Abstract
Background:
Cervical Cancer is the second most common cancer among women in the world leading to 90% deaths in low and middle income countries. About 96,922 new Cervical Cancer cases are diagnosed annually in India.
Objective:
To study the knowledge, attitude and practice on Cervical Cancer and screening among women in India.
Materials and Methods:
Health sciences electronic databases PubMed and Google Scholar were searched for studies published between 2012 to March 2020. Keywords used for the search were (“Cervical Cancer screening”), (“knowledge”),(“attitude”), (“practice”) AND (“India”). 19 articles were included in the review based on the eligibility criteria. Statistical software SPSS-V.23 was used for the statistical application.
Results:
7688 women were included in the study. Age of study participants ranged from 12-65 years. Overall knowledge on Cervical Cancer among women was 40.22%. Knowledge of risk factors and signs and symptoms was fairly adequate among the women. 32.68% of women knew that early age of marriage was a risk factor for Cervical Cancer followed by 23.01% women who mentioned that early age of initiation of sexual activity was a common risk factor for Cervical Cancer. Inter menstrual bleeding and foul smelling discharge was the most common sign and symptom reported in 30.75% and 28.86% women respectively. Knowledge, attitude and practice regarding Cervical Cancer screening was seen in 20.31%, 43.64% and 13.22% of women respectively.
Conclusion:
Effective information, education and communication strategies are required to improve the level of awareness of women on Cervical Cancer.
Introduction
Globally, 570 000 cases of Cervical Cancer and 311000 deaths from the disease occurred in 2018. Cervical Cancer is the fourth most common cancer in women, ranking after breast cancer (2.1 million cases), colorectal cancer (0.8 million) and lung cancer (0.7 million). 1 It is the 2nd most leading cause of female cancer among women aged 15-44 years in India. About 96 922 new Cervical Cancer cases are diagnosed annually in India (estimates 2018). 2 While Cervical Cancer cases are declining in the developed world, they pose a heavy burden on developing countries, where the risk of developing Cervical Cancer is 35% greater compared to developed countries. 3 About 25% of global mortality due to Cervical Cancer occurs in India. 3
Cervical Cancer can be cured, because it has a long pre invasive period. Early diagnosis and treatment of Cervical Cancer at women are crucial for reducing mortality rates. 4 Fortunately Cervical Cancer has a long premalignant period that provides an opportunity for screening and treating before it turns to be invasive Cervical Cancer. Population-based screening with Pap smear or cytology is an important secondary preventive measure for Cervical Cancer that leads to a high-cure rate among Cervical Cancer patients. Early detection and treatment via screening can prevent up to 80% of Cervical Cancers in developed countries, where efficient screening programs are in place. In developing countries, however, there is limited access to effective, wide scale screening, leading to increased deaths due to Cervical Cancer. According to various reports, in developed countries 68%-84% of women are being screening by Pap smear, but in India this proportion is 2.6%-5% only. 5 This is one of the main reason that in India patients are being diagnosed at advanced stages. The main risk factor for development of Cervical Cancer is infection with human papilloma virus (HPV) types (HPV 16 and HPV 18), 6 HPV-DNA viral load quantification and integration, and E6/E7 expression are promising biomarkers that can predict the progression of lesions to Cervical Cancer. 7
Despite sufficient evidence supporting the use of screening as an effective intervention, there are still few large-scale screening programs being implemented in India. 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 and preventive methods are the major causes to increase the incidence of disease.
In spite of a dedicated cancer control program in place in India, screening has not been effective to decrease the burden of disease. The studies show that women have suboptimal level of knowledge of Cervical Cancer, their attitude is also favorable however the uptake of actual practice is low due to social stigma. Due to dearth of literature regarding knowledge, attitude, and practice (KAP) toward Cervical Cancer and its screening among Indian women this review was conducted. The outcome of this study provides information regarding current awareness, attitude and practice about Cervical Cancer and screening, which is helpful for designing population-based educational program leading to knowledge enhancement about Cervical Cancer and its screening.
