|Year : 2013 | Volume
| Issue : 1 | Page : 25-28
Awareness of cervical cancer, Papanicolau's smear and its utilization among female, final year undergraduates in Durban, South Africa
Muhammad Ehsanul Hoque
Graduate School of Business and Leadership, University of KwaZulu-Natal (Westville Campus), South Africa
|Date of Web Publication||10-Apr-2013|
Muhammad Ehsanul Hoque
Graduate School of Business and Leadership, University of KwaZulu-Natal (Westville Campus)
Source of Support: None, Conflict of Interest: None
Context: Cervical cancer is a preventable disease; it is the primary cancer amongst women in South Africa.
Aims: The objective of this study is to assess the awareness and detection methods of cervical cancer.
Settings and Design: This was a cross-sectional study conducted among 180 full time final year undergraduate female university students.
Materials and Methods: A multistage sampling technique was used to select the sample and self administered questionnaire was used to collect the information.
Statistical Analysis Used: Chi-square test and logistic regression were used to find association and the significant predictor for doing Pap smear test.
Results: Over half (53.3%) of the participants had heard about cervical cancer and its detection method. More than half (60%) and over a third (37.8%) of the participants knew about human papilloma virus (HPV) and multiple sexual partner respectively as risk factors for cervical cancer. More than half (55.3%) indicated that they were not aware if cervical cancer can be prevented. Majority (76.7%) knew that Papanicolau's (Pap) smear test is used for detection or prevention of cervical cancer. Among those who were sexually active and knew about Pap smear test 79.3% did not do the test mainly because of personal factors such as fear of the procedure, or were not ill.
Conclusions: Level of awareness regarding cervical cancer and its detection method was low among these female students. The university management should focus on developing policies on health education and promotion to prevent transmission of the HPV.
Keywords: Awareness, cervical cancer, pap smear, South Africa, undergraduate students, utilization
|How to cite this article:|
Hoque ME. Awareness of cervical cancer, Papanicolau's smear and its utilization among female, final year undergraduates in Durban, South Africa
. J Can Res Ther 2013;9:25-8
|How to cite this URL:|
Hoque ME. Awareness of cervical cancer, Papanicolau's smear and its utilization among female, final year undergraduates in Durban, South Africa
. J Can Res Ther [serial online] 2013 [cited 2019 Mar 22];9:25-8. Available from: http://www.cancerjournal.net/text.asp?2013/9/1/25/110350
| > Introduction|| |
Cancer of the cervix is a serious burden on the reproductive health of women world-wide, despite the fact that it is preventable. Cervical cancer globally is the second most common cause of cancer-related deaths among adult women. There were about 500000 new cases and more than 250000 deaths recorded as a result of this preventable diseases in 2009. 
Organized cytology-based screening programs to achieve high coverage rates by using Papanicolaou smears and treatment of pre-cancerous lesions, has led to a significant decrease in the cervical cancer incidence and mortality in developed countries. , This successes of the organized based screening have not been replicated in developing countries reflecting an enormous global-cervical-cancer-burden of 83%. , The imbalances are alarming; developed countries have an average screening coverage of 63%, compared to 19% in developing countries.  The sub-Saharan African region, one of the most affected areas of cervical cancer has scarce access to only 5% to the global-cervical-cancer-prevention resources. , In addition, 85% of all cervical cancer related deaths reported were from developing countries which have poor set ups of screening programs or minimally effective. ,, Screening is found to be the best method for early detection of cervical cancer. ,
Cervical cancer is currently the primary cancer amongst the women in South Africa, with annual new cases of 6742 in African women and 3681 deaths.  HIV-positive women are 3 to 5 times more likely to develop cervical lesions that could become cancerous.  This makes a high-risk environment for the acquisition of cervical cancer in South Africa because about 13.3% of the female are living with HIV/AIDS.  The incidence rate has doubled compared to that of global estimates at 30.2 per 100,000 women per year. ,, During the year 2000, deaths related to cervical cancer in South Africa have exceeded that of maternal deaths. , In SA, the cervical cancer screening coverage (proportion of women over the age of 30 years) is low e.g. 20% nationally.  A population -based -study conducted in rural KwaZulu-Natal reported that 18% only of the women had a Pap smear test done. 
