Gynaecology Oncology Symposium:

Knowledge, attitude and practice of cervical cancer screening in women visiting a tertiary care hospital of Delhi

Original Article

Departments of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospitals, 1National Institute of Health and Family Welfare, New Delhi, India Correspondence to: Dr.  Meenakshi Singh, E‑mail: [email protected]

Singh M, Ranjan R1, Das B, Gupta K

Abstract

BACKGROUND: Cervical cancer being a major cause of morbidity and mortality in women in developing countries, its awareness is essential. AIM:

The aim of this study is to assess the knowledge, attitude and practices of women regarding the basic screening test for detection of cancer cervix. SETTINGS AND DESIGN: Population based cross‑sectional study. MATERIALS AND METHODS: Cross‑sectional prospective study was conducted. Information from consenting participants (450) was collected using structured questionnaire. Answers were described in terms of knowledge, attitude and practice and their respective adequacy with respect to Papanicolaou (Pap) test, the most common test used for early detection of cervical cancer. Adequacy was compared between the categories of socio demographic and clinical variables. STATISTICAL ANALYSIS: The data collected was analyzed using statistical package (SPSS version 18.0). Adequacy was compared between the categories of the control variables by χ2 test with a 5% significance level. RESULTS: Knowledge, attitude and practices regarding Pap test were adequate in 32.7%, 18.2% and 7.3% of women respectively. Major impediment to adequate practice was lack of request by physician. Knowledge, attitudes and practices were found to increase significantly with increasing age and education. CONCLUSION: Effective information, education and communication strategies are required to improve the level of awareness of public. Health‑care professional should be proactive in imparting knowledge at every opportunity. Key Words: Attitude, awareness, cervical cancer, knowledge, papanicolaou smear, practice, screening

Introduction Among the women, cervical cancer is one of the most common gynecological malignancies. The global burden of cervical cancer is disproportionately high among the developing countries where 85% of the estimated 493, 000 new cases and 273, 000 deaths occur world‑wide.[1] Cervical cancer is the single largest killer of middle‑aged women in India. The incidence of cervical cancer per 100, 000 Indian women of all ages varied between 30.0 and 44.9 (WHO, 2010). India bears about one‑fifth of the world’s burden of cervical cancer.[2] More than 100,000 new cases are detected in India per year and the disease causes almost 20% of all female deaths in India.[3] The relative proportion of cervical cancer has been reported to vary from 13.1 to 35.0 per lac population according to the National Cancer Registry Program.[4] The morbidity and mortality rates of cervical cancer are very high, so early detection and treatment is the only solution to it. The primary underlying cause is human papilloma virus, the most common sexually transmitted infection worldwide. Cervical cancer is more common in women having multiple sex partners or who have sex with men who had many other partners. Other causes include smoking and poor sexual hygiene. Public health programs will be of great success only if the level of awareness among women is immense. The Papanicolaou (Pap) test has been proved to be a very useful and effective tool to reduce mortality through early diagnosis.[5,6] In addition, the Pap test is relatively easy, cheap/free of cost and reliable. In a meta‑analysis, a sensitivity of 30‑87% and specificity of 86‑100% for the Pap smear test were reported.[7] Accordingly, Pap smear screening Access this article online Quick Response Code:

Website: www.indianjcancer.com DOI: 10.4103/0019-509X.146780 PMID: *******

Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

is therefore included in national cancer screening programs of many countries. Still world‑wide consensus about the starting period, interval and the ending period for screening test has not been reached. The differences observed between developed and developing countries with respect to mortality due to cervical cancer may be attributed directly to the frequency as well as acceptance of the Pap test. Various studies show a positive correlation between reduced mortality and Pap testing.[8,9] Despite availability of an effective and simple screening test, cervical cancer remains to be the most common cancer among Indian women. The aim of this study was to evaluate socio demographic predictors of knowledge and utilization of Pap test. Understanding the factors associated with the underutilization of cervical cancer screening is important in order to increase overall cancer screening rates and eventually reduce cervical cancer related morbidity and mortality. Studies identifying factors that determine adherence to Pap testing in Indian women are scarce; there is no study in tertiary care hospitals of Delhi. The objective of the present study is to assess knowledge, attitude, practice about cervical cancer and its screening and various impediments to their adequacy in women visiting a tertiary care hospital in Delhi. Materials and Methods This cross‑sectional study was performed in the Department of Obstetrics and Gynecology of a tertiary care hospital of Delhi. A total of 450 women between 15 years and 64 years of age were selected randomly from those who visited the out‑patient department irrespective of reason (s) for the visit. Women were interviewed with semi structured confidential interview schedule for duration of 3 months applied by trained interviewers. Women were provided information about the study, its objectives and assurance of confidentiality and those who met the inclusion criteria were invited to participate in the study. Those who voluntarily agreed to participate signed a free informed consent and were interviewed. Women who were not aware about the cervical cancer, its risk factors, preventive measures and its vaccine were informed and counseled for the same. 319

