shows that three fourths of the respondents

(78.5percent) married between 15-18 years of age followed by more than two

thirds of the respondents (69.8 percent) married between 19-22 years, two thirds

224
of the respondents (60.0 percent) married in between 27-30 years and half of the

respondents (50.0 percent) married between 23-26 years felt there were no

benefits in going for screening of cervical cancer. However in post-test none of

the respondents stated no benefits and all the respondents stated low, high and

medium.

In pretest only 11.1 percent of the respondents married in between 15-18

years had low knowledge whereas more than half of the respondents (56.3

percent) had high knowledge after STP. In pretest a minor proportion (12.8

percent) of the respondents married in between 19-22 years had low knowledge

whereas less than two thirds of the respondents (60.5 percent) had high

knowledge after STP. More than one third (37.5 percent) of the respondents

married between 23-26 years had moderate knowledge in pre-test whereas half

(5.0 percent) of the respondents had high knowledge in post-test. In pre-test a

minor proportion (14.3 percent) of the respondents married in between 31-34

years had moderate knowledge whereas less than three fourths (71.4 percent) of

the respondents had high knowledge on benefits of cervical cancer screening

after STP.

The association between education and level of perceived benefits of

cervical cancer screening in pretest reveals that three fourth of the (75.4 percent)

illiterates followed by a similar proportion (73.6 percent) with primary education

and (72.4 percent) with secondary education felt there were no benefits for going

cervical cancer screening. However in post test none of the respondents stated no

benefits and all the respondents stated low, high and moderate.

225
 In pre-test a minor proportion of the (14.2 percent) illiterates had low

knowledge where as more than half of the respondents (54.5 percent) had high

knowledge after STP. A minor proportion (5.7 percent) of the respondents with

primary education had moderate knowledge in pretest whereas 65.2 percent of

the respondents had high knowledge in post test. In pretest one fifth (20.7

percent) of the respondents with secondary education had low knowledge

whereas, more than half of the (51.7 percent) respondents had high knowledge

on benefits of cervical cancer after STP.

The relation between number of children and perceived benefits of

cervical cancer screening shows that in pretest majority of the respondents (81.6)

having one child followed by three fourth of the respondents (77.6 percent) with

two children, less than three fourth (73.7 percent) having three children, less than

two thirds (62.5 percent) having five and above children and half of the

respondents with no children (52.2 percent) felt that there were no benefits in

going for screening of cervical cancer. However in post test none of the

respondents, stated no benefits and all the respondents stated low, high and

medium.

In pre-test more than one fifth of the respondents (21.7 percent) with no

children perceived low benefits whereas less than three fourth (73.9 percent) of

the respondents perceived high benefits after STP. Only 6.1 percent of the

respondents having single child perceived low benefit in pretest whereas more

than half of the respondents (55.1 percent) perceived high benefits after STP. In

pretest only 3.5percent of the respondents having two children perceived low

226
benefits whereas half of the respondents (50.6 percent) with two children

perceived high benefits after STP.A minor proportion (8.8 percent) of the

respondents with three children perceived moderate benefits in pretest whereas

70.2 percent of the respondent perceived high benefits after STP. In pretest only

7.1 percent of the respondents with four children perceived moderate knowledge

and 56.6 percent of the respondents perceived moderate benefits after STP. One

fourth of the respondents (25.0 percent) having five and above children

perceived low benefits in pre-test whereas less than two thirds (64.5 percent) of

the respondents perceived high benefits of cervical cancer screening after STP.

The association between occupation and perceived benefits of cervical

cancers screening shows that in pre-test majority of the respondents (83.3

percent) having petty trade followed by more than three fourth (76.6 percent) of

house wives and less than three fourth (71.8 percent) of the coolie / daily

laborers felt there were no benefits for screening of cervical cancer. However in

post test none of the respondents stated no benefits and all the respondents stated

low, high and medium.

In pretest a minor proportion 12.1 percent of the cooli / daily laborers

perceived low benefits in pretest whereas less than two thirds (61.7 percent) of

the respondents perceived high benefits on benefits after STP.A minor

proportion 7.8 percent of the house wives perceived moderate benefits in pretest

whereas half of the respondents (52.6 percent) of the respondents perceived high

benefits after STP. In pretest none of the respondents (0.0) in petty trade

perceived moderate benefits as against half (50.0 percent) of the respondents

227
 perceived high benefits of cervical cancer screening after STP.

The association between income and perceived benefits of cervical cancer

screening shows that in pre-test more than three fourth of the respondents (77.4

percent) with a monthly family income of Rs.11000-15000 followed by three

fourth of the respondents (75.1 percent) monthly family income Rs.1000-5000,

as against less than three fourth (72.7 percent) of the respondents monthly family

income 6000- 10000 and half of the respondents (50.0 percent) in monthly

family income Rs.16000- 20000 felt there were no benefits in going for

screening of cervical cancer. However in post test none of the respondents stated

no benefits and all the respondents stated low, high as medium.

In pretest a minor proportion (8.3 percent) of the respondents monthly

family incomebetweenRs.1000-5000 perceived low benefits whereas more than

half of (56.8 percent) the respondents perceived high benefits after STP. Less

than one fifth of the respondents (18.2 percent) monthly family income Rs.6000-

10000 perceived low benefits in pretest whereas more than half of the

respondents (56.8 percent) perceived high benefits after STP. In pretest only 3.2

percent of the respondents having monthly family income Rs.11000-15000

perceived high benefits whereas two thirds of the respondents (64.5 percent)

perceived high benefits after STP. One third of the respondents (33.3 percent)

monthly family income Rs.16000-20000 perceived low benefits in pretest

whereas half of the respondents (50.0 percent) perceived high benefits on

benefits of cervical cancer screening after STP.

228
 On the whole the respondents in all the age groups perceived high

benefits of cervical cancer screening after STP. However women in younger age

perceived moderate and high benefits than the other ages. Same pattern was

observed with age at marriage. Those married in younger ages perceived

moderate and high benefits than those married at later ages. The, age at marriage

number of children, occupation were found to have a statistical significance of

1% level with the perceived benefits of cervical cancer screening. In post test

more number of illiterates had moderate and high perceptions on the benefits of

cervical cancer screening. However education and income were observed to have

a statistical significance of 5% level with the perceived benefits of cervical

cancer screening.

5.20 Socio- demographic characteristics and perceived barriers of

cervical cancer screening

The below (Table No.5.54) shows the relation between socio-

demographic characteristics like age, age at marriage, number of children,

education, occupation and income with perceived barriers of cervical cancer

screening.

229
 Table No. 5.54: Distribution of Respondents by socio-
demographic characteristics and perceived barriers to cervical
cancer screening

Socio Demographic Pre-test(250) Posttest(250)

variable No
Low Moderate High Low Moderate High
barriers
Age
94.2 5.8 0.0 0.0 21.2 28.8 50.8
20-29
(49) (3) (0) (0) (11) (15) (26)
95.9 1.6 1.6 0.8 17.6 32.4 50.0
30-39
(117) (2) (2) (1) (6) (11) (17)
91.2 2.9 2.9 2.9 31.0 33.3 35.7
40-49
(31) (1) (1) (1) (13) (14) (15)
92.9 2.4 4.8 0.0 23.0 29.8 40.6
50-59
(39) (1) (2) (0) (29) (32) (61)
94.4 2.8 2.0 0.8 23.6 28.8 47.6
Total
(236) (7) (5) (2) (59) (72) (119)
*P<0.05, Significant at 5% level
Age at marriage
93.8 2.1 3.5 0.7 19.4 30.6 50.0
15-18
(135) (3) (5) (1) (28) (44) (72)
95.3 3.5 0.0 1.2 26.7 30.2 43.0
19-22
(82) (3) (0) (1) (23) (26) (37)
12.5 0.0 0.0 25.0 12.5 62.5
23-26 87.5(7)
(1) (0) (0) (2) (1) (5)
100.5 0.0 0.0 0.0 20.0 0.0 80.0
27-30
(5) (0) (0) (0) (1) (0) (1)
100.5 0.0 0.0 0.0 28.6 14.3 57.1
31-34
(7) (0) (0) (0) (2) (1) (4)
94.4 2.8 2.0 0.8 23.6 28.8 47.6
Total
(236) (7) (5) (2) (59) (72) (119)
**P<0.01, Significant at 1% level
Education
94.8 3.0 1.5 0.7 20.9 27.6 51.4
Illiterates
(127) (4) (2) (1) (28) (37) (69)
93.1 3.4 3.4 0.0 27.6 27.6 44.8
Primary
(81) (3) (3) (0) (24) (24) (39)
96.6 0.0 0.0 3.4 24.1 37.9 37.9
Secondary
(28) (0) (0) (1) (7) (11) (11)
94.4 2.8 2.0 0.8 23.6 28.8 47.6

