DOI:http://dx.doi.org/10.7314/APJCP.2012.13.4.

1093
Risk Factors of Cervical Cancer and Knowledge, Attitude and Practice in Rural and Urban Areas of North Bengal

RESEARCH COMMUNICATION

Socio-Demographic and Behavioural Risk Factors for Cervical

Cancer and Knowledge, Attitude and Practice in Rural and
Urban Areas of North Bengal, India
Sreejata Raychaudhuri*, Sukanta Mandal
Abstract
Background: Cervical cancer is common among women worldwide. A multitude of risk factors aggravate
the disease. This study was conducted to: (1) determine the prevalence and (2) make a comparative analysis of
the socio-demographic and behavioural risk factors of cervical cancer and knowledge, attitude and practice
between rural and urban women of North Bengal, India. Study Design: Community-based cross-sectional study.
Methods: A survey (first in North Bengal) was conducted among 133 women in a rural area (Kawakhali) and
88 women in an urban slum (Shaktigarh) using predesigned semi-structured questionnaires. The respondents
were informed of the causes (including HPV), signs and symptoms, prevention of cervical cancer and treatment,
and the procedure of the PAP test and HPV vaccination. Results: The prevalence of risk factors like multiparity,
early age of marriage, use of cloth during menstruation, use of condom and OCP, early age of first intercourse
was 37.2%, 82%, 83.3%, 5.4%, 15.8% and 65.6% respectively. Awareness about the cause, signs and symptoms,
prevention of cervical cancer, PAP test and HPV vaccination was 3.6%, 6.3%, 3.6%, 9.5% and 14.5% respectively.
Chi-square testing revealed that in the study population, significant differential at 5% exists between rural and
urban residents with respect to number of children, use of cloth/sanitary napkins, family history of cancer and
awareness regarding causes of cervical cancer. Regarding KAP, again using chi-square tests, surprisingly, level
of education is found to be significant for each element of KAP in urban areas in contrast to complete absence of
association between education and elements of KAP in rural areas. Conclusions: A large number of risk factors
were present in both areas, the prevalence being higher in the rural areas. The level of awareness and role of
education appears to be insignificant determinants in rural compared to urban areas. This pilot study needs to
be followed up by large scale programmes to re-orient awareness campaigns, especially in rural areas.
Keywords: Cervical cancer - HPV - PAP test - risk factor - chi-square test - rural urban differentials
Asian Pacific J Cancer Prev, 13, 1093-1096
Introduction for the primary prevention of cervical cancer. HPV assays
to improve secondary prevention (screening programs)
There are a multitude of risk factors for cervical may offer the possibility of bringing cost effective cervical
cancer worldwide (Varghese et al., 1999). Virtually all cancer prevention strategies.
cases of cervical cancer are attributable to persistent The present study was carried out randomly on a total
infection by certain strains of Human Papilloma Virus of 221 women of North Bengal, 88 urban and 133 of rural
(HPV) especially HPV-16 and HPV-18. These HPV types background. Both the areas were inhabited by people of
also cause other cancers. Although cervical cancer can low to medium economic status. The rural study area
be detected at stages I or II with routine Papanicolaou Kawakhali, is situated in the Matigara Gram Panchayat
tests, it is a slow growing disease in which women do not area in the Siliguri subdivision of Darjeeling district in
experience problematic symptoms until the later stages of West Bengal. The village is bounded by Balason river
manifestation when chances of survival are lower (Roy & in the east, North Bengal Medical College in the west,
Tang, 2008). Kadamtala Border Security Force Camp in the North
Although screening, primarily with the Pap smear and Parashar village in the south.. The other urban study
technology, has reduced the incidence of this disease, area Shaktigarh, is situated in the Dabgram Urban Area of
cervical cancer remains the second most common cause of Jalpaiguri District. It is situated on the bank of Mahananda
death from cancer in women worldwide. This is because River. The main purpose of the study is to find differences
of lack of resources for widespread high quality screening. in KAP between residents in rural and urban areas. This is
In addition to application of Pap smear technology, the the first recorded attempt to analyze the risk factors and
identification of HPV as the etiologic agent has led to the generate small scale awareness about cervical cancer in
development of a preventive vaccine (Lowy et al., 2008) this region.

Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India *For correspondence:
sreejata1@gmail.com
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 1093
Sreejata Raychaudhuri and Sukanta Mandal
Table 1. Socio-Demographic Characteristics Materials and Methods
Category Percentage of total study population
This cross sectional study of two months duration was
Occupation: Skilled labor 9.4 done in a village Kawakhali and an urban slum Shaktigarh.
Unskilled labor 22.8 221 married and unmarried women, (88 urban and 133
Business 3.7
rural) of reproductive age group (15-49 years) were
Unemployed 4.6
Housewife 60.2
randomly selected. Seriously ill and lunatic women were
Age: 15-24 24.9 excluded. Sample size was determined using EPI-INFO
25-34 37.6 software version 3.5.1.
35-49 37.6 Necessary permission from the concerned authorities
Caste: General 15.8 was taken and a survey was conducted using pretested
SC 82.4 predesigned semi structured questionnaires. Prior
ST 0.9 informed consent was taken. For those not available in
OBC 1 the first interview another visit was made to minimize
Marital status Married 88.7
non response.
Divorced 0.5
Single 5.4
Statistical data analysis was carried out using SPSS
Widow 5.4 software version 16.0. Chi square test was performed to
Monthly income <Rs.1000 6.8 determine association between rural and urban prevalence
Rs.1000-2000 23.5 of risk factors.
Rs.2001-3000 38.9
Rs.3001-4000 12.7 Results
Rs.4001-5000 10.4
>Rs.5000 7.7 In the present study socio- demographic characters
were the foundation of research on randomly selected
Table 2. Categories for Health History and Data on Awareness
Health History Information Data on Awareness
Category Percentage of total study population Category Percentage of total study population
Age of marriage: <10 0.5 Educational qualification: Illiterate 28.1
10-14.5 30.4 Just literate 13.1
15-18 51.1 1 to 4 5.9
>18 12.9 5 to 10 46.6
Unmarried 5.4 >10 6.5
Age of first sexual intercourse: <13 13.6 Heard of cervical cancer/ not: Yes 87.3
14-18 65.6 No 12.7
>18 15.6 Source of information: Friends 41.6 100.0
No intercourse 5.4 Relatives 3.2 6.3
Number of sex partners: 0 5.4 Health worker 11.8
1 94.6 Radio 1.8
Number of children: 0 10.4 Television 29.4 75.0
1 15.4 Not heard 12.2
2 37.1 Awareness of cause: Yes 3.6 56.3
3 23.5 No 96.4
50.0
>3 13.7 Awareness of signs and symptoms: Yes 6.3
Number of abortions: 0 97.3 No 93.7
1 1.8 Aware of prevention: Yes 3.6
3 0.9 No 96.4 25.0
Use of Condom: Yes 5.4 Aware of PAP test: Yes 9.5
No 94.6 No 90.5 31.3
Use of other contraceptive measures: Permanent 45.7 Willingness to undergo PAP test: Yes 84.6
methods No 15.4 0
OCP 15.8 Aware of HPV vaccine: Yes 14.5
Newly diagnosed without treatment

Use of branded/homemade napkin: Homemade 83.3 No 85.5

Branded 16.7 Not gone 14.5
Presence of white discharge: Yes 15.8 No 3.2
No 84.2 Access to nearest PHC: Yes 82.4
Smoking habit: Yes 0.5 Maintains personal hygiene: Yes 99.1
No 99.5 No 0.9
Betel / tobacco chewing: Yes 45.7 Aware that multiple partners is a risk factor:
No 54.3 Yes 68.8
Family history of cancer: Yes 9.5 No 31.2
No 90.5 Aware of warning signals: Yes 9.5
Family history of cancer: Yes 9.5 100.0
No 90.5 6.3 10.1 12.8
20.3

