REPORT OF PROBLEM SOLVING

AT

COMMUNITY HEALTH CENTRE

ST. STEPHEN’S HOSPITAL
SUNDER NAGRI, NEW DELHI

Submitted to :- Submitted by :-
Mrs. Jahanara Rehman Jincy Daniel
Tutor MSc. Nursing 2nd year
Rufaida College of Nursing Rufaida College of Nursing
Jamia Hamdard Jamia Hamdard
INSTITUTIONAL PROFILE
St. Stephen's Hospital is situated in the northern part of Delhi and is a non-profit-making,
state-of-art, 650 bedded, autonomous Society. The hospital was founded by a missionary lady
named Priscilla Winter in 1885. She was not a doctor but she responded to the immense
needs of the people she came across, especially of the women in the Old Delhi area. Slowly
she worked to establish the hospital with inputs from qualified people. It began as a small
maternity centre and has grown into to a state of the art super specialty hospital. The advent
of high technology has not dimmed the original vision of the founder. The hospital continues
to provide much needed quality care to the underprivileged around the area at an affordable
cost. To many who cannot afford even this, the treatment is given totally free.

ABOUT THE CENTRE

The Community Health Department St Stephen’s started its operations in the 1980s from a
slum called Sunder Nagri. It is situated in the Trans-Yamuna area, about 16 Kms from St
Stephen’s Hospital.
Popularly known as Khaddiyon Wali Dispensary, the centre is a branch of Delhi's oldest
hospital, St. Stephen's Hospital. It is the main health care facility for the underprivileged
community of Sunder Nagari. In the beginning a small outreach clinic was established in a
hut, donated by the local community. It provided clinical health care, immunization and
antenatal care. It serves underprivileged people living in slums and rural areas, in and around
Delhi and also provides comprehensive health, education and development services to over
15000.
The Community Health Department provides regular home visits, Maternal and Child Health
care, a tuberculosis control programme and a Day Care Centre (Creche) for underprivileged
children.
As per the annual report dated June 2013, the urban centre covers 68,522 populations, which
includes nearly 10,602 families.

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Areas covered by them include AB Jhuggi, M block, Mochi colony, F2 DDA Flats, H block,
D block, Rajeev colony, G4 areas, O Block, and N block.

AB JHUGGI

VISION OF COMMUNITY HEALTH CENTRE

Jesus showed the world a path of extreme level of compassion, love, and caring. He also
demonstrated a path of empowerment. Walking on the path showed by Him would lead us to
a healthy, respectful, harmonious and caring society.

MISSION OF COMMUNITY HEALTH CENTRE

 Community Health Department of St. Stephen’s Hospital will always work to fulfill
basic commitment of the hospital towards the service of the underprivileged, without
any discrimination of caste, creed, or religion.

 It will work with the communities, empower them to achieve sustainable, continual
improvement in their quality of life.

 We strive for healthy, respectful, harmonious and caring society.

 We also commit ourselves to enriching the body of knowledge, through Research,

training and sharing of experiences.

URBAN COMMUNITY PROFILE

Sunder Nagri is situated in the north east of Delhi. It is one of the largest resettlement
colonies of the 1975-1976 Clean Delhi Drive by the Government Of India. As a result of the
drive many displaced people migrated to the inner-city slum area of Sunder Nagri, where
previously the land had been donated (by Mrs Indria Gandhi) to the existing community.
Following this mass migration more people started to move into the area from neighboring
communities and from failing farms. An exodus of desperate jobless villagers put incredible

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pressure on the Sunder Nagri community and its resources. The present population is around
64,500. This large community is mainly accommodated in 11 blocks (F-J) spread over 200
acres. The numbers living in each house range from 5-8 members. Around 60% own their
homes but 40% live in basic rental accommodation or in Jhuggis (make shift houses). The
majority of the community are low wage earners such as: factory worker, security guards,
clerks, shopkeepers (of small business), taxi drivers, small auto drivers, mechanics, weavers,
tailors and vegetable venders (who operating from road-side-carts). There are also a
considerable number who are the lowest paid and most vulnerable such as peddle-rickshaw
drivers, street-waste collectors (Rag-pickers) and there is growing unemployment.

