|Year : 2015 | Volume
| Issue : 2 | Page : 105-110
Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India
Hafizur Rahman1, Sumit Kar2
1 Department of Obstetrics and Gynecology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
|Date of Web Publication||16-Jun-2015|
Department of Obstetrics and Gynecology, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
Objectives: To assess baseline knowledge of cancer cervix, screening and practice of Pap smear screening among Sikkimese staff nurses in India. Materials and Methods: Between April 2012 and February 2013, a predesigned, pretested, self -administered multiple responses questionnaire survey was conducted among staff nurses' working in various hospitals of Sikkim. Questionnaire contained information about their demographics, knowledge of cervical cancer, its risk factors, screening methods, attitudes toward cervical cancer screening and practice of Pap smear amongst themselves. Results: Overall, 90.4% nurses responded that they were aware of cancer cervix. Three quarter of the staff nurses were not aware of commonest site being cancer cervix in women. Of the 320 participants, who had heard of cancer cervix, 253 (79.1%) were aware of cancer cervix screening. Pap smear screening should start at 21 years or 3 years after sexual debut was known to only one-third of the nursing staff. Age was found to be a significant predictor of awareness of Pap smear screening among nursing staff. Awareness was significantly more prevalent among older staff (P < 0.007). Married nursing staffs were significantly more likely to be aware of screening methods, and nursing staff of Christian and Buddhist religion were 1.25 times and 2.03 times more likely to aware of screening methods than Hindu religion respectively. Only 16.6% nurses, who were aware of a Pap smear (11.9% of the total sample), had ever undergone a Pap smear test. Most common reason offered for not undergoing Pap smear test were, they felt they were not at risk (41%), uncomfortable pelvic examination (25%) and fear of a bad result (16.6%). Conclusion: Knowledge of cancer cervix, screening and practice of Pap smear was low among Sikkimese nursing staff in India. There is an urgent need for re-orientation course for working nurses and integration of cervical cancer prevention issues in the nurses' existing curriculum in India and other developing countries.
Keywords: Cervical cancer, knowledge, nursing staff, Pap smear, screening
|How to cite this article:|
Rahman H, Kar S. Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol 2015;36:105-10
|How to cite this URL:|
Rahman H, Kar S. Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol [serial online] 2015 [cited 2019 May 20];36:105-10. Available from: http://www.ijmpo.org/text.asp?2015/36/2/105/158840
| Introduction|| |
Worldwide, cervical cancer is the second most common (12%) cancer in women, however, in developing countries; it is the most common cancer among women.  With 528,000 new cases detected every year, cervical cancer is most notable among lower resource countries of sub-Saharan Africa. It is also the fourth most common cause of cancer death in women worldwide with 266,000 deaths in 2012. Almost 70% of the global burden falls in areas with lower levels of development.  India bears about one fifth of the world's burden of cervical cancer, and >100,000 new cases are detected every year in India, which causes 20% of all female deaths in India. , According to 3 year report (2009-2011) of population based cancer registries in India, cancer cervix continues to be leading site of cancer in India and Sikkim, and two-thirds of the cases are reported in advanced stage. 
The key to reducing cervical cancer morbidity and mortality is early detection and treatment of cervical precancerous lesions. Among all malignant tumors, cervical cancer is the one that can be most effectively controlled by organized screening programs.  An organized screening program can reduce incidence and mortality by 80% as shown in developed countries.  Despite being effective, most of the women in developing and under-developed countries do not have access to Pap smear More Details screening. The major problem is low participation in the screening program. ,
In India also, both early detection and screening remains a major area of concern coupled with poor literacy and low level of awareness amongst Indian women. Because of low doctor patient ratio in India, nursing staff are the major workforce in rural public health centers and Sub centers of India. The staff nurses are responsible, as primary gate keepers for giving information about cervical cancer and creating and conducting Pap smear screening tests among rural Indian women. 
To have a successful cancer control program, nursing staff must be aware of facts about cervical cancer and screening tests themselves. Furthermore, negative attitude toward and inaccurate knowledge of cervical cancer and screening methods among health care providers especially among nurses can pose substantial barriers to cervical control program in India and other developing countries. Moreover, if nurses themselves undergo screening tests regularly, they can be role models for other females in carrying out cervical cancer screening tests.
