Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India.
ABSTRACT To determine the baseline information about the knowledge of cervical cancer and explore attitude and practice of Pap smear screening among staff nurses.
A pretested structured self administered questionnaire based survey was done on 205 staff nurses working in Rural Institute of Medical Sciences & Research, Saifai, Etawah, containing mostly recognition and some recall type questions about demographics, knowledge about cervical cancer, its risk factors, screening techniques, attitudes towards cervical cancer screening and its practices.
In this study, 74% knew that Pap smear is used for detection of cervical cancer, but only 59% knew that it can detect both cancerous as well as precancerous lesions of the cervix. Only 18% of the respondents knew about human papillomavirus vaccine. A 47% of respondents had never taken a Pap smear; 63% never referred patients for the screening. Most nurses (79%) thought that a speculum examination and Pap smear are procedures to be performed by the doctors. Among all the respondents, only 11% had ever undergone a Pap smear on themselves.
Despite knowledge of the gravity of cervical cancer and prevention by screening, attitudes and practices towards screening were negative.
- SourceAvailable from: Rajamanickam Rajkumar[show abstract] [hide abstract]
ABSTRACT: Cervical cancer is an important public health problem among adult women in developing countries in South and Central America, sub-Saharan Africa, and south and south-east Asia. Frequently repeated cytology screening programmes--either organized or opportunistic--have led to a large decline in cervical cancer incidence and mortality in developed countries. In contrast, cervical cancer remains largely uncontrolled in high-risk developing countries because of ineffective or no screening. This article briefly reviews the experience from existing screening and research initiatives in developing countries. Substantial costs are involved in providing the infrastructure, manpower, consumables, follow-up and surveillance for both organized and opportunistic screening programmes for cervical cancer. Owing to their limited health care resources, developing countries cannot afford the models of frequently repeated screening of women over a wide age range that are used in developed countries. Many low-income developing countries, including most in sub-Saharan Africa, have neither the resources nor the capacity for their health services to organize and sustain any kind of screening programme. Middle-income developing countries, which currently provide inefficient screening, should reorganize their programmes in the light of experiences from other countries and lessons from their past failures. Middle-income countries intending to organize a new screening programme should start first in a limited geographical area, before considering any expansion. It is also more realistic and effective to target the screening on high-risk women once or twice in their lifetime using a highly sensitive test, with an emphasis on high coverage (>80%) of the targeted population. Efforts to organize an effective screening programme in these developing countries will have to find adequate financial resources, develop the infrastructure, train the needed manpower, and elaborate surveillance mechanisms for screening, investigating, treating, and following up the targeted women. The findings from the large body of research on various screening approaches carried out in developing countries and from the available managerial guidelines should be taken into account when reorganizing existing programmes and when considering new screening initiatives.Bulletin of the World Health Organisation 01/2001; 79(10):954-62. · 5.25 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: To measure the effectiveness of unaided visual inspection (UVI) of the cervix as a primary means of cervical cancer screening. A cross sectional study. Five primary health care clinics in Mashonaland Province, Zimbabwe. 1,000 women aged between 25 and 55 years. Sensitivity and specificity of UVI. 1,000 women attending primary health care clinics were screened for cervical cancer by six qualified nurses. An unlubricated bivalve speculum was inserted into the vagina under good light to visualize the cervix and a cervical cytology specimen was obtained followed by visual inspection of the cervix stained by 4% acetic acid. All women found to have abnormal cervices by visual inspection and/or by cervical cytology report were scheduled for colposcopy examination at Harare Central Hospital. 236 (23.6%) women had an abnormal cervical appearance after application with 4% acetic acid, out of which 157 (15.7%) were reported abnormal by cytology. True disease as defined by positive colposcopy and positive cytology was confirmed in 38 (3.8%) women. The sensitivity of UVI using colposcopy and cytology as a reference standard was 68.4%, specificity was 3.4%. The results of this study suggest that naked eye inspection of the cervix after application of acetic acid is a practical alternative to cervical cytology in screening for cervical cancer in countries with few resources like Zimbabwe.The Central African journal of medicine 03/1999; 45(2):30-3.