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PROBLEM SOLVING:

Definition-

 It is a systematic process of solving simple or complex, short term or long term

problem, by applying certain observational thoughts and action process in scientific
way.

 It is a process of proceeding from a state of dissatisfaction to a state of satisfaction,

which is the attainment of desired objectives or goals.

 It is a scientific process that provides a theoretical framework utilized in attaining the

solution to complex problem.

PROBLEM SOLVING PROCESS

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 Problem solving and decision making are essential skills in nursing practice. Problem
solving is focused on solving an immediate problem and includes a decision making steps.

Keeping in view of above situation I have identified women and assessed their knowledge
regarding breast cancer and breast self examination and after that administer health education
on breast cancer and breast self examination using a leaflet on breast cancer awareness and its
prevention and also evaluate the effectiveness of health education.

INTRODUCTION
Globally breast cancer is one of the most common cancers and a major public health
challenge to women health. It is seen that there is an immense increase in the annual
incidence of breast cancer, especially among those countries where its incidence was low.
According to the findings World Health Organization (WHO) each year, over 1.15 million
women are diagnosed with breast cancer, with an annual reported death of 502,000
worldwide.

The onset of breast cancer is more abrupt among young women's cancers, with an aggressive
onset resulting in lower survival rates. This immediate onset makes it difficult for the
clinicians to diagnose it within time.

Breast cancer is the most commonly occurring female cancer in the world with an age-
standardized incidence rate of 39.0 per 100,000, which is more than double that of the
second ranked cancer (cervical cancer ASR=15.2 per 100,000. Breast cancer accounts for
23% of all newly occurring cancers in women worldwide and represents 13.7% of all cancer
deaths).

In India, breast cancer is the second most common cancer (after cervical cancer) with an
estimated 115,251 new diagnoses and the second most common cause of cancer-related
deaths with 53,592 breast cancer deaths in 2008. The age-standardised incidence rate for
breast cancer in India is 22.9 per 100,000, one-third that of Western countries and the
mortality rates are disproportionately higher.

Breast cancer accounts for 22.2% of all new cancer diagnoses and 17.2% of all cancer deaths
among women in India. Breast cancer in urban areas of India is three times higher than in
rural parts of the country.

One potentially important strategy in reducing breast cancer mortality is the use of screening
to achieve earlier detection of cancer. This is very important because an excellent prognosis
is directly associated with the stage at which the tumor is detected and how localized the
lesion is.
Early diagnosis usually results in treatment before metastasis and signifies a better outcome
of management. Breast self examination is an important method for early detection.

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Breast self examination (BSE) can have a significant impact on the survival rate, since
approximately 90% of breast cancers are discovered via self examination.

I identified women coming with the complaints of lump and pain in breast in the O.P.D. Two
staff of the Community Centre were also suffering from problems of breast. One of them
have painful lump in the breast.

During my interaction with community people especially women, I realized that they had
deficit knowledge regarding breast cancer and breast self examination.

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PROBLEM
Knowledge deficit regarding breast cancer and breast self examination among women
residing in a selected urban slum of New Delhi.
OBJECTIVES
1. To assess the knowledge and awareness of women regarding breast cancer and breast
self examination.
2. To design and disseminate a leaflet on breast cancer, and to provide health education
on breast cancer and breast self examination.
3. To assess the efficiency of the health education session.

