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3]

Original Article

Awareness of cervical cancer and

willingness to participate in screening
program: Public health policy implications
ABSTRACT Somdatta Patra,
Background: Cervical cancer is one of the most common malignancies among women in India. There is a high mortality as patients Madhu
usually present at an advanced stage because of lack of awareness and nonexistent screening programs. Upadhyay,
Pragti Chhabra
Aim: This study was planned to find out awareness about cervical cancer among women and their willingness to utilize screening
services in an urban resettlement colony of Delhi, India. Department of
Settings and Design: A community‑based, cross‑sectional study was carried out in a resettlement colony of North‑West Delhi. Community Medicine,
University College
Materials and Methods: Semi‑structured interview schedule was used to collect information regarding different aspects of cervical of Medical Sciences
cancer. Analysis was done using SPSS package (SPSS version 16 (UCMS and GTBH, Delhi, India)). and GTB Hospital,
New Delhi, India
Results: A total of 373 women were included in the study. Mean age of study participants was 39.14 years. Two‑third of the study
population were illiterate. Half of the study population was aware of cervical cancer, and only one‑fourth of population were willing to For correspondence:
participate in a screening test. Willingness was higher among educated, ever user of family planning method and having knowledge Dr. Somdatta Patra,
about at least one risk factor, signs or symptoms, or possibility of early diagnosis of cancer cervix. Department of
Community Medicine,
Conclusions: The country’s national program advocates for opportunistic and targeted screening of women. An understanding of University College
the factors that influences womens’ willingness to participate in screening program is essential for the success of such programs. of Medical Sciences
Hence, this study emphasizes the need for dissemination of knowledge about various aspects of cancer cervix which is critical for and GTB Hospital,
uptake of any screening program in a developing country. New Delhi, India.
E‑mail: somdattap@
gmail.com
KEY WORDS: Awareness, cervical cancer, screening, willingness to participate

INTRODUCTION to the attention of doctors at an advanced stage

In India, cervical cancer is one of the leading
malignancies among women, with about 130,000
new cases and 74,000 deaths every year[1] accounting
for 30% of global cervical cancer mortality. [2]
India’s cervical cancer age‑standardized incidence
rate (30.7 per 100,000) and age‑standardized
mortality rate (17.4 per 100,000) are the highest
in South Central Asia. Data from some cancer
registries suggest that there may have been a slight
decline in cervical cancer incidence in the recent
years. However, the absolute incidence is still very
high, especially in rural areas, and the number
of cases is increasing due to high population
growth.[3] Although cervical cancer can be treated
effectively if detected in Stage I and II, it does not
when hardly any curative management is possible.
Cervical cancer is a subject that is not freely
discussed in India because of cultural taboo. There
is an urgent need for information and education on
awareness of cervical cancer and early detection
measures. Furthermore, important is to find out the
willingness of women to utilize screening services
and to comply with follow‑up treatment protocol.
Global evidence demonstrates that the key to
reducing cervical cancer morbidity and mortality
is early detection coupled with timely treatment of
cervical precancerous lesions.[4] Cervical cytology Access this article online
often referred to as the Papanicolaou test (Pap test) Website: www.cancerjournal.net
DOI: 10.4103/0973-1482.187279
This is an open access article distributed under the terms of the Creative Commons PMID: ***
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as the author is credited
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cause any symptom in early stages. In the absence and the new creations are licensed under the identical terms.
of a screening program, most of these cases come For reprints contact: reprints@medknow.com

Cite this article as: Patra S, Upadhyay M, Chhabra P. Awareness of cervical cancer and willingness to participate in screening
program: Public health policy implications. J Can Res Ther 2017;13:318-23.

