https://doi.org/10.33698/NRF0235-Mandeep Kaur,Meenakshki Agnihotri, Karobi Das, Bhavana Rai, Sandhya Ghai
Background: Cervical cancer is the second most common cancer in India. Patients are having very little knowledge about the treatment modalities, diet, side effects and methods to decrease treatment related side effects. Objective: To evaluate the effectiveness of interventional package on treatment related knowledge and practices among cervical cancer patients. Methods: Ethical approval was obtained from institute ethics committee PGIMER, Chandigarh. An experimental pretest posttest design was used in the study. Sixty patients receiving radiotherapy/chemotherapy were assigned in two groups of 30 each. Baseline assessment of treatment related knowledge and practices was assessed among both groups. Patients in experimental group received interventional package which included Jacobson progressive muscle relaxation technique, counseling, home care technique. Routine care was received by control group. Post test was conducted after four and half weeks of administration of interventional package. Results: Gain in treatment related knowledge about Radiotherapy and Chemotherapy was statistically signicant(p<0.001) in experimental group. Signicant increase in knowledge and practices was related to headache, fatigue, loss of appetite, nausea, vomiting, diarrhea burning micturition, uid intake, nutrition and personal hygiene were also found to be statistically signicant in experimental group as compared to control group. Conclusion: Interventional package which included Jacobson progressive muscle relaxation technique, counseling, home care technique is effective in improving knowledge and practices of patients and can be incorporated routine in the radiotherapy department.
Keywords: Cervical Cancer; Interventional package; treatment related knowledge and practices.
Address for correspondence
Meenakshi Agnihotri
Tutor, National Institute of Nursing Education, PGIMER, Chandigarh
Introduction:
Cancer of cervix is the foremost cause of cancer mortality in women and more than a quarter of its burden is contributed by developing countries. In India cervical cancer contributes approximately 6-29% of all cancers in women.1 The treatment modalities for cancer patients are chemotherapy, radiotherapy and surgery. Radiotherapy and chemotherapy with its benecial effects in treating cancer, some adverse effects also appear during treatment2.
Some researchers have carried out studies to manage the symptoms and to improve the general condition and quality of life of cancer patients. They have also conducted few therapies on cancer patients to relieve psychological and physiological symptoms. Jacobson progressive muscle relaxation ( JPMR) technique and counseling have been found to be valuable and preferred non pharmacological method of reducing these symptoms.3 Cancer patients require to readjust to changes in body image, lifestyle, and reduced life expectancy.4 The side- effects of Chemotherapy and Radiotherapy includes mucositis, nausea and vomiting, anorexia, diarrhea, constipation, anemia, leukopenia, thrombocytopenia, alopecia, radiation skin changes, fatigue etc.5A study conducted among women showing side effects of radiotherapy and chemotherapy on their reproductive health, revealed that radiotherapy and chemotherapy can increase the survival of young adults but the major toxicities of these treatment modalities might include ovarian failure and infertility.6
A study conducted on chemotherapy induced dermatological toxicity among women cancers. For these 91 patients received chemotherapy between April 2001 to October 2001 were taken. Malignancies include cancer of breast (43%), cancer of ovary (35%), cancer of cervix (13%), cancer of endometrium (2%), cancer of fallopian tube (2%), and cancer of vagina. There was overall 86.8%incidence of skin, nail, and hair side effects. Dermatological side effects of chemotherapy were frequent after treatment of women’s cancer. These side effects affect the quality of life. Thus counseling was considered before administering chemotherapeutic agents to the patients.7
Another study conducted on 78 cervical cancer patients as to how they perceive health status such as associated treatment and side effects. For this the various scales such as modied Standard Gamble (SG) and Visual Analog Scale (VAS) were used to know the preferences of women. Results revealed that patients were preferring the less invasive surgeries for the early stage. Higher VAS scores for menopause was associated with increasing age. Women who were getting radiation had comparatively more encouraging VAS scores for menopause as compared to women undergoing radical surgical intervention such as hysterectomy (p=0.05). Women getting chemotherapy were having less encouraging VAS score c o m p a r e d t o t h o s e n o t g e t t i n g chemotherapy (p=0.045).8
A study conducted on treatment related toxicity and efcacy in women with cancer of cervix. The toxicities included neuropathy, fatigue, hematological and gastrointestinal. T h e c e r v i c a l c a n c e r p a t i e n t s experience a bunch of symptoms. So instead of single intervention, the interventional package might be more effective in reducing the selected symptoms. Hence the need was felt to study the effect of an interventional package that includes Jacobson progressive muscle relaxation technique, Counseling and home care techniques in managing the chosen cancer symptoms.
