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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 63-66
 

Awareness of cervical cancer and Pap smear among nursing staff at a rural tertiary care hospital in Central India


Department of Obstetrics and Gynecology, MGIMS, Sevagram, Maharashtra, India

Date of Web Publication28-Apr-2016

Correspondence Address:
S M Jain
Department of Obstetrics and Gynecology, MGIMS, Sevagram, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.180823

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 » Abstract 

Background: Cancer cervix is the leading cause of cancer deaths in females in developing countries and one in five women suffering from cervical cancer lives in India. Aims: The aim of this study is to determine the awareness about cervical cancer and Pap smear among nurses working in a tertiary care institute. Study Setting and Design: Cross-sectional survey in a tertiary care institute. Materials and Methods: Nurses working at our institute excluding those who have worked or working in the Obstetrics and Gynecology department were provided with a pre-designed questionnaire testing their knowledge about cervical cancer. Results: Approximately, 86% were aware about cancer cervix and 69% were aware of a pre-cancerous stage. 42.3% were not aware of any risk factor and 27.6% were not aware of any symptom of cancer cervix. 86.2% were aware about Pap smear, but only 58.6% were aware that facilities of Pap smear were available at our hospital. Conclusions: Knowledge about cervical cancer and awareness of Pap smear as screening test was inadequate in nursing staff. Awareness programs about cervical cancer and screening are needed to increase awareness for this preventable condition. Recommendation: There is a need to arrange reorientation programs to sensitize nurses and establish cytology clinics to offer facilities for easily accessible and affordable screening.


Keywords: Awareness, cervical cancer, rural


How to cite this article:
Jain S M, Bagde M N, Bagde N D. Awareness of cervical cancer and Pap smear among nursing staff at a rural tertiary care hospital in Central India. Indian J Cancer 2016;53:63-6

How to cite this URL:
Jain S M, Bagde M N, Bagde N D. Awareness of cervical cancer and Pap smear among nursing staff at a rural tertiary care hospital in Central India. Indian J Cancer [serial online] 2016 [cited 2019 Dec 11];53:63-6. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/63/180823



 » Introduction Top


The health of the community is a sensitive indicator of a nation's development.

Cancer cervix is the leading cause of cancer deaths in females in developing countries and 80% of the cases of cervical cancer occur in these areas.[1],[2] It is the second most common malignancy in females [3],[4] and the most common malignancy in females in Eastern Africa, South Central Asia and Melanesia.[5] In the year 2008, there were 529,000 new cases of cervical cancer world-wide and it accounts for 13% of all female cancers in the developing world.[5]

Cancer cervix is the most common cancer among Indian women [3] and approximately, 1/5th-1/6th cases of Cancer cervix world-wide occur in India.[6],[7] Invasive cervical cancer is preceded by a long phase through various stages characterized microscopically as a spectrum of pre-cursor lesions progressing from cellular atypia to various grades of cervical intraepithelial neoplasia.[8],[9],[10] If early diagnosis is made at a pre-cancerous stage, invasive cervical cancer can be prevented. Medical personnel, health-care authorities and women must join hands together to make the screening program a success. Similar study has been reported from India that focused on the awareness of cervical cancer screening in nursing staff at Etwah India. This study reported negative attitudes toward cancer screening among nurses despite being aware of its gravity as a disease.[11] Roy and Tang report a need to increase cervical cancer awareness in the community and development of community based screening programs.[12]

Knowledge about screening is an immense barrier that leads to higher prevalence as well as advanced disease stage at the time of detection.

Nurses form a large proportion of the health-care provider workforce. They act as primary care providers, especially in resource poor and remote areas. They are also a useful link in providing health education.

This survey was undertaken with an intention to address this important health issue by determining the awareness of screening of cervical cancer among nurses at a tertiary care center in rural India.


 » Objectives Top


The objective of this study is to determine the awareness of cervical cancer among nurses involved in patient care excluding those working in Obstetrics and Gynecology Department in a Tertiary Care Institute in Central India.