318 © 2017 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow
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Patra, et al.: Cervical cancer and health policy implications
is perhaps the most well known of available screening
methods.[5] The present study was done to find out awareness
of carcinoma cervix, early detection measures, and willingness
of the women to utilize screening services.
MATERIALS AND METHODS
A community‑based cross‑sectional study was done from
January to June 2012 among women residents aged 30–60 years
in an urban resettlement colony (A resettlement colony is defined
as a colony created by removing a group of households from
the congested city core or an encroachment in public places
and locating them generally in the periphery of the city)[6] at
Swarnjayanti Vihar, at Narela in North‑West Delhi, India. This
area is the Intensified Field Practice area of Department of
Community Medicine of a Medical College in Delhi harboring
a population of 8500 approximately with nearly 82% of the
population being original residents of the area.
As no data were available about awareness of cervical cancer
among women from resettlement colony in India, assuming a
prevalence of 50%, an absolute error of 5% and with confidence
level of 95%, the sample size was calculated to be 400. There
were around 1200 households in the study area. One eligible
participant (female, aged between 30 and 60 years) from
every 3rd household was included in the study by systematic
random sampling method. If there were more than one eligible
woman in a household, the eldest was selected for the study.
If a house was found locked or no eligible woman was found
in the house, then the next house was visited.
A pretested semi‑structured interview schedule was used
to collect information. The interview schedule had three
parts. The first part had details about sociodemographic
variables (age, education, marital status, number of children,
and family income) and family planning practices. The second
part had questions to find out the awareness about risk factors,
signs and symptoms of cervical cancer and its prevention.
The questions were developed based on review of literature
and previously established facts about cervical cancer.
Two questions were included, which were not associated
with cervical cancer, to assess alternative beliefs and deter
patterned responses.[7] One of these questions was about
a potential association of frequent sexual activity with the
same partner and cervical cancer risk, and the other asked
about a potential association of multiple miscarriages with
cervical cancer.
In the third part, all study participants were asked, after
explaining the procedure of Pap smear, if they were willing
to participate in a cervical cancer screening program if that
was available in the nearby hospital. Cervical cancer screening
was not done on a regular basis in the nearby secondary level
of hospital. The interview schedule was applied with the
help of a community volunteer who was adequately trained
for this purpose and was experienced in conduct of similar
Journal of Cancer Research and Therapeutics - Volume 13 - Issue 2 - April-June 2017
field‑based health surveys. She was directly supervised by
the investigators.
The data thus collected were entered into MS Excel and after
cleaning was analyzed using SPSS version 16 (UCMS and GTBH,
Delhi, India). Simple descriptive tables were generated to denote
frequencies. Cross‑tabulation and Chi‑square test were applied to
study the association of various sociodemographic characteristics
with awareness about cancer cervix and willingness to
participate in the screening program for cancer cervix.
Approval of Institute’s (Medical College) Ethics Review
Committee was obtained before initiation of the study.
Informed written consent was obtained from all study
participants and as and when required they were appropriately
treated or were referred to a higher center for any reported
morbidity. During the study, it was ensured that if any of
the study participants were willing to undergo screening,
she would be facilitated for further investigations and
management. This study was done before the department
organized a health education program to spread awareness
about cancer cervix.
RESULTS
Characteristics of the study population
A total of 373 women were included in the study. Mean age
of the study participants was 39.14 years ± 7.59 standard
deviation with majority (66%) being in the age group of
30–40 years. Two‑third of the study population (65%) were
illiterate and half of them had never used any family planning
method. Mean income per capita was Rs. 764.10 with 61%
of the population having per capita income of Rs. 501–1000.
Awareness of cervical cancer
Out of the 373 women interviewed, 80% (n = 298) were aware
of cancer as a disease. However, a little more than half of
women (n = 201) were aware of cervical cancer.
The proportion of women who were aware of cancer cervix
increased as the literacy status increased, and this association
was statistically significant. Similarly, those who had a
higher per capita income were more aware of cervical cancer
as compared to those belonging to a family with a lower
per capita income and this difference was also statistically
significant. Statistically significant association was also seen
between ever use of a family planning method and awareness
about this particular cancer. However, we did not find
statistically significant association between age and awareness
of cervical cancer [Table 1].
Knowledge about established risk factors of cancer cervix
The women who were aware of cancer cervix (n = 201) were
asked about the risk factors of this cancer. Only 55% (n = 110)
mentioned at least one risk factor correctly. Twenty‑nine percent
of women (n = 58) mentioned advancing age as a risk factor.
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Patra, et al.: Cervical cancer and health policy implications

Table 1: Association of awareness of carcinoma cervix with sociodemographic characteristics of study subjects (n=373)
Variable Number Aware Not aware P* OR (95% CI)
Age (years)
30-40 246 131 (53.3) 115 (46.7) 0.10 1
41-50 96 58 (60.4) 38 (39.6) 0.74 (.46-1.20)
51-60 31 12 (38.7) 19 (61.3) 1.8 (0.83-3.87)
Educational status
Illiterate 239 112 (46.9) 127 (53.1) <0.01 3.46 (1.89-6.34)
years 65 37 (56.9) 28 (43.1) 2.31 (1.1-4.83)
>5 years 69 52 (75.4) 17 (24.6) 1
Per capita income (rupees)
≤500 104 44 (42.3) 60 (57.7) 0.012 2.27 (1.07-4.80)
501-1000 229 132 (57.7) 97 (42.3) 1.22 (0.61-2.44)
>1000 40 25 (62.5) 15 (37.5) 1
Use of modern methods of family planning
Ever user 189 131 (69.3) 58 (30.7) <0.01 3.67 (2.39-5.64)
Never used 184 70 (38.0) 114 (62.0)
*P value calculated using Chi‑square test. OR=Odds ratio, CI=Confidence interval

