A Cross Sectional Study on Knowledge, Attitude and Practice of Cervical Cancer Screening Among Women in Thiruvanmiyur, Chennai Sneha Sethumadhavan (1), Chitra. A (1) Abstract Aims: To assess the knowledge, attitude, practice and behaviour of cervical cancer screening, among women in Thiruvanmiyur, Chennai. Settings and Design: Cross sectional descriptive study Methods and Material: A cross sectional survey was carried out in Thiruvanmiyur, Chennai. A total of 225 women of 25~64 years of age were interviewed. A questionnaire consisting of 30 questions was given and it collected data on Socio-demographic characteristics, knowledge, attitude, practice and behaviour towards cervical cancer. Statistical analysis used: Data was fed into excel sheet and statistical analysis was done using SPSS v.20 package. Results: 50.2% had poor score for knowledge. They all showed positive attitude towards cervical cancer screening. There was a significant relationship between i.) Age and knowledge score ii.)age and pain, feeling embarrassed, general negative attitude towards health care, difficulty to get to pap smear clinic, pap smear test alone is unnecessary and cost as barrier and iii.) Age and practice of pap smear test. In terms of practice,63.6% of the population had had a pap smear test in the past and all had it only once. Most women preferred a women to conduct the pap smear test, at a clinic or private hospital and to receive their results face to face. Conclusions: The findings of this study highlight some important barriers to pap smear testing. The challenge for health care providers is to come up with better strategies to deal with these barriers for the uptake of pap smear testing to improve. Key-words: Pap smears, barriers, attitude, behavior, knowledge Key Messages: The general attitude of the women are positive towards cervical cancer and if their knowledge is also improved then the practice of having pap smear test, the follow-up of abnormal results and the overall treatment will also improve thus reducing the morbidity and mortality caused due to cervical cancer. INTRODUCTION: Cervical cancer remains as one of the leading cause (3rd largest) of cancer mortality in India, next to breast cancer and oropharyngeal cancer. Chennai is one among the top cities with increased incidence rate of 24.4%(2). It is a deadly disease once it reaches the invasive stage, but it is also the only cancer of female genital tract, which can be prevented if detected in the early stage. It was one of the leading cause of death in developed countries like the US however, incidence of cervical cancer mortality have declined steadily over the years in these countries due to the use of pap smear test. The only problem we are faced with now, is that, even though, this Pap smear screening test have been widely used all over the world, the morbidity and mortality rates continues to be a burden especially in developing countries like India and also very few studies have been done on the awareness and usage of Pap smear screening.(3) In India, the prevalence and burden of cervical cancer is much higher among women of low socio-economic status as well as among rural women.(4) The primary reason given for this is lack of access to screening and health services, and lack of awareness of the risk factors of cervical cancer. Due to the difficulties in accessibility and affordability, compliance to and follow up of the condition, treatment is much worse for women of low socio-economic status, leading to further morbidity and mortality from the disease. Similarly in tertiary care institutes, one of the major problems that need to be addressed is the inadequacy of the lab to accommodate high number of smears for screening as this could be a limitation for conduction of Pap smear screening. 1.Institute of Community Medicine, Madas Medical College 7
Vol 2 Issue 3 July-September 2015 8 SUBJECTS AND METHODS: 1. Study design: Cross sectional descriptive study. 2. Study population: According to WHO guidelines the target population for pap smear screening is 25~64 years. Thus the study population was defined as follows:- Inclusion category: Women of 25~64 years of age living in Thiruvanmiyur, Chennai. Exclusion category: Those who do not give consent for the study. 3. Study area: Study area was selected as Thiruvanmiyur by lot method from all the wards of Chennai, to represent the general population of women of 25~64 years of age. 4. Study period: The study was conducted during the months of August and September of the year 2012. 5. Sample size: Based on the studies conducted previously in various developing countries [28], the sample size was calculated using the formula 4pq/d2 and found to be 225 (with p=33 and d=20). Sample frame of all the women between 25~64 years of age living in Thiruvanmiyur area was obtained and 225 participants were selected from them by computer generated random numbers. 6. Study instrument: Standard semi-structured questionnaire used in similar studies conducted previously in developing countries was modified according to the needs and population of this study and used. It consists of 30 questions divided into 4 sections to assess the i. Socio-economic character ii. iii. iv. Knowledge level Attitude Behaviour and Practice The questionnaire was in English and was translated into Tamil for those who don t have good understanding of English. The Tamil questionnaire was back translated into English for checking accuracy. 7. Data management and analysis: Data was fed into excel sheet and statistical analysis was done using SPSS v.20 package. 