 » Materials and Methods Top


This is cross-sectional survey carried out in a tertiary care institute in rural India.

Sample size calculation

The target population was 230. We used a 95% confidence level and 5% error with a response rate of 50% the sample size needed was 145. All nurses except those that were either working or had ever worked in the obstetrics and gynecology department were approached and 158 agreed to participate in the survey. Those having a history of cancer cervix were excluded. The final sample size was 157. Approval from the institutional ethics committee was obtained and verbal informed consent for filling the questionnaire was taken before administering the questionnaire. The questionnaire included:

  1. Knowledge about cancer as a disease, cervical cancer and precancerous stage. There were no predetermined criteria and the questions were mostly open-ended reflecting patient's perception of the disease rather than actual theoretical knowledge
  2. Knowledge about high risk factors, symptoms and  Pap smear More Details. For this, we asked the patients if they knew about any high risk factors and noted their responses. Similar open-ended questions were asked for knowledge regarding symptoms and availability of Pap smear. The responses were tabulated and their frequencies were analyzed
  3. The willingness to undergo a Pap test.


Both closed and open-ended questions were used for data collection. The options for closed ended questions included yes/no.

The nurses were interviewed at their respective workplaces by a single data collector and responses noted in a pre-coded data collecting instrument. Post-coding was carried out for open-ended responses. Pretesting was carried out on 10 nurses and the results analyzed. Any short-comings were corrected after consulting all the authors.

Data was analyzed using STATA version 10. Stata SE 10.0 (Stata corp Texas 77845, USA) Only descriptive summary statistics were used for analysis as this is a cross sectional survey.


 » Results Top


Out of the 157 women interviewed, 89.8% nurses were aware about cancer cervix. When asked about their understanding about cervical cancer, 13.7% responded that it was a curable disease, 20.7% thought it was a dangerous disease, 20.7% thought it was a fatal disease, 68.9% responded that it was a disease in which prognosis was not good and 27.6% thought that treatment was possible.

In our study, 86.2% nurses were aware about the existence of a disease called cervical cancer and 68.9% were aware that a precancerous stage exists. Respondents were asked about any three high risk factors for development of cancer cervix. Almost 1/3rd (35.7%) of the respondents did not have any knowledge about risk factors leading to cervical cancer. Poor hygiene was reported as a risk factor by 35.7%. The other risk factors reported include, early marriage (32.1%), multiple sex partners (17.8%), high parity (14.8%), infection (10.7%), hereditary (7.1%). White discharges, bleeding per vaginum, negligence and coitus at early age were the least reported risk factors (3.4% each).

Nearly, 86.2% respondents felt that they were aware about symptoms of cervical cancer. When asked about, which symptoms they were aware of, 68.96% of all study subjects felt that bleeding per vaginum was a symptom of cervical cancer, foul smelling discharge and swelling of cervix were reported by 20.7% each, 10.3% reported weight loss and 6.8% thought that frequency of micturition as a symptoms of cervical cancer.

Nearly, 79.3% thought that early diagnosis was possible. 157 women gave their verbal consent for the interview. Majority of these nurses were in the age group 20-34 years (58.7%) married (69%) and had done graduation (61.5%) [Table 1] 86.2% were aware about availability of screening tests to detect cancer cervix [Table 2] and had heard about Pap smear. 58.6% were aware that facilities for Pap smear test were available at our hospital, but only 3% had ever undergone a Pap smear examination. 62.1% said that they would like to get their Pap done.
Table 1: Demographic characteristics

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Table 2: Knowledge and awareness regarding cervical cancer and Pap smear

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 » Discussion Top


Cervical cancer as a disease was correctly identified by most of the nursing staff. This is expected as it is the leading cancer amongst females in India and our hospital has a sizeable number of patients with cervical cancer. Nurses were also aware that a precancerous stage existed.

