2Assistant Professor, Maulana Azad Medical College, New Delhi.
3Undergraduate MBBS, AIIMS, Rishikesh
4Professor and Head, Department of Obstetrics &Gynaecology, AIIMS, Rishikesh
Aims: To assess the knowledge, attitude and practice towards screening of cervical cancer among women visiting the outpatient clinic.
Settings and Design: A cross-sectional descriptive Knowledge Attitude Practice, (KAP) study including the women who visited the outpatient clinic of All India Institute of Medical Sciences, Rishikesh.
Methods and Material: The principal investigator interviewed 400 women (18 to 65 years) over three months, with a structured validated pre-tested questionnaire. Informed consent was obtained.
Statistical analysis used: The mean age and knowledge- attitude score with standard deviation was calculated using MS Excel. Mann- Witney test was used to compare scores between plains and hills.
Results: Ninety three percent (372/400) of the respondents had no knowledge regarding cervical cancer. The remaining 7% (28/400) had a mean score of 35.60% (9.97/28). There was no significance in the difference in mean scores between respondents from plains and the hills. Only 3.25% (13/400) respondents had knowledge about Pap smear as a screening technique but none had undergone the test voluntarily.
Conclusions: The awareness about cervical cancer and its screening is extremely poor. There is a dire need to generate awareness as accessibility, logistics and education already pose a negative impact in making implementation of screening programmes effective in this low resource setting with a high incidence of cervical cancer.
Keywords: Cervical cancer screening; KAP on cervical cancer; Low resource setting; Uttarakhand;
The mean age of patients with in situ lesions is 15.6 years younger than the age of patients with invasive carcinoma, providing a window for effective screening [2]. In addition to evaluating the infrastructure & manpower, it is essential to assess the Knowledge, Attitude and Practice (KAP) of clients, before implementing any screening/awareness programme.
Several studies have been conducted worldwide with variable results. While a study from Yemen shows 80.6 % participants with various levels of knowledge, 81.2% of participants from an Ethiopian study had never heard of Pap smear screening [3,4].
About 861 females might be affected by cervical cancer every year, extrapolating the Age Adjusted Incidence Rates (AAR) of cervical cancer (17.4 per 1 lakh; New Delhi) from the Population Based Cancer Registry (PBCR) on the population of Uttarakhand a low resource setting [5].
Hence, this study aims to assess the knowledge, attitude and practice and help in formulating screening programmes, as scarce data is available and there are no routine screening programmes for prevention of cervical cancer in Uttarakhand, which caters to a population of both plain (68%) and hilly (32%) areas[Method]
This is a cross-sectional descriptive questionnaire based Knowledge, Attitude and Practice (KAP) study involving females who visited the outpatient clinic over a duration of three months from July 2015 through September 2015. This methodology was found to be apt for a KAP study.
Assuming that knowledge, attitude, and practice (KAP) regarding cervical cancer screening among females in the general population as 50%, sample size is calculated using the formula:
N = z2* p*(1-p)/ c2
where,
N= sample size
z = standard normal deviation at 95% confidence level [1.96]
P = percentage of primary indicator in decimal [0.5]
c = standard error in decimal [0.05]. The sample size was calculated to be 400.
Out of the 403 subjects approached, 400 responded positively to the study.
The study received Institutional Ethical Committee clearance.
Study tool: A structured pre-tested and validated questionnaire was used. It consisted of three sections.
Section 1: Demo graphic profile [6].
Section 2: To assess the knowledge and attitude [20].
Section 3: To assess the practice [11].
Each correct response was given a score of 1.Cumulative score was added for each participant with maximum being 28 points. The mean score with standard deviation was calculated using MS Excel. Mann-Whitney test was applied (as the sample size with positive responses was less than 20 in the study) to determine the significance in difference of scores in between respondents from plains and hills.
Knowledge: About 73.75% (295/400) of the respondents have never heard of cervical cancer and 19.25% (77/400) have just heard of it but have no knowledge regarding cervical cancer. It is only the remaining seven percent (28/400) who have some knowledge about carcinoma cervix of which only 3.25% (13/400) know about screening techniques.
The response given by the seven percent (28 subjects), to questions pertaining to knowledge regarding cervical cancer, its risk factors, symptoms and screening techniques are given in tables 2. Genital tract infections and multiple sex partners were considered important risk factors by 40% of subjects and lower abdominal pain and contact bleeding were considered as more common symptoms of cervical cancer by 42%.