Singh, et al.: Knowledge, attitude and practice of cervical cancer screening in women

They were enquired regarding their socio demographic profile and questions reflecting their knowledge, attitude and practices towards cervical cancer screening. Demographic variables such as age, educational status, occupation, family income, residence, religion and marital status etc., were considered as independent variables.

groups (15‑24 years) and 95.3% were housewives. Most of the respondents (67.1%) were residing in urban slum areas. About 79.3% had monthly income less than Rs. 5000. Most of them (74.0%) had less than three children. Majority (87%) were Hindus. Most of the women (90%) had normal menstrual history.

The inclusion criteria included sexually active women aged 15‑64 years and willing to participate in the study. The study was approved by the Independent Ethics Committee.

As regarding the level of knowledge of Pap test, although 40% of women had heard about it only 32.7% had adequate knowledge. The main source of information was from health‑care professionals (40%) [Table 1].

For the analysis of data about knowledge, attitude and practice of women related to Pap test, definitions were adopted as described by Gamarra et al.[8] as follows: Adequate knowledge

Women who had heard of cervical cancer and its screening tests and knew the ways/tests for detecting and preventing cervical cancer. Inadequate knowledge

Women who had never heard of the cervical cancer and its screening tests, or who had heard of it, but were not aware of screening methods aimed to detect cervical cancer. Adequate attitude

Women, who considered it as necessary to undergo the screening test for cervical cancer periodically i.e. once in 3 years, which is related to their knowledge on screening policy. Inadequate attitude

Women who had heard or never heard of the test; women who do not consider it a necessity to undergo the test; women who had no opinion on the matter. Adequate practice

Women who underwent test within 3 years, prior to data collection. Inadequate practice

Women who underwent the test more than 3 years prior to data collection or who never had the test. Responses were described in terms of their adequacy. Data analysis

Data was simultaneously entered into proforma and was updated. It was entered into Microsoft excel (MS Office 2007) and Master Chart prepared. The data was analyzed using SPSS software version 18.0. Statistical analysis of data among groups was carried out, performed by nominal data (such as gender, marital status, profession), were presented as number and percentages. Continuous data (such as age etc.) were expressed as mean and standard deviation and Chi‑square test were applied as appropriate for comparison of nominal data. P value of 0.05 was considered as statistically significant. (Confidence interval of 95% was taken into account). Results The study sample comprised of 450 women between 15 years and 64 years, mean age being 36.5 years (SD 9.7). Of these, only 33.4% were educated up to 10th or above, 44% of patients belonged to younger age 320

A very small percentage (only 10%) of role was played by electronic and print media as source of information for cervical cancer screening. Knowledge about the test was significantly associated with some of the socio demographic and reproductive characteristics studied. Significantly greater proportions of adequate knowledge, attitude and practice were identified among women in higher age group, better educational status, better family income, women belonging to urban slum areas, working women and nulliparous or women with more than equal to three children. In addition, increased proportion of adequate knowledge and attitude were seen among menopausal women although adequate practice was found to be evidently higher among those with abnormal uterine bleeding [Table 2a and b]. Only 20% women considered any sort of testing necessary and just 18.2% showed adequate attitude and were aware of its advantage, correctly stating the significance of periodical testing [Table 3]. With respect to their practices, the majority (80.4%) women responded that they had never been tested. However, only 7.3% reported to have been tested at least once every 3 years according to the ACOG recommendations for adequate practice [Table 4]. Our results have shown that there is great disparity between adequate knowledge and practice. This means that only having knowledge is not sufficient for undergoing Pap test. There are some hindrances, which need to be overcome. Major impediment to adequate practices of Pap test identified among these women was a lack of request/ prescription by the physician/doctor [Figure 1]. The main Table 1: Awareness of women regarding Papanicolaou test and source of knowledge Variable Awareness of the test Yes No Knowledge Adequate Inadequate Source of knowledge Electronic media Family members and relatives Friends Health care professionals

n (450)

