European Journal of Cardiovascular Medicine

Carcinoma cervix ranks as the fourth most common cancer in women worldwide¹ and is the leading cause of cancer deaths especially in sub Saharan Africa, South-east Asia and South America.

The World Health Organization (WHO) Global Strategy for Cervical Cancer Elimination has set a target incidence rate of below 4 per 100,000 women by 20302. The targets aim at 90% of all girls under age 15 to be complete vaccinated with Human papilloma virus (HPV) vaccine, 70% all women by 35 years to be screened with a high performance test and 90% women identified with cervical disease to receive treatment.

HPV infection along with poor genital hygiene, high parity, smoking and other sexually transmitted infections like Human immunodeficiency virus and chlamydia have been the major factors in development of cancer cervix. Late diagnosis in advanced stages results in higher cancer mortality rates.

Cervical cancer is almost a completely preventable malignancy due to a highly effective and promising HPV vaccine and very simple reliable screening tests1 like the Pap smear, visual inspection with Acetic acid (VIA). Less than 30% of Low or Medium Income (LMIC) countries have national HPV vaccination programs and only 44% women in LMICs have ever been screened for cervical cancer, as compared to more than 80% in high income countries1.

India contributes to one-fifth of the cervical cancer burden3. A very high crude cervical cancer incidence of 18.7 per 100,000 women and cumulative risk of 2% for age 0-74 has been reported4. HPV vaccination is not yet included in the national vaccination schedule. A national screening program for cervical cancer screening with a target age of 30 to 65 years and VIA as the offered test exists, but only less than 0.1% women have been actually screened as per the program4.

Only 1.9% women in India have ever been screened for cervical cancer5. This dismal statistics reflect the nonexistence of a single comprehensive national cervical cancer eradication program.

Opportunistic screening in gynecologic outpatient settings with a motivated gynecologist and primary health care provider still continues to be the mainstay6. In our country, there is a significant information asymmetry and lack of preventive health awareness. Subsequently, screening for diseases where there is no obvious symptoms is perceived to be unnecessary, especially among the lower socioeconomic sections.

The onus of eradication hence depends on the front line health workers. They are the contact personnel, who if aware can act as the key personnel in educating the public at the most ground level and also help in screening, clinical handover for management and subsequent follow up. This, if backed up with documentation, cancer registries and regional cancer centres can bring down the cancer burden on the healthcare.

Our study here aims at understanding the education of frontline heath care workers regarding cancer cervix. Nurses and hospital faculty are the most visible, frontline personnel providing health education to patients and health promotion in the general population. They influence cervical cancer screening adherence and health activities among most women. Recommendation of cervical cancer screening and prevention to individuals by medical professionals effectively improves screening coverage among the general population. Therefore, nurses and health care workers should have current and accurate knowledge to promote informed decisions.

This cross-sectional observational study was conducted amongst 242 female staff working at Subbaiah Institute of Medical Sciences, Shivamogga, Karnataka. The study population included 30 staff nurses, 46 housekeeping, 12 laboratory technicians, 14 interns, 77 medical students, 52 office clerks, 11 office attenders aged from 18 to 65 years.

The pre-designed questionnaire of 25 questions included demographic characteristics, knowledge about cervical cancer, Pap smear screening and HPV vaccines. The women were personally interviewed and a written informed consent was taken. They were also questioned regarding inhibitions and myths regarding screening and prevention of cervical cancer.

The women were then made aware about viral etiology, screening potential, early diagnosis and effective prevention of cervical cancer in our population. Also, stress was imprinted on them being the pivot for education of the general population with respect to preventive measures of cervical cancer.

Data was analyzed as descriptive statistics and expressed as percentages. Continuous variables were represented as mean± Standard Deviation form

Of the 242 women respondents, 223(92%) were in the active reproductive age group of 20 to 40 years. Hinduism was the commonly (84.7%) followed religion, followed by Christianity (9.5% and Islam (5.7%). Women were almost matching in being single (55.78%) and married (44.21%). One fourth (25.6%) of the women had education of 10th grade or less and about 6% had no basic schooling at all. The remaining (68.58%) had completed college. The women with no or only basic schooling were mostly (23.5%) working as housekeeping and attenders in the hospital and the others were working in the capacity of laboratory technicians, office clerks, staff nurses, and medical and nursing interns.(Table: 1)

Table 1: Demography

Table 2: Survey

Figure 1: Justification for not practicing screening for cancer cervix

Figure 2: Acceptance of screening (PAP smear) and prevention (HPV vaccination) after counselling