- [show abstract] [hide abstract]
ABSTRACT: The purpose of this study was to compare the results of cytologic examination, cervicography, direct acetic acid test, and magnified acetic acid test (speculoscopy) with the results of histologic examination. The study was a prospective, descriptive, and analytic study that included 1286 women in a primary health facility who were screened by cytologic examination, cervicography, direct acetic acid test, and magnified acetic acid test (speculoscopy). Histologic evidence was obtained on all patients by means of cervical punch biopsies. The biopsy specimens were taken from aceto-white areas or areas suspicious of cancer. In normal individuals, the specimens were taken from the external cervical os at the 12 or 6 o'clock position, whichever was most convenient. Positive cases were treated by colposcopy and large loop excision of the transformation zone. Testing for human immunodeficiency virus infection was not done. Of the 1286 women who were screened, 1093 women (85%) were eligible for analysis. The mean age of the women was 38.6 years. Because histologic evidence was obtained on all women, direct sensitivities and specificities could be calculated for each screening method. The sensitivity, specificity, and positive predictive values for cytologic examination were 53%, 95%, and 47%, respectively; for cervicography were 49%, 88%, and 26%, respectively; for the direct acetic acid test were 79%, 49%, and 12%, respectively; and for speculoscopy were 77%, 45%, and 11%, respectively. Of the 876 patients who were eligible for colposcopy, only 468 women (56%) eventually returned for colposcopy. Cytologic examination, cervicography, the direct acetic acid test, and speculoscopy are not suited for screening in developing countries because of the low sensitivity of the cytologic examination and the low specificity of the other tests. Two or more tests combined will increase the sensitivity, but the specificity remains low. Screening methods in developing countries remain an urgent problem.American Journal of Obstetrics and Gynecology 03/2003; 188(2):395-400. · 3.88 Impact Factor
Globally, cervical cancer is one of the most common cancers
in women, with an estimate of 468,000 new cases annually,
and 80% of these cases occurring in developing and undevel-
oped countries . India accounts for one-fifth of the world
burden of cervical cancer . In many of the developed coun-
tries the annual incidence and mortality from this cancer has
gone down by 50-70% since the introduction of population
based screening . But it is still a major killer among develop-
ing countries, especially in rural settings due to absence of a
nationally organized screening program, and also as a result
of infrastructural, financial and personnel constraints. In devel-
oping countries like ours, more than three-fourths of cervical
cancer patients are diagnosed at advanced stages leading
to poor prospects of long-term survival and cure . As the
doctor to patient ratio is low in India i.e., 1:2,000 according to
Medical Council of India (Press Information Bureau, Govern-
ment of India, Ministry of Health and Family Welfare, 29 No-
vember 2011), staff nurses if trained properly, can make aware
Awareness of cervical cancer screening among nursing
staff in a tertiary institution of rural India
Ekta Singh1, Shikha Seth1, Vidya Rani2, Dhiraj Kumar Srivastava2
Departments of 1Obstetrics and Gynaecology and 2Community Medicine, Uttar Pradesh Rural Institute of Medical Sciences &
Research, Etawah, India
See accompanying editorial on page 137.
Received Nov 18, 2011, Revised Apr 1, 2012, Accepted Apr 11, 2012
Correspondence to Ekta Singh
Department of Obstetrics and Gynaecology, Uttar Pradesh Rural Institute
of Medical Sciences & Research, Saifai 206301, Etawah, India. Tel: 91-
9411674145, Fax: 91-5688-276509, E-mail: email@example.com
Copyright © 2012. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Objective: To determine the baseline information about the knowledge of cervical cancer and explore attitude and practice of
Pap smear screening among staff nurses.
Methods: A pretested structured self administered questionnaire based survey was done on 205 staff nurses working in Rural
Institute of Medical Sciences & Research, Saifai, Etawah, containing mostly recognition and some recall type questions about
demographics, knowledge about cervical cancer, its risk factors, screening techniques, attitudes towards cervical cancer
screening and its practices.
Results: In this study, 74% knew that Pap smear is used for detection of cervical cancer, but only 59% knew that it can detect
both cancerous as well as precancerous lesions of the cervix. Only 18% of the respondents knew about human papillomavirus
vaccine. A 47% of respondents had never taken a Pap smear; 63% never referred patients for the screening. Most nurses
(79%) thought that a speculum examination and Pap smear are procedures to be performed by the doctors. Among all the
respondents, only 11% had ever undergone a Pap smear on themselves.
Conclusion: Despite knowledge of the gravity of cervical cancer and prevention by screening, attitudes and practices towards
screening were negative.