University students have higher risk of acquiring sexually transmitted infections (STIs) than the general population because of the high-risk sexual behavior in which they engaged. Many university students underestimate their risk of contracting various STIs, and HPV has become a common sexually transmitted infection on college campuses. Risky sexual behavior, a lack of knowledge and preventive care, such as a regular Pap test have lead to a high incidence of HPV infection in university students. These lead to cervical cancer later. Thus, the objectives of this study were to assess the awareness of the risk factors associated with, and detection methods of cervical cancer among the final year female students at Mangosuthu University of Technology (MUT), South Africa.
| > Materials and Methods|| |
This was a descriptive cross sectional study carried out in August 2008 among the full time final year undergraduate female MUT students. For minimum sample size calculation for the study, assuming that 50% of the university students' had sufficient knowledge of cervical cancer, a sample of 180 students was selected by stratified random sampling techniques with 95% confidence and statistical power as 80%. Faculties of the University were considered as strata. From each faculty, number of students were selected based on the proportion of students were in the faculty. The study was conducted by means of a questionnaire survey. The questionnaire included questions on behavioral profile, awareness on cervical cancer and its prevention method, and participants' source of information. The questionnaires were translated into isiZulu by an isiZulu expert from the university's language centre. Questions were simple and concise.
The questionnaire was pre-tested using 10 female students from 2 nd year students who were not part of the study to identify gaps and modify the questionnaire appropriately. The questionnaire was then pilot tested to a representative sample of 10 final year female students of MUT and modified to ensure it answered the research questions.
Ethical permission for the study was obtained from the Ethics task team of the Faculty of Natural Sciences Research and Publications Committee of MUT. Informed consent of participants was obtained. Confidentiality of participants was maintained at all times. To further maintain confidentiality no form of identifiers were in the questionnaires. Participation was voluntary and participants were informed that they could withdraw from the study at any stage of the interview if they so desired without any penalty.
Data were entered into Microsoft Excel 2003 spread sheet and imported to SPSS 18.0.1 for Window version for analysis. The results were summarized using descriptive summary measures: expressed as mean (standard deviation or range) for continuous variables and percent for categorical variables. Chi-square test was used to find association between categorical variables. Binary logistic regression was carried out to find the significant predictor for doing Pap smear test. All statistical tests were performed using two-sided tests at the 0.05 level of significance. For regression models, the results were expressed as effect (or odds ratios for binary outcomes), corresponding two-sided 95% confidence intervals and associated P-values. P-values reported to three decimal places with values less than 0.001 reported as <0.001.
| > Results|| |
One hundred and sixty nine (n = 169) students completed the survey questionnaire for a 94% response rate. Overall the mean age of the participants was 20.81 years (SD = 1.7 yrs). Only one student was married but the rests (168) were single. An analysis of the behavioral questions on the survey provided a behavioral profile of the university student participants [Table 1]. About two-thirds of the students (65.7%) were currently involved in a sexual relationship and among them 14.4% reporting having multiple sexual partners in the past year. Condom use was quite high (83.8%) and among them 66.7% reported they always using condoms. Only over a tenth (11.7%) of the respondents used oral contraceptives, perhaps explaining the high rate of condoms use by them or their partners.
[Table 2] summarizes student's awareness regarding cervical cancer. Over half (53.3%) of the participants heard about cervical cancer, and 60% heard from medical or community health workers. Equal number of students heard about cervical cancer from their classmates or from media (15.6%). More than half (60%) and over a third (37.8%) of the participants knew about HPV virus and multiple sexual partner respectively as risk factors for cervical cancer. More than half (55.3%) indicated that they do not know if cervical cancer can be prevented.
