|GYNAECOLOGICAL - ORIGINAL ARTICLE
|Year : 2011 | Volume
| Issue : 4 | Page : 477-482
Perceptions and concerns of women undergoing Pap smear examination in a tertiary care hospital of India
A Tiwari1, J Kishore1, A Tiwari2
1 Department of Community Medicine, Maulana Azad Medical College, Delhi, India
2 Department of Gynecology-Obstetrics, Kasturba Hospital, Delhi, India
|Date of Web Publication||25-Jan-2012|
Department of Community Medicine, Maulana Azad Medical College, Delhi
Source of Support: None, Conflict of Interest: None
Background: Cervical cancer is one of the major causes of deaths due to cancer among women in India. Pap smear is one of the best methods to detect early changes in cervix. However, there is lack of data on awareness level of women about Pap smear and various risk factors for cervical cancer. Objectives: To study the awareness about various risk factors for cervical cancer, health-seeking behavior and hygienic practices among women and to assess the distress experienced by these women before the Pap smear examination. Materials and Methods: This cross-sectional study was carried out on women coming for a Pap smear examination in a tertiary teaching hospital in New Delhi. A pretested interview schedule was used to get information after obtaining their informed consent. Results: Fifty-seven percent stated that they did not consult a doctor when they noticed the symptoms the first time. Sixty-one percent did not know what a cervical cancer is and a same percentage of women did not know what a Pap smear examination was. Older age group, Muslim and literate women had higher number of abnormal Pap smear results. Women who reported being stressed in their lives had higher number of abnormal smears as compared to women who claimed to lead a stress free life. Poor hygienic practices among these women from urban areas were also associated with abnormal Pap smear results. Conclusion: The study concluded that factors such as poor awareness, shyness, poor hygiene, and old age could be responsible for abnormal Pap smears and this needs special attention in cancer prevention activities of the government.
Keywords: Cervical cancer, hygienic practices, perception, Pap smear examination
|How to cite this article:|
Tiwari A, Kishore J, Tiwari A. Perceptions and concerns of women undergoing Pap smear examination in a tertiary care hospital of India. Indian J Cancer 2011;48:477-82
|How to cite this URL:|
Tiwari A, Kishore J, Tiwari A. Perceptions and concerns of women undergoing Pap smear examination in a tertiary care hospital of India. Indian J Cancer [serial online] 2011 [cited 2020 Jun 4];48:477-82. Available from: http://www.indianjcancer.com/text.asp?2011/48/4/477/92261
| » Introduction|| |
Cervical and breast cancers are commonest among female cancers and responsible for 50% of all cancer deaths in India. , Currently there are 70,000 cases of cervical cancer in the country (Cancer patients Aid Association). According to SEER (Surveillance, Epidemiology and End Results Program), invasive cervical cancer incidence is 9 and cancer mortality is 2.8 per 100,000 persons.  However, they have very good prognosis if detected and treated early. Pap smear More Details is an outpatient diagnostic tool for diagnosis of early cancer cervix. It can detect 90% of cervical cancers and 75% endometrial cancers.  Early cancer detection is also a part of Indian national cancer control program which aims at early detection thereby saving several lives. The study aimed to understand the association between known risk factors for cervical cancer and Pap smear results, health-seeking behavior and hygienic practices among the women and to assess the distress experienced by these women before the examination. The purpose of the research was also to gain understanding of the knowledge among Indian women regarding cervical cancer and the methods available for its early detection such as Pap smear, especially among those who are living in urban areas and coming to tertiary health care center for their health care needs.
| » Materials and Methods|| |
A cross-sectional study was conducted in a tertiary teaching hospital in New Delhi where gynecology OPD attendance is above 250 patients everyday. These women presented with vaginal discharge, pruritis vulvae, various sexually transmitted diseases (including Condylomata acuminata and Herpes) and also with, postcoital bleeding, leukoplakia of cervix and vagina and carcinoma in situ. One hundred women were selected from the OPD by systematic sampling technique on one particular day of the week over a span of 3 months (November 2007-January 2008). The selected women were those who had been advised Pap smear examination by a gynecologist.
A pretested interview schedule was used to get the information from patients. A prior written informed consent was obtained from the patients. Questions asked were pertaining to demography, perception about cervical cancer and methods of detection, apprehension felt before examination, hygienic practices and various known risk factors for cervical cancer. Reports of Pap smear examination were made by the pathologist.