Clinically, cervical cancer commonly presents with foul smelling and/or blood stained vaginal discharge or post-coital discharge; inter menstrual bleeding and pelvic pain. Some of the risk factors for development of cervical cancer are early sexual intercourse, multiple sexual partners, sexually transmitted infections and smoking.[13] A substantial number of our study subjects thought they had an idea about risk factors for cancer cervix. Only 62% correctly knew about at least one risk factor for development of cancer cervix. Only 35% of the nurses felt that poor hygiene led to development of cervical cancer. Only 14.8% thought that infection was a risk factor in contrast to 78% reported in the study by Ali et al.[14] This difference may be due to the fact that the latter study included interns as well as nurses. While a high number of nurses felt that they were aware about clinical features of cervical cancer, their perception about symptoms were erroneous. Most of them felt that bleeding per vaginum may be one of the presenting features, which is almost similar to 82% reported in a study by Ertem.[15] Almost 20.68% felt that edema of cervix is a presenting symptom of cancer cervix. 34% of nurses reported incorrect symptoms of cancer cervix. These results explain the fact that as the awareness of nurses themselves is incorrect regarding the disease, it is reflected in low levels of screening self as well a motivating others for screening and prevention of this disease.

A similar finding regarding awareness of cervical cancer was reported by Mutyaba et al. in which 93% of medical workers considered cancer a public health problem and 83% had knowledge about Pap smear. This study included doctors and final year medical students in addition to nurses.[16]

Even though, most of the nurses were aware about Pap smear as a screening test only 58% were aware that the test was actually available in our institute. Thus, even though knowledge about the disease exists, but low awareness about availability of screening precludes early detection. The work force is aware that early detection helps for a cure, but since they lack knowledge about availability of screening facilities, directing patients to avail these facilities is an issue leading to lesser use of screening practices. Such ignorance in nursing staff is a matter of concern for the society.

Only 3% had ever undergone a Pap smear and the probable reasons for this may be a pseudo sense of not being vulnerable to the disease or unwillingness to get a speculum examination in the absence of any complaints. However, the study encouraged the nursing staff to undergo a screening themselves and motivate others for screening, which was reflected in the number of Pap smears for screening performed in the subsequent days. We feel that this may have resulted from sensitization of nurses toward easy and accessible screening procedure for detecting cervical cancers. We feel that this itself is a positive indicator for the need of educating nurses regarding screening for cancer cervix. Similar results have been reported after sensitization for cancer screening where the acceptability and increased utilization of screening services was seen after sensitization.[17],[18] As screening is not provided free of cost the need for low cost or free screening needs to be addressed. In our hospital, we have an insurance scheme where Pap smear is carried out for free. Even for the general population, it costs only rupees 30, which is very less.

The nursing staffs that are primarily involved in patient care are inaccurately aware of symptoms and high risk factors for cancer cervix. Ignorance among educated class regarding simplicity, easy availability and unwillingness for routine screening will create a major health problem in future. The cost of hospitalization, chemotherapy, radiotherapy and extensive surgery for a patient presenting in later stage is an economic and emotional burden for the state and the relatives. Deterioration of quality-of-life, poor prognosis and survival are added problems.


 » Conclusion Top


Our study found that the level of awareness about cervical cancer as a disease was good in the nurses at our hospital. However, knowledge about screening and availability of screening procedure as a routine in our own out-patient department was limited. The acceptability and willingness to undergo screening was good, but very few had actually undergone the procedure before this study.

Recommendations

There is a need to provide special reorientation programs to sensitize nurses about cervical cancer. The training curriculum of nurses needs to be modified to include knowledge about cervical cancer etiology, clinical features, risk factors and screening methods. It is important to lay emphasis on the need to refer females for cervical cancer screening so that early detection and treatment is possible. Special cytology clinics should be established in the public hospitals with branches in the periphery.

The need to target health-care providers as key players in creating health awareness must be emphasized as they play a critical role in modifying health behavior awareness in the general population. “Preventable, but not yet prevented” remains the reality of cancer cervix today. For cancer cervix, there is still an unfinished agenda and everyone needs to address it.


 » Acknowledgment Top


We heart fully thank our study participants without whose cooperation this study would not have been possible.

