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ORIGINAL ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 4  |  Page : 374-380  

Awareness on cancer cervix, willingness, and barriers for screening of cancer cervix among women: A community-based cross-sectional study from urban Pondicherry


1 Final Year MBBS Student, Department of Community Medicine, SVMCH and RC, Puducherry, India
2 Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, India
3 Scientist C, Division of Public Health, RMRC, Bhubaneswar, Odisha, India

Date of Submission07-Feb-2020
Date of Decision03-Jun-2020
Date of Acceptance12-Aug-2020
Date of Web Publication11-Dec-2020

Correspondence Address:
Bijaya Nanda Naik
Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_29_20

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   Abstract 


Background: Early detection of cervical cancer can significantly reduce the associated morbidities and mortality. However, uptake of screening for cervical cancer in India is not encouraging. Objectives: To assess the awareness about cervical cancer, willingness, and barriers for undergoing screening of cervical cancer among women in urban Pondicherry. Methods: This cross-sectional study was conducted among women of 30–65 years in urban Pondicherry during January – July 2019. A total of 219 women, selected using two-stage random sampling, were interviewed using a pretested semi-structured questionnaire. Multistep multivariable logistic regression was done to identify the independent correlates of willingness to undergo screening for cervical cancers. Results: About one-third women were aware of cervical cancer. Awareness was more among women who were young, had higher education, had family history of cancer, and currently working. Awareness of risk factors, signs and symptoms of cancer cervix was low. Although 60% of the women, who have been aware of cervical cancer, were aware of possibility of early detection, <15% were aware of the various methods. 32% of the women were willing to undergo screening for cervical cancer, and occupation, family history of cancer, and knowledge about risk factors were found to be independent correlates. Fear and “not having signs and symptoms” were the major reasons for unwillingness. Conclusion: Level of awareness and willingness for undergoing screening of cervical cancer was low in study area. Targeted interventions for awareness and health system efforts for addressing the reasons behind unwillingness are required.

Keywords: Awareness, cervical cancer, screening, visual inspection with acetic acid, willingness


How to cite this article:
Chandrika K, Naik BN, Kanungo S. Awareness on cancer cervix, willingness, and barriers for screening of cancer cervix among women: A community-based cross-sectional study from urban Pondicherry. Indian J Public Health 2020;64:374-80

How to cite this URL:
Chandrika K, Naik BN, Kanungo S. Awareness on cancer cervix, willingness, and barriers for screening of cancer cervix among women: A community-based cross-sectional study from urban Pondicherry. Indian J Public Health [serial online] 2020 [cited 2021 Jan 24];64:374-80. Available from: https://www.ijph.in/text.asp?2020/64/4/374/303093




   Introduction Top


Nearly 20%–25% of the cervical cancer related death globally occurs in India. Cervical cancer, which accounts for 6%–29% of all cancers among women, is the 2nd most common cause of cancer among females in India after cancer of breast.[1],[2] In India, the age-standardized rate of cervical cancer varies from 4.9 to 23.7 per lakh population.[2],[3] Although the various cancer registries in India have witnessed slight decline in the incidence of cervical cancer, the absolute number of cancer cases still remains high.[4]

Key to reduce the burden of cervical cancer is early detection with timely treatment. Cervical cancer can be treated effectively if detected in the initial precancerous stages.[5] Because it does not produce signs and symptoms, the patient does not seek health care in early precancerous stage. The absence of an established cervical cancer screening program in India also adds to nondiagnosis of cervical cancer at an early stage. Hence, most of the cervical cancer patients present to the hospital in the advanced stage, leading to high morbidity, sufferings, and mortality in India.[6],[7],[8]

Cervical cancer can be detected early through screening with Papanicolaou (PAP) smear examination or visual inspection with acetic acid (VIA).[9],[10] VIA is simple, safe, cost-effective, and can be done by trained female health worker in the field setting.[11] Because of infrastructure, logistic, and manpower issues, the cancer screening is non-existent in major parts of India.[3] The National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke, launched in 2010, advocates for facility based opportunistic screening of cervical cancer among women aged >30 years.[12] The more recent Operational Framework for Screening of Common Cancers developed by Government of India, 2016, recommends screening of cervical cancer using VIA by ANM among women in 30–65 years age group every five years.[13]

The cervical cancer screening coverage is very low (22%–36%) among women in India.[14] But a study from Tamil Nadu reported the screening coverage for cervical cancer to be around 63%.[15] Several reasons have been cited behind low coverage such as lack of resources for doing cervical cancer screening, poor awareness, and lack of demand/willingness for screening of cervical cancer among women. Generally, women in India do not discuss freely about diseases related to female reproductive system such as sexually transmitted diseases (STDs) and cervical cancer due to cultural taboo. All these factors contribute toward unwillingness and thereby nonuptake of screening of cervical cancer among women in India.

