|Year : 2012 | Volume
| Issue : 4 | Page : 124-128
A cross-sectional study on knowledge, attitude, and practice on cervical cancer and screening among female health care providers of Chennai corporation, 2013
VV Anantharaman, S Sudharshini, A Chitra
Institute of Community Medicine, Madras Medical College, Chennai, Tamil Nadu, India
|Date of Web Publication||19-Sep-2014|
Dr. S Sudharshini
Institute of Community Medicine, Madras Medical College, Chennai - 600 003, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background and Objective: Carcinoma cervix (CC) is a preventable disease, but still remains as the most common cancer among women in India. This study examines the knowledge, attitude, and practice (KAP) concerning CC and screening among female health care providers (HCPs) of Chennai Corporation in 2013.
Materials and Methods: In a descriptive cross-sectional study, 107 female HCPs working in Chennai Corporation were interviewed using a standardized questionnaire.
Results: About 100% of HCPs were aware of CC. 85% of the HCPs were aware of the major risk factors and symptoms of cancer cervix. About 95.3% of HCPs were aware of the cervical cancer screening either Pap smear or visual inspection using acetic acid or Lugol's iodine. Only 57.9% felt that they were at risk of cervical cancer. About 80.4% felt that they should undergo cervical cancer screening for themselves. Only 18.4% of the female HCPs have ever undergone cervical cancer screening.
Conclusion: There was a KAP - gap among HCPs. Misconceptions regarding screening need to be urgently addressed among HCPs.
Keywords: Attitude and practice, cancer cervix, health care providers, knowledge, screening
|How to cite this article:|
Anantharaman V V, Sudharshini S, Chitra A. A cross-sectional study on knowledge, attitude, and practice on cervical cancer and screening among female health care providers of Chennai corporation, 2013. J Acad Med Sci 2012;2:124-8
|How to cite this URL:|
Anantharaman V V, Sudharshini S, Chitra A. A cross-sectional study on knowledge, attitude, and practice on cervical cancer and screening among female health care providers of Chennai corporation, 2013. J Acad Med Sci [serial online] 2012 [cited 2018 Jan 21];2:124-8. Available from: http://www.e-jams.org/text.asp?2012/2/4/124/141132
| Introduction|| |
Cervical cancer is the second most common cancer among women worldwide.  Eighty-six percent of all cervical cancer diagnosed and 88% of death due to cervical cancer occur in developing regions of the world. , In India, cervical cancer is the most frequent cancer among women between 15 and 44 years of age.  Multiple social barriers in accessing basic screening and treatment services have posed Indian women at greater risk of developing the disease. ,
Human papilloma virus, a common sexually-transmitted infection, is the primary underlying cause of cervical cancer. Multiple sexual partners, early age of onset of sexual activity, increasing parity, use of hormonal contraceptives for 5 years or longer,  current or previous sexually-transmitted infection  and smoking  are the risk factors for cervical cancer.
Cervical cancer has a very long precancerous period, which provides a considerable window of opportunity to detect and treat it completely. If regular screening is made a part of the routine check-up for all women, the onset of cancer can be detected at an early stage and combated effectively. However, implementing effective screening programs for detecting carcinoma of cervix has been difficult in our country. ,
Chennai Corporation, in which this study has been conducted, is providing mass cervical cancer screening program through all the Health Posts and Emergency Obstetric Care Centers since April 2008. Under this program, all women >30 years age are screened for cervical cancer using visual inspection with acetic acid and Lugols' iodine (VIA/VILI). The female health care providers (HCPs) play a big role in creating awareness and promoting cervical cancer screening among women in their field practice area. Their attitude is often crucial in gaining women's confidence. It is therefore relevant to appraise the perception and utilization of cervical cancer screening services by female health care workers. 
Hence, this study is planned
- To assess the knowledge of female HCPs regarding cervical cancer and screening
- To assess their attitudes and practice toward cervical cancer screening.
The study findings and resulting recommendations will help in the design modifications and provision of future training and refresher courses on cervical cancer for health care workers.
| Materials and Methods|| |
Study design: Cross-sectional study.
Study area: Health Posts and Emergency Obstetric Care Centers in Chennai Corporation.
