Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 13  |  Issue : 2  |  Page : 318--323

Awareness of cervical cancer and willingness to participate in screening program: Public health policy implications


Somdatta Patra, Madhu Upadhyay, Pragti Chhabra 
 Department of Community Medicine, University College of Medical Sciences and GTB Hospital, New Delhi, India

Correspondence Address:
Somdatta Patra
Department of Community Medicine, University College of Medical Sciences and GTB Hospital, New Delhi
India

Abstract

Background: Cervical cancer is one of the most common malignancies among women in India. There is a high mortality as patients usually present at an advanced stage because of lack of awareness and nonexistent screening programs. Aim: This study was planned to find out awareness about cervical cancer among women and their willingness to utilize screening services in an urban resettlement colony of Delhi, India. Settings and Design: A community-based, cross-sectional study was carried out in a resettlement colony of North-West Delhi. Materials and Methods: Semi-structured interview schedule was used to collect information regarding different aspects of cervical cancer. Analysis was done using SPSS package (SPSS version 16 (UCMS and GTBH, Delhi, India)). Results: A total of 373 women were included in the study. Mean age of study participants was 39.14 years. Two-third of the study population were illiterate. Half of the study population was aware of cervical cancer, and only one-fourth of population were willing to participate in a screening test. Willingness was higher among educated, ever user of family planning method and having knowledge about at least one risk factor, signs or symptoms, or possibility of early diagnosis of cancer cervix. Conclusions: The country's national program advocates for opportunistic and targeted screening of women. An understanding of the factors that influences womens' willingness to participate in screening program is essential for the success of such programs. Hence, this study emphasizes the need for dissemination of knowledge about various aspects of cancer cervix which is critical for uptake of any screening program in a developing country.



How to cite this article:
Patra S, Upadhyay M, Chhabra P. Awareness of cervical cancer and willingness to participate in screening program: Public health policy implications.J Can Res Ther 2017;13:318-323


How to cite this URL:
Patra S, Upadhyay M, Chhabra P. Awareness of cervical cancer and willingness to participate in screening program: Public health policy implications. J Can Res Ther [serial online] 2017 [cited 2022 Sep 25 ];13:318-323
Available from: https://www.cancerjournal.net/text.asp?2017/13/2/318/187279


Full Text

 Introduction



In India, cervical cancer is one of the leading malignancies among women, with about 130,000 new cases and 74,000 deaths every year [1] accounting for 30% of global cervical cancer mortality.[2] India's cervical cancer age-standardized incidence rate (30.7 per 100,000) and age-standardized mortality rate (17.4 per 100,000) are the highest in South Central Asia. Data from some cancer registries suggest that there may have been a slight decline in cervical cancer incidence in the recent years. However, the absolute incidence is still very high, especially in rural areas, and the number of cases is increasing due to high population growth.[3] Although cervical cancer can be treated effectively if detected in Stage I and II, it does not cause any symptom in early stages. In the absence of a screening program, most of these cases come to the attention of doctors at an advanced stage when hardly any curative management is possible. Cervical cancer is a subject that is not freely discussed in India because of cultural taboo. There is an urgent need for information and education on awareness of cervical cancer and early detection measures. Furthermore, important is to find out the willingness of women to utilize screening services and to comply with follow-up treatment protocol. Global evidence demonstrates that the key to reducing cervical cancer morbidity and mortality is early detection coupled with timely treatment of cervical precancerous lesions.[4] Cervical cytology often referred to as the Papanicolaou test (Pap test) is perhaps the most well known of available screening methods.[5] The present study was done to find out awareness of carcinoma cervix, early detection measures, and willingness of the women to utilize screening services.

 Materials and Methods



A community-based cross-sectional study was done from January to June 2012 among women residents aged 30–60 years in an urban resettlement colony (A resettlement colony is defined as a colony created by removing a group of households from the congested city core or an encroachment in public places and locating them generally in the periphery of the city)[6] at Swarnjayanti Vihar, at Narela in North-West Delhi, India. This area is the Intensified Field Practice area of Department of Community Medicine of a Medical College in Delhi harboring a population of 8500 approximately with nearly 82% of the population being original residents of the area.

As no data were available about awareness of cervical cancer among women from resettlement colony in India, assuming a prevalence of 50%, an absolute error of 5% and with confidence level of 95%, the sample size was calculated to be 400. There were around 1200 households in the study area. One eligible participant (female, aged between 30 and 60 years) from every 3rd household was included in the study by systematic random sampling method. If there were more than one eligible woman in a household, the eldest was selected for the study. If a house was found locked or no eligible woman was found in the house, then the next house was visited.