Materials and Methods
Search Strategy
A comprehensive search of literature published from 2012 onward till March 2020 in the electronic databases PubMed and Google Scholar was conducted. We retrieved all English language studies that contained information on knowledge, awareness, attitude and practice on Cervical Cancer and its screening in India. Articles were included if they reported quantitative data of women’s knowledge, awareness, attitude or practice of Cervical Cancer and its screening in India. Primary concepts of “Cervical Cancer” “Cervical Cancer screening” “Cervical Cancer knowledge,” “Cervical Cancer attitude”, “Cervical Cancer awareness”,”Cervical Cancer practice” were expanded to generate additional medical terms (cervix, cervical, cancer, neoplasm, cervical neoplasms, screening, and primary diagnosis of cancer) for the search. The subject search and text word search were done separately in PubMed and Google Scholar and then combined with “OR” and “AND” operators. Combined terms were used, for example, (“Cervical Cancer screening” or ‘cervical screening’) AND (‘Cervical Cancer knowledge’ or ‘Cervical Cancer attitute’). Gray literature and additional articles were identified using the bibliography of included articles and some excluded review articles, along with forward citation searches.
Study Selection
Only articles that had reported quantitative evidence data of knowledge, awareness, attitude and practice of Cervical Cancer and its screening in India were included. Figure 1 shows the selection process of the articles retrieved. Our review was done according to PRISMA guidelines. 8 The initial database search retrieved 1380 published English-language studies. 1188 studies were excluded based on title and studies conducted outside India. Of the remaining 192 studies, the abstracts were read of which 163 articles were excluded as they were either duplicate articles, were not cross-sectional study designs or published before 2012. Of the remaining 29 studies,10 studies were excluded as they were conducted among health care professionals and provided incomplete information. 19 cross sectional study designs conducted in diverse settings like hospitals or communities published between 2012 and March 2020 that met the inclusion criteria and focused on KAP related to Cervical Cancer and its screening was finally included for the review. 3,9 -26
Summary of literature search and review process.
Inclusion Criteria
Cross-sectional, English language studies conducted in diverse settings like hospitals or communities of India published from 2012 till March 2020, on knowledge, awareness, attitude, practice of Cervical Cancer and its screening.
Exclusion Criteria
Case reports, case series, earlier reviews, and qualitative studies of Cervical Cancer and its screening uptake. Studies conducted in low or high-income countries other than India, articles published in languages other than English and articles conducted among health professionals.
Data Extraction and Synthesis
We extracted the following key characteristics of the studies: lead author and country, year published, study design, sampling technique, sample size, age group and knowledge of Cervical Cancer, Cervical Cancer signs and symptoms and risk factors, screening, attitude and practice toward screening. After the removal of duplicates, primary outcome data of all articles were indexed in Microsoft Excel. Later, interpretation of textual data was extracted to a Microsoft Word document. Two authors independently carried out the literature search and identified citations for KAP on Cervical Cancer and screening independently. Full-text articles were identified and assessed for eligibility after applying the inclusion and exclusion criteria. Statistical software like SPSS-V.23 was used for statistical application.
Results
Nineteen studies that met the inclusion criteria were included in the review. These studies included total of 7688 women aged between 12 and 65 years across 19 independent studies. The included studies were hospital and community based cross sectional studies. Majority studies were conducted in urban cities such as Delhi, Noida, Punjab, Kerala, Bengal, Lucknow, and Tamil Nadu. Majority women were married, and the illiteracy rate ranged from 5% to 66% (Table 1).
Studies included in review concluded that in India women still lack in appropriate knowledge and attitude toward Cervical Cancer and screening techniques due to low literacy rate. The articles reviewed showed that age, 9,10,12,18 education 3,13 -20 and per capita income 12,17,18 were significant factors independently associated with adequacy of knowledge, attitude, and practice of Cervical Cancer screening. (Table 1)
Characteristics of Studies Included in the Review.
Among 19 studies reviewed, 18 3,9 -13,15 -26 reported the knowledge on Cervical Cancer. The overall knowledge on Cervical Cancer among women was 40.22%. The awareness level of women regarding the risk factors was adequate. Among 19 studies 13, 3,10,12,13,16,17,19 -23,25,26 reported knowledge on risk factors. 32.68% women reported early age of marriage as the most common risk factor followed by 23.01% women who mentioned early age of initiation of sexual activity as a common risk factor. 25.22% women mentioned that non maintenance of personal hygiene was also common risk factor for Cervical Cancer (Figure 2).
Distribution of knowledge of risk factors of cervical cancer.