Objectives:
To assess and compare the effect of an interventional package treatment related knowledge and practices among patients with Cervical Cancer undergoing treatment.
Material and methods :
An experimental study was conducted to assess the effectiveness of an interventional package on treatment related knowledge and practices among cervical cancer patients undergoing treatment in the department of Radiotherapy at PGIMER Chandigarh. Ethical clearance was sought from Institute Ethics Committee of PGIMER Chandigarh. Using total enumerative sampling technique 60 patients were recruited in the study, 30 each in experimental and control group. Patients having history of prior malignancy other than cervical cancer were excluded. Opaque envelope method was used to randomize the patient in the experimental and control group. The tool used for the data collection was an interview schedule consisting of (a) Sociodemographic prole (b) treatment related knowledge and practices. Treatment related knowledge and practices consisted of questions related to knowledge and practices of cervical cancer patient in their home in order to prevent the side effects related to chemotherapy, radiotherapy and nutritional needs and to manage her health condition. There were total seventeen questions regarding knowledge and practices in the interview schedule. Interventional package included Jacobson progressive muscle relaxation, counseling and home care techniques. Pre test was done at the starting of the treatment. Total of seven sessions of Jacobson progressive muscle relaxation were conducted with patients in the four and half weeks of treatment. Two individual counseling sessions were conducted with each patient in a separate quiet room during their treatment period. Home care techniques were tought to the patients verbally during counseling sessions and a printed booklet in Hindi and English was given to each patient for ready reference. Post test was done after completion of the treatment i.e. after four and half weeks. Data was coded and analyzed by using SPSS 20 version.
Results:
Socio demographic characteristics of the subjects: Table 1 depicts the socio demographic prole of the patients. The mean age in experimental group was 54.00 ± 10.72 (Range:25-73) years and in control group it was 49.20 ±10.73(Range:25-73) yrs. Both the groups were comparable as per age, marital status, occupational status, educational status, family type, monthly income, habitat, religion, spouse occupation.
Table 1: Sociodemographic profle of the study subjects
N=60
| Sociodemographic variable | Experimental group n1(%)=30 | Control group n2(%)=30 | χ2,df , p value |
| Age (yrs)
25-50 51-75 |
14(46.7)
16(53.3) |
20(66.7)
10(33.3) |
2.44,(1),0.12 |
| Marital status
Married Widower |
25(83.3) 05(16.7) |
20( 66.7) 10(33.3) |
2.22,(1,)0.14 |
| Occupational status
Unemployed/ housewife Working |
25(83.3)
05(16.7) |
23( 76.7)
07(23.3) |
1.17,(2),0.56 |
| Educational status
Less than primary More than Primary |
27(90.0)
03(10.0) |
24(80.0)
06(20.0) |
2.05,(1),0.06# |
| Family type
Nuclear Joint |
11(36.7)
19(63.3) |
13(43.3)
17(56.7) |
0.28,(1),0.59 |
| Monthly income (Rs.)