8. Ethical considerations: Approval from the ethical committee was obtained before starting the study.the respondent identity was kept confidential. Consent from the participants was obtained for the study. RESULTS: 1.SOCIO-DEMOGRAPHIC CHARCTERISTICS : The first part of the questionnaire dealt with socio-demographic characteristics which were categorized into age, educational status and marital status. These variables were re-categorized wherever necessary. AGE The majority of women(47.6%) participating in the study were found to be between 41-50 years of age and only one participant above 60 years of age. The mean age was found to be 44.7. A cross tabulation of Age vs. practice of pap smear shows a chi-square value of 13.564 and p-value of 0.003 which is significant. Maximum number of people who had undergone pap smear falls under the age group of 41-50 years and minimum number among the age group of more than 50 years of age. EDUCATION More than half of the women are well educated with either a degree/diploma (88.4%).10.2% finished up to secondary school or only 3% up to primary school. There were no illiterate women in the study. A cross tabulation was made between Educational level and practice of pap smear and it was found to have a chi-square value of 3.472 and p-value of 0.163 which is not significant indication that educational level has no influence on uptake of pap smear test. But it is seen that the trend of pap smear practice increases with the level of education. 2.SCORE FOR KNOWLEDGE: 5 questions were given to the study group to assess their knowledge and based on the scores the knowledge level is graded as follows 0, 1, 2 poor 3 Average 4, 5- Good It was found that approximately half of the study population (50.2%) have poor knowledge, 27.1% has average
knowledge and only 22.7% has good knowledge. Overall, the trend seen was that irrespective of education level, a large proportion had poor knowledge levels of cervical cancer and pap smear screening. However, it is worth noting that education level increased the level of poor knowledge level decreased as shown in the comparisons of proportions in the good and poor column. Knowledge scores and Age was cross tabulated and found to have a chi-square value of 29.13 and p-value of 0.000 which is very significant indicating the difference in knowledge levels among different age groups. It is seen from the table that age group of 41-50 has the highest number of participants with a good score, whereas age group under 30 was found to have least number of participants with good score. A cross tabulation between knowledge score and practice of pap smear shows a chi-square of 0.685 and p-value of 0.722 which is not significant. It is found that among the study group which had not had Pap smear, 44 people had poor knowledge and only 18 people had good knowledge. 3.ATTITUDE 3 questions were given to assess the attitude of the study population towards cervical cancer screening. Most of the participants (77.3%) agree that they will be satisfied after having a pap smear test with only 4% coming up with a negative response that they would not be satisfied. Similar result is obtained for the second question with 77.3% agreeing that it is valuable to have pap smear regularly and only 13% disagreed. 61.3% of the study group agreed that pap smear detects pre-cancerous cells before symptoms appear but 21.8% responded as pap smear has no role in detecting pre-cancerous lesions. 4.BARRIERS 1)EMOTIONAL Emotional barriers were assessed by 3questions. 56.9% disagreed that pap smear test is painful. 21.8% agreed that it is painful and 21.3% didn t know as they had never undergone pap smear test. Also majority of the participants(64.9%) disagreed that having a pap smear test is unpleasant / embarrassing and 35.1% agreed. 86.2% disagreed that health care in general is unpleasant. 2)TIME CONSUMING For the barrier of time 77.8% of the study population disagreed that it is difficult to get to the pap smear clinic and 72% responded that being busy and the priority for other things do not get in the way of pap smear check. 3)ECONOMICAL Under economical barrier, 76.0% disagreed that pap smear is unnecessary if there are no signs and symptoms and 82.2% disagreed that it is unnecessary to go only for pap smear. Majority (64.9%) disagreed that going for pap smear screening is too expensive. 4)FEELING OF ANXIETY 32.9% agreed that they were afraid that something wrong will be detected if they go for pap smear test but more than half of the study population (67.1%) disagreed. Cross tabulations were made between Age and all the barrier factors ( Emotional, Time, Economical and Feeling of anxiety ) and significant finding was found only in the cross tabulation between Age and pain as the barrier factor, with chi-square of 27.629 and p-value of 0.000. Women of 31-40 years of age has responded maximum (26.3%) that it is painful to have a pap smear test and almost half (45.7%) of the women above the age of 50 did not know if it is painful or not. Different barriers for pap smear screening were assessed by categorizing them into 4 groups- Emotional, Time consuming, Economical and Feeling of anxiety with sub-questions under each group. There was a significant relationship(p<0.05) between age and feeling unpleasant/embarrassed as a barrier. Women of 41-50 years of age have responded maximum(42.1%) as it is unpleasant and women above 50 years disagreed the most(84.8%). 9
Vol 2 Issue 3 July-September 2015 10 There was significant relationship between age and feeling that health care in general is unpleasant. Again women of 41-50 years of age tops the list with 20.6%.women below 30 years of age disagreed the most (93.3%) There was a significance (p<0.05) between age difficulty to get to pap smear as a barrier. Women of 41-50 years of age had agreed most(28.0%) and women above 50 years of age had disagreed(93.5%) the most. A significant relation was found between age and feeling that it is unnecessary to go only for pap smear test (p<0.05). 31-40 years old agreed the most (29.8%) and less than 30 years disagreed the most (93.3%). (Table 4.11) A significant relationship between age and cost of the pap smear as a barrier (p<0.05). women of 41-50 years agreed the most (33.6%) and women of 31-40 disagreed the most(77.2%). 5.PRACTICE/BEHAVIOUR 63.6% of the study population have undergone a pap smear test earlier and 86.7% are willing to show up for further follow up if some cancer changes are detected. 35.1% of the study group prefers to receive the pap smear results face to face, 30.2% in writing and 16.9% doesn t mind either way. Majority (79.6%) of the study group prefer a woman conducting the pap smear test and only 6.2% prefer a man conducting pap smear test and 16.9% responded as it didn t matter. 