APPROVAL SHEET

This is to certify that research on Knowledge Regarding Prevention of Cervical Cancer among Married Women is a splendid work of Srijana Shrestha as the requirement for the Bachelor of Nursing Programme in Hospital Nursing from P.U NIHs, Nursing Campus, Baudha, Kathmandu. . Srijana Shrestha Candidates Roll no 22 . Ms Renuka Devi Pradhananga Research Advisor: Lecturer of Maharajgunj Nursing Campus, Maharajgunj, Kathmandu.

ACKNOWLEDGEMENT An understanding of this research study is not the result of single mind; there are so many helping hands behind it. So, investigator wants to acknowledge all of them for their kind suggestion, guidance and help throughout the study. First of all, the investigator would like to acknowledge to the Purbanchal University, NIHS, Nursing campus, Baudha for providing golden opportunity to carry out this study as partial fulfilment of Bachelor Degree in Hospital Nursing. The investigator wishes to extend her sincere gratitude and appreciation to her research advisor Lecturer Renuka Devi Pradhananga, Baudha Nursing Campus for providing me valuable guidance, suggestion and encouragement during the course of work. My deep and cardinal gratitude also goes to BN faculty chief and subject teachers, Professor Dr.Sarala Shrestha, Professor Kamala Tuladhhar and associate professor Milon Lopchan for their valuable suggestion as well as I'm also grateful for research team. The investigator would like to acknowledge to the Director, Matron and Dr. Mira Upadhaya,head of the Department of Gynae and Obstetric of Lumbini Zonal Hospital, Butwal., for giving permission, cooperation and guidance to carry out this study. My sincere thanks also goes to all library staffs of Maharajgunj Nursing Campus, TUTH library, and NHRC library for providing valuable literatures, books, Journals etc for completion of this study. The investigator wishes to express lot of thanks to all respondents of the study for their kind cooperation in fulfil the questionnaire. At Last, but not the least thanks goes to all her colleagues and other known and unknown sources of inspiration and encouragement to carry out this study.

Srijana Shrestha BN Second Year

ABSTRACT The descriptive exploratory type of study was carried out to explore the knowledge of cervical cancer prevention and screening among married women attending in Gyane OPD in Lumbini Zonal Hospital, Butwal. The objectives of this study were to find out the knowledge of cervical cancer prevention screening. 50 samples collected by using structured and semi structured questionnaire through probability purposive sampling technique. Major findings drawn from this study shows that most of the respondents 45(90%) had heard of cervical cancer screening. Most of the respondents35 (77.77%) had answered cervical cancer can be early detected and main sources of information regarding cervical cancer had been relatives/friends and media (67% and 33%). Most of the respondents 22(48.88%) answered predisposing factor of cervical cancer is suffered from STI(HIV/HPV) and multiple sexual partner.35(77.77%) respondents felt necessary to prevent cervical cancer,34(68%) respondents were not doing cervical cancer screening because of don' t have problem. The women who were included in the study had inadequate knowledge regarding cervical cancer screening and prevention. Therefore, it is necessary to make them aware of cervical cancer and its consequences.

TABLE OF CONTENT

Contents Title Page Approval Sheet Acknowledgement Abstract Table of content List of Table List of Figure Abbreviation CHAPTER I: INTRODUCTION Background of the study Statement of the problem Rational of the study Research Question Significance of the study Objectives of the study Variables of the study Operational Definition Delimitation of the study CHAPTER II: LITERATURE REVIEW 2.1 Literature review related on age for commencing screening 2.2 Literature review related on when to discontinue scorning 2.3 Literature review related on incidence 2.4 Literature review related to knowledge 2.5 Summary of the literature CHAPTER III: RESEARCH METHODOLOGY 3.1 Research Design 3.2 The study area 3.3 Population of the study 3.4 Sample size 3.5 Sampling technique 3.6 Data collection instrument 3.7 Validity and reliability of the instrument 3.8 pretesting of the instrument 3.9 Data collection procedure 3.10 Data analysis and processing 3.11 Ethical consideration 3.12 Budgeting 3.13 Work plan CHAPTER IV: ANALYSIS AND INTERPRETATION 4.1 Bio-demographic data of study 4.2 Information regarding cervical cancer prevention and screening CHAPTER V: DISCUSSION, CONCLUSION AND RECOMMENDATION 5.1 Summary of findings 5.2 Discussion of findings with Related Literature review 5.3 Conclusion 5.4 Implication of study

5.5 Recommendation 5.6 Strength of the study 5.7 Limitation of the study 5.8 Difficulties faced during study 5.9 Learning from this study 5.10 Plan for disseSrijanation Bibliography Appendix Annex I: Work Plan Annex II: Consent form Annex III: English questionnaire Annex IV: Nepali questionnaire Annex V: Official letter LIST OF TABLE Tables Table 1: Age distribution of respondents Table 2: Ethnicity of respondents Table 3: Education status of respondents Table 4: Economies status of respondents Table 5: Age at marriage of respondents Table 6: Age at first child birth Table 7: Frequency of pregnancy of respondents Table 8: Having cancer of family member Table 9: Meaning of cervical cancer Table 10: Respondent's response on predisposing factors of cervical cancer Table 11: Knowledge regarding need screening Table 12: Knowledge regarding starting of cervical screening Table 13: Factors affecting screening Table 14: Knowledge on preparation needed before screening LIST OF FIGURES Figures Figure 1: Family income of respondents Figure 2: Smoking habit of respondents Figure 3: Having cancer of family member Figure 4: Respondents heard about cervical cancer Figure 5: Knowledge on early detection of cervical cancer Figure 6: Knowledge regarding method of cervical cancer detection Figure 7: Heard about cervical cancer screening Figure 8: Knowledge on sources of information of cervical cancer Figure 9: Knowledge on prevention of cervical cancer Figure 10: Practice of cervical screening Figure 11: Knowledge of place where cervical screening facility available Figure 12: Knowledge on need of preparation before screening ABBREVIATION ACCP-Alliance for Cervical Cancer Prevention. BPKMCH- B.P Koirala Memorial Cancer Hospital. CIN-Cervical Intraepithelial Neoplasia. HIV-Human Immune deficiency Virus. HPV-Human papiloma Virus. ICC-Invasive Cervical Cancer. n = Sample Size. OPD-Out Patient Department.

