Knowledge, attitude, and practice toward cervical cancer among women attending Obstetrics and Gynecology Department

A cross-sectional, hospital-based survey in South India

Abstract

INTRODUCTION: 

Cervical cancer-related deaths among women in India are often due to late diagnosis of disease. Knowledge about disease and early screening is the most effective measure for cervical cancer prevention. Lack of awareness, negative attitude, and poor practice about cervical cancer and screening are the major causes to increase the incidence of disease.

AIM: 

The study is designed to assess knowledge, attitude, and practice (KAP) toward cervical cancer, screening, and prevention.

SETTINGS AND DESIGN: 

A cross-sectional, hospital-based survey was conducted in women attending Obstetrics and Gynecology Department of a secondary care referral hospital.

MATERIALS AND METHODS: 

A total of 403 subjects were enrolled and subjected for interview using prevalidated KAP questionnaire on cervical cancer.

STATISTICAL ANALYSIS: 

Descriptive statistics were used to represent the sociodemographic characteristics and KAP levels. Association of sociodemographic variables with KAP levels is determined using Chi-square test.

RESULTS AND DISCUSSION: 

Most of (301; 74.6%) the respondents had heard about cervical cancer and majority of them are heard from media (168; 41.6%) and friends (83; 20.5%). Most women knew symptoms (259; 64.2%), risk factors (253; 62.7%), screening methods (310; 76.9%), and preventive measures (249; 61.7%) for cervical cancer. More than half of the women (252; 62.5%) having positive attitude toward screening. More than three-fourth of women (349; 86.6%) are not having practice toward cervical cancer screening. Sociodemographic characteristics are strongly associated with KAP levels.

CONCLUSION: 

Although women are having good knowledge, positive attitude toward cervical cancer screening and prevention still there is a gap to transform it into practice. There is a need for more educational programs to connect identified knowledge slits and uplift of regular practice of cervical cancer screening.

Introduction

Cervical cancer is the second most common cancer among women worldwide.[¹] Almost half a million of women are newly diagnosed with invasive cervical cancer each year, and majority of them were never screened for the disease. If this will continue by year 2050 over, one million women will be newly diagnosed with cervical cancer. In these, over 80% of women are residing in developing countries where most of the women do not have access to screening, treatment, and prevention programs.[²]

In India, cervical cancer is one of the most common causes of cancer-related deaths. According to National Institute of Cancer Prevention and Research, one woman dies of cervical cancer every 8 minutes in India.[³] Cervical cancer is the third largest cause of cancer mortality in India accounting for nearly 10% of all cancer-related deaths in the country.[⁴] The average 5-years survival rate is 48.7%. Length of survival depends on cancer stage at the time of diagnosis. The survival rate of a person becomes better if the cervical cancer is diagnosed and treated at earlier stages. Most cases of cervical cancer in India are diagnosed at later and more serious stages which will reduce the survival rate of women with cervical cancer. The prime reason for late stage diagnosis of disease is a lack of awareness about screening and preventive methods of cervical cancer. Screening for cervical cancer is essential as the women often do not experience symptoms until the disease has advanced.[⁵] The most common symptoms present in cervical cancer are bleeding between periods, persistent back pain, pelvic pain, bleeding after intercourse, urinary urgency, unexplained weight loss, and severe swelling in one or both legs. Infection with human papillomavirus (HPV), particularly HPV 16 and 18 strains causes 75% of cervical cancers globally.[⁶] Other risk factors include having multiple sexual partners, early age of sexual intercourse, tobacco consumption, prolonged use of oral contraceptive pills, increased parity, and early age of giving birth.[⁷]

Even though visual inspection with acetic acid and visual inspection with Lugol's iodine (VIA/VILI) and Pap smear test were credited for early detection and screening of cervical cancer. Unfortunately, there are various obstacles to screen cervical cancer that includes lack of awareness and misconceptions about female cancers and gynecological diseases, socioeconomic limitations, and overall lack of national cervical cancer screening guidelines and policies. The prevention and control of cervical cancer depend on awareness about disease, screening procedures, and preventive measures.[⁷] There is a lack of information regarding knowledge, attitude, and practice (KAP) toward cervical cancer and its screening, hence this study was conducted. This study aims to assess the level of KAP toward cervical cancer and its screening among women attending obstetrics and gynecology department of secondary care referral hospital and to measure the association between sociodemographic characteristics with KAP toward cervical cancer. The outcome of this study provides information regarding current awareness about cervical cancer, which is helpful for designing population-based educational program and to overcome barriers associated for knowledge enhancement about cervical cancer and its screening.