230
 (236) (7) (5) (2) (59) (72) (119)
Total
*P<0.05, Significant at 5% level
No. of Children
87.0 8.7 4.3 0.0 21.7 34.7 43.5
No Children
(20) (2) (1) (0) (5) (8) (10)
98.0 2.0 0.0 0.0 32.7 4.08 26.5
Single Child
(48) (1) (0) (0) (16) (20) (13)
95.3 2.4 1.2 1.2 23.5 3.5 32.9
Two children
(81) (2) (1) (1) (20) (37) (28)
94.7 1.8 3.5 0.0 22.8 56.1 21.1
Three children
(54) (1) (2) (0) (13) (32) (12)
92.9 3.6 0.0 3.6 14.3 53.5 32.1
Four children
(26) (1) (0) (1) (4) (15) (9)
0.0 12.5 0.0 12.5 87.5 0.0
Five and above 87.5(7)
(0) (1) (0) (1) (7) (0)
94.4 2.8 2.0 0.8 23.6 47.6 28.8
Total
(236) (7) (5) (2) (59) (119) (72)
*P<0.05, Significant at 5% level
Occupation
95.3 1.3 2.7 0.7 26.2 26.8 46.9
Cooli
(142) (2) (4) (1) (39) (40) (70)
93.5 3.9 1.3 1.3 20.8 27.3 51.9
Housewife
(72) (3) (1) (1) (16) (21) (40)
91.7 8.3 0.0 0.0 16.7 45.8 37.5
Petty trade
(22) (2) (0) (0) (4) (11) (9)
94.4 2.8 2.0 0.8 23.6 28.8 47.6
Total
(236) (7) (5) (2) (59) (72) (119)
*P<0.05, Significant at 5% level
Income
94.7 1.8 2.4 1.2 23.7 29.6 46.7
Rs.1000-5000
(160) (3) (4) (2) (40) (50) (79)
93.2 6.8 0.0 0.0 31.8 22.7 45.4
Rs.6000-10000
(41) (3) (0) (0) (14) (10) (20)
93.5 3.2 3.2 0.0 12.9 32.3 54.8
Rs.11000-15000
(29) (1) (1) (0) (4) (10) (17)
100.0 0.0 0.0 0.0 16.7 33.3 50.0
Rs.16000-20000
(6) (0) (0) (0) (1) (2) (3)
94.4 2.8 2.0 0.8 23.6 28.8 47.6
Total
(236) (7) (5) (2) (59) (72) (119)
*P<0.05, Significant at 5% level

231
 An over whelming proportion of the respondents in all the age groups

perceived low barriers of cervical cancer screening. However after the STP more

number of respondents in 30-39 years, 20-29 years perceived high and moderate

barriers. Still less than one third of the respondents in 40-49 years of age (31.0

percent) and a quarter in 50-59 (23.0 percent) years of age perceived low barriers

for cervical cancer after STP.

The association between age at marriage and perceived barriers of

cervical cancer screening shows that in pretest an overwhelming proportion of

the respondents in all age group except 23-26 years perceived no barriers of

cervical cancer screening. Where as in post test all respondents stated low high

and moderate.

In pretest only 2.1 percent of the respondents married in between 15-18

years perceived low barriers whereas half of the respondents (50.0 percent)

perceived high barriers after STP. Only 1.2 percent of the respondents married in

between 19-22 years perceived more barriers whereas in pretest whereas two

fifths 43.0 percent whereas two fifths (43.0 percent) of the respondents perceived

high knowledge eon barriers after the STP. In pretest only a minor proportion

(12.5 percent) of the respondents married in between 23-26 years perceived low

barriers whereas fewer two thirds of the respondents (62.5 percent) perceived

high barriers after STP. None of the respondents (0.0 percent) married between

27-30 years perceived low barriers in pretest whereas against more than three

fourth (80.0 percent) of the respondents perceived high barriers on barriers after

STP. In pretest none of the respondents (0.0 percent) married between 31-34

years perceived high barriers whereas more than half of the respondents (57.1

232
percent) perceived high knowledge on barriers of cervical cancer screening in

post test.

The relation between education and perceived barriers of cervical cancer

shows that in pretest an over whelming proportion of the illiterates, primary and

secondary educators perceived no barriers for cervical cancer screening whereas

in post test all respondents stated low, high or moderate.

In pre-test only 3.0 percent of the illiterates perceived low barriers

whereas more than half of the (51.4 percent) respondents perceived high level of

barriers to cervical cancer screening after STP. In pretest none of the (0.0

percent) primary educators perceived high where as in post test less than half

(44.8 percent) of the respondents perceived high level of barriers of cervical

cancer screening after STP. In pretest none of the respondents (0.0 percent) with

secondary education perceived moderate knowledge on barriers as against more

than one third of the (37.9 percent) respondents perceived high barriers of

cervical cancer screening after STP.

The association between number of children and perceived barriers of

cervical cancer screening shows that an over whelming proportion of the

respondents with single child, two children, three children and four children as

against a major proportion of the respondents with no child and with five

children perceived no barriers for cervical cancer screening where as in post test

all of the respondents stated low, high or moderate.

In pre-test only 4.3 percent of the respondents not having children

perceived low barriers whereas two fifths of the respondents (43.5 percent)

perceived high barriers of cervical cancer screening after STP. In pre-test none of
233
the respondents (0.0 percent) having single child perceived moderate barriers

however less than one third (32.7 percent) of the respondents perceived high

barriers of cervical cancer screening. In pre-test only 2.4 percent of the

respondents having two children perceived low barriers whereas less than one

third (32.0 percent) of the respondents perceived high barriers of cervical cancer

screening in post test. None of the respondents (0.0 percent) having four children

perceived moderate barriers in pretest however more than half (53.5 percent)

respondents perceived moderate barriers of cervical cancer screening in post test.

In pretest none of the respondents (0.0 percent) having five and above children

perceived low barriers whereas a major proportion of the (87.5 percent)

respondent perceived high barriers of cervical cancer screening after STP.

The relation between occupation and perceived barriers of cervical cancer

screening shows that in pre-test an over whelming proportion of the cooli, house

wives and in petty trade perceived no barriers of cervical cancer screening where

as in posttest all respondents stated low, high are moderate.

In pretest only 1.3 percent of the cooli / daily labor perceived low barriers

whereas less than half of the (46.9 percent) respondents perceived high barriers

of cervical cancer screening after STP. Only 1.3 percent of the house wives

perceived low barriers in pre-test whereas more than half (51.9 percent)

perceived high barriers of cervical cancer screening. In pretest none of the

respondents (0.0 percent) in petty business perceived high barriers of cervical

cancer screening whereas less than half (45.8 percent) of the respondents

perceived moderate barriers for cervical cancer screening in post test.

The data showing the relationship between income and perceived barriers
234
of cervical cancer screening shows that an over whelming proportion of the

respondents of all income groups perceived no barriers of cervical cancer

screening whereas in post test none of the respondents stated no barriers, all

respondents felt low, high or moderate.

In pretest 1.8 percent of the respondents monthly family income in

between Rs.1000-5000 perceived low barriers of cervical cancer screening

whereas less than half of the respondents (46.7 percent) perceived high barriers

of cervical cancer screening.6.8 percent of the respondents having monthly

family income Rs.6000- 10000 perceived moderate barriers in pretest whereas

one fifths (22.7 percent) of the respondents perceived moderate barriers of

cervical cancer screening after STP. In pretest only 3.2 percent of the

respondents monthly family income Rs.11000-15000 perceived low barriers

whereas more than half of the respondents (54.8 percent) perceived higher of

barriers of cervical cancer screening. In pretest none of the residents (0.0

percent) perceived higher barriers of cervical cancer screening whereas against

half of the respondents (50.0 percent) had high perception of barriers for cervical

cancer screening in post test.

To sum up with all the socio demographic variables the respondents

perceived high barriers to cervical cancer screening after the post test. However

women in younger ages, married between 27-30 years of age, perceived high

barriers when compared with other groups. Age at marriage has been observed to

be statistically significant at 1% level with the perceived barriers of cervical

cancer screening of the respondents and age, education, occupation, income and

number of children has been observed to be significant at 5% level.

235
5.21 Socio-demographic characteristics level by knowledge on

preventive practices

The below (Table No.5.55)shows the association between socio-

demographic characteristics like age ,age at marriage ,number of children,

education, occupation and income with level of knowledge on preventive

practices of cervical cancer.

236
Table No.5.55: Distribution of Respondents by socio-demographic
characteristics and level by knowledge of preventive
practices

Socio Demographic Pre-test(250) Posttest(250)

variable Low Moderate High Low Moderate High
Age
76.9 21.2 1.9 11.5 42.2 50.2
20-29
(40) (11) (1) (5) (28) (26)
72.1 23.0 4.9 18.0 32.8 49.2
30-39
(88) (28) (6) (22) (40) (60)
91.2 0.0 23.5 35.3 41.2
40-49 8.8(3)
(31) (0) (8) (12) (14)
73.8 21.4 4.8 19.0 42.9 42.9
50-59
(31) (9) (2) (8) (18) (18)
76.0 20.4 3.6 17.6 38.1 48.2
Total
(190) (51) (9) (44) (16) (115)
*P<0.05 ,Significant at 5% level
Age at marriage
76.4 20.8 2.8 20.1 36.1 43.8
15-18
(110) (30) (4) (29) (52) (63)
79.1 16.3 4.7 12.8 34.9 52.3
19-22
(68) (14) (4) (11) (30) (45)
62.5 25.0 12.5 0.0 62.5 37.5
23-26
(5) (2) (1) (0) (5) (3)
40.0 60.0 0.0 20.0 40.0 40.0
27-30
(2) (3) (0) (1) (2) (2)
71.4 28.6 0.0 28.6 14.3 57.1
31-34
(5) (2) (0) (2) (1) (4)
76.0 20.4 3.6 16.6 34.2 49.2
Total
(190) (51) (9) (41) (89) (17)
**P<0.01, Significant at 1% level
Education
79.9 17.9 22 20.1 35.1 44.8
Illiterates
(107) (24) (3) (27) (47) (60)
73.6 20.7 5.7 13.8 39.1 47.1
Primary
(64) (18) (5) (12) (34) (41)
65.5 31.0 3.4 17.2 36.4 51.4
Secondary
(19) (9) (1) (5) (4) (4)
76.0 20.4 3.6 17.6 37.2 45.2
Total
(190) (51) (9) (44) (93) (113)