A pretested semi-structured interview schedule was used to collect information. The interview schedule had three parts. The first part had details about sociodemographic variables (age, education, marital status, number of children, and family income) and family planning practices. The second part had questions to find out the awareness about risk factors, signs and symptoms of cervical cancer and its prevention. The questions were developed based on review of literature and previously established facts about cervical cancer. Two questions were included, which were not associated with cervical cancer, to assess alternative beliefs and deter patterned responses.[7] One of these questions was about a potential association of frequent sexual activity with the same partner and cervical cancer risk, and the other asked about a potential association of multiple miscarriages with cervical cancer.

In the third part, all study participants were asked, after explaining the procedure of Pap smear, if they were willing to participate in a cervical cancer screening program if that was available in the nearby hospital. Cervical cancer screening was not done on a regular basis in the nearby secondary level of hospital. The interview schedule was applied with the help of a community volunteer who was adequately trained for this purpose and was experienced in conduct of similar field-based health surveys. She was directly supervised by the investigators.

The data thus collected were entered into MS Excel and after cleaning was analyzed using SPSS version 16 (UCMS and GTBH, Delhi, India). Simple descriptive tables were generated to denote frequencies. Cross-tabulation and Chi-square test were applied to study the association of various sociodemographic characteristics with awareness about cancer cervix and willingness to participate in the screening program for cancer cervix.

Approval of Institute's (Medical College) Ethics Review Committee was obtained before initiation of the study. Informed written consent was obtained from all study participants and as and when required they were appropriately treated or were referred to a higher center for any reported morbidity. During the study, it was ensured that if any of the study participants were willing to undergo screening, she would be facilitated for further investigations and management. This study was done before the department organized a health education program to spread awareness about cancer cervix.

 Results



Characteristics of the study population

A total of 373 women were included in the study. Mean age of the study participants was 39.14 years ± 7.59 standard deviation with majority (66%) being in the age group of 30–40 years. Two-third of the study population (65%) were illiterate and half of them had never used any family planning method. Mean income per capita was Rs. 764.10 with 61% of the population having per capita income of Rs. 501–1000.

Awareness of cervical cancer

Out of the 373 women interviewed, 80% (n = 298) were aware of cancer as a disease. However, a little more than half of women (n = 201) were aware of cervical cancer.

The proportion of women who were aware of cancer cervix increased as the literacy status increased, and this association was statistically significant. Similarly, those who had a higher per capita income were more aware of cervical cancer as compared to those belonging to a family with a lower per capita income and this difference was also statistically significant. Statistically significant association was also seen between ever use of a family planning method and awareness about this particular cancer. However, we did not find statistically significant association between age and awareness of cervical cancer [Table 1].{Table 1}

Knowledge about established risk factors of cancer cervix

The women who were aware of cancer cervix (n = 201) were asked about the risk factors of this cancer. Only 55% (n = 110) mentioned at least one risk factor correctly. Twenty-nine percent of women (n = 58) mentioned advancing age as a risk factor. Thirty-eight percent (n = 77) women rightly identified onset of sexual intercourse at an early age do have some consequence on occurrence of carcinoma cervix. Over 53% (n = 107) of participants mentioned nonmaintenance of hygiene at the time of menstruation as a risk factor for cancer cervix. Other established risk factors which were rightly interpreted were multiparty (24%, n = 49), smoking (12%, n = 24), and absence of Pap testing (3.5%, n = 7). Only 10% (n = 21) wrongly identified frequent sexual activity with the same partner, whereas 41% (n = 83) believed multiple miscarriages as a risk factor for cervical cancer [Table 2].{Table 2}

Knowledge of signs and symptoms

Out of 201 participants who were aware of cervical cancer as a disease, 46% were aware of at least one signs and symptoms correctly. Forty percent (n = 80) of them were aware that bleeding between two menstrual cycles could be a sign of cervical cancer. Thirty-two percent (n = 65) of study population mentioned bleeding after intercourse as a symptom. Almost one-fourth of the study population were aware of postmenopausal bleeding and discomfort during intercourse (n = 90 and 92) as signs of this cancer. Twenty-one percent of the study population mentioned abnormal vaginal discharge as a symptom. Only twenty women mentioned pain in pelvic region as a symptom.

Knowledge about early detection methods

Only 11% of the participants (n = 23) were aware that cervical cancer can be detected early. Fifteen respondents (7%) said that it could be detected by Pap smear. Ten percent of the women thought it could be detected by clinical examination by a doctor. Thirty-nine percent women (n = 78) thought a treatment for this particular form of cancer is available.

