Introduction

According to the World Cancer Research Fund International, cervical cancer is the 7th most common malignancy in women worldwide in 2020. It is responsible for 341,841 deaths according to the International Agency for Research on Cancer (IARC). Cervical cancer can be prevented by detecting it in its pre-invasive stage with the help of a pap smear as a screening tool.^1–3

According to IARC, in 2020, Nepal’s estimated age-standardized mortality rate (ASR) from cervical cancer is among the top 6 countries in South Asia with an ASR of 11.1, whereas Nepal’s all cancer ASR is among the bottom five with an ASR of 53.9.¹ This data sheds light on the current inadequate uptake of screening tools for the diagnosis of cervical cancer.

According to Institute Catalga d’Oncologia (ICO), the cervical cancer screening rate is 2.8% in Nepal. Considering that Nepal has a population of 11.4 million women aged 15 years and older who are at risk of developing cervical cancer, an appropriate screening program constitutes a big need at the national level.⁴

Nepal Cervical Cancer Prevention Situation Analysis, 2008 estimated that there were about 10,020 new cases of invasive cervical cancer and about 26,000- 45,000 precancerous lesions.⁵ Moreover, WHO (2021) ranked cervical cancer as the most frequent cancer among Nepalese women aged between 15 and 44 years with the annual crude cervical cancer incidence per 1,00,000 women (2020) 14.2 and Cervical cancer deaths (2019) of 2000.⁶

The National Guidelines for Cervical Cancer Screening and Prevention in Nepal, 2010, which sought to screen women of the age group of 30-60 years at an interval of a 5-year cycle, intended to cover 50% of the target population by 2015.⁷ In light of the recent statistics, the screening does not seem adequate.

The failure of the national screening program can be attributed to difficulties in organizing cancer-screening programs in Nepal such as limited human resources, limited medical services, and the difficult geographical terrain.⁸ Due to the lack of knowledge and inadequate access to healthcare far too many women do not get screened for cervical cancer or are often diagnosed at an advanced stage.⁹

This study was done to assess knowledge, attitude, and practice for cervical cancer screening among Nepalese women and to explain the barriers to screening. This would serve as background information to understand the practice and barriers to screening so that specific interventions can be advocated to improve screening practices among Nepalese women.

Methods

This was an observational cross-sectional study. Participants were selected by convenience non-random sampling (non-probability). For calculating sample size, the formula for sample size by proportion was used N = ((Z_α)²) (pq)/e² . Alpha (α) was taken as= 5%, Margin of error (e) = 10% of p (which is the allowable error in hospital-based studies like in TUTH), p = 0.429 (This p value is taken from the study conducted by Shesthra S. at Clinic of Kathmandu Medical College from January to March 2011), q = 0.571. Hence, the required sample size is 512. Adding 10% for the non-response, the total sample size is 563.

This study was conducted in the Department of Gynecology and Obstetrics of Tribhuvan University Teaching Hospital (TUTH), Maharajgunj, Kathmandu between April 13, 2016, and April 13, 2017. Five hundred sixty-seven women, in the age group of 30-60 years attending the Gynecology Clinic at TUTH were included in the study. The sample size Consent was taken and women not willing to participate were excluded. Also, women less than 30 years old and more than 60 years old were excluded.

A validated, structured questionnaire, previously used by Awasty S et al in Kerala, was used.¹⁰ It was translated to Nepali and pre-tested on 10 cases before the study period to test the feasibility and to find out the practical problems and difficulties that might be encountered in the process of this study. As the clinic days were three days of the week from 10 am to 3 pm, the first seven patients that consented were enrolled into the study and the interview was conducted verbally during the lunch break. Even women who had visited the clinic for a routine pap smear were included in the study. It was not possible to interview more than 7 patients/day due to time constraints. Women not willing to wait for the interview were excluded, which included a total of 59 women. The questionnaire was written in Nepali. However, English and Hindi versions of the questionnaire were available too provided the patient was more comfortable in these languages. It was noted though that no patient needed a non- Nepali questionnaire.

The questionnaire was structured in three parts: 1. Sociodemographic description (age, parity, address, marital status, education), 2. Yes/No questions regarding knowledge, attitude, and practice of screening, 3. Multiple choice questions regarding the source of information regarding screening and barriers towards the practice of screening. The questionnaire was verbally administered by an interviewer to the participants.

The knowledge was assessed using a 20 points scale which has a dichotomous response: correct and incorrect. Each correct response was scored as 1 and incorrect as 0. A score of 50% (≥10 correct responses) was considered as optimal.

Attitude was assessed by 7 statements regarding cervical cancer screening and risk factors responses which were categorized on a 3-point scale Disagree, Neutral, and Agree. Attitude was considered as favorable for screening if four or more “Agree” responses were obtained.

