Original Article 21

DOI: https://doi.org/10.62143/9sbdcg94

Knowledge, Attitude and Practice regarding Cervical Cancer

Screening among Married Women Attending in a Tertiary Hospital
Biva Shrestha1, Durga Subedi2, Krishna Devi Shrestha3*
Author(s) Affiliation
1
Man Mohan Memorial Medical College and Teaching Hospital, Kathmandu
2
Department of Women’s Health & Development, Maharajgunj Nursing Campus
3
Department of Adult Health Nursing, Maharajgunj Nursing Campus
*Corresponding Author: Krishna_kr06@yahoo.com

ABSTRACT
Introduction: Globally, cervical cancer is a serious burden on reproductive health of women
which is preventable through early detection. The objective of this study was to find out the
knowledge, attitude, and practice regarding cervical cancer screening among the married
women.

Methods: Descriptive cross-sectional research was conducted in Tribhuvan University Teaching

Hospital (TUTH). Non- probability purposive sampling technique was adopted. Data was
collected using a structured interview questionnaire among 195 respondents from Gynae OPD.
Data analysis was done by descriptive and inferential statistics.

Results: More than two third of the respondents (67.7%) had adequate knowledge regarding
cervical cancer screening, 60% had inadequate practice and all the respondents had positive
attitudes of screening. Most of the respondents (86.2%) said that having multiple sexual partner
followed by sexually transmitted infection (84.1%) & multiparty (75.4%) were the causes and
84.6% stated that increased vaginal discharge, post-menopausal bleeding (79.5%) and irregular
menstruation (67.2%) were the symptoms of cervical cancer. Almost all respondents (97.4%)
said that early screening as preventive measures. The level of knowledge tends to be associated
with age of the respondents and their socio-economic status (p=<0.05) whereas in practice,
there was no association between selected variables.

Conclusion: Although respondents had adequate knowledge and positive attitude on cervical
cancer and its screening, less than half of the respondents only practice Pap smear test as
screening. The level of knowledge tends to be significantly associated with age of the respondents
and their socio-economic status.

Keywords: Attitude, Cervical Cancer, Knowledge, Practice, Screening

INTRODUCTION frequent cancer among women2 and is emerging

as the leading cause of death caused by poor
Cancer of the cervix is a serious burden on the
health seeking behavior, poor access to screening
reproductive health of women world-wide.1It is
and treatment services.3 Cervical cancer has very
the fourth most common cancer globally among
poor prognosis as 80% of them are diagnosed
women with an estimated 570,000 new cases in
at an advanced clinical stage. Nepal has one of
2018 representing 6.6% of all female cancers.
the highest incidences and mortality rates in
Approximately 90% of deaths in low- and middle-
Southeast Asian region.4
income countries are due to cervical cancer.
In Nepal, cervical cancer ranks as the 1st most

