Motivation and Barrier towards screening for Cervical cancer among rural women in the Northeastern Region of India
Shyama Devi1, Azhar S M2, Sujata Mohapatra2
1Assistant Professor, College of Nursing, AIIMS, Bhubaneswar, Odisha, India.
2Tutor, College of Nursing AIIMS, Bhubaneswar, Odisha, India.
*Corresponding Author Email: con_shyama@aiimsbhubaneswar.edu.in
ABSTRACT:
Motivation among women to undergo the cervical cancer screening program is essential for early diagnosis of the precancerous cell, eventually reducing the burden of cervical cancer. This study aims to determine the motivation and barriers towards cervical cancer screening among rural women in the northeastern region of India. Randomly 235 women were interviewed using a structured questionnaire. The result shows that 36.2% of participants heard of cervical cancer, and only two had undergone cervical cancer screening. 71.5% of participants were motivated towards cervical cancer screening. Significant barriers reported by subjects include lack of awareness about cervical cancer (74.9%), lack of information regarding screening of cervical cancer (74.9%), Distance of health center (47.7%), and Lack of communication from health care providers (41.3%). Awareness of cervical cancer prevention and screening may be more accessible to women. The health care provider's approach may significantly improve the uptake of cervical cancer screening.
KEYWORDS: PAP screening, Precancerous cervical cell, Community screening, Cervical Cancer screening, acceptance.
INTRODUCTION:
Cervical cancer is the 2nd commonest cancer in women. In today's era, in spite of the availability of affordable and effective methods for early detection and treatment of cervical cancer precursor lesions, cervical cancer still continues to be a public health problem in India. The age-adjusted incidence rates of cancer cervix reported by majority of Indian cancer registries are much higher than the world age-adjusted incidence rate of 7.9/100,000 population.1
The studies conducted in India provide sufficient evidence that cervical cancer screening through simple test like VIA/VILI is affordable, feasible, and an accurate tool for implementation in all health-care settings. However, for any cervical screening program to be successful in addition to the use of a reliable and accurate screening test, high rates of coverage are at most important.2
There are multiple barriers exist which resist the success of screening program and lead to lower motivation among women for undergoing screening. So, this study is being conducted to assess the motivation and barrier towards Screening for cervical cancer among women of Rural community.
The objectives of the study were to assess the level of motivation and barrier towards screening of cervical cancer among women and to determine association of motivational level with barrier toward screening of cervical cancer.
MATERIAL AND METHODS:
A Cross-sectional study was done in Jaggannath prasad Villages which comes under Andharwa panchayat. The public health facility of this village is catered under CHC Mendhasala. It covered around 4000 population. Married Women aged between 30-60 yrs of Jaggannath prasad Villages were included in the study. The Unmarried women and known case of cervical cancer were excluded from the study. A sample size of 235 was calculated with 95% confidence interval and 5% margin of error. The tool used for data collection was self developed tool which was validated by a panel of experts. It consisted of three section;
Section I: Structured demographic questionnaire consisted of age, education, occupation, religion, menstrual history, age of marriage, duration of marriage, number of children and family planning status.
Section II: to assess motivation level Semi Structured awareness checklist and Structured acceptance checklist was used. The response yes was given a score of one and no was scored as zero on awareness checklist. The range of score was between 0 to 5. score 0-2 was categorized as unaware and 3-5 as aware. The acceptance checklist asses the willingness of the participants for cervical cancer screening as yes and no response. The level of motivation was categorized as motivated and unmotivated on the basis of the awareness and acceptance.
|
Motivation |
Awareness of cervical cancer and its prevention |
Acceptance toward screening for cervical cancer |
|
Motivated |
Aware |
Accepted |
|
Unaware |
Accepted |
|
|
Unmotivated |
Aware |
Not accepted |
|
Unaware |
Not accepted |
Section III: Semi structured barrier questionnaire for screening of cervical cancer was used to the assess barrier towards screening of cervical cancer. It consisted of 12 identified barrier on the basis of review of literature. One item was open ended for barrier other than the list. Each item were having response of yes and no.
Ethical approval was obtained from institutional ethical committee. Approval to conduct the study in the village was sought from Medical officer. To obtain local support to conduct the study the village Sarpanch was informed regarding the purpose and duration of the study. Home visit was made to every second house and randomly one female of the house meeting the inclusion criteria was explained regarding the study through Participant information sheet Written informed consent was obtained from the participants on next day. Data was collected from the informants using the structured questionnaire. After completion of data collection all the informants were provided with the information regarding cervical cancer screening through the pamphlet and their query were addressed. Data was analysed using descriptive and inferential statistics.