Source of information

Most of the respondents had heard about cervical cancer from friends and relatives.

Other sources of knowledge were health-care personnel (28%), print media (25%), television (24%), and radio (11%).

Willingness to participate in a cervical cancer screening program

All study participants were explained about the importance and procedure of the established screening test for carcinoma cervix and were asked if such a facility was available to them whether they would be willing to undergo such a test. Only one-fourth (n = 90) of the study population were willing to go through a screening test for cancer cervix. It was found that willingness to participate was higher with higher literacy status and ever use of family planning methods. Study participants who were aware of at least one correct risk factor or one sign/symptom or possibility of early detection of this particular form of cancer were more willing to participate in screening program than people who were not aware these aspects. No significant association was found between willingness to participate and participant's awareness of cervical cancer as a form of cancer, age, and income per capita [Table 3].{Table 3}

 Discussion



In the present study, we found that only 54% of the respondents were aware of cervical cancer as a disease. Those who were aware were more likely to be educated and have a higher per capita income than those who were not aware.

The present study population had very poor knowledge about established risk factors of cancer cervix which is consistent with findings elsewhere from India.[8],[9] Only 11% of women who were aware of cancer cervix thought that early detection was possible, and only 7% were aware of Pap smear as a screening technique. The findings of our study concurred with a similar study done in Malaysia in 2009.[10] Two-third of the study population who were aware of cervical cancer had heard about it from neighbors and relatives. Television, a very popular mass media, was mentioned as a source of information only by 16% of study population. Similar findings were reported from a study done in Mangalore, which mentioned television as a source of information for cervical cancer by only 14% women.[11]

Our study revealed that willingness to participate in a screening procedure was higher among those who were educated and had ever used any modern method of family planning which was consistent with reports from other studies conducted across Maharashtra and rural Uttar Pradesh, India.[12],[13] Although we did not find age as a significant factor for willingness to participate in a screening program for cancer cervix, a study from Kerala reported an increase in participation with increase in age.[14] The probable reason for this difference could be better awareness levels and access to health care and more exposure to the health-care providers in that region. We found that women who were aware of some risk factors, signs and symptoms, were willing to participate than who were not aware. All the women (100%) who were aware that early detection is possible were willing to participate in a screening program.

Studies of various aspects of knowledge have demonstrated that the lack of knowledge about cervical cancer appears to be an important factor to determine women's willingness to participate in cervical cancer screenings program.[15],[16],[17]

Till now, there is no established national screening program for cervical cancer in India. Screening programs have been shown to reduce the incidence and mortality from cervical cancer in many developed countries.[18],[19],[20],[21],[22] The National Programme for Prevention and control of Cancer, Diabetes, Cardio Vascular Diseases, and Stroke (NPCDCS) advocates for opportunistic and targeted screening of women of the age group >30 years at district NCD clinic for early detection of cervix cancer.[23]

Success of any screening program primarily depends on screening uptake or high level of screening attendance. Prior-understanding of the factors that determine women's willingness to participate is the central key for this. This study reported willingness to participate in a screening program was higher among participants who were aware of risk factors, signs and symptoms, and possibility of early diagnosis. Association between awareness about cervical cancer and willingness to participate in cervical cancer screening program has been documented by other studies too.[24],[25] This finding emphasizes the need for dissemination of knowledge about this cancer to ensure uptake of screening services. It was also found that the primary source of knowledge was from relatives and neighbors. It has been reported that anxiety associated with cervical cancer screening results from insufficient information or magnification of different facts.[26] There is a need to disseminate the correct knowledge which is sensitive to religious and cultural need. Popular mass media and commercials can be used to raise awareness.[27] Trained nonmedical personnel like Accredited Social Health Activist who are females and are from the same or nearby community can also act as a key link for raising awareness.

 Conclusion



Women in this community were ignorant about risk factors, signs and symptoms, and early detection measure of this particular cancer. Specific knowledge on cervical cancer and its early detection in precancerous stage and subsequent treatment is needed.

The limitation of this study was that it was a quantitative study and hence psychosocial and cultural reasons for not willing to participate in screening test could not be explored in depth. Other limitations were the study participants belonged to low income and less educated group, and so the results may not be generalized to other parts of India.

Our study recommends an urgent need to educate women in the community on different aspects of cervical cancer. Special efforts would be required for the core group of illiterate women for a better impact on screening acceptance. We recommend the establishment of policy guidelines for enhancement of knowledge among women for cervical cancer.

Financial support and sponsorship

Intramural Research Grant, University College of Medical Sciences and GTB Hospital, Delhi, India.

Conflicts of interest

There are no conflicts of interest.