<10,000 >10,001-20,000 |
19(63.3)
11(36.6) |
22(73.3)
08(26.7) |
1.57,(1),0.66 |
| Habitat
Urban Rural |
11(36.6) 19(63.3) |
09(30.0) 21(70.0) |
0.32,(1),0.85 |
| Religion
Hindus Sikhs and others* |
22(73.3) 08(26.6) |
22(73.3) 08(26.7) |
0.01,(2),<1.00 |
| Spouse occupation Unemployed Unskilled
Semiskilled |
07(23.3) 07(23.3) 16(53.3) |
04(33.3) 10(13.3) 05(20.0) |
1.506,(3),.826 |
#{Mean±SD} age in years: Experimental group 54.00±10.72, Range (25-73)yrs, Control group 49.20±10.73,Range(25-73)yrs
#Yates corrected chi square
*Others = Only one subject was Muslim
Clinical profile of the patients : The control group reported higher percentage of complaints than experimental group except the bleeding. Bleeding was equal in both the groups. Half of the patients (50.0%) in the experimental group and more than half (53.3%) in control group were having past history of comorbidity – Majority of the patients (76.7%) in experimental group and more than half (56.7%) had history of any surgery in the past. About 33.3 % patients in the experimental group and 40.0% in the control group had history of use of complimentary therapy. Both the groups were comparable.
Table 2 indicate that only 10% patients had knowledge related to radiotherapy that it is use of rays to destroy cancer cells. After intervention every patient in experimental group had this knowledge while in control group it increased to 16.7% patients only. The chemotherapy enhances the effect of radiotherapy was known to only 6.7% patients in both groups while after post test this knowledge increased to 60% in experimental group and 13.3% in control group. Nearly half of patients had knowledge of disease condition as cancer cervix during pre test. It remained same in control group after post test while in experimental group it increased to 70%. There was signicantly increase in the knowledge of patients in experimental group related to radiotherapy and chemotherapy.
Table 2: Comparison of treatment related knowledge between experimental and control group
N=60
| Treatment related knowledge and practices (Correct response) | Experimental group n1(%)=30 | χ2,df,p value | Control group n2 (%)=30 | χ2,df,p value | ||
| pre test | posttest | pretest | post test | |||
| Radiotherapy: It is the use of rays to destroy cancer cells |
03(10.0) |
30(100.0) |
——— |
03(10.0) |
05(16.7) |
21.66,(1),1.00 |
| Chemotherapy: It enhance the effect of radiotherapy | 02(6.7) | 18(60.0) | 1.43,(1),<0.001 | 02(6.7) | 04(13.3) | 13.92,(1),0.50 |
| Disease condition: Cancer of cervix |
14(46.7) |
21(70.0) |
1.84,(1),0.06 |
16(53.3) |
16(53.3) |
16.08,(1),1.00 |
(Mcnemer p value)
Table 3 depicts the comparison of treatment related knowledge and practices amongst the subjects. There was statistically signicant increase in knowledge about management of headache (p=0.001), loss of appetite (p=<0.001), nausea (p=<0.001), vomiting (p=<0.001), diarrhea (p=<0.001) and burning micturition (p=<0.001). All the patients( 100 . 0 %) had increase in knowledge about management of fatigue, amount of daily uid Intake required, type of food taken and personal hygiene practices in experimental group. While in control group the change in knowledge about management of various symptoms was not statistically signicant during posttest.
Table 3: Comparison of treatment related knowledge between experimental group and control group
N=30
| Treatment related knowledge and
practices(correct response) |
Experimental group n1(%)=30 | Control group n2(%)=30 | ||||
| Pre test
Knowledge |
Post test
Knowledge |
χ2,df,p value | Pre test
Knowledge |
Post test
Knowledge |
χ2,df,p value | |
| Headache: Adequate hydration, take
medicine according to prescription of doctor. Fever: Above 100.40F take medicine according to prescription
Fatigue: Rest and Jacobson progressive muscle relaxation(JPMR)
Pain : For acute Pain JPMR and pain medication according to prescription.
Loss of appetite: High protein,donot miss meal, several meals in a day
Nausea : Lemon water
Vomiting: More uids,Oral Rehydration solution(ORS) and medication according to prescription. Diarrhea: 4-5 litre uids, medication according to prescription.
Abdominal cramps : Contact physician if moderate to severe cramping is there.
