Knowledge, attitude and practice regarding cervical cancer prevention among women attending the outpatient Department of Obstetrics and Gynaecology at All India Institute of Medical Sciences (AIIMS), Bilaspur, Himachal Pradesh, India: a cross-sectional study

¹Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India, ²Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India, ³Department of Community and Family Medicine, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India

^&Corresponding author
Bhavna Bhavna, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India

Introduction    

Cervical cancer is largely a preventable cause of death occurring globally among women, yet it is the second most common cancer seen in women worldwide. As per the ICMR-National Institute of Cancer Prevention and Research, cervical cancer accounts for 22.86% of all cases of cancer in women, with 1,23,000 new cases registered and 67,500 deaths [1]. Cervical cancer primarily results from persistent infection with high-risk human papillomavirus (HPV) strains, which is widely known, and it accounts for more than 90% of cases of cervical cancer. This persistent infection can lead to changes causing precancerous lesions, followed by cervical cancer; however, the progression is slow. Hence, screening plays an important role in disease prevention due to the long latent phase [2]. Precancerous lesions can be detected by screening years before their progression to cancer, and these lesions can be managed using either ablative or excisional procedures according to existing guidelines [3].

Various screening modalities, such as visual inspection with acetic acid, visual inspection with Lugol's iodine, pap smear, liquid-based cytology, and HPV DNA testing, are available. WHO suggests using HPV-DNA as a primary test for screening, and screening to start at the age of 30 years [4]. Despite the availability of effective vaccines and screening modalities, cervical cancer remains a significant public health issue due to a lack of awareness and inadequate knowledge [5,6]. According to the National Family Health Survey-5, the overall cervical cancer screening rate was 0.7% in Himachal Pradesh, India [7].

Himachal Pradesh is predominantly a rural state with challenging geographical terrain, which may limit access to health information, screening services, and preventive healthcare. According to previous studies and NFHS-5, cervical cancer screening uptake is very low in India. Understanding existing awareness levels and identifying gaps in the utilization of cervical cancer preventive measures is essential. This survey was conducted with the aim of evaluating the knowledge of participants about cervical cancer risk factors, symptoms, and prevention strategies, and exploring their attitude and practice towards preventive measures. This will identify loopholes responsible for low screening and vaccination uptake despite the available options.

Methods     

Study design: a cross-sectional study.

Study setting and population: this study was carried out at All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India, and all consenting participants who reported to the Obstetrics and Gynaecology Outpatient Department for routine check-up were included in the study. This study was conducted from the 1^st of April 2023 to the 31^st of March 2024. After obtaining written informed consent, we administered a questionnaire to the participants.

Variables: to measure knowledge, attitude, and practice towards cervical cancer in women.

Data collection tool: a structured questionnaire consisting of questions about knowledge of symptoms/risk factors, attitude, and practice toward cervical cancer preventive measures was handed over to participants. All the participants were managed as per the Outpatient Department (OPD) protocol.

Data collection: data about the sociodemographic profile of participants and their knowledge, attitude, and practice towards cervical cancer prevention were collected in a questionnaire. Assessment of knowledge was done, and scoring according to answers given (yes=1, no=0, and do not know=0) was done, totalling a score of 20, and it was then divided into good knowledge (>14), average (7-14), and poor (<7) knowledge. All questions were in Hindi/ English for a better understanding of the participants. For some participants who were willing to participate but were not able to understand Hindi, for such patients, translation to the local language was done by staff who were addressing queries to participants. Participants were assessed through this questionnaire.

Sample size: the sample size has been calculated to be 1300 study subjects, using the formula for a descriptive observational study:

Where N = number of participants; Z= 1.95 at a 95% confidence interval; P is the expected proportion; 1-P is the complementary proportion; and d is the desired precision. Considering the prevalence of knowledge about cervical cancer as 15%, taken from previous studies, and a precision of 13 was taken to calculate the sample size [6]. The sample size came out to be 1,289, and a round figure of 1300 was taken.