It is with this in mind, the aim of this study was to assess knowledge of cancer cervix, screening methods, attitude toward and practice of Pap smear screening among nursing staff working in Sikkim.
| Materials and Methods|| |
Sikkim is a small state of Indian union located in the eastern Himalayas. The population of Sikkim is different in their culture, religion, customs and traditions from other states of India. The three different communities living in Sikkim-the Nepalis, Bhutias and Lepchas, constitute a homogeneous blend. There are two referral hospitals in Sikkim, Central Referral Hospital-teaching hospital of Sikkim Manipal Institute of Medical Sciences (SMIMS), and the Sir Thutob Namgyal Memorial Hospital at Gangtok, four district hospitals, 24 primary health centers and 147 sub centers in Sikkim. These hospitals provide comprehensive health care to the population of different communities of Sikkim.
It was a cross-sectional study conducted between April 2012 and February 2013. The study was approved by SMIMS institutional ethics committee. Initially major hospitals nursing staff (including trainee nursing staff, that is, nursing students, who were in their final year internship and yet to obtain their full registration) were invited in a group in a big hall and explained about the nature and purpose of the research. The staff nurses who agreed to participate were given a consent form along with a predesigned, pretested, self-administered multiple response questionnaires with both closed and open ended questions. The staff nurses, who could not come in groups and those who were working small hospitals; to them, an invitation letter along with consent form and questionnaire was sent in a sealed envelope to participate. Those who agreed to participate were requested to fill the questionnaire along with consent form and send back to the principal author.
The questionnaire items consisted of various basic facts about cervical cancer and screening, attitude of nursing staff toward screening, and about their practice habits. The questionnaire items were standard items that are very much important in practical aspects. Some items were modified, and some were adapted from review articles and added to the questionnaire by the principal investigator to suit the context of the study.
The data collected were thoroughly screened and entered into MS-excel (Microsoft, Redmond, WA, USA) spread sheets for analysis. The procedures involved were transcription, preliminary data inspection, and interpretation. The data were analyzed by computer software Instat Graph Pad version 3 (GraphPad Software, La Jolla, CA, USA). Descriptive statistics Chi-square tests were done, and the significance of tests was decided at P = 0.05. Data were analyzed using both univariate and multivariate analysis/binary logistic regression.
| Results|| |
A total of 396 questionnaires were distributed during the study period of which 354 nursing staff returned the questionnaire in completed form with a response rate of 89.4%. Majority of the nursing staff were between 21 and 40 years of age, married, Hindu and belonged to Nepali community. Among the participants, 28.8% were trainee staff. [Table 1] presents their socio-demographic characteristics.
|Table 1: Socio demographic characteristics of 354 nursing staffs from the state of Sikkim, India who participated in the survey|
Click here to view
To the question "are you aware of cancer cervix" 320 of 354 nursing staff (90.4%) responded that they knew about it. Those who were aware of cancer cervix proceeded with further questions about cancer cervix. [Table 2] shows the detailed knowledge of the participants who had heard of cancer cervix. Three-quarter of the nursing staff were not aware that commonest site of cancer cervix is ectocervix. Although almost half of the participants were aware of cervical intraepithelial neoplasia (CIN), they had poor knowledge about association of CIN with cancer cervix. Most common risk factors identified by participants were multiple sex partners (52%), early age of coitus (35%) and multiple births (24%). Most common symptom responded by participants were offensive foul-smelling vaginal discharge (63%). Only half of the participants knew that the treatment of cancer cervix is radiotherapy or surgery.
|Table 2: Detailed knowledge among 320 nursing staff who ever heard of cancer cervix|
Click here to view
Of the 320 participants those who heard of cancer cervix, 253 (79.1%) were aware of cancer cervix screening or a Pap smear screening [Table 2]. Of these 62.5% (n = 158) responded that they had heard about it from doctors. Other source of knowledge were medical text book 47.4% (n = 120), television, radio or internet 22.1% (n = 56), print media 14.6% (n = 37) and friends, spouse and colleagues 5.1% (n = 13). [Table 3] presents detailed knowledge of and attitudes toward Pap smear screening of the participant nursing staff. That Pap smear screening should start at 21 years or 3 years after sexual debut was known by one-third nursing staff, while recommended Pap smear interval of 3 years were known to 60% of the staff [Table 2]. Only 61% staff nurses were willing to attend Pap smear screening.