Keywords: Cervical cancer, Pap smear, Screening attitude
J Gynecol Oncol Vol. 23, No. 3:141-146
Ekta Singh, et al.
and screen all the women coming / admitting to hospital for
any of their problems, along with motivating the peripheral
health workers to bring all the sexually active females to the
hospital for the cervical screening. KAP (knowledge, attitude
and practice) study will bring forth the weak points among
nurses, so that a comprehensive practical training for staff
nurses can be organized. In India it is estimated that there
were 112,609 new cervical cancers in the year 2004 and this
number is expected to rise to 139,864 in 2015 . Therefore
awareness among nurses is a basic requirement to implement
a successful screening program and actually reduces the inci-
dence of cervical cancer in developing countries like India.
In India, despite the public health importance that cervical
cancer merits, there are only sporadic efforts in hospitals and
research settings to minimize the mortality from the cancer.
The present study was undertaken with the following objec-
tives: 1) to determine the baseline information of the knowl-
edge on risk factors of cervical cancer as well as awareness
of the related symptoms and 2) to explore the attitudes and
practices among nurses in terms of cervical cancer screening
programs such as Pap smear with a view to sensitize them as
a first step towards increasing screening uptake in the com-
MATERIALS AND METHODS
This descriptive cross-sectional study was conducted in Uttar
Pradesh Rural Institute of Medical Sciences & Researches, Sai-
fai, Etawah, which is a referral tertiary care hospital and teach-
ing institute, on 190 female staff nurse over the period of two
months from 1st September to 31st October 2010. Working
since 2005 it is the largest and busiest government hospital
in western Uttar Pradesh. Among 190 nurses, 171 (90%) ac-
cepted to participate in the study. A total of 160 question-
naires were retrieved giving a 93.5% return rate, out of which
27 were incomplete and were excluded, leaving the number
to 133 only for the study analysis. Thus the final sample size
was limited to 133 only (Fig. 1). The self-administered struc-
tured questionnaire was developed in collaboration with the
gynecological and community medicine department to cover
most of the aspects related to cervical cancer and its screen-
ing, containing some recall and mostly recognition questions.
Recall questions were about demographics, the knowledge of
risk factors, sign and symptoms of cervical cancer, diagnosing
modalities other than Pap smear and vaccine for human papil-
loma virus (HPV), whereas rest questions (as on knowledge of
eligibility for screening and its interval, practices and attitudes
about cervical cancer screening) were of the recognition type.
Recognition questions tried to have all relevant alternatives
with one or multiple correct answers. Extra space provided at
the end of some recognition questions as ‘other comments’.
Questions tried to be short, clear, readable and understand-
able to the staff nurses with only few medical terminologies.
The questionnaire was pretested initially on a small group of
randomly selected staff nurses and subsequent modifications
were made before the final study was undertaken. These data
were not included in the final analysis of the study.
We elicited knowledge about eligibility for screening and
screening interval according to American Congress of Obste-
tricians and Gynecologists (ACOG) guidelines . Practices
Fig. 1. Study frame. RIMS & R, Uttar Pradesh Rural Institute of Medical
Sciences & Researches.
Table 1. Sociodemographic characteristics of respondents
Pills, injectable contraceptives
Intrauterine contraceptive device
Awareness of cervical cancer screening among nursing staff
J Gynecol Oncol Vol. 23, No. 3:141-146
were evaluated as screening patients for cervical cancer, refer-
ring patients for screening and having ever been screened
themselves. Attitudes referred to the various reasons for not
screening patients, not referring patients for screening, and
not getting screened themselves. After verbal consent, the
questionnaire was provided and participants were asked to fill
it individually without discussing with others. The study proto-
col was approved by the institutional ethical committee. The
data was entered into MS Excel software. Proportion and chi-
square was applied for the analysis and interpretation of the
result using 95% confidence interval.
Mean age of respondents was 27.82±3.85 years. A 62% of
participants were married, and 70% were not using any con-
traceptive method (Table 1). Of all respondents, 127 (96%)
had heard about the Pap smear but 22% were unaware that it
is used for detection of cervical cancer. Only 59% knew that it
could detect both cancerous and precancerous lesions of the
cervix. More than three quarters, 76% of them knew that if cer-
vical changes were found early then they were easily curable.