237
*P<0.05, Significant at 5% level
No. of Children

82.6 13.0 4.3 8.7 38.5 51.8

No Children
(19) (3) (1) (2) (9) (12)

69.4 26.5 4.1 16.3 49.0 34.7

Single Child
(34) (13) (2) (8) (24) (17)

81.2 16.5 2.4 18.8 50.6 30.6

Two children
(69) (14) (2) (16) (43) (26)

75.4 21.1 3.5 14.6 38.6 48.8

Three children
(43) (12) (2) (11) (22) (24)

67.9 28.6 3.6 10.7 42.9 46.4

Four children
(19) (8) (1) (3) (12) (13)

75.0 12.5 12.5 12.5 25.0 62.5

Five and above
(6) (51) (1) (1) (2) (5)

76.0 20.4 3.6 17.6 41.2 37.2

Total
(190) (51) (9) (41) (112) (97)
*P<0.05, Significant at 5% level
Occupation
77.2 17.4 5.4 19.5 34.9 45.6
Cooli
(115) (26) (8) (29) (52) (68)
75.3 24.7 0.0 18.2 32.5 49.4
Housewife
(58) (19) (0) (14) (25) (38)
70.8 25.0 4.2 4.2 66.7 29.2
Petty trade
(17) (6) (1) (1) (16) (7)
76.0 20.4 3.6 17.6 37.2 45.2
Total
(190) (51) (9) (44) (93) (113)

**P<0.01, Significant at 1% level

Income

78.37 18.3 3.0 18.9 39.6 41.4

Rs.1000-5000
(133) (31) (5) (32) (67) (70)

75.0 22.7 2.3 15.9 27.3 56.8

Rs.6000-10000
(33) (10) (1) (7) (12) (25)

71.0 22.6 6.5 12.9 45.2 41.9

Rs.11000-15000
(22) (7) (2) (4) (14) (13)

33.3 50.0 16.7 16.7 0.0 83.3

Rs.16000-20000
(2) (3) (1) (1) (0) (5)

76.0 20.4 3.6 17.6 37.2 45.2

Total
(190) (51) (9) (44) (93) (113)

*P<0.05, Significant at 5% level

238
 The relation between age and level of knowledge on preventive practices

of cervical cancer shows that in pretest more than three fourth of the respondents

(76.9 percent) in the age 20-29 years had low knowledge whereas half of the

(50.2 percent) respondents had high knowledge on preventive practices after

STP. Less than one fourth (23.0 percent) of the respondents in the age 30-39

years had moderate knowledge in pretest where as in post test two fifths (42.9

percent) of the respondents had high knowledge on preventive practices after

STP. In pretest an over whelming proportion of the respondents (91.2 percent) in

the age less than 40-49 years had low knowledge as against less than half of the

respondents (41.2 percent) had high knowledge on preventive practices in post

test. More than one fifth (21.4 percent) of the respondents in the age 50-59 years

had moderate knowledge and only 42.9 percent of the respondents had high

knowledge on preventive practices after STP.

The association between age at marriage and level of knowledge a

preventive practices of cervical cancer shows that in pretest more than three

fourth (76.4 percent)of the respondents married between the age of 15-18 years

had low knowledge as against two fifths (43.8 percent) of the respondents had

high knowledge on preventive practices after STP. In pre-test only 16.3 percent

of the respondents married in between the age group of 19-22 years had

moderate knowledge whereas 52.3 percent with high knowledge in post-test.

One fourth of the respondents(25.0percent) married in between the age group of

23-26 years had moderate knowledge in pretest whereas 62.5 percent of the

respondents had moderate knowledge on preventive practices in post test .More

239
than half of the respondents (60.0 percent) married in between the age 27-30

years had moderate knowledge and only 40.0 percent of the respondents had low

knowledge on preventive practices in post test. Less than two fourth (71.4

percent) of the respondents married in between the age 31-34 years had high

knowledge in pre-test whereas more than half of the respondents (51.1 percent)

had high knowledge on preventive practices after STP.

The association between education and level of knowledge on preventive

practices of cervical cancer shows that in pretest more than three fourth of the

(79.9 percent) of the illiterates had low knowledge whereas less than half (44.8

percent) of the respondents had high knowledge on preventive practices after

STP. Only 20.7 percent of the respondents with primary education had moderate

knowledge in pre test as against whereas 47.1 percent of the respondents had

high knowledge on preventive practices in post test. In pretest two thirds of the

respondents (65.5 percent) with secondary education had low knowledge

whereas more than half of the respondents (51.4 percent) had high knowledge on

preventive practices of cervical cancer after STP.

The relation between number of children and level of knowledge on

preventive practices of cervical cancer reveals that in pretest a major proportion

of the respondent (82.6 percent) without children had low knowledge as against

more than half of the (51.8 percent) respondents had high knowledge on

preventive practices after STP. In pretest more than one fourth of the respondents

(26.5 percent) with one child had moderate knowledge whereas 49.0percent of

the respondents had moderate knowledge on preventive practices after STP.A

240
major proportion of the respondents (81.2 percent) having two children had low

knowledge whereas half of the respondents(50.6percent) had moderate

knowledge on preventive practices in post- test. In pre-test more than one fifth

(21.1 percent) of the respondents with three children had moderate knowledge as

against only 14.6 percent of the respondents had low knowledge on preventive

practices after STP. More than one fourth of the respondents (28.6 percent)

having four children had moderate knowledge in pre-test against and only 10.7

percent of the respondents had low knowledge on preventive practices after STP.

In pre test three fourth of the respondents (75.0 percent) having five children and

above had low knowledge whereas less than two thirds (62.5 percent) of the

respondents had high knowledge on preventive practices of cervical cancer after

STP.

The association between occupation and level of knowledge a preventive

practices of cervical cancer shows that in pretest more than three fourth of the

(77.2 percent) of coolie / daily laborers had low knowledge as against less than

half (45.6 percent) of the respondents had high knowledge on preventive

practices after STP. In pre test one fourth of the (24.7 percent) house wives had

moderate knowledge as against half (49.4 percent) of the respondents with high

knowledge on preventive practices after STP. One fourth of the respondents

(25.0 percent) in petty trade had moderate knowledge in pretest whereas 66.2

percent of the respondents had moderate preventive practices of cervical cancer

in post test.

The relation between income and level of knowledge on preventive

241
practices of cervical cancer reveals that in pretest more than three fourths (78.7

percent) of the respondents monthly family income in between 1000-5000 had

low knowledge as against less than half of the respondents (41.4 percent) had

high knowledge on preventive practices after STP. In pretest less than one fourth

(22.7 percent) of the respondents family income in between Rs.6000-10000 had

moderate knowledge as against half (56.8 percent) of the respondents had high

knowledge on preventive practices after STP.22.6 percent of the respondent’s

monthly family income in between 11000-15000 had moderate knowledge

before the STP whereas 45.2 percent of the respondents had moderate

knowledge on preventive practices in post-test. In pre test one third of the (33.3

percent) respondent’s monthly family income in between 16000-20000 had low

knowledge whereas major proportion of the (83.3 percent) respondents had high

knowledge on preventive practices of cervical cancer after STP.

To sum up the knowledge of the respondents on preventive practices of

cervical cancer increased with all the variables after the STP. In all the age

groups the respondent’s knowledge increased to both moderate and high levels.

However higher knowledge has been observed among the younger respondents,

with lesser age at marriage, secondary education, with five and above number of

children, house wives and with income levels between Rs.6, 000-10,000.Age at

marriage and occupation have been observed to be statistically significant at 1%

level, whereas Age, education number of children and income of the respondents

were statistically significant at 5% level.

242
5.22 T-test

T-test is based on t-distribution and is considered an appropriate test for

judging the significance of a sample mean or for judging the significance of

difference between the means of two samples in case of small samples.

Whenpopulationvarianceisnotknownincaseiftwosamplearerelatedweusepairt-test

(or what is known as difference test) will be used for judging the significance of

the mean of different between the two related samples. It can also be used for

judging the significance of the coefficients of simple and partial correlations.

The relevant test statistics ‘t’ is calculated from the sample data and then

compared with its probable value based on t-distribution at a specified level of

significance for concerning degrees of freedom for accepting as rejecting the null

hypothesis.

In order to observe the impact of STP on knowledge on cervical cancer

among the women‘t’ tests have been calculated. The results were presented in

table No 5.56.

The results shows that the STP (structured teaching program) had significantly

influenced the knowledge on Anatomy & physiology of the women. The results

showed a highly significant value (P0.0001).The mean scores of the

respondents before STP is 5.7240 is which was much lower than the mean score

27.1240 of the women after the STP showing highly significant t values.

