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ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 64-69

A study of knowledge, attitude, and practice of Pap smear test in the early detection of cervical cancer among qualified working women in an urban area


Department of Pathology, Fr. Muller Medical College, Mangalore, Karnataka, India

Date of Submission14-Aug-2021
Date of Acceptance22-Sep-2021
Date of Web Publication28-Feb-2022

Correspondence Address:
Dr. T Umashankar
Fr Muller Medical College, Kankanady, Mangalore - 575 003, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjmsr.mjmsr_34_21

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  Abstract 


Introduction: Cervical cancer (CC) is being one among the leading causes for cancer-related deaths worldwide contribute to a massive portion of mortality which can be reduced to a great extent with the help of a screening test – Pap smear test; with which early detection and thus prevention of this cancer is made possible. Despite the fact that Pap smear test has proved itself to be an easily available and cost-effective method to screen the early signs of CC among prone women, a large group of women is hesitant to get it done due to various reasons. Hence, this was conducted to study the degree of knowledge, attitude, and practice of Pap smear test among qualified working women in urban areas. Materials and Methods: In this cross-sectional study, 334 working-class women who had an undergraduate/postgraduate qualification and were engaged in different types of occupation were selected. These participants were requested to answer a questionnaire which extracted information about the individual's demographic data; knowledge, attitude, and practice regarding CC, Pap smear test, and Human papillomavirus vaccination. Data so collected were analyzed using the SPSS version 23 software. Results: The participants belonged to the age group of 22–59 years with mean age being 33.4 years. The study population was broadly categorized into two groups as teaching occupation (n = 221; 66.2%) and nonteaching occupation (n = 113; 33.8%). Overall, 45% of the participants knew that CC is the cancer of the lower part of uterus. Forty-five percentage did not know the benefits of Pap smear test. Knowledge sourced from family, friends, and health care professionals was 30% and 6%, respectively. Medical camps contributed to 17% of the knowledge in the overall study group. Forty-nine percentage of the participants did not know Pap smear test has to be done regularly. Overall, only 26 participants (8%) underwent Pap smear test. Most of them were in the age range of 31–40 years and the least were in the age range of 21–30 years. Knowledge and attitude toward Pap smear test are the major indicators and predictors of the utilization and performance of this test. The practice of doing Pap smear test and thus the performance of this test was higher among those who had higher knowledge (Group II P < 0.005) and better attitude toward Pap smear test. Studies reveal that pain, lack of knowledge, insufficient medical recommendations, and health education, time constraints, embarrassment, and fear of bad results are the main barriers in getting Pap smear test done. This brings to light the need to revamp our strategy in health education.

Keywords: Attitude, cervical cancer, knowledge, pap smear test, practice


How to cite this article:
Vincy R, Umashankar T. A study of knowledge, attitude, and practice of Pap smear test in the early detection of cervical cancer among qualified working women in an urban area. Muller J Med Sci Res 2021;12:64-9

How to cite this URL:
Vincy R, Umashankar T. A study of knowledge, attitude, and practice of Pap smear test in the early detection of cervical cancer among qualified working women in an urban area. Muller J Med Sci Res [serial online] 2021 [cited 2022 Aug 10];12:64-9. Available from: https://www.mjmsr.net/text.asp?2021/12/2/64/338500




  Introduction Top


Cervical cancer (CC) is one of the most common cancer in women worldwide causing about 3,00,000 deaths each year. It is a preventable and treatable cancer. Human papillomavirus (HPV) infection, a sexually transmitted disease is the most important risk factor in the development of cervical intraepithelial neoplasia and invasive CC.[1],[2] The current estimates indicate approximately 97,000 cases diagnosed and 60,000 deaths annually in India with crude mortality rate of 9.2/1,00,000 women per year.[2]

Chances of developing CC begin the moment a woman is sexually active. The incidence rises by 30–34 years of age and reaches its highest peak at the age 55–65 years, with a median of 38 years.[3]

Large-scale morbidity and mortality due to CC are because of the lack of knowledge among females of India. Due to the lack of obvious symptoms and failing to undergo screening test, it is diagnosed at the late stage which turns out to be fatal. The relative 5-year survival averages to 46%.[4] Earlier detection and better access to the treatment lead to higher survival.[5]

Early detection of precancerous lesions by  Pap smear More Details technique and initiation of treatment before they progress have shown to reduce mortality. Vaccines against the causative agent HPV can reduce the incidence of CC and also is cost effective.[6] HPV vaccines are expensive and may not be affordable by every Indian woman. Presently, HPV vaccines are not covered under the National Immunization Program of India.[7] In India, presently the drive to hunt down CC and its incidence is not been so effective. Therefore, a comprehensive National CC Prevention Strategy is the need of the hour.