%

180 270

40 60

147 303 n=180 18 28 62 72

32.7 67.3 10.0 15.6 34.4 40.0

Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

Singh, et al.: Knowledge, attitude and practice of cervical cancer screening in women

Table 2a: Association of the adequacy of knowledge, attitude and practice regarding cervical cancer screening with various socio demographic characteristics Characteristic Age (years) 15‑24 5‑34 35‑64 years Education status Illiterate Less than 8th 8th pass 10th pass 12th pass Graduate Residence Urban slum Urban non slum Rural Family income in Rs.(p.m) 10000 pm

P value

Adequate practice n (%)

P value

0.000

17 (8.6) 4 (2.5) 12 (13.3)

0.004

23 (13.5) 3 (6.2) 11 (13.6) 19 (23.5) 8 (20.5) 18 (60.0)

0.000

6 (3.5) 0 (0.0) 0 (0.0) 12 (14.8 0 (0.0) 15 (50.0)

0.000

0.000

70 (23.2) 10 (7.9) 2 (9.5)

0.001

28 (9.3) 4 (3.1) 1 (4.8)

0.07

0.185

27 (19.3) 35 (16.1) 12 (15.4)

0.004

11 (7.9) 14 (6.5 4 (5.1)

0.028

Total

Adequate knowledge n (%)

Adequate attitude n (%)

198 162 90

45 (22.7) 51 (31.5) 51 (56.7)

0.000

27 (13.6) 24 (14.8) 31 (34.4)

171 48 81 81 39 30

45 (26.3) 8 (16.7) 21 (25.9) 30 (37.0) 18 (46.2) 25 (83.3)

0.000

302 127 21

137 (45.4) 8 (6.3) 2 (9.5)

140 217 78

50 (35.5) 63 (29.0) 26 (33.3)

15

8 (53.3)

P value

8 (53.3)

4 (26.7)

Table 2b: Association of the adequacy of knowledge, attitude and practice regarding cervical cancer screening with various socio demographic characteristics Characteristic Occupation Housewife Working Parity 0 1 2 3 4 ≥5 Religion Hindu Muslim Others Menstrual history Normal Abnormal uterine bleeding Postmenopausal Age at marriage 12‑6 years 17‑21 years >21 years

P value

Adequate practice n (%)

P value

0.0208

23 (22.5) 3 (14.3)

0.021

10 (47.6) 25 (15.7) 12 (7.8) 15 (26.3) 14 (38.9) 6 (25.0)

0.000

9 (42.9) 11 (6.9) 3 (2.0) 1 (1.8) 9 (25.0) 0 (0.0)

0.000

0.299

66 (17.7) 3 (22.2) 0 (0.0)

0.014

27 (6.8) 6 (11.1) 0 (0.0)

0.002

122 (30.3) 3 (33.3) 22 (61.6)

0.001

66 (16.4) 3 (33.3) 13 (36.1)

0.014

24 (6.0) 3 (33.3) 6 (16.7)

0.002

108 270

31 (28.7) 82 (30.4)

0.007

17 (15.7) 48 (7.8)

0.306

6 (5.6) 18 (6.7)

0.138

69

34 (49.3)

Total

Adequate knowledge n (%)

429 21

135 (31.5) 12 (57.1)

0.014

30 (7.0) 3 (14.3)

21 159 21 57 36 24

12 (57.1) 46 (28.9) 28 (18.3) 30 (52.6) 18 (50.0) 13 (54.1)

0.000

392 54 4

126 (31.8) 21 (38.8) 0 (0.0)

405 9 36

reason behind up taking of Pap test was prevention of cervical cancer. Discussion Despite its effectiveness as a method of controlling the incidence of cervical cancer, there is significant underutilization of Pap test. Its promotion in health‑care sector can provide Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

Adequate attitude n (%)

17 (24.6)

P value

9 (13.0)

an important opportunity for intervention. Availability of Pap smear facility for early detection of cervical cancer is not by itself sufficient for reducing the mortality by this type of cancer among women. The impact of the test depends upon its proper utilization by the target population. The level of adequacy of knowledge, attitude and practice in our subjects were found to be very low as compared with 321