Though 179(73.96%) women were aware of cervical cancer, only 142(58.67%) knew it to be preventable. Viral etiology of cancer cervix was known by 46.6% women and the remaining were unaware (32.64%) or refused to believe (20.66%) it. Only 42.56% participants believed the virus to be detected before it caused malignancy. Positively, 71.07% women had heard of Pap smear, but they (39.62%) did not know that it detected early precancerous lesions and that the malignancy could be averted. Only 38.42% women knew about Human Papilloma Virus (HPV) vaccines against cervix cancer and its availability in India. Awareness regarding safe sexual practices to prevent cancer cervix was understood by 80.1% participants. (Table-2)

Only 41% subjects believed that all women should have a Pap smear done. One tenth (9.5%) of the women had Pap testing done for themselves, whereas 90% had never undergone Pap screening. This depicts the lacuna in being aware and being practical. Though 71% women had heard of Pap smear and 41% believed that pap testing should be offered to all women, only 9.5% had actually practiced it.

Interestingly, when asked about the reason for not having a Pap test, 19.3% women believed themselves to be self- immune to cancer, 9.2% could not afford the test, 15.6% were reluctant to pelvic examination, 45.9% were not aware that they can ask for a Pap test and the remaining willfully refused any testing.(Figure 1)

After counselling, 80.16% women voted for getting vaccinated and 71.4% for Pap testing. Around 13.6% refused vaccination and 21% still refused Pap testing, the remaining being equivocal. (Figure 2)

There is need to identify gaps in public awareness and practice, to take account of local culture and behaviour which will later reflect in the success of the program and control or eradication of the disease. Though guidelines for screening for cervical Cancer2 are clear and its role in averting malignancy is proven, a universal screening program worldwide is yet to materialise, especially in the developing countries.

The burden of community counselling, education and influencing preventive medicine is still on the shoulders of the primary health care providers. Most of the hospital based studies on knowledge and attitudes regarding cancer cervix have targeted medical students7, 8, 9,10, nurses and nursing students8, 11, 12, doctors12,13 and community health workers14. In our study, Inclusion of Paraclinical (laboratory technicians) and hospital support staff (office clerks, house-keeping) along with staff nurses, medical and nursing interns and final year medical students was intentional. It is noted that people working in any capacity in hospitals are always relied upon to provide sound advice on varied levels of medical care in their respective localities and societies.

A review15 of hospital and community based cross-sectional studies from 2012 to 2020 included 7688 women in age range of 12- 65 years. These include rural and urban community surveys, school surveys and hospital based Outpatient studies. Most of the working hospital staff studies7,8,9,10,11,12,13,14 had participants in the younger age group of up to 50 years. The age of our study subjects ranged from 20 to 60 years and 92% were in the active reproductive group wherein need for screening of cancer cervix is most relevant.

Hinduism was the more practiced (84.7%) religion followed by Christianity (9.5%) and Islam (5.7%). This is similar to the study population of Ganju et al8 where 96.5% participants comprised of Hindus. Our women subjects were almost matched in being single (55.78%) and married (44.21%). The previous studies mostly dealt with either a married population or a predominantly un-married study subjects as depicted in the comprehensive review by Taneja N et al15.

Level of education determines level of knowledge. Still, experience and life lessons also widen the horizon of the mind. This is found to be true when we assess the practical knowledge of our study subjects. Though one fourth (25.6%) of our women had only basic schooling and another 6% had no schooling at all, it was worth noting that almost three fourth (73.96%) of our participants were aware of cervical cancer and 58.67% knew it to be preventable. Moreover, 71.07% women had heard of Pap smear. Interestingly, our students and nursing faculty had obtained information through standard medical literature like textbooks followed by media forums, whereas, other hospital faculty had gained knowledge from hospital bulletins, direct conversations among hospital staff, hospital based health camps and schemes and media forums. This observation is in alignment with Singh J et al7 where majority of the study participants had learned information via standard medical textbooks (65.3%) followed by internet forums (43.8%) and radio broadcasts. However, Awareness of cancer cervix ranged from 15% to 80% across various cross-sectional studies done across India and across both rural and urban masses and illiterate to a literate population15.

Knowledge regarding Pap test ranged between 2% to 15% and practice of preventive medicine (5%- 13%) was even more dismal in cross sectional studies done across India from 2012 to 202015. Here, we found that though 71% women had heard of Pap smear, 39.62% women did not know that it detected precancerous lesions and that with early intervention, malignancy could be averted. Only one tenth (9.5%) of our women had Pap testing done for themselves. There was a huge gap in knowledge and practice of screening methods, as is evident in most of the studies across our country15.