RESULT:
Table 1: Distribution of participants based on age, education, occupation and religion (n=235)
|
Category |
Frequency |
Percentage |
|
Age group (in yrs) |
||
|
30-39 |
121 |
51.5 |
|
40-49 |
69 |
29.4 |
|
50-60 |
45 |
19.1 |
|
Education |
||
|
No formal education |
36 |
15.3 |
|
Primary education |
58 |
24.7 |
|
Secondary education |
103 |
43.8 |
|
Higher Secondary |
23 |
9.8 |
|
Graduates and above |
15 |
6.4 |
|
Occupation |
||
|
Home maker |
217 |
92.3 |
|
Manual labour |
7 |
3.0 |
|
Government employee |
4 |
1.7 |
|
Private employee |
1 |
.4 |
|
Others |
6 |
2.6 |
|
Religion |
||
|
Hindu |
234 |
99.6 |
|
Christian |
1 |
0.4 |
|
|
235 |
100 |
Table 1 shows that 51.5% of participants were in the age group 30-39 years, 43.8% have secondary education, 92.3% were doing household jobs and 99.6% belongs to hindu religion.
Table 2: Distribution of participants based on menstrual history, age of marriage, duration of marriage, number of children and family planning status (n=235)
|
Category |
Frequency |
Percentage |
|
Menstural history |
||
|
Regular |
168 |
71.5 |
|
Irregular |
36 |
15.3 |
|
Menopause |
31 |
13.2 |
|
Age of marriage |
||
|
Less than 18 years |
45 |
19.1 |
|
18-25years |
176 |
74.9 |
|
26-35years |
14 |
6.0 |
|
Duration of marriage |
||
|
Less than 10years |
42 |
17.9 |
|
10-20 years |
104 |
44.3 |
|
More tha 20years |
89 |
37.9 |
|
Number of children |
||
|
Nil |
13 |
5.5 |
|
1-2 |
154 |
65.5 |
|
More than 2 |
68 |
28.9 |
|
Family planning method |
||
|
Oral pills |
1 |
0.4 |
|
IUD |
3 |
1.3 |
|
Condom |
8 |
3.4 |
|
Tubectomy |
41 |
17.4 |
|
Miscellaneous |
5 |
2.1 |
|
Nil |
177 |
75.3 |
|
|
235 |
100 |
Table 2 depicts that 36 participants are having irregular menstrual periods, 45 participants married before the age of 18 years and 154 participants have either one or two child. 75.3% participants are not using any methods of family planning.
Figure 1: Distribution of participants based on substance abuse
Figure shows that 21.7 % participants were having the habit of betel chewing and 0.4% participants were addicted to smoking.
Table 3: Distribution of participants based on their screening status for cervical cancer and whether attended awareness programme for cervical cancer (N=235)
|
Category |
Frequency |
Percentage |
|
Done screening for cervical cancer |
||
|
Yes |
2 |
0.9 |
|
No |
233 |
99.1 |
|
Attended awareness programme for cervical cancer |
||
|
Yes |
1 |
0.4 |
|
No |
234 |
99.6 |
|
|
235 |
100 |
Table 3 shows that two participants had done screening for cervical cancer and one had attended awareness programme for cervical cancer.
Table 4: awareness of cervical cancer among womens
|
Category |
Frequency |
Percentage |
|
Heard of cervical cancer |
85 |
36.2 |
|
Risk of developing cervical cancer |
31 |
13.2 |
|
Knowledge on risk factors of cervical cancer |
33 |
14 |
|
Knowledge on signs and symptoms of cervical cancer |
16 |
6.8 |
|
Is cervical cancer preventable |
38 |
16.2 |
Table 4 shows that 36.2% of participants heard of cervical cancer and 13.2% responded that they are at risk of developing cervical cancer. 14% respondent said that they have knowledge of the risk factors and very few (6.8%) were aware about the sign and symptom of cervical cancer. Only 16.2% participants knew that cervical cancer is preventable.
Figure 2: Knowledge of participants on risk factors of cervical cancer
Figure 2 shows frequencies beside each risk factor represent the number of participants who rightly considered the said variable as a risk factor of cervical cancer.
Table 5: Knowledge of participants on signs and symptoms of cervical cancer
|
Signs and symptoms |
Frequency |
Percentage |
|
Pain and discomfort during intercourse |
7 |
3 |
|
Bleeding between two menstruation cycle |
3 |
1.3 |
|
Continuous lower backache |
6 |
2.6 |
|
Bad odor from vaginal discharge |
7 |
3 |
|
Long menstrual cycle and excessive bleeding |
4 |
1.7 |
|
Continuous diarrhea |
2 |
0.9 |
|
Pelvic Pain |
7 |
3 |
|
Bleeding after menopause |
6 |
2.6 |
|
Bleeding during and after intercourse |
2 |
0.9 |
|
Blood in urine and stool |
4 |
1.7 |
|
Unusual weight loss |
8 |
3.4 |
Table 5 shows frequencies beside each signs and symptoms represent the number of participants who rightly considered the said variable as a sign and symptom of cervical cancer.
