A cross-sectional study on knowledge and attitude towards cervical cancer screening methods among women of reproductive age group in an urban area

smear test, screening Cervical cancer, a malignant tumour of the cervix, the lowermost part of the uterus, is usually associated with Human Papilloma Virus (HPV) infection. Asymptomatic in early stages, it becomes symptomatic as the disease progresses. Cancer cervix can be prevented with HPV vaccines and regular screening practices like the Pap smear test. Poor awareness, lack of knowledge on risk factors, signs and symptoms and socioeconomic limitations serve as barriers for women to take up cancer screening. This study was done to assess the knowledge and attitude towards cervical cancer screening practices among women. A cross-sectional study was conducted using a self-structured questionnaire among urban women of reproductive age group. Data were recorded, tabulated and analysed. Of the 248 women of the reproductive age group who were interviewed, 63% knew that cervical cancer is a leading cause of death among Indian women. Although 68.5% knew that HPV is the causative organism, only a quarter of them knew about the vaccination sched-ule. Only 42% of those who were aware of the Pap smear test knew the age at which screening had to be started. In conclusion, most of the participants knew about cervical cancer and its causative organism. However, their knowledge on preventive measures, HPV vaccine and Pap smear test was poor.


INTRODUCTION
Cervical cancer is a malignant neoplasm arising from cells originating in cervix uteri. Almost all cervical cancer cases are associated with high-risk Human Papilloma Virus (HPV) infection, a common virus that is usually transmitted through sexual contact (Cooper and McGee, 1997). Effective primary preventive approaches will help in preventing most cervical cancer cases. When diagnosed, cervical cancer is one of the most successfully treatable forms of cancer, as long as it is detected early and managed effectively (Cancer, 2020).
Cancer cervix may be completely asymptomatic in the early stages. In advanced stages, it may present as persistent pelvic pain, unexplained weight loss, bleeding between periods, unusual vaginal discharge, bleeding, and pain after sexual intercourse. Infection with HPV types 16 and 18 cause 75% of cervical cancer globally (Kumar et al., 2007). Risk factors for cervical cancer are many. They include HPV infection, sexual intercourse before 18 years of age, having multiple sexual partners, delivery of the irst baby before 20 years of age, poor personal hygiene, Sexually Transmitted Dis-eases (STD), low socioeconomic status, tobacco and drug abuse (Kaku et al., 2008).
According to reports from the World Health Organization (WHO), cervical cancer is the fourth most common cancer in women. In India, the prevalence of cervical cancer, one of the leading cause of death among women of reproductive age group, ranges between 6-29% (Bobdey et al., 2016). Cancer cervix is a preventable disease. But inadequate knowledge and awareness on cervical cancer, its screening and other preventive measures among women have been responsible for the rise in the number of cases each year (Raychaudhuri and Mandal, 2012). Preventive measures for cervical cancer can be primary and secondary measures. They include the administration of the HPV vaccine (primary) and regular screening practices (secondary). Screening methods include Pap smear test and colposcopy. Access to the HPV vaccine and early detection has helped in preventing a large number of cases of cervical cancer. Pap smear test has been found to show a signi icant reduction in the number of cases of cervical cancer in developed countries (Gadducci et al., 2011). Unfortunately, despite the availability of prevention methods, the majority of women in India have never been screened for cervical cancer.
This study aims at assessing the awareness, knowledge and attitude towards cervical cancer screening and preventive methods among women of reproductive age group.

Study design
A cross-sectional study was conducted to assess the knowledge and attitude towards cervical cancer screening methods among women of the reproductive age group who belonged to the urban population in Kancheepuram district. The study duration was three months, with data collection followed by discussion and analysis.

Inclusion criteria
Responses from women belonging to the reproductive age group (15 to 50 years), who were willing to be a part of this study were only taken into account.

Exclusion criteria
People with psychiatric illness and those who attained menopause were excluded from the study.
Taking prevalence of knowledge and attitude on cervical cancer to be 17.1% (Raychaudhuri and Mandal, 2012) and assuming 95% con idence limit with 5% allowable error, with the formulae N= 4PQ/L2, the sample size was found to be N = 225. To account for the non-response rate (about 10%), a total of 248 subjects were interviewed for the study. Women between the age group of 15 to 50 years were interviewed in the study. Convenience sampling method was followed. Before beginning the study, ethical approval was obtained from the institutional ethical committee. The purpose of the study was explained to the participants, and written informed consent was obtained from them. A structured and pretested questionnaire with 20 questions was prepared and distributed among study participants. The responses, along with necessary sociodemographic details, were collected, recorded and analysed. The questions were based on cervical cancer screening practices, importance, and necessity. Questions on cervical cancer, Pap smear test, HPV vaccine were also included. The questions were of multiple choice type, and participants had to choose the right option for each question.