The articles reviewed showed that the awareness level of signs and symptoms was also adequate. Thirty-eight percent women told that bleeding per vagina is one of the major sign and symptom of Cervical Cancer. Inter menstrual bleeding and foul smelling discharge were the most common sign and symptom reported by 30.75% and 28.86% women, respectively (Figure 3).
Distribution of knowledge of signs and symptoms of cervical cancer.
Based on the review the knowledge of screening through PAP Smear was 20.31%. Positive attitude toward screening was seen in 43.64% women. 13.22% women practiced screening. Regarding knowledge and practice of HPV vaccination it was observed that, 20.14% women had knowledge on HPV Vaccine and 35.68% women had already taken HPV Vaccine (Figure 4).
Knowledge, attitude and practice toward screening of cervical cancer.
Discussion
This review examined the current literature on knowledge, attitude, and practice toward Cervical Cancer and its screening among women in India. The low uptake of Cervical Cancer screening can be attributed to a number of factors, including low level of knowledge and awareness, low level of perceived risk, delayed signs and symptoms in initial stage, social stigma associated with cancer, fear of cancer, cost, familial obligations, and embarrassment. 24
The current review found that only 40.22% of population had heard about Cervical Cancer. Similar results were observed among studies conducted in developing and underdeveloped countries by Anorlu 27 and Yifru and Asheber. 28 However these results are in contrast with a study conducted among women attending Obstetrics and Gynecology Department of a hospital in South India where knowledge of Cervical Cancer was 74.6%. Another study conducted by Chande and Kassim showed that more than 3-quarters of population had heard about Cervical Cancer. 29 Inspite of introducing National Cancer Control Programme in India, the knowledge level about Cervical Cancer was low among the participants which could probably be because the primary health care facilities are often over burdened and under resourced. 13 Due to limited resources VIA is being offered to women for screening between 30 and 69 years of age even though cytology is considered a better screening tool. 13 It was seen in the review that almost 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. 30 The review highlighted that early age of marriage, non maintenance of personal hygiene, and multiple sexual partners were reported as major risk factors for developing Cervical Cancer among 32.68%, 25.22%, and 23.01% women, respectively. Dhodapkar SB et al reported that risk factors for Cervical Cancer were young age at first intercourse, multiple sex partners, and lower socio-economic status by 13%, 48%, and 13%, respectively. 31 Amos D Mwaka et al found that 88.3% knew Cervical Cancer risk factors as multiple male sexual partners, sexually transmitted germ or virus (82.0%). 32 In a study by Shah et al only 8 (11.5%) respondents were aware of multiple sexual partners as one of the risk factors. 33 Improvement in lifestyle and personal hygiene has reduced the incidence of Cervical Cancer in recent times. The decline rates for Cervical Cancer may be partly explained by greater awareness for genital hygiene, and visiting clinicians at pre-clinical stage. 34
With regard to signs and symptoms of Cervical Cancer, 38% knew bleeding per vaginum, 30.75% knew intermenstrual bleeding, 29.72% knew loss of weight, and 28.87% knew foul smelling discharge as common symptoms of Cervical Cancer. Similarly a study done by Singh et al 35 reported that 79% females knew vaginal bleeding between menses as symptom of Cervical Cancer and 66% knew symptom as foul-smelling vaginal discharge. A study done by Shah et al 33 found that 94.2% respondents stated vaginal discharge as one of the symptoms, 86.9% as menstrual abnormality and 66.6% as pain as symptoms. Also a study conducted by Narayana et al 23 (2017), among the 403 women who completed the survey, 64.2% had some knowledge about signs and symptoms. Lack of awareness about Cervical Cancer in women residing at rural and urban areas emphasizes the need for conducting 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. 31
Much of the literature highlighted a gap between knowledge of Cervical Cancer and actual uptake of screening among community women. While many women have heard of Cervical Cancer, fewer are aware of its symptoms, and far fewer have undergone any type of screening. Yet, many women expressed a positive attitude and willingness to undergo screening despite the low uptake.
The level of adequacy of knowledge, attitude and practice toward Cervical Cancer screening in the current review was 20%, 40.8% and 13.8%.These findings were very low as compared with similar studies in Argentina, Kuwait, N. E. Brazil. 14 The review showed that only 20.3% participants had knowledge about Cervical Cancer screening. 40.2% showed positive attitude toward Cervical Cancer screening, but still there is a gap between perception and practice as it was only 13.8%. When considering PAP smear as a screening test, it was observed that only 16.21% had undergone a PAP test. It was seen that most of the women showed positive attitude toward screening. Women having knowledge of Cervical Cancer were most likely to get early detection and seeking early medical advise. Also there was positive attitude because women were willing to participate in screening programmes if provided.
