Abstract
BACKGROUND:
India suffers a quarter of the global burden of cervical cancer (CC) but is controllable by taking some precautions. The major issue is the low amount of participation among women in screening and vaccination for disease. The objective of the research is to evaluate knowledge, attitude, and practice (KAP) regarding CC among college going students residing in the Rayalaseema region of Andhra Pradesh—India.
MATERIAL AND METHODS:
A cross-sectional study was conducted on a total of 380 subjects whose ages ranged from 15 to 25 and older. The questionnaires were circulated through google forms. The socio-demographic variables and KAP levels are represented by descriptive statistics. The Chi-square test is used to determine the relationship between sociodemographic factors and KAP levels.
RESULTS:
Among 380 subjects, 172 (54.7%) are aware of CC, 71% have poor knowledge, and 20% have good knowledge about CC. More than three-fourths of women 374 (98.4%) are not having regular practice towards CC.
CONCLUSION:
The awareness about CC is very low in the population, so prevention of CC relies on routine screening, proper vaccination, and treatment. Awareness programs and promoting knowledge about cervical health in social media are required.
Keywords: Cervical cancer, college students, human papilloma virus, pap smear test, Rayalaseema
Introduction
Over the past 30 years, there has been an increase in the percentage of young women with cervical cancer (CC), which ranges from 10% to 40%.[1] According to the National Institute of Cancer Prevention, in India for every eight minutes, one woman dies due to CC.[2] The primary cause of CC is believed to be the human papillomavirus (HPV).[3,4] Pelvic pain or pain during sexual activity, bloody or watery vaginal discharge, bleeding between periods, chronic back pain, bleeding after sexual activity, unexplained weight loss, and severe swelling in one or both legs are symptoms of CC.[5] The well-known risk factors for CC include HPV, low socioeconomic position, smoking, getting married before turning 18, being young when the first coitus occurred, having several sexual partners, and having multiple children. These elements increase the chance of developing CC.[6] CC is now understood to be predominantly caused by HPV; the most frequently associated HPV types with invasive CC are 16, 18, 31, 33, and 45. The majority of studies demonstrate that having more stable relationships and initiating sex earlier in life enhance the likelihood of acquiring CC.[7,8]
Due to its lengthy pre-invasive stage, CC is a disease that is preventable. If robust screening is used, early detection and adequate treatment may be achievable.[9] Pap smear test helps us to detect the early changes in the cervical epithelium (Invasive stage). It is also used in screening test for precancerous cervical intraepithelial neoplasia. The detection rate of the pap test for identifying high-grade squamous intraepithelial lesions (HSIL) is 70.80%.[10] Creating awareness among the people about the symptoms, risk factors, and early measures like taking screening test regularly and getting vaccination against HPV helps in preventing the CC. People with low socio-economic status and those who are poor are needed to be motivated to visit the hospital for a cancer screening. Thus, creating a proper awareness program and educating the people about the screening test and preventive measures for CC are required. The purpose of the present research is to understand the knowledge, attitude, and practice of CC among college-attending students including boys and girls.
Materials and Methods
Study design and setting
This is a college-based cross-sectional study design. It is conducted through online google form which is conducted in various degree colleges across the Anantapur district, Andhra Pradesh, India. Anantapur district is the biggest district with respect to the land size and population in the Rayalaseema region of Andhra Pradesh, India. The study was conducted from August to September 2022.
Study sample and sample size calculation
The study targeted the female population of age ranges from 15 to 25 years. The minimum recommended sample size was 380 subjects calculated using the Raosoft® sample size calculator. This was decided by using the single population proportion formula with the assumption of 95% confidence interval, 5% margin of error, and 50% response distribution.
Study tools and data collection process
Analyzing many research studies that have taken place in India from the past decade, the self-administered, structured, and closed-ended questionnaire was designed.[11] Four sections of questionnaires are created to gather data on the socio-demographic features of the study population, KAP towards CC and screening. The survey questionnaire was created using Google forms. The socio-demographic questionnaires include age, marital status, education field and level, religion, smoking, and family history of cancer status.