Table 6: Distribution of participants based on their willingness for cervical cancer screening and awareness of cervical cancer
|
Category |
Frequency |
Percentage |
|
Willingness for cervical cancer screening |
||
|
No |
67 |
28.5 |
|
Yes (Free of cost) |
162 |
68.9 |
|
Yes (Paid) |
6 |
2.6 |
|
Awareness of cervical cancer |
||
|
Unaware |
226 |
96.2 |
|
Aware |
9 |
3.8 |
|
|
235 |
100.0 |
Table 6 shows that 169 participants were willing for cervical cancer screening and 226 participants are not aware regarding cervical cancer. Figure 3 shows that 71.5% of participants were motivated towards screening for cervical cancer.
Figure 3: Distribution of participants based on motivation towards screening for cervical cancer
Table 7: Distribution of participants based on their barriers towards screening of cervical cancer
|
Barriers towards screening |
Frequency |
Percentage |
|
Lack of awareness about cervical cancer |
176 |
74.9 |
|
Lack of information regarding screening of cervical cancer |
176 |
74.9 |
|
Perceived threat of Pain |
48 |
20.4 |
|
Fear of result of screening |
73 |
31.1 |
|
Lack of communication from health care provider |
97 |
41.3 |
|
Lack of privacy |
56 |
23.8 |
|
Distance of health centre |
112 |
47.7 |
|
Transport facility |
81 |
34.5 |
|
Unavailability of female practitioner |
56 |
23.8 |
|
Economic status |
109 |
46.4 |
|
Lack of decision-making power |
100 |
42.6 |
|
Lack of support from family |
41 |
17.4 |
Table 8: Association between motivation and barrier towards screening of cervical cancer
|
Barriers |
|
Motivated |
Unmotivated |
Chi square |
df |
P |
|
Lack of awareness about cervical cancer |
Yes |
129 |
47 |
1.122 |
1 |
0.29 |
|
No |
39 |
20 |
||||
|
Lack of information regarding screening of cervical cancer |
Yes |
130 |
46 |
1.939 |
1 |
0.164 |
|
No |
38 |
21 |
||||
|
Percieved threat of pain |
Yes |
39 |
9 |
2.82 |
1 |
0.093 |
|
No |
129 |
58 |
||||
|
Fear of result of screening |
Yes |
55 |
18 |
0.771 |
1 |
0.380 |
|
No |
113 |
49 |
||||
|
Lack of communication from health care provider |
Yes |
77 |
20 |
5.048 |
1 |
0.025 |
|
No |
91 |
47 |
||||
|
Lack of privacy |
Yes |
45 |
11 |
2.837 |
1 |
0.126 |
|
No |
123 |
56 |
||||
|
Distance of health centre |
Yes |
87 |
25 |
4.022 |
1 |
0.045 |
|
No |
81 |
42 |
||||
|
Transport facility |
Yes |
61 |
20 |
0.885 |
1 |
0.347 |
|
No |
107 |
47 |
||||
|
Unavailability of female practitioner |
Yes |
43 |
13 |
1.012 |
1 |
0.314 |
|
No |
125 |
54 |
||||
|
Economic status |
Yes |
82 |
27 |
1.395 |
1 |
0.238 |
|
No |
86 |
40 |
||||
|
Lack of decision-making power |
Yes |
78 |
22 |
3.62 |
1 |
0.057 |
|
No |
90 |
45 |
||||
|
Lack of support from family |
Yes |
26 |
15 |
1.589 |
1 |
0.208 |
|
No |
142 |
52 |
Table 7 shows frequencies beside barrier represent the number of participants who responded the said variable as a barrier towards screening for cervical cancer.
Table 8 shows that there is a significant association of motivation towards screening of cervical cancer with the barriers like lack of communication from health care provider (χ2 = 5.048, P =0.025) and distance of health centre (χ2 = 4.022, P =0.045).