1094 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012

75.0 25.0 30.0

56.3 46.8
51.1
 DOI:http://dx.doi.org/10.7314/APJCP.2012.13.4.1093
Risk Factors of Cervical Cancer and Knowledge, Attitude and Practice in Rural and Urban Areas of North Bengal
Table 3. Chi-square Tests of Independence for Variables and Attributes
Item Area of Residence p-value Item Area of Residence p-value
Monthly Income 2.88 0.09 Heard of Cervical Cancer c12
0.23 0.64
Age of Marriage c12 0.59 0.45 Aware of Cause c12 4.29 0.04*
Use of Condom c12 3.81 0.05 Aware of signs and symptoms c12 1.87 0.17
Other Methods of Contraception c12 5.89 0.12 Aware of prevention c12 1.78 0.18
Number of Children c12 6.06 0.01* Aware of PAP Test c12 0.03 0.87
Use of cloth/sanitary napkins c12 9.25 0.00* Willingness to undergo PAP test c12 0.03 0.86
Presence of White Discharge c12 3.45 0.06 Aware of HPV Vaccine c12 0.01 0.92
Family History of Cancer c12 6.98 0.01* Maintenance of Personal Hygiene c12 1.34 0.25
*implies significant at 5% level
Table 4. Comparison of KAP with Area of individuals (Dasgupta et al., 2002; Roy & Tang, 2008;
Residence Mitra, 2009), without focusing on the locational
Item Urban (p-value) Rural (p-value)
significance.
From the health history information of the study
Level of education and Awareness of cause subjects, it was evident that both the rural as well as
c 12 3.31 (0.00*) c12 20.48 (0.07) urban respondents consummated marriage at a tender
Level of education and Awareness of signs
age (Table 1) which posed a very high risk for cervical
c12 7.04 (0.01*) c12 0.45 (0.5)
Level of education and Awareness of HPV vaccine
cancer. According to Mitra (2009), low age at first
c12 5.64 (0.02*) c12 0.38 (0.54) sexual intercourse exposed the young subjects to semen
Level of education and Awareness of prevention which is a potential carcinogen. Biswas et al. (1997),
c12 10.79 (0.00*) c12 0.3 (0.58) highlighted that cervical epithelium is more susceptible
to carcinogenic agents during adolescence. Early age at
asymptomatic female individuals in rural and urban marriage indicated an early exposure to sexual activities
backdrop of North Bengal. Age range of the respondents and early pregnancy which are well known etiological
was 15 to 49 years. Most of them (88.7%) were married factors for cancer cervix. Mitra (2009), also noted that
and a few of them were single (12%) or widowed (5.4%). large number of child births gave rise to high parity
Only a single case of divorcee was found. Most families which increased risk factor for cervical cancer. Apart from
earned (38.9%) between Rs 2001 to 3000/- per month repeated hormonal influences on the risk of infection by
Table 1. HPV, labour related trauma might also enhance chances
Regarding educational qualification 28.1% were of infection by HPV.
illiterate and 5.9% of the women received primary Yasmeen et al. (2010), suggested that absence of
education. However most of them (46.6%) received promiscuity in a population from Kashmir was the cause
education between Class V and X. In terms of livelihood, of absence of cervical cancer in that community. Women
majority were house wives (60.2%). Only 7.3% owned of the present study group were mostly healthy adults
small business, while 32.2% were engaged either as skilled including 70.1% of the population with regular menstrual
or unskilled labour (Table 2). With this perspective of low cycle. Irregularity was reported by 25 respondents and 36
to medium economic status our study was conducted. reported menopause. Most of the population used home-
In our study 23.5% of the population had 3 children and made sanitary napkins made of cotton cloth which was
13.7% showed birth record of more than three children. reused after washing. Bayo et al. (2002), in their study
History of abortion was negligible being negative in 97.3% also found that reusing home-made sanitary napkins is a
cases. All married respondents had a single sex partner risk factor for cervical cancer. Use of different methods
and this may be a reason for absence of cervical cancer of contraception has been exhaustively studied in our
in our study population. Although 28% are illiterates and investigation. 94.6% of women never used condom and
almost 82% have heard of cervical cancer, surprisingly preferred to use OCP or tubal ligation. Mitra (2009),
about 90% are not aware of the warning signals. observed that use of condoms may not be very effective in
The most important issue investigated is whether preventing HPV infection. This is because the papilloma
location has influenced the prevention and hygiene of virus lives in the skin covering the pubic area as well as
the persons surveyed. This is true for 3 variables, namely the cells lining the vagina and cervix in women and urethra
number of children, sanitary napkin use and family and anus in both sexes. Condoms do not block contact with
history at 5% level of significance. Regarding awareness, pubic skin and hence unable to give protection from HPV.
significant difference is observed only for causation. Our investigation also included the data on addiction
However, as Tables 3 and 4 show, educational level plays to potential carcinogens among the study subjects.
an important role for awareness of cause, preventive Interestingly 99.5% of the women did not smoke tobacco
measures and vaccination only in the urban areas. and none of them were addicted to alcohol. But an alarming
number of respondents (45.7%) were addicted to chewing
Discussion betel leaf with areca nut and/or tobacco. Many authors
have implicated these substances as causative agent of
Most of the studies in this context concentrated various cancers. Chen et al. (2006), correlated oral non
on comparisons between disease afflicted and control malignant lesions with HPV infection, betel leaf chewing
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 1095
Sreejata Raychaudhuri and Sukanta Mandal
and cigarette smoking. According to these authors HR areas of such reoriented awareness campaigns.