PAHO-Pan American Health Organization SIL-Squamous Intraepithelial Lesion STI-Sexual Transmitted Infection. VIA-Visual Inspection with Acetic acid WHO-World Health Organization FDA-Food and Drugs Administration LSIL-Low-grade Squamous Intraepithelial Lesion HSIL-High-grade Squamous Intraepithelial Lesion UK-United Kingdom

CHAPTER I INTRODUCTION Background of the study Most of the people of Nepal live a hard life of subsistence in agriculture. The population of Nepal is 26427399 and 13187166 is female population. About 84.26 percent of population in Nepal is the residents in rural areas. The literacy rate of total population is 54.1 percent. Among them women literacy rate is 42.8 percent and life expectancy is 64.2 years. About 60 percent of women (15-19years) had involved sexual intercourse. (Nepal in figure 2007) The disease result from the abnormal growth and division of cells at the cervix is developed from epithelial dysphasia and for carcinoma in situ (CIN III). Some of yearly lesions developed in to the invasive cervical cancer. The risk for cervical cancer is increased for women who have had their first sexual intercourse at early age, multiple sex partners and a high number of pregnancies, recurrent vaginal infection, or sexually transmitted disease including genital herpes, genital warts and HIV, use of hormonal contraceptive, use of tobacco. Infection with human papiloma virus (HPV) is cancer in early stage; cervical cancer produces unexplained vaginal bleeding pain and bleeding after intercourse, or persistent vaginal discharge.

Cervical cancer is the second most common malignancy in women worldwide and it remains or leading cause of cancer related death for women in developing countries. In the United States, it is the fourth most common malignant neoplasm in women, after carcinoma of the breast, colorectal and endometrial. The highest number of cases reported in Asia. In India, an estimated 1320 new cases of more than of the world wide total are reported annually. (ferlayet et al 2002) Worldwide, more than 500,000 women are diagnosed with cervical cancer each year. In 2005, in the United States alone, there were an estimated 10,370 new cervical cancers diagnosed and 3,710 cervical cancer deaths.2 Annually, an additional 1,250,000 American women are diagnosed with precancers by cytology using the Papanicolaou (Pap) smear. These precancers include a continuum of pathologic changes ranging from atypical squamous cells of undetermined significance to low-grade squamous intraepithelial lesions (LSIL) to highgrade squamous intraepithelial lesions (HSIL) to invasive cancer. The precancerous conditions LSIL and HSIL are also referred to as cervical intraepithelial neoplasia (CIN) 1, 2, and 3. Lesions can regress, persist, or progress to an invasive malignancy, with LSIL (CIN 1) more likely to regress spontaneously and HSIL (CIN 2/CIN 3) more likely to persist or progress. The average time for progression of CIN 3 to invasive cancer has been estimated to be 10 to 15 years. Nearly all cases of cervical cancer are associated with human papilloma virus (HPV) infection, which is transmitted during sexual activity.4-6 Although most women with cervical cancer have the human papillomavirus (HPV) infection, not all women with an HPV infection will develop cervical cancer. Many different types of HPV can affect the cervix and only some of them cause abnormal cells that may become cancer. While some HPV infections go away without treatment, the presence of HPV indicates increased vulnerability to cervical cancer and the need for adherence to a regular schedule of screenings. Thus, women that do not have regular Pap and HPV tests are at increased risk of cervical cancer. (American Cancer Society, 2005) According to WHO, cancer is three times more common in developing countries like Nepal the true figures of cancer morbidity and mortality are not available in Nepal due to lack of cancer survey, resisters of adequate medical records. Only WHO estimates that there are about 3500 to 40000 cancer patients diagnosed each year in Nepal. [Journal of Nepal nursing council] Approximately 1.4 million women worldwide are living with cervical cancer. This estimate reflects the accumulation of new cases each year and few women in developing countries receive treatment based on knowledge about how the cancer develops. Up to 7 millions worldwide may have precancerous condition that need to be identified and treated. Lack of effective screening and treatment strategies is a major reason of higher cervical cancer rates in developing countries. Barriers for prevention and screenings may include a lack of awareness of cervical cancer and ways to prevent the diseases and difficulty to get health services because of Topography geographical background of Nepal and high cost associated to screening. . Despites the barriers, cervical cancer can be prevented by low cost. Health care provides can use relatively simple technologies to screen women from precancerous condition and treat abnormal tissue only. The pathway to preventing death from cervical cancer is simple and effective. Precancerous changes in cervical tissue can tinger for years, if they are identified and successfully treated for precancerous changes and treating the abnormal tissue seems to protect women from developing cervical cancer. (American Cancer Society 26 March 2008)www.who.int/hinarypubmet)

1.2 Statement of the Problem Knowledge regarding prevention of cervical cancer among married women attending in gynae OPD in Lumbini Zonal Hospital. 1.3 Rational of the study Cervical cancer is preventable problem. It kills an estimated 274000 women every year. It affects the poorest and most vulnerable women. Lack of effective screening and treatment strategies is the major reason for the sharply higher cervical cancer rates in developing countries. The true figure of cancer morbidity

and mortality are not available in Nepal due to lack of cancer survey, register and adequate medical records. The majority of cervical cancer patients are undiagnosed or diagnosed only in advanced stage due to illiteracy, poverty, physical topography, lack of awareness of cervical cancer and ways to prevent the disease, difficult getting to clinics and hospitals and cost associate with screening. Usually Nepalese women hide their gynecological problems due to shyness and lack of knowledge. So cervical cancer, has diagnosed in advance and incurable stage. Screening is to reduce incidence of/or death from cancer by detecting early preclinical disease when treatment may be easier and more effective than for advances cancer diagnosed after the symptoms occur. This situation encourages me to explore the knowledge of cervical cancer screening and prevention among married women (age 20-70 years). Therefore this topic was selected for the research studies. 1.4 Research Question What type of knowledge present on prevention and screening of cervical cancer? 1.5 Significances of the study This study had help to explore knowledge about cervical cancer screening and prevention This study was provide base line information for future study and will help to make strategies for improving knowledge about cervical cancer screening and prevention for health care planner and health care provider. 1.6 Objectives A. General objectives The main objective of this study is to find out the knowledge about prevention and screening of cervical cancer among married women. B. Specific objectives To explore the knowledge about prevention of cervical caner To identified knowledge of cervical cancer screening To i1.7 Variables A. Independents variables Sources of information Age Education B. Dependent Variables Knowledge on prevention of cervical cancer 1.8 Operational Definition Screening:- It refers to exaSrijanation of asymptomatic people in order to classify them as likely or unlikely to have disease. It is preventive measure to identify pre- cancerous lesion of the cervices. Pap smear- It is diagnostic procedure where doctor or experienced nurses removing cell from the cervices by brushing it with a special instrument of spatula.

