J Canc Educ DOI 10.1007/s13187-015-0863-7
Community-Based Health Education has Positive Influence on the Attitude to Cervical Cancer Screening among Women in Rural Nepal Sunila Shakya 1,2 & Biraj Man Karmacharya 3 & Jan Egil Afset 2,4 & Anna Bofin 2 & Bjørn Olav Åsvold 5,6 & Unni Syversen 6,7 & Solveig Tingulstad 2,8
# American Association for Cancer Education 2015
Abstract The main purpose of this study was to assess the knowledge of cervical cancer among women in rural Nepal and explore the feasibility and impact of a community-based awareness program on cervical cancer. Community-based educational meetings on cervical cancer and its prevention were conducted among women’s groups in rural Nepal. Through a questionnaire, the women’s baseline knowledge of risk factors, symptoms, and perceived risk of cervical cancer were identified. The willingness to participate in cervical cancer screening was compared before and after the educational meeting. The meetings were followed by a cervical cancer screening program. Among the 122 participants at the educational meeting, only 6 % had heard of cervical cancer. Their baseline knowledge of risk factors and symptoms was poor.
The proportion of women willing to participate in cervical screening increased from 15.6 to 100 % after attending the educational meeting. All the study subjects participated in the screening program. Additionally, the study participants recruited a further 222 of their peers for screening. Poor knowledge of cervical cancer among women in rural Nepal highlights the urgency of public awareness programs for cervical cancer at a national level. A community-based awareness program can change women’s attitude to cervical screening, and women’s groups can play a major role in promoting participation in cervical cancer screening programs.
* Sunila Shakya [email protected]; [email protected]
2
Department of Laboratory Medicine, Children’s and Women’s Health, Faculty of Medicine, Norwegian University of Science and Technology, 7491 Trondheim, Norway
3
Jan Egil Afset [email protected]
Department of Community Medicine, Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel Hospital, Kavre, Nepal
4
Anna Bofin [email protected]
Department of Microbiology, St. Olav’s Hospital, 7006 Trondheim, Norway
5
Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, N-7491 Trondheim, Norway
6
Department of Endocrinology, St. Olav’s Hospital, 7006 Trondheim, Norway
7
Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, N-7491 Trondheim, Norway
8
Department of Gynecologic Oncology, St. Olav’s Hospital, 7006 Trondheim, Norway
Biraj Man Karmacharya [email protected]
Keywords Cervical cancer . Awareness . Health education . Women’s group . Nepal
Bjørn Olav Åsvold [email protected] Unni Syversen [email protected] Solveig Tingulstad [email protected] 1
Department of Gynecology and Obstetrics, Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel Hospital, Kavre, Nepal
J Canc Educ
Introduction Cervical cancer is one of the major public health problems in Nepal. In 2013, 2332 diagnosed cases and 1367 deaths from cervical cancer were reported in Nepal [1]. Cervical screening has been very successful in developed countries, lowering cervical cancer mortality by 80 % [2]. In Nepal, a national cervical screening program is not yet commenced. Cervical cancer screening services are available only in tertiary level hospitals and private clinics in cities. Occasionally, cost-free screening camps are organized by non-governmental organizations. Through these opportunistic screening, only 4.7 % of women aged 18–69 years in urban areas and 2 % in rural areas are screened every 3 years [1]. A few years before the study was conducted, the National Health Education, Information and Communication Center (NHEICC), Department of health service Nepal, developed awareness and educational materials for cervical cancer. These educational materials have mainly been used at tertiary level health-care centers. In these materials, the Nepali term Pathegharko mukhko cancer for cervical cancer was applied. However, the lay term for womb cancer, which includes cervical cancer, is Pathegharko cancer. Addressing cervical cancer as women’s major health problem in Nepal, national guidelines for cervical cancer screening and prevention were prepared in 2010 with the strategic coverage goal of 50 % of the target population within a time span of 5 years [3]. In the current situation of low public awareness of cervical cancer in Nepal, more efforts are needed to implement the screening program and to reach its coverage goal. The screening coverage corresponds to women’s knowledge of cervical cancer and their attitude towards screening [4]. Data from a hospitalbased study conducted in the capital Kathmandu showed that screening participation among the study population was only 10.5 %, and the participants’ level of knowledge of cervical cancer was very low [5]. However, there are no published data on knowledge of cervical cancer among women from rural Nepal. As the female illiteracy rate in Nepal is high (42.6 %) [6], and 80 % of the population live in rural regions, it is a major challenge to motivate women to take part in screening. Among the existing interventions aimed at increasing screening participation, strategies using social network, lay healthcare workers, and community-based education can increase screening rates [7]. Women’s groups (Mother’s group) and female community health volunteers (FCHVs) are examples of such social networks at grassroots level in Nepal and are well-accepted key messengers and community mobilizers in Maternal and Child Health (MCH) programs in the country. A randomized controlled trial from Nepal has reported a significant reduction in maternal and neonatal mortality through intervention in these groups [8]. However, to date, there has been no published study from rural Nepal exploring awareness of cervical cancer among women and the potential role of
the women’s groups at grassroots level in cervical cancer prevention. Therefore, the main purpose of this study was to assess the knowledge of cervical cancer and its prevention among women in rural Nepal. Additionally, the study aimed to investigate the feasibility and impact of a community-based cervical cancer awareness program.
