n income per capita was quite less with 60% of the population having monthly per capita income of less than 5000 (score 1 - 2). All the data presented in Table 1, shows that the study population enrolled in this current study belonged to financially weaker section because most of them were from rural setup with low education and low paying jobs. Since Indian villages still have the majority population getting married at an early age, the data in Table 1 represent the same.

Table 2 shows the gynecological history of the respondents enrolled in this study. As shown, more than half (84.4%) of the subjects got married before 30 years and 50.7% had 3 or more than 3 live children. 41% of the enrolled subjects belonged to large family set up with more than 5 persons living together. 63.7% of these people were dependent on local health workers, compounders and chemists for their health issues because they did not have access to proper nursing and medical staff. Since most of the study subjects (64%) got married within 18 - 27 years, we can see the percentage of failed pregnancies with different methods of miscarriages or pregnancy termination to be quite high (76.3%). Out of this, 26.3% of the subjects met spontaneous miscarriages while 50% had their pregnancies terminated by induced, medical and surgical termination methods.

Table 2. Gynecological history of the respondents enrolled in the study.

All the data presented in Table 2 show that most of the study population enrolled in this current study belonged to early marriage category and hence had higher number of live pregnancies with most of them having history of terminated pregnancies and miscarriages which were either induced or spontaneous.

As per the observations in Table 3, out of the 300 women interviewed, 85% (n = 254) were aware of cancer as a disease. However, a little more than half of women (66%, n = 198) were aware of cervical cancer. The proportion of women who were aware of cervical carcinoma 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 use of a family planning method and awareness about this particular cancer.

Source of information about Cervical Cancer

Most of the respondents (40.4%, n = 80) had heard about cervical cancer from friends and relatives. Other sources of knowledge were health-care personnel (23%), print media (10%), television (20%), and radio (7%).

Knowledge about established risk factors of cervical cancer

The women who were aware of cervical cancer (n = 198) were asked about the risk factors of this cancer. Twenty-three percent of women (n = 45) mentioned family history as a risk factor. Thirty-three percent (n = 65) women identified early marriage followed by multiple pregnancies as the risk factor for CX CA. Over 32% (n = 63) of participants rightly mentioned uterine infection especially HPV infection as the most common risk of CX CA. Other established risk factors which were rightly interpreted were multiparty (3%, n = 6), oral contraceptives (4.5%, n = 9), smoking (5.1%, n = 10) as a risk factor for cervical cancer.

Knowledge of signs and symptoms

Out of 198 participants who were aware of cervical cancer as a disease, forty three percent (n = 85) of them were aware that bleeding between two menstrual cycles could be a sign of cervical cancer. Twenty-two percent (n = 43) of study population mentioned vaginal discharge and seventeen percent (n = 33) identified pain in the pelvic region as a symptom. Almost nineteen percent of the study population were aware of post-coital bleeding and discomfort during intercourse, pain in pelvic region, weight and appetite loss (n = 37) as signs of this cancer.

Knowledge about early detection methods

Only 30% of the participants (n = 161) were aware that cervical cancer can be detected early. Eighty three respondents (20%) 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. Seventy percent of women (n = 139) thought that the early detection for this particular form of cancer is not possible.

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

Table 3. Awareness of cervical cancer screening and vaccination.

*Others included post-coital bleeding, bladder and rectal involvement, weight loss, loss of appetite and pelvic pain.

was available to them whether they would be willing to undergo such a test. Only sixty eight percent (n = 205) 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 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 of 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. Those who were still not willing to undergo this test (n = 95, 32%) mentioned different reasons like being against vaccination, religious reasons, family restrictions etc. for their denial to be screened and vaccinated.

Knowledge about mode of HPV transmission and protection by CX CA vaccination

Out of the three hundred women participants enrolled in the study, only forty three percent rightly identified sexual intercourse with multiple partners as the mode of HPV transmission. Forty two percent were under the impression that HPV could be transmitted either by physical contact or through air/aerosol droplets while fifteen percent had no knowledge about this infection. When asked about the various types of abnormalities against which CX CA vaccination provides protection, fifty three percent (n = 158) participants identified that it provides protection against cervical cancer while eighteen percent (n = 54) had no knowledge about this, twenty percent (n = 88) identified that it provides protection against anal cancer, vulvar cancer, warts, HIV/IDS and breast cancer. After explaining all the signs, symptoms, possible modes of transmission and dangers related to the ignorance of cervical cancer screening, 68.3 percent of the women participants agreed to allow their female relatives for CX CA screening and vaccination while 32% still had certain hesitations related to the screening and vaccination program. This calls for a better, extensive awareness program to generate awareness and allow the women candidates to explore the issue and get themselves and their relatives prepared for CX CA screening and vaccination from the deadly disease.

