AWARENESS ON CERVICAL CANCERS AND UTILIZATION OF PAP-
SMEAR (PAPANICOLAOU) TEST AMONG ADULT WOMEN – A
HOSPITAL BASED STUDY
Koirala Arun Kumar
School of Health and Allied Sciences
Pokhara University,
Pokhara, Kaski, Nepal
e-mail: arunkoirala@gmail.com
Mob: +977-9849264178
AWARENESS ON CERVICAL CANCERS AND UTILIZATION OF PAP-
SMEAR (PAPANICOLAOU) TEST AMONG ADULT WOMEN – A
HOSPITAL BASED STUDY
Abstract:
Cervical cancer, a major public health problem is the most common and stood in 2nd position
among other cancers in women and accounts more than 84% new cases worldwide and more
than 85% death from middle and low income countries. It can be prevented by vaccination,
Screening and treatment before progression along with health education are the most efficient
and cost effective way of controlling the cervical cancer, unfortunately it is very low and it ranks
as the 1st most frequent cancer among women of age 15 to 44 years in Nepal. Therefore, the aim
of the study is to assess the awareness on cervical cancer and screening test and its practice
among women in Nepal. A cross sectional study was conducted at the Gynecology Out Patient
Department (OPD) of Helping Hands Community Hospital Kathmandu from June 2017 to
August 2017. The participants were the women visiting the Gynecological Department for
various other gynecological problems. A total of 409 sample was taken through purposive
nonprobability sampling method and data were analyzed. Mean SD age of the women was
33.52 where minimum age was 17 and maximum age was 67 years. More than 4/5th (84.8%)
were married and among them more 78.5% were married before the age of 20 years. Among
total respondents, 32.8% heard about cervical cancer and among them only 13.4% of them had
knowledge of causative agent the HPV and about 21.1% of them had an idea about the HPV
vaccine. Women who had heard about cervical cancer, 47.8% had an idea about the screening
test and only 13% had knowledge on Pap smear test, but most of them (89.7%) had no idea when
to be performed. Among the women who have heard about cervical cancer, only 23.9% had
experienced on the Pap smear test. Among the women who had knowledge of cervical cancer,
only 9.7% of them had heard about the HPV vaccine and only 7.6% of them had inoculated HPV
vaccine. This study showed that heard about cervical cancer, knowledge on Pap smear test and
knowledge of the HPV vaccine are significantly associated with the education level of the
respondents (P<0.01). Enrollment of women in academic education and adequate information
through different media targeting eligible women is needed to raise awareness to change their
behaviors to utilize the screening facility.
Key words: Cervical cancer, screening, HPV, Nepal
Introduction:
Cervical cancer is the most common, but preventable cancer in women worldwide, which stood
2nd position among other cancers estimating in women living in less developed regions estimated
570000 new cases in 2018 which is 84% of the new cases worldwide and died of cervical cancer
about 311000 women and more than 85% of these deaths from middle and low income
countries.1. It is now becoming a major public health problem in South-east Asia Region that
contributes 35% of global burden, where mortality is also very high. It is due to certain
carcinogenic type of Human Papilloma virus (HPV) mainly HPV 16 and 18, which is sexually
transmitted infection and commonly prevalent in sexually active men and women. 2 HPV is the
most common infection acquired during sexual relations, usually early in sexual life.3
Though cervical cancer is now a major public health problem in South-east Asia Region, it can
be prevented by vaccination to the adolescent girls before initiation of sexual activity and
cervical cancer screening and treatment before progression of invasive nature along with health
education which are the most efficient and cost effective way of controlling the cervical cancer.2
It is estimated that only about 5 % of women in developing countries goes under screening test
by pap smear4 due to different reasons as illiteracy, lack of awareness and benefits of screening
test, cultural barriers, disempowered women, no accessibility of health facilities and its’
availability at all health facilities, competing health needs, lack of human and financial resources
etc.5,6
It has been estimated that every year 2942 women are diagnosed as the new cases of cervical
cancer and 1928 die from the that disease. Cervical cancer ranks as the 1st most frequent cancer
among women between the age of 15 and 44 years in Nepal. It is also estimated that about 2.0%