Methods Study Population The study was conducted during January–March 2010 in five rural community-based Outreach Health Centers (OHCs) run by Dhulikhel Hospital in the following Village Development Committees: Dapcha, Baluwa, Kattike-Deurali, Salambu, and Bahunepati, which are all located in rural, hilly regions of the Kavre and Sindhupalchowk districts of Nepal. The OHCs provide primary level facilities by a team comprising a medical doctor, an auxiliary nurse midwife, and a community medical assistant. Additionally, the OHCs are platforms for numerous community-based preventive health and community development programs. One of these is the micro-finance program which provides loan to members of women’s group to start and run the small business that help them support their family financially. The study participants were all members of these women’s groups and were permanent residents in catchment areas of the OHCs. These groups were established to lead public health efforts in the communities, particularly in Maternal and Child Health. The invitation to participate in the study was given to the women’s group leader who disseminated the invitation to all the group members a week prior to the initiation of the awareness program. The awareness program was presented in a total of eight health educational meetings held twice at Dapcha, Baluwa, and Bahunepati and once at Kattike-Deurali and Salambu. The meeting was led by the principle investigator (PI) who was a female gynecologist from Dhulikhel hospital. The PI had previously made regular consultation visits to the study sites and was well known by the community. Each meeting lasted from 3 to 4 h, and was divided into three sessions: pre-education session, education session, and post-education session. Pre-Education Session A questionnaire with open-ended and closed-ended questions was administered through face-to-face interview. All interviews were performed by the PI and a doctor trained in interviewing. The questionnaire consisted of sociodemographic information (age, education level, and income source), personal information (age at marriage, number of live births, number of marriage), and questions listed in Table 1 on knowledge and attitudes related to cervical cancer
J Canc Educ Table 1 Questions asked during pre-education session to assess participant’s knowledge of cervical cancer Outcome measures
Definition
Questions
Awareness of cervical Having previously Have you heard of the cancer/human heard of cervical term Bpathegarko papillomavirus/ cancer; human mukhko cancer^ or Papanicolaou (Pap) papillomavirus; Pap Bpathegharko test test cancer^? Have you heard of human papillomavirus? Have you heard of the Pap test? Knowledge of risk Ability to correctly What can affect a factors and identify known risk woman’s chance of symptoms of factors and developing cervical cervical cancer symptoms of cancer? What are cervical cancer the health problems of the women with early cervical cancer? Perceived risk Aware of being at risk Do you believe you are at risk of developing cervical cancer? Screening attitude Indication of Are you willing to willingness to undergo a test to participate in costprevent cervical free cervical cancer if the test is screening program offered free of cost? Why?