Statistical analysis was carried out with the help of Epi - Info WHO software. Simple proportions were calculated and comparisons were made to understand the association between abnormal Pap smear results and the concerned factors. A significant difference was accepted if there was less than 5% error.
| » Results|| |
The study group comprised of women mostly in the age group 20-30 years (44%). Most of the women interviewed were second or third gravida (40%). Literacy rate (at least 5 years of schooling) was 63%. Majority of the women (82%) was unemployed. Most of the women belonged to nuclear families (54%) and number of members per family were in the range of 6-10 (50%). Seventy-two percent of women were living in urban areas. More than 50% of women belonged to the upper middle class (57%). Twenty-two percent women reported as having a consanguineous marriage. The commonest symptom among women was vaginal discharge (42%). After noting their symptoms the first time, 57% did not consult a doctor but either ignored the symptoms (56%), tried a home remedy (self-treatment; 26%) or consulted a local practitioner such as Hakim or Moulvi or Pundit or Faith Healer (18%). The time elapsed between detection of symptoms and visit to the doctor was generally 1-3 months. Infection (26%) was perceived as the main factor responsible for the symptoms, followed by the perception that there is a problem in their diet (21%). Fifty-three percent of the women reported being aware of genital tract malignancies. Awareness was mostly by word of mouth, through a relative or a friend. Sixty-one percent did not know what a cervical cancer is and a same percentage of women did not know what a Pap smear exam is. Out of those who claimed to know of any method of detection, only three out of eight (<50%) answered as Pap smear. Sixty-eight percent of the women did not know that getting a Pap smear examination would lead to early detection of disease. Eighty percent of women had no knowledge of any Government Program for early detection of cancer. Only 10% of women, who had got a Pap smear examination done earlier, came for a repeat exam as a follow-up.
Out of the 100 Pap smear examinations, 40% had some abnormal findings such as atypical squamous cells, metaplasia (7.5%), mild inflammation (70%), mild dysplasia (2.5%) and moderate dysplasia (2.5%) [Table 1].
Women more than 34 years of age, literate and those belonging to the Muslim community had a higher proportion of abnormal smears as compared to women who were <34 years, illiterate and Hindu. But the difference was not found to be significant between the groups [Table 2].
|Table 2: Association of Pap smear results with population characteristics|
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Women using cloth, especially old washed cloth had higher proportion of abnormal smears as compared to women who used sanitary napkins and a new cloth during menstruation. But the difference between these groups was not found to be significant (P-values were 0.64 and 0.63, respectively). Higher number of abnormal results was seen in women who did not wash their genitalia after urination and sexual intercourse. Women who did not wash their genitalia during bath had a higher number of abnormal smears. The difference was significant in this case. (P=0.02) [Table 3].
|Table 3: Association of Pap smear results with hygiene practices among women coming for Pap smear examination|
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The data pertaining to Pap smear results was also compared to known risk factors for cervical cancer such as: Early onset of sexual activity, circumcision, use of douches, smoking or exposure to second hand smoke and stress. Equal number of abnormal Pap smears was found between women who had early onset of sexual activity and women who did not. The difference was not significant in present study (P=0.962). Higher proportion of abnormal Pap smears was seen among women who had circumcised partners than in women without circumcised partners. The difference was not found to be significant (P=0.554). Half of the women who used douches had an abnormal Pap smear. Half of the women who were exposed to smoke had abnormal results but as compared to women who were not exposed to smoke, the difference was not significant (P=0.41).
Women who reported being stressed in their lives had higher number of abnormal smears as compared to women who claimed to lead a stress-free life. The difference was significant (P=0.01) [Table 4].
|Table 4: Association between known risk factors for cervical cancer and Pap smear results|
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Out of 45 women who reported being anxious, 19 (42.2%) had an abnormal Pap smear. Out of eight women who felt ashamed before the exam, six (75%) had an abnormal Pap smear and out of 15 women who expressed fear of cancer, five (33.3%) had an abnormal Pap smear [Table 5].
|Table 5: Association between state of mind before the exam and Pap smear results|
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| » Discussion|| |
The Pap smear originally developed by George Papanicolaou in the 1930s to detect cervical cancer, is one of the most effective screening tools in the world. However, awareness of this test in general population is low. In the present study, out of 40 cases of abnormal Pap smears, only five (12.5%) cases could be classified as ones which were at risk of carcinoma in situ. Similar findings were reported in a retrospective analysis of a prospectively collected database of females undergoing colposcopy in an urban clinic, and it was found that only 15% cases with abnormal Pap smears had high-grade CIN. 
According to the present study the early age of first sexual intercourse did not prove to be a significant factor in causing abnormal Pap smears. However, in another observational study conducted on patients referred to a colposcopy clinic over a decade, 66.7% of the adolescents who had sexual intercourse before the age of 16 years had moderate or severe dyskaryosis in their Pap smear analysis.  This difference could be due to the study design and a small sample taken in the present study.