|Table 3: Unadjusted associations between participant's socio demographic characteristics and awareness of pap smear screening and results of multivariate binary logistic regression analysis to determine factors independently associated with awareness of pap smear screening among the participants|
Click here to view
[Table 3] presents the unadjusted associations between participants' socio-demographic characteristics and awareness of Pap smear and results of multivariate analysis of selected independent variables and their associations with awareness of Pap smear. Age was found to be a significant predictor of awareness of Pap smear screening among nursing staff. Awareness was significantly more prevalent among older staff (P < 0.007) and awareness increased with advancing age. Married nursing staff were significantly more likely to be aware of screening, and nursing staff of Christian and Buddhist religion were 1.25 times and 2.03 times more likely to be aware of screening methods than Hindu religion respectively. When the nursing staff was categorized by community, 85% Bhutia staff were aware of Pap smear that made them most aware of Pap smear screening. Bhutia staff was 1.96 times, and Lepcha staff was 1.39 times more likely to be aware of Pap smear. Sexually active staffs were significantly more aware of Pap smear screening [Table 3].
Only 16.6% (n = 42) of the 253 nursing staff who were aware of Pap smear had actually undergone a Pap test. Of these three-fourth (76%) staff underwent test only once, 21.4% twice, while only one (2.4%) staff underwent the test thrice. Thirty one percentage (n = 13) nursing staff were not satisfied with the test [Table 4].
|Table 4: Practice of pap smear among 253 nursing staffs who were aware of pap smear screening test|
Click here to view
Among the participant staff nurses, who were aware of Pap smear test 83.4% (n = 211) had never undergone a test. The most common reason offered were-they felt that they were not at risk (41%). Twenty five percentage (n = 53) nurses offered uncomfortable pelvic examination as the reason for not undergoing the test, while 16.6% (n = 35) never underwent Pap smear for fear of a bad result [Table 4].
| Discussion|| |
The findings of the present study show that knowledge of cancer cervix and Pap smear screening is low among the participant nursing staff. This study also shows that awareness about cancer cervix and Pap smear screening is lower among Sikkimese nursing staff than staff from high income countries,  but slightly higher than that had been reported from other Indian states. 
An important finding is the low level of awareness of cancer cervix and Pap smear screening among younger nursing staff. When 80% cervical cancer cases occur in developing countries including India and increasing importance has been given for controlling cervical cancer, it is worrying to find a low level of awareness about cancer cervix and Pap smear screening among young nursing staff. This also implies that more importance in teaching curriculum and training programs should be incorporated about cancer cervix and screening.
Cancer cervix is preventable, and one of the important aspects in prevention is detection of the premalignant lesions by screening.  Although 49% of the participants had heard of CIN, only 17% knew CIN occurs in younger women, which if left untreated may progress to advanced carcinoma. In our study, 52% participants were aware that multiple sexual partner is an important risk factor for cervical cancer, while in a study of Ali et al. 45% nursing staff mentioned multiple partners and other promiscuous behavior as the most common risk factor. 
The most common symptom of cancer cervix reported by nursing staff in our study were offensive foul-smelling discharge (63.8%), irregular bleeding (50.6%) and postmenopausal bleeding (26%) while in a study by Nganwai et al. 77.7% and 92.4% knew that common symptoms of cervical cancer include postcoital bleeding, inter-menstrual bleeding and abnormal blood-stained vaginal discharge. About 57% knew that the cervical cancer could be treated by surgery while only 50% aware of radiotherapy as treatment options. These results are not surprising since most patients suspected or diagnosed of having cancer are referred to higher oncology centers for confirmation of diagnosis and treatment. The nurses, therefore, do not get to see the management of cervical cancer.