in order to determine the outcome measures of interest. We asked the women if they had heard about cervical cancer in general. Pathegharko cancer, which is the local term for womb cancer, including cervical cancer, was used. Additionally, we also asked them if they had heard of Pathegharko mukhko cancer, to investigate whether the NHEICC’s educational message on cervical cancer had reached the public. Education Session The education session was conducted by the PI at all the study sites, and was focused on cervical cancer and its prevention. The scope of the session was to fill the lack in knowledge that was identified during the pre-education session. The messages that were emphasized during education session were: (1) cervical cancer is preventable, (2) risk factors, signs, symptoms, and asymptomatic nature of early cervical cancer, and (3) importance of undergoing gynecological examination and cervical screening. A gynecologic simulator model (ZOE®) with normal and abnormal cervices was used to make the women aware of the different parts of the female reproductive organs, the uterine cervix in particular, and to demonstrate normal and abnormal cervix. Further, the simulator was used to demonstrate how gynecological examination is done and how the Pap smear is taken to illustrate that these procedures are
simple. Other educational materials comprised pictures illustrating risk factors and symptoms of cervical cancer. The participants were informed about the upcoming cost-free cervical cancer screening program, the importance of follow-up, and the referral system and treatment alternatives for abnormal findings, if required. At the end of the education session, the women were advised to disseminate the received information to their peers and motivate them to participate in the upcoming cervical screening program. Post-Education Session The participants were asked whether they were willing to participate in an upcoming cost-free cervical cancer screening program 2 weeks after the educational meeting. Cervical Cancer Screening Program Approximately 2 weeks following the health educational meeting, a 1-day cervical cancer screening program was conducted in each of the study sites. Name, age, and address were registered for all women attending the screening. Screening was performed by the PI. Data Analyses Collected data were analyzed using SPSS software (IBM SPSS version 21). Sociodemographic characteristics, perceived risk factors, and symptoms of cervical cancer are presented as frequencies and percentages. McNemar’s test was used to assess any changes in the participants’ willingness to participate in cervical cancer screening before and after the education session. The efficiency of the community-based educational session was measured by the number of study participants who took part in the cervical cancer screening and the number of their peers that they managed to recruit for participation in the screening program. Finally, we used chi-square tests or Fisher’s exact test to explore whether the participants’ pre-education willingness for screening or knowledge on symptoms and risk factors for cervical cancer differed by age group. Ethical Approval The study was approved by the Institutional Review Board of Kathmandu University School of Medical sciences/ Kathmandu University (KUSMS/KU-IRB). Verbal informed consent was obtained from all study participants after information was given regarding the purpose of the study, its anticipated benefits to the community and the individual, potential risks to the study participant, and confidentiality concerning the data that were collected.
J Canc Educ Sociodemographic characteristics of the study participants
Results
Table 2 (n=122)
One hundred and twenty-two members of the women’s groups participated in the study. Their median age was 35 years (range 18–68 years), and the majority (74.6 %) was aged 30 years or above. All the women were married, the mean age at marriage was 17.3 years (range 7– 28 years), and more than half of the participants (54.9 %) married before the age of 18. The average number of births was 3.1 (range 0–9), and 62.3 % of the participants had three or more children. Nearly two thirds of the participants (62.3 %) were illiterate, but all had their own source of income. Only one woman had been married more than once, while 14 % of the participants’ husbands had been married two or more times. Sixty percent of the husbands had informal or formal education, 51.6 % were farmers and 14 % were drivers by occupation. The details of sociodemographic characteristics are shown in Table 2. The majority of the participants were familiar with the local term Pathegharko cancer, but only 6 % had heard of the term Pathegarko mukhko cancer, the specific term for cervical cancer used in the educational material from NHEICC. However, none of the women had heard of human papillomavirus (HPV), Pap test, or cervical smear test. The majority of the participants (95.9 %) could mention one or more factors which they considered to be risk factors for cervical cancer, while only five (4.1 %) admitted that they were unaware of any risk factors. Among those women who mentioned risk factors, 87.2 % cited correctly at least one of the known risk factors for cervical cancer, while the remaining 12.8 % quoted incorrect factors. The most commonly reported factors perceived by the women to be risk factors were, in order of decreasing frequency: abnormal vaginal discharge, multiple sexual partners, multi-parity, and early onset of sexual activity. The risk factors that were mentioned by the study participants are listed in Table 3. The baseline knowledge about symptoms of cervical cancer among the study participants was poor. The majority (60.7 %) admitted that they did not know of any symptoms at all. Among the remaining 39.3 % women, 25 % cited incorrect symptoms. The different symptoms mentioned are listed in Table 4. Before the education session, only 19 participants (15.6 %) were willing to undergo cervical cancer screening and the majority of them (17/19, 89.5 %) regarded themselves to be at risk of developing cervical cancer. Among the 72 (59 %) participants who did not know if they wanted to participate in screening, 52 (72.2 %) admitted that they were unsure if they were at risk of developing cervical cancer. Thirty-one women (25.4 %) did not want to attend the screening, and most of them (27/31, 87.1 %) did not believe that they were at risk of developing cervical cancer. After completing the education
Characteristics
n
(%)
Age (years)
Community-Based Health Education has Positive Influence on the Attitude to Cervical Cancer Screening among Women in Rural Nepal Sunila Shakya 1,2 & Biraj Man Karmacharya 3 & Jan Egil Afset 2,4 & Anna Bofin 2 & Bjørn Olav Åsvold 5,6 & Unni Syversen 6,7 & Solveig Tingulstad 2,8
# American Association for Cancer Education 2015
Abstract The main purpose of this study was to assess the knowledge of cervical cancer among women in rural Nepal and explore the feasibility and impact of a community-based awareness program on cervical cancer. Community-based educational meetings on cervical cancer and its prevention were conducted among women’s groups in rural Nepal. Through a questionnaire, the women’s baseline knowledge of risk factors, symptoms, and perceived risk of cervical cancer were identified. The willingness to participate in cervical cancer screening was compared before and after the educational meeting. The meetings were followed by a cervical cancer screening program. Among the 122 participants at the educational meeting, only 6 % had heard of cervical cancer. Their baseline knowledge of risk factors and symptoms was poor.
