Introduction

Cervical cancer is the most prevalent cancer among women in developing countries and one of the most common causes of cancer-related death.12 Cancer of the uterine cervix is the second most common cancer in Indian women. The age-standardized incidence of invasive cervical cancer in India is 27/100,000 women and mortality is 15.2/100,000 women. Cancer cervix accounts for 10% of cancer-related mortality in India.34 As per GLOBOCAN (2018), an estimated 96,922 individuals developed cervical cancer and 60,0678 died of cervical cancer in India.5 India ranks highest in the age-standardized incidence of cervical cancer in South Asia at 22 (19.2 in Bangladesh and 13 in Sri Lanka).126

Chronic persistent high-risk genotype human papillomavirus (HPV) infection is implicated with 99.7% of cervical cancer worldwide.7 Other risk factors contributing to cervical carcinogenesis are poor sexual habits, high parity, early age of sexual intercourse and pregnancy, sexually transmitted infections (STIs), poor genital hygiene, and smoking.8

Cervical cancer is a slow-growing malignant neoplasm, and symptoms appear when the disease has advanced. Cancer cervix has premalignant lesions, and it takes 10 to 20 years for these lesions to develop malignancy. Early detection of these premalignant lesions, through screening and their appropriate treatment, can significantly help in the reduction of cervical cancer incidence and associated mortality.9 Cervical cytology in the form of Pap smear test has shown a significant reduction in mortality in developed countries.10 Visual inspection after application of 3 to 5% acetic acid (visual inspection with acetic acid [VIA]) and Lugol’s iodine (visual inspection with Lugol’s iodine [VILI]) are alternative screening methods which are cost-effective in resource-poor settings.11 There is evidence for reduction of cervical cancer-associated mortality with usage of VIA through population-based trial.1213

Utilization of screening in India is just 2.6 to 5%, mostly being opportunistic.14 Several factors have been implicated with poor utilization of cervical cancer screening. The Ministry of Health, Government of India, had launched a framework for noncommunicable disease screening in 2016 for oral, breast, and cervical cancers. These guidelines have designated subcenter as the first point of screening for cervical cancer.15

To a certain extent, it is the women’s awareness level for health care that determines her health-seeking behavior. Women may demand screening if they are aware of its importance.12 The current study aims to assess the awareness of cervical cancer and its prevention among women attending a community health center (CHC) in a rural setting in Uttar Pradesh and to determine the bio-socio-demographic characteristics that are associated with satisfactory awareness.

Materials and Methods

A descriptive cross-sectional study was performed among women attending CHC of Ghaziabad district from Uttar Pradesh, India. All women aged ≥30 years who were never diagnosed or treated for cervical cancer and have never undergone cervical screening were enrolled between April and October 2017. The sample size was calculated based on the assumption that 50% of women will have an optimal knowledge score (> 50%). Thus, the required sample size to estimate the proportion of women with optimum knowledge score with 95% confidence interval (CI) of 50% (95% CI: 45–55%) was 384. The final sample size with 10% nonresponse rate was 422. Purposive sampling was used to enroll all women who were attending the gynecology outpatient department at the health center and met eligibility criteria. A total of 1088 women were enrolled in the study period.

A semistructured pretested questionnaire was used which had four parts to gather information regarding the (1) bio-socio-demographic characteristics; (2) sexual practices and personal habits of the participant as well her husband; (3) knowledge about symptoms, risk factors, and prevention of cervical cancer; and (4) source of information for cancer (family, friends, health caregivers, and audio-visual and print media). The sociodemographic details included age, marital status, literacy level, place of residence (rural/urban), occupation of the participant and her husband, and parity. The questions related to sexual practices and personal habits included the number of sexual partners of both the participant and her husband, smoking and alcohol intake habits of both participant and her husband, usage of condom by husband during sexual intercourse, and if the participant was a known case of diabetes mellitus.

Questions related to cervical cancer were (1) if they knew that females can have cancer arising from cervix (yes/no); (2) symptoms of cervical cancer (1 point for at least two correct responses among symptoms such as bleeding per vaginal [p/v] in between periods, postmenopausal [p/v] bleeding, postcoital [p/v] bleeding, and excess foul-smelling vaginal discharge); (3) risk factors of cervical cancer (1 point for at least two correct responses among risk factors for cervical cancer such as multiple sexual partners, young age at the time of the first sexual intercourse, young age at the first childbirth, poor genital hygiene, multiple pregnancies, and STIs); (4) whether cervical cancer can be detected early by screening (1 point for responding yes); (5) name of any test available for screening (1 point for selecting any tests among Pap, VIA, and VILI); and (6) any vaccine is available for prevention of cervical cancer (1 point for responding yes). Each question had a score of 1 point for the correct answer, with a total score of 6. A score of ≤2 was considered poor knowledge and ≥3 was considered satisfactory knowledge.

Finally, participants were asked for the source of information for cervical cancer (multiple responses for family, friends/neighbors, health caregivers, and print or audio-visual media). Pretesting of the questionnaire was done on 10% of the total sample size, and the necessary modifications were made. For assessing socioeconomic status, modified Prasad’s scale based on Consumer Price Index for 2017 was used.16 After interviewing participants, health education regarding cervical cancer was provided.