In our study, 50% of the people who consumed tobacco/smoked had abnormal Pap smears. Similar observation was made in another study conducted on women with oncogenic HPV and minimally abnormal Pap smears, which showed that those who smoked were up to three times more likely to be diagnosed with CIN III than nonsmokers.  Similarly, exposure to second-hand smoke has also been shown to increase the risk of cervical cancer. In a study conducted in Kaohsiung County, Taiwan, women who were exposed to cigarette smoke had a greater risk for developing CIN II.  This highlights the need to educate and promote awareness among women about the role of smoking in promoting cervical cancer.
We also studied the relation between the use of douches and Pap smear results, and found that 50% of women who used douches had abnormal Pap smear results. In a study conducted among Chinese women, frequent vaginal douching was found to be a correlate with HPV prevalence, the main cause of cervical cancer.  Another aspect which was studied was the effect of stress on Pap smear results and it was noted that those women who claimed to experience stress in their daily lives due to some reasons such as disharmony in family, had a higher number of abnormal Pap smear results and the difference was significant (P=0.01). However, a different observation was obtained in another study conducted to understand the effect of psychosocial factors on the grade of CIN, which claimed no correlation between the two. 
Presently it is believed that circumcision is associated with lesser risk of infection of the cervix and thus lesser number of abnormal Pap smears. But present study observed a higher rate of abnormal Pap smears among women whose partners were circumscribed. Similarly a study conducted in the Muslim Community showed that 67% of these women presented in Stages II to IV and only 12% presented early at stages 0 or I. This reflects a greater severity of disease in this community as far as the number of cases detected and the grade of abnormal Pap smear is concerned. Such an observation could also be due to late reporting or poor health seeking behavior among women in this community.
The mental status of women coming for Pap smear examination was also studied. Most of women were found to be anxious, few reported feeling ashamed and a few others expressed fear regarding their diagnosis of cancer. Seventy-five percent of those who felt shy had abnormal Pap smear results. This finding indicates that women who have a submissive and shy nature might be delaying seeking help for their problems. It has been demonstrated that psychosocial factors such as stress, pessimism and shyness quality may play a role in HPV-mediated cervical cancer in HIV-positive patients.  Thus such groups of women should be specifically targeted. All women coming for screening should be counseled before and after the procedure, to eliminate feelings of fear, shame thereby relieving them of their stresses and improving their quality of life.
While evaluating the demographic factors, older age group had a higher rate of abnormal Pap smears. While assessing the educational status of these women we found that higher number of abnormal Pap smears was seen in women who were literate. This may be due to their higher health-seeking behavior. This also reflects that while educating women regarding Pap smear examination, our focus should not only be illiterate women but also literate women living in urban areas. Another study conducted in this regard concluded that knowledge, resources and presence of a regular medical doctor were important factors associated with increased rates of preventive screening. 
A higher rate of abnormal Pap smear was observed among women using cloth especially old washed cloth than sanitary napkin. Fifty percent of women who did not wash their genitalia after urination had abnormal Pap smears. Similarly higher rates of abnormal smears were found among women who did not wash their genitalia after sexual intercourse. It was noted that almost 67% of women who did not wash their genitalia during bath had abnormal Pap smear results. Thus special importance should be laid on these practices while educating these women regarding Pap smear and cervical cancer as simple measures taken to modify these practices will go a long way in preventing abnormal Pap smears.
A striking observation was that even in women coming for check-ups in the presence of symptoms, knowledge about screening techniques in a major teaching hospital was poor. This could be due to inadequate devotion of time by consulting doctors to their patients. There is a need to understand why doctors and health care workers are not devoting enough time and effort to educate the women coming for examination. This could be due to tremendous work load in the tertiary care hospitals or the lack of infrastructure and resources which also prevents health professionals from reaching out to women in far flung areas. Most of the women stated that their reason for not visiting the doctor was ignorance. This highlights the need to educate the people for very basic things such as seeking health care from a doctor in case of presence of signs and symptoms of disease.
Apparently, the lack of health education makes it difficult for the health personnel to implement their screening program such as a yearly Pap smear examination as per international guidelines. Thus, we need to target the concerned population with basic knowledge first before we proceed with early detection and prevention of cervical cancer.
Not only doctors but nurses, auxiliary nurses, midwives and other health care workers should be trained to reach out to these women so as to improve their knowledge and awareness regarding Pap smear examination. All women who come for screening should be educated regarding the benefits and implications of Pap smear examination which will not only improve knowledge among these women but will also improve compliance regarding follow up. For information, education and communication various methods such as posters, role play and audiovisual films can be shown in outpatient departments and mass media may also be involved to further promote this cause. Another point to be noted is that health related messages targeting smokers may misfire in case of individuals who do not perceive themselves as smokers but are nonetheless at risk for smoking-related consequences and increased use.
The study concluded that there are significant worries among women coming for Pap smear examination which were focused on fear of developing cancer and procedural discomfort. This data will be useful in providing patients focused education and counseling thereby improving clinical practices.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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