Study population: Female HCPs who render clinical services related to reproductive health. The study included doctors, staff nurses, sector health nurse, urban health nurse, maternity assistants, and female counselors.
Assuming that knowledge, attitude, and practice (KAP) regarding cervical cancer screening among female HCPs as 50%, sample size is calculated using the formula: where, z = standard normal deviant at 95% confidence level that is, 1.96, P = prevalence of knowledge 50%, d = relative precision of 20%.
Allowing a 10% nonresponse rate the sample size comes around 107.
Based on literature review of KAP materials on cervical cancer and expert guidance, a questionnaire was designed for HCPs. The questionnaire was field tested and validated for content and procedure by conducting a pilot study. The questionnaire had sections on sociodemographic details, knowledge on cervical cancer and screening, attitude toward cervical cancer screening and practice. The respondents were asked to tick the appropriate option, which were provided for each question.
All the female HCPs were explained about the purpose of the study and informed oral and written consent was obtained. They were assured confidentiality of their personal identifiable information. The interviews were carried out between July 2013 and August 2013.
In this study, awareness is defined as having previously heard of the term cervical cancer. Specific questions on knowledge regarding risk factors, symptoms of cervical cancer and screening (e.g. aware of Pap smear, VIA/VILI, purpose of screening test, age at screening) were asked. Knowledge about cervical cancer is considered good if a respondent is able to identify at least three of the known risk factors and symptoms correctly. Knowledge on cervical cancer screening is considered adequate if a respondent knew the exact purpose of Pap smear and VIA/VILI and if they knew the age at which screening should be done.
Perceived susceptibility to cervical cancer is measured by the question, "Do you think you are at risk for cervical cancer?" Attitude toward screening is measured by asking, "Do you think you should undergo cervical cancer screening?"
Practice is evaluated as referring patients for screening, and having ever been screened themselves.
Data were entered and analyzed using SPSS version 16 (SPSS Inc. 233 South Wacker Drive, 11 th Floor Chicago, IL 60606-6412). Appropriate statistical test were used to analyze the data. The level of statistical significance was defined as a two-sided P < 0.05.
The study received Institutional Ethics Committee clearance.
| Results|| |
A total of 107 female HCPs were interviewed. The mean age of the participants interviewed is 44.07 years. All the women interviewed were married and among them 7 (6.5%) are widows. Nurses and doctors (including general practitioners and obstetricians-gynecologists) represented 24 (22.4%) of all respondents, while 71 (66.4%) were midwives (including Urban health nurse and sector health nurse). The sociodemographic details of the respondents are shown in [Table 1].
All the female HCPs were aware of cervical cancer. Knowledge on risk factors and symptoms is shown in [Table 2].
Overall, 85% (95% confidence interval [CI]: 78.23-91.77%) of the respondents had a good knowledge on cervical cancer risk factor and symptoms. About 92% of the HCPs believed that cervical cancer can be prevented.
Knowledge on Cervical Cancer Screening
Knowledge on cervical cancer screening is shown in [Table 3]. Overall, 58.9% (95% CI: 49.58-68.22%) of the HCPs had adequate knowledge on cervical cancer screening. When asked about the facilities for cervical cancer screening in their health care centers, 95.3% were aware of the screening procedure, which is being done in their facility.
Attitude towards Cervical Cancer and Screening[Table 4]
[Table 4] shows the attitude of the HCPs toward cervical cancer and screening.
42.1% of the female HCPs perceived themselves as not at risk of developing cervical cancer. The most common reasons for perceiving not at risk include:
- No symptoms (28.9%)
- No risk factors (20%)
- Hysterectomy done (8.9%)
- It is a sexually-transmitted infection and hence not at risk (6.7%)
- Maintaining good personal and sexual hygiene (4.4%)
- Having a single partner (0.9%).
The most common reasons for not wanting to do screening are: No symptoms (19%), confidence that they will not get the disease (19%), no risk factors (14.3%), fear of being diagnosed with the disease (14.3%), hysterectomy done (23%), and shyness to undergo the procedure (4.8%).