Materials and Methods

This is a hospital-based cross-sectional study which was conducted in Outpatient Department of Obstetrics and Gynecology of secondary care referral Hospital, Bathalapalli, Anantapur district, Andhra Pradesh, India, during a period of February and March 2017. The study was approved by the Institutional Review Board (IRB) with a number of RIPER/IRB/2017/015. Women who aged 18 years or above attending obstetrics and gynecology unit and willing to participate in the study are included in the study. Women who are mentally and critically ill and diagnosed with cervical cancer are excluded from the study. To determine the number of women to be included in the study, single population proportion formula was used with assumption of 50% of women have optimal knowledge, 95% confidence interval, and 5% precision, which was calculated as 384. Final sample size with 5% nonresponse rate was 403. All women who met study criteria are included and interviewed using prevalidated questionnaire about cervical cancer, screening, and prevention.

The questionnaire comprises four parts to gather information regarding sociodemographic characteristics of study population, KAP toward cervical cancer and screening. The sociodemographic details included are age, gender, location, religion, marital status, parity, level of education, income, and usage of contraceptive.

The knowledge of cervical cancer, screening, and its prevention was assessed using 16-point scale. There were 19 knowledge-related multiple choice questions that carried 16 correct answers. Each correct answer was given a point of 1 and wrong answer a point of 0. The maximum points expected were 16 and minimum of 0. Points to aware about cervical cancer (1 point), symptoms of cervical cancer (2 points for any two correct responses among symptoms such as vaginal bleeding, foul smell discharge, bleeding between periods, and bleeding after intercourse), risk factors for acquiring cervical cancer (2 points for any two correct responses among risk factors such as early sexual intercourse, multiple sexual partners, HPV infection, cigarette smoking, young age at first birth, and prolonged use of oral contraceptives), preventive measures (2 points for any two correct responses among avoid multiple sexual partners, quit smoking, avoid early sexual intercourse, HPV vaccination, avoid birth at young age, and avoid usage of oral contraceptives), treatment options available (2 points for any two correct answers among radiotherapy, chemotherapy, and surgery), aware about cost of cervical cancer treatment (1 point), screening methods (1 point for any of one among VIA, VILI, and Pap Smear), description about screening method (1 point), eligibility of screening (1 point), frequency of screening (1 point), screening location (1 point), and vaccination against cervical cancer (1 point). After assessment of knowledge points, original Bloom's cutoff points were used to categorize knowledge levels, where 80%–100% correct responses comprise a score of 13–16 meant a good knowledge, 60%–79% correct responses comprise a score of 10–12 meant a moderate knowledge, and <60% correct responses comprise a score of 9 or <9 meant a poor knowledge.[⁸]

Attitude was assessed by putting eight statements regarding risk factors and screening of cervical cancer on Likert's scale; the statement on Likert's scale has positive and negative responses that ranged from strongly agree 5, agree 4, neither agree or nor disagree 3, disagree 2, and strongly disagree 1. The maximum score expected from all statements is 40 and minimum of 8. If the persons scored above or equal to 20 will be considered as positive attitude and <20 considered as negative attitude toward cervical cancer screening.[⁹]

Practice was assessed by response toward screening for cervical cancer in the past 3 years. If the respondents were screened within the past 3 years are considered as regular practice, those who are screened more than past 3 years are considered as irregular practice, and those who never screened were considered as no practice.