Various studies from India have reported that despite moderate level of awareness about screening of cervical cancer, the uptake of screening test was very less.[16],[17] The willingness to undergo cancer screening varies from 25% to 76% in India.[17],[18],[19],[20] Not having any apparent signs and symptoms, apprehension about cancer, inability to leave household works, preoccupied with family problems, and denial by husbands are some of the barriers for not undergoing screening for cervical cancer among Indian women.[21]

Pondicherry is one of the States/Union Territories in India with high density of health-care institutions. Despite that Pondicherry has high incidence of cervical cancer compared to neighboring districts of Tamil Nadu.[22],[23] The awareness of cervical cancer, and willingness and barriers for undergoing screening of cervical cancer has not been explored among women in community setting in Pondicherry. In this background, the current study was undertaken to assess the awareness about cervical cancer, willingness, and barriers for undergoing screening of cervical cancer among women in urban Pondicherry.


   Materials and Methods Top


Study design and study population

This study adopted a community-based cross-sectional design and was conducted during the months of January–July 2019.

The study population included female residents of the study areas who satisfied the inclusion and exclusion criteria. The inclusion criteria were females aged ≥30 years and ≤65 years, residing in the study area for at least 6 months. The exclusion criteria were already diagnosed with cervical cancer, already undergone screening for cervical cancer, and self-reporting to be under psychiatric care.

Study area/setting

The study was conducted in an urban area of Pondicherry. Pondicherry is one of the best performing States/Union Territories in terms of health indicators in India. Pondicherry is one of the two States/Union Territories which have favorable sex ratio (1037/1000 males).[24] Pondicherry has nine medical colleges apart from various primary and secondary level health care centers. This study was conducted in the urban field practice areas attached to the Department of Community Medicine of a medical college. The Urban Health and Training Centre (UHTC) attached to the Department of Community Medicine of the concerned medical college provides comprehensive primary health care to a population of around 7500, which also includes community based outreach activities. An obstetrics and gynecology specialist is also posted at the UHTC to provide specialist care to the population in the catchment areas.

Sample size and sampling technique

The minimum sample size was calculated to be 220 using Open Epi V 2.3 software (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version, Emory University, Rollins School of Public Health, Atlanta, GA, USA). The sample size was calculated assuming willingness for screening of cervical cancer among women as 29%,[19] absolute precision of 5%, and 95% confidence interval (CI) (5% alpha error).

This study adopted a two-stage sampling technique for recruitment of participants. The primary and secondary sampling units were household and adult woman respectively. The number of households to be selected from each area under UHTC was determined according to proportion of females in that area to the total female population under UHTC. Then, the required numbers of households in the particular area were selected using systematic random sampling (First Stage). One participant from each household was selected and enrolled after obtaining written informed consent. If there were more than one eligible woman in a household, one was selected randomly using lottery method (second stage). If there was no eligible woman, eligible woman not giving consent, or locked house, replacement household was chosen as per sampling method in the study.

Tools and techniques – Data collection

Information was collected using a pretested, semistructured study tool through face-to-face interview by the investigators. The study tool had three sections. The information on sociodemographic details of the participants such as age, gender, education, occupation, socioeconomic status, marital status, number of children, contraceptive use, and family history of cancer was collected in the first section. The information on cervical cancer (awareness, risk factors, prevention modalities, and screening) was collected in the second section. The information on willingness to undergo cervical cancer screening and barriers for undergoing cervical cancer screening was collected in the third section of the study tool.

