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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 81-87

Knowledge on human papillomavirus and cervical cancer awareness among women in South India


1 Genetics Laboratory, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India
2 Department of Immunology and Microbiology, The American College, Madurai, Tamil Nadu, India
3 Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India

Date of Web Publication13-Sep-2019

Correspondence Address:
Dr. V Ramakrishnan
Genetic Laboratory, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Kelambakkam - 603 103, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_69_18

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  Abstract 


Background: Cervical malignancy is a major health problem threatening women community in the developing countries. Aims: The main objective of this study is to investigate the awareness, knowledge of human papillomavirus (HPV) and cervical cancer (CC) risk factors among women. Methods: A cross-sectional, questionnaire-based, survey was conducted among females aged from 15 to 64 years in Tamil Nadu. It contained questions on sociodemographic data, awareness, knowledge of HPV and CC. Results and Conclusion: Of the 573 participants, only about 19% of women in Tamil Nadu were aware of CC and they know it is the second-most common gynecological cancer found among women in the country. About 14% of women were aware of HPV and HPV vaccine. Merely about 9% recognize that CC can be prevented and 7% say that HPV can be sexually transmitted. This study reveals that there is a low level of awareness and knowledge of HPV, CC among women in Tamil Nadu. The present study indicates the need for government organizations, health-care providers to join hands to educate middle-aged women with low educational status, create social awareness about the disease, its symptoms and reduce the risk of having CC in the population.

Keywords: Awareness, cervical cancer, human papillomavirus, papanicolaou, Tamil Nadu


How to cite this article:
Husain R S, Ramya D, Pradeep M A, Govindaraju S, Ramakrishnan V. Knowledge on human papillomavirus and cervical cancer awareness among women in South India. Saudi J Health Sci 2019;8:81-7

How to cite this URL:
Husain R S, Ramya D, Pradeep M A, Govindaraju S, Ramakrishnan V. Knowledge on human papillomavirus and cervical cancer awareness among women in South India. Saudi J Health Sci [serial online] 2019 [cited 2019 Dec 12];8:81-7. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/2/81/261541




  Introduction Top


Cervical cancer (CC) is the most common gynecological malignancy worldwide. In the current scenario, this disease is primarily found in developing and in low-income countries.[1] It is easily preventable through routine screening, follow-up, and treatment; 80% of women who are sexually active get affected by persistent human papillomavirus (HPV) infection leading to cervical malignancy. Annually 527,624 lakh new cases are being reported, and 265,653 deaths have been occurred due to cervical malignancy worldwide in the year 2012.[2] One-fourth of the global burden of cancer cervix is contributed equally by the countries located in the South Asian region.[3]

The prevalence of HPV infection was found to be increased with age; it has been reported to 6.6%, 11.4%, and 19.2% in preadolescent girls, adolescents, and young adults residing in north India, respectively.[4] The mortality and morbidity rates of the uterine cervix are highly elevated, so early diagnosis followed by the treatment is the way of prevention. The infection caused by HPV is very commonly found in young women who have sexual activity at an early stage or before 25 years of age without any clinical consequence.[5] Approximately in 10% of cases, HPV infection persists and is associated with lesions getting regressed or remains stable progressing to invasive CC. The prime etiologic agent causing cervical neoplasia is HPV; nearly 200 serotypes of the virus are reported to date, among that HPV 16 and 18 genotypes accountable for nearly 70% of cervical malignancies.[6] The additional risk factors for CC include coinfection with human immune deficiency virus (HIV), herpes simplex virus type II, infection by Chlamydia trachomatis, poor personal hygiene, early marriage, tobacco usage, multiple sexual partners, and usage of oral contraceptives over a long term.[7]

Papanicolaou (PAP) smear test-based screening is well established and followed worldwide for detecting the precancerous/malignant lesions. It is cost-effective and detection of sexually transmitted infections can also be performed in a single smear.[8] There are several factors contributing CC screening ineffective in low-income countries, such as the nonexistence of national screening system, low access of rural population to health-care facilities, and lack of technical and laboratory expertise followed by less awareness in public. Accessing the correct information has also been prohibited by the respondents' illiteracy and their religious beliefs.[9] The American Cancer Society has been recommended to screen for cervical neoplasia for the women aged from 21 years, repeating the tests every 3 years up to 30 years and every 5–65 years of age combining PAP, HPV testing.[10]