The practice was assessed using 4 questions regarding the practice of screening. It has a dichotomous response: correct and incorrect. Each correct response was scored as 1 and incorrect as 0. A score of 50 % was considered optimal.

All the data was coded in the pre-designed structured questionnaire first and then the data were entered daily into MS Excel 2007 and analyzed using SPSS. The data collected was entered in the excel chart sheet. Analysis was done using simple percentages. Chi-square tests were used to test the significance among categorical variables. An independent sample t-test was used to test the significance between categorical and numerical variables such as total score. A p value of <0.05 was regarded as statistically significant.

Limitations

The main limitation faced in the study was that the study evaluated women who attended the hospital. A community-level study would have been more appropriate to understand the barriers to screening. The results obtained in the study may not apply to the general Nepalese population; the rates of pap smear and the attitude towards screening might differ if this study was conducted in a rural health center or a center that primarily serves minority populations.

Ethical Consideration

Approval from the institutional review board of TUTH was taken.

All the patients in the study were explained in detail about the study, and afterward written consent was taken from all the patients prior to them being included in the study. Only those patients who gave consent were included in the study.

Operational Definition

1. Adequate knowledge: Women who had heard of cervical cancer and its screening tests; women who attain score more than 50%

2. Adequate attitude: Women who considered it as necessary to undergo the screening test for cervical cancer, i.e. women who answer at least 4 out of the 7 as agree

3. Adequate practice Women who score at least 50%

Results

A total of 57,600 women presented to the Gynecology Clinic of TUTH between April 13, 2016, to April 13, 2017.

Demographic profile: The age of the patients included in the study ranged from 30-60 years. The mean age of the studied population was 40.56 years. The average age of marriage was 21.62 years. Most participants i.e. 250 had 2 children (44.1%). The average number of children was 2.29. Of the total number of 567 participants, 554 (97.7%) were found to be married, 1(0.2%) were found to be unmarried, 2(0.4%) were found to be divorced and 10(1.8 %) were found to be widowed. Also, it was found that 371 patients i.e. 65.4% who presented to the Gynecology Clinic at TUTH were from urban areas. Only 196 patients (34.6%) were found to be from rural areas. It was found that 442 patients i.e. 78% who presented to the Gynaecology Clinic at TUTH were literate. Only 145 patients (22%) were found to be illiterate. Most participants i.e. 194 (34.2%) had a higher secondary level of education, and 153 participants (27%) had primary level education.

Upon surveying the population, it was noted that the level of knowledge was generally inadequate, 317 people (55.9% ). A statistically significant correlation (p value <0.05) was noted between knowledge and education, age, and living status. Also, the level of knowledge was higher in married women. (See Table No 1) A hundred percent of the respondents in this study showed a positive attitude towards cervical cancer screening. Only 17.6% of the total women had a cervical screening even though 44.1% demonstrated adequate knowledge and 100% had a positive attitude towards screening. Also, practice was related to the level of education (p value<0.05), age, and living status. (See Table No 2) A statistically significant correlation was noted between the level of practice and knowledge. Most patients cited recommendations by doctors/nurses as the impetus to the decision of undergoing screening.

The major barrier to screening was the reluctance to get the pap smear done by a male doctor (21.5%), followed by the misconception that screening is not necessary if there are no symptoms (20.5%). Other barriers include geographical location (rural women, difficult access to health facilities), the lack of advocacy, and the lack of screening programs at the national level. Also, it was found out that unmarried women are less likely to undergo screening due to social issues and embarrassment. (See Chart 3)

Chart 3.Reasons for not having Pap Smear done

Discussion

Knowledge of Cervical Cancer Screening

A study done by Shrestha in a tertiary center in Kathmandu also showed a similar level of knowledge (42.1%) regarding cervical cancer screening.¹¹ However, women in developed countries appear to be more aware of carcinoma of the cervix and screening as indicated in a study done in Illinois in which 74% of 176 responding women understood that pap tests evaluate the cervix, whereas 78% understood that pap tests should be repeated at intervals of 1-3 years.¹² This can be explained by the fact that the literacy rate of the United States is higher than that of Nepal and a positive correlation has been found between literacy and knowledge of cervical cancer screening. In our setup, 22% of the population is illiterate, and only 3% of the respondents had a Bachelor’s level education or more. Also, most people undergoing screening in the United States belong to the urban population, and living status (rural vs. urban) also shows a positive correlation with cervical cancer screening. In our setup, 34.6% of the respondents came from rural areas. This difference in the literacy level and the knowledge about cancer screening highlights the lack of education about cervical cancer and its screening in Nepal. Since literacy is a barrier, methods that target the population with a lower level of education like radio talk shows, tv programs, and community level programs would help improve the situation.

