Knowledge of Cervical Cancer Screening among Women in Rural Areas

Introduction: Cervical cancer is the most preventable and successfully treatable form of cancer, as long as it is detected early and managed effectively. Cancers diagnosed in late stages can also be controlled with appropriate treatment and palliative care. Screening is therefore an important tool in detecting cancer. The objective of this research is to find about the depth of knowledge about cervical cancer among rural women. This is a cross – sectional study done in rural areas of Pondicherry (Koodapakkam and Katterikuppam) (around 10 Km). Our subjects were patients and attenders attending the PHC OPD in between January and March 2021. Women attending OPDs of PHC in and around Koodapakkam and Katterikuppam who are > 15 years of age were the study sample excluding pregnant women, lactating women, mentally ill women and post hysterectomy patients with sample size of 300 using a questionnaire. Our study Signifies that among 277 Hindu women, 68.59% were aware of Cervical cancer screening. Among 12 Muslims 75% were aware of Cervical cancer screening. Among 11 women following Christianity 63.63% were aware of cervical cancer screening. This proves that there is no significant association between religion and awareness. (p=0.43) In our study, among 67 illiterates, 64.17% were aware of Cervical cancer screening. Among 81 women with primary school education ,65.43 % were aware of Cervical Original Research Article Kannan et al.; JPRI, 33(45B): 474-481, 2021; Article no.JPRI.73606 475 cancer screening. Among 57 women who went to high school 77.19% were aware of Cervical cancer screening. Among 38 women with higher secondary education, 68.42% were aware of Cervical cancer screening. among 49 graduates, 71.42% were aware of Cervical cancer screening. Among 8 post graduates 37.5% were not aware of Cervical cancer screening. There is association between education and awareness. (p=0.001). Totally, among 208 women under 45 years of age, 73.07% were aware of Cervical cancer screening and among 92 women more than 45 years of age 58.69% were aware of Cervical cancer screening. There is significant association between age and awareness (p=0.005).


INTRODUCTION
Cervical cancer is abnormal growth/proliferation of cells in the woman's cervix (cervix is the connection between vagina and uterus). Long lasting infection with certain types of HPV is the main cause of cervical cancer (transmitted mainly by sexual contact). It is usually slow growing cancer that may not have symptoms but can be found with regular PAP tests.
Cervical cancer is the fourth most common cancer among women. In 2018, an estimated 5,70,000 women were diagnosed with cervical cancer worldwide and about 311000 women died from the disease [1]. Women living with HIV -six times more likely to get cervical cancer. Recent studies state that the burden of cervical cancer is increasing in India. More than three-fourth of these patients are diagnosed in advanced stages leading to poor prospects of long-term survival and cure.
Effective primary (HPV Vaccination) and secondary prevention approaches (screening for and testing precancerous lesions) will prevent most cervical cancer cases. Screening is one method of diagnosing cervical cancer at an early stage [2]. Though screening for cervical cancer is present for quite a long time, knowledge about it is very less. Uneducated people and women living in rural areas have less or no idea about this already existing PAP smear. It is a noninvasive test and a effective method in diagnosing cervical cancer. New treatment methods have been developed in treating the cancer.
It is the most preventable and successfully treatable form of cancer, as long as it is detected early and managed effectively. Cancers diagnosed in late stages can also be controlled with appropriate treatment and palliative care. Screening is therefore an important tool in detecting cancer.
Women who are sexually active should be screened for abnormal cervical cells and precancerous lesions starting from 30 years. Women who are sexually active and living with HIV should start screening once they have tested positive for HIV [3].
The objective of this research is to find about the depth of knowledge about cervical cancer among rural women.