Only 79% of the staff nurses, who had known cervical cancer, was aware of Pap smear. Similar observations were made by Ali et al.  where 75% nursing staff knew that Pap smear is a screening test for cervical cancer. Most of the nurses (67%) were not aware of recommended timing of Pap smear. Comparatively a larger proportion of Thai nurses could correctly identify the timing was found by Nganwai et al.  The recommended Pap smear screening interval was known to only 60% nurses.
Our finding that elderly and married nurses were more likely to be aware and undergo screening was also reported by other authors.  The proposed reason is that elderly and married women may receive more frequent gynecological care and the common belief that cervical cancer only occurs in older women, making them more responsive to their health. 
An interesting finding of the present study was that the Buddhist and Christian's staff were more aware of cervical cancer screening compared to Hindus. This is possibly due to the fact that the Orthodox Christians and Buddhists may have benefitted from the health awareness programs or discussions at their religious institutions.
Nurses have an important role in cancer prevention and health education. Therefore, knowledge and awareness of cervical cancer are the most important for general women, who are educated by nurses. In the literature, some studies have shown that nurses who knew very well about symptoms, risk factors, and screening methods of cancer were more likely to use cervical cancer screening methods.  However, although 72% nursing staff were aware of Pap smear only 16.6% (11.9% of total nurses participated) had ever undergone a Pap smear test. A more disappointing low level of Pap smear test was reported by other authors from developing countries, 7% by Shekhar et al.  in Indian nurses and 5.5% by Udigwe  among Nigerian nursing staff. All the staff nurses, who underwent Pap smear in our study were married. Because sexual relationships outside marriage are not culturally accepted in India,  unmarried sexually active women would refuse to undergo screening out of fear of the potential social stigma they would suffer if they had a test perceived to be used for married women.
Among the eligible respondents 83.4%, had never undergone Pap smear test. Most common (41%) had never screened themselves because they did not feel at risk to the disease. Additionally, one fourth of the eligible nursing staff offered uncomfortable pelvic examination as the reason for not undergoing test could be attributed to their routines, but this would not explain the reluctance to get screened themselves despite the availability of a free service almost any time they wished to. Sixteen percent never underwent Pap smear for fear of a bad result. The belief that cervical cancer is a terminal illness and death is inevitable when cancer is detected has been identified as a barrier to participation in cancer screening, detection and treatment.  It is unlikely that this staff will ever motivate others or advise them until their doubts are cleared.
The lack of depth on knowledge of cervical cancer in staff nurses can be explained by their training curriculum. In the present study also, only 47% participants obtained knowledge of cervical screening from their curriculum book. Until recently, cervical cancer prevention issue has been the concern of physicians.  In the proposed cervical cancer prevention strategies, there is an urgent need to integrate cervical cancer prevention issues in the nurses' training curriculum. The attitudes that screening has to be done only by doctors or gynaecologists needs to change. Studies have shown it is possible to train nurses or other health care workers to screen for cervical cancer, and they play an important role in successful screening against cancer cervix. , Nurses are the backbone of health care system in developing countries including India. This calls for a re-orientation course for nurses to give more importance on cervical cancer screening methods.
The strength of the present study is that it is the first to assess knowledge and practice about cervical cancer screening among nursing staff in eastern India, where incidence of cervical cancer is high.  On the other hand, the study has some limitations. Firstly, some questions were recognition, and some were recall type. Both the recall and recognition questions have limitations. Recall underestimates awareness because it is limited by memory, while recognition overestimates awareness because participants find it easy to guess. Secondly, the method used for estimating the practice of Pap smears were self-reported history, which may not give the actual picture due to inaccurate recall or desirability bias. 
| Conclusion|| |
Knowledge about cancer cervix, screening and practice of Pap smear is low among nursing staff working in Indian state of Sikkim. There is an urgent need for integration of cervical cancer prevention issues in the nurses' existing training curriculum. Nursing staff, if properly aware of cervical cancer and screening methods, can educate the women in the community and increase health-seeking behavior among eligible women.
| Acknowledgments|| |
The authors would like to thank all the resident medical officers, and interns for their help in collecting data.
| References|| |
Standard & Guidelines, Cervical and breast cancer screening by VIA & CBE. New York: The United Nations Population Fund; 2006.