Cervical caner-It is a fatal disease there is abnormal growth of cell in the cervices. Literate-Respondent who can read and write through formal education up to bachelor. Illiterate-Respondent who cannot read and write. Awareness-Conscious having knowledge or well informed about cervical cancer and its screening. Early detection-It means detecting cancer at a stage when it is still curable. 1.9 Delimitation of the Study Area - this study was conducted in Lumbini zonal hospital in gynae OPD. Time - 2065-03-24 to 2065-05-06. Period - 7 weeks Respondents - literate and illiterate any type of married women Sample size - up to 50 samples

CHAPTER II LITERATURE REVIEW 2.1 Literature review related on age for commencing screening James a tickinsen (June 2002). The recommended age for starting screening and American college of obstetricians and gynecologist recommend screening all women from age 18, even if they have that commend cervical activity a recommendation that must survey , be ignored by most doctors . UK guide line group recommended screening should start at the latest before the age of 30 years and definitely not before 20 years. Saslow, et al. (2002). Cervical cancer screening should begin approximately 3 years after the onset up vaginal intercourse. Screening should begin no later than 20 years of age. It is critical that adolescent who may not need a cervical cytology test obtain appropriate preventive health care, including assessment of health risks, contraception and prevention counseling, screenings and treatment of sexually transmitted disease. The need for cervical cancer screening should not be the basis for the onset of gynecologic care. 2.2 Literature reviews related on when to discontinue screening Saslow, et. al. (2002). Women who are age the age 70 and older with intact cervix and who have had 3 or more documented, consecutive technically satisfactory normal / negative cervical cytology test and no abnormal test with 10 years period prior age 70 may elect to cease cervical cancer screening. 2.3 Literature review related on incidence Joronimo, et. al. (Jan 2005).The screening method known as visual inspection with acetic acid or VIA has been recommended for use in low recourse setting but could help save

women's life if it is were more aggressively promoted as an alternative or supplement to the papanicolau smear, or pap smear according to the study. Cervical cancer is the second most common form of cancer in women after breast cancer. It is caused by a sexual transmitted virus, human papiloma virus, which cause lesion on the cervical that, if left untreated, can develop into cancer. Because of wide spread screening with pap smear, cervical cancer incidence and mortality rate have declined steeply in north America, to below 10 per 100000 women in Canada and united states. However, rates in most Latin American and Caribbean countries remain above 20 per10000. Population Reference Bureau, PATH (Accessed February 28, 2006, at http://www.path.org/files/RH_prp-accp_cervical_cancer_worldw.pdf.) The Pap smear has transformed cervical cancer from a leading killer to a rare disease in the United States. But few countries have the resources and infrastructure necessary to run organizedscreening programs, so the poorest regions of the world bear the brunt of this disease. Most women in low-income countries do not have access to routine screening: only 5 When screening is available to women of all ages, it has a major impact. In the United States, rates of cervical cancer have fallen by 75 percent since the Pap smear's introduction more than 40 years ago. Prevention efforts targeting only young women have had limited success, however, since cervical cancer predoSrijanantly affects older women. In Mexico, a nationwide screening initiative failed to reduce mortality rates, in part because young women in urban areas were screened repeatedly, whereas many older women had no access to testing.2 One study suggested that the lifetime risk of cervical cancer is reduced by 25 to 35 percent if women over 35 undergo a single screening by means of either visual inspection with acetic acid or HPV testing and precancerous lesions are treated. In many regions, however, gynecologic exaSrijanations remain deeply stigmatized. In South Africa, for example, pelvic exams are often referred to as "surrendering oneself." The introduction of the HPV vaccine may assist prevention campaigns by reducing the spread of high-risk strains of the virus (HPV types 16 and 18). Although there appears to be regional heterogeneity in the prevalence of high-risk types, many still hope that the HPV vaccine will revolutionize cervical-cancer prevention programs.3 Unfortunately, the women who are most in need may have the hardest time getting vaccinated, since the vaccine, at an estimated $300 to $500 per course, may be too expensive for many developing countries. In addition to cost, there is the worry that the vaccine could have a negative effect on screening offering false security to vaccinated women, who may incorrectly believe that they no longer need to undergo Pap smears. Although future prevention efforts may focus on optimizing the HPV vaccine or developing targeted molecular tests to prevent the spread of the virus, most experts believe that these advances will not make screening tools obsolete, since millions of women have already been exposed to HPV. Instead, they argue, it will be crucial to make simplified screening and widespread vaccination the new standard of care.

FDA News (June, 2006). Stated that HPV is the most common sexually-transmitted infection in the United States. The Centers for Disease Control and Prevention estimates that about 6.2 million Americans become infected with genital HPV each year and that over half of all sexually active men and women become infected at some time in their lives. On average, there are 9,710 new cases of cervical cancer and 3,700 deaths attributed to it in the United States each year. Worldwide, cervical cancer is the second most common cancer in women; and is estimated to cause over 470,000 new cases and 233,000 deaths each year. Four studies, one in the United States and three multinational, were conducted in 21,000 women to show how well Gardasil worked in women between the ages of 16 and 26 by giving them either the vaccine or placebo. The results showed that in women who had not already been infected, Gardasil was nearly 100 percent effective in preventing precancerous cervical lesions, precancerous vaginal and vulvar lesions, and genital warts caused by infection with the HPV types against which the vaccine is directed. While the study period was not long enough for cervical cancer to develop, the prevention of these cervical precancerous lesions is believed highly likely to result in the prevention of those cancers. Since the most common form of cervical cancer starts with pre-cancerous changes, there are 2 ways to stop this disease from developing. The first way is to prevent the precancers, and the second is to find and treat pre-cancers before they become cancerous. American Cancer society (March 26,2008). Stated that things to do to prevent pre-cancers are following: Avoid being exposed to HPV: You can prevent most pre-cancers of the cervix by avoiding exposure to HPV. Certain types of sexual behavior increase a woman's risk of getting HPV infection, such as: having sex at an early age having many sexual partners having a partner who has had many sex partners having sex with uncircumcised males Delay sex: Waiting to have sex until you are older can help you avoid HPV. It also helps to limit your number of sexual partners and to avoid having sex with someone who has had many other sexual partners. Remember that someone can have HPV for years yet have no symptoms - it does not always cause warts or any other symptoms. Someone can have the virus and pass it on without knowing it. Use condoms: Condoms provide some protection against HPV. One study found that when condoms are used correctly they can lower the HPV infection rate by about 70%25 if they are used every time sex occurs. Condoms cannot protect completely 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 they also protect against HIV and some other sexually transmitted diseases. Don't smoke: Not smoking is another important way to reduce the risk of cervical precance and cancer. The American Cancer Society recommends the following guidelines for early detection:

All women should begin cervical cancer testing (screening) about 3 years after they start having sex (vaginal intercourse). A woman who waits until she is over 18 to have sex should start screening no later than age 21. A regular Pap test should be done every year. If the newer liquid-based Pap test is used, testing can be done every 2 years. Beginning at age 30, women who have had 3 normal Pap test results in a row may be tested less often- every 2 to 3 years. Either the conventional (regular) Pap test or the liquid-based Pap test can be used. Some women should continue getting tested yearly - such as women exposed to DES before birth and those with a weakened immune system (from HIV infection, organ transplant, chemotherapy, or chronic steroid use). Another reasonable option for women over 30 is to get tested every 3 years (but not more frequently) with either the regular Pap test or liquid-based Pap test, plus the HPV DNA test (see below for more information on this test). Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having cervical cancer testing. Women with a history of cervical cancer, DES exposure before birth, HIV infection, or a weakened immune system should continue to have testing as long as they are in good health. Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having cervical cancer testing, unless the surgery was done as a treatment for cervical cancer or precancer. . Women who have had a hysterectomy without removal of the cervix (simple hysterectomy) need to continue cervical cancer screening, and should continue to follow the guidelines above. Some women believe that they can stop having Pap tests once they have stopped having children. This is not correct. They should continue to follow American Cancer Society guidelines. Although the Pap test has been more successful than any other screening test in preventing a cancer, it is not perfect. One of the limitations of the Pap test is that it needs to be examined by humans, so an accurate analysis of the hundreds of thousands of cells in each sample is not always possible. Engineers, scientists, and doctors are working together to improve this test. Because some abnormalities may be missed (even when samples are examined in the best laboratories), it is not a good idea to have this test less often than American Cancer Society guidelines recommend. Making your Pap tests more accurate You can do several things to make your Pap test as accurate as possible: Try not to schedule an appointment for a time during your menstrual period. Do not douche for 48 hours before the test. Do not have sexual intercourse for 48 hours before the test. Do not use tampons, birth control foams, jellies, or other vaginal creams or vaginal medicines for 48 hours before the test.

January 27,2005 (PAHO). Cervical cancer kills women annually than child birth it is estimated that it could affect as many as 7,50,000 women by 2020 and many as 1 million new cases by 2050 currently , about 2,30,000 women die annually of cervical cancer and nearly 80 percent of these cases occur in under develop and poverty stricken countries. Wider user of simpler cervical cancer screening could benefit women in developing countries, and easy in expensive method using ordinary vinegar in screening women for cervical cancer could be applied in more situations in developing countries around the world, thus increasing the number of women whose disease is caught early and treated. Cervical cancer statistic (March 4, 2005) Statistics about cervical cancer from the American society are; Approximately 10,370 women are diagnosed with cervical cancer. Cervical cancer may develop in women who have been infected with human papiloma virus (HPV), a sexually transmitted virus. Over the past 20 years or so, death rates from cervical cancer have steadily declined. This is due to prevention and detection by screening. Cervical cancer usually affect women between 30 and 55 years of age For pre-cancerous lesion in the cervix, many women are cured without the need for hysterectomy. Women with invasive cervical cancer are usually curable with surgery of radiation treatment or combination of the two. Parking D M et.al (2003).Stated that cervical cancer is the second most common cancer among women world wide with an estimated 4,68,000 new cases and 2,33,000 death in the year2000.Almost 80%25 of cases occur in developing countries, where in many regions the principal risk factors are like as demographical variables, social status, occupation, marital status, religion and ethnicity. Dr. Shrestha Binuma and Dahal Kabita(2059-7-26) Patheghar ko much ko cancer ra upachar Kantipur daily publication, stated that total 4680 patients registered in gyane OPD in BPKMCH Bhratpur, among them 805 patients suffered from cancer related to female reproductive organ and also among them 593 cases were cervical cancer.(2002 Janauary-2002 August). Pradhan,M. (2001).Described the gynecological malignancy in BPKMCH Bharatpur. A retrospective analysis of 321 cases from July 1999 June 2001 ( duration of 19 month) total 321 cases of gynecological malignancy were diagnosed, out of which 272(84.73%25) cases of cervical cancer were detected. This study indicates cervical cancer is an emergency as a major health problem of women in Nepal. Fylan, (1999. Conducted a study that revealed that reasons for nonparticipation included administrative failure, unavailability if female screener, inconvenient clinic time, lack awareness of the test indication and benefits, considering oneself not a ask of developing cancer and fear, embarrassment, pain are the factors, which influenced cervical cancer screening practices. 2.4 Literature reviews related to knowledge