Singh, et al.: Knowledge, attitude and practice of cervical cancer screening in women

Table 3: Attitude of women regarding cervical cancer screening test Variable

n (450)

%

90 360

20 80

82

18.2

368

81.8

Need of testing Necessary Unnecessary Attitude Adequate Inadequate

Table 4: Practices and adequacy of practice and reasons for adequate practice Variable

Response

n (450)

%

Type of practice

Have been tested Never been tested Adequate Inadequate To prevent cervical cancer

88 362

19.6 80.4

33 417 18

7.3 92.7 54.5

Advice of health‑ care personnel Friends or family advice

5

15.2

4

12.2

Test was free

6

18.1

Practice Reasons of adequate practice toward testing (n=33)

absorb information. More awareness and good practices among working women is similar to other studies. [10‑12] This might be owing to more access to information about the test through colleagues and media and more opportunities to get tested. Higher knowledge, attitude and practice in nulliparous patients can be explained owing to the fact that they more often seek medical advice for infertility. Women with higher parity too reflected higher awareness, which might be due to their visits to doctors to prevent unplanned pregnancies. As seen in various other studies our results also show a greater proportion of adequate knowledge, attitude and practice among women with higher income.[12,13,17] The women with abnormal uterine bleeding showed increased rates of adequate attitude and practices. This can be explained by the fact that these women might be visiting hospital due to fear of being ill or might have been offered the test by the medical professional based on the symptoms. The most cited barriers to screening were lack of advice by the physician or that patient did not consider themselves being ill. Similar findings were seen in other studies.[10,12,15] This calls upon need of support system from healthcare professionals to make the patients aware of the test and offer them as per requirement. In addition, communication through electronic and print media needs to be strengthened. Conclusion A well‑designed health education program focusing on effective IEC strategies including multipronged approach utilizing pictorials, audio‑visual and personal communication on cervical cancer could yield beneficial results. Lost opportunities for Pap smears would be minimized if healthcare providers will optimize their efforts to use each contact with their patients to request the test and properly counsel and inform them about the test according to the established criteria. There is a need for active participation of health‑care professionals. It gives an insight for formulation of strategies of strategies for optimal utilization of Pap test, the women for the same.

Figure 1: Impediments to adequate practice

similar studies in Argentina, Kuwait, N. E. Brazil.[10‑12] Our study identified age[12,13] and education[10‑18] as significant factors independently associated with adequacy of knowledge, attitude and practice of cervical cancer screening consistent with many studies conducted in other parts of the world. Increase in knowledge, attitude and practice with increasing age can be explained by the fact that younger women tend to be healthier and thus would not seek medical advice or would have relatively less contact with the health service providers. Furthermore, physicians and patients usually behave differently in response to illness level according to the patient’s age, which makes it less likely that health‑care provider will advise for testing in younger age group unless symptomatic. The increase of knowledge of cervical cancer screening in educated women may indicate that women with better education have better communication skills and ability to 322

References 1. Ali F, Kuelker R, Wassie B. Understanding cervical cancer in the context of developing countries. Ann Trop Med Public Health 2012;5:3‑15. 2. Indian Council of Medical Research. National cancer registry programme, two‑year report of the hospital based cancer registries 1999‑2000. Bangalore: ICMR; 2005. p. 3. 3. Koss LG. The Papanicolaou test for cervical cancer detection. A triumph and a tragedy. JAMA 1989;261:737‑43. 4. Lăără E, Day NE, Hakama M. Trends in mortality from cervical cancer in the Nordic countries: Association with organised screening programmes. Lancet 1987;1:1247‑9. 5. Nanda K, McCrory DC, Myers ER, Bastian LA, Hasselblad V, Hickey JD, et al. Accuracy of the Papanicolaou test in screening for and follow‑up of cervical cytologic abnormalities: A systematic review. Ann Intern Med 2000;132:810‑9. 6. Isla V. Cervico‑uterine cancer: The cancer that should not kill. Agenda Salud 2002;25:1‑8. 7. Robles S, White F, Peruga A. Trends in mortality from cervical cancer in the Americas. Bol Oficina Sanit Panam 1996;121:478‑90. 8. Gamarra CJ, Valente JG, Silva GA. Correction for reported cervical cancer mortality data in Brazil, 1996‑2005. Rev Saude Publica 2010;44:629‑38. 9. Al Sairafi M, Mohamed FA. Knowledge, attitudes, and practice related to cervical cancer screening among Kuwaiti women. Med Princ Pract 2009;18:35‑42. Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