Thirty‑eight percent (n = 77) women rightly identified onset of Table 2: Respondents’ knowledge about various aspects of
sexual intercourse at an early age do have some consequence cancer cervix (n=201)
on occurrence of carcinoma cervix. Over 53% (n = 107) of Response Number (percentage)
participants mentioned nonmaintenance of hygiene at the of correct response
time of menstruation as a risk factor for cancer cervix. Other Risk factor
Mentioned at least one risk factor correctly 110 (54.7)
established risk factors which were rightly interpreted were Increasing age 58 (28.9)
multiparty (24%, n = 49), smoking (12%, n = 24), and absence Sexual intercourse at young age 77 (38.3)
of Pap testing (3.5%, n = 7). Only 10% (n = 21) wrongly Having multiple sexual partners 82 (40.8)
identified frequent sexual activity with the same partner, Having frequent sexual activity with the 21 (10.4)
same man*
whereas 41% (n = 83) believed multiple miscarriages as a risk Having sexual activity with a man who has 87 (43.3)
factor for cervical cancer [Table 2]. had multiple sexual partners
Nonmaintenance of menstrual hygiene 107 (53.2)
Knowledge of signs and symptoms Having a history of a sexually transmitted 73 (33.6)
disease
Out of 201 participants who were aware of cervical cancer Having several miscarriages* 82 (41.3)
as a disease, 46% were aware of at least one signs and Giving birth to many children 49 (24.4)
symptoms correctly. Forty percent (n = 80) of them were Smoking/consumption of tobacco 24 (11.9)
aware that bleeding between two menstrual cycles could Lack of Pap smear testing 7 (3.5)
Signs and symptoms
be a sign of cervical cancer. Thirty‑two percent (n = 65) of Mentioned at least one sign or symptom 92 (45.7)
study population mentioned bleeding after intercourse as a correctly
symptom. Almost one‑fourth of the study population were Bleeding between the cycles 80 (40.2)
Bleeding after intercourse 65 (32.3)
aware of postmenopausal bleeding and discomfort during
Postmenopausal bleeding 90 (44.7)
intercourse (n = 90 and 92) as signs of this cancer. Twenty‑one Discomfort during intercourse 92 (45.7)
percent of the study population mentioned abnormal vaginal Abnormal vaginal discharge 77 (20.6)
discharge as a symptom. Only twenty women mentioned pain Pelvic pain 20 (9.9)
Early detection measures
in pelvic region as a symptom. Early detection possible 23 (11)
Early detection through Pap smear 15 (7)
Knowledge about early detection methods Early detection through clinical examination 20 (10)
Only 11% of the participants (n = 23) were aware that cervical Source of information
Friends and relatives 132 (65.6)
cancer can be detected early. Fifteen respondents (7%) said Health‑care personnel 56 (27.8)
that it could be detected by Pap smear. Ten percent of the Print media 50 (25)
women thought it could be detected by clinical examination Television 33 (16)
by a doctor. Thirty‑nine percent women (n = 78) thought a Radio 23 (11.4)
*Was asked to assess alternative beliefs and deter patterned responses
treatment for this particular form of cancer is available.

Source of information Willingness to participate in a cervical cancer screening

Most of the respondents had heard about cervical cancer from
friends and relatives.
Other sources of knowledge were health‑care personnel (28%),
print media (25%), television (24%), and radio (11%).
program
All study participants were explained about the importance
and procedure of the established screening test for carcinoma
cervix and were asked if such a facility was available to
them whether they would be willing to undergo such a

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Patra, et al.: Cervical cancer and health policy implications