REVIEW OF LITERATURE

 A pre experimental study conducted by Shalini and Varghese D among 40 degree

female students by using cluster sampling method from selected colleges of Udupi
district to assess the level of knowledge of degree college female students on BSE.
The data analyzed showed that majority (52%) of them was in the age group of 18-19
years and 72% of them were had average knowledge on BSE in the pretest score. Out
of 40 participants only one student was performing BSE occasionally. Awareness
regarding breast self examination among young generations is useful and it is the
most important viable tool for early detection.
 A cross sectional study conducted by Koklkar Anita among 441 women teachers
from 8 of the schools located in Delhi, to determine the level of knowledge about
breast cancer screening and its awareness found that 92.7% of the teachers were
aware of at least one sign or symptom of the disease and 63.0% knew at least one
high risk factor and only 36.1% had heard of the term breast self examination. Only
13.4% knew the correct frequency of once a month, only 7.3% the correct position
and only 1.36% participants the correct time. None had ever practiced breast self-
examination. Similarly, very few attended regular clinics. There is clearly a need to
increase the level of awareness regarding breast cancer and its screening.
 A study conducted by K gupta, Pal D. K, Tiwari R, and Bansal Mohan to assess the
impact of a health education intervention program regarding breast self examination
among 1000 women in a semi-urban area of Madhya Pradesh, India. Interventional
health education in the form of a lecture, pamphlets, flip charts and demonstration of
the five step method of breast self examination using audio-visual aids was
administrated. There was a significant improvement in knowledge regarding all
aspects of breast self examination of the intervention group from pre- to post-test.
Results shows 590 (59%) women had good knowledge and among them 90.7%
practiced (BSE) compared to 0% pre-test. An overall increase in the awareness of
43% and 53% of BSE practice was observed after intervention. The knowledge and
practices of women toward breast self examination for early detection was observed
to be inadequate but there was a significant improvement after the intervention.

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METHODOLOGY
Approach
Evaluative approach was considered appropriate because the primary objective was to assess
the knowledge and awareness of breast cancer and breast self examination among women and
the effectiveness of health education.

Research Design
Single group design with pre and post test O1 x O2 .

Tool
Structured interview schedule with two parts
Part I is related to demographic data.
Part II consists of 18 questions
 Questions No. 1 -5 questions are related to awareness of breast cancer and breast self
examination.
 Questions No. 6 – 13 are related to knowledge of breast cancer and breast self
examination.

Validation of Tool
Tool was validated by Dr. Joyous and Mrs. Urmila Bhardwaj (Associate Professor, Rufaida
College Of Nursing).

Sample
It consisted of women residing in a selected urban slum.

Setting: - G4 Sundernagri and Rajeev colony.

Sample Size: - 30.

Sampling Technique: - Purposive Sampling

Assessment of the problem

A pre-test was taken to assess the knowledge of the women.
After this a health education session was taken to explain them about breast cancer and breast
self examination. Steps of breast self examination was demonstrated to them
This was followed by a discussion with the women.
Later a post-test was conducted and participants were asked to re demonstrate the breast self
examination.

CRITERIA FOR SELECTION OF SOLUTION OF PROBLEM

The above mentioned solutions were implemented depending upon:
1. Ability of the sample group
2. Practicability
3. Utility
4. Resources available
5. Availability of time
6. Economy

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ALTERNATIVE SOLUTIONS PLANNED
 Arrange a group discussion
 Plan for incidental teaching
 Give hand outs, pamphlet
 Health education programme
 Preparation of posters and charts on the selected topic

Selection of best alternative

Considering the feasibility, time, resource, economy and availability of women health
education programme and leaflet on breast cancer was chosen from the alternatives.

IMPLEMENTATION OF THE PROGRAMME

The programme was conducted in community (G4 sunder Nagri and Rajeev Colony) on 18
June 2013, 20 June 2013 and 24 June 2013 between 10am -1pm. 30 women had participated.
 Information regarding programme was given to Dr. Amod Kumar, Dr. Joyce
Wagela and Supervisor well in advance.
 Community health visit was conducted in G4 Sunder Nagri and Rajeev colony.
 Interviews were conducted to assess the existing knowledge of the mothers.
 The health education was conducted for 20 min with help of the leaflet.
 The participants were able to clear their doubts by asking questions.
 Post test was also conducted.

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ANALYSIS & INTERPRETATION
I. DEMOGRAPHIC DATA

 The maximum respondents found were in the age group of 20 – 29 years (63%)
followed by 30- 39 yrs (23%), 40-49 years (7%) respectively. 7% were 50 years and
above.

Table 1: -Table showing the classification of samples according to age groups

Age Group No. %

20-29 years 19 63

30-39 years 7 23

40-50 years 2 7

50 years and above 2 7

Total 30 100

20
19
18
16
14
12
10
8 7
6
4
2 2
2
0
20-29 years 30-39 years 40-50 years 50 years and above

Figure 1:- A Bar Graph shows the classification of samples according to age groups.