Pap smear test is a simple, reliable screening tool to detect CC and it is the most effective cancer prevention measure developed so far.[8] Active participation of the target population is essential for the success of the screening program and to prevent deaths due to CC. Despite the test being widely available, it is not reaching each and every woman in India. Therefore, it is important to analyze the knowledge, attitude, and practice of Pap smear test to know the various reasons responsible for unwillingness among women in getting screening done and help them to overcome this issue.


  Materials and Methods Top


This cross-sectional questionnaire-based observation study was taken up after the approval by the institutional ethical committee in a tertiary care hospital in a South Indian city with the prime objective to analyze the knowledge, attitude, and practice of Pap smear test among Indian females within the age range of 21–60 years.

The data were procured by interviewing women working in nonmedical establishments having undergraduate or postgraduate qualification within the age range of 21–60 years with the help of a set of questionnaires. A prior permission was sought from the head or chief of the workplace. A written informed consent was obtained from the participant and confidentiality of the data was maintained. A total of 334 women were interviewed. Women working in medical establishment were excluded from the study.

The questionnaire was divided into four parts. The first part of the questionnaire was aimed at gathering details regarding the participant's social and demographic characteristics. The second part was to assess the knowledge and awareness of the participant regarding CC, its screening, and prevention. The third part was to collect the information related to the attitude of the participant. The final part of the questionnaire focused on the behavior and practice of the participant. The questionnaire was translated to the preferred regional language (Kannada) in case the participant does not follow English. The collected data are analyzed by frequency, percentage, mean, and Pearson Chi-square test using the SPSS version 23 software SPSS software (IBM SPSS Statistics for Windows, Version 24.0. Armonk, New York, IBM Corp). The responses were scored on a scale of 1–3.


  Results Top


This study included 334 women with undergraduate or postgraduate qualification working other than health care establishments. The age of the participants ranged from 22 years to 59 years. Forty-six percentage were in the age range of 21–30 years and 34% in the age range of 31–40 years. The mean age was 33.4 years [Table 1].
Table 1: Distribution of the participants according to the age range

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The study population was broadly categorized into two groups as teaching occupation (Group – 1; n = 221; 66.2%) and nonteaching occupation (Group 2; n = 113; 33.8%) with the mean age being 34.2 years and 31.8 years, respectively [Table 2].
Table 2: Categorization of study population according to type of work

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Scoring of responses

The scoring was done according to the responses given by the participants. A correct answer was given a score of “1” and the wrong answer/cannot decide/I do not know was given a score of “0.” Overall, six questions in the knowledge category, seven in the attitude category, and two in the practice category were chosen for scoring purpose. For knowledge questions, a total score of 0 and 1 was chosen as poor knowledge, a score of 2–4 was chosen as fair knowledge, and a score of 5 and 6 was chosen as good knowledge. Similarly, a score 0 and 1 as poor attitude, 2–4 as fair attitude, and 5–7 as good attitude. In practice questions, it was 0 as poor practice, 1 as fair practice, and 2 as good practice.

Knowledge-based questions

Cervical cancer

Overall, 45% of the participants knew that CC is the cancer of the lower part of uterus; 28% knew it was in the uterus, and 16% of the participants did not know what cancer of cervix is. Sixty-nine percentage of the participants knew that the major risk factor for CC is HPV.

Source of information

Thirty percentage knew CC through the family and friends; 16% by medical camps; 17% by newspaper, and 12% by television. However, only 6% knew about CC by their obstetrician or treating doctors.

Pap smear test

Fifty-eight percentage of the participants were aware of Pap smear test and is done to detect CC. Thirty-nine percentage were not aware of Pap smear test at all.

Preventive methods of cervical cancer

Sixty-three percentage aware that CC can be prevented by HPV vaccine and by avoiding risk factors. Thirty-seven percentage of the participants did not have the knowledge of preventive methods.

Human papilloma virus vaccine

About HPV vaccine, 30% knew it has to be obtained before being sexually active, 56% knew its benefits in preventing CC. However, 65% of the participants did not know when to take HPV vaccine and 36% did not know how it is beneficial. About 77% were not aware of the cost of the vaccine.

Overall, 35.3% had good knowledge, 50.6% had fair knowledge, and 14.1% poor knowledge [Table 3].
Table 3: Group-wise knowledge, attitude, and practice scores

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Attitude-based questions

Benefits of Pap smear test

Forty-nine percentage of the participants opined that Pap smear test can benefit them in detecting CC whereas 45% did not know the benefits. Only 6% of the participants opined that Pap smear test cannot benefit them.

