Tzu Chi Medical Journal 2019; 31(4): 240–243

Original Article

Knowledge, attitude, and practice regarding the screening of cervical cancer

among women in New Delhi, India
Neha Dahiyaa*, Kavita Aggarwalb, Megha Chandra Singhb, Suneela Gargb, Rajesh Kumarb

a
Department of Community
Medicine and School of Public
Abstract
Health, Postgraduate Institute of Objective: Cervical cancer is one of the major concerns of public health importance in today’s
Medical Education and Research, world. It is a leading cause of mortality in women of reproductive age group worldwide,
Chandigarh, India, bDepartment mainly in developing countries. Reduction in mortality and morbidity due to cervical cancer
of Community Medicine,
is possible through early detection and treatment. The major factors influencing the early
Maulana Azad Medical College,
Delhi, India detection of cervical cancer are knowledge regarding risk factors, screening, Pap smear, and
symptoms among women. Materials and Methods: The present cross‑sectional study was
carried out to assess the knowledge, attitude, and practice of women about the risk factors,
symptoms, and prevention of cervical cancer. Data were obtained from 220 women who
visited international trade fair using a pretested self‑administered questionnaire. Results:
Only 75 study women (50.0%) had ever heard of cervical cancer. The knowledge regarding
cervical cancer and its various domains was significantly higher in students and unmarried
women. The foul‑smelling vaginal discharge was the most common early symptom of
cervical cancer according to most of the study women (26, 17.3%). Most of the study
women (19, 12.7%) reported tobacco and smoking as the most common risk factor associated
with cervical cancer. Only 39 women (26%) had ever heard of cervical cancer screening.
Only 27 women (18.0%) ever had Pap smear done in the past and 87 women (58.0%) were
willing to undergo cervical cancer screening is offered free of cost. Conclusion: The study
demonstrates the lack of awareness in women regarding cervical cancer and its screening
modalities. This necessitates spreading awareness regarding early symptoms and risk factors
associated with cervical cancer for early detection and treatment initiation.
Received : 15‑Aug‑2018
Revised : 21‑Aug‑2018
Accepted : 28-Oct-2018 Keywords: Attitude, Cervical cancer, Knowledge, Screening

Introduction cases were diagnosed worldwide, of which 123,000 were diag-

nosed in India. Approximately 266,000 women died from this
I n the modern era, the world is heading toward the rising
epidemic of noncommunicable diseases (NCDs). Out
of these NCDs, cancer is the second leading cause of death
disease in 2012 worldwide, of which 67,000 died in India [4].
Most of the cervical cancer cases are found to be associated
globally. There were approximately 14.1 million new cancer with carcinogenic human papillomavirus (HPV) infection. The
cases and 8.2 million cancer deaths worldwide in 2012. Out other factors involved in the occurrence of cervical cancer
of which, 8 million new cancer cases and 5.3 million cancer include promiscuous sexual habits, reproductive factors such as
deaths occurred in economically developing countries [1]. The genital hygiene, early menarche, the interval between menarche
number of new cases is expected to rise by 70% over the next and first sexual intercourse, early age at marriage, high parity,
two decades [2]. At present, India is facing health transition. other sexually‑transmitted infection, and smoking. The peak
In addition to the unfinished agenda to control communi- age of infection with HPV infection is in women after initiation
cable diseases, nutritional deficiencies, there is an escalating of sexual activity in their 20s. Early invasive cervical cancer
epidemic of NCDs. In India, NCDs are estimated to account typically occurs after 10 years of persistent HPV infection.
for 60% of total deaths including cancers accounting for 7%
*Address for correspondence:
deaths [3]. Dr. Neha Dahiya,
Department of Community Medicine and School of Public
Cervical cancer is the fourth most common cancer in women Health, Postgraduate Institute of Medical Education and Research,
worldwide leading to the death of which 85% occur in low‑ and Chandigarh ‑ 160 012, India.
middle‑income countries. In 2012, 528,000 new cervical cancer E‑mail: drnehadahiya@gmail.com

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How to cite this article: Dahiya N, Aggarwal K, Singh MC, Garg S, Kumar R. Knowledge,
DOI: 10.4103/tcmj.tcmj_145_18
attitude, and practice regarding the screening of cervical cancer among women in
New Delhi, India. Tzu Chi Med J 2019;31(4):240-3.

240 © 2019 Tzu Chi Medical Journal | Published by Wolters Kluwer - Medknow
 Dahiya, et al / Tzu Chi Medical Journal 2019; 31(4): 240-243

