Premenopausal Women’s Awareness and Barriers Regarding Cervical Cancer and its Screening

Introduction

Cervical cancer is a major public health concern globally and a significant cause of mortality and morbidity in women. It is the 4th most common cancer amongst women globally, with an estimated 311,000 deaths and 570,000 new cases reported worldwide in 2018, with about 85% of these cases occurring in low- to middle-income countries (LMICs). (Chisale et al., 2021).

Cervical cancer is a malignant tumour of the cervix that can be divided into two histological types, adenocarcinoma (AC) and squamous cell carcinoma (SCC). SCC is more common and has an occurrence rate of 70%. AC originates from glandular cells that line the cervical canal (the endocervix), whereas SCC originates from squamous cells lining the outer part of the cervix that opens to the ectocervix. The region in which the squamous and the thin, flat glandular cells are located is termed the transformation zone, and the majority of tumours originate from this zone. 
(Hull et al., 2020).

Despite its preventable nature, globally cervical cancer is regarded as the third most common form of cancer among women after breast and colorectal cancer. The women of poorer communities are mostly affected by the disease. It is evidenced that, approximately 83% of the world’s new cases and 85% of all cervical cancer deaths reported are from developing countries. (Mengesha et al., 2020).

Cervical cancer screening is an essential part of a woman’s routine health care. Cervical cancer screening can be done in a medical office, a clinic, or a community health center.. The primary goal of screening is to identify precancerous lesions caused by HPV so they can be removed to prevent invasive cancers from developing. A secondary goal is to find cervical cancers at an early stage, when they can usually be treated successfully. Routine cervical screening has been shown to greatly reduce both the number of cervical cancer cases and deaths from the disease. 
(Henke et al., 2021)

Barriers for undergoing screening practice were knowledge-related barriers (lack adequate information regarding cervical cancer), symptom-related barriers (lack of symptoms as a barrier for screening). And health system-related barriers (the service is not available at health center. (Getachew et al ., 2019)

The nurse has the essential role in avoidance of cervical cancer owing to being a vital cog in the healthcare delivery system. Fortunately, the nurse plays a key role in health education and promotion. Moreover, the nurse has an important task of imparting information on risk factors, discovering early signs of cervical cancer, HPV, and encouraging females to undergo cervical cancer screening frequently. (Ebrahim et al., 2021).

Significance of the study

Egypt has a population of 30.55 million, where women aged 19 years and older are at a risk of acquiring cervical cancer. According to recent estimates, 866 women are diagnosed with cervical cancer each year, with 373 dying as a result. Cervical cancer is the tenth most common malignancy in Egyptian women between the ages of 19 and 44.
(Ahmed et al., 2022).

Globally, cervical cancer is the third most common cancer in women, with the highest incidence occurring in those aged 40–49 years. Although common worldwide, the burden of cervical cancer is greater in developing regions, with significant disparities in mortality due to economic, regional, and racial disparities. Knowledge about disease and early screening is the most effective measure for Cervical Cancer prevention. Lack of awareness, negative attitude, and poor practice about Cervical Cancer and screening and preventive methods are the major causes to increase the incidence of disease. Early detection and treatment via screening can prevent up to 80% of Cervical Cancers.
(Taneja et al., 2021).

 Awareness raising among the general public about the cervical cancer issue and the prevention mechanisms as well as campaigning for effective policies and services are important strategies for reducing population cervical cancer. Early detection of cervical cancer is also of great importance for improving women's health and reducing the risk of death from cancer. (Zagloul et al., 2020).

Aim of the study:

To determines the level of premenopausal women^’s awareness and barriers regarding cervical cancer and itʼs screening.

Research question:

1. What are the awareness and barriers of cervical cancer and It’s screening among   premenopausal women?
2. What are the socio –demographic factors associated with awareness and barriers of cervical cancer and It’s screening among   premenopausal women?

Subjects and Methods:

Research Design: A descriptive cross sectional research study.