International agency for research on cancer. Latest world cancer statistics global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. GLOBOCAN 2012, World Health Organization Press release, 12 th
December 2013. Available from: http://www.iarc.fr/en/media-centre/pr/2013/pdfs/pr223_E.pdf. [Last accessed on 2014 Oct 11].
Shanta V. Perspectives in cervical cancer prevention in India,. The international network for cancer treatment and research; 2003. Available from: http://www.inctr.org/meetings/past-meetings/annual-meeting-2003/. [Last accessed on 2013, Aug 12].
National Cancer Registry Programme. Three year report of population based cancer registries 2009-2011. Indian Council Med Res, New Delhi; 2013. Available from: http://www.icmr.nic.in/ncrp/PBCR_Report%202009_2011/ALL_CONTENT/ALL_PDF/preliminary_pages.pdf. [Last accessed on 2014 Oct 11].
Arbyn M, Rebolj M, De Kok IM, Fender M, Becker N, O'Reilly M, et al.
The challenges of organising cervical screening programmes in the 15 old member states of the European Union. Eur J Cancer 2009;45:2671-8.
Anttila A, Pukkala E, Söderman B, Kallio M, Nieminen P, Hakama M. Effect of organised screening on cervical cancer incidence and mortality in Finland, 1963-1995: Recent increase in cervical cancer incidence. Int J Cancer 1999;83:59-65.
Anttila A, Arbyn M, Veerus P, Viberga I, Kurtinaitiene R, Valerianova Z, et al.
Barriers in cervical cancer screening programs in new European Union member states. Tumori 2010;96:515-6.
Bos AB, Rebolj M, Habbema JD, van Ballegooijen M. Nonattendance is still the main limitation for the effectiveness of screening for cervical cancer in the Netherlands. Int J Cancer 2006;119:2372-5.
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.
Ezem BU. Awareness and uptake of cervical cancer screening in Owerri, South-Eastern Nigeria. Ann Afr Med 2007;6:94-8.
Shekhar S, Sharma C, Thakur S, Raina N. Cervical cancer screening: Knowledge, attitude and practices among nursing staff in a tertiary level teaching institution of rural India. Asian Pac J Cancer Prev 2013;14:3641-5.
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.
Nganwai P, Truadpon P, Inpa C, Sangpetngam B, Mekjarasnapa M, Apirakarn M, et al.
Knowledge, attitudes and practices vis-a-vis cervical cancer among registered nurses at the Faculty of Medicine, Khon Kaen University, Thailand. Asian Pac J Cancer Prev 2008;9:15-8.
Sankaranarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahé C, et al.
Determinants of participation of women in a cervical cancer visual screening trial in rural south India. Cancer Detect Prev 2003;27:457-65.
Siahpush M, Singh GK. Sociodemographic predictors of pap test receipt, currency and knowledge among Australian women. Prev Med 2002;35:362-8.
Yaren A, Ozkilinc G, Guler A, Oztop I. Awareness of breast and cervical cancer risk factors and screening behaviours among nurses in rural region of Turkey. Eur J Cancer Care (Engl) 2008;17:278-84.
Udigwe GO. Knowledge, attitude and practice of cervical cancer screening (pap smear) among female nurses in Nnewi, South Eastern Nigeria. Niger J Clin Pract 2006;9:40-3.
Bott S, Jejeebhoy S, Shah I, Puri C. Towards adulthood: Exploring the sexual and reproductive health of adolescent in South Asia. Geneva: World Health Organization; 2003.
Powe BD, Finnie R. Cancer fatalism: The state of the science. Cancer Nurs 2003;26:454-65.
Denny L, Kuhn L, De Souza M, Pollack AE, Dupree W, Wright TC Jr. Screen-and-treat approaches for cervical cancer prevention in low-resource settings: A randomized controlled trial. JAMA 2005;294:2173-81.
Chirenje ZM, Chipato T, Kasule J, Rusakaniko S. Visual inspection of the cervix as a primary means of cervical cancer screening: Results of a pilot study. Cent Afr J Med 1999;45:30-3.
[Table 1], [Table 2], [Table 3], [Table 4]