Early diagnosis can decrease the chance of CC approximately 40% on the other side, reducing the mortality and incidence rate.[11] Currently, the available vaccines for HPV such as “cervarix” bivalent and “gardasil” quadrivalent are used to prevent HPV infection caused by high risk 16, 18 types; both of them are highly effective.[12] A previous report from north India showed that there was a low percentage (15%) of awareness on HPV and cancer cervix among the students attending schools and along with their parents. In the total, only 13% of the respondents were aware of HPV and CC, were agreeable to get vaccinated for HPV.[10] The diagnosis of cervical malignancy, when made in an earlier stage such as 1A1–1B2 (FIGO staging) are linked with higher survival rates from 80% to 99%. Knowledge and awareness is the major social tool in any disease prevention. Adapting them to good personal hygiene, sticking with the balanced diet, information about the risk factors of the disease should be well-known to women community in eradicating the disease in early stages. The present study has been carried out on a total of 573 women residing in Tamil Nadu to assess their awareness and knowledge on HPV, CC. The findings from this current study might be useful to know the awareness percentage on CC in the women community.


  Methods Top


A cross-sectional, descriptive intervention study design has been used. Six places (three places from North and three from South Tamil Nadu) were randomly selected, and it was planned to collect opinion about CC among women living in these places. The participants were working in nongovernmental organizations (NGOs), educational institutions, homemakers, college students and they were personally interviewed by the two investigators (AH and RM) independently from July to December 2015 for 6 months. The questionnaire was prepared in two languages such as English and Tamil (native) language, framed based on the objectives of our study using published literature for the past 5 years.[1],[8],[13],[14],[15],[16],[17] The questionnaire consists of three segments. The first segment contained information such as age, religion, place of birth, current residential area, marital status, socioeconomic status, level of study, study stream, and their working status. The second section had questions on knowledge of CC and HPV, followed by the third segment containing questions about risk factors, awareness of signs, symptoms of the disease, and finally about HPV vaccine. After completing the questionnaire, the correct answers were provided by the investigators to educate the study participants for getting awareness and knowledge on CC.

A total of 600 respondents were personally interviewed, and after omitting incomplete/missing information of some participants, opinions of only 573 respondents were included in the final analysis. The present study was reviewed and approved by a review board of The American College, Madurai, Tamil Nadu. For all the study subjects, informed consent has also been obtained as per the ethical guidelines, by explaining the purpose of CC awareness study. The information collected from the designed questionnaires was coded, verified, and carefully entered into an Excel spreadsheet. All the data were analyzed using SPSS software version IBM SPSS (version 21.0, IBM, New York, United States) to evaluate the association between the demographic factors with CC and HPV.


  Results Top


Data collected from 573 respondents were used for the analysis. Demographic characteristics, such as age, religion, marital status, and socioeconomic status of the respondents, were summarized in [Table 1]. It contains the number of respondents along with the percentages for the complete data. Of a total of 573 respondents covered in the study, 459 women were not aware and 114 women were aware of CC. From the analysis of the data, it is found that nearly 83% of women were in the age group of 15–34 years. Based on the participants' religion, nearly 71% were Hindus, about one-fifth of the women follow Christianity, and 9.4% were Muslims. Among the above-mentioned religions in India, the awareness observed was less in Muslims when compared with Hindus and Christians; this demonstrates that Muslims in Tamil Nadu were less aware of cervical malignancy. When compared with all the demographic characteristics, about 56% women were unmarried, nearly 93% hail from the middle-income group, 81% of women were either graduates or postgraduates, about 91% were from arts, science or engineering streams, about 42% of women were employed and 37% were students.
Table 1: Sociodemographic characteristics of the studied population

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The awareness of top-ranked cancers in women was asked to the participants, 81% of the women responded for breast and ovary followed by 7% for breast and CC, respectively. In 114 women, who knew about CC, 67% have said that they heard about CC from various sources such as TV/radio and FM/Newspapers/Magazines/Internet/NGOs and 58% knew that infection as the major cause/reason for cervical malignancy. Only 9% of the respondents said the peak age of getting CC was from 45 to 54, and about 18% of the 114 women's relatives were affected with CC. To analyze whether the percentages in each one of categories listed under a group as the same, Chi-square tests were applied with the assumption that the percentage remains the same in all the categories listed under an item. If the significance value (i.e., P < 0.05), the null hypothesis of equal proportion or percentage has been rejected. If there are only two categories under an item, the equality of 50% (or 0.5 proportion) in each one of the two categories was tested using a Binomial test. If P < 0.05, the hypothesis has been rejected.

As far as, the awareness of CC was concerned, only about one-fifth of women were aware of CC and have said it is very common in our country, 16% knew that cervix is the mouth of the uterus, and only about 12% agree that CC ranks the second-most common disease in India. Nearly 14% of women were aware of HPV, and they also knew about the HPV vaccine. 7% of the women knew about the PAP test, and they also know it is being used to diagnose CC. About 9% of women knew that CC can be prevented. Out of the women who knew about CC, about 70% were aware of HPV and HPV vaccine, 36% know about  Pap smear More Details test and confirm that it is being used to diagnose CC. Only about 46% of women who knew about CC believe that it is curable [Supplementary Table 1].