243
 TableNo.5.56: Impact of STP on knowledge of Cervical Cancer

Std. p-
Status Mean N t-value
deviation value

Knowledge on Before STP 5.7240 250 4.46403

Anatomy and 53.913** 0.001
Physiology After STP 27.1240 250 4.78332

Knowledge on Before STP 7.4680 250 10.05212

susceptibility to 22.878** 0.001
cervical cancer After STP 26.1920 250 8.97627

Knowledge on Before STP 2.6200 250 4.23359

symptoms of 21.897** 0.001
Cervical cancer After STP 10.7640 250 4.12606

Knowledge on Before STP 7.0120 250 8.08414

diagnoses and 26.548** 0.001
Treatment After STP 40.3400 250 17.67467

Knowledge on Before STP .2760 250 .52241

preventive practices 48.847** 0.001
After STP 3.1560 250 .80390

Overall knowledge Before STP 23.1000 250 15.61413

on Cervical 30.673** 0.001
After STP 80.4520 250 24.54223

244
 The impact of the STP on the knowledge on susceptibility to cervical

cancer has been observed to be highly significant with a p value of 0.001.The

mean score before STP was only 7.4680 which was much lower than the mean

scores of 26.1920 after the STP.

The structural teaching program also had a significant impact on the

knowledge on symptoms of cervical cancer of women. The t value was observed

to 21.897 which was found to be highly significant (P0.0001).The women had

lesser knowledge on symptoms before the STP as their mean scores were only

2.6200 which has been increased to 10.7640 after the STP. This shows the

significant impact of the interventional program on the knowledge on symptoms

of cervical cancer.

The respondents knowledge on diagnosis & treatment was very less

before the STP as their mean scores were only 7.0120.However after the STP the

mean scores has been increased to 40.3400 showing a highly significant t value

(P≤0.0001).

The impact of STP on knowledge on preventive practices can also be

observed with t values showing 48.847, the mean scores before the STP was only

0.2760 as against the mean scores of 3.1560 after the STP. The respondents

knowledge on preventive practices significantly improved after the STP.

The overall knowledge on cervical cancer with a‘t’ value of 30.673 has

been found to be highly significant (0.0001) with the STP program. The mean

score of the respondents before the STP was only 23.1000 which has been

245
increased to 80.4520 after the STP.

To sum up the impact of STP on knowledge about cervical cancer on all

the six variables has been found to be highly significant. Hence structured

intervention programs have been proved to be very useful to improve the

knowledge of women on various issues related to cervical cancer. The various

programs related to reproductive health more specifically related to cervical

cancer should be more focused towards structured intervention programs.

246
Chapter-VI

Logistic Regression Analysis

247
 CHAPTER – VI

LOGISTIC REGRESSION ANALYSIS

Regression is the determination of a statistical relationship between

two or more variables. In simple regression, we have only two variables, one

variable (defined as independent) is the cause of the behavior of another one

(defined as dependent variable).

The main objective of regression analysis is to explain the variation in

one variable (called the dependent variable), based on the variation in one or

more other variable (called the independent variables). Hence regression

analysis will be used to bring a change in the dependent variables. If there is

only one dependent variable and one independent variable is used to explain

the variation in it, then the model is known as a simple regression. If multiple

independent variables are used to explain the variation in a dependent

variable, it is called a multiple regression model. Standard logistic regression

is a method for modeling binary data.

In order to find out the major factors that have affected the knowledge

of the respondents on cervical cancer, logistic regression analysis has been

carried out considering the measuring of the dependent variables in

dichotomous nature. Socio demographic variables and biological variables of

the respondents are categorical variables hence logistic regression has been

used for the present study. In this analysis, the net effects of each of the

categories of the explanatory variables on the dependent variable have been

computed based on the odds ratio & corresponding p- values in comparison

248
with a reference category (of the respective explanatory variable),

controlling all other explanatory variables used in the model. (Kendall,

1975). This analysis has been done after the structured teaching program has

been used among the respondents.

The technique of logistic regression has been employed to estimate the

net effect of each of the explanatory variables on the knowledge on the

cervical cancer, symptoms, and screening since the dependent variable has

been dichotomous. For the explanatory variables in a categorized form, a

category is designated as influence and the logistic regression provides

estimates of the odd ratios (Odds) for each of the other categories, that is the

ratio of odds for the specified category to the odds for the reference category,

controlling for the effects of all other variables.

The question in the present research is regarding the awareness of

women on cervical cancer, knowledge on symptoms of cervical cancer &

knowledge on the benefits of cervical cancer screening and it has been coded

in dichotomous variables yes or no.

Knowledge on reproductive health occupies a central position in the

identity of the health as well as the development of a given population.

However, the events of reproductive health are usually found in women who

due to their biological function invariably bear the greater burden of the

shortcomings of reproductive health. Due to poor access to screening and

treatment services, more than 90% of the deaths occur in women living in

low-and middle-income groups. Women’s education can reduce morbidity

249
and mortality of cervical cancer due to the effect utilization, early

identification and treatment and thereby improving the quality of life of the

women.

6.1 Explanatory Variables for the Logistic Regression Analysis

6.1.1 Age of the Respondent

In many countries majority of women under the age of 25 were not

been vaccinated before becoming sexually active. The cervical cancer

incidence is expected to increase in the younger ages, giving rise to an

increase in human papilloma virus (HPV) infections a necessary cause of

cervical cancer.

Cervical cancer incidence is related to age, but it is unusual in that it

does not follow the same pattern of increasing incidence with age seen for

most cancers. In UK the age-specific incidence of cervical cancer has been

observed in two peaks: the first in women aged 30-34 (at 21 per 100,000

women) and the second in women aged 80-84 (at 13 per 100,000 women).

The earlier peak is related to many women becoming sexually active in their

late teens / early 20s giving rise to an increase in human papilloma virus

(HPV) infections-a necessary cause of cervical cancer. The second smaller

peak is due to increasing cancer incidence with age. In the UK between 2008

and 2010, averages of 20% of cervical cancer cases were diagnosed in

women aged 65 years and over (Foley, et al., 2011).

In United States of America most women with cervical cancer were

250
diagnosed before the age of 50; from 2006-2010, the median age was 49.

However, older women remain at risk. The incidence rate for cervical cancer

rises steeply with age and the highest rate occurs in women in their 40s. In

the US, the median age at diagnosis for cervical cancer is in the late 40s.

However, nearly 20% of women with cervical cancer are diagnosed when

they are over 65. The mortality rates for cervical cancer increased

consistently with age and the highest rate occurs in women over 80 (SEER,

2013).

In India cervical cancer mostly affects middle –aged women (rises in

30-34 years of age & peaks at 55-65 years) especially those from the lower

economic status who fail to carryout regular health check-ups due to

financial inadequacy (Singh, 2005).

6.2 Education of the Respondent

Education has been linked to level resources, cognition, and reception

of health education messages thus the increased risk for advanced cancer of

women with shorter education might be related to insufficient knowledge about

cervical cancer and the prevention opportunities. Women who received the

education program exhibited a greater knowledge about cervical cancer

prevention and were more likely to have reported had a pap smear within the

past year than women who did not receive the program.

Davoud Shojaeizade at al., (2012) conducted study on the effect of

Educational program on increasing cervical cancer screening behavior among

women in Hamadan, Iran. Health beliefs and practice of the target group
251
were evaluated after the intervention. The findings indicated that education

was effective and could enhance the participant’s knowledge significantly

and improved perceived susceptibility, severity, benefits, and barriers.

Furthermore, there was a significant relationship between knowledge and

both age and educational level, Health education based can enhance women’s

knowledge of cervical cancer, change their health beliefs and improve their

behaviors regarding screening programs like pap test.

6.3 Number of Pregnancies

According to studies is relation to number of pregnancies and cervical

cancer women, many developing countries do not have proper screening

facilities and women in developing countries are more likely to have large

families. Women who had 7 or more children have double the risk of women

than only 1 or 2 children. Having the first baby early, before 17, also doubles

the risk, compared to having the first baby at 25 or older. Literatures looked

at the different types of cervical cancer found a doubling of risk of squamous

cell cervical cancer with 3 or more children, compared to no children.

Klitsch (2011), conducted study on HPV-positive woman’s likelihood

of developing cervical cancer is also associated with the number of times she

has given birth to children compared with those who have never given birth

to a child. HPV- infected women who have had 1-2 births have twice the

odds of developing cervical cancer, and those who have given birth seven or

more times have four times the odds. Oral contraceptive use and high parity

long have been thought to be tied to the development of cervical cancer.

252
 William A. O’Brien (2010), conducted study on the relation of

pregnancy to carcinoma of the cervix. Carcinoma of the cervix occurs more

often in married women who have borne children than in any other class.

The trauma incident to childbirth and the after effects on the cervix have been

considered to be the significant cause, by most observers. This shows that the

injuries inflicted upon the cervix uteri during labor are a definite casual

factors in subsequent cervical carcinoma.

6.4 Family Income

Economic status is known to be directly or indirectly related to

cervical cancer incidence since it affects accessibility to health-related social

resources, preventive medical checkups, and lifestyle. According to studies

cervical cancer is most common in low income groups. Low income was

related to stage at diagnosis of cancers cervical cancer and income was

divergent in studies. Moreover, cervical cancer incidence was found to be

associated with low social status and, importantly, this relation was found to

vary in developed and developing countries. Women living in low-or middle

– income neighborhoods were more likely to have advanced cervical cancer

at diagnosis than those in high-income areas, studies shows that these

societies have free access to most health care services.