MATERIALS AND METHODS
Data Sources: The literature search was conducted in 2010 -2020, using the following databases: PubMed, Google Scholar, Embase, and CINAHL. The following terms and keywords were used: 'cervical cancer,' 'India,' 'South Asia,' 'knowledge,' 'attitudes,' 'screening,' 'vaccine,' 'barriers to cervical cancer screening.' Literature published between 2010 and 2020 was reviewed.
Subjects and Methods: This is a crosssectional study done in rural areas, in and around Koodapakkam and Katterikuppam (around 10 Kms). Our subjects were patients and attenders attending the PHC OPD in between January and March 2021. The information given by respondents was kept confidential. All data are collected from patient using face to face interview method. Data was analyzed using SPSS version 18. In descriptive statistics frequency table and mean was used. In inferential statistics chi-square test was used. Table 1 shows the frequencies of socio demographic profile in a study of cervical cancer awareness. The study comprised of 300 women from the rural area aged between 20 and 70 years. Of these, women aged >45 were 208 (69.3%) and aged above 45 were 92 (30.7%) mean age of the participants was 38.6 years (mean +/-SD) with the majority of them currently married 237 (79%), followed by being single 29 (9.7%), widower 25 (8.3%) and divorced 9 (3%). Regarding the educational status of the participants, about 81 (27%) were had primary schooling, after which 57(19%) had only high schooling, 49 (16.3%) were graduates, 38 (12.7%) were had went higher secondary schooling and only 8 (2.7%) are post-graduates. According to occupational status, about 168 (56%) were home maker, around 116 (38.7) are currently employed, over 16 (5.3%) are students. Of these participants nearly 277 (92.3%) are Hindus, subsequently 12 (4%) are Muslims and 11 (3.7%) are Christians. Majority of the participants are from rural area 261 (87%) and only about 39 (13%) are from urban area. Based on modified BG Prasad scale, among 300 participants, most of them 111 (37%) belongs to class 2 (Upper middle class) following that 83 (27.7%) belongs to class 3(Middle class), 50 (16.7%) belongs to class 1 (Upper class), 44 (14.7%) belongs to class 4 (Lower middle class) and the rest 12 (4%) belongs to class 5 (Lower class). Table 2 describes their awareness about cervical screening. About 108 (36%) study participants had heard about the term "Cervical screening" and hence only they could answer the subsequent questions regarding cervical screening. Source of information regarding cervical screening it was claimed to be through Health camps contributed to about 41 (13.7%) while from doctors 24 (8%) and mass media contributed to about 21 (7%) and through friends and relatives 7 (2.3%) of the information.
In addressing the awareness about signs & symptoms, About 257 (85.7%) had no idea about signs & symptoms were only 43 (14.3%) had an idea about signs & symptoms. Of these (14.3%) participants, about 32 (11.3%) knew unusual vaginal discharge as a sign of cervical cancer, after this 22 (7.3%) knew weight loss as a sign, post menopausal bleeding 6 (2%), postcoital bleeding 6 (2%) and breast tenderness 2 (0.7%  Women who were employed were observed to lack adequate knowledge about cervical cancer and screening than those who were home makers. This contradicts the findings of a study conducted by At Meer & et al in Quatar [8].
Women belonging to Class 2 Socioeconomic status displayed better knowledge score in the study. This is in concordance with the study by Narayan & et al where in participants with low income exhibited poor knowledge and unfavourable attitude towards cervical cancer screening [9].
Over 90% subjects opened that regular screening services should be made available in their areas. This findings is consistent with result of studies done by Barsal & et al from Bhopal, Sheestha et al and Thapa et al from Nepal [10].
Regarding age category, younger women 45 tears and below were observed to have 69.3% knowledge about cervical cancer. The higher levels of knowledge among the participants with young age would be due to the availability and ease of accessibility of information in this era of information technology. Similarly in a study conducted by Ramaiah. R. et al. [11] with the age population younger women were observed to have higher scores (age>45).
Cervical cancer awareness and practice of PAP smear test among women with gynecological complaints revealed that women who were educated till primary level readily accepted which was significant (27%). This finding is consistent with the study conducted by Shrestha J, Saha R et al shows that women with illiteracy level were found to be with better knowledge [12]. participants, about 32 (11.3%) knew unusual vaginal discharge as a sign of cervical cancer, after this 22 (7.3%) knew weight loss as a sign, post menopausal bleeding 6 (2%), post coital bleeding 6 (2%) and breast tenderness 2 (0.7%). Witnessing the awareness of hereditary factors 182 (60.7%) did not know about the hereditary factors whereas 103 (34.3%) were aware and 14 (4.7%) were not aware and only 1 (0.3%) did not participate.
A total of 232 (77.3%) have not heard about pap smear, were the remaining 68 (27.7%) women said pap test could be used for detection of cervical cancer.similarly in a study conducted by Rai G , more than half (53.8%) of women didn't have knowledge about Pap smear [15].

CONCLUSION
Our country has an urgent need to develop health system capacity to ensure efficient cervical cancer screening by organizing more health camps and education to women in rural areas. Mass media being a great help in promoting the awareness of cervical cancer screening, encouraging people to undergo screening also helps in reducing the burden of cervical cancer.

ETHICAL APPROVAL
We conducted our research after obtaining proper IEC approval.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).