The proportion of women willing to participate in cervical screening increased from 15.6 to 100 % after attending the educational meeting. All the study subjects participated in the screening program. Additionally, the study participants recruited a further 222 of their peers for screening. Poor knowledge of cervical cancer among women in rural Nepal highlights the urgency of public awareness programs for cervical cancer at a national level. A community-based awareness program can change women’s attitude to cervical screening, and women’s groups can play a major role in promoting participation in cervical cancer screening programs.
* Sunila Shakya [email protected]; [email protected]
2
Department of Laboratory Medicine, Children’s and Women’s Health, Faculty of Medicine, Norwegian University of Science and Technology, 7491 Trondheim, Norway
3
Jan Egil Afset [email protected]
Department of Community Medicine, Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel Hospital, Kavre, Nepal
4
Anna Bofin [email protected]
Department of Microbiology, St. Olav’s Hospital, 7006 Trondheim, Norway
5
Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, N-7491 Trondheim, Norway
6
Department of Endocrinology, St. Olav’s Hospital, 7006 Trondheim, Norway
7
Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, N-7491 Trondheim, Norway
8
Department of Gynecologic Oncology, St. Olav’s Hospital, 7006 Trondheim, Norway
Biraj Man Karmacharya [email protected]
Keywords Cervical cancer . Awareness . Health education . Women’s group . Nepal
Bjørn Olav Åsvold [email protected] Unni Syversen [email protected] Solveig Tingulstad [email protected] 1
Department of Gynecology and Obstetrics, Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel Hospital, Kavre, Nepal
J Canc Educ
Introduction Cervical cancer is one of the major public health problems in Nepal. In 2013, 2332 diagnosed cases and 1367 deaths from cervical cancer were reported in Nepal [1]. Cervical screening has been very successful in developed countries, lowering cervical cancer mortality by 80 % [2]. In Nepal, a national cervical screening program is not yet commenced. Cervical cancer screening services are available only in tertiary level hospitals and private clinics in cities. Occasionally, cost-free screening camps are organized by non-governmental organizations. Through these opportunistic screening, only 4.7 % of women aged 18–69 years in urban areas and 2 % in rural areas are screened every 3 years [1]. A few years before the study was conducted, the National Health Education, Information and Communication Center (NHEICC), Department of health service Nepal, developed awareness and educational materials for cervical cancer. These educational materials have mainly been used at tertiary level health-care centers. In these materials, the Nepali term Pathegharko mukhko cancer for cervical cancer was applied. However, the lay term for womb cancer, which includes cervical cancer, is Pathegharko cancer. Addressing cervical cancer as women’s major health problem in Nepal, national guidelines for cervical cancer screening and prevention were prepared in 2010 with the strategic coverage goal of 50 % of the target population within a time span of 5 years [3]. In the current situation of low public awareness of cervical cancer in Nepal, more efforts are needed to implement the screening program and to reach its coverage goal. The screening coverage corresponds to women’s knowledge of cervical cancer and their attitude towards screening [4]. Data from a hospitalbased study conducted in the capital Kathmandu showed that screening participation among the study population was only 10.5 %, and the participants’ level of knowledge of cervical cancer was very low [5]. However, there are no published data on knowledge of cervical cancer among women from rural Nepal. As the female illiteracy rate in Nepal is high (42.6 %) [6], and 80 % of the population live in rural regions, it is a major challenge to motivate women to take part in screening. Among the existing interventions aimed at increasing screening participation, strategies using social network, lay healthcare workers, and community-based education can increase screening rates [7]. Women’s groups (Mother’s group) and female community health volunteers (FCHVs) are examples of such social networks at grassroots level in Nepal and are well-accepted key messengers and community mobilizers in Maternal and Child Health (MCH) programs in the country. A randomized controlled trial from Nepal has reported a significant reduction in maternal and neonatal mortality through intervention in these groups [8]. However, to date, there has been no published study from rural Nepal exploring awareness of cervical cancer among women and the potential role of
the women’s groups at grassroots level in cervical cancer prevention. Therefore, the main purpose of this study was to assess the knowledge of cervical cancer and its prevention among women in rural Nepal. Additionally, the study aimed to investigate the feasibility and impact of a community-based cervical cancer awareness program.