Data analysis: data were collected and entered into an Excel sheet and analyzed using SPSS version 26.0. Descriptive statistics, chi-square tests, and logistic regression analysis were performed using SPSS version 26.0. Significance was assessed at a 5% level of significance; p-values and confidence intervals were calculated. A logistic regression model was applied to all variables that showed significance on initial analysis.

Ethical consideration: this study was approved by the Institutional Ethics Committee IEC clearance, (vide Ref. No 23/23). All participants were recruited after obtaining consent for participation in the survey. Anonymity and confidentiality were ensured during data collection.

Results     

A total of 1,300 participants were included in the present study. The mean age of participants was 31.41 ± 9.65 years, and most were from rural areas and married. Most of the women (78.7%) reported that their age at first sexual contact was after 20 years. Out of 1,300 participants, only 283 (21.8%) had heard about cervical cancer, whereas 1,017 (78.2%) had not heard about cervical cancer (Table 1). Assessment of knowledge revealed that 785 (60.4%) participants had poor knowledge, 384 (29.5%) had average knowledge, and only 131 (10.1%) demonstrated good knowledge about cervical cancer. On analysis, it was seen that a significantly higher proportion of urban women had heard about cervical cancer compared to rural women (P=0.022). Evaluation of participants' attitude and practice towards cervical cancer prevention showed that 629 (48.4%) had poor attitude and inadequate practice, 373 (28.7%) had average attitude and practice, while 298 (22.9%) exhibited good attitude and practice. Overall, the findings indicate that a majority of the participants had inadequate knowledge regarding cervical cancer, with fewer than one in ten demonstrating good knowledge. A higher level of awareness was also seen among employed and educated women when compared to women who were unemployed and had a lower level of education (P<0.001). Women with higher income (>30,000 rupees/month) were more aware of cervical cancer when compared to those with a lower income level (Table 2).

In this study, knowledge about symptoms such as intermenstrual bleeding per vaginum (P<0.001), foul-smelling or blood-mixed discharge p/v (P<0.001), and postcoital bleeding (P=0.004) was significantly higher in the high-income group than in the low-income group. Knowledge about risk factors was also higher in the high-income group. Women in the high-income group identified multiple sexual partners (P=0.038), early age at sexual intercourse (P=0.029), HPV infection (P=0.003), and cigarette smoking as a risk factor (P=0.018), and the difference was statistically significant. Knowledge regarding HPV vaccination as a preventive measure did not differ significantly between the two income groups (P=0.108). Participants from high-income groups were more likely to believe that cervical cancer can be prevented by screening (P<0.001). They were also of the belief that maintaining a single sexual partner (P=0.008), avoiding sexual activity at a younger age (P=0.01), perineal hygiene (P=0.003), and quitting smoking (P=0.002) may prevent cervical cancer. It was noted that participants reporting first sexual contact after 20 years of age were more aware of cervical cancer when compared to younger women (P=0.006). Awareness through news media (P<0.001), health workers (P<0.001), family/neighbours/friends/teachers (P=0.043), and doctors during routine clinic visits (P=0.006) also showed a significant association with family income and was high in the high-income group (Table 3).

