RESEARCH ARTICLE


Cervical Cancer Related Knowledge, Attitude and Behaviour Among Women in Makasar District Primary Health Care Centre in 2018



Hariyono Winarto1, *, Skolastika Mitzy B.2, Aji Budi Widodo2, Aan Kurniawan2, Yudi Reza Phallaphi2
1 Gynecologic Oncology Division, OBGYN Dept. Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
2 Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia


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© 2019 Winarto et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Gynecologic Oncology Division, OBGYN Dept. Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia; Tel: +62 21 3914806; E-mail: hariyono.winarto@ui.ac.id


Abstract

Introduction:

Cervical cancer is the 4th most prevalent cancer in women worldwide. Mortalities and morbidities are still increasing despite its preventability. The knowledge, attitude and behaviour of women in fighting cervical cancer are very important.

Objective:

This study aims to record knowledge, attitude, and behaviour of women in reproductive age regarding cervical cancer at Makasar District Primary Health Care Centre, East Jakarta in 2018

Material and Methods:

Descriptive cross-sectional study was conducted. Knowledge, attitude, and behaviour of cervical cancer were obtained using an assisted interview and recorded. The receipt of services towards cervical cancer prevention is referred to be favourable and unfavourable

Results:

Of the total 105 samples, the mean age was 30 years and mostly graduated from Junior High School (66.7%). More than half (59%) participants had poor knowledge about cervical cancer, but 89% of the participants had favourable attitude in receipt of services towards cervical cancer prevention. Despite the poor knowledge, 21.9% of the participants had been screened before.

Conclusion:

The knowledge and behaviour towards cervical cancer among women in Makasar Primary Health Care Centre are still inadequate but have favourable attitude.

Keywords: Cervical cancer, Knowledge, Behaviour, Attitude, Therapeutic measures, Prevention.



1. INTRODUCTION

Cervical cancer is the 4th most prevalent cancer in women worldwide [1]. Undoubtedly, it is one of the most frequent forms of cancer that affect women, hence causes high morbidities and mortalities. The methods of prevention and therapeutic measures of cervical cancer have advanced, as in the United States, cervical cancer incidence decreased to 8 cases per 100,000 women per year on 2003-2007 [2]. Meanwhile in Indonesia, cervical cancer is still a big problem that is yet to be solved. This is contradictory to the advancement of prevention and screening methods of cervical cancer. According to the Indonesian Ministry of Health Data (2015), cervical cancer is the third most common cause of cancer in women. [2] In Dharmais National Cancer Centre, the mortality of patients with cervical cancer in 2013 reaches 65 cases, with 356 new cases. The trend of both mortality and incidence is increasing each year [3].

Facilities have been given to primary health centres throughout Indonesia, but lack of awareness and the knowledge of cervical cancer among women is still considered to be important. This study is aimed to find out the knowledge, attitude, and behaviour of women in reproductive age regarding cervical cancer.

2. MATERIALS AND METHODS

We conducted a descriptive, cross-sectional study to assess the knowledge, attitude, and behaviour of cervical cancer among women in reproductive age (>15 years old) who came to Makasar Primary Health Care Centre. Makasar Primary Health Care Centre is a government-owned clinic which serves primary health care. There were 121 patients who came to the health centre, but only 105 (86.7%) agreed to participate. According to Jakarta Health Profile 2017, 58.49% of the women who come to the health centres are among reproductive age [4]. Participants were asked to give their consent and will be assisted in an interview to answer questionnaires. The questionnaires used are cited from previous research, translated into Bahasa Indonesia and was validated by an expert in oncology division, Obstetric and Gynaecologic Department in Cipto Mangunkusumo Hospital in Jakarta [5].

The participant’s knowledge was assessed by a questionnaire consisting of 26 questions. Any correct answer will be given 1 point and the wrong answer will be given 0 point. The maximum score was 26. Attitude score was assessed by a questionnaire consisting of 4 statements about the receipt of services towards cervical cancer prevention. They were given closed questions and were told to answer agree, neutral or disagree towards the questions. The responses were categorised to 3 categories: “positive”, “neutral” and “negative”. The response was considered positive if the participant answered correctly. End results will be grouped into favourable attitude if positive responses were recorded towards >2 statements, and unfavourable if positive responses were less than 2. The practice was grouped into screened, and never screened. Good practices are referred to those who have screened for cervical cancer.

Socio-demographic status and basic questions regarding cervical cancer were recorded, analysed using SPSS version 20. Descriptive statistics were translated into tables.