 
 » References Top

1.
Ezem BU. Awareness and uptake of cervical cancer screening in Owerri, South-Eastern Nigeria. Ann Afr Med 2007;6:94-8.  Back to cited text no. 1
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2.
Winkler JL, Lewis K, Del Aguila R, Gonzales M, Delgado JM, Tsu VD, et al. Is magnification necessary to confirm visual inspection of cervical abnormalities? A randomized trial in Peru. Rev Panam Salud Publica 2008;23:1-6.  Back to cited text no. 2
    
3.
Sankaranarayanan R, Basu P, Wesley RS, Mahe C, Keita N, Mbalawa CC, et al. Accuracy of visual screening for cervical neoplasia: Results from an IARC multicentre study in India and Africa. Int J Cancer 2004;110:907-13.  Back to cited text no. 3
    
4.
Kahesa C, Mwaiselage J, Wabinga HR, Ngoma T, Kalyango JN, Karamagi CA. Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: The need for dual screening. BMC Public Health 2008;8:262.  Back to cited text no. 4
    
5.
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917.  Back to cited text no. 5
    
6.
Murthy NS, Mathew A. Screening for cancer of uterine cervix and approaches adopted in India. Indian J Cancer 1999;36:154-62.  Back to cited text no. 6
    
7.
Ananth R. Downstaging of cervical cancer. J Indian Med Assoc 2000;98:41-4.  Back to cited text no. 7
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8.
Agorastos T, Miliaras D, Lambropoulos AF, Chrisafi S, Kotsis A, Manthos A, et al. Detection and typing of human papillomavirus DNA in uterine cervices with coexistent grade I and grade III intraepithelial neoplasia: Biologic progression or independent lesions? Eur J Obstet Gynecol Reprod Biol 2005;121:99-103.  Back to cited text no. 8
    
9.
Crum CP, McLachlin CM. Cervical intraepithelial neoplasia. J Cell Biochem Suppl 1995;23:71-9.  Back to cited text no. 9
    
10.
Grizzle WE, Srivastava S, Manne U. The biology of incipient, pre-invasive or intraepithelial neoplasia. Cancer Biomark 2010;9:21-39.  Back to cited text no. 10
    
11.
Singh E, Seth S, Rani V, Srivastava DK. Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India. J Gynecol Oncol 2012;23:141-6.  Back to cited text no. 11
    
12.
Roy B, Tang TS. Cervical cancer screening in Kolkata, India: Beliefs and predictors of cervical cancer screening among women attending a women's health clinic in Kolkata, India. J Cancer Educ 2008;23:253-9.  Back to cited text no. 12
    
13.
Dutta DC. Genital malignancies and premalignant lesions. In: Dutta DC, editor. Textbook of Gynecology. 5th ed. Kolkatta: New Central Book Agency (P) Ltd.; 2008. p. 312, 332.  Back to cited text no. 13
    
14.
Ali SF, Ayub S, Manzoor NF, Azim S, Afif M, Akhtar N, et al. Knowledge and awareness about cervical cancer and its prevention amongst interns and nursing staff in Tertiary Care Hospitals in Karachi, Pakistan. PLoS One 2010;5:e11059. Available from: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone. 001105 and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883573/. [Cited on 2012 Mar 10].  Back to cited text no. 14
    
15.
Ertem G. Awareness of cervical cancer risk factors and screening behaviour among nurses in a rural region of Turkey. Asian Pac J Cancer Prev 2009;10:735-8.  Back to cited text no. 15
    
16.
Mutyaba T, Mmiro FA, Weiderpass E. Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda. BMC Med Educ 2006;6:13.  Back to cited text no. 16
    
17.
Kelley CG, Daly BJ, Anthony MK, Zauszniewski JA, Stange KC. Nurse practitioners and preventive screening in the hospital. Clin Nurs Res 2002;11:433-49.  Back to cited text no. 17
    
18.
Tessaro I, Herman C. Changes in public health nurses' knowledge and perception of counseling and clinical skills for breast and cervical cancer control. Cancer Nurs 2000;23:401-5.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2]

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