Only 20% knew more than 3 risk factors, whereas more than
Table 2. Knowledge about cervical cancer and screening (n=133)
Cervical cancer is a disease of public health concern
Pap smear used for detection of cervical cancer
Pap test can detect both cancerous and precancerous lesions
If cervical changes are found early they are easily curable
Cervical cancer can present as*
Without any symptom
Foul smelling excessive vaginal discharge
Irregular abnormal vaginal bleeding
Post coital vaginal bleeding
More than three risk factors known
≤3 risk factors known
Knew human papillomavirus infection as a risk factor
Cervical cancer screening: Who should be screened
Married women only
Women above 30 years of age
Women above 21 years of age or those who are sexually active for last 3 years (whichever is earlier)
Should only be done when there are symptoms
Diagnosing modalities other than Pap*
Visual inspection after acetic acid application
Knowledge about cervical cancer acquired from*
RIMS & R, Saifai
HPV vaccine known to
Correct responses, no. (%)
HPV, human papillomavirus; RIMS & R, Uttar Pradesh Rural Institute of Medical Sciences & Researches.
*More than one answer possible for each respondent (sum>100%).
Ekta Singh, et al.
half respondents (54%) knew that HPV infection is one of the
risk factors of cervical cancer. According to 54% respondents,
women above 21 years of age or those who are sexually active
for last 3 years (whichever is earlier) were eligible candidates
for Pap smear. A 31% of respondents thought Pap screening
should only be done in the presence of symptoms. A 90% of
respondents knew about the cervical biopsy, although only 7%
respondents knew about visual inspection after acetic acid ap-
plication (VIA), and 20% knew about colposcopy as diagnostic
modalities of cervical cancer screening other than Pap smear.
Only 18% of the respondents knew about the HPV vaccine.
Only 21% respondents gained information about Pap smear
while working in this institute (Table 2).
A 74% of the study participants routinely managed female
patients, and 53% had frequently performed vaginal exami-
nations, although the use of speculum was surprisingly low
(21%). A large number of respondents (47%) had never taken
a Pap smear; 59% never asked patients whether they were
ever screened for cervical cancer or not, and 63% never re-
ferred patients for screening. Among all the respondents only
15 (11.3%) had ever undergone a Pap smear on themselves
Most nurses (79%) thought that a speculum examination and
Pap smear were procedures to be performed by doctors only.
A 25% of respondents had no reason for not screening them-
selves; 61% not felt at risk; 24% never screened themselves as
they thought that they had no symptoms; 1% thought that if
a woman is a virgin, the Pap test will take away her virginity;
for 6% it was embarrassing to have a Pap test done; 3% were
Table 5. Association of respondents’ marital status and Pap smear done of women by them
Pap smear screening of women by them
Pap smear taken
Pap smear not taken
Table 6. Association of respondents’ marital status and Pap smear got done on self
Pap smear got done on self
Pap smear not done
Pap smear done
Table 3. Practices on cervical cancer screening
Practices No. (%)
Routine management of female patients
Frequently performing vaginal examinations
Using speculum during vaginal examinations
Never taken a Pap smear test
Don’t ask patients routinely whether screened
for cervical cancer
Don't refer patients for screening
Respondents who have ever been screened
(undergone a Pap smear)
Table 4. Attitude about cervical cancer screening
Attitudes No. (%)
Not screening patient because* (n=62)
Absence of indication
Lack of vaginal specula
Speculum examination and Pap smear are
Never been self screened because* (n=118)
Not feeling at risk
Lack of symptoms
If a woman is a virgin, Pap test will take away
It is embarrassing to have a Pap test 7 (5.9)
Afraid of possible outcome
If I am destined to get cancer, I will
*More than one answer possible for each respondent (sum>100%).
†Screened patients for cervical cancer. ‡Underwent the test at least
once in lifetime.
Awareness of cervical cancer screening among nursing staff
J Gynecol Oncol Vol. 23, No. 3:141-146
afraid of the possible outcome, and 4% thought that if “I am
destined to get cancer, I will” (Table 4).
Out of 82 married respondents 39 had taken Pap smear of
patients, in comparison to 32 out of 51 unmarried and this
difference was statistically insignificant (p>0.05) (Table 5). The
respondents who had had Pap smear were from the married
group only, so the association between respondents’ mari-
tal status and Pap smear history was statistically significant
(p<0.05) (Table 6).