4. Discussion

In the present study, we found that only 66% of the respondents were aware of cervical cancer as a disease and those who were aware were educated and have a higher per capita income than those who were not aware. Subjects enrolled in the present study had very poor knowledge about established risk factors of cervical cancer which is consistent with findings of some other studies [12]. Out of 30% of women who were aware of cervical cancer, 20% were aware of Pap smear as one of the screening techniques for this disease. This finding of our study concurred with a similar study [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 20% of study population. Similar findings were reported from a study done in Mangalore region in India, which mentioned television as a source of information for cervical cancer by only 14% [12] [13].

Our study coincided with a similar study and revealed that willingness to participate in a screening procedure was higher among those who were educated and had used method of family planning [13]. We found that women who were aware of the risk factors, signs and symptoms, of cervical cancer were willing to participate than those who were not. All the women (100%) who were aware that early detection is possible were willing to participate in a screening program. Studies on various aspects of knowledge about cervical cancer revealed that the lack of knowledge about this disease appears to be an important factor to determine women’s willingness to participate in cervical cancer screenings and vaccination program [14] [15].

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 [16] [17]. 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 [18]. Success of any screening program primarily depends on prior-understanding of the factors that determine women’s willingness to participate in the screening procedures. Association between awareness about cervical cancer and willingness to participate in cervical cancer screening and vaccination program has been documented in this study are supported by similar studies [19] [20]. These findings emphasize the need for dissemination of knowledge about cervical cancer to ensure the uptake of HPV screening and vaccination services. It was also found that the primary source of CXCA related knowledge to the subjects enrolled in the study 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 [21]. Hence there is a need to disseminate the correct knowledge keeping in view the sensitivity of the issue that is affected by religious and cultural beliefs. Popular mass media and commercials and trained nonmedical personnel like accredited social health activists who are females and are from the same or nearby community can be used as a key link for raising awareness about the risk factors, signs, symptoms, screening procedures and vaccination available for CXCA [22].

5. Conclusion and Recommendations

Women in North India were ignorant about risk factors, signs and symptoms, and early detection measure of cervical cancer. Specific knowledge on cervical cancer and its early detection in precancerous stage and subsequent treatment is the immediate need of the hour. 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 who were from rural background and 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 north India on different aspects of cervical cancer, the associated risks, and its screening and vaccination facilities available in the medical centers. Special efforts would be required for the core group of illiterate women for a better impact on screening acceptance. We recommend the drafting of proper policy guidelines that will help the women in developing countries to accept the screening and vaccination of cervical cancer without any preset notion and thus could take care of themselves and their relatives against this deadly disease.

Limitations of This Study

The study has limitation of being completely based on the choice of the participants to enroll in the study. There was no compulsion to any of the participant from any community. If any of the participants chose to withdraw from the study, she was free to do so.

Acknowledgements

The authors acknowledge the encouragement and infrastructural support provided by DRMLIMS to conduct the study.

Conflicts of Interest

The authors declare no conflict of interest to compete.

Cite this paper

Misra, M., Tiwari, V. and Tripathi, P. (2020) Awareness, Attitude and Practices Regarding Cervical Cancer Screening and Vaccination among North Indian Women Population. Journal of Biosciences and Medicines, 8, 73-88. https://doi.org/10.4236/jbm.2020.83008

References

  1. 1. Cervical Cancer: Estimated Incidence, Mortality and Prevalence Worldwide in 2012. http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp

  2. 2. Global Burden of Cancer in Women. Current Status, Trends, and Interventions. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/global-cancer-facts-and-figures/global-burden-ofcancer-in-women.pdf

  3. 3. Ferlay, J., Ervik, M., Lam, F., Colombet, M., Mery, L., Pineros, M., Znaor, A., Soerjomataram, I. and Bray, F. (2018) Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer, Lyon, France.