HPV is quite common in the oral cavity of normal mucosa.
On the other hand other reports indicated that irrespective Acknowledgements
of copy number, the integrated form of HR HPV is
related to tumourigenesis of invasive cervical carcinoma The authors are grateful to the Department of
(Hopman et al., 2004). Thomas et al. (1994), observed Community Medicine, North Bengal Medical College for
mutations in the conserved regions of p53 to be infrequent the facilities provided. They would also like to thank the
in betel associated oral cancer. However, according to volunteers from Shaktigarh and Kawakhali for their wilful
Scheffner et al. (1990), inactivation of p53 gene may not participation. Funding: Sreejata Raychaudhuri sincerely
require mutations but may involve cellular/viral protein acknowledges the award of Short Term Studentship
(E6 protein) interaction and provided an explanation for (STS) 2010 Fellowship from Indian Council of Medical
the low frequency of p53 mutations in HPV associated Research (ICMR). Conflict of Interest: None declared.
cervical cancers. Transmission mechanisms of these Ethical approval: Obtained from the Ethical Committee
strains of HR HPV from mouth to other organs in the same of the North Bengal Medical College and accepted by
subject are not well documented. But substance addiction ICMR (Attached below). Informed Consent: Obtained
leading to any form of cancer caused by infective HPV from all participants
might pose a serious medical problem.
In the present study, family history of cancer of 21 References
respondents was positive. A significant association (5%
level) between the area of residence and the presence Bayo S, Bosch FX, De Sanjose S, et al (2002). Risk factors of
of family history of cancer was observed. The urban invasive cervical cancer in Mali. Int J Epidemiol, 31, 202-9.
Biswas LN, Manna B, Maiti P, et al (1997). Sexual risk factors for
population showed a higher percentage (14%) as
cervical cancer among rural Indian women : a case-control
compared to the rural population. Previous testing of study. Int J Epidemiol, 26,491-5.
cervical cancer was reported only by one woman and the Chen PCH, Pan CC, Kuo C, et al (2006). Risk of oral
result was found to be negative. No medical treatment nonmalignant lesions associated with human papilloma
was required / received for cervical cancer. Occurrence virus infection, betel quid chewing and cigarette smoking
of white discharge was reported by 15.3% respondents of in Taiwan, Arch Pathol Lab Med, 130, 57-61.
our study sample. However this could not be associated Dasgupta A, Naskar NN, Ram R, et al (2002). A community
with area of residence. based study on the prevalence of risk factors of cancer cervix
Data on awareness was not very encouraging, although in married women of a rural area of West Bengal. Ind J Com
Med, 27, 35-8.
87% women were aware of the term cancer, and few
Hopman AH, Smedts F, Dignef W et al (2004). Transition of
about cervical cancer. An illustrated demonstration in high grade cervical intraepithelial neoplasia to microinvasive
Bengali language (locally spoken) made them curious carcinoma is characterized by integration of HPV 16/18 and
about the cause and consequences, signs and symptoms numerical chromosome abnormalities. J Pathol, 202, 23-33.
of cancer. The section of population aware of cervical Lowy DR, Solomon D, Hildeshein A, et al (2008). Human
cancer came to know about this disease through friends Papiloma Virus Infection and the primary and secondary
or media like radio and television (Table 3). However, it prevention of cervical cancer. Cancer, 113, 1980-93.
was observed that 96.4% of the population were unaware Mitra S (2009). Study of the risk factors for cancer cervix in a
of the causes of the disease, 93.7% were not aware of speciality hospital in Kolkata. J Com Med, 5, 1-5.
Roy B, Tang TS (2008). Cervical cancer screening in Kolkata,
the signs and symptoms and 96.4% of the prevention of
India: Beliefs and predictors of cervical cancer screening
cervical cancer. 90.5% were unaware of the Pap test as among women attending a women’s health screening in
a screening procedure although 84.6% were willing to Kolkata, India. J Cancer Edu, 23, 253-9.
undergo the test as they felt it would benefit them in the Scheffner M, Werness BA, Huibregtse JM, et al (1990). The E6
long run. This is in agreement with a study conducted in oncoprotein encoded by human papilloma virus types 16
Kolkata (Roy and Tang, 2008). In our study 85.5% of the and 18 promotes the degradation of p53. Cell, 63, 1129-36.
population had not heard of the HPV vaccine before but Thomas S, Brennan J, Martel G, et al (1994). Mutations in the
almost all were willing to make use of it. conserved regions of p53 are infrequent in Betel associated
Given this overall acute lack of awareness, a significant oral cancers from Papua New Guinea. Cancer Research,
54, 3588-93.
association was seen between the level of education and
Varghese C, Amma N S, Chitrathara K, et al (1999). Risk factors
their awareness of the disease only in the urban areas for cervical dysplasia in Kerala, India. Bull the WHO, 77,
. Those who had received higher education had greater 281-3.
knowledge of the disease and this was evident among Yasmeen J, Qurieshi MA, Manzoor NA, et al (2010). Community
the urban women. This emphasizes the importance of based screening of cervical cancer in a low prevalence area
education in generating awareness among the population at of India: a cross sectional study. APJCP, 11, 231-4.
large. On the other hand, such an association is completely
absent in a rural area inhabited by relatively poor people.
This difference in KAP between rural and urban residents
needs deeper probe. Therefore, awareness campaigns,
especially in rural areas, need a major reorientation so that
fruits of education is realised by them more effectively.
Larger scale follow-up surveys are needed to focus on
1096 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012