Burning micturition : Adequate hydration and cleaning from front to back Any bowel complaints : Contact physician if any problem arises
Daily fluid intake: 4- 5 litres
Nutrition : Avoid raw, outside food. Eat well cooked food
Personal hygiene :Took bath daily, clean and dry |
05(16.7)
08(26.7)
01(3.3)
10(33.3)
05(16.7)
01(3.3)
01(3.3)
01(3.3)
01(3.3)
01(3.3)
01(3.3)
06(20.0)
——
22(73.3) |
18(60.0)
12(40.0)
30(100.0)
13(43.3)
27(90.0)
27(90.0)
17(56.7)
22 (73.3)
04(13.3)
16(53.3)
01(3.3)
30(100.0)
30(100.0)
30(100.0) |
0.25,(1)
0.001
0.06,(1) ,0.38
——
0.83(1) 0.55
0.00,(1), <0.001 0.11,(1), <0.001 0.79,(1) <0.001
2.84,(1) ,<0.001
0.16,(1),0.37
1.18,(1),<0.001
——
——
——
—— |
05(16.7)
06(20.0)
01(3.3)
06(20.0)
04(13.3)
03(10.0)
06(20.0)
01(3.3)
01 (3.3)
02(6.7)
01(3.3)
13(43.3)
07(23.3)
18(60.0) |
06(20.0)
05(16.7)
—-
08(26.7)
04(13.3)
05(16.7)
08(26.7)
07(23.3)
——
04(13.3)
01(3.3)
17(56.7)
06(20.0)
19(63.3) |
9.37,(1),1.00
9.37,(1),1.00
—–
0.86,(1),0.20
2.33,(1),1.00
0.00,(1),0.68
0.00,(1),0.75
0.41,(1),0.31
——
0.33,(1),0.68
0.00,(1),1.00
7.29,(1),0.28
5.13,(1),1.00
1.53,(1),1.00 |
Mcnemer’s p value
Table 4 depicts the comparison of treatment related practices among experiment and control group during pre and posttest. It shows that in experimental group there was signicant improvement during posttest in practices related to management of headache (p<0.004), fatigue, loss of appetite (p<0.001), nausea (p<0.001), vomiting (p<0.001), diarrhea (p<0.001), burning micturition (p<0.001) and proper uid intake required (p<0.001). While in control group the change in practices of management of various symptoms were not statistically signicant from its baseline.
Table 4: Comparison of Treatment related practices between experimental and control group
N=30
| Treatment related knowledge and practices(correct response ) | Experimental group n2(%)=30 | Control group n2(%)=30 | ||||
| Pre test
Practice |
Post test
Practice |
χ2,df,p value | Pre test
Practice |
Post test
Practice |
χ2,df,p value | |
| Headache :Adequate hydration, take medicine according to prescription Fever : Above 100.40F take medicine according to prescription
Fatigue : Rest and Jacobson progressive muscle relaxation(JPMR) Pain : For acute Pain JPMR and pain medication according to prescription Loss of appetite : High protein, do not miss meal, several meals
Nausea : Lemon water Vomiting: More uids,Oral Rehydration Solution(ORS) and medication according to prescription Diarrhea: 4-5 litres uids, medication according to prescription Abdominal cramps : Contact physician if moderate to severe cramping is there Burning micturition : Adequate hydration and cleaning from front to back
Any bowel complaints : Contact physician if any problem arises
Daily fluid intake: 4- 5 litres Nutrition :Avoid raw,outside food. Eat cooked food
Personal hygiene : Take bath daily, clean and dry |
04(13.3) | 17(56.7) | 0.69,(1),0.004 | 03(10.0) | 02(6.7) | 9.28,(1),1.00 |
| 07(23.3) | 12(40.0) | 0.38,(1),0.23 | 07(23.3) | 05(16.7) | 7.30,(1),0.62 | |
| 01(3.3) | 30(100.0) | ——- | —- | —– | —– | |
| 10(33.3) | 13(43.3) | 0.83(1)0.55 | 06(20.0) | 08(26.7) | 0.86,(1),0.72 | |
| 04(13.3) | 27(90.0) | 0.03,(1)<0.001 | 05(16.7) | 07(23.3) | 2.38,(1),0.68 | |
| 01(3.3) | 27(90.0) | 0.11,(1)<0.001 |
03(10.0) |
06(20.0) |
4.54,(1),0.375 |
|
| 01(3.3) | 17(56.7) | 0.79,(1)<0.001 | 07(23.3) | 08(26.7) | 0.38,(1),1.000 | |
| 01(3.3) | 22(73.3) | 2.84,(1),<0.001 |
— |
07(23.3) |
—– |
|
| 04(13.3) | 04(13.3) | ——— | —- | —– | —– | |
| 02(6.7) | 16(53.3) | 0.00,(1),<0.001 | 03(10.0) | 04(13.3) | 0.51,(1),1.00 | |
|
—— |
—— |
—— |
01(3.3) |
01(3.3) |
0.00,(1),1.00 | |
|
02(6.7) |