More than half (53.3%) of the participants heard about Pap smear test, and among them 27.8% heard from health facility workers [Table 3]. Pap smear test is used for detection or prevention of cervical cancer was known to majority (76.7%) of the respondents. Only seven participants had done Pap smear test and all of them knew their Pap test result [Table 3]. Among those who were sexually active and knew about Pap smear test (n = 63), majority of them (79.3%) did not do the test mainly because of personal factors such as fear of the procedure, or were not ill. Binary logistic regression (backward stepwise) did not find any significant predictor for doing Pap smear test among the respondents.
| > Discussion|| |
This study assesses the awareness and detection methods of cervical cancer among the final year female students at a University in South Africa. It was found that level of awareness regarding cervical cancer, its risk factors and detection method was low among these female students.
About two-thirds of the students were currently involved in a sexual relationship and among them 14.4% reporting having multiple sexual partners in the past year. Condom use was quite high and among them a third reported of using condoms sometimes or never. Studies have shown high engagement by students in unsafe sexual behaviors such as a high average number of partners, sex with unknown persons, use condoms inconsistently, negative views about condom use, and abuse of various substances. , For example, a study conducted among South African youth concluded that at least 50% of young people are sexually active by the age of 16 years; and between 50% and 60% of sexually active youth report never using condoms.  Another South African study reported about three-quarter of unplanned pregnancy occurred among unmarried women.  Women are generally infected with HPV in their teens, twenties, or in their 30 years of age.  So, large numbers of these students are involved in risky sexual behavior towards acquiring cervical cancer.
About half of the participants heard about cervical cancer and its detection method. This result is less than the Nigerian and American study. In the Nigerian study, it was found that 71% of the female undergraduate students were aware of cervical cancer where as the American study reported 70%. ,
This present study also found that 60% knew about HPV as risk factor for cervical cancer and a third knew about multiple sexual partners as risk factors. Also more than half mentioned that they do not know if cervical cancer can be prevented. A Korean study reported only 13.3% of the adults were aware of HPV infection which cause cervical cancer.  Another study from Malaysia conducted among ethnically diverse female students attending a public university found that knowledge regarding HPV, cervical screening and cervical cancer risk factors was remarkably poor as the sample mean of total knowledge score (14 items) was only 3.25 (SD = 2.41). 
Among those who were sexually active and knew about Pap smear test, majority did not do the test mainly because of personal factors such as fear of the procedure, or were not ill. These indicate that the female students in this institution are having less knowledge regarding cervical cancer which is very important as to protect them from getting this preventable disease. This low level of knowledge may have translated to action as not to do the screening test as they might not know the benefit of the Pap smear test.
The university should consider improving health promotion program that will educate students about risk factors for cervical cancer and practicing preventive behavior. The role of media campaigns should be considered as these are known to work best in promoting cervical cancer knowledge, its risk factors and screening when multiple media are used.  Provisions should also be made available for female students when attending the university health clinics for any condition. Healthcare workers at the clinic can educate healthcare users, targeting the risk population on risk factors for cervical cancer and motivate them to have a Pap smear performed. This can improve the university community's knowledge of cervical cancer and practices on the Pap smear test when they seek medical care.
There were possible limitations that could arise from the study methodology. Because the study population consisted of students at one university, the results might not be generalized to other universities. Students' behaviors were self-reported, although the surveys were anonymous, some students may have been reluctant to report sensitive information regarding sexual behavior which would lead to underestimates of risky behaviors. To minimize this type of bias, their confidentiality was ensured.
| > Conclusion|| |
Results indicate poor knowledge of cervical cancer, its risk factors, detection method and utilization among these female university students. The university should thus concentrate on informing students about the risk factors for cervical cancer and strategies to prevent transmission of the HPV virus. Students should be encouraged to inform their older female relatives and friends who are eligible for cervical screening, to have cervical smear performed and to return for the results.
| > Acknowledgment|| |
The authors wish to acknowledge the academic board of Mangosuthu University of Technology for support and providing funding for the study. The author declares that there is no conflict of interest in this study.