After obtaining written informed consent, the participants were interviewed face to face in their houses. The participants who were not willing to undergo screening for cervical cancers were explained about the screening procedure with a pamphlet. The pamphlet had the pictures to explain the steps and procedure in cervical cancer screening using VIA technique and was face validated by an obstetric and gynecology specialist. Willingness for undergoing screening test for cervical cancer was again assessed. The final willingness included both groups of women, those showing willingness on their own, and those showing willingness after explaining the screening procedure.

Ethical issues

This study has been approved under the ICMR-STS scheme for 2019–2020. The study was approved by Institute Ethics Committee of the Medical College (SVMCH/IEC/2019-May/3 Dated: July 22, 2019). Informed consent was obtained from each participant before collecting data and throughout the study privacy and confidentiality was maintained.

Statistical analysis

The data were checked for completeness and entered in MS excel and analyzed using SPSS version 20.0 and OpenEpi version 2.3. Sociodemographic variables, awareness about various aspects of cervical cancer, and screening method for cervical cancer were expressed in terms of proportion and percentages. Multivariable binary logistic regression was used to identify independent correlates of the willingness for screening of cervical cancer. For this purpose, women who were unaware of cervical cancer were assumed to be unaware of risk factors, signs and symptoms, screening methods for cervical cancer, free availability in government health facilities, etc., as well. P ≤ 0.05 was considered statistically significant.

Identification of correlates for willingness for undergoing screening of cervical cancer was done using multistep multivariable logistic regression modeling. Sociodemographic characteristics with P ≤ 0.1 or around 0.1 on bivariate analysis were used for building Model 1. The next model (Model 2) used sociodemographic factors with P ≤ 0.1 or around 0.1 from model 1 and factors having P ≤ 0.1 or around 0.1 in the multivariable binary logistic regression for cervical cancer-related factors. The final model used variables with P ≤ 0.1 or around 0.1 from Model 2.


   Results Top


Background characteristics

Among the participants, 66.7% were below or 45 years of age; majority (80.4%) studied beyond class 5th; were housewives (83%); more than 95% were married and not using any contraceptive method currently; and about 39% belonged to below poverty line. Nearly a quarter of the women had more than two living children. Only 16% of the participants reported family history of cancer.

Awareness about cervical cancer

Almost all (218/219) the women were aware of cancer. The five cancers most commonly affecting women as per the participants were cancers of breast (78.9%, 172/218), uterus (69.3%, 151/218), mouth (39.9%, 87/218), cervix (32.9%, 70/218), and blood (20.2%, 44/218). Other responses were lungs (16.1%), brain (11.9%), throat (9.2%), stomach (7.3%), skin (5.9%), bone (4.6%), intestine (1.4%), and liver (0.5%). About 34% (75/219) (95% CI: 28.3%–40.8%) of the women were aware of cervical cancer. Higher proportion of women, who were aware of cervical cancer, were young (≤45 years - 38%; >45 years – 26%), more educated (≤ class 5th – 14%; > class 5th – 39%), had less number of children (≤2%–38%; >2%–21%), and working women (housewife – 31%; working women – 49%). Among the women who were aware of cervical cancer, 36% aware of any risk factors for cervical cancer and around 49% were aware of signs and symptoms of cervical cancer. The various risk factors and signs and symptoms of cervical cancer according to the participants are depicted in [Table 1].
Table 1: Awareness about cervical cancer, risk factors and signs and symptoms of cervical cancer according to study participants (n=219)

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About three-fourth (73.3%, 55/75) of the women, who were aware of cervical cancer, knew that cervical cancer is treatable/curable. However, only 21 of 55 (38.2%) could name any treatment available for cervical cancer. The various treatment modalities named by women were surgery (66.7%, 14/21), chemoradiation therapy (61.9%, 13/21), and medicine (4.8%, 1/21).

Awareness about screening of cervical cancer

Majority (61%, 46/75) of the women, who were aware of cervical cancer, were aware of the early detection of cervical cancer through various screening methods. However, almost 85% (39/46) did not know or responded wrongly the name of screening method; PAP smear was reported as screening method by rest of the participants (15%).

Most of the participants, who were aware of screening of cervical cancer, were aware of the availability of screening methods at various government facilities and JIPMER (Jawaharlal Institute of Postgraduate Medical Education and Research) in Puducherry. About 85% (39/46) of the women were aware of availability of cervical cancer screening free of cost; but majority (27/46, 58.7%) were unaware of frequency of screening. Only 4 out of the 19 women, who were aware of frequency of cervical cancer screening, knew correctly that it should be screened once in 3 years. More than 90% (42/46) of the women believed that cervical cancer screening would improve women's quality of life.