Edity My Cheng et al., (2011) conducted study on elucidating the

spatially varying relation between cervical cancer and socio-economic

conditions in England. A global (stationary) regression model revealed a

significant correlation between cervical cancer incidence rates and social

status. As a result, it was shown that if low social status sectors of the
253
population are to be targeted preferentially, this targeting should be done on

a region-by-region basis such as to optimize health outcomes.

6.5 Logistic Regression Analysis

In the present research information about the socio economic

characteristics of the sample respondents shows that a majority of the

respondents were in the age group of below 35 years (61.0 percent) and the

reaming 49.0 percent were in above 35 years of age. It can be observed from

the data that majority of respondents were in between the ages of 30-39

years. This age group women will be mostly sexually active, more likely to

have exposure to HPV and to develop pre-cancerous lesions.

More than half of the respondents (52.8 percent) were with the 1 st and

2nd pregnancies against 48.0 percent with pregnancies three and above. More

than half of the respondents (55.6 percent) were illiterates as against 44.4

percent of literates. Studies by Lockwood Rayermann (2004, p. 335) and Lee

(2000) have reported that the level of education is a contributing factor to a

woman’s ability to understand the importance of healthcare, the diagnosis of

cervical cancer and the benefits of screening. Generally, the better educated a

woman is, the healthier she is likely to be. The better the education, the more

likely the women is to adopt health behaviors and healthy lifestyles. In the

present study two thirds of the respondents (68.2 percent) were with a family

income below Rs.4000 per month. The income health relationship occupies a

central place in the domain of research on factor influencing household

decision making in health care services.

254
 The association of dependent variables by reported awareness on

cervical cancer with every explanatory variable included in this study has

been first checked by chi-square statistics. Chi-square is also used to test the

goodness fit of the model as well as the significance of the variable.

In the present study binary logistic regression model has been

considered in different specifications to check the effect of different

independent co-variates. Several authors (Nath & Leonetti, 1999, Nath &

Leonetti, 2001; Adinarayana, 2001) used such type of analysis to have

deeper insight in understanding successfully the effect of different covariates

on dependent variable. Results under these covariates by considering some of

the variables involved in the modeling were presented in tables 1, 2 & 3.

6.5.1 Model 1

Model I estimated the effects of Age, education, number of

pregnancies & family income on the knowledge & on the awareness on

cervical cancer and presented in Table-6.1.The analysis shows that all the

four covariates were found to have insignificant effects. The Age of the

respondents, education, numbers of pregnancies and family income have not

shown any significance showing that these variables were not really

significant to the model. These variables were found to be not significant

factors for the knowledge on cervical cancer in the present research (Table -

1).

255
 Table No.6.1: Binary Logistic Regression Model – 1

Dependent variable Awareness on cervical cancer (Yes = 1;

n=0)

Variables B S.E. Wald Df Sig. Exp. (B)

Age
.048 .206 .055 1 .815 1.049
Age  35 ® and
 36

Education
.063 .199 .100 1 .752 1.065
Illiterates ® Literates

Number of Pregnancies
.093 .198 .219 1 .640 1.097
1&2®
>3

Family Income (per

month)
-.119 .210 .318 1 .573 .888
< 4000 ®
> 4000

-.833 .181 21.117 1 .000 .435

6.5.2 Model – II

In model II in order to find out the principle factors that have

affected the knowledge on the symptoms of cervical cancer of the

respondents, the logistic regression analysis has been carried out and the

results were presented in Table 6.2. Controlling for all the other variables used

in the model, the odds of knowing on the symptoms of cervical cancer has

been observed to be significantly higher among those respondents with

pregnancies three & above with reference to the respondents with Pregnancies

256
1 & 2. The knowledge on symptoms of cervical cancer was observed to be 43.0

percent more among the respondents with third and above number of

pregnancies. The number of pregnancies irrespective of the outcome,( a

biological variable) emerged as a significant factor which had influenced the

knowledge of the respondents on the symptoms of cervical cancer. If women

becomes pregnant more times, in the long run if may lead to the risk of

developing cervical cancer for women. In the present research women who

had more pregnancies, irrespective of the outcome have more knowledge on

the symptoms of cervical cancer than the women with less pregnancies. Hence

more pregnancies have been found to be a risk factor presumed by the

respondents. Women were presuming more number of pregnancies as the

cause of cervical cancer, hence they desire to know more about it.

Table No.6.2: Binary Logistic Regression Model – 2

Dependent variable: Knowledge on symptoms of Cervical Cancer (Yes = 1;
n=0)

Variable B S.E. Wald Df Sig. Exp. (B)

Age
Age ≤ 35 ® and -.228 .207 1.216 1 .270 .796
≥ 36

Education
Illiterates ® -.231 .198 1.364 1 .243 .794
Literates

Number of
Pregnancies .360 .196 3.364 1 .047 1.433
1&2®
>3
Family Income
(per month) .081 .205 .156 1 .693 1.084
< 4000 ®
> 4000
-.715 .178 16.078 1 .000 .489

257
 The variables like age and education of the respondents though not

significant ( 0.5 percent) still were very close to the reference items. 80%

of literate women were having knowledge on the symptoms of cervical

cancer when compared with illiterates. As the sample contains more number

of primary educators even education was not found to be significant. The

same pattern can also be found with reference to the age of the women. 80%

of women above the age of 36 years had knowledge on the symptoms of

cervical cancer. Though these variables doesn’t show any significance, along

with other variables, if there are less number of variables, then these two may

show significance with a larger sample population. Hence an indepth

analysis of these variables with a larger sample size of the population can

give better understanding. However family income has not shown any effect

on the knowledge on the symptoms of cervical cancer.

Hence in this model, number of pregnancies emerged as a strong and

significant factor for knowing about the symptoms of cervical cancer, though

age & education were somewhat important and family income has been

found to have an insignificant effect.

6.5.3 Model-III

The logistic analysis results of the model III has been presented in

table No.6.3. The model explains the effects of Age, Education, number of

pregnancies and Family Income on the knowledge on the benefits of cervical

cancer screening. Out of the all the socio demographic variable, the number

of pregnancies emerged as the significant factor for knowing about the

258
benefits about the screening of cervical cancer. Women with higher number

of pregnancies of 3 and above were found to have 46% of more knowledge

on the benefits of cervical cancer screening when compared with women

of pregnancies 1 & 2. In chi-square analysis it has been found that women

who have more pregnancies had higher knowledge of cervical cancer with

STP. Hence women with more pregnancies perceived that number of

pregnancies as a cause for cervical cancer. Hence, women with more

pregnancies were more inclined to know about the screening of cervical

cancer. The other factors were found to be insignificant in knowing about

the benefits of cervical cancer screening. Age & family income of the

respondents though insignificant may emerge as strong factors if fewer

variables were there. However number of pregnancies has been found to be a

significant factor.

Table No.6.3: Binary Logistic Regression Model – 3

Dependent variable: Knowledge on the benefits of screening for cervical
cancer (Yes = 1; n=0)

Variable B S.E. Wald df Sig. Exp. (B)

Age
-.228 .207 1.216 1 .270 .796
Age ≤ 35 ® and
≥ 36

Education
-.231 1.198 1.364 1 .243 .794
Illiterates ®
Literates
Number of Pregnancies
.360 .196 3.364 1 0.47 1.433
1&2®
>3

Family Income (per month)

.081 .205 .156 1 .693 1.084
< 4000 ®
> 4000

259
-.715 .178 16.078 1 0.000 .489

260
 To summarize, the analysis of knowledge symptoms and screening of

cervical cancer, logistic regression model has been used because the response

variables were categorical variables. The summary results, three sets of odds

ratio, for the knowledge about cervical cancer, knowledge about symptoms

of cervical cancer and knowledge about screening of cervical cancer. The

respondents have been found to have substantial knowledge about cervical

cancer. A number of background variables were observed to influence the

knowledge levels of the respondents. Among the socio demographic &

economic variables, number of pregnancies emerged as strong and

significant factor which had effect on the knowledge levels of the

respondents on cervical cancer. Women with more pregnancies were

presuming it as a risk factor and they were more inclined to know about the

symptoms & screening of cervical cancer. Though the other variables like

Age, education & income were found to be insignificant, they may emerge as

significant factors if they were grouped with other factors, or if the sample

size was more. An in depth analysis with a larger sample size may be helpful

in knowing about the effects of these background variables on the knowledge

of the respondents. The odds of knowledge about cervical cancer, symptoms

& screening have been observed to be high among the women with more

pregnancies than women with lesser pregnancies. The difference has been

observed to be statistically significant. Higher numbers of pregnancies have

been emerged as the predictor of cervical cancer in the present analysis.

Hence, this biological variable can be recognized as a special focus

intervention area to improve the knowledge of the women on cervical cancer.

To sum up the impacts of STP on knowledge about cervical cancer on

261
all the six variables have been found to be highly significant. Hence

structured intervention programs can be very useful to improve the

knowledge of women on various issues related to cervical cancer. The

various programs related to reproductive health more specifically related to

cervical cancer should be more focused towards structured intervention

programs. As it impractical to give interventions to all women, at least

women at high risk of getting cervical cancer, like women with multiple

partners, HIV positive women, prolonged use of oral pills, high parity, poor

genital hygiene, and early age at first cautious and above 50 years of age

should be focused.