The 16-point scale is used to analyze the knowledge of CC. A total of 11 knowledge-related multiple-choice questions are asked and for each right response received one point, and each incorrect response received zero point. Thus, scores range from 0 to 16. Subjects who are aware of CC are given 1 point. Two points for any two correct responses among given options for symptoms, risk factors, causes, preventive measures, and treatment for CC. One point for any one option answered correctly among given for screening tests, frequency of screening, who should undergo screening, knowledge about HPV transmission, and preventive measures for HPV infections. Furthermore, the knowledge points were evaluated by bloom’s cutoff points where knowledge levels are classified as good knowledge was outlined as 80%-100% correct responses comprising a score of 13-16; moderate knowledge as 60% to 79% correct responses with a score of 10-12; and poor knowledge as 60% correct responses with a score of 9 or <9.[12]
Attitude was evaluated by using Likert’s scale. Eight statements about CC risk factors and screening were put on a Likert scale, with responses ranging from strongly agree to strongly disagree (Strongly agree = 5, agree = 4, neither agree nor disagree = 3, disagree = 2, and strongly disagree = 1). Scores of 20 or higher indicate a positive attitude toward CC screening, whereas scores of 20 or lower indicate a negative attitude.[13] Practice was assessed by frequency of screening towards CC. The screening of subjects within the last three years is regarded as regular practice, screening more than past three years is regarded as irregular practice, and those who never screened are regarded as no practice.
Statistical analysis was performed using SPSS software version 27. The socio-demographic variables and KAP of the study population were represented using descriptive statistics like frequency and proportion. By using the Chi-square test, the relationship between socio-demographic factors and KAP levels is evaluated. P < 0.05 was considered statistically significant.
Results
A total of 380 women responded to questionnaires. The majority of 37.1% (n = 141) of the survey participants were between the age of 19-22 years, 22.6% (n = 86) between the age of 16-18, 25.3% (n = 96) between the age of 23-25, and the remaining 15.0% (n = 57) were above 25 years. Majority of the women are unmarried (354; 93.2%). The education field of these participants includes engineering (87; 22.9%), medical (16; 4.2%), pharmacy (139; 36.6%), agriculture (28; 7.4%), nursing (1;0.1%) secondary education (80; 21.1%), and others (29; 7.6%). Most of them are graduates. (266;70%) has never smoked (374; 98.4%) and has no family history of cancer (313;82.4%) as shown in Table 1.
Table 1.
Sociodemographic data of study participants (n=380)
| Characteristic | Categories | Frequency (%) |
|---|---|---|
| Age (years) | 16-18 | 86 (22.6) |
| 19-22 | 141 (37.1) | |
| 23-25 | 96 (25.3) | |
| 25 above | 57 (15.0) | |
| Marital status | Married | 26 (6.8) |
| Unmarried | 354 (93.2) | |
| Education field | Engineering | 87 (22.9) |
| Medical | 16 (4.2) | |
| Pharmacy | 139 (36.6) | |
| Agriculture | 28 (7.4) | |
| Nursing | 1 (0.3) | |
| Secondary education | 80 (21.1) | |
| Others | 29 (7.6) | |
| Education level | Undergraduate | 89 (23.4) |
| Graduate | 266 (70.0) | |
| Post-graduation and above | 25 (6.6) | |
| Religion | Christian | 18 (4.7) |
| Muslim | 57 (15.0) | |
| Hindu | 305 (80.3) | |
| Smoking | Never smoked | 374 (98.4) |
| Used to smoke | 2 (0.5) | |
| Currently smoke | 4 (1.1) | |
| Family history of cancer | Yes | 50 (13.2) |
| No | 313 (82.4) | |