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22 Biva Shrestha, et al.,

National Guideline for Cervical Cancer Screening with selected variables among married women.
and Prevention program in Nepal had the objective Non- probability purposive sampling technique
to screen at least 50% of women aged 30 to 60 was adopted to collect data among 195
years to reduce 10% cervical cancer burden respondents attending at Gynae OPD of TUTH
within 5years 5. Majority (about 95%) of women after obtaining Ethical approval (Ref. 97 (6-11)E2
still never have done cervical cancer screening. 076/077) from Institutional Review Committee of
Among them, proportion of unscreened women Institute of Medicine, Tribhuvan University. After
is much higher among the illiterate women and taking administrative written permission from
living in the rural region 6. Cervical cancer is one of TUTH, written consent was obtained from each
the preventable cancers that can be prevented by respondent prior to data collection. Voluntary
early detection and treatment 7. Cervical cancer participation and withdrawal from the study at
screening services coverage rate is very low (2.4%) any time without giving reason was considered.
in Nepal. The low coverage may be associated to Anonymity was maintained during data collection
a variety of factors, including socio-economic by giving code numbers, Confidentiality was
and cultural barriers. Studies have documented maintained by keeping the information for study
poverty, lack of knowledge, myths, lack of time, purpose only and privacy was maintained by
asymptomatic condition, support from husbands collecting data in a separate area for each woman.
& families, and lack of routine screening as major
Data was collected using a structured
obstacles to screening in Nepal. Moreover, lack
interview questionnaire from 1st September to
of privacy during screening, embarrassment
27th September 2019. A structured interview
among women, and low importance given to
schedule was prepared by the researcher herself
women’s health issues have also been cited as
based on research objective, reviewing the
factors contributing to the reluctance of women
related literature, consultation, and validation of
to access cervical cancer screening services in
instrument with research expert. The instrument
low-income countries 8.
consisted of four parts; Part I: Questions
Prevention and control of cervical cancer related to Socio-demographic variables, Part II:
depends on awareness about disease, screening Questions related to knowledge about cervical
procedures, and preventive measures 9..Although cancer screening, Part III: Questions related to
numerous studies have been conducted practice on cervical cancer screening, Part IV:
to evaluate the awareness level of cervical Questions related to attitude towards cervical
cancer, contributing and risk factors, cervical cancer screening. For each correct response
screening test, the attitude towards it as well as was given 1 score and 0 for incorrect response
the preventative practices, the effectiveness of and additional score was given for each correct
cervical cancer screening depend to a great extent multiple response. Pre-testing was done in
on the level of awareness10.. Moreover, despite 10% of the respondents attending Gynae OPD
availability of HPV vaccines, cervical cancer of Manamohan Memorial Medical College and
continues to be a major public health problem. Teaching Hospital. Necessary modification was
Hence, knowledge, attitude and practice towards done based on the feedback of pretest. Data
cervical cancer screening should be studied and was edited, coded, and entered into IBM SPSS
comprehended profoundly 11. version 16 program. Data was analyzed by using
descriptive statistics (as frequency, percentage,
METHODS mean and standard deviation) and inferential
Descriptive cross-sectional research design was statistical test (chi-square test) was used to
adopted to assess the level of knowledge and to measure the association between variables.
measure the association of level of knowledge

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 Knowledge, Attitude and Practice regarding Cervical Cancer... 23

RESULTS Table 1 shows that nearly one third of respondents

(32.8%) were between the age of 40 to 49 years.
Table 1: Socio-demographic Characteristics of The mean age was 37.44±9.57 years. Among
the Respondents (n=195) them most of the respondents (86.7%) were able
to read and write. Half of the respondents (50.9)
Characteristics Number Percentage
had University level education. Majority of the
respondents (80.0%) were Hindus and 54.9 were
Age in completed years
Brahmin/Chettri followed by Janajati (36.9%).
20-29 47 24.1 Table 2: Respondents’ Knowledge on Preventive
Measures of Cervical Cancer (n=195)
30-39 62 31.8

40-49 64 32.8 Variables Number Percentage

50-59 22 11.3
Preventive
Measures*
Mean Age ±SD;
37.44±9.57
Early screening 190 97.4
Education status
Treating STI 164 84.1
Read and write 169 86.7

Cannot read and write 26 13.3 Practice safe sex 136 69.7

Education level(n=169) HPV vaccination 29 14.8

Basic/Elementary 47 27.8
Knowledge of 154 79.0
screening test
Secondary 36 21.3

University level 86 50.9 Screening tests*

(n=154)
Religion
Pap smear 154 100.0
Hinduism 156 80.1
VIA 18 11.6
Buddhism 27 13.8

Christianity 10 5.1 HPV test 2 1.2

Islam 2 1.0
*Multiple Responses

Ethnicity Table 2 shows that cent percent respondents

said that having knowledge regarding cervical
Bhrahmin/Chettri 107 54.9
cancer can prevent cervical cancer. Almost all
Janajati 72 36.9 respondent (97.4%) said that early screening
as a preventive measure followed by treating
Dalit 13 6.7 STI (84.1%) and only 14.8% answered that HPV
vaccination can prevent cervical cancer. The
Muslim 2 1
majority of the respondents (79%) had knowledge
Madhesi 1 0.5 of screening test.