  4. 4. Burd, E.M. (2003) Human Papillomavirus and Cervical Cancer. Clinical Microbiology Reviews, 16, 1-17. https://doi.org/10.1128/CMR.16.1.1-17.2003

  5. 5. Denny, L., Herrero, R., Levin, C. and Kim, J.J. (2015) Cervical Cancer. In: Gelband, H., Jha, P., Sankaranarayanan, R. and Horton, S., Eds., Cancer: Disease Control Priorities, Third Edition, Volume 3, World Bank, Washington DC, 69-84. https://doi.org/10.1596/978-1-4648-0349-9_ch4

  6. 6. Jassim, G., Obeid, A. and Al Nasheet, H.A. (2018) Knowledge, Attitudes, and Practices Regarding Cervical Cancer and Screening among Women Visiting Primary Healthcare Centres in Bahrain. BMC Public Health, 18, Article No. 128. https://doi.org/10.1186/s12889-018-5023-7

  7. 7. Ferlay, J., Bray, F., Pisani, P. and Parkin, D.M. (2004) Cancer Incidence, Mortality and Prevalence Worldwide, GLOBOCAN 2002. IARC Cancer Base No. 5 Version 2.0. IARC, Lyon.

  8. 8. Drain, P.K., Holmes, K.K., Hughes, J.P. and Koutsky, L.A. (2002) Determinants of Cervical Cancer Rates in Developing Countries. International Journal of Cancer, 100, 199-205. https://doi.org/10.1002/ijc.10453

  9. 9. Sankaranarayanan, R., Budukh, A.M. and Rajkumar, R. (2001) Effective Screening Programmes for Cervical Cancer in Low- and Middle-Income Developing Countries. Bulletin of the World Health Organization, 79, 954-962.

  10. 10. Patra, S., Upadhyay, M. and Chhabra, P. (2017) Awareness of Cervical Cancer and Willingness to Participate in Screening Program: Public Health Policy Implications. Journal of Cancer Research and Therapeutics, 13, 318-323. https://doi.org/10.4103/0973-1482.187279

  11. 11. Moyer, V.A. (2012) U.S. Preventive Services Task Force. Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine, 156, 880-891. https://doi.org/10.7326/0003-4819-156-12-201206190-00424

  12. 12. Tripathi, N., Kadam, Y.R., Dhobale, R.V. and Gore, A.D. (2014) Barriers for Early Detection of Cancer amongst Indian Rural Women. South Asian Journal of Cancer, 3, 122-127. https://doi.org/10.4103/2278-330X.130449

  13. 13. Asthana, S. and Labani, S. (2013) Factors Associated with Attitudes of Rural Women toward Cervical Cancer Screening. Indian Journal of Community Medicine, 38, 246-248. https://doi.org/10.4103/0970-0218.120163

  14. 14. Jia, Y., Li, S., Yang, R., Zhou, H., Xiang, Q., Hu, T., et al. (2013) 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, 8, e67005. https://doi.org/10.1371/journal.pone.0067005

  15. 15. Ansink, A.C., Tolhurst, R., Haque, R., Saha, S., Datta, S. and van den Broek, N.R. (2008) Cervical Cancer in Bangladesh: Community Perceptions of Cervical Cancer and Cervical Cancer Screening. Transactions of the Royal Society of Tropical Medicine and Hygiene, 102, 499-505. https://doi.org/10.1016/j.trstmh.2008.01.022

  16. 16. Breen, N., Wagener, D.K., Brown, M.L., Davis, W.W. and Ballard-Barbash, R. (2001) Progress in Cancer Screening over a Decade: Results of Cancer Screening from the 1987, 1992, and 1998 National Health Interview Surveys. Journal of the National Cancer Institute, 93, 1704-1713. https://doi.org/10.1093/jnci/93.22.1704

  17. 17. Nygard, J.F., Skare, G.B. and Thoresen, S.O. (2002) The Cervical Cancer Screening Programme in Norway, 1992-2000: Changes in Pap Smear Coverage and Incidence of Cervical Cancer. Journal of Medical Screening, 9, 86-91. https://doi.org/10.1136/jms.9.2.86

  18. 18. Peto, J., Gilham, C., Fletcher, O. and Matthews, F.E. (2004) The Cervical Cancer Epidemic That Screening Has Prevented in the UK. The Lancet, 364, 249-256. https://doi.org/10.1016/S0140-6736(04)16674-9