Even though 13 females (03.25%) knew about Pap smear, none (0/13) were aware of the recommended interval between regular screenings.
The average knowledge-attitude score of 28 subjects was 35.60% (9.96/28). The age wise distribution of score is given in table.3.
Years |
%(number) |
18 – 27 |
17.50% (70) |
28 – 37 |
38.00% (152) |
38 – 47 |
24.75% (99) |
48 – 57 |
11.50% (46) |
> 57 |
08.25% (33) |
Knowledge regarding cervical cancer |
Correct response (n =28) |
Q. Is cervical cancer preventable? |
78.57(22) |
Q. Can cervical cancer be detected at early stage? |
64.28(18) |
Q. Is cervical cancer curable? |
85.71(24) |
Q. Can Cervical cancer present without symptoms in early stage? |
46.64(13) |
Q. Is there any vaccine for prevention of cervical cancer? |
25.00(07) |
Response to risk factors for cervical cancer |
Correct response(n = 28) |
a) Multiple sex partners |
39.28(11) |
b) Early coitus |
21.42(06) |
c) Family history |
35.71(10) |
d) Smoking |
25.00(07) |
e) Prolonged OCP use |
35.71(10) |
f) Genital infections |
42.28(12) |
g) Don’t know |
14.28(04) |
Cervical cancer can present as : |
Correct response(n = 28) |
a) Intermittent bleeding |
32.14 (09) |
b) Bleeding after intercourse |
42.85 (12) |
c) Discharge |
39.28 (11) |
d) Dyspareunia |
28.57 (08) |
e) Bleeding and spotting after menopause |
39.28 (11) |
f) Lower abdominal pain |
42.85 (12) |
g) Don’t know |
03.57 (01) |
Screening methods for cervical cancer |
Correct response (n = 28) |
a) Pap smear |
46.42% (13) |
b) VIA,VILLI,Colposcopy,HPV detection |
0.00 |
Attitude: The attitude towards screening techniques was evaluated as shown in table.5. Around 40% (5/13) considered Pap smear screening essential only if symptomatic.
Practice: None of the subjects had undergone a Pap smear screening voluntarily in their life time. Four subjects had undergone Pap smear who had consulted for gynecological complaints which was followed by hysterectomy in all of them (diagnosis unknown).The reason for not getting the test done was that they never considered it important.
Age group |
Average score |
Respondents |
18-27 |
35.00(9.8) |
5 |
28-37 |
43.39(12.14) |
13 |
38-47 |
34.28(9.59) |
5 |
48-57 |
39.28(10.99) |
2 |
>57 |
26.07(07.29) |
3 |
Average score |
35.60(9.97) |
|
*maximum score = 28 |
Topography |
Total participants |
No:of participants withknowledge |
Average score |
Plains |
321 |
19 |
37.96(10.62) |
Hillyregions |
79 |
9 |
38.46(10.76) |
*maximum score= 28 |
Attitude towards PAP smear |
Correct response |
Should be screened if symptomatic? |
38.46 % (05) |
It causes genital tract infection? |
15.38 % (02) |
It can be done during pregnancy? |
07.69 %(01) |
It is only for elderly females |
07.69 %(01) |
- Globocan 2012: WHO certified International agency for research on cancer, Cervical cancer: Estimated incidence, mortality and prevalence worldwide. 2012.
- Bapsy PP, Jain A. Gynaecological malignancies; API Textbook of Medicine, 9th Ed.Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,2012; P. 1606
- 3.Abdul-Aziz M.Knowledge, Attitude and Practice towards Cervical Cancer among Reproductive Health Clients at the University of Science & Technology Hospital-Sana'a in Yemen; YJMS. 2012;6(1) .
- 4.Terefe Y, Gaym A. Knowledge, attitude and practice of screening for carcinoma of the cervix among reproductive health clients at three teaching hospitals, Addis Ababa, Ethiopia. EJRH, 2008;2.
- A. Nandakumar, T. Ramnath, Chaturvedi M. The magnitude of cancer cervix in India; National Cancer Registry Programme (ICMR), Bangalore, India; Indian J Med Res 130,2009;:219-221.
- Uttarakhand population Census data, 2011; Census Organization of India.