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24 Biva Shrestha, et al.,

Table 3: Respondents’ Practice on Cervical Table 3 shows that less than half of the
Cancer Screening (n=195) respondents (45.6%) had cervical cancer
screening. Among them 75.3% respondents used
Variables Number Percentage to screen yearly for cervical cancer and 14.7%
respondents screen every 3 yearly, and 40.4%
Screened for cervical 89 45.6 were screened between 30-39 years. Similarly,
cancer almost all respondents (96.6%) had screened
within three years as per health personnel advice
Frequency of screening
(n=89) (78.6%) . Among the respondents who were not
screened for cervical cancer were due to feeling
Yearly 67 75.3 of being not at risk (54.8%) followed by lack of
awareness (33%).
Two yearly 6 6.7
Table 4: Respondents’ Level of Knowledge and
Three yearly 13 14.7
Practice on Cervical Cancer Screening (n=195)
Four yearly 3 3.3
Levels Number Percentage
Age of Screening (n=89)
Knowledge
20-29 17 19.1

30-39 36 40.4 Adequate Level ≥ 50% 132 67.7

40-49 32 36.0 Inadequate Level < 50% 63 32.3

50-59 4 4.5
Practice
Time of last screening
(n=89) Adequate Level ≥ 50% 78 40

Within 3 years 86 96.6 Inadequate Level < 50% 117 60

Before 3yrs 3 3.4
Table 4 reveals that two third of the respondents
Reason for screening
(n=89) (67.7%) had adequate level of knowledge and
more than half of the respondent (60%) had
Health personnel advice 70 78.6 inadequate practice of screening.
Self-initiative 19 21.4 Table 5 reflects almost all respondents (92.8%)
Attend to seek care strongly agreed that cervical cancer screening is
(n=195) very important whereas most of all respondents
(90.3%) strongly disagreed in the statement
Go to health center 123 63.1 cervical cancer screening is recommended only
Consult doctor 72 36.9 for sexually active women. Thirty six percent
respondents agreed that women having sexually
Reason for not transmitted disease are more prone to have
screening (n=106) cervical cancer. Majority of the respondents
Feeling of being not at risk 58 54.8 (76.9%) strongly disagreed that cervical
cancer screening is not recommended for HPV
Lack of awareness 35 33.0 vaccinated women. Most of the respondents
(89.7%) strongly agreed that cervical cancer can
Not recommended 13 12.2
be managed after its diagnosis in the early stage.

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 Knowledge, Attitude and Practice regarding Cervical Cancer... 25

Table 5: Respondents’ Attitude towards Cervical Cancer Screening (n=195)

Statements Strongly Disagree Neutral Agree Strongly

Disagree Agree

No. (%) No. (%) No. (%) No. (%) No. (%)

Cervical cancer is life threatening 11 (5.6) 37 (19) 31 (15.9) 55(28.2) 61 (31.3)

disease

Women having sexually transmitted 9 (4.6) 27(13.8) 24 (12.3) 72 (36.9) 63(32.4)

disease are more prone to have cervical
cancer*

Cervical cancer screening is very 0 (0.0) 0 (0.0) 2 (1) 12 (6.2) 181 (92.8)
important

Cervical cancer can be managed after 0 (0.0) 3 (1.5) 5 (2.6) 12 (6.2) 175 (89.7)
its diagnosis in the early stage.

Cervical cancer screening is suggested 1 (0.5) 14 (7.2) 63 (32.3) 21 (10.8) 96 (49.2)

for all gynecological cancer*

All women above 20 years should have 3 (1.5) 3 (1.5) 17 (8.7) 58 (29.8) 114 (58.5)
done cervical screening

Cervical cancer screening is not 150 (76.9) 16 (8.3) 25 (12.8) 2 (1) 2 (1)
recommended for HPV vaccinated
women. *

Cervical cancer screening is 176 (90.3) 11 (5.6) 4 (2.1) 3 (1.5) 1 (0.5)

recommended only for sexually active
women*

Cervical cancer screening is not 175 (89.8) 9 (4.6) 7 (3.6) 2 (1) 2 (1)
needed for women above 65 years. *

Cervical cancer screening is a painful 77 (39.5) 16 (8.2) 98 (50.3) 4 (2.0) 0 (0.0)

procedure*

Cervical cancer is a time-consuming 84 (43.1) 13 (6.7) 97 (49.7) 1 (0.5) 0 (0.0)

procedure*

If proper information and chance 5 (2.5) 2 (1.0) 7 (3.6) 28 (14.4) 153 (78.5)
is provided, I will be prepared to
participate in cervical cancer screening