Regularity of Pap smear test

Forty-nine percentage of participants did not know Pap smear test has to be done regularly and 47% knew it has to be done once in 3 years.

Availability of Pap smear test

Forty-one percentage of the participants knew the Pap smear test is available at the nearest referral hospital and 52% did not know that PAP test is available at the nearest hospital.

Willingness to get Pap smear test if available

Fifty-four percentage showed willingness to get tested if Pap smear test is available and 40% could not decide. Six percentage were not willing to get tested even if the facility is available.

Cost of Pap smear test

Sixty-five percentage of the participants did not know the cost of Pap smear test. Twenty-two percentage mentioned that it is affordable and 13% mentioned it is expensive.

Follow-up after positive Pap smear test

Eighty-nine percentage of the participants were willing to go for follow-up if the test turns positive and 11% were not willing for further follow-up. Overall, 29% had good attitude, 55.4% had fair attitude, and 15.6% poor attitude [Table 3].

Practice-based questions

Pap smear test

Overall, only 26 participants (8%) underwent Pap smear test. Most of them were in the age range of 31–40 years and the least were in 21–30 years (8%). About 62% belonged to Group – I and 38% belonged to Group – II. About 50% got it done once in 3 years, 15% got once in 5 years, and 35% got it done only once.

Three hundred and eight (92%) did not get their Pap smear test at all. Fifty percentage were in the age group of 21–30 years and 33% in the age range of 31–40 years. Sixty-seven percentage were in Group – I and 33% in Group – II. About 47% felt that it was not necessary as there were no symptoms, 29% mentioned that their obstetrician did not advise to get a Pap smear test done.

Human papilloma virus vaccination

Out of 334 participants, only 4 (1%) had got HPV vaccination. Ninety-five percentage were not aware or their doctor did not advise and 4% mentioned that vaccine is expensive.

[Table 3] displays group-wise scores for knowledge, attitude and practice and [Table 4] displays scores for overall knowledge, attitude and practice.
Table 4: Overall knowledge, attitude, and practice scores

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Using the SPSS version 23 software, Pearson Chi-Square test was run to know the correlation between various parameters. A “P” <0.05 was considered statistically significant. [Table 5] displays the “p” value and its significance.
Table 5: P values and its significance with respect to knowledge/practice and attitude/practice

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With respect to knowledge and practice, there is no correlation between entire study group and Group – I. In Group – II there is correlation between knowledge and practice. With respect to attitude and practice there is correlation between both groups and entire study population.


  Discussion Top


Literacy plays an important role in acquiring knowledge. The level of knowledge improves with the level of education. One can gain knowledge by print media, electronic media, social networking, and interaction with family and friends. A better knowledge determines a better attitude and financial status of an individual; allowing him/her put the knowledge into practice.

Thus, this study was undertaken to assess the knowledge, attitude, and practice toward CC and its diagnostic and preventive aspects in a well-educated, working, and economically independent women. The study included 334 women with nonmedical undergraduate/postgraduate qualification working in nonmedical establishments. Nonmedical establishments were chosen to avoid the bias.

Knowledge

Knowledge of cervical cancer and its screening and prevention

Overall, only 35.3% of women had good knowledge about CC, Pap smear test, and HPV vaccine. Group – I fared better (39.8% with a mean score of 3.75) compared to Group – II (26.5% with a mean score of 2.75) which is statistically significant (“P” <0.05). This showed that the level of knowledge is better among those who are in professional teaching as they have access to a number of study materials. Various studies showed that the knowledge of CC and Pap smear test range from 5% to 81.2%.[9],[10],[11],[12],[13] Knowledge is directly proportional to the level of education.[11],[13],[14] An Indian study revealed a wide gap in knowledge and attitude in rural and urban population. This was attributed to literacy status, income, and health education.[12]

Knowledge of human papillomavirus vaccine

Knowledge of HPV vaccine in India in the general population is poor regardless of education status, occupation, and demographic location.[15] Studies done on medical students[16] and school teachers[17] showed that knowledge varied from 18% to 49.3%. In our study, the correct knowledge about HPV vaccine is only 3.6%; and all those who responded correctly were in group– I (teaching occupation).