Cervical cancer despite being the commonest genital cancer
of women in India, there are no properly organized or high-
level opportunistic screening programs for cervical cancer in
any of the provincial states of India . Data from population-
based cancer registries indicate a slow, but steady, decline
in the incidence of cervical cancer. However, the rates are
still too high, particularly in the rural areas, and the absolute
number of cases is on an increase due to population growth
. In the absence of a systematic screening program the ex-
pected practice is to opportunistically screen eligible women
when they come to health units for other services. In the op-
portunistic screening system (at antenatal, postnatal, family
planning visits, reproductive tract infection/sexually transmit-
ted infection clinic, anti retroviral therapy centre centre or for
any health complaint) the onus is on the health worker who
handles the eligible women to offer screening or refer her to
a unit where screening can be done. In our institution the Pap
smear is exclusively performed in the gynecological depart-
ment and all eligible women from other units are referred
there for screening. Studies have shown it is possible to train
nurses to screen for cervical cancer . Attitudes that screen-
ing is to be done by doctors or gynaecologists only needs to
change. The survey revealed that the hospital played a limited
role as a source of information on Pap smear. Although the
Pap smear based screening program is not feasible in low
resource settings like India due to economical and logistic
reasons as there is a lack of trained pathologists and equipped
laboratories. This calls for a re-orientation of nurses, paramedi-
cals and health workers and a need for introduction of simpler
cervical cancer screening methods such as visual inspections
that are more sustainable .
Our results resemble the similar study from Turkey  and
shows that almost all respondents had heard about the Pap
smear, but only one-half of them knew that it can detect both
cancerous and precancerous lesions of cervical cancer. The
rest believed that it is to detect existing cancer and required
to be done in symptomatic cases only. Despite considerable
awareness of a link between cervical cancer and sexual activ-
ity, as well as the role of sexually-transmitted infections, only
54% of the respondents had heard of the HPV; while most
were ignorant about HPV vaccine.
Our finding that married women are more likely to be
screened is consistent with previous studies in India . The
pro posed reason is that married women may receive more
frequent obstetric or gynecological care, making them more
responsive to reproductive health care . Because sexual
relationships outside marriage are not culturally accepted in
many rural areas of India , unmarried women normally
refuses to screen themselves out of fear of the potential social
stigma they would suffer if they had a test perceived to be
used for sexually active women.
A quarter of respondents perceived cervical cancer as a ter-
minal illness with no hope for a cure, even when detected in
the early stages. The pessimistic attitude towards cancer and
death needs to be addressed. The belief that death is inevi-
table when cancer is present has been identified as a barrier
to participation in cancer screening, detection and treatment
. In departments other than gynecology, the negative
practice among nurses of not screening patients who come
under their care 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. Among the eligible respondents 89% had never
screened themselves because they did not feel vulnerable
to the disease. It is unlikely that these medical workers 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.
Until recently, cervical cancer prevention issue has been the
concern of physicians. In the proposed diagnosis and treat
strategies  there will be need to integrate cervical cancer
prevention issues in the nurses' training curriculum. Nurses
will form the backbone for informing the population, as they
are the first port of entry into the health system. It remains to
be seen which approach is best for cervical cancer control for
There are certain limitations inherent to the design of the
present study; firstly, regarding the questions which are
mainly recognition and some recall type. Both the recall and
recognition questions have limitations. We predicted that
recognition scores would be greater than recall scores ,
but it is difficult to determine which better captures the con-
cept of cancer awareness. Recall underestimates awareness
because it is limited by memory, while recognition overesti-
mates awareness because participants find it easy to guess.
Ekta Singh, et al.
Secondly, the method used for estimating the practice of Pap
smears-namely self-reported test history, which may be faulty
due to inaccurate recall or desirability bias . Thirdly, the
order of the questions may have an impact on the findings.
However, in most situations it is not pragmatically feasible to
randomize the order in which the questions are asked, and
possible priming effects were considered when designing the
measure. However, there is a need for further investigation on
different approaches to measure cancer knowledge related to
behavioral outcomes, and identifying best measure to predict
The study showed that despite knowledge of the gravity
of cervical cancer and prevention by screening using a Pap
smear, attitudes and practices among nurses towards cervi-
cal cancer screening were negative; especially uptake of Pap
smear test is abysmally poor.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was
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