of women in the general population harbor the cervical HPV-16/18 infection at a given point of
time and those infections constitute 80.3% of invasive cervical cancers. Crude incidence rates of
HPV related cervical cancers are 19.3 in Nepal which has made Nepal a country with one of the
highest cervical cancer rates in South Asia. It is also found that sexual behaviors of men and
women in Nepal starts in early age. It is found that percentage of 15-year-old who have had
sexual intercourse is 3.7% in men and 4.6% in women. In Nepal women rarely go under
screening test for cervical cancer, therefore the Cervical screening practices in Nepal is very low,
i.e. 2.8%.7 where the study conducted in the US from 1976 to 2009 has shown the significant
decrease in the incidence of cervical cancer in widespread pap test screening. 8 It shows that the
risk of HPV transmission starts from the early puberty age in Nepal. It is also seen that
frequently detected malignancy among all cancers is cervical cancer in Nepal. 9. A study
conducted in Nepal showed overall, the HPV prevalence among women in Nepal was 14.4%, 10
and a study conducted in Nepal showed over 80% of the cervical cancer is diagnosed in Nepal at
an advance clinical stage and that study also said that the at a later time, the illiterate women are
8 times more likely to be diagnosed with cervical cancer than the literate women. 11 Hence,
Cervical Cancer has come across as an important public health problem for Nepal. Therefore,
this study aims to assess the awareness on cervical cancer and screening and its practice among
women in Nepal. The outcome of this study helps concern authority to efforts accelerate the
screening test and HPV vaccine coverage in Nepal.
Method:
A cross sectional study was conducted at the Gynecology Out Patient Department (OPD) of
Helping Hands Community Hospital, Kathmandu has out patient load about 50 patients daily.
The study was conducted from June 2017 to August 2017. The participants were women visiting
the Gynecological OPD for various other gynecological problems. A verbal informed consents
were taken from those who want to take part in the study and failing to give consent were
excluded from the study. The women presented for obstetric checkup and those with a history of
cervical cancer and hysterectomy were also excluded from the study. Face to face interview was
conducted with the patients using pre-tested questionnaire which was pre tested with the 5%
female patients of required sample visited to a health center in Kathmandu. A total of 409 sample
was taken through purposive nonprobability sampling method from women. The sample size was
calculated based on 35% of prevalence of adequate knowledge, margin of error was 5% using
Cochrane formula, n=z2pq/d212 and obtained 350 samples. By adding 15% non-response rate on
calculated sample final required sample was decided 403. But on the last day, additional 6
women attended in OPD had shown interest to enrolled in the study, hence total 409 samples was
decided to take for the study. Ethical approval was obtained from concern authority and concern
hospital for the study. Collected data were entered into the Statistical Package for Social
Sciences version 16 and EpiTools epidemiological calculator along with Graph pad for analysis.
Results:
Among the total participated women (409) in this study, the Mean SD age of the women was
33.52 where minimum age was 17 and maximum age was 67 years. Among the total
respondents, 347 (84.8%) married and among them more than 3/4 th (76.9 %) were married before
the age of 20 years. About 1/5th of the respondents were illiterate or having a primary level
education; about half (49.6%) were of lower secondary to secondary levels and 30.1 per cent
were of Higher Secondary and above level. Among the married 347 women, 81.2% having
children and among them more than half (53.3%) delivered their first baby before the age of 20
years and more than two-fifth (22.3%) having two or more children.
Regarding knowledge of cervical cancer and its risk factors, among total respondents of 409,
only 32.8 per cent women heard about cervical cancer from different sources where more than
2/3rd had got information through News media. Among the women of 134 who have heard about
cervical cancer had different knowledge on risk factors of cervical cancer, but only 13.4 per cent
of them had knowledge of causative agent the HPV. In total 134 women who had heard about
cervical cancer only 96 women (71.6%) said that they know the symptoms, but among them
some considered pain during sexual intercourse and lower pain abdomen were also the main
symptoms of cervical cancer.