262
Chapter-VII

SUMMARYAND
IMPLICATIONS

263
 CHAPTER- VII

SUMMARY AND
IMPLICATIONS

7.1 Introduction

Cervical cancer is the second most common cancer in the world. Every

year cervical cancer is diagnosed in about 500,000 women globally and was

responsible for more than 280,000 deaths annually. About 14.0 percent cervical

cancers occur in the developed countries and about 86 percent cervical cancers

occur in developing countries. In India, cervical cancer is the largest killer of

middle aged women, followed by breast cancer. In India, each year cervical

cancer accounts for 26.7 percent of world wide incidence and 72,825 Indian

women die due to cervical cancer. It is a major cause of morbidity and mortality

in India and more than 1,32,000 women are diagnosed with cervical cancer every

year, in fact 200 women are dying for every 24 hours in India due to cervical

cancer. Incidence and mortality of cervical cancer vary according to age,

reaching a peak in women aged around 40 years. The age distribution of cervical

cancer is pyramidal with a higher percentage of younger women being diagnosed

with pre-cancer symptoms and invasive disease.

Cancer is a generic term for a large group of diseases that can affect any

part of the body. Other terms used are malignant tumors and neoplasm. One

defining feature of cancer is the rapid creation of abnormal cells that grow

beyond their usual boundaries, and which can then invade in to adjoining parts of

the body and spread to other organs. Cancer of the cervix is also called cervical

264
cancer, begins in the cells lining the cervix. The cervix is a part of a woman’s

reproductive system connecting the uterus to the vagina. These cells do not

suddenly change into cancer. Instead, the normal cells of the cervix first slowly

change in to pre-cancer cells that can turn into cancer (five years to as long as 20

years). These changes may be called dysplasia. The change can take many years,

but sometimes it happens faster and it can be found by the Pap test.

Cervical cancer can affect women of all socio-economic strata, both in

rural and urban areas. All sexually active women are at risk of having cervical

cancer. There are number of risk factors attributed to cervical cancer. These are

early age at marriage or early onset of sexual activity, multiple pregnancies,

pregnancies in quick succession, and more than one sexual partner, long-term

use of oral contraceptives, malnutrition, unhygienic genital health, individual's

immune status, and smoking or even genetic predisposition.

In early stages, it’s often show no symptoms. That’s why it’s important to

consult a doctor for regular screening with a pap test. (a procedure in which cells

are scraped from the cervix and looked at under a microscope). When symptoms

do occur, they may include Pain or bleeding during or after intercourse, unusual

discharge from the vagina, Blood spots or light bleeding other than a normal

period.

These symptoms can be caused by cervical cancer or by a number of

serious conditions, and should be evaluated promptly by a medical professional.

Cervical cancer can be prevented by regular screening and vaccination. A

majority of cervical cancer cases can be detected by screening. Regular screening

265
with pap smears/HPV DNA, etc. can help to detect it in the early stages.

Vaccination is given for all girls and women aged 10–45 years in three doses

over a period of six months. For the best form of protection, it is very important

to get all the three doses of the vaccination as per schedule. Regular screening

should be continued after vaccination to offer the best possible protection against

cervical cancer IAP (Indian Academy of Pediatrics) and FOGSI (Federation of

Obstetrics and Gynecology Society of India) recommends that regular screening

and vaccination can help women fight this disease which is the biggest cause of

cancer-related deaths amongst Indian women.

In India large number of female population is vulnerable to cervical

cancer. There cognized risk factors for cancer cervix are, illiteracy, low socio-

economic status, early marriage, multiparty, first child birth at early age, poor

genital hygiene and genital infections and it is widely prevalent. However, the

risk of development of cervical cancer is due to the life style of the individual,

social customs and personnel hygiene. The present study tries to analyze the

socio-economic and Health practices relating to knowledge on cancer cervix

among married women. However, there were few studies which focused on the

preventive practices towards the cervical cancer among women. The present

study focused on knowledge on cervical cancer, female reproductive system;

symptoms and the barriers to access the health services, preventive health

practices of women, through structured teaching program.

In India Cervical cancer is a major health problem among women. One of

the reasons may be lack of early detection as means that women often access the

266
health services when disease is in advanced stage. There is a limited resource of

the health care services and as tunted health care system which does not have the

capacity to offer treatment for more advanced cases of cervical cancer such as

radiation combined with chemotherapy. In addition to that, referral to higher

recognized institutions for specialized care is difficult due to huge travel and

treatment costs. Hence, knowing about the barriers to health services and

interventions to improve the survival due to cervical cancer is needed.

There are certain studies relating to knowledge levels, barriers and

preventive modes on cervical cancer in Indian context. However to fill the gap,

this study tries to focus on effective structured teaching program on cervical

cancer among women as many women were not aware of the severity of the

disease. Hence knowledge on cervical cancer through structured teaching

program can make them understand and improve their decision making in health

checkups.

The health problems of women were varied and they are related to the

customs and beliefs, which they follow according to norms of particular society.

In order to reach the women on cervical cancer perspectives, there was a need to

implement inclusive specialized policies and programs by the policy makers. An

awareness programs on primary prevention can bring change in their lifestyle,

social customs and hygiene practices. So the studies, to promote preventive

behavior and to prevent cancer cervix by detecting it at early stage through

screening will be helpful in bringing the policies & programs on reproductive

health and also to get the support of the family in screening.

267
 As there is a dearth of literature on the cervical cancer especially in Indian

context, it is significant that this study bridge the gap by providing effective

teaching program on cervical cancer to increase the knowledge levels among

women. It will in turn help to develop appropriate policies and new innovative

approaches to address and prevent the cervical cancer among women.

There is a need to educate women on importance of cervical cancer

screening and of responsibilities for their own reproductive health matters is a

critical element in fighting against cervical cancer. So, community based studies

focused on the importance of educating the women especially in rural areas are

significantly important.

Hence, an attempt has been made to study the effectiveness of structured

teaching program on knowledge about cervical cancer among married women in

rural areas.

7.2 Methodology

The major objective is to

 To assess the effectiveness of structured teaching program on the knowledge

of cervical cancer among married women.

And the specific objectives are

 To determine the women’s knowledge on preventive health practices of

cervical cancer before and after teaching program.

 To determine the women’s perceived severity of cervical cancer by

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 collecting pre-test and post-test knowledge.

 To find association between socio demographic variables and knowledge on

preventive practices of women through pre-test & post test.

 To describe the association between socio demographic variables &

perceived susceptibility and severity of cervical cancer.

 To study socio demographic variables and perceived benefits from and

barriers to seeking cervical cancer screening before & after the STP.

A quasi experimental research design has been selected for the study. The

present research investigation is undertaken from Dunera, Pathankot district in

the state of Punjab by using multi stage random sampling. In the first stage of

study from the Pathankot district four mandals are selected they are Pathankot,

Sujanpur, Gharota and Bamial. In the second stage, from each mandal 5 villages

are selected constituting 20 villages are randomly selected from all the four

mandals .The villages selected are Abadgarh, Bhoa, Dunera, Gharota Kalan and

Najo Chak villages from Pathankot mandal, Nuagarh, Patanapur, Ratanapur,

Sujanpur, Gauradeipur villages from Sujanpur Mandal, Kanwan, Jalampur,

Hayati Chak, Haibo and Danour villages from Gharota mandal and Bhakhari,

Chak Amir, Dostpur, Janial and Samrala villages from Bamial mandal. In the

third stage from each village, 25 married rural women were selected by simple

random sampling technique to collect the data. Like that, from 20 villages 500

married women were selected. The information was collected from all the 500

women using the interview schedule without any STP. For the structured

teaching program, 250 married rural women from above mandals and from

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same villages were selected. From each village, 10-13 were selected through the

lottery method by preparing the slips with names of married rural women (who

are the respondents of the pre-test study). The data has been collected during

October, 2024 to November, 2024 by using interview schedule. Same schedule

was used for pre-test and post test to collect data by the researcher.

The data collection comprised of three phases

Pre-intervention phase-involved the collection of cross sectional base

line information using questionnaire consisting of multiple choice, open and

closed ended questions. The study instrument was divided into sections

comprising of socio- economic and demographic data, knowledge on cervical

cancer, anatomy & physiology of female reproductive system, severity of

cervical cancer, symptoms, diagnosis and treatment, benefits of cervical cancer

screening, barriers, and preventive health practices.

The intervention phase - includes health education and communication

through the audio visual aids like teaching aids and lecturer consists of various

issues on cervical cancer, charts on female reproductive system and short-films

on cervical cancer. Intervention phase also includes exhibiting the cards on risk

factors, symptoms, importance of screening and preventive practices with

regards to cervical cancer prepared in Telugu language. Each session took

around two hours. The women were also informed that the post test will be

conducted after two weeks.

Post-Intervention phase - was carried out with 250 members after two

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 weeks of the intervention phase and researcher provide sufficient time for

collecting the interventional effect information on cervical cancer by using the

same instrument in both the preliminary survey and the post assessment.

7.3 Results and Discussion

7.3.1 Socio-demographic factors of the respondents

More than two fifth of the respondents were in the age group of 30-39

years followed by only a minor proportion in the age group of 40-49 years. More

than two thirds of the respondent puberty age was in between 13-14 years

followed by only a minor proportion of the respondents’ age at puberty in

between 15-16years. More than half of the respondents were married between

15-18 years by followed a very minor proportion were married between the age

of 27-30 years, One third of the respondents had two children followed by more

than five children and only 6.6 percent of the respondents were not having

children. One third respondents were having II nd gravida and a minor proportion

with more than 5th gravida. Two thirds of the respondents were in nuclear

families as against a very minor proportion in extended families.

