Determinants of cervical cancer screening adherence among rural women of Chengalpattu district

INTRODUCTION

Cervical cancer is the second most common cancer among women in India even though it is a vaccine-preventable disease.¹ Significant number of cervical cancers and mortalities occur in Asian countries, and more than one-third of the world’s cervical cancer burden is seen in India and China.² Crude cervical cancer incidence per 100000 women in India (2020) is 18.7.³ According to NFHS-5, the percentage of women ever undergone a screening test for cervical cancer in India is only 2.2% in urban and 1.7% in rural, even after the nationwide screening program (National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke, 2017) is being implemented.

Due to certain barriers like embarrassment, anticipation of pain, fear of finding out cancer, and lack of knowledge about risk factors there is a disparity in the compliance of pap smear testing. Studies show that knowledge about cervical cancer, its prevention, and screening is limited among Indian women of various settings.¹ Economic, cultural, and psychosocial factors have been identified as barriers for the low cancer screening uptake among women.⁴ Due to differences in cultural, biological, medical, geographic, genetic, and socioeconomic factors, there is a large variation in cancer occurrence and survival not only among different countries but also within the country.⁵

In developed countries the burden of cervical cancer has started to reduce, whereas in developing countries the burden is still high, the risk of developing Cervical Cancer is 35% greater in developing countries in comparison with developed countries.⁹ Not participating in cervical screening examination can delay the diagnosis of cervical cancer which could have resulted in advanced intraepithelial lesion by the time of diagnosis. According to WHO, fewer than 1 in 10 women have been screened for cervical cancer in India.³ Hence, the aim of this study is to determine those factors affecting cervical cancer screening.

METHODS

A community based Cross-sectional study was conducted among 12 villages in the field practising area of RHTC (Rural Health Training Centre) of Chettinad hospital and Research Institute in Chengalpattu district, Tamil Nadu among 220 women of age 30 to 65 years residing in study setting during the period of 3 months (November 2022 to February 2023). The sample size was calculated based on the study conducted by Reichheld et al where the prevalence of poor knowledge about cervical cancer is p =84.6%.¹ Simple random sampling technique was used to select the required number of study participants. Data was collected using pre tested semi structured questionnaire and was entered into Microsoft excel sheet and analyzed by SPSS software version 21. Categorical data were expressed in the form of percentages. Illustrations of data were done by using tables. The descriptive representation of data was done in the form of frequencies and percentages.

Operational definition: WHO recommends primary screening test for cervical cancer starting from the age of 30 years till 65 years for women of general population.⁵

RESULTS

Among the participants, 34.1% were in the age group of 40 to 40 years, 18.2% were illiterate, 51.8% were semi-skilled workers, and most participants (49.5%) belonged to middle-class socio-economic status according to modified BG Prasad classification (Table 1).

The mean age of participants was 45.85±10.17 and the mean age of marriage in most of the participants was 19.63±2.51. On average most of the participants had 2 children and the mean age of first childbirth was 21.35±2.44 (Table 2).

About 82.3% of the participants were unaware about any method of cervical cancer screening. 43.2% believe that cervical cancer is contagious and 90% of the participants have never undergone cervical cancer screening in their lifetime. Only 7.3% have had contact with person suffering from cervical cancer. 43.2% of the participants disagree to the statement that cervical cancer is preventable (Table 3).

Lack of adequate awareness in the society remains the major factor that prevents women from getting screened for cervical cancer. 61.4% had very much to extreme fear of finding out cervical cancer, 55.4% had anticipation of pain, 54.1% avoid cervical cancer screening due to the feeling of being healthy and 51.8% have no family support in getting screened for cervical cancer (Table 4).

DISCUSSION

Goal of this study was to assess the knowledge of rural women on cervical cancer and the barriers that prevent them from getting screened for cervical cancer. In this discussion we focus on, descriptive analysis done on responses to questions that assessed risk factor knowledge and barriers.