In total, of 134 Women who have heard about cervical cancer, 95 (70.9%) of them had
knowledge on prevention by avoiding different risk factors, but only 20 (21.1%) of them had an
idea of HPV vaccine; and regarding curability of the disease, only 62.7% of them were believed
that the disease is curable if get proper treatment, but few of them (3%) only were found aware
that the treatment service is free from the Government. Women who had heard about cervical
cancer, less than half (47.8%) had an idea about screening tests and most of them (71.9%) heard
from News media, and only 39% said that the screening is for early diagnosis of the cervical
cancer even though about 11 per cent had no knowledge on all women to be screened. In total
respondents, only 13 per cent (53) had knowledge on Pap smear test, but most of them (89.7%)
had no idea when to be performed. Likewise, among the women who had knowledge on Pap,
only half (50.9%) of them had an idea on who should go under the Pap smear test. The majority
(mean score is 3.26) of the women among those who have heard about cervical cancer agreed
that the disease is highly prevalent and leading cause of death in Nepal but most of them (mean
score is 2.51) are not agreed that they also can get the cervical cancer. Likewise majority of them
(mean score 3.23) agreed that the screening helps in prevention of cervical cancer. Though
screening for cervical cancer is free of cost in Nepal, most of them were not aware about (mean
score is less than 3) and it is seen that even if they know the screening is free and causes no
harm, only some are agreeing to go under screening test (mean score is above 3). Among the
women who have heard about cervical cancer, only 23.9% (32 persons) of them had experienced
on Pap smear test and about 87% of them had done the test once. Three-fourth of total
experienced on Pap smear test had done the test more than 3 years ago and mostly (87.5%) of
them done test while visited hospital for other gynecological problem. Among the women who
had knowledge of cervical cancer (134), only 9.7% (13) of them had heard about the HPV
vaccine and only (1) 7.6% of them had inoculated HPV vaccine.
This study showed that heard about cervical cancer, knowledge of the Pap smear test and
knowledge of the HPV vaccine are significantly associated with the education level of the
respondents (P<0.01).
Discussion:
This study showed that among the total women about one third (32.8%) had heard about cervical
cancer, which is very low, even different activities regarding awareness is continued by the
different I/NGOs and the Government, which is found about half of the previous study
conducted in a tertiary hospital at Kathmandu, Khokana, the suburban community of central
Nepal and Saphebagar, a remote hill district in Far-Western Nepal and rural and urban women of
DPR of Korea in 2011.13,14,15 This study revealed that among the women who have heard about
cervical cancer only 13.4 percent had heard about the causative agent HPV, which is also less
than the findings of study conducted in suburban and rural community of Nepal 14 and in a study
of 2009 conducted among the Turkish women in different city of Turkey i.e. 45 per cent 16.
Likewise, in total 32.8 per cent of women had no idea about the sign and symptoms and about
71.6 percent women among the familiar with cervical cancer had no idea of sign and symptoms.
This study also showed that among the total respondents, 24.9 percent and among those who had
heard about cervical cancer, 70.9 percent had idea of different risk factors and ways of
prevention, but in total 4.8 percent and those who have idea of risk factors, only 21.1 per cent
had an idea about the HPV vaccine that to be injected for prevention; whereas in total 15 per cent
women were found aware of HPV and 10 percent can relate the cancer and its causative agent
HPV and 34 percent among whom had knowledge of HPV had heard about HPV vaccine in a
previous study conducted in Khokana and Saphebagar of Nepal. 14,Likewise, nearly half of the
women (64%) knowledge of Javarnahalli, a rural area of Karnataka, India were aware of the
symptoms of cervical cancer and in total only 39 percent were aware of the risk factors and
among all only 1 percent had knowledge of HPV which is the main risk factor.17
In total, 15.6 per cent and among who had heard about cervical cancer, less than half (47.8%)
had heard about screening, which is found less in total (34.5%) than that of study conducted in
Karnataka, and previous study (42.9%) conducted in Kathmandu. Likewise, in a study conducted
in Mangalore, India, only 14.5% women had knowledge of screening. 13,17,18 Among the total who
had heard about screening only about two-fifth had an idea of screening is for early diagnosis of
the cervical cancer and also about 11 per cent had no knowledge that all women to be screened,
which is a bit better than the previous study (32%) about the reason for screening. Among total
women, only 13 percent have heard about the Pap smear test which is less than the previous
study (42.9%) conducted in Kathmandu.13and those who have heard only 11.3 per cent gave the
right answer on how often a Pap test to be performed.