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 Majority of Respondents were married (93%) compared with un-married (7%).

Table 2:- Table showing the distribution of samples according to marital status

Marital Status No. %

Married 28 93%

Un-Married 2 7%

Divorce 0 0

Death of spouse 0 0

Total 30 100%

0% 0%
7%

Married
Un-Married
Divorce
93% Death of spouse

Figure 2: A pie chart showing classification according to Marital Status

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 Majority of respondents (53%) were illiterate. Only 27% were having primary
education. 10 % were educated up to secondary level and 7% were educated up to
higher secondary and 3 % was graduate.

Table 3: Table shows the classification of samples according to Educational Status

Educational Status No. of samples %

Illiterate 16 53
Primary School 8 27
Secondary School 3 10
Higher secondary School 2 7
Graduate 1 3
Total 30 100%

3% Illiterate

7%
10%
Primary School
53%
27%
Secondary School

Higher secondary
School

Graduate

Figure 3:- Pie Chart showing classification of samples according to education

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  Majority of the samples were Hindu 70 %, 24% were Muslim and 6% were Sikh.

Table 4:- Table showing classification of samples according to religion

Religion No. %

Hindu 21 70%

Muslim 7 24%

Sikh 2 6%

Christian 0 0%

Total 30 100%

80%
70%
70%

60%

50%

40%

30% 24%

20%
6%
10%
0%
0%
Hindu Muslim Sikh Christian

Figure 4:- A Cylindrical Bar Graph showing classification of samples according to religion

14
  Majority of samples has two children (36%), 30% have only one child and 17% have
3 or more children and 17% have no children.
Table 5:- Table showing the classification of samples according to number of children

No. of children No %

0 5 17%

1 9 30%

2 11 36%

3 or more 5 17%

Total 30 100%

3 or more children 17%

2 36%

1 30%

0 17%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Figure 5:- A Bar diagram showing the distribution of the samples according to the number of
children.

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  Majority of them were Vegetarian (57%) and 43% were non vegetarian.
Table 6:- Table showing the distribution of samples according to the food habits

Food Habits No. %

Vegetarian 17 57%

Non - Vegetarian 13 43%

43%

57% Vegetarian
Non Vegetarian

Figure 6: - A Pie Chart showing the distribution of the samples on basis of their food habits

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  On an average the women had their menarche at an age of 15 yrs and no. of days of
menstruation is 4 days.
Table 7:- Table showing the distribution of the samples on the basis of their age at menarche
and no. of days of menstruation

Samples Age at menarche No. of days of menstruation

1 14 6
2 17 4
3 13 3
4 12 3
5 16 5
6 16 6
7 18 4
8 15 5
9 16 7
10 13 8
11 16 5
12 16 4
13 16 3
14 15 3
15 16 4
16 17 0
17 12 4
18 14 3
19 15 0
20 16 5
21 19 4
22 18 4
23 16 0
24 13 7
25 17 6
26 16 3
27 16 4
28 14 5
29 11 4
30 16 4

17
 20
18
16
14
12
10
Age at menarche
8
No. of days of mensturation
6
4
2
0
1 3 5
7 9 11 13
15 17 19
21 23 25
27 29

Figure 7:- Bar Graph showing the distribution of samples according their age at menarche
and no. of days of menstruation

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II. RESULTS REGARDING THE AWARENESS OF BREAST CANCER AND
BREAST SELF EXAMINATION AMONG WOMEN

 Among 30 women 10 % have heard of breast cancer

Table 8:- Table showing the awareness among women regarding breast cancer

Awareness of breast cancer No. %

Aware 3 10%

Not aware 27 90%

Aware Not aware

10%

90%

Figure 8:- A Pie chart shows the awareness among women regarding breast cancer.

 No one was aware of breast self examination as a measure to assess the sign of breast
cancer.
Table 9:- Table showing the awareness among women regarding breast self
examination

Awareness of breast cancer No. %

Aware 0 0%

Not aware 30 100%

150%

100%

50%

0%
Aware Not aware

Figure 9:- Bar Graph showing the awareness among women regarding breast self
examination

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  Among the 3 (10%) women who have heard about breast cancer, friends and relatives
were the keen informant for breast cancer.
Table 10:- Table showing the source of information of breast cancer among women.