Willingness for screening of cervical cancer and its correlates

About 32% (95% CI: 26%–36%) of the women were willing to undergo screening for cervical cancer. Out of them, about 15% showed willingness to undergo screening for cervical cancer after explaining the screening procedure by the interviewer. Willingness was more among younger women, women educated beyond 5th standard, working women and women with no or <2 children compared to their counterparts. About 47% of women with family history of cancer were willing for screening as compared to 29% without family history of cancer [Table 2].
Table 2: Association of sociodemographic factors with willingness for screening of cervical cancer among the study participants (n=219)

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Willingness for cervical cancer screening was more among women who were aware of cancer (38.7%), risk factors for cervical cancer (51.4%), signs and symptoms (48%), treatability of cervical cancer (41.8%), screening for cervical cancer (41.3%), place of availability of screening test (41.4%), availability of screening test free of cost (43.6%), and belief that early detection of cervical cancer improve quality of life (40%) [Table 3].
Table 3: Association of cervical cancer related factors and screening with willingness for screening of cervical cancer among the study participants (n=219)

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Finally, a multistep multi variables logistic regression analysis was done. Age, education, occupation, and family history of cancer were included in the Model 1 (Nagelkerke R2 = 0.104; P ≤ 0.002) for 1st step of multivariable binary logistic regression. Factors from Model 1 (with P ≤ 0.1 or around 0.1) and knowledge of risk factors for cervical cancer (with P ≤ 0.1 or around 0.1 from multivariable binary logistic regression analysis of cervical cancer and screening related factors) were included in Model 2 (Nagelkerke R2 = 0.133; P ≤ 0.001) for the 2nd step of multivariable binary logistic regression. Factors (with P ≤ 0.1 or around 0.1 from Model 2) were included in the final model (Nagelkerke R2 = 0.125; P ≤ 0.000) of multivariable binary logistic regression. Occupation, family history of cancer, and knowledge about risk factors of cervical cancer were found to be independent factors for undergoing screening of cervical cancer [Table 4].
Table 4: Independent correlates of willingness for screening of cervical cancer among the study participants (n=219)

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Barriers for undergoing screening of cervical cancer

Fear (46%, 72/157) followed by “no signs and symptoms” (43%, 67/157) was found to be the major barrier among participating women who were unwilling to undergo screening for cervical cancer Other barriers were “ignorance” (6%, 10/157) and “shyness” (5%, 8/157).


   Discussion Top


Almost all the women in the present study were aware of cancer. Comparatively lesser proportion of women from Delhi (80%) and Tamil Nadu (70%) were reported to be aware of cancer.[18],[19] This could be due to the high density of health institutions in Puducherry and their outreach activities.

Higher proportions of women compared to our study were found to be aware of cervical cancer in other studies.[17],[18],[25],[26] However, compared to our study, a study from rural Tamil Nadu reported lower level of awareness.[19] Most of these studies were facility based. The women attending the health facility are better informed than those in the community. However, the community-based studies help in efficient planning for behavioral change of population. Similar to a study from Delhi,[18] the younger and highly educated women were more likely to be aware of cervical cancer than older and less educated women.

Similar to other parts of India, the participants in our study were less aware of risk factors and signs-symptoms of cervical cancer.[17],[18],[19],[27],[28] However, a hospital-based study from Andhra Pradesh has reported higher level of awareness on risk factors, signs and symptoms, and preventive measures for cervical cancer.[20] Compared to majority of the women in our study, lower awareness level on cervical cancer screening methods among women has been reported by Patra et al. (11%), Bansal et al. (35%), Nigar et al. (8%), and Kumar et al. (20%).[17],[18],[19],[28] Only 15% of the participants, who were aware of screening of cervical cancer, were aware of PAP smear in our study. Consistent findings have been reported by Elamurugan et al. and Narayana et al.[20],[25] Findings from our study imply inadequacy in knowledge among the participants on various aspects of cervical cancer and its screening methods. This inadequate level of knowledge/awareness could be due to poor mass media campaign on specific aspects of prevention and control for cervical cancer, cultural barriers preventing open discussion with peers, as well as health field staffs despite Pondicherry having a high density of health institutions.