*Negative Responses

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26 Biva Shrestha, et al.,

Table 6: Association of Level of Knowledge regarding Cervical Cancer Screening with Selected Variables (n=195)

Variables Level of Knowledge

Adequate Inadequate χ2Value p-value
No.( %) No.( %)
Age group (in years)
Below 40 67(60.4) 44(39.6) 6.334 0.012*

40 and above 65(77.4) 19(22.6)

Educational Status
Basic Level 33(70.2) 14(29.8) 0.699 0.705

Secondary Level 25(69.4) 11(30.6)

Higher Secondary Level 65(75.6) 21(24.4)
Religion

Hinduism 102(65.4) 54(34.6) 1.899 0.168

Others (Buddhism, Christianity, Islam) 30(76.9) 9(23.1)
Ethnicity
Brahmin/Chettri 68(67.5) 39(32.5) 6.557 1.000**
Janajati 49(68.1) 23(31.9)
Others (Dalit, Muslim, Madhesi) 12(66.7) 4(33.3)
Duration of Marriage
Less than 20 years 88(66.7) 44(33.3) 0.197 0.658
20 years and above 44(69.8) 19(30.2)
Socio economic Status
Enough up to 12 months 51(58.1) 37(41.9) 6.954 0.008*
More than 12 months 81(75.7) 26(24.3)
Note: *Significance level at ≤ 0.05 at 95% confidence interval **Fisher Exact Test

Table 6 shows that there was statistically The present study shows that 86.2% had
significant association between level of knowledge on multiple sexual partners, STI
knowledge and age with p value 0.012 and socio- (84.1%) and Multiparity (75.4%) and sex at early
economic status with p value 0.008 but other age (70.6%) as the causes of cervical cancer The
variable shows insignificant association. findings were inconsistent with a study done by
Chaudhari, Dutt, Goswami, Roychowdhary14
DISCUSSION where very few knew about other factors like
The findings of the study revealed that all the multiple sexual partner 20% as risk factor.
respondents had heard about cervical cancer. Regarding sign and symptom of cervical cancer,
More than half of the respondents (67.7%) had majority of the respondents (84.6%) stated that
adequate knowledge regarding cervical cancer increased vaginal discharge, post-menopausal
screening and 60% had inadequate practice. bleeding (79.5%) and irregular menstruation
This finding is not supported by the literature as (67.2%) were the symptoms whereas only 33.3%
cited in Singh et al12 which showed 32.7% of the respondents were aware of pain during sexual
respondents had adequate knowledge and the intercourse is the symptoms of cervical cancer.
practice was supported by the study conducted These findings are consistent with study done
by Shrestha and Dhakal13in which 72.2% had by Shrestha, Sapkota in Bharatpur, Chitwan15 in
inadequate practice. which 71.3% agreed increased vaginal discharge,

Journal of Nursing Education of Nepal/ 2023 Vol. 14

 Knowledge, Attitude and Practice regarding Cervical Cancer... 27

and 60.7% stated post-menopausal bleeding screening but less than half of the respondents
as symptoms of cervical cancer. Almost all only practice the cervical cancer screening.
respondent (97.4%) said that early screening The level of knowledge tends to be associated
as a preventive measure followed by treating with age of the respondents and their socio-
STI (84.1%), practicing safe sex (69.7%)and economic status whereas in practice, there was
only 14.8% answered that HPV vaccination can no association between selected variables.
prevent cervical cancer. About 80% respondent
had knowledge on screening test. This finding CONFLICT OF INTEREST: NONE
is consistent with the study conducted by ACKNOWLEDGEMENT
Shrestha16 which showed that Pap smear (68.8%)
as the screening test for cervical cancer. We would like to express our gratitude to hospital
director and nursing director of the TUTH for
The study revealed that less than half of the granting permission to collect data. Our heartfelt
respondents (45.6%) had cervical cancer thanks go to all participants for giving time to
screening practice. Among them 40.4% participate in the study.
respondents had screened in 30-39 years and
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