Source of information No. %

Friends and relatives 2 67%

Magazines and Newspaper 1 33%

Radio and Television 0 0%

Health Professionals 0 0%

70%
60%
50%
67%
40%
30%
20%
33%
10%
0%
Friends and Relatives Magazines and
Newspapers

Figure 10:- Figure showing the source of information of breast cancer among women.

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  It is evident from the findings that 93% of respondents had no family history of breast
cancer and only 7% respondents had family history of breast cancer.
Table 11: - Table showing the classification of respondents by Family History of Breast
Cancer.

Family History of Diabetes No. %

Present 2 7%

Absent 28 93%

Total 30 100%

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Present Absent

Figure 11: - Figure showing the classification of respondents by Family History of Breast
Cancer.

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 III. RESULTS REGARDING THE KNOELEDGE AND EFFECTIVENESS OF
HEALTH EDUCATION ON BREAST CANCER AND BREAST SELF
EXAMINATION
Table 12: - Table showing the Pre-Teaching & Post-Teaching Knowledge Score of
Samples on Items Related Breast Cancer and breast self examination.
Total Items: 13
Maximum Score: 13

S.No. PRE-TEACHING SCORE POST-TEACHING DIFFERENCE

(Out of 13) SCORE IN SCORES
(Out of 13)
1. 04 10 06
2. 05 12 07
3. 04 09 05
4. 03 11 08
5. 06 13 07
6. 02 10 08
7. 03 13 10
8. 03 12 09
9. 02 10 08
10. 01 09 08
11. 03 09 06
12. 04 10 06
13. 02 10 08
14. 04 11 07
15. 05 11 06
16. 01 08 07
17. 04 09 05
18. 06 11 05
19. 05 12 07
20. 04 11 07
21. 01 10 09
22. 03 13 10
23. 06 12 06
24. 02 11 09
25. 04 10 06
26. 03 11 08
27. 04 12 08
28. 05 13 08
29. 02 07 05
30. 05 10 05

22
 14

12

10

8
PRE-TEACHING SCORE

POST-TEACHING
6 SCORE

0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29

Figure 12: - Bar Graph showing the Pre-Teaching & Post-Teaching Knowledge Score of
Samples on Items Related Breast Cancer and breast self examination

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 Pre-test Mean: (106/30= 3.53) i.e. women have poor knowledge
Post-test Mean: (320/30=10.66) i.e. women gained good knowledge
Mean Difference = 7.13
Table 13: - Table showing the Mean Difference of Pre-Teaching Knowledge and Post-
Teaching Knowledge Score of Sample on breast cancer and breast self examination

Pre-test Post-test Mean difference

3.53 10.66 7.17

12
10
8
10.66
6
4
3.53
2
0
Pre-test Post-test

Figure: 13 Bar Diagram Depicting Comparison between Pre teaching and post teaching
knowledge scores of samples on breast cancer and breast self examination
EVALUATION
Evaluation of health education was done by statistically analysing pre test and post tests score
and by re demonstration of breast self examination procedure. Result showed marked
improvement in knowledge regarding breast cancer and breast self examination.

RESULT
The mean post-test knowledge score (10.66) is more than mean pre-test knowledge score
(3.53). There is mean difference of 7.13 between mean pre-test and post-test score. Hence the
teaching programme was found to be effective in improving the knowledge of the women
regarding breast cancer and breast self examination.

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SUMMARY
On the basis of the findings of study the following conclusion were drawn:

 Majority of women were not aware of breast cancer and no one was aware of breast
cancer.
 Women were having less knowledge regarding breast cancer and breast self
examination.

 The health education with the help of leaflet was found to be effective in increasing
the knowledge of the women on breast cancer and breast self examination.

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 DATA COLLECTION TOOL
STRUCTURED INTERVIEW SCHEDULE to collect Data on problem of “Knowledge
deficit regarding breast cancer and breast self examination among women in a selected urban
slum”
This consists of 2 parts as listed below: -
PART I – DEMOGRAPHIC DATA
PART II – QUESTTIONAIRE TO ASSESS THE KNOWLEDGE AND AWARENESS OF
WOMEN ON BREAST CANCER AND BREAST SELF EXAMINATION
NOTE

 Kindly listen to each item of interview schedule carefully. The interviewer places a
tick mark corresponding to the statement in the column of your choice.