| Don’t know | 17 (4.5) |
Among 380 participants, (172; 54.7%) had heard about CC rom friends (134; 35.2%), social media (132; 34.7%), awareness programs (73;19.2%), health professionals (72; 18.9%), and relatives (43;11.3%).) Concerning knowledge on symptoms of CC resulted as pain in lower abdomen (80; 21.1%), post-coital bleeding (58;15.3%), post-menopausal bleeding (65;17.1%), urine urgency (42;11.1%), vaginal discharge (90;23.7%), foul smell discharge (127;33.4%), and menstrual bleeding (93;24.5%). Knowledge on causes of CC was sex (189;49.7%), virus (120;31.6%), old age (32;8.4%), family history (58;15.3%), and more children (28;7.4%). Knowledge on risk factors includes generalized infections (88;23.2%), HPV infections (108;27.1%), genetics (47;12.4%), history of STD’S (81;21.3%), multiple of sexual partners (110;28.9%), intercourse at early age (85;22.4%), not maintenance of personal hygiene (126;33.2%), and early of marriage (61;16.1%). The most well-known CC prevention strategies for women include avoiding multiple sexual partners (113;29.7%), avoiding early sexual intercourse (85;22.4%) and vaccination against HPV (92;24.2%). Knowledge on treatment options for CC includes drug therapy (55;14.5%), radiotherapy (58;15.3%) and surgery (104;27.4%). Participants who are aware about screening tests for CC involves pap smear (113;29.7%), VILI (37;9.7%), and VIA (27;7.1%). Knowledge about persons who should undergo screening include women age of 25 years above (51;13.4%) and women having multiple sexual partners (53;13.9%). Knowledge about HPV transmission (116;30.5%) and preventive measures for HPV transmission are listed in Table 2.
Table 2.
Knowledge about cervical cancer and its screening among respondents (n=380)
| Variable | Frequency (%) | Variable | Frequency (%) |
|---|---|---|---|
| Aware of CC | Knowledge about treatment | ||
| Yes | 172 (54.7) | Drug therapy | 55 (14.5) |
| No | 208 (45.3) | Radiotherapy | 58 (15.3) |
| Knowledge about cause of CC | Surgery | 104 (27.4) | |
| Sex | 189 (49.7) | Do not know | 200 (52.6) |
| Virus | 120 (31.6) | Knowledge about Screening tests | |
| Old age | 32 (8.4) | VILI | 37 (9.7) |
| Family history | 58 (15.3) | VIA | 27 (7.1) |
| More children | 28 (7.4) | Do not know | 81 (21.3) |
| Don’t know | 153 (40.3) | Knowledge about persons who undergo screening | |
| Knowledge about symptoms of CC | Elderly women | 9 (2.4) | |
| Pain in lower abdomen | 80 (21.1) | Women age of 25 yrs and above | 51 (13.4) |
| Post coital bleeding | 58 (15.3) | Women having multiple sexual partners | 53 (13.9) |
| Post-menopausal bleeding | 65 (17.1) | Do not know | 233 (61.3) |
| Urine urgency | 42 (11.1) | Knowledge about screening frequency | |
| Vaginal discharge | 90 (23.7) | Once every year | 28 (7.4) |
| Foul smell discharge | 127 (33.4) | Once every 3 yrs | 62 (16.3) |
| Intermenstrual bleeding | 93 (24.5) | Once every 5 yrs | 18 (4.7) |
| Do not know | 163 (42.9) | Do not know | 205 (53.9) |
| Knowledge about Risk factors | Knowledge about HPV transmission | ||
| Generalized Infections | 88 (23.2) | Sexually Intercourse | 116 (30.5) |
| HPV Infections | 108 (27.1) | Knowledge about HPV transmission prevention | |
| Genetics | 47 (12.4) | Condom use | 105 (27.6) |
| Tobacco and smoking | 36 (9.5) | Vaccination | 90 (23.7) |
| History of STD’s | 81 (21.3) | Oral contraceptives | 38 (10.0) |
| Multiparity | 21 (5.5) | Pap test | 78 (20.5) |
| Multiple of sexual partners | 110 (28.9) | Late start of sexual activity | 61 (16.1) |
| Intercourse at early age | 85 (22.4) | Late start of sexual activity | 83 (21.8) |
| Not maintenance of personal hygiene | 126 (33.2) | ||