Ajaya, IO Adewole if (1998). Conducted a study among 254 women in Nigeria, which related that only 15 percent had heard of cervical cancer. The media (38 percent) and peers (36 percent) were the major sources of information on cancer. Jubelirer ss et. al. Conducted a study, which shows that 84 percent of total respondents had heard of cervical cancer and 33 percent had heard of Pap smear among 279 tenth grade girls. American society for cancer pathology, pap revealed that 70 percent cervical cancer could be decreased through primary Pap smear test. Dr. Vaidya Achala (1999).Stated that Pap smear in high risk women reported that risk has closely related to sexual habit. Early sexual experience at multiple partners, smoking women and grand multi-Para women are related to high risk of cervical cancer. YU,CK, Rymerj (1998). Conducted across sectional survey consisting of a questionnaire of 560 randomly selected women aged 15 to 78 years were performed to gain and insight into women's attitudes to and awareness of smear testing and cervical cancer. Overall, women appeared to be well informed of the link between the number of sexual partners and cervical cancer as well as recognizing smoking to be contributing factors. A substantial proportion (99.7 percent) of women was of the attitude that cancer can be treated if detected early enough. The perceived barrier such as embarrassment that discomfort played a part in women's decision in returning for a regular smear. Vantil et. al. (2000). Stated that 90 percent of cervical cancer can be prevented by regular pap screening, many women are not screened regularly, particularly older women. 2.5 Summary of the literature Cervical cancer kills more women annually than child birth, and it is estimated that it could affect as many as 7, 50,000 women by 2020 and as many as 1 million new case by 2050. Currently about 2, 30,000 women die annually of cervical cancer and nearly 80 percent of these cases occur in under develop and poverty stricken countries. The recommended age for starting screening should begin approximately 3 years after the onset of vaginal intercourse. Screening no later 21 years of age (saslow,et.al.2002). Women who are aged 70 and older with and intact cervix and who have had 3 or more documented , consecutive , technically satisfactory normal/negative cervical cytology test and no abnormal / positive cytology test within 10 years period to age 70 may elect to cease cervical cancer screening. Cervical cancer is the second most common form of cancer in women after breast. It is caused by sexually transmitted virus, human papiloma virus which cause lesion on the cervical that if left untreated can develop into cancer. Population based cytological screening and early treatment reduces morbidity and mortality associated with cervical cancer. Lack of knowledge is found to be on the main reasons for not having had a screening. reason for non participation include administrative failures, unavailability of female screener, inconvenient clinic times, lack of awareness of the test indication and benefits , considering onset not a risk of developing cancer and fear of embracement , pain or detection of cancer are the factors , which is influenced cervical cancer screening CHAPTER III

RESEARCH METHODOLOGY 3.1 Research design:The design of the study was descriptive type. 3.2 The study area:The study was conducted in Lumbini Zonal Hospital, Gynae OPD. 3.3 Study population:The population was studied only in women who are married and interested. 3.4 Sample Size:The sample size was 50 respondents 3.5 Sample Technique Non probability purposive sampling technique was adopted in this study 3.6 Data Collection Instruments: Structured and semi-structured question were prepare for this study. According to the objective of the study the questionnaire consists of: Demographic data Question for assessing knowledge about cervical cancer Question for assessing knowledge about cervical screening 3.7 Validity and reliability of instruments: Related literature was reviewed to maintain validity and reliability of the tool. The validity and reliability of instrument was assured by consulting research guide, related teacher and related personal in the campus Validity and reliability was checked by pretesting 10 %25 of the total population 3.8 Pretesting of the Instrument:Pretesting was done on 10%25 of the total population Necessary modification was made according to the result of pretest 3.9 Data collection procedure: Formal questions were made for permission from concern authority. Informed permission was taken from each respondent Data was collected by Interview Method by investigator herself. The investigator was made every possible attempt to reduce bias in the data collection. (Interview was taken after clear instruction and explanation) 3.10 Data analysis/ processing: Collected data was checked by for its completeness All the data was rechecked after finishing the interview and questioning. All the data was kept in order for editing and coding Data processing was done manually and by using computer Data was analyzed by using different statistical techniques Interpretation of data had done on the basis of verified data. The data was presented on the relevant table and graph. 3.11 Ethical Consideration: Study was conducted after the approval of research guide. The permission was obtained by related authority of Lumbini Zonal Hospital.

The subject was explained verbally about the research study by using the informed consent. Nobody had forced for participation and confidentiality and anonymity was maintained. Insure that the respondent's confusion was explained. .12. Budget:Budget was self financed 3.13 Work Plan:The research was completed within 7 weeks. CHAPTER IV ANALYSIS AND INTERPRETATION This chapter deals with the analysis and interpretation of the data concerning the knowledge of cervical cancer screening of married women. Data are analyzed and interpreted according to the objectives and the nature of the research questionnaire. The data were collected from 50 married women at Lumbini Zonal Hospital. The study is presented mainly in two-section. 4.1 Bio-demographic data of Study Population. Table 1: Age Distribution of the Respondents. Age of respondent Number n=50 percentage 1 20-29 2 30-39 3 40-49 4 50-59 5 60 and above Total 11 12 18 9 50 22 24 26 18 100

The above table shows the majority of respondents 18(36 %25) were 40-49 years where as least of the respondents 9(18%25) were 50-59 years. Table 2: Ethnicity of the Respondents The above table shows that majority of the respondents 22(44%25) were others cast,15(30%25) were Brahmin, 10(20%25) were Chhetri and 3(6%25) were Newar. S No Ethnicity Number n=50 percentage 1 2 3 4 Total Brahmin 15 Chhetri 10 Newar Others 3 22 50 30 20 6 44 100 Number n=50 percentage

Table 3: Educational Status of Respondents S No Education

1 2 3 4 5 Total

Illiterate Literate primary secondary

17 17 0 8 50

34 34 0 16 16 100

Higher(SLC or above 8

The above table shows that 17(34%25) were illiterate respondents, 17(34%25) were literate respondents, 8(16%25) were secondary class respondents and 8(16%25) were higher class educated respondents. Table 4: Economic Status n=50 S No Occupation Husband percentage wife percentage 1 2 3 4 5 Total Business service Labors Housewife 13 16 3 26 32 6 36 4 3 0 21 22 50 8 6 0 42 44 100

Agriculture 18

The above table shows that 22(44%25) respondents were housewife, 21(42%25) respondents were Agriculture, 4(8%25) respondents were business and 3(6%25) respondents were service holders.

The above figure shows that 30(60%25) respondents had sufficient family income and 20(40%25) respondents had insufficient family income for health screening. Table 5: Age at Marriage

S No Age at marriage Number n=50 percentage 1 2 3 Total 15-19 20-30 31 & above 37 13 0 50 74 26 0 100

The above table shows that 37(74%25) of respondents had married at the age of 15-19 years and 13(26%25) of respondents had married at the of 20-30 years. Table 6 :Age at first Child birth S No Age 1 2 3 4 Total 15-19 20-30 No child Number n=50 percentage 25 23 2 50 50 46 0 4 100

30 & above 0

The above table shows that 25(50%25) of respondents gave birth to the first child at the age of 15-19 years, 23(46%25) at 20-30 years and 2(4%25) of respondents did not have a child. Table 7: Frequency of Pregnancy S No pregnancy 1 2 3 4 Total 1-2 times 3-4 times >4 times Number n=50 percentage 13 13 22 50 26 26 44 4 100

Never pregnant 2

The above table shows that 13(26%25) respondents became 1-2 pregnant, 13(26%25) 3-4 times, 22(44%25) more than 4 times and 2(4%25) had never got pregnant.