Research Setting: This study was conducted at inpatient department and outpatient   clinic for obstetrics and  gynecological diseases at Minia university maternity and children hospital were included in this study.

Time of data collection: The data collection period began from the beginning of April 2021 till October 2021 for six months.

Sample size: Convenience Sample of (235) premenopausal women were recruited in to this study.

Inclusion criteria:

• Premenopausal women with gynecological diseases.
• Women at age from 40-50 years

Exclusion criteria:

• Psychiatric disorders.
• Women suffering from cervical cancer.

Tools of data collection:

Interviewing questionnaire were developed by the researcher after reviewing of related literature.  It consisted of three tools:

First tool: Interviewing assessment tool.

It consisted of (30) items. It encompassed three main parts: 

Part 1: concerned with women’ socio -demographic characteristics: such as age, Level of education, occupation, residence and marital status. In addition to source of knowledge about cervical cancer and it’s screening.

Part 2: Obstetrical and Family history: such as age atfirst birth, gravidity, parity, number of abortions, breastfeeding and Family history of cancer and cervical cancer.

Part 3: concerned with assessment knowledge of the studied women regarding cervical cancer and it ^̕s screening. It was adopted by (Thapa et al., 2018) included (17) multiple choice questions about definition of cervical cancer, risk factors, signs &symptoms of disease,Prevention of cervical cancer, diagnosis, methods of treatment, complications of disease, knowledge about pap smearand cervical cancer screening procedure.

Scoring system:

The answer was evaluated using model key answer prepared by the researcher, the women s answer related to knowledge were scored and calculated. the score was (1) score for correct answer & (0) score for incorrect answer and don’t know, the total knowledge score (17) was classified as adequate knowledge if the total score equal and higher 50% and inadequate knowledge if the total score less than 50%.

Second Tool: Attitude assessment tool   

It was adopted by ‏(Riaz et al., 2019)

Α modified Likert scale was used to assess the attitude of Premenopausal women to cervical cancer and it̕ s screening. The scale consisted of 14 statements related to cervical cancer & early detection measures.

Scoring for attitude:

 Assessed the attitude using a 5-point Likert scale. The scoring system used was: strongly disagree =1, disagree=2, neither agree nor disagree =3, agree= 4, strongly agree=5.The responses were summed and a total score was obtained and was classified as:

-          Positive attitude if total score ≥ 50 %.

-          Negative attitude if total score < 50

Third tool: Women ^̕s screening barrier for cervical cancer It was adopted by (Thapa et al., 2018).It consisted of 14 statements

Assessment of women's screening barriers for cervical cancer such as the following statements: Lack of awareness, Fear of vaginal examinations, absence of symptoms for cervical cancer, the Pap screening is too expensive, It is embarrassing to have a cervical cancer screening test.

Validity and Reliability:

To establish validity, the questionnaire was reviewed and validated by the Jury committee that was composed of a panel of 5 experts of Obstetrics and Gynecological Nurse professors staff (Minia University), To establish reliability, we was use alpha Cronbach’s way to check the stability of the internal consistency of tools.   .

Pilot Study:

A pilot study was carried out on 10% (24) women from the total number of sample to assess the tools clarity, objectivity and feasibility. As well to estimate the time needed to be applied. According to the results of the pilot all required and necessary modifications were done and the women who were tested in the pilot study were not included in the study sample.

Ethical consideration: Before the conduction of the pilot study as well as the actual study ,this study was approved by ethical committee of the Minia university hospital and faculty of Nursing.Verbalconsent was  obtained from premenopausal women that were to participate in this study, after explaining the nature and purpose of the study. Study subject have the right to refuse to participate and or withdraw from the study without any rational any time . Participants were assured that all their data are highly confidential

Study Procedure:

Verbal consent was obtained from the patients to participate in this study. For six months, the researcher visited inpatient department and outpatient clinic for gynecological diseases two days per week. The number interviewed subjects were from 6 to 8 women per day.

All of the women were informed that their participation was completely voluntary, and they were reassured that their responses would be kept private. The researcher explained the nature and purpose of the study through direct personal contact, which took between 15 and 20 minutes and taken oral consent.