Among the total women who had heard about cervical cancer 23.9% had done Pap smear test
and mostly (87.5%) had done once, which is even found better than the previous study of
Kathmandu and lesser than the study conducted in Bharatpur, Nepal, but still only 12.5% of them
had knowledge on reason why to do the Pap smear test. 13, 19 Among the women who had
knowledge of cervical cancer, only some were agreed (mean is 3.7 on Lickert scale) to do the
screening test if screen would be free and causes no harm, though government has provided free
services, where study conducted in Karnataka, India showed more than three-forth women (76.2)
found interested to go under the test if offered free of cost.17
This study showed the education can play the significant role in getting knowledge about
cervical cancer, knowledge on Pap smear test and knowledge on HPV vaccine (p <0.01),
Conclusion: Knowledge of cervical cancer, causative agent, screening and its importance, HPV
vaccine and its’ availability are still low even in the capital of Nepal. Therefore, enrollment of
women in academic education and adequate information through different media source focusing
news media targeting eligible women is needed to raise awareness that can play an important
role to change their behaviors to utilize the screening facility that ultimately helps to address the
high morbidity and mortality of cervical cancer among women in Nepal.
Conflict of Interest: There is no any conflict of interest.
Acknowledgement: I acknowledge Dr. Aalisha Koirala, who had supported me in the process of
data collection and Mr. Swarnim Abiral Koirala for cleaning the data.
Table no.1 Socio-Demographic distribution of mother (n=409)
Frequency Confidence Interval (95%)
Age of the respondents
<20 years 31 (7.6%) (0.05 – 0.11)
20 and above 378 (92.4%) (0.89 – 0.95)
MeanSD 33.52 9.978
Marital status
Married 347 (84.8%) (0.81 – 0.88)
Unmarried 62 (15.2%) (0.12 – 0.19)
Age at marriage
<20 years 267 (76.9%) (0.72 – 0.81)
20 and above 80 (23.1%)
Education status
Primary or none 83 (20.3%) (0.17 – 0.24)
L. Sec. to Secondary 203 (49.6%) (0.45 – 0.54)
H. Secondary & above 123 (30.1%) (0.26 – 0.35)
Table 2. Behavioral and biological characteristics
Frequency Confidence Interval
Having children (n=347)
Yes 332 (81.2%) (0.93 – 0.97)
No 15 (18.8%) (0.03 – 0.07)
Age at first childbirth (n=332)
<20 years 177 (53.3%) (0.48 – 0.59)
20 years 155 (46.7%) (0.41 – 0.52)
Number of children
One child 258 (77.7%) (0.73 – 0.82)
Two or more children 74 (22.3%) (0.18 – 0.27)
Table 3. Knowledge on Cervical cancers and its risk factors
Frequency Confidence Interval
Heard about cervical cancer (n=409)
Yes 134 (32.8%) (0.93 – 0.97)
No 275 (67.2%) (0.75 – 0.83 )
Information on Cer. Ca received from* * Multiple answers
(n=134)
News Media 83 (61.9%) (0.53 – 0.69)
Health worker 53 (39.6%) (0.32 – 0.48)
Friends and family 65 (48.5%) (0.40 – 0.57)