 This information will be kept confidential and will be used for study only.

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 TOOL
Structured interview schedule.

Tick the appropriate answer: -

PART I
DEMOGRAPHIC DATA
(AS REPORTED BY THE RESPONDENT)
1. Age (in years)
1.1 20yrs – below 30yrs ( )
1.2 30yrs – below 40yrs ( )
1.3 40yrs – below 50 yrs ( )
1.4 50 yrs and above ( )

2. Educational Status
2.1 Illiterate ( )
2.2 Primary ( )
2.3 Secondary ( )
2.4 Higher secondary ( )
2.5 Graduation and above ( )

3. Marital status
3.1 Married ( )
3.2 Unmarried ( )
3.3 Divorced ( )
3.4 Death of spouse ( )
4. Religion
4.1 Hindu ( )
4.2 Muslim ( )
4.3 Sikh ( )
4.4 Christian ( )

5. Number of children
5.1 Nil ( )
5.2 1 ( )
5.3 2 ( )
5.4 3 or more ( )

6. Food Habits
6.1 Vegetarian ( )
6.2 Non Vegetarian ( )

7. Age of menarche ____________________

8. No. Of days of menstruation _____________________

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 PART II

QUESTTIONAIRE TO ASSESS THE KNOWLEDGE AND AWARENESS OF

WOMEN ON BREAST CANCER AND BREAST SELF EXAMINATION

1. Have you ever heard of breast cancer before?

a. Yes b. No

2. Do you have any family history of breast cancer?

a. Yes b. No
if yes who has the disease _________________________________________

3. Have you ever heard of breast self examination before?

a. Yes b. No

4. Which of the following was the source of information for breast cancer and breast self
examination?
a. Friends b. Magazines and c. Radio and d. Health
and realtives Newspaper Television professionals

5. Do you practice breast self examination?

a. Yes b. No
if yes, how frequently ________________________________

6. Breast cancer only occurs in __________________

a. Only in females b. Only in males c. both females and males d. Don’t know

7. Most common age group who are at risk of getting breast cancer is __________
a. 10 -19 yrs b. 20 – 29 yrs c. 30 – 39 yrs d. above 40 yrs

8. Which one of the following decreases the risk of getting breast cancer?
a. breast implants b. breast feeding c. cigarette smoking d. alcohol

9. High rates of breast cancer is found in

a. Short women b. Tall women c. Obese women d. thin women

10. Which one of the following increases the risk for getting breast cancer?
a. Use of Oral b. Healthy lifestyle c. breast feeding d. loose garments
Contraceptives

11. Which one of the following is the early sign of breast cancer?
a. crackled nipples b. painless lump c. fever d. Pain in breast

12. Which of the following are the symptoms of breast cancer?

a. Change in the size or b. Swelling, warmth or redness c. Nipple discharge d. Scars
shape of the breast of breast that starts suddenly

13. Preventive measures for breast cancer includes

a. healthy lifestyle b. abstinence from c. breast implants d. breast massage

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 breast feeding

14. At what age should a woman begin breast self-examination?

a) 20 b) 30 c) 35 d) Don’t know

15. Breast self examination must be done

a. daily b. monthly c. yearly d. don’t know

16. Women should do breast self examination

a. before onset b. during menstruation c. after cessation of menses d. don’t know
of menses

17. Breast self examination should be done

a. using pads of fingers b. palms of fingers c. tips of fingers d. don’t know

18. Breast cancer can be treated by

a. surgery only b. radiation only c. diet and d. radiation and
exercise only surgery both

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SCORING
PART II
Q. 1 – Q. 5 - Questions regarding awareness about breast cancer and breast self examination.
Q. 6 – Q. 18 carries one mark
RATING
TOTAL SCORING = 13
0- 5 = POOR KNOWLEDGE
6- 9 = AVERAGE KNOWLEDGE
10-13 = GOOD KNOWLEDGE

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