Perception of Nursing Students towards Palliative Care of Cervical Cancer in Sudan

Objective: The primary objective was to determine awareness, attitude, and practice of undergraduate nursing students towards prevention and treatment of cervical cancer. The Secondary objective was to ensure their participation in raising awareness, screening, management of pre cancel conditions, and invasive cervical cancer, as well as palliative care. Materials and methods: A descriptive - cross sectional study was carried out in the nursing colleges at Khartoum state universities. A total of 246 female undergraduate students, selected through simple random sample were interviewed. A pretest was done among 10 students to ensure validity of the study. The knowledge, and practice towards treatment of cervical cancer and palliative care were identified according to a certain scale, being as good, fair, and poor on the basis of correct items. Result: Most of the students have poor information about the burden of cervical cancer and current situation of disease in Sudan. Students have poor information about the management of precancerous conditions, with significant difference between students in this aspect (P 0.000) and less than half (40.7%) of the respondents were not familiar with palliative care (P 0.012). Nearly one third of the respondents received their information mainly from the mass media p (0.000). Most of the students did not know the component of palliative care and how to provide relief rise symptoms of advancing disease.


Introduction
Cervical cancer is the second most common women cancer worldwide, representing 13% of female cancers. It ranks as the second most frequent cancer among women after breast cancer in Sudan. The majority of cases present with advanced stage when the treatment either by surgery or radiotherapy is expensive and not always available. Breast and Cervical Cancer account for about 50% of all cancers in Sudanese women. Therefore, there is an urgent need for better early detection of cancer in Sudan to make treatment more effective, less costly, less invasive, more accessible and acceptable to patients [1,2]. Cervical cancer is potentially preventable, and curable, effective screening programs can lead to significant reduction in morbidity and mortality related to cervical cancer and eradicating a pre-invasive disease as shown by studies done in high income countries [3]. Studies have shown sensitivity and specificity of Pap smear screening to be 50-75% and 98-99% respectively. Nurses in high income countries play a role in cancer prevention and participates in cervical cancer screening by carrying out Pap smear tests [4]. Since survival rates for cervical cancer are over 90% if it is detected early and properly managed it's crucial that women of all ages should be armed with a strong knowledge base of HPV, including its acquisition, it's potentially serious consequences and prevention strategies to make informed decisions for their own health and wellness [5].
Most countries which have significantly reduced morbidity and mortality rate have attributed it to effective cervical cancer screening program and early treatment. All women who were, or who have had been sexually active and between age 20-65 years old are recommended to undergo Pap smear screening. Screening every three years is recommended if the first two consecutive screenings are negative [6].
The vast majority of women who suffer from cervical cancer in Sub-Saharan Africa present with disease that is advanced far beyond the capacity of surgery or other treatment modalities to offer a cure. Palliative care services are very poorly developed and therefore these unfortunate women are sentenced to a miserable end of life [7]. The Palliative care nurse practitioner offers training to the family members in care-giving and controls at least once a week. Moreover, the nurse managed drug supply, including morphine in the absence of the physician following his advice. Hospital-at home nurses have great importance in developing countries [8]. In Uganda, a network of trained palliative care nurses, licensed to prescribe liquid oral morphine. Knowledge about palliative care, including pain relief, as a way of providing clinical and psycho social support for terminally ill patients was generally poor among most providers, and cervical cancer issues were not included in the theoretical or practical training of nurses [9]. British palliative care nurse Esther Walker has developed the palliative care in Sudan 2010. It launched with a nine-bedded palliative care ward and a clinic that opens daily at Radio Isotope Center, Khartoum (RICK) Patients who were being cared at RICK have great advantages of a dedicated palliative care team and access to opiates is being promoted. The palliative care team consists of nurses, a registrar, medical officers, psychologists and volunteers. In 2010 a three-day workshop -'Palliative Care in Practice' was held at the University Hospital (SUH). It considered that the main barriers to palliative care in Sudan were lack of trained human resources and infrastructure8. Research suggests that nurses may not be adequately prepared for working with individuals at the end of life and strongly supports the integration of palliative care into the undergraduate curriculum [10]. Barrie et al. identified that nursing student's attitudes toward care of the dying was positively influenced by the integration of palliative care into the undergraduate nursing program.
Although, exploration was based on the use of an end of life education package designed within the United States of America the significance of changing student's attitudes by the integration of palliative education into curriculum cannot be discounted [9]. In a workshop conducted in Sudan participants agreed on recommendations to introduce palliative care in undergraduate medical schools and postgraduate training curriculum as was suggested by Stannebergerr in his review article [8].