Leader of women group 13 (9.8%) (0.05 – 0.16)
Knowledge on causative agent (HPV)
(n=134)
Yes 18 (13.4%) (0.09 – 0.20)
No 116 (86.6%) (0.80 – 0.91)
Knowledge on different risk factors
(n=134)*
Prolong infection 63 (47%) (0.39 – 0.55)
Multiple sex partners 43 (32.1%) (0.32 – 0.48)
Multiple childbirth 57 (42.5%) (0.34 – 0.51)
Poor genital hygiene 68 (50.7%) (0.42 – 0.59)
Early marriage / sexual exposure 52 (38.8%) (0.31 – 0.47)
Early pregnancy 57 (42.5%) (0.34 – 0.51)
Prolong use of OCP 35 (26.1%) (0.19 – 0.34)
Weak immune system 45 (33.6%) (0.26 – 0.42)
Smoking 49 (36.8%)
Knowledge on signs and symptoms of
Cer Cancer (n=134)
Yes 96 (71.6%) (0.63 – 0.79)
No 38 (28.4%) (0.21 – 0.36)
Knowledge on symptoms ** (n=96)
Irregular Vaginal bleeding 80 (83.3%) (0.74 – 0.89)
Postmenopausal bleeding or spotting 41 (42.7%) (0.33 – 0.52)
Increase vaginal discharge with foul 22 (22.9%) (0.15 – 0.32)
smelling
Pain during sexual intercourse 14 (14.6%) (0.08 – 0.23)
Lower pain abdomen 10 (10.4%) (0.05 – 0.18)
4. Knowledge on prevention and curability of cervical cancer
Knowledge on prevention (n=134)
Yes 95 (70.9%) (0.63 – 0.78)
No 39 (29.1%) (0.22 – 0.37)
Knowledge on prevention (n-95)**
Treatment of Infection 61 (64.2%) (0.54 – 0.73)
Avoid multiple sex partner 50 (52.6%) (0.43 – 0.62)
No many children 57 (60%) (0.50 – 0.69)
Maintain genital hygiene 59 (62.1%) (0.52 – 0.71)
Avoid early sexual intercourse 54 (56.8%) (0.47 – 0.66)
Follow doctor advice on OCP 33 (34.7%) (0.26 – 0.45)
Avoid smoking 50 (56.2%) (0.43 – 0.62)
Through HPV vaccine 20 (21.1%) (0.14 – 0.30)
Knowledge on cure of Cervical cancer
(n=134)
yes 84 (62.7%) (0.54 – 0.70)
No 42 (31.3%) (0.24 – 0.39)
Don’t know 8 (6.0%) (0.03 – 0.11)
Knowledge on cost of treatment
(n=134)
Free of charge from the government 4 (3%) (0.01 – 0.07)
Reasonably priced 15 (11.2%) (0.07 – 0.18)
Moderately expensive 11 (8.2%) (0.04 – 0.14)
Very expensive 54 (40.3%) (0.32 – 0.49)
Do not know 50 (37.3%) (0.29 – 0.46)
5. Knowledge on screening
Hearing about screening test (n=134)
Yes 64 (47.8%) (0.39 – 0.56)
No 70 (52.2%) (0.44 – 0.60)
Hearing the sources of screening test
** (n=64)
News Media 46 (71.9%) (0.59 – 0.89)
Health worker 40 (62.5%) (0.50 – 0.73)
Friends and family 23 (35.9%) (0.25 – 0.48)
Leader of women group 8 (12.5%) (0.06 – 0.23)
Others 0
Knowledge on all women to be
screened (n=64)
Yes 57 (89.1%) (0.79 – 0.95)
No 7 (10.9%) (0.05 – 0.21)
knowledge on need of screening (n=64)
For cancer prevention 33 (51.6%) (0.39 – 0.63)
For early diagnosis of cancer 25 (39.1%) (0.28 – 0.51)
For treatment of cancer 3 (4.7%) (0.01 – 0.13)
Don’t know 3 (4.7%) (0.01 – 0.13)
Knowledge on Pap smear test
Yes 53 (13%) (0.10 – 0.16)
No 356 (87%) (0.83 – 0.89)
knowledge on how often pap smear to
be performed (n=53)
Yes (Write answer) 6 (11.3%) (0.05 – 0.23)
No (Wrong answer) 47(89.7%) (0.77 – 0.96)
Knowledge on who should go for Pap
smear test (n=53) ** (multiple
answers)