Source of information

Our study revealed that 30% of women knew CC through family and friends; 29% by newspaper, and 12% by television. Studies showed that print media, electronic media, friends, and relatives are the major source of information.[18] Furthermore, the health behavior of family and friends can influence a person to seek better knowledge and practice.[18] This study shows that 16% had the knowledge of CC and Pap smear test by medical camps and only 6% by their obstetrician or doctors. These facts highlight that in India health education is substandard. Even the health care professionals fail to give adequate health education to their clients. Thus, we need to revamp our strategy in health education.

Attitude

Overall, only 29% of women had good attitude with regards to availability, cost of Pap smear test, and follow-up or repeat Pap smear test. Various studies showed the good or positive attitude ranging from 51% to 80%.[9],[10],[12] In this study, Group – I had a mean score 3.67 and Group – II had a mean score of 3.19 that is statistically significant ('P' <0.05). A surprising fact in this study is, out of 136 (41%) women who were aware that Pap smear test is available in the nearest hospital, only 49% were willing to get the test done. About 46% of women responded that they could not decide to get a Pap smear test done. Of these women, 54% were in the age range of 21–30 years and 62% were in Group – I (teaching occupation). This reveals that despite the barriers such as embarrassment, fear, and cost there are other barriers that make these women fail to take their own decision despite them being well educated and economically independent. These findings also show that the barrier-driven negative attitude is high in young and in teaching occupation probably because of the time constraints.

Practice:

Pap smear test

In this study, only 8% (n = 26) of the women had their Pap smear test done and most of them belonged to Group – I (62%). The majority were in 31–40 years age group and the least were in 21–30 years age group. Of those, who did not get their Pap smear test done, most of them responded that it was not necessary as there were no symptoms (47%) and their doctor did not advise about the test (29%). More than 50% were in the age group of 21–30 years. These facts highlight that younger age group is most vulnerable to be missed for the screening test and they must be targeted for the Pap smear test. Studies reveal that pain, lack of knowledge, lack of doctor's recommendation, time constraints, embarrassment, and fear of bad results are the main barriers in getting Pap smear test done.[9],[14],[15]

Human papilloma virus vaccination

The practice of HPV vaccination is poor in India because of the high cost and accessibility and it may take decades to vaccinate each and every woman at risk. In this study, only 1% had received HPV vaccine. Ninety-five percentage were not aware of the vaccine or their doctor did not advise to take it. Four percentage could not afford as it is expensive. This necessitates to revamp our system to educate the target population to access the preventive methods.

A statistically significant better practice in Group – II (nonteaching profession) compared to Group – I (teaching profession) may be attributed to health policies at workplaces, better access to health facility, leave benefits, and after working hours work pattern.


  Conclusions Top


The overall knowledge and attitude were good in 35.3%, 29.0% of the participants, respectively.

The practice was poor in 91% and fair in 9% of the participants. Only 8% of the participants had their Pap smear test done and only 1% received HPV vaccine.

Thirty percentage of women knew information about CC through their family and friends. Only 6% knew through their obstetrician or doctors.

The correlation between attitude and practice was statistically significant among the entire study population, Group – I and Group – II.

The correlation between knowledge and practice was statistically significant only in Group – II.

Limitations

Here, we would like to focus attention on the various barriers and obstacles which were faced in this study.

Lack of cooperation from institutions. The concerned authorities of various institutions, especially IT firms and a few banks, had shown disinterest and therefore have rejected the request to enroll their staffs to participate in this research project even after providing a detailed elucidation about the purpose, the questionnaire, aims, and objectives of the study.

Lack of cooperation from individuals who were requested to participate in this study. A few were nonchalant; whereas many others were worried about their identity being revealed. Although the study assures complete confidentiality of their identity, these individuals refused to answer the questionnaire which was provided to them. Many of the participants lost the questionnaire set which was provided to them.

Suggestions

Health care providers and medical professionals have a major role as promoters of Pap smear test. They must further encourage, guide, and strongly emphasize the importance as well as the need to be get screened.

Firms and companies, who provide health care amenities and general routine checkups, must include Pap smear test also in it.

It is also recommended to introduce HPV vaccine in the National Immunization Schedule of India.

Social media, television, and newspapers are a great platform to address awareness and practice. The usage of these media is recommended to educate the common man. This would make sure that a larger group of people are targeted and brought to awareness. Social media can be employed to keep the mass well informed about the importance of Pap smear test from time to time using illustrations and easy-to-follow videos which would have a significant impact.

Setting up of camps led by healthcare officers in both urban as well as rural setups is also recommended.

Moreover, it is the responsibility of an individual to have a better attitude and practice toward their personal health. Education and economic independence do not guarantee better health practices although it is affordable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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