3. RESULTS

Table 1 shows the socio-demographic profile of the respondents in this study. The mean age of the respondents was 30 ± 5,94 years. Majority of the respondents (66.7%) education level was Junior High School. Most of the women are housewives (74%) and were married at their reproductive age or over 20 years (89%).

Majority of the participants (95.2%) have heard about cervical cancer. Most of the participants answered “bleeding that does not fit the menstrual cycle” and “having more than one sex partner” when asked about the symptoms and risk factors. Twenty-three participants didn’t know the answer to the questions given about cervical cancer symptoms and 8 participants (7,61%) didn’t know the answer to the questions about the risk factors (Table 2). Only 43 (41.9%) participants knew more than half of the aspects of cervical cancer knowledge in this study (Table 3).

Table 1. Socio-demographic profile of the respondent.
       Characteristic     Number (%)
       Age (yrs) (mean +/- SD) 30,0 ± 5,94
       Level of education
           Primary School 4 (3,8)
           Junior High School 70 (66,7)
           Senior High School 6 (5,7)
           Diploma 8 (7,6)
           Undergraduate 17 (16,2)
       Occupation
           Housewife 74 (70,5)
           Student 3 (2,9)
           Employee 23 (21,9)
           Entrepreneur 5 (4,8)
       Marital status
           Single 7 (6,7)
           Young marriage (< 20 yrs) 9 (8,6)
           Marriage at age ≥ 20 years 89 (84,8)
       Number of children
           Do not have 19 (18,1)
           1-2 child(ren) 70 (66,7)
           >2 children 16 (15,2)
SD: Standard Deviation
Table 2. Knowledge and attitudes of respondents on cervical cancer.
Variable N = 105 (%)
Ever heard of cervical cancer 100 (95.2)
Knowledge of the symptoms of cervical cancer
          Bleeding that does not fit the menstrual cycle 65 (61.9)
          Foul odour vaginal discharge 62 (59.0)
          Bleeding after menopause 14 (13.3)
          Longer or more bleeding in the menstrual cycle 48 (45.7)
          Do not know 23 (21.9)
Knowledge of the risk factors for cervical cancer
          HPV infection 56 (53.3)
          More than one sex partner 85 (81.0)
          Smoking 31 (29.5)
          Coitus on early age 53 (50.5)
          History of sexually transmitted diseases 70 (66.7)
          Poor hygiene 38 (36.2)
          Prolonged use of birth control pills (> 5 yrs) 5 (4.8)
          Pregnant more than 5 times 4 (3.8)
          Do not know 8 (7.61)
Knowledge of cervical cancer screening
          Ever heard of cervical cancer screening 61 (58.1)
          Method used 54 (51.4)
          Recommended age 54 (51.4)
          Screening frequency 33 (31.4)
Knowledge of vaccines that can prevent cervical cancer
          Availability of HPV vaccine 48 (45.7)
          The recommended age for HPV vaccination
Bleeding that occurs outside the menstrual cycle is normal 89 (84.9)
Women should have their first child at the age of 20 years 72 (68.6)
Having more than 5 children makes a better family relation 95 (89.5)
Women who have multiple sex partners are prone to cervical cancer 101 (96.2)
Women should be checked every 3 years by health workers 85 (81)
We should avoid neighbours who have been diagnosed with cervical cancer 76 (72,4)
Attitude Statements Number agreed (%)
         You are willing to check if offered cervical cancer screening for free 94 (89,5)
         You are willing to check if offered paid cervical cancer screening (Rp 400.000,00 -600.000,00) 18 (17,1)
          You are willing that your child be vaccinated if offered free cervical cancer vaccination 92(87,6)
          You are willing that your child be vaccinated if offered paid cervical cancer vaccinations (injections, Rp 500.000,00 -800.000,00/times) 20 (19,0)
HPV: Human Papilloma Virus
Table 3. Adequacy of knowledge, attitudes and behaviour related to cervical cancer.
    Variable     Number (%)
       Knowledge
           < 50% (poor)          62 (59)
           ≥ 50% (good)          43 (41,9)
       Attitudes
           Favourable          89 (84.8)
           Not favourable          16 (15.2)
       Behaviour
           Been screened          23 (21,9)
           Never been screened          82 (78,1)

Despite the poor knowledge, majority of the participants showed favourable attitude in receipt of services towards cervical cancer (89%). Only 21.9% of the participants had been screened before. Ninety-four percent (89.5%) of participants were willing to be screened if offered free. Majority of respondents told us that they had not known the availability of cervical cancer screening at the Makassar Health Centre. Some participants said they were embarrassed to get screened.