| > References|| |
|1.||WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in Africa. Summary Report 2009. Available from: http://www.who.int/hpvcenre. [Last accessed on 2010 Jul 15]. |
|2.||World Health Organization. Cervical Cancer Screening in Developing Countries. Report of a WHO Consultation. Geneva: WHO; 2002. |
|3.||Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74-108. |
|4.||Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programs for cervical cancer in low- and middle-income developing countries. Bull World Health Organ 2001;79:954-62. |
|5.||Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: Low average levels and large inequalities. PLoS Med 2008;5:e132. |
|6.||Denny L. Prevention of cervical cancer. In: Ijumba P, Padarath A, editors. South African Health Review 2006. Durban: Health Systems Trust; 2006. |
|7.||Jamal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al. Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30. |
|8.||Moodley J, Kawonga M, Bradley J, Hoffman M. Challenges in implementing a cervical screening program in South Africa. Cancer Detect Prev 2006;30:361-8. |
|9.||GLOBOCAN. Cancer incidence and mortality worldwide in 2008, 2008. Available from: http://www.globocan.iarc.fr/factsheets/populations/factsheet.asp?uno=900#KEY. [Last accessed 2010 Oct 11]. |
|10.||Blair AR, Casas CM. Gynecologic cancers. Prim Care 2009;36:115-30. |
|11.||Hughes C. Cervical cancer: Prevention, diagnosis, treatment and nursing care. Nurs Stand 2009;23:48-56. |
|12.||Plus News. Global HIV/AIDS news and Analysis. South Africa: Cervical cancer vaccine offers distant hope. 2007. Available from: http://www.plusnews.org. [Last accessed on 2007 Jun 19]. |
|13.||Avert. South Africa: HIV and AIDS Statistics; 2008. Available from: http://www.avert.org/safricastats.htm. [Last accessed on 2010 Jun 21]. |
|14.||Mqoqi N, Kellett P, Sitas F, Jula M. Incidence of histologically Diagnosed cancer in South Africa, 1998 - 1999. Johannesburg: The National Cancer Registry of South Africa, National Health Laboratory Service; Dec, 2004. |
|15.||Abouzahr C, Wardlaw T. Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA. Available from: http://www.who.int/reproductivehealth/publications/maternal_mortality_2000/tables.html. [Last accessed on 2007 Sep 27]. |
|16.||Ferlay J, Bray F, Pissani P, Parkin DM. GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide, IARC Cancer Base No. 5, version 2.0. Lyon, France: IARC Press; 2004. Available from: http://www.depdb.iarc.fr/globocan/GLOBOframe.htm. [Last accessed on 2009 Sep 30]. |
|17.||Fonn S, Bloch B, Mabina M, Carpenter S, Cronje H, Maise C, et al. Prevalence of pre-cancerous lesions and cervical cancer in South Africa-a multicentre study. S Afr Med J 2002;92:148-56. |
|18.||Hoque M, Hoque E, Kadar SB. Evaluation of cervical cancer screening program at a rural community of South Africa. East Afr J Public Health 2008;5:111-6. |
|19.||Ayinde OA, Omigbodun AO, Ilesanmi AO. Awareness of cervical cancer, Papanicolau's smear and its utilization among female undergraduates in Ibadan. Afr J Reprod Health 2004;8:68-80. |
|20.||The Kaiser Family Foundation. National Survey of Public Knowledge of HPV, the Human Papillomavirus. Available from: http://www.kff.org/womenshealth/upload/The-HPV-Test-Coming-Soon-to-a-Doctor-s-Office-Near-You-Is-It-Better-than-the-Pap-Smear-for-Detecting-Cervical-Cancer-Chart-Pack.pdf. Last updated: February 17, 2000. Last accessed on 2008 Sep 28]. |
|21.||Oh JK, Lim MK, Yun EH, Lee EH, Shin HR. Awareness of and attitude towards human papillomavirus infection and vaccination for cervical cancer prevention among adult males and females in Korea: A nationwide interview survey. Vaccine 2010;28:1854-6. |
|22.||Wong LP, Sam IC. Ethnically diverse female university students' knowledge and attitudes toward human papillomavirus (HPV), HPV vaccination and cervical cancer. Eur J Obstet Gynecol Reprod Biol 2010;148:90-5. |
|23.||Marcus AC, Crane LA. A review of cervical cancer screening intervention research: Implications for public health programs and future. Prev Med 1998;27:13-31. |
[Table 1], [Table 2], [Table 3]
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