| Early of marriage | 61 (16.1) | ||
| Do not know | 165 (43.4) | ||
| Knowledge about preventive measures | |||
| Avoid multiple sexual partners | 113 (29.7) | ||
| Avoid early sexual intercourse | 85 (22.4) | ||
| Vaccination against HPV | 92 (24.2) | ||
| Quit smoking | 30 (7.9) | ||
| Avoid birth at young age | 36 (9.5) | ||
| Avoid usage of oral contraceptives | 56 (14.7) | ||
| Do not know | 181 (47.6) |
Among all respondents, 95 (25.0%) were strongly agreed, 135 (35.5%) agreed, and 81 (21.3%) neither agreed nor disagreed that late stage of diagnosis of CC is due to lack of awareness about screening and preventive methods is the prime reason. Majority of the respondents 293 (77.1%) has never done any cytological examination of cervix and only 6 (1.78%) are screened for CC within past 3 years shown in Table 3. Among all respondents 77 (20.3%) have good knowledge, 32 (8.4%) have moderate knowledge, and 271 (71.3%) have poor knowledge. Majority of the respondents have positive attitude towards CC 326 (85.8%) as shown in Table 4. Statistically significant association of good knowledge, positive attitude, and regular practice socio-demographic was observed as shown in Table 5.
Table 3.
Attitude and practice about cervical cancer and its screening among respondents (n=380)
| Variables | Frequency (%) |
|---|---|
| For every 8 minutes a women die due to cervical cancer | |
| Strongly Disagree | 162 (42.6) |
| Disagree | 138 (36.3) |
| Neither agree nor disagree | 8 (2.1) |
| Agree | 4 (1.1) |
| Strongly Agree | 68 (17.9) |
| CC is not transmitted from one person to another | |
| Strongly Disagree | 41 (10.8) |
| Disagree | 159 (41.8) |
| Neither agree nor disagree | 24 (6.3) |
| Agree | 132 (34.7) |
| Strongly Agree | 24 (6.3) |
| Late stage of diagnosis of disease is due to lack of awareness about screening and preventive methods is the prime reason | |
| Strongly Disagree | 16 (4.2) |
| Disagree | 53 (13.9) |
| Neither agree nor disagree | 81 (21.3) |
| Agree | 135 (35.5) |
| Strongly Agree | 95 (25.0) |
| Misconception about female cancers and gynaecological diseases, socioeconomic limitations are the obstacles for screening of cervical cancer | |
| Strongly Disagree | 9 (2.4) |
| Disagree | 66 (17.4) |
| Neither agree nor disagree | 62 (6.3) |
| Agree | 150 (39.5) |
| Strongly Agree | 93 (24.5) |
| HPV vaccination can prevent cervical cancer | |
| Strongly Disagree | 9 (2.4) |
| Disagree | 70 (18.4) |
| Neither agree nor disagree | 150 (39.5) |
| Agree | 136 (35.8) |
| Strongly Agree | 15 (3.9) |
| Screening rate increases if the screening for CC is not expensive and cause no harm | |
| Strongly Disagree | 37 (9.7) |
| Disagree | 152 (40.0) |
| Neither agree nor disagree | 84 (22.1) |
| Agree | 49 (12.9) |
| Strongly Agree | 58 (15.3) |
| Is it important to consult a doctor in case of bleeding between periods | |
| Strongly Disagree | 72 (18.9) |
| Disagree | 92 (24.2) |
| Neither agree nor disagree | 69 (18.2) |
| Agree | 86 (22.6) |
| Strongly Agree | 61 (16.1) |
| In your opinion screening is harmless procedure for the client | |
| Strongly Disagree | 36 (9.5) |
| Disagree | 115 (30.3) |
| Neither agree nor disagree | 94 (24.7) |
| Agree | 109 (28.7) |
| Strongly Agree | 26 (6.8) |
|
| |
| Practice | n (%) |
|
| |
| Cytological examination of cervix | |
| Never done any cytological examination | 293 (77.1) |
| Cytological examination of cervix more than past 3 yrs | 18 (4.7) |
| Cytological examination of cervix within past 3 yrs | 69 (18.2) |
| Screened for cervical cancer | |
| Never screened before for cc | 374 (98.42) |
| Screened for cc within past 3 yrs | 6 (1.57) |
Table 4.