Results

A total of 1088 eligible women who attended the CHC, Ghaziabad, during the study duration participated in the study.

Discussion

Our study from the northern state of India revealed that majority of the study population had poor knowledge related to cervical cancer and its prevention. Population-based and health facility-based studies from Kerala,14 Tamil Nadu,17 and Andhra Pradesh18 (southern states of India) revealed better knowledge for cervical cancer among rural women. Our study found that although most women (61.8%) knew about cervical cancer as a type of cancer in women, just one-fourth (26.4%) could enumerate two correct symptoms of the disease, and less than one-fourth (23.4%) knew that cervical cancer can be detected early by a screening test. Very few knew about risk factors and HPV vaccination. In contrast, a study from Andhra Pradesh found that nearly two-third knew symptoms, risk factors, and screening methods of cervical cancer.18 A hospital-based study done in Lucknow, Uttar Pradesh,16 was also in line with our findings concerning cervical cancer awareness. These findings may suggest the role of demographic variations in awareness of cervical cancer.

We observed that the major source of awareness for cervical cancer was friends and family, followed by health caregivers, and finally media. Other studies from India observed media1418 and health caregivers17 as the major source of information. The reason why media was not found as a major source of information in our study can be explained by the formative study done by Ganju et al who observed that the reach of mass media in the rural population of Uttar Pradesh is only approximately 20%. They found that irrespective of gender, the reach of mass media is low among nonliterate groups (around 20%). They also observed that women with no education, belonging to scheduled castes/tribes, from households with a poor standard of living, and residing in small villages (≤1000 population) had the least exposure to any mass media (9%) as compared with those with secondary or higher education, belonging to general castes, from households with a high standard of living, and residing in large villages (≥3000 population) (87%).19 This explains the reason why rural illiterate women with poor socioeconomic status, which constituted the majority of our study population, did not report mass media as an important source of information.

In our study, sociodemographic variables of participants such as illiteracy, being a homemaker, poor socioeconomic status, and occupation of the husband as semi-unskilled workers/farmers increased the odds of having poor score for knowledge. Our findings are in line with studies from other states of India.162021

We observed that on unadjusted logistic regression, higher parity (≥3) was statistically significantly associated with poor knowledge for cervical cancer. However, after adjustment, the finding was no longer significant. The study from Andhra Pradesh also supports our finding.18 High parity is itself a risk factor for development of cervical cancer.2223 There is a possibility that these women with high parity may have received awareness of cervical cancer by health caregivers during their ante-/postnatal visits. This emphasizes the role of health caregivers in imparting awareness to all the ante- and postnatal women for cervical cancer, especially for risk factor prevention and early screening.

We observed that participants with a history of multiple sexual contacts or participants who reported their husband having multiple sexual contacts were less likely to have poor knowledge of cervical cancer. Multiple sexual partners of both women and their husband are likely to expose women with HPV and other STIs such as HIV and chlamydia trachomatis, which have been linked with cervical oncogenesis.2425 Such persons who are exposed to multiple sexual contacts are also more likely to attend hospital for STI-related complaints. Therefore, they are likely to have received health education for cervical cancer by caregivers. A study conducted by in Japan observed that that the number of sex partners (> 5) during a women’s lifetime and STI was positively associated with their behavior toward lifetime cervical cancer screening. They discussed that the reason being women who have more sex partners are more likely to visit obstetrics and gynecology clinics to access oral contraceptive pills or STI testing and are likely to be advised for cervical cancer screening.26 These findings suggest that women who themselves, or their partners, indulge in multiple sexual contacts are also likely to be aware of the risk involved in the development of cervical cancer.

We found that preexisting diabetes mellitus also increased the chance of having better knowledge score for cervical cancer. Obesity and diabetes mellitus are known to be an independent risk factor for mortality associated with cervical cancer. Furthermore, they have a familial tendency. Diabetes mellitus, through hormonal actions, may play a role in the pathogenesis of cervical adenocarcinoma.2728 These findings suggest that women who are obese or have diabetes mellitus may have received information about experiences of cervical cancer from their relatives and thus may be more likely to be aware than the general population. A population-based survey done in the US on 11,435 women aged between 18 and 75 years found that overweight and obese women were less likely to be screened for cervical and breast cancers with Pap smears and mammography, even after adjustment for other known barriers to care.29 Thus, there is a doubt whether the awareness on cervical cancer in these women may reflect into early screening. Negative body image, fear of being judged or scolded, and technical difficulties in screening may impede early screening.27

Conclusions

Our study revealed poor knowledge of cervical cancer among women who were attending the secondary health care center from a rural northern state of India. Women’s education status, working status, husband occupation, socioeconomic status, number of sexual partners of women and her husband, and women being known case of diabetes mellitus were found statistically significantly related with a poor score for cervical cancer awareness.

We observed that mass media, which is effective in imparting correct health-related information, was seen as the least important source of information. The quality of information received by population remains doubtful when their main source of information is family and friends. Lack of accurate knowledge on cervical cancer is one of the limiting steps in determining whether a woman will undergo early screening. It is the need of the hour to develop multipronged strategies for imparting health education for cervical cancer and its screening, especially for socially disadvantaged women, which will potentially contribute to improving cervical cancer screening coverage.