Singh, et al.: Knowledge, attitude and practice of cervical cancer screening in women 10. Fernandes JV, Rodrigues SH, Costa YG, Silva LC, Brito AM, Azevedo JW, et al. Knowledge, attitudes, and practices related to Pap test by women, Northeastern Brazil. Rev Saude Publica 2009;43:851‑8. 11. Nguyen TT, McPhee SJ, Nguyen T, Lam T, Mock J. Predictors of cervical Pap smear screening awareness, intention, and receipt among Vietnamese‑American women. Am J Prev Med 2002;23:207‑14. 12. Hadi N, Azimirad A. Knowledge Attitude and practice of women in Shiraz about cervical cancer and Pap smear 2009. Iran J Cancer Prev 2010;3:117‑26. 13. Nwankwo KC, Aniebue UU, Aguwa EN, Anarado AN, Agunwah E. Knowledge attitudes and practices of cervical cancer screening among urban and rural Nigerian women: A call for education and mass screening. Eur J Cancer Care (Engl) 2011;20:362‑7. 14. Sabates R, Feinstein L. The role of education in the uptake of preventative

health care: The case of cervical screening in Britain. Soc Sci Med 2006;62:2998‑3010. 15. Qi V, Phillips SP, Hopman WM. Determinants of a healthy lifestyle and use of preventive screening in Canada. BMC Public Health 2006;6:275. 16. Maxwell CJ, Bancej CM, Snider J, Vik SA. Factors important in promoting cervical cancer screening among Canadian women: Findings from the 1996‑97 National Population Health Survey (NPHS). Can J Public Health 2001;92:127‑33. How to site this article: Singh M, Ranjan R, Das B, Gupta K. Knowledge, attitude and practice of cervical cancer screening in women visiting a tertiary care hospital of Delhi. Indian J Cancer 2014;51:319-23. Source of Support: Nil. Conflict of Interest: None declared.

Interview Schedule 1. Age (in completed years) _________ 2. Educational Status Illiterate/Less than 8th/8th pass/10th pass/12th pass/graduate. 3. Occupation Working/House wife 4. Family Income p.m 10,000 Rs 5. Residence Urban slum/Urban Non slum/Rural 6. Religion: 1. Hindu () 2. Muslim () 3. Others () 7. Marital status: 1. Unmarried () 2. Married () 3.Widowed/Divorced/Separated () 8. G P A L 9. Age at marriage: _____Age of first intercourse (in case of Unmarried) ________ 10. Sexual Partners: 1 () 2 () >2 (). 11. Menstrual History: Normal () Abnormal uterine bleeding () Post‑menopausal bleeding () 12. Have you ever heard about cervical cancer? Yes/No 13. Have you ever heard about any screening test for cervical cancer (Pap test)? Yes/No 14. If Yes what is the source of knowledge i. Electronic media ii. Family members and relative iii. Friends iv. Health care professionals v. Others 15. Are you aware that screening methods were aimed to detect cervical cancer? Yes/No 16. Do you consider necessary to undergo the screening test for cervical cancer periodically? Yes/No 17. If yes, what should be the frequency? a. Once in life time b. Every year c. After 2‑3 years d. After 5‑10 years e. Don’t know 18. Have you ever undergone Pap test? Yes/No 19. If yes, when did you undergone the test_______________ 20. What was the reason for pap testing periodically? a. To Prevent cervical cancer b. Advice of health care personnel c. Friends or family advice d. Test was free of cost 21. What was the impediment for not undergoing Pap test periodically? a. Physician did not advise b. Did not feel ill or show symptoms c. Lack of money for test d. Carelessness e. Cannot miss work f. Place of consultation too far g. Embarrassment h. No one to care for children/relatives i. others Indian Journal of Cancer | July–September 2014 | Volume 51 | Issue 3

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Knowledge, attitude and practice of cervical cancer screening in women visiting a tertiary care hospital of Delhi.

Background: Cervical cancer being a major cause of morbidity and mortality in women in developing countries, its awareness is essential. Aim: The aim ...
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