Awareness and knowledge about cervical cancer screening and prevention among women attending gynecology clinics

INTRODUCTION

Cervical cancer is the fourth most common cancer among women worldwide. According to the World Health Organization (WHO), approximately 660,000 new cases were reported in 2022.^[1,2] Cervical cancer claims around 311,000 lives each year, with the vast majority occurring in low- and middle-income nations.^[3] According to the International Agency for Research on Cancer, during 2020, 123,907 new cervical cancer cases were diagnosed in India, making it the second most common cancer in females after breast cancer.^[4] Approximately 99% of cervical cancer cases are associated with high-risk strains of the Human Papillomavirus (HPV), a virus predominantly spread through sexual contact.^[5] In countries with well-established screening programs, progress is seen in decreased incidence and mortality associated with cervical cancer. However, in India, the mortality rates are still high, as 70% of cases are diagnosed in late stages.^[6]

Although there is clear evidence that HPV infections are a major cause of cervical cancer and that HPV-based screening and vaccination offer effective prevention, the adoption of these preventive measures remains limited in many developing countries, including India.^[7,8] Awareness about the signs, symptoms, and risk factors of cervical cancer significantly influences women’s health-seeking behavior. Increasing public knowledge about HPV vaccination can play a vital role in lowering the incidence of cervical cancer.^[9]

Therefore, the present study aims to assess the knowledge and awareness of patients toward cervical cancer and the use of the Pap smear as a screening tool.

MATERIALS AND METHODS

RESULTS

Among the participants, the highest proportion of women (43.1%, n = 127) was aged 41-50 years, followed by 40% (n = 118) in the 31-40 age range and 11.5% (n = 34) in the 51-60 age group. The mean age of study participants was 44.09 ± 8.82 years. Regarding parity, 38.6% (n = 114) of women had two children, and 47.1% (n = 139) had three or more children. A majority of the women (55.3%, n = 163) resided in urban areas, while 44.7% (n = 132) were from rural areas [Table 1].

Abnormal uterine bleeding was the most frequently reported symptom (47.4%), followed by vaginal discharge (14.2%), postmenopausal bleeding (11.9%), cervicitis (8.8%), and irregular menstrual bleeding (6.8%) [Table 2 and Figure 1].

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Figure 1:

Age-wise distribution of symptoms among study participants. *** These are significatly observed symptoms, AUB: Abnormal uterine bleeding, PV: Per vaginam.

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Out of 295 women, only 7.8% (n = 23) had undergone a gynecological examination. Awareness of cervical cancer and its early detection was reported by just 3.7% (n = 11), while only 3.0% (n = 9) had knowledge of the Pap smear test. None of the women had ever undergone Pap smear screening or had any awareness of the HPV vaccine or the recommended frequency of Pap smears. No participant expressed willingness to receive HPV vaccination [Table 3 and Figure 2]. Awareness about Pap smears was reported in 4.3% of women from urban areas and 1.5% from rural areas. A higher proportion of rural women (9.1%) had undergone a gynecological examination compared to 6.7% of urban women [Figure 3].

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Figure 2:

Age-wise distribution of responses to questionnaire.

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Figure 3:

Association of cervical cancer awareness and use of Pap smear by geographic location.

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DISCUSSION

Increasing awareness of cervical cancer screening can enhance women’s proactive health behaviors, resulting in higher rates of early diagnosis and treatment. Early-stage cervical cancer treatment is generally more cost-effective, which can significantly reduce associated morbidity and mortality. However, limited awareness regarding screening is linked to delays in diagnosis and high mortality rates.

In our study, out of 295 women, only 23 (7.8%) had previously undergone a gynecological examination. Only 11 (3.7%) women were aware that cervical cancer could be detected early, and merely nine (3.0%) knew about the Pap smear test. None had ever received a Pap smear or had knowledge of the HPV vaccine or the recommended screening age and frequency. Surprisingly, although over half of the participants (55.3%) were from urban areas, Pap smear awareness was still low. These findings are lower than those reported in similar studies conducted in Kuwait,^[10] Singapore,^[11] Kenya,^[12] and among Vietnamese-American women.^[13] The discrepancy may be attributed to variations in study populations or differing health promotion strategies used to raise awareness about Pap smear screening. The present study, along with similar research from India, highlights that despite Pap smear testing being an effective tool for cervical cancer control, it remains underutilized.^[14,15]

Interestingly, symptom distribution varied significantly by age group [Table 2]. Abnormal uterine bleeding, cervicitis, and postmenopausal bleeding showed statistically significant differences (P < 0.05), highlighting that a considerable proportion of women presented with symptoms warranting cervical evaluation. Yet, awareness of screening and preventive measures remained critically low even among symptomatic patients, indicating a missed opportunity for timely intervention.