[Table 5] shows that 4.8% of the female HCPs who believe that they were at risk did not want to undergo cervical cancer screening and the reason for this is fear of being diagnosed to have the disease. On the other hand, 60% of the respondents wanted to undergo screening in spite of their belief that they are not at risk.
|Table 5: Relationship between perceived susceptibility and attitude to screening|
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Pattern of Utilization of Cervical Cancer Screening
[Table 6] shows the respondents' pattern of utilization of cervical cancer screening. Only 20 (18.7%) of the respondents had done cervical cancer screening for themselves.
Most common reasons for not utilizing cervical cancer screening include:
- Not thought about it (20.7%)
- No symptoms (18.2%)
- No time (11.5%)
- No risk factors (11.5%)
- Embarrassment to do it in their own facility and shyness (10.3%).
[Table 7] shows that the attitude toward cervical cancer screening was better than the knowledge in all the professions except for sector health nurses. When it comes to practice, the knowledge and attitude did not translate into action in most of them.
|Table 7: Comparison of the knowledge, attitude and practice on cervical cancer screening stratified by profession|
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| Discussion|| |
Cancer cervix is the most common cancer among women and it is also a preventable disease. The key to address cervical cancer is effective screening. This study has tried to capture the perception and utilization of cervical cancer and screening among female HCPs.
Nearly 56% of the female health care workers have been in the service for >20 years. About 40% of them have ever attended training on cervical cancer. All the female HCPs are aware of cervical cancer. Overall 85% had a good knowledge on risk factors and symptoms on cervical cancer. Approximately, 92.5% nurses believed that Cancer cervix is preventable. These findings are consistent with Udigwe assertions that in any community, trained nurses and midwives constitute a knowledgeable class with regards to medical information and intervention.  The current study also reveal that the knowledge level is high when compared to other similar studies done among HCPs elsewhere. , This could be attributed to the training they have attended and also the various health promotion advertisements on cervical cancer through mass media.
With respect to cervical cancer screening, 81.3% of the female HCPs believed that cervical cancer can be detected even before the symptoms appear. 95.3% of them were aware of Pap smear and VIA/VILI. Of these people who were aware, 62.1% and 78.4% knew the exact purpose of Pap smear and VIA/VILI respectively. The knowledge on screening procedure is similar to the findings of Mutyaba et al. and Arulogun and Maxwell. , In spite of the mass cervical cancer screening program being implemented since 2008, nearly 22% of the HCPs are not aware of the exact purpose of the screening procedure which is being offered in their health care facility. This finding needs attention and warrants a training program.
About 63.2% of the respondents suggested that screening should start for women >30 years of age. This finding is in contrast to Arulogun and Maxwell study where 81.7% of the respondents mentioned that screening should commence when a woman starts having sex. 
Despite having high knowledge on cervical cancer and screening, only 57.9% felt that they were at risk of developing cervical cancer. 85% of the respondents felt that they should undergo cervical cancer screening and only 18.7% of the HCPs have ever undergone cervical cancer screening. This low uptake rate is very similar to other studies conducted among health care workers. ,,,,, The reason enlisted include having not thought about it and absence of symptoms, which illustrates how cervical screening is conceptualized and understood.
Nearly 19.6% of the female HCPs have not recommended cervical cancer screening to women who did not show symptoms. While the current health system stresses regular screening for all women above 30 years irrespective of symptoms,  this finding calls for a complete reorientation on the idea of screening.
When stratified based on the profession, the study showed that the knowledge on cervical cancer screening was good among Medical Officers and Sector Health Nurses than the other professions. This could be because of their educational status and the long duration of service in the health system. The utilization was more among the medical officers and the maternity assistants. This finding explains that just having adequate knowledge does not get translated into action. The maternity assistants had relatively higher utilization of screening despite not having adequate knowledge on cervical cancer screening. This could be because of the other motivational factors which this study was not able to capture.
| Conclusion|| |
This study concludes that there is satisfactory knowledge and attitude among female HCPs about cervical cancer and screening, but uptake of screening services for cervical cancer is minimal. Knowledge is a necessary but usually not sufficient in changing individual behavior. Motivation usually comes from sources other than, or in addition to, factual knowledge.