Only one-third of the women were willing to undergo screening for cervical cancer in our study. Studies from other parts of the country have reported varied results with respect to willingness for cervical cancer screening. Studies from Delhi (25%) and Tamil Nadu (29%) have reported lower level of willingness for cervical cancer screening among women.[18],[19] However, studies from Bhopal (76%), Andhra Pradesh (63%), and Nepal (85%) have reported a higher level of willingness in their respective facility-based study.[17],[20],[26] In our study, we found employment, family history of cancer, and knowledge about risk factors of cervical cancer to be independent correlates of willingness for screening of cancer cervix. The higher willingness among employed women could be due to accessibility to information on prevention and control of cancer cervix. Knowledge about risk factors improves the health seeking behavior of women with respect to management of cervical cancer. Education status, place of availability, and availability screening test free of cost were found to be significantly associated with willingness for undergoing screening of cervical cancer on bivariate analysis but not on multivariable analysis.

Studies from Delhi and Bhopal have reported education as an important correlate for willingness to undergo screening which is consistent with our findings.[17],[18] Other studies from India have also reported higher level of willingness among younger women.[15],[18],[20] However, a study from Kerala has reported increase in participation for cervical cancer screening among older women.[4] Narayana et al. also have reported employment as an important determinant for undergoing screening of cervical cancer among women.[20] In contrast to our study and study by Narayana et al., higher parity was reported to be associated with higher willingness for undergoing screening of cervical cancer by Sankaranarayanan et al.[15],[20] Women with knowledge about various aspects of cervical cancer and screening for cervical cancer were found to have higher level of willingness for undergoing screening for cervical cancer in our study as has been reported by previous literature.[19],[29],[30],[31],[32] All these indicate a complex phenomenon which involves interaction of multiple factors at various levels that drive the decision of willingness of women to undergo screening for cervical cancer. Hence, comprehensive strategies addressing various aspects of cervical cancer need to be worked out for improving the screening and control of cervical cancer.

We found increase in willingness for undergoing screening for cervical cancer by 15% following explanation of the procedure and various other aspects of screening to women who were not willing initially. The lack of awareness of screening procedure acts as an important hurdle in uptake screening of cervical cancer and this hurdle can be avoided through health education intervention tailor made for prevention of cervical cancer in local context. Regular house visits by health workers and informed decision-making have been proposed as an intervention to increase the cervical cancer screening by women.[33] Studies from Mumbai, India, and Brazil have demonstrated the increase in the uptake of screening of cervical cancer following community level interventions.[34],[35]

Fear, shyness, and “not having signs and symptoms” were found to be important barriers of willingness for cervical cancer screening among our study population. Studies from Maharashtra also reported fear and shyness as reasons for not accepting screening of cervical cancer.[27],[36] A systematic review also reported shyness as an important barrier for screening of cervical cancer.[37] In contrast to findings from earlier research,[37] lack of knowledge about cervical cancer, family support, or lack of time were not mentioned as barriers for undergoing screening of cervical cancer by our study population. Instead, most of the women showed noninterest in cervical cancer screening due to lack of signs and symptoms. May be the women were not aware of curability of cervical cancer at precancerous stage. This brings the importance of implementation of intensified health education and health promotion strategies at the community level about prevention and control of cervical cancer.

We did not collect information at the health system level such as frequency of health education related to cervical cancer being conducted in the study area, availability of screening test, and promotion of cancer screening methods in the studied community.


   Conclusion Top


Level of awareness for cervical cancer and willingness for undergoing screening for the same was low in our study population. Being employed, family history of cancer and knowledge of risk factors were found to be independent correlates for showing willingness for screening of cervical cancer. Repeated campaigns through mass media and personal house visits by the health workers to disseminate knowledge on various aspects of cervical cancer and screening, and efforts at various levels of health system directed at prevention and control of cervical cancer can improve the cervical cancer screening uptake by the community.

Acknowledgment

This study has been conducted as a part of ICMR-STS project approved for 2019–2020. We thank Ms Amsa, the field staff from the UHTC, for her help in enrolling the participants in the study

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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