Statistical analysis

Epi-Info 7 for Dos version 3.5.1software (Centers for Disease Control and Prevention, Clifton Road Atlanta, USA) was used to analyze collected data from all study participants. Descriptive statistics such as mean, standard deviation (SD), frequency, and proportion were used to represent the sociodemographic characteristics and KAP of the study population. Association of sociodemographic variables with KAP levels is determined using Chi-square test. P< 0.05 was considered statistically significant.

Results

A total of 403 women responded to questionnaire, in these most were between 30 and 39 years of age. The mean age of women was 34.8 (SD = 6.7) and majority (314; 77.9%) are belonging to rural area. More than half of the women are belonging to Hindu religion (269; 66.7%). Majority of women were married (359; 89.0%), given birth to one or two children (290; 71.96%), illiterate (209; 51.8%), farmer (186; 46.1%), and homemaker (110; 27.3%) as shown in Table 1.

Table 1: Sociodemographic profile of study participants (n=403)

Among 403 women (301; 74.6%) had heard about cervical cancer and majority of them heard form media (168; 41.7%), friends (83; 20.6%), family members (22; 5.4%), and medical personnel (18; 4.4%). Regarding knowledge about signs and symptoms of cervical cancer (259; 64.2%), bleeding between periods (195; 48.3%), foul smell discharge (112; 27.8%), urinary urgency (96; 23.8%), bleeding after intercourse in women of any age (83; 20.6%), and postmenopausal bleeding (74; 18.3%). More than one-third of the respondents are not aware of signs and symptoms of cervical cancer. Knowledge about risk factors for cervical cancer was high (253; 62.8%), most respondents are stating that multiple sexual partners (155; 38.4%), early sexual intercourse (146; 36.2%), sexually transmitted diseases (110; 27.3%), HPV infection (98; 24.3%), and poor menstrual hygiene (85; 21.1%) increases the risk of getting cervical cancer in women. Around 150 respondents are unaware about risk factors for getting cervical cancer. The most known preventive measures for cervical cancer among women avoid multiple sexual partners (152; 37.7%), avoid early sexual intercourse (145; 36.0%), and HPV vaccination (90; 22.3%). More than half of the respondents are aware of treatment options (256; 63.5%), expenditure (231; 57.3%), screening methods (310; 76.9%), and HPV vaccination (301; 74.6%) for cervical cancer as shown in Table 2.

Table 2: Knowledge about cervical cancer and its screening among respondents (n=403)

Among all respondents, 71 (17.6%) were strongly agreed, 65 (16.1%) agreed, and 57 (14.1%) neither agreed nor disagreed that cervical cancer is highly prevalent and leading cause of death among all cancers in India. More than half of the respondents not agreed that they may susceptible for cervical cancer. Most of the respondents believed early screening and HPV vaccination can prevent cervical cancer. Most of the participants (349; 86.6%) were never screened for cervical cancer as shown in Table 3.

Table 3: Attitude and practice about cervical cancer and its screening among respondents (n=403)

Among all respondents, 152 (37.7%) have good knowledge, 148 (36.7%) moderate knowledge, and 103 (25.5%) poor knowledge. More than half of the respondents (252; 62.5%) have positive attitude toward cervical cancer screening as shown in Table 4.

Table 4: Adequacy of knowledge, attitude, and practice regarding cervical cancer and its screening among respondents (n=403)

Statistically significant associations of good knowledge, positive attitude, and regular practice with age, residence, religion, marital status, parity, educational status, occupation, and monthly household income was observed as shown in Table 5.

Table 5: Association of sociodemographic characteristics with good knowledge, positive attitude, and regular practice toward cervical cancer and its screening (n=403)

Discussion

The present study explored the KAP among women who are attending obstetrics and gynecology department of secondary care referral hospital which resides at resource-limited settings of Anantapur district were a lack of formal education, primary health facility, and revenue resources. Hence, among 403 respondents, most of them were illiterate, farmers, homemakers, and low economic status group. It is not uncommon, even in the 21^st century also, the era will continue to find young women with little formal education and no training who are homemakers with children.