Sick women 30 (56.6%) (0.43 – 0.69)
Married healthy women 27 (50.9%) (0.38 – 0.64)
Older women 4 (7.5%) (0.02 – 0.18)
6. Knowledge on disease prevalence; self-risk; availability and attitude towards utilization of
screening services
Knowledge on highly prevalent and Frequency scoring Average
leading cause of death in Nepal among
women (n=134)
Strongly Agree 5 5x5=25 =438/134
Agree 37 37x4=14 =3.26
8
Neither agree nor disagree 84 84x3=25
2
Disagree 5 5x2=10
Strongly Disagree 3 3x1=3
Knowledge on any women including
you can get Cervical ca (n=134)
Strongly Agree 7 (5.2%) 7x5=35 =337/134
Agree 48(35.8%) 48x4=19 =2.51
2
Neither agree nor disagree agree 61(45.5%) 61x3=18
3
Disagree 9 (6.7%) 9x2=18
Strongly Disagree 9 (6.7%) 9x1=9
Knowledge on Screening helps in
prevention of cervical cancer (n=134)
Strongly Agree 1 (7%) 1x5=5 =433/134
Agree 33 (24.6%) 33x4=13 =3.23
2
Neither agree nor disagree 98 (73.1%) 98x3=29
4
Disagree 0 0
Strongly Disagree 2 (1.5%) 2x1=2
Knowledge on screening is free in
Nepal (n=134)
Strongly Agree 0 0 =356/134
Agree 12(9%) 12x4=48 =2.65
Neither agree nor disagree 91(67.9%) 91x3=27
3
Disagree 4(3%) 4x2=8
Strongly Disagree 27(20.1%) 27x1=27
If screen is free and causes no harm
will you screen (n=134)
Strongly Agree 9(6.7%) 9x5=45 =452/134
Agree 36(26.9%) 36x4=14 =3.37
4
Neither agree nor disagree 87(64.9%) 87x3=26
1
Disagree 0 0
Strongly Disagree 2(1.5%) 2x1=2
7. Pap smear test and HPV vaccine utilization
Ever done Pap smear test (n=134) Frequency (%) CI (95%)
Yes 32 (23.9%) (0.17 – 0.32)
No 102 (76.1%) (0.68 – 0.82)
How many times you have done Pap smear
test (n=32)
Once 28 (87.5%) (0.71 – 0.96)
More than one 4 (12.5%) (0.04 – 0.29)
Reason for uptake Pap smear test (n=32)
For diagnosis of cancer 4 (12.5%) (0.04 – 0.29)
For other reason 28 (87.5%) (0.71 – 0.96)
Last time screened with Pap smear (n=32)
Within past 3 years 8 (25%) (0.13 – 0.42)
More than 3 years ago 24 (75%) (0.58 – 0.87)
Heard about HPV vaccine (n=134)
Yes 13(9.7%) (0.06 – 0.16)
No 121(90.3%) (0.84 – 0.94)
Received HPV Vaccine (n=13)
Yes 1 (7.6%) (0.0 – 0.3)
No 12 (92.4%) (0.64 – 1.0)
8. Association of education with knowledge on cervical cancer, Pap smear test, and HPV
vaccine.
Education of mother VS Heard about Yes (%) No (%) 2 value P value
cervical ca
Primary (1-5 class) or none 13 (15.7%) 70 (84.3%)
L.Sec to Sec Level (6-10 classes) 47 (23.2%) 156(76.8%) 61.447 P<0.01
Higher Sec. and above (11+) 74 (60.2%) 49 (39.8%)
Education of mother vs knowledge on Pap
smear test
Primary (1-5 class) or none 2 (2.4%) 81(97.6%)
L.Sec to Sec Level (6-10 classes) 13(6.4%) 190(93.6%) 51.001 P<0.01
Higher Sec. and above (11+) 38(30.9%) 85 (69.1%)
Education of mother vs knowledge on HPV
Vaccine
Primary (1-5 class) or none 1 (1.2%) 82 (98.8%)
L.Sec to Sec Level (6-10 classes) 2 (1%) 201 (99%) 14.023 P<0.01
Higher Sec. and above (11+) 10(8.1%) 113
(91.9%)
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