Adequacy of knowledge, attitude, and practice regarding cervical cancer and its screening among respondents (n=380)
| Variable | Frequency |
|---|---|
| Knowledge | |
| Good knowledge | 77 (20.3) |
| Moderate knowledge | 32 (8.4) |
| Poor knowledge | 271 (71.3) |
| Attitude | |
| Positive attitude | 326 (85.8) |
| Negative attitude | 54 (14.2) |
| Practice | |
| Regular practice | 6 (1.57) |
| No practice | 374 (98.4) |
Table 5.
Association of sociodemographic characteristics with good knowledge, positive attitude, and regular practice toward cervical cancer and its screening (n=380)
| Variable | Total (n=380) |
Good knowledge |
Positive attitude |
Regular practice |
|||
|---|---|---|---|---|---|---|---|
| n (%) | x2 (P) | n (%);lll | x2 (P) | n (%) | x2 (P) | ||
| Age (yrs) | |||||||
| 15-18 | 86 | 17 (19.8) | 23.57 (<.001) | 62 (72.1) | 39.44 (<.001) | 0 | 16.79 (<0.001) |
| 19-22 | 142 | 34 (24.1) | 112 (79.4) | 0 | |||
| 23-25 | 96 | 7 (7.3) | 95 (99.0) | 6 (100) | |||
| 25 above | 56 | 19 (33.3) | 57 (100) | 0 | |||
| Marital status | |||||||
| Married | 26 | 6 (23.1) | 0.144 (0.931) | 26 (100) | 8.2 (0.004) | 1 (16.7) | 0.68 (0.409) |
| Unmarried | 354 | 71 (20.1) | 300 (84.7) | 5 (83.3) | |||
| Education field | |||||||
| Engineering | 125 | 21 (24.1) | 12.42 (0.412) | 78 (89.7) | 12.9 (0.045) | 1 (16.7) | 7.69 (0.261) |
| Medical | 12 | 2 (12.5) | 14 (87.5) | 0 | |||
| Pharmacy | 148 | 33 (23.7) | 123 (88.5) | 5 (36.3) | |||
| Agriculture | 31 | 3 (10.7) | 23 (82.1) | 0 | |||
| Nursing | 1 | 0 (0) | 1 (100) | 0 | |||
| Paramedical | 5 | 14 (17.5) | 59 (73.8) | 0 | |||
| Others | 58 | 4 (13.8) | 28 (96.6) | 0 | |||
| Education level | |||||||
| Under graduate | 38 | 15 (16.9) | 3.621 (0.460) | 30 (81.3) | 10.09 (0.006) | 0 | 4.36 (0.113) |
| Graduate | 316 | 55 (20.8) | 270 (85.4) | 6 (100) | |||
| Postgraduate & above | 26 | 7 (26.9) | 26 (100.0) | 0 | |||
| Religion | |||||||
| Christian | 19 | 3 (16.7) | 5.83 (0.212) | 14 (77.8) | 4.02 (0.134) | 0 | 0.58 (0.745) |
| Muslim | 58 | 15 (26.3) | 46 (79.3) | 1 (16.7) | |||
| Hindu | 303 | 59 (19.4) | 266 (87.5) | 5 (83.3) | |||
| Smoking | |||||||
| Never smoked | 374 | 74 (19.8) | 4.85 (0.302) | 321 (85.8) | 0.93 (0.626) | 6 (100) | 0.19 (0.908) |
| Used to smoke | 2 | 1 (50.0) | 2 (100) | 0 | |||
| Currently smoke | 4 | 2 (50.0) | 3 (75.0) | 0 | |||
| Family history of cancer | |||||||
| Yes | 50 | 9 (18.0) | 0.53 (0.970) | 44 (88.0) | 0.37 (0.830) | 0 | 2.38 (0.309) |
| No | 313 | 65 (20.8) | 268 (85.6) | 6 (100) | |||
| Don’t know | 17 | 3 (17.6) | 14 (82.4) | 0 | |||
Discussion
The best thing about this cancer is that it may be treated and prevented in its early stages. Thus, educating the people about causes and preventive measures in the early age is helpful in preventing the disease. Majority of the people heard about CC through friends followed by media in the current study, and these findings are similar to those published by Abdullahi et al.[14] and Narayana et al.[15] In this study, we reported that lack of knowledge and no regular practice towards CC. Women aged 25 above have shown good knowledge and positive attitude in relation to other age groups with P < 0.001. Women in education field like engineering and pharmacy, and education level like post graduates have shown positive attitude with P = 0.004 and P = 0.006, respectively. In the present study, we have compared the knowledge of CC between paramedical students (nursing, pharmacy), medical, and other courses of the study. In one study which is conducted on medical students concluded that most of the population are aware about the CC but lacking the knowledge on risk factors and prevention of CC.[16] Furthermore, in another study which is conducted on female dental students concluded that even health professionals are lacking awareness about CC, HPV, and its screening.[17]