More than half of the respondents were illiterates as against only

11.0percent of the respondents with secondary education. Nearly three fifths of

the women (59.2 percent) were coolie/daily laborers as against only 10.2 percent

of the respondents in petty trade like selling fruits, vegetables and milk. More

than two third of the respondents monthly family income was in between is

Rs.1000-5000followed by a very minor proportion (2.80 percent) of the

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 respondents monthly family income is in between Rs.16000-20000. Among

those who had abortions less than two thirds of respondents had spontaneous

abortions followed by only 10.6 percent of the respondents had induced

abortions by doctor. Nearly two third of the respondents were Hindus followed

by only 7.2 percent of Christians. Three fifths of the respondents were not having

any habits as against the remaining two fifths were having habits like chewing

betel leaves and tobacco.

7.3.2 Effectiveness of Structured Teaching Program on knowledge of cervical

cancer

Awareness of Cervical Cancer

In pre-test only one third of the respondents were aware of cervical cancer

where as an over whelming proportion were aware of cervical cancer after the

structured teaching program. Axillaries Nurse Midwife was the major source of

awareness in pre-test however in post-test for more than two third of the

respondents teaching module was the major source of awareness.

Knowledge of Anatomy & Physiology

In pre-test more than half of the respondents correctly stated uterus as an

organ of female reproductive system Whereas in post-test an over whelming

proportion of the respondents correctly stated uterus as an organ of female

reproductive system. One fourth (24.4 percent) of the respondents stated fundus,

body and cervix were the parts of uterus in pre-test where as in post-test more

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than three fourths of the respondents correctly stated fundus, body and cervix

were the parts of uterus. Only a minor proportion of the respondents correctly

stated cervix was located between the uterus and vagina in pre test where as in

post test a major proportion of the respondents correctly stated cervix was

located between the uterus and vagina.

Knowledge of Perceived Severity of Cervical Cancer

In pre-test nearly two thirds do not know about the severity of cervical

cancer whereas after the structure teaching program three fourths of the

respondents were aware of severity of cervical cancer.

Knowledge of Causative Organism

In pre-test only a minor proportion of the respondents had idea about the

organism involved in the causation of cervical cancer where as in post test a

major proportion of the respondents knew about the organism involved in the

causation of cervical cancer. Only a minor proportion of the respondents know

that the Human Papilloma Virus will spread through contacts in pre-test on other

hand in post-test majority of the respondents knew that Human Papilloma virus

will spread through sexual contacts.

Knowledge of Susceptibility to Cervical Cancer

In pre-test more than one third of the respondents were aware about the

susceptibility to cervical cancer Where as in post an test an over whelming

proportion of the respondents were aware about susceptibility to cervical cancer.

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Knowledge of Symptoms of Cervical Cancer

In pre-test one third of the respondents were aware of symptoms of

cervical cancer where as in post-test an over whelming proportion was aware

about symptoms of cervical cancer majority of the respondents knew that Human

Papilloma virus will spread through sexual contacts.

Knowledge of Susceptibility to Cervical Cancer

In pre-test more than one third of the respondents were aware about the

susceptibility to cervical cancer Where as in post an test an over whelming

proportion of the respondents were aware about susceptibility to cervical cancer.

Knowledge of Symptoms of Cervical Cancer

In pre-test on third of the respondents were aware of symptoms of

cervical cancer where as in posttest an over whelming proportion was aware

about symptoms of cervical cancer.

Knowledge of Screening, Diagnoses & Treatment

In pre test only 0.4 percent of the respondents correctly stated pap smear

was the screening test for cervical cancer. On the other hand in post test more

than two thirds of the respondents correctly stated Pap smear was the screening

test for cervical cancer. Only 0.4% of the respondents have undergone for

cervical cancer screening by the motivation of Health worker/ ANM in pre test

where as in post test more than one fourth of the respondents have under gone

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for screening after the structured teaching program. In pre-test only more than a

quarter of the respondents know about the benefits of cervical cancer screening.

However after the STP in post test an over whelming proportion was aware

about the benefits of cervical cancer screening. Only a minor proportion of the

respondents stated that they had barriers for cervical cancer screening in pre test

on the other hand in post test more than two thirds of the respondents had

barriers for cervical cancer screening. In pre-test one third (34.8 percent) of the

respondents know about the treatments available, for cervical cancer. However

after the STP an over whelming proportion of the respondents had (89.2 percent)

known about the availability of treatment for cervical cancer.

Knowledge of Preventive Practices

Only 0.4 percent of the respondents in pre-test correctly stated Gardasil

vaccine will prevent cervical cancer, whereas in post-test two thirds of the

respondents correctly stated Gardasil vaccine will prevent the cervical cancer.

Only 4.0 percent of the respondents correctly stated that the ideal age to give

vaccine for cervical cancer is between 9-26 years before the STP. Where as in

post test a major proportion of the respondents correctly stated the ideal age for

the vaccination is between 9-26 years.

Menstrual & Sexual Hygiene

More than one third of the respondents have been using old cloth during

menstruations in pre-test, whereas in post-test more than one fourth of the

respondents were using old cloth to absorb menstrual blood. In pre test more
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 than one third of the respondents had the habit of cleaning private parts before /

after the changing pads / napkins on the other hand in post test more than two

thirds of the respondents had the habit of cleaning private parts before / after the

changing pads / napkin. Only a minor proportion of the respondents were

cleaning private parts before sexual intercourse before the STP whereas after the

STP less than half of the respondents were cleaning private parts before sexual

intercourse.

7.3.4 Socio-demographic characteristics and knowledge of anatomy and

physiology of female reproductive system

The knowledge of the respondents on Anatomy and Physiology of female

reproductive system increased with all the variables after the STP. In all the ages

the respondents’ knowledge has been increased to high. However higher

knowledge has been observed among those in between 23-26 years with lesser

proportion in 50-59 years of age, primary education, with three children,

coolie/daily lab ours and with income levels between Rs11000-15000. However,

only education & occupation of the women has been observed to be statistically

significant at 1% level and all the other variables were found to be statistically

significant at 5% level.

7.4.5 Socio-demographic characteristics and knowledge of susceptibility to

cervical cancer screening

The socio demographic variables were found to have an effect on the

level of knowledge of susceptibility of cervical cancer screening. The knowledge

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 of the respondents on the susceptibility of cervical cancer screening has been

increased in the post test after the STP program for all the variables. However

age at marriage and number of children were found to be statistically significant

at 1% level on the knowledge of the respondents on susceptibility of cervical

cancer screening. Education, Occupation and income have been observed to be

significant at 5% level.

7.3.6 Socio-demographic characteristics and knowledge of symptoms of

cervical cancer

Effective structured teaching program has been observed to have an

impact on the knowledge of symptoms of cervical cancer. In all the age group in

post-test knowledge of the respondents has increased to high from low levels in

the pre-test. Age & Occupation of the respondents has been statistically

significant at 1% level with the knowledge on symptoms of cervical cancer. The

increase in the knowledge levels can also be observed with the differences in age

at marriage and education of the respondents. Ages at marriage, education,

income and Number of Children of the respondents have been statistically

significant at 5% level with the knowledge on symptoms of cervical cancer.

Women with three & four children had high knowledge than the children with no

children and single child. More number of respondents in petty business acquired

high knowledge after the STP. Respondents of all income levels had high

knowledge in post test.

7.3.7 Socio-demographic characteristics and knowledge of diagnosis and

treatment
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 Knowledge of respondents on diagnosis and treatment of the respondents

increased after the post test with the socio demographic variables. The

respondents’ level of knowledge has showed an inverse relationship with Age,

women in younger ages had higher level of knowledge on diagnosis and

treatment after the STP. More number of illiterates with low level of knowledge

had high knowledge on diagnosis and treatment after the STP. The same pattern

can also be observed with number of children occupation, income of the

respondents. However education and occupation were observed to be statistically

significant at 1%level.Age, age at marriage, number of children and income were

observed to be significant at 5% level with the knowledge on diagnosis &

treatment of cervical cancer.

7.3.7 Socio-demographic characteristic and perceived benefits of cervical

cancer screening

The respondents in all the age groups perceived high benefits of cervical

cancer screening after STP. However women in younger age perceived moderate

and high benefits than the other ages. Same pattern can be observed with age at

marriage. Those married in younger ages perceived moderate and high benefits

than those married at late ages. The age, age at marriage, numbers of children,

occupation were found to have a statistical significance of 1% level with the

perceived benefits of cervical cancer screening. However education & income

have been observed to be a statistically significant at 5% level with the perceived

benefits of cervical cancer screening.

7.3.8 Socio-demographic characteristics and perceived barriers of cervical

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cancer screening

With all the socio demographic variables the respondents perceived high

barriers to cervical cancer screening after the post test. However women in

younger ages, married between 27-30 years of age, perceived high barriers when

compared with other groups. Age at marriage has been observed to statistically

significant at 1% level with the perceived barriers of cervical cancer screening of

the respondents. Ages, education, occupation, Income and Number of children

have been observed to be significant at 5% level.

7.3.9 Socio-demographic characteristics and level of knowledge of preventive

practices of cervical cancer

The knowledge of the respondents on preventive practices of cervical

cancer increased with all the variables after the STP. In all the age groups the

respondents’ knowledge increased in both moderate and high levels. However

higher knowledge have been observed among the younger respondents, those

with lesser age at marriage, secondary education, with five and above number of

children, house wives and with income levels between Rs.6,000-10,000.Age at

marriage and occupation observed to be statistically significant at 1% level,

whereas age, education, number of children and income of the respondents were

statistically significant at 5% level.