4. DISCUSSION

Majority of the participants in this study had poor knowledge level (n=62). This is supported by other researches in developing countries which have similar sample characteristics [6, 7]. Majority of the participants were graduated from Junior High School, which was in accordance with the data published from the Jakarta Health Profile 2017 [4]. Higher level of education correlates positively with a higher level of awareness [8]. However, other researches with sample with higher education level also showed a suboptimal level of knowledge [5, 9]. Study conducted by Endarti et al. in Yogyakarta Province, Indonesia, also revealed the same socio-demographic as found in Makasar Disctrict [10]. This showed that women, in general, have poor knowledge about cervical cancer regardless of their educational status.

Most of the participants (95.1%) have heard about cervical cancer but only 61 participants (58.1%) acknowledged the way to prevent this disease by screening. Moreover, only 45% knew that cervical cancer can be prevented by vaccination. This is supported by researches done in India, South Africa, and Nigeria which showed that most women didn’t know about either cervical cancer screening or vaccination [5, 11, 12].

Women in our sample population have access to be screened freely provided by the primary health care centre, but most of them still lack awareness regarding this issue. Mostly claimed they didn’t know about the programme. Factors impacting the attendance of routine screening are lack of knowledge, low-risk perceptions of cervical cancer, lack of symptoms and fear and fatalism. Distances from their home to the health centre also contribute to the perception of disease [14]. This was supported by researches claiming that primary health care has a great impact in lowering the incidence and mortality rates of cervical cancer [14, 15].

Most of the participants knew at least one symptom (n=82) and one risk factor (n=97). The most often cited symptoms is “bleeding that does not fit the menstrual cycle” and “foul odour vaginal discharge”. This is consistent with several studies conducted in the Maldives, and Ethiopia [11, 13, 14]. On the other hand, “multiple sexual partners” was the risk factor which was cited the most in the interview (n=81). This is in correspondence with many studies which showed the same results [5, 6, 9, 16]. Only half of participants can identify HPV infection as risk factors (n=56). This study showed that most women have misperception towards cervical cancer risk factors as 99,7% cervical cancers are associated with several HPV subtypes [17].

Despite the suboptimal level of knowledge, 89% of participants in this study showed favourable attitude towards cervical cancer. They were willing to be screened for cervical cancer (n=94) or having themselves/their children vaccinated for HPV (n=92) for free. These findings are also consistent with several studies. This is an advantage as they already have the willingness to screen, they just need additional information regarding the programmes.

Most non-favourable attitudes are found towards paid screening of cervical cancer or paid HPV vaccination for their children. This issue might be caused by the lack of knowledge regarding HPV risk factors. This was according to the previous study in Indonesia where high cost of vaccine and screening was the barrier [10]. Research in Kenya showed that women who acknowledged risk for cervical cancer were tendinous to be screened even if they have to pay [18].

In this present study, 21.9% have screened for cervical cancer at least once. Despite the good attitude, fewer actions were taken towards cervical cancer screening. This is in conjunction with other studies that showed that a positive attitude doesn’t correspond with good practices [5, 19, 20]. Several possible causes are misperception and lack information regarding the programs.

Limitation of this interview-based study was the sampling technique (purposive sampling).

CONCLUSION

Women in Makasar District Primary Health Care Centre are mostly housewives with an education level of Junior High School. Most of the participants were at reproductive age and were married. They still lack knowledge despite the good attitude towards cervical cancer, including the methods of prevention such as screening and vaccination. Most of them were willing to be screened if the prevention methods were given freely. The government and other health care institutions need more massive and efficient measures of health promotion regarding cervical cancer screening and prevention, especially in primary health care facilities which is the first health system easily approachable by most of the women.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Informed consent was obtained from all the participants.