The researcher then filled out questionnaires from the women who had taken part in the study. The researcher evaluates the woman's expertise and activities by answering all of the questions contained in the questionnaires. The time taken for each was around 20-30 minutes depending on the response of each woman. The data collection period began from the beginning of April 2021 till October 2021. After finishing data collection needed, the researcher gave women advice and guidance about cervical cancer and it ̕ s screening as:(definition, signs and symptoms, complications, Risk factors, diagnosis, prevention, treatment, Purpose of pap smear and when should women start getting pap smear).

Statistical Design:

The collected data was be tabulated, computerized, analyzed and summarized by using descriptive statistical tests to test research hypothesis by using SPSS version (IBM 28) and excel for figures. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. The level of significance was be accepted at P< 0.05 and was be considered highly significant when P-value less than or equal 0.01. Fisher exact test / chi test was used to detect the relation between studied women knowledge/attitude based on their selected socio-demographic characteristics.

Results

Table (1): Percentage distribution of the studied women regarding their socio-demographic characteristics (n = 235)

Table (1): demonstrates that 59.6% of the studied women aged between 40 - <45years with mean age 44.12 ± 3.14 years. Nearly three–quarters (73.2%, 72.7%, & 75.3%) of them live in a rural area, had secondary educational level and housewives' studied women respectively and vast most (98.3%) was married.

Figure (1): Percentage distribution of the studied women regarding their source of knowledge about cervical cancer  and it’s screening (n = 235)

Figure (1): illustrates that 55.3% of the studied women their source of knowledge about cervical cancer was their family and 28.5% was their friends

Table (2): Percentage distribution of the studied women regarding their knowledge about pap smear screen (n = 235)

#not normally distributed (select more than one answer)

Table (2): presents that 80.9%, & 82.5% of the studied women known that early detection of cervical cancer is the purpose of  pap smear, and studied women who have experienced sexual intercourse were recommended for pap smear screening respectively. 81.3% of them don't know the time to get a pap test, 79.1% don't know the setting for HPV test/pap screening, 60.4% don't know the optimal time for pap smear screening, 76.2% don't know screening eligibility, and 56.6% don't know cervical cancer screening procedure.

Figure (2): Percentage distribution of the studied women regarding their total knowledge levels towards cervical cancer and it ʼs screening (n = 235)

Figure (2): illustrates that 83.0% of the studied women had inadequate knowledge levels toward cervical cancer screening.

Figure (3): Percentage distribution of the studied women regarding their total attitude levels towards cervical cancer screening (n = 235)

Figure (3): illustrates that around  two thirds (64) of the studied women had a negatively attitude toward cervical cancer screening.

Table (3): Percentage distribution of the studied women regarding their barriers to participation in cervical cancer screening (n = 235).

Table (3): presents that most of the studied women's barriers to participation in cervical cancer screening were fear of vaginal examinations, fear of the result, do not know where the test is done, absence of symptoms for cervical cancer, lack of awareness, and embarrassing to have a cervical cancer screening test (97.4%, 97.0%, 96.2%, 95.3%, and 90.2% respectively).

Table (4): Relations between studied women socio-demographic characteristics with their total knowledge and attitude towards cervical cancer and its screening (n = 235).

Table (4): presents that 70.4% and 37.9% of university and working women had adequate knowledge levels towards cervical cancer screening with highly statistically significant differences, P-value < 0.001, 0.001 respectively and 81.1% of the studied women's aged between 45- ≤50 years,82.4% of illiterate women, 63.7% of secondary level women and 67.8% of the housewives had negative attitude towards cervical cancer screening (P- value <0.0001; <0.0001; & 0.027 respectively).

Figure (4): Relations between the studied women's knowledge and attitude towards cervical cancer and itʼs screening (n= 235).

Figure (4): illustrates that 75.0% of the studied women who had adequate knowledge had positive attitude toward cervical cancer screening with statistically significant differences with P-value < 0.019.