Studies done among medical and nursing students7, 8 showed that knowledge of cancer cervix was fairly good (70-80%). Medical students had much in-depth knowledge of cancer cervix, vaccine and its side effects when compared to dental and nursing students9. Females fared better7,9 especially regarding screening and were more willing to get vaccinated. Males fared better8 with basic cancer information but were more sceptical regarding screening and vaccination. Undergraduate female medical and paramedical students in Ethiopia10 had good knowledge in 59.3% but less than 1% had ever been screened for cervical cancer.

In a study among female healthcare professionals in a tertiary care hospital in India12, it was noted that doctors had much better knowledge about cancer cervix risk factors and Pap test than nurses. Also, 52.6% doctors had had a Pap test as compared to 11.2% nurses. The reason for not getting screened was told to be absence of symptoms (31%) followed by a notion of immunity to cancer (29%). Here, none of the women had received HPV vaccination, probably due to the mean age being 36 years in nurses and 41 years in doctors. Almost one-fifth (19.3%) of women in our study believed themselves to be self- immune to cancer, one tenth (9.2%) could not afford the test, 15.3% were reluctant for a pelvic exam and 45.9% were not aware that they can ask for a Pap test without any symptoms. The remaining just willfully refused any testing. This depicts that there is a serious difference in making a strategy and actual implementation. On one hand is the WHO Global Strategy for cervical cancer elimination2 and Indian National program for Cervical cancer Screening4 and on the other is the fewer than one in ten women who have actually been screened under this program.

Among nurses, midwives and clinical officers in rural Uganda11, it was seen that 60% of 286 participants had adequate knowledge of cancer cervix and 75% of female participants have undergone screening. It was noted here that who had received training on cervical cancer screening had better knowledge and positive attitude regarding screening. Community health workers in Northern India14 had good knowledge and perception with a practice of less than 10%. It was perceived here that introducing more educational programs and encouraging their participation in screening campaigns may narrow this gap.

Cancer prevention by vaccination further needs to be advertised and the population educated. Even among the well-read people, vaccination in adults is still held sceptical and remains challenged often. HPV is a proven etiology of Cancer cervix and timely vaccination in young girls (9-15 years) does prevent future malignancy. In India, though bivalent and quadrivalent vaccines are available since 20083, its inclusion in National Immunization programme is still pending4. However, focal efforts in some Indian states are promising3. The indigenous quadrivalent vaccine funded by the Indian government and authorized by Drugs Controller General of India (DCGI) is to be imminently included in the National Immunization program and will further the fight against cervical cancer.

None of the female doctors or nurses in a tertiary care hospital in metropolitan city of Southern India had been vaccinated with HPV vaccine12. In a medical college hospital in north India, 80% of the 400 respondent medical and nursing students were aware of HPV vaccine, but only 5.5% were vaccinated, the major concerns being safety, efficacy, availability and cost of the vaccine. Female medical students had better knowledge score and intent to get vaccinated, the major concerns being availability of vaccine in India and the doses required7. Though medical students had in depth knowledge of cancer cervix and HPV, HPV vaccine knowledge and intention to take the vaccine was more among the female respondants9. Most males were unaware of the availability of HPV vaccine. And, cultural barriers and high vaccine cost was of concern in accepting vaccine. This study advocated educating male students and those in dental and nursing courses, healthcare provider recommendation for vaccine promotion and emphasizing their role as a future healthcare provider. In the review of various cross-sectional studies across India from 2012 to 202015, the knowledge of HPV vaccine was as low as less than 1% in urban slums to as high as 32% among urban adolescents across India. Of the 318 health care professional participants among tertiary hospitals across Chennai in south India13, 30 % of eligible respondents underwent screening tests, 19.8% were vaccinated for HPV and 77.2% were willing for vaccination and to recommend it to their family. Lack of awareness among healthcare professionals was the main hindrance to HPV vaccination. In our study, almost 38.4% women knew about HPV vaccine and its availability in India.

The role of personal hygiene and safe sexual practices is being acknowledged as one prime preventive measure across studies7,8,15 and was also emphasized by 80.1% of our study women.

After an interactive session, 80.16% women voted for vaccine uptake for themselves and their family. Also, 71.4% women agreed for Pap testing. This emphasises the need for informative interactive and positive promotional sessions among the existing hospital staff who in turn can be our messengers in the society so that the fight against cancer cervix will be boosted. A preventable malignancy can be made an extinct malignancy.