Compared to studies from other regions, the level of awareness in this population was markedly lower. For instance, Bansal et al.^[16] found that only 11% of women had adequate knowledge of cervical cancer and screening, in a study conducted in Bhopal. In contrast, 65.5% had heard of cervical cancer, and 80.5% expressed a positive attitude toward screening. A study by Dahiya et al.^[9] in Delhi showed that 23.3% of women had heard of cervical cancer screening, and 26.0% were aware of Pap smear, though only 18.0% had undergone the test. In addition, a study conducted in Delhi by Singh et al.^[17] showed that only 18.2% of participants had a positive attitude toward cervical cancer screening. Another study by Varughese et al.^[18] in Ludhiana found that 28.9% of women were aware of cervical cancer, with only 4.3% having heard of Pap smear. A recent systematic review by Malhotra et al.^[19] indicated a generally low level of awareness regarding cervical cancer screening worldwide. Possible reasons for this persistently low awareness observed in the given population, often at 0% for several key parameters, may be partly attributed to the substantial presence of the tribal population in Central India. Tribal populations in this region often face additional barriers, such as limited access to education and healthcare services, language differences, and cultural practices that can limit exposure to health information, especially concerning cervical cancer screening and HPV vaccination. These communities may have less interaction with mainstream health programs and face socio-economic challenges that further restrict awareness and utilization of preventive healthcare. In addition, traditional beliefs and stigma related to reproductive health can contribute to reluctance in seeking information or care. Thus, the combination of socioeconomic disadvantages, cultural factors, and the specific challenges faced by tribal populations likely contributes to the markedly low awareness observed in this study compared to other Indian regions. The zero awareness about HPV vaccination reflects that the national HPV vaccination rollout remains fragmented despite the WHO recommendations, having significant practical implications. It indicates that women are unlikely to seek or accept HPV vaccination, which is a critical preventive measure against cervical cancer. This lack of awareness can lead to continued high rates of HPV infection and cervical cancer incidence, placing a greater burden on healthcare systems as well as adversely affecting health outcomes among women.

Moreover, the absence of knowledge about HPV vaccination suggests that the present public health education and outreach efforts may be insufficient or ineffective in this region. Without targeted interventions to increase awareness and accessibility, the community will remain vulnerable to otherwise preventable cervical cancer cases.

In both urban and rural settings in India and elsewhere, despite some knowledge of cervical cancer, the uptake of screening remains low. Key barriers include a lack of symptoms, limited knowledge, and apprehensions about the procedure and potential results. Simply making Pap smear testing available for early detection is insufficient to achieve effective cervical cancer control. Awareness and utilization of screening services and vaccination programs among the target population are essential to improve health outcomes and reduce cervical cancer mortality. Promoting Pap smear screening through healthcare initiatives can create vital opportunities for intervention. Mass media campaigns and informational leaflets can also play a significant role in enhancing women’s health-seeking behavior for cervical cancer screening.

CONCLUSIONS

Our study highlights an urgency to enhance women’s knowledge about HPV infection and cervical cancer. This can be effectively addressed via a multifaceted approach. Awareness campaigns using both print and electronic media should be used to disseminate accurate information to a wide audience, especially in underserved areas. Organizing free cancer screening and prevention camps in rural and semi-urban regions may increase accessibility and encourage participation. Besides, opportunistic screening for cervical cancer at Community Health Centres (CHCs) and Primary Health Centres (PHCs) should be focused. In addition, healthcare professionals, including community health workers, nurses, and physicians, can serve as trusted sources of information, educating women about cervical cancer risk factors, the importance of HPV vaccination, and the need for regular screening. Adolescent schoolgirls should be educated about HPV infection and cervical cancer as part of early awareness and prevention efforts. Age-appropriate information through school-based health education programs, including awareness and promoting the importance of HPV vaccination and regular screenings later in life, should be given. Integrating such efforts into existing public health programs will be crucial for improving awareness and ultimately reducing the burden of cervical cancer.