Attitude of Cervical Cancer Screening

In this study, it was seen that all women had a positive attitude towards cervical cancer screening and that all were willing to undergo the test once they were informed about its importance and necessity. This is similar to the findings of research done in Boston, Thailand, Qatar, Nigeria, Zimbabwe, and Nepal.^11,13–18

Practice of Cervical Cancer Screening

It was noted that 17.6% of the women in our study had cervical cancer screening done at least once, which is similar to the findings of a study done in Kuwait (23%).¹⁹ It has been estimated that only about 5%–10% of women in developing countries^20,21 have been screened for cervical cancer with a pap smear compared to 40%–50% in developed countries.²² A study in England showed cervical screening practice to be more than 80%.²³ In the study in Qatar, 40% of the women had pap smear done. This may be attributed to better education and dissemination of knowledge of cervical cancer and screening in developed countries. As far as studies in Nepal are concerned, Shrestha as well as Ranabhat, et. al. found that 10.5% of the respondents underwent pap smear.^11,13 Lack of advocacy for screening and insufficient screening programs at the national level are the reasons behind the low uptake of pap smears in Nepal. In the study done by Shrestha, lack of knowledge about pap smear tests played a significant role in poor uptake of pap smear by women.¹¹ A more recent cross-sectional study in 2017 in Kavre, Nepal found a significant association between cervical cancer screening behavior and the education level of participants.²⁴ A similar observation was made in an Iranian study in which pap smear coverage was found to be 27% due to gaps in literacy and knowledge. History of pap smear utilization and good knowledge about pap smears were significantly associated with each other.²⁵

In our study, it was seen that there is a positive correlation between the place of residence and the uptake of pap smears (urban vs. rural). Similar findings were noted in a study done in Mexico, where it was seen that rural women were less likely to have had a pap smear.²⁶ This may be because rural women have less access to facilities and also may be less educated and aware of cervical cancer. In the study in Mexico, 29% had had their first pap in accordance with the timing recommended by the official Mexican norm.²⁶ However, in our study none of the women had testing done as per the national guidelines. This further shows the poor dissemination of knowledge about the national cervical cancer screening program in Nepal.

In our study, it was noted that married women were more likely to undergo cervical cancer screening and similar findings were noted in studies done in Kerala and also among Sikkimese women in India.^10,27 Yi reported that level of education and marital status contributed significantly toward cervical screening among Vietnamese and Cambodian women living in the United States.²⁸ Similar findings were noted in our study. This may be because unmarried women are less likely to undergo screening due to social issues and embarrassment. In societies where premarital sex is taboo, screening practices may not be utilized because of actual or perceived negative attitudes or judgmental behaviors from health professionals and from family members.

In our study, it was noted that there was a positive correlation between the duration of marriage and practice. Similar findings were noted by Shrestha in a study done in Kathmandu.¹¹ Longer duration of marriage would probably expose women more to health centers for various other reasons. So, they would be more aware of their health status and hence their level of knowledge and practice. This could also be the reason why the practice was better with higher parity index. Similar findings were noted by Shrestha, though the results in that study were not statistically significant.¹¹ Similar was the results of the study conducted by Al Meer, et. al. in Qatar.²⁹

After the study was conducted, all the women involved were offered to get a pap smear done and a further study would be conducted to evaluate the new response of the population after the first part of the study.

Recommendation

1. Nepal National Cervical Cancer Screening would benefit from a community-based screening for 100% of the eligible population every 2-3 years like developed countries.

2. Screening program has to be institutionalized and standardized so every eligible female has access to it regardless of marital status, socioeconomic background, address, education level, etc.

3. Increase awareness in females by using flyers, television, radios, and social media platforms.

4. From our study it was clear that the attitude towards screening was favorable. The identified barriers to screening, if removed, would further increase the overall screening uptake and incidence of cervical cancer in Nepal. Education of the population would overcome many barriers that the cultural taboos represent.

Conclusion

Knowledge and practice of screening for cervical cancer are poor in gynecological patients evaluated. However, the attitude of women to undergo the screening test was very positive. This opens the door for improvement in the Nepal Cervical Cancer Screening and highlights the need for systematic interventions in rural and urban areas to increase the educational level and practice of cancer screening in Nepal.

Conflict of Interest

No conflicts of interest

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical statements

This research got ethical clearance from Institutional Review Board, Tribhuvan University Institute of Medicine, Maharajgunj. The reference number is 328(6-11-E) 2/72/073

Acknowledgement

I would like to give a special note of thanks to Prof. Dr. Geeta Gurung, HOD, Department of Obstetrics and Gynecology, TUTH for her guidance and positive feedback.

Author contributions

1. Swati Kumari: conception and design, data collection and assembly, data analysis, manuscript writing
2. Neebha Ojha: manuscript writing and proofreading
3. Kesang Bista: conception and design, manuscript writing and proofreading

All authors approve the submission of the manuscript