DISCUSSION:
In this current study, out of total 235 subjects 51.5% were of 30 years to 39 years; ideal group for cervical cancer screening were identified, followed by 29.4% were of 40-49years old. Similar findings have also been reported in other study conducted in south Africa revealed the ages of the sample ranged from 18 to 72 years with most from 30-39 years group (43.8%) and the average age of 33 1. Mean age of the study population was 34.5 + 9.23 yr calculated by S Aswathy et.al 2. Most possess education upto secondary level (43.8%) whereas 15.3% were functionally illiterate. Maximum study subjects were reported unemployed and dependent on spouse or family (92.3%) in one south Indian study.1
Most women reported age of marriage between 18-25years (74.9%) and marriage duration between 10-20years (444.3%) with total no of children between 1-2 (65.5%) and regular menstruation history (71.5%). More participants reported with total no of children more than five (30.5%) followed by more than two children (26%) in one study in rural districts of Tanzania for cervical screening, which shows different demographic trends of different races3. Similar demographic trend found among respondents in Tanzania with no children had the lowest percentage (58.6%) of awareness about cervical cancer and women who had one to four children had the highest awareness (71.4%) about cervical cancer (p<0.001).4
There were only 24.7% of subjects were using family planning methods, out of which 17.4% had undergone tubectomy followed by condom (3.4%) and miscellaneous methods (2.1%) of contraception. Contrary to this study another study findings shows the prevalence of current use of contraception among employed and unemployed women were 67.2% and 60.9% respectively, among them 56.5% employed women and 51.7% unemployed women used modern contraceptive method. The most commonly used contraceptive method by employed women was pill (27.7%), followed by injection (11.4%), periodic abstinence (8.3%) and condom (7.2%) whereas these proportions were 26.8%, 11.2%, 7% and 5.9% respectively among unemployed women.5
In this study, 21.7 % participants were having the habit of betel chewing and 0.4% participants were addicted to smoking. Similar findings suggest chewing betel is widely observed in south and southeast Asian countries including India.6
Result shows 36.2% of participants heard of cervical cancer and 13.2% responded that they are at risk of developing cervical cancer whereas 38 participants responded that cervical cancer is preventable. From these above data it is concluded that 63.8% of subjects were unaware of cervical cancer. Less number of participant reported to be previously screened for cervical cancer (2 out of 235) and only one subject reported to be attended awareness programme for cervical cancer, which denotes lack of awareness about cervical cancer screening among women of rural India.
Awareness regarding cervical cancer increase the likelihood of acceptance for cervical cancer screening as reported by Rawlance Ndejjo et.al, those who knew where cervical cancer screening services were provided were 6 times more likely to have undergone the procedure [AOR = 6.24 (95% CI: 1.81–21.56), p = 0.004] while those who knew someone who had ever been screened where 9 times more likely to have screened for the disease [AOR = 9.48 (95% CI: 2.39–37.56), p = 0.001]7
Among 36.2% subjects, who reported to be aware about cervical cancer responded continuous lower backache, bleeding after menopause, unusual weight loss, long menstrual cycle and heavy bleeding were the common signs and symptoms of cervical cancer.
Similar study revealed that the majority of participants recognized symptoms of cervical cancer including inter‐menstrual bleeding (85%), post‐menopausal bleeding (84%), and offensive vaginal discharge (83%). 70% of participants believed that cervical cancer is preventable and 92% believed that it could be cured if diagnosed at an early stage.8
This study shows that 168 participants (68.9%) were willing for cervical cancer screening and among them 6 were consented to undergo screening in paid category whereas 162 were agree to undergo with free of cost and 67 (28.5%) were not possess willingness for cervical cancer screening. Somdatta Patra et. al reported one-fourth of populatio were willing to participate in a screening test. Willingness was higher among educated, ever user of family planning method and having knowledge about at least one risk factor, signs or symptoms, or possibility of early diagnosis of cancer cervix.9
Major barriers reported by subjects include, lack of awareness about cervical cancer (74.9%), lack of information regarding screening of cervical cancer (74.9%), Distance of health centre (47.7%), Lack of communication from health care provider (41.3%). Other similar studies concluded anxious feeling once the disease was diagnosed” (47.6%), “No symptoms/ discomfort” (34.1%) and “Do not know the benefit of cervical cancer screening” (13.4%) were the top three reasons for refusing cervical cancer screening.10 This study result also revealed association of motivation towards screening of cervical cancer with the barriers like lack of communication from health care provider (χ2 = 5.048,P =0.025) and distance of health centre (χ2 = 4.022, P =0.045).
Limitations of this study include; subjects were recruited by convenience sampling which limits the findings, women were from one selected rural community which may not represent all rural women additionally this study is a cross-sectional study which limits the study visits and follow-up. Despite these limitations, this study provide a basis for future study.
This is an important study to provide knowledge on factors of women participation in cervical screening in rural area, where most women are deprived of education and socio-economic status. Cervical cancer education will certainly raise public awareness so as to motivate unwilling women for cervical cancer screening which ultimately prevent a large no of cervical cancer burden in society. Barriers for cervical cancer screening has to be addressed by policy makers and health experts to improve women health at a large.
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Received on 11.12.2024 Revised on 05.04.2025 Accepted on 06.06.2025 Published on 13.08.2025 Available online from August 20, 2025 Asian J. Nursing Education and Research. 2025;15(3):137-142. DOI: 10.52711/2349-2996.2025.00029 ©A and V Publications All right reserved
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