Furthermore, the respondents were asked about the major risk factors leading to cervical malignancy, and the results were summarized in Supplementary Table 2]. As far as, the risk factors of CC are concerned, smoking habits and tobacco usage were cited as reasons for getting CC by about 13% of the respondents, having multiple sexual partners as a factor by 10% of women, 13% said that nutrient deficiency as the reason, followed by 11% of the respondents mentioning that maintaining poor personal hygiene has been reasonable, and finally, 8% said that high usage of oral contraceptives and HIV infection may be cause for getting CC. When comparing the knowledge of risk factors with urban and rural population, 15% of the participants residing in urban areas know the risk factors of CC whereas only about 5% of the rural people know about the risk factors of CC.



It is of our interest to know whether awareness of CC can be associated with demographic characteristics such as age, religion, place of residence, marital status, level of education, socioeconomic, and working status. [Table 2] shows details such as odds ratio (OR), 95% confidence interval (CI), Z statistics and significance between awareness level of CC with various demographic characteristics of the women respondents of the present study. None of the demographic characteristics played a role in the awareness of CC as the significance value of the Z statistics were all >0.05. Similarly, the ORs for different demographic characteristics were not significant since 95% CIs of all ORs contain the value 1. It can be inferred from [Table 2] that awareness of CC was not being associated with any of the demographic characteristics such as age, religion, place of residence, marital status, level of education, and socioeconomic or working status. The awareness of CC with respective of age with two groups such as ≥25 years and<25 years yielded an OR = 0.95, 95% CI: 0.63–1.44 and Z = 0.2. Likewise, the awareness of CC in their residential area such as rural and urban showed OR = 0.93, 95% CI: 0.56–1.52 with Z = 0.28. Both the demographic characteristics were not statistically significant with the awareness of cervical malignancy.
Table 2: Demographic characteristics and the awareness of cervical cancer

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An attempt has been made to examine the association between the demographic characteristics and knowledge about various aspects of cervical malignancy among women who were aware of CC. The aspects which were found to be significantly associated have been summarized in [Table 3]. The associations were tested using Fisher's exact and Pearson's Chi-square tests. It was found from the table that the age of women was significantly associated with awareness, signs, and symptoms of CC. The value of OR is 3.00, with 95% CI: 1.28–7.0 with (Fisher's exact test) P = 0.010 for the parameter cervical malignancy as the second-most common cancer between the students and employed/homemaker. Similarly, for the awareness of CC between the above-mentioned two groups were significantly associated and yielded OR = 3.21, 95% CI: 1.25–8.21 with a P value (Fisher's exact test) = 0.012, respectively. Working status was significantly associated with aspects such as “CC the second-most common cancer found among women in India” and “aware of signs and symptoms of cervical malignancy.” The place of residence of women was also significantly associated, with the belief that hereditary factor was also a cause for CC.
Table 3: Demographic characteristics of women who are aware of cervical cancer and the odds ratio of the significant parameters studied

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Knowledge on PAP smear test between middle-income group and low-/high-income group showed significant association with OR = 0.30, 95% CI: 0.09–0.99; P value (Fisher's exact test) =0.041. Similarly, socioeconomic status was associated with hearing about PAP smear test, and PAP is used to diagnose CC. As far as, the awareness of CC was concerned, a woman whose age ≤25 years had 2.33 times higher chances of having the awareness of CC compared to a woman whose age was >25 years. Similarly, a younger woman (25 years or less) has 2.4 times higher chance knowing about the signs and symptoms of CC compared to an older woman (>25 years). As far as, the working status was concerned, there was three times higher chance of a student knowing that CC as the second-most common cancer and to know about the signs, symptoms of CC compared to a homemaker or a working woman. Finally, by combining all the parameters, the majority of women were from the age group of 15–34 years, follow Hindu religion, belong to a middle-income group, studied up to graduate or postgraduate levels and were employed or homemakers. Only about one-fifth of women in Tamil Nadu were aware of cervical malignancy, and they know it as the second-most common cancer found among women in the country. Only 14% of women respondents were aware of HPV and the vaccine for HPV. In that 7% of women were heard of PAP smear and know that it can be used to diagnose cervical malignancy. About 9% of women in Tamil Nadu say that CC can be prevented. Out of 114 women who knew about CC, nearly 70% were aware of HPV and HPV vaccine in which only 36% of these women knew about PAP smear and the purpose for which it has been used. Nearly 46% of these groups have said that CC can be prevented.