Women remain asymptomatic for many years after acquiring was ascertained using the Mann–Whitney test and Kruskal–
HPV infection, but the pathological changes during this long Wallis test for non‑normally distributed data.
interval can be detected by various screening methods, i.e., Pap
smear. Thus, it is possible to decrease morbidity and mortality Results
associated with cervical cancer by diagnosing and treating it at A total of 220 women were approached for this study and
precancerous stages. 150 women out of 220 women were willing to participate in
Knowledge regarding various signs, symptoms, and risk the study. The mean age of women participated in the study
factors associated with cervical cancer influences health‑seek- was 35.87 ± 12.11 years (ranging from 19 years to 70 years).
ing behavior. Moreover, with their knowledge and positive One hundred and thirty women (86.7%) were Hindu, 7 (4.7%)
attitude toward cervical cancer vaccine, the risk of getting HPV were Muslim, 5 (3.3%) were Christian, and 8 (5.3%) were
infection may be further reduced. This study was done with the Sikh. Most of the participants had completed 15 years of
objectives to study the knowledge of women about the symp- education (100, 66.7%) followed by 10 years of education
toms, risk factors, prevention, and early diagnosis of cervical (35, 23.3%) and only 5 women (3.3%) were illiterate. Students
cancer and to assess the attitude and practice of women toward comprised 14.7% (22), homemakers 48.0% (72), and skilled
cervical cancer. professionals 37.3% (56) of the study participants. Majority of
study participants were married (79.3%, 119). Forty study par-
Materials and methods ticipants (26.7%) were married at the age of ≤20 years. Four
This cross‑sectional study was conducted at an interna- women (2.7%) reported a family history of cervical cancer.
tional health fair in New Delhi. The general public attending Out of a total of 150 participants, only 75 women (50.0%)
the fair were provided health‑promoting services in the form had ever heard of cervical cancer. The mean knowledge
of free health check‑up, feasible‑free laboratory investigations, score of the study participants was 3.21 ± 3.75. The knowl-
and health education in addition to various cultural programs edge score was significantly higher in students and unmarried
for school children, college students, and the general public. women [Table 1].
The study was conducted in accordance with the Declaration of Knowledge about cervical cancer among study partici-
Helsinki and was approved by the Local Ethics Committee of pants is shown in Table 2. Knowledge of cervical cancer
the institute. Informed written consent was waived because the was measured under the domains of symptoms, risk factors,
study was a retrospective data analysis.
Women aged 18 years or more who consented were included Table 1: Distribution of cervical cancer knowledge scores in
in the study through consecutive sampling. Women with diag- subjects
nosis or having a history of cervical cancer in the past were Sociodemographic Number of Average knowledge P
excluded from the study. A predesigned pretested self‑admin- factor subjects, n (%) score (0-19)
istered questionnaire was used to assess the knowledge of Age (years)
cervical cancer regarding symptoms, risk factors, screening ≤30 56 (37.3) 4.30±4.771 0.111a
methods, and vaccination; and attitude toward cervical cancer >30 94 (62.7) 2.55±2.819
patients and screening tests. The questionnaire was developed Religion
in English and later on translated in Hindi (national language) Hindu 130 (86.7) 3.24±3.803 0.108b
understandable by the participants. It was pretested in 30 adult Muslim 7 (4.7) 2±1.826
women in Delhi Gate urban health center in New Delhi. Sikh 5 (3.3) 6.80±5.167
Christian 8 (5.3) 1.50±1.069
The study participants reply to each questionnaire item Literacy level
related to knowledge about cervical cancer was allocated a 10th 27 (18.0) 2±1.544 0.100b
score of 1 for every correct response. The cumulative scores 12th 21 (14.0) 4.86±4.881
were calculated for every study participant for cervical cancer 15 or higher 102 (68.0) 3.19±3.807
knowledge. The knowledge score was ranging from 0 to 19. Occupation
The sample size for the study was calculated using Epi‑info Homemaker 72 (48.0) 2.10±1.594 0.008b
Version 7, Centers for Disease Control and Prevention (CDC), Skilled professional 56 (37.3) 3.13±3.537
Georgia, Atlanta, USA which was based on a previous study Student 22 (14.7) 7.05±6.237
done by Bansal [5] in which 15.1% of participants were aware Marital status
of cervical cancer screening. The sample size at 95% con- Unmarried 31 (20.7) 5.94±5.645 0.001a
fidence levels, and 5% margin of error was calculated to be Married 119 (79.3) 2.50±2.687
196. Taking into account, 10% nonresponse, the final sample Age at marriage (years)
size was estimated to be 216. Data were entered in Excel sheet. ≤20 40 (26.7) 2.47±2.935 0.874a
Statistical analysis was performed using SPSS version 20 >20 79 (52.7) 2.51±2.571
(IBM, Armonk, NY, USA). Data were expressed in frequency History of cervical
and proportion for categorical variables while quantitative vari- cancer in family
ables were expressed in terms of mean and standard deviation. Present 4 (2.7) 1.50±0.577 0.530a
The presence of a statistically significant difference between Absent 146 (97.3) 3.25±3.793
knowledge score in terms of their sociodemographic categories a
Mann-Whitney test, bKruskal-Wallis test