AVAILABILITY OF DATA AND MATERIALS

The data that support the finding of this study are available on request from the corresponding author.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] World Health Organization. Cervical Cancer 2014.https://www.who. int/cancer/prevention/diagnosis-screening/cervical-cancer/en/
[2] Kementerian Kesehatan RI. Situasi Penyakit Kanker Jakarta: Pusat Data dan Informasi Kementerian Kesehatan 2015.http://www.depkes. go.id/resources/download/pusdatin/ infodatin/infodatin-kanker.pdf
[3] NIH Fact Sheets - Cervical Cancer [Internet] Reportnihgov 2018.https://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=76
[4] Satriono Profil Kesehatan Provinsi DKI Jakarta Tahun 2017 Jakarta: Badan Pusat Statistik Provinsi DKI Jakarta 2017.https://jakarta.bps. go.id/publication/download.html?nrbvfeve=Y2Y1Y2Q5ZjI3ODRiMjYwZWVmMzY5MGRl&xzmn=aHR0cHM6Ly9qYWthcnRhLmJwcy5nby5pZC9wdWJsaWNhdGlvbi8yMDE4LzA2LzI5L2NmNWNkOWYyNzg0YjI2MGVlZjM2OTBkZS9wcm9maWwta2VzZWhhdGFuLWRpLWRraS1qYWthcnRhLXRhaHVuLTIwMTcuaHRtbA%3D%3D&twoadfnoarfeauf=MjAxOS0wNi0xNyAxMjo0ODoyMw%3D%3D
[5] Bansal AB, Pakhare AP, Kapoor N, Mehrotra R, Kokane AM. Knowledge, attitude, and practices related to cervical cancer among adult women: A hospital-based cross-sectional study. J Nat Sci Biol Med 2015; 6(2): 324-8.
[6] Aweke YH, Ayanto SY, Ersado TL. Knowledge, attitude and practice for cervical cancer prevention and control among women of childbearing age in Hossana Town, Hadiya zone, Southern Ethiopia: Community-based cross-sectional study. PLoS One 2017; 12(7)e0181415
[7] Ebu NI, Mupepi SC, Siakwa MP, Sampselle CM, Sampselle C. Knowledge, practice, and barriers toward cervical cancer screening in Elmina, Southern Ghana. Int J Womens Health 2014; 7: 31-9.
[8] Anwar SL, Tampubolon G, Van Hemelrijck M, Hutajulu SH, Watkins J, Wulaningsih W. Determinants of cancer screening awareness and participation among Indonesian women. BMC Cancer 2018; 18(1): 208.
[9] Mruts KB, Gebremariam TB. Knowledge and Perception Towards Cervical Cancer among Female Debre Berhan University Students. Asian Pac J Cancer Prev 2018; 19(7): 1771-7.
[10] Endarti D, Satibi S, Kristina SA, Farida MA, Rahmawanti Y, Andriani T. Knowledge, Perception, and Acceptance of HPV Vaccination and Screening for Cervical Cancer among Women in Yogyakarta Province, Indonesia. Asian Pac J Cancer Prev 2018; 19(4): 1105-11.
[11] Wright KO, Faseru B, Kuyinu YA, Faduyile FA. Awareness and uptake of the Pap smear among market women in Lagos, Nigeria. J Public Health Africa 2011; 2(1)e14
[12] Basu P, Hassan S, Fileeshia F, et al. Knowledge, attitude and practices of women in maldives related to the risk factors, prevention and early detection of cervical cancer. Asian Pac J Cancer Prev 2014; 15(16): 6691-5.
[13] Ahmed SA, Sabitu K, Idris SH, Ahmed R. Knowledge, attitude and practice of cervical cancer screening among market women in Zaria, Nigeria. Niger Med J 2013; 54(5): 316-9.
[14] Hoque M, Hoque E, Kader SB. Evaluation of cervical cancer screening program at a rural community of South Africa. East Afr J Public Health 2008; 5(2): 111-6.
[15] Kim YM, Ati A, Kols A, et al. Influencing women’s actions on cervical cancer screening and treatment in Karawang District, Indonesia. Asian Pac J Cancer Prev 2012; 13(6): 2913-21.
[16] Geremew AB, Gelagay AA, Azale T. Comprehensive knowledge on cervical cancer, attitude towards its screening and associated factors among women aged 30-49 years in Finote Selam town, northwest Ethiopia. Reprod Health 2018; 15(1): 29.
[17] Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999; 189(1): 12-9.
[18] Sudenga SL, Rositch AF, Otieno WA, Smith JS. Knowledge, attitudes, practices, and perceived risk of cervical cancer among Kenyan women: brief report. Int J Gynecol Cancer 2013; 23(5): 895-9.
[19] Shrestha J, Saha R, Tripathi N. Knowledge, attitude and practice regarding cervical cancer screening amongst women visiting tertiary centre in Kathmandu, Nepal. Nepal J Med Sci 2013; 2: 85-90.
[20] Narayana G, Suchitra MJ, Sunanda G, Ramaiah JD, Kumar BP, Veerabhadrappa KV. Knowledge, attitude, and practice toward cervical cancer among women attending Obstetrics and Gynecology Department: A cross-sectional, hospital-based survey in South India. Indian J Cancer 2017; 54(2): 481-7.