17(56.7) |
0.00,(1),<0.001 |
03(10.0) |
04(13.3) |
0.00,(1),1.00 | |
| 01(3.3) | 30(100.0) | —— | 10(33.3) | 09(30.0) | 4.46,(1),1.00 | |
|
23(76.7) |
29(96.7) |
—— |
18(60.0) |
19(63.3) |
1.53,(1),1.00 | |
Mcnemer p value
Discussion:
Cervical cancer is a cancer of the cervix, due to abnormal growth of cells which may invade the surrounding tissues of the cervical area. In the starting phase no symptoms are seen, but later vaginal bleeding, pelvic pain or pain during sexual intercourse indicates the presence of cervical cancer. Human Papillomavirus (HPV) infection is the important cause of cancer of cervix. Other risk factors may include smoking, early intercourse, early marriage, and having multiple sexual partners. Not only the cancer but the treatment modalities of cancer also causes adverse effects.
Cancer patients’ experience many side effects due to radiation therapy and c h e m o t h e r a p y . T h e y r e q u i r e prechemotherapy and preradiotherapy information, counseling to overcome the side effects of treatment modalities, some physical exercises in order to decrease their fatigue. Provision of information related to chemotherapy and radiotherapy helps in reduction of the side effects and improves their self care practices. Instead of single i n t e rvention i f we a r e providing intervention package, it may be more benecial to the patients. Hence in present study the effect of an intervention package including Jacobson progressive muscle relaxation technique, Counseling and home care techniques in managing the chosen cancer symptoms was observed T h e i n t e r v e n t i o n a l p a c k a g e signicantly improved the knowledge and practices related to reduce nausea and vomiting (p=<0.001). The ndings are suggested by s tudy conducted by Molassiotis on the use of PMRT considerably decreased the duration of nausea and vomiting in the experimental group compared with the control group.10
The ndings of the present study revealed that only 46.7% patients in experimental group and 53.3% patients in control group had knowledge about cancer of cervix which increased to 70% in experimental group and remained same in control group. Nuwasiima et al has reported that 88.7% women heard about cervical cancer and only 20% had knowledge about the standard cervical cancer preventive factors11.
The intervention was found effective in increasing the knowledge and practice in managing various s ide effects of radiotherapy such as headache, Fatigue, Loss of appetite, nausea, vomiting, Diarrhea and burning micturition among patients of cancer cervix receiving radiotherapy and chemotherapy. There was also improvement in knowledge and practices related to required uid intake.
This leads to the conclusion that Jacobson progressive muscle relaxation technique(JPMR), counseling along with information booklet increases the treatment related knowledge and improves the practices related to management of side effects because of radiotherapy and chemotherapy. There is need to adopt all these activities at the starting of the cancer directed therapy. Hence, the present study raises the evidence in support of JPMR and counseling in reduction of anxiety and depression. The information booklet has been invaluable in increasing the level of treatment related knowledge and practices among cervical cancer patients. Similar study can be conducted in different research settings and different patient populations. Newer techniques for diversion therapy can also be included in the interventional package for the improvement in treatment related knowledge and practices
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