In our study the knowledge about risk factors is very poor among the respondents, Only17.7% had knowledge about cervical cancer, its screening and risk factors. The study conducted by Reichheld et al 85% had poor knowledge on cervical cancer which is similar to our study.¹ And 55.9% believe that cervical cancer is not preventable and 43.2% have an idea that cervical cancer is contagious. Among the respondents only 10% have undergone screening for cervical cancer in their lifetime which is similar to Reichheld et al where only 7.1% had undergone screening at least once in their lifetime for cervical cancer. About 30.9% people agree to the fact that cervical cancer screening must be started at 30 years of age.¹

In our study about 38.6% agree that poor hygiene is a risk factor and 87.3 % do not agree that OCP is a risk factor for cervical cancer. From the previous study by Akinlotan et al, where only a few recognized long-term uses of OCPs as a risk factor and 90.5% believe that multiple pregnancies cannot be a risk factor.³ Our study participants majority 88.6% of people they do not believe that early marriage can be risk factor and 61.8% acknowledged that foul smelling vaginal discharge is an early symptom for cervical cancer. A similar study by Thulaseedharan et al, shows that majority of the females in child bearing age group was unaware of the signs and symptoms of cervical cancer.^6,12

Poor knowledge among our study participants was identified as the major factor that prevented rural women from getting screened for cervical cancer. Apart from that, fear of finding out cancer was another major determinant. Almost 79.6% did not want to get screened for as they had the feeling of being healthy. In a study conducted by Mahalakshmi et al, 72% of the participants had the fear of finding out cancer similar to our study results. And about 68% of the people had anticipation of pain due to the screening test as a barrier.⁴

Apart from other factors expenditure for the screening test was also a barrier for 45.9% of the participants.^4,13 Embarrassment plays a major role in about 45.5% of the people. Lack of family support in cervical cancer screening was a barrier among 48.1% of the participants. Only 6.3% said that lack of time as a barrier and 51.4% of the participants believed that they would be called up for multiple visits. Only 5% had a language barrier with the health care provider.3.2% said that they do not have a nearby health facility that can provide cervical cancer screening test facility.^4,9,11

CONCLUSION

Psychosocial factors, the major barriers for screening uptake in women have remained unchanged over the years. Increasing awareness campaigns, usage of decision-making aids and changes in government policies are crucial for improving the rate of uptake and successful implementation of national screening programs.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Reichheld A, Mukherjee PK, Rahman SM, David KV, Pricilla RA. Prevalence of cervical cancer screening and awareness among women in an urban community in South India-A cross sectional study. Ann Glob Health. 2020;86(1):30.
2. 2. Salehiniya H, Momenimovahed Z, Allahqoli L, Momenimovahed S, Alkatout I. Factors related to cervical cancer screening among Asian women. Eur Rev Med Pharmacol Sci. 2021;25(19):6109-22.
3. 3. WHO. Cervical cancer India 2021 country profile, 2021. Available at: https://www.who.int/publications/m/item/cervical-cancer-ind-country-profile-2021. Accessed 18 March 2023.
4. 4. Mahalakshmi S, Suresh S. Barriers to cancer screening uptake in women: a qualitative study from Tamil Nadu, India. Asian Pac J Cancer Prev. 2020;21(4):1081–7.
5. 5. Screening for cervical cancer. Available at: https://www.who.int/activities/screening-for-cervical-cancer. Accessed 17 Oct 2022.
6. 6. Thulaseedharan JV, Malila N, Swaminathan R, Esmy PO, Cherian M, Hakama M, et al. Effect of screening on variation in cervical cancer survival by socioeconomic determinants--a study from rural South India. Asian Pac J Cancer Prev. 2015;16(13):5237–42.
7. 7. Pimple SA, Mishra GA. Global Strategies for Cervical Cancer Prevention and screening. Minerva Ginecologica. 2019;71(4).
8. 8. Akinlotan M, Bolin JN, Helduser J, Ojinnaka C, Lichorad A, McClellan D. Cervical cancer screening barriers and risk factor knowledge among uninsured women. J Comm Health. 2017;42(4):770–8.
9. 9. Taneja N, Chawla B, Awasthi AA, Shrivastav KD, Jaggi VK, Janardhanan R. Knowledge, attitude, and practice on cervical cancer and screening among women in India: a review. Cancer Control. 2021;28:10732748211010799.
10. 10. Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical cancer and role of screening in India. Indian J Med Paediatr Oncol. 2016;37(4):278-85.
11. 11. Venkata Lakshmi S, Deepa Lakshmi KP, Bharath C, Saravanan N, Shaik SS, Nagilla J. Cervical cancer knowledge and attitude among a cohort of female schoolteachers in Salem city-A cross-sectional survey. J Family Med Prim Care. 2022;11(7):3459-64.
12. 12. Salehiniya H, Momenimovahed Z, Allahqoli L, Momenimovahed S, Alkatout I. Factors related to cervical cancer screening among Asian women. Eur Rev Med Pharmacol Sci. 2021;25(19):6109-22.
13. 13. Gilham C, Crosbie EJ, Peto J. Cervical cancer screening in older women. BMJ. 2021;372:n280.