Methods Study Population The study was conducted during January–March 2010 in five rural community-based Outreach Health Centers (OHCs) run by Dhulikhel Hospital in the following Village Development Committees: Dapcha, Baluwa, Kattike-Deurali, Salambu, and Bahunepati, which are all located in rural, hilly regions of the Kavre and Sindhupalchowk districts of Nepal. The OHCs provide primary level facilities by a team comprising a medical doctor, an auxiliary nurse midwife, and a community medical assistant. Additionally, the OHCs are platforms for numerous community-based preventive health and community development programs. One of these is the micro-finance program which provides loan to members of women’s group to start and run the small business that help them support their family financially. The study participants were all members of these women’s groups and were permanent residents in catchment areas of the OHCs. These groups were established to lead public health efforts in the communities, particularly in Maternal and Child Health. The invitation to participate in the study was given to the women’s group leader who disseminated the invitation to all the group members a week prior to the initiation of the awareness program. The awareness program was presented in a total of eight health educational meetings held twice at Dapcha, Baluwa, and Bahunepati and once at Kattike-Deurali and Salambu. The meeting was led by the principle investigator (PI) who was a female gynecologist from Dhulikhel hospital. The PI had previously made regular consultation visits to the study sites and was well known by the community. Each meeting lasted from 3 to 4 h, and was divided into three sessions: pre-education session, education session, and post-education session. Pre-Education Session A questionnaire with open-ended and closed-ended questions was administered through face-to-face interview. All interviews were performed by the PI and a doctor trained in interviewing. The questionnaire consisted of sociodemographic information (age, education level, and income source), personal information (age at marriage, number of live births, number of marriage), and questions listed in Table 1 on knowledge and attitudes related to cervical cancer
J Canc Educ Table 1 Questions asked during pre-education session to assess participant’s knowledge of cervical cancer Outcome measures
Definition
Questions
Awareness of cervical Having previously Have you heard of the cancer/human heard of cervical term Bpathegarko papillomavirus/ cancer; human mukhko cancer^ or Papanicolaou (Pap) papillomavirus; Pap Bpathegharko test test cancer^? Have you heard of human papillomavirus? Have you heard of the Pap test? Knowledge of risk Ability to correctly What can affect a factors and identify known risk woman’s chance of symptoms of factors and developing cervical cervical cancer symptoms of cancer? What are cervical cancer the health problems of the women with early cervical cancer? Perceived risk Aware of being at risk Do you believe you are at risk of developing cervical cancer? Screening attitude Indication of Are you willing to willingness to undergo a test to participate in costprevent cervical free cervical cancer if the test is screening program offered free of cost? Why?