83.1% of the study group prefers to have their pap smear test at a private clinic or a hospital, 4.4% in organized screening camps and only 1.8% in Government hospitals. 86.7% of the women agree for a regular follow-up if they are detected to have abnormal pap smear result. DISCUSSION: The knowledge level on cervical cancer and pap smear testing was poor in almost half (50.2%) of the participants. Judging by the results of the level of knowledge of the participants, more awareness programs should be directed to the target group of women to provide them with information they need to know about cervical cancer so that they understand the purpose of the pap smear screening test and come forward for testing and follow-up. There is a significant difference (p<0.05) in the knowledge score among women of different age group, where women among the age group of 41-50 have scored the maximum. This may be explained by the fact that more women in this age group have only undergone Pap smear test earlier when compared to other age groups, hence they are more aware. Efforts must be taken to educate women of all age groups, especially women below 30 years of age so that Pap smear can be practiced from very early in life. It is also seen that there is no co-relation between the education level of the participant and their knowledge score which indicates a general lack of awareness even among educated women. Similarly, the level of education does not seem to influence the uptake of pap smear, as, even among well educated women the uptake of pap smear test is found to be low. It can also be noted that even though the level of knowledge is poor, majority of the women with this poor knowledge have had a pap smear test but since the association is not significant, it can be assumed that a lot of women coming for pap smear test are merely having the test without knowing the actual purpose of it and this could explain the non-compliance on follow-up when an abnormality is detected in their smear results. In regards to the attitude of women towards cervical cancer and pap smear screening, more than 75% of the women agreed that they would be satisfied after having a pap smear test and that it is valuable to have pap smear test. Around 60% of the women knew that pap smear detects pre-cancerous changes thus realising the true usage and benefit of undergoing a pap smear test. Thus there is a positive attitude towards cervical cancer and pap smear test and it is hoped that they will practice and comply with follow-up schedules. Majority of women have had pap smear test in the past, as revealed in the result section (63.6%) but there is a significant difference in the level of uptake among women of different age group, with women of 41-50 years of age topping the list (73.8%) and women below 30 years and above 50 years in the bottom of the list. This is probably because women of younger age group do not think it is necessary to get a pap smear test done so early in life since they are healthy and there are no symptoms. Even though majority of women have had pap smear test in the past, their knowledge level is poor. These women have stated reasons such as feeling of fear, embarrassment, uneasiness, not aware, thinking about it and planning to go, have not heard about pap smear and think that its only for elderly women. Also,
majority of the women (76.9%) preferred a female to conduct their pap smear test, they associate it with clinics or private hospitals and they want to discuss their results face to face. Almost all the women agreed that they will continue with the pap smear test and those who have not had any test are planning to start (76.0%). Also, they agreed that they will go for further follow-up clinics if any abnormality was detected in their pap. A significant relationship (p<0.05) was established between the age of the patient and whether they perceived the test painful or not. Women between 31-40 responded the most that pap smear is painful whereas majority of women above 50 years of age and below 30 years of age did not know if it is painful or not. Also similar significant relationships (p<0.05) is seen between Age and various barriers like embarrassment, general unpleasantness of health care, difficulty to get to the pap smear clinic, unnecessary to go only for pap smear test and the cost of the pap smear test. This indicates that the barriers differ with each age group, and this must be kept in mind while educating and motivating the women so that maximum benefits can be obtained. 4. Kirby E, Webster R, Symonds A, Pezzutti B, Arena F, Evans B, Walker J and Chadwick V. Pap Smear Testing Matter of Public Interest. Parliament of New South Wales 1992; 5. Mutyaba T, Mmiro FA, and Weiderpass E. Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda. BMC Medical Education 2006;6(13): ACKNOWLEDGEMENT: I would like to thank my guide and the Institute of community medicine, Madras medical College for their immense support and guidance to undertake this project. I would also like to thank the ICMR STS programme for funding the project. Since majority of the women prefer females to conduct the pap smear test, more nurse and other female health workers can be trained so that these services can be provided in many rural areas and also in primary health care centres all over India. Overall, the general attitude of the women are positive towards cervical cancer and if their knowledge is also improved then the practice of having pap smear test, the follow-up of abnormal results and the overall treatment will also improve thus reducing the morbidity and mortality caused due to cervical cancer. REFERENCES: 1. Fylan F. Screening for cervical cancer: a review of women s attitudes, knowledge and behavior. British Journal of General Practice 1998;48:1509-1514 2. Gharoro EP. And Ikeanyi EN. An appraisal of the level of awreness and utilization of the pap smear as a cervical cancer screening test among female health workers in a tertiary health institution. International Journal of Gynecology Cancer 2006;16:1063-1068 3. Cracchiolo B. and Leitao M. Jr. Update on cervical cancer. HealthLink 2006; 11