The study found that more than one-fourth of population never heard about cervical cancer which is similar with results of studies conducted in developing and underdeveloped countries by Anorlu and Yifru and Asheber.[¹⁰¹¹] However, these results are contrast with a study conducted by Chande HM et al. show more than three-quarters of population are heard about cervical cancer.[¹²] In this study, media, friends, and family members are the principle information resources of cervical cancer, which are similar with findings of study conducted by Abdullahi et al.[¹³]

The study found that more than half of proportion of women are aware of symptoms, risk factors, and preventive measures for cervical cancer. This is consistent with findings from a similar study conducted in Northern Uganda by Mukama et al.[¹⁴] Still there is a lack of awareness about cervical cancer in women residing at rural area, where there is a need to conduct campaigns to improve their knowledge regarding symptoms, risk factors, and preventive measures. Women who are aware about cervical cancer they are more likely to take up measures of prevention by seeking medical attention and early screening.[¹⁵]

Most of the women showed positive attitude toward cervical cancer. Women who are aware of symptoms, risk factors, and preventive measures showed positive attitude toward cervical cancer screening. Early screening and HPV vaccination will helpful in prevention of cervical cancer. Some studies report that even providing of screening opportunities to women may not be utilized well due to some barriers such as fear of positive cervical cancer diagnosis, fear of cervical screening, and vaginal examination.[¹⁶] Continuous conducting of cervical cancer awareness program will bring change in the attitude and perception of women toward cervical cancer screening.

The study findings show that more than half of the percentage of respondents are having knowledge about cervical cancer, screening, and preventive measures. Most of the women showed positive attitude toward cervical cancer screening, but still there is a gap between perception and practice. In this hospital–based, cross-sectional survey, prevalence of screening for cervical cancer was extremely low at 5.4%; it is close with the 5-year screening prevalence estimated for developing countries by the WHO (5%).[¹⁷]

The study found association between sociodemographic characteristics with adequate knowledge, positive attitude, and regular practice toward cervical cancer. We found that adequate knowledge and positive attitude were associated with seven sociodemographic characteristics: age, residing area, marital status, parity, level of education, occupation, and monthly income. Women aged between 30 and 39 years are having adequate knowledge and positive attitude in relation to other age groups with P = 0.003 and 0.0003, similar findings are observed in the study conducted by Ogunbode and Ayinde.[¹⁸] Women who are residing in urban and semi-urban area were strongly associated with adequate knowledge and positive attitude toward cervical cancer in comparison with women residing in rural area with P = 0.0007 and 0.003. These findings are parallel to study conducted by Lyimo and Beran.[¹⁹] Married women given birth to one or two children and finished secondary level of education are having adequate knowledge and positive attitude toward cervical cancer screening in relation to others. Women, household income is <10,000 Indian Rupee (INR), and farmers are having poor knowledge and negative attitude toward cervical cancer and its screening. Women residing in rural area, college, or university level of education, health-care worker, and household income more than 20,000 INR are having regular practice with P< 0.05.

Strengths and limitation

The study provides insights into the KAP of women toward cervical cancer screening and attributable demographic characteristics. These data are useful to design educational program on cervical cancer screening and prevention to bring awareness in women. The major limitation was it is a hospital-based survey conducted in resource-limited settings, so findings are not transferable to other settings.

Conclusion

The study found that women have good knowledge, positive attitude toward cervical cancer screening, and prevention; still there is a gap to transform it into practice. Since high knowledge and positive attitudes themselves are not enough to ensure uptake of practice of screening, there is a need to uplift such cervical cancer screening services so that more women can access them irrespective of where they reside. Planned communication aiming eligible women, complete availability of screening services in public health facilities may increase the acceptance of screening. There is a need for more educational programs to channel identified knowledge slits and scale up of regular practice of cervical cancer screening in women.

Acknowledgments

The authors would like to thank all participants who are involved in this research study. We also thank Dr. Sudheer Kumar, Director, RDT Hospital, Anantapur, for his support to conduct study in hospital. All the authors are wholeheartedly thankful to the people who are directly or indirectly responsible for the completion of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.