The above figure shows that majority 42(84%25) of respondents did not have smoking habit, only 8(16%25) used to smoke.

The above figure shows that 46(92%25) of respondent had no family history of cancer and 4(8%25) had history of cancer. Table 8: If yes, having cancer of Family Member S No Family member Number n=4 percentage 1 2 3 4 Total Grand mother Grand father Mother Father 0 0 4 0 4 0 0 8 0 8

The above table shows that respondent's mother only had history of cancer.

4.2 Information regarding cervical cancer prevention and screening

The above figure shows that almost all respondents 45(90%25) had heard cervical cancer only 5(10%25) of them had not heard about it. Table 9 If yes, meaning of cervical cancer S No Meaning of cervical cancer 1 2 3 4 Total Cervical wound Number n=45 percentage 23 51.11 28.88 11.11 8.88 100

Abnormal cell growth of cervix 13 Bleeding due to cervical wound 5 Don't know 4 45

The above table indicate that 23(51.11%25) respondents had answered that cervical cancer means cervical wound, 13(28.88%25) had answered abnormal cell growth of cervix, 5(11.11%25) had answered bleeding due to cervical wound and 4(8.88%25) had not known the actual meaning of cervical cancer. Table 10 Respondent's response on predisposing factors of cervical cancer S No Predisposing factors of cervical cancer Number n=45 percentage 1 2 3 4 5 6 Total Lack of personal hygiene more than 4 pregnancy multiple sexual partner suffered form STI(HIV/HPV) Smoking Early sexual exposure 5 2 14 22 2 0 45 11.11111 4.444444 31.11111 48.88889 4.444444 0 100

The above table shows that 22(48.88%25) of respondents answered suffered from STI(HIV/HPV),14(31.11%25) answered multiple sexual partner,5(11.11%25) answered lack of personal hygiene, 2(4.44%25) answered more than 4 pregnancy and 2(4.44%25) answered smoking.

The above figure indicate that mostly 35(78%25) respondents had answered cervical can be detected early, and 10(22%25) answered it cannot be detected early.

The above shows that 45(100%25) respondents answered that cervical cancer can be detected by early cervical screening.

The above figure shows that 35(78%25) respondents had heard about cervical cancer screening but 10(22%25) had not heard about it.

The above figure shows that majority 30(67%25) had information from relatives/ friends and 15(33%25) from media.

The above s figure shows that 35(77.77%25) respondents felt necessary to prevent, 5(11.11%25) felt can't prevent so not necessary, 5(11.11%25) don't know about prevention. Table 11: Knowledge regarding need of screening S No Need of Screening 1 2 3 4 5 Total Women with STD All married women Grand multi-Para Smoking Number n=45 percentage 44.44 22.22 15.55 8.88 8.88 100 10 7 4 4 45 Women with prostitution 20

The above table shows most of the 20(44.44%25) respondents answered women who are in prostitution need cervical screening,10(22.22%25) answered women with STD(HIV/HPV),7(15.55%25) answered all married women,4(8.88%25) answered grand multipara and 4(8.88%25) answered smoking women. Table 12: Knowledge regarding starting of cervical screening S No Starting cervical screening Number n=45 percentage 1 2 3 4 Immediately after marriage 20 After 3years of marriage After first child birth Total 4 16 45 44.44 8.88 35.55 11.11 100

After 10 years of marriage 5

The above table shows that most of the 20(44.44%25) respondents answered that starting of cervical cancer screening was immediately after marriage,16(35.55%25) answered after 3 years of marriage and 5(11.11%25) answered after 10 years of marriage.

The above figure shows that minority of respondents 16(32%25) had been done cervical screening and majority 34(68%25) respondents had not doing screening. Table 13: Factors affecting screening S No Not doing screening 1 2 3 4 5 Total Fear of exaSrijanation Economic problems Don't have problems Don't feel necessary Number n=34 percentage 0 2 20 10 34 0 5.88 58.82 29.41 5.82 100

Don't have screening facility nearly 2

The above table shows that 20(58.82%25) respondents answered that they were not doing screening because of don't have problem 10(29.41%25) answered don't feel necessary, 2(5.82%25) answered economic problem and 2(5.82%25) answered don't have screening facility nearly.

The above figure shows that 40(80%25) respondents answered that Zonal Hospital, 8(16%25) answered Cancer Hospital and 2(4%25) answered District Hospital.

The above figure shows that most of the 46 (92%25) respondents had no knowledge about cervical screening preparation and only 4 (8%25) had knowledge about cervical screening preparation. Table 14: Knowledge on preparation needed before screening S Knowledge on preparation No 1 Number n=4 percentage 8

Don't take an appointment for a time during your menstrual 4 period

2 3 4 5

Don't have sexual intercourse for 48 hours before the test Don't douche for 48 hours before the test

0 0

0 0 0 0 8

Do not use vaginal foams ,jellies, or other medicine for 48 0 hours before the test Others 0 4