References

1Ferlay J, Bray F, Pisani P, Parkin DM. Cancer Incidence, Mortality and Prevalence Worldwide, GLOBOCAN 2002. IARC Cancer Base No. 5 Version 2.0. Lyon: IARC, 2004.
2Drain PK, Holmes KK, Hughes JP, Koutsky LA. Determinants of cervical cancer rates in developing countries. Int J Cancer 2002;100:199-205.
3Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ 2001;79:954-62.
4Miller AB. Cervical Cancer Screening Programmes: Managerial Guidelines. Geneva: World Health Organization; 1992.
5Moyer VA; U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive services task force recommendation statement. Ann Intern Med 2012;156:880-91, W312.
6Banerji M. Provision of Basic Services in the Slums and Resettlement Colonies of Delhi; 2010. Available from: http://www.dspace.africaportal.org/jspui/bitstream. [Last accessed on 2015 May 02].
7Ralston JD, Taylor VM, Yasui Y, Kuniyuki A, Jackson JC, Tu SP. Knowledge of cervical cancer risk factors among Chinese immigrants in Seattle. J Community Health 2003;28:41-57.
8Siddharthar J, Rajkumar B, Deivasigamani K. Knowledge, awareness and prevention of cervical cancer among women attending a tertiary care hospital in Puducherry, India. J Clin Diagn Res 2014;8:OC01-3.
9Tripathi N, Kadam YR, Dhobale RV, Gore AD. Barriers for early detection of cancer amongst Indian rural women. South Asian J Cancer 2014;3:122-7.
10Wong LP, Wong YL, Low WY, Khoo EM, Shuib R. Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: A qualitative study. Singapore Med J 2009;50:49-53.
11Harsha Kumar H, Tanya S. A Study on knowledge and screening for cervical cancer among women in Mangalore City. Ann Med Health Sci Res 2014;4:751-6.
12Sankaranarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahé C, et al. Determinants of participation of women in a cervical cancer visual screening trial in rural South India. Cancer Detect Prev 2003;27:457-65.
13Asthana S, Labani S. Factors associated with attitudes of rural women toward cervical cancer screening. Indian J Community Med 2013;38:246-8.
14Aswathy S, Quereshi MA, Kurian B, Leelamoni K. Cervical cancer screening: Current knowledge and practice among women in a rural population of Kerala, India. Indian J Med Res 2012;136:205-10.
15Jia Y, Li S, Yang R, Zhou H, Xiang Q, Hu T, et al. Knowledge about cervical cancer and barriers of screening program among women in Wufeng County, a high-incidence region of cervical cancer in China. PLoS One 2013;8:e67005.
16Fylan F. Screening for cervical cancer: A review of women's attitudes, knowledge, and behaviour. Br J Gen Pract 1998;48:1509-14.
17Ansink AC, Tolhurst R, Haque R, Saha S, Datta S, van den Broek NR. Cervical cancer in Bangladesh: Community perceptions of cervical cancer and cervical cancer screening. Trans R Soc Trop Med Hyg 2008;102:499-505.
18Gustafsson L, Pontén J, Zack M, Adami HO. International incidence rates of invasive cervical cancer after introduction of cytological screening. Cancer Causes Control 1997;8:755-63.
19Gustafsson L, Pontén J, Bergström R, Adami HO. International incidence rates of invasive cervical cancer before cytological screening. Int J Cancer 1997;71:159-65.
20Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. Progress in cancer screening over a decade: Results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001;93:1704-13.
21Nygård JF, Skare GB, Thoresen SØ. The cervical cancer screening programme in Norway, 1992-2000: Changes in Pap smear coverage and incidence of cervical cancer. J Med Screen 2002;9:86-91.
22Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004;364:249-56.
23National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (Npcdcs). Directorate General of Health Services Ministry of Health and Family Welfare Government of India. Operational Guidelines. Available from: http://www.health.bih.nic.in/Docs/Guidelines/Guidelines-NPCDCS.pdf. [Last accessed on 2015 May 02].
24Wallington SF, Luta G, Noone AM, Caicedo L, Lopez-Class M, Sheppard V, et al. Assessing the awareness of and willingness to participate in cancer clinical trials among immigrant Latinos. J Community Health 2012;37:335-43.
25Ndikom CM, Ofi BA. Awareness, perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: A qualitative study. Reprod Health 2012;9:11.
26Baileff A. Cervical screening: Patients' negative attitudes and experiences. Nurs Stand 2000;14:35-7.
27Hussain SM. Cancer control in South Asia: Awareness is key to success. South Asian J Cancer 2013;2:55-6.