The overall knowledge on cervical cancer with ‘t’ value of 30.673 is

found to be highly significant (0.0001) with the STP program. The mean score of

the respondents before the STP is 23.1000 which have been increased to 80.4520

after the STP.

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7.4 Logistic Regression Analysis

To analyze the knowledge of the respondents on cervical cancer,

symptoms of screening, logistic regression model has been used. The summary

results, three sets of odds ratio for the knowledge about cervical cancer,

knowledge about symptoms of cervical cancer and knowledge about screening of

cervical cancer. The respondents had substantial knowledge about cervical

cancer. Number of background variables influenced the knowledge levels of the

respondents. Among the socio demographic & economic variables, number of

pregnancies emerged as strong and significant factor which had an effect on the

knowledge levels of the respondents. Women with more pregnancies predicted it

as a risk factor and they were more inclined to know about the cervical cancer its

symptoms & screening. Though the other variables like Age, education &

income have been found to be insignificant, they may emerge as significant

factors if they were grouped with other factors, or if the sample size was more.

An in depth analysis with a larger sample size maybe helpful in knowing about

the effects of these background variables on the knowledge of the respondents.

The odds of knowledge about cervical cancer, symptoms & screening have been

high among the women with more number of pregnancies than women with less

number of pregnancies. The differences were observed to be statistically

significant.

7.5 Policy recommendations

Carcinoma of the cervix is the only human cancer that is almost entirely

preventable. It is also 100 per cent curable if picked at very early stage.

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Treatment is cheap and simple in early stages requiring minimal manpower to

achieve the high cure rate.

Cancer of the cervix has an established screening method that works.

Today, vaccines are available for primary prevention of cervical cancer. The

vaccine for cervical cancer should be part of the country’s immunization plan

and like in other countries. Control of cervical cancer depends on increase in

public awareness of the disease. Government should subsidize the treatment and

incorporate screening program into the primary health care as well as improve

infrastructure and development of health facilities. To reduce the burden, there

should be constant training and re-training of personnel.

As the present study shows the effectiveness of the STP, as a strategy to

reduce the burden of disease in the community providing education on this

particular issue should be considered.

In order to stimulate regular screening among women, there should be an

aggressive health promotion intervention designed to increase knowledge levels

and to correct impressions about cervical cancer in the community. Importantly,

the outcome of such screening would guide management of conditions

throughout life, including the decision-making process, in which the individual

would be an important part .The need of the hour is that we should begin to talk

about cervical cancer especially in our rural communities so that the health of the

women at the gross root level can be improved.

Women in rural areas rely mostly on health care professionals to educate

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and recommend health care practices that were beneficial in terms of health

promotion. Lack of information was the main barrier. Information on pamphlets

or posters should be user friendly i.e. translated to the local language and also

distributed to the female population as widely as possible. The health managers

should review packaging of information so as to simplify complex terminology

when necessary to enhance understanding by all women. Hence cervical cancer

and screening messages should form part of the basic health education package

offered to all women, irrespective of their health status. Mini surveys should also

be periodically conducted to elicit the level of understanding on cervical cancer

and the importance of screening. Information obtained would then assist health

professionals to further improve the screening services. This should be coupled

with staff training and periodic in-service education, but also revision of basic

health programs would also be necessary. Health educational initiatives should

also target men since studies suggest that male partners could play a vital role in

increasing the awareness of this service.

More emphasis on awareness on symptoms, screening and benefits can be

given to the women with higher number of pregnancies can have positive effects

on the knowledge levels of women on cervical cancer. Hence the programs on

cervical cancer should focus more on the women with more number of

pregnancies. The findings of the present analysis may be useful in policy making

on cancer awareness for all sections of women. It can be recommended that

initiatives of national cancer programs should focus on women with higher

pregnancies, lesser literacy and with higher age .Hence information, education &

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 communication strategies focus on these women need to be strengthened. For

these women provision of information regarding early detection of cancer

symptoms, would reduce the burden of delayed care seeking & treatment and the

concomitant increase in mortality & morbidity burden.

Comprehensive cervical cancer control encompasses prevention, early

detection, diagnosis, cure and monitoring and requires collaboration among

relevant programs, departments and organizations. To this end, the following

additional recommendations were made.

7.5.1 Strengthen action to consolidate cervical cancer control

The steps to be taken would vary from country to country depending on

the control measures existing in the countries.

7.5.2 Appoint a leading body responsible for cervical cancer prevention

This body could be an institution or department responsible not only for

preventive activities, such as screening, but also for health education, vaccination

(if it is to take place), and the collection, monitoring and evaluation of data.

7.5.3 Ensure the availability and accessibility of treatment services before

initiating a screening program

The treatment of precancerous lesions should be administered on an

outpatient basis whenever possible, using LEEP and/or cryotherapy.

Centralization of the treatment of cancerous lesions and a referral system should

be recommended. The needs of women with incurable disease should be

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 addressed by palliative care services. Any cervical cancer program needs to

ensure that morphine is available.

7.5.4 Organize screening programs

If an opportunistic screening program were in place, concrete measures

would be needed to organize it according to evidence-based guidance. Evidence

is defined at international level but countries also need national data. In defining

the screening methodology, the following WHO guidelines should be taken into

account:

(1)Cytology is recommended for large-scale cervical cancer screening programs,

if sufficient resources exist. (2) Visual screening methods are recommended for

use in pilot projects or other closely monitored settings. (3) HPV tests can be

used in conjunction with cytology or other screening tests, where sufficient

resources exist. (4) Colposcopy is recommended only as a diagnostic tool (not as

a screening tool) and should be performed only by trained and skilled providers.

The man power required for the different tasks needs to be defined, taking into

account the resources (human and financial) available and the international

guidelines. Nurses and midwifes have the competency to be involved in

screening.

Capacity building should be organized according to needs. In defining the target

population and screening interval, it is necessary to take into account that it is

more important to achieve high coverage than to repeat tests on the same

women.

According to the WHO guidelines: (1) screening should not take place before the
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 age of 25 and should not be done on an annual basis; (2) screening should start at

age 25and continue with three-year intervals until the age of 49; (3) from age 50

to age 64, screening should be with five-year intervals; and (4) screening should

stop at age 65 if the last two smears were negative.

7.5.5 Improve screening implementation

Implementation is a continuous process and should be continuously

monitored. The evaluation of existing infrastructures and gaps is part of this

process. To achieve a high level of participation, the target population should be

invited through call recall systems. Starting information and awareness-raising

campaigns. Seeking the active collaboration of service providers and develop

communication strategies. If cytology is used as a screening test, this should

include quality control of the whole process of smear taking, fixation,

transportation and reading.

7.5.6 Make use opportunities for primary prevention

Health education should be an integral part of comprehensive cervical

cancer control. Health and sexual health education, including the promotion of

condom use, are valuable strategies for the primary prevention of cervical

cancer.

7.5.7 Assess the introduction of HPV vaccines

Preparing for evidence-based decision-making on the introduction of

HPV vaccines as part of comprehensive cervical cancer prevention package by

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making use of WHO guidance and other relevant technical documentation and

information.

7.6 Country wide activities for cervical cancer prevention

 Political will and commitment, including assured resources, are needed to

start and sustain a cervical cancer prevention program.

 Health authorities should be instructed to promote organized screening,

discourage opportunistic (over-) screening and implement guidelines.

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 Current screening practices have to be improved by optimizing

participation and assuring quality. A high coverage rate can only be

attained if general practitioners are involved and if the communities are

better informed and educated. Training of health staff is an important

element in quality assurance.

 A frame work is required for evidence-based decision-making with regard

to:

(1) Screening policy (start and stop ages, intervals, population groups);

(2) Screening method; (3) diagnostic, follow-up and treatment methods;

(4) vaccination; and (5) delivery services.

 There is a need for comprehensive sexual education as well as

information and education on the use of innovative methods, such as the

ABC approach, HPV vaccination, screening, etc., in cancer prevention.

 A comprehensive information system, including registries of the target

population, participation details, screen-test results, follow-up, links to the

cancer registry and HPV surveillance systems, would allow monitoring of

the quality of the screening and vaccination programs and evaluation of

the impact.

 In introducing the HPV vaccine, it is important to clarify how to avoid

misperceptions and stigmatization in providing sensitive information and

how to organize the registration and monitoring of data so that they can

be linked with those of the screening registries.

 It is important to have an international assessment of the effectiveness of

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new technologies.

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  Involving civil societies, such as anticancer leagues and NGOs, can be

helpfulinsettingupcervicalcancerprogrammesandkeepingthemhighonthe

agenda.

7.7 Recommendations for Further Research

 A comparative research can be done on knowledge and compliance of the

high risk women and their husbands in terms of their preventive practices

and health seeking behavior.

 Similar research can be undertaken with a true experimental design on

women with more number of pregnancies.

 Similar studies with descriptive approach can be undertaken with large

sample to generalize the findings.

 Similar research can be conducted among female health worker / ANMs who

have more contact with the women and thus cervical cancer can be prevented

by imparting knowledge to them at their door step.

 Large scale studies should conducted focusing on exploring health care

resources that influence access across the district so as to better understand

reasons for the low uptake of the screening service in this rural community.

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