  19. 19. Wallington, S.F., Luta, G., Noone, A.M., Caicedo, L., Lopez-Class, M., Sheppard, V., et al. (2012) Assessing the Awareness of and Willingness to Participate in Cancer Clinical Trials among Immigrant Latinos. Journal of Community Health, 37, 335-343. https://doi.org/10.1007/s10900-011-9450-y

  20. 20. Ndikom, C.M. and Ofi, B.A. (2012) Awareness, Perception and Factors Affecting Utilization of Cervical Cancer Screening Services among Women in Ibadan, Nigeria: A Qualitative Study. Reproductive Health, 9, Article No. 11. https://doi.org/10.1186/1742-4755-9-11

  21. 21. Baileff, A. (2000) Cervical Screening: Patients’ Negative Attitudes and Experiences. Nursing Standard, 14, 35-37. https://doi.org/10.7748/ns2000.07.14.44.35.c2880

  22. 22. Hussain, S.M. (2013) Cancer Control in South Asia: Awareness Is Key to Success. South Asian Journal of Cancer, 2, 55-56. https://doi.org/10.4103/2278-330X.110480

Appendix

Questionnaire

Part-I: Socio-demographic characteristics of study population.

1) Age (years)

21 - 30

31 - 40

41 - 50

51 - 60

≥60

2) Marital status

Married

Single

Widow/divorced/separated

3) Background

Rural

Urban

4) Education

Illiterate

Below matriculation

Intermediate or post high school diploma

Graduate

Postgraduate

5) Occupation score

Unemployed (Score 1)

Unskilled/semi-skilled worker (Score 2)

Skilled worker (Score 3)

Clerical/shop owner/farmer (Score 4)

Professional (Score 5)

6) Family monthly income

<3000 (Score 1)

3000 - 5000 (Score 2)

5001 - 10,000 (Score 3)

10,001 - 20,000 (Score 4)

Above 20,000 (Score 5)

Part II: Gynecological history of the respondents enrolled in the study

7) Approximate age of marriage

18 - 23 years

23 - 27 years

27-30 years

30 - 35 years

>35 years

8) No. of previous live children

Nil

1

2

3

More than 3

9) Family structure (nuclear/joint)

2

2 - 5

>5

10) Health facilities at the rural/urban setting

Local Health worker (LHW)

Compounder

Chemist

Proper nursing and medical staff

11) Any previous history of miscarriage/pregnancy termination

Spontaneous

Induced

Medical termination method

Surgical termination method

None

Part III: Awareness of cervical cancer screening and vaccination

12) Are you aware of cancer?

Yes

No

13) Are you aware of cervical cancer?

Yes

No

If yes, how do you know about it (CX CA)

Friends and relatives

Health-care personnel

Print media

Television

Radio

14) Do you use family planning methods?

Yes

No

15) Knowledge about established risk factors of cervical cancer

Family history

Early marriage

Multiple full term pregnancies

Uterine infections

HPV infections

Smoking

Oral contraceptives

Multiple sex partners

16) Knowledge of signs and symptoms

Menstrual abnormality

Vaginal discharge

Pain

Others (post-coital bleeding, bladder and rectal involvement, weight loss, loss of appetite and pelvic pain)

17) Knowledge about early detection methods

PAP smear test

Clinical examination

Early detection not possible

18) How often do you think you need PAP smear test?

No idea

6 monthly

1 yearly

3 yearly

19) How many times have you been screened?

Never

Once

Twice

Thrice

20) Willingness to participate in a cervical cancer screening program

Yes

No

If no, reason

I am against all vaccinations

The vaccine is not safe

The vaccine may have side effect

Religious reasons

HPV vaccination not necessary

Family restrictions/other reasons (not specified)

21) Mode of HPV transmission

Physical contact

Aerosol/air droplet

Sexual intercourse

No knowledge

22) CX CA vaccination protects against

Cervical cancer

Anal cancer

Vulvar cancer

Warts

HIV/AIDS

Breast cancer

No knowledge

23) Would you allow your daughter or close relatives to get HPV vaccination?

Yes

No

If not (reason)

I am against any vaccination

Family restrictions

The vaccine will initiate early sexual desires/activity in young girls

No one in my family is having CX CA

Others (reason not known)

----------

NOTES

*Corresponding author.

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