in order to determine the outcome measures of interest. We asked the women if they had heard about cervical cancer in general. Pathegharko cancer, which is the local term for womb cancer, including cervical cancer, was used. Additionally, we also asked them if they had heard of Pathegharko mukhko cancer, to investigate whether the NHEICC’s educational message on cervical cancer had reached the public. Education Session The education session was conducted by the PI at all the study sites, and was focused on cervical cancer and its prevention. The scope of the session was to fill the lack in knowledge that was identified during the pre-education session. The messages that were emphasized during education session were: (1) cervical cancer is preventable, (2) risk factors, signs, symptoms, and asymptomatic nature of early cervical cancer, and (3) importance of undergoing gynecological examination and cervical screening. A gynecologic simulator model (ZOE®) with normal and abnormal cervices was used to make the women aware of the different parts of the female reproductive organs, the uterine cervix in particular, and to demonstrate normal and abnormal cervix. Further, the simulator was used to demonstrate how gynecological examination is done and how the Pap smear is taken to illustrate that these procedures are
simple. Other educational materials comprised pictures illustrating risk factors and symptoms of cervical cancer. The participants were informed about the upcoming cost-free cervical cancer screening program, the importance of follow-up, and the referral system and treatment alternatives for abnormal findings, if required. At the end of the education session, the women were advised to disseminate the received information to their peers and motivate them to participate in the upcoming cervical screening program. Post-Education Session The participants were asked whether they were willing to participate in an upcoming cost-free cervical cancer screening program 2 weeks after the educational meeting. Cervical Cancer Screening Program Approximately 2 weeks following the health educational meeting, a 1-day cervical cancer screening program was conducted in each of the study sites. Name, age, and address were registered for all women attending the screening. Screening was performed by the PI. Data Analyses Collected data were analyzed using SPSS software (IBM SPSS version 21). Sociodemographic characteristics, perceived risk factors, and symptoms of cervical cancer are presented as frequencies and percentages. McNemar’s test was used to assess any changes in the participants’ willingness to participate in cervical cancer screening before and after the education session. The efficiency of the community-based educational session was measured by the number of study participants who took part in the cervical cancer screening and the number of their peers that they managed to recruit for participation in the screening program. Finally, we used chi-square tests or Fisher’s exact test to explore whether the participants’ pre-education willingness for screening or knowledge on symptoms and risk factors for cervical cancer differed by age group. Ethical Approval The study was approved by the Institutional Review Board of Kathmandu University School of Medical sciences/ Kathmandu University (KUSMS/KU-IRB). Verbal informed consent was obtained from all study participants after information was given regarding the purpose of the study, its anticipated benefits to the community and the individual, potential risks to the study participant, and confidentiality concerning the data that were collected.
J Canc Educ Sociodemographic characteristics of the study participants
Results
Table 2 (n=122)
One hundred and twenty-two members of the women’s groups participated in the study. Their median age was 35 years (range 18–68 years), and the majority (74.6 %) was aged 30 years or above. All the women were married, the mean age at marriage was 17.3 years (range 7– 28 years), and more than half of the participants (54.9 %) married before the age of 18. The average number of births was 3.1 (range 0–9), and 62.3 % of the participants had three or more children. Nearly two thirds of the participants (62.3 %) were illiterate, but all had their own source of income. Only one woman had been married more than once, while 14 % of the participants’ husbands had been married two or more times. Sixty percent of the husbands had informal or formal education, 51.6 % were farmers and 14 % were drivers by occupation. The details of sociodemographic characteristics are shown in Table 2. The majority of the participants were familiar with the local term Pathegharko cancer, but only 6 % had heard of the term Pathegarko mukhko cancer, the specific term for cervical cancer used in the educational material from NHEICC. However, none of the women had heard of human papillomavirus (HPV), Pap test, or cervical smear test. The majority of the participants (95.9 %) could mention one or more factors which they considered to be risk factors for cervical cancer, while only five (4.1 %) admitted that they were unaware of any risk factors. Among those women who mentioned risk factors, 87.2 % cited correctly at least one of the known risk factors for cervical cancer, while the remaining 12.8 % quoted incorrect factors. The most commonly reported factors perceived by the women to be risk factors were, in order of decreasing frequency: abnormal vaginal discharge, multiple sexual partners, multi-parity, and early onset of sexual activity. The risk factors that were mentioned by the study participants are listed in Table 3. The baseline knowledge about symptoms of cervical cancer among the study participants was poor. The majority (60.7 %) admitted that they did not know of any symptoms at all. Among the remaining 39.3 % women, 25 % cited incorrect symptoms. The different symptoms mentioned are listed in Table 4. Before the education session, only 19 participants (15.6 %) were willing to undergo cervical cancer screening and the majority of them (17/19, 89.5 %) regarded themselves to be at risk of developing cervical cancer. Among the 72 (59 %) participants who did not know if they wanted to participate in screening, 52 (72.2 %) admitted that they were unsure if they were at risk of developing cervical cancer. Thirty-one women (25.4 %) did not want to attend the screening, and most of them (27/31, 87.1 %) did not believe that they were at risk of developing cervical cancer. After completing the education
Characteristics
n
(%)
Age (years)