Total

The above table shows that among4 (8%25) respondents who had knowledge about cervical Cancer screening preparation, they had knowledge about only don't take an appointment during menstrual period. CHAPTER V DISCUSSION, CONCLUSION AND RECOMMENDATION 5.1 Summary of findings The major findings of the study are following a. Bio demographic Characteristics o Most of the18 (36%25) respondents were at the age of 40-49 years. o Most of the respondents 22(44%25) were others and only 3(6%25) were Newar. o Equal 25(50%25) respondents were literate and25(50%25) were illiterate o Majority of the 22(44%25) respondents were engaged in%25 housewife, 21(42%25) were engaged in agriculture, 4(8%25) were engaged in business and only 3(6%25) were in labor. o Majority of the 30(60%25) respondents family income had sufficient for health maintain screening and 20(40%25) had insufficient family income. o Majority 37(74%25) of respondents were married at the aged of 15-19 years and only 13(26%25) were married at the aged of 20-30 years. o Most of the 25(50%25) respondent gave birth to first child at the aged of 15-19 years, 23(46%25) at 20-30 years and only 2(4%25) respondents did not have child. o Majority 22(44%25) of the respondents became pregnant more than 4 times and 2(4%25) were not pregnant. o Majority 42(84%25) of respondents did not have smoking habit, only 8(16%25) used to smoke. o Most of the 46(92%25) of respondents had no family history of cancer and 4(8%25) respondent's mother had history of cancer. b. Knowledge regarding prevention of cervical cancer o Most of the respondents 45(90%25) had heard about cervical cancer only 5(10%25) of them had not heard. o Most of the23 (51.11%25) respondents had answered that cervical cancer means cervical wound,13(28.88%25) had answered abnormal cell growth of

cervix,5(11.11%25) had answered bleeding due to cervical wound and 4(4.88%25) had not known the actual meaning of cervical cancer. Most of the 22(48.88%25) of respondents answered suffered from STI(HIV/HPV),14(31.11%25) answered multiple sexual partner,5(11.11%25) answered lack of personal hygiene, 2(4.44%25) answered more than 4 pregnancy and 2(4.44%25) answered smoking. Most of the 35(77.77%25) respondents had answered cervical can be detected early, 10(22.22%25) answered it cannot be detected early. Most of the 35(77.77%25) respondents had answered cervical can be detected early,10(22.22%25) answered it cannot be detected early. Majority 45(100%25) respondents answered that cervical cancer can be detected by early cervical screening Most of the 35(78%25) respondents had heard about cervical cancer screening but 10(22%25) had not heard about it. Most of the 30(67%25) respondents had received information from relatives/ friends and 15(33%25) received from mass media. Majority 35(77.77%25) respondents felt necessary to prevent, 5(11.11%25) felt can't prevent so not necessary, 5(11.11%25) don't know about prevention. Most of the 20(44.44%25) respondents answered women who are in prostitution need cervical screening,10(22.22%25) answered women with STD(HIV/HPV),7(15.55%25) answered all married women,4(8.88%25) answered grand multipara and 4(8.88%25) answered smoking women Most of the 20(44.44%25) respondents answered that starting of cervical cancer screening was immediately after marriage,16(35.55%25) answered after 3 years of marriage and 5(11.11%25) answered after 10 years of marriage. Minority of respondents 16(32%25) had been done cervical screening; majority 34(68%25) respondents had not doing screening Most of the 20(58.82%25) respondents answered that they were not doing screening because of don't have problem, 10(29.41%25) answered don't feel necessary, 2(5.82%25) answered economic problem and 2(5.82%25) answered don't have screening facility nearly. Majority (80%25) respondents answered that cervical cancer screening facility provided in Zonal Hospital, 8(16%25) answered Cancer Hospital and 2(4%25) answered District Hospital. Most of the 46 (92%25) respondents had no knowledge about cervical screening preparation and only 4(8%25) had knowledge about cervical screening preparation. Among 4(8%25) respondents who had knowledge about cervical cancer screening preparation, answered that can not perform cervical screening during menstrual period.

5.2 Discussion of Findings with Related Literature Review

The findings shows that 90%25 of the total respondents had heard of cervical cancer and 78%25 respondents had heard of cervical screening, the literature support this finding: jubelier et.al. Conducted a study, which shows that 84%25 of total population had heard of cervical cancer and 83%25 had heard of Pap smear among 279tenth grade girls. The finding shows that majority of respondents (77.77%25) had answered cervical cancer can be early detected. The literature supports this finding: Yuck, Rymer j stated that 91.7%25 be lived cervical cancer could be treated if early detected. The finding shows that Highest 30(67%25) had information from relatives/ friends and 15(33%25) from media. The literature support this finding: Ajya IO, Adewole conducted a study in Nigeria, which reveled that only 15%25 had heard of cervical cancer. The 38%25 and the peers 36%25 were the major sources of information on cancer. The findings shows that most of the 20(44.44%25) respondents answered women who are in prostitution need cervical screening,10(22.22%25) answered women with STD(HIV/HPV),7(15.55%25) answered all married women,4(8.88%25) answered grand multipara and 4(8.88%25) answered smoking women. The literature supports this findings: Vaidya Achala stated that high- risk women are closely related to sexual habit, multiple sexual partner, smoking women and grand multipara women. Yuck, Rymer J conducted a cross sectional survey, which revealed that 76.2%25 perceived cervical cancer to be a common disease and there was a good awareness of the association between this, concerned both smoking and the number of sexual partners. The findings show that 35(77.77%25) respondents felt necessary to prevent cervical cancer. The literature supports this finding: Van til I, et. al. revealed that 90%25 of cervical cancer can be prevented by regular Pap smear. The findings shows that 20(58.82%25) respondents answered that they were not doing screening because of don't have problem, 10(29.41%25) answered don't feel necessary, 2(5.82%25) answered economic problem and 2(5.82%25) answered don't have screening facility nearly. The literature supports this findings: Fylan F conducted a study revealed that reasons for nonparticipation included administrative failures, unavailability of female screener, lack of awareness of the test indication and benefits, considering oneself not a risk of developing cancer and fear of embarrassment and pain are the factors which influenced cervical cancer screening practices. 5.3 Conclusion This study was conducted to identify the knowledge about prevention of cervical cancer among 50 married women in Lumbini Zonal Hospital, Butwal, in which non-probability purposive sampling technique was used. Data was collected through interview method using semi-structured and structured question. Validity and reliability was maintained by taking suggestion from export and concerned teacher by preliSrijanary testing on pilot study. In the same way, data was interpreted through tables, charts and diagrams. In the whole study, ethical consideration was under taken Existing knowledge was assessed according to the findings of the study. The findings revealed that most of the respondents 45(90%25) had heard about cervical cancer. Almost

