Dear Editor,
Cervical cancer is the seventh most common cancer in the world and it has the highest burden in India. It is the second largest killer in India (after cardiovascular disease). Every year, approximately 2,000 new cases are diagnosed in India at the last stage of cervical cancer and 1,200 new cases in the early stage of cancer.[1] Screening has been launched at a national level in all sectors as a public health program to control and prevent the increasing burden of this disease. Despite having access to early detection and basic treatments which make this type of cancer preventable at earlier stages, less than 10% women undergo screening.[2,3] Not much research has been done pertaining to the factors that hinder Indian women from undergoing screening for cervical cancer.
This study was conducted with the aim of finding out the knowledge, attitude, and practice among the hospital visiting females in order to shed some light on the challenges faced by cervical cancer screening programs in India. Understanding the reasons that hinder Indian women from undergoing cervical cancer screening is paramount to improving the overall screening rate, and to halt the rising death toll.
The study was conducted as a descriptive cross-sectional study. All females visiting the hospital above the age of 18 years were included in the study. Doctors and nurses were excluded from the study population. Data was collected through survey forms. A questionnaire composed of four sections: demographic details, questions regarding knowledge, practice, and attitude was used. A total of 406 females aged between 18 and 68 years were included in this study. The detailed purpose and procedure of the study was explained to them and a signed consent form was obtained. All of the participants were assured confidentiality of the collected data.
Of the respondents, 303 (74.6%) were married, while 103 (25.4%) were single. We found that 339 (83.5%) of the participants were aware of cervical cancer as a disease, while only 200 (49.3%) were aware of available screening methods. Most of the respondents had heard about cervical cancer from print media. Their sources of knowledge were healthcare personnel (28.8%), print media (41.8%), television (34%), friends (25.5%), and the internet (20.9%). Those who were aware were more likely to be educated. Out of participants who were aware of cervical cancer as a disease, 82.3% were aware of at least one sign or symptom. It was quite alarming that only 27.3% knew about HPV infection being a risk factor for the development of cervical cancer and only 37% even knew about the HPV vaccine. Knowledge is essential in order to develop a behavior. However, attitude plays a pivotal role in formulating a behavior. Only 44.1% felt the need for screening; most of them had no particular reason for not undertaking any screening [Table 1]. Only 23.5% of the study population underwent screening for cervical cancer. It was found that patients with a higher literacy status underwent testing.
Table 1.
Knowledge, attitude and practice regarding cervical cancer and screening (n=406)
| Yes (%) | No (%) | |
|---|---|---|
| KNOWLEDGE | ||
| Cervical cancer | 339 (83.5%) | 67 (16.5%) |
| Cervical cancer screening | 200 (49.3%) | 206 (50.7%) |
| Risk factors (N=339) | ||
| Early start of sexual activity | 98 (24.1%) | |
| Multiple sexual partners | 126 (31%) | |
| Having HIV | 100 (24.6%) | |
| HPV infection | 111 (27.3%) | |
| Family history of cervical cancer | 135 (33.3%) | |
| Use of birth control pills for a long time (5 or more years) | 91 (22.4%) | |
| Smoking | 68 (16.8%) | |
| Excessive alcohol | 69 (17%) | |
| Symptoms of cervical cancer (N=339) | ||
| Irregular menstruation | 120 (29.6%) | |
| Foul smelling vaginal discharge | 113 (27.8%) | |
| Post menstrual bleeding | 82 (20.2%) | |
| Bleeding after sexual act | 98 (24.1%) | |
| Heavy bleeding | 84 (20.7%) | |
| Excessive pain during menstruation | 75 (18.5%) | |
| Who should get tested | ||
| Only married women | 65 (16%) | |
| Unmarried women | 27 (6.7%) | |
| Any female | 314 (77.3%) | |
| Appropriate age for getting tested | ||
| After 50 years of age | 64 (15.8%) | |
| 20-50 years of age | 292 (71.9%) | |
| 12-19 years | 50 (12.3%) | |
| Link between HPV and cervical cancer | 104 (25.6%) | 302 (74.4%) |
| HPV vaccine | 150 (37%) | 255 (63%) |
| STDs can be prevented by condoms | 351 (86.9%) | 53 (13.1%) |
| ATTITUDE | ||
| Feel at the risk of cervical cancer | 93 (22.9%) | 313 (77.1%) |
| Need screening for cervical cancer | 179 (44.1%) | 227 (55.9%) |
| Responses for not screening (n=227) | ||
| Not suggested by the doctor | 53 (23.3%) | |
| No reason | 72 (31.7%) | |
| Not feeling at risk | 36 (15.8%) | |
| Lack of symptoms | 23 (12.3%) | |
| Feeling shy to have pap smear | 19 (08.3%) | |
| Afraid of outcome | 11 (04.8%) | |
| Not applicable | 13 (05.7%) | |
| Advised other women | 113 (27.8%) | |
| PRACTICE | ||
| Has regular gynecological screening | 152 (37.4%) | 254 (62.6%) |
| Undergone cervical cancer screening | 95 (23.5%) | |
| Had gynecological check-up in past 2 years | 220 (54.2%) | 186 (45.8%) |
| Reasons for irregular gynecological screening (n=254) | ||
| Because of economy problem | 36 (14.2%) | |
| Because of lack of awareness of the importance of regular examination | 123 (48.4%) | |
| Because of lack of time | 95 (37.4%) | |
Though women from our research have approached doctors in the last 2 years, very few women were educated about cervical cancer screening. The second most common reason for not being screened was “not suggested by a doctor.” This indicates that healthcare professionals did not educate their patients. This might have deprived their patients the benefit of an early diagnosis of cervical cancer. A similar finding was observed regarding HPV vaccination which showed that adolescents who were not suggested vaccination by their physicians were less likely to get vaccinated.[4] Primary care physicians act as the first line of information about cancer and assessment of individual risk. Therefore, they become a public health liaison by educating and recommending screening to women. Physicians should focus on making women aware about cervical cancer, with an emphasis on the benefits of screening and vaccination. Physicians should try to get into the habit of asking every female patient in the appropriate age group if they have undergone cervical cancer screening. If the patient has not undergone screening, the doctor should provide a brief explanation of cervical cancer and its screening so that the patient can undergo the same. The emotional toll of cancer and fears associated with screening can prevent patients from obtaining earlier treatment. It is important as physicians that we make sure that the patients feel supported as they might be experiencing fear and anxiety about undergoing the screening test or waiting for the results.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Bhushan S. The invisible killer: How cancer is eating up Indian women. News18. 2018. Available from: https://www.news18.com/news/lifestyle/health-and-fitness-the-invisible-killer-how-cancer iseating-up-indian-women-1828273.html .
- 2.Khanna D, Khargekar N, Budukh A. Knowledge, attitude, and practice about cervical cancer and its screening among community healthcare workers of Varanasi district, Uttar Pradesh, India. J Family Med Prim Care. 2019;8:1715–9. doi: 10.4103/jfmpc.jfmpc_143_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Siddharthar 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. doi: 10.7860/JCDR/2014/8115.4422. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sriram S, Ranganathan R. Why human papilloma virus vaccination coverage is low among adolescents in the US? A study of barriers for vaccination uptake. J Family Med Prim Care. 2019;8:866–70. doi: 10.4103/jfmpc.jfmpc_107_19. [DOI] [PMC free article] [PubMed] [Google Scholar]