Among the HCPs who participated in the study, relatively low proportion of urban health nurses had adequate knowledge on cervical cancer screening. This group has to be given adequate training as they are the ones who go to the field for outreach activities, maintain a close relationship with the public and play a very important role in educating and motivating the females to undergo cervical cancer screening. Hence, this group has to be given high focus. The other HCPs also need to be oriented towards cervical cancer and screening.
The study also shows that health of the HCPs is not being given priority by them, which is evident from the reasons given for not utilizing screening for cancer cervix. The perceived barriers towards screening needs to be addressed.
| Recommendations|| |
The findings of this study are descriptive. Qualitative studies should be done, to explain and explore HCPs' understanding and very low uptake of cancer screening, despite having a good knowledge and direct access to screening facilities. This study also emphasizes the need for addressing the misconceptions and incorrect practices on cancer screening. Health care practitioners need to be targeted first for cervical cancer screening because of their essential role in the implementation of any future screening programs and in their educative role with patients. HCPs need to be trained not only to provide health education services, but to also motivate themselves to practice what they teach and to be a role model.
This study has tried to capture the perceptions and utilization of cervical cancer screening among selected HCPs working in an urban set up only.
| References|| |
|1.||Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://www.globocan.iarc.fr. [Last accessed on 2013 Aug 13]. |
|2.||WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World. Summary Report 2010. Available from: http://www.who.int/hpvcentre. [Last accessed on 2013 Aug 13]. |
|3.||Nene B, Jayant K, Arrossi S, Shastri S, Budukh A, Hingmire S, et al. Determinants of womens participation in cervical cancer screening trial, Maharashtra, India. Bull World Health Organ 2007;85:264-72. |
|4.||Moreno V, Bosch FX, Muñoz N, Meijer CJ, Shah KV, Walboomers JM, et al. Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: The IARC multicentric case-control study. Lancet 2002;359:1085-92. |
|5.||Koskela P, Anttila T, Bjørge T, Brunsvig A, Dillner J, Hakama M, et al. Chlamydia trachomatis infection as a risk factor for invasive cervical cancer. Int J Cancer 2000;85:35-9. |
|6.||Louie KS, Castellsague X, de Sanjose S, Herrero R, Meijer CJ, Shah K, et al. Smoking and passive smoking in cervical cancer risk: Pooled analysis of couples from the IARC multicentric case-control studies. Cancer Epidemiol Biomarkers Prev 2011;20:1379-90. |
|7.||Mutyaba T, Mmiro FA, Weiderpass E. Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda. BMC Med Educ 2006;6:13. |
|8.||Sait KH. Knowledge, attitudes, and practices regarding cervical cancer screening among physicians in the Western Region of Saudi Arabia. Saudi Med J 2011;32:1155-60. |
|9.||Perry MA. How can the uptake of cervical cytology screening be improved? Nurs Stand 2001;16:33-6. |
|10.||Udigwe GO. Knowledge, attitude and practice of cervical cancer screening (pap smear) among female nurses in Nnewi, South Eastern Nigeria. Niger J Clin Pract 2006;9:40-3. |
|11.||Arulogun OS, Maxwell OO. Perception and utilization of cervical cancer screening services among female nurses in University College Hospital, Ibadan, Nigeria. Pan Afr Med J 2012;11:69. |
|12.||Thippeveeranna C, Mohan SS, Singh LR, Singh NN. Knowledge, attitude and practice of the pap smear as a screening procedure among nurses in a tertiary hospital in North Eastern India. Asian Pac J Cancer Prev 2013;14:849-52. |
|13.||Awodele O, Adeyomoye AA, Awodele DF, Kwashi V, Awodele IO, Dolapo DC. A study on cervical cancer screening amongst nurses in Lagos University Teaching Hospital, Lagos, Nigeria. J Cancer Educ 2011;26:497-504. |
|14.||Gharoro EP, Ikeanyi EN. An appraisal of the level of awareness and utilization of the Pap smear as a cervical cancer screening test among female health workers in a tertiary health institution. Int J Gynecol Cancer 2006;16:1063-8. |
|15.||Government of Tamilnadu. Tamilnadu Health System Project. Clinical Manual on NCD for Medical and Paramedical Workers, Department of Health and Family Welfare; 2012. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]