Knowledge about cervical cancer did not differ significantly between sexually experienced and sexually inexperienced women (P=0.96). Knowledge about signs, symptoms, and risk factors for cervical cancer was similar in both groups, whether women were sexually experienced or inexperienced. In the present study, it was noted that knowledge regarding HPV vaccination as a preventive measure against cervical cancer was higher in sexually inexperienced women (P<0.001). Knowledge that quitting smoking may prevent cervical cancer (P<0.001) and knowledge that maintaining a single sexual partner may prevent disease (P=0.042) was higher in sexually inexperienced women. A higher proportion of sexually inexperienced women had the perception that cervical cancer is treatable (P=0.043). Knowledge regarding the recommended frequency of screening also differed in both groups (P=0.005). More sexually inexperienced women thought that annual screening was appropriate when compared to sexually experienced women (16.5% vs 8.2%); however, this perception of annual screening frequency was not true (Table 4). Logistic regression analysis was performed to identify independent predictors associated with the outcome variable. Variables included knowledge regarding HPV vaccination, a single sexual partner as a preventive measure, quitting smoking as a preventive measure, treatment of cervical cancer, treatment options, and opinion regarding frequency of cervical cancer screening. Among all the variables included in the regression model, knowledge that maintaining a single sexual partner can prevent cervical cancer was found to be a significant predictor (OR=0.594, CI=0.401-0.880). Knowledge that quitting smoking can prevent cervical cancer was also identified as a significant predictor (OR=1.767, CI=1.213-2.575). The opinion regarding the appropriate frequency of cervical cancer screening showed a significant association (OR=1.254, CI=1.021-1.540), indicating higher odds of the outcome variable among participants with greater knowledge of screening frequency.

However, awareness regarding HPV vaccination as a preventive measure for cervical cancer (P=0.267, OR=1.267, CI=0.834-1.925), belief that cervical cancer can be treated (P=0.695, OR=1.057, CI=0.8-1.397), and knowledge regarding treatment options (P=0.384, OR=1.133, CI=0.855-1.5) were not significant predictors in the regression model (Table 5).

Discussion     

This cross-sectional study assessed knowledge about symptoms and risk factors among women and their attitudes and practices towards cervical cancer prevention. With a sample size of 1,300 women, this study provides a snapshot of women's awareness levels and health-seeking behaviour in this region. The target population was women belonging to District Bilaspur of Himachal Pradesh. In this study, it was found that 785 (60.4%) participants had poor knowledge, 384 (29.5%) had average knowledge, and only 131 (10.1%) demonstrated good knowledge about cervical cancer. Evaluation of participants' attitude and practice towards cervical cancer prevention showed that 629 (48.4%) had poor attitude and inadequate practice, 373 (28.7%) had average attitude and practice, while 298 (22.9%) exhibited good attitude and practice. Knowledge about risk factors, symptoms, and preventive measures was significantly higher in urban, educated, employed, and high-income group women.

The mean age of participants was 31.39 ± 9.63 years, which was also comparable to studies conducted by Ghosh S et al. and Thapa N et al. [8,9]. One of the significant findings of this study is that a large proportion (1018; 78.3%) of the study population had not heard about cervical cancer, which was comparable with the studies conducted by Patil et al. [10]. Studies conducted before have indicated that a lack of knowledge and awareness about the disease and its symptoms often leads to late-stage diagnosis, which leads to poorer outcomes for cervical cancer patients [11]. In our study, 28.2% of participants were aware of the fact that HPV infection is a risk factor for cervical cancer, 24.5% opined that early age at sexual debut is a risk factor, and 29.5% of participants thought multiple sexual partners are a risk factor for the disease with was also seen by Patil et al. [10] and Mengesha et al. [12].

In the present study, it was seen that awareness about cervical cancer was higher in educated and employed women. Women with high income group were also more aware of cervical cancer. It was also seen that the majority of women in our study came from rural areas, but the awareness level was more in urban participants than in rural women. It was also noted that women from the high-income group have significantly higher knowledge of symptoms/signs and risk factors for cervical cancer. More women in the high-income group had knowledge that HPV is a risk factor for this disease; however, knowledge that HPV vaccination is a preventive measure was the same in both income groups. It was the lack of knowledge about the vaccination importance and hesitancy. The most important measure that can be taken to overcome it will be to educate more and more women about preventive measures. This finding was consistent with studies from the past, which say that knowledge about screening and screening uptake was higher in educated, urban women with high incomes and women with access to social media [13-15].