This study has mainly focused on the women age between 15 and 25 years as this is the phase of the age where the extra hygiene conditions are required. A simple thing to prevent the CC is by having regular screening by pap test and vaccinating by HPV. By educating the people about the disease in every field will be helpful for prevention. Taking personal hygiene seriously is a simplest way to avoid unnecessary illnesses. Neglecting to practice good hygiene is a major contributor for development of CC as stated in a study.[18] Specifically, during menstruation bathing regularly, using cleaned clothes and changing tampons or pads habitually are necessary. Regular visits to gynecologists will also ensure that of any early detection of CC, breast cancer, vaginal infections, and others. In one of the research work, it stated that it is important to include men in HPV education and prevention efforts.[12]
HPV vaccination is needed for all age groups of women for preventing the CC. However, but despite of these recommendations, the HPV vaccination rate is declining as stated by Perkins et al. (2013).[19] In this study, only few people are willing to take pap test (179;47%) and mentioned that reasons for not having HPV vaccine are due to lack of knowledge about HPV (298; 78%), no risk as not exposed (76; 20%) and high cost (6;1.5%). Based on the results, the current study suggests that there is no improvement in HPV awareness in developing countries like India even though the HPV vaccine is accessible. People will be more likely to use disease prevention techniques if they have a thorough awareness of the disease and its effects.
The limitations of this study include that we focused on only female responses excluding the male population. Because of the small sample size, the results from this study could not be generalized to the larger Indian women population. Further studies are needed to design that are needed to know more about the CC KAP levels across India. Furthermore, more awareness programs on CC and HPV vaccine should be recommended. The KAP of CC from these age respondents is needed to design an awareness program about CC and HPV. In the current study, the respondents have poor knowledge of CC (71.3%). Having awareness about HPV and CC at an early age will help us to accomplish the mission of the National Cancer Control Program. The general public can immediately spot the early symptoms of the disease and take necessary precautions if they are aware about CC.
Conclusion
Based on the conducted study, the majority of the subjects have poor knowledge about CC. Educating the adolescents in their early age about the sexuality and its related diseases (STDs) will impact their decision making and how to interact with the world around them. To reduce the mortality rate of CC, special attention must be paid to improving the knowledge on CC risk factors and its prevention in young adolescents.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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