Methods
This is a cross sectional descriptive study, which targeted final year undergraduate nursing students for assessment of their knowledge, attitudes, and practice in relation to use of palliative care in cervical cancer. A study conducted in nursing colleges at all universities in Khartoum had final year undergraduate students. Non-probability sampling technique was an appropriate method to select 246 students from selected universities for the study. Data collection was done through a self-structured interview questionnaire, with closed-ended questions. The purpose and importance of the study were explained to participants before filling the questionnaire. Nurses who assisted in data collection received two days additional training. Names were not used for identification, but coding numbers were used instead.
The pretest study is the collection of data before the basic study is executed, the rationale for the pretest study was to determine whether the survey instrument was clearly stated. The total score for each respondent was obtained by summing the correct number of responses, then categorizing the samples according to respondents knowledge score, and graded as poor, satisfactory, and good. A higher score indicated better knowledge and Scores were expressed as percentages the total. The interpretation of knowledge score was done as poor (0-33.3% satisfactory (33.4-66.7%) and good (66.7%). The study approval was taken from the Research and Ethical Committee of Alneealin University, Faculty of Medicine and Health Sciences. And Permission obtained from them to carry out the study. Statistical analysis was performed with Statistical Package for Social Sciences software (SPSS) version [11]. Chi square test (χ 2 ) was used to determine the association between variables. The level of significance was set at p=0.05.

Results
Approximately one quarter (25.2%) of the respondents were aware about that, sexual dysfunction occurs after radiotherapy treatment, there was a significant association between groups P=(0.012). About half of the respondents (50.4%) were not oriented about the component of palliative care with significant differences between groups among universities (P=0.0004) (Tables 1-3).

Discussion
Palliative care supports patient with advanced disease and those who do not respond to curative treatment, especially in developing countries, as the majority of the cases present in advanced stages. The idea is to manage these cases in a special hospice under the care of trained personnel. The true fact is that hospice care is not always available in low-resource setting, therefore women with cervical cancer usually cared for at home by family members, and that is a big burden especially many of them are working personnel. Less than half of the respondents in our study were not well aware about the component of palliative care and how to deal with women in advance stage of the disease (P=0.0012). Palliative care should be part of the training program for nurses because it is an important component of cervical cancer treatment and it is not available in our country [8]. In Uganda, a network of trained palliative care nurses, licensed to prescribe liquid oral morphine, has demonstrated how palliative care can be provided safely and effectively in the community without access to a large number of doctors. As the result of Stephan Tanneberger in his review article, that workshop conducted in Sudan, participants had agreed on recommendations that to introduce palliative care in undergraduate medical schools and postgraduate training curriculum, that have been adopted by WHO-EMRO as guidelines for Ministers of Health [8]. An advanced stage of cervical cancer is a situation that usually associates with adverse clinical presentation, such as foulsmelling vaginal discharge, a palliative nurse manages these symptoms through simple procedure such as Periodic packing of the vagina with clean gauze soaked with a solution of Soda bicarbonate powder, dilute vinegar or metronidazole solution [11]. Most of our respondents demonstrate good practice to relive the bad smell from cervical cancer woman. We find association between students' knowledge of treatment and the ability of the students to relive the bad smell from women affected with cervical cancer. From a researchers point of view, we appreciated this finding because the bad smell becomes dominant barriers for nurses to work with cervical cancer woman (p= 0.000). Less than half of students (41.5%) were satisfied with cervical cancer curricula and considered it to be complete and informative, the rest of students consider it incomplete and non-informative. Nganwai et al. conducted a study, which showed that most nurses requested extra information about cervical cancer; this is similar to our finding when 93.5% of respondents also showed interest in extra information regarding cervical cancer prevention and treatment [4,12]. In spite of the poor knowledge in our present study, approximately all respondents demonstrated great interest to work in cervical cancer prevention program area and in oncology hospital after graduation. Involvement of the nurses in awareness raising of treatment of cervical cancer as well as participating in palliative care. Nursing college curricula should include modules for better training of nurses in all aspects of palliative care and patient end of life. Media in all kinds is very important in promoting awareness about prevention and treatment of cervical cancer, therefore involvement of the media in the development and implementation of the program was important. Palliative care education is gradually being incorporated into preregistration nurse training programs. Palliative care an important component of cervical cancer treatment needs more evaluation, analysis, and structured quantitative research.

Conclusion
Most of the students did not know the component of palliative care and how to relieve the arising symptoms of advancing disease such as bad smell which is the dominant reason preventing nurses from working in a palliative care area as well as end of life patient.