In our study, awareness about symptoms of cervical cancer, like irregular/intermenstrual bleeding p/v, was noted in 24.3% of participants; foul-smelling discharge as a symptom in 31.6% of cases and postcoital bleeding as a symptom reported by 22.9% of participants, which is in concordance with a study by Patil et al. [10]. Furthermore, our study found that only 20.5% of participants were aware that HPV vaccination as preventive measure, which was consistent with research conducted in India by Patil et al. [10] and Taneja et al. [16], where awareness about HPV vaccination is often limited due to factors such as lack of education, misinformation, and cultural stigma. This finding is concerning, given the fact that HPV vaccination is one of the most effective preventive measures against cervical cancer.

Another key finding was that 91.5% of the participants had never undergone cervical cancer screening. This aligns with studies conducted by Thapa et al. [9], who reported that the majority of women in rural India have limited access to cervical cancer screening programs. Knowledge of screening through pap smear/LBC/HPV-DNA was 19.8% in our study, which was comparable with other studies by Mengesha et al. [12] and Taneja et al. [16]. Positive attitude toward getting screened was noted in 36.1% of participants, and willingness to be screened increased to 45.2% when the test was offered free of cost, which aligns with a study by Taneja et al. [16]. In this survey, it was found that the reasons for not participating in screening programs were primarily due to the perception of good health (44.3%) and lack of awareness (32.9%) about available screening methods. However, lack of knowledge about the screening methods remains the main cause for lower uptake of screening, as shown by a study conducted by Verma et al. [17].

Lastly, our findings reveal a disparity in the level of awareness between rural and urban women. A majority of the participants were from rural areas, where access to healthcare services and information is often limited, but participants belonging to urban areas were more knowledgeable than the rural population. Studies have shown that knowledge about cervical cancer and HPV vaccination is higher among urban and educated women [18]. So, it clearly points towards the importance of awareness camps and education in rural, geographically tough terrains. The biggest strength of the study is its large size, and all participants were assessed using a structured questionnaire, and assistance was provided whenever required, improving comprehension and data quality. The main limitation of the study was that this study is a cross-sectional hospital-based study, so results may not be generalizable to the wider community. Another limitation was that all the participants were women seeking healthcare services, who may have different health-seeking behaviour compared to the general population, so this may have either overestimated or underestimated awareness levels.

Conclusion     

This survey concluded that the lack of knowledge about the disease among rural women underscores the urgent need for comprehensive health education programs specifically targeting rural women in Himachal Pradesh. So, this study will help us make strategies specifically targeting women from rural areas. Hence, targeted clinical counselling and educational interventions during routine outpatient visits/outreach camps are essential to address knowledge deficits and improve screening utilization.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Poojan Dogra Marwaha and Bhavna Bhavna; data collection: Bhavna Bhavna, Asmita Kaundal, Sushruti Kaushal, and Shradha Anil Jadhav; data analysis and interpretation: Asmita Kaundal, Sushruti Kaushal, and Sunidhi Karol; manuscript drafting: Bhavna Bhavna and Asmita Kaundal; manuscript revision: Asmita Kaundal, Sushruti Kaushal, and Poojan Dogra Marwaha; guarantor of the study: Bhavna Bhavna. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors are thankful to the staff of the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India, for their support in the collection of data. The authors are thankful to all participants for their valuable time.

Tables     

Table 1: association of sociodemographic profile and baseline characteristics of participants of the knowledge, attitude, and practice survey towards cervical cancer: a survey conducted at All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh

Table 2: association between socio-demographic characteristics and knowledge, attitude, and practice towards cervical cancer in a study conducted at All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh

Table 3: association of income with knowledge and attitude towards cervical cancer in participants of the survey conducted at All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India

Table 4: association of income with practice towards cervical cancer in participants of the survey conducted at All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India

Table 5: application of the logistic regression model to find out significant predictors in the KAP survey conducted on participants reporting to All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh

References