Similarly in this hospital–based, cross-sectional survey done by Narayan et al (2017), 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%). 23 In contrast in a cross-sectional study among women at a primary health center in Tamil Nadu, the majority of participants were aware of Cervical Cancer (75.42%) and many believed that they were at risk (50.58%). 13 However, only 31% had undergone a Pap smear, but 69.96% of those unscreened were willing to undergo it. Bansal et al 16 also found similar results in a study of women of reproductive age who presented to the outpatient department of a hospital in Bhopal where of the 400 respondents, 65.5% had heard of Cervical Cancer, only 9.5% had ever undergone a screening test, but 76.25% favored positively or showed positive attitude to the idea of screening. In Kerala, among 809 women interviewed, three-fourths were aware that Cervical Cancer can be detected through early screening, yet a mere 6.9% had actually undergone any sort of screening test15. 36 Similarly in a study by Dhodapkar SB et al, none of the participants knew about the VIA method of screening. Those participants who knew that Cervical Cancer can be detected by Pap smear, only 5 (4%) had ever undergone Pap smear examination. 32
In our review it was observed that 20.14% participants had knowledge of HPV vaccination and 35.68% practiced HPV vaccination. Similarly in a study by Narayana et al 23 (2017) participants believed that early screening and HPV vaccination could prevent Cervical Cancer; yet, the majority of the women (86.6%) had never been screened. In our review it was seen that only 8% females knew HPV vaccination as a risk factor for Cervical Cancer. Governments in the LMICs and health development agencies need to make available population-based HPV vaccinations alongside awareness campaigns about the role of HPV in the etiology of Cervical Cancer. Otherwise prevention practices related to cervical HPV infections including vaccinations, delay of sexual activity and multiple male sexual partners may receive limited attention from the community.
Our study identified age, 9,10,12,18 education, 3,13 -20 and per capita income 12,17,18 as significant factors independently associated with adequacy of knowledge, attitude, and practice of Cervical Cancer screening consistent with many studies conducted in other parts of the world. The increase of knowledge of Cervical Cancer screening in educated women may indicate that women with better education have better communication skills and ability to absorb information.
Our review reported that there was slight increase in knowledge of women regarding Cervical Cancer with increase in time. This was shown significant in some places like study conducted in Delhi in year 2014 where only 16.36% participants had knowledge of Cervical Cancer. Similarly KAP study conducted in year 2017 and 2018 showed 53.88% and 56.80% knowledge of Cervical Cancer respectively., 22,23 Cervical Cancer-related deaths among women in India are often due to late diagnosis of disease. The review conducted essentially demonstrates that health literacy with regard to Cervical Cancer is essentially lacking among Indian women. Health literacy including 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. Despite availability of an effective and simple screening test, Cervical Cancer remains to be the most common cancer among Indian women.
Conclusion
The review concludes that although fair knowledge and a positive attitude toward Cervical Cancer and screening exists among Indian women, still there is a gap to transform it into practice. India has urgent need to develop health system capacity to ensure efficient Cervical Cancer screening program and community level efforts to improve knowledge about Cervical Cancer and screening programs. These efforts would help save thousands of young women and their families from a great calamity.
Strengths
To our knowledge, it is one of the first reviews that provides an insight into the KAP of Indian women toward Cervical Cancer and its screening and attributable demographic characteristics. It will serve as a guiding knowledge for policy makers useful to design educational program on Cervical Cancer screening and prevention to bring awareness in women and increase uptake of screening thus resulting in the decline in burden of Cervical Cancer.
Limitations
Studies from different geographical area and heterogeneity of diversified population data collected and pooled from various studies. Variations such as age range and sampling techniques were also not uniform. Merging such data may lead to high heterogeneity which is a potential source of bias.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding received from Indian Council of Medical Research Funding for the following paper is provided by ICMR (Indian Council of Medical Research) under the project entitled “Artificial Intelligence enabled early detection of Cervical Cancer in tertiary care setting and extended community”.