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 Dahiya, et al / Tzu Chi Medical Journal 2019; 31(4): 240-243

and cervical cancer screening. The most common symptom Table 2: Knowledge about cervical cancer (n=150)
answered by the study participants was foul‑smelling vaginal n (%)
discharge (26, 17.3%), followed by bleeding in between Knowledge about symptoms
periods and periods heavier and of longer duration (25, 16.7%), Bleeding in between periods 25 (16.7)
bleeding after intercourse (13, 8.7%), and postmenopausal bleed- Foul smelling vaginal discharge 26 (17.3)
ing (11, 7.3%). The most common risk factor was tobacco and Postmenopausal bleeding 11 (7.3)
smoking (19, 12.7%), followed by HPV infection (17, 11.3%), Periods heavier and of longer duration 25 (16.7)
multiple sexual partners (16, 10.7%), prolonged use of birth Bleeding after intercourse 13 (8.7)
control (15, 10.0%), history of sexually‑transmitted dis- Knowledge about risk factors
eases (14, 9.3%), poor menstrual hygiene (12, 8.0%), coitus at HPV infection 17 (11.3)
early age (10, 6.7%), and multiple (>5) pregnancy (7, 4.7%). Multiple sexual partners 16 (10.7)
Only 35 women (23.3%) ever heard of cervical cancer screen- Coitus at early age 10 (6.7)
ing, and 39 women (26.0%) ever heard of Pap smear, but not Tobacco and smoking 19 (12.7)
all of them knew that Pap smear is a tool for cervical cancer History of STD 14 (9.3)
Poor menstrual hygiene 12 (8.0)
screening. According to 13 (8.7%) women, Pap smear should
Prolonged use of birth controlled (>5 years) 15 (10.0)
be started at the age of <21 years, >21 years (17, 11.3%) and
Multiple pregnancy (>5) 7 (4.7)
after 3 years of sexual exposure (9, 6.0%). When asked about
Knowledge about cervical cancer screening
frequency of Pap smear 21 (14.0%) said that Pap smear should
Heard of cervical cancer screening 35 (23.3)
be done in 1 year, 2 years (2, 1.3%), and 3 years (1, 0.7%).
Ever heard of Pap smear test 39 (26.0)
Out of a total of 150 participants, only 27 women (18.0%) ever Pap smear should be started at age
had Pap smear done in the past. Only 18 women (12.0%) were <21 years 13 (8.7)
aware of cervical cancer vaccination, but only 6 women (4.0%) >21 years 17 (11.3)
knew the correct age for HPV vaccination. After 3 years of sexual exposure 9 (6.0)
The attitude of participants toward cervical cancer is shown Pap smear frequency
Every years 21 (14.0)
in [Table 3]. According to 88 (58.7%) women, intermenstrual
Every 2 years 2 (1.3)
bleeding should not be considered as normal. 83 (55.3%)
Every 3 years 1 (0.7)
women said that a woman should not bear her first child by the
Vaccine available for cervical cancer 18 (12.0)
age of 20 years. 91 (60.7%) women were in favor of women
Age for HPV vaccination
not bearing 5 or more children to increase family strength.
<5 years 2 (1.3)
76 women (50.7%) realized the importance of gynecological 5-10 years 0
examination at least every 3 years. Eighty (53.3%) women 10-26 years 6 (4.0)
would not keep a distance from a neighborhood female suffer- Immediately after marriage 7 (4.7)
ing from cervical cancer. Eighty‑seven women (58.0%) were HPV: Human papilloma virus, STD: Sexually transmitted disease
willing to be screened for cervical cancer if offered a free cer-
vical cancer screening.
Table 3: Attitude towards cervical cancer
Discussion Statements n (%)
Intermenstrual bleed should not be considered as normal 88 (58.7)
Awareness about cervical cancer screening can improve
A woman should not bear her first child by the age of 20 years 83 (55.3)
women’s approach leading to an increased rate of early diag- Women should not bear 5 or more children to increase family 91 (60.7)
nosis and treatment of cervical cancer. Treatment started at an strength
early stage of cervical cancer is more cost‑effective which can Women should get an internal examination done by a 76 (50.7)
help in reducing the overall morbidity and mortality associated gynecologist at least once in 3 years
with cervical cancer. The deficit in awareness regarding screen- If any lady in the neighborhood is suffering from cervical 80 (53.3)
ing leads to delayed reporting and high mortality. The present cancer, you would not keep distance from her
study was conducted in 150 adult women in New Delhi to If you were offered a free cervical cancer screening you would 87 (58)
assess the knowledge and attitude of cervical cancer screening be willing to be screened
among them. Out of 150 study participants, 75 (50%) women
had heard of cervical cancer. This proportion was much higher In the present study, 35 women (23.3%) had heard of cervi-
as compared to the proportion found in previous studies [6‑8].
cal cancer screening. Thirty‑nine (26%) women knew about the
This may be due to an increase in health promotion activi-
Pap smear test. This is lower as compared to studies done in
ties conducted by Government of India in the past few years,
and the study population was residing in urban areas. In this Kuwait [9], Singapore [10], Vietnamese‑American women [11],
regard, the National Program for Prevention and Control of the United Kingdom [12], and Kenya [13]. This difference may
Cancer, Diabetes, CVD, and Stroke has been launched in 2010 be due to different study population or differences in the level
to decrease mortality associated with NCDs. Despite having and method of health promotion to create awareness about Pap
knowledge about cervical cancer, the awareness regarding smear screening. In addition to similar studies done in India,
symptoms and risk factors was low in study participants. the present study shows that despite being an effective tool

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