Statistics
Data obtained was entered into Microsoft Of ice Excel Spreadsheet, and then analysis was done using SPSS software. Response to each question was tabulated, analysed, and percentage for the same was also calculated. Chi-square test was used to determine the association between categorical variables. P-value was calculated at a 95% con idence interval with signi icant levels at p < 0.05.

RESULTS AND DISCUSSION
A total of 248 responses were obtained from women aged between 15 and 50 years. Majority of them were in the age group of 18 to 22 years (Table 1)     The study revealed that a good proportion of women are aware of cervical cancer, but they don't have adequate knowledge of cervical cancer screening practices. All women in the study have completed their schooling, and some even have completed their post-graduation. Despite good education, most of them don't have the necessary knowledge on preventive measures of cervical cancer. This study has shown poor knowledge of cervical cancer screening practices. Similar results were shown in a study from Nepal, where out of 105 respondents only 65.7% had heard about cervical cancer and only 42.9% and 18.1% had knowledge about screening for cervical cancer and Pap smear test respectively (Shrestha et al., 2013).
HPV is the most important etiological agent causing cancer cervix. A good proportion of the participants know that it causes cervical cancer and believe that improper personal hygiene and having multiple sexual partners are some of the risk factors for cervical cancer. This inding is different from the study done in Bhopal, where most of their respondents mentioned that having multiple sexual partners is the only common risk factor (Kokane et al., 2015). Primary prevention of cervical cancer can be done with the HPV vaccine. It is advised that all adolescents or pre-adolescents receive the HPV vaccine to get protected against cervical cancer. Ideally, vaccination should be done at the age of 9 to 14 years. 2 doses of the vaccine at six months interval should be administered. The Centers for Disease Control and Prevention recommends all boys and girls get HPV vaccine at age 11 or 12 (Asha sexual health, 2014). Males are at risk for HPV and related diseases, too, so boys and young men are also recommended to be vaccinated. Apart from cervical cancer, the HPV vaccine protects against warts also. It was evident from the study that almost half of the participants had no clue to why the vaccine is taken, who should get it, at what age should it be given. This concurred with the indings in the study from Kolkata, where a large number of students haven't even heard of HPV which is the single most important etiological factor for cervical cancer (Saha et al., 2010). Low levels of knowledge on HPV and cervical cancer was reported among undergraduate and graduate college women aged 18 to 30 years in the US (Ingledue et al., 2004). In another study in the US, it was found that 21.5% of the college women to have never heard of HPV (Lopez and McMahan, 2007).  (Mutyaba et al., 2006).When asked about how comfortable they would be when a Pap smear test is done, only 21% agreed to be feeling comfortable; 40 % gave an opinion of feeling uncomfortable, and 38% weren't sure about it. It was probably since the majority of them had not undergone a pelvic examination. This was in contrast to the study from Uttar Pradesh that showed out of 168 women previously who had a pelvic examination, 148 (88.1%) had a comfortable experience (Asthana and Labani, 2013).
When educational quali ication and knowledge of cancer screening practices were compared, it was found that the more educated participants had a good idea of what cervical cancer was. However, their knowledge on HPV vaccine and Pap smear test was not satisfactory. Irrespective of their educational quali ication, almost all women had a similar level of knowledge on cancer screening practices. Their knowledge on the Pap smear test was average, and that on HPV vaccine was too little.

CONCLUSIONS
Cancer cervix is a preventable disease. This study revealed that though many women are aware of cervical cancer, their knowledge and attitude towards cancer screening practices are poor. Good education and creating awareness of cancer screening practices is necessary to overcome this. Though cancer screening facilities are available in public and private health setups, many are not aware. There are even some who hesitate to get a screening test done.
Conducting awareness programmes at workplaces and emphasising the importance of cancer screening and preventive methods can help more women take up screening practices and vaccination, thereby contributing to a reduction in cancer burden in the country.