test. Only one‑fourth (n = 90) of the study population were
willing to go through a screening test for cancer cervix.
It was found that willingness to participate was higher
with higher literacy status and ever use of family planning
methods. Study participants who were aware of at least one
correct risk factor or one sign/symptom or possibility of
early detection of this particular form of cancer were more
willing to participate in screening program than people who
were not aware these aspects. No significant association was
found between willingness to participate and participant’s
awareness of cervical cancer as a form of cancer, age, and
income per capita [Table 3].
DISCUSSION
In the present study, we found that only 54% of the respondents
were aware of cervical cancer as a disease. Those who were
aware were more likely to be educated and have a higher per
capita income than those who were not aware.
The present study population had very poor knowledge about
established risk factors of cancer cervix which is consistent
with findings elsewhere from India.[8,9] Only 11% of women
who were aware of cancer cervix thought that early detection
was possible, and only 7% were aware of Pap smear as a
screening technique. The findings of our study concurred
with a similar study done in Malaysia in 2009.[10] Two‑third of
the study population who were aware of cervical cancer had
heard about it from neighbors and relatives. Television, a very
popular mass media, was mentioned as a source of information
only by 16% of study population. Similar findings were
reported from a study done in Mangalore, which mentioned
television as a source of information for cervical cancer by
only 14% women.[11]
Our study revealed that willingness to participate in a
screening procedure was higher among those who were
educated and had ever used any modern method of
family planning which was consistent with reports from
other studies conducted across Maharashtra and rural
Uttar Pradesh, India.[12,13] Although we did not find age
as a significant factor for willingness to participate in a
screening program for cancer cervix, a study from Kerala
reported an increase in participation with increase in
age.[14] The probable reason for this difference could be
better awareness levels and access to health care and more
exposure to the health‑care providers in that region. We
found that women who were aware of some risk factors,
signs and symptoms, were willing to participate than who
were not aware. All the women (100%) who were aware
that early detection is possible were willing to participate
in a screening program.
Studies of various aspects of knowledge have demonstrated
that the lack of knowledge about cervical cancer appears to
be an important factor to determine women’s willingness to
participate in cervical cancer screenings program.[15‑17]
Till now, there is no established national screening program
for cervical cancer in India. Screening programs have been
shown to reduce the incidence and mortality from cervical
cancer in many developed countries. [18‑22] The National
Programme for Prevention and control of Cancer, Diabetes,
Cardio Vascular Diseases, and Stroke (NPCDCS) advocates for
opportunistic and targeted screening of women of the age
group >30 years at district NCD clinic for early detection of
cervix cancer.[23]
Success of any screening program primarily depends on
screening uptake or high level of screening attendance.
Prior‑understanding of the factors that determine women’s
willingness to participate is the central key for this. This study
reported willingness to participate in a screening program was
higher among participants who were aware of risk factors,

Table 3: Willingness to participate in a screening program in relation to sociodemographic characteristics and awareness of
various aspects of cancer cervix (n=373)
Variable Number Willing Not‑willing P* OR (95% CI)
Age (years)
30-40 246 56 (22.8) 190 (77.2) 0.57 1
41-50 96 27 (28.1) 69 (71.9) 0.75 (0.44-1.28)
51-60 31 7 (22.6) 24 (77.4) 1.01 (0.41-2.46)
Educational status (years of education)
Illiterate 239 49 (20.5) 190 (79.5) 0.01 2.34 (1.31-4.18)
1-5 years 65 15 (23.1) 50 (76.9) 2.01 (0.94-4.28)
>5 years 69 26 (37.7) 43 (62.3) 1
Per capita income (rupees)
≤500 104 22 (21.2) 82 (78.8) 0.66 1.41 (0.61-3.27)
501-1000 229 57 (24.9) 172 (75.1) 1.14 (0.53-2.43)
>1000 40 11 (27.5) 29 (72.5) 1
Use of modern methods of family planning
Ever user 189 58 (30.7) 131 (69.3) <0.01 2.10 (1.28-3.43)
Aware of cancer cervix 201 43 (21.4) 158 (78.6) 0.09 0.72 (0.44-1.16)
Knowledge of at‑least one risk factor 110 36 (32.7) 74 (67.3) 0.01 1.87 (1.14-3.09)
Mentioned at least one correct sign or symptom 92 29 (31.5) 63 (68.5) 0.02 1.66 (0.98-2.80)
Early detection possible 23 23 (100)
*P value calculated using Chi‑square test. OR=Odds ratio, CI=Confidence interval

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Patra, et al.: Cervical cancer and health policy implications
signs and symptoms, and possibility of early diagnosis.
Association between awareness about cervical cancer and
willingness to participate in cervical cancer screening program
has been documented by other studies too.[24,25] This finding
emphasizes the need for dissemination of knowledge about
this cancer to ensure uptake of screening services. It was
also found that the primary source of knowledge was from
relatives and neighbors. It has been reported that anxiety
associated with cervical cancer screening results from
insufficient information or magnification of different facts.[26]
There is a need to disseminate the correct knowledge which
is sensitive to religious and cultural need. Popular mass media
and commercials can be used to raise awareness.[27] Trained
nonmedical personnel like Accredited Social Health Activist
who are females and are from the same or nearby community
can also act as a key link for raising awareness.
CONCLUSION
Women in this community were ignorant about risk factors,
signs and symptoms, and early detection measure of this
particular cancer. Specific knowledge on cervical cancer and
its early detection in precancerous stage and subsequent
treatment is needed.
The limitation of this study was that it was a quantitative study
and hence psychosocial and cultural reasons for not willing to
participate in screening test could not be explored in depth.
Other limitations were the study participants belonged to low
income and less educated group, and so the results may not
be generalized to other parts of India.
Our study recommends an urgent need to educate women in
the community on different aspects of cervical cancer. Special
efforts would be required for the core group of illiterate women
for a better impact on screening acceptance. We recommend
the establishment of policy guidelines for enhancement of
knowledge among women for cervical cancer.
Financial support and sponsorship
Intramural Research Grant, University College of Medical
Sciences and GTB Hospital, Delhi, India.
Conflicts of interest
There are no conflicts of interest.
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