all respondents had given accurate meaning of cervical cancer, who has heard about cervical cancer. 35(77.77%25) of the respondents answered cervical cancer could be detected early.45 (100%25) respondents answered cervical cancer could be detected by early cervical screening. Majority35 (78%25) of respondents had heard cervical cancer screening but only 16(32%25) respondents had been done cervical screening. Barriers of cervical screening founded 34 (68%25), among them 20(58.82%25) respondents answered that don't have problem and 10(29.41%25) answered that not necessary to screening. The overall findings shows that the existing knowledge of respondents are relatively limited and inadequate in response to cervical cancer screening and its prevention .It is essential to provide more education regarding cervical cancer screening and prevention. 5.4 Implication of study This study would be helpful to the investigator regarding the future study of related topic. The finding of this study may be useful for health personnel in order to give health education to prevent cervical cancer. This study may be helpful for the nurses as well as health personnel to gain in depth knowledge about cervical cancer screening, prevention and factors affecting screening. As baseline information for future study, it may be helpful to other researcher to conduct abroad study in the related topic. This study may be helpful for health care planner in order to make strategies for improving knowledge of women about cervical cancer screening and prevention. 5.5 Recommendation A comparative study related to this topic can be done to find out the knowledge among married women in urban and rural communities and in hilly region and Terai region. This study can be done in rural community rather than urban community. Cervical cancer screening programme such as Pap smear, VIA should be integrated into existing health facilities. Advocacy regarding cervical cancer screening and prevention through mass media such as TV, Radio, Newspaper etc. 5.6 Strength of the study Researcher had consulted adequate literature from different sources, which provider detail information about the subject matter. Research is complete new subject for an investigator, so it is very beneficial for carry out further research study. The researcher has gained confidence from this study to do large-scale research. Tools prepared for this research study found suitable to obtain required information about cervical cancer screening and prevention.

The researcher has experienced easy in data collection due to cooperation of the respondents. For literature review, various books, journals, research reports were studied and searched website, from which researcher has gained a lot of information on this topic. The researcher has gained knowledge on the importance of communication and cooperation with different respondents and different institution staffs for completion of this study. The researcher has learnt to write proposal and research report. 5.7 Limitation of the Study Relevant of recent literature was not found on the same research topic in the context of Nepal Sometimes interview took longer than estimated time as respondents wanted to express their personal problem and as many questions regarding the information, education provided. This small-scale study cannot be generalized. This is done for partial fulfillment if academic requirement and within the short period of time and facilities. Data were collected by using interview schedule, so findings of the study depend upon the respondent's honesty. 5.8 Difficulties faced during the Study Researcher faced some difficulties during proposal writing, instrument development, analysis and interpretation due to unexperience in research tools and method. Time period for research was very short. 5.9 Learning from this study This research study helped to gain knowledge and skill on how to select research problem, review related literature and prepare research report. Researcher gained much more knowledge about prevention and screening of cervical cancer. Could understanding why research study is necessary and its importance in Nursing profession. 5.10 Plan for disseSrijanation Concerned research adviser Library of Baudha Nursing Campus Library of Lumbini Zonal Hospital Researcher herself. BIBLIOGRAPHY American cancer society recommendation for the early detection of cancer in average risk women (2004). American cancer society 52(2), 42-44 American society for cervical pathology (2004), should I have a pap smear?

www.ascp.org/general/pubsourse/pap.com American cancer society for prevention of cervical cancer (2008). Can cervical cancer be prevented ? ww.who.int/hinarypubmed Ajya IO, adewole if, knowledge attitude of general outpatient attendants in Nigeria to cervical cancer central African medical journal 44 (20); 14-3 February 1998 Berek , J.S, Adashi, E.K.,and Hillard, A.P. (1996). Novak's gynecology (12th edition). Bobak , M.I., Perry, e.S., and Lowermik.L.D. (1999). Maternity nursing (5th edition) USA Mosby Company Bobak. (1998). Maternity and gynecological care (3rd edition) USA Mosby Company BPKMCH. (1997). ( cancer of the uterine cervix ) . Report BPKMCH Chitwan Nepal Bruce , G. , & Stephen , P (2000). Out patient management of abnormal smears. Austrelian and new eland journal of gynecology and obstetrics. 43 (2), 50-53. California : Awaverly Company Central bureau of statistics. (2007). Nepal in figures. HMG Nepal: Kathmandu Ramshahpath . Darorn , G. (2004). Cervicography for triage of women with mildly abnormal cervical cytology results. American journal of obstetrics and gynecology 4. 184-185 Devita, V.T., Hellman . S. J. and Roseborg, S. A. (1997). Cancer principle and practice of gyanocology (5th edition) New York: Lipincott. Dr. Bafna V. D. cervical cancer central strategies in developing countries health promotion and education south east Asia. Volume XVII, No 3, July 2003 Dr. Shrestha Binuma and Dahal , Kabita (2059-7-26). Patheghar ko much ko cancer ra upachar Kantipur daily publication. Fylan F screening of cervical cancer : a review of women's attitude , knowledge and behavior jouranal of general practice 48 (433), 1509-14 august 1998. FDA News (june 8, 2006), http://www.fda.gov/cber/products/hpvmeer060806.htm. Haristova L, Hakama M. Effects of screening for cancer in the Nordic countries on deaths, costs and quality of life, up to the year 2017. Acta oncol 1997, 36; 1-60 Health and fitness (April 24, 2005). Cervical cancer, www.indystor.com, http://www.thegcf.org/. INCTR Newsletter, perspectives in cervical cancer prevention in India http://www.incter.org/publication. Jeronimu , et. al . (January 2005) Wider use of cervical screening could save life Pan American journal of public health. Fallen, R., & Anderson, P. cervical cancer prevention: could spectroscopy still the spotlight. Available at www.rho.org.htm/cxca. Jane, M. & John, T. (2003) . Human papiloma virus infection update, impact on women's health, The nurse practitioner 22, 24-37. James A. Dickinson. cervical screening time to change the policy the medical journal of Australia 176(11):547-550, 3 June 2002 Jose, S., & Shankarnarayan, R (2000). Visual inspection of the uterine cervix with acetic acid and Lugol's Iodine (VILLI). India: Trivandrum center.

Preventing cervical cancer worldwide, Acceptance for cervical cancer prevention 2006, http:www.prb.org. Saslow et. Al., American cancer society guideline for the early detection of cervical neoplasia and cancer CA cancer J clin 2002, 52: 342-362. .Van Till , et. al. understanding the barriers to cervical cancer screening among older women wual health res.2003 October 13 (8) 1116-31. WHO, cancer control program (March 9, 2005): cervical cancer statistics. Yuck, Rymer J women's attitude to and awareness of smear testing and cervical cancer brifum plan, 1998 January.

Appendixes