  Discussion Top


The majority of our respondents in this awareness survey were unable to identify CC as a public health problem threatening the women community. Nearly about one-fifth of women in Tamil Nadu were aware of CC, and they also knew it as the common malignancy found in women. About 12% agree that CC as the second-most common cancer and only about 14% of women aware of HPV. A similar study in the year 2011 from the educated youth residing in three countries such as India, Nepal, and Srilanka had less knowledge of CC and its risk factors such as HPV, sex with multiple partners and low-nutrient consumption in developing cervix cancer.[16] Poor awareness and knowledge of cervical malignancy among women have been well documented in diverse ethnic populations from various countries.[18],[19] Numerous studies have been performed worldwide to evaluate the knowledge, attitude, and awareness about cervical malignancy, HPV vaccines. Those studies have reported better knowledge in the developed countries such as Australia, Belgium, and the USA but less knowledge of HPV, CC in other countries such as China, Turkey, and Thailand.[20],[21],[22]

According to knowledge, awareness, and prevention studies published over a period of past 15 years targeted at young women worldwide with a range from 13% to 93%.[23] A study from 2500 school, undergraduate students along with their parents in the year 2014 from north India showed a low percentage (15%) in CC and also in HPV awareness. In addition, only about 13% of respondents who were aware of HPV and CC were willing to accept HPV vaccines.[15] Earlier studies published between the years from 2005 to 2014, the sociodemographic characteristics of the study participants had a huge influence on the rate of having their PAP testing for cancer diagnosis.[24] In the present study, demographic characteristics were not significantly associated with awareness of CC and PAP smear among women in Tamil Nadu. Our results showed low levels of CC and HPV knowledge up to 19% of participants in the medical stream. A study conducted among medical students from India in the year 2012 documented that 89.6% of the participants were aware that cancer cervix can be preventable.[25] Similarly, results from our study noted that 35% of awareness regarding the relation between HPV sexual activity and CC.

In another study published in 2010 from India reveal that 41% of the respondents were aware of the link between cervical malignancy and sexual behavior.[26] Comparing with other studies published from countries such as China, Korea, and Malaysia have reported low level of knowledge sexually transmitted infections and HPV in the development of cervical neoplasia as a causative risk factor of the disease.[27],[28] A study from north India demonstrated that the women residing in urban areas had fine knowledge about “HPV infection causing genital cancer” than the women from rural areas[15] and similarly we also found in this current study, that knowledge about HPV was higher in the urban areas. With these data, we can infer that more attention should be given to educating the women residing in rural areas. In the developed countries such as the USA and the UK having a well-integrated screening program for cervical malignancy with the PAP test, the knowledge about HPV was also reported to be very low.[29] In contrast to the above results, a study published from Australia has shown a relatively high rate of HPV awareness of 51.2%, which may be due to the implementation of HPV vaccination programs.[30] A study published in the year 2014 from Mangalore in Karnataka showed awareness among married women attending the family planning, postnatal clinics, and nearly 36% have heard about HPV infection by sources such as media and also by their gynecologist/physician.[15] In China, school-based or government-sponsored programs were also recommended as one of the initiative measures in improving HPV awareness, knowledge, and acceptability of HPV vaccination.[13] Health-care professionals should provide information to the women attending the hospitals/clinics, to increase knowledge, awareness on cervical malignancy, risk factors, and seriousness of PAP smear test as the preventive strategy in early diagnosis of this malignancy.[14] There were few limitations in this cross-sectional study such as (i) The study has been limited only to six places in Tamil Nadu and (ii) Most of the females were from an urban background. Hence, a detailed study covering several districts with large sample sizes are required, it might throw more light on awareness, knowledge in cervical malignancy among women in Tamil Nadu.


  Conclusion Top


During this survey, we have identified low levels of knowledge and awareness of cervical malignancy in women, the absence of nationwide mass cervical screening program might be the reason for lack of awareness in both urban/rural women. Currently, there is a strong need of knowledge, awareness on CC in Tamil Nadu region; so that, the women community can identify the symptoms of CC and also take the preventive measures in eradicating the disease. If the women have adequate knowledge, symptoms of this disease, they can plan for regular HPV testing every 3 years, and early diagnosis of genes associated with cervical malignancy. Cancer screening programs should be organized freely in urban/rural sectors, and women community should be sensitized for accepting, administering the HPV vaccines.

Acknowledgments

We express our gratitude to all the volunteers who agreed to take part in the current study. The author (AH) wishes to acknowledge Chettinad Academy of Research and Education for providing Chettinad Research fellowship. The authors (RM, AP) were thankful to the Principal and Secretary of The American College for the constant support and encouragement during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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