India is estimated to be the country with world’s highest expected burden of cervical cancer16 and has very poor access to cancer preventive measures17. Public health decisions to set health targets and allocate adequate resources for screening, diagnosis and vaccination will depend on actual burden of disease in a particular population. For cancer cervix epidemiology, the key aspects are sexual behaviour, HPV prevalence and cervical cancer incidence. By applying Footprinting framework18, available data in cancer registries and community survey in local population can be extrapolated to those populations who have similar characters and having no available data. In the Indian context, by this Footprinting technique, India was divided into two groups of 19 and 6 states with low and high cancer cervix incidence. As expected, it was seen that individuals, especially men in high incidence areas had more sexual activity with non- regular partners and here, cancer cervix incidence and HPV positivity was also higher. This Indian case study was in contrast to GLOBOCAN1 as the nationwide cervical cancer incidence derived from aggregating state specific data was lower than the estimate by GLOBOCAN. This is because here, data from 17 additional cancer registries with lower incidence were also included. Lack of data and missing data is always a challenge when preventive strategies are planned.

Local studies and surveys go a long way in understanding the basic culture, behavioural patterns, and acceptance of interventions in preventable diseases. Now, with advent and increasing acceptance of screening tests and vaccination, carcinoma cervix may be categorized as a preventable malignancy. Though our women were always ahead in the education or knowledge aspect, there is definitely a gap in being aware and in being practical.

Our hospital based study included all those women who are the first contact individuals (nurses, final year medical students, medical interns, laboratory technicians, clerks, housekeeping staff ) other than the treating doctor. They are the ones who take care of the people when they come to the hospital and make their visit a comfortable one. They listen kindly to the patient’s woes and add to their recovery, be it in the out-patient department or as an in-patient. Their role as representatives of health care is crucial and improving their knowledge and attitudes about preventive interventions is essential. Specially, the hospital workers other than doctors usually belong to the local population and their data may be extrapolated to the entire area. And, hence, based on these studies, we may be able to plan our strategy in screening the eligible women in our area and vaccinate those young girls to make the now preventable cancer cervix extinct.

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49.
2. World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020.
3. Ahuja M, Sharma P, Sarkar A. Universal cervical cancer immunization: India ready for a quantum leap. J Midlife Health. 2022;13(4):260–2.
4. World Health Organization. Cervical Cancer India 2021 Country Profile. Geneva: World Health Organization; 2020.
5. Ministry of Health and Family Welfare. National Family Health Survey-5 (NFHS-5), 2021. Government of India.
6. Ministry of Health and Family Welfare. Operational framework: management of common cancers. Government of India; 2016.
7. Singh J, Baliga SS. Knowledge regarding cervical cancer and HPV vaccine among medical students: a cross-sectional study. Clin Epidemiol Glob Health. 2021;9:289–92.
8. Ganju SA, et al. Assessment of knowledge and attitude of medical and nursing students towards screening for cervical carcinoma and HPV vaccination in a tertiary care teaching hospital. Int J Community Med Public Health. 2017;4(11):4186–93.
9. Shetty S, et al. An exploratory study of undergraduate healthcare student perspectives regarding human papillomavirus and vaccine intent in India. Womens Health (Lond). 2021;17:1–9.
10. Getaneh A, et al. Knowledge, attitude and practices on cervical cancer screening among undergraduate female students in University of Gondar, Northwest Ethiopia: an institution-based cross-sectional study. BMC Public Health. 2021;21:775.
11. Obol JH, et al. Knowledge, attitudes and practice of cervical cancer prevention among health workers in rural health centres of Northern Uganda. BMC Cancer. 2021;21:110.
12. Swapnajaswanth M, et al. Perception and practices on screening and vaccination for carcinoma cervix among female healthcare professionals in tertiary care hospitals in Bangalore, India. Asian Pac J Cancer Prev. 2014;15(14):6095–8.
13. Chellapandian P, et al. Knowledge on cervical cancer and perceived barriers to the uptake of HPV vaccination among health professionals. BMC Womens Health. 2021;21:65.
14. Khanna D, Khargekar N, Budukh A. Knowledge, attitude and practice about cervical cancer and its screening among community healthcare workers of Varanasi district, Uttar Pradesh, India. J Family Med Prim Care. 2019;8(5):1715–9.
15. Taneja N, et al. Knowledge, attitude and practice on cervical cancer and screening among women in India: a review. Cancer Control. 2021;28:1–11.
16. Bonjour M, et al. Global estimates of expected and preventable cervical cancers among girls born between 2005 and 2014: a birth cohort analysis. Lancet Public Health. 2021;6(8):e510–e521.
17. Sankaranarayanan R, et al. Current status of human papillomavirus vaccination in India’s cervical cancer prevention efforts. Lancet Oncol. 2019;20(11):e637–e644.
18. Man I, et al. Approximating missing epidemiological data for cervical cancer through footprinting: a case study in India. eLife. 2023;12:e81752.